eMedicine Specialties > Emergency Medicine > Neurology

Multiple Sclerosis: Differential Diagnoses & Workup

Author: Marjorie Lazoff, MD, Editor-in-Chief, Medical Computing Review
Contributor Information and Disclosures

Updated: Jul 16, 2009

Differential Diagnoses

Amyotrophic Lateral Sclerosis
Stroke, Hemorrhagic
Bell Palsy
Stroke, Ischemic
Brain Abscess
Subdural Hematoma
Guillain-Barré Syndrome
Syphilis
HIV Infection and AIDS
Systemic Lupus Erythematosus
Lumbar (Intervertebral) Disk Disorders
Tick-Borne Diseases, Lyme
Neck Trauma
Transient Ischemic Attack
Sarcoidosis
Trigeminal Neuralgia
Spinal Cord Infections
Spinal Cord Injuries

Other Problems to Be Considered

Behçet disease
Brainstem tumors
Central nervous system infections
Cerebellar tumors
Friedreich ataxia
Hereditary ataxias
Leukodystrophies
Neurofibromatosis
Pernicious anemia
Progressive multifocal leukoencephalopathy
Ruptured intervertebral disk
Small cerebral infarcts
Spinal cord tumors
Syringomyelia
Vasculitides

Workup

Laboratory Studies

  • CBC with differential
  • Serum glucose
    • To rule out hypoglycemia and chronic hyperglycemia as causes of neurological findings
    • Helps in CSF glucose interpretation
  • Serum electrolytes: Determine abnormalities associated with neurologic, muscle, or systemic dysfunction (K+, Ca2+, P+, and Na+).
  • Coagulation studies prior to lumbar puncture: These are indicated in patients with history of easy bleeding, liver disease, malnutrition, or alcoholism.
  • Urinalysis and microscopy

Imaging Studies

  • CT scan of head with contrast
    • This imaging study is indicated in the ED to assess focal neurological examination or acute changes in mental status prior to lumbar puncture.
    • For all other investigations, MRI is unarguably more sensitive and specific in diagnosing MS and related disorders. In selected patients, MRI will be the preferred imaging study in the ED.
  • MRI of head with gadolinium
    • Typical MRI findings support the diagnosis (ie, 50% progress to clinically definite MS within 2 years), but 5% of suspected patients with normal MRI findings similarly progress to MS.
    • T1 shows active lesions (2-6 weeks) reflecting perivascular inflammation and breakdown of blood-brain barrier (BBB). T2 most commonly shows old lesions in periventricular supratentorial white matter, but old lesions occasionally are seen in the cerebellum and brain stem.
    • To visualize the optic nerve, a special MRI technique is required to suppress the fat signal.
    • Acute disseminated encephalitis may be radiographically indistinguishable from MS.
  • MRI of spine with gadolinium
    • For patients with acute transverse myelitis, this is indicated to rule out a compressing lesion.
    • For MS lesions of the spine, a special MRI technique is required to obliterate CSF signal on T2-weighted images.
  • CT scan of the cervical vertebrae: This is used as a screening test for cervical radiculopathy secondary to trauma and for osteoarthritis.

Other Tests

  • CSF analysis is indicated if diagnosis is uncertain and neurological presentation or neuroimaging raises suspicion of CNS infection.
    • Typical findings in MS and acute disseminated encephalitis include 0-50 mononuclear cells on cell count, 25% elevated protein, normal glucose level, selective increase in immunoglobulin G (eg, oligoclonal bands, free kappa chains), and an abnormal colloidal gold curve.
    • Some patients with MS will have normal or atypical CSF findings.

More on Multiple Sclerosis

Overview: Multiple Sclerosis
Differential Diagnoses & Workup: Multiple Sclerosis
Treatment & Medication: Multiple Sclerosis
Follow-up: Multiple Sclerosis
Multimedia: Multiple Sclerosis
References
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References

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Further Reading

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Keywords

multiple sclerosis, MS, central nervous system, CNS, neurologic disorder, idiopathic inflammatory demyelinating disease of the CNS, optic neuritis, transverse myelitis, internuclear ophthalmoplegia, paresthesias, relapse-remitting MS, RR-MS, chronic progressive MS

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Contributor Information and Disclosures

Author

Marjorie Lazoff, MD, Editor-in-Chief, Medical Computing Review
Marjorie Lazoff, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University
Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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