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Spencer PS, Valdes Angues R, Palmer VS. Nodding syndrome: A role for environmental biotoxins that dysregulate MECP2 expression? J Neurol Sci 2024; 462:123077. [PMID: 38850769 DOI: 10.1016/j.jns.2024.123077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 05/15/2024] [Accepted: 05/30/2024] [Indexed: 06/10/2024]
Abstract
Nodding syndrome is an epileptic encephalopathy associated with neuroinflammation and tauopathy. This initially pediatric brain disease, which has some clinical overlap with Methyl-CpG-binding protein 2 (MECP2) Duplication Syndrome, has impacted certain impoverished East African communities coincident with local civil conflict and internal displacement, conditions that forced dependence on contaminated food and water. A potential role in Nodding syndrome for certain biotoxins (freshwater cyanotoxins plus/minus mycotoxins) with neuroinflammatory, excitotoxic, tauopathic, and MECP2-dysregulating properties, is considered here for the first time.
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Affiliation(s)
- Peter S Spencer
- Department of Neurology, School of Medicine and Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA; Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA; Gulu University School of Medicine, Gulu, Uganda.
| | - Raquel Valdes Angues
- Department of Neurology, School of Medicine and Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA
| | - Valerie S Palmer
- Department of Neurology, School of Medicine and Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA; Gulu University School of Medicine, Gulu, Uganda
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2
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Olal E, Nantale R, Kitara DL. Nodding syndrome and doxycycline: promising findings with open questions. Lancet Glob Health 2024; 12:e1077-e1078. [PMID: 38754458 DOI: 10.1016/s2214-109x(24)00182-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024]
Affiliation(s)
- Emmanuel Olal
- UMA Acholi Branch, Uganda Medical Association, Gulu, Uganda; Adroit Consult International, Kampala, Uganda
| | - Ritah Nantale
- Department of Maternal and Child Health, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - David Lagoro Kitara
- Department of Surgery, Faculty of Medicine, Gulu University, Gulu, Uganda; UMA Acholi Branch, Uganda Medical Association, Gulu, Uganda; Gulu Centre for Advanced Medical Diagnostics, Research, Trainings, and Innovations (Grudi BioNTech Initiative), Gulu, Uganda.
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3
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Qi C, Kobayashi R, Kawakatsu S, Kametani F, Scheres SHW, Goedert M, Hasegawa M. Tau filaments with the chronic traumatic encephalopathy fold in a case of vacuolar tauopathy with VCP mutation D395G. Acta Neuropathol 2024; 147:86. [PMID: 38758288 PMCID: PMC7616110 DOI: 10.1007/s00401-024-02741-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
Dominantly inherited mutation D395G in the gene encoding valosin-containing protein causes vacuolar tauopathy, a type of behavioural-variant frontotemporal dementia, with marked vacuolation and abundant filamentous tau inclusions made of all six brain isoforms. Here we report that tau inclusions were concentrated in layers II/III of the frontotemporal cortex in a case of vacuolar tauopathy. By electron cryomicroscopy, tau filaments had the chronic traumatic encephalopathy (CTE) fold. Tau inclusions of vacuolar tauopathy share this cortical location and the tau fold with CTE, subacute sclerosing panencephalitis and amyotrophic lateral sclerosis/parkinsonism-dementia complex, which are believed to be environmentally induced. Vacuolar tauopathy is the first inherited disease with the CTE tau fold.
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Affiliation(s)
- Chao Qi
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK
| | - Ryota Kobayashi
- Department of Psychiatry, Yamagata University School of Medicine, Yamagata, Japan
| | - Shinobu Kawakatsu
- Department of Neuropsychiatry, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Fuyuki Kametani
- Department of Brain and Neurosciences, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Sjors H W Scheres
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK.
| | - Michel Goedert
- Medical Research Council Laboratory of Molecular Biology, Cambridge, UK.
