MS

Question 1

What is MS?

Answer 1

Inflammatory demyelinating disorder the central nervous system
Female >Men
30-40 yrs
MS plaques occurring in multiple parts of the central nervous system (CNS) and over the course of time
- Much more common in white populations and with increasing distance from the equator
- Causes of MS are not completely understood but the autoimmune process appears to be caused both by genetic and environmental factors
-Environmental factors which have been implicated include viral infections (e.g. EBV), and vitamin D deficiency

Question 2

MS courses?

Answer 2

• Relapsing-remitting MS (RRMS) (85-90%) - symptoms occur in attacks (relapses) with a characteristic time course: onset over days and typically recovery, either partial or complete, over weeks
• Secondary progressive MS - this late stage of MS consists of gradually worsening disability progressing slowly over years; some 75% of patients with relapsing-remitting MS will eventually evolve into a secondary progressive phase by 35 years after onset
• Primary progressive MS (PPMS) (10-15%) - characterized by gradually worsening disability without relapses or remissions

Question 3

Pyramidal dysfunction; Clinical presentation?

Answer 3

• Increased tone
• Spasticity
• Weakness
• Affects extensors of upper limbs and flexors of lower limbs

Question 4

Optic neuritis;Clinical presentation?

Answer 4

• Painful visual loss over 1-2 weeks - blurred vision in one eye and loss (or reduction) in colour vision
• Most improve
• RAPD (relative afferent pupilary defect) on examination

Question 5

Sensory symptoms;Clinical presentation?

Answer 5

“Feeling that water going down my legs”

• Pain
• Paraesthesia
• Dorsal column loss - proprioception and vibration
• Numbness
• Trigeminal neuralgia

Question 6

Cerebellar dysfunction; Clinical presentation?

Answer 6

• Dysarthria
• Ataxia
• Intention tremor
• Past pointing
• Pendular reflexes
• Dysdiadokinesis

Question 7

Brainstem dysfunction; clinical presentation?

Answer 7

• Diplopia - CN VI palsy
  
  • Facial weakness - CN VII palsy

Question 8

Lower urinary tract dysfunction; clinical presentation?

Answer 8

• Increased frequency and urgency
  
  • Nocturia
  • Urge incontinence
  • Retention
• increased tone at bladder neck
  retention
• detruser hypersensitivity
  frequency, urgency, nocturia, urge incontinence
• detruser sphyncteric dyssenergia; i.e. inappropriate involuntary urethral sphincter contraction

Question 9

Internuclear opthalmoplegia; clinical presentation?

Answer 9

-When two eyes don’t move together
-VERY COMMON in MS
- Involves the medial longitudinal fasciculus
- Distortion of binocular vision
- Failure of adduction - diplopia
- Nystagmus in abducting eye
- Lag

Question 10

What is the most complain MS patient would have?; clinical presentation

Answer 10

FATIGUE

Question 11

To diagnose MS consider 3 facts. what are they?

Answer 11

Clinical episode suggestive of demyelination

Dissemination in time and place

Alternative diagnosis excluded

Question 12

what are the common diff diagnosises?

Answer 12

Vasculitis
Granulomatous disorder
Vascular disease
Structural lesion
Infection
Metabolic disorder

Question 13

Investigations?

Answer 13

Bloods

• Before referring to a neurologist, exclude differential diagnoses by checking FBC, inflammatory markers, U&E, LFT, TFT, glucose, HIV serology, calcium and B12 levels, vitamin D

Neurophysiology

• Can detect demyelination in apparently unaffected pathways with characteristic delays

MRI

• Periventricular lesions
• Discrete white matter abnormalities
• Areas of focal demyelination
• Active inflammatory plaques can be distinguished from inactive ones by using a contrast agent

CSF

• Oligoclonal bands present in 90+% of cases - distinct bands of IgG on Western blot that are unmatched with serum testing

Question 14

Managemet for acute relapse?

Answer 14

• Mild - symptomatic treatment
• Moderate - oral steroids (5mg)
• Severe - admit/IV steroids (100ml)

Question 15

Mx for Pyramidal dysfunction?

Answer 15

• Physiotherapy
• Occupational therapy
• for spasticity: Anti-spasmodic agent e.g. oral baclofen, oral tizanidine, botulinum toxin, intrathecal baclofen

Question 16

Mx for the sensory symptoms?

Answer 16

• Anticonvulsant e.g. gabapentin
• Antidepressant e.g. amitriptyline
• TENS machine
• Acupuncture

Question 17

Mx of Lower urinary tract dysfunction

Answer 17

• Bladder drill
• Anti-cholinergics e.g. oxybutynin
• Desmopressin
• Catheterisation

Question 17

Mx for fatigue?

Answer 17

• Amantadine
• Modafinil if sleepy
• Hyperbaric oxygen

Question 17

Disease modifying therapy; 1st line?

Answer 17

• Tecfedira, aubagio; tablet form; First line indication in RR MS
• Interferon beta; injectable
• Glitiramer acetate; injectable

Question 18

Disease modifying therapy; 2nd line?

Answer 18

• Monoclonal antibody : (highly active in RRMS)
• Anti CD 20 ocrelizumab (comonest)
• Anti CD 50 alemtuzemab (high toxicity;no use)
• Anti integrin natilizumab (Very safe as long as the JC virus is negative)
• Fingolimod, cladrabine; reboosting IS

Note: The monoclonal antibodies have greatest efficacy but also highest side effect profile

Question 19

MRI report
The imaging of this brain is abnormal.
There are several areas which give a high signal on the T2 weighted sequences
within the white matter. These are infratentorial, juxtacortical and
periventricular in site. They each measure between 1 and 2.5cm.
The appearance is highly suggestive of a diagnosis of multiple sclerosis.

Answer 19

infratentorial-pic below
juxtacortical-sort of near the cortex
periventricular- situated or occurring around a ventricle, especially a ventricle of the brain