Misdiagnosis of MS

[Matt]

http://www.docguide.com/news/content.nsf/PaperFrameSet?OpenForm&newsid=8525697700573E1885256D7200579200&topabstract=1&u=http://www.ima.org.il/imaj/ar03jul-7.pdf

[Matt]

That link didn't seem to work. If you want the tables, try googling it yourself. I don't know why the link doesn't work.

Here is the text.


IMAJ 2003;5:489±490

Patterns of Misdiagnosis of Multiple SclerosisNetta LevinMD, Michal MorRNand Tamir Ben-HurMD PhDDepartment of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah University Hospital, Jerusalem, IsraelAffiliated to Hebrew University-Hadassah Medical School, Jerusalem,

IsraelKey words: multiple sclerosis, diagnosis, presentation, gender bias, sensory complaints

Abstract

Background: Multiple sclerosis is a chronic demyelinating diseaseof the central nervous system that presents with variable signs andsymptoms. This variability in the clinical presentation may result inmisdiagnosis, unnecessary referrals and misleading information to thepatients.

Objectives: To identify the types of misdiagnoses made on thepresentation of MS.Methods: Fifty consecutive MS patients were questioned on theirearly symptoms, their mental status, the disease course until thediagnosis was confirmed, and the different diagnoses they received.Results: The patients had been referred to 2.2 + 1.3 specialistsbefore seeing a neurologist, and learned about their disease 3.5 yearsafter the onset of symptoms. Twenty-nine patients (58%) were initially given 41 wrong diagnoses. While the majority of women were misdiagnosed mentally, orthopedic work-up was offered to the men.Misdiagnosis of MS occurred most often in patients who presented with non-specific sensory symptoms that did not conform to a specific neurologic syndrome. The patients emphasized the fact that not knowing worsened their anxiety, whereas receiving the diagnosis enabled them to begin coping with their disease.

Conclusions: MS is often overlooked when patients present withnon-specific sensory complaints. The difference in type of misdiagnosisbetween men and women may reflect a gender-dependent bias in theway physicians interpret sensory complaints.IMAJ 2003;5:489±490

