Axonal TDP-43 aggregates in sporadic amyotrophic lateral sclerosis.

AIMS: Axonal aggregates of phosphorylated (p-) transactive response DNA-binding protein 43 kDa (TDP-43) in sporadic amyotrophic lateral sclerosis (sALS) were examined in relation to propagation of the protein in the nervous system. METHODS: Brains and spinal cords of Japanese patients with sALS and control subjects were examined immunohistochemically using formalin-fixed paraffin-embedded specimens with special reference to the topographical distribution, microscopic features, presynaptic aggregates, and correlation between the aggregates in axons and the clinical course. RESULTS: (i) Aggregates of p-TDP-43 were frequently present in axons of the hypoglossal and facial nerve fibres and the spinal anterior horn cells. (ii) Aggregates of p-TDP-43 in the axons showed two characteristic microscopic features - dash-like granuloreticular aggregates (GRAs) and massive aggregates (MAs). (iii) MAs were surrounded by p-neurofilaments, but p-neurofilament immunnoreactivity decreased at the inside of axons with GRAs. (iv) Patients showing MAs and GRAs had a relatively shorter clinical course than patients without the aggregates. (v) Some neurones in the red nucleus in patients were surrounded by synapses containing p- and p-independent (i)-TDP-43, and almost all neurones had lost their nuclear TDP-43 immunoreactivity; 17% of those neurones in the red nucleus also had TDP-43-immunopositive neuronal cytoplasmic inclusions, but no postsynaptic p-TDP-43 deposition was evident. CONCLUSIONS: There are two types of axonal p-TDP-43 aggregates, MAs and GRAs, located predominantly in the facial and hypoglossal nuclei and anterior horn cells. These aggregates may influence the function of neurones, and presynaptic aggregates of the protein induce loss of p-i-TDP-43 in the nuclei of postsynaptic neurones.

Serological evidence that Mus musculus is the natural host of Theiler's murine encephalomyelitis virus.

Theiler's murine encephalomyelitis virus (TMEV) infection is maintained in mouse colonies by fecal-oral spread (with no apparent role for persistent central nervous system infection) from an acutely infected animal to another. Therefore, serological methods offer the principal way to assess infection in mice and related rodent populations. Infection of mouse colonies with TMEV appears to be worldwide, yet no systematic serologic studies have been reported. In this study, enzyme-linked immunoassay and neutralization analysis of sera from feral Mus musculus obtained from four locations in the United States and one in Russia revealed antibodies to purified TMEV and two linear viral peptide epitopes in more than 50% of the sera derived from the five different locations. A similar analysis of sera from 26 species of related rodents trapped at multiple locations in North America and Europe indicated the presence of anti-TMEV antibodies only in a small proportion of water and bank voles that belong to a different subfamily. These results indicate that Mus musculus is the natural host of TMEV.

Recurrent steroid-responsive trismus and painful ophthalmoplegia.

A 63-year-old woman experienced two episodes of trismus and painful ophthalmoplegia at an interval of six years. She suffered left visual loss, and enhanced CT scan and MR imaging revealed heterogeneous enlargement of the left extraocular muscles extending to the orbital apex. In addition, the left pterygopalatine fossa was filled with a mass isointense with muscle without evidence of surrounding tissue invasion; 67Ga scintigraphy showed high uptake in this lesion. Steroid administration dramatically resolved the trismus, and the mass in the orbit and extraorbit vanished completely. Orbital pseudotumor is characterized by self-limited, relapsing, steroid-responsive painful ophthalmoplegia, and this case could be a variant of this entity with inflammation extending into the extraorbital area.

Persistent hemiballism with striatal hyperintensity on T1-weighted MRI in a diabetic patient: a 6-year follow-up study.

The combination of hemiballism, hyperglycemia and hyperintensity of the striatum on T1-weighted MRI constitutes a unique syndrome. We report the follow-up of a patient with this disorder whose hemiballism was sustained for over 5 years. High density on CT of the right striatum turned into normodensity in 4 months, and hyperintensity on T1-weighted MRI and hypointensity on T2-weighted MRI of the lesion were resolved in 18 months. A decreased perfusion of the lesion by SPECT remained 37 months after onset. There was no volume change of the lesion during the course of the illness. The radiological features support the possible pathology of either or both petechial hemorrhage and astrocytosis with high protein concentration after ischemic insult. The hemiballism may result from selective damage of GABA/enkephalin-containing neurons in the striatum and can persist without the primary histological changes causing the striatal T1-hyperintensity in this disorder.

