Incoordination. Intention tremor, dysarthria, truncal ataxia, and oculomotor dysfunction are common. Gait unsteadiness due to motor incoordination is often experienced by the patient as dizziness or lightheadedness. Acute vertigo with nausea, vomiting, and nystagmus can also occur.
Autonomic dysfunction. Bladder dysfunction (p. 156) frequently develops in the course of MS, causing problems such as urinary urgency, incomplete voiding, or urinary incontinence. Urinary tract infection is a not infrequent result. Fecal incontinence (p. 154) is rare, but constipation is common. Sexual dysfunction (e. g., erectile dysfunction or loss of libido) is also common and may be aggravated by spasticity or sensory deficits in the genital region. Psychological factors such as depression, insecurity, and marital conflict often play a role as well. If its cause is organic, sexual dysfunction in MS is usually accompanied by bladder dysfunction.
Behavioral changes. Mental changes (depression, marital conflict, anxiety) and cognitive deficits of variable severity can occur both as a reaction to and as a result of the disease. Paroxysmal phenomena in MS include epileptic seizures, trigeminal neuralgia, attacks of dy-sarthria with ataxia, tonic spasms, episodic dy-sesthesiae, pain, and facial myokymia.
There is no single clinical test, imaging study, or laboratory finding that alone establishes the diagnosis of MS (p. 218; Table 27, p. 375). A meticulous differential diagnostic evaluation is needed in every case.
(Cerebral) Vasculitis (p. 180). Systemic lupus erythematosus, Sjögren syndrome, Behçet syndrome, granulomatous angiitis, polyarteritis nodosa, antiphospholipid syndrome, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP, p. 328).
Inflammatory diseases. Neurosarcoidosis, neu-roborreliosis, neurosyphilis, Whipple disease, postinfectious acute disseminated encephalomyelitis (ADEM), progressive multifocal leukoencephalopathy (PML), subacute sclerosing panencephalitis (SSPE), HIV infection, HTLV-1 infection.
Neurovascular disorders. Arteriovenous fistula of spinal dura mater, cavernoma, CADASIL (p. 172).
Hereditary/metabolic disorders. Spinocerebellar ataxias, adrenoleukodystrophy, endocrine diseases, mitochondrial encephalomyelopathy, vitamin B12 deficiency (funicular myelosis). Tumors of the brain or spinal cord (e.g., lymphoma, glioma, meningioma). Skull base anomalies. Arnold-Chiari malformation, platybasia.
Myelopathy. Cervical myelopathy (spinal stenosis).
Somatoform disturbances in the context of mental illness.
Favorable prognostic indicators in MS include onset before age 40, monosymptomatic onset, absence of cerebellar involvement at onset, rapid resolution of the initial symptom(s), a re-lapsing-remitting course, short duration of relapses, and long-term preservation of the ability to walk. A relatively favorable course is also predicted if, after the first 5 years of illness, the MRI reveals no more than a few, small lesions without rapid radiological progression and the clinical manifestations of cerebellar disease and central paresis are no more than mild. A benign course, defined as a low frequency of recurrences and only mild disability in the first 15 years of illness, is seen in 20-30% of patients. The disease takes a malignant course, with major disability within 5 years, in fewer than 5 % of patients. Half of all MS patients have a second relapse within 2 years of disease onset.
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