Multiple sclerosis and inflammatory CNS disorders Flashcards
What is multiple sclerosis (MS)?
An inflammatory demyelinating disorder of the CNS
When does MS typically present?
- 30s and 40s
- Female>Male (3:1)
What are the clinical features of MS?
Pyramidal dysfunction, optic neuritis, sensory symptoms, LUT dysfunction, cerebellar & brain stem features, cognitive impairment
What are the signs of pyramidal dysfunction?
Increased tone, spasticity and weakness in the extensors of the upper limbs and flexors of the lower limbs
What are the signs of optic neuritis?
Painful visual loss, 1-2 weeks, most improve, relative afferent pupillary defect (RAPD)
What are the sensory symptoms associated with MS?
Pain, paraesthesia, dorsal column loss (proprioception and vibration), numbness and trigeminal neuralgia
What are the symptoms associated with cerebellar dysfunction in MS?
Ataxia, intention tremor, nystagmus, past pointing, pendular reflexes, dysdiadokinesis, dysarthria
What are the symptoms associated with brain stem dysfunction in MS?
- Diplopia - CN VI palsy
- Facial weakness - CN VII palsy
What occurs as a result of internuclear ophthalmoplegia?
- Involves the medial longitudinal fasciculus
- Distortion of binocular vision
- When an attempt is made to gaze contralaterally (relative to the affected eye), the affected eye adducts minimally, if at all. The contralateral eye abducts, however with nystagmus.
- Divergence of the eyes leads to horizontal diplopia. That is, if the right eye is affected the patient will “see double” when looking to the left
- Lag also occurs
What are the symptoms associated with lower urinary tract dysfunction in MS?
Frequency, nocturia, urgency, urge incontinence and retention
What can be used to manage fatigue in MS?
Amantadine, modafinil if sleepy and hyperbaric oxygen
How is MS diagnosed?
- At least 2 episodes suggestive of demyelination
- Dissemination in time and place
- McDonald criteria
- MRI, CSF, neurophysiology
- Blood tests
What blood tests are done to investigate MS?
PV, FBC, CRP, renal liver bone profile, auto-antibodies, borellia, HIV, syphilis serology, B12 and folate - negative
What is usually present in the CSF in MS patients?
Oligoclonal bands in 90% of cases
How is an acute exacerbation of MS managed?
- Mild - symptomatic treatment
- Moderate - oral steroids
- Severe - admit/IV steroids
How is pyramidal dysfunction managed?
Physiotherapy, occupational therapy, anti-spasmodic agent e.g. baclofen, tizanidine
Botulinum toxin
How are sensory symptoms in MS managed?
- Anti-convulsant e.g. gabapentin
- Anti-depressant e.g. amitriptyline
- Tens machine
- Acupuncture
- Lignocaine infusion
How is lower urinary tract dysfunction managed?
- Bladder drill, anti-cholinergics e.g. oxybutynin
- Desmopressin, catheterisation
What are first and second line disease modifying agents used in MS?
1st line:
- Interferon beta - avonex, betaseron
- Glitiramer acetate (copaxone)
- Tecfedira
2nd line:
- Monoclonal antibody - tysabri, lemtrada, ocrelizumab
- Fingolimod
What is the route of administration and how effective are interferon beta and copaxone in treating MS?
- Injectable agents - SC or IM
- Decrease relapse rate by 1/3
- Decrease severity by 50%
- Effect on disability
What is the route of administration and how effective is tecfidera in treating MS?
- Oral agent
- First line in relapsing remitting MS
- 44% reduction in relapse rate
What is the route of administration and how effective is fingolimod in treating MS?
- Oral agent
- >50% reduction in relapse rate
- Significant effect on disease progression
- Second line therapy
How effective are monoclonal antibodies in treating MS?
Used in patients with rapidly evolving RRMS and in patients with high disease activity despite treatment with an interferon
Ocrelizumab delays progression by 25%
Describe the inflammatory cascade in MS
- Immune cells pass through BBB
- Immune cells may re-activate and produce cytokines
- Immune cells mount autoimmune attack against myelin
