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MS Differential dx Health Page

May 14, 2015 - 0 comments

What Neurologists Must Consider
What Neurologists  MUST Consider when Looking for Possible MS: Differential Diagnosis



There is great  frustration when a person is ill with suspected MS but can’t begin  treatment because the neurologist won’t/can’t move forward with a positive diagnosis;  it is entirely too easy to blame the doctor for being noncommittal and sometimes rightly so.  But often it might be that the doctor is trying to make the symptoms and evidence fit, and it just doesn’t.



A differential diagnosis is a standard medical practice – doctors must always consider what else might be bothering a patient and not jump to the first possible answer without considering other possibilities.  The doctor must be reasonably sure that the treatment offered is appropriate.  

Retrospective studies (looking back on large groups of people who already have the diagnosis) consistently show that about 10% of people with the diagnosis of MS are misdiagnosed; that  is another great point for strong consideration of the differential diagnosis .



The doctor doesn't need to investigate or look for everything that has ever mimicked MS, but must be thorough in investigating all the things that could cause the patient's problems, given the clues and flags.   The doctor who is not thorough in considering all the options is skating on the thin malpractice ice.



With Multiple Sclerosis, the list of other possible diseases is extensive, and the differential diagnosis list contains a wide variety of diseases, from Systemic Lupus to Migraines, Sarcodoisis, to many variations of cancer.



It is common for patients to feel that time is being wasted while going through the diagnostic process and better communication would help this misunderstanding .  Some doctors  do NOT discuss the differential with patients - fearing (often rightly so) of raising huge anxiety at the mention of the other possibilities.  Some patients NEED to know what is being considered and should convey this to the doctor.  The downside to knowing the differentials being considered  is 1) increased anxiety, 2) time commitment, and 3) being drawn into discussions about "What if?"  eg: What will we do if this is cancer?"  and wasting time discussing things that are still unknown.



In general, it seems neurologists tend to  discuss less than more.  The doctors should realize that the less they communicate, the more the patient is driven to go elsewhere to get answers - often this results in symptom surfing.  Or this sends the patient looking for a different doctor - this is part of the "shopping" process where we should be looking for the doctor whose communication style fits the needs of the patient.



To look at ways that doctors can process information as presented by patients and their exams and move forward with a diagnosis, an international panel of experts worked through a differential diagnostic process for Multiple Sclerosis.  The entire text of their report, Differential diagnosis of suspected  multiple sclerosis: a consensus approach,  can be accessed for free at



http://msj.sagepub.com/content/14/9/1157.full.pdf+html



This group of renowned experts from a variety of specialties independently evaluated clinical and diagnostic test criteria and developed an extensive list of 79 red flags that can be used by doctors to tell them how the clinical signs they are looking at may relate to the diagnosis of MS.   These flags come from MRI data as well as clinical observation and are in three categories: major, intermediate and minor flags.



The major flags were almost unanimously selected by the experts as being a symptom of something other than MS.  That is important.  The major flags point toward a different diagnosis.  Are they proof-positive that no MS is present?  No , but the odds are pretty strong that the person does not have MS based on these symptoms.

Intermediate flags mean that there was a lack of agreement among the experts and the symptoms could  possibly eliminate MS from the choices.  The Intermediate  Flags indicate that a very thorough investigation must be made because of  that flag.  The diagnosis might still be MS, but the exclusion must be thoroughly investigated .



Minor red flags are the lowest grouping of differential symptoms.  The minor flags indicate that another disease may be causing the symptoms and should be considered,  but it is also possible that the symptom is caused by MS.   These are the symptoms that are least likely to cause a different diagnosis than MS.



The other significant part of this work was they developed  a grouping of strategies for doctors to consult when working up a diagnosis.  There are a number of Idiopathic Inflammatory Demyelinating Diseases  (IIDD) that could suggest MS but are really something else.    They tackled the tough process of labeling NMO and CIS as well.    The details of these, along with several  easy to understand flowcharts are also in this paper, and worth spending time to review.



Table 1 in the paper gives examples of alternative diagnosis for each of the red flag items.  The following list of flags and alterative diagnosis (in parenthesis)  is given as a partial example; the entire list and more details can be found within the text of the paper.

