Sarcoidosis of the spinal cord and medulla oblongata. A pathological and neuroradiological case report

A case of 68-year-old woman with symptoms of slowly progressive diffuse myelopathy, is presented, which could only temporally be reversed by immunosuppression. Contrast enhanced magnetic resonance (MR) scan demonstrated multifocal patchy enhancing lesions from cervical to mild thoracic segment and a circumscribed lesion of the whole medulla oblongata. Postmorten examination disclosed a histological confirmed, multifocal sarcoidosis of the spinal cord and medulla oblongata, with few sarcoid granulomas in one hilar lymph node and skeletal muscle of the upper extremities. Only nine similar cases of intramedullary sarcoidosis confirmed by autopsy with symptoms solely attributable to the spinal cord have been reported. A review of the pathological manifestations, diagnostic and treatment of intramedullary sarcoidosis is given.

Pheochromocytomas, multiple endocrine neoplasia type 2, and von Hippel-Lindau disease

BACKGROUND

Pheochromocytoma is a feature of two disorders with an autosomal dominant pattern of inheritance--multiple endocrine neoplasia type 2 (MEN-2) (with medullary thyroid carcinoma and hyperparathyroidism) and von Hippel-Lindau disease (with angioma of the retina, hemangioblastoma of the central nervous system, renal-cell carcinoma, pancreatic cysts, and epididymal cystadenoma). The frequency of these syndromes in patients with pheochromocytoma is not known.

METHODS

In an unselected group of patients with pheochromocytoma, we performed pentagastrin tests, parathyroid hormone assays, computed tomography (CT) or magnetic resonance imaging (MRI) of the brain, ophthalmoscopy, CT imaging of the abdomen, and ultrasonography of the testes. We also screened members of families with MEN-2 or von Hippel-Lindau disease for pheochromocytoma by measuring plasma and urine catecholamines and plasma chromogranin A and by performing abdominal ultrasonography, CT and MRI, and metaiodobenzylguanidine scintigraphy.

RESULTS

Nineteen of 82 unselected patients with pheochromocytomas (23 percent) were carriers of familial disorders; 19 percent had von Hippel-Lindau disease and 4 percent had MEN-2. Prospectively, in 36 of 79 subjects at risk for pheochromocytoma (46 percent), 42 unsuspected pheochromocytomas were found. Overall, there were 130 patients with 185 pheochromocytomas; 43 had von Hippel-Lindau disease, 24 had MEN-2, and 63 had sporadic tumors. The patients with familial and those with sporadic pheochromocytomas differed in mean age at diagnosis (32 vs. 46 years, P < 0.001), multifocal localization (55 vs. 8 percent, P < 0.001), and cancer (0 vs. 11 percent, P = 0.005); but not in the frequency of extraadrenal tumors (24 vs. 16 percent). Thirty-eight percent of carriers of von Hippel-Lindau disease and 24 percent of carriers of MEN-2 had pheochromocytoma as the only manifestation of their syndrome.

CONCLUSIONS

All patients with pheochromocytomas should be screened for MEN-2 and von Hippel-Lindau disease to avert further morbidity and mortality in the patients and their families. All patients in families with MEN-2 or von Hippel-Lindau disease should be screened for pheochromocytoma, even if they are asymptomatic.

Cytoplasmic expression of the leu-4 (CD3) antigen in developing Purkinje cells in the rat cerebellum

Although commonly known to represent a T cell receptor (CD3) associated polypeptide, the leu-4 (CD3) antigen occurs in cerebellar Purkinje cells (PCs) of many species. The monoclonal pan T lymphocyte marker anti-leu-4 (CD3) recognizes both the lymphocytic and the Purkinje cell type of this antigen [22]. To obtain more information about the merit of anti-leu-4 (CD3) as an investigational tool, we evaluated the expression of leu-4 (CD3) in PCs of the developing rat cerebellum (in situ) by light microscopy. Positive anti-leu-4 (CD3) immunoreaction of PCs did not occur prior to post-natal day (D) 4. The analysis of immunostaining during cell differentiation revealed three major phases of post-natal PC maturation including antigenic development of cell somata (phase 1: until D6), dendrites (phase 2: D7-D11), and axons (phase 3: D12-D14). A massive post-weaning expansion of the dendritic arborization led then to the mature PC architecture. Additionally, the leu-4 (CD3) antigen was observed in ectopic PC dendrites (D10) and in ectopic (mature) PCs. Throughout post-natal development as well as in mature PCs, the leu-4 (CD3) antigen was found to be cytoplasmic. Due to its labile nature, neither an ultrastructural localization nor molecular characterization could be achieved. For the same reason, its application is basically restricted to cryo-fixed cerebellar tissue. However, at the level of light microscopy, the monoclonal human T cell marker anti-leu-4 (CD3) proved to be a useful tool for specific and sensitive labelling of differentiated cerebellar PCs in the rat.

