Respiratory failure is a condition rarely associated with multiple sclerosis (MS). However, in some instances, it may lead rapidly to death. In the literature, the lesions relevant to respiratory failure were only estimated by clinical features or proved by the autopsy findings. We present a case in which the lesion leading to respiratory failure was identified by magnetic resonance imaging (MM).
A 23-year-old woman was admitted to the hospital on Nov 20, 1986. Six months earlier, she had suddenly developed visual disturbance. She rapidly improved and was asymptomatic after two months. In September 1986, she experienced visual disturbance again, followed by painful tonic seizure and quadriplegia. Her symptoms progressed, and she developed a respiratory arrest.
On admission, the neurologic examination showed clear consciousness, atrophy of the optic nerves, quadriplegia, and hyperreflexia, with positive bilateral Babinskis sign. There were no bulbar or sensory abnormalities. cheap cialis canadian pharmacy
A CSF examination result was normal. Serum antimyeline antibody was positive. A chest x-ray film showed elevation of the diaphragms bilaterally and plate-like atelectasis at the lung bases. The CT findings of the skull and spine were negative. MRI in the T2-weighted spin-echo image demonstrated a lesion with high signal intensity in the cervical spinal cord between CI and C3, suggesting involvement with multiple sclerosis (Fig 1). There were no lesions in the cerebrum or brain stem.
Figure 1. The T2-weighted spin-echo sagittal image of MRI demonstrated the high signal intensity lesion in the cervical spinal cord between CI and C3 (arrow), which suggested the MS plaque as a responsible lesion.
Her weakness and visual disturbance gradually improved with administration of high-dose methylprednisolone. She was still quadriplegic but was able to be weaned from the ventilator on the 50th hospital day. She used her accessory muscles of respiration with tidal breathing. Paradoxic excursion of the abdomen and chest wall was also seen. The chest x-ray films taken at deep inspiration and expiration showed that her diaphragms were almost fixed at the 6th intercostal space. The pulmonary function study was done through the tracheostomy tube in the supine position and showed a VC of 0.78 L (25 percent of predicted), an FEV, of 0.72 L, and a peak flow rate of 2.11 Us. Arterial blood gases on room air were: Po2, 83.1 mm Hg; Pco2, 40.0 mm Hg; and pH, 7.428. We monitored the thoracoabdominal movement with inductive plethysmography and the pressures in esophagus and stomach (Fig 2). They showed that the excursions of her rib cage and abdominal wall were in opposite directions during quiet breathing and maximal inspiration. They also showed that the transdiaphragmatic pressure (Pdi) was less than 5 cm HaO) at maximal inspiration, indicating the weakness of her diaphragm.
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FIGURE 2. Movements of the rib cage (RIB) and abdominal wall (ABD) monitored with the inductive plethysmography, and changes in pleural pressure (Ppl), gastric pressure (Pg), and transdiaphragmatic pressure (Pdi) recorded with balloon-tipped catheters in the esophagus and stomach.
Although paradoxic excursion of the abdomen and chest wall was still seen, her weakness improved steadily, and she was discharged six months later.