What mimics multiple sclerosis symptoms?

What mimics multiple sclerosis symptoms?

A more recent article on multiple sclerosis is available.

Am Fam Physician. 2004;70(10):1935-1944

Multiple sclerosis, an idiopathic inflammatory disease of the central nervous system, is characterized pathologically by demyelination and subsequent axonal degeneration. The disease commonly presents in young adults and affects twice as many women as men. Common presenting symptoms include numbness, weakness, visual impairment, loss of balance, dizziness, urinary bladder urgency, fatigue, and depression. The diagnosis of multiple sclerosis should be made by a physician with experience in identifying the disease. Diagnosis should be based on objective evidence of two or more neurologic signs that are localized to the brain or spinal cord and are disseminated in time and space (i.e., occur in different parts of the central nervous system at least three months apart). Magnetic resonance imaging with gadolinium contrast, especially during or following a first attack, can be helpful in providing evidence of lesions in other parts of the brain and spinal cord. A second magnetic resonance scan may be useful at least three months after the initial attack to identify new lesions and provide evidence of dissemination over time. It is critical to exclude other diseases that can mimic multiple sclerosis, including vascular disease, spinal cord compression, vitamin B₁₂ deficiency, central nervous system infection (e.g., Lyme disease, syphilis), and other inflammatory conditions (e.g., sarcoidosis, systemic lupus erythematosus, Sjögren’s syndrome). Symptom-specific drugs can relieve spasticity, bladder dysfunction, depression, and fatigue. Five disease-modifying treatments for multiple sclerosis have been approved by the U.S. Food and Drug Administration. These treatments are partially effective in reducing exacerbations and may slow progression of disability.

Multiple sclerosis (MS) typically presents in adults who are 20 to 45 years of age. Occasionally, the disease presents in childhood or late middle age. Twice as many women are affected as men, and persons of Northern European descent appear to be at highest risk for the disease.

The onset of MS may be insidious or sudden. Common presenting symptoms include monocular visual impairment with pain (optic neuritis), paresthesias, weakness, and impaired coordination (Table 1). Frequent accompanying signs and symptoms include bladder urgency or retention, constipation, sexual dysfunction, fatigue, depression, diplopia, gait and limb ataxia, and Lhermitte’s sign (electrical sensation down the spine on neck flexion).

MS frequently is overlooked because initial symptoms resolve spontaneously in most patients. Relapses occur within months or years. In some patients, however, MS has a primary progressive course from onset.

Diagnosis

The diagnosis of MS is based on the presence of central nervous system (CNS) lesions that are disseminated in time and space (i.e., occur in different parts of the CNS at least three months apart), with no better explanation for the disease process. Because no single test is totally reliable in identifying MS, and a variety of conditions can mimic the disease (Table 2), diagnosis depends on clinical features supplemented by the findings of certain studies.

Magnetic resonance imaging (MRI) has been shown to be highly sensitive in detecting clinically silent MS plaques. Consequently, findings of this imaging modality are included in diagnostic criteria that have been proposed by one set of investigators. 1 The major advantage of the proposed criteria is that an early diagnosis of MS can be made if an MRI scan performed three months after a clinically isolated attack demonstrates formation of a new lesion. The proposed diagnostic criteria also define MRI lesion characteristics that increase the likelihood of MS, including number of lesions (nine or more), location of lesions (position abutting the ventricles; juxtacortical, infratentorial, or spinal position), and lesion enhancement with the use of contrast medium (Table 3).

Conditions That Can Seem Like MS

Multiple sclerosis (MS) is a long-lasting disease that affects the nerves in your brain and spinal cord. It’s often hard to diagnose because symptoms vary so much from person to person. They can be mild or serious. They may come and go, or they may get worse over time.

Also, many other conditions have symptoms similar to those of MS. They include:

• Fatigue
• Weakness
• Numbness
• Vision problems
• Trouble walking

Your doctor will need to rule out these other conditions before diagnosing you with MS.

Epstein-Barr Virus

One condition that can also cause long-lasting fatigue is the Epstein-Barr virus (EBV). It’s a common type of herpes virus usually spread through body fluids, like spit. It’s probably best known for causing mononucleosis, or «mono.» Most people will get Epstein-Barr sometime during their lives.

Along with fatigue, EBV symptoms include:

• Head and body aches
• Fever
• Sore throat
• Swollen spleen or liver
• Inflamed lymph nodes in your neck
• Rash

EBV often infects children, who usually have mild or no symptoms. Teenagers and adults may show more clear signs of EBV. Most symptoms tend to clear up in 2-4 weeks, but the fatigue may last for many weeks or months. Once you have this virus, it stays in your body. It can reactivate, and it may or may not cause symptoms.

Vitamin B12 Deficiency

If you don’t get enough vitamin B12, you might end up with symptoms that look like those of MS.

