Multiple sclerosis (MS)

Question 1

What is MS?

Answer 1

Chronic and progressive condition that involves demyelination of the myelinated neurons in the CNS. This is caused by an inflammatory process involving the activation of immune cells against the myelin

Question 2

What is the pathophysiology of MS?

Answer 2

Inflammation around myelin and infiltration of immune cells that cause damage to the myelin. This affects the way electrical signals travel along nerves, resulting in the symptoms of MS

Question 3

Why do symptoms become more permanent later in the disease process?

Answer 3

Re-myelination can occur earlier in the disease process which results in symptoms resolving. Re-myelination is incomplete and symptoms gradually become more permanent later in the disease process

Question 4

1) What is the main risk factor for developing of MS?
2) Name 2 other factors that can increase the risk of developing MS
3) Who is the classic patient that develops MS?

Answer 4

1) Infection with Epstein-Barr virus
2) Smoking, low vitD, genetic predisposition, obesity
3) Woman aged 20-40

Question 5

Disease patterns in MS
1) What is the most common disease pattern at initial diagnosis?
2) What is this disease pattern characterised by?
3) What is secondary progressive MS?
4) What is primary progressive MS?

Answer 5

1) Relapsing-remitting
2) Episodes of disease and neurological symptoms (relapse) followed by recovery (remitting)
3) Where there was relapsing-remitting disease at first, but now there is a progressive worsening of symptoms with incomplete remissions
4) There is a worsening of disease and neurological symptoms from the point of diagnosis without initial relapses and remissions

Question 6

1) What is the commonest presentation of MS?
2) What is this?
3) If there is a lesion in the abducens nerve, how can patients present?
4) What are the 2 key phrases when describing abducens nerve palsy?

Answer 6

1) Optic neuritis
2) Pain with eye movement and temporary vision loss in one eye
3) Double vision
4) Internuclear ophthalmoplegia and conjugate lateral gaze disorder

Question 7

1) What is internuclear ophthalmoplegia?
2) What is conjugate lateral gaze disorder?
3) Name a sensory feature of MS
4) Name a motor feature of MS
5) Name a cerebellar feature of MS
6) Name another feature of MS
7) What is Lhermitte’s sign?

Answer 7

1) Ocular movement disorder
2) Inability to move both eyes together in a single horizontal (most commonly) or vertical direction
3) Pins/needles, numbness, trigeminal neuralgia, Lhermitte’s sign
4) Spastic weakness most commonly seen in the legs
5) Ataxia, tremor
6) Sexual dysfunction, urinary incontinence, intellectual deterioration
7) Electric shock sensation that travels down the spine and into the limbs when flexing the neck

Question 8

1) Diagnosis of MS requires a demonstration of what?
2) Name 2 features/investigations that a diagnosis of MS is made based upon

Answer 8

1) Lesions disseminated in time and space
2) Clinical picture and symptoms, McDonald criteria, MRI, lumbar puncture can detect oligoclonal bands in the (CSF)

Question 9

1) How is acute MS/relapsed MS treated?
2) Name a disease modifying therapy (DMT) that can be used
3) Name a monoclonal antibody DMT that can be used

Answer 9

1) Glucocorticoid - methylprednisolone
2) Beta-interferon, glatiramer, dimethyl fumarate, teriflunomide and fingolimod
3) Natalizumab and alemtuzumab

Question 10

Symptomatic management of MS
1) How can neuropathic pain can be managed?
2) How can depression can be managed?
3) How can bladder dysfunction be managed?
4) How can spasticity can be managed?

Answer 10

1) Medication such as amitriptyline or gabapentin
2) Antidepressants such as SSRIs
3) Anticholinergic medication i.e. tolterodine or oxybutynin
4) Baclofen, gabapentin and physiotherapy