Multiple sclerosis

Question 1

Describe the pathophysiology of MS

Answer 1

Inflammatory plaques of demyelination in the CNS disseminated in time and space (occurring at multiple sites with >30days between attacks)
Demyelination heals poorly, eventually causing axonal loss

Question 2

What causes MS?

Answer 2

Unknown
Environment plus genetics
Vitamin D deficiency

Question 3

What is the mean age of onset of MS

Answer 3

30yo

Question 4

Which gender does MS affect more?

Answer 4

Females

3:1 F:M

Question 5

Describe the presentation of MS

Answer 5

Monosymptomatic
20% present with unilateral optic neuritis
Corticospinal tract
Sensory - dysesthesia, pins and needles decreased vibration sense, trigeminal neuralgia
Motor - Spastic weakness, myelitis
Sexual/GU - bladder involvement, erectile dysfunction, urine retention, incontinence, anorgasmia
GI - swallowing, constipation
Eye - diplopia, hemianopia, optic neuritis, visual phenomena, bilateral internuclear ophthalmoplegia, pupil defects
Cerebellum - trunk and limb ataxia, intention tremor, scanning, falls, speech
Cognitive and visuospatial decline

Question 6

What may exacerbate symptoms of MS?

Answer 6

Heat - baths and exercise

Question 7

What tests may be done to diagnose MS

Answer 7

MRI - sensitive but not specific for plaque detection
CSF - oligoclonal bands of IgG on electrophoresis that are not present in the serum, suggest CNS inflammation
Evoked potentials - delayed visual acuity, auditory and somatosensory evoked potentials

Question 8

Which criteria is used to diagnose MS

Answer 8

McDonald criteria

Question 9

Describe the evidence needed for diagnosis of MS in the McDonald criteria

Answer 9

Evidence of dissemination in time and space plus clinical presentation. >2 attacks and >2 objective clinical lesions

Question 10

Describe the progression of MS

Answer 10

Relapsing remitting course with initial recovery in between relapses
With time, remission becomes incomplete and so disability accumulates

Question 11

List some poor prognostic signs

Answer 11

Older age
Male
Motor signs at onset
Many early relapses 
Many MRI lesions
Axonal loss

Question 12

Describe the effect of pregnancy on MS

Answer 12

Does not alter the rate of progression

Relapses may reduce during pregnancy and increase 3-6months after, but return to their previous rate thereafter

Question 13

Describe the management of MS

Answer 13

Lifestyle
Disease modifying drugs
Treat relapses
Symptom control

Question 14

What lifestyle measures may be advised in the management of MS

Answer 14

Regular exercise, stopping smoking, avoiding stress

Question 15

List some disease modifying drugs

Answer 15

Dimethyl fumarate
Alemtuzumab
Natalizumab

Question 16

Describe alemtuzumab

Answer 16

Monoclonal antibodies

Act against T cells

Question 17

Describe natalizumab

Answer 17

Monoclonal antibodies

Acts against VLA4 receptors that allow immune cells to cross the blood brain barrier

Question 18

What drug is given to treat relapses

Answer 18

Methylprednisolone 0.5-1g/24h/IV/PO for 3-5days shortens acute relapses
Use sparingly
Does not alter overall prognosis

Question 19

Which drugs are given to treat spasticity

Answer 19

Baclofen
Gabapentin 
Tizanidine 
Dantrolene
Benzodiazepines

Question 20

Which drugs are given to treat tremor

Answer 20

Botulinum toxin type A injections

Question 21

Which drugs are given to treat urinary urgency/frequency

Answer 21

Self catheterization if >100ml residual volume

Tolterodine if <100ml residual volume

Question 22

What may help treat fatigue in MS

Answer 22

CBT
Amantadine
Exercise

Question 23

List some MS eponyms

Answer 23

Devic's syndrome
Lhermitte's sign 
Uhthoff's phenomenon 
Charles Bonnet syndrome 
Pulfrich effect
Argyll Robertson pupil

Question 24

Describe devic’s syndrome

Answer 24

MS variant with transverse myelitis - loss of motor, sensory, autonomic reflex and sphincter function below the level of the lesion
Optic atrophy
Anti-aquaporin 4 antibodies

Question 25

Describe Lhermitte’s sign

Answer 25

Neck flexion causes electric shocks in trunk/limbs

Question 26

What conditions is Lhermitte;s sign seen in?

Answer 26

MS
Cervical spondylosis
Cord tumours
B12 deficiency

Question 27

Describe Uhthoff’s phenomenon

Answer 27

Worsening of symptoms with heat

Question 28

Describe Charles bonnet syndrome

Answer 28

Decreased acuity/temporary blindness with complex visual hallucination of faces, shapes and animals

Question 29

Describe Pulfrich effect

Answer 29

Unequal eye latencies, causing disorientation in traffic as straight trajectories seem curved and distances are misjudged on looking sideways