Case Study: Dysautonomia or MS?

Found on Neurology Web Forum of Massachusetts General Hospital (9/23/98)
From: http://dem0nmac.mgh.harvard.edu/forum/AutonomicF/9.23.984.09PMMistakeDysautonom (note: this site is dated and the formatting has changed, so I reconstructed the web page. Click Here.)

This is the patient's account of his/her symptoms:

I need an expert...To me symptoms are not adding up. I was diagnosed as having dysautonomia. I am wondering if I was misdiagnosed. My MRI (10 yrs ago) was normal, spinal fluid for oligobands normal and fluid normal in all other ways. … The things that were not normal are: anti-mylelin IgG was positive and the anti-myelin IgM was positive. Also my standing catecholamines were excessively increased. These are some of my symptoms: dizziness, balance problems, bladder problems, eyeball pain, double vision, nystagmus, severe vascular headaches, symptoms get worse in heat and sultry weather, muscle twitching, involuntary jerking, weakness, wasting, electrical shooting pains down both legs and sides of legs, memory loss, continuous parasthesia, numbness, gastrointestinal problems, breathing weakness, heart beating real fast and too low at other times. What seems so strange to me is that a leg or something will be affected and then get better only to get worse next time it happens. Do you have nystagmus, double vision, ocular neuritis with dysautonomia? Is it possible that I have MS but the autonomic nervous has been severely affected? Is that possible based on what I said? Please someone with some expert advice, come forward...The MRI was done only on the brain. Should it have been done on the spine also?????? I sincerely appreciate anyone's time and effort that it tookto respond.

(Note: I've modified the original post, took out misspellings, etc)

NOTES/DEFINITIONS

Catecholamines: e.g., norepinephrine and epinephrine belong to the chemical class of catecholamines. In dysautonomia, the levels of catecholamines can be too high or too low.

IgG and IgM are classes of immunoglobins (antibodies). Since multiple sclerosis is due to an immune attack on the the myelin of nerves (central and peripheral nervous system), antibodies to myelin are typically found in cases of MS.

Ocular neuritis = inflammation of the optic nerve.

Nystagmus = lateral twitch-like movements of the eye. May indicate lesions to the cerebellum.

"Oligobanding refers to discrete populations of immunoglobulin detected by electrophoresis in CSF which are NOT paralleled in serum from the same patient. Oligo banding is seen in ~85-95% of patients with clinically proven multiple sclerosis. The assay is useful as a confirmatory test in multiple sclerosis but bands are not specific for this disease as they also occur in cerebrovascular accidents, in infections of the CNS and in pathological processes involving an immune response e.g.: encephalitis, neurosarcoid and SLE. Please note that paired samples of CSF and serum are essential for this assay." From http://rheumb.bham.ac.uk/teaching/clinimmunol/ci_chap9.htm

"Paresthesia if the general medical word for sensory symptoms including pins & needles, fizzing, numbness and yes, vibratory sensations. There are numerous other manifestations of parathesia such as burning, itching, even feeling as if something is crawling on you or biting you." From http://dem0nmac.mgh.harvard.edu/neurowebforum/MultipleSclerosisArticles/Parasthesia.html

CASE STUDY QUESTIONS (From chapter notes)