Intrathecal catheter-associated inflammatory mass in a neurofibromatosis type-1 patient receiving fentanyl and bupivacaine.

BACKGROUND: Catheter-associated inflammatory masses (CIMs) are a rare but serious complication of intrathecal drug delivery devices. CIM formation is influenced by local medication concentration, which is determined in part by flow dynamics at the catheter tip. Underlying spinal pathologies, such as neoplasms, may alter flow at the catheter tip, thereby contributing to CIM formation. Moreover, they may also complicate the clinical and radiologic diagnosis of a CIM. CASE DESCRIPTION: A 36-year-old man with neurofibromatosis type 1 presented to our emergency department with complaints of increased back pain and leg weakness. To treat pain secondary to his multiple spinal masses, he had previously undergone placement of an implantable drug delivery system, which infused a compounded drug of fentanyl and bupivacaine. Imaging studies depicted numerous masses consistent with neurofibromatosis, including a compressive mass located circumferentially at the porous catheter terminus and proximal to the catheter tip. Surgical removal of this mass was performed; pathologic findings were consistent with a catheter tip granuloma. CONCLUSIONS: In the described case, CIM formation likely resulted from a combination of, 1) an unusually high fentanyl concentration, and, 2) altered infusate flow due to spinal neurofibromas. Consideration of underlying spinal pathologies, particularly mass lesions, is critical to the management of intrathecal drug delivery devices.

Abscess Formation in a Nonfunctioning Pituitary Adenoma.

BACKGROUND: Pituitary abscesses are rare clinical entities that can occur in the setting of a normal gland or underlying disease, including adenoma, craniopharyngioma, or Rathke cleft cyst. Although once believed to be indolent, when these secondary abscesses occur in the setting of an adenoma, they can be associated with significant clinical morbidity. Most patients present with visual disturbances or headache without fever or meningitis. CASE DESCRIPTION: We present the case of a 63-year-old woman with remote history of Staphylococcus osteomyelitis who presented with 1 week of diplopia, partial left third nerve palsy, and bitemporal hemianopsia who was found to have a pituitary abscess in the setting of an adenoma. She underwent drainage of the abscess and resection of her adenoma followed by complete resolution of her symptoms. CONCLUSIONS: This case highlights the need for prompt treatment of pituitary abscesses, with the possibility of excellent neurologic recovery.

Analytical and clinical performance characteristics of the Simplexa BK virus quantitative PCR assay for the diagnosis of polyomavirus-associated nephropathy in renal transplant recipients using plasma and urine specimens.

BACKGROUND: Polyomavirus-associated nephropathy is a significant cause of kidney rejection in renal transplant recipients. Quantification of BK viral load in plasma and urine can predict the development of polyomavirus-associated nephropathy, though each assay requires careful evaluation of analytical and clinical performance characteristics for optimal use. OBJECTIVES: This study evaluated the analytical and clinical performance characteristics of the Simplexa BK virus quantitative PCR assay. STUDY DESIGN: Analytical validation was performed using commercial standards, BK virus stock culture, and patient specimens. Clinical performance was evaluated using biopsy-proven BK nephropathy as the gold standard. RESULTS: The Simplexa BK virus quantitative PCR assay was linear over a range of 2.7-10.4 log(10) copies/mL. Limit of detection was 2.7-2.8 log(10) copies/mL in plasma and urine samples. Sensitivities were 100% and 100% and specificities were 84% and 86% for plasma and urine samples, respectively, when compared to a reference BK assay. Clinical cutoff values of 4.0 log(10) copies/mL (plasma) and 7.5 log(10) copies/mL (urine) yielded 100% sensitivity and specificities of 87.5% and 85%, respectively, for biopsy-proven polyomavirus nephropathy. CONCLUSIONS: The Simplexa BK virus quantitative PCR assay has high sensitivity and acceptable analytical characteristics for clinical use. The clinical cutoff values presented here provide a rational approach to the monitoring and treatment of renal transplant recipients for polyomavirus-associated nephropathy.

Early dysregulation of cripto-1 and immunomodulatory genes in the cerebral cortex in a macaque model of neuroAIDS.

