A 3T MR imaging investigation of the topography of whole spinal cord atrophy in multiple sclerosis.

BACKGROUND AND PURPOSE: Spinal cord atrophy is a common feature of MS. However, it is unknown which cord levels are most susceptible to atrophy. We performed whole cord imaging to identify the levels most susceptible to atrophy in patients with MS versus controls and also tested for differences among MS clinical phenotypes. MATERIALS AND METHODS: Thirty-five patients with MS (2 with CIS, 27 with RRMS, 2 with SPMS, and 4 with PPMS phenotypes) and 27 healthy controls underwent whole cord 3T MR imaging. The spinal cord contour was segmented and assigned to bins representing each C1 to T12 vertebral level. Volumes were normalized, and group comparisons were age-adjusted. RESULTS: There was a trend toward decreased spinal cord volume at the upper cervical levels in PPMS/SPMS versus controls. A trend toward increased spinal cord volume throughout the cervical and thoracic cord in RRMS/CIS versus controls reached statistical significance at the T10 vertebral level. A statistically significant decrease was found in spinal cord volume at the upper cervical levels in PPMS/SPMS versus RRMS/CIS. CONCLUSIONS: Opposing pathologic factors impact spinal cord volume measures in MS. Patients with PPMS demonstrated a trend toward upper cervical cord atrophy. However patients with RRMS showed a trend toward increased volume at the cervical and thoracic levels, which most likely reflects inflammation or edema-related cord expansion. With the disease causing both expansion and contraction of the cord, the specificity of spinal cord volume measures for neuroprotective therapeutic effect may be limited.

HLA B*44: protective effects in MS susceptibility and MRI outcome measures.

OBJECTIVE: In addition to the main multiple sclerosis (MS) major histocompatibility complex (MHC) risk allele (HLA DRB1*1501), investigations of the MHC have implicated several class I MHC loci (HLA A, HLA B, and HLA C) as potential independent MS susceptibility loci. Here, we evaluate the role of 3 putative protective alleles in MS: HLA A*02, HLA B*44, and HLA C*05. METHODS: Subjects include a clinic-based patient sample with a diagnosis of either MS or a clinically isolated syndrome (n = 532), compared to subjects in a bone marrow donor registry (n = 776). All subjects have 2-digit HLA data. Logistic regression was used to determine the independence of each allele's effect. We used linear regression and an additive model to test for correlation between an allele and MRI and clinical measures of disease course. RESULTS: After accounting for the effect of HLA DRB1*1501, both HLA A*02 and HLA B*44 are validated as susceptibility alleles (p(A*02) 0.00039 and p(B*44) 0.00092) and remain significantly associated with MS susceptibility in the presence of the other allele. Although A*02 is not associated with MS outcome measures, HLA B*44 demonstrates association with a better radiologic outcome both in terms of brain parenchymal fraction and T2 hyperintense lesion volume (p = 0.03 for each outcome). CONCLUSION: The MHC class I alleles HLA A*02 and HLA B*44 independently reduce susceptibility to MS, but only HLA B*44 appears to influence disease course, preserving brain volume and reducing the burden of T2 hyperintense lesions in subjects with MS.

Spinal cord lesions and clinical status in multiple sclerosis: A 1.5 T and 3 T MRI study.

