Disclosing a Diagnosis in the Workplace: Perspective of People With Multiple Sclerosis

Should Spinal MRI Be Routinely Performed in Patients With Clinically Isolated Optic Neuritis?

We present a case report of diagnosis of cervical spine multiple sclerosis by a chiropractic physician. This unique case contributes an account of a challenging differential diagnosis to the literature. A 30-year-old male presented with a three-year history of diffuse left upper extremity motor strength deficits and paresthesia (numbness and tingling). The patient had seen multiple physicians for these symptoms with no diagnosis of multiple sclerosis and no advanced imaging. The differential diagnosis included lower cervical spine nerve root compression or neurological disorders such as amyotrophic lateral sclerosis, cerebral lesion, motor neuropathy, multiple sclerosis, or spinal cord lesion. MRI of the cervical spine with and without IV contrast revealed evidence of spinal cord multiple sclerosis. The patient was referred to a neurologist where the diagnosis of multiple sclerosis was confirmed. A 10-year follow-up showed the patient was controlling his condition with medications and had no disability. This case underscores the importance for physicians to consider neurological conditions and advanced imaging in the presence of diffuse motor strength deficits and paresthesia in the absence of injury, pain, or any other symptoms.

Multiple sclerosis, brain radiotherapy, and risk of neurotoxicity: The Mayo Clinic experience

Antibiotic drug use in the five years preceding the diagnosis of multiple sclerosis.

A few cases of multiple sclerosis (MS) onset after COVID-19 vaccination have been reported, although the evidence is insufficient to establish causality. The aim of this study is to compare cases of newly diagnosed relapsing-remitting MS before and after the outbreak of the COVID-19 pandemic and the impact of COVID-19 vaccination. Potential environmental and genetic predisposing factors were also investigated, as well as clinical patterns. This is a single-centre retrospective cohort study including all patients who presented with relapsing-remitting MS onset between January 2018 and July 2022. Data on COVID-19 vaccination administration, dose, and type were collected. HLA-DRB1 genotyping was performed in three subgroups. A total of 266 patients received a new diagnosis of relapsing-remitting MS in our centre, 143 before the COVID-19 pandemic (until and including March 2020), and 123 during the COVID-19 era (from April 2020). The mean number of new MS onset cases per year was not different before and during the COVID-19 era and neither were baseline patients' characteristics, type of onset, clinical recovery, or radiological patterns. Fourteen (11.4%) patients who subsequently received a new diagnosis of MS had a history of COVID-19 vaccination within one month before symptoms onset. Patients' characteristics, type of onset, clinical recovery, and radiological patterns did not differ from those of patients with non-vaccine-related new diagnoses of MS. The allele frequencies of HLA-DRB1*15 were 17.6% and 22.2% in patients with non-vaccine-related disease onset before and during the COVID-19 era, respectively, while no case of HLA-DRB1*15 was identified among patients with a new diagnosis of MS post-COVID-19 vaccine. In contrast, HLA-DRB1*08+ or HLA-DRB1*10+ MS patients were present only in this subgroup. Although a causal link between COVID-19 vaccination and relapsing-remitting MS cannot be detected, it is interesting to note and speculate about the peculiarities and heterogeneities underlying disease mechanisms of MS, where the interactions of genetics and the environment could be crucial also for the follow-up and the evaluation of therapeutic options.

