Activation of the contact system in cerebrospinal fluid of patients with Alzheimer disease

Several converging lines of evidence suggest that beta-amyloid and inflammation may be linked in the pathogenesis of Alzheimer disease (AD), but the mechanism of beta-amyloid neurotoxicity is unclear. In this study, by demonstrating that high molecular weight kininogen may be massively cleaved in the cerebrospinal fluid (CSF) of patients with AD, we provide evidence of the potential involvement of the contact system in the inflammatory processes taking place in this disease. In the CSF of patients with neuroimmune inflammatory disease (multiple sclerosis, chronic inflammatory demyelinating polyneuropathy), there was no evidence of increased cleavage of high molecular weight kininogen, suggesting that this finding may be characteristic of the Alzheimer brain. The data obtained from in vitro experiments seem to indicate that the cleavage of high molecular weight kininogen in vivo may be the result of the interaction of beta-amyloid with factor XII and of kallikrein generation. The actual relevance of such a phenomenon remains to be established in vivo. However, the demonstration that the contact system may be activated in the brains of Alzheimer patients points to the potential involvement of the kallikrein-kinin system in the inflammatory process of this disease.

Intrathecal activation of the complement system and disability in multiple sclerosis

BACKGROUND

The pathogenesis of multiple sclerosis (MS) appears to involve autoimmune phenomena in the central nervous system. Activation of the complement system is suggested to be involved in the pathogenesis.

PATIENTS AND METHODS

Cerebrospinal fluid (CSF) and plasma samples from 65 patients with acute optic neuritis (ON) as a possible first symptom of MS (n=18), ON (n=16) or other attacks of clinically definite MS (n=15), and neurological control subjects (n=16) were studied. Activation of the initial part of the complement activation cascade was assessed by measuring activation of the C3 molecule; terminal activation of the complement cascade was assessed by measuring the terminal complement complex (TCC). Demyelination was estimated by the CSF concentration of myelin basic protein and neurological disability was assessed with the Kurtzke expanded disability status scale (EDSS) score.

RESULTS

Activation of the initial part of the complement activation cascade occurred in each of the three groups of patients with demyelinating disease, but was not correlated to demyelination or disability. Increased concentrations of TCC were detected in patients with attacks of MS other than ON. The CSF concentrations of TCC, myelin basic protein (MBP) and neurological disability correlated significantly. The strongest correlation was between neurological disability and the CSF concentration of TCC (r=0.55, P=0.003).

INTERPRETATION

Full activation of the complement cascade during attacks of MS may be restricted to patients with more advanced disease and is significantly correlated to the degree of neurological disability. This suggests that specific treatment with agents that inhibit complement activation may interfere with mechanisms involved in the pathogenesis of neurological disability in patients with MS.

Cerebrospinal fluid analysis differentiates between relapsing-remitting and secondary progressive multiple sclerosis

OBJECTIVES

To find whether CSF analysis may differentiate between relapsing-remitting and secondary progressive multiple sclerosis.

METHODS

In 17 patients with relapsing-remitting and 16 patients with secondary progressive multiple sclerosis, all without current or recent relapses, albumin CSF: peripheral blood ratio, mononuclear cell number, CD4+, CD8+, and B1+ subsets, CD4+:CD8+ ratio, IgG, IgG index, IgM, IgM index, complement components C3 and C4, and C3 and C4 indices, myelin basic protein, neuron specific enolase, S100, and lactate were determined. For each measure the statistical distance measure D2 was calculated. For computation of a discriminant score variables with a P value< or =0.15 were included (two sided univariate t test). These were albumin CSF: peripheral blood ratio, mononuclear cell number, IgM, IgM index, C3, C4, neuron specific enolase, S100, and lactate. Simultaneous distributions of the variables were compared between both groups (multivariate t test) and a discriminant score was computed (linear discriminant analysis).

RESULTS

The discriminant score allocated all 14 relapsing-remitting patients to the relapsing-remitting group (positive score) and 12 of 13 secondary progressive patients to the secondary progressive group (negative score). One secondary progressive patient was allocated to the relapsing-remitting group.