OBJECTIVE: Assess the relationship between spinal cord T2 hyperintense lesions and clinical status in multiple sclerosis (MS) with 1.5 and 3 T MRI. METHODS: Whole cord T2-weighted fast spin-echo MRI was performed in 32 MS patients [Expanded Disability Status Scale (EDSS) score (mean+/-SD: 2+/-1.9), range 0-6.5]. Protocols at 1.5 T and 3 T were optimized and matched on voxel size. RESULTS: Moderate correlations were found between whole cord lesion volume and EDSS score at 1.5 T (r(s)=.36, p=0.04), but not at 3 T (r(s)=0.13, p=0.46). Pyramidal Functional System Score (FSS) correlated with thoracic T2 lesion number (r(s)=.46, p=0.01) and total spinal cord lesion number (r(s)=0.37, p=0.04) and volume (r(s)=0.37, p=0.04) at 1.5 T. Bowel/bladder FSS correlated with T2 lesion volume and number in the cervical, thoracic, and total spine at 1.5 T (r(s) 0.40-0.57, all p<0.05). These MRI-FSS correlations were non-significant at 3 T. However, these correlation coefficients did not differ significantly between platforms (Choi's test p>0.05). Correlations between whole cord lesion volume and timed 25-foot walk were non-significant at 1.5 T and 3 T (p>0.05). Lesion number and volume did not differ between MRI platforms in the MS group (p>0.05). CONCLUSIONS: Despite the use of higher field MRI strength, the link between spinal lesions and MS disability remains weak. The 1.5 T and 3 T protocols yielded similar results for many comparisons.

CTLA4Ig treatment in patients with multiple sclerosis: an open-label, phase 1 clinical trial.

BACKGROUND: The modulation of costimulatory pathways represents an original therapeutic approach to regulate T cell-mediated autoimmune diseases by preventing or reducing autoantigen-driven T-cell activation in humans. Autoreactive CD4(+) T cells play a critical role in initiating the immune response leading to the chronic inflammation and demyelination characteristic of multiple sclerosis (MS). METHODS: We used IV infusions of CTLA4Ig to block the CD28/B7 T-cell costimulatory pathway in a phase 1 dose-escalation study in MS. Sixteen patients with relapsing-remitting MS received a single CTLA4Ig infusion and were monitored for up to 3 months after treatment. In an extension study, four additional subjects received four doses of CTLA4Ig. RESULTS: CTLA4Ig was well tolerated in patients with MS, and most adverse events were rated as mild. Immunologic assessment of the patients showed a reduction in myelin basic protein (MBP) proliferation within 2 months of infusion and decreased interferon-gamma production by MBP-specific lines. CONCLUSIONS: Inhibiting costimulatory molecule interactions by using CTLA4Ig seems safe in multiple sclerosis (MS), and the immunologic effects suggest that it may be a promising approach to regulate the inflammatory process associated with MS.

HTLV-I-infected T cells evade the antiproliferative action of IFN-beta.

Human T-cell lymphotropic virus type I (HTLV-I)-infected T-cell clones enter the S-phase of the cell cycle in the absence of exogenous IL-2. The pathway by which HTLV-I activates the host T cell may circumvent normal immunoregulatory mechanisms and thus be important for the pathogenesis of HTLV-I-induced diseases. The early control of viral infections is in part mediated by interferons (IFNs), which possess both antiviral and antiproliferative functions. In order to investigate the antiproliferative effect of IFN-beta on HTLV-I-induced T-cell activation, we generated T-cell clones from patients with HTLV-I-associated myelopathy/tropical spastic paraparesis by single-cell cloning under limiting dilution conditions. Here we demonstrate that HTLV-I-induced T-cell proliferation is resistant to the antiproliferative action of IFN-beta. Moreover, HTLV-I-infected T-cell clones continue to constitutively secrete IFN-gamma in the presence of high doses of IFN-beta. HTLV-I-infected T cells express normal levels of IFNAR1 and are able to respond to IFN-beta by phosphorylation of STAT1 on Tyr701, although they display a relative increase in phosphorylation of the transcriptionally inactive STAT1beta when compared with STAT1alpha. Thus, HTLV-I promotes cell cycle progression in G1 by a mechanism that overcomes inhibitory signals, thereby circumventing an innate immune defense mechanism.

Direct analysis of viral-specific CD8+ T cells with soluble HLA-A2/Tax11-19 tetramer complexes in patients with human T cell lymphotropic virus-associated myelopathy.

