Focal cranial nerve involvement in chronic inflammatory demyelinating polyneuropathy: clinical and MRI evidence of peripheral and central lesions

Summary Five cases of chronic inflammatory demyelinating polyneuropathy are described in which cranial nerve involvement accompanied a more generalized neuropathy. Clinical, electrophysiological, radiological and nerve biopsy findings are presented. Cranial nerve lesions in this form of polyneuropathy may be related to lesions of the peripheral nerves or of the central nervous system, when they may be accompanied by MRI evidence of more widespread CNS demyelinating lesions. In cases of early onset, the occurrence of focal cranial nerve lesions may serve to distinguish chronic inflammatory from inherited demyelinating polyneuropathies.     

STRINGHALT IN HORSES: A DISTAL AXONOPATHY

A detailed investigation of the neuropathology of a horse affected with stringhalt was performed. Qualitative and quantitative light and electron microscopy, and single teased fibre preparations of peripheral nerve demonstrated predominantly axonal degeneration, the stage of which was appropriate for the duration of clinical signs. There was selective involvement of large myelinated nerve fibres. A proximal to distal increase in the severity of pathological changes was present in the peripheral nerves. The long left recurrent laryngeal nerve was the most severely affected, followed in order by its right counterpart, the hindlimb and forelimb nerves. Neurogenic atrophy of muscles innervated by affected peripheral nerves also showed a distally graded increase in severity. No lesions were observed in the central nervous system. It was concluded that this disease should be classified as a distal axonopathy.     

Multiple neurologic manifestations of Borrelia burgdorferi infection

The neurological spectrum of Borrelia burgdorferi infections is still enlarging. We review epidemiological, pathological and serological data of Lyme disease. The course of the disease is divided in three stages: stage 1 during the first month is characterised by erythema chronicum migrans and associated manifestations; stage 2 includes not only the classical European meningoradiculitis but also less specific neurological symptoms: isolated lymphocytic meningitis with an acute or even relapsing course, apparently idiopathic facial palsy, neuritis of other cranial nerves, polyneuritis cranialis, Argyll-Robertson sign, peripheral nerve involvement, acute transverse myelitis, severe encephalitis, myositis. During stage 3, three to five months or longer after the onset of the disease, chronic arthritis, acrodermatitis chronica atrophicans and various neurological symptoms can be observed: chronic neuropathy with mainly sensory or motor signs, recurrent strokes due to cerebral angiopathy and progressive encephalomyelitis; this third stage the central nervous system involvement is characterised by slowly progressive or fluctuating course during months or years, ataxic or spastic gait disorder, bladder disturbances, cranial nerve dysfunction including optic atrophy and hypoacusia, dysarthria, focal and diffuse encephalopathy. This chronic central nervous system disease can mimic multiple sclerosis, anorexia nervosa, psychic disorders or subacute presenile dementia. It is often associated with pleiocytosis, abnormal EEG and evoked potentials, sometimes multifocal and mainly periventricular white matter lesions visualised by CT or MRI, and as a rule high antibody titers against Borrelia burgdorferi. High doses of penicillin can halt the disease, sometimes induce spectacular regression of symptoms or sometimes be inefficient; ceftriaxone could be a more powerful therapy. Similarities between syphilis and Borreliosis are multiple: both of these spirochetes contain plasmids, can be transmitted through the placenta and progress for many years through successive stages, with multiorgan symptoms, including parenchymatous and vascular lesions of the central nervous system. Borrelia burgdorferi is the new great imitator.     

