Navigating the challenges of diagnosing multiple sclerosis

In their Personal View in The Lancet Neurology, Andrew Solomon and colleagues 1 Solomon AJ Arrambide G Brownlee WJ et al. Differential diagnosis of suspected multiple sclerosis: an updated consensus approach. Lancet Neurol. 2023; 22: 750-768 Google Scholar provide a comprehensive summary of the differential diagnosis of multiple sclerosis. They aim to address the prelude to the McDonald 2017 diagnostic criteria for multiple sclerosis, 2 Thompson AJ Banwell BL Barkhof F et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol. 2018; 17: 162-173 Summary Full Text Full Text PDF PubMed Scopus (3500) Google Scholar which is to rule out other disorders before using the criteria. Taking an approach based predominantly on lesion location and symptoms, the Personal View describes disorders that can present with white matter lesions and can be mistaken for multiple sclerosis. Typical and atypical clinical and MRI features for multiple sclerosis and clinical red flags against a diagnosis of multiple sclerosis are listed in the tables and figures, which provide a comprehensive summary of alternative diagnoses and clinical pearls for the diagnosing clinician. Algorithms are included for the differential diagnosis of patients with predominant involvement of the optic nerve or spinal cord myelopathies. In future papers on differential diagnosis, the frequency of the alternative disorders would help guide clinicians in what to look for in specific patient groups. Differential diagnoses also differ substantially between different age groups (table), which is mentioned, but not explicitly summarised, in the Personal View. TableCommon multiple sclerosis differential diagnoses by age group Prevalence among people with multiple sclerosis Differential diagnoses <11 years Rare 3 Belman AL Krupp LB Olsen CS et al. Characteristics of children and adolescents with multiple sclerosis. Pediatrics. 2016; 138e20160120 Crossref PubMed Scopus (80) Google Scholar ADEM, MOGAD, NMOSD, leukoencephalopathies, and mitochondrial disease 11–17 years 5% of cases 4 Chitnis T Glanz B Jaffin S Healy B Demographics of pediatric-onset multiple sclerosis in an MS center population from the Northeastern United States. Mult Scler. 2009; 15: 627-631 Crossref PubMed Scopus (199) Google Scholar MOGAD, NMOSD, ADEM, and vasculitis 18–50 80–85% of cases 4 Chitnis T Glanz B Jaffin S Healy B Demographics of pediatric-onset multiple sclerosis in an MS center population from the Northeastern United States. Mult Scler. 2009; 15: 627-631 Crossref PubMed Scopus (199) Google Scholar MOGAD, NMOSD, migraine, and rheumatological diseases >50 years 5–10% of cases 5 Bove RM Healy B Augustine A Musallam A Gholipour T Chitnis T Effect of gender on late-onset multiple sclerosis. Mult Scler. 2012; 18: 1472-1479 Crossref PubMed Scopus (81) Google Scholar Stroke, vasculitis, neurodegenerative diseases, cerebral amyloid angiopathy, and lymphoma ADEM=acute disseminated encephalomyelitis. MOGAD=myelin oligodendrocyte glycoprotein antibody disease. NMOSD=neuromyelitis optica spectrum disorder. Open table in a new tab ADEM=acute disseminated encephalomyelitis. MOGAD=myelin oligodendrocyte glycoprotein antibody disease. NMOSD=neuromyelitis optica spectrum disorder. Differential diagnosis of suspected multiple sclerosis: an updated consensus approachAccurate diagnosis of multiple sclerosis requires careful attention to its differential diagnosis—many disorders can mimic the clinical manifestations and paraclinical findings of this disease. A collaborative effort, organised by The International Advisory Committee on Clinical Trials in Multiple Sclerosis in 2008, provided diagnostic approaches to multiple sclerosis and identified clinical and paraclinical findings (so-called red flags) suggestive of alternative diagnoses. Since then, knowledge of disorders in the differential diagnosis of multiple sclerosis has expanded substantially. Full-Text PDF