Ask the Experts: Diagnosis
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Q: Is it possible to have MS without having optic neuritis and with normal evoked potentials?
Q: Is it possible to have MS without having optic neuritis and with normal evoked potentials?
A: The short answer is yes. Optic neuritis is not required to be present for a person to have MS. Evoked potentials are almost invariably abnormal in optic neuritis but may be normal in MS. It depends on where the lesions are.
Hope this is helpful.
Q: I was diagnosed with Lupus 14 years ago. My ANA (blood test for Lupus) levels have been normal for years. For several years doctors have been bringing up the MS diagnosis. I have not pursued this for multiple reasons, but have had episodes of temporary visual impairment in one of my eyes, numbness, extreme dizziness, my clumsiness, etc. Is it possible to have both? Is it possible to be misdiagnosed? Is it possible to have had a positive ANA at one point and is there a correlation with MS?
A:
- It is possible to have both
- Positive ANA tests are not rare in MS
- It is sometimes very difficult to distinguish these conditions as both can cause MRI and spinal fluid changes which may be similar in nature
- Sometimes more sophisticated testing can be helpful in attempting to separate the conditions. In this circumstance, an evaluation at a major medical center with expertise in both rheumatology and in MS may be helpful.
- You might consider asking your neurologist to suggest another point of view and to help you select a site.
A: Atypical MS is a condition which does not satisfy all the criteria to make the diagnosis, or has a course or clinical or laboratory features which are not generally identified with MS.
Q: I have had MS for 18 years. Most of the lesions are on my brain. Is there any technology to tell how long a lesion takes to form? If I can back date my lesions 5 years, I may be able to qualify for VA disabity.
A: There is no reliable way to date lesions that old. On the other hand, if there are any medical records which suggest relevant symptoms or any testimony by friends, or colleagues, it may serve just as well as a contemporaneous MRI.
Q: Hi I have MS, but also someone I know thinks she has it. She has been having a really hard time walking and has optic neuritis. But the MRI did not show any lesions. Can you have MS without any lesions showing up on your MRI?
A: If you mean MS without lesions seen in an MRI yes, although rare. If you mean MS without lesions present in the brain or spinal cord, the answer is no. The condition is defined by the presence of MS plaques.
Q: I would like to know if an open MRI can detect MS? I had a broken leg at the time of my MRI and couldn't do a regular one, I was told it would be able to detect. I had one MRI in a closed setting which was negative. 6 months later, I had another MRC in an open setting, also negative. I still have symptoms should I ask for another MRI in a closed setting? Thank you.
A: Much depends on the technique used in the MRI test, and the part of the brain, or spinal cord being scanned. Without a clearer indication of the reasons MS is suspected, it would be difficult to decide about whether to recommend another study.
There are other ways to make the diagnosis, although if proper technique is used, and the proper areas examined, the yield exceeds 90%. I hope this is helpful. Given your concerns, a second opinion in an MS center might be helpful.
Q: I was diagnosed with MS over 5 years ago and have had no symptoms. Right before the diagnosis, I had been having severe headaches for months and was rushed to emergency one day because I was having a hard time breathing. My blood pressure was very very high and probably had been for quite some time, which explains the headaches. Because of the prolonged high blood pressure I have damage to my kidneys and my heart and was diagnosed with hypertension. I then went to an opthamologist because my vision was blurry. He ordered an MRI and I was immediately diagnosed by a neurologist as having MS based on the MRI test results. Is it possible that the hypertension could have caused my eye blurriness and lesions to show up on my MRI? I was under the impression that MS could not be diagnosed so quickly. That other things had to be ruled out first. So I asked the Dr. about this and he said that based on the MRI results he was sure that I have MS.
A: It is difficult to rely on a single MRI to make a definite diagnosis of MS. At times migraine alone can cause changes in the brain which mimic it. Given the circumstances you describe, it might be useful to consider a second opinion from an additional neurologist or a Multiple Sclerosis Center. You might ask you doctor to recommend a colleague or a center. If that is not comfortable or successful, the MS society maintains a list of neurologists with a particular interest in the condition.
