Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 52, Num. 2, 2004, pp. 282-283

Neurology India, Vol. 52, No. 2, April-June, 2004, pp. 282-283

Letter To Editor

Multiple sclerosis in a patient with chronic ulcerative colitis

Pandian JD, Pawar G, Singh GS, Abraham R

Departments of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab - 141008

Correspondence Address:Departments of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab - 141008

Code Number: ni04099

Sir,
We report a patient with chronic ulcerative colitis who developed multiple sclerosis after 5 years of remission from ulcerative colitis.

A 34-year-old lady had recurrent bouts of loose stools mixed with blood and mucus for 8 years and a non-healing ulcer on the lateral aspect of left leg. Investigations revealed ulcerative colitis. Skin biopsy revealed features of pyoderma gangrenosum. She was treated with prednisolone and 5-aminosalicylate following which there was improvement in colonic symptoms and the ulcer over the leg healed. Five years after the treatment the patient complained of diminution of vision in both eyes and pain in the orbit on eye movements for 5 days. She was treated with oral prednisolone and showed significant recovery. Three months later, she developed weakness in both lower limbs over 6 days. She was treated with oral steroids and her symptoms ameliorated in 2 weeks. One month after recovery, she was readmitted with complaints of progressive weakness and heaviness in the left upper and lower limb for 15 days. Neurological examination revealed a visual acuity of 6/9 in both eyes and a relative afferent pupillary defect in the left eye. Pronator drift could be elicited in the left upper limb; in the left lower limb the power was Grade 4/5. The deep tendon jerks were Grade 3 in the upper limbs and Grade 4 in the lower limbs bilaterally. Spasticity was demonstrable in the left side with extensor plantar response. MRI brain showed white matter lesions [Figure - 1]a and [Figure - 1]b. Visual evoked potential was abnormal in both sides. Cerebrospinal fluid (CSF) findings were as follows: cells were absent; proteins were raised (74 mgms%) with normal sugar. CSF-albumin 2 mgs/dl (13.6 - 34.6 mg/dl), IgG 19.6mgs/dl (1.7-4.4 mg/dl), serum IgG 1722 mgs/dl (1000 - 2000mgs/dl) and serum albumin 3.8 gms/dl (3.5 -8gm/dl). The CSF IgG level was greater than 12% of the total protein (26.4%). CSF electrophoresis revealed decreased albumin, 35.57% (53.5 - 70.2%) and b1 globulins - 1.89% (5.1-11.4%). She received a course of methyl prednisolone followed by oral prednisolone for 21 days. At 2 years follow-up the patient′s visual acuity was normal and there was marked improvement in the power of all the four limbs.

The various neurological manifestations of ulcerative colitis reported in the literature are myelopathy, peripheral neuropathy, myopathy, cerebral venous thrombosis, cerebrovascular disease and myasthenia gravis.[1] There are reports about the association between multiple sclerosis and inflammatory bowel disease.[2],[3],[4] Twenty-seven instances of familial concurrence were identified from British Columbia.[4] In another series from Alberta, 17 instances of familial concurrence of both disorders were ascertained.[5] The family history in our patient didn′t reveal any such familial association of two disorders. Familial concurrence of inflammatory bowel disease and multiple sclerosis may represent shared genetic or environmental causes.[5] Sadovnick and his co-investigators postulated that one or more loci contributing specifically to inflammatory bowel disease may also determine susceptibility to multiple sclerosis.[4] Multiple sclerosis and inflammatory bowel disease share common predisposing factors, but not enough information is available to speculate about possible mechanisms.

References

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