Apr 23, 2009
Is it Multiple Sclerosis or a Look-Alike? International Society Task Force Offers Guidelines for Diagnosing MS and its Mimics
An international task force convened by the National MS Society has published a landmark paper to guide neurologists through the complex process of distinguishing MS from other disorders. The consensus-based guidelines should greatly enhance the accuracy of diagnosing MS and its look-alikes, and speed the delivery of appropriate therapies. David Miller, MD, FRCP (University College London), Chris Polman, MD, PhD (Free University Medical Centre, Amsterdam) and colleagues present these guidelines in Multiple Sclerosis 2008 Nov;14[9]:1157-74 . Because of its potential impact, the National MS Society provided funds to make this paper available to all at no charge.
Background: At this time, there are no symptoms, physical findings or laboratory tests that can, by themselves, determine if a person has MS. In order to make a diagnosis of MS, the physician must find evidence of damage in at least two separate areas of the central nervous system (CNS, which includes the brain, spinal cord and optic nerves) AND find evidence that the episodes of damage occurred at least one month apart AND rule out all other possible diagnoses.
In efforts to improve care for people with MS, the National MS Society and its advisors have vigorously pursued ways to refine and speed the diagnosis of MS – especially in light of evidence suggesting benefits when treatment is started early in the course of the disease. The efforts of the Society’s International Panel on the Diagnosis of MS in 2001 and 2005 led to the updated “McDonald Criteria” for diagnosing MS.
The McDonald Criteria specify that other possible disorders must be ruled out before MS is diagnosed. To address this critical need, in 2006 the Society’s International Advisory Committee on Clinical Trials convened an International Task Force on Differential Diagnosis in MS. Using available literature, and achieving a consensus through conference calls and meetings, the group developed a series of guidelines that can serve as a practical tool to help physicians diagnose MS more speedily, or to rule it out.
Task Force Guidelines: The task force identified 79 ‘red flags’ that would point away from MS diagnosis in individuals with central nervous system involvement. Detailed in a comprehensive table, these include major, intermediate and minor red flags and alternative disorders to consider. For example, one major red flag listed is kidney involvement, which might indicate that the person has systemic lupus erythematosus or other disorders.
The paper also offers a more precise definition of CIS (clinically-isolated syndrome, in which a person experiences one attack of neurological symptoms that can sometimes lead to the development of definite MS).The guidelines also describe features of neuromyelitis optica (NMO, a demyelinating disease commonly mistaken for MS), and acute disseminated encephalomyelitis (ADEM, a brief but intense attack of inflammation in the brain and spinal cord) that help distinguish them from MS.
The authors acknowledge that additional research will be needed to confirm these consensus-driven guidelines, and that having sensitive disease biomarkers – the subject of intense, ongoing investigation – will greatly improve differential diagnosis. In an accompanying editorial, the editors of Multiple Sclerosis invite readers who are experts in some of the MS-mimicking disorders to offer their own views to help shape these guidelines in the future.
Comment: “These guidelines provide a very practical tool to help clinicians distinguish MS from other look-alikes,” says Rosalind Kalb, PhD, head of the Society’s Professional Resource Center. “They have the potential to help not only neurologists, but also people living with the uncertainty of undiagnosed neurological symptoms, who may well get clarity and treatment sooner as a result.”
Further details about these guidelines are available in a version of this bulletin for health care professionals.