Q: I have had MS for 30 years - relapsing/remitting. I've lost two family members to chronic/progressive and two of us remain. What do I tell my daughters in their 30s who are now exhibiting neurologic symptoms? I know where I stand (I may have MS, but MS doesn't have ME!!), but how about my children and their children?
A: I'm sorry to hear about you family losses. It's tough when there is that kind of bad news looking at everybody.
In general, the effect of heredity in causing MS is less than it is in truly hereditary diseases, like hemophilia or Huntington's disease. In MS, you have to have the heredity, plus some other outside factor. No one knows what that is. Possibly it is a virus, and it may be a different virus in different people. The virus of infectious mono is probably the relevant virus in some people. So your daughters may or may not run into the outside factor.
In general, there is a 1 per 1,000 risk of having MS for any person in New England. For the daughter of an MSer, the risk is about 1 in 50. (If you had an identical twin, that twin would have a risk of 1 in 3.)
If your daughters have gotten to their 30's without MS, that by itself is good news.
It is pretty clear that if they have typical MS symptoms they should have an MRI and find out if they have the disease. Everybody knows by now that early treatment is very important.
Good luck to you, and to your daughters.
Q: My wife is 58 years old. A year and a half ago she was diagnosed with Breast Cancer. She had a mastectomy and radiation, plus four reconstruction surgeries. Sometime during the past year, she developed double vision and fatigue. MRI ruled out brain cancer, but show lesions on the brain. Two doctors suggested MS. A spinal tap was negative for MS, and we were referred to a neurologist MS specialist.
He said my wife does not have MS because of where the lesions are located. In reading your other responses you state that there are other things that mimic the symptoms of MS. Can you tell me what those are and what tests we need to be looking to conduct?
A: There are many causes of double vision. Any imbalance of the eye muscles will cause that symptom. If it is getting worse it is important to follow through diagnostically, but if there is no worsening then it may not be too important.
MS is not the first diagnosis that comes to mind.
Most likely the MRI scan showed some white spots in areas of the brain that are not typical of MS. Therefore the neurologist that your wife has seen, did not reach the conclusion that MS was part of the picture. As a guess, some form of vascular disease---even including migraine--would be more likely. If that is the case, then follow-up MRI scans months later would be the usual approach.
The double vision could be evaluated by a neuro-ophthalmologist. That would probably require a visit to a large medical center since a specialist of that type isn't available everywhere.
Q: Two years ago my Dad was diagnosed with MS. He is 72. He has had some hip and knee issues in the past but nothing that would have given us this conclusion. When my Dad had his MRI two lesions were found on his brain supporting the diagnosis. Within the last two years, he has lost most of his mobility in his legs but there has not been as great an impact on other parts of his body. He has been taking Copaxone but without much success. As I have been doing research I have noticed an increase in cases of elderly onset MS. However, given his age is it possible that he has been misdiagnosed. We are due for a second opinion in late February. Are there anything other suggestions I can request that the doctors to look for that may rule out a MS diagnosis in someone his age?
A: When MS begins in older men, it usually follows a progressive course and is likely not responsive to the standard disease modifying agents. There certainly are other possible causes for this kind of problem including vascular disorders, and spinal cord disorders since the description of the MRI you provided certainly does not make the diagnosis of MS definite. I think you are wise to ask for a second opinion and hope there turns out to be a condition which is more likely to respond to treatment.
Q: I was tested for MS 7 years ago. I received a negative MRI and a negative spinal fluid test. At the time of testing I was having symptoms that consisted of my legs feeling numb and I was also told I had hyperactive reflexes. I recently saw another neurologist because of headaches and he has started more testing for MS. A recent MRI was also negative. I do occasionally have some tingling on my left thigh and my left hand but I have no other symptoms. This neurologist also said that I have hyperactive reflexes. I am now 34. Is it possible to have MS after negative MRIs and a negative spinal fluid test?
