Multiple sclerosis patients’ journey delay in diagnosis and treatment: a multicenter study

Abstract

Objective

To determine factors that contribute to delayed diagnosis and treatment of MS patients. Additionally, the study aimed to evaluate the correlation between diagnostic and therapeutic delay and disease outcome.

Methods

The current cohort observational multicenter study was performed at neurology clinics in four cities in Egypt. In this study, 239 MS patients were enrolled. Multiple Sclerosis Severity Scale (MSSS) and Expanded Disability Status Scale (EDSS) were utilized to measure disease severity and disability, respectively. Lag times for diagnosis were calculated in months from the time of the first symptoms to the accurate diagnosis.

Results

The results revealed that multiple important variables had a negative impact on the timely diagnosis, including the clinical type, as PPMS had longer delayed diagnoses versus RRMS/SPMS (p < 0.001). Conversely, the occurrence of sensory symptoms at disease onset is linked to prolonged diagnostic delay (p < 0.001). Multivariate logistic regression showed that young age, PPMS, and sensory symptoms were independently associated with delay in MS diagnosis. Patients initially sought medical assistance from ophthalmologists and neurologists, resulting in a significantly more delay in diagnosis (p < 0.001). A statistically positive correlation exists between the time for diagnosis and deterioration of MS assessed by EDSS, MSSS, or PI (p < 0.001). In addition, logistic regression analysis demonstrated that EDSS at diagnosis, delayed diagnosis, and illness duration were independently linked to MS severity (p < 0.001).

Conclusion

Many factors prolong the duration of MS diagnosis, including the age at disease onset, the delay in being referred from other medical specialties, and the presence of sensory symptoms at disease onset. Furthermore, MS delayed diagnosis and treatment leads to high disease disability with poor functional outcomes.

Introduction

Multiple sclerosis (MS) is a chronic condition marked by the presence of inflammation, demyelination, and degeneration in the central nervous system. It is widely regarded as a primary factor contributing to neurological disabilities in young adults [1, 2].

MS is a heterogeneous disease characterized by a diverse range of symptoms. Its diagnosis is determined by established criteria that require evidence of dissemination in both time and space [3]. MS has a preclinical stage with demyelinating plaques detected utilizing magnetic resonance imaging (radiologically isolated syndrome) [4]. Clinically isolated conditions, relapsing-remitting, and progressive form are the three main stages of MS, occurring in nearly 90% of cases [5].

In the initial phases of MS, inflammation significantly contributes to the progression of the condition and serves as the primary focus of disease-modifying medications [6]. Furthermore, there is compelling data indicating that these medications enhance disease prognosis [7]. The significance of early diagnosis has been emphasized in recommending early intervention, particularly in high-risk cases [8]. A delay in diagnosis can restrict the range of treatment options and the chance for early intervention, which could result in irreversible consequences [9].

The delay in diagnosing and initiating treatment may be partly attributed to the complex nature of the disease, which makes it challenging to meet the diagnostic criteria while ruling out other potential conditions [10]. According to a prior study, the rate of misdiagnosis in MS cases is approximately 5–10% [11].

It is crucial to examine the factors implicated in delayed diagnosis in MS patients, particularly in developing countries such as Egypt. Consequently, the current study was carried out to investigate the factors linked to the delayed MS diagnosis.

Patients and methods

This cohort observational multicenter study was carried out during the interval from January 2022 to August 2023. We included 239 subjects over the age of 18 years with clinically defined MS based on the 2017 McDonald criteria [3]. We collected retrospective data from MS clinics in various places in Egypt, including El Gharbia, Kafr El Sheikh, Cairo, and El Sharkia. Therefore, it is highly likely that all MS patients in these clinics are included in the sample. Patients with unclear diagnoses or incomplete records were excluded from the study (Fig. 1).

Fig. 1.

