Characterization of amyloid deposits in biopsies of 15 with "sporadic" (non-familial or plasma cell dyscrasia amyloid polyneuropathy

Review of the clinical and laboratory findings of 39 patients with amyloid polyneuropathy (AP) showed 12 cases to be hereditary and 12 to be associated with plasma cell dyscrasia (PCD). The remaining 15, termed "sporadic" AP, had neuropathy clinically indistinguishable from the other two groups but without a clinicopathologically identified PCD or positive family history. In an attempt to identify the type of amyloid in "sporadic" AP, the immunoreactivity of amyloid deposits was investigated using specific antisera raised against the following different chemical types of amyloid fibril proteins: variable regions of amyloid light chains kappa (A kappa) and lambda (A lambda), amyloid protein AA, and prealbumin. It was found that the amyloid in "sporadic" AP had A lambda antigenic determinants in ten cases, A kappa in one and prealbumin in three; in one case, the A lambda nature of amyloid was confirmed biochemically on the extracted amyloid fibrills. Thus, the most common type of AP in our population appears to be the "sporadic" form. In "sporadic" AP, the amyloid is most commonly of immunoglobulin light chain origin, even in the absence of overt PCD, and it can be rapidly categorized immunocytochemically to determine therapeutic directions or provide genetic guidance.

New neuromuscular symptoms in patients with old poliomyelitis: a three-year follow-up study

Fourteen survivors of paralytic poliomyelitis experienced new symptoms after years of stability. Seven patients had lost functional capacity, with joint pain, instability and recurrent falls, but were again stable and remained essentially unchanged during a 3-year follow-up period. Seven others had late postpoliomyelitis muscular atrophy (PPMA) with new weakness, wasting, fasciculations and myalgia in muscles originally spared or seemingly recovered. Muscle biopsy from newly affected muscles showed new and chronic denervation with interstitial inflammation in 3 patients. Antibody titers to poliomyelitis virus were not elevated in the CSF, but oligoclonal IgG bands were found in 3 PPMA patients. During the 3-year follow-up period, PPMA patients showed signs of slow progression which continued to be focal. It is concluded that the new symptoms in postpolio patients may be musculoskeletal and relatively stable, or due to a slowly progressive, focal, and apparent benign new motor neuron deterioration.

Monoclonal IgM in a patient with paraproteinemic polyneuropathy binds to gangliosides containing disialosyl groups

Monoclonal IgM kappa from a patient with polyneuropathy associated with paraproteinemia was found to bind to several polysialogangliosides. Binding of IgM to gangliosides was shown by enzyme-linked immunosorbent assay (ELISA) and by overlaying thin-layer chromatograms of human brain and peripheral nerve gangliosides with the patient's serum followed by radioiodinated goat antihuman IgM. The latter technique showed that the IgM paraprotein reacted with a number of gangliosides. In an ELISA the IgM paraprotein reacted strongly with GD2, GD3, GD1b, and GT1b, but not with GM1, GM3, and GD1a. Thus, the epitope for the patient's IgM paraprotein appears to involve the disialosyl configurations.

Nature of amyloid deposits in hypernephroma. Immunocytochemical studies in 2 cases associated with amyloid polyneuropathy

Two patients who presented with amyloid polyneuropathy were found to have an amyloid-positive hypernephroma. The amyloid extracted from the tumor of one patient was purified by gel filtration and found to immunoreact by immunodiffusion, only with antiserum against denatured lambda-type amyloid protein but not with antisera against denatured kappa amyloid, AA, or prealbumin. With the unlabeled immunoperoxidase method or immunofluorescence in combination with these specific antisera, it was shown that in both patients the amyloid deposits in the tumor, kidney, lymph node, muscle, and nerve had lambda-type amyloid antigenic fibril determinants. Some regions, amyloid-negative by congo red, immunoreacted with anti-lambda antiserum and were shown to represent amyloid fibrils electron microscopically. Several plasma cells found in the tumor and lymph node immunoreacted specifically with the anti-amyloid lambda antiserum. The findings provide the first observation that the amyloid in hypernephroma can be of immunocytic origin, even in the absence of overt signs of plasma cell dyscrasia, and suggest that amyloid polyneuropathy could be the presenting sign of hypernephroma.

