Chronic multifocal demyelinating neuropathy associated with central nervous system demyelination

Atypical chronic inflammatory demyelinating polyradiculoneuropathy with ophthalmoplegia and anti-sulfatide IgM positivity

BACKGROUND

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a heterogeneous group of chronic immune-mediated polyradiculoneuropathies. The clinical presentation of CIDP is mainly characterized by a classic peripheral demyelinating sensory-motor type and persists for a minimum of 2 months. However, CIDP may also present with atypical symptoms.Case presentation: This report presents the case of a patient with CIDP with ophthalmoplegia and anti-sulfatide IgM antibodies. Maintenance intravenous immunoglobulin and glucocorticoid therapies were administered to the patient in accordance with the clinical, laboratory, and electrophysiological findings, which were indicative of CIDP. The treatment partially improved the symptoms, and no recurrence was detected throughout the 3-month monitoring phase.

CONCLUSIONS

This study combines a retrospective analysis and a literature review to explore the possible mechanism of CIDP.

Chronic inflammatory demyelinating polyradiculoneuropathy: A case report

RATIONALE

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disorder characterized by a symmetrical, sensorimotor involvement and slowly progressive onset peripheral neuropathy. Peripheral neuropathies have been reported in some central demyelination patients. However, the central nervous system focus in the CIDP patient can mimic neuromyelitis optica have not been recognized by most of us.

PATIENT CONCERNS

The numbness and weakness of limbs about eight weeks.

DIAGNOSES

Chronic inflammatory demyelinating polyradiculoneuropathy.

INTERVENTIONS

Immunotherapy with intravenous immunoglobulins was applied to this patient.

OUTCOMES

After 1 year follow-up, the results showed there was still slight numbness of all limbs, and he could walk slowly without help. Gastrocnemius muscle atrophy did not aggravate.

LESSONS

So It is suggest that CIDP can combine with central lesions mimicking neuromyelitis optica. We should take the diagnosis of CIDP into consideration when we find focus in central nervous system.

Spinal cord involvement in chronic inflammatory demyelinating polyradiculoneuropathy: a clinical and MRI study

Concomitant central nervous system (CNS) involvement in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is rare. Although the spinal nerve roots may present MRI abnormalities in CIDP, hitherto, the spinal cord has been investigated in a single study. We retrospectively investigated clinically and with MRI a cohort of patients with definite CIDP diagnosis (EFNS/PNS criteria) for evidence of brain and spinal cord involvement, who were initially admitted in our department during the last 4 years. Among 12 patients with CIDP (men: 8, mean age: 59.3 years, mean disease duration: 3.8 years), nine patients had their MRI scan during a clinical relapse and three during remission. Brain MRI did not document typical multiple sclerosis lesions in any patient. We did not identify any MRI abnormalities in ten patients without clinical evidence of spinal cord involvement. Conversely, MRI disclosed extensive lesions of the thoracic cord in two patients with an overt spinal cord syndrome, whom we describe. This represents the biggest MRI study of CIDP patients who have been investigated for spinal cord involvement. Our data support earlier observations that a minority of CIDP patients may additionally develop CNS involvement of variable degree.

Subacute peripheral and optic neuropathy syndrome with no evidence of a toxic or nutritional cause

BACKGROUND

The syndrome of subacute simultaneous peripheral neuropathy and bilateral optic neuropathy is known to occur in tropical countries, probably due to malnutrition or toxicity, but not often seen in developed countries. We report seven patients in London who were not malnourished or alcoholic, and in whom no clear cause was found.

METHODS

We retrospectively reviewed the case notes and arranged some further investigations.

RESULTS

All patients developed peripheral and bilateral optic neuropathy within 6 months. Patients were aged 30-52, and all of Jamaican birth and race but lived in the UK. Most had subacute, painful ataxic sensory axonal neuropathy or neuronopathy, some with myelopathy. Nerve conduction studies revealed minor demyelinating features in two cases. The optic neuropathy was symmetrical, subacute and monophasic, usually with marked reduction in visual acuity. CSF protein concentration was usually elevated but other laboratory investigations were normal. Patients showed only modest improvement at follow-up.

CONCLUSION

These patients share a common clinical and electrophysiological phenotype, age, ethnicity and elevated CSF protein, but otherwise normal laboratory investigations. The syndrome is a cause of significant morbidity in young people. The cause remains uncertain despite thorough investigation.

