Multiple Sclerosis

Question 1

What is the prevalence of MS in Scotland?

Answer 1

Scotland has the highest prevalence in the world. Approx. 1 in 600 people have MS

Question 2

What is multiple sclerosis?

Answer 2

It is an inflammatory demyelination disease of the CNS which has acute episodes of inflammation which are associated with focal neurological deficits such as weak leg, visual loss and urinary incontinence.
The deficits develop gradually and last for more than 24 hours and can gradually improve.

Question 3

What are the different subtypes of multiple sclerosis?

Answer 3

• Relapsing remitting MS,
• Primary progressive MS (doesn’t have attacks)
• Secondary progressive MS (initial relapsing-remitting but then continues to progress without attack)
• Benign multiple sclerosis

Question 4

What are some symptoms which may develop into MS?

Answer 4

• Optic neuritis,
• Transverse myelitis
• Clinically isolated syndromes
• Radiologically isolated symptoms

Question 5

What is optic neuritis?

Answer 5

• Inflammation and demyelination of the optic nerve.
• Painful vision loss that comes on over a few days and may resolve.
• Increased risk of developing MS

Question 6

What is Transverse myelitis?

Answer 6

• Inflammation of the spinal cord which may cause weakness, sensory loss or urinary incontinence or sexual dysfunction.
• Can occur secondary to a viral infection

Question 7

What are clinically isolated syndromes in the context of MS?

Answer 7

• A single episode of neurological disability due to focal CNS inflammation. It can include optic neuritis or transverse myelitis
• May be the first attack of MS

Question 8

What are radiologically isolated symptoms in the contect of MS

Answer 8

• When brain scans show clinical features of MS but the patient doesn’t have the signs or symptoms.
• Usually an incidental finding and not all patients will definitely develop MS

Question 9

What virus has a strong association with multiple sclerosis?

Answer 9

EBV

Question 10

What is the diagnostic criteria of multiple sclerosis?

Answer 10

• 2 or more episodes of demyelination dissemination in space and time

Question 11

When should you suspect MS (What are the symptoms)

Answer 11

• Neurological symtpoms which develop over a few says, last for more than 24 hours and then spontaneously resolve. This can include:
• Optic neurtitis,
• Bell’s Palsy,
• Labyrinthitis,
• Sensory symptoms,
• Bladder symptoms in young men/women w/o children.
• Main symptoms are: fatigue, cognitive impairment, nystagmus, diplopia, dysarthria, dysphagia, muscle weakness/spasm/ataxia, paraesthesia, incontinence

Question 12

What are contraindications for a MS diagnosis?

Answer 12

• Sudden onset,
• Peripheral signs such as Areflexia, muscle waiting, fasciculations.
• Major cognitive impairment,
• Reduced consciousness,
• Prominant seizures,
• Pyrexia
• Normal MRI scan

Question 13

What are the investigations for suspected MS?

Answer 13

• MRI brain and cervical spine with gadolinium contrast,
• Lumbar puncture to look for CSF oligoclonal bands, cell count, glucose and protein.
• Bloods - B12/folate, ACE, Lyme serology, ESR/CRP, ANCA/ANA/Rhumatoid factor.
• Visual evoked potentials - slow conduction in optic nerve if there has been optic neuritis
• Chest x ray to exclude sarcoidosis

Question 14

What are oligoclonal bands?

Answer 14

• Immunoglobulin band seen on electrophoresis of blood and spinal fluid.
• if present in spinal fluid but not blood then it suggests immunoglobulin production/inflammation in CNS

Question 15

What is the definition or relapse vs psuedo-relapse

Answer 15

Relapse - New neurological deficit which lasts more than 24h without pyrexia/infection.
Pseudo-relapse - re-emergence of previous neurological symptoms related to an area of old demyelination in the context of heat/infection

Question 16

Explain the treatment of a MS relapse?

Answer 16

• Not all will require treatment however can treat with steroids eg, 500mg of oral methylprednisolone for 5 days with PPI for gastric protection.
• Physiotherapy/rehabilitation which is where most treatment is aimed at

Question 17

What are two disease modifying monoclonal antibodies used in the treatment of multiple sclerosis?

Answer 17

• Alemtuzumab (two short courses over a year, good drug but high risk of secondary autoimmune disease).
• Natalizumab (monthly infusions, very effective but fatal if infected with JC virus)

Question 18

Name some anti CD-20 monoclonal antibodies used in MS

Answer 18

• Ocrelizumab, ofatmumab.
• Targets B cells but increased infection risk

Question 19

What are two oral treatments for MS?

Answer 19

• Fingolimod
• Dimethyl fumarate (used commonly but less effective than fingolimod)

Question 20

What chemotherapy agent can be used in the treatment of MS?

Answer 20

Cladribine

Question 21

What drug is used in primary progressing multiple sclerosis?

Answer 21

Ocrelizumab

Question 22

What drug is used in secondary progressive MS?

Answer 22

Siponimod

Question 23

What drug can be used in pregnant women with MS?

Answer 23

Copaxone