MS

Question 1

definition of MS

Answer 1

Inflammatory demyelinating disease of the CNS

Question 2

different classifications of MS

Answer 2

relapsing remitting

clinically isolated syndrome

primary progressive MS

marburg variant

Question 3

relapsing remitting MS

Answer 3

• Commonest
• Clinical attacks of demyelination
• Complete recovery in between attacks

Question 4

clinically isolated syndrome MS

Answer 4

• Single clinical attack of demyelination
• Doesn’t qualify as MS
• 10-50% progress to MS

Question 5

primary progressive MS

Answer 5

• Steadily accumulation of disability
• No relapsing-remitting

Question 6

marburg variant of MS

Answer 6

• Severe fulminant variant of MS
• Leading to advanced disability of death in a period of weeks
• Distinct from acute disseminated encephalomyelitis (ADEM)

Question 7

acute disseminated encephalomyelitis

Answer 7

Uncommon acute monophasic CNS demyelinating condition – thought to be a post-viral autoimmune phenomenon

Intubation may be needed

Treated high dose steroids

Question 8

Neuromyelitis optica (Devic’s syndrome)

Answer 8

Rare demyelinating condition which is typified by optic neuritis and extensive transverse myelitis.

Associated with anti-aquaporin-4 antibodies

Question 9

aetiology of MS

Answer 9

Unknown

Autoimmune bases with postulated env trigger in genetically susceptible

Immune mediated damage to CNS myelin = impaired conduction

Grey matter atrophy

Question 10

RF for MS

Answer 10

• EBV exposure
• Prenatal vit D levels
• Strong concordance in monozygotic versus dizygotic twins(25% vs 3%)
• Geographical variation – (temporate>tropical) with individuals carrying risk of pre-pubertal (<13yr) country of origin

Question 11

epidemiology of MS

Answer 11

Prev in UK 1 in 1000

Rare in far east

Female more

20-40yrs

increasing incidence with latitude in some parts of the world (NB: adult migrants take their risk with them; children acquire the risk of where they settle) - leading to hypothesis of roles of vitamin D and infection

Question 12

systems MS can effect

Answer 12

usually monsymptomatic, symptoms may worsen with heat eg hot bath/exercise

optic

sensory

motor - corticospinal tract

psychological

autonomic

uhthoff’s phenomenon

bladder

Question 13

optic effects of MS

Answer 13

optic neuritis:

• Unilateral deterioration in visual acuity and colour perception
• Pain on eye movement
• reduced rapid central vision

diplopia

hemianopia

visual phenomena eg on exercise

bilateral internuclear ophthalmoplegia

pupil defects

argyll robertson pupil - The pupil is constricted and unreactive to light, but reacts to accommodation. The iris may be patchily atrophied, irregular, and depigmented

Question 14

motor Sx of MS

Answer 14

• Limb weakness
• Spasms
• Stiffness
• Heaviness
• myelitis

Question 15

sensory sx of MS

Answer 15

• Pins and needles
• Numbness
• Burning

Question 16

psychological sx of MS

Answer 16

• Depression
• Psychosis
• accidents
• amnesia
• reduced executive functioning

Question 17

autonomic sx of MS

Answer 17

• Urinary urgency
• Hesitancy
• Incontinence
• Impotence

Question 18

uhthoff’s phenomenon

Answer 18

• Transient increase or recurrence of symptoms due to conduction block precipitated by a rise in body temp

Question 19

signs of optic nueritis - MS

Answer 19

• Impaired acuity (most common)
• Loss of colour vision
• On fundoscopy in active disease – swollen optic nerve head, in chronic disease may be optic atrophy

Question 20

signs of MS

Answer 20

optic neuritis

visual field testing - Central scotoma (optic nerve not affected) or field defects (optic radiations affected)

relative afferent pupillary defect - swinging torch test = Both pupils contractwhen light is shone on the unaffected side, both pupils dilate when light is swung to the diseased (eye).

intranuclear opthalmoplegia - Lateral horizontal gaze = failure of adduction of the contralateral eye, Indicates lesion of contralateral medial longitudinal fasciculus

sensory - Parasthesia (vibration and joint position sense loss more common than pain and temp), dysaesthesia, trigeminal neuralgia

motor - UMN signs – spastic weakness, brisk reflexes

cerebellar:

