Upstate doctor published in Journal of Neurological Sciences
June 1, 2015
GREENVILLE, SC – The Journal of Neurological Sciences recently published an article that urges physicians to rethink the early diagnosis for multiple sclerosis (MS), written by Dr. Jagannadha R. Avasarala of Greenville Health System’s Neurology Associates.
The article is important because Dr. Avasarala calls for a change in the way that MS is initially diagnosed; Dr. Avasarala notes that by ignoring data on cerebrospinal fluid (CSF) as it is now done, the diagnosis of clinically isolated syndrome (CIS), which is defined as the first presentation of neurological symptoms suggestive of (MS), may be missed.
To be considered CIS, the symptoms—typically optic neuritis or transverse myelitis—need to be isolated in time and accompanied by MRI evidence of demyelination.
“This is something that patients need to know,” he said. “Failure to accurately identify patients with CIS represents a missed opportunity. While the lumbar puncture necessary for testing CSF may present some risk, I believe the risk is dwarfed by the potential benefit of early treatment.
Avasarala cites a review article in Lancet Neurology in 2012, by Miller, Chard, and Ciccarelli of University College London that showed that 20 percent of patients do not have typical MRI evidence of the disease. This means that it is likely medical community is failing to identify 20 percent of patients who will go on to develop clinically definite MS, he says. Early treatment favors better long-term outcomes. Delay or no treatment early affects African-American patients disproportionately, in whom transverse myelitis is typically the first symptom. In contrast, optic neuritis is typically the first symptom of CIS in Caucasian patients.
However, Avasarala said there is a relatively simple and rational way to address this problem.
According to a 2008 study by Tintore et al., 23 percent of patients who had normal MRI findings but were found to have oligoclonal bands in their cerebrospinal fluid (CSF) went on to develop clinically definite MS. In addition, a 2006 study by Masjuan et al. shows the presence of more than two oligoclonal bands in the CSF has a positive predictive value of 97 percent, a sensitivity of 91 percent, and specificity of 94 percent for developing MS after CIS.
“We must include CSF data in the formal diagnostic criteria of CIS,” he says. “African-American populations typically have a higher disease burden in MS, and these patients tend to recover more poorly from relapses and hence it is crucial not to miss options to treat the disease early.”
About Greenville Health System (GHS) – www.ghs.org
South Carolina’s largest healthcare system and the nation’s newest named academic health center is committed to advancing patient care through breakthroughs in healthcare delivery, access and affordability. To support these efforts, GHS launched the Greenville Health Research Development Corporation (RDC), a not-for-profit supporting entity, to further bolster the health system’s commitment to the communities it serves through technology transfer, business development, and economic development projects, such as IMED. IMED – Innovations in Medical Economic Development – is a visionary public-private initiative created to support and accelerate the development of a growing life sciences and healthcare industry cluster in South Carolina that will expand the regional economy and generate quality jobs. GHS and RDC provide strategic leadership and administrative support for IMED. The centerpiece of the vision will be the long-term establishment of the IMED corridor, to include a series of innovation campuses in Greenville County which will be home to biomedical and life sciences start-ups and established businesses in coming years.
