The young woman has tears in her eyes. You can practically see everything collapsing inside her. Even the patients who come to my clinic with a premonition are shocked when they hear the diagnosis of MS. One can imagine the images that pass before their inner eye and how fear of the future sets in.
I often wonder if we really have to be so brutal. A week ago, the young patient was admitted to us with an inflammation of the optic nerve. The visual acuity of the right eye was reduced – as through frosted glass – the eye hurt when moving. Otherwise, she is missing nothing, she had never been sick before, has lived healthily, played sports.
The MRI showed that not only was the optic nerve inflamed, but other inflammatory changes in the brain could also be detected. The subsequent cerebrospinal fluid removal confirmed the suspicion of an inflammatory disease of the central nervous system.
Today, shortly after being discharged from the hospital, she presents herself for discussion of the findings. I explain the findings to her and inform her that she has multiple sclerosis. I sense the misunderstanding – how I came to make such a diagnosis. After all, the eye had quickly improved again after cortisone administration, she had absolutely no other problems. And anyway, whether I am sure.
I’m usually sure – and if not, I would also express my doubts. In the age group between 20 and 40 years, MS is the most common cause of neurological deficits. If the MRI and the cerebrospinal fluid show typical inflammatory changes and other causes of inflammation can be excluded with a detailed laboratory diagnosis, the diagnosis can be made with very high reliability – provided the investigation was carried out with due care.
It should also be noted that other causes of brain inflammation, such as vasculitis, usually cause much more severe disease patterns than MS. The often mentioned neuroborreliosis in the context of MS diagnosis is a disease that usually shows a completely different clinical course and leaves a completely different signature in the cerebrospinal fluid than MS. For this reason, chronic neuroborreliosis is a rather rare differential diagnosis, even though almost every one of my patients initially thinks they have undiagnosed neuroborreliosis.
The fundamental principle for the diagnosis of MS is that MS is a disease that leads to neurological failures at different times in different locations of the central nervous system (i.e., brain and spinal cord). This happens in the form of disease relapses that can occur at any time (the technical term for this is “spatial and temporal dissemination”). In the past, at least two disease relapses were needed to diagnose MS. This was then more impressive and believable for many patients, but had the disadvantage that valuable time was often lost with this diagnostic strategy. Since the regular use of MRI, we know that clinically unnoticed inflammations occur between two clinical relapses, which can be detected with MRI. It is assumed that for each clinically noticed relapse, at least 10 new foci come in the MRI, which – even if they are not noticed – still damage the brain. However, the receipt for such unbraked inflammation is usually only received in later years, as the brain of young people has a considerable reserve – but this is eventually used up!
Therefore, our diagnostic strategy today is based on looking for indications after the first clinical relapse that indicate a temporally and spatially disseminated disease. We use MRI for this. If we see inflammatory foci in different locations here and these foci have different ages, which we can find out with the help of contrast agent administration, we can say after the first relapse that this is a disease that leads to inflammatory attacks on the brain at different times and places. This means the definition of MS – which is therefore also referred to as disseminated encephalomyelitis – is fulfilled, provided there are no indications of a differently structured disease based on laboratory examinations. That’s how it works with making a diagnosis …..
We therefore try to foresee at the earliest possible point – namely after the first relapse – whether there is a risk that further disease relapses will occur. And for this reason, I believe, we have to be so brutal and confront our mostly very young patients with this information after the first disease relapse and make the working diagnosis of MS. By the way, I am also firmly convinced that this clarity is very important because only if you “know your enemy” can you react sensibly and keep the initiative in your own hands.
From a medical point of view, too, early diagnosis is very crucial. All our drugs are active ingredients that effectively suppress the inflammatory reaction in the central nervous system. We know that this inflammatory reaction is very pronounced in the early phase of the disease – accordingly, MS drugs work particularly well here and can effectively prevent damage and thus lead to good courses of MS.
I therefore see the quick and clear diagnosis at the earliest possible point as a very essential point and think that for many patients it is the chance to effectively counteract the disease. Even if many patients naturally need time to process the initial shock of such a diagnosis.
The young woman will also need this time. However, I hope that she will be able to process the diagnosis with the help of friends, family members and her medical environment in such a way that she derives the maximum benefit for herself and does not suffer any damage from the disease through consistent action. A good recipe in this case is also not to bury your head in the sand and to inform yourself sufficiently so that you become the greatest expert on the disease yourself.
In this sense, she sends you her warmest regards
Your Mathias Mäurer