Human immunodeficiency virus type 1 (HIV-1) and related primate lentiviruses are known to enter the central nervous system (CNS) during the primary phase of infection. Neuroinvasion by simian immunodeficiency virus and simian human immunodeficiency virus (SHIV) is characterized by transient meningitis and astrocytosis. In this report, we used targeted cytokine cDNA arrays to analyze cortical brain tissue from four pig-tailed macaques inoculated for 2 weeks with pathogenic SHIV(50OLNV) and a normal age-matched pig-tailed macaque. Our results revealed that eight genes were significantly upregulated in all four macaques. These included: leukocyte interferon inducible peptide, corticotrophin releasing factor receptor 1, interleukin 6, CDW40 antigen, cysteine-rich fibroblast growth factor, neurotrophin 3, ciliary neurotrophin factor receptor and cripto-1. The upregulation of three of these genes was confirmed by reverse transcriptase PCR (RT-PCR). Since cripto-1 had not been previously identified within specific cell types within the primate central nervous system, we performed immunohistochemical studies, which revealed the presence of cripto-1 in neurons. RT-PCR studies demonstrated that cripto-1 mRNA was widely expressed in the CNS. These results indicate that immunomodulatory genes are upregulated during the primary phase of infection of the central nervous system. Cripto-1, which acts as a survival factor in tumor cells and may be neuroprotective, is expressed in neurons within the CNS and is upregulated during viral invasion.

Serotonin in trigeminal ganglia of female rodents: relevance to menstrual migraine.

OBJECTIVES: We examined changes in the serotonin system across the estrous cycle in trigeminal ganglia of female rodents to determine which components are present and which are regulated by the variations in levels of ovarian steroids that occur during the estrous cycle. BACKGROUND: Migraine is 2-3 times more prevalent in women than in men and attacks are often timed with the menstrual cycle, suggesting a mechanistic link with ovarian steroids. Serotonin has been implicated in the pathogenesis of migraine, and the effectiveness of triptans, selective 5HT-1B/D/F agonists, has provided further support for this concept. It is not known whether serotonin, its rate-limiting enzyme tryptophan hydroxylase (TPH), or its receptors are regulated by ovarian steroids in trigeminal ganglia. METHODS: We used reverse transcription-polymerase chain reaction to examine gene expression in cycling mice, Western blots to examine protein expression, double-labeling immunohistochemistry using markers of nociceptors and nonnociceptors and confocal microscopy to identify specific types of neurons, and primary tissue culture to examine effects of estrogen on trigeminal neurons in vitro. RESULTS: In C57/BL6 mice mRNA levels of TPH-1, the rate-limiting enzyme in serotonin synthesis, were over 2-fold higher and protein levels were 1.4-fold higher at proestrus, the high estrogen stage of the cycle than at diestrus, the low estrogen stage. TPH protein also was present in primary trigeminal cultures obtained from female Sprague-Dawley rats, but levels were not affected by 24-hour treatment with physiological levels (10(-9) M) of 17beta-estradiol. Gene expression of 5HT-1B and 5HT-1D receptors in trigeminal ganglia was not regulated by the estrous cycle. Serotonin was present in trigeminal neurons containing CGRP, a potent vasoactive neuropeptide, peripherin, an intermediate filament present in neurons with unmyelinated axons, neurofilament H, which is present in neurons with myelinated axons, and in neurons binding IB4, a marker of nonpeptidergic nociceptors. Serotonin was also present in neurons containing 5HT-1B. The serotonin-positive population was significantly larger in diameter than the serotonin-negative population. Conclusions.-Expression of the rate-limiting enzyme required for serotonin synthesis is regulated during the natural estrous cycle, and serotonin is present in larger trigeminal neurons of all the major subtypes. Colocalization of serotonin with 5HT-1B suggests that this receptor functions as an autoreceptor to regulate serotonin release. Cyclical changes in serotonin levels in trigeminal ganglia could contribute to the pathogenesis of menstrual migraine.

Altered expression of pro-inflammatory and developmental genes in the fetal brain in a mouse model of maternal infection.

