Poser criteria

Poser criteria are diagnostic criteria for multiple sclerosis (MS). They replaced the older Schumacher criteria,^[1] and now they are considered obsolete as McDonald criteria have superseded them. Nevertheless, some of the concepts introduced have remained in MS research, like CDMS (clinical definite MS), and newer criteria are often calibrated against them.^[2]

The article that introduced them also defined the concepts of attack, historical information, clinical evidence, paraclinical evidence, lesion typical of MS, remission, separate lesions and laboratory support, which are necessary to apply the criteria.

The criteria considers MS as the presence of demyelinating lesions disseminated in time and space, and they are oriented specially to prove the dissemination. Based on this, the authors defined a set of rules that can yield five conclusions:^[3] CDMS, LSDMS, CPMS, LSPMS or noMS. Poser diagnosis of CDMS is known to have a sensitivity of 87% respect postmortem autopsy examination^[4]

Definitions

Poser et al. define several concepts. The most important for diagnosis are:

Attack: Occurrence of a symptom of neurological dysfunction for more than 24 hours
Clinical evidence: Neurological dysfunction demonstrable by neurological examination
Paraclinical evidence: Demonstration by any test of the existence of a non-clinical lesion in the CNS

Diagnosis conclusions

The criteria can yield five conclusions:

CDMS – Clinically definite MS. Needs two attacks and some clinical or paraclinical evidences
LSDMS – Laboratory supported definite MS, showing oligoclonal bands and clinical or paraclinical evidences
CPMS – Clinically probable MS, with less restrict combinations.
LSPMS – Laboratory supported probable MS. Only two attacks is enough to enter this category
No MS – There is no clinical evidence of having MS.

Summary of requirements

Any of the five conclusions have subpossibilities. Here a table is shown with each one of them:

Diagnosis conclusion	Clinical Presentation	Additional Data Needed
CDMS	* Two or more attacks (relapses)	Two clinical evidence One clinical and one paraclinical evidence
LSDMS	* At least one attack and oligoclonal bands	Two attacks and one evidence (clinical or paraclinical) One attack and two clinical evidences One attack, one clinical and one paraclinical evidences
CPMS	* At least one attack	Two attacks and one clinical evidence One attack and two clinical evidences One attack, one clinical and one paraclinical evidences
LSPMS	* Two attacks	No more evidence is required

If none of these requirements is accomplished, the diagnosis is "No MS", meaning that there is not enough clinical evidence to support a clinical diagnosis of MS.

Sensitivity and specificity

Poser diagnosis of CDMS was initially reported to have a sensitivity of 87% respect postmortem autopsy examination.^[5] Poser criteria were published in 1983 and their sensitivity increased with time. For example, in 1988 a 94% specificity vs. postmortem analysis was reported ^[6]

Anyway, in initial cases, the sensitivity was low respect pathologically defined MS because around 25% of MS cases are silent MS cases.^[7]

Two pathologically disseminated inflammatory demyelinating lesions should be considered MS even if they are silent. Therefore, Poser criteria should be considered as deprecated.

Extension of the concepts

As more knowledge about the underlying pathology of MS has been gathered, the concepts of subclinical, preclinical and CIS have been used together with the Poser original classification.

The first manifestation of MS is the so-called clinically isolated syndrome, or CIS, which is the first isolated attack. The Poser diagnosis criteria for MS does not allow doctors normally to give an MS diagnosis until a second attack takes place. Therefore, the concept of "clinical MS", for a MS that can be diagnosed is sometimes too strong because until MS diagnosis has been established, nobody can tell whether the disease dealing with is MS.

