Multiple Sclerosis (Free Trial)

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

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Doctor Instruction:

You are a doctor working in family medicine. You have a 34-year-old woman, Sakura Haruno, presenting with numbness + tingling sensation affecting both hands and feet. Please take a history and perform an appropriate examination.

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Patient History:

Sakura Haruno - a 34-year-old female - product manager in a health tech company.

You noticed tingling + numbness affecting both your hands and feet 2 weeks ago. You still have these symptoms– however, you think the symptoms are improving slightly recently. You have also noticed weakness affecting both your hands and feet. You recently had a COVID vaccination one week before developing these symptoms - you are not sure if this is related as you heard many stories about the side effects of the vaccination. You also felt sick after having the vaccination with flu-like symptoms for a few days.

Nowadays you also feel really tired – wanting to sleep more than usual. You don't feel like your usual self – always forgetting things. You have found yourself quite unsteady sometimes. Because of this, you had a few falls at home. Luckily you didn't hit your head. You just want to get better.

No incontinence/pain/Lhermitte’s sign/balance issues/weight loss/fever/problems with waterwork or bowel movement.

Mention only if asked: You remember having a problem with your right eye 5 months ago, and you remember having pain moving your eyes, a problem with vision and a bit of double vision. You can't remember much about this.

Ideas, Concerns, Expectations:

• You think it is related to your COVID vaccination, and you are worried that you might also get blood clots from the vaccination, which can cause a stroke! Ask if this is true. You want to find out what is going on and see if you can have any blood thinners.

Past Medical History:

• Obesity

• Coeliac Disease

• Hypertension

Drug History:

• Atorvastatin

• Rampiril

• NKDA

Family History:

• Mum has SLE.

• Dad developed a stroke at the age of 50.

Social History:

• You are a smoker who smokes 10 cigarettes/day for 3 years

• Drink 2 cans of lager every night

• Occupation: Product Manager in Healthtech

• Managing well at home, living with a partner.

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Examination Findings:

• Weakness affecting both feet and hands

• Spasticity/Increased muscle tone in the legs

• Broad-based gait

• Sensory ataxia – Romberg’s test positive

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Differentials:

1. Multiple Sclerosis (symptoms/signs + history of optic neuritis)

2. Vitamin B12 Deficiency - Tiredness + coeliac disease + neurological signs

3. Guillain Barre Syndrome - Possible flu before symptoms, vaccination association, but would be primarily motor neuron dysfunction

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Investigations:

Bedside:

• Basic Observations

• Capillary Glucose - assess for Hypoglycaemia as a cause of neurological symptoms

Bloods:

• Baseline bloods – FBC/U&E/ LFTs/ CRP

• FBC – may show macrocytic anaemia in B12 deficiency

• LFTs – elevated AST + ALP in GBS

• FBC – may show macrocytic anaemia in B12 deficiency

• Vitamin B12 - low in B12 deficiency

• Anti-ganglioside antibodies – may be positive in GBS

Imaging:

• Fluid Attenuated Inversion Recovery (FLAIR) MRI of the brain and spinal cord to look for demyelinating lesions.

Special Tests:

• Lumbar Puncture

  • oligoclonal bands & raised IgG in CSF in MS

  • elevated CSF protein in Guillain-Barre syndrome

• Nerve conduction studies – slow nerve conduction velocity in GBS

• Spirometry – reduced vital capacity in GBS

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Data Interpretation:

Result Interpretation

Candidate should note patient name and age are correct with the date of the study. They should also note the type of study "FLAIR MRI". They should comment on the alignment of the image and the basic anatomical structures. Note gross anatomy is normal, but there are hyperintense demyelinating lesions.

