2021 CMSC Annual Meeting

Multiple Sclerosis Diagnosis: Challenges in Telehealth

Background: The COVID-19 pandemic ushered in a new era of telehealth to decrease transmission of the SARS-CoV-2 virus. While this increased access to care for all patients, unanticipated challenges arose, creating barriers to the accurate diagnosis Objectives: To identify key limitations of telehealth in evaluating new patients for MS. Methods: Using retrospective chart reviews from the USF MS Center, patients who were diagnosed with MS after telehealth evaluation during the pandemic were identified, and charts were analyzed for contributors to delayed diagnosis and treatment. Results: Patient 1: A 30-year-old man presented via telehealth for evaluation after two prior stroke-like episodes with residual right hemiparesis. Video-based neurological exam was unable to elicit pathology indicative of MS. Neurological exam on in-person follow-up showed upper motor neuron signs and cerebellar dysfunction. Due to barriers to obtaining records, repeat MRIs were obtained, revealing classical lesions for MS. A confirmed diagnosis was delivered 3 months after his initial telehealth evaluation. Patient 2: A 43-year-old woman presented via telehealth for evaluation of an abnormal brain MRI ordered by her primary care provider for workup of migraines and systemic symptoms. Her limited virtual neurologic exam was unremarkable. MRI imaging for MS was incomplete. During in-person follow-up, neurological exam showed a relative afferent pupillary defect on the right, and vibratory loss in her left hand and feet. MRI imaging brought in by the patient was suggestive of MS. Diagnosis was confirmed approximately a month after initial evaluation. Patient 3: A 47-year-old woman presented via telehealth with a prior diagnosis of MS from 2014. There were challenges in acquiring records due in part to the COVID-19 pandemic. Documentation from her previous neurologist received later enabled a confirmation of diagnosis. Initiation of disease-modifying therapy was delayed by approximately 3 months from initial evaluation. Conclusions: Telehealth, with its many benefits, is not without pitfalls. In these cases, physicians were unable to elicit pathology over telehealth neurological exam, but in-person follow-up exam revealed findings suggestive of MS. Additionally, limitations in access to MRI images and records contributed to delayed diagnosis and treatment. Neurologists should exercise caution in evaluating MS diagnosis over telehealth when clinical data is incomplete.