A number of other interesting manifestations of MS have come to attention over the years and have given rise to difficulties in diagnosis. The occurrence of typical tic douloureux in young patients has already been mentioned; only their young age and the bilaterality of the pain in some of them raised the suspicion of MS, confirmed later by sensory loss in the face and other neurologic signs. It is notable, however, that facial palsy along the lines of Bell’s palsy is almost never a sign of MS. Brachial, thoracic, or lumbosacral pain consisting mainly of thermal and algesic dysesthesias was a source of puzzlement in several of our patients until additional lesions developed. In 2 of our cases, the relatively acute occurrence of a right hemiplegia and aphasia first raised the probability of a cerebrovascular lesion; in still others, a more slowly evolving hemiplegia had led to an initial diagnosis of a cerebral tumor. Several times we have seen coma during relapse of longstanding MS, including in children, and in each instance it continued to death but that was in the era before aggressive treatment of inflammatory demyelination was available. In one case it occurred in a 64-year-old woman who had had 2 previous episodes of nondisabling spinal MS at 30 and 44 years of age. A confusional state with drowsiness was the initial syndrome in another patient whom we saw later with a relapse involving the cerebellum and spinal cord.
There may be a slightly increased incidence of seizures in patients with MS but the frequency of the problem varies greatly among studies. It should be emphasized that seizures are usually in relation to an obvious cerebral lesion and advanced disease of many years’ duration. Seizures at an early stage of illness are almost always attributable to previous head injury, idiopathic epilepsy, or withdrawal of sleep medication, but not to MS.
While there is little question that a febrile illness such as urinary infection can exaggerate or unmask existing symptoms from MS, there is debate about whether a new relapse can be triggered by possible precipitating factors such as infection or trauma. The incidence of respiratory, urinary, or gastrointestinal viral infections that precede the onset or exacerbations of the disease varies greatly in different series, from 5 to 50 percent; however, in our view, none of these has been convincingly related to an increased risk of new attacks of MS. We have had experience with 2 patients who regularly had acute exacerbations of MS following each outbreak of labial genital herpes. The swine influenza vaccine, which was given to 45 million persons in the United States in late 1976, caused a slight increase in the incidence of Guillain-Barré disease but not of MS (Kurland et al), and more recent surveys of immunization programs, such as the one by Confavreux and colleagues (2001), have shown similar results.
The possible role of trauma in precipitating MS is more difficult to assess. McAlpine and Compston found that the incidence of trauma within a 3-month period preceding the onset of MS was slightly greater than in a control group of hospital patients. Furthermore, there appeared to be a relationship between the site of the injury and the site of initial symptoms, particularly in patients who developed symptoms within a week of injury. We do not find this evidence convincing, particularly when given as an explanation for a large number of attacks. Other forms of trauma (including lumbar puncture and general surgical procedures) that occur after the onset of the neurologic disorder have not been shown to have an adverse effect on the course of the illness. Matthews, who has extensive personal experience with survivors of penetrating head wounds, did not find a single instance of MS among them. One of the most meaningful prospective studies of the relation of physical injury to MS is that of Sibley and colleagues, who followed 170 MS patients and 134 controls for an average of 5 years, during which they recorded all (1,407) instances of trauma and measured their effects on exacerbation rate and progression of the disease. With the possible exception of a case or 2 of electrical injury, there was no correlation between traumatic episodes and exacerbations.