title: Flash pulmonary edema in multiple sclerosis.
abstract: BACKGROUND
  Neurogenic pulmonary edema (NPE) occurs in the setting of an acute neurological insult and in the absence of a primary cardiopulmonary cause. No unifying theory on NPE pathogenesis exists. NPE triggered by a discrete neurological lesion is rare, but such cases offer valuable insight into NPE pathogenesis.
  
  
  OBJECTIVE
  To describe an unusual and instructive case of NPE in multiple sclerosis.
  
  
  METHODS
  A young woman with multiple sclerosis presented to the Emergency Department in acute respiratory failure. She was cyanotic centrally, hypertensive, and tachycardic. The chest X-ray study suggested pulmonary edema. She required non-invasive mechanical ventilation for 12 h. Echocardiography revealed left ventricular hypokinesis. The asymmetrical pulmonary infiltrate raised the suspicion of pneumonia; she was given intravenous antibiotics. By 36 h, she had persistent dyspnea, paroxysmal tachycardia, nausea, and facial flushing; carcinoid syndrome was excluded. By 48 h, she had facial numbness and ataxia. Magnetic resonance imaging (MRI) revealed a demyelinating lesion at the rostromedial medulla. Her symptoms promptly resolved with intravenous steroids, as did the perilesional edema on follow-up MRI.
  
  
  CONCLUSIONS
  Life-threatening pulmonary edema can complicate medullary demyelination. Lack of awareness of this diagnostic possibility and an asymmetrical pulmonary infiltrate culminated in diagnostic delay in this case. The case provides clinico-radiological evidence of the pathogenic link between medullary lesions and NPE. The pathogenesis is likely to rely on lesion involvement of the nucleus tractus solitarius or its immediate pathways. Non-uniform vasoconstriction of the pulmonary arterial bed might account for the other peculiarity of this case: the asymmetrical pulmonary infiltrate. Timely diagnosis of NPE is essential because the condition is best managed by nullifying the "neurogenic" trigger.
authors.affiliation: Centre for Neuroscience and Neurological Research, St Vincent's Hospital, Fitzroy, Melbourne, Victoria, Australia.
authors.forename: Chris
authors.initials: C
authors.lastname: Plummer
authors.forename: Robert
authors.initials: R
authors.lastname: Campagnaro
mesh_terms: D000328:Adult; D001929:Brain Edema / Q000150:complications* / Q000628:therapy; D003711:Demyelinating Diseases / Q000209:etiology; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D008279:Magnetic Resonance Imaging; D009103:Multiple Sclerosis / Q000150:complications*; D063087:Noninvasive Ventilation; D011654:Pulmonary Edema / Q000209:etiology* / Q000628:therapy
chemical_list: D005938:Glucocorticoids