Inclusion body myositis: an underdiagnosed condition?

Inclusion body myositis is an increasingly recognised form of inflammatory myopathy with characteristic clinical and histopathological features which has seldom been reported in the United Kingdom. This paper presents the clinicopathological features of a series of patients diagnosed in Nottingham from 1986 to 1990. During this period, 1319 muscle biopsy samples were processed by this laboratory and rimmed vacuoles were seen in 17 patients. Eleven patients had definite or probable inclusion body myositis according to published criteria. The mean age of the group was 69.4 years with a male to female ratio of 8:3. Typical clinical features were a slowly progressive painless, proximal lower limb weakness, with muscle wasting and early loss of reflexes. The median duration of illness from first symptom to presentation was five years (range 2-18 years). Falls were a prominent symptom in six patients and distal weakness occurred in nine patients. Creatine kinase was increased in 10 patients but only one had a level > 1000 IU/l; the erythrocyte sedimentation rate was normal in five patients. Treatment with steroids or cytotoxic drugs, or both, did not prevent disease progression. It is confirmed that inclusion body myositis is a distinct cause of inflammatory myopathy which is probably underdiagnosed in the United Kingdom. Clinically, it should be suspected in older patients presenting with muscle weakness of insidious onset. Pathologically, a careful search should be made for rimmed vacuoles and inflammation; ultrastructurally, the presence of inclusions will confirm the diagnosis.

Ubiquitin in neurodegenerative diseases

Immunochemical staining to detect ubiquitin has become an essential technique in evaluating neurodegenerative processes. Age related staining is seen in myelin, in nerve processes in lysosome-related dense bodies, and in corpora amylacea. There is a constant association between filamentous inclusions and the presence of ubiquitin. Intermediate filaments associated with ubiquitin, alpha B crystallin and enzymes of the ubiquitin pathway are the basis of Lewy bodies and Rosenthal fibres, as well as related bodies outside the nervous system. Neurofibrillary tangles in diverse diseases are associated with ubiquitin as are several other tau containing inclusions in both neurones and glia. Inclusions in motor neurones and non-motor cortex characterizing amyotrophic lateral sclerosis (ALS) and certain related forms of frontal lobe dementia can only be readily detected by anti-ubiquitin. Anti-ubiquitin also identifies both filamentous and lysosomal structures in neuronal processes as well as in some swollen neurones. Involvement of ubiquitin-containing elements of the lysosomal system appears important in pathogenesis of prion encephalopathies. Despite great advances in understanding cell biology of the ubiquitin pathway there are as yet few insights into the precise role played by ubiquitin in neuronal disease.

Immunoreactivity to ubiquitin-protein conjugates is present early in the disease process in the brains of scrapie-infected mice

Brains from mice infected with either the 87V or the ME7 strains of mouse-passaged sheep scrapie were taken at stages during the disease process and immunostained to show the localization of ubiquitin-protein conjugates. In both models, conjugates were seen as fine, dot-like structures; as coarser, granular lesions within or adjacent to neurones; and in areas surrounding plaques. The dot-like structures were visible at 28 days post-ME7 infection and at 55 days in 87V-infected mice. In both models, the extent of immunoreactive changes increased as the disease progressed and terminal infection was as described earlier by us (Lowe et al., J. Pathol 1990; 162: 61-66). The patterns of development of these features were distinctive in two ways: progression from region to region was observable and the density of the pathological lesions grew exponentially as the clinical symptoms appeared. The earliest pathological dot-like structures corresponded temporally with the earliest detection of PrPSC by Western blotting, and immunogold electron microscopic investigation of the dot-like lesions indicated that they were the multi-vesicular, lysosome-related, dense bodies that we have described previously in terminal disease (Laszlo et al., J Pathol 1992; 166: 333-341). Until now, ubiquitin-protein conjugates were seen mainly in inclusion bodies associated with the terminal stages of a range of human degenerative diseases. This study establishes that ubiquitin-protein conjugates accumulate in lysosome-related bodies very early and appear to be intimately related to the pathological processes in the animal disorders that we have studied.

