A case of clinically and neuropathologically atypical corticobasal degeneration with widespread iron deposition

A 65-year-old woman was admitted to our hospital for forgetfulness, depression and eccentric behavior that had been first noticed 2 years prior to admission. She showed memory impairment, perseveration and repeated violent actions, but no limb-kinetic apraxia. She died 12 years after the onset of symptoms. At autopsy, the unfixed brain weighed 820 g. Atrophy was circumscribed in the frontal lobe on both sides. The globus pallidus and the caudate nucleus were markedly atrophic and gold yellow in color, and the substantia nigra was strikingly pale. The cortical area showed neuronal loss and status spongiosus of the second and third cortical layers with ballooned neurons. Marked neuronal loss was observed in the dorsomedial nucleus of the thalamus, Meynert basal nucleus and substantia nigra. With Holzer stain, fibrillary gliosis was found to be severe in the frontal lobe, globus pallidus, subthalamic nucleus, hippocampus, dorsomedial nucleus of thalamus, substantia nigra, pontine tegmentum and inferior olivary nucleus. With Bielschowsky-Hirano stain, neurofibrillary tangles were observed in the cortex, hippocampus, substantia nigra, dentate nucleus, subthalamic nucleus, pontine nucleus, the inferior olivary nucleus, dorsomedial nucleus of the thalamus and, to a lesser extent, the neostriatum. Strikingly numerous argyrophilic and tau-positive threads were present in the cerebral white matter. These neuropathological findings corresponded to corticobasal degeneration, but lesions characteristic of progressive supranuclear palsy were also found. Moreover, widespread iron deposition throughout the central nervous system was the most striking finding of the present case. To our knowledge, such a case has not been reported in the literature to date.

Familial Parkinson's disease. Alpha-synuclein and parkin

We have reviewed recent progress in establishing the function of alpha-synuclein and parkin in relation to nigral degeneration in autosomal dominant and autosomal recessive PD. Mutations of alpha-synuclein (Ala53Thr and Ala30Pro) cause a form of autosomal dominant PD with early onset. Parkin is a novel protein expressed in the cytoplasm, including the terminal regions and Golgi apparatus. Mutations of parkin cause a form of autosomal recessive young-onset PD (ARJP). Both proteins appear to be associated with fast axonal transport. In addition, in sporadic PD, normal alpha-synuclein shows an increased tendency to self-aggregate. Thus, altered axonal transport of presynaptic proteins appears to play a crucial role in neurodegeneration in PD.

Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men

We examined substance use in relationship to transmission risk behavior (unprotected insertive, UIAI, or receptive anal intercourse, URAI) between HIV-positive men who have sex with men (MSM) and their HIV-negative or unknown serostatus partners. Men who engaged in transmission risk behavior with casual partners were more likely than men who did not engage in such behavior to have used various substances. Users of certain drugs were specifically less likely to use condoms with HIV-negative or unknown status partners than users. Of men who drank alcohol, those who drank more frequently before or during sex engaged in significantly more UIAI with casual partners. Of men who used drugs, those who used more frequently before or during sex were more likely to engage in URAI with casual partners. In multivariate analyses, use of inhalants as well as drinking before or during sex predicted UIAI, while use of inhalants as well as noninjection drug use before or during sex predicted URAI. HIV prevention programs for HIV-positive MSM should focus on decreasing substance use and use specifically before or during sex. Developing prevention programs for substance-using MSM is critical to improve community health and decrease HIV transmissions.

Pollutant runoff from non-point sources and its estimation by runoff models

In order to attain a sound and sustainable water environment, it is important to carry out the environmental management of the watershed. For this purpose, knowledge on the pollutant runoff mechanism from non-point sources becomes very important especially under rainy conditions. At Isahaya, Nagasaki, Japan, a big project of construction of sea-dyke and reclamation is now going on, so reducing the pollutant runoff, especially from non-point sources, becomes more important. Some runoff models of rainwater are developed to predict the rate of pollutant loads from the non-point sources, and their results are compared with each other to investigate the accuracy of prediction. In this paper, runoff analysis of both rainwater and pollutants has been carried out using three models: the tank model, the kinematic wave (K-W) model, and a model using the digital elevation model (DEM). For precise estimation, it becomes necessary to identify the parameters included in these models. Here, total nitrogen has been considered as pollutants, and detachment rates are evaluated, correlated with a class of land use, soil type, and moisture content. Finally, it has been shown that pollutant runoff from non-point sources can be predicted fairly well, identifying the model parameter appropriately.

