Changes in Th17 and regulatory T cells after fingolimod initiation to treat multiple sclerosis

Fingolimod has demonstrated efficacy in patients with multiple sclerosis (MS), and patients become gradually lymphopenic after a few days of treatment, with selective reductions in CD4+ subsets. We observed an increase in the frequencies of circulating regulatory T cells after fingolimod administration. However, we also found that half of patients had increased proportion of circulating Th17 cells in CD4+ T cells after treatment (including a patient with MS relapses), whereas the others showed lower frequencies of Th17 cells, indicating some variability among patients. Further studies may confirm if slower reduction of circulating Th17 cells following fingolimod initiation predisposes to relapses.

A case of systemic lupus erythematosus with severe acute pancreatitis

Abstract  A 39-year-old woman with systemic lupus erythematosus (SLE) developed severe acute pancreatitis during a well-controlled disease stage. Treatment with intraarterial injections of antipancreatic enzyme and a small amount of prednisone (20 mg/day) led to remission of the pancreatitis. Disease activity of the SLE did not flare up throughout the course of this treatment. The development of severe acute pancreatitis in SLE is rare. We discuss the cause of pancreatitis in SLE, and whether corticosteroids may induce or improve pancreatitis.

[Case of recurrent encephalomyelitis associated with eosinophilia in CSF]

We report a 30-year-old man with recurrent eosinophilic encephalomyelitis. He had a history of childhood asthma and allergic rhinitis. A half year before admission, when he suffered from a headache, a few lesions were indicated by brain MRI at another hospital. From a month before admission, he noticed gait disturbance, sensory impairment, difficulty in micturition, and constipation. Neurological examination revealed moderate muscle weakness in the feet, hypoesthesia below Th6, and bladder-bowel disturbance including impotence. Lumbar T(2) weigthed MRI showed a severe swelling and a hyperintense lesion at the conus medullaris. Brain MRI revealed several asymptomatic white matter lesions. Eosinophilia was documented in the cerebrospinal fluid (CSF) but not in the peripheral blood. Clinical symptoms and MRI findings were remarkably improved after steroid pulse therapy. Note that eosinophils in the CSF were also decreased after the treatment with apoptosis-like cells. We thought that CSF eosinophilia was the core pathogenic feature of this case, but clinical settings that provoke CSF eosinophilia such as parasites and other infectious agents, neuromyelitis optica, atopic myelitis, eosinophilic leukemia and hypereosinophilic syndrome could be ruled out. The remarkable responses to steroids without any additional therapy, compatible with idiopathic eosinophilic syndromes, confirmed that this was a case of idiopathic eosinophilic recurrent encephalomyelitis.

Postural leg tremor in X-linked spinal and bulbar muscular atrophy

X-linked spinal and bulbar muscular atrophy (SBMA) is an adult-onset neuromuscular disorder caused by a CAG repeat expansion in the androgen receptor gene. Postural hand tremor is well known as a non-motor neuron sign, but to our knowledge postural leg tremor has not been reported. We studied the occurrence and physiological features of postural leg tremor in 12 male patients (38-64 years old) with genetically proven SBMA. Three patients had postural leg tremor with a frequency of 4-7Hz. In these patients, sensory nerve action potential (SNAP) was not detected in the lower limbs. There were significant differences between the patients with postural leg tremor and those without postural leg tremor in both the SNAP of the sural nerve and the length of the CAG repeat. Phenotypical differences between shorter CAG repeats, which indicate a sensory-dominant phenotype, and longer CAG repeats, which indicate a motor-dominant phenotype, have been previously reported. In the present study, 60% of patients with shorter CAG repeats (<47) showed leg tremor and none of the patients with longer CAG repeats (≥47) did. Postural leg tremor could be a clinical feature that predicts shorter CAG repeats of the androgen receptor gene.

Proliferative lesions of intra-epidermal cytokeratin CAM5.2-positive cells in canine nipples

Non-keratinocyte cells with clear or vacuolated cytoplasm are frequently observed in the epidermis of canine nipples. Most of these cells express cytokeratin (CK) CAM5.2, a marker of luminal epithelial cells. The morphological and immunohistochemical characteristics of these clear cells were investigated. Nipple tissue from 36 dogs of both sexes was collected and labelled immunohistochemically for CAM5.2, CK7, CK14, CK18, CK20, α-smooth muscle actin, p63, melan-A, E-cadherin, epidermal growth factor receptor and oestrogen receptor (OR). The intra-epidermal CAM5.2(+) clear cells were present singly or as small clusters, mostly within the basal layer, in 22 dogs (61%). These cells also expressed CK7, CK18, E-cadherin and OR. Electron microscopy revealed that some of these cells had surface microvilli. Multifocal proliferative lesions consisting of these cells were observed in the nipples of four dogs. In these lesions, proliferating cells formed bilayered tubules with CAM5.2(+) inner and CK14/p63(+) outer cells. This is the first report describing intra-epidermal CAM5.2(+) clear cells, distinct from melanocytes and Merkel cells in dog nipples. These cells might arise from the luminal epithelium of the papillary duct.

