Phenotypic and neuropathologic heterogeneity of anti-Hu antibody-related paraneoplastic syndrome presenting with progressive dysautonomia: report of two cases

The anti-Hu antibody (HuAb) is directed against RNA-associated neuronal proteins and is known to cause paraneoplastic encephalomyelitis/sensory neuronopathy syndrome mostly when associated with small cell lung cancer (SCLC). Paraneoplastic encephalomyelitis/sensory neuronopathy syndrome with concurrent autonomic neuropathy has been reported to occur in paraneoplastic syndromes, although its occurrence concomitant with acute pandysautonomia is less frequent. The authors describe the clinical, neuropathologic, and serologic features of two cases with an anti-Hu-related paraneoplastic syndrome presenting with progressive autonomic neuropathy. Both patients showed features of dysautonomia, including postural dizziness, abdominal pain, and diarrhea, and symptoms of sensory neuropathy. Investigations disclosed severe sensory and autonomic neuropathy and positive HuAb titers. The disease of patient 1 had a very rapid progression, and the patient died of cardiac arrest within 2 months of the onset of symptoms. The autopsy revealed SCLC. In contrast, the disease of patient 2 had a less aggressive course. An extensive tumor search disclosed SCLC only 28 months after onset of symptoms, and the patient died 1 month later of cardiorespiratory arrest. Autopsies in both cases showed inflammation involving the intermediolateral columns and the dorsal root ganglia. These two cases illustrate the association of early dysautonomia with HuAb-related paraneoplastic syndrome and the variations of clinical, neuropathologic, and serologic findings in these types of cases.

In vivo regulation of Na/Ca exchanger expression by adrenergic effectors

The Na/Ca exchanger encoded by the NCX1 gene plays an important role in calcium homeostasis in cardiac muscle. We previously identified three in vitro signaling pathways that are of major importance in the regulation of Na/Ca exchanger gene expression in neonatal cardiac myocytes, the protein kinase A (PKA) and protein kinase C (PKC) pathways, and intracellular Ca(2+). To determine whether these pathways are important in vivo, we stimulated the PKA and PKC pathways and examined functional expression of the Na/Ca exchanger in adult rat heart. After a 3- and 7-day treatment, norepinephrine (200 microg x kg(-1) x h(-1)), isoproterenol (150 microg x kg(-1) x h(-1)), and phenylephrine (200 microg x kg(-1) x h(-1)) each stimulated a significant increase in NCX1 mRNA levels (35-85%, P < 0.05). Norepinephrine also stimulated a 35% increase in protein abundance (P < 0.05), a 20% decrease in relaxation duration (P < 0.05), and a 25% reduction in the fluorescence decay constant (P < 0.05) after a 7-day treatment. We conclude that a 7-day treatment of alpha- and beta-adrenergic agonists increases the expression of functional Na/Ca exchangers in adult rat heart.

Relevance of residual histologic and electrocorticographic abnormalities for surgical outcome in frontal lobe epilepsy

PURPOSE

To estimate the significance of residual electrocorticographic and neuropathologic abnormalities on seizure control after surgery for frontal lobe epilepsy with the purpose of determining their relevance in deciding the extent of the surgical procedure.

METHODS

The presence of epileptiform discharges in intraoperative electrocorticograms (ECoGs) and the nature and extent of neuropathologic abnormalities were reviewed for 35 patients who underwent frontal lobe resections for the treatment of epilepsy at our institution. The relations between surgical outcome and presence of the following features were studied: (a) presence of abnormal tissue at the limits of the resection; (b) presence of sporadic spikes and seizure patterns in the preresection ECoG; (c) their abolition in the postresection ECoG; and (d) the topography of residual discharges with respect to the margins of the resection.