CONCLUSIONS

Patients with relapsing-remitting or secondary progressive multiple sclerosis differ in CSF profile and CSF analysis may help to differentiate between relapsing-remitting and secondary progressive multiple sclerosis.

Chronic inflammatory demyelinating polyradiculoneuropathy in children: I. Presentation, electrodiagnostic studies, and initial clinical course, with comparison to adults

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is rare in children. We reviewed features of 15 children with idiopathic CIDP, and compared these to 69 adults with idiopathic CIDP. Children demonstrated many similarities to adults: (1) Antecedent events were uncommon. (2) There was a high frequency of weakness and reflex loss, a relatively high frequency of sensory loss, and a low frequency of pain and cranial neuropathies. (3) Cerebrospinal fluid protein levels were usually elevated. (4) On electrodiagnostic testing, not all nerve segments were abnormal, and not all children satisfied electrodiagnostic criteria for CIDP. Children differed from adults with CIDP in several ways: (1) The onset of symptoms was usually more precipitous. (2) Gait abnormalities were a more frequent presenting symptom. (3) Children always presented with significant neurological dysfunction, and not with the minor symptoms initially seen in some adults. The initial response of children with CIDP to immunomodulating therapy was excellent.

Cytokine pattern in the cerebrospinal fluid from patients with GBS and CIDP

Macrophage-colony stimulating factor (M-CSF) and, less frequently, IL-1 beta and IL-6 were detected in the cerebrospinal fluid (SF) from Guillain-Barré syndrome (GBS) patients. IL-1 alpha, IL-2, IL-10, TNF alpha, and IFN gamma were not found. Detectable cytokine levels were not observed in chronic inflammatory demyelinating polyneuropathy (CIDP) SF nor in any of the sera studied. These findings suggest a prominent intrathecal activation of cells of the monocyte/macrophage lineage (Mø) in GBS, and further support the hypothesis of a crucial role for Mø in GBS immunopathology.

Cerebrospinal-fluid ciliary neurotrophic factor in neurological patients

We developed a double sandwich immunoassay for the dosage of ciliary neurotrophic factor (CNTF) in cerebrospinal fluid (CSF). The detection limit was 100 pg/ml. This assay was applied to human CSF samples from 14 normal subjects, 26 patients with multiple sclerosis (MS), 17 with Guillain-Barré syndrome (GBS) or chronic inflammatory demyelinating polyneuropathy (CIDP), and 22 with tumours of the central nervous system (CNS) or leucaemic meningosis (LM). Samples from normal control subjects and from patients with tumours did not contain detectable CNTF. Only 2 patients with LM were positive, and all the patients with inflammatory diseases of the CNS and peripheral nervous system were positive. The MS group presented a mean value of 240 pg/ml CNTF and the GBS/CIDP group a value of 430 pg/ml.

The human endogenous local anesthetic-like factor (ELLF) is functionally neutralized by serum albumin

The cerebrospinal fluid (CSF) of patients with multiple sclerosis or Guillain-Barré syndrome contains a factor that inhibits excitation of nerve and muscle cells like local anesthetics. CSF samples containing the endogenous local anesthetic-like factor (ELLF) were analyzed by gel filtration chromatography and ultraviolet (UV) absorption at 210 nm. The active component was in a single peak corresponding to a molecular weight of 600-800 Da. This peak was decreased and the Na+ channel blocking activity was neutralized by the addition of 40 g/l human serum albumin to the CSF. When the albumin was separated from the CSF/albumin mixture by acetonitrile treatment, the Na+ channel blocking activity reappeared. The ELLF and its neutralization may be of relevance for the clinical fluctuations known with these diseases.

