Differential diagnosis of multiple sclerosis, approach

Rolak LA, Fleming JO. The Differential diagnosis oo multiple sclerosis. The Neurologist 2007;13:57-72.

Below is a brief synopsis of the diseases that can be confused with multiple sclerosis.

Rolak states that 2 factors most reliably identify patients without MS. The first is absence of typical symptoms such as ON, L'Hermitte's sign, sensory level, NGB, etc. The other is normal brain MRI and/or CSF.

Rolak identifies 20 MRI patterns that mimic MS, 15 diseases disseminated in space but not time, 15 disseminated in time but not space, and 20 disseminated in both, all in tables. He suggests against extensive screening for these diseases, arguing that is rarely cost and time productive use of resources and may generate false positives.

Most helpfully, Rolak outlines the seven most common diagnoses for patients without MS. By far, the commonest is psychiatric disease in several large series, including somatization, malingering, hypochondriasis, depression, anxiety. The second most common is everyday sensations that are misconstrued as abnormal, including vision changes, loss of power, and poor balance. Psych symptoms tend to be generalized, such as "weak all over" or "numb everywhere" whereas MS has a clear anatomic localization. The time course of MS symptoms-- onset with regression over days to weeks-- also differs from psychiatric disease. Third most common is migraine. Unilateral numbness and rarely, weakness can mimic MS and MRI shows whitish lesions which can be confused. Other less common causes include peripheral neuropathy, cervical stensosis, and vertigo.