Flowchart of patient selection

All patient records were reviewed and scrutinized to collect data on sex, age, diagnosis time, the time of disease onset, and course of disease. MS onset was determined as the first occurrence of neurological impairments that indicate MS [12]. The time of diagnosis was determined as the time when a neurologist officially established the diagnosis. The diagnostic delay in months was determined by subtracting the stated date of disease onset from the date of the definitive diagnosis of MS.

The causes of delayed MS diagnosis were divided into two main factors: patient-related causes and medical-related causes. Patient-related causes include denial of symptoms or reluctance to seek medical assistance. Medical-related causes include insufficient knowledge or the lack of specialized centers as well as diagnostic facilities. We gathered this information through detailed patient histories obtained during structured interviews. This approach enabled us to document the timeline of symptom onset, initial medical consultations, and eventual diagnosis comprehensively. By directly engaging with patients, we could capture important contextual details, such as personal and systemic factors contributing to delays. While self-reported data can be influenced by recall bias, we mitigated this by using a structured interview format with specific prompts, ensuring accuracy and consistency. Where possible, we also cross-referenced patient accounts with medical records.

The patients with MS were categorized into three groups according to their clinical course: primary progressive (PP-MS) (N = 8), secondary progressive (SP-MS) (N = 78), and relapsing-remitting (RR-MS) (N = 153). The evaluation of clinical disability was conducted utilizing the Kurtzke EDSS [13], whereas MS severity was assessed utilizing the MSSS, which is an algorithm that establishes a correlation between the EDSS scores in MS patients with comparable disease durations [14]. Disease duration in our study is defined as the time from the onset of the first symptoms to the last available visit. The number of attacks was counted as the total number of relapses that occurred from the onset of symptoms to the last available visit. This includes all documented relapses during the patient’s disease course.

Statistical analysis

Collected data were statistically analyzed utilizing the Jamovi project (2022) (Version 2.3). Qualitative data was represented in the form of numbers and percentages (N. %), while quantitative data was presented as mean ± SD and median (IQR). Interferential statistics: The chi-square and Fisher’s exact tests were used for qualitative data analysis. In contrast, quantitative data with normal distribution were analyzed using the t-test and ANOVA tests. For skewed data, both Kruskal-Wallis and Mann-Whitney tests were used. The significance level, denoted as the P-value, can be categorized as follows: P < 0.001 indicates high significance, P > 0.05 indicates non-significance, and P ≤ 0.05 indicates significance. Pearson’s correlation was utilized to determine correlations between two continuous, normally distributed variables. Multiple linear regressions were employed to examine and determine the correlation between a quantitative variable and a set of independent variables.

Results

The sociodemographic and clinical variables related to the diagnosis procedure are displayed in Table 1. The average period between the initial clinical symptoms and the diagnosis of MS was 14.01 ± 9.8 months (a median diagnostic delay of 14 months). Our study revealed that the delay in diagnosis was statistically longer in patients aged < 30 years compared to those aged ≥ 30 years (p = 0.01). The mean age was 32 years (range: 16 to 59 years), and the mean age at diagnosis was 30 years (range: 15 to 46 years). The majority of subjects were females (69.5%; female/male ratio: 2.27). There were no significant differences between males and females in terms of the delay in diagnosis (p = 0.726). No variation in diagnosis delays was found between patients according to their academic qualifications, residence, or employment state.

Table 1.