[Two cases with chronic inflammatory demyelinating polyneuropathy showing high signal and enlargement of the brachial plexus in short TI inversion recovery of MRI].

We reported valuable MRI findings of the brachial plexus seen in two cases with chronic inflammatory demyelinating polyneuropathy (CIDP). Case 1 was a 44-year-old man who developed slowly progressive weakness and atrophy of the extremities with no sensory disturbances. Studies of CSF showed a normal level of protein and no increase of cell counts but nerve conduction studies demonstrated a significant conduction block between the axilla and the elbow in the right ulnar nerve. Case 2 was a 34-year-old male who had been suffering from distal limb weakness and sensory disturbance. Protein content in CSF was markedly elevated without pleocytosis, and nerve conduction studies revealed a conduction block between the elbow and the wrist in the right ulnar nerve. He received corticosteroid therapy, resulting in a good recovery. Brachial plexus in both cases showed enlargement with marked high signal on short TI inversion recovery (STIR) of MRI. STIR is a fat suppressed T2 weighted image and this technique is known to be useful to identify the morphology of peripheral nerve tissues. CIDP is one form of hypertrophic neuritis and the MRI findings seen in these two cases strongly support the diagnosis of CIDP.

Suppressive effect on Theiler's murine encephalomyelitis virus-induced demyelinating disease by the administration of anti-IL-12 antibody.

We examined the role of IL-12, a cytokine critical to the evolution of cellular responses, in the development of Theiler's murine encephalomyelitis virus-induced demyelinating disease (TMEV-IDD). Treatment with mAbs to IL-12, especially during the effector phase, resulted in significant suppression of the development of this disease both clinically and histologically. In mice treated with these mAbs, the production of inflammatory and Th1-derived cytokines such as TNF-alpha and IFN-gamma in the spleen cells was decreased, and that of Th2-derived cytokines such as IL-4 and IL-10 was increased. The delayed type hypersensitivity and T cell proliferative response specific for TMEV were decreased by this treatment. These data suggest that IL-12 is critically involved in the pathogenesis of TMEV-IDD and that Abs to IL-12 could be a novel therapeutic approach in the clinical treatment of demyelinating diseases such as human multiple sclerosis.

Role of individual T-cell epitopes of Theiler's virus in the pathogenesis of demyelination correlates with the ability to induce a Th1 response.

Intracerebral inoculation of susceptible strains of mice with Theiler's murine encephalomyelitis virus (TMEV) results in immune-mediated demyelination. Three major T-cell epitopes have previously been identified within the VP1 (VP1233-250), VP2 (VP274-86), and VP3 (VP324-37) capsid proteins in virus-infected SJL/J mice. These epitopes appear to account for the majority ( approximately 90%) of major histocompatibility complex class II-restricted T-cell responses to TMEV. Interestingly, the effect of immunization with synthetic peptides bearing the predominant T-cell epitopes on the course of TMEV-induced demyelination indicates that T cells reactive to the VP1 and VP2 epitopes, but not VP3, accelerate the pathogenesis of demyelination. The predominant pathogenic role of the T cells is verified by similar immunization with the fusion proteins containing the entire individual capsid proteins. The order of appearance and level of T cells specific for the individual epitopes during the course of demyelination are similar to each other. However, cytokine profiles of T cells from virus-infected mice indicate that T cells specific for the VP1 (and perhaps the VP2) epitope are Th1, whereas T cells reactive to VP3 are primarily Th2. These results suggest that Th1-type cells specific for VP1 and VP2 are involved in the pathogenesis of viral demyelination induced by TMEV. Thus, a predominance of Th1-inducing viral epitopes is likely critical for the pathogenesis of demyelination.

Major linear antibody epitopes and capsid proteins differentially induce protective immunity against Theiler's virus-induced demyelinating disease.