Cupular response and functional anatomy to pressure application in the pigeon

In this study, horizontal semicircular canal of the pigeon was inserted with a microfill, 164 micrometers in outer diameter, to gauge the pressure change in the canal and to clarify two things. One is whether the endolymph passes through the crista ampullaris or not. The other is as to the space where the endolymph passes through in the crista ampullaris if the endolymph goes through the crista. The pressure applications were performed by using Evans blue solution and as a result three pressure groups, i.e., 1) high, 2) moderate and 3) low were discriminated. Our results suggest that the endolymphatic fluid passes through the subcupular space or the top of the crista ampullaris when the pressure is enough small like the head rotates in daily life. Accordingly we present a new hypothesis as to the functional anatomy of the cupula in contrast to current hypotheses e.g. drum membrane or revolving door.

Passage of dextran magnetite nanoparticles through the subcupular space of the pigeon

We examined the permeability of the subcupular space for endolymph flow in the pigeon. A new technique was developed in which nanoparticles consisting of dextran magnetite were attracted by use of a magnet, instead of injecting a dye solution. The method was revealed to prevent an excess pressure application by the injection of dye solution. The Berlin blue color resulting from the dextran magnetite nanoparticles was found mainly within the subcupular space contacting with the sensory hairs. Further formation of the Berlin blue was found within the sensory cells. The result supports the idea that the fluid passes through the subcupular space.

[A case of convergence spasm in hysteria improved with a brief psychiatric assessment]

We report a 16-year-old female who developed double vision. The diplopia was in the horizontal plane and persisted for 3 weeks. She also complained of headache and nausea. She kept her eyes closed unless she was told to open. When eyelids were passively open, both eyes deviated inward in an adducted position. The pupil size and the reaction to light were normal. No weakness was noted in the extraocular muscles when each eye was examined individually. The rest of the neurologic examinations were normal. We thought that she had a convergence spasm. Brain CT and MRI were normal. The CSF and blood chemistries were also normal. We treated her with supportive psychotherapy and her convergence spasm disappeared. We concluded that her convergence spasm was a manifestation of conversion hysteria.

[A quadriplegic patient with chronic inflammatory demyelinating polyneuropathy (CIDP) who responded well to corticosteroids and intravenous immunoglobulin therapy]

We report an elderly patient with chronic inflammatory demyelinating polyneuropathy (CIDP) presenting with complete quadriplegia who responded well to the treatment. A 74-year-old woman was transferred to our hospital from a hospital for the elderly patients. The patient had a history of progressive limb weakness over three years, and has been quadriplegic for the last six months. The patient was unable to move her extremities, but neither respiratory nor bulbar dysfunction was observed. Deep tendon reflexes were absent. Glove and stocking type sensory disturbance was noted. Nerve conduction studies showed slowed motor and sensory conduction velocities with diminished compound muscle action potentials (CMAP). Abnormal temporal dispersion and conduction blocks were also demonstrated. Cerebrospinal fluid examination revealed an elevated protein level of 78 mg/dl with normal cell counts. The patient was diagnosed as having CIDP. She was treated with methylprednisolone pulse therapy and oral prednisolone, followed by high dose intravenous immunoglobulin treatment. Significant recovery occurred during the first week, and she became able to walk four months later. Motor nerve conduction velocity (MCV) and CMAP were also improved. It is suggested that CIDP must be considered in patients with quadriplegia of unknown etiology: such patients may be seen in hospitals for elderly patients.

