Is the Diagnosis Lupus or Multiple Sclerosis?
I recently spoke with a woman who had been diagnosed with systemic lupus erythematosus (lupus), but several months later she was told her diagnosis was multiple sclerosis instead. How could the doctors get it wrong, she wanted to know?
Fortunately, she spoke with a physician who took the time to explain how it can be difficult to make an accurate diagnosis during the early stages of the disease. Although she was not pleased with the misdiagnosis and delay in getting a correct one, overall, she was glad to have an answer so she can take the actions necessary to live her life to its fullest. Unfortunately, her experience is not unusual.
Diagnosis of multiple sclerosis can be a challenge. If you talk to men and women who are going through the diagnostic ordeal or who have already done so, they will likely tell you it is so. One of those challenges may include distinguishing between lupus and multiple sclerosis.
Systemic lupus erythematosus
Systemic lupus erythematosus (SLE) is a chronic, inflammatory autoimmune disorder that can affect the skin, joints, kidneys, lungs, blood vessels, nervous system, and other organs of the body. Multiple sclerosis likewise is a chronic, inflammatory, autoimmune (although some experts dispute the latter claim) condition that affects the central nervous system and a host of bodily functions.
Both conditions typically appear during the second to fourth decade and are more common among women. In addition, both have some similar symptoms in the early stages. Multiple sclerosis, for example, often (but not always) presents with
- Double or blurry vision
- Problems with memory or thinking
- Lack of coordination
- Balance problems
- Numbness and/or tingling
- Weakness in the legs and/or arms
Lupus also typically has several of the same early symptoms, plus a few others. For example:
- Memory problems
- Swelling, stiffness, and pain in the joints (arthritis)
- Butterfly rash on the face (less than 50% of people have this rash)
- Other rashes
- Chest pain and/or shortness of breath
Since the early stages of both conditions share some symptoms and many people only have a few of them in the beginning, this can cast a shadow over the ability to make an accurate diagnosis. For example, although a rash and arthritic symptoms are common in early lupus, some individuals don’t develop them until later in the course of the disease.
One step individuals can take to assist in the diagnostic process is to write down as many details as possible about their symptoms and other information associated with them, such as:
- When the symptoms started and frequency
- Severity and patterns of occurrence (e.g., only during the day or at night, cyclical—such as following a menstrual cycle—or when exposed to temperature changes)
- Events or circumstances that occurred around the same time, such as travel to another country, exposure to toxins, exceptionally stressful situations
- Changes in diet or dietary issues
- Any injuries that occurred such as falls, insect or other bites, cuts or bruises, other trauma
- Changes in the use of medications and/or supplements
If you have difficulty remembering any of these items or other situations that could have an impact on your health, ask your spouse, friends, or family to help you. Also make notes about your personal and family health histories.
Keep all your notes and take them with you to your doctor. If you have any questions about your symptoms, write those down as well. Also bring along a list of any medications and supplements you are taking. Be fully prepared when you see your doctor.
Another factor that can complicate the diagnostic process is that lupus and multiple sclerosis can be present at the same time. In addition, occasionally individuals who have lupus develop transverse myelitis or optic neuritis. These events indicate another condition called neuromyelitis optica, which is similar to but not the same as multiple sclerosis.
Diagnosing lupus and multiple sclerosis
Doctors often use an antinuclear antibody (ANA) test to help them confirm a diagnosis of lupus. Although the ANA is not specifically for lupus, it is capable of detecting the antibodies in 97 percent of individuals who have the disease.
Unfortunately, multiple sclerosis can also cause positive results on this test while some people with lupus can have negative results. In fact, the ANA test can be positive in people who have other conditions or none at all.
Along with the ANA test, doctors also can look for other special antibodies when considering lupus, some of which include the following:
- Double-stranded DNA, which are present in about 50 percent of people who have lupus. Someone with a negative result on this test may still have lupus, however.
- Histone, a protein. Antibodies to histone are typically seen in people who have drug-induced lupus.
- Sm proteins, which reside in the nucleus of cells. Antibodies to Sm are found in 30 to 40 percent of people who have lupus.
- Phospholipids, including antibodies to lupus anticoagulant, anticardiolipin and anti-beta2 glycoprotein 1. Nearly one third of people with lupus have a positive test result for antiphospholipid antibodies.
Doctors may also conduct other blood tests when looking for lupus, such as C-reactive protein, complement, and erythrocyte sedimentation rate, all of which are indicators of inflammation. Urine tests can be done to determine if there is any impact on kidney function, which is a sign of lupus.
One of the most helpful tests when exploring a diagnosis of multiple sclerosis is a magnetic resonance imaging (MRI) test. An MRI can reveal the presence of lesions (demyelination) on the spinal cord, which is indicative of MS.
However, this approach is not foolproof, as about 5 percent of people who seem to have MS based on other symptoms do not initially show lesions on their MRI early in the discovery process. An MRI may need to be repeated one or more times to see if lesions develop. If they do not, then a diagnosis of MS is questionable.
If lesions are seen in multiple sites in the central nervous system over time and no other diagnosis fits, then MS is likely. An MRI is also capable of showing other abnormalities such as growths that could cause symptoms that make it look like a person has MS. Another factor to consider is that some lesions observed on an MRI may reside in areas of the brain that don’t produce symptoms, which means it is not always possible to make draw definite conclusions between the MRI and an individual’s signs and symptoms.
Evaluation of the spinal fluid also can help with diagnosis. Individuals with multiple sclerosis usually have elevated levels of immunoglobulin G antibodies in their cerebrospinal fluid, as well as certain proteins (oligoclonal bands) and the metabolic waste products from myelin. However, up to 10 percent of people with MS do not show these signs in their cerebrospinal fluid, so this test cannot be used alone to diagnose multiple sclerosis.
Two other tests can assist in diagnosing multiple sclerosis. Evoked potential studies measure how the nervous system responds to auditory, sensory, and visual input. Nerve conduction studies measure how fast electrical impulses travel along a nerve in the legs or arms. Both of these tests also can be used to diagnose conditions that mimic multiple sclerosis.
Reaching an accurate diagnosis of lupus or multiple sclerosis (or another condition that mimics MS) can be a challenge. If you work with your healthcare professionals by providing as much information as possible and educating yourself about the possible alternative conditions, you can increase your chances of getting a faster, proper diagnosis.
Lupus Foundation of America
Magro Checa C et al. Demyelinating disease in SLE: is it multiple sclerosis or lupus? Best Practice & Research. Clinical Rheumatology 2013 Jun; 27(3): 405-24
Multiple Sclerosis Society