COVID-19-associated myelitis: Difference between revisions

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Revision as of 17:23, 20 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Musadiq Ali M.B.B.S.[2] Tayebah Chaudhry [3]

Synonyms and keywords:

Overview

In the current pandemic state, COVID-19 should be considered as a differential diagnosis in a patient presenting with acute myelitis. Acute Transverse Myelitis is a neurological condition characterized by inflammation and injury of the spinal cord. In a confirmed or newly diagnosed patient of COVID-19, it is thought to be either a direct consequence of viral infection or a sequalae of autoimmune-mediated response. COVID-19-associated myelitis is diagnosed based on the hallmark symptoms of acute myelitis and confirmed with changes on spinal MRI, after ruling out other possible etiologies of myelitis. The symptoms show marked improvement after treatment with steroids and plasma exchange.

Historical Perspective

First case of acute myelitis as a COVID-19 complication was reported in February 2020 in Wuhan by Kang Zhao et al, in a 66 year old male patient. ^[1]
The second case was reported in Boston by Sarma et al in a 28 year old female patient who developed acute myelitis 7 days after symptoms of upper respiratory tract infection. ^[2]
As of now, only few case reports have been published in literature showing an association of COVID-19 with acute myelitis as a neurological complication.

Classification

There is no established system for the classification of COVID-19-associated myelitis.

Pathophysiology

The pathogenesis of the disease behind this manifestation is not fully understood yet.
There is a strong evidence suggesting that COVID-19 virus uses angiotensin-converting enzyme2 (ACE2) as its receptor to interact with host cells.
This evidence is based on the previous extensive SARS-CoV structural analyses that showed interactions between the SARS-CoV virus and ACE2 receptors and because of the marked sequence similarities between Covid-19 and the SARS-CoV virus it is hypothesized that COVID 19 virus pathogenesis is comparable.
The ACE2 receptors are expressed on alveolar epithelial cells, intestinal enterocytes and arterial and venous endothelial cells.
The brain only the vascular cells were expressing ACE2 as a cell receptor not the neurons; yet this could be a potential mechanism for dissemination of the virus into the brain by the blood circulation^[3].
It is also hypothesized that the virus can disseminate into the nervous system through the olfactory bulb in which sensory neurons connect the nasal cavity to the central nervous system by the axons, which terminate in the olfactory bulb and passes through the cribriform plate^[4].
Early‐phase COVID‐19‐affected patients who exhibit loss of smell and taste^[5].
Advanced stages of the disease the neurological signs and symptoms observed in the COVID‐19 cases could be due to the effects of hypoxia, respiratory, and metabolic acidosis^[6].

Causes

Apart from COVID-19 other causes of viral myelitis include^[7]:

Herpes viruses, including the one that causes shingles and chickenpox (zoster)
Cytomegalovirus
Epstein-Barr
HIV
Enteroviruses such as poliovirus and coxsackievirus
West Nile
Echovirus
Zika
Influenza
Hepatitis B
Mumps, measles and rubella

Other causes of myelitis are:

Bacterial myelitis
Fungal myelitis
Parasitic myelitis
Multiple Sclerosis
Transverse Myelitis
Autoimmune disorders like SLE and Sjogren’s Syndrome
Sarcoidosis
Vaccinations

Differentiating COVID-19-associated myelitis from other Diseases

To view the differential diagnosis of COVID-19, click here.

Epidemiology and Demographics

As of now, the incidence of acute myelitis associated with Covid-19 infection in unknown. ^[8]^[9]
To view epidemiology and demographics for COVID-19, click here.

Risk Factors

There are no established risk factors for COVID-19-associated myelitis. However, since this condition is a direct consequence of infection by the novel coronavirus, risk factors for COVID-19 should be considered.
To view the risk factors of COVID-19, click here.

Screening

Screening for COVID-19-associated myelitis is not currently done.
To view screening for COVID-19, click here.

Natural History, Complications, and Prognosis

Natural History

Myelitis associated with COVID-19 is an acute condition. The first case of COVID-19 associated myelitis developed the symptoms 5 days after the onset of fever. ^[1]The second case developed symptoms of myelitis 7 days after the upper respiratory symptoms. ^[2]

Complications

Lack of prompt recognition and management may result in lasting neurological complications (such as residual loss of sensation in lower extremities) after novel corona virus infection. ^[2]

Prognosis

Exact prognosis of COVID-19-associated myelitis is not known.
Marked improvement in symptoms is seen with steroids and plasma exchange.

