Multiple Sclerosis or not? MS-allied diseases and conditions to rule out

Some conditions present similar symptoms to those caused by Multiple Sclerosis (MS) . To confirm diagnosis, the health care provider must be able to rule out other possible conditions. Some of these conditions are easy to rule out with a simple blood test (e.g., vitamin B12 deficiency), while others, such as sarcoidosis, may require a biopsy. Some are much rarer than others. It’s important to work with a healthcare provider who is familiar with these conditions to arrive at a correct diagnosis as quickly as possible — and begin the appropriate treatment — whether you have MS or not. 1- Infections of the central nervous system (CNS) Lyme disease — An infection caused by the Borrelia burgdorferi organism, which is transmitted to humans by a deer tick. Lyme disease in humans can have serious symptoms, including neurological symptoms like those seen in MS, but can generally be treated with antibiotics. Lyme disease can cause rashes and joint symptoms unlike MS. Neurological symptoms may include meningitis, encephalitis, Bell’s palsy, weakness, impaired language, fatigue, and impaired memory. Brain MRI may or may not show lesions in the white matter. These lesions are usually non-specific, but sometimes may mimic MS lesions Syphilis — A sexually-transmitted infection caused by the acterium Treponema pallidum, which can cause neurologic symptoms many years after the initial infection. Progressive multifocal leukoencephalopathy (PML) — A potentially fatal infection of the white matter of the brain caused by the JC virus (a virus common and inactive in the general population), which can be reactivated in people with MS who take Natalizumab. Human immunodeficiency virus (HIV) — A virus that can lead to acquired immunodeficiency syndrome, or AIDS. Human T-cell lymphotropic virus-1 (HTLV-1) – associated myelopathy/tropical spastic paraparesis — A chronic progressive disease of the nervous system 2- Inflammatory disorders of the CNS Sjögren’s syndrome — A chronic autoimmune disease that attacks the body’s moisture producing glands, causing dry eyes and mouth, generalized fatigue, joint pain and sometimes neurologic symptoms Vasculitis — An autoimmune disorder that attacks the blood vessels that supply the brain and spinal cord, producing neurologic symptoms. Systemic lupus erythematosus — Also called SLE or lupus. A chronic, inflammatory autoimmune disorder that can affect the skin, joints, kidneys, lungs, nervous system, and other organs of the body. It usually appears between the ages of 20 and 40 and is approximately 10 times more common in women than men; it occurs more frequently in blacks and Asians than in other groups. The most common symptoms of lupus include skin rashes and arthritis, which are often accompanied by fatigue and fever. The disease course, which can range from very mild to quite severe, often includes alternating periods of relapse and remission. The most common symptoms of neurological involvement from lupus are migraine headaches, changes in personality and cognitive function, epileptic seizures, and occasionally stroke — which are not typical manifestations of multiple sclerosis (MS) Occasionally patients with lupus develop transverse myelitis or optic neuritis; these may indicate the presence of a condition that is similar to but distinct from MS, called neuromyelitis optica (NMO), that requires different treatment Sarcoidosis — A chronic, probably autoimmune condition that produces collections of inflammatory cells (granulomas) in the lungs, skin, lymph nodes, liver, and central nervous system, commonly producing respiratory symptoms and, sometimes, neurologic symptoms. Behçet’s disease — An autoimmune disease that damages blood vessels, particularly veins. In addition to mouth sores, genital sores, inflammation inside of the eye and skin problems, Behcets can affect the white matter in the brain 3- Genetic disorders Hereditary myelopathies — Several inherited disorders involving the spinal cord, including hereditary cerebellar degeneration, the leukodystrophies and motor neuron disorder (involving nerve tracts in the spinal cord). Cerebral Autosomal-Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) — An inherited disease that primarily affects small blood vessels in the white matter of the brain, causing numerous progressive neurologic symptoms. Leukodystrophies — Rare inherited progressive disorders that damage the myelin in the central nervous system and cause neurological symptoms. Hereditary cerebellar degeneration — A group of hereditary disorders that cause slowly progressive incoordination of gait, as well as poor coordination of hands, speech, and eye movements. Mitochondrial disease — Malfunctioning of the mitochondria (structures in cells that produce energy) that interferes with various body functions and can produce neurologic symptoms. 4- Brain Tumors Metastases — Cancer that has spread from its original location to another is considered metastatic. Some cancers — breast, lung, kidney, and skin (melanoma) — are more likely to spread to the central nervous system and cause neurologic symptoms. Lymphoma — A blood cancer involving rapid replication of abnormal T or B lymphocytes (types of white blood cells) that form tumors — which sometimes occurs in the central nervous system (CNS) or spreads to the brain from other locations. 