Significant dermatological side effects of intravenous immunoglobulin.

Intravenous immunoglobulin (IVIg) is an essential treatment for many neurological, immunological and haematological conditions. However, the severity of its rare adverse effects is often underrecognised. We report a series of 15 patients receiving IVIg for neurological and immunological disorders who developed severe skin reactions. Despite pre-medication, nearly all patients ceased IVIg due to the severity of the adverse response. Interestingly, the majority of patients were male and two-thirds were receiving treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) or another inflammatory or demyelinating neuropathy. This marked propensity for male patients with CIDP to develop significant dermatological reactions following IVIg administration has not previously been described. Mechanisms involving the underlying autoimmunity inherent to this condition may play a role.

Revisiting cerebral thromboangiitis obliterans.

We describe a 56-year-old patient with progressive cognitive decline in the context of heavy tobacco use and migraine, and imaging evidence of an occlusive terminal cerebral vasculopathy. The results of brain biopsy recapitulated the pathological features described by Lindenberg and Spatz in their classic 1939 treatise on cerebral thromboangiitis obliterans, or cerebral Buerger's disease. Although the condition is associated with heavy smoking, the identification of a hypercoagulable state in our patient suggests a multifactorial pathogenesis. The diagnosis of cerebral thromboangiitis obliterans in life is facilitated by modern neuroimaging and should prompt immediate cessation of smoking and a search for an underlying prothrombotic tendency.

Increased capacity for axonal outgrowth using xenogenic tissue in vitro and in a rodent model of Parkinson's disease.

BACKGROUND: It has previously been proposed that grafted neurons may have the potential for more extensive axonal outgrowth in a xenogenic environment, and may thus possess a primary advantage over allografts in central nervous system repair and circuit reconstruction. In order to directly address this issue, fibre outgrowth from primary dopaminergic neurons was examined both in vitro and in vivo in an allogenic or xenogenic environment. A combination of species was used to circumvent problems relating to different gestational/developmental periods for such cells. METHODS: In the in vitro experiments, axon length was measured over 2 to 14 days in cultures derived from either rat or mouse ventral mesencephalon (VM) tissue co-cultured onto either a monolayer of the rat Neu7 inhibitory cell line or fetal rodent cortical tissue. In the in vivo experiments, fetal rat or mouse VM tissue was transplanted into the striatum or substantia nigra of 6-hydroxydopamine-lesioned athymic rats. Amphetamine-induced rotations were observed for 3 months post-transplantation and the degree of graft-mediated neurite outgrowth was analyzed. RESULTS: Embryonic VM manifested a greater capacity for neurite formation and outgrowth on xenogenic tissue, which was shown to be significant using co-cultures of cortical cells. The transplantation study showed that xenograft-derived fibres had a greater capacity for extensive fibre projection compared with those originating from allografts. CONCLUSION: Results from the present study provide evidence for the hypothesis that xenografts are less responsive to inhibitory molecules present in the adult host environment and as such can project over great distances. Thus neural xenotransplantation may have the potential for more complete circuit reconstruction within the damaged host brain than equivalent allografted tissue.

Migration of cells from primary transplants of allo- and xenografted foetal striatal tissue in the adult rat brain.

Primary neural cells derived from human xenografts migrate extensively following transplantation into the adult rat CNS. However, it is unknown whether cells from allografts have the same capability to migrate within the adult rat brain. Moreover, it is unclear whether human-derived cells migrate to this extent as an inherent property of being in a xenograft environment, or whether it is due to the large size of the developed human brain compared with the adult rat brain. In order to address these issues we have designed an experimental paradigm to investigate the potential for cells derived from grafts of primary rat, mouse and human foetal striatal tissue to migrate following intrastriatal transplantation in an adult rat model of Huntington's disease (HD). Green fluorescent protein (GFP)-expressing rat and mouse donors and an antibody specific to human nuclear antigen enabled identification of graft-derived cells within the host brain, and double-labelling with GFP and neuronal nuclear antigen or immunostaining with human-specific tau identified graft-derived neurons. Twelve weeks post-transplantation, cells had migrated throughout the host in all groups; however, human cells and neurons had migrated significantly more than rat or mouse cells. These results demonstrate that neural cells derived from allografts are capable of migrating in the adult rat CNS and that the extent of migration is most likely determined by the size of the mature donor adult brain. This has important implications for the use of allo- and xenogeneic tissue as a source for transplantation in treating diffuse neurodegenerative disorders such as HD.

The use of the Actiwatch-Neurologica system to objectively assess the involuntary movements and sleep-wake activity in patients with mild-moderate Huntington's disease.

Huntington's disease (HD) is a neurodegenerative disorder characterised by cognitive, psychiatric and motor abnormalities including a range of involuntary movements. Currently, assessment of these movements involves the use of subjective rating scales such as the Unified Huntington's Disease Rating Scales (UHDRS) for bradykinesia and maximal dystonia and chorea, without any objective measures. As new therapies emerge, it is critical that an objective means of evaluating these abnormal movements is developed and we have investigated the use of a wrist-worn activity monitor, the Actiwatch-Neurologica, to determine whether these movements can be measured. In addition, this activity monitor and subjective reports were used to objectively measure the degree of sleep disruption in these same HD patients. Eight patients with mild-moderate HD and 8 age- and sex-matched control subjects wore the monitor for a period of 48 hours and recorded in a diary whether they were asleep or awake for each hour over the 2-day period. Assessment of various movement parameters revealed that HD patients exhibited significantly greater total and maximum activity levels and spent longer performing high acceleration movements while they were awake compared with controls. During sleep, patients not only showed significantly more activity and spent more time making high acceleration movements, but they also made significantly more movements than control subjects. These results demonstrate that the Actiwatch-Neurologica activity monitor can be used to objectively assess movements in HD patients during periods of high activity as well as during sleep.

