Multiple Sclerosis

Introduction

o Multiple sclerosis (MS) is a chronic autoimmune demyelinating disorder of the central nervous system (CNS).
o The cause is unknown, however it is assumed that abnormal immune responses to environmental triggers in genetically predisposed individuals leads to acute and chronic inflammation.
o Affects approximately 100,000 people in the UK.
o Commonest cause of serious physical disability in adults of working age.
o Three types of MS
• Relapsing-remitting MS (RRMS)
• Secondary progressive MS
• Primary progressive MS
• Presentation
o There are a wide range of possible presenting symptoms and signs dependent on where in the CNS the inflammation has occurred.
o Consider MS in young patients with new onset neurological symptoms and/or signs.

Common presentations include:

• Optic neuritis
• Brainstem lesions:
• Diplopia
• Vertigo
• Facial numbness
• Dysarthria/dysphagia
• Bilateral internuclear ophthalmoplegia (pathognomic sign)
• Spinal cord lesions
• Paraparesis
• Limb numbness/tingling
• Lhermitte’s sign – altered sensation travelling down the back and occasionally limbs on neck flexion

Common symptoms include:

• Visual changes
• Sensory symptoms
• Clumsy limbs
• Unsteadiness or ataxia
• Urinary symptoms
• Neuropathic pain
• Fatigue
• Spasticity
• Depression
• Sexual dysfunction
• Temperature sensitivity – transient worsening of pre-existing symptoms with increases in body temperature (uhtoff’s phenomenon).

History

o Previous episodes? – MS usually presents with discrete symptoms separated in time (associated with newly formed plaques)
o Did these previous episodes improve?
o Family history of MS?
o Family history of other autoimmune disease such as SLE? (Weak association with MS)
o Smoking history? (Increased risk with smoking)

Examination

o Full neurological examination findings vary.

Potential finding include:

• Upper motor neuron signs (common)
• Wide-based gait
• Pale optic disc
• Incorrect responses to ishihara colour tests.

Laboratory investigations

o Before referral to a neurologist the initial investigations should be carried out to rule out other causes of symptoms:
• Full blood count
• Inflammatory markers (Erythrocyte sedimentation rate, C-reactive protein)
• Liver function tests
• Renal function tests
• Calcium
• Glucose
• Thyroid function tests
• Vitamin B12
• HIV serology

Radiological investigations

o A magnetic resonance imaging (MRI) scan of the brain and spinal cord.
o MRI brain common findings:
• Hyperintensities in the periventricular white matter.
o MRI spinal cord common findings:
• Demyelinating lesions in the spinal cord, particularly in the cervical region.

Other investigations

o Anti-NMO antibody – recommended in patients with long segments of spinal cord demyelination or recurrent optic neuritis.
• Present in neuromyelitis optica (Delvic’s syndrome)
o CSF evaluation – performed after all non-invasive tests if needed
• Glucose, protein, and cell count should be normal
• Oligoclonal bands and elevated CSF immunoglobulin G (IgG) commonly present
o Evoked potentials – useful to assist in establishing the diagnosis but not helpful in monitoring.
• Prolongation of conduction

Management

o After a diagnosis of MS has been confirmed by the neurologist, information should be provided to the patient and family (if allowed)

Care for MS patient is provided by a multidisciplinary team consisting of:

• Consultant neurologists
• MS nurses
• Physiotherapists and occupational therapists
• Speech and language therapists, psychologist, dietitians, social care and continence specialists
• GPs
• A single point of care should be offered to the patient to access services.

Lifestyle advice

• Regular exercise
• Stop smoking

Symptom management

• Urinary incontinence – lifestyle modification first (avoid caffeine and vitamin waters)
• Oxybutynin 5mg orally (immediate-release) twice daily
• Emotional lability – amitriptyline
• Neuropathic pain – gabapentin 100mg orally o.d or pregabalin 150mg o.d (divided into 3 doses initially).
• Spasticity – try to treat conservative first (improve factors that aggravate spasticity such as constipation and gentle stretching).
• Baclofen 5mg orally t.d.s
• Fatigue – regular exercise and good sleep hygiene should be encouraged
• Amantadine 100mg o.m and o.n
• Movement (gait impairment) – physiotherapy should be offered
• Dalfampridine 10mg orally twice daily.
• Cognition including memory problems – refer to occupational therapy and neuropsychology.

Disease-modifying therapies

• Beta interferon-1a(30micrograms intramuscularly once weekly).
• Beta interferon-1b (250micrograms subcutaneously once daily on alternate days).
• Glatiramer acetate (20mg subcutaneously once daily or 40mg subcutaneously three times weekly).
• Oral therapies can be used instead such as teriflunomide (7-14mg o.d) or dimethyl fumarate (120-240mg b.d).

Acute management

• MS patients who present to A&E with an acute relapse symptoms affecting functioning should be managed as follows:
• Stabilise the patient’s airways, breathing and circulation.
• Patients should be screened for infection.
• Intravenous methylprednisolone 1g o.d for 3-5 days or oral methylprednisolone 0.5 g o.d. for 5 days.
• Plasma exchange can be considered in acutely presenting patients with severe or rapidly progressing disability.

Complications

o The time frames for the following complications are variable and are dependent on the severity of the patient’s condition.
• Urinary tract infection
• Osteopenia and osteoporosis
• Depression
• Visual impairment
• Erectile dysfunction
• Cognitive impairment
• Impaired mobility

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