Tremor as a feature of chronic relapsing and dysgammaglobulinemic polyneuropathies. Incidence and management

Seven patients with chronic relapsing polyneuropathy and four patients with dysgammaglobulinemic polyneuropathy had tremor during the course of their illness. The tremor was coarse, irregular, and unrelated to proprioception loss, muscle weakness, or fatigue; it appeared to represent disease activity or an early sign of a new relapse. None of these patients had clinical signs of CNS disease or family history of essential tremor. The tremor in all seven patients with relapsing neuropathy and in one of the three treated patients with dysgammaglobulinemia responded to immunosuppressive drugs that controlled the underlying immune mechanism(s) of the disease. In two patients with dysgammaglobulinemic polyneuropathy, the tremor improved with propranolol hydrochloride.

Paraproteins in the spinal fluid of patients with paraproteinemic polyneuropathies

High-resolution agarose gel electrophoresis, combined with immunofixation electrophoresis, was used to detect and identify immunoglobulins in the cerebrospinal fluid of six patients with paraproteinemic polyneuropathy. In four patients with serum IgM kappa monoclonal protein, we found a discrete band in the cerebrospinal fluid identified also as IgM kappa; one patient with serum IgG kappa had an IgG kappa cerebrospinal fluid band, and one patient with serum IgA kappa had an IgA kappa monoclonal band in the cerebrospinal fluid. The permeability of the blood-cerebrospinal fluid barrier was increased 3 to 10 times in all these patients. The findings indicate that in patients with paraproteinemic polyneuropathy, the increased permeability of the blood-cerebrospinal fluid barrier results in influx of serum proteins into the cerebrospinal fluid, including high-molecular-weight IgM. Because monoclonal IgM, unlike monoclonal IgG and IgA, is not found in the cerebrospinal fluid of neurologically intact patients, its presence in the cerebrospinal fluid of patients with paraproteinemias should lead the physician to suspect neurological involvement and can be of diagnostic value.

Late postpoliomyelitis muscular atrophy: clinical, virologic, and immunologic studies

Seventeen relatively young patients, ages 31-65 years (average, 45) with prior poliomyelitis, who after a number of years of stability had experienced new neuromuscular symptoms, were studied. Seven patients had deterioration of functional capacity and then stabilization without new muscular weakness. The other 10 had late postpoliomyelitis muscular atrophy (late PPMA ) characterized by focal progressive muscle weakness, wasting, fasciculations, and muscle pains affecting previously spared muscles or muscles previously affected but recovered. Four patients with late PPMA had lymphorrhages or lymphocytic infiltrates in their biopsied muscle; three of three patients had oligoclonal IgG bands in their spinal fluid, and five had variable peripheral T lymphocyte-subset ratios. In one patient with late PPMA , antibodies to poliovirus were specifically elevated in the cerebrospinal fluid. Our findings indicate that new motor-neuron disease can occur in patients with prior poliomyelitis and that immunopathologic mechanisms may play a role.

IgM in a human neuropathy related to paraproteinemia binds to a carbohydrate determinant in the myelin-associated glycoprotein and to a ganglioside

The IgM in three patients with paraproteinemia and peripheral neuropathy was shown to bind to human myelin-associated glycoprotein (MAG) that had been purified to homogeneity by gel filtration on Sepharose CL-6B. The antigenic determinant reacting with the IgM from all three patients was in the carbohydrate part of the MAG molecule. In addition, the IgM from the same three patients bound to a single ganglioside of human sciatic nerve. The results indicate that the IgM paraproteins in these patients react with a carbohydrate determinant that is shared between MAG and a peripheral nerve ganglioside.