Intrastriatal cerebellar grafts: differentiation of cerebellar anlage and sprouting of Purkinje cell axons

Pieces of cerebellar primordia were obtained from G16 (day 16 of gestation) rat fetuses and stereotaxically injected into the striatum of adult Wistar rats. The transplants were allowed to integrate with the host brain for 2 h up to 6 months after implantation. Ninety four out of 105 transplants perfectly integrated with the host brain (90%) and established the typical trilaminar histoarchitecture of cerebellar cortex. The transplants were sufficiently vascularized. Vessels seen within the grafts provided all ultrastructural elements of a blood-brain barrier. Light microscopic evaluation of graft development showed no considerable retardation of cerebellar histogenesis. Electron microscopic examination disclosed normal ultrastructure of cerebellar neurons, as well as elements of regular synaptic organization. The topic of efferent graft-to-host projections was investigated 2.5 months after transplantation using the monoclonal Purkinje cell marker anti-Leu-4 (CD3). This method allowed us to detect immunoreactive, morphologically intact axons of grafted Purkinje cells running over long distances (at least 500 microns) within the host striatum. Whilst afferent but in no case efferent connections of heterotopic cerebellar transplants had been demonstrated elsewhere, we could now prove the reciprocal modus of graft-host interaction with heterotopic cerebellar grafts.

Influence of phenytoin on cytoskeletal organization and cell viability of immortalized mouse hippocampal neurons

Phenytoin (PHT) is a commonly used anticonvulsant drug; several side effects have been described, including morphological changes in brain cortex and cerebellar neurons and teratogenic lesions in infants of epileptic mothers. Evidence of other authors indicate that PHT may exert its action through the modification of phosphorylation patterns of cytoskeletal polypeptides. We have studied the influence of the anticonvulsant drug phenytoin on immortalized mouse hippocampal neurons in culture. This was done by means of MTT-assays, immunocytochemical and immunoblot analyses, measurements of cell metabolism, measurements of the length of neuronal processes, and electron microscopy. A distinct and pronounced effect of PHT could be characterized with regard to the formation of neuronal processes, involving malfunction of an assembly-mechanism of cytoskeletal constituents. These accumulated within appendages (blebs) or cytoplasmic condensations, instead of forming normally organized processes. However, PHT did not interfere with bulk synthesis of cell proteins and specific cytoskeletal components.

Effects of interleukin-1 and interleukin-6 on metallothionein and amyloid precursor protein expression in human neuroblastoma cells. Evidence that interleukin-6 possibly acts via a receptor different from the 80-kDa interleukin-6 receptor

Since immunohistochemical studies indicated the presence of interleukin-6 in the cortices of patients with Alzheimer's disease, we were interested in the eventual biological effects of this cytokine on neuronal cells. We found that interleukin-6 and interleukin-1 induced metallothionein expression in a human neuronal (SH-SY5Y neuroblastoma) cell line. In contrast to metallothionein, amyloid precursor protein expression was unaffected by both cytokines. When searching in the same cell line for the expression of the classical 80-kDa interleukin-6 binding protein, which is part of the dimeric interleukin-6 receptor, we were unable to detect the respective mRNA. Our findings either indicate that the interleukin-6 receptor in these cells is expressed in extremely low levels or that interleukin-6 may act upon neuronal cells via a different, yet unknown neuronal receptor.

Effects of perinatal hypo- and hyperthyroidism on the levels of nerve growth factor and its low-affinity receptor in cerebellum

