Acute pulmonary oedema: presenting symptom of multiple sclerosis

A Case Report on Multiple Sclerosis Associated With Atrial Fibrillation and Neurogenic Hypertension: Area Postrema Syndrome?

Multiple sclerosis (MS) is an autoimmune demyelinating neurological disorder primarily manifesting with a range of neurological symptoms, with cardiovascular autonomic involvement being a rare occurrence. We report a case where a patient initially presented with Bell's palsy, without other notable symptoms or signs, and subsequently developed atrial fibrillation, hypertension, and hemiparesis. Magnetic resonance imaging (MRI) revealed extensive demyelination in the cerebral hemispheres, brainstem, and notably, the area postrema. The anatomy of the area postrema and its connections, in relation to neurogenic hypertension, are discussed. The demyelination in the area postrema was thought to be the cause of our patient's arrhythmias and acute hypertension. Furthermore, we discuss the cerebral origins of cardiac arrhythmias, with a focus on MS and other neurological conditions. This case underscores the rarity of isolated cranial neuropathies, such as Bell's palsy, as an initial sign of MS, marking the onset of a relapse.

Internal comorbidities and complications of multiple sclerosis therapy - don't be caught off guard!

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system, mainly affecting young adults. Factors positively influencing its course include early antiinflammatory treatment and the influencing of other comorbidities. The most common comorbidities occurring in MS patients with a higher frequency than in the general population are neurological, psychiatric, cardiovascular, metabolic and autoimmune. Just as comorbidity compensation affects the course of MS, in some cases, MS decompensation is associated with a worse course of associated diseases. Due to common risk factors and partially shared immunopathogenesis, treatment covering multiple conditions can be used, especially for some autoimmune diseases. On the other hand, some drugs may potentiate the development of other autoimmunity or disorder. A special topic is the side effects and complications of treatment (especially infections and malignancies) of disease-modifying therapies used in patients with MS. However, the potential treatment discontinuation carries significant risks and should always be discussed with the MS specialist. Therefore, close interdisciplinary collaboration is crucial.

A Narrative Review of Respiratory Impairment, Assessment, and Rehabilitation in Multiple Sclerosis

<b><i>Background:</i></b> Respiratory impairment is a problem seen in people with multiple sclerosis (pwMS) from the early stages of the disease but not frequently recognized by clinicians until the later stages. It is seen in different ways, such as respiratory muscle weakness, change in pulmonary volumes, and decrease in cough efficiency. This situation has consequences affecting individuals’ physical fitness, participation in daily life, and quality of life. <b><i>Summary:</i></b> This review explains possible respiratory impairment mechanisms, related problems, assessment, and rehabilitation approaches in pwMS. <b><i>Key Messages:</i></b> It is recommended a comprehensive assessment of respiratory functions in pwMS regardless of the disease severity and stage. In addition, pulmonary rehabilitation and other exercises can have positive effects on the respiratory functions of pwMS. In future studies, specific training parameters should be determined for pwMS to achieve optimal benefits. There is also a need for studies that apply respiratory muscle training in pwMS who have a high disease severity and limited participation in the activities of daily living.

The spectrum of acute cardiopulmonary events associated with multiple sclerosis exacerbations

Diverse acute neurological injuries may cause acute cardiopulmonary events including neurogenic pulmonary edema (NPE) and neurogenic stunned myocardium (NSM). The mechanism is probably mediated by sympathetic nervous system activation. Focal central nervous system (CNS) lesions, such as demyelinating lesions in multiple sclerosis (MS), may also cause cardiopulmonary disturbances. We aim to review the acute cardiopulmonary events associated with MS relapses. We performed a literature search using PubMed, and selected case reports of acute cardiac and/or pulmonary events related to MS exacerbations. We grouped these events into three categories: 1) NPE with normal cardiac function; 2) NSM and Takotsubo cardiomyopathy (TTC); 3) coexisting myocardial dysfunction and pulmonary edema. In some cases, cardiac and pulmonary symptoms preceded the onset of neurological symptoms. The majority of cases were associated with acute demyelinating lesions located in the medulla. Acute brainstem MS relapses, with demyelinating lesions affecting the medulla, may cause acute cardiac and pulmonary events presumably secondary to sympathetic hyperstimulation. Specific regions in the medulla that regulate cardiac function, systemic blood pressure and pulmonary hydrostatic pressure seem to be responsible for these events.

An uncommon first manifestation of multiple sclerosis: Tako-Tsubo cardiomyopathy

Background:

Clinically isolated syndromes affecting the brainstem may present with rare manifestations such as neurogenic pulmonary oedema (NPO).

Objectives:

We present the case of a 23 year-old man with NPO caused by Tako-Tsubo cardiomyopathy (TTC) as a first manifestation of multiple sclerosis (MS).

