Multiple sclerosis and hypertrophic demyelinating peripheral neuropathy

Possible Combined Central and Peripheral Demyelination Presenting as Optic Neuritis, Cervical Myelitis, and Demyelinating Polyneuropathy with Marked Nerve Hypertrophy

A 27-year-old woman with optic neuritis and cervical myelitis developed hypertrophic demyelinating polyneuropathy. It was hypothesized that the diagnosis was combined central and peripheral demyelination. A hypertrophic nerve was observed subcutaneously, and magnetic resonance imaging demonstrated marked hypertrophy of the nerve roots. The patient was negative for anti-aquaporin 4 antibodies. Her anti-neurofascin 155 antibody levels was slightly elevated, but it was not definitely positive. Pulsed steroid therapy and the administration of immunoglobulin ameliorated her symptoms. Molecules in both the peripheral and central nervous systems might be target antigens, but further investigations will be needed to clarify the precise pathogenic mechanisms.

Fulminant Central Plus Peripheral Nervous System Demyelination without Antibodies to Neurofascin

Background

Combined central and peripheral nervous system demyelination is a rare and poorly described phenomenon. Recently, anti-neurofascin antibodies were reported to be positive in 86% of these patients in a Japanese cohort. Yet, there seems to be a clinical, radiological, and serological heterogeneity among these patients. In this report, our aim is to describe characteristics of our patients with this entity and compare with others in the literature.

Methods

We report clinical, electrophysiological, radiological, and laboratory characteristics of five patients with both multiple sclerosis and chronic inflammatory demyelinating polyradiculoneuropathy from our institutional database containing 1890 MS patients.

Results

Three patients presented with extensive, active demyelination of both central nervous system and peripheral nervous system with hypertrophic peripheral nerves. Plexuses, trunks, division and cords were involved in the process. Oligoclonal band was negative. Conduction block was not detected. Corticosteroid treatment was not adequate. Others had a slowly progressive clinical course. Serum anti-neurofascin antibody was negative. Review of the literature revealed similar cases with active disease, early-onset hypertrophic peripheral nerves, and central demyelination, in addition to other cases with an insidious course.

Conclusions

Patients with combined central and peripheral demyelination form a spectrum. Some patients may have an antibody-mediated syndrome with or without anti-neurofascin antibodies and others seem to represent a coincidence.

[A case of combined central and peripheral demyelination]

A 22-year-old man had had difficulty running fast since about he was 10 years old. In June 2011, he was referred to us because of worsened unsteady gait. A neurological examination revealed mild ataxic speech, weakness of the four limbs, with spasticity, and pes cavus. Magnetic resonance T2-weighted images showed multiple high-intensity lesions in the bilateral periventricular white matter, brainstem, and thoracic spinal cord. Peripheral nerve conduction studies revealed marked motor conduction velocities were markedly reduced and sensory nerve velocities were not evoked in the upper and lower limbs. A sural nerve biopsy showed highly active demyelinating lesions. The patient was treated with high-dose steroid therapy (intravenous methylprednisolone, 1,000 mg/day × 3 days) followed by self-injection of interferon β. With these treatments, his symptoms gradually improved. In this case, we could not detect the causative factors, and all autoantibodies tested, except for the anti-neurofascin antibody, were negative. The anti-neurofascin antibody might induce demyelination in the central and peripheral nervous systems. However, in the literature, the evidence of an association between this antibody and these clinical characteristics is not conclusive. We need more studies on the pathogenesis of combined central and peripheral demyelination to establish more effective therapies.

The sad plight of multiple sclerosis research (low on fact, high on fiction): critical data to support it being a neurocristopathy

