MS Flashcards

1
Q

What is MS?

A

Inflammatory demyelinating disorder the central nervous system
Female >Men
30-40 yrs
MS plaques occurring in multiple parts of the central nervous system (CNS) and over the course of time
- Much more common in white populations and with increasing distance from the equator
- Causes of MS are not completely understood but the autoimmune process appears to be caused both by genetic and environmental factors
-Environmental factors which have been implicated include viral infections (e.g. EBV), and vitamin D deficiency

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2
Q

MS courses?

A
  • Relapsing-remitting MS (RRMS) (85-90%) - symptoms occur in attacks (relapses) with a characteristic time course: onset over days and typically recovery, either partial or complete, over weeks
  • Secondary progressive MS - this late stage of MS consists of gradually worsening disability progressing slowly over years; some 75% of patients with relapsing-remitting MS will eventually evolve into a secondary progressive phase by 35 years after onset
  • Primary progressive MS (PPMS) (10-15%) - characterized by gradually worsening disability without relapses or remissions
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3
Q

Pyramidal dysfunction; Clinical presentation?

A
  • Increased tone
  • Spasticity
  • Weakness
  • Affects extensors of upper limbs and flexors of lower limbs
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4
Q

Optic neuritis;Clinical presentation?

A
  • Painful visual loss over 1-2 weeks - blurred vision in one eye and loss (or reduction) in colour vision
  • Most improve
  • RAPD (relative afferent pupilary defect) on examination
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5
Q

Sensory symptoms;Clinical presentation?

A

“Feeling that water going down my legs”

  • Pain
  • Paraesthesia
  • Dorsal column loss - proprioception and vibration
  • Numbness
  • Trigeminal neuralgia
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6
Q

Cerebellar dysfunction; Clinical presentation?

A
  • Dysarthria
  • Ataxia
  • Intention tremor
  • Past pointing
  • Pendular reflexes
  • Dysdiadokinesis
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7
Q

Brainstem dysfunction; clinical presentation?

A
  • Diplopia - CN VI palsy
    • Facial weakness - CN VII palsy
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8
Q

Lower urinary tract dysfunction; clinical presentation?

A
  • Increased frequency and urgency
    • Nocturia
    • Urge incontinence
    • Retention
  • increased tone at bladder neck
    retention
  • detruser hypersensitivity
    frequency, urgency, nocturia, urge incontinence
  • detruser sphyncteric dyssenergia; i.e. inappropriate involuntary urethral sphincter contraction
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9
Q

Internuclear opthalmoplegia; clinical presentation?

A

-When two eyes don’t move together
-VERY COMMON in MS
- Involves the medial longitudinal fasciculus
- Distortion of binocular vision
- Failure of adduction - diplopia
- Nystagmus in abducting eye
- Lag

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10
Q

What is the most complain MS patient would have?; clinical presentation

A

FATIGUE

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11
Q

To diagnose MS consider 3 facts. what are they?

A

Clinical episode suggestive of demyelination

Dissemination in time and place

Alternative diagnosis excluded

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12
Q

what are the common diff diagnosises?

A

Vasculitis
Granulomatous disorder
Vascular disease
Structural lesion
Infection
Metabolic disorder

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13
Q

Investigations?

A

Bloods

  • Before referring to a neurologist, exclude differential diagnoses by checking FBC, inflammatory markers, U&E, LFT, TFT, glucose, HIV serology, calcium and B12 levels, vitamin D

Neurophysiology

  • Can detect demyelination in apparently unaffected pathways with characteristic delays

MRI

  • Periventricular lesions
  • Discrete white matter abnormalities
  • Areas of focal demyelination
  • Active inflammatory plaques can be distinguished from inactive ones by using a contrast agent

CSF

  • Oligoclonal bands present in 90+% of cases - distinct bands of IgG on Western blot that are unmatched with serum testing
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14
Q

Managemet for acute relapse?

A
  • Mild - symptomatic treatment
  • Moderate - oral steroids (5mg)
  • Severe - admit/IV steroids (100ml)
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15
Q

Mx for Pyramidal dysfunction?

A
  • Physiotherapy
  • Occupational therapy
  • for spasticity: Anti-spasmodic agent e.g. oral baclofen, oral tizanidine, botulinum toxin, intrathecal baclofen
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16
Q

Mx for the sensory symptoms?

A
  • Anticonvulsant e.g. gabapentin
  • Antidepressant e.g. amitriptyline
  • TENS machine
  • Acupuncture
17
Q

Mx of Lower urinary tract dysfunction

A
  • Bladder drill
  • Anti-cholinergics e.g. oxybutynin
  • Desmopressin
  • Catheterisation
17
Q

Mx for fatigue?

A
  • Amantadine
  • Modafinil if sleepy
  • Hyperbaric oxygen
17
Q

Disease modifying therapy; 1st line?

A
  • Tecfedira, aubagio; tablet form; First line indication in RR MS
  • Interferon beta; injectable
  • Glitiramer acetate; injectable
18
Q

Disease modifying therapy; 2nd line?

A
  • Monoclonal antibody : (highly active in RRMS)
  • Anti CD 20 ocrelizumab (comonest)
  • Anti CD 50 alemtuzemab (high toxicity;no use)
  • Anti integrin natilizumab (Very safe as long as the JC virus is negative)
  • Fingolimod, cladrabine; reboosting IS

Note: The monoclonal antibodies have greatest efficacy but also highest side effect profile

19
Q

MRI report
The imaging of this brain is abnormal.
There are several areas which give a high signal on the T2 weighted sequences
within the white matter. These are infratentorial, juxtacortical and
periventricular in site. They each measure between 1 and 2.5cm.
The appearance is highly suggestive of a diagnosis of multiple sclerosis.

A

infratentorial-pic below
juxtacortical-sort of near the cortex
periventricular- situated or occurring around a ventricle, especially a ventricle of the brain