Establishment of monoclonal antibodies against the extracellular domain that block binding of NMO-IgG to AQP4

Neuromyelitis optica is a demyelinating disease characterized by a disease-specific autoantibody designated as NMO-IgG that specifically recognizes aquaporin-4, and the binding of NMO-IgG to AQP4 causes the progress of the disease. Prevention of the binding of NMO-IgG, therefore, may alleviate the disease. Here we have developed monoclonal antibodies against AQP4 with a baculovirus display system in order to obtain high affinity monoclonal antibodies against the extracellular domains of AQP4. Our monoclonal antibodies can block the binding of NMO-IgG in spite of their heterogeneity. Taken together, we propose that our monoclonal antibodies can be applied in clinical therapy for NMO patients.

Aquaporin-4 antibody-positive cases beyond current diagnostic criteria for NMO spectrum disorders

OBJECTIVES

To analyze aquaporin-4 (AQP4) antibody-positive patients who do not fulfill the current diagnostic criteria of neuromyelitis optica (NMO) and NMO spectrum disorders (NMOSD).

METHODS

We used a cell-based assay (CBA) with AQP4-transfected cells to detect AQP4 antibody in 298 consecutive patients with inflammatory CNS disorders seen at Tohoku University Hospital from 2007 to 2012. The patients were diagnosed as NMO, NMOSD, multiple sclerosis, or others using the respective current diagnostic criteria. The seropositive samples by CBA were also tested using a commercial ELISA.

RESULTS

Seventy-two patients were AQP4 antibody positive. Among them, 18.1% (13/72) did not meet the NMO or NMOSD criteria (7 with monophasic optic neuritis, 2 with attacks restricted to the brainstem, and 4 with myelitis with less than 3 vertebral segments) and 84.6% (11/13) of these had only a single attack. The ELISA results were negative in 38.4% (5/13) of those patients, and they had lower antibody titers by CBA than patients with NMO/NMOSD. Although these patients had a shorter follow-up and few attacks, they shared some clinical features with NMO/NMOSD patients such as onset age, female predominance, presence of other autoantibodies, severe optic neuritis attacks, centrally located spinal cord lesions, persisting hiccups, and nausea or vomiting episodes.

CONCLUSIONS

AQP4 antibody-positive patients with single or recurrent attacks of optic neuritis, myelitis, or brain/brainstem disease not fulfilling the current criteria of NMO or NMOSD may not be uncommon, and they should also be included in the NMO spectrum.

Aquaporin-4 antibody-positive cases beyond current diagnostic criteria for NMO spectrum disorders

OBJECTIVES

To analyze aquaporin-4 (AQP4) antibody-positive patients who do not fulfill the current diagnostic criteria of neuromyelitis optica (NMO) and NMO spectrum disorders (NMOSD).

METHODS

We used a cell-based assay (CBA) with AQP4-transfected cells to detect AQP4 antibody in 298 consecutive patients with inflammatory CNS disorders seen at Tohoku University Hospital from 2007 to 2012. The patients were diagnosed as NMO, NMOSD, multiple sclerosis, or others using the respective current diagnostic criteria. The seropositive samples by CBA were also tested using a commercial ELISA.

RESULTS

Seventy-two patients were AQP4 antibody positive. Among them, 18.1% (13/72) did not meet the NMO or NMOSD criteria (7 with monophasic optic neuritis, 2 with attacks restricted to the brainstem, and 4 with myelitis with less than 3 vertebral segments) and 84.6% (11/13) of these had only a single attack. The ELISA results were negative in 38.4% (5/13) of those patients, and they had lower antibody titers by CBA than patients with NMO/NMOSD. Although these patients had a shorter follow-up and few attacks, they shared some clinical features with NMO/NMOSD patients such as onset age, female predominance, presence of other autoantibodies, severe optic neuritis attacks, centrally located spinal cord lesions, persisting hiccups, and nausea or vomiting episodes.

CONCLUSIONS

AQP4 antibody-positive patients with single or recurrent attacks of optic neuritis, myelitis, or brain/brainstem disease not fulfilling the current criteria of NMO or NMOSD may not be uncommon, and they should also be included in the NMO spectrum.