Alpha-synuclein pathology of the spinal and peripheral autonomic nervous system in neurologically unimpaired elderly subjects

Studies on cases with incidental Lewy body disease (ILBD) suggest that alpha-synuclein (alphaSN) pathology of Parkinson's disease (PD) starts in lower brainstem nuclei and in the olfactory bulb. However, medullary structures as the induction site of alphaSN pathology have been questioned as large parts of the nervous system, including the spinal cord and the peripheral autonomic nervous system (PANS), have not been examined in ILBD. Thus, the time course of PD lesions in the spinal cord or PANS in relation to medullary lesions remains unknown. We collected 98 post mortem cases with no reference to PD-associated symptoms on clinical records. alphaSN pathology was found in the central nervous system, including the spinal cord, and in the PANS in 17 (17.3%) cases. alphaSN pathology was encountered in autonomic nuclei of the thoracic spinal cord, brainstem and olfactory nerves in 17/17, in sacral parasympathetic nuclei in 15/16, in the myenteric plexus of oesophagus in 14/17, in sympathetic ganglia in 14/17, and in the vagus nerve in 12/16 cases. In addition to the thoracic lateral horns, a high number of alphaSN lesions was also found in non-autonomic spinal cord nuclei. Considering supraspinal structures our cases corresponded roughly to the recently described sequential order of alphaSN involvement in PD. Our study indicates, however, that the autonomic nuclei of the spinal cord and the PANS belong to the most constantly and earliest affected regions next to medullary structures and the olfactory nerves. A larger cohort of ILBD cases will be needed to pinpoint the precise induction site of alphaSN pathology among these structures.     

Giant axonal neuropathy: clinical, electrophysiologic, and neuropathologic features in two siblings

Giant axonal neuropathy is a progressive central-peripheral axonopathy characterized by distention of axons by aggregated neurofilaments. We report two female siblings with giant axonal neuropathy. Both patients developed symptoms of a chronic progressive polyneuropathy at age 3 years. Clinical evidence of central nervous system involvement was present in both cases. Autopsy neuropathologic examination of the older sibling at the age of 11 years revealed numerous giant axons, Rosenthal fibers, and gliosis throughout the brain and spinal cord and typical giant axons in the peripheral nerves. Electrophysiologic studies in the younger sibling indicated brain stem dysfunction, and her sural nerve biopsy revealed enlarged axons packed with neurofilaments. These patients illustrate that neurologic deficits of giant axonal neuropathy result from widespread lesions in the central, as well as peripheral (including autonomic), nervous systems. This occurrence of giant axonal neuropathy in two siblings supports a genetic origin of this disease. This is the first report of autopsy findings in giant axonal neuropathy in an affected sibling.     

Congenital neuropathy with the absence of large myelinated fibers

Twelve patients with hereditary motor and sensory neuropathy with the absence of large myelinated fibers have been reported. All of these patients had central nervous system involvement. In this report, we describe the first patient with pure motor and sensory neuropathy with the absence of large myelinated fibers without central nervous system involvement. Morphometric analysis of the biopsied sural nerve specimen revealed extremely small myelinated fibers compared with previously reported patients. It is supposed that the cause of this disease might be the abnormal development of axons of the peripheral nerves.     

Distribution of neuropeptide Y immunoreactivity in the central and peripheral nervous systems of amphioxus (Branchiostoma lanceolatum Pallas)

Immunocytochemistry techniques were employed to investigate the distribution of neuropeptide Y-like-immunoreactive (NPY-ir) cells and fibers in the central and peripheral nervous systems of adult amphioxus. NPY-ir neurons of the commissural type were abundant in the brain and present but more scarce in the spinal cord. These neurons gave rise to conspicuous NPY-ir tracts that coursed along the entire length of the nerve cord. Some fibers exhibited conspicuous Herring body-like swellings. In the peripheral nervous system, small NPY-ir neurons and a large number of thin, beaded NPY-ir fibers were observed in the atrial region, indicating the involvement of this substance in visceral regulation. A few NPY-ir fibers, possibly afferent to the spinal cord, coursed in the ventral branches of the spinal nerves of this region, whereas no NPY-ir fibers coursed in the preoral or velar nerves or in the dorsal branches of the other spinal nerves. These results indicate that NPY is widely used as a neuroregulator/neurotransmitter in the central and peripheral nervous systems of this primitive chordate. In addition, this study demonstrates the presence of tall, thin NPY-ir cells in the putative adenohypophyseal homologue, the Hatschek's pit organ, which is located in the roof of the preoral cavity (vestibule).     