Theiler's murine encephalomyelitis virus-induced immunologically mediated demyelinating disease (TMEV-IDD) in susceptible mice provides a relevant infectious model for multiple sclerosis. Previously, we have identified six major linear antibody epitopes on the viral capsid proteins. In this study, we utilized fusion proteins containing individual capsid proteins and synthetic peptides containing the linear antibody epitopes to determine the potential role of antibody response in the course of virus-induced demyelination. Preimmunization of susceptible mice with VPI and VP2 fusion proteins, but not VP3, resulted in the protection from subsequent development of TMEV-IDD. Mice free of clinical symptoms following preimmunizations with fusion proteins displayed high levels of antibodies to the capsid proteins corresponding to the immunogens. In contrast, the level of antibodies to a particular linear epitope, A1C (VP1(262-276)), capable of efficiently neutralizing virus in vitro increased with the progression of disease. Further immunization with synthetic peptides containing individual antibody epitopes indicated that antibodies to the epitopes are differentially effective in protecting from virus-induced demyelination. Taken together, these results suggest that antibodies to only certain linear epitopes are protective and such protection may be restricted during the early stages of viral infection.

Ictal muscle discharge pattern and SPECT in paroxysmal kinesigenic choreoathetosis.

We studied the pattern of muscle activity of the limbs during attacks and measured post-ictal regional cerebral blood flow (rCBF) in 3 patients with paroxysmal kinesigenic choreoathetosis (PKC). During attacks, a "Jacksonian march" pattern of tonic muscle activity in the limbs was observed. Two of 3 patients, who suffered from unilateral attacks, showed a noticeable increase in rCBF in the basal ganglia on the contralateral side of the attacks. Treatment with phenytoin improved symptoms and reduced the difference in rCBF between the right and left side. These observations suggest that abnormal hyperactivity of neurons in the basal ganglia may cause choreoathetotic movements in patients with PKC.

The level of tumor necrosis factor-alpha producing cells in the spinal cord correlates with the degree of Theiler's murine encephalomyelitis virus-induced demyelinating disease.

The levels of tumor necrosis factor (TNF)-alpha producing cells were analyzed in mice with Theiler's murine encephalomyelitis virus-induced demyelinating disease (TMEV-IDD). Using an ELISPOT assay, we demonstrate an increase in TNF-alpha producing cells in the spinal cords of TMEV-infected SJL/J mice, especially at an active disease stage. The numbers of TNF-alpha producing cells were extremely high in susceptible SJL/J mice compared with the numbers in resistant BALB/c and C57BL/6 mice. TNF-alpha producing cells were also immunohistochemically identified in active lesions of TMEV-IDD at acute as well as chronic stages. The percentage of TNF-alpha producing cells compared with the total number of cells isolated from spinal cords was higher in TMEV-infected SJL/J mice than resistant BALB/c and C57BL/6 mice. Correspondingly, the level of TNF-alpha was much higher in the culture supernatants of both infiltrating cells in the spinal cords and spleen cells from clinically affected animals than that from similarly treated resistant mice. Treatment of virus-infected mice with a mAb specific for TNF-alpha at the beginning of the onset of disease suppressed the development of the demyelinating disease. These findings suggest that TNF-alpha may play an important role in the pathogenicity of TMEV-IDD.

[A study on the pathogenesis of hepatomegaly in patients with Crow-Fukase syndrome].

We studied pathogenesis of hepatomegaly in Crow-Fukase syndrome. Hepatocytes were isolated from BALB/c mice and cultured with serum or ascites of three patients with Crow-Fukase syndrome. After 24 hours culture, total number of hepatocytes was counted. The levels of human hepatocyte growth factor (h-HGF) in the serum were also measured. In the hepatocyte culture study, the numbers of hepatocytes after 24 hours cultured in the serum of two patients were significantly larger than those of the control group. When the hepatocytes were cultured with patients' serum after corticosteroid therapy, the survival numbers were markedly reduced. The serum levels of h-HGF in our three patients were 0.62, 0.52, 0.53 ng/ml respectively. They were all slightly higher than normal values (< or = 0.39 ng/ml). Our study indicates that in the serum or ascites of patients with Crow-Fukase syndrome, there may be some humoral factors other than h-HGF, which promote proliferation of hepatocyte or protect hepatocyte.