Diagnosis

Diagnostic Study of Choice

Diagnosis of COVID-19-associated myelitis is based on the hallmark symptoms of acute myelitis in a known case of COVID-19 or a positive PCR nasal swab for COVID-19 in a new patient. And classic contrast-enhancing lesions on MRI spine.
Hallmark symptoms of acute myelitis include bilateral symmetric weakness and sensory changes in extremities, urinary retention and lower back pain.
Absence of visual symptoms such as eye pain or vision loss ( classically seen in Multiple Sclerosis or Neuromyelitis optica), negative immunoglobulin G auto-antibodies or oligoclonal bands, negative anti-nuclear antibody (ANA) test (very sensitive test for autoimmune diseases such as lupus), absence of other system involvement (such as skin rash, nodules, cardiac arrhythmias or arthritis seen in lupus or sarcoidosis) rule out other possible etiologies. ^[8]

History and Symptoms

Symptoms of COVID-19-associated myelitis include:

Paraplegia ^[8]

Urinary retention ^[8]
Lower back pain ^[2]
Weakness in lower extremities ^[8]
Paresthesias in lower extremities with possible ascension to upper extremities ^[2]
Numbness in lower extremities with possible ascension to upper extremities^[2]
Numbness in tip of tongue ^[2]

Physical Examination

Vitals:

Abnormal vitals can be seen due to COVID-19 association. These include:

Decreased O2 saturation
Tachycardia
Tachypnea

Abdominal exam:

Palpable distended bladder

Neurological exam:

Neurological findings are symmetric and more severe in lower extremities. ^[1] ^[2] ^[8]

Wide based gait
Decreased muscle strength
Decreased sensation
Decreased proprioception
Hyporeflexia
Paresthesias
Positive Lhermitte's sign
Positive Babinski's sign bilaterally.

Laboratory Findings

Nasal swab:

PCR nasal swab may give positive result for COVID-19.

Other Viral Screening:

Viral PCR screening including Adenovirus, Herpes Simplex Virus (Type 1&2), Epstein Barr Virus, Cytomegalovirus, Human Immunodeficiency Virus (HIV) will yield negative results.
Viral serology for Influenza Virus A and B, Parainfluenza 1-4, Respiratory Syncytial virus, Enterovirus and Rhinovirus with negative results.
Negative antibody results for bacteria such as Chlamydia Pneumoniae, Bordetella Pertussis, Mycoplasma Pneumoniae and Borrelia.

MRI spine:

MRI findings consistent with Acute Transverse Myelitis (involving more than three spinal cord segments) are seen. This includes widespread elongated signal changes throughout the gray matter of spinal cord, with no disc pathology or spinal canal narrowing. ^[2]

Urinary retention:

Foley catheter insertion will show and relieve retained urine.

Lumbar Puncture (LP):

CSF analysis may show lymphocytic pleocytosis and elevated protein level. ^[10]

To view the laboratory findings on COVID-19, click here

Electrocardiogram

There are no ECG findings associated with COVID-19-associated myelitis.
To view the electrocardiogram findings on COVID-19, click here.

X-ray

Chest X-ray may or may not show opacities in lungs depending on the degree of lung damage caused by COVID-19.
To view the x-ray finidings on COVID-19, click here.

Echocardiography or Ultrasound

There are no echocardiography findings associated with COVID-19-associated myelitis.
Abdominal ultrasound may show bladder distension due to urinary retention.
To view the echocardiographic findings on COVID-19, click here.

CT scan

CT scan exclude other causes that can cause myelitis.
To view the CT scan findings on COVID-19, click here.

MRI

MRI may be used to exclude other causes.
MRI findings consistent with Acute Transverse Myelitis (involving more than three spinal cord segments) are seen.
This includes widespread elongated signal changes throughout the gray matter of spinal cord, with no disc pathology or spinal canal narrowing.
T2-weighted fast spin-echo and short-tau inversion recovery (STIR) are the best sequences to view the spinal cord lesions^[11].
To view other imaging findings on COVID-19, click here.

Treatment

Medical Therapy

Oxygen inhalation treatment with high-flow nasal catheters.
Ganciclovir ( 0.5g once daily) for 14 days, Lopinavir/ritonavir (500mg twice daily) for 5 days. "Coronavirus Disease 2019 (COVID-19) Treatment Guidelines".
Moxifloxacin (400mg once daily) for 6 days.(Treatment with arbidol and moxifloxacin could be helpful in reducing viral load and inflammation during SARS-CoV2 infection, especially for negatively regulating fatal inflammation in severe COVID-19 patients)^[12].
Glutathione (1.8g once daily) for 14 days. (Glutathione inhibits replication of various viruses at different stages of the viral life cycle and decreasing viral load. It also prevents the massive release of inflammatory cells into the lung “cytokine storm”)^[13].
Dexamethasone (10mg once daily) for 10 days^[14]. (NIH COVID-19 Treatment Guidelines Panel recommends using dexamethasone (at a dose of 6 mg per day for up to 10 days) in patients with COVID-19 who are mechanically ventilated and in patients with COVID-19 who require supplemental oxygen but who are not mechanically ventilated. And recommends against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen.
Human immunoglobulin (15g once daily) for 7 days.
Pantoprazole (80mg once daily) for 10 days.
Mecobalamin (1000ug once daily) for 14days.^[15] (Vitamin B12 may inhibit RNA-dependent-RNA polymerase activity of nsp12 protein from the COVID-19 Virus).
Plasma exchange.
Foley's catheter to relieve urinary retention

Surgery

Surgical intervention is not recommended for the management of COVID-19-associated myelitis.