MAJOR RED FLAG EXAMPLES (= probably not MS)

Bone lesions  (Histiocytosis)

Lung Involvement (Sarcodoisis)

Peripheral neuropathy (B12 deficiency, Lyme disease)

Cerebral venous sinus thrombosis (Vasculitis, Chronic meningitis)

Cardiac Disease  (cerebral infarcts. Brain abscesses)

Calcifications on CT scans (Mitochondrial disorders)

Lacunar infarts (Hyperintensive ischemic disease)

Diabetes Insipidus (Sarcoidosis, neuromyelitis optica)

Persistent GD-enhancement and continued enlargement of lesions (Lymphoma, glioma, vasculitis)

Hypothalamic disturbance (Sarcoidosis, neuromyelitis optica)

Simultaneous enhancement of all lesions ((Vaculitis, lymphoma)

Rash (Lupus, Lyme disease, T-cell lymphoma)

Headache (Venous sinus thrombosis, vasculitis, Lupus, meningitis)

Persistent monofocal  manifestations  (structural lesion, such as Chiari malformation)

Large and infiltrating brain stem lesions (pontine glioma)



INTERMEDIATE RED FLAG EXAMPLES  (strong evidence not MS but can’t be ruled out )

Punctiform parenchymal enhancement (Sarcoidosis, vasculitis)

Atrophy of the brainstem (Behcets disease, Alexander’s disease)

Loss of hearing (Susac’s syndrome, glioma)

Symmetrically distributed lesions (Leukodystrophy))



Complete ring enhancement  (Brain abscess, metastatic cancer)

Progressive ataxia alone (Multisystemm atrophy, cerebellar syndrome(

Central brainstem lesions (Hypoxicischim conditions, infarct)

Seizure (Whipple’s disease, vasculitis)

Dilation of the Virchow-Robin spaces (Primary CNS angitis)

Gradually progressive course from onset  (B12 deficiency)



MINOR RED FLAGS (MS must be considered as well as other diseases)

No enhancement (PML, Ischemic lesions)

No optic nerve lesions (metastatic carcinoma, toxoplasmosis)

Onset before age 20 (Mitochondrial encephalomyopathy, leukodystrophy)

Onset after age 50 (Cerebral infarction, lymphoma)

Marked asymmetry of white matter lesions (Gioblastoma, lymphoma, cerebral infarction)

No spinal cord lesions (Multiple infarcts, vasculitis, PML)

Large lesions (Gioblastoma, lymphoma, PML)







The patient perspective often is diagnosing neurological disorders such as MS should be a simple process; this cited work,  Differential diagnosis of suspected  multiple sclerosis: a consensus approach,  gives a different view of how complex the path to an Multiple Sclerosis diagnosis can be.



The bottom line to all this is if you are undiagnosed , the frustration of not having answers is understandable, but the neurologist is not necessarily to blame.  The doctors must proceed with caution and make sure that the diagnosis is accurate.   If your doctor is uncommunicative as to what the process is for your particular case, you may need to ask the questions about the differentials or move on to another doctor.





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I'd like you to LIKE me as well

Jul 26, 2012 - 10 comments

HI All,

As Laura has already posted on her journal, there is a scholarship on social media  available from the Mayo Clinic .  The first part of the judgment process is how many "likes" you get on the Mayo  Clinic site, Facebook or Twitter. The Mayo link is:
http://socialmedia.mayoclinic.org/2012/07/26/brenda-t-scholarship-contest-essay/

Below is my essay. Any positive comments can be posted on the Above link. Thank you!!!!

From an early age, I became a frequent patient and it was after reading a book brought to me as a gift while I was hospitalized that I decided on my career choice, nursing. To this day I am a caregiver and a patient, this time a patient suffering from multiple sclerosis (MS). In my heart, if not on my paycheck, I will always be a nurse.

I was unaware of my MS diagnosis when I went back to school to obtain a paralegal degree; I was simply rejoining the workforce when the oldest of my children started college. While raising my three children, I also became a private caregiver to my youngest child. He was hospitalized many times for a myriad of perplexing symptoms and illnesses. It was at this time; in the very early 1990s that I learned that there wasn’t an easy way to access the collective thoughts of the medical field, short of subscriptions to print medical journals. I spent up to 8 hours a day researching and reading in large academic libraries on what might be ailing my child.  I would read abstracts from PubMED and published articles when I could access them. What I would have given to have had access to today’s version of the internet.

Fast forward to the year 2005 when I began work as a Nurse Paralegal. My job description was to read medical records, research any unknown illnesses and then explain in laymen terms, the disease process to the assigning attorney. In some cases, it was my duty to write portions of Federal Statements of Fact for legal briefs or illustrate a medical concept for a jury’s understanding. I still was a caregiver, but to an audience not to an individual. My research in this job introduced me to blogs, forums, and personal webpages.

