The first part of this newsletter introduced the idea of “Hidden Diseases” of MS, and provided information about two of these Hidden Diseases, osteoporosis and spine disease.  This newsletter will review several other Hidden Diseases.

Vitamin B12 Deficiency
Vitamin B12 is important for maintaining normal nerve function.  Deficiencies of this vitamin produce MS-like symptoms, such as fatigue, tingling, and numbness.  Severe deficiencies cause weakness and walking difficulties.

Importantly, there may be a small subgroup of people with MS who have vitamin B12 deficiency.  For these people, it may be impossible to distinguish between symptoms that are due to MS and those that are caused by vitamin B12 deficiency.  As a result, it is important to identify and treat deficiencies so that this is not a confounding issue when trying to monitor or treat MS.

Vitamin B12 deficiency may be diagnosed with simple blood tests.  There are established normal ranges for the blood levels of this vitamin.  People with levels that are below the normal range may experience serious symptoms and should definitely be treated.  In addition, those with levels that are in the low end of the normal range may have mild symptoms and may also benefit from treatment.

Treatment for vitamin B12 deficiency is with oral or injected preparations of the vitamin.  For severe deficiency, initial treatment should be with injections.  Subsequently, oral vitamin B12 may be taken.  For mild deficiency, oral vitamin B12 is probably adequate.  For any type of vitamin B12 deficiency, lifetime treatment is often necessary and follow-up vitamin B12 testing should be done on an intermittent basis.

The Bottom Line:  Most people with MS do not have vitamin B12 deficiency.  However, without a blood test, it is impossible to determine whether a person with MS also has vitamin B12 deficiency.  As a result, in my opinion, everyone with MS should have a blood test for vitamin B12 deficiency.

Thyroid Disease
Like vitamin B12 deficiency, thyroid disease is a condition to which people with MS are vulnerable.  In addition, it may be difficult to recognize thyroid disease in someone with MS because the symptoms of MS, especially fatigue, resemble those of thyroid disease. 

The thyroid gland produces a hormone that regulates the metabolic activity of various organs of the body.  Low levels of thyroid hormone, which is known as “hypothyroidism,” produce multiple symptoms, including fatigue.  If someone with MS is experiencing fatigue, it may be quickly assumed that the fatigue is due to MS and little or no consideration may be given to other fatigue-producing conditions, including hypothyroidism.  In addition to fatigue, hypothyroidism may cause constipation, weight gain, and dry hair and skin. 

“Hyperthyroidism,” which is due to high levels of thyroid hormone, causes anxiety, tremor, sensitivity to warm temperatures, and weight loss.

People with MS are prone to thyroid disease for various reasons.  MS is believed to be an “autoimmune disease,” which means that the immune system mistakenly attacks the body.  Those with MS are at increased risk for developing other autoimmune diseases, which include some forms of thyroid disease.  Also, the interferons that are used to treat MS (Avonex, Betaseron, Rebif) may cause hypothyroidism or hyperthyroidism.

Thyroid disease is generally straightforward to diagnose and treat.  Blood tests are typically used to diagnose the condition.  For hypothyroidism, thyroid hormone may be taken as pills.  For hyperthyroidism, there are several medication-based approaches.

The Bottom Line:  Since people with MS are prone to thyroid disease and it may be difficult to distinguish thyroid disease from MS, all people with MS should be tested at least once for this condition.  Intermittent thyroid monitoring should be considered in people with significant fatigue or in those who are treated with interferons (Avonex, Betaseron, Rebif).

Very Rare Spine Diseases
“Part I” of this newsletter considered common forms of spine disease that should be considered in many people with MS.  There are other, rarer forms of spine disease that should be considered in some, but not all, people with MS.

For some people who are believed to have MS, it may be difficult to actually make a definitive diagnosis of MS.  Among these people, some may have MS-like lesions in the spinal cord and, consequently, may have walking difficulty and weakness or changes in sensation in the arms and legs.  For these people, there are diseases other than MS that should be considered.  It is important to diagnose these conditions because their treatment is very different than that of MS.

These conditions include:

  • “NMO” (or “neuromyelitis optica”):  this condition, which is characterized by weakness of the arms or legs and visual difficulties, may be diagnosed with MRI and a specific blood test.
  • “Sjogren’s syndrome”:  this inflammatory disorder, diagnosed with a blood test, may cause spinal cord abnormalities as well as dry eyes and dry mouth.
  • Copper deficiency:  this recently identified disease is diagnosed with blood tests and causes tingling in the legs and walking instability.
  • Spinal cord “AVMs”: (arteriovenous malformations):  this disorder, caused by abnormal blood vessels (AVMs) in the spine, is typically diagnosed with a special test known as an “angiogram.”


The Bottom Line:  Most people with MS do not need to be evaluated for these conditions.  These disorders should be considered in those with an uncertain MS diagnosis and symptoms suggestive of spinal cord disease (such as walking problems and sensory changes or weakness in the arms or legs).

Other Rare Conditions
In addition to “very rare spine diseases,” there are other rare conditions which should be considered in people who are thought to have MS but who do not actually have a definitive diagnosis.  These conditions, which do not need to be considered in everyone with an MS diagnosis, include some rare and exotic disorders, such as Lyme disease, lupus, and other inflammatory conditions. 

The Bottom Line:  These conditions should be considered in those who do not have a definitive MS diagnosis and who have symptoms, diagnostic tests, or other findings that suggest some other disease process.

Summary
People with MS may develop “Hidden Diseases,” conditions which may be overlooked for a variety of reasons.  It is beneficial to diagnose and treat these conditions.  Working with a health provider, it is essential to consider these disorders within the context of one’s individual situation.  All people with MS should be considered for an evaluation for osteoporosis, thyroid disease, and vitamin B12 deficiency. 

For those with walking difficulty or weakness or numbness of the arms or legs, spine diseases should be considered.  Finally, for those who do not have a definitive diagnosis, the rarer disorders (“very rare spine diseases” and “other rare conditions”) should also be considered.  To discuss these “Hidden Diseases” with your health provider, it may be helpful to bring a copy of this newsletter to your next medical appointment.

See Related Articles
Learn more about reducing the side effects of Multiple Sclerosis (MS) and Osteoporosis, in Osteoporosis and Other "Hidden Diseases" in MS: Part One.

See MS Treatment: Advances in MS Therapy for more information about currently approved Multiple Sclerosis (MS) medications and therapies.