Deficits or excesses of thyroid hormones during critical periods of mammalian cerebellar development can lead to profound biochemical and morphological abnormalities in this system. The goal of this study was to investigate the effects of perinatal hypo- and hyperthyroidism on the ontogeny of nerve growth factor (NGF) and its low-affinity receptor (p75NGFR) in the rat cerebellum. The concentration of NGF and of p75NGFR immunoreactivity (IR) were measured, several days after birth, in cerebella of rats which had received propylthiouracil (PTU) or thyroxine. NGF concentration was markedly enhanced only on postnatal day 2 (P2) in hyperthyroid rats, whereas in hypothyroid (PTU-treated) rats NGF values were similar to age-matched controls. These observations suggest that thyroid hormone affects NGF synthesis during early periods of cerebellar development. In Purkinje cells of control animals, p75NGFR IR peaked at P10. In hypothyroid rats, the expression of p75NGFR was retarded, peaking at P15, whereas in hyperthyroid rats it was advanced, peaking at P8. The increased p75NGFR IR found in Purkinje cell bodies and the delayed disappearance of p75NGFR IR from the external granular layer of hypothyroid rats suggest different roles for thyroid hormone in the developing cerebellum. We conclude that p75NGFR and NGF are independently regulated by thyroid hormone during critical periods of cerebellar development. The effect of thyroid hormone deficiency on p75NGFR content in Purkinje cells may involve complex mechanisms such as impaired efficiency of axonal transport.

Central nervous system lesions in von Hippel-Lindau syndrome

CNS manifestations were studied in 97 gene carriers of von Hippel-Lindau syndrome (HLS). Haemangioblastomas of the CNS were found in 43 patients (44%), 23 females and 20 males. The mean age at diagnosis was 39 years (12-73 years). A total of 93 haemangioblastomas were detected of which 74% were intracranial and 26% were located in the spinal cord; 75% were predominantly cystic and 25% presented as solid lesions. Multiple lesions were found in 42% of HLS-associated haemangioblastomas, but in none of 51 patients with CNS haemangioblastoma without HLS. Haemangioblastoma was the cause of death in 82% of patients with HLS. Although microsurgery has considerably improved post-operative results, multifocal tumour development and recurrence remain a serious problem in the clinical management of HLS gene carriers.

Primary cerebral malignant non-Hodgkin's lymphomas: a retrospective clinical study

In this retrospective study a series of 54 patients (seen from 1982 to 1989) with sporadic primary cerebral malignant lymphomas (PCML), which were uniformly classified with the support of immunocytochemical data, is presented. The analysis shows that on CT PCML are shown as cirumscribed, homogeneous, contrast-enhanced multifocal (70%) or solitary (30%) mass lesions within the subcortical white matter; they were found mainly close to the ventricular system or the subarachnoid space. To prove the histological diagnosis and for the purposes of differential diagnosis, low-risk CT-stereotactic biopsy is necessary and is the method of choice. Immunomorphological techniques are valuable adjuncts to confirm the histological diagnosis of PCML. In the series presented these tumours have been predominantly classified as high-grade blastic B-cell lymphomas. For this reason, this type should be regarded as the prevalent variant of malignant brain lymphomas. The evaluation of possible prognostic factors suggests that age at admission and morphological features of regression are relevant determinants of survival time. A correlation between neuroradiological evidence of a decrease in tumour size, morphological signs of regression and glucocorticoid administration has been found. Thus, patients suspected of having PCML require rapid diagnosis prior to corticosteroid administration. PCML have been shown to be radioresponsive, but not curable. Because of the lack of uniformity in management of this rate brain neoplasm, the different treatment protocols are not comparable, and hence the optimum therapy has not been satisfactorily determined.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of interleukin-6 and alpha 2-macroglobulin immunoreactivity in cortex and hippocampus of Alzheimer's disease patients

We examined brains from Alzheimer's disease (AD) patients by immunohistochemistry for the presence of protease inhibitors. Immunoreactivity for alpha 2-macroglobulin (alpha 2-M), the most potent of the known human protease inhibitors, was found in a subgroup of cortical and hippocampal AD senile plaques. In addition, large hippocampal neurons in AD brains displayed intracellular alpha 2-M immunoreactivity which was consistently stronger than in normal aged brains. In cultured human cells of neurogenic origin (SH-SY5Y neuroblastoma cells), alpha 2-M synthesis could be strongly induced by the inflammatory cytokine interleukin-6 (IL-6) indicating that human alpha 2-M behaves as an acute-phase protein in the nervous system. Therefore, we also examined AD brains for the presence of IL-6 and found strong immunostaining in and around a subgroup of senile plaques as well as around large cortical neurons. Only very few senile plaques also stained for C-reactive protein, an acute phase protein known to be inducible by IL-6. We propose that the presence of IL-6 and alpha 2-M immunoreactivity in AD brains is functionally linked and that a sequence of immunological events is part of the pathology of AD.