[The detection of factors that may promote the hepatocyte proliferation in the serum of a patient with crow-fukase syndrome].

We reported a case of Crow-Fukase syndrome and examined the mechanism of hepatomegaly in Crow-Fukase syndrome. A 67-year-old woman was presented with polyneruopathy, hepatosplenomegaly, pericardial effusion and M proteinemia. On examination, all laboratory data and clinical symptoms were compatible with Crow-Fukase syndrome. The patient was treated with prednisolone and immunoadsorption plasmaphresis therapy. All the clinical manifestations including hepatomegaly gradually improved. In order to examine whether some factors that promote the prolifelation of hepatocyte may exist in the patient's serum, we cultured mouse hepatocyte in the presence of patient's or control serum together. Though the number of hepatocytes decreased after 2 days culture, the number of hepatocytes cultured with patient's serum in active disease stage remained significantly greater than of hepatocytes cultured with either control serum or patient's serum in healing stage. There were no abnormal pathological findings in biopsied liver. Liver suggesting that hepatomegaly was the results of normal hepatocytes proliferation. Taken together, these findings suggest there were some factors that may promote the proliferation of hepatocytes or may have protective effect of hepatocyte in patient's serum. Though the level of human hepatocyte growth factor (h-HGF) in patient's serum in active disease stage was slightly increased, hepatomegaly cannot be attributable solely to h-HGF. Organomegaly is one of the important symptoms of the Crow-Fukase syndrome, however, in so far as we are aware its mechanism is not examined. In this report it is suggested that several unknown factors other than h-HGF may contribute the hepatomegaly of the Crow-Fukase syndrome.

[A patient with a relapse of myasthenia gravis after a 13-year remission following successful treatment by mediastinal irradiation and corticosteroid therapy].

We report a patient with myasthenia gravis who experienced a relapse 13 years after apparently successful treatment by mediastinal irradiation and corticosteroid therapy. A 20-year-old male was admitted to Shinshu University Hospital with a chief complain double vision and drooping eyelids. These symptoms had appeared 2 months prior to admission. They tended to be more severe late in the day, and varied from day to day. Prior to this admission the patient had been healthy for the 13 years since undergoing 45-Gy mediastinal irradiation and corticosteroid therapy. MRI and CT studies revealed no thymic hyperplasia. Total thymectomy was performed, and his myasthenic symptoms, including the opthalmoplegia, improved. Histological examination of the resected thymus revealed an active thymus with germinal centers. Immunohistological studies showed an abundance of intracellular adhesion molecule-1 (ICAM-1) in the germinal centers and thymic medullary epithelium, and the presence of lymphoid function-associated antigen-1 (LFA-1) in thymic lymphocytes. ICAM-1 and LFA-1 are ligand of adhesion molecules which interact with each other and play an important role in antigen presentation. Acetylcholine receptor (ACh-R) antigen is known to be present in the thymus. The presence of both ICAM-1 and LFA-1 in the active thymus in this patient suggests that these adhesion molecules may have a role in ACh-R antigen presentation, causing myasthenia. These findings suggest that patients with myasthenia gravis who do not undergo total thymectomy have a risk of recurrence, even after long-term remission.

[Characterization of infiltrating mononuclear cells in the spinal cords of Lewis rats with experimental autoimmune encephalomyelitis (EAE)].

Mononuclear cells (MNCs) infiltrating in spinal cords (SCs) of Lewis rats with EAE were isolated in order to permit flow cytometric (FCM) analysis of these cell populations, using monoclonal antibody to T cell, CD4, CD8. MHC class II antigen (Ia), intercellular adhesion molecule-1 (ICAM-1) and lymphocyte function associated antigen-1 (LFA-1). The number of MNCs isolated from SC varied from 5 to 620 x 10(4). They were increased and reached a peak on day 2 post clinical onset, and subsequently declined through the clinical course. The increase of infiltrating cells in SC paralleled the severity of the disease development. The surface phenotypes of MNCs from rats on the day of clinical onset were determined by flow cytometry. The phenotypes found in these rats were as follows: T cells (70.3%); CD4 + (58.3%); CD8 + (40.3%); Ia (51.9%); ICAM-1 (62.6%); LFA-1 (75.8%). These findings suggest that high proportion of ICMA-1 and LFA-1 expression may be important in antigen presentation in the inflammatory lesions of SC and in promoting lymphocyte extravasation across the blood-brain barrier during the disease. The approach we employed offered more sophisticated and quantitative analysis of CNS inflammatory cells, which is unobtainable by tissue section staining.