The 2024 McDonald criteria provide new recommendations for multiple sclerosis (MS) diagnosis, but validation of the criteria is lacking. We wanted to investigate the application and performance of the 2024 McDonald criteria in patients with suspected MS seen in routine clinical practice. We retrospectively identified patients referred with clinical and/or radiologic suspicion for MS between January and December 2024. All patients had a minimum diagnostic evaluation with brain and spinal cord MRI. The 2017 McDonald criteria were applied prospectively, and the 2024 McDonald criteria were applied retrospectively after the initial diagnostic workup and at last follow-up. We investigated (1) the number of patients diagnosed with MS using the 2017 McDonald criteria or the 2024 McDonald criteria, and (2) the diagnostic performance of the 2024 McDonald criteria when applied during the initial diagnostic workup, with an MS diagnosis using the 2017 McDonald criteria as the reference-standard. In 347 patients (mean age 39.4 years, 66% female) with suspected MS followed up for mean 15.3 (range 8-20) months, 73 (21%) had alternative disorders and were excluded. After applying the 2024 McDonald criteria in the remaining 274 patients, more patients were diagnosed with MS after the initial diagnostic workup (220 vs 172, p < 0.01), and at follow-up (237 vs 204, p < 0.01), compared with the 2017 McDonald criteria, and fewer patients were diagnosed with clinically or radiologically isolated syndrome. The median time to diagnosis was 40 vs 84 days (p < 0.01), respectively. After initial diagnostic workup, the 2024 McDonald criteria demonstrated high sensitivity (92.6%, 95% CI 88.1%-95.8%) and accuracy (83.6%, 95% CI 78.7%-87.8%), for an MS diagnosis using 2017 McDonald criteria at last follow-up, but moderate specificity (57.8%, 95% CI 45.4%-69.4%). The increased rate of MS diagnosis and the diagnostic performance of the revised criteria was similar in children (<18 years) and older adults (>50 years). Use of the 2024 McDonald allows for earlier MS diagnosis, but also more frequent diagnosis including in patients with radiologically isolated syndrome. The revised criteria have similar performance across the lifespan. Limitations include the lack of data on central vein sign and kappa free light chains, and missing optic nerve assessment in some patients.

Magnetic resonance imaging (MRI) is the most powerful tool for the early (differential) diagnosis of multiple sclerosis (MS) and has been part of the International Panel criteria (2001, 2005, 2010) for more than 10 years. The role of brain and spinal cord MRI in the diagnosis of MS is well established. New MR techniques and markers will further improve the diagnostic value in a research and clinical routine setting. In addition to diagnosis, MRI is widely used for prognostic evaluation as well as treatment efficacy and safety monitoring. This field has gained importance with the introduction of new MS therapeutics. Therefore, the scope of MRI-guided MS disease monitoring has been widened to include rigorous treatment monitoring aiming at "no evidence of disease activity (NEDA)". Next, safety monitoring of treated MS patients has become major concern to enable early detection of opportunistic infections such as progressive multifocal leukoencephalopathy (PML). Driven by these new developments, recently published expert panel guidelines stressed the need for standardized imaging protocols and targeted specialized imaging markers for MS diagnosis and disease monitoring. This review article aims to give an update on the role of MRI in the diagnosis and monitoring of MS with particular emphasis to treatment efficacy and safety, both in clinical practice and in research.

