Neurol Sci. 2001 Nov;22 Suppl 2:S98-102. Related Articles, Links
� The differential diagnosis of multiple sclerosis: classification and clinical features of relapsing and progressive neurological syndromes.
Trojano M, Paolicelli D.
Department of Neurological and Psychiatric Sciences, University of Bari, Italy.
In the absence of pathognomonic clinical features or a definitive laboratory test, multiple sclerosis (MS) remains ultimately a diagnosis of exclusion. Accurate diagnosis is increasingly important with available disease modifying therapy. Unfortunately the rate of misdiagnosis remains around 5%-10%, indicating that 1 in 20 patients thought to have MS has, instead, a condition resembling MS. In this review we describe conditions that may be confused with MS because they can present as lesions disseminated in time, space, or both. Conditions often confused with MS may be inflammatory (systemic lupus erythematosus, Sjogren's syndrome, vasculitis, sarcoidosis, Behcet's disease), infectious (Lyme disease, syphilis, progressive multifocal leukoencephalopathy, HTLV-1 infection, herpes zoster), genetic (lysosomal disorders, adrenoleukodystrophy, mitochondrial disorders, CADASIL), metabolic (vitamin B12 deficiency), neoplastic (CNS lymphoma) and spinal (degenerative and vascular malformations) diseases. The key to the accurate diagnosis of MS is vigilance for atypical features, suggesting the possibility of an alternative diagnosis.
It sounds like to me that when using either or both Avonex and/or Tysabri, one should lay off the steroids.
However, given there is a blood test with an inappropriate finding, then a spinal tap should be perforomed and tested. The results may indicate something that on the surface looks like MS but is something very different.
was to show everybody that medicine is not a yes or no answer - it is a question of additive risks and genetic predispositions
I was most intrigued with the idea that many normal people from time to time have reactivation of JC virus in their brain - and that without the steroid treatment patient #1 may have actually mounted an immune response against the jc virus and could have been fine
I also was interested in the fact that treatment with chemo for melanoma has been linked to several cases of PML
But the most important point to consider to that both patients had a more aggressive progression of their MS - and that meant that they probably had steroid treatment for every flare-up and could have had novantrone (chemo) to try to slow the disease progression - thus they probably had more additive risk factors than other people in the trial because of all the extra immunosuppressive treatment and that would explain why only two patients in 500 would develop PML on avonex + tysabri - but it is probably important to consider that these patients were in the tysabri + avonex group - because patients were put in that group because they had previously progressive disease on everything else - THAT MEANS THEY GOT THE MOST EXTRA STEROID TREATMENT - and hence their risk for PML was higher - but also their other risk factors should be taken into account - only 5% of AIDS patients with almost no immune response left develop PML - those are the ones that are genetically susceptible or possibly were re-infected with JC or had the particularly aggressive subtype 2b that is rather rare in the population and linked to a much larger proportion of PML cases
please remember that in the tysbari + avonex trials there were a few patients that had between 3 and 6 MS flare ups during the clinical trial in the treated and the control groups - those people got the most steroids and other immunosuppressive treatments and thus could have been the ones at the greatest risk