Ophthalmic presentation of giant cell arteritis in African-Americans.

PurposeTo determine the differences in the presentation of ophthalmic giant cell arteritis between African-Americans and Caucasians.MethodsThis was a multicenter retrospective case series comparing African-American patients with ophthalmic GCA to a previously published Caucasian cohort. Neuro-ophthalmic centers across the United States were contacted to provide data on African-American patients with biopsy-proven ophthalmic giant cell arteritis. The differences between African-American and Caucasian patients with respect to multiple variables, including age, sex, systemic and ophthalmic signs and symptoms, ocular ischemic lesions, and laboratory results were studied.ResultsThe Caucasian cohort was slightly older (mean=76.1 years) than the African-American cohort (mean=72.6 years, P=0.03), and there was no difference in sex distribution between the two cohorts. Headache, neck pain, and anemia were more frequent, while jaw claudication was less frequent in African-Americans (P<0.01, <0.001, 0.02, and 0.03 respectively). Acute vision loss was the most common presentation of giant cell arteritis in both groups, though it was less common in African-Americans (78 vs 98% of Caucasians, P<0.001). Eye pain was more common in African-Americans (28 vs 8% of Caucasians, P<0.01).ConclusionsThe presenting features of ophthalmic giant cell arteritis in African-Americans and Caucasians are not markedly different, although a few significant differences exist, including higher rates of headache, neck pain, anemia, and eye pain, and lower rates of jaw claudication and acute vision loss in African-Americans. Persons presenting with suspicious signs and symptoms should undergo evaluation for giant cell arteritis regardless of race.

The role of orbital ultrasonography in distinguishing papilledema from pseudopapilledema.

PURPOSE: To determine the sensitivity and specificity of orbital ultrasonography in distinguishing papilledema from pseudopapilledema in adult patients. METHODS: The records of all adult patients referred to the neuro-ophthalmology service who underwent orbital ultrasonography for the evaluation of suspected papilledema were reviewed. The details of history, ophthalmologic examination, and results of ancillary testing including orbital ultrasonography, MRI, and lumbar puncture were recorded. Results of orbital ultrasonography were correlated with the final diagnosis of papilledema or pseudopapilledema on the basis of the clinical impression of the neuro-ophthalmologist. Ultrasound was considered positive when the optic nerve sheath diameter was ≥3.3 mm along with a positive 30° test. RESULTS: The sensitivity of orbital ultrasonography for detection of papilledema was 90% (CI: 80.2-99.3%) and the specificity in detecting pseudopapilledema was 79% (CI: 67.7-90.7%). CONCLUSIONS: Orbital ultrasonography is a rapid and noninvasive test that is highly sensitive, but less specific in differentiating papilledema from pseudopapilledema in adult patients, and can be useful in guiding further management of patients in whom the diagnosis is initially uncertain.

Caspase inhibitors block zinc-chelator induced death of retinal ganglion cells.

Zinc-chelating agents, including ethambutol and its metabolite 2,2'(ethylenediamino)-dibutyric acid (EDBA) are toxic to retinal ganglion cells through a glutamate dependent mechanism. We explored whether such cell death was mediated through the caspase family of cysteine proteases. Retinal cultures were treated with EDBA alone, or EDBA plus a variety of known caspase inhibitors, and ganglion cell viability was assayed. EDBA killed 20-30% of ganglion cells. A general caspase inhibitor, BAF, prevented EDBA induced ganglion cell death. Specific inhibitors of caspase-3 and caspase-6 showed a similar ability to BAF in preventing EDBA mediated ganglion cell loss, whereas inhibitors of caspase-8 and caspase-9 were not able to rescue EDBA treated ganglion cells. A caspase-1,4 inhibitor was less effective than BAF. These studies show that a caspase mediated mechanism of apoptosis accents for a portion of EDBA mediated retinal ganglion cell death. This toxicity was mediated by downstream effector caspases, 3 and 6. Caspase inhibitors may prevent ganglion cell death secondary to ethambutol treatment.

Epistatic and independent functions of caspase-3 and Bcl-X(L) in developmental programmed cell death.

The number of neurons in the mammalian brain is determined by a balance between cell proliferation and programmed cell death. Recent studies indicated that Bcl-X(L) prevents, whereas Caspase-3 mediates, cell death in the developing nervous system, but whether Bcl-X(L) directly blocks the apoptotic function of Caspase-3 in vivo is not known. To examine this question, we generated bcl-x/caspase-3 double mutants and found that caspase-3 deficiency abrogated the increased apoptosis of postmitotic neurons but not the increased hematopoietic cell death and embryonic lethality caused by the bcl-x mutation. In contrast, caspase-3, but not bcl-x, deficiency changed the normal incidence of neuronal progenitor cell apoptosis, consistent with the lack of expression of Bcl-X(L) in the proliferative population of the embryonic cortex. Thus, although Caspase-3 is epistatically downstream to Bcl-X(L) in postmitotic neurons, it independently regulates apoptosis of neuronal founder cells. Taken together, these results establish a role of programmed cell death in regulating the size of progenitor population in the central nervous system, a function that is distinct from the classic role of cell death in matching postmitotic neuronal population with postsynaptic targets.