Human studies of unexplained cerebral palsy (CP) suggest an association with maternal infection. We used an established model of maternal infection, lipopolysaccharide (LPS) administration, to investigate the molecular changes in the fetal brain that may link maternal infection and CP. We compared gene expression in brains from mouse pups exposed to LPS in utero to those from saline-treated controls. Dams were injected with 50 microg LPS or saline on E18 with surgical delivery from 0.5 to 6h later. Differential gene expression was analyzed in the whole mouse brain using RT-PCR. When compared to control mice, pups exposed to LPS showed increased expression of pro-inflammatory genes monocyte chemoattractant protein-1 (MCP-1), interleukin-6 (IL-6), and interleukin-1beta (IL-1beta), as well as VEGF, a regulator of vascular development and permeability, the anti-apoptotic protein Y-box-binding protein-1 (YB-1), and the neuronal differentiation factor necdin. LPS-exposed mice also showed downregulation of semaphorin 5b and groucho, involved in axon guidance and neurogenesis, respectively, providing evidence that LPS may disrupt normal developmental pathways. These data suggest possible mechanisms for adverse neurological outcomes following maternal infection involving elevated cytokine levels and altered expression of developmental genes in the fetal brain.

Ovarian steroids regulate neuropeptides in the trigeminal ganglion.

Women are more than three times as likely as men to experience migraine headaches and temporomandibular joint pain, and painful episodes are often linked to the menstrual cycle. To understand how hormone levels may influence head and face pain, we assessed expression of pain-associated neuropeptides and estrogen receptor alpha (ERalpha) during the natural estrous cycle in mice. Gene expression was analyzed in the trigeminal ganglia of cycling female mice at proestrus, estrus and diestrus using RT-PCR. Peptide/protein expression in trigeminal neurons was analyzed using immunohistochemistry. ERalpha mRNA was present at all stages and highest at estrus. ERalpha protein was present in the cytoplasm of medium-sized and small trigeminal neurons. ERalpha immunoreactive neurons were most common at diestrus. CGRP and ANP mRNAs did not change across the estrous cycle, while expression of galanin and NPY mRNAs were strongly linked to the estrous cycle. Galanin mRNA levels peaked at proestrus, when expression was 8.7-fold higher than the diestrus levels. Galanin immunoreactivity also peaked at proestrus. At proestrus, 7.5% of trigeminal neurons contained galanin, while at estrus, 6.2% of trigeminal neurons contained galanin, and at diestrus, 4.9% of trigeminal neurons contained galanin. NPY mRNA peaked at estrus, when levels were 4.7-fold higher than at diestrus. Our findings suggest that estrogen receptors in trigeminal neurons modulate nociceptive responses through effects on galanin and NPY. Variations in neuropeptide content in trigeminal neurons across the natural estrous cycle may contribute to increases in painful episodes at particular phases of the menstrual cycle.

Response of the brain to oligemia: gene expression, c-Fos, and Nrf2 localization.

Oligemia is blood flow reduction without acute tissue damage that occurs in shock, migraine, and stroke penumbra. We developed a mouse model of oligemia by lowering mean arterial pressure to 30-40 mm Hg, resulting in a 50% reduction in cerebral blood flow as measured by laser Doppler, and reperfusing the blood after 30 min. Control experiments included anesthesia-only and surgery without blood withdrawal. Using immunohistochemistry, we localized the transcription factors Nrf2, which regulates expression of antioxidant and detoxification protein, and c-Fos, a marker of neuronal activation. Nrf2 was found only in oligemia mice and was localized in neurons of the cingulate cortex and cerebellar Purkinje cells. By contrast, c-Fos was found widely expressed in both groups and was localized in neurons in regions associated with response to stress, immunomodulation, and fluid homeostasis, including the periaqueductal gray and periventricular nucleus. These data indicate that c-Fos expression occurs as a result of surgical stress, but Nrf-2 upregulation is specific to oligemia. The CLONTECH Atlas 1.2 Mouse Array was used to assess genes that were up or down-regulated in oligemia versus surgery controls. Of 1176 genes, 29 differed between oligemia and surgery groups. Upregulation of oxidative stress induced (OSI) protein, heat shock protein (HSP) 84 and transthyretin (TTR) precursor in the oligemia group was confirmed with RT-PCR. The expression of HSP 84, transthyretin precursor, and OSI genes adds further evidence that oligemia induces an oxidative stress response in the brain.