Cases of MS before the CIS are sometimes found during other neurological inspections and are referred to as "subclinical MS".^[8] "Preclinical MS" refers to cases after the CIS but before the confirming second attack.^[9] After the second confirming attack the situation is referred to as CDMS (clinically defined multiple sclerosis).^[10]

References

↑ Schumacher GA, Beebe G, Kibler RF, Kurland LT, Kurtzke JF, McDowell F, Nagler B, Sibley WA, Tourtellotte WW, Willmon TL (March 1965). "PROBLEMS OF EXPERIMENTAL TRIALS OF THERAPY IN MULTIPLE SCLEROSIS: REPORT BY THE PANEL ON THE EVALUATION OF EXPERIMENTAL TRIALS OF THERAPY IN MULTIPLE SCLEROSIS". Ann N Y Acad Sci. 122: 552–568. doi:10.1111/j.1749-6632.1965.tb20235.x. PMID 14313512.
↑ Christopher J. Lisanti, Patrick Asbach, and William G. Bradley, Jr. The Ependymal “Dot-Dash” Sign: An MR Imaging Finding of Early Multiple Sclerosis, AJNR Am J Neuroradiol 26:2033–2036, September 2005
↑ Poser CM, Paty DW, Scheinberg L, et al. (March 1983). "New diagnostic criteria for multiple sclerosis: Guidelines for research protocols" (PDF). Annals of Neurology. 13 (3): 227–31. doi:10.1002/ana.410130302. PMID 6847134.
↑ Izquierdo G, Hauw J-J, Lyon-Caen O, et al: Value of multiple sclerosis diagnostic criteria: 70 Autopsy-confirmed cases. Arch Neurol 1985;42:848-850.
↑ Izquierdo G, Hauw J-J, Lyon-Caen O, et al: Value of multiple sclerosis diagnostic criteria: 70 Autopsy-confirmed cases. Arch Neurol 1985;42:848-850.
↑ A clinico-pathoanatomical study of multiple sclerosis diagnosis, Engell T. Acta Neurol Scand. 1988 Jul;78(1):39-44. PMID 3176880
↑ Engell T (May 1989). "A clinical patho-anatomical study of clinically silent multiple sclerosis". Acta Neurol Scand. 79 (5): 428–30. doi:10.1111/j.1600-0404.1989.tb03811.x. PMID 2741673.
↑ Hakiki B, Goretti B, Portaccio E, Zipoli V, Amato MP (2008). "Subclinical MS: follow-up of four cases". European Journal of Neurology. 15 (8): 858–61. doi:10.1111/j.1468-1331.2008.02155.x. PMID 18507677.
↑ Lebrun C, Bensa C, Debouverie M, et al. (2008). "Unexpected multiple sclerosis: follow-up of 30 patients with magnetic resonance imaging and clinical conversion profile". J Neurol Neurosurg Psychiatry. 79 (2): 195–198. doi:10.1136/jnnp.2006.108274. PMID 18202208.
↑ Frisullo G, Nociti V, Iorio R, et al. (Dec 2008). "The persistency of high levels of pSTAT3 expression in circulating CD4+ T cells from CIS patients favors the early conversion to clinically defined multiple sclerosis". J Neuroimmunol. 205 (1-2): 126–134. doi:10.1016/j.jneuroim.2008.09.003. PMID 18926576.

Multiple sclerosis and other demyelinating diseases of CNS (G35–G37, 340–341)

Signs and symptoms	Ataxia Depression Diplopia Dysarthria Dysphagia Fatigue Incontinence Neurological fatigue Nystagmus Optic neuritis Pain Uhthoff's phenomenon Dawson's fingers

Diagnosis and evolution following	Diagnostic criteria for MS McDonald criteria Poser criteria EDSS Clinically isolated syndrome

Investigation	Pathophysiology Experimental autoimmune encephalomyelitis Multiple sclerosis drug pipeline Multiple sclerosis research

Approved Treatment	Interferon beta 1b Glatiramer acetate Interferon beta 1a Mitoxantrone Natalizumab Fingolimod Teriflunomide Dimethyl fumarate Alemtuzumab Daclizumab

Borderline forms	Acute disseminated encephalomyelitis Balo concentric sclerosis Neuromyelitis optica Marburg multiple sclerosis Schilder's disease Tumefactive multiple sclerosis (Autoimmune PNS diseases like Guillain-Barré syndrome and CIDP are normally set apart) AntiMOG associated encephalomyelitis

Other	List of people with multiple sclerosis List of multiple sclerosis organizations

Pathology of the nervous system, primarily CNS (G04–G47, 323–349)

Inflammation

Brain	Encephalitis Viral encephalitis Herpesviral encephalitis Limbic encephalitis Encephalitis lethargica Cavernous sinus thrombosis Brain abscess Amoebic