[A 64-year-old man with parkinsonism as an initial symptom followed by dementia associated with marked abnormal behaviours]

We report a 64-year-old man with parkinsonism as an initial symptom, which was followed by dementia and abnormal behaviours. He was well until 1985, when he was 49 years old, when he noted rest tremor in his right hand. Soon tremor appeared in his left hand as well. He was seen in our clinic and levodopa was prescribed. He was doing well with this medication, however, in 1993, he started to suffer from on-off phenomenon. He also noted visual hallucination. In 1994, he stole a watermelon and ate it in the shop. He repeated such abnormal behaviours. In 1995, he was admitted to the neurology service of Hatsuishi Hospital. On admission, he was alert and oriented. He did not seem to be demented; however, he admitted stealing and hypersexual behaviours. No aphasia, apraxia, or agnosia was noted. In the cranial nerves, downward gaze was markedly restricted. He showed masked and seborrhoic face, and small voice. No motor palsy was noted, but he walked in small steps with freezing and start hesitation. Marked neck and axial rigidity was noted. Tremor was absent except for in the tongue. No cerebellar ataxia was noted. Deep tendon reflexes were diminished. Plantar response was extensor bilaterally. Forced grasp was noted also bilaterally. He was treated with levodopa and pergolide, but he continued to show on-off phenomenon. His balance problem and akinesia became progressively worse; still he showed hypersexual behaviour problems. He also showed progressive decline in cognitive functions. In 1997, he started to show dysphagia. He developed aspiration pneumonia in July of 1998. In 1999, he developed emotional incontinence and became unable to walk. He also developed repeated aspiration pneumonia. He died on March 1, 2000. He was discussed in a neurological CPC and the chief discussant arrived at a conclusion that the patient had corticobasal degeneration. Other diagnoses entertained included dementia with Lewy bodies, diffuse Lewy body disease, and frontotemporal dementia. Majority of the participants thought that diffuse Lewy body disease was most likely. Post-mortem examination revealed marked nigral neuronal loss, gliosis and Lewy bodies in the remaining neurons. Abundant Lewy bodies of cortical type were seen wide spread in the cortical areas, but particularly many in the amygdaloid nucleus. Lewy bodies were also seen in the subcortical structures such as the dorsal motor nucleus, oculomotor nucleus, Meynert nucleus, putamen, and thalamus. What was interesting was marked neuronal loss of the pontine nuclei, demyelination of the pontocerebellar fiber, and moderate neuronal loss of the cerebellar Purkinje neurons, a reminiscent of pontocerebellar atrophy. However, the inferior olivary nucleus was intact.

[A patient with intravascular malignant lymphomatosis presenting subacute dementia one year after sustained urinary retention and high serum LDH activity from the onset]

We report a 71-year-old man with intravascular malignant lymphomatosis who showed high serum LDH and urinary disturbance for one year before manifesting dementia. High serum LDH was found at a health check at age 70. Two months later, he had an onset of backache and urinary retention. MRI of the spinal cord was unremarkable. One year later, he showed decline of mental activities and was admitted to our hospital. He was agitated and confused. However cranial nerve palsy or limb weakness was not noted. The MRI of the brain showed T2-high signal in bilateral occipital, right temporal lobe and the left insular cortices. The abdominal CT scan showed swelling of the adrenals on both sides. Adrenal biopsy revealed diffuse large B cell lymphoma. He developed respiratory distress and he died two months after the admission. Post mortem examination revealed intravascular and extravascular proliferation of lymphoma cells in most of the internal organs including adrenals, spleen, liver and the kidneys. In the brain, the laminar necrosis was seen in the left occipital cortex and hemorrhagic infarctions were noted in the insular and temporal cortices and the medial temporal cortex. Sacral spinal cord showed necrosis of the gray matters and loss of myelinated fibers in the white matter. Intravascular proliferation of the lymphoma cells were also seen in the vessels of the brain and the spinal cord. This patient suggests the importance of survey for intravascular malignant lymphomatosis, when high serum LDH and myelopathy of lumbosacral area are seen.