Motor deficits in patients with large-fiber sensory neuropathy

The issue of whether brain signals in the absence of peripheral feedback are sufficient to specify accurate movement was evaluated by studying motor performance in patients with loss of somesthetic afferent input as a result of acquired large-fiber sensory neuropathy. With visual guidance, movements and postures were impaired relatively little, but when visual guidance was unavailable, the patients exhibited postural drift and gross inaccuracy of movement. Impairments were more apparent for smaller (3 degrees) than for larger (15 degrees) movements. Previous studies that have failed to show major motor impairments in deafferented subjects examined movements involving rather large joint displacements, and this may have been a factor in the failure of these studies to reveal severe deficits. The present results demonstrate a critical role for somesthetic feedback in regulating centrally generated levels of motor output and show that central motor programs deprived of such feedback are unable to subserve accurate motor control.

Transmission of simian acquired immunodeficiency syndrome (SAIDS) with blood or filtered plasma

Simian acquired immunodeficiency syndrome (SAIDS), a disease clinically and pathologically similar to acquired immunodeficiency syndrome in humans, was transmitted from diseased rhesus monkeys (Macaca mulatta) to normal monkeys by inoculation with heparinized whole blood or plasma that had been passed through filters of 0.45 micrometer pore size. This suggests that the causative agent is small and most probably a virus. No viruses, however, were isolated by standard cell culture techniques from the blood or filtered plasma which caused SAIDS. Both cellular and humoral immunity were markedly depressed in animals with advanced SAIDS.

Treatment of polyneuropathy in Waldenström's macroglobulinemia: role of paraproteinemia and immunologic studies

A patient with polyneuropathy due to Waldenström's macroglobulinemia (WM) was treated successfully with chlorambucil and prednisone. Before therapy, 60% of peripheral lymphocytes were B cells, the nerve had IgM-bearing B-cell infiltrates, and the circulating IgM had antibody-binding activity to autologous and homologous nerves. Neurologic improvement, sustained for 4 years, began 3 months after therapy and coincided with the return to normal of bone marrow and circulating B cells. Binding of IgM to autologous and homologous nerves persisted after therapy, suggesting that not the IgM alone but other B-cell factors, possibly complexed to IgM, may have been responsible for the nerve damage.

Experimental transmission of simian acquired immunodeficiency syndrome (SAIDS) and Kaposi-like skin lesions

A disease that is similar to human AIDS may occur in monkeys. Simian AIDS (SAIDS) was experimentally transmitted from 2 rhesus monkeys dying of the disease to 4 cytomegalovirus (CMV) antibody-negative rhesus monkeys. The inocula consisted of the supernatant fluid from 10% homogenates of various tissues with or without buffy-coat cells from blood. Lymphadenopathy, splenomegaly, neutropenia, polymyositis, and other signs of the disease appeared in recipients within a few weeks after inoculation. Two animals developed Kaposi-like "patch" and "plaque" skin lesions and one died of sepsis and profound lymphoid depletion. A second animal also died with lymphoid depletion. All animals became infected with CMV but antibody levels were low in two animals, appeared and then disappeared in one, and never developed in the second monkey which died.

Treatment of "permanent" muscle weakness in familial Hypokalemic Periodic Paralysis

Three patients with Hypokalemic Periodic Paralysis (HOPP)-associated progressive interattack muscle weakness, who became unresponsive or worsened by acetazolamide, responded favorably to dichlorophenamide, a more potent carbonic anhydrase inhibitor. Dichlorophenamide in single-blind placebo-controlled trials, considerably improved functional strength in two of the patients and had a moderate but definite effect in the third. Muscle groups graded 4/5 (MRC scale)returned to normal; very weak (0-3/5) atrophic muscles, improved to a minor degree. In one patient with acetazolamide-resistant paralytic attacks, dichlorophenamide also diminished the frequency and severity of the acute attacks. Dichlorophenamide had, in the present study, less effect than acetazolamide in reducing serum HCO3(-) and elevating Cl-. Its effectiveness may be related to the degree of sensitivity of certain HOPP patients to alterations of Cl- and/or HCO3(-) serum levels or to a different action of the drug unrelated to carbonic anhydrase inhibition or acidosis. Dichlorophenamide should be considered as an alternate to acetazolamide in the treatment of patients with HOPP-associated interattack muscle weakness who have become unresponsive or worsened by acetazolamide.