RESULTS

On neuropathologic examination, 18 patients showed focal cortical dysplasia (CD), and 17 showed other abnormalities (non-CD). Ten CD patients and 11 non-CD patients experienced a favourable outcome. Seizure patterns were significantly more common in patients with focal cortical dysplasia than in those without, with a sensitivity of 94% and a specificity of 75%. Abolition of seizure patterns was associated with a favourable surgical outcome (p = 0.031). Abolition of sporadic spikes or their presence in the postresection ECoG did not influence outcome. There was no clear relation between outcome and location of residual sporadic discharges. Seizure patterns persisted in the postresection ECoG in three CD patients, were located at the margins of the resection in all three, and these patients had a poor outcome. Incomplete removal of abnormal tissue was not associated with a poorer outcome in either patient group or in the complete sample.

CONCLUSIONS

Seizure patterns were significantly more common in patients with cortical dysplasia, and their abolition on postresection ECoG recordings was associated with a favourable surgical outcome. Persistence of sporadic ECoG spikes and incomplete removal of histologic abnormalities did not affect outcome significantly.

Acetylation of a specific promoter nucleosome accompanies activation of the epsilon-globin gene by beta-globin locus control region HS2

On stably replicating episomes, transcriptional activation of the epsilon-globin promoter by the beta-globin locus control region HS2 enhancer is correlated with an increase in nuclease sensitivity which is limited to the TATA-proximal nucleosome (N1). To elucidate what underlies this increase in nuclease sensitivity and the link between chromatin modification and gene expression, we examined the nucleoprotein composition and histone acetylation status of transcriptionally active and inactive promoters. Micrococcal nuclease digestion of active promoters in nuclei released few nucleosome-like nucleoprotein complexes containing N1 sequences in comparison to results with inactive promoters. We also observed that N1 DNA fragments from active promoters are of a subnucleosomal length. Nevertheless, chromatin immunoprecipitation experiments indicate that histones H3 and H4 are present on N1 sequences from active promoters, with H3 being dramatically hyperacetylated compared with that from inactive promoters and vector sequences. Strikingly, H3 in the adjacent upstream nucleosome (N2) does not appear to be differentially acetylated in active and inactive promoters, indicating that the nucleosome modification of the promoter that accompanies transactivation by HS2 is highly directed and specific. However, global acetylation of histones in vivo by trichostatin A did not activate transcription in the absence of HS2, suggesting that HS2 contributes additional activities necessary for transactivation. N1 sequences from active promoters also contain reduced levels of linker histone H1. The detection of a protected subnucleosomal sized N1 DNA fragment and the recovery of N1 DNA sequences in immunoprecipitations using anti-acetylated H3 and H4 antibodies argue that N1 is present, but in an altered conformation, in the active promoters.

Prognostic significance of tumor burden in the blood of patients with erythrodermic primary cutaneous T-cell lymphoma

Erythrodermic cutaneous T-cell lymphoma (CTCL) includes patients with erythrodermic mycosis fungoides who may or may not exhibit blood involvement and Sézary syndrome and in whom hematological involvement is, by definition, present at diagnosis. These patients were stratified into 5 hematologic stages (H0-H4) by measuring blood tumor burden, and these data were correlated with survival. The study identified 57 patients: 3 had no evidence of hematologic involvement (H0), 8 had a peripheral blood T-cell clone detected by polymerase chain reaction (PCR) analysis of the T-cell receptor gene and less than 5% Sézary cells on peripheral blood smear (H1), and 14 had either a T-cell clone detected by Southern blot analysis or PCR positivity with more than 5% circulating Sézary cells (H2). Twenty-four patients had absolute Sézary counts of more than 1 x 10(9) cells per liter (H3), and 8 patients had counts in excess of 10 x 10(9) cells per liter (H4). The disease-specific death rate was higher with increasing hematologic stage, after correcting for age at diagnosis. A univariate analysis of 30 patients with defined lymph node stage found hematologic stage (P =.045) and lymph node stage (P =.013) but not age (P =.136) to be poor prognostic indicators of survival. Multivariate analysis identified only lymph node stage to be prognostically important, although likelihood ratio tests indicated that hematologic stage provides additional information (P =.035). Increasing tumor burden in blood and lymph nodes of patients with erythrodermic CTCL was associated with a worse prognosis. The data imply that a hematologic staging system could complement existing tumor-node-metastasis staging criteria in erythrodermic CTCL.

