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      Multiple sclerosis presented as clinically isolated syndrome: the need for early diagnosis and treatment

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          Abstract

          Objective

          To aid in the timely diagnosis of patients who present with clinically isolated syndrome (CIS).

          Patients and methods

          We studied 25 patients (18 women, 7 men), originally presented in our clinic with a CIS suggestive of multiple sclerosis (MS). All patients underwent the full investigation procedure including routine tests, serology, cerebrospinal fluid (CSF) examinations, evoked potentials (EPs), and magnetic resonance imaging (MRI) of brain and cervical spinal cord. Patients were imaged at baseline, and every three months thereafter up to a year.

          Results

          The CIS was consisted of optic neuritis in 12 cases, incomplete transverse myelitis (ITM) in 7 cases, Lhermitte sign in 2 cases, internuclear ophthalmoplegia (INO) in 2 cases, mild brainstem syndrome in 1 case, and tonic-clonic seizures in 1 case. Using the baseline and three-month scans 18/25 (72%) patients developed definite MS in one year of follow up while 7 (28%) had no further findings during this observation period. Immunomodulatory treatments were applied to all definite MS patients.

          Conclusion

          In light of new treatments available, MRIs at 3 month intervals are helpful to obtain the definite diagnosis of MS as early as possible.

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          Most cited references 24

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          Neurologic manifestations in primary Sjögren syndrome: a study of 82 patients.

          Neurologic involvement occurs in approximately 20% of patients with primary Sjögren syndrome (SS). However, the diagnosis of SS with neurologic involvement is sometimes difficult, and central nervous system (CNS) manifestations have been described rarely. We conducted the current study to describe the clinical and laboratory features of SS patients with neurologic manifestations and to report their clinical outcome. We retrospectively studied 82 patients (65 women and 17 men) with neurologic manifestations associated with primary SS, as defined by the 2002 American-European criteria. The mean age at neurologic onset was 53 years. Neurologic involvement frequently preceded the diagnosis of SS (81% of patients). Fifty-six patients had CNS disorders, which were mostly focal or multifocal. Twenty-nine patients had spinal cord involvement (acute myelopathy [n = 12], chronic myelopathy [n = 16], or motor neuron disease [n = 1]). Thirty-three patients had brain involvement and 13 patients had optic neuropathy. The disease mimicked relapsing-remitting multiple sclerosis (MS) in 10 patients and primary progressive MS in 13 patients. We also recorded diffuse CNS symptoms: some of the patients presented seizures (n = 7), cognitive dysfunction (n = 9), and encephalopathy (n = 2). Fifty-one patients had peripheral nervous system involvement (PNS). Symmetric axonal sensorimotor polyneuropathy with a predominance of sensory symptoms or pure sensory neuropathy occurred most frequently (n = 28), followed by cranial nerve involvement affecting trigeminal, facial, or cochlear nerves (n = 16). Multiple mononeuropathy (n = 7), myositis (n = 2), and polyradiculoneuropathy (n = 1) were also observed. Thirty percent of patients (all with CNS involvement) had oligoclonal bands. Visual evoked potentials were abnormal in 61% of the patients tested. Fifty-eight patients had magnetic resonance imaging (MRI) of the brain. Of these, 70% presented white matter lesions and 40% met the radiologic criteria for MS. Thirty-nine patients had a spinal cord MRI. Abnormalities were observed only in patients with spinal cord involvement. Among the 29 patients with myelopathy, 75% had T2-weighted hyperintensities. Patients with PNS manifestations had frequent extraglandular complications of SS. Anti-Ro/SSA or anti-La/SSB antibodies were detected in 21% of patients at the diagnosis of SS and in 43% of patients during the follow-up (mean follow-up, 10 yr). Biologic abnormalities were more frequently observed in patients with PNS involvement than in those with CNS involvement (p < 0.01). Fifty-two percent of patients had severe disability, and were more likely to have CNS involvement than PNS involvement (p < 0.001). Treatment by cyclophosphamide allowed a partial recovery or stabilization in patients with myelopathy (92%) or multiple mononeuropathy (100%). The current study underlines the diversity of neurologic complications of SS. The frequency of neurologic manifestations revealing SS and of negative biologic features, especially in the event of CNS involvement, could explain why SS is frequently misdiagnosed. Screening for SS should be systematically performed in cases of acute or chronic myelopathy, axonal sensorimotor neuropathy, or cranial nerve involvement. The outcome is frequently severe, especially in patients with CNS involvement. Our study also underlines the efficacy of cyclophosphamide in myelopathy and multiple neuropathy occurring during SS. Copyright 2004 Lippincott Williams & Wilkins
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            The clinical profile of optic neuritis. Experience of the Optic Neuritis Treatment Trial. Optic Neuritis Study Group.