The literature for evidence of autoimmunity in multiple sclerosis (MS) is analysed critically. In contrast to the accepted theory, the human counterpart of the animal model experimental autoimmune demyelinating disease, experimental allergic encephalomyelitis (EAE), is not MS but a different demyelinating disorder, i.e. acute disseminated encephalomyelitis and acute haemorrhagic leucoencephalitis. Extrapolation of EAE research to MS has been guided largely by faith and a blind acceptance rather than sound, scientific rationale. No specific or sensitive immunological test exists that is diagnostic of MS despite the extensive application of modern technology. Immunosuppression has failed to have any consistent effect on prognosis or disease progression. The available data on MS immunotherapy are conflicting, at times contradictory and are based on findings in animals with EAE. They show predominantly a 30% effect in relapsing/remitting MS which suggests powerful placebo effect. Critical analysis of the epidemiological data shows no association with any specific autoimmune diseases, but does suggest that geographic factors and age at development posit an early onset possibly dependent on environmental influences. Certain neurological diseases are, however, found in association with MS, namely hypertrophic peripheral neuropathy, neurofibromatosis-1, cerebral glioma, glioblastoma multiforme and certain familial forms of narcolepsy. These share a common genetic influence possibly from genes on chromosome 17 affecting cell proliferation. A significant number of these disorders are of neural crest origin, the classical example being abnormalities of the Schwann cell. These and other data allow us to propose that MS is a developmental neural crest disorder, i.e. a cristopathy, implicating glial cell dysfunction with diffuse blood-brain barrier breakdown. The data on transcription factor SOX10 mutations in animals may explain these bizarre clinical associations with MS and the phenotypic variability of such alterations (Cossais et al. 2010). Research directed to the area of neural crest associations is likely to be rewarding.

Chronic inflammatory demyelinating polyradiculoneuropathy associated with multiple sclerosis

OBJECTIVE

To describe temporal profile of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) in patients with definite, relapsing multiple sclerosis (MS).

BACKGROUND

Peripheral demyelinating neuropathy has been rarely reported in association with central nervous system demyelinating disorder indistinguishable from MS.

METHODS

In addition to usual diagnostic studies for CIDP and MS in all 5 patients, we studied proximal segments of nerves using deep tendon reflex latency measurements of biceps reflex, patellar reflex, and ankle reflex.

RESULTS

All patients with MS subsequently (4-22 years) developed definite CIDP. Two of these patients developed multiple cranial nerve and spinal root enhancement on subsequent imaging without new intraparenchymal enhancement after a diagnosis of CIDP. The deep tendon reflex latencies were prolonged at more than 2 sites in all patients. Cerebral spinal fluid protein increased (70 +/- 19 to 144.8 +/- 17.4 mg/dL, P = 0.0001) at time of diagnosis of CIDP. Clinical improvement was observed in all patients after intravenous immunoglobulin therapy.

CONCLUSIONS

When patients with MS develop CIDP, manifestations of central and peripheral disease involvement seem to respond to intravenous immunoglobulin. These cases suggest that there may be common antigenic targets in central and peripheral nervous system in this subset of patients.

Up-regulation of slow K(+) channels in peripheral motor axons: a transcriptional channelopathy in multiple sclerosis

Spinal lesions produce plastic changes in motoneuron properties. We have documented the excitability of motor axons in the median nerve of 12 patients with multiple sclerosis and 50 normal subjects, hypothesizing that plastic changes in the properties of spinal motoneurons might be reflected in the properties of peripheral motor axons and be demonstrable in vivo. In the patients, there were changes in physiological measures of axonal excitability attributable to increased slow K(+) channel activity. Other measures were within control limits. These changes could be modelled by an 11% increase in slow K(+) current, with compensatory changes in membrane potential, suggesting increased expression of the responsible channels. The changes cannot be explained solely by changes in membrane potential and are not those expected if peripheral nerve axons were involved in the inflammatory process of multiple sclerosis. They probably represent a transcriptional channelopathy, due to up-regulation of channel expression. The abnormalities do not imply that peripheral nerve function has been significantly compromised, but they do suggest that the properties of the parent motoneurons have changed. This study thus provides evidence for plasticity in motoneuronal properties at a molecular level, the first such evidence for intact human subjects.

Multiple sclerosis and peripheral multifocal demyelinating neuropathies occurring in a same patient

The co-occurrence of multiple sclerosis and peripheral demyelinating neuropathy is rare. It has been disputed whether these are pathologically related or coincidental findings. We report a 36-year-old woman who presented with diplopia, right facial palsy and left-sided weakness. Brain magnetic resonance imaging showed a lesion indicative of central demyelinating disease. Nerve conduction studies revealed peripheral multifocal demyelinating neuropathies. We suggest that the central and the peripheral lesions may be continua of a demyelinating process.