Methods and Results:

A brain magnetic resonance imaging scan at admission showed multiple supra and infratentorial white matter inflammatory demyelinating lesions. This examination was repeated 2 and 4 weeks after symptoms onset and active lesions showing contrast uptake were identified, two of them involving the pons and the medulla oblongata, probably affecting the solitary tract nucleus. Cerebrospinal fluid oligoclonal bands were detected. The patient was treated with a 3-day course of 1g intravenous methylprednisolone presenting a significant and progressive improvement. The proposed underlying physiopathology is an excessive secretion of catecholamines resulting in myocardial stunning and ventricular failure. Two months later he developed optic neuritis and disease-modifying treatment was initiated.

Conclusions:

Clinicians should consider a possible neurological origin of TTC, and according to the clinical characteristics of the patient, MS may be suspected.

Respiratory dysfunction in multiple sclerosis

Respiratory dysfunction frequently occurs in patients with advanced multiple sclerosis (MS), and may manifest as acute or chronic respiratory failure, disordered control of breathing, respiratory muscle weakness, sleep disordered breathing, or neurogenic pulmonary edema. The underlying pathophysiology is related to demyelinating plaques involving the brain stem or spinal cord. Respiratory complications such as aspiration, lung infections and respiratory failure are typically seen in patients with long-standing MS. Acute respiratory failure is uncommon and due to newly appearing demyelinating plaques extensively involving areas of the brain stem or spinal cord. Early recognition of MS patients at risk for respiratory complications allows for the timely implementation of care and measures to decrease disease associated morbidity and mortality.

Neurogenic pulmonary edema in pediatric multiple sclerosis: patient report and summary of cases

BACKGROUND

Neurogenic pulmonary edema may be a complication of multiple neurological processes. Although there is debate regarding the underlying pathophysiology, the recognition of neurogenic pulmonary edema is vitally important because of the high-potential for mortality and need for treatment of the underlying disorder.

METHODS

We present an example of recurrent neurogenic pulmonary edema in an adolescent boy with multiple sclerosis who was diagnosed with pneumonia at the time of initial presentation. We also review the presenting symptoms, physiologic parameters, and imaging findings from published reports of patients with multiple sclerosis presenting with neurogenic pulmonary edema.

RESULTS

Although all 11 cases found via literature review presented with respiratory symptoms, cardiac dysfunction was variable, as was the presence of other neurological findings. All but one case had a documented medullary lesion. Corticosteroids were effective in resolving symptoms. Three patients were not treated with corticosteroids, and one of these died (onset of pulmonary edema during sleep).

CONCLUSIONS

Awareness of these patients may expedite recognition and treatment of future patients, thus minimizing time to appropriate treatment and reducing mortality.

Biventricular Tako-Tsubo cardiomyopathy: usefulness of 2D speckle tracking strain echocardiography

Tako-Tsubo cardiomyopathy is a transient left ventricular apical ballooning syndrome also known as stress-induced cardiomyopathy. This reversible cardiomyopathy without epicardial coronary artery disease mimics acute myocardial infarction. Right ventricular involvement, which has been infrequently reported, is present in about a quarter of cases of Tako-Tsubo cardiomyopathy and is associated with a more severe clinical outcome. We report the case of a 55-year-old postmenopausal woman with transient biventricular apical ballooning. She recently had acute exacerbation of multiple sclerosis. Regional and global function of both ventricles was estimated using two-dimensional speckle tracking strain echocardiography.

Transient cardiomyopathy as the presenting feature of acute disseminated encephalomyelitis

Brainstem lesions are rarely associated with neurogenic pulmonary oedema (NPO) in multiple sclerosis and other disorders. The exact mechanism for this is unknown. We describe a case of a 15-year-old boy who presented with transient cardiomyopathy and severe acute pulmonary oedema. Several days after his initial presentation he developed an ataxic syndrome with limb, truncal and gait ataxia and nystagmus on primary gaze. Investigations confirmed acute disseminated encephalomyelitis (ADEM). For the first time, we describe a case of transient cardiomyopathy and NPO as the initial manifestation of ADEM.

Cardiogenic shock in a young female with multiple sclerosis

A 24-year-old patient with no previous cardiovascular illness or symptoms, was admitted in profound cardiogenic shock related to severe left ventricular systolic dysfunction, accompanied by multiple sclerosis (MS) exacerbation. Initially the patient required mechanical ventilation, inotropic support, and intra-aortic balloon counter-pulsation along with invasive haemodynamic monitoring. Within a few days of high dose corticosteroid therapy patients left ventricular systolic dysfunction returned almost completely to normal, and this was accompanied by dramatic clinical improvement. We review the current literature on the relation between MS and left ventricular systolic dysfunction and heart failure.

Relapsing and remitting multiple sclerosis: pathology of the newly forming lesion

The study describes the clinical and pathological findings in 12 patients with relapsing and remitting multiple sclerosis, who died during or shortly after the onset of a relapse. Pathological changes not previously associated with the formation of new symptomatic lesions were observed in seven cases, namely, extensive oligodendrocyte apoptosis and microglial activation in myelinated tissue containing few or no lymphocytes or myelin phagocytes. No current laboratory model of multiple sclerosis, in particular, experimental allergic encephalomyelitis, is known with these features, which raises the possibility of some novel process underlying new lesion formation in multiple sclerosis.