[A case of acute disseminated encephalomyelitis (ADEM) associated with demyelinating peripheral neuropathy]

A 41-year-old man had common cold on April 10, 1991. Five days after this illness he developed fever, dysarthria, visual field impairment, gait disturbance and consciousness disturbance followed. On admission in another hospital, cerebrospinal fluid showed 341/mm3 cells (303 mononuclear cells, 33 polynuclear cells, 5 red cells), protein of 238 mg/dl, and sugar of 59 mg/dl. One month later, the neurological examinations revealed flaccid paraparesis, decreased deep tendon reflexes in the lower extremities, bilateral positive Babinski and Chaddock reflexes, positive Beevor sign, stocking type superficial sensory disturbance, diminished vibration sense in the lower extremities and neurogenic bladder. Eight months later, he improved to be able to walk by himself, but decreased Achilles tendon reflexes, bilateral positive Babinski and Chaddock reflexes and paresthesia over both feet were noted neurologically. Nerve conduction study revealed reduced conduction velocities at tibialis anterior nerves, sural nerves and no response on both deep peroneal nerves. A 1 micron thick epon section of a biopsied sural nerve with toluidine blue stain showed a decreased number of myelinated fibers (6394/mm2) with many thinly myelinated fibers and Renaut bodies. There was no edema nor cell infiltration. Electronmicroscopical findings of their ultrathin sections showed many collagen pockets, denervated Schwann cell clustering and a few onion bulb formations. Teased fiber preparations suggested segmental demyelination and remyelination in many fibers. This case could be regarded as a case of ADEM associated with demyelinating peripheral neuropathy, and the possibility of the simultaneous demyelinating process in the central and peripheral nervous system was discussed.