Primary Prevention

Effective measures for the primary prevention of COVID-19-associated myelitis are the same as of COVID-19.

Secondary Prevention

Effective measures for the secondary prevention of COVID-19-associated myelitis are the same as of COVID-19.

References

↑ ^1.0 ^1.1 ^1.2 "www.medrxiv.org" (PDF).
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 ^2.6 ^2.7 ^2.8 "A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection".
↑ Manji H, Carr AS, Brownlee WJ, Lunn MP (2020). "Neurology in the time of COVID-19". J Neurol Neurosurg Psychiatry. 91 (6): 568–570. doi:10.1136/jnnp-2020-323414. PMID 32312872 Check |pmid= value (help).
↑ Wan Y, Shang J, Graham R, Baric RS, Li F (2020). "Receptor Recognition by the Novel Coronavirus from Wuhan: an Analysis Based on Decade-Long Structural Studies of SARS Coronavirus". J Virol. 94 (7). doi:10.1128/JVI.00127-20. PMC 7081895 Check |pmc= value (help). PMID 31996437.
↑ Baig AM (2020). "Neurological manifestations in COVID-19 caused by SARS-CoV-2". CNS Neurosci Ther. 26 (5): 499–501. doi:10.1111/cns.13372. PMC 7163592 Check |pmc= value (help). PMID 32266761 Check |pmid= value (help).
↑ Pastor Bandeira, Isabelle; Machado Schlindwein, Marco Antônio; Breis, Leticia Caroline; Schatzmann Peron, Jean Pierre; Magno Gonçalves, Marcus Vinicius (2020). doi:10.20944/preprints202004.0304.v1. Missing or empty |title= (help)
↑ Pekcevik Y, Mitchell CH, Mealy MA, Orman G, Lee IH, Newsome SD; et al. (2016). "Differentiating neuromyelitis optica from other causes of longitudinally extensive transverse myelitis on spinal magnetic resonance imaging". Mult Scler. 22 (3): 302–11. doi:10.1177/1352458515591069. PMC 4797654. PMID 26209588.
↑ ^8.0 ^8.1 ^8.2 ^8.3 ^8.4 ^8.5 AlKetbi, Reem; AlNuaimi, Dana; AlMulla, Muna; AlTalai, Nouf; Samir, Mohammed; Kumar, Navin (2020). "Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings". Radiology Case Reports. doi:10.1016/j.radcr.2020.06.001. ISSN 1930-0433.
↑ Munz M, Wessendorf S, Koretsis G, Tewald F, Baegi R, Krämer S; et al. (2020). "Acute transverse myelitis after COVID-19 pneumonia". J Neurol. doi:10.1007/s00415-020-09934-w. PMC 7250275 Check |pmc= value (help). PMID 32458198 Check |pmid= value (help).
↑ "Acute transverse myelitis after COVID-19 pneumonia".
↑ Scotti G, Gerevini S (2001). "Diagnosis and differential diagnosis of acute transverse myelopathy. The role of neuroradiological investigations and review of the literature". Neurol Sci. 22 Suppl 2: S69–73. doi:10.1007/s100720100038. PMID 11794482.
↑ Yu, Dongshan; Sun, Shuilin; Li, Yanhua; Xi, Wenna; Jin, Di; Sun, Ke; Yu, Rongyan; Yao, Xuebing; Song, Zhiying; Yang, Aoyu; Luo, Ruixia; Zou, Biaoshu; Liu, Yun (2020). doi:10.1101/2020.05.30.20117598. Missing or empty |title= (help)
↑ De Flora, S.; Grassi, C.; Carati, L. (1997). "Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". European Respiratory Journal. 10 (7): 1535–1541. doi:10.1183/09031936.97.10071535. ISSN 0000-0000.
↑ Sotoca, Javier; Rodríguez-Álvarez, Yensa (2020). "COVID-19-associated acute necrotizing myelitis". Neurology - Neuroimmunology Neuroinflammation. 7 (5): e803. doi:10.1212/NXI.0000000000000803. ISSN 2332-7812.
↑ nair, deepak t; narayanan, naveen. doi:10.35543/osf.io/p48fa. Missing or empty |title= (help)

Template:WikiDoc Sources

[urlwww.medrxiv.org-1] 1.0 ^1.1 ^1.2 "www.medrxiv.org" (PDF).

[urlA_Case_Report_of_Acute_Transverse_Myelitis_Following_Novel_Coronavirus_Infection-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 ^2.6 ^2.7 ^2.8 "A Case Report of Acute Transverse Myelitis Following Novel Coronavirus Infection".