The first year following a new multiple sclerosis (MS) diagnosis may be a critical time for individuals as they learn to manage their disease. Effective self-management of MS likely requires healthy self-efficacy levels, yet little is known about self-efficacy in the postdiagnosis period. This study aims to improve our understanding of self-efficacy in individuals newly diagnosed with MS by examining self-efficacy trajectories and identifying patient characteristics associated with trajectories in the first postdiagnosis year. Newly diagnosed adults with MS/clinically isolated syndrome (CIS) (N = 230) completed a battery of questionnaires, including the University of Washington Self-Efficacy Scale, at 1, 2, 3, 6, 9, and 12 months, postdiagnosis. Sankey diagrams characterized self-efficacy trajectories and a multiple regression model tested patient characteristics as predictors of self-efficacy change scores. Mean self-efficacy T-scores ranged from 50.79 to 52.04 (SD = 9.40 and 10.12, respectively) across the postdiagnosis year. MS diagnosis (vs. CIS), higher disability levels, and higher MS symptom severity were associated with lower self-efficacy levels at baseline. Baseline symptom severity predicted change in self-efficacy levels from baseline to month 12 (B = -0.05, p = .030). Self-efficacy remains relatively stable in the first year following a MS diagnosis, though high symptom severity is associated with decreased self-efficacy at 12-months postdiagnosis. Clinical characteristics (e.g., MS diagnosis, disability level) also appear to play a role in setting the course of self-efficacy in this postdiagnosis year. Timely interventions that enhance self-efficacy and/or improve certain clinical characteristics may promote healthy self-management of MS that carries forward in disease course. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective We aimed to examine the clinical features of psychotic symptoms preceding or concomitant to multiple sclerosis (MS) diagnosis. Method From the 1st to 10th of January 2020 a systematic review was conducted through an electronic search of different databases. Results were limited to English, French, German, Italian and Spanish language articles. Results We identified 599 titles, and included 32 cases from case-report and case series. One case report from our department was added. The mean age of first psychiatric symptoms was 25.8 ± 10.2 years, the mean age of MS diagnosis was 31.2 ± 10.7 years and the mean delay until MS diagnosis was 2.7 ± 3 years. Most reported symptoms were delusions (81%), auditory hallucinations (59%) and visual hallucinations (50%). Upon the MS diagnosis, immunosuppressive therapy was significantly more effective for psychotic symptoms than antipsychotics (OR = 9.0; 95%CI: 2.15-37; p = 0.002). Diffuse periventricular lesions were found in 95.6% of cases, with mostly temporal or frontal predominant lesions. In cases affected by predominant temporal lesions, 83% of cases presented visual hallucinations (p < 0.05). Conclusion Poor response or resistance to antipsychotics treatment should alert clinicians on the need to consider a differential diagnosis. Considering the impact of delay in MS diagnosis further research regarding this subject is warranted. KEY POINTS Insight into the occurrence of psychotic symptoms in multiple sclerosis (MS) is mainly limited to case reports and case series. Delay in MS management between initial psychotic symptoms and the MS diagnosis is 2.73 ± 3 years and 0.8 ± 1.2 years for patients presenting a first episode of psychosis. The resistance and poor response to antipsychotics found in most cases (75%) were associated with an excellent improvement (95%) of both psychiatric and neurologic symptoms with corticosteroids. Prospective studies are needed to investigate the spectrum of psychosis in MS.

Population-based registers are widely used in epidemiological studies. We aimed to estimate the validity of multiple sclerosis (MS) diagnoses registered in the Swedish National Patient Register (NPR) by two sequential register-based case-definition algorithms. Prevalent MS patients aged 16–64 years were identified from the in- and specialised out-patient NPR in 2001–2013, using International Classification of Diseases code G35. These identified MS diagnoses were validated through two sequential register-based case-definition algorithms, as the ‘gold-standard’ reference, by linking individual-level data longitudinally to other nationwide registers. The primary algorithm first sought to corroborate the MS diagnoses with MS-specific information in other nationwide registers. The exploratory secondary algorithm identified individuals with MS-related information in other registers and those who were unable to be followed sufficiently. Through multi-register linkage, we estimated the number of confirmed and uncertain individuals with an MS diagnosis recorded in the NPR. A total of 19,781 individuals (mean age at first visit 45.2 years; 69.5% women) had at least one MS diagnosis recorded in the NPR during 2001–2013. Using the two case-definition algorithms, 92.5% (n = 18,291) of the MS diagnoses recorded in the NPR were confirmed, while 7.5% (n = 1490) remained uncertain. Our findings indicate that a very high percentage of patients coded with an MS diagnosis in the Swedish NPR actually have MS, and supports the use of the NPR as a viable source to identify individuals with an MS diagnosis for population-based research. This exploratory methods paper suggests an alternative novel method to verify individuals’ diagnoses in register-based settings.

