Ask the Doctor
By Dr. Jack Burks
Chief Medical Officer for MSAA
Dr. Jack Burks
Distinguishing a Diagnosis of Lupus from MS
Q: My daughter was diagnosed with lupus, and then diagnosed with MS on the very next day. She was treated for MS and put on a disease-modifying therapy, but she had a reaction to the shots and needed to discontinue her treatment. After seeing many doctors in Tampa (including the specialists at the University of South Florida), we were finally able to go to Mayo Clinic in Minnesota.
She had lesions on the front right of her brain, which have affected her short-term memory, and at times, her emotions. At Mayo, they are pretty sure about the lupus, but not as sure about the MS. She has had three spinal taps and no bands have shown up on any of them. The doctors at Mayo said she is a very difficult case.
She has received almost a year of chemotherapy (which is the maximum), and while she seemed to be doing better at first, she has progressively gotten worse over the last few months. Is it possible that my daughter does have MS as well as lupus, and the MS is causing her elevated numbers on the blood tests, even though she is on the chemo?
Do you have any suggestions for where we should go or what we can do from here? We are wondering if the lupus and MS are fighting each other, and if anything can be done to treat both.
A: You are right in that your daughter presents the sometimes difficult task of diagnosing MS in the presence of a lupus diagnosis. It would be unusual that lupus and MS might affect someone at the same time, but it is possible. Young women are more prone than men to develop these conditions.
In distinguishing these two diseases, MS is limited to the central nervous system, while lupus may also affect the skin, joints, heart, and other organs. However, lupus can affect the brain only and resemble MS initially. Specific blood tests for lupus may be helpful in differentiating these two diseases. MS cannot be detected through blood tests at this time, although some MS patients can have blood-test abnormalities resembling lupus. MS and lupus both involve an over-active immune system.
You have explained that your daughter has been given chemotherapy, although I don't know which type specifically. Some chemotherapies are helpful in both illnesses. In addition, steroids can help with both conditions during acute flare-ups.
I am not able to give specific patient-related opinions without a complete evaluation. However, if her doctors are puzzled in regards to therapy, you can always seek other opinions. For example, in addition to Mayo Clinic in Minnesota, Mayo Clinic in Jacksonville, Florida has expertise in multiple sclerosis.
The book, Lupus Q & A, Everything You Need to Know, by Robert G. Lahita, MD, PhD, and Robert H. Phillips, PhD (Avery, 2004) may be a useful resource and is available through MSAA's free Lending Library. This publication is featured in this issue's Spread the Word column, where you will also find instructions for borrowing a copy of the book.
Q: My husband was exposed to Agent Orange in Vietnam, but the VA still denies this causes MS. About a year ago we learned that while we were living at Camp Lejeune, the well water was contaminated by chemicals from a dry cleaning plant adjacent to the base. Could this have caused his MS?
A: Toxic exposure has been suspected in many "outbreaks" of MS. Extensive investigations have not proven any cause and effect. However, I would ask your State Health Department or the federal agency called the Center for Disease Control (CDC) in Atlanta for guidance. You may visit their website at www.cdc.gov, or call them at (800) 232-4636. If your husband's MS symptoms began within seven years of military discharge, he may be eligible for "service connected disability" for his MS. The Paralyzed Veterans of America (PVA) may also be able to help you. For more information, you may visit their website at www.pva.org or call them at (800) 555-9140.
Q: I am 80 years old and was diagnosed with MS 23 years ago. I have been on Betaseron® (interferon beta-1b) since 1993 and I am able to walk for short distances with a walker or two canes. However, I have problems sleeping most nights. I hesitate to take drugs, but occasionally take an over-the-counter sleeping aid such as Excedrin PM®, which is somewhat helpful. It seems like I have no trouble napping in the day time for short periods of time. Do you have any suggestions?
A: When I read your question, my first thought was "congratulations." At age 80, you are still walking after 23 years of MS and 16 years on DMT's. AND, you're still actively seeking help to make your life better.
In brief, I believe that sleep disturbances in MS are more common than recognized. Some problems that you are experiencing may be directly related to MS, but many can be related to other issues such as sleep apnea, medications, heart failure, depression, anxiety, and/or other factors which can be identified by sleep disorder experts.
Your doctor can help you to find experts in your area for these types of conditions. The diagnosis is important before settling on a specific treatment. The occasional use of sleeping pills may be helpful, but continued use can lead to loss of effectiveness, and other side effects are possible.
I can also refer you to this issue's Symptom Awareness column of this issue. This article discusses the strategies and treatments for improving sleep, as well as the health benefits that sleep provides. MSAA also has books on these topics, which may be borrowed at no charge through MSAA's Lending Library. For more information, please refer to this issue's Spread the Word column.
Q: I was diagnosed with relapsing-remitting MS in 2008. My initial acute symptoms of numbness from my knees on down were improved somewhat with a three-day IV of Solu-Medrol® (intravenous steroids), followed by a tapered dosage of (oral) prednisone for 12 days. While that improved the symptoms somewhat, I never fully regained feeling in this area - although my balance has improved considerably.