Analysis of nociception, sex and peripheral nerve innervation in the TMEV animal model of multiple sclerosis

Although pain was previously not considered an important element of multiple sclerosis (MS), recent evidence indicates that over 50% of MS patients suffer from chronic pain. In the present study, we utilized the Theiler's murine encephalomyelitis virus (TMEV) model of MS to examine whether changes in nociception occur during disease progression and to investigate whether sex influences the development of nociception or disease-associated neurological symptoms. Using the rotarod assay, TMEV infected male mice displayed increased neurological deficits when compared to TMEV infected female mice, which mimics what is observed in human MS. While both male and female TMEV infected mice exhibited thermal hyperalgesia and mechanical allodynia, female mice developed mechanical allodynia at a faster rate and displayed significantly more mechanical allodynia than male mice. Since neuropathic symptoms have been described in MS patients, we quantified sensory nerve fibers in the epidermis of TMEV-infected and non-infected mice to determine if there were alterations in epidermal nerve density. There was a significantly higher density of PGP9.5 and CGRP-immunoreactive axons in the epidermis of TMEV-infected mice versus controls. Collectively these results indicate that the TMEV model is well suited to study the mechanisms of MS-induced nociception and suggest that alterations in peripheral nerve innervation may contribute to MS pain.

Alteration of motor nerve recovery cycle in multiple sclerosis

OBJECTIVE

To study peripheral motor nerve excitability in patients with multiple sclerosis (MS).

METHODS

Twenty MS patients with normal nerve conduction parameters and no predisposing factors for peripheral neuropathy were included. Compound muscle action potentials were recorded from the abductor digiti minimi muscle to paired-pulse stimulation of the ulnar nerve at the wrist, with various interstimuli intervals (ISIs) ranging from 1 to 7 ms. The motor nerve recovery cycle was studied using a subtraction method. We measured the durations of the absolute and relative refractory periods (ARP, RRP) and the percentages of refractoriness and supernormality at 2.6 and 7 ms ISIs. The results obtained in MS patients were compared to normative values established in 20 age-matched healthy subjects. Correlations were made between excitability parameters and MS type (relapsing-remitting or progressive), EDSS score, disease duration, and motor evoked potential (MEP) abnormalities.

RESULTS

Supernormality was extremely reduced, refractoriness was increased and both ARP and RRP were prolonged in MS patients vs. healthy controls. These alterations did not correlate to clinical features or to the presence of MEP abnormalities.

CONCLUSIONS

Changes in motor nerve recovery cycle revealed the existence of subtle impairment in the peripheral nervous system of MS patients, mainly characterized by a reduced supernormality.

SIGNIFICANCE

Peripheral nerve excitability alterations in MS may be due to axoglial paranodal dysjunction or juxtaparanodal dysfunction.

Spinal and cranial hypertrophic neuropathy in multiple sclerosis

Two patients with multiple sclerosis developed symptomatic chronic inflammatory demyelinating polyneuropathy with massive spinal or cranial nerve hypertrophy revealed by neuroimaging. Sural nerve biopsy in one showed only moderate demyelination, axonal loss, and onion-bulb formation, illustrating dichotomy between severe proximal and milder distal nerve involvement. Patients with coexistent central and peripheral demyelination usually are symptomatic from dysfunction at one site or the other, but not from both. Our patients showed minimal response to steroids, intravenous immunoglobulin, or azathioprine. These cases suggest that the mechanism of disease in symptomatic central and peripheral demyelination may differ from that of disease in only one region, and that optimal therapy in this situation must be explored further.

Sclérose en plaques et atteinte du système nerveux périphérique

Multiple sclerosis is a demyelinating disease limited to the central nervous system, but the literature has provided recurring evidence which raises the question of associated peripheral nervous system abnormalities. The prevalence of peripheral neuropathy during multiple sclerosis remains controversial without prospective study. Nevertheless, some data have reported well documented case reports describing the co-occurrence of multiple sclerosis and radiculopathy or mononeuropathy or polyneuropathy in the same patients. By contrast, more frequent subtle nerve abnormalities may be found by using electrophysiological and neuropathological examinations. Some hypotheses have been proposed by Waxman to decipher the electrophysiological and neuropathological findings. The mechanisms for demyelinating disease and peripheral nerve pathophysiology may imply the antigenic properties or the presence of diffusing factors between peripheral nervous system and central nervous system myelin and the molecular plasticity of myelinated fibers.

Proximal motor conduction evaluated by transcranial magnetic stimulation in acquired inflammatory demyelinating neuropathies

OBJECTIVES

To evaluate conduction abnormalities in the proximal motor nerve in patients with acquired inflammatory demyelinating neuropathies by transcranial magnetic stimulation (TMS).

