Differential Diagnosis

The patient's presentation of multiple neurologic abnormalities, including diffuse muscle cramps, numbness, and episodic numbness, along with a history of brain fog, intermittent numbness, and tingling in extremities, and nonspecific white matter lesions on MRI, suggests a complex neurological condition. The recent increase in blood pressure is also a significant factor to consider. Here is a differential diagnosis organized into the requested categories:

• Single Most Likely Diagnosis
  • Multiple Sclerosis (MS): Given the patient's history of neurological symptoms, including brain fog, numbness, and tingling, along with nonspecific white matter lesions on MRI, MS is a strong consideration. The recent exacerbation of symptoms could indicate a relapse. MS is known for its unpredictable course, which can include periods of remission and exacerbation.
• Other Likely Diagnoses
  • Small Vessel Disease: The patient's recent increase in blood pressure could be contributing to small vessel disease, which affects the small blood vessels in the brain and can cause white matter lesions and neurological symptoms.
  • Migraine: Although not typically associated with diffuse muscle cramps, migraines can cause a variety of neurological symptoms, including numbness and tingling, and are often accompanied by other symptoms like brain fog.
  • Vitamin Deficiency (e.g., Vitamin B12): Deficiencies in certain vitamins, particularly Vitamin B12, can cause neurological symptoms similar to those described, including numbness, tingling, and muscle cramps.
• Do Not Miss Diagnoses
  • Stroke or Transient Ischemic Attack (TIA): Although the patient's symptoms have been episodic and not necessarily indicative of a classic stroke presentation, it's crucial to rule out stroke or TIA, especially given the recent increase in blood pressure.
  • Central Nervous System Vasculitis: This is an inflammation of the blood vessels in the brain and spinal cord, which can cause a wide range of neurological symptoms and must be considered due to its potential severity.
  • Neurosyphilis: A less common but critical diagnosis to consider, as it can present with a variety of neurological symptoms and requires prompt treatment.
• Rare Diagnoses
  • Neuromyelitis Optica Spectrum Disorder (NMOSD): An autoimmune disorder that primarily affects the optic nerve and spinal cord but can also cause brain symptoms. It's less common than MS but should be considered, especially if there are optic neuritis or longitudinal extensive spinal cord lesions.
  • Mitochondrial Disorders: These are a group of disorders caused by dysfunctional mitochondria, which can affect various parts of the body, including the nervous system, and might present with a wide range of neurological symptoms.
  • CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy): A rare, hereditary condition that affects the blood vessels in the brain, leading to subcortical strokes and dementia. It's characterized by migraine with aura, stroke, and dementia, typically starting in mid-adult life.

Each of these diagnoses requires careful consideration of the patient's history, physical examination, and potentially additional diagnostic tests to determine the underlying cause of her symptoms.