Multiple Sclerosis

Question 1

Is MS more common in males or females?

Answer 1

Females

Question 2

MS is a disease of

Answer 2

the white matter of the CNS which causes demyelination and relapsing, remitting disease

Question 3

Factors of pathogenesis of MS

Answer 3

Complex genetic inheritance
Association with autoimmune disease
More common in temperate climates
Possible relationship to viruses and vitamin D exposure

Question 4

Initial presentation of MS

Answer 4

80% present with a relapse - attack of demyelination or inflammation
Gradual onset over days
Stabilises over days/weeks
Gradual resolution to complete or partial recovery

Question 5

Symptoms of relapse of MS

Answer 5

Optic neuritis 
Sensory symptoms 
Limb weakness 
Diplopia/vertigo/ataxia 
Bilateral symptoms and signs of spinal cord pathology 
Bladder and bowel symptoms

Question 6

Presentation of optic/retrobulbar neuritis

Answer 6

Subacute vision loss in one eye
Pain on moving eye
Colour vision disturbed/desaturated

Question 7

Process of optic neuritis

Answer 7

Initial swelling of optic disc followed by optic atrophy

Question 8

Affect of optic neuritis on pupillary reflex

Answer 8

Relative afferent pupillary defect - dilation rather than constriction when light shone on pupil

Question 9

Possible differential diagnoses for optic neuritis

Answer 9

Neuromyelitis optica 
Sarcoidosis 
Ischaemic optic neuropathy 
Toxin/drugs/B12 deficiency 
Wegners granulomatosis 
Local compression 
Leber's hereditary optic neuropathy

Question 10

Presentation of brainstem relapse

Answer 10

Cranial nerve invovlement 
Internuclear opthalmoplegia 
Diplopia 
Vertigo 
Nystagmus 
Ataxia 
Upper motor neurone changes in limbs

Question 11

Presentation of myelitis

Answer 11

Numbness/pins and needles in legs
Weakness/upper motor neurone changes below the level of numbness/pins and needle
Bladder and bowel invovlement
Increased reflexes

Question 12

Presentation of further relapses of MS

Answer 12

May occur within months or years of first relapse 
Variable site and severity 
Optic nerve involvement 
Sensory involvement 
Limb weakness 
Diplopia 
Vertigo 
Ataxia 
Sphincter disturbance

Question 13

Describe process of demyelination

Answer 13

Autoimmune process
Activated T cells cross blood-brain barrier and cause demyelination
Demyelination can repair, full recovery if normal repair, or scarring and gliosis if not completely repaired

Question 14

How does demyelination appear on MRI?

Answer 14

As lesions or plaques

Question 15

Describe the progression of demyelination in MS

Answer 15

Axonal loss - may be important in progression and development of disability
Black holes appear on MRI, later seen as cerebral atrophy

Question 16

Presentation of progressive phase of MS

Answer 16

Accumulation of symptoms and signs 
Fatigue, temperature sensitivity 
Sensory involvement 
Stiffness/spasms
Poor balance 
Slurred speech 
Difficulty swallowing 
Diplopia, oscillopsia, visual loss 
Cognitive - dementia, emotional liability

Question 17

Most patients who present with relapsing remitting MS will go on to develop

Answer 17

secondary progressive disease

Question 18

Possible examination findings in MS (depends on location of demyelination and stage of disease)

Answer 18

Afferent pupillary defect 
Nystagmus/abnormal eye movements 
Cerebellar signs 
Sensory signs 
Weakness 
Spasticity 
Hyperreflexia 
Plantar extensor reflex

Question 19

How is MS diagnosed?

Answer 19

Based on clinical presentation, MRI and evidence of demyelination separated in time and space

Question 20

Investigations that should be done in suspected MS with an atypical clinical picture or MRI

Answer 20

Lumbar puncture
Visual/somatosensory evoked response
Bloods to exclude other inflammatory conditions
CXR

Question 21

Differential diagnoses for suspected MS with atypical presentation

Answer 21

Acute disseminated encephalomyelitis 
Other autoimmune conditions e.g. SLE 
Sarcoidosis 
Vasculitis 
Infection e.g. Lyme disease 
Adrenoleukodystrophy

Question 22

Type of MS

Answer 22

Relapsing remitting 
Secondary progressive 
Primary progressive 
Sensory 
Malignant

Question 23

First line agents for disease-modifying treatment of MS

Answer 23

Beta-interferons/glatiramer acetate daily/weekly IM/SC injection
Oral treatments - teriflunomide, dimethyl fumarate

Question 24

Possible side effects of first line agents for disease modifying treatment of MS

Answer 24

Flu-like symptoms
Injection site reaction
Abnormalities of blood count and liver function

Question 25

Second line agents for disease-modifying treatment of MS

Answer 25

Natalizumab
Fingolimod
Alemtuzumab

Question 26

Treatment of Progressive Multifocal Leukencephalopathy

Answer 26

Natalizumab, dimethyl fumarate or fingolimod
Annual MRI
JC virus antibody blood and urine 6-monthly

Question 27

Treatment of acute relapse of MS

Answer 27

Look for underlying infection 
Exclude worsening of usual symptoms with intercurrent illness 
Oral prednisolone 
Rehabilitation 
Symptomatic treatment

Question 28

Treatments for spasticity in MS

Answer 28

Muscle relaxants
Antispasmodics
Physiotherapy

Question 29

Treatments for dysaesthesia in MS

Answer 29

Amitriptyline

Gabapentin

Question 30

Treatments for urinary problems in MS

Answer 30

Anticholinergics
Bladder stimulation
Catheterisation

Question 31

Treatment for constipation in MS

Answer 31

Laxatives

Question 32

Treatment for vision problems/oscillopsia in MS

Answer 32

Carbamazepine

Question 33

Features of upper motor neurone lesion

Answer 33

Muscle weakness (pyramidal) 
Decreased control of active movement 
Spasticity 
Clasp-knife response 
Babinski sign 
Increased deep tendon reflex 
Pronator drift

Question 34

Features of lower motor neurone lesion

Answer 34

Muscle paresis/paralysis 
Fibrillation 
Fasciculations 
Hypotonia/atonia 
Hyporeflexia 
Strength not affected 
Muscle wasting (end stage)