The diagnosis of multiple sclerosis

Delivering patient-centred care in rural family practice: using the patient's concept of health to guide treatment

Through an examination of the life of an 83-year-old patient diagnosed clinically with secondary progressive multiple sclerosis (MS), general practice specialists, consultants and junior doctors will see the importance of assessing their patient's concept of health and how to use this understanding to target healthcare options within their healthcare system. This article highlights, in a resource limited context of rural family practice, the utility of a strong physician–patient relationship, recalls the definition of patient-centred care, and the role of judicious inaction in certain contexts. These lessons can be extrapolated for use in more resource rich or specialised settings such as academic hospitals throughout Europe.

Care ethics for guiding the process of multiple sclerosis diagnosis

Multiple sclerosis (MS) is a chronic neurological disorder for which there is no definitive diagnostic test. Uncertainty characterises most of its features with diagnosis reached through a process of elimination. Coping with uncertainty has been recognised as a significant problem for MS patients. Discussions in the literature concerning the ethics of MS diagnosis have focused on an ethics of duty emphasising the rules for disclosure and healthcare professionals' obligations to provide information to patients. This narrow construal of the ethics at stake with MS diagnosis may be driven by a common misperception that diagnosis is an event, or series of events, rather than a process. Scant attention has been given to the dynamic, situated relational space between patient and physician as they journey potentially together (or apart) through the process of diagnosis. The healthcare provider cannot properly judge 'the how, what and when' of MS disclosure merely by applying rules pertaining to general professional duties to tell the truth and patients' rights to know their medical status. Proper disclosure and effective communication require the practice of flexible, caring responsibility and sustained, ongoing attention to the particular relational needs of 'this' patient in her own situational context. Accordingly, this article argues that care ethics is especially useful (but not without certain limitations) for attending to a broader swath of responsibilities (different from minimal duties) and affective components implicated in meeting patients' overall needs for care as the patient and physician cope with uncertainty through the process of establishing an MS diagnosis.

The Differential Diagnosis of Multiple Sclerosis

OBJECTIVE

This article will discuss the diagnosis of multiple sclerosis (MS), with particular attention to differentiating it from other diseases that can mimic it.

METHODS

We reviewed our own data, as well as the published experience on the differential diagnosis of MS and the most common errors leading to misdiagnosis.

RESULTS

Psychiatric diseases are mistaken for multiple sclerosis more often than any other conditions. Other multifocal illnesses or white-matter diseases are seldom confused with multiple sclerosis.

CONCLUSION

Neurologists are most likely to misdiagnose multiple sclerosis in patients who have psychiatric problems or who have uncommon presentations of common diseases such as migraine, stroke, or neuropathies.

Detection of Oligoclonal Immunoglobulins in Cerebrospinal Fluid by an Immunofixation-Peroxidase Method

Background: The detection of intrathecal synthesis of immunoglobulins is used in the diagnosis of multiple sclerosis (MS). We tested the semiautomated immunofixation-peroxidase (IFPOD) technique, which uses high-resolution agarose gel electrophoresis (HRAGE) directly followed by immunofixation with a peroxidase-labeled anti-IgG antiserum to detect oligoclonal immunoglobulins in cerebrospinal fluid (CSF).

Methods: We analyzed 230 consecutive matched serum/CSF pairs that arrived in the laboratory over a 6-month period with both IFPOD and our routine techniques, immunofixation electrophoresis (IFE) and HRAGE. For IFPOD, CSF samples were not concentrated before testing.

Results: Among the 230 samples were 12 clinically definite MS, 33 clinically probable, and 20 clinically possible MS samples. IFPOD and HRAGE + IFE each detected oligoclonal IgG in CSF in 10, 16, and 7 cases of these respective groups. For clinically definite MS, sensitivity and specificity (95% confidence intervals) were, respectively, 83% (51–97%) and 79% (73–84%).

Conclusions: The IFPOD technique performs comparably to other analytical methods, without the requirement for sample concentration, and may represent an attractive alternative in testing for intrathecal immunoglobulin synthesis.

[Recommendations for the use of immunomodulatory drugs in multiple sclerosis: the BCTRIMS consensus] [Brazilian Committee for Treatment and Research in Multiple Sclerosis]

After brief considerations about clinical course and diagnosis in multiple sclerosis, the members of the BCTRIMS present some recommendations for the use of the immunomodulatory drugs in the treatment of this disease.

[Multiple sclerosis: descriptive study of its clinical forms in 302 cases]

Multiple sclerosis (MS) is one of the most common causes of chronic neurologic disability in young adults. We evaluate, through retrospective study, the epidemiological characteristics, the manifestations ways, the clinical manifestations, the evolution and the level of physical disability of MS in 302 patients. The average patients age was 37.7 and the relation between genders was 3.13F:1M. The average age at the beginning of MS was 29.6; 283 patients were white (94%), 15 patients were black (5%) and 4 patients were yellow; 220 patients (72%) presented relapsing-remmiting clinical form; 82 patients (28%) presented the progressive form (50% secondary form and 50% primarily progressive form). The most common initial symptoms were sensitive (31.7%) and optical (26.8%). The most common evolutive symptoms were pyramidal (72.5%) and of the spinal cord (64.9%). The average of the final EDSS was 3.37 and final NRS was 85.17. The index of the annual outbreak was 0.45. Our findings coincide to the ones in the worldwide literature, however it is important to point out that 60 patients (19.8%) presented benign MS of prognostic value.