Increased circulation of T lymphocytes bearing surface thymosin alpha 1 in patients with myasthenia gravis: effect of thymectomy

We studied the interaction of the thymic hormone thymosin alpha 1 with peripheral blood B and T lymphocytes in patients with myasthenia gravis (MG), using antibodies against thymosin alpha 1 in an immunofluorescence technique. Eleven of 16 patients with symptomatic MG had an increased number of T lymphocytes bearing surface thymosin alpha 1 (T alpha 1); 5 patients with asymptomatic disease had normal levels of T alpha 1. In six young adults with symptomatic MG who subsequently responded to thymectomy, the number of T alpha 1 cells returned to normal 1 month after thymectomy. Because levels of T alpha 1 correlated with symptoms and thymosin alpha 1 specifically recruits helper T cells, our findings suggest that T alpha 1 may play an immunoregulatory role in the pathogenesis of MG. Determination of T alpha 1 levels may prove to be helpful in assessing residual thymic activity after thymectomy.

Splenic and total-body irradiation treatment of myasthenia gravis

X-irradiation is introduced as a new therapeutic technique in the treatment of otherwise intractable myasthenia gravis (MG) and polymyositis (PM), on the basis that these dysimmune diseases are "lymphocyte dyscrasias" and that lymphocytes are the circulating cells most sensitive to x-irradiation. Splenic irradiation, 1000 rads per two-week course, repeated up to three courses, in five MG patients produced objective improvement in three and subjective improvement in another. The improvement was transient and accompanied by a temporary lymphocytopoenia. Total Body Irradiation (TBI), 150 rads over five weeks, in one polymyositis patient was followed by remarkable improvement, sustained and still increasing now after one year, associated with a sustained lymphocytopoenia. One MG patient has had definite improvement, maintained to the present, seven months after TBI, associated with persistent lymphocytopoenia. We suggest TBI may also be a treatment applicable to other types of dysimmune (autoimmune) diseases.

Identification of human thymic epithelial cells with antibodies to thymosin alpha 1 in myasthenia gravis

Thymosin-alpha 1 (alpha 1) is a potent thymic polypeptide hormone. Using anti-alpha 1 antibodies, we applied indirect immunofluorescence to human normal thymus of different ages and to hyperplastic, thymomatous, and "involuted" thymus of myasthenia gravis (MG) patients. Alpha 1 was localized only in the epithelial cells, lying singly, grouped, in Hassell's corpuscles, and proliferated in thymomas. Whereas normal thymuses and fewer and weakly stained cells, MG thymuses had many strongly positive epithelial cells; this was more evident in thymomas. Germinal centers were unstained. "Involuted" MG thymuses had small islands of brightly stained cells lying among the fatty tissue. In cultured thymuses from three MG patients, epithelial cells but not fibroblasts were brightly stained for alpha 1. Our findings (a) demonstrate the location, and presumably the origin, of alpha 1 to be the thymic epithelial cell; (b) suggest the possibility that excess alpha 1, because of its known effect on T-lymphocyte maturation and transformation of precursors to helper T-cells, may act pathologically to facilitate and perpetuate the dysimmune mechanism in MG; (c) may partially explain the beneficial effect of thymectomy in MG patients of any age; and (d) indicate that epithelial cells may be autonomous for the production of alpha 1 as evidenced by their alpha 1 positivity in culture.

