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Neurology TOSCE 3

A 32 year old woman presented to her GP with pain and blurred vision affecting her right
eye. She was given a prescription for topical chloramphenicol eye drops however after 1
week had no improvement in her symptoms. She re-presented to her GP who performed
fundocsopy. This revealed a swollen optic disc on the right side.

What is the most likely diagnosis?


Optic Neuritis

List 3 differential diagnoses:


Ischaemic Optic Neuropathy
Retinal Migraine
Acute Angle Closure Glaucoma
Cluster headache
Conjunctivitis

Mention 4 other symptoms you should enquire about:


Symptoms of Demyelinating Disease including:

Diplopia (gaze palsy)


Focal weakness
Focal parasthesia
Unsteady Gait
Exacerbation of symptoms in hot climate (Uthoffs phenomenon)
Lhermittes (electric-shock type sensation on flexion of neck)
Urinary retention
Sexual Dysfunction
Fatigue
Depression

Mention 3 signs you should look for on physical examination:


Swollen optic disc
Internuclear Ophthalmoplegia
Cranial nerve palsy
Spastic Paraparesis
Focal Sensory Deficits
Focal Weakness

How is the Diagnosis of the Underlying Condition Made?


Clinical Diagnosis: 2 lesions separated in time and place

Mention 3 investigations which may assist in making the diagnosis:

MRI (DWI may show plaques that are not seen on other series)
LP-CSF analysis-unmatched oligoclonal bands
Visual Evoked Potentials-Delayed
Somatosensory Evoked Potentials-Delayed
Brainstem Auditory Evoked Potentials-Delayed

What criteria may be used to aid in diagnosis of MS?

Mc Donald
Posers

The patient was referred for further investigation. A lumbar puncture was
performed. CSF analysis revealed the following:

Sample 1 2 3

RCC (/mm3) 46 18 6
WCC(/mm3) 7 4 1
CSF Protein (mg/dL) 44 {15-45}
CSFGlucose (mmol/L) 4.1
CSF IgG Index Elevated
CSF IgG pattern Oligoclonal
Serum Glucose (mmol/L) 5.6

Comment on the above results:


Traumatic tap: progressive decline in RCC in serial samples
WCC mildly elevated as a result of blood in CSF
Normal glucose (>2/3 serum glucose)
Unmatched Oligoclonal Bands-MS

Describe the abnormality demonstrated on the following MRI Brain (Saggital


section, FLAIR sequence):
Dawsons fingers- plaques of demyelination in the corpus callosum orientated at right
angles along the medullary veins.

What are the most common locations for MS Plaques?


Corpus Callosum
Centrum Semiovale
Less often basal ganglia and deep white matter

What would be seen on histological section of the above lesion?


Loss of oligodentrocytes. Possibly axonal loss also.

How is MS Classified?
Primary Progressive
Relapsing Remitting
Secondary Progressive
Relapsing Progressive

When is treatment of an acute attack of MS indicated?


Functional impairment with objective evidence of neurological deficit

How is an acute relapse of MS treated?


High dose IV corticosteroids- Methylprednisolone 1g IV x 5/7

What treatment options exist for Relapsing Remitting MS?


MDT Management (MS specialist nurse, PT, OT)

Immunomodulating Treatment:
Decrease relapse rate
Slow dx progression
Slow accumulation of lesions on MRI

Interferons
Glatiramer Acetate
Natalizumab
Mitoxantrone

RR MS should be treated with Interferon or Glatiramer Acetate.

What significant concern arose with the use Natalizumab in Clinical Trials?
Development of Progressive Multifocal Leucoencephalopathy

What infectious agent is implicated in the pathogenesis of this condition?


JC Virus