MRI Scan Question

[Dianne]

I had an MRI scan with the following results:  Gandolinium enhanced images normal.  Tiny low signal in posterior internal capsule on right.  T1 normal in signal intensity on the FLAIR and slightly increased signal on 2.  FLAIR and T2 exhibit a tiny high signal in medial uncus on left and somewhat larger signal in the corona radiata posteriorly on left.  Two tiny high signals visible on FLAIR in basal ganglia.  Tiny high signal visible on FLAIR and T2 in the pons.  Findings numerous and minimal.  Differential considerations would include demylinating process.

With this MRI, the neurologist I saw said I most likely had MS, even though the problems I had described previously did not fit the pattern.  I do have considerable nerve pains in fingers and toes, some burning in the forearms, muscle cramps, minor headaches, and the feeling of heavy legs when I walk.  Most symptoms come and go, with the exception of the nerve pains, which are frequent.  I also have autoimmune hepatitis, and high titers of CMV.  In all my research, I cannot find any link between MS and AIH.  I also don't seem to fit MS patterns.  I experience no numbness or one-sided events. He did not suggest followup tests which didn't bother me at the time, as MS usually will show itself over time.  My question is whether based on that scan, could other interpretations be made?  I have moved to another state and am having some problems with these things again, and I am tired of trying to explain such vague symptoms.  I do not expect a diagnosis, only any suggestions you may have in regard to options and how to explain how I feel to a doctor without sounding like a total nutcase.  As an academic I find this very frustrating.  Thanks

[CCF Neuro[P] MD, RPS]

Dear Dianne:

Depending on the type of titer of CMV antibodies, one can tell if the infection was chronic or acute.  If the antibodies were of the IgG type and not IgM, then the infection was remote and old.  If the antibody IgM was elevated then the infection was recent, several weeks old.  Most of us have been infected by the CMV virus but in a normal patient the symptoms are mild and very "cold-like" in symptoms.  One can have high IgG antibody levels many years after an infection.  Since you have more demyelinating-looking plaques on your MRI, this may mean that your MS has had exacerbations.  However, there are other things that can give plaques that are hyperintense on T2 or Flair sequence (different types of MRI images), such as acute stroke.  Since your CSF was clear of oligoclonal bands and IgG synthesis, then I would say that if you have MS, it is not the garden variety of MS.  I would follow this closely with your neurologist.  I would think another MRI with and without contrast looking for new lesions would be appropriate, ask your neurologist about timing-likely in about a year.

I hope I help you abit.

Sincerely,

CCF Neuro MD

[Dianne-Follow-up question]

I have had no success finding a doctor to consider the CMV in realtionship to either the autoimmune hepatitis or the MRI.  I did have a previous MRI about 5 years previous to the one I described that was done without contrast and showed two spots.  A followup MRI a year later showed only one spot.  At that time, I did have a lumbar puncture which was only tested for MS (not aware of the CMV at the time).  It was negative.  The hole did not seal and so I had to go back in and get it sealed.  Not fun, and hope to avoid that.  Though I have asked several doctors about the meaning of the high titers of CMV I get no response and it does not appear to be a concern.  The literature I am able to dig up seems to focus on either preventing the spread in care settings, or links it to HIV or transplants.  I did find a source that indicated that it can show up on an MRI and in the spinal fluid.  I guess I am very confused about how CMV could affect a non-HIV, non-transplant individual.  Finally, to determine change over time, how often would an MRI need to be done?  Thanks, hope you see this in the post!

[CCF Neuro[P] MD, RPS]

Dear Dianne:

Sorry to hear about your symptoms.  Based solely on the MRI scan, it would be difficult to say specifically you have MS. Although we frequently see demyelination occuring in the temporal lobes, the most classic findings are in the periventricular areas.  So, although the findings are consistent with demyelination, they aren't the classic findings of MS. The confounding data would be the CMV infection, that might cause similar findings, but couldn't say for sure.  I guess the real test will be the MRI findings over a period of time, together with the symptoms that you may or may not have.  If desired, it might help to see what the CSF finding might be (CNS antibody synthesis, oligoclonal bands, kappy chains).  I would suggesting finding a neurologist with whom you can follow the progression or no progression of your symptoms and what is seen on the MRI.  Certainly, if the lesions increase in number and show age related changes (some new lesion, some old) then likely you do have MS.  At that time a decision concerning treatment should be made.

I am sorry that I can't be more definite.  I hope that the lesions do not progress or change in number and your symptoms are due to the CMV induced hepatitis.

Sincerely,

CCF Neuro MD