Online Health Chat with Karen Nater Pineiro, MD

June 16, 2016


Diagnosing multiple sclerosis (MS) correctly can be a complicated process. MS varies from person to person and there is no ‘standard’ set of symptoms. Seeking a prompt evaluation for MS symptoms is vital, not only for diagnosing and treating the disease, but also for ruling out other conditions with symptoms that mimic those of MS. Some of the common symptoms of MS can include:

  • Numbness or tingling in various parts of the body
  • Walking difficulties
  • Weakness of one or more body part
  • Fatigue
  • Visual blurring, and occasionally, double vision
  • Dizziness
  • Urinary symptoms, such as hesitancy when trying to urinate, or a feeling of urgency
  • Lhermitte's phenomenon, a symptom in which people feel electrical tingling or shocks down their back, arms, or legs when they bend their neck forwards

Neurologists at Cleveland Clinic Florida’s Egil and Pauline Braathen Center utilize modern tools and expertise to effectively diagnose MS early on, slow the disease’s debilitating advance and, in some cases, delay the long-term progression to severe disability. And the multidisciplinary team of specialists at the center provides the comprehensive care that allows patients with MS to spend more time living their normal lives and less time in a doctor’s office.

About the Speaker

Karen Nater Pineiro, MD is a Neurologist in the Pauline M. Braathen Neurological Center at Cleveland Clinic Florida. She received her medical degree from the San Juan Bautista School of Medicine in Puerto Rico. Dr. Nater Pineiro went on to complete her residency as well as a fellowship in Multiple Sclerosis at the University of Maryland in Baltimore. Her specialty interests include Multiple Sclerois, Neuromyelitis Optica, Devic's Disease, Optic Neuritis, Transverse Myelitis, Acute Disseminated Encephalomyelitis, Sarcoid and Inflammatory/Autoimmune Encephalopathies Spasticity management.

Let’s Chat About Multiple Sclerosis or Mimic? What Your Symptoms Mean

Welcome to our Online Health Chat “Multiple Sclerosis or Mimic? What Your Symptoms Mean" with Karen Nater Pineiro, MD. We are thrilled to have her here today for this chat. Let’s begin with the questions.


Nanat426: My mother passed away from what I was told was an MI brought on from severe MS. I now have Sarcoidosis and am wondering if it is possible she actually had neurosarcoidosis. She never saw any "specialist" just our primary, who back then did just about everything. I have numbness (was told is SFN), I also have random dizziness and trouble walking. When just standing still, I sway and have to hang on to something. Walking ,I'm always bumping into things as I'm unbalanced. All this has me thinking of my mother. When I had a MRI as few years ago there was no lesions so no diagnosis. Is it possible to be either MS or neurosarcoidosis with no lesions?

Karen_Nater_Pineiro_: Sarcoidosis triggers a strong immune response in some patients. It's most often a systemic disease and not a neurologic one. Very rarely, it can cause Peripheral nervous system or, even less often, the Central Nervous System. It's not hereditary and/or genetic. It will be very unlikely to have MS with no lesions but we need to evaluate clinical and radiographic findings.

suzyq: Can migraines be caused by NMO and mimic diseases?

Karen_Nater_Pineiro_: Migraines are unfortunately very common in the general population and not "caused" by NMO. We however don't know exactly what cause migraines and many patients with other neurologic conditions suffer from migraines. Therefore, a possible correlation may exist but not specific for NMO. Treatment for migraines is symptomatic regardless of the cause.

AnthonyRusso: Are there different symptoms for different types of MS? And how do the symptoms vary?

Karen_Nater_Pineiro_: MS is a heterogeneous disease. It can present with many different symptoms and those can evolve over time. Sometimes it's related to specific anatomic region in which demyelination occurred. For example, demyelination of the ON leading to painful visual loss. However this is not always the case and "MS lesions/demyelinating plaques" don't necessary correlated with patients’ symptoms. Relapsing Remitting MS is the most common type. Symptoms "come and go" but can leave residual deficits. However there are other types, including Progressive, in which patients accumulate symptoms/disability gradually over time. We focus on symptom management along with prevention of relapses and disability.

Conditions that Mimic MS

keroppi: What other conditions (that don't show on MRIs) could mimic MS with the specific symptom of numbness (not the full, no feeling at all type, but rather diminished sensation) gradually spreading to most parts of the body in random order (i.e. leg, back, arm, genitals, face, throat, etc.) and remaining there? Do nonspecific foci in the white matter ever turn into more MS-looking spots? and/or cause any MS-like symptoms?