[pmid32312872-3] Manji H, Carr AS, Brownlee WJ, Lunn MP (2020). "Neurology in the time of COVID-19". J Neurol Neurosurg Psychiatry. 91 (6): 568–570. doi:10.1136/jnnp-2020-323414. PMID 32312872 Check |pmid= value (help).

[pmid31996437-4] Wan Y, Shang J, Graham R, Baric RS, Li F (2020). "Receptor Recognition by the Novel Coronavirus from Wuhan: an Analysis Based on Decade-Long Structural Studies of SARS Coronavirus". J Virol. 94 (7). doi:10.1128/JVI.00127-20. PMC 7081895 Check |pmc= value (help). PMID 31996437.

[pmid32266761-5] Baig AM (2020). "Neurological manifestations in COVID-19 caused by SARS-CoV-2". CNS Neurosci Ther. 26 (5): 499–501. doi:10.1111/cns.13372. PMC 7163592 Check |pmc= value (help). PMID 32266761 Check |pmid= value (help).

[Pastor_BandeiraMachado_Schlindwein2020-6] Pastor Bandeira, Isabelle; Machado Schlindwein, Marco Antônio; Breis, Leticia Caroline; Schatzmann Peron, Jean Pierre; Magno Gonçalves, Marcus Vinicius (2020). doi:10.20944/preprints202004.0304.v1. Missing or empty |title= (help)

[pmid26209588-7] Pekcevik Y, Mitchell CH, Mealy MA, Orman G, Lee IH, Newsome SD; et al. (2016). "Differentiating neuromyelitis optica from other causes of longitudinally extensive transverse myelitis on spinal magnetic resonance imaging". Mult Scler. 22 (3): 302–11. doi:10.1177/1352458515591069. PMC 4797654. PMID 26209588.

[AlKetbiAlNuaimi2020-8] 8.0 ^8.1 ^8.2 ^8.3 ^8.4 ^8.5 AlKetbi, Reem; AlNuaimi, Dana; AlMulla, Muna; AlTalai, Nouf; Samir, Mohammed; Kumar, Navin (2020). "Acute Myelitis as a Neurological Complication ofCovid-19:A Case Report and MRI Findings". Radiology Case Reports. doi:10.1016/j.radcr.2020.06.001. ISSN 1930-0433.

[pmid32458198-9] Munz M, Wessendorf S, Koretsis G, Tewald F, Baegi R, Krämer S; et al. (2020). "Acute transverse myelitis after COVID-19 pneumonia". J Neurol. doi:10.1007/s00415-020-09934-w. PMC 7250275 Check |pmc= value (help). PMID 32458198 Check |pmid= value (help).

[urlAcute_transverse_myelitis_after_COVID-19_pneumonia-10] "Acute transverse myelitis after COVID-19 pneumonia".

[pmid11794482-11] Scotti G, Gerevini S (2001). "Diagnosis and differential diagnosis of acute transverse myelopathy. The role of neuroradiological investigations and review of the literature". Neurol Sci. 22 Suppl 2: S69–73. doi:10.1007/s100720100038. PMID 11794482.

[YuSun2020-12] Yu, Dongshan; Sun, Shuilin; Li, Yanhua; Xi, Wenna; Jin, Di; Sun, Ke; Yu, Rongyan; Yao, Xuebing; Song, Zhiying; Yang, Aoyu; Luo, Ruixia; Zou, Biaoshu; Liu, Yun (2020). doi:10.1101/2020.05.30.20117598. Missing or empty |title= (help)

[De_FloraGrassi1997-13] De Flora, S.; Grassi, C.; Carati, L. (1997). "Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment". European Respiratory Journal. 10 (7): 1535–1541. doi:10.1183/09031936.97.10071535. ISSN 0000-0000.

[SotocaRodríguez-Álvarez2020-14] Sotoca, Javier; Rodríguez-Álvarez, Yensa (2020). "COVID-19-associated acute necrotizing myelitis". Neurology - Neuroimmunology Neuroinflammation. 7 (5): e803. doi:10.1212/NXI.0000000000000803. ISSN 2332-7812.

[nairnarayanan-15] r, deepak t; narayanan, naveen. doi:10.35543/osf.io/p48fa. Missing or empty |title= (help)