Sociodemographic and clinical characters of MS patients

Parameter		Total (239) (N %)	Time from onset of symptoms to Diagnosis (Months)		P value
			Mean ± SD	Median (Range)
Age of onset	< 30 y	100 (41.8%)	15.29 ± 11.52	12 (2–42)	0.01
	≥ 30 y	139 (58.2%)	12.09 ± 9.92	11 (1–38)
Gender	Female	166 (69.5%)	14 ± 11	12 (1–42)	0.726
	Male	73 (30.5%)	14 ± 10	12 (1–38)
Residence	Rural	102 (42.7%)	14 ± 10	12 (1–39)	0.971
	Urban	137 (57.3%)	14 ± 11	12 (1–42)
Education	< 12y	69 (28.9%)	14 ± 12	9 (1–39)	0.635
	≥ 12y	152 (63.6%)	14 ± 10	12 (1–42)
	Illiterate	18 (7.5%)	16 ± 12	17 (2–38)
Employment status	unemployed	88 (36.8%)	15 ± 12	11 (1–39)	0.1
	Retired	33 (13.8%)	16 ± 10	16 (2–37)
	Student	20 (8.4%)	9 ± 8	6 (1–27)
	Working	98 (41.0%)	14 ± 10	12 (1–42)
Marital status	Married	169 (70.7%)	14 ± 11	12 (1–42)	0.505
	Single	70 (29.3%)	14 ± 11	12 (1–39)
Family history	Absent	210 (87.9%)	14 ± 11	12 (1–42)	0.547
	History of MS	10 (4.2%)	9 ± 6	11 (1–18)
	Other autoimmune	19 (7.9%)	15 ± 11	12 (2–38)
Onset of illness	Before 2017	103 (43.1%)	16.9 ± 11.3	14 (1–42)	0.003
	After 2017	136 (56.9%)	12.4 ± 9.02	12 (1–38)
Type of MS	PPMS	8 (3.3%)	19 ± 13	16 (6–38)	< 0.001
	RRMS/SPMS	231 (96.7%)	12 ± 6	10 (5–35)
Initial assessed by	Neurologist	117 (50.2%)	11 ± 10	9 (1–39)	< 0.001
	Ophthalmologist	33 (14.2%)	9 ± 7	7 (1–24)
	Orthopedic	33 (14.2%)	19 ± 10	18 (3–39)
	Internal medicine	5 (2.1%)	19 ± 3	19 (16–24)
	Neurosurgery	31 (13.3%)	20 ± 12	20 (4–39)
	Family physician	14 (6.0%)	19 ± 14	15 (3–42)
Reasons of diagnosis delay	Medical cause	102 (42.7%)	13.55 ± 9.76	11 (4–38)	0.004*
	Patient cause	118 (49.4%)	9.42 ± 11.7	4 (1–39)
	Patient/Medical cause	19 (7.9%)	16.63 ± 11.71	14.5 (1–42)
Center	Cairo	53 (22.2%)	12.43 ± 11.33	8 (1–42)	0.26
	Kafr Elsheikh	52 (21.8%)	9.75 ± 7.33	8.5 (1–29)
	Tanta	74 (31%)	16.41 ± 13.6	13 (1–39)
	Zagazig	60 (25.1%)	10.55 ± 6.36	9 (2–27)

^aData were reported as mean ± SD. ^b Data were reported as number (%). P < 0.05 is considered significant. P > 0.05 is considered non-significant. RRMS, Relapsing-remitting MS; SPMS, Secondary progressive MS; PPMS, Primary progressive MS

According to MS classification, cases with PPMS experienced a substantially longer time to diagnosis (19 ± 13 months) compared to other MS clinical phenotypes (p < 0.001).

Our investigation found no substantial variation in the diagnostic delay between the four studied centers (p = 0.26).

Before 2017, the mean duration of delay in diagnosis of MS was 16.9 ± 11.3 months, significantly higher than those diagnosed after 2017 (p = 003).

Among our patients, the first health professional consulted was a neurologist (50%), an ophthalmologist (14%), an orthopedic surgeon (14%), a neurosurgery (13%), a family physician (6%), and an internal medicine specialist (2%). Patients who were initially evaluated by an ophthalmologist or a neurologist had a considerably shorter time to diagnosis compared to those examined by other medical specialties (9 ± 7 months and 11 ± 10 months, respectively; p < 0.001). Most causes of delayed diagnosis are a combination of patient and medical causes (p = 0.004).

The most prevalent initial clinical symptom was optic symptoms, occurring in 33.5% of cases. This was followed by pyramidal symptoms in 30.5% of cases, sensory symptoms in 24.3% of cases, brainstem/cerebellar symptoms in 11.3% of cases, sphincteric symptoms (4.2%), and mental symptoms in 0.4% of cases (Table 2).