Human T cell lymphotropic virus-I (HTLV-I)-associated myelopathy is a slowly progressive neurologic disease characterized by inflammatory infiltrates in the central nervous system accompanied by clonal expansion of HTLV-I-reactive CD8+ T-cells. In patients carrying the HLA-A2 allele, the immune response is primarily directed to the Tax11-19 peptide. The frequency, activation state, and TCR usage of HLA-A2/Tax11-19 binding T cells in patients with HTLV-I-associated myelopathy was determined using MHC class I tetramers loaded with the Tax11-19 peptide. Circulating Tax11-19-reactive T cells were found at very high frequencies, approaching 1:10 circulating CD8+ T cells. T cells binding HLA-A2/Tax11-19 consisted of heterogeneous populations expressing different chemokine receptors and the IL-2R beta-chain but not the IL-2R alpha-chain. Additionally, Tax11-19-reactive CD8+ T cells used one predominant TCR Vbeta-chain for the recognition of the HLA-A2/Tax11-19 complex. These data provide direct evidence for high frequencies of circulating Tax11-19-reactive CD8+ T cells in patients with HTLV-I-associated myelopathy.

HTLV-I-induced T-cell activation.

Infection by the human T-cell lymphotropic virus type I (HTLV-I) causes T-cell activation by at least two separate mechanisms. One mechanism involves activation of the T cells harboring the virus and is exemplified by in vivo infected nonimmortalized T-cell clones that display a prolonged state of activation. This HTLV-I-induced T-cell activation is inhibited by rapamycin, a drug that inhibits p70 S6-kinase and blocks cell cycle in G1, but is not inhibited by FK506 or cyclosporin A, both of which inhibit interleukin-2 (IL-2) production. The phenotype of this pathway is consistent with an hyperactive IL-2R pathway or CD28 pathway, indicating that HTLV-I may contribute a costimulatory signal to the infected T cell. As a separate mechanism, HTLV-I-infected T cells can induce activation of uninfected T cells via T-T-cell interaction mediated by the LFA-3-CD2 pathway. This may induce IL-2 production from the uninfected T cells, leading to a more generalized activation of the immune system that potentially could provide a basis for some of the diseases associated with HTLV-I. Moreover, this THTLV-I-T-cell interaction could explain the spontaneous proliferation observed in patients with HTLV-I-associated myelopathy/tropical spastic paraparesis.

Lack of JC viral genomic sequences in multiple sclerosis brain tissue by polymerase chain reaction.

With DNA extracted from brain specimens from 19 multiple sclerosis, 5 progressive multifocal leukoencephalopathy, 1 Alzheimer's disease, and 8 nonneurological control subjects, polymerase chain reaction was performed using nested sets of primer pairs amplifying segments of the large T and VP1 antigen-encoding sequences of JC virus. Both sequences were detected in each of the 5 brain specimens of progressive multifocal leukoencephalopathy but in none of the 19 multiple sclerosis, 1 Alzheimer's disease, or the 8 control brain specimens.

Belgrade virus: a new hantavirus causing severe hemorrhagic fever with renal syndrome in Yugoslavia.

Two biologically and genetically distinct hantaviruses were isolated from blood and urine specimens collected from four Yugoslavian patients with clinically severe hemorrhagic fever with renal syndrome (HFRS). Viral isolates from three patients, designated strains Belgrade 1-3, were distinct from Hantaan, Seoul, Puumala, and Prospect Hill viruses as determined by plaque-reduction neutralization tests and restriction analysis of enzymatically amplified M-segment fragments. The fourth isolate, called Kraljevo, was indistinguishable from Hantaan virus. Strains Belgrade 1 and 2, like the Kraljevo strain, caused a fatal meningoencephalitis in newborn mice inoculated with 100 pfu of virus intracerebrally and intraperitoneally. Strain Belgrade 3 was much less neurovirulent, requiring 30,000 pfu of virus to cause fatal disease in mice. These data indicate that two distinct hantaviruses, one of which constitutes a new serotype, cause clinically severe HFRS in Yugoslavia.

Blood donors with antibody to the human immunodeficiency virus--the Natal experience.

