Dilemmas in the differential diagnosis of pediatric multiple sclerosis

Multiple sclerosis (MS) is a chronic, inflammatory, and neurodegenerative disease of the central nervous system (CNS). It typically presents in early or middle adulthood, and pediatric-onset MS (POMS), defined by the first MS attack occurring before the age of 18, is less common. Current data from the Danish Multiple Sclerosis Registry indicates that nearly 3% of patients had the onset before the age of 18. In comparison with adult-onset MS, POMS patients typically have a more inflammatory-active disease course, resulting in more frequent relapses, but slower long-term disability accumulation. In POMS, diagnostic dilemmas may include differentiating MS from acute disseminated encephalomyelitis (ADEM) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), both of which most commonly occur among children and share some clinical and imaging features with MS. Inherited leukodystrophies should be considered in the differential diagnosis only in select cases, as their hallmark clinical feature-a progressive disease course-distinguishes them from the typically non-progressive acquired demyelinating syndromes, including neuromyelitis optica spectrum disorder. It's important to remember that magnetic resonance imaging (MRI) of the brain and spinal cord is essential for establishing a timely and accurate diagnosis of POMS. MRI helps exclude alternative diagnoses, allowing for the prompt initiation of effective treatment.