Table 2.

Initial symptoms and diagnostic delay

		Total (N %)	Time from onset of symptoms to Diagnosis (Months) Mean ± SD	P value
Type of First Symptoms	Optic	80 (33.5%)	8 ± 7	< 0.001
	pyramidal	73 (30.5%)	14 ± 10
	sensory	58 (24.3%)	24 ± 11
	Brainstem/cerebellar	27 (11.3%)	10 ± 4
	mental symptoms	1 (0.4%)	9
	sphincteric	10 (4.2%)	10 ± 3
Number of relapses before diagnosis	0–1	3 (1.3%)	22 ± 16	< 0.001
	2–3	114 (47.7%)	18 ± 10
	> 3	122 (51.0%)	10 ± 9

^aData were reported as mean ± SD. ^b Data were reported as number (%)., P < 0.05 is considered significant. P > 0.05 is considered non-significant

Patients who exhibited visual impairment were diagnosed at an earlier stage. Furthermore, individuals who had a sensory deficit experienced the most significant delay in diagnosis (p < 0.001). Furthermore, patients with low relapses had a statistically significant longer duration before the diagnosis (p < 0.001).

Figures (2 & 3) show a statistically positive correlation between diagnostic delay and a more severe disease deterioration as assessed by EDSS and MSSS (p < 0.001), respectively.

Fig. 2.

Correlation between diagnostic delay and Current EDSS (expanded disability status scale)

Fig. 3.

Correlation between diagnostic delay and MSSS (multiple sclerosis severity scale)

The multivariate logistic regression demonstrated that age at disease onset < 30 years and sensory symptoms at onset are more likely to experience a prolonged diagnostic delay (Table 3).

Table 3.

Multivariate logistic regression for lower time until diagnosis (< 14 month)

		Univariate analysis		P value	Multivariate analysis		P value
		OR	95% CI		OR	95% CI
Sex	Male	-	ref	0.39
	Female	0.78	(0.45–1.37)
Age	≥ 30years	-	ref	0.04*
	< 30 years	0.46	(0.21–0.99)		0.44	(0.2–0.98)	0.04
Education	< 12 y	-	ref
	≥ 12 y	1.24	(0.69–2.22)	0.47
	Illiterate	2.57	(1.59–4.19)	0.03*	0.74	(0.41–1.33)	0.31
MS Phenotypes	RRMS/SPMS	-	ref
	PPMS	4.57	(1.02–20.52)	0.05*	13.9	(6.3–30.66)	0.02
First symptoms	Optic	-	ref
	Motor	0.35	(0.12–1.79)	0.02*	0.99	(0.98–1.03)	0.6
	Sensory	0.03	(0.009–0.12)	< 0.001*	0.04	(0.009–0.18)	< 0.001
	Ataxia	0.54	(0.28–1.07)	0.08
	Psychiatric	0.68	(0.007–1.68)	0.18

OR: odds ratio; 95%CI: 95% confidence interval, Ref: category versus the one is making comparisons, P < 0.05 is considered significant. P > 0.05 is considered non-significant; RRMS, Relapsing-remitting MS; SPMS, Secondary progressive MS; PPMS, Primary progressive MS

Finally, linear regression depicted results in Table 4 reveal that EDSS at the time of diagnosis, delayed diagnosis, and illness duration are independently associated with MS severity.

Table 4.

Linear regression analysis for disease severity measured by MSSS

Variables	Estimate	SE	P
Age of onset	0.0186	0.015	0.220
Number of attacks	0.1023	0.046	0.028
EDSS At time of diagnosis	2.0011	0.13	< 0.001
Duration from diagnosis to treatment (months)	0.107	0.064	0.009

SE, Standard error. P < 0.05 is considered significant. P > 0.05 is considered non-significant. EDSS, Expanded Disability Status Scale

Discussion

Given the increasing incidence and prevalence of MS in recent times, the effects of disease activity and the resulting accumulated damage significantly result in a decline in quality of life. Diagnostic delays resulting from diagnostic uncertainty can cause delays in initiating therapy. Early MS diagnosis is crucial in order to minimize the impact of disability and the associated financial burden. Therefore, we conducted a study to examine the duration between the onset of clinical symptoms and MS diagnosis and determine the potential factors that can lead to a diagnostic delay in a cohort of MS patients in Egypt.