Multiple sclerosis is a chronic disease of the central nervous systemthat often results in significant disability [1]. The diagnosis ofclinically definite MS has been traditionally based on theoccurrence of at least two neurologic episodes, disseminated intime and in neuroanatomic location. The mean interval between thefirst and second relapse is approximately 6 years in benign andintermediate cases [2]. Thus, the diagnosis of MS can be delayed.Technologic advances in neuroimaging have allowed the detectionof subclinical lesions, and thus earlier diagnosis [3]. When newpatients present with a distinct neurologic syndrome, such as opticneuritis or internuclear ophthalmoplegia, the diagnosis is relativelyeasy. However, the presenting symptoms and signs of MS areextremely variable [4]. Corticospinal tract involvement maymanifest not only as weakness but also as non-specific symptoms,such as "heaviness," "stiffness" or limb pain. Moreover, somatosen-sory complaints as the presenting symptom may perplex theclinician because they are frequently unaccompanied by objectiveneurologic signs and may fail to correspond to a recognizableanatomic pattern. The temporal profile of MS attacks may also vary,and the disease may develop indolently. The variability of clinicalpresentations, temporal profiles and disease course can makeclinical evaluation difficult, possibly resulting in misdiagnosis,unnecessary referrals, and misinformation to the patient [5±7].The purpose of the present study was to identify the types ofmisdiagnoses made on the presentation of MS.Patients and MethodsFifty consecutive MS patients who came to the outpatient MS clinicfor routine follow-up were asked to complete a brief questionnaireon their early symptoms, their mental status, and the range andspecialty of physicians they visited until the diagnosis wasconfirmed. They were questioned regarding the different diagnosesthat were disclosed to them and on their general feeling during thetime since symptom onset until they learned of their true diagnosis.The information obtained in this survey related entirely to thesubjective point of view of the patients and not to the physicians'considerations.ResultsThe study group included 33 women and 17 men, whose averageage at the time of the interview was 34.5 years. The patients' initialsymptoms started at age 29.5 + 8.2 and they were correctlydiagnosed at age 33 + 9 years. The patients were referred to 2.2 +1.3 specialists (excluding the primary care physician) before referralto a neurologist [Table 1]. Twenty-one patients (42%) werediagnosed at presentation as suffering from demyelinating disease,while 29 patients (58%) were initially given 41 different diagnoses,including 29 non-neurologic and 12 neurologic diagnoses. Ninepatients were told they suffered from a psychiatric problem such asanxiety, somatization or conversion. Another eight patients weretold that there was no medical problem and their symptoms wereattributed to "tight jeans" or "contact lenses." In addition, 12 otherphysical diagnoses were given, including orthopedic problems, suchas discopathy (5 patients) and viral infection (2 patients). The typeof misdiagnosis was unevenly distributed between women andmen. Of the 17 patients who were told that they suffered frompsychiatric problems or medically unexplained problems, 14 werewomen and only 3 were men (P= 0.074, Fisher's exact test). Therewas no apparent difference in subjective feeling of anxiety betweenthe two groups of patients, since 6 of these 17 (35%) supposedlypsychiatric patients reported anxiety compared to 14 of the other 33patients (42%).The patients were classified according to their major self-reported presenting symptom into four groups [Table 1]: motorweakness (12/50, 24%), gait disturbance (10/50, 20%), ophthalmicproblems such as visual loss or diplopia (9/50, 18%), and sensorycomplaints such as numbness, parasthesia and pain (19/50, 38%).Original ArticlesMS = multiple sclerosis489IMAJ. Vol 5 . July 2003Patterns of Misdiagnosis in Multiple SclerosisOf the 24 patients who were misdiagnosed initially as suffering fromnon-neurologic diseases, 15 presented with mainly sensorysymptoms (62.5%). Only 4 of 26 (15%) patients with an initialsuspicion of a neurologic disease reported sensory symptoms. Thisdifference was statistically significant (P= 0.0007, Fisher's exacttest). Ten of 12 women, but only 3 of 6 men who presented withsensory complaints and were misdiagnosed with a non-neurologicdisease were told that they have psychiatric or medicallyunexplained symptoms. This gender difference was statisticallysignificant (P= 0.048, Fisher's exact test). Finally, the patients werequestioned on their feelings during the period since symptom onsetuntil final diagnosis of MS. Thirteen misdiagnosed patientsspontaneously expressed their need to know their diagnosis. Theyfavored truth-telling and emphasized the fact that not knowingworsened their anxiety, whereas revealing the diagnosis wouldenable them to start coping with their disease.DiscussionIn the present study we asked a representative group of MS patientsabout the time and way they learned about their disease. Thisretrospective survey reflects a totally subjective recollection fromthe patients' viewpoint. At the same time however, it provides uswith information regarding the impact of the diagnostic process inMS patients on their future trust in the medical system. Manypatients with a non-specific clinical presentation, especiallysubjective sensory complaints, were incorrectly diagnosed. Primarynon-neurologic diagnoses were given equally to men and women.While psychiatric explanations were given to the majority of women,orthopedic work-up was offered to the men. This difference in typeof misdiagnosis between men and women may reflect a gender-dependent bias in the way physicians interpret sensory complaints.The difficulty in diagnosing MS may be due to both a lack ofawareness of MS and to non-specific symptoms that do notconform to a specific neurologic syndrome. The long time courseuntil diagnosis may be related to many unnecessary referrals tospecialists. In addition, the delay in conveying to the patient a firmdiagnosis of MS may also be related to the problem physicians havein importing bad news to their patients. However, many patientsreported a need to know their diagnosis as early as possible. Inorder to consolidate an approach policy, the first question to beasked is which patients need further evaluation [8]. Though theanswer is relatively clear-cut in patients with optic neuritis, it is notso when sensory complaints are involved. The vast majority ofpatients who present with sensory complaints will probably notdevelop a disabling neurologic disease. However, it is important tokeep in mind that non-specific sensory complaints are physicallyreal and one should avoid underestimating the patient's feelings.We therefore suggest caution in dismissing the patient with apsychiatric diagnosis or having "nothing." Assuring the patients thatthe likelihood of their symptoms developing into a serious illness islow does not necessarily mean that the physician is compelled toprovide a clear diagnosis. On the other hand, a long follow-up andreevaluation in case of recurrent complaints is needed. We confermuch importance to the "time factor," where after close follow-up inwhich no other disease symptoms or signs have appeared there isan increased certainty of the patient's general health.

References1. Weinshenker BG. Natural history of multiple sclerosis.Ann Neurol1994;36(Suppl):S6±11.2. Confavreux C, Aimard G, Devic M. Course and prognosis in multiplesclerosis assessed by the computerized data processing of 349 patients.Brain 1980;103:281±300.3. Rolak LA. The diagnosis of multiple sclerosis.Neurol Clin 1996;14(1):27±43.4. Miller A. Diagnosis of multiple sclerosis.Semin Neurol 1998;18(3):309±16.5. Nelson RF. Ethical issues in multiple sclerosis.Semin Neurol1997;17(3):227±34.6. Poser CM, Brinar VV. Diagnostic criteria for multiple sclerosis.ClinNeurol Neurosurg 2001;103(1):1±11.7. Achiron A, Barak Y. Multiple sclerosis ± from probable to definitediagnosis: a 7-year prospective study.Arch Neurol 2000;57(7):974±9.8. Riaz S, Nowack WJ. Diagnostic problems in multiple sclerosis: over-reliance on neuroimaging.South Med J 1998;91(3):270±2.Correspondence: Dr. T. Ben-Hur, Dept. of Neurology, HadassahUniversity Hospital, P.O. Box 12000, Jerusalem 91120, Israel.Phone: (972-2) 677-6941Fax: (972-2) 643-7782

[jumpstart]

The link worked for me Matt.

What a great article. Thanks for posting. Now if only doctors would realize how they are harming their patients by misdiagnosing them for so long.

[agate]

Thanks for posting this!

The link worked for me--though because it's a PDF file, it may take a while to download it.

[lady_express_44]

Great article, Matt!
_________________
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You can tell whether a man is wise by his questions.
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