The use of Mitek pins in the mandibular lingual releasing approach to oral and/or oropharyngeal carcinomas: a technical note

Resection of carcinoma of the oral cavity and oropharynx requires adequate exposure. The purpose of this paper is to demonstrate the approach employed (mandibular lingual releasing approach) for resection of some oral cavity or oropharyngeal carcinomas and to point out the indications, advantages, complications, and refinements of this technique. The technique was carried out on 23 patients with oral cavity or oropharyngeal squamous cell carcinomas. A lingual floor-of-mouth flap was created allowing delivery of the tongue and floor of mouth without lip splitting, mandibulotomy, or mandibulectomy. After resection of the tumour and repair of the defect, the musculature of the floor of the mouth was reattached to the lingual cortex of the mandible using Mitek minianchors. There was adequate exposure in all the patients. Wound margin dehiscence occurred in four patients resulting in an orocervical fistula in three patients. Mandibular osteotomy and subsequent osteosynthesis were avoided. Thus instability and infection of the osteotomy site were avoided. However, additional mandibular osteotomy is feasible.

The relationship of magnetic source imaging to ictal electrocorticography in a neuronavigational workspace

Magnetic source imaging (MSI) registers magnetoencephalographic (MEG) activity to a three-dimensional MRI volume. State-of-the-art MSI allows concurrent whole head coverage, but is practically restricted to interictal recording. However, the purpose of the presurgical evaluation of epileptic patients, in which MSI is playing an increasing role, is the elucidation of the ictal epileptogenic focus. The manner in which interictal MSI activity relates to the ictal focus has not yet been adequately examined. To facilitate this analysis, we are developing techniques to precisely coregister MSI to the ictal onset zone as defined by extraoperative intracranial grid/strip monitoring. The neuronavigational workspace is a convenient area in which to precisely coregister these (and other) imaging and physiological data sets.

Locations of the regulatory sites for isocitrate dehydrogenase kinase/phosphatase

Isocitrate dehydrogenase (IDH)(1) of Escherichia coli is regulated by a bifunctional protein, IDH kinase/phosphatase. In this paper, we demonstrate that the effectors controlling these activities belong to two distinct classes that differ in mechanism and in the locations of their binding sites. NADPH and isocitrate are representative members of one of these effector classes. NADPH inhibits both IDH kinase and IDH phosphatase, whereas isocitrate inhibits only IDH kinase. Isocitrate can "activate" IDH phosphatase by reversing product inhibition by dephospho-IDH. Mutations in icd, which encodes IDH, had parallel effects on the binding of these ligands to the IDH active site and on their effects on IDH kinase and phosphatase, indicating that these ligands regulate IDH kinase/phosphatase through the IDH active site. Kinetic analyses suggested that isocitrate and NADPH prevent formation of the complex between IDH kinase/phosphatase and its protein substrate. AMP, 3-phosphoglycerate, and pyruvate represent a class of regulatory ligands that is distinct from that which includes isocitrate and NADPH. These ligands bind directly to IDH kinase/phosphatase, a conclusion which is supported by the observation that they inhibit the IDH-independent ATPase activity of this enzyme. These effector classes can also be distinguished by the observation that mutant derivatives of IDH kinase/phosphatase expressed from aceK3 and aceK4 exhibited dramatic changes in their responses to AMP, 3-phosphoglycerate, and pyruvate but not to NADPH and isocitrate.