The clinical significance of a single abnormal immunoglobulin band in cerebrospinal fluid electrophoresis

The finding of oligoclonal immunoglobulin (Ig) bands in the cerebrospinal fluid (CSF) is considered a cornerstone in the diagnosis of multiple sclerosis, but can be observed in other diseases as well. In a small subset of patients only a single Ig band, confined to the CSF, is identified. We evaluated the possible diagnostic significance of such a finding. Agarose gels of 6000 CSF samples were re-examined. In 1013 samples (16.8%) there were oligoclonal bands, and in 33 additional samples (0.55%) a single band was found (without a correlating band in the serum). Full data was available for 20 single band patients. Seven patients had clinical definite multiple sclerosis. Of these, 6 had a typically prominent affective disorder and 5 had a relatively malignant course of disease. Seven additional patients had other white matter diseases of the central nervous system (CNS). The remaining patients had inflammatory diseases of peripheral nerves or CNS gray matter and non-inflammatory brain diseases. The frequency of demyelinating diseases of the CNS in patients with a single abnormal Ig band in the CSF was significantly less than in a control group of patients with oligoclonal bands. In conclusion, the finding of a single Ig band confined to the CSF may hint for a disease other than multiple sclerosis, and mark an aggressive course with affective disorder in those who do have multiple sclerosis.

[Cerebrospinal fluid findings in patients with acute and chronic inflammatory demyelinating polyradiculoneuropathies]

We studied the cerebrospinal fluid (CSF) in patients with acute (AIDP) and chronic inflammatory demyelinating poliradiculoneuropathy (CIDP). In order to assess its possible contribution in establishing the diagnostic approach, we analyzed the cell content, concentrations of total proteins, albumin and IgG, CSF/serum albumin quotient and the qualitative study of IgG. Sixteen patients with AIDP and 16 patients with CIDP, fulfilling the accepted diagnostic criteria, were included in this study. CSF features were not used as exclusion criteria. The cell count and concentration of total proteins were determined by standard procedures. CSF albumin was performed and IgG were done by single radial immunodiffusion, and the qualitative analysis of IgG by agarose isoelectric focusing of unconcentrated CSF. The incidence of elevated levels of total CSF proteins was identical in patients with AIDP and CIDP, reaching 94%. The mean level of CSF protein was similar in patients with AIDP and CIDP, 1100 and 1150 mg/l, respectively. The cell count was elevated in 3 (19%) patients with AIDP and normal in patients with CIDP. There were no significant differences in the mean level of any of CSF parameters between patients with AIDP and CIDP. Local synthesis of CSF oligoclonal IgG was found in 2 patients with CIDP and was not detected in patients with AIDP. No association between CSF and clinical parameters was recorded. The results of this study confirm that an elevated CSF protein and low CSF cell count are features highly supportive of the diagnosis of both AIDP and CIDP. The most intriguing finding is the detection of locally produced CSF oligoclonal IgG which may suggest the associated inflammation within the central nervous system in a number of patients with CIDP, and furthermore a pathogenic link between CIDP and multiple sclerosis.

Cerebral magnetic resonance imaging pathology and cerebro-spinal fluid protein in sporadic amyotrophic lateral sclerosis (sALS)

In 3 out of 20 patients with sporadic amyotrophic lateral sclerosis (sALS), cranial magnetic resonance imaging detected multiple demyelinating lesions. All 3 patients died from definite upper and lower motor neuron degeneration. In all 3 cases total cerebro-spinal fluid (CSF) protein remained within normal ranges, and a blood-CSF barrier dysfunction was not detectable. In one of the patients multifocal CNS demyelination coincided with an intrathecal synthesis of immunoglobulin-G and autochthonous CSF oligoclonal IgG banding (OCB) early in disease. Neither absolute or age-corrected survival nor disease progression differed for patients with and without cerebral MR lesions, or normal vs. elevated CSF total protein. Evaluating the CSF in an extended patient sample (n = 29), we found the total CSF protein elevated in 5 of 16 men and none of 13 women (p < 0.05). The mean age-corrected CSF protein content [practical reference limit = (age x 3.3) + 300 mg/l] was higher in male (465 mg/l +/- 32 SE) than in female (350 mg/l +/- 26 SE) sALS patients (p < 0.01). This coincides with a male preponderance in sALS.

Increased CSF C4d in demyelinating neuropathy indicates the radicular involvement

Plasma and cerebrospinal fluid (CSF) levels of C4d and the circulating immune complex (CIC) to C1q were measured in 12 patients with chronic inflammatory demyelinating polyneuropathy and Guillain-Barré syndrome. CSF C4d values more than 2 SD from the mean of 8 cervical spongylosis cases were demonstrated in the patients with proximal demyelination. The CSF C4d probably originated from both intrathecal synthesis and the systemic circulation. CSF levels of C4d may serve as a sensitive indicator for the radicular involvement in demyelinating polyneuropathy.

