Multiple Sclerosis Flashcards
1
Q
Who is usually affected by MS?
A
- It is a disease of young people
- F:M 2-3:1
2
Q
What is MS?
A
It is a white matter disease of the centre nervous system with focal disturbance of function
3
Q
What do most MS patients develop?
A
Progressive disability
4
Q
What type of course does MS have?
A
Relapsing remitting course
5
Q
What is demyelination?
A
An auto immune process where there is acute inflammation of myelin sheath which leads to loss of function
6
Q
What is the cause of demyelination?
A
Activated T cells cross blood brain barrier causing demyelination
7
Q
What signs of demyelination may be seen on MRI?
A
Lesions or plaques
8
Q
What may post inflammatory gliosis produce?
A
May have functional deficits
9
Q
What process may be important in disease progression?
A
Axonal loss may be important in disease progression and development of persistent disability
10
Q
What suggest cerebral atrophy on MRI?
A
Black holes on MRI
11
Q
What is the prevalence of MS?
A
Prevalence ~190 per 100 000 in Scotland
12
Q
What is MS associated with?
A
It has complex genetic inheritance and is associated with autoimmune disease
13
Q
Where is MS commoner?
A
Temperate climate
14
Q
What do 80% of MS cases present with?
A
A relapse
15
Q
What is the usual timeline of initial presentation of MS?
A
- Gradual onset over days
- Stabilises days to weeks
- Gradual resolution to complete or partial recovery-
16
Q
How may MS relapse present?
A
- Optic neuritis -Sensory symptoms
- Limb weakness
- Brainstem Diplopia/Vertigo/Ataxia
- Spinal cord-bilateral symptoms and signs +/- bladder
17
Q
Describe optic/retrobulbar neuritis which can occur in MS.
A
- Subacute visual loss
- Pain on moving eye
- Colour vision disturbed
- Usually resolves over weeks
- Initial swelling optic disc
- Optic atrophy seen later
- Relative afferent pupillary defect
18
Q
What is the differential diagnosis for optic neuritis?
A
- Neuromyelitis optica
- Sarcoidosis
- (Ischaemic optic neuropathy)
- Toxic/ drugs/ B12 deficiency
- Wegeners granulomatosis
- (Local compression)
- Lebers hereditary optic neuropathy
- Infection-borrelia
19
Q
What signs/symptoms can occur with a brainstem relapse?
A
- Cranial nerve involvement
- Pons- internuclear ophthalmoplegia
- Cerebellum -vertigo, nystagmus, ataxia
- Upper motor neurone changes limbs
- Sensory involvement
20
Q
How does myelitis present?
A
- Partial or Transverse (complete)
- Sensory level often with band of hyperaesthesia
- Weakness/ upper motor neurone changes below level
- Bladder and bowel involvement
- May be painful
21
Q
What is the differential for myelitis?
A
- Inflammation: Devics, SLE, sarcoidosis
- Infection/Post infection: HIV, HTLV, HSV, TB, Borrelia, Mycoplasma
- Tumour
- Paraneoplastic process
- Stroke
22
Q
What must occur for a diagnosis of MS?
A
Separate episodes of demyelination disseminated in space and time
23
Q
When may further relapses occur?
A
May occur within months or years of first relapse
24
Q
How can further relapses present?
A
Vary in site and severity
- Optic nerve
- Sensory
- Limb weakness
- Diplopia
- Vertigo
- Ataxia
- Sphincter disturbance
25
What can occur in the progressive phase of MS?
Accumulation of symptoms and signs
- Fatigue, temperature sensitivity
- Sensory
- Stiffness or spasms
- Balance, slurred speech
- Swallowing
- Bladder & bowel
- Diplopia/ oscillopsia/ visual loss
- Cognitive-dementia/ emotional lability
26
What may be found on examination of MS?
Depends on where demyelination has occurred and stage of disease:
- Afferent pupillary defect
- Nystagmus or abnormal eye movements
- Cerebellar signs
- Sensory signs
- Weakness
- Spasticity
- Hyperreflexia
- Plantars extensor
27
How can MS be diagnosed?
May be clinical or MRI based diagnosis
- Posers criteria (requires 2 clinical episodes)
- Macdonald Criteria (MRI)
28
What is a lesion/plaque?
Area of demyelination on MRI scan
29
How do lesions correspond to relapses?
For 10 lesions (approximately) patient experiences 1 relapse
30
How should MRIs be interpreted?
- White areas do not necessarily mean MS
| - Active lesions will appear white whereas old lesions cannot be seen without contrast
31
How should MS be investigated?
Depends on clinical picture……
- Lumbar puncture-oligoclonal bands present in CSF but not serum
- Visual/ somatosensory evoked response
- Bloods-exclude other inflammatory conditions
- Chest X Ray
32
What does the differential diagnosis for MS depend on?
