Multiple Sclerosis

Question 1

Multiple Sclerosis

define

Answer 1

most common immune mediated inflammatory demyelingating disease of the CNS

Question 2

Multiple Sclerosis

epidemology

gender, age, genetics, environmental

Answer 2

• female gender
• age of onset: 28-31
• genetic susceptibility
• environmental

Question 3

Multiple Sclerosis

characteristic feature on imaging

Answer 3

• presence of focal demyelinated plaques in CNS (optic nerve, spinal cord, brainstem, cerebellum, juxtacortical/periventricular white matter)

Question 4

Multiple Sclerosis

dx

2

Answer 4

• clinical dx
• get good PMHx, PE, MRI

Question 5

Multiple Sclerosis

clinical manifestations

2

Answer 5

• monosymptomatic: single lesion
• polysymptomatic: > 1 lesion

Question 6

Multiple Sclerosis

sensory sx

5

Answer 6

1. numbness/tingling
2. tightness (“MS hugs”)
3. coldness
4. swelling of lumbs/trunk
5. intense pruritis (unilateral, cervical dermatomes)

Question 7

Multiple Sclerosis

Neurologic Sx

5

Answer 7

cognitive impairment
* difficulty w/ attention
* short term memory
* speed of information processing
* abstract conceptualization

• Frank Dementia

Question 8

Multiple Sclerosis

sx of unilateral optic neuritis

Answer 8

• painful monocular vision loss (visual blurring, partial vision loss)
• 90% will recover their vision w/in 2-6 mo

Question 9

Multiple Sclerosis

pain sx

4

Answer 9

• paroxysmal (sudden) pain
• persistent pain (burning, cold dyesthesias)
• musculoskeletal
• soft tissue

Question 10

Multiple Sclerosis

descrive uhthoff phenomenon

3 components

Answer 10

• heat sensitivity
• small increases in body temp will worsen sx temporarily
• due to conduction block in central pathways as temp increases

Question 11

Multiple Sclerosis

GU Sx

5 components

Answer 11

• urge incontinence
• overactive bladder
• functional bladder outlet obstruction
• Urination: hesitancy, interrputed stream, incomplete emptying
• Sexual: ED, decreased libido

Question 12

Multiple Sclerosis

GI sx

4

Answer 12

• urge incontinence
• constipation
• poor evacuation
• incontinence

Question 13

Multiple Sclerosis

Neurologic PE Findings

6 components

Answer 13

1. Paraplegia/Paraparesis: lesions in the descending tract of the spinal cord
2. Spasticity: tonic (resistance to movement) or phasic (involuntary jerks and spasms)
3. lhermitte sign
4. coordination problems (dysmetria, hypotonia)
5. gait disturbances
6. cerebellar dysarthria

Question 14

Multiple Sclerosis

why might pts have diminished DTRs

Answer 14

lesions interrupting the reflex arc

Question 15

Multiple Sclerosis

what is lhermitte sign

Answer 15

electric shock shooting down the spine or into the limbs (most often after flexion of the neck)

Question 16

Multiple Sclerosis

sensory PE findings

Answer 16

• vibtration/joint position sense impairment
• patchy areas of reduced pain and light touch perception in limbs/trunk
• Brown-Sequard Syndrome

Question 17

Multiple Sclerosis

describe Brown-Sequard Syndrome

2

Answer 17

• testing sensation w/ sharp object, feeling is increased or spreads like ripple effect
• contralateral weakness

Question 18

Multiple Sclerosis

Ocular PE Findings

4 components

Answer 18

• optic neuritis (afferent pupillary defect w/ swinging flashlight test)
• disc edema if head of optic nerve is involved
• internuclear ophthalmoplegia
• pendular nystagmus

Question 19

Multiple Sclerosis

what is seen on brain MRI

3 components

Answer 19

• hyperintense white matter lesions
• plaques (ring enhancing, ovoid)
• black hole lesions (severe demyelination and axonal loss)

Question 20

Multiple Sclerosis

what would MRI spine show

5 components

Answer 20

• if here, pt is less likely to be asx
• size > 3mm but < 2mm
• occupy only part of SC
• little to no cord swelling
• focal: clearly delineated, well-circumscribed

Question 21

Multiple Sclerosis

Spinal MRI describe chronic lesions

2

Answer 21

• smaller
• well-defined margins

Question 22

Multiple Sclerosis

Spinal MRI describe acute lesions

3 components

Answer 22

• larger
• ill defined
• more gadolinium uptake (dissipates over a few wks)

Question 23

Multiple Sclerosis

when to do LP

Answer 23

if atypical clinical features, imaging features, or in an atypical population (kids or adults)

Question 24

Multiple Sclerosis

describe evoked potentials

Answer 24

• electrical events generated in the CNS by peipheral stimulation of a sensory organ
• detects subclinical abnormal CNS function
• define anatomic site of lesion not easily visualized by imaging

Question 25

# Multiple Sclerosis describe optical coherence tomography | 3

Answer 25

* uses infrared light waves that reflect off the internal microstructure of biologic tissue to produce images * non-invasive way to image the retina * measure thickness of retinal nerve fiber layers

Question 26

# Multiple Sclerosis describe relapsing remitting MS | 3

Answer 26

* 80-95% of pts * attacks w/ full or incomplete recovery * minimal disease progression between relapses

Question 27

# Multiple Sclerosis describe Secondary Progressive MS

Answer 27

* initial relapsing-remitting course followed by gradual worsening w/ or w/out occasional relapses, minor remissions, and plateaus * retrospective dx, no clinical criteria

Question 28

# Multiple Sclerosis describe Primary Progressive MS

Answer 28

* progressive accumulation of disability from onset w/ occasional plateaus, temporary minor improvements or acute relapses * typical presentation: spinal cord syndrome worsening over months to years * clinical dx, only 10% of cases

Question 29

# Multiple Sclerosis describe clinically isolated syndrome

Answer 29

first clinical episode * resembles typical MS relapse * no known hx, doesn't meet dx criteria

Question 30

# Multiple Sclerosis describe radiologically isolated syndrome

Answer 30

* MRI findings suggestive of MS * no signs/sx * no hx of MS * risk factors: male, age > 37, spinal cord lesions

Question 31

# Multiple Sclerosis different tx strategies

Answer 31

* tx of acute exacerbations w/ corticosteroids * reduction of biologic activity w/ DMARDs * sx management * rehab and psychosocial support

Question 32

# Multiple Sclerosis criteria for an acute attack

Answer 32

* episode of focal neurologic disturbance > 24 hrs * preceding clinical stability for > 30d * consider MRI brain

Question 33

# Multiple Sclerosis acute attack tx

Answer 33

* goal: lessen recovery time * glucocorticoids (methylprednisone IV or prednisone PO) * corticotropin injection gel * plasma exchange

Question 34

# Multiple Sclerosis IV Monocloncal Antibody tx | 3

Answer 34

* Natalizumab * Ocrelizumab * Alemtuzumab

Question 35

# Multiple Sclerosis which med has side effect of progressive multifocal leukoencephalopathy

Answer 35

natalizumab

Question 36

# Multiple Sclerosis Oral therapies: S1P Receptor Modulators | 4

Answer 36

* Fingolimod * Siponimid * Ozanimid * Ponesimod

Question 37

# Multiple Sclerosis Injectable Tx

Answer 37

* Ofatumumab * Interferons

Question 38

# Multiple Sclerosis monitoring fot tx

Answer 38

* routine visits every 3 mo * laboratory evaluation * imaging (MRI) repeat- baseline, 6 mo post tx, then annually