The findings of our investigation indicate that the average time between the emergence of symptoms and the diagnosis of MS was 14 months. Our findings follow those reported by Khodaie et al. [15] who reported the meantime interval of diagnosis was 13.42 months. This duration was shorter than the durations reported in the studies done by Ghiasian et al. [16] (18.23 months), Thormann et al. [17] (47.5 months) and Bahou et al. [18] (23 months). and longer than the study by Aires et al. [19] (9 months) and Mobasheri et al. [20] (7 months). According to a recent study conducted in upper Egypt, around 49% of patients with MS had a diagnosis that was delayed by more than three months [21]. The National Institute for Clinical Excellence (NICE) recommended that MS be diagnosed within three months at the latest. This means that there should be no more than six weeks between the onset of MS symptoms and the first consultation with a neurologist, followed by an additional six weeks until all necessary investigations are completed [22]. Differences between countries may be due to differences in referral processes, utilizing different diagnostic methods, the level of health literacy among different ethnic groups, and the accessibility and strength of specialized healthcare facilities. According to the Multiple Sclerosis International Federation Atlas of MS, low-income countries are more likely to report at least one major barrier to early diagnosis of MS than high/upper middle-income countries [23].

Regarding the age at onset, 58.2% of our patients were older than 30 years, and the diagnostic delay was more common in patients under 30 years. This finding aligns with Khedr et al. [21] and Tohamy et al. [24] studies on Egyptian MS patients. Furthermore, Marrie et al. [25] reported that younger age was associated with diagnostic delay. Additionally, Cárdenas-Robledo et al. [26] reported no link between age and diagnostic delay. On the other hand, Patti et al. [27] found that older age at MS onset was a risk factor for delay in diagnosis. The difference in results could be due to differences in MS prevalence and risk factors leading to variability in the age at onset in different countries or even disparities in access to diagnostic facilities [16].

Based on the data analysis, this study showed that the mean delay duration in the diagnosis of MS before 2017 was significantly higher than that after 2017. This may indicate that the time to diagnosis has gradually decreased over the study period due to the improvement in diagnostic criteria [28]. Hosseinnataj et al. [29] noted that the EDSS scores showed significant differences before and after 2017. This suggests that there may have been improvements in the diagnostic process or changes in patient characteristics over time. Hence, the rise in prevalence in recent years could be attributed, in part, to advancements in diagnostic techniques, including the 3 Tesla brain MRI, which has been more accessible in recent times. Additionally, there is now an ability to identify younger patients and individuals with less severe conditions who are living longer with the condition.

Regarding residence, there was no notable disparity in the delay of MS diagnosis between patients from the four different centers or patients living in rural or urban areas. In contrast, Ghiasian et al. [16] illustrated that the average time between symptoms onset and diagnosis was longer in villagers than in citizens. Internationally, rural dwellings have been reported as a cause of delay in diagnosis of tuberculosis, cancer, congenital hearing loss, and dementia [30, 31]. This can be attributed to factors such as distance travel, patients’ tendency to seek alternative medical care first [32], and the low level of education [33]. The absence of disparity in diagnostic delay between rural and urban areas in our study can be attributed to the swift and substantial decline in functional ability and physical autonomy experienced by MS patients, which encourages them to seek medical assistance. This is further facilitated by the presence of high-quality healthcare services in Egypt, as well as the collaboration between universities, research centers, and general hospitals.