B-cell neurolymphomatosis confined to the peripheral nervous system

Patients with neurolymphomatosis show lymphoma cells within the peripheral nerves, nerve root/plexus, or cranial nerves. However, most neurolymphomatosis patients show lymphomatous infiltration not only in the peripheral nervous system (PNS), but also in the meninges, Virchow–Robin space, and brain parenchyma. Here, we report a 74-year-old woman with diffuse large B-cell lymphoma presenting with motor–sensory–autonomic polyneuropathy and multiple cranial neuropathies. A diagnosis of neurolymphomatosis was made by sural nerve biopsy. Postmortem examination indicated that lymphoma cell infiltration in the nervous system was confined to the PNS with no involvement of the central nervous system, including the meninges. This was a very rare case of B-cell neurolymphomatosis with lymphomatous infiltration confined to the PNS, suggesting specific affinity of the lymphoma cells for the PNS in this patient.     

Generalized nerve sheath tumors in neurofibromatosis type 1 (NF1). A case report

We describe a case of chronic distal sensorimotor neuropathy associated with neurofibromatosis type 1 (NF1) in a 15-year old girl. The patient showed a striking clinical picture consisting of diffuse nodular enlargements of peripheral nerves. Motor conduction velocities were decreased and sensory responses were absent after maximal stimulation. Magnetic resonance imaging (MRI) was performed throughout the body and disclosed generalized nerve sheath neurofibromas affecting all peripheral nerves. Intracranially, the patient had a glioma of the left optic nerve, but no other cranial nerve involvement. These results demonstrate the value of MRI for visualization of the peripheral nervous system in neurofibromatosis.     

Polyneuritis of cranial nerves and acquired immunodeficiency syndrome (AIDS): 5 cases

Cranial neuropathies were present in 5 patients with positive serology for the human immunodeficiency virus. Two patients presented with abnormalities of ocular movements (3rd, 4th), two with an isolated unilateral facial nerve palsy and one with a lesion of the accessory nerve. Neurological symptoms and signs are present in approximately 60 to 80 p. 100 of cases of the acquired immunodeficiency syndrome, but cranial neuropathies affect only 2 to 3 p. 100 of the patients. The isolation of the human immunodeficiency virus from the nerve suggest a direct role, but an indirect immune mechanism may also be present. Some of the patients with aseptic meningitis or subacute encephalopathy have demonstrated involvement of cranial nerves, mainly 2nd, 7th and 8th. Systemic tumors (lymphoma) may involve the central nervous system by diffuse meningeal invasion with lesions of 3rd, 4th and 6th nerves. Opportunist infections like Herpes zoster or Cytomegalovirus may produce cranial neuropathies (2nd, 5th). Isolated mononeuropathies or cranial nerves palsies have also been reported in patients treated with chemotherapeutic agents like vinca alkaloids.     

Disorders of the autonomic nervous system: Part 1. Pathophysiology and clinical features

Autonomic dysfunction may result from diseases that affect primarily either the central nervous system or the peripheral autonomic nervous system. The most common pathogenesis of disturbed autonomic function in central nervous system diseases is degeneration of the intermediolateral cell columns (progressive autonomic failure) or disease or damage to descending pathways that synapse on the intermediolateral column cells (spinal cord lesions, cerebrovascular disease, brainstem tumors, multiple sclerosis). The peripheral autonomic nervous system may be damaged in isolation in the acute and subacute autonomic neuropathies or in association with a generalized peripheral neuropathy. The peripheral neuropathies most likely to cause severe autonomic disturbance are those in which small myelinated and unmyelinated fibers are damaged in the baroreflex afferents, the vagal efferents to the heart, and the sympathetic efferent pathways to the mesenteric vascular bed. Acute demyelination of the sympathetic and parasympathetic nerves in the Guillain-Barré syndrome may also cause acute autonomic dysfunction. Although autonomic disturbances may occur in other types of peripheral neuropathy, they are rarely clinically important.     