Karen_Nater_Pineiro_: MS mimickers include infectious, inflammatory and other autoimmune processes. I recommend that you discuss with a neurologist your symptoms along with any workup. Again, a constellation of multiple symptoms don't means that a patient suffers from MS. MRI is a diagnostic tool but it's not meant to be used as "a test for MS". MS is diagnosed based on clinical, radiographic and other supporting criteria. Abnormal MRIs need to be interpreted on clinical context. Abnormal spots can be seen in migraines, microvascular disease among others. We also don't know when those "Spots" occurred and patient may have born with those. Therefore, we follow MRI on time if indicated.

dzilisch: I was diagnosed with Sarcoidosis in 2010 based on symptoms and chest Xray. A 2015 muscle biopsy showed denervation, and granulomas suggestive of Sarc. I've had progressive symptoms suggestive of secondary Autonomic Dysfunction for years. I've been on 10mg of Prednisone 4x/week, 15mg of Meloxicam and other OTC anti-inflammatories for some time now. A recent PET scan did not show inflammation and my lungs are clear. My Drs. are now looking at other causes for my ongoing leg pain/weakness and muscle spasms. In the past six weeks or so, my activities are greatly curtailed to the point of being housebound and giving up my therapies since activity triggers AD-type episodes...muscle spasms, headaches, dizziness, nausea, sweating, shaking, severe SOB, presyncope, etc. Given the current lack of inflammation, could this still be a complication of Sarcoidosis, or more likely something else, like MS? Are there any definitive tests to distinguish between the two? How would the treatment be different?

Karen_Nater_Pineiro_: I strongly encourage you to follow up with a neurologist. Sarcoidosis can rarely cause neurologic complications. Those can affect the peripheral nervous system (nerves, muscles) and, even less frequent, the Central Nervous System. You may need electrodiagnostic studies or other workup. However, I can't adequately assess specifics and strongly encourage you to make an appointment with a neurologist and bring your medical records for their review.

Brother: How likely is it that an individual can have both multiple sclerosis and sarcoidosis simultaneously?

Karen_Nater_Pineiro_: Both of those diseases are very rare. Therefore, we don't have specific statistics. Treatment is different for those. You should discuss your findings with an MS expert to be confident you have the right diagnosis and treatment.

dzilisch: Is there anything behind the internet rumors that MS is actually advanced Lyme disease, and upon autopsy Lyme spirochetes are actually found in MS patients? Are there specific tests would you recommend to rule in/out MS vs Lyme?

Karen_Nater_Pineiro_: MS is an autoimmune disease that seems to be multifactorial. Over the years, multiple viruses and bacteria have been considered including, EBV, VZV and more recently Lyme. We don't believe it's an infectious process in itself and therefore is not caused by Lyme. There seems to be a lot of non-scientific literature about Lyme disease over the internet. Please remember that our bodies carry multiple viruses and bacteria that are not necessary implicated in diseases.

MS and Genetics

54558pdc: Is MS one of the many autoimmune disorders? Are there hereditary links? Thanks, pdc.

Karen_Nater_Pineiro_: MS is not congenital/hereditary. There is however about a 3% chance of having a first line relative with other autoimmune disease. However, we believe MS has a multifactorial etiology- meaning it needs multiple "hits" for you to actually develop the disease.

Testing and Diagnosis

needs answers: Hi, I am a 59-year-old female diagnosed with MS based solely on symptoms and brain MRI. Lumbar puncture, VEP and BAEP were normal. MRI showed the radiologist noted on the report that lesions are radiating laterally from corpus callosum in a pattern consistent with Dawson's fingers. The neurologist that I sought out for a second opinion wrote on his report that the lesions did NOT clearly appear in pattern of Dawson's fingers. He felt that I probably do not have MS. He relocated before my follow-up so no other opinions as to a different diagnosis were given. I have constant numbness and tingling in arms, hands, legs and feet. I also have concerning confusion and memory issues. I was given an ambulatory 48 hour E.E.G test and that was abnormal. I am understandably seeking an accurate diagnosis. Is there any place where I could mail my brain MRI for evaluation? Any other suggestions? Thank you.

Karen_Nater_Pineiro_: As stated before, MRI findings need to be interpreted within clinical context. Radiologists are trained to "read an MRI" and they sometimes suggest probabilities but remember they don't have the clinical history. Neurologists interpret MRIs based on the clinical information. It seems you need to get a second opinion. We'll be more than happy to review your records and MRI. We can review the MRI but again, this will be in the context of a complete neurologic evaluation during an office visit as indicated.

moryan13: Over ten years ago, an MRI resulted in a lesion "consistent with MS" but the neurologist did not give me an MS diagnosis and felt he could do nothing more for me. To this day, I continue to have periodic episodes (as I call them) whereby I have tingling in my legs and feet, left side of my face and the fingers of one hand. This is accompanied by a specific headache and extreme fatigue. However, it takes several weeks to get an appointment and of course, I'm usually not in the middle of an episode when the appointment day comes along. So the doctor never sees me at my worst. Any thoughts on how to proceed? Thank you.