METHODS

TMS intensity and background voluntary contraction (BVC) to evoke maximal size of motor evoked potential (MEP) in hand muscle were investigated in 24 normal subjects. Effect of experimentally induced conduction block by injecting local anesthetics in the peripheral nerve on MEP size was also studied in two normal subjects. In 22 patients with inflammatory demyelinating neuropathies, maximal MEPs were recorded in the deteriorating and recovery stages of the illness.

RESULTS

In normal subjects, the MEP became maximal with 30-50% of maximal BVC and at more than 80% the maximal stimulator output of the 2.0 T circular coil. The change in MEP size well reflected the degree of conduction block induced by local anesthetics. Findings for patients suggested conduction abnormalities proximal to axilla in 9 patients, and that the abnormal reduction of Erb CMAP was the result of submaximal stimulation, not true conduction block, in 3 patients. The increase in MEP/wrist CMAP ratio was better correlated with improvement in muscle strength than with change in the axilla or Erb CMAP/wrist CMAP ratio.

CONCLUSIONS

Problems such as conduction abnormalities in the motor tract of the central nervous system could not fully be excluded, but we consider that maximal MEP size can be used to predict proximal motor nerve conduction abnormalities.

Can antiglycolipid antibodies present in HIV-infected individuals induce immune demyelination?

Of the eight clinically defined neuropathies associated with HIV infection, there is compelling evidence that acute and chronic inflammatory demyelinating polyneuropathy (IDPN) have an autoimmune pathogenesis. Many non-HIV infected individuals who suffer from sensory-motor nerve dysfunction have autoimmune indicators. The immunopathogenesis of demyelination must involve neuritogenic components in myelin. The various antigens suspected to play a role in HIV-seronegative IDPN include (i) P2 protein; (ii) sulfatide (GalS); (iii) various gangliosides (especially GM1); (iv) galactocerebroside (GalC); and (v) glycoproteins or glycolipids with the carbohydrate epitope glucuronyl-3-sulfate. These glycoproteins or glycolipids may be individually targeted, or an immune attack may be raised against a combination of any of these epitopes. The glycolipids, however, especially GalS, have recently evoked much interest as mediators of immune events underlying both non-HIV and HIV-associated demyelinating neuropathies. The present review outlines the recent research findings of antiglycolipid antibodies present in HIV-infected patients with and without peripheral nerve dysfunction, in an attempt to arrive at some consensus as to whether these antibodies may play a role in the immunopathogenesis of HIV-associated inflammatory demyelinating polyneuropathy.

Unusual association of multiple sclerosis and tomaculous neuropathy

We describe two cases in which multiple sclerosis (MS) occurred in association with tomaculous neuropathy, presenting as chronic, distal sensorimotor polyneuropathy. In Case 1, monoclonal gammopathy of undetermined significance with monoclonal IgG lambda reactive against GM1 ganglioside, was also detected. The diagnosis of tomaculous neuropathy was established after sural nerve biopsy. Teased fibers examination revealed focal 'sausage-like' thickenings of the myelin sheaths in intact fibers and in fibers with segmental demyelination. Electron microscopy showed them to be due, mostly, to multiple windings of redundant myelin and concentric apposition of numerous lamellae, in contact with an intact myelin sheath. These are the first reported cases of tomaculous neuropathy in patients with MS. Whether the combination of the two conditions is purely coincidental or suggests the possible causal relation between MS and tomaculous neuropathy, is not certain.

Demyelinating neuropathy in a patient with multiple sclerosis and genotypical HMSN-1

Patients with multiple sclerosis (MS) may develop a peripheral neuropathy, sometimes attributed to nutritional deficiency. Other patients present with a demyelinating neuropathy which is presumed to be the result of an autoimmune process that affects both the central and peripheral nervous systems. We report a case of concurring MS and demyelinating neuropathy, without a positive family history, in whom genetic testing proved the neuropathy to be hereditary and not autoimmune. Hereditary neuropathy should be a consideration in sporadic cases of peripheral neuropathy and MS.

