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Lectures: Differential Diagnosis
Encephalomyelitis
CNS Vasculitis
Lyme Disease
Lupus Erythematosus
Spastic Paraparesis
Behçet Syndrome
Sarcoidosis and Sjogren's Syndrome
Vitamin B-12 Deficiency and Syphilis
Leukodystrophies
Hereditary Degenerative Disorders
Multifocal Leukoencephalopathy
Postinfectious Encephalomyelitis
Postinfectious encephalomyelitis is a subacute syndrome caused by autoimmune response to a viral infection. Patients complain of acute or subacute onset of gait abnormalities, confusion, disorientation, problems with bladder or bowel control, muscle weakness, and other symptoms. Abnormalities consistent with demyelinating lesions can be seen on MRI images. This condition may or may not be reversible. Typically, however, it presents itself as a monophasic illness, but chronic cases do occur and require long term treatment.
Primary CNS Vasculitis
Primary CNS vasculitis may result in syndromes resembling MS. Most notable symptoms include severe headaches, confusion and sudden stroke like episodes. High protein levels can be seen in CSF, as well as high erythrocyte sedimentation rate. Patients may have abnormal angiogram of cerebral vessels. Antinuclear or anti phospholipid antibodies may be present.
Lyme Disease
Lyme disease is known to cause intermittent neurologic events. Some of the most frequent problems include Bell's palsy, nonspecific symptoms of numbness, fatigue and amnesia. CSF findings may resemble those found in the MS, and MRI may show a white matter disease. History of tick bites, rashes and arthralgia should be sought after. Screening for Lyme titer and/or a Lyme PCR in the CSF or blood should help in diagnosis.
Systemic Lupus Erythematosus
Systemic lupus erythematosus may cause multiple neurologic pathology such as optic abnormalities, encephalopathy, transverse myelitis, strokes. One needs to look for systemic abnormalities, such as elevated antinuclear antibody, leukopenia, hematuria, elevated erythrocyte sedimentation rate. On some occasions lupus erythematosus and MS may be found in the same patient.
Tropical Spastic Paraparesis
Tropical spastic paraparesis is a retroviral disease caused by HTLV-1 virus. It is uncommon in the continental United States, but may be seen infrequently in patients who resided for some time around the Caribbean Sea Basin. The major clinical manifestations are progressive spastic paraparesis or generalized white matter disease.
Behçet Syndrome
Behçet syndrome can cause MRI findings that are very similar to MS. However, the main distinguishing features of this condition are oral and genital ulcers, and uveitis, as well as possible involvement of lungs, joints, intestines, and heart. This group of patients may present with either quadriparesis, pseudobulbar palsy, cranial neuropathy, cerebellar ataxia or cerebral venous thrombosis.
Sarcoidosis and Sjogren's Syndrome
Sarcoidosis and Sjogren's syndrome may show lesions on MRI that resemble those found in Multiple Sclerosis. These are autoimmune conditions that affect multiple organ systems and should not be confused with MS. A chest X-ray may show granulomatous disease of the lungs, and meningeal enhancement is seen in patients with CNS involvement. Oligoclonal bands and IgG are raised in CSF of patients with sarcoidosis. Central nervous system involvement and the course of the disease may show striking similarity to MS. Angiotensin-converting enzyme determination may be used for further differential diagnosis. It may be elevated in either serum or CSF but is not reliably abnormal.
Vitamin B-12 Deficiency and Tertiary Syphilis
Vitamin B-12 deficiency and tertiary syphilis may result in dorsal column abnormalities and dementia. These two conditions need to be ruled out when patients present with the above mentioned symptoms as their chief complaints.
Leukodystrophies of Adulthood
Leukodystrophies of adulthood (metachromatic leukodystrophy, Krabbe's disease, adrenal leukodystrophy, ) show large areas of involvement on the MRI scan where no normal white matter can be found.
Hereditary Degenerative Disorders
Hereditary degenerative disorders (olivopontocerebellar degeneration, spinocerebellar degeneration, etc.) initially may resemble chronic-progressive MS. However, characteristic white matter lesions on the MRI scan are usually absent and the CSF is normal in these patients
Progressive Multifocal Leukoencephalopathy
Lesions found on the MRI scan in progressive multifocal leukoencephalopathy in immuno compromised patients (frequently in patients with AIDS) resemble MS and need to be differentiated from it.