CT and MRI: prognostic tools in patients with AIDS and neurological deficits

To determine the prognostic value of CT and MRI in AIDS we studied the survival of patients with neurological involvement, in relation to the initial imaging results. Twenty-six initial CT and 15 MRI examinations of 41 patients were reviewed for the presence of cerebral atrophy and/or focal lesions. The mean survival time of patients with initially normal imaging was longer (700 +/- 89 days) than that of patients with isolated cerebral atrophy (326 +/- 65) or isolated focal lesions (202 +/- 97). The shortest survival (78 +/- 44 days) was found in patients with both cerebral atrophy and focal lesions. The risk of death in patients with atrophy alone was 3.6 times higher, that in patients with focal lesions alone 6.4 times higher, and in patients with both changes 19.3 times higher than in patients with initially normal imaging. Cerebral imaging with CT and/or MRI thus allows identification of AIDS-related cerebral changes and may contribute to assessment of prognosis.

A clinicopathologic and immunomorphologic study of 13 cases of ganglioglioma

The authors present the clinical, histopathologic, and immunomorphologic data of 13 intracranial gangliogliomas. Preoperative computed tomography scans showed a commonly cystic tumor of variable density. Six tumors were completely excised and seven were subtotally resected. After a mean follow-up of 4.5 +/- 2.6 years, 11 patients are asymptomatic or only slightly incapacitated. All tumors were examined with a panel of neuronal and neuroendocrine markers. Immunoreactivity (IR) to anti-neurofilament polypeptide (clone 2F11) was observed in neuronal processes in ten cases and in neuronal perikarya in five. With anti-synaptophysin (clone SY38), IR was present along the lining of ganglion cell perikarya and processes in 11 tumors whereas staining of the perinuclear cytoplasm was prominent in two. IR to anti-chromogranin A (clone LK2H10) was observed within the neuronal perikarya in eight cases. Only one ganglioglioma of the brain stem showed IR for tyrosine-hydroxylase (clone 2/40/15) and dopamine-beta-hydroxylase in some neoplastic ganglion cells. In this study, synaptophysin was the most reliable neuronal marker. For immunocytochemical identification of neoplastic neurons in ganglioglioma as well as other tumors with neuronal differentiation the authors propose a panel of well-characterized monoclonal antibodies against neurofilament polypeptides, synaptophysin, and chromogranin A to support the histomorphologic diagnoses.

Gliomatosis cerebri: bioptical approach and neuropathological verification

Gliomatosis cerebri is rarely encountered and its intra vitam diagnosis has remained difficult. We present biopsy and autopsy findings in three cases that are representative of diffuse glioma, gliomatosis cerebri and diffuse glioblastosis, a modification of the subclassification proposed by Zülch31. Stereotactic biopsy in conjunction with nuclear magnetic resonance tomography (MRT) is recommended as the diagnostic procedure in suspected cases. Immunohistochemical examination with a panel of neuroectodermal markers is helpful in the differential diagnosis but has to take into account that reactive astrocytes may be closely intermingled with the neoplastic glial cells.

Pancreatic lesions in the von Hippel-Lindau syndrome

Common manifestations of the von Hippel-Lindau syndrome, an autosomally dominant inherited cancer-prone disorder, include retinal angiomatosis, hemangioblastoma of the central nervous system, renal cysts, renal cancer, pheochromocytoma, and epididymal cystadenoma. Multiple cysts and microcystic (serous) cystadenomas of the pancreas have also been reported occasionally in patients afflicted with this syndrome. In the large Freiburg study of the von Hippel-Lindau syndrome composed of 66 affected individuals, pancreatic lesions were systematically studied. Fifty-five living individuals were examined by abdominal ultrasound imaging. Abnormal findings were confirmed by computed tomographic scan and/or magnetic resonance imaging. For an additional 11 decreased patients autopsy data were available. Cystic lesions of the pancreas were found in 10 patients (15%). One of these patients presented with multiple pancreatic cysts as the only manifestation of the syndrome. In one patient, a malignant islet-cell tumor was found at autopsy. Because multiple pancreatic cysts did not cause major clinical symptoms and because follow-up examinations over an average period of 5 years did not show significant progression of the lesions, it is concluded that these patients usually do not require surgical treatment. Abdominal ultrasound screening is recommended for patients at risk as a tool to identify potential von Hippel-Lindau syndrome gene carriers with pancreatic manifestations. In all patients with multiple pancreatic cysts, the von Hippel-Lindau syndrome should be included in the differential diagnosis.

