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Neurocardiogenic Pulmonary Oedema: Initial Presentation of Multiple Sclerosis

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A previously healthy 20 year-old male presented with headache, acute pulmonary oedema and left ventricular dysfunction requiring intensive care admission. Cardiorespiratory symptoms resolved within three days; however, the patient complained of persistent headache and had gait unsteadiness. Magnetic resonance imaging showed a large demyelinating lesion in the caudal medulla with scattered cerebral plaques. The patient was subsequently diagnosed with multiple sclerosis. This case describes a rare initial presentation of multiple sclerosis with acute pulmonary oedema and cardiac dysfunction secondary to a lower brainstem lesion.

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Case Summary

A previously healthy 20 year-old male awoke as normal, developed a gradually worsening occipital headache at midday and shortness of breath that rapidly worsened over 10 min a few hours later. He arrived at the emergency department in respiratory distress with acute pulmonary oedema (APO) complaining of chest pain and vomiting. The previous day he had run 5 km as per his usual routine.

On examination he was afebrile with tachypnoea (30/min), reduced oxyhaemoglobin saturation (93–99%, 15 L/min O2),

Discussion

Here we report a rarely described initial manifestation of MS with APO and cardiac dysfunction secondary to a demyelinating lower brainstem lesion. Several case reports have shown new brainstem or cervical cord lesions associated with APO in relapses of MS [1], [2], [3], [4], [5]. Relapses with APO were typically preceded within hours or days by upper limb parasthesias, headache or visual disturbance [5]. Two cases have been fatal; one in a 14 year-old girl with relapsing-remitting MS [2] and

Acknowledgements

The authors would like to thank Dr Stephen Buchholz for helpful discussions and assistance with data collection.

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Cited by (12)

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

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    This leads to the thought that there is a direct neurological influence on the pulmonary endothelium.6 Acute pulmonary edema has been described in patients with known multiple sclerosis and as the initial presenting symptom.7 We present a 14-year-old boy with previously diagnosed multiple sclerosis who presented with the acute onset of pulmonary symptoms (a few details of this patient's care were included in an earlier imaging review8).

  • Autonomic dysfunction in multiple sclerosis

    2013, Clinical Neurology and Neurosurgery
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    This, in return, can disrupt the endocardial conduction system causing arrhythmias such as sinus bradycardia or paroxysmal atrial fibrillation [19,20]. There have even been reports of cardiogenic shock and pulmonary edema caused by MS relapse [21,22]. Although the catecholamine surge in acute brain lesions can lead to myocardial damage, such as demonstrated in Takotsubo syndrome, there is, as well, an association presence of demyelinating lesions in the brainstem and the disruption of central autonomic influence on cardiac and respiratory system [22,23].

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