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The Lyndonville Journal: Multiple Sclerosis and Chronic Fatigue Syndrome David S. Bell, MD, FAAP Published in Lyndonville News, March 1999 For the majority of patients with CFS, the diagnosis is relatively simple. The pattern of fatigue, malaise, muscle and joint pain, headaches and cognitive problems makes the diagnosis if standard blood tests are normal. There is really no other illness quite like it. The pattern of CFS is so distinct that patients are easily able to recognize it in others. But some patients have symptoms that are weighted more toward the neurological and the distinction between CFS and multiple sclerosis (MS) becomes difficult. I recently saw a patient who has been to about twenty physicians. Some said she had MS, some said CFS, and some that she was a fruitcake. In this person the thin line between CFS and MS became blurred, a very important distinction as treatment options for MS differ widely from those of CFS. After evaluating this pleasant woman, I was still not sure whether the proper diagnosis was CFS or MS, but she definitely was not a fruitcake. I will never understand why so many physicians insist on this diagnosis when they are baffled. The purpose of this article is to note the differences between MS and CFS for the minority of patients where there is confusion. Fatigue is usually different in MS than CFS. Typically the fatigue of CFS is a crushing exhaustion, while the fatigue of MS is more of a "burned-out" tiredness. The diagnosis of MS is made mostly by the true muscle weakness, muscle atrophy, and abnormal reflexes, rarely seen in CFS. MS rarely has muscle pain, temperature regulatory disturbances, sore throat, lymph node pain, and abdominal pain. But the symptoms of some patients may be strikingly similar. When symptoms are heavily neurologic, laboratory testing is useful in distinguishing between the two illnesses. In CFS the MRI scan of the brain may have small punctuate areas of high intensity, but not the big blotches of MS. While these high intensity areas are of questionable significance in CFS, the big areas of MS are not. It is rare that the high intensity areas are midway between CFS and MS, but it does happen. Visual evoked response and brain stem evoked responses are usually normal in CFS and abnormal in MS. If a patient has true optic neuritis, MS is the diagnosis. It should be noted that CFS patients have many eye symptoms, but eye examination is normal, without true optic neuritis. And most importantly, the spinal fluid of MS patients contains "oligoclonal bands" something that is not found in CFS. By itself this is probably the single most important differentiating factor, but it requires a spinal tap. If the diagnosis of MS is in doubt I would usually suggest a spinal tap to clarify the issue. While a spinal tap is not much fun, it should be able to help with the diagnosis. In summary, the separation would be as follows: Illness CFS / MS Symptoms: Fatigue +/ + Physical examination: Pallor + /+ Laboratory: Visual evoked response - / + Making a list like this makes it look as if there is no difficulty in separating the two illnesses, and in the usual cases, it is not. Usually, the diagnosis is clear, and it is rarely that confusion exists. But I have seen about five patients where, to this day, I cannot say whether it is CFS or MS. In 1988 Dr. Carolyn Warner did a study on about fifteen patients evaluated in our office, patients that were selected because they had prominent neurologic symptoms. Nearly all had at least one MS abnormality on laboratory testing, but none really fit the diagnostic criteria for MS. (1) Most importantly, to my knowledge, none have developed true MS in the ten years that have followed. And for this reason I would consider CFS and MS as completely different pathological processes. But it raises a question. If in some patients the diagnosis is so difficult, could there be a link between the two? Multiple sclerosis is an illness in which an immunologic abnormality has created plaques in the brain, which disrupt neurologic function. There has long been the assumption or hypothesis that an infectious agent is responsible for this process, but this agent has not been found. Could it be that the same agent is responsible for both CFS and MS, the difference being that the former does not develop the sclerotic plaques and the latter has? A single organism causing different illnesses is not unusual. For example the strep germ can cause no illness, strep throat, scarlet fever, rheumatic fever and glomerulonephritis. They are differences caused by the body's differing reactions to the same bacteria. (Strain differences are also important) But the point remains and must be kept in the realm of possibility: can there be a relationship between CFS and MS? Lyndonville is in the middle of the "MS belt", an area known for the high incidence of MS. Is it a coincidence that there have been three separate descriptions of CFS in this same area? If someday an organism is found to be responsible for MS, it will be easy to answer this question.
1. Warner CL, Cookfair DL, Heffner RR, Bell DS, Ley D, Jacobs L. Neurologic abnormalities in the chronic fatigue syndrome [Abstract]. Neurology 1989; 39 (S1):420.
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