Although there were criteria for diagnosis of neuromyelitis optica (NMO) and multiple sclerosis (MS), it is still difficult to differentiate NMO from MS, due to the overlapping clinical manifestations. Therefore it is necessary to characterize clinical features of NMO and MS patients in the mainland of China, to simplify the process of disease diagnosis, and to identify criteria for the differential diagnosis of NMO and MS. A total of 138 Chinese Han patients from the mainland of China including 73 NMO, 60 MS and 5 MS-like patients with positive NMO-IgG were included in the study. Clinical records were reviewed retrospectively and the results of clinical examination, laboratory experiments, magnetic resonance imaging (MRI) and evoked potentials (EPs) were compared between NMO and MS patients. In addition, the relationship between the NMO-IgG serologic status and clinical characteristics were analyzed. Compared with MS patients (1.3: 1.0), more female prevalence was observed in NMO patients (4.2: 1.0; P = 0.003). There were also statistically significant differences in visual EPs, oligoclonal bands, brainstem lesions in MRI and longitudinally extensive spinal cord lesions (LESCLs) between NMO and MS patients. Brainstem lesions observed in brain MRI were found in 17.9% of MS patients, over 3.7 times higher than in NMO patients (4.8%, P = 0.024). When stratified NMO patients by NMO-IgG, LESCLs were found in 42.1% of NMO-IgG-negative NMO patients, over 3.5 times higher than in NMO-IgG-positive patients (11.9%, P = 0.008). Statistical difference was also observed in CD4+/CD8+ ratios between NMO-IgG-positive and -negative NMO patients. Comprehensive analysis of MRI, laboratory and EPs data can facilitate differential diagnosis of MS and NMO. In addition, the combination of LESCLs and brain MRI findings failing to satisfy MRI criteria for MS is highly sensitive and specific for NMO.

Relevance of antinuclear antibody in diagnosis and characteristics of multiple sclerosis

P048 - Seizures and epilepsy in multiple sclerosis patients: A Tunisian study of 9 cases

The increasing availability of effective therapies for multiple sclerosis as well as research demonstrating the benefits of early treatment highlights the importance of expedient and accurate multiple sclerosis diagnosis. This review will discuss the classification, diagnosis, and differential diagnosis of multiple sclerosis. An international panel of multiple sclerosis experts, the MS Phenotype Group, recently revised the multiple sclerosis phenotypic classifications and published their recommendations in 2014. Recent research developments have helped improve the accuracy of multiple sclerosis diagnosis, especially with regard to differentiating multiple sclerosis from neuromyelitis optica spectrum disorders. Current multiple sclerosis phenotypic classifications include relapsing-remitting multiple sclerosis, clinically isolated syndrome, radiologically isolated syndrome, primary-progressive multiple sclerosis, and secondary-progressive multiple sclerosis. The McDonald 2010 diagnostic criteria provide formal guidelines for the diagnosis of relapsing-remitting multiple sclerosis and primary-progressive multiple sclerosis. These require demonstration of dissemination in space and time, with consideration given to both clinical findings and imaging data. The criteria also require that there exist no better explanation for the patient's presentation. The clinical history, examination, and MRI should be most consistent with multiple sclerosis, including the presence of features typical for the disease as well as the absence of features that suggest an alternative cause, for a diagnosis of multiple sclerosis to be proposed.

The diagnosis of multiple sclerosis (MS) is clinical and verifiable at post mortem. Neuropathological examination of 518 consecutive patients with clinically definite MS revealed a correct diagnosis in 485 cases (94%). Clinical diagnosis had been established by a neurologist in all cases. Erroneous diagnosis included a variety of other neurological disorders. Also investigated was a randomly selected series of 33 patients with a clinical diagnosis of probable MS: post mortem confirmation of MS was obtained in circa 66%, for the remainder the error pattern was similar to the above. Clinical diagnosis of definite MS was correct in 94% cases. Laboratory tests and examinations have not radically improved diagnosis. Neuropathological examination may occasionally fail to demonstrate MS plaques if the optic nerves are not investigated.