With regard to education level, there were no substantial differences between subjects with different levels of education and delays in diagnosis. This finding is compatible with those of Khedr et al. [21] and Aires et al. [19]. In contrast, a previous study by Ghiasian et al. [16] reported that illiterate patients experience greater delay in seeking treatment after the onset of symptoms than illiterate patients.

There is no evidence to suggest that sex, employment status, or family history of MS are linked to a delay in MS diagnosis, which is consistent with a number of prior studies [9, 19, 34]. Eccles [35] suggested that the gender correlations of MS increase the probability of its diagnosis in women and decrease the likelihood of MS being detected when comparable symptoms and signs occur in males.

Theoretically, it was hypothesized that having a partner can detect early symptoms and encourage early treatment, thus reducing the time needed for diagnosis. However, we observed no substantial disparity in the average duration between the diagnosis of MS and marital status. There is a limited number of studies examining this aspect, but these findings contradict the study conducted by Ghiasian et al. [16], which found that married patients experienced a delay in diagnosis compared to single patients.

Approximately 50% of the participants included in this study were initially examined by a non-neurologist. In contrast, patients first examined by an ophthalmologist and a neurologist had a significantly shorter diagnosis time than those examined by another medical specialty. In concordance with two Egyptian studies, the ophthalmologist is the most common non-neurology specialty first seen by MS patients [21, 24]. Previous research has indicated that the period between symptoms onset and the first medical consultation is the main factor contributing to the delay in diagnosis [4]. Kaisey and Solomon [36] highlight various factors that contribute to the challenges in diagnosing MS. These include a lack of awareness among healthcare providers regarding early symptoms of MS and difficulties in applying the established diagnostic criteria correctly. These factors can lead to both misdiagnosis and delays in diagnosis.

Although we do not know exactly where the delay occurs, it may be due to lack of knowledge about MS by other medical specialties, the time it takes for MS patient to seek medical care. MS, like other diseases, can be challenging to identify in its early stages, and there are several diseases and syndromes that may appear comparable to it. Moreover, numerous studies have demonstrated that the primary cause of the delay in diagnosing MS is the failure to recognize specific symptoms, which frequently results in misdiagnosis [37, 38]. Our study revealed that 42.7% of the patients were given an inaccurate previous diagnosis, resulting in a prolonged delay in MS diagnosis. The complexity of this condition, characterized by multiple symptoms, often poses challenges in diagnosing it, particularly for individuals unfamiliar with it. In a multicenter study evaluating the knowledge of neurologists on MS, Péloquin et al. [39] found that 27% of the participants had either no understanding or only a rudimentary understanding of the latest diagnostic criteria for MS. Additionally, over one-third of the participants had either no knowledge or only a rudimentary knowledge of atypical presentations of MS. Therefore, it is essential for the general public, primary care providers, and neurologists to have a thorough understanding of MS symptoms and diagnosis.

Our findings indicate that patients with PPMS experienced a longer diagnostic delay compared to those with RRMS, which aligns with the findings of Kingwell et al. [9] and Aires et al. [19] Khodaie et al. [15]. PPMS is characterized by a limited number of relapses and a gradual worsening of disability over time, which makes it difficult to differentiate from other conditions. In addition, patients typically experience the onset of symptoms at an advanced age, and the presence of increasing paraparesis is a prevalent characteristic that poses challenges in the diagnostic process [40, 41].

From a clinical perspective, vision problems were the predominant early symptom observed in patients with MS, which aligns with the findings of the most recent MS registry of Egyptian patients [24]. The involvement of the optic nerve was found to have a marked correlation with a short delay in diagnosis. This is because when this symptom occurs, consultation with specialists in neurology or ophthalmology is required, which leads to an early and rapid diagnosis.

Optic neuritis was shown to be correlated with a reduced time to MS diagnosis, as indicated by the findings of Fernandez et al. [4] and Ghiasian et al. [16]. Conversely, in the Canadian and Danish groups, optic neuritis was linked to a longer period of time before diagnosis due to the symptoms rapidly resolving [9, 25].