In-vitro matured human macrophages express Alzheimer's beta A4-amyloid precursor protein indicating synthesis in microglial cells

Microglia which are consistently associated with Alzheimer's disease (AD) senile plaques are part of the mononuclear phagocyte system. In-vitro matured human monocyte-derived macrophages feature many immunological characteristics of microglia. We found strong constitutive expression of Alzheimer's beta A4-amyloid precursor protein (APP) in human mononuclear phagocytes after terminal in-vitro maturation from monocytes to macrophages. Amyloid has previously been found to be associated with microglia in AD brains, however, it remained unclear whether the material was synthesized in or had been phagocytosed by the cells. The findings presented here support the assumption that brain microglia may contribute to APP synthesis in AD brain.

Alpha 2-macroglobulin synthesis in interleukin-6-stimulated human neuronal (SH-SY5Y neuroblastoma) cells. Potential significance for the processing of Alzheimer beta-amyloid precursor protein

Cultured human neuronal (SH-SY5Y neuroblastoma) cells synthesize and secrete the potent protease inhibitor alpha 2-macroglobulin (a2M) upon stimulation with interleukin-6 (IL-6) indicating that alpha 2-macroglobulin behaves as an acute-phase protein in the human central nervous system. Exogenous addition of a2M to the cultured neuronal cells resulted in only a slight inhibition of Alzheimer beta A4-amyloid precursor protein (APP) synthesis, but markedly inhibited its secretion pointing to the possibility that a2M may affect the proteolytic APP processing. Evidence is provided that IL-6 and a2M are involved in Alzheimer's disease pathogenesis.

Mapping of phenytoin-inducible cytochrome P450 immunoreactivity in the mouse central nervous system

The distribution of phenytoin-inducible cytochrome P450 in non-treated mouse brain and spinal cord was analysed immunohistochemically using polyclonal antibodies against phenytoin-induced mouse cerebral microsomal P450. This P450 protein was proved in Ouchterlony [Volk B. et al. (1988) Neurosci. Lett. 84, 219-224], Western blot, and immunohistochemical analyses to be reactive to the specific antibodies and an IgG fraction raised against phenobarbital-induced rat liver microsomal P450IIB1. The phenytoin-induced P450 is designated P450IIB1* because immunologically it is comparable with P450IIB1; however, it has not yet been analysed for other characteristics of this enzyme. Immunocytochemistry was performed on acetone-fixed serial cryosections of the whole brain using the avidin-biotin-peroxidase detection system. Negative controls included incubations with preimmune serum of the immunized animal instead of the primary antibody and preabsorption of the antibody with the corresponding immunogen. The pattern of immunoreactive sites indicates that P450IIB1* is not distributed evenly throughout the CNS. It was found to be restricted to only some cellular populations. The most striking aspect of immunostaining was a predominant reactivity in the evolutionary old brain parts. Neuropil and neuronal staining was found in the spinal cord (motor neurons of the ventral horn), medulla oblongata (hypoglossal nuclei, magnocellular part of the lateral reticular nuclei), pons (trigeminal, facial, cochlear and pontine nuclei), cerebellum (granule cells), midbrain (dorsal raphe nucleus) and limbic lobe (hippocampal pyramidal cells). Neuropil reactivity alone appeared in cerebellar nuclei, midbrain, thalamus, basal ganglia, neopallium and olfactory brain. Generally, pia mater/arachnoid, ependyma, choroid plexus, vascular system and some astrocytic populations were found to be strongly P450IIB1* immunoreactive. In comparison with astroglia, which is characterized by glial fibrillary acidic protein-positiveness, the astrocytes, which are also P450IIB1* reactive, occurred only in subpial and subependymal layers, and in large fiber tracts of the spinal cord and brainstem, where they were attached to the vascular system. Otherwise, the glial fibrillary acidic protein-positive astrocytes were not P450IIB1* immunoreactive in the cerebellar molecular layer (fibers of Bergmann glia), in remaining neuropils and in white matter areas.

[The significance of stereotaxic brain biopsy in atypical multiple sclerosis]

Multiple sclerosis (MS) is one of the most common diseases of the central nervous system. Up to now, there is no pathognomonic test to ascertain the diagnosis and in 10 to 15% of MS cases there are problems in differential diagnosis. We report 15 bioptically diagnosed MS cases with atypical clinical, C.S.F. and neuroradiological findings. In each case the diagnosis of MS was made by CT/MRI-stereotactic brain biopsy. Neoplastic and other non-tumorous lesions could be excluded. Indications for and significance of stereotactic brain biopsy in atypical cases of MS are discussed.