Autoimmune disorders affecting both the central and peripheral nervous system

Various case series of patients with autoimmune demyelinating disease affecting both the central and peripheral nervous system (CNS and PNS), either sequentially or simultaneously, have been reported for decades, but their frequency is considerably lower than that of the "classical" neurological autoimmune diseases affecting only either CNS or PNS, such as multiple sclerosis (MS), chronic inflammatory demyelinating polyneuropathy (CIDP) or Guillain-Barré-Syndrome (GBS), and attempts to define or even recognize the former as a clinical entity have remained elusive. Frequently, demyelination started with CNS involvement with subsequent PNS pathology, in some cases with a relapsing-remitting course. Three potential mechanisms for the autoimmune etiology of these conditions can be discussed: (I) They could be caused by a common autoimmunological reactivity against myelin antigens or epitopes present in both the central and peripheral nervous system; (II) They could be due to a higher general susceptibility to autoimmune disease, which in some cases may have been caused or exacerbated by immunomodulatory treatment, e.g. b-interferon; (III) Their co-occurrence might be coincidental. Another example of an autoimmune disease variably involving the central or peripheral nervous system or both is the overlapping and continuous clinical spectrum of Fisher syndrome (FS), as a variant of GBS, and Bickerstaff brainstem encephalitis (BBE). Recent data from larger patient cohorts with demonstration of common autoantibodies, antecedent infections, and results of detailed clinical, neuroimaging and neurophysiological investigations suggest that these three conditions are not separate disorders, but rather form a continuous spectrum with variable central and peripheral nervous system involvement. We herein review clinical and paraclinical data and therapeutic options of these disorders and discuss potential underlying common vs. divergent immunopathogenic mechanisms.

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.

Chronic inflammatory demyelinating polyradiculoneuropathy with tumefactive central demyelination

A 46-year-old man with a 1-year history of distal paresthesias and mild distal weakness subacutely developed paralysis of the left hand. Electrodiagnostic evaluation revealed a demyelinating peripheral neuropathy that met criteria for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Magnetic resonance imaging of the brain revealed a mass that enhanced with contrast, but revealed focal myelin loss with intense macrophage activity and axonal preservation on biopsy. The mass and hand weakness improved following steroid therapy. The combination of CIDP and central demyelination with mass effect broadens the spectrum of demyelinating disease in association with CIDP.

Visual evoked potentials study in chronic idiopathic inflammatory demyelinating polyneuropathy

BACKGROUND

The frequency of the association between chronic demyelinating inflammatory polyneuropathy (CIDP) and central nervous system (CNS) demyelinating lesions is probably underestimated.

OBJECTIVE

To investigate the occurrence of combined central and peripheral demyelination in CIDP patients and to correlate visual evoked potential (VEP) abnormalities with CNS demyelinating lesions, observed on brain magnetic resonance imaging, and antibodies against glycolipids.

METHODS

Nerve conduction studies, brain MRI and antibodies against glycolipids were prospectively studied in 17 patients who fulfilled the diagnostic criteria proposed for CIDP (Cornblath DR, Asbury AK, Albers JW, Feasby TE, Hahn AF, McLeod JG, Mendell JR, Parry GJ, Pollard JD, Thomas PK. Ad Hoc Subcommittee of the American Academy of Neurology AIDS Task Force. Research criteria for diagnosis of chronic inflammatory demyelinating polyneuropathy. Neurology, 1991;41:617-618). VEPs were performed in each case before and after 6 months treatment with either intravenous immunoglobulins (IVIG) or steroids.

RESULTS

Eight patients (47%) had increased latencies in at least one eye or showed increased interocular latency difference. Four patients (23%) presented a significant high signal intensity on T2-weighted brain MRI images. Of these 4 patients, 3 had prolonged VEP latency. Two patients with delayed VEP latency had antibodies against GM1, and SGLPG and anti-sulfatides, respectively. One patient with normal VEPs also had antibodies to GM1. VEP results were not significantly modified after treatment, either with steroids or IVIG.

CONCLUSION

This study confirmed the high frequency of abnormal VEPs in CIDP patients, and found that they are poorly correlated with CNS demyelinating lesions and antibodies against glycolipids. The VEP abnormalities of these patients may be explained by the susceptibility to immune-mediated damage of both the peripheral nervous system and the optic nerve.

Steroid-responsive multifocal demyelinating neuropathy with central involvement

We describe 2 patients with associated central and peripheral demyelination. Electrophysiological studies revealed a demyelinating polyneuropathy with sensory and motor conduction blocks. Visual evoked potentials were abnormal. Motor evoked potentials showed abnormal central conduction time in 1 patient. Magnetic resonance imaging revealed regions of abnormal high signal in the spinal cord and brain; sural nerve biopsy disclosed a demyelinating neuropathy. Both patients showed clinical and electrophysiological improvement after steroid therapy.

Central nervous system involvement in multifocal demyelinating neuropathy with persistent conduction block

We report the case of a 27-year-old man treated for bilateral optic neuritis 5 and 3 years before who within a few months developed sensorimotor disorders of the arms and legs characterized by asymmetric distribution and distal prominence. In addition to sensorimotor defects, which were particularly marked in the left arm and right leg, clinical examination showed nearly generalized areflexia. Electrophysiological studies revealed a multifocal neuropathy with persistent distal and proximal conduction blocks associated with a considerable slowing of motor nerve conduction, as well as central nervous system involvement indicated by motor-, somatosensory-, and visual-evoked potentials. CSF analysis showed a mildly elevated protein level; anti-GM1 activity was negative. Sural nerve biopsy revealed onion-bulb-like formations, and cerebral MRI showed a small, isolated, and aspecific high signal for white matter. First described by Lewis and Sumner in 1982, multifocal neuropathy with persistent conduction blocks may be associated with central demyelination. Our case is compared with 3 similar ones in the literature, and the favorable effects of steroid therapy are emphasized.

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.