In situ immunodetection of activated caspase-3 in apoptotic neurons in the developing nervous system.

Activation of caspase-3 requires proteolytic processing of the inactive zymogen into p18 and p12 subunits. We generated a rabbit polyclonal antiserum, CM1, which recognizes the p18 subunit of cleaved caspase-3 but not the zymogen. CM1 demonstrated an apparent specificity for activated caspase-3 by specifically immunolabelling only apoptotic but not necrotic cortical neurons in vitro. In the embryonic mouse nervous system, CM1 immunoreactivity was detected in neurons undergoing programmed cell death and was markedly increased in Bcl-xL-deficient embryos and decreased in Bax-deficient embryos. CM1 immunoreactivity was absent in the nervous system of caspase-3-deficient mouse embryos and in neurons cultured from caspase-3-deficient mice. Along with neuronal somata, extensive neuritic staining was seen in apoptotic neurons. These studies indicate that caspase-3 is activated during apoptosis in the developing nervous system in vivo and that CM1 is a useful reagent for its in situ detection.

Trophic support promotes survival of bcl-x-deficient telencephalic cells in vitro.

Survival of immature neurons is regulated by Bcl-xL, as targeted disruption of bcl-x significantly increases cell death in vivo and in vitro. Death of cultured bcl-x-deficient and wild-type telencephalic cells can be prevented by fetal calf serum or chemically-defined medium (ITS), suggesting trophic factors in these media potentiate survival through a pathway independent of Bcl-xL. Addition of trophic factors to basal medium revealed that insulin and insulin-like growth factors (IGFs), but not other trophic factors, reduced apoptosis of wild-type and bcl-x-deficient telencephalic cells. Antibodies raised against IGF-I receptors and wortmannin both attenuated the effects of IGF-I, indicating survival was mediated by IGF-I receptors and phosphatidylinositol 3'-kinase signaling, whereas effects of ITS were only partially reduced by these agents. The survival promoting effects of ITS were reduced in cells lacking both bcl-x and bcl-2, indicating Bcl-2 plays a supportive role to Bcl-xL in maintaining telencephalic cell survival. Furthermore, the ratio of expression of the pro-apoptotic bax gene to the anti-apoptotic bcl-2 gene was reduced in bcl-x-deficient cultures grown in ITS, suggesting that the interaction between these bcl-2 family members may, in part, regulate a Bcl-xL independent survival pathway. Finally, the pro-apoptotic bad gene does not appear to play a role in these interactions as targeted disruption of bad did not alter apoptosis in telencephalic cultures.

Bax deficiency prevents the increased cell death of immature neurons in bcl-x-deficient mice.

The intracellular balance between pro- and antiapoptotic members of the Bcl-2 gene family is thought to regulate cell death. Targeted disruption of bcl-x, a death repressing member, causes massive cell death of immature neurons in the developing mouse CNS, whereas targeted disruption of bax, a proapoptotic member, blocks the death of specific populations of sympathetic and motor neurons. In the present study, mice deficient in both Bcl-xL and Bax (bcl-x-/-/bax-/-) are used to examine the relative significance and potential interactions of Bcl-xL and Bax during early CNS development. bcl-x-/-/bax-/- mice demonstrate greatly reduced levels of apoptosis both in vivo and in vitro compared with the CNS of Bcl-xL-deficient mice, as assessed by histology and terminal deoxytransferase-mediated deoxyuridine triphosphate nick end-labeling. Bax-deficient mice, however, contain occasional apoptotic cells in the developing CNS, and cultures of bax-deficient telencephalic cells demonstrate similar levels of apoptosis as wild-type cultures. These results suggest that Bax critically interacts with Bcl-xL to regulate survival of immature neurons, but indicate that other cell death regulating proteins, in addition to Bcl-xL and Bax, also function during CNS development.

Double immunofluorescent staining using two unconjugated primary antisera raised in the same species.

Monoclonal antibodies (MAbs) capable of recognizing developmental stage-specific neuronal epitopes are becoming increasingly available. Because most of these MAbs are raised in a single species (mouse), simultaneous immunofluorescent detection of multiple epitopes has been difficult. We have taken advantage of the high sensitivity of tyramide signal amplification to develop a protocol that permits simultaneous detection of two antibodies raised in the same species. One primary antibody was applied at a concentration below the detection limit of fluorescently labeled secondary antibodies, yet sufficient for detection with the tyramide system. This first primary antibody was then effectively neglected during application of a second primary antibody that was detected by conventional fluorescently labeled secondary antibodies. Specifically, dual labeling for nestin and MAP2 was used to distinguish neuronal stem cells and precursor cells from immature postmitotic neurons, and synapsin I and GAP43 immunostaining was used to distinguish neurons with established synaptic connections from developing neurons. We have used this technique for staining both tissue sections and cultured cells from the embryonic mouse brain. This technique should be widely applicable and offers a simple procedure for simultaneously detecting two antigens when antibodies from only a single species are available.