In this study, the sensory deficit was associated with a longer diagnostic delay, which is consistent with the results of Aires et al. [19]. It is also consistent with the Egyptian study of Tohamy et al. [24], who reported that sensory symptoms initially were markedly associated with diagnostic delay due to symptom denial. Furthermore, it aligns with another Egyptian study that examined patients from upper Egypt. This study found a substantial variation in diagnostic delay of patients with motor compared to non-motor onset [21].

The linear regression analysis revealed a significant correlation between diagnosis delay and increased disease severity. Uher et al. [42] showed a significant correlation between diagnostic delays and increased levels of neurofilament light chain in the blood, which is a marker of neuronal damage. The negative impact of a delayed diagnosis on the outcome may be attributed to the ongoing progression of the disease, which exacerbates the occurrence of damage associated with the disease in the absence of proper treatment for an undetected condition. Timely intervention for MS can effectively control inflammation, hence potentially halting or even preventing the progression of neurodegeneration.

The most compelling long-term evidence from clinical studies with participants in preliminary trials of interferon beta demonstrates a significant improvement in mortality rates in patients who initiated treatment a year or two earlier. Additionally, it had a discernible effect on mitigating disability [43]. In addition, five-year follow-ups of early trials of natalizumab showed that patients in the initial treatment group had a lower EDSS score compared to those who initially received a placebo and started active treatment two years later [44].

There is growing evidence indicating that presymptomatic patients (radiologically isolated syndrome) experience substantial neuronal damage even in the prodromal phase prior to diagnosis by MRI [45]. Additionally, Cortese et al. [46] assessed the cognitive performance of over 20,000 individuals and found that men who were later diagnosed with MS had worse cognitive scores compared to healthy individuals up to 2 years prior to experiencing their first clinical symptoms. These data indicate that waiting until the clinical disease begins to start treatment may not be early enough to stop the progression of physical and cognitive impairment.

The sample size of this study is regarded as advantageous due to the fact that the prevalence of multiple sclerosis in Egypt is 25 cases per 100,000 individuals. In addition, we incorporated centers situated in key demographic regions of Egypt and conducted a comprehensive analysis of the significant clinical and sociodemographic characteristics exhibited by our patients that could potentially influence the objective of the study. The limitation of this study is the challenge of adequately determining the exact time of symptoms onset and confirmation of diagnosis, which may have introduced recall bias and influenced the results.

Conclusion

In our cohort study, MS patients with sensory symptoms or PPMS had the longest duration until diagnosis. These findings may prompt additional clinical assessment and investigation for patients experiencing psychiatric or non-specific neurological symptoms.

Implementing educational and awareness initiatives in primary care, specialized MS centers, and optimized accelerated access routes to neurologists, can lead to an earlier diagnosis and improved outcomes.

Our study emphasizes the correlation between the delay in diagnosing MS and various disease outcome measures, including disease severity and disability. Therefore, early diagnosis may improve outcomes for MS patients.

Abbreviations

MS

Multiple sclerosis

RR-MS

Relapsing-remitting MS

EDSS

Expanded Disability Status Scale

MSSS

Multiple Sclerosis Severity Score

SPSS

Statistical Package for the Social Sciences Software

SPMS

Secondary progressive MS

PPMS

Primary progressive MS

Author contributions

S.R.: Methodology, Writing - original draft, Visualization, Investigation. N.A.H.: Conceptualization, Data curation, Writing - review & editing. A.A. and B.H.F.: Writing - review & editing. A.A.S.: conceptualization, methodology. A.M.H.: Writing - review & editing. A.E.: Software, Visualization.

Funding

There is no source of funding for the research.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study was approved from the Institutional Ethics Committee of the Faculty of Medicine, Kafrelsheikh University (MKSU 50-7-4) according to the ethical criteria of the Declaration of Helsinki. A Written informed consent was obtained from all participants, as well as from the parents or legal guardians of those under the age of 16, after explaining the study’s details, benefits, and potential risks.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.