OBJECTIVES: ALS may be diagnosed although affection of other organs suggests 
another pathogenetic back-ground.
CASE REPORT: In a 72yo non-smoking male progressive gait disturbance with 
recurrent falls since 2y was initially attributed to axonal polyneuropathy. 
Additionally, he had arterial hypertension, diabetes, hyperlipidemia, 
hyperuricemia, hyper-CK-emia, hepatopathy, atrial fibrillation, recurrent 
heart-failure, pulmonary hypertension, mitral insufficiency, and restrictive 
cardiomyopathy. Possible causes of polyneuropathy were diabetes, long-standing 
alcoholism, folate-deficiency, or hereditary disease. Later the patient was 
re-diagnosed as ALS despite absence of upper motor-neuron or bulbar signs, the 
presence of multiple risk factors for polyneuropathy, of stocking-type sensory 
disturbances, and of cardiac abnormalities, which could explain dyspnea. 
Misdiagnosing polyneuropathy as ALS stigmatized the patient and prevented him 
from further diagnostic work-up for cardiac disease and adequate treatment for 
heart-failure. Though the diagnosis of ALS was withdrawn, he was put on comfort 
care and opiates were given when dyspnea acutely deteriorated to death without 
further cardiac or pulmonary investigations or specific cardiac treatment.
CONCLUSIONS: ALS should be diagnosed only if the Awaji-shima criteria are 
fulfilled and if all differential diagnoses were profoundly excluded. 
Respiratory insufficiency should not be attributed to bulbar involvement in ALS 
as long as cardiac, pulmonary, or myopathic causes were excluded.