Multiple sclerosis

Question 1

Multiple sclerosis

Answer 1

1. inflammatory demyelinating disease of the CNS
2. leading cause of neurological disability in the UK
3. Age of onset 20 - 45 years
4. More common in females than males

Question 2

Pathogenesis

Answer 2

1. activated T lymphocytes which cross the blood-brain-barrier
2. T cells initiate as inflammatory cascade resulting in areas of demyelination
3. Plaques of demyelination in
   - optic nerve
   - corpus collosum
   - brainstem
   - tracts
4. demyelinated neurons then heals poorly causing relapsing and remitting symptoms
5. acute episodes are due to focal inflammation causing myelin damage and conduction block

Question 3

Causes of MS

Answer 3

Both genetic and environmental factors play a part

1. Multiple genes increase risk of MS - HLA and MHC polymorphisms
2. Environmental factors such as viral infections of EBV and HHV

Question 4

Types of MS

Answer 4

1. relapsing-remitting (80-90%)
2. primary progressive (10-20%)
3. secondary progressive

Question 5

Clinical features

Answer 5

1. Optic neuritis - demyelination of the optic nerve
   - blurred vision
   - reduced visual acuity / reduced colour vision
   - optic disc swelling
2. Brainstem demyelination
   - Diplopia
   - Vertigo
   - Facial numbness/weakness
   - Dysarthia/Dysphagia
3. Spinal chord lesions
   - gradually progressive paralysis over days and weeks
   - neuropathic pain]
   - spasticity
   - tingling
   - Bladder dysfunction

Question 6

Diagnosis

Answer 6

1. positive history of symptoms
2. MRI of brain.spinal chord - demonstrates area of demyelination
3. CSF from an LP shows oligoclonal IgG bands

Question 7

Treating symptoms of MS

Answer 7

1. Muscle spasticity - anti spastic drugs like Baclofen and Diazepam
   - botulin toxin injections into affected muscles
2. Bladder dysfunction - Anticholinergic drugs e.g. Oxybutynin
3. Trigeminal neuralgia - Antiepileptic drugs
4. Neuropathic pain and dysaethesia - pain modulating drugs ( amitriptyline + gabapentin)
5. Fatigue - Modafinal
6. Mood disturbance - Antidepressant

Question 8

Treating acute attacks of MS

Answer 8

1. Controlled by IV corticosteroids ( methylprednisilone)

2. Monoclonal antibody Alemtuzumab is used to attack T cells

Question 9

Maintainance treatment of MS

Answer 9

1. Relaspsing remitting MS
   - Interferon Beta-1A & Beta-1b
   - Glatiramer Acetate
   - Mitoxantrone
2. Progressive MS
   - Mitoxantrone - only shown to have positive impact on disease progression

Question 10

Relapsing Remitting form of MS

Answer 10

1. characterised by clearly defined relapses caused by appearance of new areas of demyelination
2. Symptoms develop gradually over days or weeks and resolve over several weeks
3. May resolve completely or incompletely
4. no disease progression between specific relapses

Question 11

Primary progressive from

Answer 11

1. slow progression of neurological symptoms and disability
2. tends to present at older age
3. commonly with paraparesis caused by thoracic spinal chord demyelination
4. NO relapsises or remisiions

Question 12

Secondary progressive form

Answer 12

1. Approximately 75% of those with relapsing-remitting MS go on to develop secondary progressve disease
2. slowly progressive disability
3. with or without ocurrences of relapses or remissions