Vestibular dysfunction in chronic inflammatory demyelinating polyneuropathy

Chronic inflammatory demyelinating polyneuropathy (CIDP) has occasionally been associated with clinical or laboratory evidence (magnetic resonance imaging,[MRI], visual evoked response, and brainstem auditory evoked response [BAER] of cranial neuropathy. In most cases, the relationship of cranial nerve involvement to CIDP remains unclear. A 45-year-old woman noted foot numbness, limb weakness, gait and postural instability, and oscillopsia. An IgG kappa monoclonal gammopathy of undetermined significance was found. Bilateral vestibulopathy was documented by clinical examination, bithermal calorics, rotary chair testing, BAERs, and dynamic posturography. MRI with gadolinium demonstrated enhancement of cranial nerve VIII bilaterally. Over the next 6 years, the patients's relapsing and remitting course of CIDP and vestibulopathy was assessed by quantitative muscle and vestibular function testing (clinically and neurophysiologically), and dynamic visual acuity. There was a striking synchronization between her CIDP and vestibulopathy with respect to clinical course including relapses and responses to immune therapy. The response to therapy, and evidence derived from clinical and laboratory investigations, suggest that the vestibular dysfunction was immune mediated.

Inflammatory demyelinating polyradiculitis in a patient with acute disseminated encephalomyelitis (ADEM)

A patient with severe acute disseminated encephalomyelitis died 12 days after the first symptom. Necropsy showed widespread severe demyelination in the CNS and some foci of demyelination in the spinal roots. The lesions in the peripheral nervous system were characterised by myelin stripping and the presence of macrophages, being severest in the spinal nerve roots. Some axons were completely demyelinated, whereas the axons themselves were preserved. Pathologically established ongoing demyelination in both CNS and peripheral nervous systems raises the possibility of a shared pathological epitope.

Childhood multiple sclerosis: MR images and clinical variations in four Japanese cases

We report four Japanese cases of multiple sclerosis (MS) starting during childhood. In three of them, onset occurred in the prepubertal period. Case 1 showed a rare clinical condition: the patient presented with Devic disease, and 2 years later she was complicated by chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The other three cases had symptoms of gait disturbance, cerebellar signs, weakness of the extremities and impaired visual acuity. Headache was seen in Case 2 and medial longitudinal fasciculus (MLF) syndrome in Case 4. In Cases 2, 3 and 4, diagnoses were conclusively made by T2-weighted magnetic resonance imaging (MRI). MRI, brain stem auditory, visual and somatosensory evoked potentials are extremely useful for evaluating the clinical conditions of children with MS.

Combined central and peripheral acute demyelination

We describe a patient with multiple sclerosis who had a bout of central demyelination associated with an acute inflammatory demyelinating polyneuropathy. The contemporary involvement of central and peripheral nervous system due to a demyelinating disease has been reported anecdotically in humans, and can be induced experimentally in animals. It may be sustained by a common pathogenetic factor.

Associated polyneuropathy and demyelinating disease. Case report

We report a case in which an acute Guillain-Barré-like syndrome was quickly followed by a central demyelinating disease, documented by the clinical findings as well as by magnetic resonance imaging (MRI), electrophysiological and cerebrospinal fluid examinations. The close follow-on of the clinical signs seems to exclude a simple coincidence of two separate diseases and it may constitute further evidence for a possible etiological link between central and peripheral myelin damage. We discuss the possibility of a common pathogenic factor underlying central and peripheral demyelination.

Multiple sclerosis and hypertrophic demyelinating neuropathy

Images

Involvement of the central nervous system in chronic inflammatory demyelinating polyneuropathy: a clinical, electrophysiological and magnetic resonance imaging study

In a consecutive series of 30 patients with chronic inflammatory demyelinating polyneuropathy (CIDP) minor clinical evidence of CNS involvement was found in five. Cranial magnetic resonance imaging (MRI) was performed in 28 and revealed abnormalities consistent with demyelination in nine patients aged less than 50 years and abnormalities in five aged 50 years or over. Measurements of central motor conduction time (CMCT) were obtained in 18 and showed unilateral or bilateral abnormalities in six. It is concluded that subclinical evidence of central nervous system (CNS) involvement is common, at least in patients with CIDP in the United Kingdom, but that clinically evident signs of CNS disease are infrequent. The association of a multiple sclerosis-like syndrome with CIDP is rare.

