Multiple Sclerosis

Question 1

Define multiple sclerosis

Answer 1

chronic and progressive autoimmune disorder characterised by demyelination in the central nervous system (CNS)

Question 2

What structures comprise the CNS

Answer 2

Brain

Brainstem

Spinal cord

Question 3

What process causes the activatin of the immune cells against the myelin in the CNS leading to demyelination

Answer 3

Inflammatory

Question 4

What is the hallmark of MS

Answer 4

Demyelination

Question 5

multiple sclerosis is an autoimmune disorder in which the immune cells act against what in the CNS

Answer 5

Myelin leading to demyelination

Question 6

What is the typical age of diagnosis of multiple sclerosis

Answer 6

20-40 years old

Question 7

Multiple sclerosis is more commonly seen in what gender?

Answer 7

Females

Question 8

Name a gene that has been linked as a risk factor of Multiple sclerosis

Answer 8

HLA DRB1

Question 9

Name an infection that has been linked to the development of Multiple sclerosis

Answer 9

Epstein-Barr virus (EBV)

Question 10

Name some of the risk factors multiple sclerosis

Answer 10

Age - commonly diagnosed in 20-40

Gender - more common in females

Genetic component

Geographic latitude: increase incidence in the greater distance north or south

Sunlight exposure

Epstein–Barr virus (EBV) e.g. glandular fever

Low vitamin D

Smoking

Obesity

Question 11

Name a protective factor of multiple sclerosis

Answer 11

Symptoms tend to improve in pregnancy and in the postpartum period.

Question 12

Name the cell that produces myelin in the peripheral nervous system

Answer 12

Schwann cells

Question 13

Name the cell that produces myelin in the central nervous system

Answer 13

Oligodendrocytes

Question 14

Multiple sclerosis typically affects the:

a) CNS
b) PNS
c) Both

Answer 14

a) CNS

Question 15

What causes the damage to the myelin (demyelination) in multiple sclerosis

Answer 15

Inflammation and infiltration of immune cells around the myelin

Question 16

Why do symptoms early in the disease resolve whilst in late multiple sclerosis they dont?

Answer 16

• In early disease, re-myelination can occur and symptoms can resolve
• In the later stages, re-myelination is incomplete and the symptoms gradually become more permanent.

Question 17

Define clinical isolated syndrome

Answer 17

• Referred as the first episode of suspected MS
• MS cannot be diagnosed on one episode as the lesions have not been “disseminated in time and space”

Question 18

Why cant multiple sclerosis be diagnosed on one episode

Answer 18

lesions have to “disseminated in time and space”

i.e. the symptoms change over time (as different nerves are affects)

Question 19

Multiple sclerosis can be categorised depending on the disease patterns.

Name the 3 types of MS disease patterns

Answer 19

Relapsing-remitting

Primary progressive

Secondary progressive

Question 20

What is the most common disease pattern for multiple sclerosis

Answer 20

Relapsing-remitting (90% of cases)

Question 21

Describe the characteristics of the relapsing-remitting multiple sclerosis pattern

Answer 21

Characterised by episodes of disease and neurological symptoms followed by recovery (remissions)

Question 22

Describe the characteritics of the secondary progressive multiple sclerosis disease pattern

Answer 22

Characterised by a relapsing-remitting phenotype initially but eventually there is progressive worsening of symptoms with incomplete remissions

Disease course changes with gradual, sustained worsening in neurological function.

Relapses may still occur but without remission.

Question 23

What percetange of patients with relapse-remitting multiple sclerosis will develop secondary progressive pattern within 15 years since onset

Answer 23

50% of patients with relapse-remitting phenotype will develop secondary progressive pattern within 15 years of onset

Question 24

Secondary progressive multiple sclerosis pattern has a close relationship with another disease pattern - in case over 50% of the other disease pattern ultimately develop secondary progressive pattern.

Name the other disease pattern

Answer 24

Remitting-remission multiple sclerosis

Question 25

Describe the characteristics of the primary progressive multiple sclerosis disease progression

Answer 25

Characterised by worsening of disease and neurological symptoms from the onset of diagnosis May have periods where disease is not active or non-progressive, however there is no relapses or remission

Question 26

What multiple sclerosis disease pattern has: Relapse without remission

Answer 26

Secondary progressive multiple sclerosis

Question 27

What multiple sclerosis disease pattern has: No Relapse and no remission

Answer 27

Primary progressive multiple sclerosis

Question 28

What other disease pattern may patients with relapse-remittin develop as their disease progresses

Answer 28

Secondary progressive multiple sclerosis

Question 29

Name this multiple sclerosis disease pattern

Answer 29

Secondary progressive multiple sclerosis

Question 30

Name this multiple sclerosis disease pattern

Answer 30

Primary progressive multiple sclerosis

Question 31

Name this multiple sclerosis disease pattern

Answer 31

Relapsing-remitting multiple sclerosis

Question 32

Define the term: relapse period

Answer 32

refers to a period of new symptoms

Question 33

Define the term: remission period

Answer 33

Remission follows a relapse, a period with no or few symptoms – the symptoms they experience at this stage is residual damage

Question 34

How long will MS symptoms tend to last at first presentation

Answer 34

Symptoms tend to last days-weeks and then improve

Question 35

Multiple sclerosis (MS) is multifocal and therefore there is large variability of symptoms – depends on the plaque location within the CNS. Name the two most common clinical manifestations of MS

Answer 35

Optic neuritis Lethargy

Question 36

The clinical manifestations of multiple sclerosis is broadly grouped into 4 groups. Name these groups

Answer 36

o Visual o Motor and coordination o Sensory and autonomic o Cognitive and psychological

Question 37

Optic neuritis involves the demyelination of what structure

Answer 37

the optic nerve

Question 38

Optic neuritis involves the demyelination of the optic nerve. What is the result of this?