A: It is possible but unlikely. The most recent symptoms are vague and could reflect a number of different processes. Even an earlier single sensory episode (numbness, tingling,etc.) with two negative MRI's 7 yrs apart would be unlikely to convert to clinically definite MS and if same were to happen a course of benign sensory disease would be more likely than an aggressive one.
Q: I am 51 years old. In January 2008, my left eye started twitching and six weeks later my right eye. They are very painful at times which the doctor informed me that it might be muscles contractions from the twitching. I was taking Reglan and was told to stop at that time. Upon distcontinuing Reglan, I began having twitching in my hands and legs. I was diagnosed with tardive dyskinesia, and prescribed Xanax .025 twice a day.The Xanax has helped wonderfully with the twitching. I have now experieced insomnia and episodes of crying and ringing in my ears. I had a MRI in April which was clear. On November 18, 2008, the left side of my face and left arm and hand went numb, and this symptom continues to come and go. Three weeks later, my right leg started to tingle.
My doctor is sending me for another MRI to check for MS. Do you think I need to worry about this being MS? I have also had celiac sprue and was told my thyroid was being attacked by celiac. Could this be why I am having these symptoms? I did look into Xanax and it does cause numbness and tingling. I am very confused and scared I need some advice.
A: Your doctor is correct to suspect the possibility of multiple sclerosis, but your features are quite atypical. Reglan might have been related to your initial twitching movements but should not be the cause of ringing in the ears or asymmetric numbness. Xanax should not cause asymmetric numbness.
There are some conditions which cause both neurologic and intestinal symptoms, and depending on the results of the MRI scan (which should generally be done both with and without contrast injection) and include both the spinal cord and brain, more testing may well be necessary. At some point, an evaluation by a neurologist would seem reasonable. There is insufficient information to date to make a diagnosis. I hope this is helpful.
Q: I'm a 49 year old woman, and Over the last year Ive experienced loss of sensation to my left foot, my vision has severely declined escpecially in one eye, my memory is becoming a real concern, and when I get overheated I begin to shake in my hands, along with other varying concerns, I have seen a neurologist who has sent me for an MRI on both the brain and spine, as she said that MS was a possibility; the report is as as follows: Several small subcortical white matter hyperintensities within both frontal lobes consistent with small post ischaemic gliotic foci secondary to small vessel disease..also at the t1 level. There is a lesion of low signal on t1 and high signal on t2 involving the vertebrae. As I'm not seeing her for awhile as she is away, could you tell me if MS is a possibility?
A: Your history and the MRI findings certainly are consistent with multiple sclerosis. I suspect the T1 and T2 lesions you describe are in the spinal cord rather than in the vertebrae but I would have to review the actual films. There should be another neurologist on call for you if your doctor is away for any period of time, who may have access to your actual records and be able to give you a better answer. There are certainly other possibilities as well.
Q: My daughter-in-law was been told she has brain lesions in Feb 2008. She has had a spinal tap (clear) and another MRI done Oct 2008 and the lesions are the same. Her neurologist will be doing some further visual and memory testing and wants to start treating her for MS. He says she is a "possible MS".
She is also seeing a Rheumatologist for fibromyalgia. She was on steriods for years with colitis (colon removed 12 years ago). She has 3 bulging dics in her neck and arthritis in her neck. Headaches, numbness in her right arm (occasionally),always tired - sleeps all the time (currently unemployed), aches and pains (back mainly). Is it possible she has both diseases?
A: It is certainly possible she may have more than one condition, but brain lesions seen in an MRI are not usually confused between these diagnoses. It would be important to define what clinical symptoms she has which led to the MRI study. Fatigue is common to both. The spinal fluid may be quite normal in appearance in MS (clear) but immunologic testing of the fluid is usually abnormal in MS. Given your description I would suggest you ask your neurologist for suggestions about a second opinion at an MS center for confirmation. A review of the MRI's may also be quite helpful in making a distinction.
