Tuesday, January 20, 2009

Doctor, Do I have Lyme or MS

Many patients are diagnosed with multiple sclerosis because they present to a neurologist with a variety of neurological symptoms and an abnormal MRI of the brain showing white matter lesions. A diagnosis cannot be made on the basis of an abnormal MRI. The findings in Lyme disease and MS can be identical. Medical diagnoses, including MS must be based on a history and clinical examination of the patient.

Most of the "MS" patients I see have a collection of symptoms which are not typically associated with MS. For example, MS patients do not have generalized muscle and joint pains. The two groups of patients usually have different histories and different physical.

MS is a disease of the brain, central nervous system and optic nerve. Neurological disease found in other areas is not compatible with MS. Many of the symptoms of MS and Lyme are the same: Optic neuritis, motor and sensory loss, vertigo, weakness, cognitive changes and many others. The history tends to be different however. Classically, MS is associated with discrete neurological events which tend to improve over time which is/are followed by additional discrete events involving different aspects of the central nervous system. Traditionally, MS is considered a relapsing and remitting disorder. Lyme tends to be a progressive disorder associated with a bewildering array of symptoms which tend to evolve in a progressive manner over time, without the relapsing and remitting feature.

With MS the neurological abnormalities are specifically associated with disease of the central nervous system. Lyme disease, on the other hand, tends to attack a wide spectrum of the nervous system. These diffuse, seemingly unrelated lesions are bewildering to neurologists, but par for the course for physicians accustomed to treating Lyme disease.

Lyme patients frequently have cranial nerve abnormalities of the type not seen in MS.
Lyme patients have upper motor neuron disease- as seen in MS, but may also have lower motor neuron disease, as seen with nerve entrapment syndromes or less frequently ALS. Lyme patients almost invariably have findings of sensory peripheral neuropathy, as seen with diabetes, hypothyroidism, Lyme disease and others. Sometimes neurologists perform EMG/NCV electrical studies to exclude the presence of peripheral neuropathy. These tests are relatively insensitive and are only revealing when the neuropathy is profound.

Despite proclamations made on the TV show House, there is no definitive diagnostic test for MS. It is a clinical diagnosis.

MS is an autoimmune disease. The neurological manifestations of Lyme disease are also for the most part mediated by autoimmune effects. The cause of MS is felt to be unknown. There are clear geographical differences in its prevalence. Many have felt that infections may be the root cause of the autoimmune process causing MS.

Dr. David Weldon in England, building on the work of Dr. Charles Stratton at Vanderbilt, has promoted the hypothesis that MS is causally related to infection with Chlamydia pneumonia. He has reported that his experimental therapy with antimicrobial therapy has shown benefits to patients with early MS.

The patient I refer to has had a protracted disabling illness. She has suffered with a progressive illness. She has had optic neuritis, vertigo, numbness and tingling, weakness, speech difficulties and progressive cognitive effects. She also lives in a wooded, Lyme endemic area and has suffered with severe muscle and joint pain. Her pain has required the use of narcotic pain killers. She had been treated for MS for several years, without much benefit. Her physical exam was not characteristic of MS. She has multiple neurological abnormalities which do not occur in MS. Recently, lab tests for Lyme and Babesia were positive. After several months of intensive antibiotic therapy she is now showing a great deal of improvement.

When I saw her last she was quite confused: "What do I have- is it Lyme or MS- I don't know what to tell my family?"

I stammered- and gave her a convoluted answer. I was soon clear that the technical details were contributing nothing to her understanding. Finally I said: "Just tell them that you have both."

Both Lyme and MS are associated with autoreactive T cells and autoantibodies directed against the lipoprotein coat of neurons called myelin. Both are Th1 mediated processes. Both are exacerbated by inter-current infections. MS therapies, like beta interferons, have anti-viral effects. They also may down regulate MHC molecules on antigen presenting cells and inhibit pro-inflammatory cytokines and T cell proliferation. These effects should benefit neuroborrelios patients. If a neurologists prescribes such drugs for MS they should dovetail nicely with antibiotic therapy prescribed by LLMDS.