Mandibular distraction in temporomandibular joint ankylosis

Condylar damage during childhood can produce ankylosis and alteration of the mandibular growth. In case of unilateral ankylosis occurring in early childhood, a mandibular hypoplasia of the affected side may develop. The patients have limitation of mouth opening, facial asymmetry, and chin deviation toward the affected side. The aims of this study are to show the use of distraction osteogenesis in mandibular hypoplasia associated with ankylosis and to present our experience with a new therapeutic option for the treatment of mandibular hypoplasia with unilateral ankylosis in the childhood consisting of the association of arthroplasty to treat the ankylosis and mandibular distraction to correct the facial asymmetry, both accomplished in the same surgical procedure. From November of 1996 to November of 1997, three male patients aged 2, 7, and 13 years with mandibular hypoplasia and ankylosis were treated by distraction osteogenesis. An arthroplasty consisting of the resection of the ankylotic block and interposition of a temporalis muscle flap, plus coronoidectomy was done in two of them and mandibular distraction was done in all three patients. Articular functional rehabilitation began on the first postoperative day. Mandibular distraction began on the fifth postoperative day with a rate of 1 mm per day, ending when the facial symmetry was achieved. From the first postoperative day, an increase in the mouth opening was achieved; this increase continued until ending the distraction. The average duration of distraction was 22 days. Average duration of consolidation was 6 weeks. Oral opening increased from 10 mm to 35 mm in the 7-year-old patient, from 9 mm to 27 mm in the 2-year-old patient, and from 14 mm to 38 mm in the 13-year-old patient. To date, oral opening and facial symmetry persist. Osseous mandibular distraction together with arthroplasty offers an excellent new alternative for treatment of patients with mandibular hypoplasia and associated ankylosis, with minimal morbidity and complications.

Structural and functional cross-talk between a distant enhancer and the epsilon-globin gene promoter shows interdependence of the two elements in chromatin

We investigated the requirements for enhancer-promoter communication by using the human beta-globin locus control region (LCR) DNase I-hypersensitive site 2 (HS2) enhancer and the epsilon-globin gene in chromatinized minichromosomes in erythroid cells. Activation of globin genes during development is accompanied by localized alterations of chromatin structure, and CACCC binding factors and GATA-1, which interact with both globin promoters and the LCR, are believed to be critical for globin gene transcription activation. We found that an HS2 element mutated in its GATA motif failed to remodel the epsilon-globin promoter or activate transcription yet HS2 nuclease accessibility did not change. Accessibility and transcription were reduced at promoters with mutated GATA-1 or CACCC sites. Strikingly, these mutations also resulted in reduced accessibility at HS2. In the absence of a globin gene, HS2 is similarly resistant to nuclease digestion. In contrast to observations in Saccharomyces cerevisiae, HS2-dependent promoter remodeling was diminished when we mutated the TATA box, crippling transcription. This mutation also reduced HS2 accessibility. The results indicate that the epsilon-globin promoter and HS2 interact both structurally and functionally and that both upstream activators and the basal transcription apparatus contribute to the interaction. Further, at least in this instance, transcription activation and promoter remodeling by a distant enhancer are not separable.

The effect of vigabatrin (gamma-vinyl GABA) on cerebral blood flow and metabolism

OBJECTIVE

To investigate the effect of vigabatrin (VGB; gamma-vinyl gamma-aminobutyric acid [GABA]), a selective irreversible GABA-transaminase inhibitor, on cerebral metabolic rate for glucose (CMRGlc) and cerebral blood flow (CBF) measured with 18F-fluorodeoxyglucose (FDG) PET and 15O water PET.

BACKGROUND

Antiepileptic drugs (AEDs) reduce CMRGlc to varying degrees. Phenobarbital causes a mean decrease of 30 to 40%. Phenytoin, carbamazepine (CBZ), and valproate (VPA) cause milder reductions in CMRGlc. The combination of VPA with CBZ results in a greater decrease than either drug alone. The effect of novel AEDs on both CBF and CMRGlc has not been studied extensively.

