Multiple sclerosis differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
- Overview
Differentiating multiple sclerosis from other diseases
Multiple sclerosis must be differentiated from other diseases that can mimic this disease clinically or radiologically such as:
Inflammatory/autoimmune conditions:
- systemic lupus erythematosus: Systemic lupus erythromatosus can cause neurological manifestations such as seizures, movement disorders, transverse myelitis, cranial and peripheral neuropathies and optic nerve involvement. In the brain MRI of SLE patients there are evidences of atrophy and subcortical white matter lesions. SLE is diagnosed based on systemic manifestations, present of oligoclonal bands and IgG in CSF and high titer of antinuclear antibodies.[1]
- Sjögren’s syndrome: Sjogren disease can cause neurological manifestations including cerebral vasculitis, myopathy, transvers myelitis and acute optic neuropathy. There are evidence of oligoclonal band and increased IgG in CSF and white matter lesions in MRI. Sicca syndrome, rheumatic manifestation and high titers of ANA,SSRo and SS-La will confirm the diagnosis.[2]
- Vasculitis: Wegner’s granulomatosis and polyarteritis nodosa are sometimes categorized as a differential diagnosis of MS, but the most common vasculitis which can mimic MS is isolated angitis of the central nervous system (IACNS).[3] IACNS is an inflammatory disease with an unknown cause. It affects small and medium sized arteries in the brain parenchyma and meninges. Neurological manifestation of this disease is headache, personality change, paresis, seizures, cranial neuropathy and intracerebral /subarachnoid hemorrhages.[4] There are monoclonal bands and increased protein and lymphocytic pleocytosis and IgG levels in the CSF of this patients. MRI may show patchy or diffuse increased signal in periventricular and subcortical white matter.[5] diagnosis is made by evidences of vasculitis changes in angiography or biopsy.[6]
- Neuro-behçet’s disease: Behcet’s disease is an idiopathic inflammatory disorder and can manifest as a triad of oral and genital ulcers and anterior uveitis. Lungs, gastrointestinal tract, joint and skin can be involved too. Rarely, neurologic signs can be the first manifestation of the disease.[7] The most common neurological manifestation of behcet’s disease is psychiatric symptoms, intranuclear ophthalmoplegia, headache and sensory/motor deficits. The course of the disease can be relapsing remitting or progresive.[8] In the CSF specimen we can see high levels of protein, pleocytosis (granulocytic, unlike MS) and oligoclonal bands (which can be suppressed by corticosteroid treatment).[9] In the MRI the most common involvment can be seen in brain stem and basal ganglia.[10]
- sarcoidosis: Sarcoidosis is an inflammatory disease with formation of non caseating epitheloid granulomata. It’s a multisystem disease but affects lungs more than other organs. There is 5_10% change of neurological involvement[11] and in 50 % of these patients neurological involvement can be the first sign or symptoms.[12] It usually affects cranial nerves, hypothalamus and pituitary gland. involvement of optic nerve, brain stem and spinal cord can mimic MS symptoms. In MRI we can see an isolated or diffuse lesion in brain parenchyma or even periventricular white matter lesion like MS.[13] CSF analysis can be very same to MS[14] but in sarcoidosis we have elevated amount of angiotensin converting enzyme.
- Antiphospholipid (Hughes) Syndrome: In antiphospholipid syndrome, the presents of anticardiolipin and/or lupus anticoagulant can cause arterial and venous thrombosis.[15] It can cause neurological manifestations like transient ischemic attack, ischemic encephalopathy, thrombosis of cerebral veins, seizure, headache, guillain barre syndrome, dementia, chorea and optic nerve neuropathy.[16] In MRI there is evidence of white matter T2 hyperintense and/or cortical lesions. The latter is in favor of APS. In CSF analysis lack of oligoclonal bands is against the MS diagnosis. Differentiating MS from APS is so difficult that it’s recommended to treat MS patients for APS too.[17]
- Susac Syndrome
Infections:
- Lyme disease:
- syphilis:
- Progressive multifocal leukoencephalopathy:
- HTLV-1 infection:
- Herpes zoster:
Metabolic and genetic disorders:
- Vitamin B12 deficiency:
- Lysosomal disorders:
- Adrenoleukodystrophy:
- Mitochondrial disorders:
- Clinically defined genetic disorders:
CNS lymphoma
spinal diseases
References
- ↑ Barned S, Goodman AD, Mattson DH (1995). "Frequency of anti-nuclear antibodies in multiple sclerosis". Neurology. 45 (2): 384–5. PMID 7854544.