Ballooned neurons in several neurodegenerative diseases and stroke contain alpha B crystallin

alpha B crystallin is a protein which has homology with the small cell stress proteins. A characterized antibody to residues 1-10 of alpha B crystallin was used to immunostain tissues containing ballooned (chromatolytic, achromasic) neurons. The tissues included two cases of classical Pick's disease, one case of dementia with swollen achromasic neurons in the cortex, two cases of Alzheimer's disease with large numbers of ballooned neurons, two cases of motor neuron disease, four cases of cortico-basal degeneration, and four cases with areas of brain showing swollen neurons adjacent to recent cerebral infarcts. The anti-alpha B crystallin showed strong diffuse cytoplasmic immunoreactivity of swollen cortical neurons in all the diseases. Astrocytes and oligodendroglial cells were also stained in normal tissues as previously described. Weak diffuse immunoreactivity with an antibody to ubiquitin-conjugates was also seen in the swollen neurons from cases of neurodegenerative disease but not following infarction. Ballooned neurons have been shown to contain phosphorylated neurofilament epitopes not normally present in the perikaryonal region. The presence of alpha B crystallin in ballooned neurons, together with previous data which also indicate its close association with intermediate filaments, suggest that alpha B crystallin may be involved in aggregation and remodelling of neurofilaments in disease. The presence of alpha B crystallin in neurons at the edge of areas of cerebral infarction is likely to reflect cells which are regenerating following damage; its detection may therefore be a marker for such cells. On a practical level, the antibody greatly facilitates the localization of such abnormal neurons in diagnostic histology.

Protein processing in lysosomes: the new therapeutic target in neurodegenerative disease

A little recognised feature of neurons is their large complement of lysosomes. Studies of the accumulation of the abnormal isoform of the prion protein (PrPSC) in the prion encephalopathies and the formation of beta/A4 protein from its precursor in Alzheimer's disease suggest that generation of these key proteins takes place in lysosome-related organelles. The release of hydrolytic enzymes from lysosomes may be a primary cause of neuronal damage. Although molecular genetic approaches have identified protein mutations central to the main neurodegenerative disease, cell biological observations are now beginning to unravel the intracellular pathways involved in the molecular pathogenesis of neurodegeneration: as a result, it is now appropriate to consider therapeutic manipulation of the lysosomal system as an approach to treatment.

The risk of severity of limb injuries in racing thoroughbred horses

A retrospective study was carried out to identify factors which predisposed Thoroughbred horses to severe injuries, as compared to less severe injuries, while racing on New York Racing Association (NYRA) tracks during the period of January 1986 to June 1988. A severe injury was defined as an injury which led to humane destruction of the horse. A less severe injury was defined as a horse which didn't race within 6 months following a muscular, ligament, tendon, or skeletal injury on the racetrack. The data were obtained from the Horse Identification Department records kept by the Chief Examining Veterinarian of NYRA and included 55 severely injured horses and 245 less severely injured horses. Multiple logistic regression analysis was used to identify factors associated with the risk of severe injuries compared to less severe injuries in those horses. There was a significant association between track and the risk of severe injury (horses raced on Belmont and Saratoga were more likely to develop a severe injury compared to horses raced on Aqueduct Main). The track surface was also associated with the risk of severe injury (horses raced on a firm turf had a significantly lower risk of severe injury associated with the track was significantly modified by the track condition (horses raced at Belmont when it was muddy had a significantly increased risk compared to Aqueduct dirt). Horses were more likely to experience severe injury in the early part of the race (less than or equal to 6 furlongs) than the latter part of the race (greater than 6 furlongs). The risk of severe injury decreased with the age of the horse.

Detection of spores of Bacillus anthracis using the polymerase chain reaction

The polymerase chain reaction (PCR) was used to identify spores of Bacillus anthracis. By using an assay capable of amplifying a 1247-bp fragment from the gene that encodes the edema factor of B. anthracis, as few as 10(3) copies of a plasmid containing the edema factor gene and as few as 2 x 10(4) spores were detected. Subjecting the product of this PCR to a second PCR designed to amplify a 208-bp fragment nested within the 1247-bp product improved detection to a single plasmid copy per PCR and to two spores of B. anthracis per PCR.