Bilateral optic neuritis with branch retinal artery occlusion associated with vaccination

A case of a 40-year old marine with bilateral optic neuritis and a branch retinal artery occlusion after vaccination is presented. Blood investigations showed no abnormalities. Cerebrospinal fluid studies revealed a lymphocytic pleocytosis and IgG antibodies against hepatitis A and rabies. Computerized tomography and magnetic resonance imaging of the brain were negative. A diagnosis of vaccine-induced auto-immune demyelinative optic neuritis was made. The clinical picture improved after systemic corticosteroid treatment.

Heat shock protein immunoreactivity in CSF: correlation with oligoclonal banding and demyelinating disease

The detection of raised immunoglobulin and the presence of oligoclonal bands (OCBs) on electrophoresis of multiple sclerosis (MS) CSF has been a useful diagnostic test, but a universal antigen to which these MS antibodies are directed has yet to be found. Potentially immunogenic heat shock proteins (HSPs) are preferential expressed in vitro in human oligodendrocytes compared with other glia, and in situ in oligodendrocytes found within the plaques of MS. Immunoreactivity directed against HSPs might therefore contribute to the immune-mediated demyelinating process found in MS. We examined this possibility by quantitatively (ELISA) measuring antibodies directed against a recombinant human HSP (HSP60) in CSF from 18 MS patients, and compared them with eight patients with acute disseminated encephalomyelitis, 12 with demyelinating peripheral neuropathies, and 59 with other neurologic diseases. Immunoblotting was used to confirm the specificity of the antibodies for binding to HSP60. We found a statistically significant correlation between antibody titers to HSP60 and the presence of OCBs in CSF. These results support the notion that HSP expression in the CNS, such as that observed in MS, may be immunogenic, leading to localized HSP antibody secretion. Such HSP-directed immunoreactivity could play a role in the pathogenesis of MS and other immune-mediated disorders of the nervous system.

Elevation of human cerebrospinal fluid clusterin concentration is associated with acute neuropathology

Clusterin is a serum glycoprotein which is an inhibitor of complement and is expressed in many tissues in cell injury and death. It has been identified normal and pathological brain tissue and is a component of normal human cerebrospinal fluid (CSF). We have measured the clusterin concentration of 115 abnormal and normal human CSF samples and related these data to the patient's clinical diagnoses. CSF clusterin levels in patients with neurodegenerative and meningeal disease were within the normal range. Twelve of 15 patients with demyelination, however, had significant elevation of CSF clusterin concentration. This was not a specific finding for multiple sclerosis as elevated clusterin levels were also seen in patients with other acute neuropathology. Determination of CSF clusterin concentration may be of clinical value in neurological diagnosis.

Detection and measurement of an endogenous clonidine-displacing substance in human cerebrospinal fluid

Clonidine-displacing substance (CDS) is a novel endogenous ligand for clonidine receptors previously detected in bovine brain and human serum. We examined for the first time whether CDS can be detected and measured in human cerebrospinal fluid (CSF). Using the [3H]clonidine displacement assay, we found that CDS could be identified and quantified in each of the CSF samples obtained from 81 patients with various neurological disorders. Mean level of CDS in CSF was 4.66 units/ml. Exceedingly high levels were observed in the CSF of patients with neoplastic meningitis (mean, 36.75 units/ml) and stroke (mean, 19.5 units/ml) (P < 0.0001). No correlation was found between CDS levels in CSF and age, gender, CSF protein or number of cells. CDS levels in CSF were higher than those in the serum (P < 0.01). We conclude that CDS is present and can be measured in human CSF. High CDS levels in CSF from patients with leptomeningeal metastases may serve as a tumor marker for malignant infiltration of the meninges. Additional studies in stroke patients will determine whether this endogenous ligand plays a role in the pathogenesis of cerebral ischemia.

