By Annette M. Boyle
EAST ORANGE, NJ — Diagnosing multiple sclerosis in its early stages can be difficult in the best of circumstances.
When recent veterans present with symptoms, however, diagnosis becomes even more difficult because another condition with a variety of presentations and symptoms is common in this cohort and could easily be confused with MS early in the course of the disease.
Chronic multisymptom illness, a condition previously associated with veterans of the Persian Gulf War, affects more than 50% of veterans who deployed to Iraq or Afghanistan after 2001, according to research recently published in the Journal of Rehabilitation Research and Development. Both multiple sclerosis (MS) and chronic multisymptom illness (CM) can present with a broad range of similar symptoms and are generally diagnoses of exclusion. 1
MS is a chronic inflammatory, demyelinating disease of the central nervous system. Among the most common early symptoms are fatigue, pain, emotional and cognitive changes, weakness, dizziness, vision problems and bowel and bladder issues, according to the National Multiple Sclerosis Society. More than 50% of individuals with MS report difficulty sleeping, the University of Washington Multiple Sclerosis Rehabilitation Research and Training Center notes.
CMI can look very similar. Among the 319 Army National Guardsmen and Army Reservists who served in Operation Iraqi Freedom and Operation Enduring Freedom in the study, 159 had symptoms consistent with chronic multisymptom illness. Of those, 51.4% reported difficulty sleeping, 50.8% said they were moody or irritable, 46% experienced joint pain, 39.5% reported fatigue, 39.8% had difficulty remembering or concentrating, and 36% suffered from headaches.
Those symptoms are consistent with the definition for CMI used by the national Centers for Disease Control and Prevention (CDC). For a diagnosis of CMI, the CDC requires one or more chronic, unexplained symptoms from at least two of the following three groups: 1) fatigue; 2) mood and cognition issues such as depression, memory or concentration impairment, trouble finding words or insomnia; and 3) musculoskeletal pain or stiffness.
No consensus set of signs and symptoms has been adopted, however, so clinicians also use the Kansas definition of CMI, explained lead author Lisa McAndrew, PhD, of the War-Related Illness and Injury Study Center (WRIISC) at the VAs New Jersey Healthcare System in East Orange, NJ. The Kansas description arose from a 1998 study of Persian Gulf veterans in that state. It says CMI is indicated in cases where there have been:
- No diagnoses or treatment for exclusionary conditions (cancer, lupus, multiple sclerosis, stroke or serious psychiatric condition)
- Chronic symptoms in at least three of six symptom groups: fatigue and sleep problems, pain, neurologic and mood, gastrointestinal, respiratory and skin symptoms.
- At least one moderately-severe symptom or two or more symptoms within a symptom group.
Because there is no definitive test for CMI or MS, clinicians typically evaluate the various possible causes of the primary symptoms and test to see whether those could be caused by other conditions such as infections, vitamin B12 deficiency, sarcoidosis, Lyme disease or human T-cell lymphotrophic virus-1.
“If the provider suspects multiple sclerosis, they should follow current guidelines and standards of care to investigate and confirm the diagnosis. This may include magnetic resonance imaging (MRI) of the brain and spinal cord, analysis of cerebral spinal fluid and referral to an appropriate specialist, such as a neurologist,” McAndrew said.
To distinguish between MS and CMI, clinicians should keep in mind that MS tends to have a waxing and waning course with periodic remissions and affects women at higher rates, study authors suggested. CMI symptoms might be more consistent over time and appear to affect men and women equally, according to McAndrew and Peter D. Rumm, MD, MPH, director of the VHA’s Pre-911 Era Environmental Health Program Post-Deployment Health Service in Washington.
“Physicians should consider CMI in veterans who have multiple, chronic (six months or longer) symptoms that are impacting their daily life. On average, people with CMI have impairment in quality of life equivalent to people with more familiar, serious, chronic conditions, such as cancer,” Rumm advised.
If a patient’s symptoms are consistent with CMI, and MS and other possible explanations have been ruled out, CMI is likely the appropriate diagnosis, he added, noting, “If the physician gives a diagnosis of CMI, they should continue to monitor changes in presentation and symptoms and conduct appropriate investigations when indicated. This will also allow physicians to correctly diagnose and optimize treatment of medically known conditions as they develop, including that of MS.”
Getting the right diagnosis can make a significant difference in the lives of veterans affected by MS or CMI, either by utilizing disease modifying therapies that can reduce the frequency and seriousness of relapses in the case of MS or tailoring medications to address the symptoms of CMI in light of the condition’s complexity.
One early indicator of possible CMI is chronic pain. More than 90% of veterans from the recent conflicts in Iraq and Afghanistan who report experiencing chronic pain also met the criteria for CMI. The number and nature of other symptoms associated with the illness “likely necessitate modification of pain management treatments,” according to the authors. Both impaired sleep and impaired cognition can affect pain therapy, for instance.
A patient with CMI can benefit from a variety of treatments to ameliorate symptoms. Physicians should validate the veteran’s experience and cooperatively develop treatment goals, create and implement a plan and establish follow-up assessments, said McAndrew. First-line treatments include self-management strategies and behavioral therapy, such as cognitive behavioral therapy for chronic pain.
“There is some evidence directing providers away from certain medications, including opioids, steroids and antibiotics and indicating possible benefit from others, such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors,” McAndrew said.
In recent veterans as well as the older Gulf War cohort, “CMI is a real condition that causes significant suffering,” McAndrew emphasized. “By working with the veteran, providers can effectively manage CMI and improve veterans’ lives. No patient should be told ‘It’s all in your head.’ or be turned away.”
- McAndrew LM, Helmer DA, Phillips LA, Chandler HK, Ray K, Quigley KS. Iraq and Afghanistan Veterans report symptoms consistent with chronic multisymptom illness one year after deployment. J Rehabil Res Dev. 2016;53(1):59-70.