Outline

Background 

• Multiple sclerosis is an autoimmune condition 

Assessment

Presentation

• Optic neuritis- unilateral painful 

• L'hermitte's sign (Myelopathy): sharp shooting pain down spine upon neck flexion

• Limb weakness or numbness

Examination

• Motor weakness with UMN signs (hypertonia, hyper-reflexia)

• Sensory impairment

• Ataxia- cerebellar or sensory ataxia

Investigation

• MRI Spine + brain

• Lumbar Puncture

Diagnosis

Diagnostic criteria: two lesions separate by time and place

• This can be MRI + CSF findings as oligoclonal bands represent old damage. 

History:

• Sensory lesions

• UMN > LMN lesions

Examination:

Ix

• Clinical 

• MRI

• LP

MRI can be used to monitor serial change, e.g. yearly MRI reasonable (CRP poor marker)

Differentials

Management

Acute

1.  High dose Steroids, often IV methylprednisolone (after negative urine dip/ septic screen)

PACES

Introduction

• • MS is a common condition in PACES, particularly the Nervous System Examinations. 

  • Remember PACES assesses whether you'd be a safe out of hours medical registrar, i.e. tailor your answers as if you were having to see this presentation acutely overnight by stating you'd call neurology and ask for advice- showing you know your limits and you're safe

Signs

• Younger lady

• Either or Both

  • Motor weakness: UMN- increased tone, hyper-reflexia, clonus/ hoffman's syndrome, jaw jerk

  • Sensory disturbance

• Multiple vascular or anatomical lesion distributions

Questions

Differentials

• Bilateral UMN lesion: myelopathy- SoL(insidious onset), spinal infarct (acute onset),

• Unilateral UMN lesions: cerebral lesion- SoL, stroke (older, acute onset)

• Mixed UMN motor + sensory: vascular, SoL

• Isolated sensory: peripheral sensory neuropathy

Investigations

• MRI Spine & Head: 

  • Can start at focal site of symptoms but if suspect MS worth imaging whole central nervous system

Acute Flare

• IV Steroids:

  • Side effects: 

    • Acute- hyperglycaemia, mood swings, GI bleed, weight gain

    • Chronic- osteoporosis, catarcts, central obesity

• Neurology Consult

Chronic

• Neurology MDT- Consultant specialist interest in MS, PT- rehab, OT- home adjustments, dietician prevent sarcopenia, speech and language if swallow issues, psychologist - accepting diagnosis

• Disease modifying medications- not required in depth knowledge here

Deeper Dive

Pregnancy

• Prednisolone causes maternal weight gain, fetal macrosomnia & gestational diabetes

• No management recommended where possible

Progressive Multifocal Leukoencephalopathy (PML)

• Complication of MS

• Presentation: progressive confusion, memory loss & ataxia

• CT-Head: patchy white hypodense white matter lesions

• CD4+ count: reduced

Management 

• Ocrelizumab (primary progressive)

• Fingolimod (active relapsing remitting)

• Natalizumab: active rapidly progressing

References

Page written in 2024. 

Produced off FOAM basis: free, open access, medical education. This is not clinical advice, education for multiple choice questions only! 

Produced to the best of the author's ability. Any issues please contact contact: MunroMedics@gmail.com