5- Deficiencies Copper deficiency — A relatively rare deficiency seen with excessive zinc intake or some types of stomach surgery, which can cause neurologic symptoms. Vitamin B12 deficiency — A deficiency of this vitamin, which is critical to neurologic function, can occur because of dietary limitations or absorption problems and is a common cause of neurologic symptoms. 6- Structural damage in the brain or spinal cord Cervical spondylosis — A degeneration of the spine associated with normal aging that can press on the spinal cord and cause neurologic symptoms. Herniated disc — A disc that acts as a cushion between the vertebrae (bones) of the spine can deteriorate with age – moving or slipping out of place (referred to as ‘herniated’). A herniated disc places pressure on the nerves in the area, producing neurologic symptoms. Chiari’s malformation — An abnormality in the position of the cerebellum — a brain structure responsible for balance and coordination. When the cerebellum sits too low, it puts pressure on the spinal cord or brainstem, producing neurologic symptoms. 7- Other non-MS demyelinating disorders Neuromyelitis optica (NMO) — A separate disease from MS that shares several clinical features. NMO most often causes visual changes in both eyes and symptoms caused by long lesions in the spinal cord. Is a demyelinating disease of the central nervous system that affects the optic nerve and spinal cord. The main clinical features of NMO are optic neuritis (inflammation of the optic nerve) and transverse myelitis (inflammation of the spinal cord). Transverse myelitis (TM) —Is a neurological disorder caused by inflammation of the spinal cord. It can occur in individuals of all ages and affects both genders. Symptoms of TM can include weakness of the legs and arms, pain, abnormal sensations (burning, prickling, tingling etc.) and bowel and bladder dysfunction. Most individuals will only have one TM attack although some may have a recurring attack. Transverse myelitis can also be the first symptom of MS or NMO Acute disseminated encephalomyelitis (ADEM) — A brief but intense attack of inflammation in the brain, spinal cord and occasionally the optic nerve that causes damage to myelin. Symptoms of ADEM come on quickly, often beginning with behavior changes. It is generally seen in children but can affect individuals of any age. ADEM is sometimes misdiagnosed as a severe first attack of MS since some of the symptoms of the two disorders may be similar. However, ADEM usually — but not always — consists of a single episode or attack lasting weeks or months, while MS features many attacks over the course of time. Doctors will often MRI to search for old and new lesions on the brain and spinal cord; old areas of damage suggest that the condition is ongoing and may be MS rather than ADEM. In the absence of old lesions, it is difficult to discriminate severe first attacks of what will eventually be diagnosed as MS from ADEM. For this reason, the physician carefully monitors the person with ADEM to see if a recurrence or progression suggests MS. Differentiating ADEM from MS is important because the treatment recommendations differ significantly; people with MS will usually require some form of continuing disease-modifying medication while those with ADEM will not. 8- Other conditions to rule out Chronic Fatigue Syndrome (CFS) — Chronic Fatigue Syndrome is a disorder characterized by extreme fatigue without an underlying medical condition. There is no one test to diagnose CFS. Some CFS symptoms are like MS symptoms however CFS symptoms also include sore throat and swollen lymph nodes in the neck or armpit, which are not seen in MS Lupus (systemic lupus erythematosus) — Lupus is a chronic inflammatory disease where an individual’s immune system attacks its own tissues and organs. Inflammation caused by lupus can affect different body systems, including the joints, skin, kidneys, blood cells, brain, heart and lungs. Lupus can be difficult to diagnose because signs and symptoms are similar to those seen in other conditions however there are distinct symptoms that are not seen in MS such as skin rash, shortness of breath and fever. References: www.nationalmssociety.org/Symptoms-Diagnosis/Other-Conditions-to-Rule-Out https://mssociety.ca/about-ms/diagnosing-ms/ms-allied-diseases-and-conditions-to-rule-out mssociety.ca/about-ms/diagnosing-ms/neuromyelitis-optica-spectrum-disorder www.nationalmssociety.org/Symptoms-Diagnosis/Other-Conditions-to-Rule-Out/Lupus www.nationalmssociety.org/Symptoms-Diagnosis/Other-Conditions-to-Rule-Out/Neuromyelitis-Optica https://pdf.hres.ca/dpd_pm/00060546.PDF www.nationalmssociety.org/Symptoms-Diagnosis/Other-Conditions-to-Rule-Out/ADEM

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Multiple Sclerosis or not? MS-allied diseases and conditions to rule out

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Nancy Banoub

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