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 ==Differentiating COVID-19-associated myelitis from other Diseases==
-COVID-19-associated myelitis must be differentiated from other diseases that may cause [[hypotonia]], [[muscle weakness]], or [[paralysis]]:<ref name="pmid29433111">{{cite journal |vauthors=Kira R |title=[Acute Flaccid Myelitis] |language=Japanese |journal=Brain Nerve |volume=70 |issue=2 |pages=99–112 |date=February 2018 |pmid=29433111 |doi=10.11477/mf.1416200962 |url=}}</ref><ref name="pmid29433111">{{cite journal |vauthors=Kira R |title=[Acute Flaccid Myelitis] |language=Japanese |journal=Brain Nerve |volume=70 |issue=2 |pages=99–112 |date=February 2018 |pmid=29433111 |doi=10.11477/mf.1416200962 |url=}}</ref><ref name="pmid29181601">{{cite journal |vauthors=Hopkins SE |title=Acute Flaccid Myelitis: Etiologic Challenges, Diagnostic and Management Considerations |journal=Curr Treat Options Neurol |volume=19 |issue=12 |pages=48 |date=November 2017 |pmid=29181601 |doi=10.1007/s11940-017-0480-3 |url=}}</ref><ref name="pmid27422805">{{cite journal |vauthors=Messacar K, Schreiner TL, Van Haren K, Yang M, Glaser CA, Tyler KL, Dominguez SR |title=Acute flaccid myelitis: A clinical review of US cases 2012-2015 |journal=Ann. Neurol. |volume=80 |issue=3 |pages=326–38 |date=September 2016 |pmid=27422805 |pmc=5098271 |doi=10.1002/ana.24730 |url=}}</ref><ref name="pmid29028962">{{cite journal |vauthors=Chong PF, Kira R, Mori H, Okumura A, Torisu H, Yasumoto S, Shimizu H, Fujimoto T, Hanaoka N, Kusunoki S, Takahashi T, Oishi K, Tanaka-Taya K |title=Clinical Features of Acute Flaccid Myelitis Temporally Associated With an Enterovirus D68 Outbreak: Results of a Nationwide Survey of Acute Flaccid Paralysis in Japan, August-December 2015 |journal=Clin. Infect. Dis. |volume=66 |issue=5 |pages=653–664 |date=February 2018 |pmid=29028962 |pmc=5850449 |doi=10.1093/cid/cix860 |url=}}</ref><ref name="pmid29482893">{{cite journal |vauthors=Messacar K, Asturias EJ, Hixon AM, Van Leer-Buter C, Niesters HGM, Tyler KL, Abzug MJ, Dominguez SR |title=Enterovirus D68 and acute flaccid myelitis-evaluating the evidence for causality |journal=Lancet Infect Dis |volume=18 |issue=8 |pages=e239–e247 |date=August 2018 |pmid=29482893 |doi=10.1016/S1473-3099(18)30094-X |url=}}</ref><ref name="pmid30200066">{{cite journal |vauthors=Chen IJ, Hu SC, Hung KL, Lo CW |title=Acute flaccid myelitis associated with enterovirus D68 infection: A case report |journal=Medicine (Baltimore) |volume=97 |issue=36 |pages=e11831 |date=September 2018 |pmid=30200066 |pmc=6133480 |doi=10.1097/MD.0000000000011831 |url=}}</ref><ref name="urlBotulism | Botulism | CDC">{{cite web |url=https://www.cdc.gov/botulism/index.html |title=Botulism &#124; Botulism &#124; CDC |format= |work= |accessdate=}}</ref><ref name="pmid3290234">{{cite journal |vauthors=McCroskey LM, Hatheway CL |title=Laboratory findings in four cases of adult botulism suggest colonization of the intestinal tract |journal=J. Clin. Microbiol. |volume=26 |issue=5 |pages=1052–4 |date=May 1988 |pmid=3290234 |pmc=266519 |doi= |url=}}</ref><ref name="pmid16614251">{{cite journal |vauthors=Lindström M, Korkeala H |title=Laboratory diagnostics of botulism |journal=Clin. Microbiol. Rev. |volume=19 |issue=2 |pages=298–314 |date=April 2006 |pmid=16614251 |pmc=1471988 |doi=10.1128/CMR.19.2.298-314.2006 |url=}}</ref><ref name="pmid17224901">{{cite journal |vauthors=Brook I |title=Botulism: the challenge of diagnosis and treatment |journal=Rev Neurol Dis |volume=3 |issue=4 |pages=182–9 |date=2006 |pmid=17224901 |doi= |url=}}</ref><ref name="pmid23642721">{{cite journal |vauthors=Dimachkie MM, Barohn RJ |title=Guillain-Barré syndrome and variants |journal=Neurol Clin |volume=31 |issue=2 |pages=491–510 |date=May 2013 |pmid=23642721 |pmc=3939842 |doi=10.1016/j.ncl.2013.01.005 |url=}}</ref><ref name="pmid23418763">{{cite journal |vauthors=Walling AD, Dickson G |title=Guillain-Barré syndrome |journal=Am Fam Physician |volume=87 |issue=3 |pages=191–7 |date=February 2013 |pmid=23418763 |doi= |url=}}</ref><ref name="pmid21969911">{{cite journal |vauthors=Gilhus NE |title=Lambert-eaton myasthenic syndrome; pathogenesis, diagnosis, and therapy |journal=Autoimmune Dis |volume=2011 |issue= |pages=973808 |date=2011 |pmid=21969911 |pmc=3182560 |doi=10.4061/2011/973808 |url=}}</ref><ref name="pmid14977560">{{cite journal |vauthors=Krishnan C, Kaplin AI, Deshpande DM, Pardo CA, Kerr DA |title=Transverse Myelitis: pathogenesis, diagnosis and treatment |journal=Front. Biosci. |volume=9 |issue= |pages=1483–99 |date=May 2004 |pmid=14977560 |doi= |url=}}</ref><ref name="pmid24305450">{{cite journal |vauthors=Amato AA, Greenberg SA |title=Inflammatory myopathies |journal=Continuum (Minneap Minn) |volume=19 |issue=6 Muscle Disease |pages=1615–33 |date=December 2013 |pmid=24305450 |doi=10.1212/01.CON.0000440662.26427.bd |url=}}</ref><ref name="pmid24365430">{{cite journal |vauthors=Berger JR, Dean D |title=Neurosyphilis |journal=Handb Clin Neurol |volume=121 |issue= |pages=1461–72 |date=2014 |pmid=24365430 |doi=10.1016/B978-0-7020-4088-7.00098-5 |url=}}</ref>
-{|
-|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
-! rowspan="2" |<small>Diseases</small>
-! colspan="8" |<small>History and Physical
-! colspan="2" |<small>Diagnostic tests</small>