The major incursion of human immunodeficiency virus type I (HIV-1) infection into the South African heterosexual population has been by southerly migration of the heterosexual HIV-1 epidemic from central Africa. Much important information can be obtained from blood donor seroprevalence data and cohort studies of those individuals infected during the early stages of the epidemic in South Africa. By the end of April 1989, over half a million blood donors in Natal had been screened and the presence of antibody to HIV-1 confirmed in more than 200. The majority of these anti-HIV-1 positive donors are young and single (many of them still at school), although a substantial proportion already have children of their own and a recent history of sexually transmitted disease is common. The Natal Blood Transfusion Service experience indicates that the heterosexual HIV-1 epidemic in Natal is essentially no different from the earlier stages of heterosexual epidemics elsewhere in Africa. There is still time for effective programmes to have a major impact on progression of the epidemic in South Africa, particularly if these programmes are directed at the young population in educational institutions.

Immunocytochemical examination of bone marrow in disseminated neuroblastoma.

To assess the usefulness of immunocytochemical analysis of bone marrow in patients with neuroblastoma, marrow smears from 33 staging procedures in 12 patients were examined using an indirect immunoalkaline phosphatase technique with monoclonal antibodies raised against human neural tissue. Marrow aspirate and trephine collagenase digest specimens from individual sites were each tested with the monoclonal antibody UJ13A and with a pool of three related antibodies. The results were compared with morphological assessment of conventionally stained aspirates and trephine specimens taken at the same time. Immunostaining suggested the presence of tumour in seven of 18 staging procedures in which conventional techniques had shown infiltration. Tumour infiltration was also suggested in four of 10 staging procedures with suspicious trephine specimens, but in none of three with relatively innocent histological and cytological features. Immunological investigation provides no additional information about the presence of infiltration if conventional microscopy has shown definite tumour. When histological appearances are suspicious, immunostaining of stored aspirate smears or collagenase digest specimens may provide evidence of infiltration. There are insufficient data to comment on the value of immunostaining when conventional techniques reveal "normal" marrow, but the impression gained from this study is that immunostaining has a limited role in the detection of metastatic neuroblastoma, which yet remains to be defined.

Haematological differences in three population groups.

The increased absolute lymphocyte counts of Indians and Blacks in comparison with Whites, observed in a former study, were shown, in a study on blood donors, to occur in women rather than men of these two groups. Neutrophil counts showed no sex differences, but were significantly highest in Whites and lowest in Blacks. Indians of both sexes had significantly higher mean red cell counts, together with smaller red cells, than subjects in the other two groups. In no group was a significant correlation observed between body mass and haemoglobin level.

Computer simulation as a method for evaluating the copper sulfate test for hemoglobin in diverse populations.

The copper sulfate hemoglobin screening method was separately evaluated for three local population groups which do not conform to accepted normal standards of hemoglobin and/or plasma specific gravity (SG). This was carried out by a computer which simulated the distribution of plasma specific gravity and hemoglobin levels in random samples of blood donors. Simulations of 1,000 were carried out for males and for females in each of the three main population groups in Natal (Caucasians, Negroes and Asians). These were compared with a simulation of hypothetical normal subjects whose hemoglobin and plasma SG conformed to accepted standards. Variations in accuracy, relating to differences in plasma specific gravity and in hemoglobin, were demonstrated. Acceptances of donors who should be rejected (Type II errors) were most common in Negroes, but did not occur in the normal group. Type II errors did not occur in males with hemoglobin levels below 12.5 gm/dl or in females under 11.5 gm/dl. Erroneous rejections of prospective donors who, in fact, satisfied the criterion of acceptance (Type I errors) occurred in all groups, but were fewest in the normal group.

Notes on Mycobacterium Ulcerans.

A record is given of the events leading to the discovery, the cultivation, and the animal transmission of Mycobacterium ulcerans, the causative organism of the "Bairnsdale ulcer", together with a discussion on the possible animal hosts and vectors. It is suggested as a mailer of speculation that the insectivorous bats may be incriminated as the natural hosts, and that bed-bugs or related bugs, parasitic on bats, may be the vectors.