Multiple sclerosis associated with defects in neuromuscular transmission

Three patients with multiple sclerosis characterized by exacerbations and remissions of nervous system signs and symptoms disseminated in time and space also had the kind of easy fatiguability seen in myasthenia gravis. In each case abnormal decrements to repetitive stimulation were electromyographically demonstrated and treatment with ephedrine or anticholinesterase drugs increased the patient's functional capacity while improving the electromyographic abnormality. The suggestion is that these patients represent an overlap syndrome, analogous to the overlap syndrome existing between systemic lupus erythematosus and rheumatoid arthritis where clinical and laboratory features of two diseases coexist in the same patient at the same time. Presumably some patients with multiple sclerosis have deficient production of acetylcholine, just like patients with myasthenia, and treatment with agents useful in myasthenia is able partially to correct the symptoms caused by the deficiency. The cases illustrate how in neurology greater attention to the more immediate cause of clinical symptoms, in the absence of a known aetiology, may result in benefit to the patients.