Multiple Sclerosis

Question 1

What is MS?

Answer 1

inflammatory demyelinating disease characterised by:

• presence of episodic neurological dysfunction
• in >2 areas of CNS (brain, spinal cord, and optic nerves)
• separated in time and space

Question 2

What are the 4 subtypes of MS?

Answer 2

1. Clinically isolated syndrome (CIS)
2. Relapsing-remitting MS (RRMS)
3. Primary progressive MS (PPMS)
4. Secondary progressive MS (SPMS)

Question 3

What are the risk factors for MS?

Answer 3

• female
• northern (white) race

weak:

• genetics
• smoking
• Vit D deficiency
• autoimmune disease
• EBV

Question 4

Which patients does MS classicaly present in?

Answer 4

• white women
• aged between 20-40 years
• with temporary visual or sensory loss

Question 5

Summarise the epidemiology of MS

Answer 5

• UK prevalence: 1/1000
• 2 x as common in FEMALES
• Age of presentation: 20-40 yrs

Question 6

What are the presenting symptoms of MS?

Answer 6

Varies depending on the site of inflammation

Optic Neuritis (COMMONEST)

• Unilateral deterioration of visual acuity and colour perception Pain on eye movement
• Common first symptoms of multiple sclerosis

Sensory

• Parasthesia
• Numbness
• Burning

Motor

• Limb weakness
• Spasms
• Stiffness
• Heaviness

Autonomic

• Urinary urgency
• Hesitancy
• Incontinence
• Impotence

Psychological

• Depression
• Psychosis

Uhthoff’s Sign - worsening of neurological symptoms as the body gets overheated from hot weather, exercise, saunas, hot tubs etc.

Lhermitte’s Sign - an electrical sensation that runs down the back and into the limbswhen the neck is flexed

Question 7

What are the signs of MS O/E?

Answer 7

Optic Neuritis

• Impaired visual acuity (MOST COMMON)
• Loss of coloured vision

Visual Field Testing

• Central scotoma (if optic nerve is affected)
  
  • Scotoma = a blind spot in the normal visual field
• Field defects (if optic radiations are affected)

Relative Afferent Pupillary Defect (RAPD) - i.e. Marcus Gunn pupil

Internuclear Ophthalmoplegia

• Lateral horizontal gaze causes failure of adduction of the contralateral eye
• Indicates lesion of the contralateral medial longitudinal fasciculus

Sensory

• Paraesthesia

Motor

• UMN signs

Cerebellar

• Limb ataxia (intention tremor, past-pointing, dysmetria)
• Dysdiadochokinesia
• Ataxic wide-based gait
• Scanning speech

Question 8

What are the primary investigations for ?MS ?

Answer 8

• MRI brain
  
  • high field (1.5 Tesla or above) magnet, with intravenous contrast.
• MRI spinal cord
  
  • cervical spinal cord lesions
• Bloods: FBC - to exclude other causes
• Bloods: comprehensive metabolic panel - to exclude other causes
• Bloods: TSH - to exclude other causes
• Bloods: Vit B12 - to exclude other causes

Question 9

Which bloods tests are included in the comprehensive blood panel?

Answer 9

• Glucose
• Calcium
• Proteins: Albumin and total blood protein
• Electrolytes: Sodium, potassium, carbon dioxide, and chloride
• Kidney tests: BUN (blood urea nitrogen) and creatinine
• Liver tests: ALP (alkaline phosphatase), ALT (alanine aminotransferase), AST (aspartate aminotransferase), and bilirubin

Question 10

Which blood tests are included in an FBC?

Answer 10

• Hb
• MCV
• Reticulocyte count
• Red cell count
• HCT/PCV
• MCH
• MCHC
• Red cell width (RCW)