부산대학교 도서관

A 71-year-old female first developed muscular weakness of the lower limbs with extensor plantar responses, impairment of all sensory modalities below the spinal level of Th_7 and dysuria at the age of 69. Predonisolone was adminstered at the initial dose of 60mg par day. These symptoms of transverse myelitis had gradually improved until eight months later when these symptoms again became worse, and moreover, visual loss, dysarthria, dysphagia and a slight disturbance of consciousness were newly added. On admission to Kyorin University Hospital, examination of the optic fundi revealed bilateral papillitis. The visual acuity was markedly decreased especially in the right eye. Consciousness was somnolent. The bulbar symptoms were noted. The strength of muscle was markedly reduced in the lower limbs. Deep tendon reflexes were normal in the upper limbs but diminished in the lower limbs with extensor plantar responses. Both superficial and deep sensations were impaired below the level of Th_7. There was urinary incontinence. In about three months after admission during which predonisolone initially 40mg per day was administered, the patient again showed a remission in the above symptoms except for the visual acuity of the right eye which remained almost blind. This period of remission had continued only for almost three months and the patient again showed an exacerbation of all the neurological symptoms. Facial paresis and extreme emotional lability also appeared. No improvements were obtained this time and the patient died because of pneumonia approximately sixteen months after the onset of the first neurological symptoms. Neuropathological examinations disclosed obvious demyelinating lesions in the thoracic spinal cord, medulla oblongata around the fourth ventricle, right optic nerve, thalamus, left internal capsule, and right parietal and occipital lobes of the cerebrum. No demyelinated plaque was present in the midbrain, pons and cerebellum. Axis cylinders were well preserved in the demyelinated areas for the most part. The lesions in the cerebrum were thought to be comparatively new, where the perivascular lymphocytic infiltration was remarkable, and a lot of lipid-lading macrophages were present. On the other hand, comparatively old demyelinated lesions were found in the thoracic spinal cord and medulla oblongata. These were necrotic, and slight degree of the proliferation of fibrous astrocyte in addition to a lot of lipid-containing phagocytes and a slight lymphocytic infiltration were found. However alteration to scar tissue due to glial fibrosis, indicating a longstanding lesion, was observed nowhere in the lesions. The clinical features and pathological changes of this case were not different from those seen in patients with earlier onset. Considering the fact that multiple sclerosis is rare in the old and the very young, there must be some factor(s) relating to age which might inhibit or suppress the formation of the disease.