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Neurology (Expert Forum)
ms or lupus
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ms or lupus
by kstorie, Sep 07, 2006 12:00AM
I am confused and need direction.
This past January I started to notice unusual fatigue, but at the time I brushed it off. About five weeks later I started having suspicious symptoms - altered thought process, memomry problems, could not get my words out when speaking, facial numbness, slurred speech and visual difficulities. This episode lasted about five to six days. I thought it was just my migraines...but I was worried. I went to the Neurologist - EEG(normal), MRA(normal) and MRI(several tiny hyperintentsities projecting within the deep periventricular white matter bilaterally. There is one prominent, ovoid focu of increased signal projecting int the subependymal deep white matter of the right parietal lobe. Cholesterol elevated in addition to the LDH, etc. out of normals. ANA - 160. I was then sent to the Rheumatologists...said mild form of lupus. Started on Plaquenil and Celebrex.
No changes noted - continue with extreme and persistent fatigue(SOB with five steps up, cns complications - new Neurologist(due to new job). This past week - MRA(normal), MRI(decreased areas of concern)....started on folic acid, B12 complex, vitamin c and lyrica for nerve damage(facial pain).
I was told that since there is an improvement on the MRI a diagnosis of MS cannot be made at this time - MRI every six months. Must be treated as CNS lupus for now....rheumatologist disagrees.
Is it expected for the MRI to change frequently? Should a spinal tap be completed? Should I have a second opinion?
I am so frustrated...please help.
This past January I started to notice unusual fatigue, but at the time I brushed it off. About five weeks later I started having suspicious symptoms - altered thought process, memomry problems, could not get my words out when speaking, facial numbness, slurred speech and visual difficulities. This episode lasted about five to six days. I thought it was just my migraines...but I was worried. I went to the Neurologist - EEG(normal), MRA(normal) and MRI(several tiny hyperintentsities projecting within the deep periventricular white matter bilaterally. There is one prominent, ovoid focu of increased signal projecting int the subependymal deep white matter of the right parietal lobe. Cholesterol elevated in addition to the LDH, etc. out of normals. ANA - 160. I was then sent to the Rheumatologists...said mild form of lupus. Started on Plaquenil and Celebrex.
No changes noted - continue with extreme and persistent fatigue(SOB with five steps up, cns complications - new Neurologist(due to new job). This past week - MRA(normal), MRI(decreased areas of concern)....started on folic acid, B12 complex, vitamin c and lyrica for nerve damage(facial pain).
I was told that since there is an improvement on the MRI a diagnosis of MS cannot be made at this time - MRI every six months. Must be treated as CNS lupus for now....rheumatologist disagrees.
Is it expected for the MRI to change frequently? Should a spinal tap be completed? Should I have a second opinion?
I am so frustrated...please help.
Doctor's Answer
by CCF-Neuro-M.D.-SH, Sep 09, 2006 12:00AM
First of all, keep in mind that I am unable to diagnose you because I am unable to examine you, this forum is for educational purposes.
The signs and symptoms you describe are all consistent with multiple sclerosis. The information I do not know is why the rhematologist suspects you have Lupus? I assume he did an ANA with subtyping. Neuro-Lupus is very rare, and has positive findings on MRI that are different than MS (your descripition is more consistent with MS).
I would suggest a lumbar puncture for inflammation (tourtelotte panel/IgG index, oligoclonal bands), MRI of your C-spine with contrast, and visual/somatosenosory evoked potentials. If your neurologist is unable or unwilling to do these tests, I would suggest a second opinion. I would also recommend that if you seek a second opinion, to get it at an established MS center, by a neurologist that specializes in MS.
Starting disease modifying therapy and/or a short course of IV steroids, can help with you symptoms. MS specialist neurologist also have a multi-fasceted approach to helping you with the fatigue.
As mentioned earlier, I have no information on your rheumatology workup, but from the symptoms and history you provide, it is likely that you have MS. I would complete the testing and take to your neurologist about your treatment options.
I hope this has been helpful.
The signs and symptoms you describe are all consistent with multiple sclerosis. The information I do not know is why the rhematologist suspects you have Lupus? I assume he did an ANA with subtyping. Neuro-Lupus is very rare, and has positive findings on MRI that are different than MS (your descripition is more consistent with MS).
I would suggest a lumbar puncture for inflammation (tourtelotte panel/IgG index, oligoclonal bands), MRI of your C-spine with contrast, and visual/somatosenosory evoked potentials. If your neurologist is unable or unwilling to do these tests, I would suggest a second opinion. I would also recommend that if you seek a second opinion, to get it at an established MS center, by a neurologist that specializes in MS.
Starting disease modifying therapy and/or a short course of IV steroids, can help with you symptoms. MS specialist neurologist also have a multi-fasceted approach to helping you with the fatigue.
As mentioned earlier, I have no information on your rheumatology workup, but from the symptoms and history you provide, it is likely that you have MS. I would complete the testing and take to your neurologist about your treatment options.
I hope this has been helpful.
MS possibility is still high, therefore, a more aggressive approach needs to be taken and Tx initiated.
What could confuse the picture more with MS are
1-the CSF, IgG and oligoclonal bands (seen in MS) can occur in 50-70% of patients with CNS lupus, BUT the other parameters of the CSF usually mimicks meningitis than MS (much higher protein and polymorphonuclear cell counts).
2-MRI changes may be indistinguishable from those of MS!!.
3-a positive ANA could be seen in 80%! of MS patients
However, CNS involvement almost always occurs in the setting of unmistakable systemic disease so we could confedantly say that lupus is actually seldom confused with MS==> I mean Patients with CNS lupus will have joint disease, rashes, alopecia, fevers, renal failure, and other stigmata of systemic lupus.
Bout the MRI changes, if there only ischemic changes (reduced blood to the tissue )but no necrosis , then the resolution is possible
Bob
How can one have two such contrasting results in six months?