Multiple Sclerosis

Question 1

what does relapsing remitting mean?

Answer 1

there are episodes of symptoms

Question 2

why does demyelination occur in MS?

Answer 2

> autoimmune process
activated T cells cross blood brain barrier causing acute inflammation of the myelin sheath
leads to demyelination

Question 3

what is post inflammatory gliosis?

Answer 3

functional deficit after attack

Question 4

what appears on an mri in MS?

Answer 4

> pale patches or lesions

> black holes later on

Question 5

what are the black holes seen on MRI?

Answer 5

cerebral atrophy

Question 6

what is the prevalence of MS in Scotland?

Answer 6

190 per 100000

Question 7

how are affected more males or females?

Answer 7

females

Question 8

what climate is MS commoner in?

Answer 8

temperate climate

Question 9

what sort of condition is MS associated with?

Answer 9

autoimmune disease

Question 10

what do most MS cases present with?

Answer 10

> relapse (an attack of inflammation)
gradual onset
stabilises in days to weeks with gradual resolution

Question 11

describe relapse symptoms

Answer 11

> optic neuritis
> sensory symptoms
> limb weakness
> vertigo
> ataxia
> diplopia
> bladder problems

Question 12

describe optic neuritis

Answer 12

> sub-acute visual loss (and colour vision)
> pain on eye movement
> initial swelling of optic disc
> optic atrophy seen later
> afferent pupillary defect
> resolves over a couple of weeks

Question 13

what is the differential for optic neuritis?

Answer 13

> MS
> neuromyelitis optica
> sarcoidosis
> ischaemic optic neuropathy
> B12 deficiency
> wegeners granulomatosis
> local compression
> lebers hereditary
> infection

Question 14

what can occur in a relapse involving the pons?

Answer 14

internuclear opthalmoplegia

Question 15

what can occur in relapse involving the cerebellum?

Answer 15

> vertigo
nystagmus
ataxia

Question 16

describe myelitis

Answer 16

> can be partial or transverse
>sensory level often with band of hyperaesthesia (excessive skin sensitivity)
> weakness (upper motor neuron changes)
> bladder and bowel involvement
> painful (sometimes)

Question 17

what is the differential diagnosis for myelitis?

Answer 17

> inflammation (Devics, SLE, sarcoidosis)
> infection (post)
> tumour
> paraneoplastic process
> stroke

Question 18

would an isolated incident of demyelination be enough to diagnose MS?

Answer 18

no, episodes of demyelination disseminated in space and time

Question 19

describe the progressive phase

Answer 19

there is an accumulation of symptoms and signs including: fatigue
stiffness
balance issues
bladder issues
vision issues
cognitive issues

Question 20

what will examination findings depend on?

Answer 20

where demyelination has occurred and the stage of the disease

Question 21

what eye signs might you see on examination of someone with MS?

Answer 21

> afferent pupillary defect
nystagmus
abnormal eye movements

Question 22

what might you see in a limb examination of someone with MS?

Answer 22

> weakness
spasticity
hyper-reflexia
plantar extension

Question 23

how would you diagnose MS?

Answer 23

> evidence of demyelination separated by time and space
poser criteria (clinical)
macdonald criteria (MRI)

Question 24

for 10 lesions a patient may experience how many relapses (approximately)?

Answer 24

one

Question 25

what other examination could you carry out depending on the clinical picture?

Answer 25

> lumbar puncture > visual/somatosensory evoked response > bloods (excludes other inflammatory conditions) > chest x ray

Question 26

what would you look at in a lumbar puncture?

Answer 26

if oligoclonal bands were present in the CSF but not in the serum

Question 27

what does the differential diagnosis depend on?

Answer 27

the symptoms and signs and whether the first relapse or progressive disease

Question 28

name some types of MS

Answer 28

``` > relapsing remitting > secondary progressive > primary progressive > sensory > malignant ```

Question 29

describe secondary progressive

Answer 29

after a relapsing remitting form of disease there is a steady increase in impairment

Question 30

what number of people with MS will require a wheelchair?

Answer 30

1 in 4

Question 31

what are indicators of a good prognosis?

Answer 31

> female > present with optic neuritis > long interval between 1st and 2nd relapse > few relapses in the 1st 5 years

Question 32

what are bad prognostic indicators?

Answer 32

> male > older > multifocal symptoms and signs > motor symptoms and signs

Question 33

describe primary progressive MS

Answer 33

there is a steady increase in impairment over time with no relapses and a poor prognosis. often presents in the 5th or 6th decade.

Question 34

describe devics disease(neuromyelitis optica spectrum disorder)

Answer 34

> inflammatory disorder of the CNS >optic neuritis > myelitis > involving aquaporin-4antibodies

Question 35

what is the treatment for devics disease?

Answer 35

``` > health and diet > relapse treatment > symptomatic treatment > multi-disciplinary approach > disease modifying treatment ```

Question 36

what is the management for an acute relapse of devics disease?

Answer 36

> look for underlying infection > oral prednisolone > rehabilitation > symptomatic treatment

Question 37

what is the effect of pregnancy on relapse in devics disease?

Answer 37

there are fewer relapses during pregnancy but increased risk in the first 3 months post partum

Question 38

what are the first line disease modifying treatments for devics disease?

Answer 38

> beta interferons > glatiramer acetate > teriflunomide >dimethyl fumerate

Question 39

what are the side effects of first line disease modifying treatment in devics disease?

Answer 39

> flu like symptoms > injection site reactions > abnormalities of blood count and liver functions

Question 40

what are the effects of first line disease modifying treatments in devics disease?

Answer 40

> reduced relapse rate by 1/3 | > no effect of disability progression

Question 41

what are second line agents in devics disease?

Answer 41

> natalizumab (monthly infusion) > fingolimod tablets > alemtuzumub

Question 42

what is progressive multifocal leukencephalopathy caused by?

Answer 42

jc-virus

Question 43

what is the management for multifactorial leukencephalopathy?

Answer 43

> immunosuppression (natalizumab, dimethyl fumarate, fingolimod) > annual MRI > JC antibody and urine 6monthly > symptomatic treatment