A New Report of Combined Central and Peripheral Demyelination: A Case Report

Combined Central and Peripheral Demyelination: Two Case Reports

Combined central and peripheral demyelination (CCPD) is a rare disease characterized by demyelinating lesions in both the central nervous system (CNS) and peripheral nervous system (PNS). CCPD can present with acute, subacute, or chronic onset. The initial symptom may be of CNS origin, PNS origin, or both. The clinical manifestations of CCPD are quite heterogeneous, and there are no well-defined diagnostic criteria. In MRI imaging of CCPD cases, demyelinating lesions can be seen in areas such as the brain, cerebellum, brainstem, optic nerve, and spinal cord. Common electromyography (EMG) findings in patients with CCPD include decreased motor nerve conduction velocities, decreased or absent sensory nerve action potentials, prolonged F-wave latency, and decreased amplitude of compound muscle action potentials. Neurofascin (NF) is a transmembrane protein and anti-neurofascin (anti-NF) antibodies directed against NF can be positive in cases of CCPD. Four main NF polypeptides are produced by alternative splicing: NF 186, NF 180, NF 166, and NF 155. The investigation of anti-NF in CCPD cases is therefore important for etiological considerations. Here, we discussed three cases diagnosed with CCPD based on clinical, neuroimaging, EMG, and anti-NF antibody results in light of the literature.

Central nervous system involvement in chronic inflammatory demyelinating polyradiculoneuropathy-MRS and DTI study

Objective

The current research aimed to analyze the alterations within the motor cortex and pyramidal pathways and their association with the degree of damage within the peripheral nerve fibers in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). To achieve that goal, we investigated the microstructural changes within the pyramidal white matter tracts using diffusion tensor imaging (DTI) parameters, evaluated metabolic alterations in both precentral gyri using magnetic resonance spectroscopy (MRS) ratios, and correlated them with the neurographic findings in patients with CIDP.

Methods

The spectroscopic ratios of NAA/Cr, Cho/Cr, and mI/Cr from both precentral gyri and the values of fractional anisotropy (FA), axial diffusivity (AD), and mean diffusivity (MD) from both of the corticospinal tracts were correlated with the results of neurological and neurographic findings. The comparison of DTI parameters between the patients and controls was performed using Student's t-test or the Mann-Whitney U test. Due to the lack of normal distribution of most variables, Spearman's Rho rank coefficient was used to test all correlations. All analyses were performed at a significant level of alpha = 0.05 using STATISTICA 13.3.

Results

Compared to the control group (CG), the patient group showed significantly lower ratios of NAA/Cr (1.66 ± 0.11 vs. 1.61 ± 0.15; p = 0.022), higher ratios of ml/Cr in the right precentral gyrus (0.57 ± 0.15 vs. 0.61 ± 0.08; p = 0.005), and higher levels of Cho/Cr within the left precentral gyrus (0.83 ± 0.09 vs. 0.88 ± 0.14, p = 0.012). The DTI parameters of MD from the right CST and AD from the right and left CSTs showed a strong positive correlation (0.52-0.53) with the sural sensory nerve action potential (SNAP) latency of the right sural nerve. There were no other significant correlations between other DTI and MRS parameters and neurographic results.

Significance

In our study, significant metabolic alterations were found in the precentral gyri in patients with CIDP without clinical symptoms of central nervous system involvement. The revealed changes reflected neuronal loss or dysfunction, myelin degradation, and increased gliosis. Our results suggest coexisting CNS damage in these patients and may provide a new insight into the still unknown pathomechanism of CIDP.

Combined central and peripheral demyelination: a case report resembling encephalomyeloradiculoneuropathy

Combined central and peripheral demyelination (CCPD) is an extremely rare disease characterized by inflammatory demyelination in both the central and peripheral nervous systems. Herein, we reported case of a 14-year-old teenager who initially presented with the symptoms of acute myelitis (AM). Subsequently, the patient developed symptoms consistent with Guillain-Barré syndrome (GBS), which was supported by nerve conduction studies (NCV) and cerebrospinal fluid (CSF) analysis. Throughout the course of the disease, the patient experienced abdominal pain and abnormal liver function. After a comprehensive evaluation, we determined that the abnormal liver function was a result of hepatitis E virus (HEV) infection, which may have acted as a trigger for GBS. The patient was treated with corticosteroids, intravenous immunoglobulin and Rituximab, resulting in symptom relief and clinical improvement after therapy and follow-up. This case highlights the potential responsiveness and reversibility of CCPD. Given the heterogeneous nature of CCPD, there is currently no standardized diagnostic criteria or clear consensus on its treatment. Therefore, we recommend a thorough assessment of all possibilities and the development of consolidated management guidelines based on available data for this disorder.