Long-term hibernation of human fetal striatal tissue does not adversely affect its differentiation in vitro or graft survival: implications for clinical trials in Huntington's disease.

Transplantation of human fetal CNS tissue is a promising therapy for neurodegenerative conditions such as Huntington's disease (HD), but its widespread adoption is limited by restricted tissue availability. One method of overcoming this problem would be to store the tissue in hibernation medium, an approach that we reported previously for human fetal striatal tissue stored for up to 24 h. We now demonstrate the feasibility of storing such tissue for up to 8 days in hibernation medium. When either fresh or 8-day hibernated striatal cells were cultured under standard conditions for 4 days, the proportion of DARPP-32-positive neurons did not differ significantly, although the total number of cells was significantly less from tissue that had been hibernated. Six weeks after transplantation into cyclosporin A-immunosuppressed unilateral quinolinic acid-lesioned rats, there was no significant difference between fresh and hibernated grafts, both in terms of graft volume and extent of striatal phenotypic markers. This study therefore clearly demonstrates that hibernation of human fetal striatal tissue for up to 8 days is not deleterious to its differentiation in culture or survival following transplantation, and is therefore an appropriate method of storage for this tissue.

Neural cells from primary human striatal xenografts migrate extensively in the adult rat CNS.

Primary neural cells do not appear to migrate significantly following transplantation into the adult rodent CNS, which is in contrast to expanded neural precursor cells where migration is well-documented. However, most transplant studies of primary neural tissue have been performed in an allograft situation in which it is difficult to identify graft-derived cells. We have, therefore, used a xenograft paradigm to investigate the potential for cells derived from grafts of primary human fetal striatal tissue (gestational age of 66-72 days) to migrate following intrastriatal transplantation in an athymic adult rat model of Huntington's disease. The use of an antibody specific to human nuclear antigen enabled clear identification of graft-derived cells within the host brain, and specific neural phenotypes were determined using human-specific tau for neurons, glial fibrillary acidic protein for mature astrocytes and Ki67 for proliferative cells. At 6 weeks, the graft mass was very dense with a high proliferative index, few cells had migrated away from the graft, and the cells that had differentiated both within and away from the graft were mainly neurons. In contrast, at 6 months, the graft core was dispersed significantly more and a large number of graft-derived cells had migrated throughout the brain as far rostral as the olfactory bulb and as caudal as the substantia nigra. Cells had differentiated into both neurons and astrocytes and the level of proliferation was significantly lower within the graft. These results demonstrate that primary neural xenografts contain proliferative cells that possess the ability to migrate and differentiate into both neurons and astrocytes, and suggest that these cells could contribute to normal graft function. This property may be a consequence of the xenograft situation and could potentially be exploited to provide the opportunity to target regions of distant pathology in neurodegenerative diseases using xenotransplantation of embryonic neural tissue.

The potential for circuit reconstruction by expanded neural precursor cells explored through porcine xenografts in a rat model of Parkinson's disease.

Neural precursors with the properties of neural stem cells can be isolated from the developing brain, can be expanded in culture, and have been suggested as a potential source of cells for neuronal replacement therapies in degenerative disorders such as Parkinson's disease (PD). Under such conditions an improved spectrum of functional benefit may be obtained through homotypic reconstruction of degenerated neural circuitry, and to this end we have investigated the potential of expanded neural precursor cells (ENPs) to form long axonal projections following transplantation in the 6-hydroxydopamine-lesioned rat model of PD. ENPs have been isolated from the embryonic pig, since implantation in a xenograft environment is thought to favor axonal growth. These porcine ENPs possessed similar properties in vitro to those described in other species: they proliferated in response to epidermal and fibroblast growth factor-2, expressed the neuroepithelial marker nestin, and differentiated into neurons, astrocytes, and occasional oligodendrocytes on mitogen withdrawal. The use of pig-specific markers following xenotransplantion into cyclosporin A-immunosuppressed rats revealed that many cells differentiated into neurons and displayed extensive axogenesis, such that when placed in the region of the substantia nigra fibers projected throughout the striatal neuropil. These neurons were not restricted in the targets to which they could project since following intrastriatal grafting fibers were seen in the normal striatal targets of the pallidum and substantia nigra. Staining for a pig-specific synaptic marker suggested that synapses were formed in these distant sites. A small number of these cells differentiated spontaneously to express a catecholaminergic phenotype, but were insufficient to mediate behavioral recovery. Our results suggest that when the efficiency of neurochemical phenotype induction is increased, ENP-derived neurons have the potential to be a uniquely flexible source of cells for therapeutic cell replacement where anatomical reconstruction is advantageous.