Obsessive-compulsive-like behavioral changes in pure akinesia

Pure akinesia is a disorder characterized by profound freezing in the absence of rigidity or tremor that is not improved by levodopa therapy. We report two cases of pure akinesia who developed obsessive-compulsive-disorder- (OCD-) like behavior during their illness. Although the pathophysiological mechanism underlying freezing is unclear, the coexistence of pure akinesia and OCD-like behavior suggests that both symptoms have a common pathological basis in these two cases, presumably damage to the pallidum.

Iron accumulation in the substantia nigra of autosomal recessive juvenile parkinsonism (ARJP)

Autosomal recessive juvenile parkinsonism (ARJP) is a distinct clinical and genetic entity characterized by highly selective neuronal death in the substantia nigra (SN) and locus coeruleus neurons without Lewy body formation. The mechanism of neuronal death of ARJP is still unknown. Our study demonstrated that iron staining was more intense in ARJP than in both controls and sporadic Parkinson's disease (PD), and there were differences in the pattern of distribution of iron staining between ARJP and PD. In addition neurites of SN in ARJP showed intense iron staining. Thus, we postulate that oxidative stress may play an important role in the neurodegeneration that occurs in ARJP.

An AAV-derived Apaf-1 dominant negative inhibitor prevents MPTP toxicity as antiapoptotic gene therapy for Parkinson's disease

Adeno-associated virus (AAV) vector delivery of an Apaf-1-dominant negative inhibitor was tested for its antiapoptotic effect on degenerating nigrostriatal neurons in a 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) model of Parkinson's disease. The wild-type caspase recruitment domain of Apaf-1 was used as a dominant negative inhibitor of Apaf-1 (rAAV-Apaf-1-DN-EGFP). An AAV virus vector was used to deliver it into the striatum of C57 black mice, and the animals were treated with MPTP. The number of tyrosine hydroxylase-positive neurons in the substantia nigra was not changed on the rAAV-Apaf-1-DN-EGFP injected side compared with the noninjected side. We also examined the effect of a caspase 1 C285G mutant as a dominant negative inhibitor of caspase 1 (rAAV-caspase-1-DN-EGFP) in the same model. However, there was no difference in the number of tyrosine hydroxylase-positive neurons between the rAAV-caspase-1-DN-EGFP injected side and the noninjected side. These results indicate that delivery of Apaf-1-DN by using an AAV vector system can prevent nigrostriatal degeneration in MPTP mice, suggesting that it could be a promising therapeutic strategy for patients with Parkinson's disease. The major mechanism of dopaminergic neuronal death triggered by MPTP seems to be the mitochondrial apoptotic pathway.

Parkin is linked to the ubiquitin pathway

Autosomal recessive juvenile parkinsonism (AR-JP) is one of the most common forms of familial Parkinson's disease. AR-JP is characterized by selective and massive loss of dopaminergic neurons in the substantia nigra of the midbrain and absence of Lewy bodies, the pathological hallmark of idiopathic Parkinson's disease. Parkin, the causative gene of AR-JP, encodes a 52-kDa protein that is a RING-type ubiquitin (Ub) protein ligase (E3) collaborating with a Ub-conjugating enzyme (E2) belonging to a cognate class of UbcH7 or UbcH8. Analysis of parkin mutations in AP-JP patients reveals that the functional loss of parkin as an E3 enzyme is the molecular basis of AR-JP. Thus it is now clear that AR-JP is due to failure of proteolysis mediated by the Ub-proteasome system and accumulation of as yet unidentified protein(s) causes nigral neuronal death without formation of Lewy bodies. These findings should shed new light on the mechanisms underlying neurodegeneration in sporadic Parkinson's disease as well as AR-JP.