| | - Masato Hasegawa
- Department of Brain and Neurosciences, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
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4
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Van Cutsem G, Siewe Fodjo JN, Hadermann A, Amaral LJ, Trevisan C, Pion S, Colebunders R. Onchocerciasis-associated epilepsy: Charting a path forward. Seizure 2024:S1059-1311(24)00123-7. [PMID: 38677953 DOI: 10.1016/j.seizure.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
This narrative review intends to inform neurologists and public health professionals about Onchocerciasis-Associated Epilepsy (OAE), a neglected public health problem in many remote onchocerciasis-endemic areas. For epidemiological purposes, we define OAE as sudden-onset of convulsive and non-convulsive seizure types, including head nodding seizures (nodding syndrome) in a previously healthy child aged 3 to 18 years in the absence of any other obvious cause for epilepsy, all happening within an area with high ongoing Onchocerca volvulus transmission. Several OAE pathophysiological mechanisms have been proposed, but none has been proven yet. Recent population-based studies showed that strengthening onchocerciasis elimination programs was followed by a significant reduction in the incidence of OAE and nodding syndrome. Treating epilepsy in onchocerciasis-endemic regions is challenging. More advocacy is needed to provide uninterrupted, free access to anti-seizure medication to persons with epilepsy in these remote, impoverished areas. It is crucial todevelop policies and increase funding for the prevention and treatment of OAE to reduce the associated burden of disease, notably via the establishment of morbidity management and disability prevention programs (MMDP). Moreover, effective collaboration between onchocerciasis elimination and mental health programs is imperative to alleviate the burden of OAE. This synergy promises reciprocal advantages and underscores the need for a comprehensive approach to address this multifaceted challenge.
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Affiliation(s)
- G Van Cutsem
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg; Faculty of Science, Technology and Medicine, University of Luxembourg, Luxembourg; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - J N Siewe Fodjo
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - A Hadermann
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - L-J Amaral
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - C Trevisan
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - S Pion
- Institute of Research for Sustainable Development, Montpelier, France
| | - R Colebunders
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
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5
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Qi C, Verheijen BM, Kokubo Y, Shi Y, Tetter S, Murzin AG, Nakahara A, Morimoto S, Vermulst M, Sasaki R, Aronica E, Hirokawa Y, Oyanagi K, Kakita A, Ryskeldi-Falcon B, Yoshida M, Hasegawa M, Scheres SHW, Goedert M. Tau filaments from amyotrophic lateral sclerosis/parkinsonism-dementia complex adopt the CTE fold. Proc Natl Acad Sci U S A 2023; 120:e2306767120. [PMID: 38100415 PMCID: PMC10743375 DOI: 10.1073/pnas.2306767120] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/31/2023] [Indexed: 12/17/2023] Open
Abstract
The amyotrophic lateral sclerosis/parkinsonism-dementia complex (ALS/PDC) of the island of Guam and the Kii peninsula of Japan is a fatal neurodegenerative disease of unknown cause that is characterized by the presence of abundant filamentous tau inclusions in brains and spinal cords. Here, we used electron cryo-microscopy to determine the structures of tau filaments from the cerebral cortex of three cases of ALS/PDC from Guam and eight cases from Kii, as well as from the spinal cord of two of the Guam cases. Tau filaments had the chronic traumatic encephalopathy (CTE) fold, with variable amounts of Type I and Type II filaments. Paired helical tau filaments were also found in three Kii cases and tau filaments with the corticobasal degeneration fold in one Kii case. We identified a new Type III CTE tau filament, where protofilaments pack against each other in an antiparallel fashion. ALS/PDC is the third known tauopathy with CTE-type filaments and abundant tau inclusions in cortical layers II/III, the others being CTE and subacute sclerosing panencephalitis. Because these tauopathies are believed to have environmental causes, our findings support the hypothesis that ALS/PDC is caused by exogenous factors.
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Affiliation(s)
- Chao Qi
- Medical Research Council, Laboratory of Molecular Biology, CambridgeCB2 0QH, United Kingdom
| | - Bert M. Verheijen
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA90089
| | - Yasumasa Kokubo
- Graduate School of Regional Innovation Studies, Mie University, Tsu514-8507, Japan
| | - Yang Shi
- Medical Research Council, Laboratory of Molecular Biology, CambridgeCB2 0QH, United Kingdom
| | - Stephan Tetter
- Medical Research Council, Laboratory of Molecular Biology, CambridgeCB2 0QH, United Kingdom
| | - Alexey G. Murzin
- Medical Research Council, Laboratory of Molecular Biology, CambridgeCB2 0QH, United Kingdom
| | - Asa Nakahara