Lysosomes as key organelles in the pathogenesis of prion encephalopathies

The causation, structural origin, and mechanism of formation of spongiform lesions in transmissible encephalopathies are unknown. We have used immunogold electron microscopy to locate ubiquitin conjugates, hsp 70, and beta-glucuronidase (markers of the lysosomal compartment) and prion protein (PrP) in both control and scrapie-infected mouse brain. In scrapie-infected brain, lysosomes and lysosome-related structures (multivesicular and tubulovesicular dense bodies) are present in abnormally high numbers in neuronal cell processes. These structures contain PrP, together with the lysosomal markers ubiquitin conjugates, hsp 70, and beta-glucuronidase, which could also be identified spilling from tubulovesicular dense bodies into areas of early rarefaction in neuronal processes; we suggest that these areas of rarefaction are the precursor lesions of spongiform change. We advance the hypothesis that spongiform change is brought about by cytoskeletal disruption in neuronal processes caused by liberation of hydrolytic enzymes from lysosomes overloaded with the abnormal isoform of PrP (PrPsc). We suggest that the lysosomal system is probably acting as the bioreactor for processing of normal PrP to the abnormal isoform. The continuous production of increasing quantities of abnormal PrPsc in lysosome-related bodies will eventually cause disruption of the lysosomal membrane with destruction of the neuronal cytoskeleton and the initiation of vacuolation. Later, death of the cell will be associated with release of the PrPsc isoform into the extracellular environment. Repeated rounds of phagocytosis, lysosomal biogenesis of PrPsc, lysosomal membrane rupture, hydrolytic enzyme release, and neuronal lysis will lead to an exponential increase in cell damage and cell death.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients' responses to retinitis pigmentosa

Forty-eight patients with retinitis pigmentosa completed at home a questionnaire about everyday tasks, and recorded their distance visual acuities on reduced Snellen charts. Respondents were asked to assess their own abilities for seven tasks involving visual search and mobility on a 1 to 4 scale. This revealed the relative difficulty of each task for the whole group. Other questions were open-ended to allow respondents to express their individual visual problems and experiences. Several problems came to light that were not amenable to treatment with low vision aids, but should be considered as a guide to the clinician in counseling.

Using a binocular field expander on a wide-field search task

Five patients with constricted visual fields and good central acuity were fitted with an experimental binocular field expander. They undertook a laboratory visual search task in a stationary horizontal 90 degree field with and without the device. Four of five patients adapted relatively quickly to the inherent optical distortions of the field expander. When this binocular aid was worn search efficiency improved significantly with practice; search time was highly correlated (r = -0.92; p less than 0.01) with information channel capacity in the larger visual field.

Cerebral contusional tears as a marker of child abuse--detection by cranial sonography

A series of 6 infants subjected to child abuse is presented in whom contusional tears of subcortical white matter were detected during life by intracranial sonography. The sonographic appearances of this highly pathognomonic marker of shaking injury are described for the first time and their significance discussed. On the basis of our experience we suggest that high resolution cranial sonography is an extremely valuable part of the diagnostic work up in cases of suspected non-accidental injury.

alpha B crystallin expression in non-lenticular tissues and selective presence in ubiquitinated inclusion bodies in human disease

alpha B crystallin is a lens protein which has homology with the small heat-shock proteins and is also expressed in non-lenticular tissues. Polyclonal antibodies have been raised to a synthetic peptide corresponding to residues 1-10 of alpha B crystallin. The antiserum detects a 20 kDa polypeptide on nitrocellulose replicas after polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulphate of extracts of heart muscle known to be rich in alpha B crystallin. Staining of normal human tissues reveals immunoreactivity of lens capsular epithelium, skeletal muscle, cardiac muscle, smooth muscle, renal tubular epithelium, Schwann cells, and glial cells, as has been described by other workers. In addition, positive staining of normal thyroid epithelium, colonic epithelium, and stratified squamous epithelium was seen. Tissues known to contain ubiquitinated inclusion bodies were immunostained with the anti-alpha B-crystallin antiserum. Staining of cortical Lewy bodies, astrocytic Rosenthal fibres, and hepatic Mallory bodies was seen, but only a proportion of inclusions were positive. Neurones containing the ubiquitinated inclusions of Alzheimer's disease were only very rarely immunostained and the ubiquitinated inclusions of motor neurone disease were not detected by the antiserum. Reactive astrocytes in cerebral tissues were strongly immunostained. The results suggest that alpha B crystallin is involved in the formation of ubiquitinated inclusion bodies that have associated intermediate filaments and support previous observations on the localization of a brain-specific ubiquitin carboxy-terminal hydrolase which similarly divides ubiquitinated filamentous inclusions in the central nervous system into two main groups.