急性播散性脑脊髓炎合并多发性神经病的临床研究

目的分析急性播散性脑脊髓炎合并多发性神经病的临床特点,以提高临床医生对本病的认识和诊疗水平。方法对2017-12—2019-04就诊于河南省人民医院的8例急性播散性脑脊髓炎合并多发性神经病患者的临床表现、影像学、神经电生理、脑脊液特点及全身免疫相关指标进行回顾性分析。结果本组8例患者为急性或亚急性起病,起病前多有前驱感染史。首先表现为中枢神经系统受累,其中7例影像学证实脑和(或)脊髓白质受累,1例脑电图证实中枢神经系统受损;迟缓性瘫痪、腱反射减弱或消失等周围神经受损的证据也随后出现,而后肌电图证实多发性神经根受损或神经源性损害。脑脊液检查细胞轻度升高或正常,蛋白升高或正常,只有1例见脑脊液细胞-蛋白分离。治疗上急性期激素冲击或免疫球蛋白治疗,症状和体征明显改善,缓解期辅以免疫抑制剂,随访无复发。结论中枢神经系统和周围神经系统同时或相继出现脱髓鞘性改变,可能是一种不同于单纯中枢神经系统脱髓鞘和周围神经系统脱髓鞘的新疾病体,也可能是一种新的叠加综合征。     

α‐Synuclein pathology in the cranial and spinal nerves in Lewy body disease

Accumulation of phosphorylated α‐synuclein in neurons and glial cells is a histological hallmark of Lewy body disease (LBD) and multiple system atrophy (MSA). Recently, filamentous aggregations of phosphorylated α‐synuclein have been reported in the cytoplasm of Schwann cells, but not in axons, in the peripheral nervous system in MSA, mainly in the cranial and spinal nerve roots. Here we conducted an immunohistochemical investigation of the cranial and spinal nerves and dorsal root ganglia of patients with LBD. Lewy axons were found in the oculomotor, trigeminal and glossopharyngeal‐vagus nerves, but not in the hypoglossal nerve. The glossopharyngeal‐vagus nerves were most frequently affected, with involvement in all of 20 subjects. In the spinal nerve roots, Lewy axons were found in all of the cases examined. Lewy axons in the anterior nerves were more frequent and numerous in the thoracic and sacral segments than in the cervical and lumbar segments. On the other hand, axonal lesions in the posterior spinal nerve roots appeared to increase along a cervical‐to‐sacral gradient. Although Schwann cell cytoplasmic inclusions were found in the spinal nerves, they were only minimal. In the dorsal root ganglia, axonal lesions were seldom evident. These findings indicate that α‐synuclein pathology in the peripheral nerves is axonal‐predominant in LBD, whereas it is restricted to glial cells in MSA.     

Demyelinating peripheral neuropathy associated with hemophagocytic lymphohistiocytosis. An immuno-electron microscopic study

We report the case of an 11-year-old male who developed subacute diffuse polyradiculoneuropathy, associated with digestive symptoms and Epstein-Barr virus infection. Parental consanguinity was present. The laboratory findings including bone marrow smear were consistent with hemophagocytic lymphohistiocytosis (HLH). Electrophysiological study of peripheral nerves revealed an intense and diffuse demyelinating process. The histological nerve lesions were severe and purely demyelinating. Most axons were intact. There was a diffuse infiltration of the nerve parenchyma by mononuclear cells. Immuno-electron microscopic study evidenced entry of macrophages into Schwann cell cytoplasm with dissociation of myelin sheaths. This boy died several months after the onset of the neuropathic symptoms. HLH is a rare genetic or acquired disorder in childhood characterized by abnormal immune activation, which induces an uncontrolled inflammatory response with sustained hyperactivation of T lymphocytes and macrophages. Only very rare cases of peripheral nerve involvement have been described in HLH. This is the first case showing that peripheral nerves, as other viscera, may be destroyed by the macrophagic infiltration, which characterizes HLH.     

