Multiple Sclerosis

Question 1

Which diagnostic test will the primary care provider initially order to manage a patient who reports two episodes of visual disturbances and eye pain that lasted one to two days each about two months apart?

Visual evoked potential

Magnetic resonance imaging (MRI)

Lumbar puncture

Optical coherence tomography (OCT)

Answer 1

MRI is the gold standard for MS diagnosis

Question 2

MS

Answer 2

chronic progressive inflammatory and neurodegenerative disease affecting the central nervous system. Lesions are characterized by inflammation, demyelination, axonal injury and transaction, axonal loss, and gliosi and often occur in multiple locations.

Question 3

Types of MS

Answer 3

Radiographically isolated syndrome - lesions on MIR but no symptoms
Clinically isolated syndrome - Symptoms but clinically silent lesions on MRI
Relapsing-remitting MS - Course punctuated by relapses with periods of remission (most common)
Primary-progressive MS - No clear relapses or remissions, just accumulating disability
Secondary-progressive MS - Progressive course without relapses, follows RRMS type
Progressive-relapsing MS - Steady progression from onset with acute exacerbations
Benign - Low expanded disability severity score for 3+ years but most progress into SPMS

Question 4

MS Pathophysiology

Answer 4

Triggering event activates inflammatory process outside CNS, cytokines penetrates the BBB into the CNS and inflammatory process there leads to demyelination and axonal damage

Question 5

MS Presentation

Answer 5

Patients typically have a focal neurologic deficit such as eye pain or visual disturbances associated with optic neuritis. Sometimes the initial presentation is multifocal

Sensory symptoms, diplopia, weakness, fatigue, temperature sensitivity, unsteady gait, bladder or bowel dysfunction, nystagmus, spasms, cognitive disturbances, sexual dysfunction

Question 6

MS Diagnosis

Answer 6

Clinical diagnosis, rule out other causes. MRI may show the characteristic lesions

There must be separation of time and space. Events must be at least two distinct episodes lasting more than 24 hours occurring at least 30 days apart (separation of time), and there must be evidence of at least two different locations (separation of space). Signs and symptoms need to be consistent with inflammatory demyelinating disease. No other pathologic process can be found for clinical and paraclinical findings

Question 7

MS Referral

Answer 7

Consult with neurology for all suspected cases or to confirm diagnosis
Collaborative care needed and Neurology needed to establish medication treatment

Question 8

MS Exacerbation

Answer 8

acute onset of neurologic symptom(s), lasting longer than 24 hours, which are preceded by a period of at least 30 days of clinical stability or improvement and have no underlying causes such as infection

Question 9

MS Exacerbation Treatment

Answer 9

Short course of high dose IV steroids or adrenocorticotropic hormones to down-regulate inflammatory lymphocytes

Refer to rehab for assessment of any new deficits or functional loss