B6.042 MS Big Case

Question 1

definition of MS

Answer 1

a chronic disease of the CNS characterized by intermittent episodes of neurologic dysfunction, separated in space and time
caused by inflammation and subsequent demyelination in the white matter

Question 2

epidemiology of MS

Answer 2

symptoms around ages 20-45
3:1 women: men
more common in northern latitudes
20% of MS patients have a relative with MS
very prolonged course - typically many years

Question 3

early symptoms of MS

Answer 3

blurred vision in one eye (optic neuritis)
diplopia
numbness and tingling
bladder control problems
vertigo
weakness of specific limbs
fatigue
Lhermitte's Sign

Question 4

what is Lhermitte’s sign

Answer 4

electric shock feeling when bending forward or backwards
-sensation travels into limbs or back
indication of c-spine damage

Question 5

chronic ongoing symptoms of MS

Answer 5

early symptoms PLUS
spasticity
depression
weakness/ paralysis
oscillopsia
gait abnormalities
tremor
optic atrophy
sphincter disturbance (bladder, sometimes bowels)
sexual dysfunction
pain
coordination problems
cognitive changes

Question 6

what is oscillopsia

Answer 6

sees their own nystagmus

Question 7

unusual problems seen in MS

Answer 7

seizures
bowel incontinence
trigeminal neuralgia
altered consciousness (comatose spell)
mimics a brain tumor
hearing loss
involuntary movements
narcolepsy

Question 8

definition of an MS “attack”

Answer 8

an episode of acute neurologic dysfunction, or worsening of a previous dysfunction, lasting more than 48 hours, not caused by metabolic changes in condition

Question 9

common early exam findings

Answer 9

optic nerve pallor
internuclear ophthalmoplegia
nystagmus
reflex asymmetry
babinsky and Hoffman signs
absent abdominal reflexes
spasticity
asymmetrical weakness
gait instability/ foot drop
numbness of LE or on one side of body

Question 10

what types of sensations are typically lost with MS?

Answer 10

vibration and proprioception more commonly diminished due to being transmitted via type 1 myelinated fibers
pinprick and temperature less commonly affected bc they are transmitted by type 4 fibers which are less myelinated at baseline

Question 11

common later exam findings in MS

Answer 11

dysarthria
tremor
moderate to severe gait disturbances with leg drag, incoordination, spasticity
clumsiness of the hands
bilateral INO (internuclear ophthalmoplegia)

Question 12

exam findings in severe, late MS

Answer 12

reduced voice production
difficulty with swallowing
quadriparesis
severe clumsiness of hands with tremor

Question 13

diagnostic testing in MS

Answer 13

start w physical exam
MRI scans of brain, cervical, and thoracic spine (not lumbar spine, no spinal cord present)
lumbar puncture
OCT

Question 14

characteristics of MRI in MS

Answer 14

white matter lesions seen in 95% of people with clinically definite MS
often periventricular, juxtacortical or present in posterior fossa

Question 15

white matter lesions in general population

Answer 15

10-15% normal patients under 50 have these lesions
seen in a large number of patients over age 50
also seen in patients with DM, SLE, smoking, HTN, other WM diseases of CNS

Question 16

lumbar puncture findings in MS

Answer 16

protein may be normal or moderately elevated
possibly increased WBC, mainly mononuclear cells, up to 50 (if higher, think infection)
oligoclonal bands present in 85%
increased IgG index in 70-80%
increased IgG synthesis in 70-80%
myelin basic protein elevated during an attack

Question 17

types of MS

Answer 17

relapsing
primary progressive
secondary progressive
progressive relapsing
transitional MS
benign MS

Question 18

relapsing MS

Answer 18

episodes of acute or subacute neuro changes
remission from these episodes, variable in speed and completeness
general trend is toward accumulation of permanent disability over time

Question 19

secondary progressive MS

Answer 19

course begins as a relapsing types of MS
after some time, neurologic abnormalities begin to worsen slowly without true attacks
some patients still have attacks
occurs in 40-60% of patients with relapsing MS
speed of progression is variable

Question 20

primary progressive MS

Answer 20

patient never has acute or subacute episodes
progressive deterioration of CNS function from the beginning of the illness
extremely variable in speed of progression to cause disability either in a few months or over many years
stabilizes at some point

Question 21

progressive relapsing MS

Answer 21

patient who has a progressive course from the beginning, but also some episodes of acute or subacute neurologic dysfunction with partial recovery

Question 22

treatment of an MS exacerbation

Answer 22

methylprednisolone 500-1000 mg IV daily for 3-10 days
prednisone taper options
ACTHar gel
rehab measures
**Steroids do not affect final outcome of relapse, only the speed of imporvement

Question 23

what is a pseudo-exacerbation of MS

Answer 23

an episode of worsening of current MS symptoms or recurrence of previous symptoms brought on by a metabolic or emotional disturbance, fatigue, or heat

• treatment is usually rest and treatment of the underlying disturbance
• one of the most common causes of sudden worsening in progressive patients

Question 24

effects of immunomodulators/ immunosuppressants on MS

Answer 24

reduce frequency of attacks thereby often reduce progression of the disease
don’t always work
generally a reduction of 50% in attack frequency from placebo
not expected to improve patient from baseline
not a cure!

Question 25

risk of immunosuppressive agents

Answer 25

increased risk of infections
liver abnormalities
GI abnormalities
fatigue
possible cancer risks- skin cancers, leukemias/ lymphomas, and breast cancer with ocrelizumab

Question 26

decision making w disease modifying drugs

Answer 26

match severity of disease with the invasiveness of treatment
injectables have good long term safety records with good efficacy, but may not be quite as potent as oral meds
infusions most effective but most risky

Question 27

treatment for progressive disease

Answer 27

meds are not usually useful to slow progression
patients still experiencing relapses may benefit from continuing immunomodulators
sometimes its best to stop trying to treat bc continued infections may actually speed progression of MS

Question 28

ocrelizumab in progressive disease

Answer 28

shown to work in early primary progressive MS with modest effect

Question 29

other agents tried for progressive MS

Answer 29

azathioprine
methotrexate
cellcept
pulse solmedrol

Question 30

symptom management of MS

Answer 30

important in maintaining quality of life

need to be aware of too many meds and their interactions

Question 31

good health measures to aid in MS quality of life

Answer 31

aerobic exercise
good healthy balanced diet
maintain ideal  body weight
take general good care of health
calcium and vit D
PT and OT