Q-angle influences tibiofemoral and patellofemoral kinematics

Numerous surgical procedures have been developed to correct patellar tracking and improve patellofemoral symptoms by altering the Q-angle (the angle between the quadriceps load vector and the patellar tendon load vector). The influence of the Q-angle on knee kinematics has yet to be specifically quantified, however. In vitro knee simulation was performed to relate the Q-angle to tibiofemoral and patellofemoral kinematics. Six cadaver knees were tested by applying simulated hamstrings, quadriceps and hip loads to induce knee flexion. The knees were tested with a normal alignment, after increasing the Q-angle and after decreasing the Q-angle. Increasing the Q-angle significantly shifted the patella laterally from 20 degrees to 60 degrees of knee flexion, tilted the patella medially from 20 degrees to 80 degrees of flexion, and rotated the patella medially from 20 degrees to 50 degrees of flexion. Decreasing the Q-angle significantly tilted the patella laterally at 20 degrees and from 50 degrees to 80 degrees of flexion, rotated the tibia externally from 30 degrees to 60 degrees of flexion, and increased the tibiofemoral varus orientation from 40 degrees to 90 degrees of flexion. The results show that an increase in the Q-angle could lead to lateral patellar dislocation or increased lateral patellofemoral contact pressures. A Q-angle decrease may not shift the patella medially, but could increase the medial tibiofemoral contact pressure by increasing the varus orientation.

Sensitive determination of midazolam and identification of its two metabolites in human body fluids by column-switching capillary high-performance liquid chromatography/fast atom bombardment-mass spectrometry

Midazolam is a benzodiazepine and is widely prescribed for preanesthesia or general anesthesia. Overdose or intoxication cases of midazolam have been reported. In Japan, smuggled midazolam tablets could be involved in some criminal cases. Midazolam and its two metabolites were extracted by the solid-phase extraction method using Bond Elut SCX cartridges. The compounds were analyzed by on-line capillary high-performance liquid chromatography/fast atom bombardment-mass spectrometry. Midazolam and its two metabolites were well separated on the chromatogram, and each mass spectra gave [M+H](+) ion as a base peak. Deuterium-labeled midazolam was synthesized as an internal standard; it has enabled precise and reproducible quantitation of midazolam in blood samples. The calibration curve showed excellent linearity in the range of 2-200 ng/ml in spiked serum. The detection limit was 300 pg/ml (signal-to-noise ratio=3). The whole blood and urine samples from the victim of a homicide case were analyzed, and the midazolam concentration in the whole blood was estimated to be 163 ng/ml. The present method should be useful in clinical and forensic toxicology, because of its high sensitivity and specificity.

[Aging society and an adult guardianship system]

Prior to recent revisions, civil law had established a system of interdict and quasi-incompetency. This system was begun in 1898 and, up until the revisions of April 2000, it had spanned more than one hundred years without undergoing any major changes. Statistically, there was a steady increase in the number of pronouncements and retractions of incompetency in recent years. A 1980 survey showed that people in their 40s were the most common, and that the proportions of psychiatric disorder, mental retardation, and dementia were of nearly the same level. A 1996 survey, in contrast, showed a greater proportion of elderly, with about half of cases being dementia or a vegetative state. The new adult guardianship system currently in place, as well as a voluntary guardianship system (enduring power of attorney), was established together with the change from the interdict/quasi-incompetency system to a system of assistance, curatorship, and guardianship. The care insurance system that was put in effect at the same time shifted from an enforcement system to a contract system, so the judgment ability of the person at the time of the decision to enter the contract has become an issue. Finally, in dealing with people with dementia, especially mild dementia, problems arise as to the best method of informed consent, including notifying people of their specific disease, and who should decide the treatment for incompetent people with dementia.

[(Dihydroindenyl)oxy]alkonic acid inhibits the cystic fibrosis transmembrane conductance regulator

We investigated the effects of [(dihydroindenyl)oxy]alkaonic acid (DIOA) on the Cl(-) secretion in Calu-3 human airway epithelial cells that exclusively express the cystic fibrosis transmembrane conductance regulator (CFTR) as an apical Cl(-) channel. The 5'-nitro-2-(3-phenylpropylamino) benzoate (NPPB)-sensitive short-circuit current (I(sc)) and apical conductance were markedly reduced by DIOA (100 microM) in the presence and absence of isoproterenol (10 nM). Replacement of the butyl group in DIOA with a methyl group attenuated the inhibitory effects. The ED(50) of DIOA (17.0+/-1.0 microM) was almost equivalent to that of NPPB (15.6+/-2.1 microM). In conclusion, DIOA inhibits CFTR as strongly as NPPB does.