Hemiballism with striatal hyperintensity on T1-weighted MRI in diabetic patients: a unique syndrome.

We report 3 diabetic patients who developed hemiballism without involvement of the subthalamic nucleus. Each patient exhibited vigorous, flinging, ballistic involuntary movements in the extremities and slight facial grimacing involving one side of the body. Although diabetes was poorly controlled in all 3, each patient was nonketotic at the onset of hemiballism. Magnetic resonance imaging (MRI), in these patients showed abnormalities in the striatum contralateral to the hemiballism that were characterized by an increase in intensity on T1-weighted images and a slight decrease in intensity on T2-weighted images, and these changes persisted for more than 2 months. The striatal lesions are presumed to have developed following mild ischemia in the territory of the lateral striate branches of the middle cerebral artery. This combination of hemiballism and striatal lesions in diabetic patients may constitute a unique syndrome.

[A pathogenic study of chronic inflammatory demyelinating polyradiculoneuropathy in a patient with hepatitis B infection].

We immunologically examined the pathogenesis of chronic inflammatory demyelinating polyradiculoneuropathy in a patient with HB hepatitis. A 41-year-old male clerk has been suffered from muscle weakness, tingling and numbness in the distal portion of all limbs. All symptoms were compatible with the typical patterns of chronic inflammatory demyelinating polyradiculoneuropathy. We examined the patient's serum and biopsied sural nerve, using histochemical and immunological techniques. We detected the band that reacted with anti-HBs antibody in the sural nerve in western blotting. The result indicated that HBs antigen was expressed on the peripheral nerves in the patient. There were no anti-peripheral nerve antibodies neither in the sural nerve or serum. There was no increase of immune complex in the serum. No deposition of immunoglobulins and complements were detected in the sural nerve. Immunoadsorption therapy had no effect on this patient, but administration of prednisolone improved his symptoms drastically. These findings suggest that a cytotoxic T cell may had played a more important role than humoral factors in this patient's nerve injury. Though the pathogenesis of chronic inflammatory demyelinating polyradiculoneuropathy remains unclear, our findings seem to be very interesting in that they go some way toward clarifying the pathogenesis of this disease.

Fatal and near fatal asthma.

Despite the recent development of apparently effective asthma drugs, the number of deaths from asthma has not declined. The authors tried to establish an optimal strategy for the prevention of acute asthmatic death by analyzing the circumstances of acute fatal or near-fatal asthma. Data were collected from 51 adult patients admitted to Bokutoh Tertiary Emergency Center due to acute asthma between November 1985 and May 1990 and 38 asthmatic patients admitted to Yokohama City Hospital in 1990. Pre-admission data were obtained through interviews with the patients, their families, or doctors who had seen them. A total of 89 patients were classified into three subgroups: group 1 consisted of patients dead-on-arrival (DOA); group 2, non-DOA patients with disturbed consciousness; and group 3, patients with less severe episodes. Little background information was significantly different among groups, but symptomatic episodes in group 1 patients tended to occur more rapidly. The speed of onset of the episodes was also dependent on the asthma control status. Prehospital care of groups 1 and 2 patients was very poor despite severity of the symptoms. All patients in groups 2 and 3 were successfully treated and discharged, but five of the 26 patients in group 2 died during follow-up periods. Prognosis of patients after discharge appeared to be dependent upon asthma control status before the acute episodes. It was concluded that acute fatal or near fatal asthma could occur in apparently low-risk patients as well as high-risk ones. It was also suggested that the optimal strategy for preventing asthma deaths might be variable.