Depends on symptoms and signs and on whether a first relapse or progressive disease
33
What types of MS are there?
- Relapsing remitting-85% at outset (RRMS)
- Secondary progressive (SPMS)
- Primary progressive – 10-15% (PPMS)
- Sensory – 5%
- Malignant
34
Describe relapsing remitting MS.
- Episodes vary in severity
| - Vary in duration
35
Describe secondary progressive MS.
- Relapses with recovery
| - Followed by progressive relapse with no recovery
36
Describe sensory MS
-Relapsing with low severity
37
How can MS progress?
- 1/4 MS never affects activities of daily living (ADL)
- 15% severely disabled quickly
- 1 in 4 will require a wheel chair at some point
38
What are good prognostic indicators for MS?
- Female
- Present with optic neuritis
- Long interval between 1st and 2nd relapse
- Few relapses in 1st 5 years
39
What are bad prognostic indicators for MS?
- Male
- Older age
- Multifocal symptoms and signs
- Motor symptoms and signs
40
Describe primary progressive MS.
First episode does not resolve but progresses a continuous episode
41
When does primary progressive MS usually present?
Often presents in 5th and 6th decade
42
What types of symptoms are present in primary progressive MS?
- Spinal symptoms
| - Bladder symptoms
43
Who is affected by primary progressive MS?
M:F 1:1
44
What is the prognosis of primary progressive MS?
Poor
45
What is another name for neuromyelitis optica spectrum disorder?
Devic's disease
46
How does NOSD (Devic's disease) present?
- Optic neuritis
- Myelitis
- Aquaporin-4 antibodies
- Antibody negative in some cases
47
How is MS treated?
- General health and diet
- Treatment of relapse
- Symptomatic treatment
- Multi-disciplinary approach
- Disease modifying treatment
48
What should you look for with an acute relapse?
- Look for underlying infection
| - Exclude worsening of usual symptoms with intercurrent illness
49
How should acute relapses be treated?
- Oral prednisolone (Intravenous)
- Rehabilitation
- Symptomatic treatment
50
What accounts for 25-30% of further relapses?
Underling viral infection therefore vaccination is usually advised
51
When may a women have fewer relapses?
Pregnancy
52
When may a women have an increased risk of relapse?
First 3 months post partum
53
What disease modifying treatments are 1st line?
s/c or i/m injections
- Beta-interferons
- Glatiramer acetate
Oral treatments
- Teriflunomide
- Dimethyl Fumarate
54
What are the side effects of 1st line disease modifying treatments?
Flu-like symptoms
Injection site reaction
Abnormalities of blood count and liver function
55
How effective are 1st line disease modifying treatments?
- Reduce relapse rate ~1/3
- No effect on progression of disability
- Not a cure
56
What are the 2nd line agents?
- Natalizumab monthly infusion
- Fingolimod tablets
- Alemtuzumub annual infusion
57
How effective is natalizumab?
Reduce relapse rate ~2/3
58
What is there a risk of with fingolimod?
Risk of developing Cardiac: bradyarrythmias
59
What is there risk of with alemtuzumub?
Risk of developing Autoimmune thyroid disease/ Goodpastures/ immune thrombocytopenic purpura
60
What causes multifocal leukencephalopathy?
JC virus
61
How is PML screened for?
- MRI annual
| - Check for JC antibody blood and urine 6 monthly
62
Who is usually affected by PML?
Immunosuppression (AIDS)
- Natalizumab
- Dimethyl fumarate
- Fingolimod
63
What symptomatic treatment is there?
- Spasiticity-muscle relaxants/ antispasmodics/ physiotherapy
- Dysaesthesia-amitriptyline, gabapentin etc.
- Urinary-anticholinergic Rx, bladder stimulator/ catheterisation
- Constipation-laxatives
- Sexual dysfunction-sildenafil
- Fatigue-graded exercise, medication
- Depression-CBT, medication
- Cognitive-memory aids etc
- Tremor-aids/ pharmaceutical
- Vision/ oscillopsia-carbamazepine
- Speech/ swallowing-SALT
- Motor/ sensory impairment- multi-disciplinary team
64
Who is involved in the MDT?
- MS nurse
- Physiotherapy
- Occupational therapy
- Speech and language therapy
- Dietician
- Rehabilitation specialists
- Continence advisor
- Psychology/psychiatry
65
What can the differential diagnosis of MS include?
- Acute Disseminated -Encephalomyelitis (ADEM)
- Other Auto-immune conditions eg SLE
- Sarcoidosis
- Vasculitis
- Infection eg Lyme disease, HTLV-1
- Adrenoleucodystrophy etc etc
