15 Multiple Sclerosis

Question 1

Multiple sclerosis

Mcdonald criteria

Answer 1

Different time and space
Time: New T2/gadolinium lesion/ One asymptomatic enhancing (new) and one non enhancing (old) T2

Question 2

MS features

Answer 2

prolonged fatigue, symptoms worse with exercise and heat (uthoff phenomenon, worsening vision with heat)
eye: Pain worse on movement, visual acuity, colour blind, red desaturation, central scotoma, afferent pupillary defect, 95% return to normal within 1 year,
INO MLF horizontal nystagmus on abduction,
electrical shock on bending neck (Lhermitte sign), Spastic weakness

Question 3

MS investigations

Answer 3

MRI: white matter lesions (Hyperintensities T2) dawson fingers Flair (Plaques perpendicular to corpus callosum )
3 white lesion -> 50% chance of developing ms
Next step: LP and visual evoked potentials( flash/ black and white/checkerboard pattern, proving demyelination)
Optic neuritis: better prognosis , IV prednisolone
CSF: Oligoclonal bands (other D: PML, sarcoidosis)

Question 4

MS treatment?

Answer 4

Optic neuritis: better prognosis , IV prednisolone
Acute attack: IV Prednisolone 5 days/ or oral methyl prednisilon 500 5 days (just shortens, no effect on degree of recovery)
Relapse prevention(2 attacks in 2 years): Interferon B (teratogen, hepatotoxic, increase anti inflammatory), glatiramer acetate (both outdated, mimic myelin peptide) -> Fingolimod (S1P receptor modulator, prevents lymphocytes from leaving lymph node)
Relapsing remitting: Dimethyl fumarate, Natalizumab (Alpha4 Beta 1 antagonist, CAM 4 integrin antibody, once a month injection, side effects PML, check for HIV and JC before initiation, inhibit migration, ok for pregnancy), mitoxantrone
Progressive MS: Ocrelizumab (anti CD20 humanized), alemtuzumab (52 T cell toxic),
Symptom therapy: Fatigue: Amantadine Spasm:Baclofen, gabapentin Not overflow incontinence: Anticholinergic like oxybutinin Oscillopsia: Gabapentin
Follow up and response to treatment: MRI

Question 5

MS better prognosis?

Answer 5

Good prognosis: Young female, relapsing remitting, sensory only, long interval between attacks, complete recovery between them

Question 6

MS in pregnancy?

Answer 6

decrease relapse during pregnancy, then increase in 3-6 month post partum, then return to previous state