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Psychiatry > Multiple Sclerosis > Flashcards

Multiple Sclerosis Flashcards

0
Q

Multiple sclerosis

A

A disease characterised by episodes of inflammation and demyelination in the CNS affecting the optic nerves, brain and spinal cord
Produces variable neurological symptoms depending on the regions of demyelination

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1
Q

Prevalence of MS

A

Most common neurological condition in young adults
85,000 people with MS in the UK
2.5 million people in the world
Typically starts between 20 - 40 years, but can affect kids/eldery

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2
Q

Aetiology of MS

A

Combination of environment and genetics but limited heritability
Only 30% risk in monozygotic twins
More common further from the equator, and possible role of early EBV infection

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3
Q

MS is caused by

A

Immune cells enter the CNS and release inflammatory mediators which causes demyelination by an unknown mechanism

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4
Q

Symptom development

A

Benign MS - infrequent episodes with full recovery after each
Relapsing-remitting MS- attacks with decreasing recovery
Primary progressive MS - steadily worsening condition
Secondary progressive MS - progressive worsening of condition after a period of relapsing-remitting

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5
Q

Symptoms of MS

A

Extremely variable depending on the areas affected
Can differ between attacks
People can retrospectively identify attacks long before diagnosis

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6
Q

Relapsing remitting MS

A

Onset over hours to days, with recovery taking weeks to months
Neurological deficit:
- optic neuritis (painful loss of vision)
- sensory symptoms/loss
- spinal cord ( leg weakness/numbness, urinary symptoms)
- hemiparesis or cerebellar symptoms

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7
Q

Primary Progressive MS

A

Gradual accumulation of neurological deficits

No spontaneous improvement or sudden deterioration

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8
Q

Secondary progressive MS

A

Relapsing remitting MS followed by progressive disease

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9
Q

Possible symptoms of MS

A

Sensory -double vision/optic neuritis, pins and needles,numbness, pain
Muscular- weakness, slurred speech
Central symptoms - bladder weakness, tremor, fatigue, depression, memory problems, sexual problems

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10
Q

Cranial nerves examination findings

A

Optic disc atrophy or muscle weakness (VI nerve palsy)
Reduced vision and acuity
Intranuclear ophthalmoplegia
Nystagmus and dysarthria (slurring speech)

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11
Q

Generalised examination findings

A

Upper motor neurone signs - increased tone, pyramidal distribution of weakness, brisk reflexes and up going plantars
Patchy sensory loss
Cerebellar signs
Walking difficulties due to ataxia or spasticity

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12
Q

Diagnosing MS

A

No single test, clinical diagnosis based on history and examination
Blood tests to exclude other inflammatory conditions
Lumbar puncture and visual evoked potentials and MRI can all help support diagnosis

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13
Q

Signs of MS on MRI

A

Diagnostic if can find one or more T2 lesions in two or more of the MS typical brain areas
- periventricular, juxtacortical, infratentorial and callosal

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14
Q

MS specific signs

A

Lhermitte’s sign - electric shock feeling down the spine on bending the neck
Uhtoff’s sign - temporary worsening of symptoms with increased body temperature (hot bath etc)

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15
Q

Prognosis

A

Hard to predict as MS is so variable
Symptoms gradually accumulate over the years - 50% can still walk 15yrs after diagnosis
In most cases death is unrelated to MS - 75-85% survival rate 25 years after diagnosis

16
Q

Treating relapses

A

1/4 triggered by an infection and improve as it resolves
Mainstay of treatment is to manage symptoms
Multidisciplinary support very important

17
Q

Steroid treatments for relapses

A

25% show improvement at 5 weeks, but no difference at 6 months between treated and untreated patients
Methylprednisolone IV 1g/day for 3 days or 500mg/day PO for 5 days

18
Q

Treatments for muscle stiffness

A

Physiotherapy
Baclofen - GABAb agonist
Tizanidine - alpha2 receptor agonist used as a muscle relaxant
Diazepam - benzodiazepine GABAa receptor enhancer
Botox - botulinum toxin blocks Ach release at the NMJ

19
Q

Treatments for bladder problems

A

Anticholinergics
ISC
Suprapubic catheter

20
Q

Treatments for sexual dysfunction

A

Sildenafil, tadalafil, vardenafil

PDE inhibitors

21
Q

Treatments for depression

A

Tricyclics antidepressants or SSRIs

22
Q

Treatments for fatigue

A

Occupational therapy
Amantadine
Modafanil

23
Q

Treatments for neuropathic pain

A 
Carbamazepine
Amitriptyline
Gabapentin
Prefab alien
TENS
24
Q

Treatments for shaking

A 
Propranolol
Gabapentin
Clonazepam
Isoniazid
DBS
25
Q

Lifestyle supplements in MS

A

Little evidence for lifestyle modification or dietary supplements
Recent interest in vitamin D

26
Q

Vitamin D and MS

A

MS more common in areas of low sunlight exposure and in people born in spring
Vitamin D increases during pregnancy while MS improves
People with MS tend to have less Vit D
BUT little evidence for oral Vit D helping MS sufferers

27
Q

Disease modifying treatments: Copaxone/Interferons

A

Copaxone and interferons (avonex, rebid, betaseron) indicated in 20% of patients
Require regular injections and blood tests
Reduce relapses by 1/3 and slows progression of symptoms

28
Q

When should you start Copaxone/interferon treatment?

A

Two relapses in last two years, OR one serious relapse in the last year, OR scans showing new lesions in the last year
Consider stopping if side effects out-weigh benefits
Not helpful in non-relapsing MS (progressive MS)

29
Q

Disease modifying treatments: Mitoxantrone

A

Given in 3 monthly intravenous injections up to max dose
Up to 90% reduction in relapse rate when given with Copaxone
Side effects: increased risk of infections, 12% risk of systolic dysfunction (need annual echo) and 1:400 risk of leukaemia

30
Q

What drugs can be used to reduce relapse rates in relapsing remitting MS

A 
Copaxone/interferon
Mitoxantrone
Cyclophosphamide
Azathioprine
Natalizumab
31
Q

Natalizumab

A

Given by drip every four weeks
Blocks T cell adhesion and entry through the BBB
Reduced relapses by 68% and disability by 42% over two years
Approved by NICE if two severe relapses in 1 years and MRI evidence of active disease

32
Q

Future treatments: Campath

A

Anti-CD52 monoclonal antibody, first used in leukaemia
Given once a year IV, Reduces relapse and disability
Small improvement in disability in patients with secondary progressive disease
1/4 developed thyroid problems and a few developed ITP

33
Q

Oral treatments for relapsing remitting MS

A

Steroids
Fingolimoid just licensed, in trials reduced relapse rate by half
Very few side effects

34
Q

Lhermitte’s sign

A

MS specific

Feeling of electric shock down spine when bending neck

35
Q

Uhtoff’s sign

A

MS specific
Temporary worsening of symptoms when body temperature increased
Eg hot climate, bath, sauna

Psychiatry (18 decks)

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