METHODS

Fourteen patients with refractory complex partial seizures on CBZ monotherapy for 4 weeks were included in the study. All patients had baseline 18F-FDG and 15O water PET studies followed by double-blind randomization to placebo (PLC) or VGB while on continuous CBZ treatment. PET scans were repeated after an interval of 2 months on target dose of VGB (50 mg/kg) or PLC. Quantitative PET data analysis was performed using a region of interest template. Significance was tested with the Wilcoxon rank sum test.

RESULTS

No statistically significant difference in age, duration of epilepsy, or CBZ levels was observed in the two patient groups. VGB reduced global CMRGlc by 8.1+/-6.5% and global CBF by 13.1+/-10.4%. The change in CMRGlc was different in patients taking VGB compared with those on PLC (p < 0.04). VGB patients showed regional decreases in both CMRGlc and CBF, particularly in temporal lobes. CSF total GABA increased in the VGB patient group (1.48+/-1.06 versus 4.03+/-4.19 nm/mL). The increase differed from the PLC group (p < 0.03). We found a strong relation between decreased total CSF GABA and increased CMRGlc in the VGB patient group (R2 = 0.82, p < 0.01).

CONCLUSIONS

Vigabatrin (VGB) causes mild reductions in both cerebral blood flow (CBF) and cerebral metabolic rate for glucose (CMRGlc) in contrast to other drugs such as barbiturates, which are direct agonists at the gamma-aminobutyric acid-benzodiazepine receptor complex. Conventional AEDs depress CBF and CMRGlc to a greater degree than does VGB. The relatively mild reduction could be due to pre- as well as postsynaptic effects or a use-dependent mechanism.

Inherited prion disease with an alanine to valine mutation at codon 117 in the prion protein gene

A large English family with autosomal dominant segregation of presenile dementia, ataxia and other neuropsychiatric features is described. Diagnoses of demyelinating disease, Alzheimer's disease, Creutzfeldt-Jakob disease (CJD) and Gerstmann-Sträussler-Scheinker syndrome have been attributed to particular individuals at different times. An Irish family, likely to be part of the same kindred, is also described, in which diagnoses of multiple sclerosis, dementia, corticobasal degeneration and new variant CJD have been considered in affected individuals. Molecular genetic studies have enabled the classification of this disease at the molecular level as one of the group of inherited prion diseases, with the substitution of valine for alanine at codon 117 of the prion protein gene (PRNP). Only three other kindreds have been described world-wide with this mutation and only limited phenotypic information has been reported. Here we describe the phenotypic spectrum of inherited prion disease (PrPA117V). The diversity of phenotypic expression seen in this kindred emphasizes the logic of molecular classification of the inherited prion diseases rather than classification by specific clinicopathological syndrome. Indeed, inherited prion disease should be excluded by PRNP analysis in any individual presenting with atypical presenile dementia or neuropsychiatric features and ataxia, including suspected cases of new variant CJD.

Malignant myoepithelioma of the salivary glands: clinicopathological and immunohistochemical features

Malignant myoepitheliomas (myoepithelial carcinomas) are uncommon, and we know of only 29 reported cases. We present a new case together with its clinical, histological, and immunohistochemical features. The tumour was located in the inferior vestibular sulcus of a 64-year-old woman. She was treated by wide local resection. Malignant myoepitheliomas are distinguished from benign myoepithelial neoplasms by their infiltrating and destructive growth. The tumour cells may be spindle-shaped or more rounded (plasmacytoid cells) and contain cellular pleomorphism and mitotic activity. The clinical and biological behaviour of this tumour is not yet known and there is little information about treatment and prognosis.

Listeria meningitis presenting in an immunocompetent adult patient

A case of fatal Listeria meningitis in an immunocompetent 39-year-old female is presented. Although most patients with CNS listeriosis are immunosuppressed, infection in immunocompetent individuals may also occur.