Spinal cord	Myelitis: Poliomyelitis Demyelinating disease Transverse myelitis Tropical spastic paraparesis Epidural abscess

Both/either	Encephalomyelitis Acute disseminated Myalgic Meningoencephalitis

Brain/
encephalopathy

Degenerative

Extrapyramidal and movement disorders	Basal ganglia disease Parkinsonism PD Postencephalitic NMS PKAN Tauopathy PSP Striatonigral degeneration Hemiballismus HD OA Dyskinesia Dystonia Status dystonicus Spasmodic torticollis Meige's Blepharospasm Athetosis Chorea Choreoathetosis Myoclonus Myoclonic epilepsy Akathisia Tremor Essential tremor Intention tremor Restless legs Stiff person

Dementia	Tauopathy Alzheimer's Early-onset Primary progressive aphasia Frontotemporal dementia/Frontotemporal lobar degeneration Pick's Dementia with Lewy bodies Posterior cortical atrophy Vascular dementia

Mitochondrial disease	Leigh disease

Demyelinating

Episodic/
paroxysmal

Seizure/epilepsy	Focal Generalised Status epilepticus Myoclonic epilepsy

Headache	Migraine Familial hemiplegic Cluster Tension

Cerebrovascular	TIA Amaurosis fugax Transient global amnesia Acute aphasia Stroke MCA ACA PCA Foville's Millard–Gubler Lateral medullary Weber's Lacunar stroke

Sleep disorders	Insomnia Hypersomnia Sleep apnea Obstructive Congenital central hypoventilation syndrome Narcolepsy Cataplexy Kleine–Levin Circadian rhythm sleep disorder Advanced sleep phase disorder Delayed sleep phase disorder Non-24-hour sleep–wake disorder Jet lag

CSF

Other

Spinal cord/
myelopathy

Both/either

Degenerative

SA	Friedreich's ataxia Ataxia telangiectasia

MND	UMN only: Primary lateral sclerosis Pseudobulbar palsy Hereditary spastic paraplegia LMN only: Distal hereditary motor neuronopathies Spinal muscular atrophies SMA SMAX1 SMAX2 DSMA1 Congenital DSMA SMA-PCH SMA-LED SMA-PME Progressive muscular atrophy Progressive bulbar palsy Fazio–Londe Infantile progressive bulbar palsy both: Amyotrophic lateral sclerosis

Hypersensitivity and autoimmune diseases (279.5–6)

Type I/allergy/atopy
(IgE)

Foreign	Atopic eczema Allergic urticaria Allergic rhinitis (Hay fever) Allergic asthma Anaphylaxis Food allergy common allergies include: Milk Egg Peanut Tree nut Seafood Soy Wheat Penicillin allergy

Autoimmune	Eosinophilic esophagitis

Type II/ADCC

- IgM
- IgG

Foreign

Hemolytic disease of the newborn

Autoimmune

Cytotoxic	Autoimmune hemolytic anemia Immune thrombocytopenic purpura Bullous pemphigoid Pemphigus vulgaris Rheumatic fever Goodpasture's syndrome Guillain–Barré syndrome

"Type V"/receptor	Graves' disease Myasthenia gravis Pernicious anemia

Type III
(Immune complex)

Foreign	Henoch–Schönlein purpura Hypersensitivity vasculitis Reactive arthritis Farmer's lung Post-streptococcal glomerulonephritis Serum sickness Arthus reaction

Autoimmune	Systemic lupus erythematosus Subacute bacterial endocarditis Rheumatoid arthritis

Type IV/cell-mediated
(T cells)

Foreign	Allergic contact dermatitis Mantoux test

Autoimmune	Diabetes mellitus type 1 Hashimoto's thyroiditis Multiple sclerosis Coeliac disease Giant-cell arteritis Postorgasmic illness syndrome Reactive arthritis

GVHD	Transfusion-associated graft versus host disease

Unknown/
multiple

Foreign	Hypersensitivity pneumonitis Allergic bronchopulmonary aspergillosis Transplant rejection Latex allergy (I+IV)

Autoimmune	Sjögren's syndrome Autoimmune hepatitis Autoimmune polyendocrine syndrome APS1 APS2 Autoimmune adrenalitis Systemic autoimmune disease

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