Image used under Creative Commons with adaptation of added text with fictional patient details: Lopaisankrit, T.; Thammaroj, J. Brain and Spinal Cord MRI Findings in Thai Multiple Sclerosis Patients. J. Imaging2023, 9, 27. https://doi.org/10.3390/jimaging9020027

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Management (Multiple Sclerosis):

Conservative:

• Patient & family/carer education

• Provide prognostic information

• Advise on MS support groups & charities available

• Discuss care needs & refer to social services if any help is needed

• Physiotherapy to improve mobility, strength & energy

• Lifestyle modification e.g. regular exercise to maintain strength & reduce fatigue, smoking cessation

• Shielding from infections e.g. SARS-CoV 19 or the flu where possible as infections are a common trigger of a relapse

• Appropriate driving license authority - must be informed

• Refer to neurology

• Regular review for symptoms and care needs

Medical:

• Acute Relapse of MS:

  • Non-severe & social needs can be met at home: PO 500mg methylprednisolone

  • Severe & social needs cannot be met at home: IV 1g methylprednisolone

  • Consider plasmapheresis if severe & not responsive to steroids

• Immunomodulator e.g. interferon beta to treat ongoing relapsing-remitting MS

• Anti-CD20 monoclonal antibody e.g. ocrelizumab to treat primary progressive MS

• Siponimod for secondary progressive MS

Treating Symptoms:

• Neuropathic pain: gabapentin or amitriptyline

• Mood disturbance: psychotherapy & anti-depressants e.g. SSRI

• Fatigue: exercise, balanced diet.

• Mobility: exercise referral scheme or physiotherapy

• Spasticity: baclofen or gabapentin

• Emotional Lability: Amitriptyline

• Urge Incontinence: tolterodine/oxybutynin

• Pain: Physiotherapy, exercise, analgesia

• Lhermitte’s or Trigeminal Neuralgia: Carbamazepine

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Viva Questions:

What are the common causes/associations with MS?

• Genetics: Family history increases the risk, though it's not directly inherited.

• Autoimmune Factors: Immune system attacks the myelin sheath around nerve fibers in the central nervous system.

• Environmental Factors:

• Vitamin D Deficiency: Low levels may be linked to an increased risk.

• Infections: Epstein-Barr virus and other infections are associated.

• Smoking: Increases the risk and severity of MS.

• Geography: Higher prevalence at higher latitudes, suggesting a role for sunlight and vitamin D.

• Gender and Age: More common in women, typically diagnosed between ages 20 and 50.

• Ethnicity: More prevalent in individuals of Northern European descent, but can affect any ethnicity.

What are the different clinical course patterns in multiple sclerosis?

• Relapsing-Remitting MS (RRMS):

• Clear relapses with symptom exacerbation followed by remission.

• Common initial form.

• Secondary Progressive MS (SPMS):

• Transition from RRMS to a gradual, steady worsening of symptoms.

• May or may not include occasional relapses.

• Primary Progressive MS (PPMS):

• Steady worsening of neurological function from onset.

• No distinct relapses and remissions.

• Progressive-Relapsing MS (PRMS):

• Steady progression with occasional relapses.

• Less common, includes acute symptom worsening during relapses.

What is 'clinically isolated syndrome'?

Clinically Isolated Syndrome (CIS) is a single episode of neurological symptoms suggestive of multiple sclerosis (MS) but doesn't meet the criteria for a definite MS diagnosis. It's a one-time event that may or may not progress to MS, and further evaluation is needed to determine the likelihood of future MS episodes

What are the symptoms and signs of optic neuritis?

• Blurred or loss of vision.

• Eye pain, especially with movement.

• Reduced colour perception.

• Peripheral vision loss.

• Flashing lights or phosphenes.

• Pupillary abnormalities, like a relative afferent pupillary defect (RAPD).

Optic neuritis often affects one eye and is associated with conditions like multiple sclerosis.

What is Lhermitte's Sign?

Lhermitte's Sign is a sensation of electric shock or tingling that travels down the spine or limbs when the neck is bent forward. It's often linked to spinal cord or nerve pathway issues like multiple sclerosis or spinal cord injury.

What is Uhthoff's Phenomenon?

Uhthoff's Phenomenon is when neurological symptoms worsen temporarily due to increased body temperature, often triggered by exercise or hot weather. It's common in conditions like multiple sclerosis due to sensitivity of damaged nerve fibers. Cooling down can alleviate the symptoms.