Multiple Sclerosis

Question 1

Mean age of onset of multiple sclerosis?

Answer 1

30 years

Majority of people between 20 - 40 years when diagnosed

Question 2

What is the pathophysiology of MS?

Answer 2

It is an immune mediated inflammatory disease that attacks myelinated axons in the CNS

Question 3

What sort of disease progression does MS tend to follow?

Answer 3

A relapse-remitting pattern

Onset of symptoms over days, stabilises over days - weeks, gradually resolves (not always completely), then relapses in a few months/years

Question 4

What are some common ways in which MS relapses?

Answer 4

• Optic neuritis
• Sensory loss
• Limb weakness
• Brainstem issues (diplopia/ataxia)
• Spinal cord issues (bilateral motor & sensory symptoms, bladder involvement)

Question 5

What is optic neuritis? Symptoms?

Answer 5

• Inflammation of the optic nerve
• Subacute visual loss
• Pain moving eye
• Colour vision disturbed

Question 6

Common clinical sign of optic neuritis?

Answer 6

• Abnormal pupillary reflex in one eye
• Usually only one eye affected, so do pupillary constriction test and one eye will only cause partial constriction of the pupils compared to the other

Question 7

Ways in which brainstem relapse of MS can present?

Answer 7

• Cranial nerve issues
• Pons: internuclear ophthalmoplegia (affected eye can’t adduct)
• Cerebellum: vertigo, nystagmus, ataxia
• UMN signs in limbs
• Sensory loss

Question 8

What is nystagmus?

Answer 8

• Normally when the head moves the semicircular canals of the ears sense this movement and tell the brain to rotate the eyes the opposite way so that gaze can be fixated on an object
• Nystagmus occurs when the semicircular canals are being activated when the head is not moving, causing the eyes to “dance about.” Can cause visual issues

Question 9

What is myelitis and what are some symptoms it can cause?

Answer 9

• Myelitis is inflammation of the spinal cord, can be transverse (both sides of a section of SC) or partial
• Band of hyperaesthesia (excessive sensitivity) at sensory level
• Weakness/UMN changes below level of demyelination
• Bladder & bowel involvement

Question 10

Pathophysiology of the demyelination process?

Answer 10

• Autoimmune: activated T cells cross BBB
• Loss of function, repair, recovery of all/some function
• Post inflammatory gliosis (glial cell proliferation)
• Appears as plaques/lesions on MRI

Question 11

What can cause MS relapse?

Answer 11

• Underlying infection in 25-30%

- Fewer relapses in pregnancy, increased risk in first 3 months post-partum

Question 12

What causes persistent disability in MS? How is this diagnosed?

Answer 12

• Axonal loss causes persistent disability

- Seen as black holes on MRI and later as cerebral atrophy

Question 13

What happens during the progressive phase of MS?

Answer 13

Accumulation of symptoms and signs, body can’t recover before onset of the next attack

Question 14

What are some clinical signs to look for in examination of MS patient?

Answer 14

• Afferent pupillary defect
• Nystagmus or abnormal eye movement
• Cerebellar signs
• Sensory signs
• Weakness
• Spasticity
• Hyperreflexia
• Plantars extensor (+ Babinski - toe up when foot brushed w blunt object)

Question 15

What are the three types of MS and description of their progression?

Answer 15

• Relapsing-remitting (85%): Symptoms, then resolution, then relapse a while later. Continuous
• Secondary progressive: Begins like RR, then one relapse initiates progressive disease that doesn’t resolve
• Primary progressive: progressive from onset

Question 16

When does primary progressive MS tend to present?

Answer 16

Often presents in 5th and 6th decade

Often poor prognosis with spinal and bladder symptoms being common

Question 17

What are the criteria used to diagnose MS?

Answer 17

• Clinical based diagnosis: Posers Criteria

- MRI based: Macdonald Criteria

Question 18

What compound can be administered to a patient and highlights plaques/tumours on MRI scan?

Answer 18

Gadolinium

Question 19

Some possible Differential Diagnoses for MS?

Answer 19

• Acute Disseminated Encephalomyelitis
• Autoimmune conditions (eg. SLE)
• Sarcoidosis
• Vasculitis
• Infection (eg. Lyme disease, HTLV-1)
• Adrenoleucodystrophy

Question 20

Best investigation for MS?

Other investigations?

Answer 20

• MRI is the best
• Lumbar puncture: oligoclonal (Ig) bands in CSF?
• Bloods: exclude other inflammatory conditions
• CXR

Question 21

How does MS tend to progress for patients?

Answer 21

• VERY variable
• 25% of MS never affects activities of daily living
• 15% causes severe disability quickly
• 25% will need a wheelchair at some point

Question 22

What are the treatment approaches taken to manage MS?

Answer 22

• Treatment of relapses
• Disease modifying treatment (reduce relapse rate, not a cure. Doesn’t slow progression)
• Lifestyle changes and symptomatic treatment
• Vaccines etc. to reduce infection probability

Question 23

How is an acute relapse of MS treated?

Answer 23

• LOOK FOR UNDERLYING INFECTION
• IV/oral prednisolone (anti-inflammatory steroid)
• Symptomatic treatment

Question 24

What are the first line disease modifying treatments for MS?

Answer 24

Subcutaneous/intramuscular injections:

• Beta interferons
• Glatiramer acetate

Oral treatment:

• Teriflunomide
• Dimethyl Fumarate

Question 25

Second line disease modifying agents for MS?

Answer 25

- Natalizumab - Fingolimod - Cladribine - Ocrelizumab - Alemtuzumub

Question 26

Common symptomatic treatments for MS patients?

Answer 26

- Spasticity: muscle relaxants, antispasmodics - Dysaesthesia (discomfort when touched): amitriptyline - Urinary: anticholinergics, bladder stimulator/catheter - Constipation: laxatives - Sexual dysfunction: sildenafil