Serum and CSF anti-GM1 antibodies in patients with Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy

High titers of antibodies directed against gangliosides, especially GM1, are found in the serum of patients with a variety of polyneuropathies, including those of the inflammatory type. We assayed anti-GM1 IgG and IgM levels in the serum and cerebrospinal fluid (CSF) of 23 patients with Guillain-Barré syndrome (GBS) and 10 with chronic inflammatory demyelinating polyneuropathy (CIDP) to investigate whether this immune response may also be localized within the intrathecal compartment and correlate with clinical parameters such as time interval since disease onset, disability score, preceding infectious episodes, and GM1 therapy. When compared to the control group, anti-GM1 IgG was increased in the serum of 39% of GBS and 10% of CIDP patients, whereas anti-GM1 IgM was elevated in 17% of GBS and none of the CIDP patients. In both patient groups, however, anti-GM1 antibody levels were more frequently elevated in CSF than paired sera: they belonged to the IgG class in 48% of GBS and 50% of CIDP patients, and to the IgM class in 48% of GBS and 55% of CIDP patients. In the GBS group, anti-GM1 IgM serum levels inversely correlated with time elapsed between sample collection and onset of disease (P < 0.05), whereas serum anti-GM1 IgG levels positively correlated with the loss of functional ability (P < 0.005). Increased anti-GM1 antibodies in GBS serum were not associated with clinical or serological evidence of infectious antecedents nor with previous GM1 treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Virus-associated demyelination in the pathogenesis of Bell's palsy

We examined the cerebrospinal fluid findings, including the activity of the myelin-associated enzyme 2',3'-cyclic nucleotide 3'-phosphohydrolase (CNP), and virus serology in patients with Bell's palsy. Eighty-nine of 164 patients showed hematological and/or serological evidence of an inflammatory reaction. Examinations of the CSF disclosed an elevated total protein level and pleocytosis in 33% and 10% of the 91 patients, respectively. The activity of CNP was significantly elevated in the patient group (15.5 +/- 3.8 nmol/h/ml) as compared with the control (13.2 +/- 1.3 nmol/h/ml) (p < 0.01), suggesting the presence of intrathecal myelin breakdown. Furthermore, there was an association between antibodies against herpes simplex virus (HSV) and elevated CNP activity. The inflammatory alterations and accompanying spinal fluid abnormalities, together with the high frequency of HSV antibodies suggest that HSV-associated demyelination may play a pathogenetic role in Bell's palsy.

Lecithin cholesterol acyltransferase in human cerebrospinal fluid: reduced level in patients with multiple sclerosis and evidence of direct synthesis in the brain

Several studies suggest that apolipoproteins and the low-density lipoprotein receptor are implicated in lipid transport in the brain. Given that cerebrospinal fluid has been reported to contain cholesteryl esterifying enzyme, and that lipid metabolism in the brain is abnormal in subjects with multiple sclerosis, we examined the cerebrospinal fluid from eight control subjects with a normal cerebrospinal fluid IgG index, and without active demyelinating disease, and from eight subjects (6 were diagnosed as having multiple sclerosis) with an increased IgG index and the presence of oligoclonal banding in the cerebrospinal fluid, for the presence of the enzyme lecithin cholesterol acyltransferase and apolipoprotein(a). None of the subjects demonstrated impairment of their blood-cerebrospinal fluid barrier, as estimated by the cerebrospinal fluid/serum quotient of albumin. Lecithin cholesterol acyltransferase was detected in the cerebrospinal fluid of all control subjects, being 0.12 +/- 0.06 microgram/ml (mean +/- SD) or about 2.2% of that in serum (5.4 +/- 1.4 micrograms/ml). The cerebrospinal fluid lecithin cholesterol acyltransferase index was 5.2 +/- 2.5, very similar to the cerebrospinal fluid index of apolipoprotein E, a protein known to be synthesized in the brain. Since lecithin cholesterol acyltransferase mRNA is also expressed in the brain, we can conclude that the protein is synthesized and secreted in the brain. The cerebrospinal fluid concentration of lecithin cholesterol acyltransferase in the subjects with active demyelinating disease or multiple sclerosis was only about one-half of that found in control subjects (0.06 +/- 0.02 microgram/ml).(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrospinal fluid myelin basic protein as predictive marker of demyelination in AIDS dementia complex