Karen_Nater_Pineiro_: MS can be difficult to diagnoses and MRI is not a "test for diagnosis". Sometimes, we need to follow the patient over time for clinical and radiographic evolution. You should schedule regular follow up appointments. Headaches sometimes can be very severe, and not necessary means that you suffer from MS.

MonkeyBizness8: What are “evoked potentials” and what are they used for?

Karen_Nater_Pineiro_: "Evoked potentials" is a test to measure the electrical conduction of specific regions/areas. For example Visual Evoked potentials are used to "measure" the velocity at which the ON transmit the "evoked/provided" input. Abnormalities in those can suggest demyelination among many other things. Keep in mind that evoked potentials are also used to diagnose other diseases/processes as those only document abnormal transmission.

keroppi: Can an MS diagnosis ever be made with normal brain and spine MRIs? Do you ever find that MRIs show normal for many years, and then many years later as symptoms progress, abnormalities consistent with MS show?

Karen_Nater_Pineiro_: Many years ago MS was a clinical diagnosis. However with the advent of MRI techniques, we now included MRI lesions in the diagnosis criteria. Rationale being that it will be very unlikely to have a normal physical examination and MRI. Remember that MS is a diagnosis of exclusion. A constellation of multiple symptoms can represent MS just after other diagnosis are ruled out and fulfill clinical and radiographic criteria. When we suspect MS and MRI is normal, we can consider CSF, visual field/OTC/VEP among others. Most often, we follow clinically and radiographically over time (repeat MRIs).

Pregnancy and MS

NYCgirl12: Does MS pose any health risks to becoming pregnant?

Karen_Nater_Pineiro_: No. Most MS patients are women, and usually diagnosed during reproductive ages. Most of them have uncomplicated pregnancies. The hormonal changes associated with pregnancy seems to be somewhat protective, and usually patients don't have MS relapses during pregnancy. Patients however can have attacks/relapses during pregnancy especially if they had an aggressive course beforehand. Patients can also experience relapses soon afterwards.

Treatments and Services

suzyq: Why would a patient have success for many years with rituximab in the treatment of NMO and then have it not be effective and additionally cause too much reduction of immune system?

Karen_Nater_Pineiro_: NMO is not a homogenous disease, that's why it's labeled NMO- SD (spectrum disorders). It unfortunately can have a very aggressive course and can be refractory to treatment. Rituximab has the best data on most cases. However we know that some patients can have relapses even on Rituximab. You should continue close follow up care with an expert on Neuro-inflammatory disorders (MS/NMO,etc) such as we have at the Mellen Center for MS at Cleveland Clinic.

BeachGirl87: What does Cleveland Clinic provide for MS patients?

Karen_Nater_Pineiro_: We offer a comprehensive approach to MS. This implies that we address all issues related to the disease- from diagnosis to treatment management. Patients with MS can have a constellation of symptoms that include urinary urgency, spasticity, and cognitive decline among others. We have a team of providers that specialized in the care of those conditions. Further, most MS patients benefit from rehabilitation services including PT/TO- trained specifically of neurologic disturbances- we offer those within our Center.

Exercising with MS I was finally diagnosed with MS in 2007. My neurologist found a lesion in my spinal cord and advised me to have MRI's every three months for two years. Needless to say, a thoracic MRI had not been performed and the periodic weakness that I had been experiencing for YEARS was not addressed properly and now I have great difficulty walking. What type(s) of exercise do you recommend? I have access to a family pool. Any input on this. I am still able to walk with a walker. The fatigue is not helpful. Thank you!

Karen_Nater_Pineiro_: Sometimes patient with MS can have residual deficits including weakness, paresthesias, electric sensation in the spine (Lhermite sign). I encourage you to establish a good exercise and stretch routine avoid overheat and prevent spasm. Follow up with the neurologist that diagnosed you as he may be able to evaluate if you have any spasticity that may benefit from medication. Lastly, pool exercises are very good as they avoid heat intolerance.

For Appointments

To make an appointment with Karen Nater Pineiro, MD, Neurologist or any of the other specialists in the Pauline M. Braathen Neurological Center at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at

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