Respiratory failure is an uncommon association with multiple sclerosis. We report on a patient with multiple sclerosis who developed bilateral diaphragmatic weakness and type II respiratory failure requiring mechanical ventilation, who was successfully treated with plasma exchange.
Case Report
A 38-year-old woman with multiple sclerosis presented in May 2009 with horizontal diplopia, lower limb stiffness and unsteady gait. Examination revealed a left sixth nerve palsy, bulbar dysarthria, lower limb hypertonia and global hyperreflexia. MRI FLAIR imaging revealed new and extensive increased signal in the pons/medulla compatible with a brainstem relapse. She received 3 days of methylprednisolone. Following completion of steroids her condition deteriorated. She became agitated, tachyapnoeic, tachycardic with paradoxical abdominal wall movements and type II respiratory failure. She had sluggish pupillary responses and vestibulo-ocular reflex, bilateral facial weakness, bulbar dysfunction and spastic tetraparesis. She was intubated and taken to ITU continuing methylprednisolone. Two failed extubations on day 2 and 5 necessitated tracheostomy. On day 6 she commenced plasma exchange in view of ongoing ventilatory support. By day 18 she had returned to the ward. In August, brainstem signs had fully resolved and repeat MRI imaging showed impressive resolution.
Conclusions
Respiratory failure is a rare complication of brainstem relapses and may respond to plasma exchange.
Argonne National Laboratory and Amoco Oil Co. have joined forces in a cooperative effort to develop new and improve existing technologies for converting low-grade byproducts of crude oil refining into useful fuels. These byproducts or resids are the low-grade tars and other chemicals left over after crude oil is refined. Current resid upgrade techniques depend heavily on catalytic hydroprocessing which is prone to fouling, thus reducing the efficiency of the process. The goal of current research is to improve current resid upgrade technology in order to increase yields of fuel-grade resid by a factor of about 50%. Over the next three years, the Argonne and Amoco researchers plan to study these catalytic reactions in an attempt to understand how coke forms and grows in order to develop technologies that can more effectively identify and remove carbon, sulfur compounds and other chemicals in heavy resid material.
In 1989, the US manufacturing facilities released over 18 billion pounds of toxic chemicals directly into air, water, land or underground wells. The problems associated with toxic chemicals in the United States are not confined to their borders. The impact of toxic chemicals came to forefront of their nation with the 1978-80 struggles at Love Canal where 900 families fought for and won relocation after they had discovered that their neighbourhood was built next to 21,000 tons of toxic wastes. Recent tests by EPAs National Human Adipose Survey shown that most likely all Americans have toxic compounds stored in their fatty tissues; 100 per cent of peoples tissue samples in one recent test contained styrene, xylene isomers, 1,4-dichlorobenzene and ethylphenol. The environmental organisations from the Sierra Club to the World Wildlife Fund and Environmental Defense Fund have become part of the system where being reasonable is the driving force, and there is little consideration of the impact on people.
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