             RW Beck (1991)
            The baseline characteristics of 448 eligible patients entered into the Optic Neuritis Treatment Trial are described in an effort to summarize the clinical profile of acute optic neuritis. A total of 77.2% of the patients were women. Mean age was 31.8 years. Pain accompanied the visual loss in 92.2% of cases. The optic disc appeared swollen in 35.3% of the patients and normal in 64.7%. A wide variety of visual field defects were present. Abnormalities in asymptomatic fellow eyes were noted, particularly on perimetry. Magnetic resonance imaging showed changes consistent with demyelination of the brain in 48.7% of the patients. Magnetic resonance imaging, serologic studies (such as the antinuclear antibody test and the fluorescent treponemal antibody absorption test), chest roentgenography, and lumbar puncture were of limited utility in defining a cause for visual loss other than optic neuritis associated with demyelinative disease.
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              The 5-year risk of MS after optic neuritis. Experience of the optic neuritis treatment trial.

                (1997)
              The objective of our study was to assess the 5-year risk of and prognostic factors for the development of clinically definite multiple sclerosis (CDMS) following optic neuritis. In a prospective cohort study design, 388 patients, who did not have probable or definite MS at study entry enrolled in the Optic Neuritis Treatment Trial between 1988 and 1991, and were followed for the development of CDMS. The 5-year cumulative probability of CDMS was 30% and did not differ by treatment group. Neurologic impairment in the patients who developed CDMS was generally mild. Brain MRI performed at study entry was a strong predictor of CDMS, with the 5-year risk of CDMS ranging from 16% in the 202 patients with no MRI lesions to 51% in the 89 patients with three or more MRI lesions. Independent of brain MRI, the presence of prior nonspecific neurologic symptoms was also predictive of the development of CDMS. Lack of pain, the presence of optic disk swelling, and mild visual acuity loss were features of the optic neuritis associated with a low risk of CDMS among the 189 patients who had no brain MRI lesions and no history of neurologic symptoms or optic neuritis in the fellow eye. The 5-year risk of CDMS following optic neuritis is highly dependent on the number of lesions present on brain MRI. However, even a normal brain MRI does not preclude the development of CDMS. In these patients with no brain MRI lesions, certain clinical features identify a subgroup with a particularly low 5-year risk of CDMS.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                June 2008
                June 2008
                : 4
                : 3
                : 627-630
                Affiliations
                Department of Neurology, University of Ioannina School of Medicine Greece
                Author notes
                Correspondence: Sotirios Giannopoulos Dept., of Neurology, University of Ioannina School of Medicine, University Campus Ioannina, 45110, Greece Tel +30 26510 97514 Fax +30 26510 97011 Email sgiannop@ 123456uoi.gr
                Article
                2500255
                18827858
                © 2008 Pelidou et al, publisher and licensee Dove Medical Press Ltd.
                Categories
                Original Research

                Medicine

                optic neuritis, multiple sclerosis, transverse myelitis , clinically isolated syndrome

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