Multiple sclerosis

Question 1

What is multiple sclerosis?

Answer 1

An autoimmune condition characterised by episodes of inflammation of the nervous tissue in the CNS, causing demyelination

Question 2

Describe the aetiology of MS

Answer 2

Females (3:1)
20-40 y/o
More common as you move away from the equator

Question 3

What are some factors that cause MS?

Answer 3

At least 60 genes have been implicated (HLA, MHC, etc.)
Environmental factors (EBV, VitD deficiency)

Question 4

Describe the pathophysiology of MS

Answer 4

T-cell mediated autoimmune response against the white matter of the brain and spinal cord

Plaques of demyelination can occur anywhere but occur most commonly in the optic nerve, brainstem and cervical spinal cord

Question 5

How does lower urinary tract dysfunction occur in MS?

Answer 5

CNS demyelination causes increased tone at the bladder neck as well as detrusor muscle hypersensitivity and sphincteric dyssenergia

Question 6

What are the 3 main patterns of MS?

Answer 6

Relapsing-Remitting MS
Secondary progressive MS
Primary progressive MS

Question 7

Describe the pattern of relapsing-remitting MS

Answer 7

Symptoms occur in attacks (relapses) with a characteristic time course: onset over days and typically recovery, either partial or complete, over weeks

Question 8

Describe the pattern of secondary progressive MS

Answer 8

This late stage of MS consists of gradually worsening disability progressing slowly over years; some 75% of patients with relapsing-remitting MS will eventually evolve into a secondary progressive phase by 35 years after onset

Question 9

Describe the pattern of primary progressive MS

Answer 9

Characterized by gradually worsening disability without relapses or remissions

Question 10

What are the types of presentations of MS

Answer 10

Pyramidal dynsfunction
Optic neuritis
Sensory symptoms
Lower urinary tract dysfunction
Cerebellar dysfunction
Brainstem dysfunction
Internuclear ophthalmoplegia
Fatigue

Question 11

What are some symptoms of pyramidal dysfunction?

Answer 11

• Increased tone
• Spasticity
• Weakness
• Affects extensors of upper limbs and flexors of lower limbs

Question 12

What are some symptoms of optic neuritis?

Answer 12

Painful visual loss over 1-2 weeks
Blurred vision (Unilateral)
Reduced or lost colour vision
RAPD

Question 13

What are some sensory symptoms of MS

Answer 13

• Pain
• Paraesthesia
• Dorsal column loss - proprioception and vibration
• Numbness
• Trigeminal neuralgia
• Odd sensation on neck flexion (Lhermitte’s sign)

Question 14

What are some symptoms of lower urinary tract dysfunction?

Answer 14

• Increased frequency and urgency
• Nocturia
• Urge incontinence
• Retention

Question 15

What are some symptoms of cerebellar dysfunction in MS?

Answer 15

• D - Dysdiadochokinesia
• A - Ataxia
• N - Nystagmus
• I - Intention tremour
• S - Slurred speech
• H - Hypotonia

Question 16

What are some symptoms of brainstem dysfunction in MS?

Answer 16

• Diplopia - CN VI palsy
• Facial weakness - CN VII palsy

Question 17

What is internuclear ophthalmoplegia?

Answer 17

A condition in which there is formation of a demyelinated plaque in the medial longitudinal fasciculus

Question 18

What are some symptoms of internuclear ophthalmoplegia?

Answer 18

• Distortion of binocular vision
• Failure of adduction - diplopia
• Nystagmus in abducting eye
• Lag

Question 19

What are some investigations required in MS?

Answer 19

Bloods
Neurophysiology
MRI
Lumbar puncture

Question 20

What bloods are required in MS?

Answer 20

Bloods to rule out other causes:
- FBC
- Inflammatory markers
- U&Es
- LFT, TFT
- Glucose
- HIV serology
- Calcium
- B12 levels

Question 21

What will be seen on MRI in MS?

Answer 21

• Periventricular lesions
• Discrete white matter abnormalities
• Areas of focal demyelination
• Active inflammatory plaques can be distinguished from inactive ones by using a contrast agent

Question 22

What will be seen in the CSF on lumbar puncture?

Answer 22

Oligoclonal bands

Question 23

How is acute relapse of MS managed in MS

Answer 23

Mild - Symptomatic treatment
Moderate - Oral steroids
Severe - Admit/IV steroids

Question 24

How is pyramidal dysfunction managed in MS?

Answer 24

• Physiotherapy
• Occupational therapy
• Anti-spasmodic agent e.g. oral baclofen, oral tizanidine, botulinum toxin, intrathecal baclofen

Question 25

How are sensory symptoms managed in MS?

Answer 25

- Anticonvulsant e.g. gabapentin - Antidepressant e.g. amitriptyline - TENS machine - Acupuncture - Lignocaine infusion

Question 26

How is lower urinary tract dysfunction managed in MS?

Answer 26

- Bladder drill - Anti-cholinergics e.g. oxybutynin - Desmopressin - Catheterisation

Question 27

How is fatigue managed in MS?

Answer 27

- Amantadine - Modafinil if sleepy - Hyperbaric oxygen

Question 28

What is first line disease modifying therapy in MS?

Answer 28

- Tecfedira, aubagio - Interferon beta - Glitiramer acetate

Question 29

What is second line disease modifying therapy in MS?

Answer 29

- Monoclonal antibody - tysabri, ocrevus, lemtrada - Anti-CD20, anti-CD 50, Anti-integrin - Fingolimod, cladrabine

Question 30

What is third line disease modifying therapy in MS?

Answer 30

- Mitoxantrone - HSCT (stem cell transplantation)