Cholera toxin binds to differentiating neurons in the developing murine basal ganglia.

Cell-surface expression of gangliosides in the developing mammalian central nervous system is temporally-regulated in a cell-type and regionally specific fashion. Gangliosides may be involved in cell-cell and cell-matrix interactions, and can act synergystically with several growth factors or growth factor receptors. Thus, a role for gangliosides in the regulation of neuronal stem cell proliferation and differentiation has been suggested. We have previously shown that cholera toxin B subunit (CTB), which binds to the ganglioside GM1, binds heterogeneously to dissociated neuroepithelial cells from the developing mouse telencephalon. We stained fixed sections of the ganglionic eminences (GE) of fetal mouse brains and found that CTB labels regions which contain differentiating neurons, but does not stain the rapidly dividing neuroepithelial cells in the ventricular zone. We dissociated cells from the GE on day 14 of gestation (E14), labeled the cells with CTB-FITC, and separated them by flow cytometry. We found the highest level of CTB binding in postmitotic cells which had begun to express markers of neuronal differentiation. When CTB-sorted cells were placed into short-term (48 h) cell culture, high CTB binding continued to correlate with fewer numbers of proliferating cells and larger numbers of differentiating neurons. CTB binding and fluorescence activated cell sorting appear to be useful for separating populations of differentiating neurons from immature, proliferating cells. These studies further lead us to suggest that GM1 plays a role in the differentiation of neurons in the basal ganglia.

Developmentally-regulated lectin binding in the embryonic mouse telencephalon.

Cell-surface carbohydrate epitopes are important determinants in cell-cell and cell-matrix interactions, and oligosaccharide groups are structural components of many growth factor receptors and cell adhesion molecules. These epitopes may participate in the regulation of stem cell proliferation and differentiation during central nervous system development. To further understand these cellular phenomena, it is important to define the changes in neuroepithelial cell-surface carbohydrate expression during development. We used a panel of fluorescein-conjugated lectins to label live, freshly dissociated cells from the embryonic day 11 to 18 (E11 to E18) mouse telencephalon. The intensity and heterogeneity of lectin labeling was assessed by flow cytometry. The lectins that we examined exhibited widely varying levels of labeling intensity. Lectins with the highest degree of binding included cholera toxin B subunit (CTB), which binds primarily to the gangliosides GM1 and GD1b, phaseolus vulgaris erythroagglutinating lectin (PHA-E), which binds to a variety of cell adhesion molecules, and wheat germ agglutinin (WGA). Many lectins showed increasing labeling intensity and cellular heterogeneity as development progressed. To determine if the observed cellular heterogeneity in lectin binding reflected biological differences in neuroepithelial cell subpopulations, cells from the E14 telencephalon were separated into two populations based on their intensity of CTB labeling using a fluorescence activated cell sorter. The population of weakly CTB labeled cells contained more than four times as many cells in S-phase of the cell cycle than the population of intensely CTB labeled cells. These observations suggest that lectin cytochemistry and flow cytometry can be useful in identifying specific cell subpopulations of neuroepithelial precursor cells during development, allowing their isolation and characterization in vitro.

Type IIB mutation His-505-->Asp implicates a new segment in the control of von Willebrand factor binding to platelet glycoprotein Ib.

Type IIB von Willebrand disease is characterized by increased affinity of mutant von Willebrand factor (vWF) for platelet glycoprotein Ib. Eight different missense mutations that cause this phenotype have been reported within the disulfide loop defined by Cys-509 and Cys-695 of the mature vWF subunit; this disulfide loop is required for normal binding of vWF to platelet glycoprotein Ib. A new mutation was identified in a patient with type IIB von Willebrand disease (vWD) characterized by a lifelong bleeding disorder, mild thrombocytopenia, normal levels of factor VIII, vWF antigen, and ristocetin cofactor activity but increased ristocetin-induced platelet agglutination at low concentrations of ristocetin. Exon 28 of the patient's vWF gene was amplified, cloned, and sequenced. At nucleotide 3802 (numbering the cDNA from translation initiation), a C to G transversion was identified, which changes the encoded amino acid sequence from His-505 to Asp. The corresponding mutant recombinant vWF was expressed in transiently transfected COS cells. Relative to wild type vWF, the mutant vWF exhibited markedly increased binding to platelets at low concentrations of ristocetin, confirming the association between the His-505-->Asp substitution and the type IIB vWD phenotype. The His-505-->Asp mutation lies outside the disulfide loop affected by other type IIB vWD mutations and implicates a new segment of vWF in the regulation of platelet glycoprotein Ib binding.