The floating hip. Ipsilateral pelvic and femoral fractures

A consecutive series is reported of 17 patients who underwent early surgical treatment for acetabular or unstable pelvic fractures associated with ipsilateral fractures of the femur. Treatment included external and internal fixation, and required careful consideration of the surgical approach and the positioning of the patient. The multiple injuries sustained by these patients required simultaneous procedures by several surgical teams. All the femoral fractures were internally fixed at the initial operation and eight patients had primary definitive treatment of all their other fractures as well. In nine patients the definitive treatment of their other fractures was delayed for an average of 11 days. There were no deaths, and no serious infections. The long-term morbidity resulted from the associated injuries and not from the pelvic or femoral fractures.

Disappearance of ocular malignant melanoma on computerised scan after spontaneous necrosis: clinical, radiological and pathological features

An 82 year old patient was lost to follow-up having been diagnosed both clinically and on CT scan as having a right choroidal malignant melanoma. Twenty months later she presented with a painful right proptosis, dense cataract and raised intraocular pressure. A second CT scan showed orbital cellulitis with no evidence of the previous mass. Following enucleation histopathological examination revealed that the tumour had undergone total spontaneous necrosis. The implications of the CT scan findings are discussed. Five cases of necrosed choroidal malignant melanoma producing proptosis in the absence of extrascleral tumour extension have now been described.

Risk factors associated with injuries in thoroughbred horses

A case-control study was conducted on Thoroughbred horses to identify factors associated with the risk of breakdown on racetracks. A total of 310 cases (breakdowns) were identified from the Horse Identification Department records kept by the chief examining veterinarian of New York Racing Association. For each case, two control horses were selected randomly from the Daily Racing Form Inc. records. Multiple logistic regression analysis was used to identify and quantify the risk of factors associated with breakdown, while simultaneously controlling for the effect of other putative factors. Factors associated with risk of breakdown were: track (horses raced on Saratoga racetrack were at a lesser risk of breakdown), track composition/condition (turf tracks had a lower risk compared to dirt), number of seasons in race, racing in a later race, number of starts per year, the total number of starts, season (summer had a higher risk than winter or spring) and age of the horse.

Reflex sympathetic dystrophy of the patellofemoral joint

Eighteen patients with a diagnosis of reflex sympathetic dystrophy (RSD) affecting the knee were reviewed. Minor isolated injuries and operations about the knee triggered the original episode. The symptoms, regardless of location and mechanism of injury, occurred in the patellofemoral joint. Roentgenographic features of patchy demineralization and abnormal uptake on a 99mTc scan were typically located in the patella and corresponding femoral articular surface. At the initial stage of the syndrome, pain, hypersensitivity to touch, and inhibition of the quadriceps muscle were the most prominent features. In the later stages of the syndrome, functional instability due to quadriceps weakness created dependence on a knee brace or crutch support. Six patients whose RSD was initially misdiagnosed underwent numerous unsuccessful surgical procedures. In three of these patients, the knee was ultimately fused. All patients had an initial isolated knee injury (usually after minor trauma), and prolonged periods of immobilization and a cast, and 12 of the 18 patients were involved with workers' compensation. Early diagnosis and prompt treatment with an epidural block, followed by intensive physiotherapy, are recommended. A personal doctor/patient relationship that offers guidance and encouragement is key to successful management of this syndrome.