Dec 11, 2002
Medscape Neurology & Neurosurgery
A 37-year-old woman was recently diagnosed with MS and prescribed subcutaneous interferon beta-1a. MRI of the head and spine are negative, and CSF is negative for oligoclonal bands. From age 33 to the present time, she experienced 2-3 episodes of transverse myelitis with 0-1 WBCs and negative CSF PCR. She has also experienced episodes of vertigo, cerebellar ataxia, hand tremor, vibrating legs, and heavy arms. Is this MS despite the negative MRI?
from Mark S. Freedman, MD, 12/11/2002
It would be extremely rare to consider a diagnosis of MS in the context of repeatedly normal head and spine imaging and negative CSF. This is one of the "red flags" described in the recent McDonald criteria. One needs to consider the true "objective" evidence in this woman. Was the diagnosis of transverse myelitis based on sensory disturbances or hard findings? Other than cerebellar ataxia (presumably noted objectively and not historically), all of the other symptoms could be just that -- symptoms. The new criteria also stress the presence of objective findings at the times of attacks. Historical information is inadequate, especially given the lack of positivity in the ancillary tests. The bottom line is that this is a "shaky" diagnosis at best and treatment with an interferon without even a "highly probable" diagnosis is likely unwarranted. In the largest follow-up study I have seen of CSF and MRI, in a Swedish group, virtually no one with negative imaging and negative CSF turned out to have MS.
You don't want to be in a situation where the treatment might almost justify the diagnosis, and that appears to be the case here. A full work-up for other entities that can present like MS is appropriate. That list is quite long and certain entities could be ruled out just on the basis of knowing more about the patient and her family history.
Medscape Neurology & Neurosurgery 4(2), 2002.
© 2002 Medscape