Role of somatosensory evoked potentials in the diagnosis of peripheral nerve lesions: recent advances

Short-latency somatosensory evoked potentials (SEPs) have become an important tool in the investigation of peripheral nerve lesions. Electrically evoked SEPs are most suitable because they provide results with small variations and are readily repeatable. Techniques for testing 10 different upper and lower limb nerves, dermatomes, cutaneous fibers of trigeminal nerve, and nerves supplying urogenital areas are now available. The established, principal areas of application are in the investigation of brachial plexus lesions, proximal injuries of individual nerves in upper and lower limbs, and painful dysesthesias and in the differential diagnosis of pain caused by psychogenic causes or organic lesions. The techniques have proven to be of value in demonstrating early proximal abnormalities in polyneuropathies. Abnormalities have occurred in trigeminal nerve lesions, urogenital dysfunctions, hereditary ataxias, and rare neuropathies. Unexpected abnormalities have also been reported in motor neuron disease, myotonic muscular dystrophies, and other conditions. Applications in the diagnosis of spondylopathic root lesions are not satisfactory; the techniques' usefulness in the investigation of these lesions does not extend beyond aiding the selection of patients for other diagnostic modalities, such as myelography, computed tomography (CT), and nuclear magnetic resonance (NMR) imaging. The usefulness of SEP techniques in the diagnosis of peripheral nerve lesions will remain, even if advances in organ imaging techniques can provide more specific information about the level and magnitude of lesions in the central nervous system. SEP techniques are an important complement to the other well-established methods, such as clinical testing, electromyography, and nerve conduction studies.     

铊中毒八例的神经精神表现

目的 总结铊中毒的神经精神表现，以期引起神经精神科医生对铊中毒的警惕。方法 复习8例铊中毒患者的临床资料及相关文献，探讨铊中毒的机制以及与神经系统的关系；铊中毒的神经精神表现及病理。结果 8例患者中急性重度中毒3例，表现为腹痛、恶心、呕吐；烦躁、谵妄、昏迷、抽搐；呼吸衰竭、血压降低、心动过速，均在短期死亡。5例为亚急性或慢性中毒。其临床表现以周围神经、视神经或中枢神经损害为主，部分患者有毛发脱落。8例中有6例误诊为其他神经系统疾病，2例疑诊铊中毒，因条件所限当时未确诊。5例存活病例经对症治疗，临床症状明显好转，个别病例遗留部分后遗症。结论 因误服与投毒所致铊中毒由于缺乏接触史，给临床诊断带来很大困难。对原因不明的周围神经、中枢神经损害患者应警惕铊中毒的可能，若有毛发脱落，更应怀疑铊中毒，可结合血尿铊定量确诊。     

Central nervous system involvement in hereditary neuropathy with liability to pressure palsies: description of a large family with this association

OBJECTIVE: To describe a large family with hereditary neuropathy with liability to pressure palsies associated with central nervous system demyelination. DESIGN: We examined the 18 members of a pedigree. Genetic analysis was performed on 15 subjects, standard nerve conduction studies on 10 subjects, and brain magnetic resonance imaging studies on 8 subjects. RESULTS: Hereditary neuropathy with liability to pressure palsies was confirmed in 9 patients of the pedigree. Brain magnetic resonance imaging findings showed multiple areas of demyelination in 6 of 6 affected members and were normal in 2 of 2 healthy relatives. Magnetic resonance imaging abnormalities were predominantly located in the subcortical frontal white matter. All patients had acute and recurrent nerve palsies, while clinical features of central nervous system involvement were not a characteristic of this pedigree. CONCLUSIONS: We demonstrate that this association, previously reported in sporadic cases, is not coincidental. Therefore, patients with hereditary neuropathy with liability to pressure palsies can present central nervous system white matter lesions, and the role of the PMP22 (peripheral myelin protein 22) gene deletion in the central nervous system should be further studied.     