Anti-phospholipid antibodies in patients with multiple sclerosis and MS-like illnesses: MS or APS?

OBJECTIVE

To describe the frequency, clinical, and laboratory features of patients diagnosed with multiple sclerosis (MS) or MS-like illnesses (MSL) among a large, prospectively followed cohort of anti-phospholipid antibody (aPL)-positive patients.

METHODS

Between 1990 and 1995 patients referred to a university-affiliated rheumatology clinic were prospectively evaluated for aPL based on questionnaires designed to detect aPL-related symptoms and/or a family history of aPL-related illnesses. Magnetic resonance imaging (MRI) was performed when significant neurological features were present. A subgroup of all patients diagnosed with MS or MSL was identified and their clinical, laboratory, and imaging findings were reviewed.

RESULTS

Of 322 patients evaluated for aPL-related symptoms or events, 189 (59%) were positive for at least one class of aPL. Twenty-six of 322 patients (8%) carried a diagnosis of MS or MSL, either at the initial evaluation or during the study period. Twenty-three of the 26 individuals (88%) tested positive for aPL, while the remaining 3 (11%) tested repeatedly negative. Eighteen of the 23 patients (78%) had either more than one class of aPL or had multiple positive titers. IgM aCL was noted in 18 of the 23 patients (78%). Oligoclonal bands were noted in five patients. Antinuclear antibodies (ANA) and low complement levels were frequently observed. Blinded MRI readings showed lesions consistent with MS in the majority of cases. Clinically, 7 patients had transverse myelitis (TM), while optic neuritis (ON) was present in 8 patients. Most patients had either occult symptoms of rheumatic disease or contributory family histories. None had a defined underlying connective-tissue disease.

CONCLUSION

A substantial number of aPL-positive patients have a concurrent diagnosis of MS or MSL, frequently presenting with elevated IgM aCL, optic neuritis, and transverse myelitis. The anti-phospholipid syndrome (APS) should be strongly considered as an alternative diagnosis to MS in these patients.

The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes

OBJECTIVE

To develop a standardized nomenclature system for the neuropsychiatric syndromes of systemic lupus erythematosus (NPSLE).

METHODS

An international, multidisciplinary committee representing rheumatology, neurology, psychiatry, neuropsychology, and hematology developed case definitions, reporting standards, and diagnostic testing recommendations. Before and after the meeting, clinician committee members assigned diagnoses to sets of vignettes randomly generated from a pool of 108 NPSLE patients. To assess whether the nomenclature system improved diagnostic agreement, a consensus index was developed and pre- and postmeeting scores were compared by t-tests.

RESULTS

Case definitions including diagnostic criteria, important exclusions, and methods of ascertainment were developed for 19 NPSLE syndromes. Recommendations for standard reporting requirements, minimum laboratory evaluation, and imaging techniques were formulated. A short neuropsychological test battery for the diagnosis of cognitive deficits was proposed. In the postmeeting exercise, a statistically significant improvement in diagnostic agreement was observed.

CONCLUSION

The American College of Rheumatology (ACR) Nomenclature for NPSLE provides case definitions for 19 neuropsychiatric syndromes seen in SLE, with reporting standards and recommendations for laboratory and imaging tests. It is intended to facilitate and enhance clinical research, particularly multicenter studies, and reporting. In clinical settings, consultation with other specialists may be required. It should be useful for didactic purposes but should not be used uncritically or as a substitute for a clinical diagnosis. The complete case definitions are available on the ACR World Wide Web site: http://www.rheumatology .org/ar/ar.html.

Rationale for early treatment with interferon beta-1a in relapsing-remitting multiple sclerosis

Disease-modifying therapies are now available for the treatment of relapsing-remitting multiple sclerosis (RR-MS). These drugs have transformed the management of RR-MS from simply treating symptomatic disease to providing effective but incomplete prophylaxis against further disease activity. Our ability to modify disease activity is limited to reducing exacerbations and delaying progression of disability. No intervention has yet been shown to reverse disability once it is established. To prevent disability, therapy should be initiated early in the course of the illness. The rationale for early treatment is as follows: (1) a high percentage of patients with clinically definite RR-MS progress from isolated attacks to neurologic impairment and then to disability within a short time; (2) survival in MS is directly related to disability, so delaying the onset of disability could be expected to influence survival; (3) interferon (IFN) beta-1a has been shown to slow the progression of disability when given to RR-MS patients with impairment or mild disability; and (4) magnetic resonance imaging studies indicate that MS patients frequently have evidence of central nervous system inflammation without overt clinical symptoms, and it has been postulated that treatment of subclinical disease as identified by magnetic resonance imaging may improve long-term outcome. IFN-beta reduces the number of new T2-weighted lesions, as well as the number and volume of gadolinium-enhanced lesions. Aggressive early treatment with IFN beta-1a is recommended, particularly for patients with risk factors suggesting an unfavorable prognosis.