Multiple sclerosis Flashcards
What group of patients does MS typically occur in?
Women
20-40 year olds
What are the features of MS?
An UMN disease
May present with non-specific lethargy (in 75%)
Visual: Optic neuritis (common presenting c/o) Optic atrophy Uhthoff's phenomenon - worsening of vision following rise in body temperature Intranuclear ophthalmoplegia
Sensory: Paraesthesia Numbness Trigeminal neuralgia Lhermitte's syndrome - paraesthesia in limbs on neck flexion
Motor:
Spasticity and weakness most commonly in the legs
Focal weakness:
Bells palsy
Horner’s syndrome – ptosis, anhidrosis, mitosis
Limb paralysis
Cerebellar:
Sensory or cerebellar ataxia - most often seen in acute relapse
Tremor
Other features: Dysphagia Urinary incontinence Sexual dysfunction Intellectual deterioration
What are the features of optic neuritis?
Why does it occur?
Unilateral decrease in VA Central scotoma Pain worse on eye movement Impaired colour vision RAPD
Occurs due to demyelination of optic nerve
What are the features of intranuclear ophthalmoplegia?
Why does it occur?
Impaired adduction of the eye on ipsilateral side of lesion
Horizontal nystagmus when abducting eye on contralateral side, causing diplopia
Occurs due to a lesion in the medial longitudinal fasciculus (MLF) that would normally connect optic brainstem nuclei on contralateral side of brainstem. This tract allows conjugate eye movement (3rd, 4th, 6th CN). So lesions here causes impaired ophthalmoplegia
What are the different patterns of relapse and remission in MS?
Relapsing-remitting MS:
Most common - in 85%
Primary progressive MS
Secondary progressive MS
Progressive relapsing MS:
more common in older patients
What is the criteria to diagnose MS?
Diagnosis = 2 or more relapses and either clinical evidence of 2 or more lesion OR clinical evidence of 1 lesion together with historical evidence of previous relapse
Lesions must be disseminated in time and space
What investigations are carried out in MS?
MRI:
High signal T2 lesions
Periventricular plaques
Dawson fingers - white matter plaques perpendicular to the corpus callosum
CSF: Oligoclonal bands (and not in serum) Increased intrathecal synthesis of IgG
Visual evoked potentials:
Delayed, but well preserved waveform
Bloods:
To exclude differentials
What is the management for MS?
Acute relapse:
High dose steroids - oral methylprednisolone (500mg/day for 5 days) or IV methylprednisolone (1g/day for 3 days)
Steroids also used for optic neuritis
Disease modifying drugs to reduce no. of relapses: Beta-interferon - has certain criteria Glatiramer acetate Natalizumab Fingolimod
Symptom control:
Exercise to maintain activity and strength
Amitriptyline or gabapentin can be used to manage neuropathic pain
SSRIs for depression
Tolterodine or oxybutynin can be used to manage urge incontinence - may cause or worsen cognitive impairment
Baclofen, gabapentin and physiotherapy can be used to manage spasticity
What can present similar to MS?
Transverse myelitis
Neuromyelitis optica
What is transverse myelitis and what are it’s features?
A type of myelopathy where there is inflammation of 1 or more spinal cord segment (usually thoracic)
Limb weakness and numbness
Bladder dysfunction
Autonomic dysfunction
Signs of myelopathy + CSF oligoclonal bands, think transverse myelitis
What is Neuromyelitis optica?
Optic neuritis + transverse myelitis
Antibody for aquaporin 4 (anti-AQP4) may be present
