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  1. Neil Scolding
  1. Professor Neil Scolding, Institute of Clinical Neurosciences, Department of Neurology, University of Bristol, Frenchay Hospital, Bristol BS16 1LE UK n.j.scolding{at}

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In most cases, the diagnosis of multiple sclerosis (MS) presents few difficulties. Clinical evidence of lesions disseminated in time and space, backed up by magnetic resonance imaging (MRI) and/or spinal fluid changes, commonly leave neither room nor reason for doubt. Occasionally, however, a rogue erythrocyte sedimentation rate (ESR), an atypical (or normal) MRI scan, or an unexpected symptom or sign—fever, rash, headache, fits, etc (table 1)—give rise to doubt.

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Table 1

Features which might lead to doubt concerning a diagnosis of multple sclerosis

The absence of diagnostic tests means that uncertainty can be extremely difficult to resolve. MRI, spinal fluid examination, and evoked potential recordings are sensitive tests for MS but do not have comparable specificity. The range of disorders thatcan mimic MS is vast; as the prototypical inflammatory demyelinating disorder, it may be confused with both unrelated demyelinating diseases (metabolic or inherited) and unrelated inflammatory disease; additionally, diseases which are directly related to MS must also be considered. To offer a systematic account of all would be unrealistic, and not a little unreadable. Therefore, only a few comments relating to salient clinical features or discriminating investigations will be mentioned.



A number of disorders are clearly related to MS, while nevertheless remaining distinct. Some, such as optic neuritis, appear pathologically identical, but are disseminated in neither time nor space. Whether they herald MS is plainly of huge importance to patients, who are now sufficiently informed to know of and fear this possibility. There is here a lacune in the neurological lexicon. It would be helpful to call upon a collective term for acute monophasic and monofocal syndromes that are seen in MS—idiopathic optic neuritis, sensory myelitis, and many others (after including, one suspects, episodes dismissed as labyrinthitis, trigeminal neuralgia, and Bell's palsy)—but which do not develop into MS. “Benign focal inflammatory …

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