An emergency department at an academic medical institution with a multiple sclerosis center missed diagnosing multiple sclerosis in nearly 40% of patients who were later diagnosed with the disease, calling into question what the rate of missed cases might be at smaller centers staffed by fewer specialists.

The retrospective study analyzed assessments for neurologic symptoms during 49 emergency department (ED) visits at the Mount Sinai School of Medicine in New York that were made by 49 people who were later diagnosed with MS. The researchers judged most of those presentations to be initial manifestations of the disease.

Dr. Stephen Krieger
Just 30 of the visits (61%) resulted in a diagnosis of MS or demyelinating disease, either in the ED or on subsequent admission, Dr. Stephen Krieger said at the Fourth Cooperative Meeting on Multiple Sclerosis, which was sponsored by the Consortium of Multiple Sclerosis Centers and the America’s Committee for Treatment and Research in Multiple Sclerosis.

The diagnosis was missed in the remaining 19 (39%) visits, an important finding because early diagnosis and treatment leads to better MS outcomes. About a third of the patients involved in those visits still hadn’t been diagnosed 6 months later. It took more than a year to diagnose a few of them. “Those are the patients we have to look at to see what could have been done differently,” said senior investigator Dr. Krieger, an MS specialist at the Corinne Goldsmith Dickinson Center for MS at Mount Sinai.

The risk of delayed diagnosis seemed to be greatest for men, the middle aged, and those with vague neurologic symptoms – all of whom are nontraditional MS patients – but the study didn’t have enough patients to demonstrate those findings statistically. Patients who were admitted from the ED, however, were more likely to be diagnosed quickly than were nonadmitted patients.

“Emergency department presentations for acute neurologic symptoms are an important opportunity to diagnose and treat clinically isolated syndrome and MS. There’s room to make that diagnosis more rapidly,” Dr. Krieger said.

Even though the project was a single-center study, Dr. Krieger noted that Mount Sinai is an academic center with a busy neurology department, a neurology residency, and a multiple sclerosis center. In short, “we are sort of a best case scenario. A lot of other emergency departments without as much access to MS specialists may” have a harder time making a prompt diagnosis, he said.

His team plans to analyze demographic data and symptom presentations to develop robust predictive factors for delayed MS diagnoses.

Although the findings are concerning, Dr. Lael Stone, an MS specialist at the Cleveland Clinic, noted that the situation has improved in recent years. “It used to be that [the elapsed time between] first symptoms [and] diagnosis was on the order of 9 years. That has gone down dramatically,” she said.

Even so, “we have a ways to go in terms of picking up MS in the [emergency department], which we should be able to do,” she said at the meeting.

Vague and confusing neurologic symptoms remain a problem. The demyelinating disease neuromyelitis optica, for example, can present with month-long intractable vomiting, years before the condition is diagnosed.

“The intractable vomiting goes to the GI doctor or to the [ED]. I doubt that the [ED or GI specialist] thinks this might be neuromyelitis optica,” she said.

Among the 49 ED visits for neurologic symptoms at Mount Sinai, almost half were for sensory symptoms; the remainder were for vision changes, weakness, balance problems, diplopia, and vertigo.

Bayer Healthcare Pharmaceuticals funded for the study. Dr. Krieger said he is a paid consultant for Acorda Therapeutics, Bayer Healthcare Pharmaceuticals, Biogen Idec, EMD Serono, Genzyme, Novartis, and Questcor. He receives fees from Teva Neuroscience for non-CME services. Dr. Stone said she has no relevant disclosures.