Vitamin B12 helps your body make red blood cells, DNA, and nerves, among other things. Your body doesn’t make this vitamin naturally. You get it through animal foods (like meat, poultry, eggs, and dairy), foods with B12 added to them, or supplements.

Most adults need 2.4 micrograms of B12 each day. But some people either don’t take in this much, or their bodies don’t absorb enough. If you have a B12 deficiency, you could:

• Feel tingling or numbness in your hands, legs, or feet
• Get very tired and weak
• Have a hard time walking
• Have trouble thinking
• Get a swollen tongue
• Become anemic

The symptoms can come on quickly or gradually.

Diabetes

When you have diabetes, you have too much sugar in your blood. This can lead to serious health issues. With this condition, you may:

• Be very tired or cranky
• Feel hungrier and thirstier
• Pee more
• Lose weight for no reason
• Have blurred vision, slow-healing wounds, or repeated infections

Diabetes can also damage your nerves, a condition called diabetic neuropathy. This can cause numbness, tingling, or pain in your feet and legs. You might also have issues with your urinary tract, heart, digestive system, or blood vessels.

Like MS, diabetes may also lead to vision problems. They result from damage to blood vessels in your eyes. This condition is called diabetic retinopathy.

Type 1 diabetes usually starts when you’re a child or in your teens. Type 2 diabetes is more common in people over 40.

Nerve Damage

Other things can also cause neuropathy (nerve damage). It can affect you at any age, but people over 65 are more at risk. Along with diabetes and MS, the causes include:

• Injuries
• Immune system disorders like lupus and rheumatoid arthritis
• Infections
• Certain medications (such as chemotherapy) or toxic substances like lead
• Disorders of your circulation (vascular) system
• Alcoholism
• Kidney or liver conditions

Symptoms of neuropathy vary, depending on where in your body the damaged nerves are. Some of the most common symptoms are:

• Tingling
• Numbness
• Muscle weakness
• Pain
• Loss of balance
• Muscle twitches
• Not being able to move a part of your body
• Sweating too much or too little
• Weight loss
• Sexual problems
• Bladder or bowel problems

Eye Problems

Many eye issues can cause blurred vision or vision loss, which are also symptoms of MS. Some of the most common ones are:

• Refractive issues (near- and farsightedness)
• Age-related macular degeneration
• Diabetic eye damage
• Amblyopia, or «lazy eye»
• Cataracts
• Glaucoma

Your symptoms will depend on what eye condition you have. But they might include having a hard time reading or driving, trouble seeing at night, or cloudy-looking eyes.

Stroke

You have a stroke when one of the blood vessels that carries nutrients and oxygen to your brain gets blocked or ruptures. This kills some of your brain cells. In serious cases, strokes can leave you disabled or lead to death.

• Weakness or numbness (especially on just one side of your body)
• Trouble walking
• Confusion
• Problems with speaking or understanding
• Vision trouble
• Dizziness
• An intense headache for no reason

Stroke symptoms happen very suddenly. Get medical help at once if you have them.

Anyone can have a stroke. But they’re more likely in people over 55 and those with other health problems like high blood pressure, diabetes, and heart disease.

Lupus and Other Autoimmune Diseases

Several autoimmune diseases have symptoms that mimic those of MS. An autoimmune disease is one in which your immune system attacks your body’s tissues and organs.

One of the more common autoimmune conditions is lupus. It causes inflammation that affects your skin, joints, brain, kidneys, heart, blood cells, and lungs. In some cases, you get a rash across both cheeks.

• Extreme fatigue
• Fever
• Joint inflammation or pain
• Fingers or toes that turn white or blue at low temperatures
• Chest pain
• Dry eyes
• Shortness of breath
• Headaches
• Memory loss and confusion

Women are more likely to get lupus. It’s usually diagnosed when you’re 15-45 years old.

Parkinson’s Disease

This nervous system disorder affects your movement. Symptoms start gradually and get worse over time. They differ from person to person but may include:

• Trouble walking
• Trembling
• Slowed movement
• Muscle stiffness
• Problems with posture and balance
• Changes in speech and writing

Symptoms usually begin on one side of your body and affect that side more intensely, even when you have symptoms on both sides.

Most people who get Parkinson’s are 60 or older. It’s more common in men.

Lyme Disease

You get this disease through a bite from a deer tick, so it usually happens after you’ve spent time in or near the woods. If not treated, Lyme disease can affect your heart, joints, and nervous system.

Common symptoms include:

• Fatigue
• Numbness or tingling in your arms, legs, hands, or feet
• Headache
• Fever
• Skin rash in the area of the tick bite

Myasthenia Gravis

This immune system disorder causes a breakdown in communication between your muscles and nerves. That leads to muscle weakness and fatigue.