Answer 38

Loss of vision in one eye

Question 39

Sixth nerve palsy is a potential symptom of multiple sclerosis. What two problems can this cause

Answer 39

Internuclear ophthalmoplegia Conjugate lateral gaze disorder

Question 40

Internuclear ophthalmoplegia can occur as a consequence of a sixth nerve palsy. What are the clinical features of Internuclear ophthalmoplegia

Answer 40

blurry vision Diplopia (double vision)

Question 41

Conjugate lateral gaze disorder can occur as a consequence of a sixth nerve palsy. Describe what is affected in patients with this disorder

Answer 41

The affected eye will not able abduct i.e. when looking laterally in the direction of the affected eye, the unaffected eye will adduct (move towards the nose) but the affected eye will not abduct (move laterally)

Question 42

Name some of the Motor and Co-ordination clinical manifestations of multiple sclerosis

Answer 42

Progressive paraparesis i.e. paralysis of both legs Upper motor neurone signs (spasticity, reduced power, hyper-reflexia) Ataxia – lack of muscle coordination

Question 43

Name some of the sensory and autonomic clinical manifestations of multiple sclerosis

Answer 43

Paraesthesia i.e. pins and needles Pain Numbness Uhthoff phenomenon – worsen of vision following rise in body temp.

Question 44

Uhthoff phenomenon is a potential clinical manifestation of multiple sclerosis. Describe the phenomenon

Answer 44

Worsen of vision following rise in body temp.

Question 45

Multiple sclerosis can have what type of signs: a) Upper motor signs b) Lower motor signs c) Both d) Neither

Answer 45

a) Upper motor signs

Question 46

Multiple sclerosis cannot be diagnosed on one episode as the lesion have to disseminated in time and space. Diagnosis is based on at least two of the following criteria

Answer 46

Clinical history/examination Imaging features (usually MRI) Oligoclonal bands in CSF

Question 47

What is the name of the diagnostic criteria for the diagnosis of MS based on MRI findings and clinical presentation

Answer 47

McDonald criteria

Question 48

McDonald criteria is a diganostic criteria for the diagnosis of what condition

Answer 48

for the diagnosis of MS based on MRI findings and clinical presentation

Question 49

What is the imaging modality that is useful for the diagnosis and surveillance of MS (to assess response to treatment)

Answer 49

MRI

Question 50

What is the gold standard imaging modality for multiple sclerosis

Answer 50

MRI

Question 51

MRI is the most useful imaging modality for multiple sclerosis. What aspects of the multiple sclerosis is it useful for

Answer 51

* Diagnosis - can identify the demyelinating lesions * Surveillance to assess response to treatment

Question 52

Name the two hallmark features of multiple sclerosis on MRI

Answer 52

Plaques of demyelination Eventual axonal loss

Question 53

Lumbar puncture is important in investigating multiple sclerosis. What are you trying to detect in the CSF

Answer 53

oligoclonal bands

Question 54

What are oligoclonal bands and what do their presence indicate?

Answer 54

Oligoclonal bands are bands of immunoglobulins They indicate the presence of an autoimmune response in the CNS

Question 55

Oligoclonal bands are very sensitive for multiple sclerosis although they can also be found in other auto-immune and infectious conditions. Give an example of another condition in which they are found in

Answer 55

Lyme disease, SLE.

Question 56

Multiple sclerosis patients should be under the care of a multidisciplinary MS team. There is no cure for MS however the aim of management is three fold. Name these 3 parts of the management of ms

Answer 56

Disease modification therapies Treat acute relapses symptomatic relief as symptoms develop.

Question 57

What is the aim of management with disease modification therapies in multiple sclerosis

Answer 57

Aim to decrease the number of relapses and slow disease progression

Question 58

Give an example of a disease modification therapies used in the management of multiple sclerosis

Answer 58

First-line injectables e.g. beta-interferon and glatiramer New oral agents e.g. dimethyl fumarate, teriflunomide and fingolimod Biologics e.g. natalizumab and alemtuzumab.

Question 59

How are acute relapses of multiple sclerosis managed

Answer 59

* High dose steroids e.g., methylprednisolone * 500mg orally daily for 5 days * 1g intravenously daily for 3–5 days where oral treatment has failed previously or where relapses are severe

Question 60

Why are steroids only used to treat acute relapse and not used in the long term management of multiple sclerosis

Answer 60

Steroids shorten the duration of a relapse but they do not alter the degree of recovery (i.e. whether a patient returns to baseline function)

Question 61

A part of the management of multiple sclerosis is to provide symptomatic relief as symptoms develop. Give an example of one which symptom and its management

Answer 61

Exercise to maintain activity and strength Neuropathic pain can be managed with medication such as amitriptyline or gabapentin