CNS involvement in Japanese patients with chronic inflammatory demyelinating polyradiculoneuropathy

Thirteen consecutive Japanese patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) were studied by MRI, evoked potentials, and EEG. We found 3 of these patients exhibited symptoms of CNS disorders. Of these 3, 2 with abnormal MRI and visual evoked potentials, and one with abnormal brainstem auditory evoked potentials were detected. Another case without clinical CNS signs showed abnormal EEG findings. The subclinical CNS abnormalities found in the Japanese patients were considered to be less frequent than in cases from Western countries reported previously.

[Histochemical study of the skeletal muscle in multiple sclerosis]

The authors present muscle histochemistry of ten patients of multiple sclerosis. The clinical diagnosis was based on criteria established by Poser et al. (1983). The main pathological findings observed were: lymphoplasmocitary vasculitis, increase in the number of 2B type fibers, inflammatory cells (macrophages) in the intramuscular ends of the motor nerves, amounts of lipids and 'moth-eaten' fibers. The presence of vasculitis observed in our cases contributes with the etiopathogenic hypothesis of an autoimmune lesion in multiple sclerosis. There is no correlation between the clinical and histological atrophy observed.

Associated central and peripheral demyelination: an electrophysiological study

A case is reported in which retrobulbar neuritis preceded Guillain-Barré syndrome by 4 weeks. The visual evoked potential latencies were prolonged. After peripheral nervous system signs had cleared, median and peroneal somatosensory evoked potentials showed prolonged cervical N13, scalp N20 and L3-scalp conduction times.

The peripheral nervous system in multiple sclerosis. A review and pathogenetic hypothesis

Despite the rarity of such observations in autopsy material, peripheral nervous system involvement in patients with multiple sclerosis is more common than suspected, judging from results of sophisticated electrophysiological and teased nerve fiber studies. The existence of a number of well documented cases of overt peripheral neuropathy in MS patients suggests that an etiological link may exist between the two conditions. The proposal has been made that one of the obligatory steps in the pathogenesis of MS is an alteration of the blood-brain barrier, which results in most instances from an immunologically induced vasculopathy due to a non-specific viral infection. Whereas the CNS responds by the formation of MS plaques, the PNS lesion is that of the typical post-infectious inflammatory polyneuropathy. In some MS patients an unusual degree of immunological vulnerability causes onion-bulb formations to develop as a result of repeated antigenic challenges. In MS patients the onion-bulb formation is the PNS analog of the CNS plaque: both result from the same pathogenetic mechanism.

Demyelinating optic neuropathy with Miller-Fisher syndrome. The case for overlap syndromes with central and peripheral demyelination

The syndrome of ataxia, areflexia and ophthalmoplegia, or Miller-Fisher syndrome, has been considered to be a variant of Guillain-Barré syndrome with pathology restricted to the peripheral nervous system. A patient with Miller-Fisher syndrome and bilateral demyelinating optic neuropathy suggesting associated central nervous system pathology is presented. Clinical and experimental evidence regarding the association of central and peripheral nervous system demyelination is reviewed.

Neurophysiological evaluation of associated demyelinating peripheral neuropathy and multiple sclerosis: a case report

A case of combined multiple sclerosis and demyelinating neuropathy is presented. Percutaneous electrical stimulation of the cortex and spinal cord has shown that pyramidal tract conduction time was prolonged and conduction velocity in the cord was 4 m/s. Motor conduction velocity in proximal segments of peripheral nerves was slowed to the same extent as in distal segments.

The concurrence of multiple sclerosis and amyotrophic lateral sclerosis

We report the clinical and pathological findings of the unusual combination of two idiopathic central nervous system diseases, multiple sclerosis and amyotrophic lateral sclerosis in a 56 year old physician with a twenty-seven year history of a disease initially characterized by relapses and remissions, followed by an eight year quiescent period. During the last year of life there was rapid deterioration with development of generalized weakness, atrophy, weight loss and fasciculations of body and tongue, and associated difficulty with swallowing and sudden respiratory failure. The autopsy confirmed characteristic "burned out" plaques of multiple sclerosis and anterior horn cell and axonal degeneration of amyotrophic lateral sclerosis.

Acute polyradiculoneuritis associated with demyelinated plaques in the central nervous system: report of a case

A report is given of a woman who developed acute idiopathic polyradiculoneuritis and was found at necropsy 9 weeks later to have in addition multiple recent demyelinated lesions in the central nervous system (CNS), resembling those of multiple sclerosis (MS). The possibility that in such a case there might be an immunological reaction against one or more components of myelin common to the CNS and PNS has to be considered.