Myelin basic protein (MBP) was measured in cerebrospinal fluid (CSF) of patients with acquired immunodeficiency syndrome (AIDS) dementia complex (ADC) in order to investigate the degree of white matter destruction. Results show that increased CSF levels of MBP were detected in all patients with severe ADC (10/10) and, less often, in subjects with mild (2/7) or moderate dementia (7/16). No evidence of MBP-elevated concentration was observed in 14 human immunodeficiency virus (HIV)-seropositive subjects without neurological disorders and in nine HIV-seronegative controls. Our findings suggest that the measurement of CSF MBP concentration may represent a predictive marker of myelin injury and neurologic damage during the course of ADC.

Association of demyelination with deficiency of cerebrospinal-fluid S-adenosylmethionine in inborn errors of methyl-transfer pathway

Long-term deficiency of cobalamin or folate causes a demyelinating disease of the brain and spinal cord. A reduced supply of methyl groups has been implicated as its cause. To examine the mechanisms of demyelination in human beings, we have studied three children with sequential inborn errors of the methyl-transfer pathway. One child had abnormal methylfolate metabolism, one abnormal methylcobalamin metabolism, and one hypermethioninaemia probably caused by methionine adenosyltransferase deficiency. Magnetic resonance imaging of the brain and measurement of cerebrospinal-fluid concentrations of 5-methyltetrahydrofolate, methionine, and S-adenosylmethionine were carried out before and after 6-12 months of appropriate treatment. Each patient had abnormal myelination before treatment; the scans suggested demyelination. The only consistent biochemical abnormality in the cerebrospinal fluid was a low concentration of S-adenosylmethionine. Treatment led to substantial clinical improvement, apparent remyelination, and increases in cerebrospinal-fluid S-adenosylmethionine concentration into the normal range. Cerebrospinal-fluid concentrations of S-adenosylmethionine and methionine were significantly lower in eight other children with errors of the methyl-transfer pathway than in an age-matched reference population (mean [95% confidence interval] standard deviation score -1.81 [0.57], p less than 0.001 for S-adenosyl methionine and -1.82 [0.19], p less than 0.001 for methionine). The concentrations of these metabolites increased to within the reference range on treatment. We have shown that demyelination is associated with cerebrospinal-fluid S-adenosylmethionine deficiency and that restoration of S-adenosylmethionine is associated with remyelination.

Acute parkinsonian syndrome with demyelinating leukoencephalopathy in bone marrow transplant recipients

A syndrome of rigidity, bradykinesia, spasticity, and often myoclonus and dementia developed acutely in 5 patients who had undergone successful engraftment of bone marrow transplants for the treatment of various hematologic diseases. Magnetic resonance imaging demonstrated widespread changes in white matter; brain biopsy disclosed mild demyelination associated with active phagocytosis of myelin. One patient, who was not treated, remains severely demented. Patients treated with very high-dose methylprednisolone had complete clinical recovery.

[Diagnostic value of cytological examination of the cerebrospinal fluid with the millipore membrane filter technique]

With the millipore membrane filter (MP) technic 280 samples of CSF from 203 cases with different diseases involving the central nervous system were studied. 76 of these samples were examined with the slide centrifuge technic simultaneously for comparison. In accordance with the pathological cell components (transformed lymphocytes, plasmocytes, different phagocytes, granular neurocytes and tumor cells) as well as the clinical data, the diagnostic results could be divided into three groups. The diagnoses were definitely established in 19.6% of the cases with the cytological examination of the CSF. The diagnoses were suggestive in 50.7% and not established with the cytological examination of the CSF in 29.6%. With intracranial infection, demyelinating disease, cerebrovascular accidents and brain tumors an overall higher positive diagnostic rate of 76.8% was obtained and with other neurological disorders it was only 19.2% (P less than 0.001). The advantages and disadvantages of the MP technic were compared with those of the slide centrifuge and sedimentation chamber technics. The limitation of the staining method for the MP slides remained to be further studied. More than two technics for concentrating CSF cells were recommended to be in use for the time being.