Multiple sclerosis (MS) and its associated symptoms, such as fatigue and walking difficulties, are often clearly identifiable and have established therapies.  However, as many people with MS know, diagnosing and treating the disease is not always straightforward.  One area that is particularly challenging--and often overlooked by both health care providers and people with MS--is to be aware of, diagnose, and treat other medical conditions which may mimic MS or to which people with MS may be especially prone. 

These “Hidden Diseases” are like the “Hidden Picture” or “Where’s Waldo?” games for kids.  These MS-associated diseases may be difficult to identify in the midst of all of the attention and concern over MS itself.  Furthermore, these conditions may not have clearly identifiable symptoms or may have symptoms that are very similar to those of MS.

“Hidden Diseases” are a good news-bad news situation.  The bad news is that people with MS may need to deal with yet another medical condition.  The good news is that, generally, these conditions are relatively easy to diagnose and treat.  Identifying and treating these conditions at an early stage may improve one’s level of function and may prevent future difficulties.

There are several “Hidden Diseases” in MS.  I actually learned about some of these conditions from one of my best teachers--my own patients.   What are these “Hidden Diseases?”

Osteoporosis
More than 10 years ago, a few of my patients brought me research articles that suggested that people with MS may be likely to develop the bone-thinning condition osteoporosis.  Based on that information, I started screening many of my patients and was shocked at how many actually did have osteoporosis.  Subsequent research has shown that people with MS do indeed appear to be vulnerable to osteoporosis and that this condition may often be overlooked, and thus under treated, in those with MS.

“Osteoporosis” refers to a prominent reduction in the strength and density of bones.  A milder condition, “osteopenia,” is characterized by a less severe reduction in bone density.

Osteoporosis and osteopenia are important to identify because they weaken bones and make one vulnerable to fractures.  This is especially important in those with walking difficulties because mild falls may produce significant bone fractures when osteoporosis is present. 

There are several risk factors for osteoporosis.  One that most people are aware of is being an older woman who has gone through menopause.  In MS, however, younger women and also men of all ages appear to be prone to osteoporosis.  Risk factors for osteoporosis that may be more likely to occur in people with MS are decreased “weight-bearing” exercises (such as walking), low body weight, white race, and the use of some medications, such as steroids, thyroid medications, and seizure medications.  There are several other osteoporosis risk factors.  One that I find especially helpful is a history of a bone fracture as an adult.  Other risk factors include having a family history of osteoporosis, smoking, and being older. 

Diagnosis and treatment of osteoporosis is well-established.  Typically, a test known as “bone densitometry” is performed to diagnose the condition.  Multiple non-medication measures may be taken to prevent or treat the condition, such as weight-bearing exercises, vitamin D and calcium, and eliminating or modifying risk factors.  If needed, there are several remarkable medications that can actually increase the bone density.

The bottom line:  The exact criteria for determining whether someone with MS should be screened for osteoporosis have not been established.  Everyone with MS does not need to have a test for osteoporosis.  However, since the condition is relatively common and is preventable and treatable, everyone with MS should discuss this topic with their health care provider to determine if testing is indicated.

Spine Disease
Around the same time that my patients were educating me about osteoporosis, I was asked to evaluate a patient with an MS diagnosis who was in a wheelchair and was rapidly worsening.  Through my initial evaluation of her, we made an important finding that drastically altered her treatment and her condition.  She told me that she would like me to use her story to educate people with MS and health care professionals.  Over the past 10 years, I have told her story many times.

The woman who I saw had been diagnosed with MS on the basis of her declining leg strength and her head MRI and spinal fluid tests.  In spite of aggressive MS treatment, over several months her leg weakness progressed to the point that she had to use a wheelchair.  Through my evaluation, we obtained several tests, including MRI scans of her spine.  We found that she had a benign tumor (“meningioma”) that was putting pressure on her spinal cord.  She had surgery to remove the tumor and, remarkably, developed increased strength in her legs and is now able to walk.  More detailed evaluation of her previous testing demonstrated that this testing was misinterpreted and that she actually did not have MS.

It is important to state clearly that this person’s situation is unusual--she had a spinal cord disease instead of MS.  Her story highlights a more common situation in which spinal cord disease is present in addition to MS.  This combination of diseases may be overlooked because many spinal cord conditions, like MS, produce slowly worsening walking difficulties and weakness of the extremities, especially the legs.

There are many spine diseases that may mimic MS.  One of the more common conditions occurs when pressure is placed on the spinal cord by abnormalities of the spine bones (“vertebrae”), such as arthritis, and bulging of the shock-absorbing material between these bones (“discs”), known as disc bulges or herniation.  Less commonly, the spinal cord may be slowly compressed by growths of tissue, such as fat (“lipomas”) or, as in the person described above, a benign tumor known as a meningioma.  For serious spine conditions, surgery may improve symptoms and may also prevent future difficulties.

The Bottom Line:  Since the spinal cord begins in the high neck area, spinal cord conditions typically produce symptoms, such as weakness or numbness, below the level of the neck.  Thus, spine disease (due to a condition other than MS) should be considered in people with MS who have symptoms below the level of the neck.  The standard diagnostic test is a spine MRI—this may be done on the neck (“cervical spine”), torso (“thoracic spine”), or low back (“lumbosacral spine”).