Mutiple Sclerosis

Question 1

Young patient with double vision and incoordination.
What are you going to test?

Answer 1

Cranial nerves: reduced visual acuity and INO
Fundoscopy: optic atrophy
Peripheral nerves: spasticity, weakness, brisk reflexes, altered sensation
Cerebellar: DANISH

Question 2

Define MS

Answer 2

CNS demyelination causing neurological impairment disseminated in time and space

Question 3

How is MS diagnosed?

Answer 3

It’s a clinical diagnosis combined with use of investigations such as CSF analysis for oligoclonal bands, MRI for periventricular white matter plaques and visual evoked potentials to look for evidence of previous optic neuritis

Question 4

How would you manage a patient with MS?

Answer 4

MDT approach
Acute relapse: methylprednisolone and treat any infection
Disease modifying
RRMS and EDSS of max 6.5 - interferon beta and glatiramer
Alemtuzumab, Natalizumab, Fingolimod (oral treatment)
Symptomatic relief:
Baclofen for spasticity
Carbamazepine for neuropathic pain
Laxative/Oxybutynin/Catheterisation: bladder/bowel issues

Question 5

List conditions caused by MS

Answer 5

Optic neuritis
Optic atrophy
6th nerve palsy
INO

Spinal cord: sensory loss, paraparesis, bladder/bowel issues

Cerebellar: DANISH

Cognitive impairment, depression, euphoria

Trigeminal neuralgia

ENT: dysarthria, dysphasia, vertigo

Lhermitte sign
Uhthoffs sign

Question 6

What advice would you give to a woman with MS wanting to get pregnant

Answer 6

Withdraw DMTs
Less likely to have a relapse during pregnancy but increased risk in post partum period
The condition is not a risk to the foetus

Question 7

Differential of MS

Answer 7

Vascular: TIA, stroke (causes of stroke in a young patient CADASIL, Fabry disease, antiphospholipid syndrome)
Infection: Lyme disease (rare 5% of lyme disease affect CNS), HIV (can cause a vacuolar myelopathy), syphilis (tabes dorsalis), brucellosis (transverse myelitis), Progressive multifocal leukoencephalopathy
Autoimmune: SLE, sjogrens?, Behcets?, neurosarcoidosis (can occur anywhere in nervous system, primary CNS angiitis (rare, neuromyelitis optica
Metabolic: B12 deficiency

Question 8

What are the clinical features of optic neuritis?

Answer 8

Pain behind the eye
Reduced visual acuity
Colour desaturation
RAPD

Question 9

Neuromyelitis Optica:
What is it?
How is it diagnosed?
How is it different from MS?
How is it treated in the acute and chronic setting?

Answer 9

Demyelination of the spinal cord and optic nerves
Detect antibody against aquaporin-4 in the blood
Spinal cord lesion span more the 3 vertebral segments
Acute: IV immunoglobulin and plasma exchange
Chronic: steroids and immunosuppressants