A Tincture of Time

One of the most frequent e-mail questions I have received is from someone describing their symptoms and wondering whether or not these symptoms could be due to MS.  This, of course, is a common reason for patients to visit an MS Center as well.  Given that MS affects the central nervous system, which controls almost everything we do, almost any neurological symptom could be due to MS.  I have already discussed the diagnostic criteria for MS as defined by the 2010 McDonald Criteria and written in further detail about the use of the MRI and lumbar puncture results in diagnosing MS.  Unfortunately, often times doctors and patients alike are left in an uncertain state even after these tests are done, especially if there is some equivocal finding on the MRI.

Let me then discuss part of the McDonald criteria that does not receive much attention.  This is the part that says in certain patients, in order to diagnosis MS, one should simply “await a second clinical attack.”  For many people, being advised to “wait and see” what happens is not a satisfactory answer.  Patients come to a doctor with a symptom and understandably desire a diagnosis and treatment. Unfortunately, this is not always possible, and sometimes the best thing a doctor can do is observe a patient over time and see what happens. Simply waiting can be a powerful diagnostic tool.  One of my professors in medical school would routinely prescribe a “tincture of time” to help figure out what was wrong with his patients.

If someone believes they have MS and their doctor does not feel that have MS or is unsure of this diagnosis, simply waiting will reveal the diagnosis. Patients with relapsing-remitting MS will eventually go on to have additional relapses, while patients without MS won’t. Additionally, the MRI of patients with MS will eventually show lesions consistent with the illness, so repeating the MRI after a certain amount of time has elapsed is never a bad idea in cases where the diagnosis is not clear.

Patients who are told to wait until time clarifies the diagnosis should know that in almost all such cases, a delay in starting medications will not affect long-term disability. In all but the most severe cases of MS (and certainly in those patients in whom the diagnosis is initially in doubt) disability in MS occurs over years to decades. It is true that most neurologists suggest starting a medication as soon as demyelinating disease is diagnosed, even in patients who do not meet the formal criteria for MS.  However, subjecting a patient to unpleasant, expensive, and sometimes dangerous medications to treat an illness they do not have is a mistake that should be avoided when possible.