- Department of Pathology, Brain Research Institute, Niigata University, Niigata951-8585, Japan
| | - Satoru Morimoto
- Department of Oncologic Pathology, Graduate School of Medicine, Mie University, Tsu514-8507, Japan
| | - Marc Vermulst
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA90089
| | - Ryogen Sasaki
- Department of Nursing, Suzuka University of Medical Science, Suzuka513-8670, Japan
| | - Eleonora Aronica
- Department of Neuropathology, Amsterdam University Medical Centers (UMC), University of Amsterdam, Amsterdam Neuroscience, Amsterdam1105 AZ, The Netherlands
| | - Yoshifumi Hirokawa
- Department of Oncologic Pathology, Graduate School of Medicine, Mie University, Tsu514-8507, Japan
| | - Kiyomitsu Oyanagi
- Department of Brain Disease Research, Shinshu University School of Medicine, Matsumoto390-8621, Japan
| | - Akiyoshi Kakita
- Department of Pathology, Brain Research Institute, Niigata University, Niigata951-8585, Japan
| | | | - Mari Yoshida
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute480-1195, Japan
| | - Masato Hasegawa
- Department of Brain and Neuroscience, Tokyo Metropolitan Institute of Medical Science, Tokyo156-8506, Japan
| | - Sjors H. W. Scheres
- Medical Research Council, Laboratory of Molecular Biology, CambridgeCB2 0QH, United Kingdom
| | - Michel Goedert
- Medical Research Council, Laboratory of Molecular Biology, CambridgeCB2 0QH, United Kingdom
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Kodja KG, Onzivua S, Kitara DL, Fong A, Kim P, Pollanen MS. Nodding syndrome is unlikely to be an autoimmune reaction to leiomodin-1 after infection by Onchocerca volvulus. Biochem Biophys Rep 2023; 35:101498. [PMID: 37601452 PMCID: PMC10439352 DOI: 10.1016/j.bbrep.2023.101498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 08/22/2023] Open
Abstract
Nodding syndrome is a neurological disease of children in northern Uganda. Infection with the nematode parasite Onchocerca volvulus has been epidemiologically implicated as the cause of the disease. It has been proposed that an autoantibody directed against the human protein leiomodin-1 cross reacts with a tropomyosin-like nematode protein, thus suggesting that nodding syndrome is an autoimmune brain disease due to extra-cerebral parasitism. This hypothesis is dependent on constitutive neuronal expression of leiomodin-1. We tested this hypothesis by studying the distribution of leiomodin-1 in the normal human brain and other human tissues using immunohistochemistry. We found that immunostaining for leiomodin-1 follows a smooth muscle cell specific pattern. In the brain, it is confined to the smooth muscle cells of cerebral blood vessels and is not generally present in neurons or glia. However, immunoreactivity was identified in human Purkinje cell membrane and the body wall of C. elegans (as a proxy for Onchocerca volvulus) but only when immunostained with an antibody recognizing the N-terminal of leiomodin-1. Homology between leiomodin-1 and tropomodulin, specifically at the N-terminus, could explain why leiomodin-1 antibody cross reactivity between human Purkinje cells and C. elegans. However, we cannot provide proof confirming that the immunoreactivity in the membranes of Purkinje cells is specifically caused by the expression of tropomodulin. To overcome this limitation, further investigations using additional immunohistochemical and biochemical studies are required to corroborate our findings and provide more comprehensive evidence. Nevertheless, our findings do not support to the autoimmunity hypothesis involving Onchocerca volvulus and leiomodin-1. To gain a more comprehensive understanding of the cause and pathogenesis of NS, it is essential to explore alternative hypotheses.
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Affiliation(s)
- Kenneth G. Kodja
- Department of Pathobiology and Laboratory Medicine, University of Toronto, Toronto, Ontario, Canada
- Ontario Forensic Pathology Service, Toronto, Ontario, Canada
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Sylvester Onzivua
- Department of Pathology, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Amanda Fong
- Ontario Forensic Pathology Service, Toronto, Ontario, Canada
| | - Patrick Kim
- Ontario Forensic Pathology Service, Toronto, Ontario, Canada
| | - Michael S. Pollanen
- Department of Pathobiology and Laboratory Medicine, University of Toronto, Toronto, Ontario, Canada
- Ontario Forensic Pathology Service, Toronto, Ontario, Canada
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, Ontario, Canada
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Colebunders R, Hadermann A, Siewe Fodjo JN. The onchocerciasis hypothesis of nodding syndrome. PLoS Negl Trop Dis 2023; 17:e0011523. [PMID: 37590176 PMCID: PMC10434893 DOI: 10.1371/journal.pntd.0011523] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Nodding syndrome (NS) is a phenotypic presentation of onchocerciasis-associated epilepsy (OAE). OAE is an important public health problem in areas with high ongoing Onchocerca volvulus transmission. OAE, including NS, is preventable by strengthening onchocerciasis elimination programs. The presence of tau in OAE postmortem brains could be the consequence of neuroinflammation directly or indirectly induced by O. volvulus. Omics research is needed to investigate whether O. volvulus worms contain a neurotropic virus.