Amyloid in hereditary amyloid polyneuropathy is related to prealbumin

The origin of amyloid in the several subsets of hereditary amyloid polyneuropathy (HAP) is unknown. A recent biochemical study of extracted amyloid indicated that in the "portuguese" type of HAP it consists of a prealbumin-related protein. With the use of specific antibodies against human prealbumin, AA, and kappa and lambda type proteins, we demonstrated by indirect immunofluorescence that the amyloid in muscle biopsy specimens from five Americans and one Brazilian with HAP and one Brazilian without a family history (but with typical clinical disease and no plasma cell dyscrasia) was stained exactly and specifically only with antiprealbumin. In contrast, amyloid in muscle biopsy specimens from patients with plasma cell dyscrasic polyneuropathy and in amyloid-negative control muscle biopsy specimens from patients with nonamyloid neuropathies did not bind antiprealbumin antibodies. Our findings suggest that prealbumin-like protein may be a commonality of amyloid deposits in many, and possibly all, subsets of HAP.

Polyneuropathy with monoclonal gammopathy: studies of 11 patients

Among patients with chronic idiopathic nonfamilial polyneuropathy studied 3 to 21 years after onset, we identified 11 cases associated with monoclonal gammopathy (MCG) (5 with IgGk, 4 with IgMk, 2 with IgG lambda). The patients, aged 29 to 80 years, presented with sensorimotor polyneuropathy of insidious onset and slow, nonfluctuating progression, delayed motor and sensory nerve conduction, and increased cerebrospinal fluid (CSF) protein. None of the patients in the initial or follow-up study (mean, 9.2 years) had or developed signs of multiple myeloma, malignant plasma cell dyscrasia, macroglobulinemia syndrome, amyloidosis, neoplasia, or other associated illness. The CSF revealed abnormalities of protein electrophoresis or immunoelectrophoresis in 9 of the 11 patients. Three of 5 sural nerve biopsies studied by immunofluorescence demonstrated deposition in nerve fibers of the light chain characteristic of the abnormal circulating immunoglobulin. The findings suggest that these patients form a distinct subset of the dysimmune neuropathies. Although the immunoglobulin deposition and abnormal protein patterns in serum and CSF could be secondary to nerve damage, we propose that an immunopathological mechanism underlies the neuropathy. Immunosuppressants had minimal to marked beneficial effect in 4 of 5 patients, indicating that this polyneuropathy is potentially treatable.

Immunocytochemical localization of thymosin-alpha 1 in thymic epithelial cells of normal and myasthenia gravis patients and in thymic cultures

Thymosin alpha 1 (alpha 1) is a potent thymic polypeptide hormone. With antibodies against synthetic thymosin alpha 1, indirect immunofluorescence was applied to human normal thymus and to hyperplastic, thymomatous or "involuted" thymus of myasthenia gravis (MG) patients. Alpha 1 was localized only in the epithelial cells, lying singly, grouped, in Hassall's corpuscles or proliferated in thymomas. In contrast to normal thymus, which had fewer and more weakly stained cells, MG hyperplastic thymus had many strongly positive epithelial cells: this was markedly evident in thymomas. "Involuted" MG thymus had a few but brightly stained cells lying within the fatty tissue. In tissue cultures of human thymus, anti-alpha 1 stained the epithelial cells, but not fibroblasts. These findings: (a) demonstrate the origin of the thymic hormone alpha 1 to be the thymic epithelial cell; (b) raise the possibility that excess alpha 1 may act pathologically to facilitate and perpetuate the dysimmune mechanism in MG; (c) may partially explain the beneficial effect of thymectomy in MG patients of any age; and (d) suggest that epithelial cells may be autonomous for the production of alpha 1 as evidenced by their positivity in tissue culture.