It affects only the muscles you control voluntarily. It most commonly causes problems in your:

• Eyes
• Arms and legs
• Face and throat
• Neck

The muscle weakness tends to get better after you rest. So symptoms can come and go. But they usually get worse over time.

You can get myasthenia gravis at any age, but it’s more common in women under 40 and men over 60.

ALS

Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s Disease) affects your brain and spinal cord. Eventually, it causes you to lose control of your muscles.

You may first notice twitching muscles, weakness in your arms or legs, or slurred speech. Other symptoms include:

• Trouble walking
• Weakness in your legs, feet, or hands
• Muscle cramps
• A hard time swallowing
• Changes in your behavior
• Random laughing, crying, or yawning

There’s no cure for ALS. Over time, it makes you less able to speak, eat, move, and breathe.

ALS may run in families. It’s most often diagnosed in people ages 40-65.

Guillain-Barre Syndrome

This immune system disorder attacks your nerves. It may start with tingling or weakness in your arms and legs and spread to your upper body.

You may also have:

• Trouble walking or climbing stairs
• Double vision
• Loss of facial expression
• A hard time eating
• Body aches and cramps
• Bladder and bowel issues
• Fast heart rate
• High or low blood pressure
• Breathing problems

Eventually, it can paralyze your whole body. If you have it, you’ll likely need to spend time in the hospital. There’s no cure, but most people recover. The majority are able to walk after 6 months.

Doctors don’t know what causes Guillain-Barre syndrome. But many people who get it had an infection (such as a respiratory or digestive system infection) a few weeks before.

ADEM

Acute disseminated encephalomyelitis (ADEM) is a rare brain and nervous system disorder that can follow a viral or bacterial infection (like an upper respiratory infection). Doctors believe it’s an immune reaction to the infection.

Anyone can get it, but it most often affects children. It commonly causes headaches and fever.

Other symptoms may include:

• Weakness in your arms and legs
• Tingling and numbness
• Vision problems
• Loss of balance
• Confusion
• Trouble swallowing

These symptoms tend to come on suddenly. With treatment, most people start to get better in days and are fully recovered within a few months.

Show Sources

Cleveland Clinic: «Multiple Sclerosis (MS),» «Neuropathy (Peripheral Neuropathy),» «Acute Disseminated Encephalomyelitis (ADEM).»

National Multiple Sclerosis Society: «Other Conditions to Rule Out.»

CDC: «About Epstein-Barr Virus,» «Common Eye Disorders and Diseases,» «Stroke,» «Lyme Disease.»

Harvard Medical School: «Vitamin B12 deficiency can be sneaky, harmful.»

Mayo Clinic: «Diabetes,» «Diabetic neuropathy,» «Diabetic retinopathy,» «Lupus,» «Parkinson’s disease,» «Myasthenia gravis,» «Amyotrophic lateral sclerosis (ALS),» «Guillain-Barre syndrome.»

American Stroke Association: «About Stroke.»

Multiple Sclerosis Foundation: «Diseases That Mimic MS.»

Johns Hopkins Medicine: «Risk Factors for Stroke.»

National Institutes of Health Genetic and Rare Disease Information Center: «Acute disseminated encephalomyelitis.»

The Diseases That Mimic Multiple Sclerosis (MS)

For a long time, Multiple Sclerosis (MS) has been diagnosed by exclusion of other possible diseases. With the adoption of new diagnostic criteria, such as the MacDonald 2010 Criteria, most major MS centers around the country have been able to diagnose MS with more certainty.

Yet, even with the improvement in MS diagnosis, each year I still see 8-10 patients who have been diagnosed with MS and come to me looking for second or “n-th” opinions. They are already on MS medications, but don’t really have MS. They are experiencing overwhelming fatigue and hand numbness, but it actually turns out to be sleep apnea and carpal tunnel syndrome or a pinched nerve in the neck. They have a few “spots” on their brain MRI, but they aren’t actually spots typical of MS.

One reason for this misdiagnosis is the many other diseases that affect people in the same age group with symptoms that overlap with those of MS. But, despite many of the symptoms being the same, these mimicking diseases don’t have the typical brain and spinal cord MRI findings of Multiple Sclerosis. Therefore, if anything is amiss about the symptoms or signs you are experiencing, and aren’t consistent with the imaging findings typical of Multiple Sclerosis, then other diseases need to be looked for.

The Diseases that Mimic Multiple Sclerosis (MS)

1. Hypermobility Syndrome

Benign Hypermobility Syndrome affects perhaps 5% of the population and is caused by joints that are “overly stretchy” or more flexible than normal. It is associated with symptoms such as autoimmune disease, headache, joint pain, fatigue/sleep problems, dysautonomia, and cardiac abnormalities. Through recent research, we have found that patients with hypermobility syndromes share similar symptoms to MS Patients. After comparing MRIs of patients with hypermobility to those of MS patients, we found White Matter Lesions in similar locations of both. Since both the MRI findings and symptoms overlap in MS and Hypermobility Syndromes, Hypermobility Syndromes can be mistaken for MS and should be considered in the differential diagnosis.