I am currently taking Copaxone® (glatiramer acetate) injections daily and a six-month follow-up did not show any progression of the disease. There are days where the numbness is worse than others, and I'm wondering if another Solu-Medrol IV treatment would improve this, or if this is as good as it gets? Since this is all new to me, I am unclear as to when, or if, further Solu-Medrol IV treatment should be sought.
A: Solu-Medrol IV treatment is used when there is evidence of a new MS relapse, as indicated by new MS symptoms or worsening of one or more previous MS symptoms lasting at least two days. However, other factors must be considered. For example, a urinary tract infection without obvious bladder symptoms, may cause a similar increase in MS symptoms. This is called a "pseudo MS relapse."
Unless you are experiencing a true MS relapse (also referred to as an "exacerbation"), IV steroids such as Solu-Medrol are not usually recommended. These are best reserved for times of documented disease flare-ups. IV steroids have been shown to speed the recovery time from an exacerbation, but their long-term benefits have not been established. Therefore, disease-modifying therapies (DMTs), such as the one you are taking, are advised for most individuals with relapsing forms of MS.
Aside from Solu-Medrol, symptomatic medications can sometimes be helpful if your numbness creates a painful sensation. Your doctor can give you specific recommendations. A drug called Neurontin® (gabapentin) is often my first line of therapy for these painful numbness symptoms.
Q: I have had MS for 25 years and have suffered from severe vertigo during the last few months. My neurologist has put me on both Antivert® (meclizine) and Valium® (diazepam). Neither has helped me. Now my neurologist wants me to see a physical therapist for some help. Have you ever heard of this? How would that help with my vertigo?
A: Dizziness and vertigo can often be symptoms of MS. However, there are other causes of these symptoms as well. When I hear your symptoms, I ask myself if there may be another diagnosis which is not related to MS. For example, dizziness or light-headedness can result from side effects from certain medications; allergies; low blood sugar; low blood pressure; anemia; thyroid problems; ear infections; anxiety; and less commonly, heart problems. Vertigo may be caused by inner ear disorders (such as Ménière's disease) or other conditions, such as migraine headaches.
Different systems within the body and brain work together to keep an individual balanced. These include vision, sensory functions, and functions of the inner ear. When signals are affected between the systems, one's balance can be affected.
In regard to the medications you were prescribed, these are the standard treatments for dizziness and vertigo. These symptoms may indicate an exacerbation of your MS, in which case your doctor may consider a course of steroid therapy. On the other hand, you should also look into the other causes of such symptoms to make sure you are not experiencing any of the conditions mentioned earlier.
Yes, treatments for dizziness and vertigo can include rehabilitation therapy. In fact, some rehabilitation therapists specialize in treating these symptoms. They try to improve balance by using certain types of equipment or other techniques aimed at retraining the areas of the brain that send signals to assist with balance.
Q: I was diagnosed with MS in 2004. I recently was changed to a different insurance company which does not cover Provigil® (modafinil) for the treatment of my MS-related fatigue. My doctor substituted Ritalin® (methylphenidate). I have noticed a difference in my fatigue. What are your thoughts?
A: Provigil is now being covered by most insurance companies, although many require a preauthorization from your healthcare professional, who must contact the insurance company directly. If Provigil is not covered, a new drug, Nuvigil® (armodafinil), which is similar to Provigil, may be covered. Check with your doctor to see if this drug is appropriate for you.
You mention that you have noticed a difference in your fatigue since taking the Ritalin. (From your original question, I believe you were given "methylphenidate," which is the generic version of Ritalin.) I am assuming that by "difference," you mean an improvement? If so, I am happy that you have a treatment that may be helping you. If not, you and your doctor will need to discuss other treatment options.
While drugs for fatigue may be of help, they do have limitations. For instance, side effects can be a concern, and their effectiveness can diminish over time. Other strategies for treating fatigue may also be of help to you. These include improving sleep, reducing stress, treating depression and anxiety, energy conservation, exercise, avoiding heat, and using cooling therapies.
Many neurologists and MS centers in your area are familiar with various treatments for fatigue. To find the nearest center to you, please visit www.mscare.org (once on this site, roll the mouse over the "CMSC Online" heading for the dropdown menu, then roll over "About CMSC" for another dropdown menu, and then select "Center Directory"). If you do not have internet access, you may speak with an MSAA Helpline consultant by calling (800) 532-7667. He or she can provide information to you about local MS centers.
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Questions for Ask the Doctor
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Jack Burks, MD is the chief medical officer for MSAA. He is a neurologist and the director of program development at the Multiple Sclerosis Comprehensive Care Center, Holy Name Hospital, in Teaneck, New Jersey. Dr. Burks is a member of the Clinical Advisory Board of the NMSS. He has written and edited three MS textbooks, as well as numerous chapters and articles on MS. In recent years, he has lectured and evaluated patients in more than 30 countries.