Recurrent multifocal lesions of the nervous system after herpes zoster

The authors report a case of zoster with signs of transverse myelitis and peripheral involvement of the facial nerve. The fact that tranverse myelitis developed late after zoster and was followed by facial nerve palsy is stressed. The involvement of these nervous structures occurred in a way suggesting exacerbations. In the light of literature data and the described case the authors state that zoster with complications in the form of multifocal nervous system involvement occurring at different time intervals is infrequent.     

Sarcoidosis and the nervous system

Neurologic involvement occurs in 5 per cent of patients with sarcoidosis and is a presenting symptom in about half of those affected. The neurologic symptoms are due to a granulomatous process that mirrors that seen in the systemic form. Its diagnosis is usually established by the demonstration of sarcoidosis in other systems and supported by clinical, radiographic, and laboratory evidence. Any and all portions of the nervous system can be involved in either an acute or a chronic fashion. Early acute presentations tend to have excellent outcomes and the overall prognosis for the disease is good. The cranial nerves, especially the facial nerve, are most frequently involved and have a good prognosis. CNS involvement, usually in the form of a meningoencephalitis involving the hypothalamic region, is usually chronic and associated with poor prognosis. Peripheral nerve and muscle involvement is frequently asymptomatic. Although neuropathy or myopathy may present acutely, the usual presentation is subacute or chronic. There have been no controlled studies of therapy in neurosarcoidosis. Early implementation of corticosteroids remains the mainstay of treatment. Evidence for improvement with treatment is anecdotally reported in many cases, but progression of the disease also occurs despite therapy.     

Morphometric analysis of the peripheral neuropathy of AIDS

A morphometric study of the peripheral nervous system at autopsy was undertaken in 11 AIDS patients and 10 controls. The left L4, L5, and S1 dorsal root ganglia (DRG) and samples of the sciatic nerve at the buttock, tibial nerve at the knee, and sural nerve at the ankle were collected. Indices of neuronal/axonal degeneration and of segmental demyelination/remyelination were measured at each level. The small number of cases and evidence of neuropathy in a number of the control cases resulted in statistical significance for only a limited number of comparisons. Nodules of Nageotte in the DRG were increased fivefold in AIDS cases compared with controls, and axonal degeneration in single-teased nerve fibers was increased 9-fold in the sciatic nerve, 28-fold in the tibial nerve, and 12-fold in the sural nerve. The ratios of AIDS to controls for the density of remaining DRG neurons and large myelinated axons were reduced to 0.71 in the DRG, 0.84 in the sciatic nerve, 0.84 in the tibial nerve, and 0.66 in the sural nerve. Axonal regeneration in single-teased nerve fibers was increased threefold at the sciatic nerve level in AIDS, but was markedly reduced at distal levels. Acute segmental demyelination in single-teased nerve fibers was present to a greater extent than in controls at all levels of the peripheral nerves in the AIDS cases. Remyelinating fibers were increased compared with controls only in the proximal sciatic nerve. No case showed the changes of cytomegalovirus infection. In a parallel immunohistochemical study of these AIDS peripheral nerves, T-cell and macrophage infiltration, with cytokine expression, was demonstrated. The pathological process in the neuropathy of terminal AIDS appears to be a multifocal immunologically mediated inflammatory disease, with increased density of macrophages and T cells at all levels of the peripheral nervous system, producing segmental demyelination and axonal degeneration. Reparative processes (axonal regeneration and remyelination) occurred only at the most proximal levels of the nerves. © 1998 John Wiley & Sons, Inc. Muscle Nerve 21:1188–1195, 1998.