If you choose to ask for another opinion it would be very important to bring along all the records and MRI studies.
Q: I am 23 years old, and have no history in family of MS. I had no medical conditions until returning from service in Iraq in December, 2005. I developed severe respiratory problems, dizziness, headaches, lightheadedness, blind spots, fatigue, tremor in my hands. Recently I had an LP that came back positive for Oligoclonal Bands. All MRIs have been completely unremarkable, so was chest Xray. I also have a circadian rhythm sleep disorder being treated with Melatonin. Could any of these symptoms be related to MS?
A: Multiple sclerosis is a clinical diagnosis that is supported by laboratory testing, including brain and spinal cord MRI, spinal fluid exam, and sometimes visual evoked responses (VER). Some of the symptoms you describe can be seen in MS, but none of them are specific for that diagnosis. MRI studies are nearly always abnormal in patients with MS, partcularly in the face of numerous symptoms and abnormalities on neurological examination. Although an MRI can initially be negative, this is unusual. Another set of MRIs after an interval of 3-6 months may be appropriate. The presence of oligoclonal bands in the spinal fluid is also a common feature in MS, although these can be seen in other disorders as well, including other inflammatory or autoimmune disorders, and the presence of bands does not make a diagnosis of MS without the appropriate clinical history or MRI findings! I would follow-up with your neurologist and address or re-address these questions. Best of luck with finding the correct diagnosis and treatment!
Q: I have had a history of trigeminal neuralgia for the past 12 years. For the past two years, I have had many falls, numbness, tingling, visual decline (although common problem on mom's side), and overall nerve problems. I went to a neurologist for 1/2 hr visit and had basic neurological exam, but he said I didn't have MS. I have two cousins who have MS. I trust the neurologist but feel that the diagnosis was really quick. There were 3 attempts at open MRI, but I am extremely claustrophobic. Do you think I should ask for referral from my primary for a visit to an actual MS clinic?
A: Your letter suggests that a referral to a neurologist would be a reasonable next step. There is not enough information here to make a firm diagnosis, but the symptoms you describe could be related to MS.
Q: I have recently had an MRI done that shows 15 white spots. I had a sudden onset of slurred speech, numbness and weakness on my left side. My doctor is concerned because the numbness, weakness, and speech problems have improved some but have not gone away. They are testing me for a number of things including MS, was wondering what your thoughts on it may be.
A: Multiple Sclerosis is certainly a possibility and this may be the first clinical episode, or a so-called Clinically Isolated Syndrome (CIS) event. Before the firm diagnosis can be made, there are other conditions which can mimic MS and your doctor is correct in considering other possible causes.
Q: AT 31 I was diagnosed with Trigeminal Neuralga two months later I came done with Bell's Palsy which left me paralyzed for 6 months and with residual paralysis. At 38 I had an episode where my head and face became tingling like going to the dentist this time on the left they told me it was Bell's Palsy again. At 39 soon to be 40 in the last 2 months I have the same episodes tingling in the face, heaviness in my head bilateral and pain in my neck and shoulders especially in the left arm. They once again have put me back on steriods and anti-viral medication. The have conducted two MRI s one on 2006 and one in 2007. The one in 2006 showed increases activity in the gray matter compared to the one in 1999 which could be the beginnings of MS. The head MRI in 2007 showed no chang e and the Spinal was clear, Is this really BElls' Palsy Like this? Help
A: MS cannot be excluded on the basis of information supplied. It is true that the early development of Tic Dolereaux can be associated with multiple sclerosis but there is not enough information here to make the diagnosis clear, and other causes are possible, which could include a connective tissue disorder.
You might ask your neurologist about other tests, including evoked potentials and spinal fluid examination and test for a connective tissue disorder, and about the nature of the MRI techniques used, and whether a gadolinium dye injection was made at each event. Grey matter involvement is common in MS but not usually seen in the MRI.
In the end, the diagnosis based on the material provided is not clear. If you continue to be uncertain after discussing the situation with your doctor, a second opinion might be helpful.