-! rowspan="2" |<small>Other Findings</small>
-|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
-!<small>Motor Deficit</small>
-!<small>Sensory deficit</small>
-!<small>Cranial nerve Involvement</small>
-!<small>Autonomic dysfunction</small>
-!<small>Proximal/Distal/Generalized</small>
-!<small>Ascending/Descending/Systemic</small>
-!<small>Unilateral (UL)
-or Bilateral (BL)
-or
-No Lateralization (NL)</small>
-!<small>Onset</small>
-!<small>Lab or Imaging Findings</small>
-!<small>Specific  test</small>
-|-
-| style="background: #DCDCDC; padding: 5px; text-align:center;" |Transverse myelitis
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Proximal > Distal
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL or UL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
-| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI & [[Lumbar puncture]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI
-| style="background: #F5F5F5; padding: 5px; text-align:center" |History of chronic viral or autoimmune disease (e.g. [[HIV]])
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Botulism|Adult Botulism]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Descending
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Toxin test
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Blood, Wound, or Stool culture
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Diplopia]], [[Hyporeflexia|Hyporeflexia,]] [[Hypotonia]], possible respiratory paralysis
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Infant [[Botulism]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |+
-| style="background: #F5F5F5; padding: 5px; text-align:center" |-
-| style="background: #F5F5F5; padding: 5px; text-align:center" |+
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Descending
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Toxin test
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Blood, Wound, or Stool culture
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Flaccid paralysis]] ([[Floppy baby syndrome]]), possible respiratory paralysis
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Guillian-Barre syndrome]]<ref name="pmid22081202">{{cite journal| author=Talukder RK, Sutradhar SR, Rahman KM, Uddin MJ, Akhter H| title=Guillian-Barre syndrome. | journal=Mymensingh Med J | year= 2011 | volume= 20 | issue= 4 | pages= 748-56 | pmid=22081202 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22081202  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Ascending
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
-| style="background: #F5F5F5; padding: 5px; text-align:center" |CSF: ↑Protein
-↓Cells
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Clinical & Lumbar Puncture
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Progressive [[ascending paralysis]] following infection, possible respiratory paralysis
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Eaton lambert syndrome|Eaton Lambert syndrome]]<ref name="pmid27412406">{{cite journal| author=Merino-Ramírez MÁ, Bolton CF| title=Review of the Diagnostic Challenges of Lambert-Eaton Syndrome Revealed Through Three Case Reports. | journal=Can J Neurol Sci | year= 2016 | volume= 43 | issue= 5 | pages= 635-47 | pmid=27412406 | doi=10.1017/cjn.2016.268 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27412406  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Intermittent
-| style="background: #F5F5F5; padding: 5px; text-align:center" | [[EMG]], repetitive nerve stimulation test (RNS)
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Voltage gated calcium channel|Voltage gated calcium channe]]<nowiki/>l<nowiki/> (VGCC) antibody
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Diplopia]], [[ptosis]], improves with movement (as the day progresses)
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Myasthenia gravis]]<ref name="pmid28029925">{{cite journal| author=Gilhus NE| title=Myasthenia Gravis. | journal=N Engl J Med | year= 2016 | volume= 375 | issue= 26 | pages= 2570-2581 | pmid=28029925 | doi=10.1056/NEJMra1602678 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28029925  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Intermittent
-| style="background: #F5F5F5; padding: 5px; text-align:center" | [[Electromyography|EMG]], [[Edrophonium|Edrophonium test]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Acetylcholine receptor|Ach receptor]] antibody
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Diplopia]], [[ptosis]], worsening with movement (as the day progresses)
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Electrolyte disturbance]]<ref name="pmid26813501">{{cite journal| author=Ozono K| title=[Diagnostic criteria for vitamin D-deficient rickets and hypocalcemia-]. | journal=Clin Calcium | year= 2016 | volume= 26 | issue= 2 | pages= 215-22 | pmid=26813501 | doi=CliCa1602215222 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26813501  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
-| style="background: #F5F5F5; padding: 5px; text-align:center" | Electrolyte panel
-| style="background: #F5F5F5; padding: 5px; text-align:center" |↓Ca++, ↓Mg++, ↓K+
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Possible [[arrhythmia]]