Of course, LLMDS are concerned about the routine use of high dose intravenous steroids prescribed by many neurologists for MS exacerbations when "MS" co-exists with Lyme and neuroborreliosis.

7 comments:

Sarah said...

You have mentioned that your examination of Lyme patients is mostly neurological. Could you explain the tests you do and if they are abnormal what that actually means to the patients. Are these neuro abnormalities permanent or can they heal when a patient enters into remission? Thank you. Sara

Lyme report: Montgomery County, MD said...

The "testing" relates to standard physical exam techniques taught to medical students. A neurological examination allows the physician to identify disease in a particular part of the nervous system. Brain symptoms are mostly subjective, but there are formal mental status tests and psychometric tests. The 12 cranial nerves are tested by a simple exam. For example, when I ask a patient to stick out his tongue and say "ah" I am looking for: deviation of the uvula and/or soft palate, which may be indicative of disease of the glossopharyngeal nerve, (9th) cranial nerve. I am also looking at movement of the soft palate. If the tongue protrudes in one direction, away from the mid-line, it suggests disease of the hypoglossal nerve, (12th) cranial nerve.
Testing with a sharp point for sensation and a tuning fork for the ability to feel vibrations give critical information about the sensory portion of the nervous system. Testing muscle strength, tone and reflexes provides critical data for pinpoint determination of the areas of the nervous system which may be diseased. Unfortunately, too many physicians rely only on expensive tests when they may in fact be inaccurate than the physical exam.

The findings help confirm the suspected diagnosis and also make other diagnoses unlikely; the pattern of neurological disease seen in Lyme patients is usually quite unique. Such abnormalities can provide a metric by which the physician can objectively measure progress over time.

Some findings reverse over times while others may persist despite clinical remission. As a whole, abnormal findings improve more often than not.

Andy said...

The University of Calgary has shown that minocycline is very effective in treating RRMS and, in fact, it may be the best treatment yet developed. Minocycline is proven to protect neurons, reduce inflammation, and it is effective againt BB and Cpn. Lyme or MS? Minocycline treats both.

PatJ. said...

Hold your horses!
Andy said Minocycline is doing the job, and probably is; but because many of us use this blog as a guide due to the lack of help from a Doctor, I would like to suggest to read about this drug before considering it for treatment.
Wilkipedia reads:
"In some cases Minocycline can cause a liver infection.."; "Contrary to most other tetracycline antibiotics (doxycycline excluded), minocycline may be used in renal impairment, but may aggravate systemic lupus erythematosus.[3] It may also trigger or unmask autoimmune hepatitis.[4]"; "Also, more so than other tetracyclines, minocycline can cause the rare condition of secondary intracranial hypertension which has initial symptoms of headache, visual disturbances, and confusion. Cerebral edema, as well as autoimmune rheumatoid arthritis are rare side effects to minocycline in some people.[5]"; "Minocycline, like all tetracyclines, becomes dangerous past its expiration date. While most prescription drugs lose potency after their expiration dates, tetracyclines were known to become toxic over time due to the breakdown of certain chemicals present in the manufactured capsules."If taking this drug, one should avoid prolonged or excessive exposure to direct sunlight".

chris said...

I thought lyme symptoms can also come and go,just the same has lyme.

Im still unsure if i have lyme or ms

kiran upadhyay said...

At Dr. Ajay Kumar Advpainmd Medical Center, our pain management doctors understand that chronic pain is a Neuropathy Doctors In PA complex condition that affects the whole person, body, mind and soul of the target and treat the source of your chronic pain that will help you achieve long-term stable for help.

Joanne said...

After reading this post, I'm still unsure of what the *disinct* differences are between lymes and MS. This statement for example:
"She has multiple neurological abnormalities which do not occur in MS."
Can you elaborate?
And this:
" For example, MS patients do not have generalized muscle and joint pains. The two groups of patients usually have different histories and different physical."
Generalized meaning MS patients have specific areas of muscle and joint pain? And what are the differences between their history and physicals?
I have what seems to be a progressive form of MS. I am seeing a new general neurologist this week. There are no MS specialist in our area. I'm just trying to learn about lymes ... they tested me and I came back negative, but I've read that's not uncommon.
Thank you for your time