Multiple sclerosis and hypertrophic demyelinating neuropathy

Peripheral nervous system in multiple sclerosis-understanding the involvement via autonomic nervous system

AIM

The aim of this review is to summarize the clinical and paraclinical findings that demonstrate that multiple sclerosis (MS) affects the peripheral nervous system (PNS) as well as the central nervous system (CNS). Methods: Narrative review.

RESULTS

MS is traditionally defined as a chronic demyelinating immune-mediated disease of the CNS. However, there is emerging evidence that MS is a disease that does not solely affect the CNS but can manifest with PNS involvement as well. Several pathology studies have reported on signs of demyelination in the PNS, as well as on structural and functional involvement of the PNS in persons with MS (pwMS). From the functional aspect, several studies have shown autonomic nervous system (ANS) involvement in the form of sudomotor dysfunction measured with quantitative sudomotor axon reflex test (QSART) in different stages of MS, adding to the growing body of evidence that indicate PNS involvement in MS. In this review the clinical, pathological, neurophysiological, and imaging findings that demonstrate that MS affects the PNS as well as the CNS are summarized, with the emphasis on the ANS abnormalities.

CONCLUSION

Further large-scale research is needed in order to fully understand the frequency and importance of PNS affection in MS.

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.

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.

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.

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.

Nerve root hypertrophy in chronic inflammatory demyelinating polyneuropathy

A patient with chronic inflammatory demyelinating polyneuropathy (CIDP) and central demyelinating disease is described in whom striking nodular filling defects on multiple lumbar-sacral nerve roots, mimicking neurofibromata, were observed at myelography and magnetic resonance imaging. We suggest that these lesions are secondary to recurrent segmental demyelination and remyelination and that the differential diagnosis of this radiological feature should include CIDP.