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Organophosphate poisoning|Organophosphate toxicity]]<ref name="pmid15020723">{{cite journal| author=Kamanyire R, Karalliedde L| title=Organophosphate toxicity and occupational exposure. | journal=Occup Med (Lond) | year= 2004 | volume= 54 | issue= 2 | pages= 69-75 | pmid=15020723 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15020723  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Ascending
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
-| style="background: #F5F5F5; padding: 5px; text-align:center" | Clinical diagnosis: physical exam & history
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Clinical suspicion confirmed with RBC AchE activity
-| style="background: #F5F5F5; padding: 5px; text-align:center" |History of exposure to i[[Insecticide|nsecticide]] or living in farming environment. with : [[Diarrhea]], [[Urination]], [[Miosis]], [[Bradycardia]], [[Lacrimation]], [[Emesis]], [[Salivation]], [[Sweating]]
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Tick paralysis]] ([[Dermacentor andersoni|Dermacentor tick]])<ref name="pmid23677663">{{cite journal| author=Pecina CA| title=Tick paralysis. | journal=Semin Neurol | year= 2012 | volume= 32 | issue= 5 | pages= 531-2 | pmid=23677663 | doi=10.1055/s-0033-1334474 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23677663  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Ascending
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
-| style="background: #F5F5F5; padding: 5px; text-align:center" | Clinical diagnosis: physical exam & history
-| style="background: #F5F5F5; padding: 5px; text-align:center" |-
-| style="background: #F5F5F5; padding: 5px; text-align:center" |History of outdoor activity in Northeastern United States. The tick is often still latched to the patient at presentation (often in head and neck area)
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Tetrodotoxin]] poisoning<ref name="pmid24566728">{{cite journal| author=Bane V, Lehane M, Dikshit M, O'Riordan A, Furey A| title=Tetrodotoxin: chemistry, toxicity, source, distribution and detection. | journal=Toxins (Basel) | year= 2014 | volume= 6 | issue= 2 | pages= 693-755 | pmid=24566728 | doi=10.3390/toxins6020693 | pmc=3942760 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24566728  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
-| style="background: #F5F5F5; padding: 5px; text-align:center" | Clinical diagnosis: physical exam & dietary history
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" | History of consumption of puffer fish species.
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Stroke]]<ref name="pmid8848683">{{cite journal| author=Kuntzer T, Hirt L, Bogousslavsky J| title=[Neuromuscular involvement and cerebrovascular accidents]. | journal=Rev Med Suisse Romande | year= 1996 | volume= 116 | issue= 8 | pages= 605-9 | pmid=8848683 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8848683  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+/-</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |UL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
-| style="background: #F5F5F5; padding: 5px; text-align:center" | MRI +ve for ischemia or hemorrhage
-| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden unilateral motor and sensory deficit in a patient with a history of [[Atherosclerosis|atherosclero]]<nowiki/>tic risk factors (diabetes, hypertension, smoking) or [[Atrial fibrillation|atrial fibrillation.]]
-|-
-| style="background: #DCDCDC; padding: 5px; text-align:center;" | [[Poliomyelitis]]<ref name="pmid19944665">{{cite journal| author=Laffont I, Julia M, Tiffreau V, Yelnik A, Herisson C, Pelissier J| title=Aging and sequelae of poliomyelitis. | journal=Ann Phys Rehabil Med | year= 2010 | volume= 53 | issue= 1 | pages= 24-33 | pmid=19944665 | doi=10.1016/j.rehab.2009.10.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19944665  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |+
-| style="background: #F5F5F5; padding: 5px; text-align:center" |+
-| style="background: #F5F5F5; padding: 5px; text-align:center" |+
-| style="background: #F5F5F5; padding: 5px; text-align:center" |+/-
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Proximal > Distal
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL or UL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
-| style="background: #F5F5F5; padding: 5px; text-align:center" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" |PCR of CSF
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Asymmetric paralysis following a flu-like syndrome.
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]<ref name="pmid22482824">{{cite journal| author=Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG et al.| title=Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. | journal=J Neurol Sci | year= 2012 | volume= 317 | issue= 1-2 | pages= 35-9 | pmid=22482824 | doi=10.1016/j.jns.2012.03.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22482824  }} </ref><ref name="pmid24365430">{{cite journal |vauthors=Berger JR, Dean D |title=Neurosyphilis |journal=Handb Clin Neurol |volume=121 |issue= |pages=1461–72 |year=2014 |pmid=24365430 |doi=10.1016/B978-0-7020-4088-7.00098-5 |url=}}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  -
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +/-