- ↑ Alexander EL, Malinow K, Lejewski JE, Jerdan MS, Provost TT, Alexander GE (1986). "Primary Sjögren's syndrome with central nervous system disease mimicking multiple sclerosis". Ann. Intern. Med. 104 (3): 323–30. PMID 3946977.
- ↑ Calabrese LH, Furlan AJ, Gragg LA, Ropos TJ (1992). "Primary angiitis of the central nervous system: diagnostic criteria and clinical approach". Cleve Clin J Med. 59 (3): 293–306. PMID 1516217.
- ↑ Calabrese LH, Duna GF, Lie JT (1997). "Vasculitis in the central nervous system". Arthritis Rheum. 40 (7): 1189–201. doi:10.1002/1529-0131(199707)40:7<1189::AID-ART2>3.0.CO;2-4. PMID 9214418.
- ↑ Berger JR, Wei T, Wilson D (1998). "Idiopathic granulomatous angiitis of the CNS manifesting as diffuse white matter disease". Neurology. 51 (6): 1774–5. PMID 9855557.
- ↑ Moore PM (1989). "Diagnosis and management of isolated angiitis of the central nervous system". Neurology. 39 (2 Pt 1): 167–73. PMID 2915784.
- ↑ Kidd D, Steuer A, Denman AM, Rudge P (1999). "Neurological complications in Behçet's syndrome". Brain. 122 ( Pt 11): 2183–94. PMID 10545402.
- ↑ Akman-Demir G, Serdaroglu P, Tasçi B (1999). "Clinical patterns of neurological involvement in Behçet's disease: evaluation of 200 patients. The Neuro-Behçet Study Group". Brain. 122 ( Pt 11): 2171–82. PMID 10545401.
- ↑ Sharief MK, Hentges R, Thomas E (1991). "Significance of CSF immunoglobulins in monitoring neurologic disease activity in Behçet's disease". Neurology. 41 (9): 1398–401. PMID 1891089.
- ↑ Tali ET, Atilla S, Keskin T, Simonson T, Işik S, Yuh WT (1997). "MRI in neuro-Behçet's disease". Neuroradiology. 39 (1): 2–6. PMID 9121642.
- ↑ Stern BJ, Krumholz A, Johns C, Scott P, Nissim J (1985). "Sarcoidosis and its neurological manifestations". Arch. Neurol. 42 (9): 909–17. PMID 3896208.
- ↑ Sharma OP (1997). "Neurosarcoidosis: a personal perspective based on the study of 37 patients". Chest. 112 (1): 220–8. PMID 9228380.
- ↑ Smith AS, Meisler DM, Weinstein MA, Tomsak RL, Hanson MR, Rudick RA, Farris BK, Ransohoff RM (1989). "High-signal periventricular lesions in patients with sarcoidosis: neurosarcoidosis or multiple sclerosis?". AJR Am J Roentgenol. 153 (1): 147–52. doi:10.2214/ajr.153.1.147. PMID 2735279.
- ↑ McLean BN, Miller D, Thompson EJ (1995). "Oligoclonal banding of IgG in CSF, blood-brain barrier function, and MRI findings in patients with sarcoidosis, systemic lupus erythematosus, and Behçet's disease involving the nervous system". J. Neurol. Neurosurg. Psychiatry. 58 (5): 548–54. PMC 1073484. PMID 7745401.
- ↑ Hughes GR (1983). "Thrombosis, abortion, cerebral disease, and the lupus anticoagulant". Br Med J (Clin Res Ed). 287 (6399): 1088–9. PMC 1549319. PMID 6414579.
- ↑ Levine SR, Deegan MJ, Futrell N, Welch KM (1990). "Cerebrovascular and neurologic disease associated with antiphospholipid antibodies: 48 cases". Neurology. 40 (8): 1181–9. PMID 2381525.
- ↑ Ferreira S, D'Cruz DP, Hughes GR (2005). "Multiple sclerosis, neuropsychiatric lupus and antiphospholipid syndrome: where do we stand?". Rheumatology (Oxford). 44 (4): 434–42. doi:10.1093/rheumatology/keh532. PMID 15644391.