Week 4- MS Flashcards
What is multiple sclerosis?
An inflammatory demyelinating disorder of the central nervous system.
Plaques are disseminated in TIME and PLACE.
When does multiple sclerosis initially present?
In the 30-40 age range.
What are the 4 courses that MS can follow?
Relapsing- remitting MS
Progressive relapsing
Secondary progressive
Primary progressive
Which course of MS is most common?
Relapsing-remitting MS.
Describe relapsing-remitting MS?
You have bouts of symptoms, then they go back to almost good health. This happens again and again.
E.g. visual loss for 2 weeks, they then regain complete vision afterwards.
Describe secondary progressive MS?
Like relapsing and remitting- they have bouts of symptoms, however they don’t recover as well afterwards. Their disability gradually increases.
Describe progressive relapsing MS?
More gradual onset of symptoms with occasional exacerbations.
Describe primary progressive MS?
They have gradual symptom onset and gradual disability worsening.
Clinical features of MS?
Pyramidal dysfunction Optic neuritis (inflammation of the nerve- transient, vision loss stops when the inflammation stops) Sensory symptoms Lower urinary tract dysfunction Cerebellar and brain stem features Cognitive impairment- in severe MS
What is pyramidal dysfunction?
Something affecting the corticospinal (pyramidal tract).
Causes weakness in the extensors of the arms and flexors of the legs.
Spasticity
Increased tone.
What is optic neuritis?
Painful visual loss due to inflammation at the optic nerve head.
They will have a relative afferent pupillary defect.
Lasts about 1-2 weeks.
What sensory systems are likely to show in MS?
Pain Paresthesia Numbness Dorsal column loss- loss of proprioception and vibration sense. Trigeminal neuralgia??
How would cerebellar dysfunction present in MS?
Lack of co-ordination of movement. Ataxia Dysdiadokinesis Nystagmus Intention tremor Past pointing
(REMEMBER DANISH- D-dysdiadokinesis, A-ataxia, N-nystagmus, I-intention tremor, S-stacchato, H- hypotonia
How might brainstem dysfunction present in MS?
Diplopia (cranial nerve VI palsy) Facial weakness (cranial nerve VII palsy)
What is internuclear ophthalmoplegia?
When you try and use your lateral vision- e.g. looking right.
The right eye can abduct- so moves that way. However the left eye can’t adduct and therefore stays looking forwards. This causes the right eye to go into nystagmus. Issue is with the left eye- causes double vision.
What sort of lower urinary tract symptoms may someone with MS present with?
Same as old men with prostatic hypertrophy.
Frequency, urgency, nocturia, retention
How would you manage fatigue in an MS patient?
Amantadine
Modafinil if sleepy.
Hyperbaric oxygen.
What is the diagnostic criteria for MS?
2 separate occasions of focal neurological deficit. Most show dissemination in time and space.
What are the possible differentials for a diagnosis of MS?
Vasculitis
Recurrent strokes?
Infection
What investigations will allow you to diagnose MS?
Clinical- history
Imaging- MRI
Lumbar puncture
Blood tests
Why would you do blood tests in MS?
There isn’t something you are looking for, you are just looking to rule out things like infection and vasculitis.
What blood picture would you get if the patient was suffering from vasculitis?
CRP and plasma viscosity would probably be high.
In infection, what would the blood picture look like?
Serology would show presence of infection e.g. Borrellia, HIV.
On drawing CSF, what would you expect to find if a patient was suffering from MS?
Oligoclonal bands are present. These are immunoglobulins that are present when there is inflammation in the CNS
How would you manage a mild acute exacerbation of MS?
Symptomatic relief.
If someone woke up to some tingling- then no treatment required. However if the tingling is unpleasant- offer symptomatic relief.
How would you manage a moderate acute exacerbation of MS?
This could be difficulty walking. Give oral steroids.
How would you manage a severe acute exacerbation of MS?
Admit them
Give IV steroids
What can treat the pyramidal dysfunction?
Physiotherapy- to strengthen muscles
Occupational therapy- for splintage
Anti-spasmodic agents e.g. baclofen.
What can treat the spasticity that patients experience?
Baclofen again
Or botox
However can cause floppiness/drowsiness.
How would you treat sensory symptoms
Dampen down neurotransmission with anti-convulsants and anti-depressants e.g. gabapentin and amitryptilline
Could try tens machine
Acupuncture
Lignocaine infusion
What treatment can you give for lower urinary tract symptoms?
Anti-cholinergics e.g. oxybutylin
Desmopressin
Catheterisation
What treatment can you give for the fatigue?
Amantadine
Modafinil if sleepy.
What is the first line therapy for MS (not in an acute exacerbation)?
Disease modifying therapy
- Interferon beta- e.g. Avonex
- Glitiramer acetate
- Tecfidira
What is the second line therapy for MS (not in an acute exacerbation)?
Monoclonal antibodies
Fingolomod
What is the third line therapy for MS (not in an acute exacerbation)
Mitoxantrone
How is avonex given?
Intra muscular injection once weekly.
How is tecfidira given?
Tablet
Describe interferon beta and capoxones effect?
Reduce the relapse rate and reduce severity of relapses.
When should tecfidera be used?
Its the first line in relapsing remitting MS.
What is the preferred second line from NICE?
Fingolomod
When should monoclonal antibodies be used?
In highly active relapsing remitting MS- despite treatment with interferon.
What is progressive multifocal leucoencephalopathy?
A rare disease of the white matter where inflammation and damage occurs in multiple lesions.
What causes progressive multifocal leucoencephalopathy?
Infection by the JC virus.
All second line therapies can also cause this.
What drug should be used in relapsing progressive MS?
Mitoxantrone