The vasopressin precursor is not processed in the hypothalamus of Wolfram syndrome patients with diabetes insipidus: evidence for the involvement of PC2 and 7B2

Wolfram syndrome (WS) is characterized by optic atrophy, insulin-dependent diabetes mellitus, vasopressin (VP)-sensitive diabetes insipidus, and neurosensory hearing loss. Here we report a disturbance in VP precursor processing in the supraoptic and paraventricular nuclei of WS patients. In these patients with diabetes insipidus we could hardly detect any cellular immunoreactivity for processed VP in the supraoptic and paraventricular nuclei. On the other hand, in the paraventricular nucleus a considerable number of cells immunoreactive for the VP precursor were present. In addition, the proprotein convertase PC2 and the molecular chaperone 7B2 were absent. As expression of PC2 and 7B2 was detected in the nearby nucleus basalis of Meynert of one WS patient and in the anterior lobe of the other WS patient, the absence of the two proteins in the paraventricular nucleus was not due to mutations in their genes. These results indicate that in WS patients with diabetes insipidus, not only does VP neuron loss occur in the supraoptic nucleus, but there is also a defect in VP precursor processing.

Rasmussen's encephalitis: neuroimaging findings in 21 patients with a closer look at the basal ganglia

Rasmussen's encephalitis usually presents in childhood. The clinical picture in Rasmussen's disease is protean, and the findings from direct brain imaging help to explain the variations seen in this syndrome. The role and involvement of the basal ganglia in this condition is clarified by comparing the changes seen on computerised tomography and magnetic resonance imaging with the clinical details of 21 patients described in this retrospective study.

An ecologic analysis of psychosocial stress and heart disease in British Columbia

Cardiovascular disease is the leading cause of death in Canada. However, much heart disease incidence cannot be explained by known risk factors, and evidence points to the potential role played by the psychosocial environment. This study involves an ecologic analysis exploring the relationships between psychosocial stress and ischaemic heart disease (IHD) in British Columbia. First, data from the Canada Health Promotion Survey correlated stress indicators (i.e., education, marital status) with self-reported stress levels. Results showed gender differences in stress. Stage II consisted of a multivariate analysis of ischaemic heart disease mortality in B.C. Results indicate a strong association between heart disease outcomes and educational background for both males and females. Findings of this study support a link between IHD and psychosocial factors. The results of the multiple regression must be interpreted with caution, given the use of an ecologic analysis. Additional research at the individual level is needed to fully understand these relationships.

A clinicopathological study of autism

A neuropathological study of autism was established and brain tissue examined from six mentally handicapped subjects with autism. Clinical and educational records were obtained and standardized diagnostic interviews conducted with the parents of cases not seen before death. Four of the six brains were megalencephalic, and areas of cortical abnormality were identified in four cases. There were also developmental abnormalities of the brainstem, particularly of the inferior olives. Purkinje cell number was reduced in all the adult cases, and this reduction was sometimes accompanied by gliosis. The findings do not support previous claims of localized neurodevelopmental abnormalities. They do point to the likely involvement of the cerebral cortex in autism.

An ecologic analysis of psychosocial stress and heart disease in British Columbia

Cardiovascular disease is the leading cause of death in Canada. However, much heart disease incidence cannot be explained by known risk factors, and evidence points to the potential role played by the psychosocial environment. This study involves an ecologic analysis exploring the relationships between psychosocial stress and ischaemic heart disease (IHD) in British Columbia. First, data from the Canada Health Promotion Survey correlated stress indicators (i.e., education, marital status) with self-reported stress levels. Results showed gender differences in stress. Stage II consisted of a multivariate analysis of ischaemic heart disease mortality in B.C. Results indicate a strong association between heart disease outcomes and educational background for both males and females. Findings of this study support a link between IHD and psychosocial factors. The results of the multiple regression must be interpreted with caution, given the use of an ecologic analysis. Additional research at the individual level is needed to fully understand these relationships.