Tau accumulation in a patient with pallidonigroluysian atrophy

We studied the brain of a patient with pallidonigroluysian atrophy (PNLA) in whom argyrophilic and abnormally phosphorylated tau positive neurons and glia were identified in the brain on Gallyas-Braak silver staining and immunohistochemical analysis although neurofibrillary tangles were not seen by Bodian silver stain. Immunohistochemical studies using six anti-tau antibodies that recognize the different phosphorylated epitopes of tau protein revealed that these epitopes in neurons and glial cells share common characteristics with neurofibrillary tangles in Alzheimer's disease. Immunoblot analysis of phosphorylated tau protein showed major bands of 64 and 68 kDa and after dephosphorylation, tau consisted mainly of 4 repeat tau. No mutations were detected in the coding exons and their flanking intronic regions of the tau gene. This study suggests that PNLA is one of tauopathy and the biochemical characteristics of phosphorylated tau are similar to those found in progressive supranuclear palsy and corticobasal degeneration.

Seaweed prevents breast cancer?

To investigate the chemopreventive effects of seaweed on breast cancer, we have been studying the relationship between iodine and breast cancer. We found earlier that the seaweed, wakame, showed a suppressive effect on the proliferation of DMBA (dimethylbenz(a)anthracene)‐induced rat mammary tumors, possibly via apoptosis induction. In the present study, powdered mekabu was placed in distilled water, and left to stand for 24 h at 4°C. The filtered supernatant was used as mekabu solution. It showed an extremely strong suppressive effect on rat mammary carcinogenesis when used in daily drinking water, without toxicity. In vitro, mekabu solution strongly induced apoptosis in 3 kinds of human breast cancer cells. These effects were stronger than those of a chemothera‐peutic agent widely used to treat human breast cancer. Furthermore, no apoptosis induction was observed in normal human mammary cells. In Japan, mekabu is widely consumed as a safe, inexpensive food. Our results suggest that mekabu has potential for chemoprevention of human breast

Parkin and Parkinson's disease

Parkin is the causative gene for an autosomal recessive form of Parkinson's disease. The gene was discovered in 1998. The parkin gene is a novel gene containing 12 exons spanning over 1.5 Mb and encodes a protein of 465 amino acids with a molecular mass of approximately 52,000 M(r). Various deletion mutations and point mutations have been discovered in patients with autosomal recessive Parkinson's disease. The substantia nigra and the locus coeruleus selectively undergo neurodegeneration without forming Lewy bodies. The parkin gene product, Parkin protein, has a unique structure with a ubiquitin-like domain in the amino-terminus and a RING finger motif in the carboxy terminus. The function of Parkin was not known until recently. During the year 2000, great progress was made in defining its function. First of all, Parkin was found to be a ubiquitin-protein ligase (E3), a component of the ubiquitin system, which is an important adenosine triphosphate-dependent protein degradation machinery. In addition, CDCrel-1, a synaptic vesicle associated protein, was found to be a substrate for Parkin as an E3. Although many studies still need to be performed to elucidate the molecular mechanism of the selective nigral neurodegeneration in this form of familial Parkinson's disease, it will not be too long before this is accomplished. In this review article, we evaluate the developments in this area published since 1 February 2000.

Combination therapy including pentoxifylline for entero-Behçet's disease

Behçet's disease is a chronic relapsing vasculitis characterized by recurrent aphthous oral and genital ulcerations with uveitis. Multiple organs can be involved. Entero-Behçet's disease is often uncontrollable, relapsing, and can cause acute intestinal bleeding or perforation. We utilized a combination therapy including 600 mg of pentoxifylline per day, in two doses, to treat three female patients and observed the subsequent changes in clinical symptoms, serum C reactive protein levels, and endoscopic findings. In all three patients, clinical symptoms as well as serum C reactive protein levels improved immediately. Endoscopically, lower intestinal lesions were significantly reduced or healed in all of them. Combination therapy including pentoxifylline appears to be clinically effective in the patients with entero-Behçet's disease.