Multiple Small Foci in the Subcortical White Matter

[dittledittle]

51 yr old woman diagnosed with demyelinating disease in 2002 (Multiple Sclerosis). Also have ulcerative colitis,optic neuritis,iritis, arthritis (not painful). All blood tests came back negative i.e. ANA, Rheumatoid, etc. MRI shows Multiple small foci of bright FLAIR signal in the subcortical white matter of both hemispheres in a relatively symmetric distribution.  No mass effect or midline shift. No extra-axial mass or fluid collection is demonstrated. Paranasal sinuses & temporal bones appear normal. Posterior fossa is unremarkable. No abnormal enhancement is present post gadolinium. Impression: Several small nonspecific bright T2 subcortical lesions. This might be secondary to her demyelinating disease.  I have hypo reflexes (knee). Spasticity in both legs more so right leg and right hand.  I don't have lesions in the Dawson fingers or corpus callosum.
Symptoms-balance,spasticity,chronic optic neuritis,weak legs & rt. arm,fatigue. New symptom-headaches (over eyes or top of head). Sometimes daily headaches now. Received monthly solumedrol for 1 yr till it didn't work anymore, then Novantrone for 1 yr (didn't work). Took Betaseron (1 1/2 yr.) didn't work.  RX includes sulfasalazin, Neurontin, Nabumetone,Baclofen,Trazadone(to help sleep),Cenestin (HRT). What could secondary disease be.  Neurologist thinks I am part MS and part Lupus.  Is that possible or what could I have.  Thank you.

[CCF-Neuro-M.D.-SH]

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 story and symptoms that you relate are a sad and familiar one.  Multiple sclerosis is a progressive disease that causes greater dysfunction over time, often despite our best efforts with treatments.  Your symptoms of balance problems, spasticity, visual problems, weak legs & rt. arm, and fatigue are very common symptoms in patients who suffer from multiple sclerosis.  Baclofen (orally or intra-thecal through a baclofen pump) is used to combat the spasticity.  There are new treatments that will be availible soon that may improve your course.  Your headaches are a separate issue, and may not be related to your MS.  However neck spasticity(common in MS patients) can give rise to headaches that can be treated with physical therapy and muscle relaxors, such a zanaflex, skelaxin, parafon Forte, etc.  As far as your ulcerative colitis and arthritis go I would leave that up to the experts in rheumatology.
I hope this has been helpful.

[dittledittle]

I forgot to say that lumbar puncture was done on me in 2002 and there weren't any oligoclonal bands.  It came out normal.  I don't have high blood pressure.

[JCmcc]

Hello,
   I am sorry to hear of your symptoms which are much like mine were aside from optic neuritis. Our brain reports are almost identical.
   Your symptooms and your pathology truly resemble Lyme disease. Lyme disease can present those lesions and often times Lumbar Punctures in Lyme patients show no bands.
   Please be advised that the blood tests, such as the Elisa, commonly used are known to be non-specific and worthless. IGENEX Labs in California are always complimentary. Depending upon your locale, I would, suggest that you find yourself a physician who specializes in Lyme disease. You can attain one by going to lymenet.org.
    Hope I helped. I had the same problems, by in large, that you have.

Peace.

[JCmcc]

PS, I have proven Lyme disease and it looks just like MS!

Heres my MRIS..

BRAIN:
FINDINGS:
There is no MRI evidence of midline shift or mass effect. Multiple round to ovoid foci of increased T2 weighted signal are noted in the periventricular and deep white matter of both cerebral hemispheres. Some foci within the centrum semi-ovale are oriented perpendicular to the plane of the corpus callosum and cingulate gyrus, suspicious for MS plaques. More ill-defined increased T2 weighted signal is noted in the periventricular white matter. Faint nodular areas of increased T2 weighted signal are noted within the corpus callosum. A small, 3-4 mm ovoid focus of increased T2 weighted signal is seen within the posterior aspect of the left middle cerebellar peduncle.
After IV contrast, at least five of the presumed plaques appear to enhance, the largest seen in the right frontal white matter, measuring 8 mm in maximum AP dimension.
Normal signal void is demonstrated in the major vasculature at the base of the brain. Visualized paranasal sinuses appear clear.

IMPRESSION:
Multiple round to ovoid foci of increased T2 weighted signal in the periventricular and deep white matter of both cerebral hemispheres, as well as within the left middle cerebellar peduncle and corpus callosum. Several lesions appear to enhance after IV contrast. Findings are non-specific, but are suspicious for MS plaques. Other etiologies, such as Vasculitis or Lyme disease, could produce similar findings. Clinical correlation advised.

CERVICAL SPINE:
FINDINGS:
The bone marrow signal appears well maintained. There is reversal of normal cervical lordosis. Disc space heights appear well maintained. Not acute verterbral body compression fracture is demonstrated. The carniocervical junction appears unremarkable.
Saggital STIR sequence shows extensive signal abnormality within the cervical spinal cord, throughout the entire cervical spine. No cord compression is demonstrated. The neural canal regions appear ample in size.
Gladolinium-enhanced imaging shows no abnormal enhancement.

IMPRESSION:
Extensive areas of hyperintense signal abnormality within the cervical spinal cord, most consistent with a demyelinating process. No enhancement was demonstrated. Please see report from MRI of the brain.

[dittledittle]

I appreciate your Lyme Disease theory but that has been ruled out. I saw my neurologist this week and he is baffled.  He isn't sure it is demyelinating. 3 months ago I was found to have slowed conduction in my right leg resulting from the Central nervous system. I have pretty bad muscle spasticity in my right leg and milder spasticity in left leg.  My blood work comes in negative for C-protein, ANA, Sarcoid, Lupus, Lyme, etc. He asked me if there is any genetic neuro problems and there aren't.  What runs in the family is heart disease, heart valve problems, diabetes, bowel cancer.  I keep my cholesterol at 180 or less, my weight is good, normal blood pressure and I do not have diabetes. These lesions have been known since 2002 and have gotten some new ones and the old ones don't go away.

[JCmcc]

Hi,
  Wow. This raises questions for to then. I wonder. Weird how there can be multiple lesions, symptoms and it not be a known etiology.
  I just wanted to help. I hope that you can find answers.

Peace,
JCmcc.

[Jadis]

Have you ever been to a rheumatologist? Multiple sclerosis is frequently the fall back diagnosis for neurologists who can't figure out what is wrong with you. A rheumatologist will usually realize that non-neurological symptoms that you experience are important in what is going on.

[JCmcc]

Awesome point, Jadis.

[MLWTR]

For what it's worth, a recent study (published in the journal Gastroenterology in September 2005) found that multiple sclerosis/demyelination/and/or optic neuritis were considerably more common in patients with ulcerative colitis than in the general population. There have also been various reports of demyelinating neuropathies occurring as complications of IBD patients; they are considered to result from the same autoimmune inflammatory process as the IBD itself.

It does seem unfair that these diseases come not in single spies but in battalions!

[wishinganswers]

A related discussion, mri scans was started.

[nanoo1]

A related discussion, foci was started.