Question

The Drummer with Tingling Fingers

Aaron, a 26 year-old musician, visits his physician complaining of tingling in the fingers of his right hand. The feeling is present when he plays his drums as well as at other times of the day and night. Sometimes the tingling is so bad that he has difficulty feeling anything with his right hand and ends up dropping things. He has also noted that his right hand and arm get tired more easily than his left hand. In addition, he has had problems seeing correctly for the past 3 weeks; even during the day or in bright rooms, his overall vision is "darker" than normal. At times he feels like something is crawling over the right side of his face. Finally, Aaron mentions that during the time he has been most worried about these symptoms, his legs have felt weak and he has been tripping over things.

Examination reveals weakness of the rectus muscles of Aaron’s right eye and mild weakness of his right facial muscles. Other muscles are of normal strength. Aaron exhibits normal reflexes, but his right-side reflexes are somewhat greater than those on his left side. The physician suggests that Aaron get more rest and have his eyes checked because he may need glasses. The physician also tells him to return if his condition does not improve.

Three months later, Aaron comes back. In addition to his previous symptoms, he has developed difficulty walking and speaking. Although he frequently feels the need to urinate, he is unable to fully empty his bladder. On this visit, the physical examination shows disturbances in Aaron’s gait—he has become ataxic, and his stance is wider than normal. His superficial reflexes are diminished, and his deep tendon reflexes are exaggerated. Bases on these signs, the physician orders MRI scans and a spinal tap. The MRI results show areas of demyelination and plaques in the white matter of the brain. When the CSF is analyzed, elevated concentrations of leukocytes, protein, and antibodies are found, and myelin basic protein is present. These results lead to a diagnosis of multiple sclerosis.

Why is multiple sclerosis not diagnosed initially?

Answer 1

The initial absence of definitive diagnostic markers for multiple sclerosis (MS) in the clinical presentation and diagnostic tests led to a delay in the MS diagnosis until more symptoms and precise test results emerged.

Step-by-step explanation:

Multiple sclerosis (MS) was not diagnosed initially because early symptoms can be nonspecific and may resemble other medical conditions. Initially, Aaron's symptoms such as tingling in the fingers, fatigue, weakness, and vision problems did not definitively indicate MS, which often requires evidence of dissemination in time and space of neurological symptoms to confirm the diagnosis. In the absence of more clear-cut markers for MS, like lesions visible on an MRI or specific findings in a spinal tap, a diagnosis of MS could not be confidently made.

Only after the symptoms persisted and new ones developed, and diagnostic tests such as the MRI showed areas of demyelination and elevated biomarkers of immune activity in the cerebrospinal fluid (CSF), was it possible to make a definitive diagnosis of MS.