• Limb ataxia (intention tremor, past-pointing and dysmetria on finger nose and heel-shin test)
• Dysdiadochokinesis
• Ataxic wide-based gait
• Scanning speech
• falls

lhermitte’s phenomenon - Electric shock like sensation in arms and leds, precipitated by neck flexion

Question 21

Ix for MS

Answer 21

Diagnosis based on 2 or more CNS lesions with corresponding symptoms, separated in time and space (McDonald criteria)

• LP
  
  • Microscopy to exclude other infective or inflamm causes
  • CSF electrophoresis shows unmatched oligoclonal bands that are not present in serum - suggest CNS inflammation
• MRI-brain, cervical and thoracic spine with gadolinium
  
  • Plaque detection highlighted as high signal lesions
  • Gadolinium enhancement indicates an active lesion.
  • exclude other causes eg cord compression
• Evoked potentials
  
  • Visual, Auditoy or somatosensory evoked potentials (VEP, BEP, SEP) may show delayed conduction velocity
  • VEPs are delayed in 90% pts with MS

Question 22

pathology of MS

Answer 22

inflammatory plaques of demyelination in the CNS disseminated in place and time, ie occuring at multiple sites with>30d between attacks

demyelination heals poorly = axonal loss

>80% pts develop progressive disability

Question 23

dx of MS

Answer 23

clinical

made by a consultant neurologist using criteria, after alternative dx have been excluded

early dx reduces relapse rates and disability so refer as soon as MS is suspected

Question 24

progression of MS

Answer 24

most pts have relapsing remitting with initial recovery between relapses

with time remission becomes incomplete - disability accumulates (secondary progression)

primary progressive MS - 10% pts, steadily progressive disability in the abscence of relapses

minority of patients experience no progressive disablement at all

pregnancy Does not alter the rate of progression: relapses may reduce during pregnancy and increase 3–6 months afterwards, but return to their previous rate thereafter

Question 25

Gi sx of MS

Answer 25

swallowing disorders constipation

Question 26

sexual/GU sx of MS

Answer 26

erectile dysfunction anorgasmia urine retention incontinence

Question 27

criteria to dx MS

Answer 27

Question 28

Devic's syndrome

Answer 28

(=Neuromyelitis optica, NMO.) MS variant with transverse myelitis, (loss of motor, sensory, autonomic, reflex, and sphincter function below the level of a lesion), optic atrophy, and anti-aquaporin 4 antibodies

Question 29

Lhermitte's sign

Answer 29

Neck flexion causes ‘electric shocks’ in trunk/limbs. (Also +ve in cervical spondylosis, cord tumours and low B12.)

Question 30

uhthoff's phenomenon

Answer 30

worsening of sx with heat eg bath

Question 31

charles bonnet syndrome

Answer 31

rare reduced acuity/temporary blindness +- complex visual hallucinations of faces, as well as animals, plants and trees

Question 32

pulfrich effect

Answer 32

unequal eye latencies - causing disorientation in traffic as straight trajectories seem curved and distances are misjudged on looking side ways

Question 33

Mx of MS acute relapse

Answer 33

IV Methylprednisolone consider plasma exchange

Question 34

mx for relapsing remitting MS

Answer 34

**Immunomodulation - interferon B** sensory sx - anticonvulsant/antidepressant increased tone - baclofen, physio tremor - propranolol gait - fampridine urinary frequency - oxybutinin fatigue - amantadine oscillopsia (visual fields appear to oscillate) - gabapentin

Question 35

mx of secondary progressive MS

Answer 35

siponimod or methylprednisolone

Question 36

mx for primary progressive MS

Answer 36

biologics - ocrelizumab

Question 37

complications of MS

Answer 37

UTI osteopenia, osteoporosis depression visual impairment Erectile dysfunction cognitive impairment impaired mobility

Question 38

px of MS

Answer 38

variable poor px - frequent relapse, motor/cerebellar onset higher MRI lesion burden equates to poorer px good px - female, sensory/optic neuritis onset

Question 39

monitoring for MS

Answer 39

review every 12 mo check DM, vit B12, vit D, thyroid (hypo) MRI 6mo after starting DMARDs yearly MRI in stable (also looks for complications of rx) spinal cord imaging of spinal cord phenotype