Chronic relapsing (dysimmune) polyneuropathy: pathogenesis and treatment

Chronic relapsing polyneuropathy is a distinct dysschwannian/demyelinating polyneuropathy characterized by usually slow onset, progressive or relapsing-remitting course, elevated cerebrospinal fluid (CSF) protein, marked slowing of nerve conduction velocity, segmental demyelination demonstrable in sural nerve biopsies, and absence of systemic illness or abnormal serum immunoglobulins. The cause of the disorder and the mechanisms underlying its chronicity and relapsing-remitting course are not clear. Immunoglobulin deposition observed in sural nerve biopsies and abnormal immunoglobulin patterns in the "CSF in some cases suggest a dysimmune pathogenesis; thus the term chronic relapsing (dysimmune) polyneuropathy (CRDP) is preferred. The disease is a treatable form of idiopathic polyneuropathy. In our series of 25 patients with CRDP, treatment with high-single-dose daily prednisone, slowly tapered to an alternate-day program, has been very successful in the majority. A low (10 to 20 mg) alternate-day-single-dose program, maintained indefinitely, seems to be required to prevent future recurrences. Evidence is provided that other immunosuppressants (azathioprine, cyclophosphamide, poly-ICLC) and possibly plasmapheresis, alone or in conjunction with corticosteroids, may have a beneficial role in controlling difficult cases of chronic relapsing polyneuropathy.

Immunoglobulin and complement deposits in nerves of patients with chronic relapsing polyneuropathy

Sural nerve biopsy specimens from seven patients with chronic relapsing polyneuropathy (CRP) were studied by direct immunofluorescence. Granular deposits containing IgM (7/7) and C3 (6/7) (and occasionally IgG, 3/7) were found in intraneural blood vessels. Linear deposits of IgM (6/7) (and occasionally IgG, 3/7) without C3 (0/7) were found on the Schwann cell plasmalemma (and sometimes extending deeper into the Schwann cell) of yet undemyelinated portions of nerve fibers. Albumin and fibrinogen were not found in any locus. In sural nerves of ten disease-control patients with non-dysimmune chronic perpheral neuropathies, no deposits were seen on the vessels or the nerve fibers. The Schwann cell deposits may reflect a complement-independent IgM antibody toxic to Schwann cells that underlies the pathogenesis of CRP, perhaps facilitated in its passage across the blood-nerve barrier by damage from the complement-binding IgM complexes in the intraneural vessels.

CSF "monoclonal" bands in chronic relapsing polyneuropathy

The characteristics and temporal profiles of cerebrospinal fluid (CSF) and serum immunoglobulin patterns on agarose gel electrophoresis were studied in 47 patients with acute idiopathic polyneuropathy (AIP) and 15 patients with chronic relapsing polyneuropathy (CRP). Nineteen of 47 patients with AIP had transient oligoclonal IgG bands, which disappeared when the neurologic signs subsided. By contrast, 14 of 15 patients with CRP had a "monoclonal" (single) IgG band, which (1) was unchanged on repeated CSF examinations over 18 months, (2) was unaffected by corticosteroid therapy, and (3) did not correlate with the severity or chronicity of the disease. Serum protein patterns and in situ central nervous system IGG synthesis and IgG:albumin index were normal in the CRP patients. The origin of the band and the nature of the putative antigen(s) that the band may be directed against were not identified. Our findings suggest that different immunopathogenic mechanisms may be operating in CRP, compared with AIP. The stable IgG band in CRP may reflect response to a persisting antigenic stimulation and, with further experience, may prove to be of prognostic significance by furnishing early in the illness: (1) a clue to the subsequent course of the disease, and (2) possible guidance on therapeutic decisions.

Human schwann cells in tissue culture: histochemical and ultrastructural studies

Schwann cells cultures were established from 40 human peripheral nerves that underwent biopsy according to an explant-reexplantation technique that markedly reduces non-Schwann cells and achieves cultures greatly enriched in Schwann cells suitable for a wide range of studies. Described are the growth characteristics and histochemical, ultrastructural, and ultrastructural-cytochemical patterns of normal human cultured Schwann cells from 12 patients with demonstrable peripheral nerve abnormality. These findings serve as a basis of comparison when seeking abnormalities of Schwann cells grown from peripheral nerves of patients with putative dysschwannian neuropathies.