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious<nowiki/>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI & [[Lumbar puncture]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |CSF [[VDRL]]-specifc
-CSF [[FTA-ABS|FTA-Ab]] -sensitive<ref name="pmid22421697">{{cite journal| author=Ho EL, Marra CM| title=Treponemal tests for neurosyphilis--less accurate than what we thought? | journal=Sex Transm Dis | year= 2012 | volume= 39 | issue= 4 | pages= 298-9 | pmid=22421697 | doi=10.1097/OLQ.0b013e31824ee574 | pmc=3746559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22421697  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |History of unprotected sex or multiple sexual partners.
-History of [[genital ulcer]] ([[chancre]]), diffuse [[Maculopapular rash|maculopapular ras]]<nowiki/>h.
-|-
-| style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Muscular dystrophy]]<ref name="pmid26457695">{{cite journal| author=Falzarano MS, Scotton C, Passarelli C, Ferlini A| title=Duchenne Muscular Dystrophy: From Diagnosis to Therapy. | journal=Molecules | year= 2015 | volume= 20 | issue= 10 | pages= 18168-84 | pmid=26457695 | doi=10.3390/molecules201018168 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26457695  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Proximal > Distal
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
-| style="background: #F5F5F5; padding: 5px; text-align:center" | Genetic testing
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Muscle biopsy]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Progressive proximal lower limb weakness with calf pseudohypertrophy in early childhood. [[Gowers' sign|Gower sign]] positive.
-|-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Multiple sclerosis]] exacerbation<ref name="pmid27432676">{{cite journal| author=Filippi M, Preziosa P, Rocca MA| title=Multiple sclerosis. | journal=Handb Clin Neurol | year= 2016 | volume= 135 | issue=  | pages= 399-423 | pmid=27432676 | doi=10.1016/B978-0-444-53485-9.00020-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27432676  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>+</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |NL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Sudden
-| style="background: #F5F5F5; padding: 5px; text-align:center" |'''[[CSF|↑]]'''[[CSF]] [[IgG]] levels
-(monoclonal)
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Clinical assessment and [[MRI]] <ref name="pmid8274111">{{cite journal| author=Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH et al.| title=Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group. | journal=Arch Neurol | year= 1994 | volume= 51 | issue= 1 | pages= 61-6 | pmid=8274111 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8274111  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Blurred vision|Blurry vision]], [[urinary incontinence]], [[fatigue]]
-|-
-| style="background: #DCDCDC; padding: 5px; text-align:center" |[[Amyotrophic lateral sclerosis]]<ref name="pmid27025851">{{cite journal| author=Riva N, Agosta F, Lunetta C, Filippi M, Quattrini A| title=Recent advances in amyotrophic lateral sclerosis. | journal=J Neurol | year= 2016 | volume= 263 | issue= 6 | pages= 1241-54 | pmid=27025851 | doi=10.1007/s00415-016-8091-6 | pmc=4893385 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27025851  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  +
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Generalized
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
-| style="background: #F5F5F5; padding: 5px; text-align:center" | Normal [[Lumbar puncture|LP]] (to rule out DDx)
-| style="background: #F5F5F5; padding: 5px; text-align:center" |MRI & [[Lumbar puncture|LP]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Patient initially presents with [[upper motor neuron]] deficit ([[spasticity]]) followed by [[lower motor neuron]] deficit ([[flaccidity]]).
-|-
-| style="background: #DCDCDC; padding: 5px; text-align:center;" |[[Myositis|Inflammatory myopathy]]<ref name="pmid26290112">{{cite journal| author=Michelle EH, Mammen AL| title=Myositis Mimics. | journal=Curr Rheumatol Rep | year= 2015 | volume= 17 | issue= 10 | pages= 63 | pmid=26290112 | doi=10.1007/s11926-015-0541-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26290112  }}</ref>
-| style="background: #F5F5F5; padding: 5px; text-align:center" | +
-| style="background: #F5F5F5; padding: 5px; text-align:center" | -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |  -
-| style="background: #F5F5F5; padding: 5px; text-align:center" |<nowiki>-</nowiki>
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Proximal > Distal
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Systemic
-| style="background: #F5F5F5; padding: 5px; text-align:center" |UL or BL
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Insidious
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Elevated [[Creatine kinase|CK]] & [[Aldolase]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |[[Muscle biopsy]]
-| style="background: #F5F5F5; padding: 5px; text-align:center" |Progressive proximal muscle weakness in 3rd to 5th decade of life. With or without skin manifestations.
-|-
-|}
 To view the differential diagnosis of COVID-19, [[COVID-19 differential diagnosis|click here]].<br />