Multiple Sclerosis

Question 1

Diagnosis

Answer 1

Classically described as CNS inflammation disseminated in time and space

McDonald criteria updated in 2017 to say that in patient with clinically isolated syndrome (CIS) with criteria meeting MRI findings and CSF-specific oligoclonal antibodies a diagnosis can be made if all other causes excluded (I.e without clinical dissemination in space)

For primary progressive diagnosis you need worsening symptoms for a year with MRI dissemination in space and CSF-specific oligoclonal antibodies

Question 2

Signs

Answer 2

Any CNS involvement can occur

Optic neuritis often first to appear

Motor involvement tends to be later in disease

Cerebellar involovememt generally later in disease

Lhermittes sign

Uhthoffs phenomena

Question 3

Management of RRMS

Answer 3

Acute:

• methylprednisolone (improves recovery but doesn’t affect disease progression)
• plasma exchange

Chronic

DMARDs

• interferon beta or glatiramer first line (reduce relapses by a third)
• fingolimod or siponimod or natalizumab second line
• alemtuzumab third line

Symptom management

MDT

Baclofen

Fatigue - modafinil

Urinary frequency - oxybutinin, toltoridine, solifenacin, catheter intermittent or indwelling

Natalizumab can reduce relapse by 2/3 but high hypersensitivity profile and can cause progressive multifocal leucoencephalopathy (PML) due to JC virus

Question 4

MS mimics

Answer 4

Vasculitides/autoimmune: SLE, behcets, sjogrens, sarcoidosis

Vascular: TIA stroke CADASIL Fabrys disease and antiphospholipid syndrome

Infection: HIV encephalitis, neurosarcoid, neuro syphilus, Lyme, brucellosis, PML

Metabolic: B12 deficiency

Neuromyelitis optica/devics disease

• demyelination of spinal cord and optic nerves
• optic neuritis is more severe with worse recovery
• spinal cord lesions more extensive
• mediated by aquaporin-4 ab (found in serum
• responds into Immunoglobulins and plasma exchange short term and steroids and immunosuppressants long term

Question 5

Disability rating scales

Answer 5

Expanded disability status scale (0-10) 10 means death from MS

For DMARD need score of at least 6.5

Question 6

When is beta-interferon or glatiramir stopped?

Answer 6

Worsening side effects including autoimmune Hepatitis and depression or lack of efficacy

Beta- interferon associated with developing neutralising antibodies leading to reduced efficacy. Glatiramir not associated with this so could be switched to this