In 2009 I was officially diagnosed with MS. With my many hours spent behind the computer researching and writing for others, I started researching for myself when the first mention of MS came up. I was very fortunate to have found the MS forum on MedHelp.org. Here was a wide array of people in different stages of diagnosis. From the ones who were told “maybe it’s MS” to those who had suffered many years with this disease.  I like it here and it became my new “MS home”. Not that I didn’t continue to research but these people understood what I was experiencing.

A little less than a year later, I was honored when one of the founding members of the MS forum, a retired physician, invited me to join as a Co-Community Leader after she jumped through hoops and hurdles to add a fourth CO-CL since our forum already had the normal quota of co-leaders. I was so excited! Turns out, this can be one tough job and demanding at times. I for one, will research until I have found an answer, whether it be on a medical site, a news site,  a Facebook page, a link from a personal blog or on another MS site. I still have that nurse’s training that taught me patient teaching and I can’t do patient teaching without the facts. I have a need to turn over every stone looking for an answer to questions asked by others. This was true while I was a Nurse Paralegal and it is true to this day.

The Social Media Summit would further my knowledge of social media and its advantages of reaching a larger crowd. My background in nursing and the paralegal field would provide the Summit a different point of view, mostly likely not encountered before. With the additional knowledge I obtain, I can “pay it forward” to the MS community and to the fledging National Multiple Sclerosis Society chapter in my area. I have many people approach me, usually because of my cane or other assistive device, and ask what is wrong.  When I respond, they always say they know someone with MS and with my new skills and knowledge in social media I hope to be able to make a connection that serves the intended recipient well.


October23...2:00 am

Oct 23, 2010 - 9 comments

Can't sleep despite earlier fatigue beyond belief. Two kids out running around with friends, etc can keep any mom up. While waiting for their return , I missed that golden hour where one can fall asleep in a second to wound too tight.

Anyway, too much on my mind. Received a letter and old photos  of her and my Dad from the 1940's. Guess I know where my middle daughter get some of her moves and poses. TMI. I think of my my often as she is 87 and as all of her dear friends die or move she is getting lonely. My Dad has been gone 7 years now and she misses him terribly , as do I. Mom is keeping busy sorting through all her belongings and dispersing things to each of us siblings.

Her mood seems upbeat but I know it's only show. After my Dad , she dated another man , who knew my dad, anyway, he too has passed away.  When I last saw her a few months ago she was losing weight. Not good  when there's no weight to lose. Her nosy , bratty little kids, to quote her, wrote a letter to her PCP with our concerns and asked her if she was comfortable and agreed with what was written to share it with her PCP. She did and she is on Ensure now.

But, Mom isn't the only thing on my mind. This blasted MS and it's interruption into my life is getting to me. New double vision while driving but the kibosh on me and driving independently. A messy house, no muscle strength to do half of what I need to do and no desire to want to do it anyway. Guess these feelings are the aftermath of missing our Cancun trip for our 30th wedding anniversary that was financed by our wonderful kids . Guess I'm still pouting.

So much for the 1st dose of ketamine. In  more pain now than before. I'll be calling the doc's PA on Monday with some questions regarding this and what are the normal expectations.

Well, this is disjointed as is my mind most days but , this did feel cathatrtic is some ways. Perhaps I won't wait until 2 in the morning. to write............

Dysmetria

Sep 17, 2010 - 1 comments

My impromptu neuro visit on Monday revealed bilateral dysmetria. I have had left sided symptoms for a while and this guided  most of treatment including PT, meds, etc. Now it is obvious that the dysmetria is bilateral at least as far as the finger-nose following and heel-shin test is concerned. The incoordination has been around awhile too but I'm not sure what's to blame for that.

The question that is eating at me is "Will this clear or be a permanent symptom like so many of my others?' Will the speech issues resolve?  I  HATE sounding like an idiot. I HATE not being able to find the right word to use! I HATE that that a job that I was so good at , will never come back.

Yes,  I'm angry, again. For every one step forward , I take 2 steps backwards. I am not looking forward to drug withdrawal to see which of the drugs , IF any , are contributing to my cognitive issues or if it's MS. Lucky me! I get to be miserable for the next 6 weeks or so as they wean me off...what fun!

MS S*UCKS! And right now , this very instance so does my life. Can't we fast-forward to 6 weeks from now?

I just re-read this and it is glaringly similar to my last entry. Guess I have only one thing to gripe about or else I am ignoring something else. Guess I will come back and re-read all of these entries next weekend and see if anything has changed.