Complete hemidiaphragmatic paralysis in a patient with multiple sclerosis

Area of Science:

• Neurology
• Pulmonology
• Radiology

Background:

• Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system.
• Diaphragmatic paralysis, though rare, can be a severe complication affecting respiratory function.

Observation:

• A patient with established multiple sclerosis presented with acute unilateral diaphragmatic paralysis.
• Symptoms included decreased vital capacity (600 mL), impending respiratory failure, increased lower extremity spasticity, and neck stiffness.
• Radiographic and fluoroscopic imaging confirmed diaphragmatic paralysis; phrenic nerve stimulation showed a normal response latency and amplitude.

Findings:

• High-dose intravenous steroids led to significant improvement in neck stiffness and spasticity.
• The patient's vital capacity increased to 1500 mL.
• Follow-up imaging demonstrated restored diaphragm position and movement.

Implications:

• This case suggests demyelinating plaques in brainstem fibers to the phrenic nucleus as a potential cause of diaphragmatic paralysis in MS.
• It highlights a rare presentation of MS involving upper motor neuron phrenic nerve paralysis.
• Early diagnosis and treatment with steroids may be crucial for managing this critical complication.