2. Lupus

Lupus and MS share many similarities. Both are diseases of the immune system and affect women more than men. They share several symptoms such as fatigue, pain, and headaches. Lupus stands out from MS with it’s most common symptom— a rash on the face that resembles a butterfly. However, not everyone suffering from Lupus experiences the rash immediately — resulting in a disease that sometimes starts out very similarly to MS. And in very rare cases, a person can have both diseases. Lupus is usually ruled out by blood tests.

3. Sarcoidosis

Sarcoidosis is an inflammatory disease with an unknown cause. It usually starts in the lungs, and the lymph nodes that drain the lungs become enlarged. But sarcoid can affect the brain, resulting in several neurological symptoms similar to MS. These include vision loss, depression, tender joints, numbness, and bladder changes. Just like MS, Sarcoidosis affects women more than men and is found most frequently in people 20 – 40 years old. Sarcoid is usually ruled out by biopsy or taking a tissue sample.

4. Vitamin B12 deficiency

Vitamin B12 is responsible for a lot of important functions for your body, such as making your red blood cells and your DNA, and helping make neurotransmitters in your brain. When your body doesn’t get enough Vitamin B12, serious conditions such as vision loss, fatigue and muscle weakness, lack of bladder control, and depression can occur. Vitamin B12 deficiency is ruled out through a blood test.

5. Central Serous Chorioretinopathy

Central Serous Chorioretinopathy is an eye disease where fluid is leaked under the retina and causes loss of vision in one eye. Even if we think a patient has MS, we always perform Optical Coherence Tomography on patients with sudden or pretty rapid visual loss. This helps to see if there is any swelling in the retina and if Central Serious Chorioretinopathy is present.

6. Neuromyelitis Optica (NMO)

Also known as Devic’s disease, NMO is an autoimmune disorder affecting the optic nerves and the spinal cord. We used to think NMO was just a special type of MS, but now we know they’re different and we treat them differently. NMO parallels MS in that it can be a relapsing-remitting disease. Each relapse of NMO further damages the optic nerves and further contributes to the patient’s growing disability.

Additionally, NMO and MS share many symptoms – vision loss, weakness and fatigue, loss of bladder control, and numbness and tingling. NMO affects people of African-American and Asian descent disproportionally as well as older people. The drugs used to treat MS can be harmful to a person with NMO and NMO left undiagnosed can have detrimental effects. Thus, it’s important to rule out NMO when diagnosing MS. This is usually done by special blood testing for anti-aquaporin 4 antibodies, and by the pattern on MRI of spinal cord involvement.

7. Inflammation

A major symptom of MS is the loss of vision. However, vision loss is also frequently caused by inflammation that affects the optic nerves. Luckily, most of these types of inflammation can be ruled out through various tests. Cysts, aneurysms, and various types of tumors can press on the optic nerves and cause visual loss. These would usually be detected on an MRI, or a special type of MRI called an “MRA,” which shows the arteries in the brain.

Inflammation of the nerves or of the blood vessels supplying the optic nerves with blood can occur too, and these have their separate types of testing. Your MS doctor should know about these.

8. Vision Loss Caused by Other Factors

We know MS can cause vision loss, as can inflammation. But, your problems seeing could be attributed to a variety of other issues. Various types of toxins, like methanol (in fuel), several drugs, tobacco use, and excessive alcohol consumption can also result in visual loss. Acute angle-closure glaucoma, or increased intraocular pressure, can lead to loss of vision and pain because it prevents fluid from getting out of one of the chambers of the eye.

Finally, thyroid disease and other intra-orbital diseases cause an impairment in vision.

As you can see, there are a number of autoimmune and inflammatory diseases and disorders whose symptoms overlap with those of MS. This is one of the factors that makes diagnosing MS so difficult. There is no one test that will both diagnose MS and rule out all the other possibilities.

Because of that, when getting tested for MS, it’s safer to conduct all the tests above necessary to make sure other diseases are not present. Ruling out these mimicking diseases will lead to a more accurate diagnosis and more effective treatment plan. And it’s better to be evaluated in an MS center, where research on MS and testing of new drugs for MS is being carried out. This generally means that center is up to date in the diagnostic criteria for MS.

Experiencing symptoms of MS? If you live in or near Kansas City, our specialists at Rowe Neurology Institute (RNI) can help. We specialize in accurately diagnosing and monitoring Multiple Sclerosis. And if your symptoms are found to be MS, we will provide you the close, coordinated care that is crucial for your health and optimal quality of life.

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