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Affiliation(s)
| | - Amber Hadermann
- Global Health Institute University of Antwerp, Antwerp, Belgium
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Pollanen MS, Onzivua S. The tau hypothesis of nodding syndrome in Africa. PLoS Negl Trop Dis 2023; 17:e0011526. [PMID: 37590172 PMCID: PMC10434949 DOI: 10.1371/journal.pntd.0011526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Affiliation(s)
- Michael S. Pollanen
- Centre for Research in Neurodegenerative Diseases and Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
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Qi C, Verheijen BM, Kokubo Y, Shi Y, Tetter S, Murzin AG, Nakahara A, Morimoto S, Vermulst M, Sasaki R, Aronica E, Hirokawa Y, Oyanagi K, Kakita A, Ryskeldi-Falcon B, Yoshida M, Hasegawa M, Scheres SH, Goedert M. Tau Filaments from Amyotrophic Lateral Sclerosis/Parkinsonism-Dementia Complex (ALS/PDC) adopt the CTE Fold. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.26.538417. [PMID: 37162924 PMCID: PMC10168338 DOI: 10.1101/2023.04.26.538417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The amyotrophic lateral sclerosis/parkinsonism-dementia complex (ALS/PDC) of the island of Guam and the Kii peninsula of Japan is a fatal neurodegenerative disease of unknown cause that is characterised by the presence of abundant filamentous tau inclusions in brains and spinal cords. Here we used electron cryo-microscopy (cryo-EM) to determine the structures of tau filaments from the cerebral cortex of three cases of ALS/PDC from Guam and eight cases from Kii, as well as from the spinal cord of two of the Guam cases. Tau filaments had the chronic traumatic encephalopathy (CTE) fold, with variable amounts of Type I and Type II filaments. Paired helical tau filaments were also found in two Kii cases. We also identified a novel Type III CTE tau filament, where protofilaments pack against each other in an anti-parallel fashion. ALS/PDC is the third known tauopathy with CTE-type filaments and abundant tau inclusions in cortical layers II/III, the others being CTE and subacute sclerosing panencephalitis. Because these tauopathies are believed to have environmental causes, our findings support the hypothesis that ALS/PDC is caused by exogenous factors.
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Affiliation(s)
- Chao Qi
- MRC Laboratory of Molecular Biology, Cambridge, UK
| | - Bert M. Verheijen
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, USA
| | - Yasumasa Kokubo
- Graduate School of Regional Innovation Studies, Mie University, Tsu, Japan
| | - Yang Shi
- MRC Laboratory of Molecular Biology, Cambridge, UK
- Current address: MOE Frontier Science Center for Brain Science and Brain-machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
| | | | | | - Asa Nakahara
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Satoru Morimoto
- Department of Oncologic Pathology, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Marc Vermulst
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, USA
| | - Ryogen Sasaki
- Department of Nursing, Suzuka University of Medical Science, Suzuka, Japan
| | - Eleonora Aronica
- Department of Neuropathology, University of Amsterdam, Amsterdam, The Netherlands
| | - Yoshifumi Hirokawa
- Department of Oncologic Pathology, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Kiyomitsu Oyanagi
- Department of Brain Disease Research, Shinshu University School of Medicine, Matsumoto, Japan
| | - Akiyoshi Kakita
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | | | - Mari Yoshida
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute, Japan
| | - Masato Hasegawa
- Department of Brain and Neuroscience, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
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Hadermann A, Amaral LJ, Van Cutsem G, Siewe Fodjo JN, Colebunders R. Onchocerciasis-associated epilepsy: an update and future perspectives. Trends Parasitol 2023; 39:126-138. [PMID: 36528471 DOI: 10.1016/j.pt.2022.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Abstract
Onchocerciasis-associated epilepsy (OAE) is an important neglected public health problem in areas with high ongoing onchocerciasis transmission. The risk that children in such areas develop epilepsy is related to their Onchocerca volvulus microfilarial (mf) load. Before the implementation of mass treatment with ivermectin, microfilariae were detected in cerebrospinal fluid (CSF). More recently, neither O. volvulus microfilariae nor DNA were detected in CSF or brain tissue; however, these samples were obtained years after seizure onset. It is possible that during fever-induced increased blood-brain barrier permeability, microfilariae enter the brain and, upon dying, cause an inflammatory reaction inducing seizures. Including OAE in the onchocerciasis disease burden estimation may mobilise extra resources for onchocerciasis disease elimination and treatment/care of OAE-affected persons/families.
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Affiliation(s)
- Amber Hadermann
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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Preliminary seroprevalence study of neurotropic virus antibodies in Nodding syndrome. eNeurologicalSci 2022; 29:100423. [PMID: 36133256 PMCID: PMC9483776 DOI: 10.1016/j.ensci.2022.100423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/29/2022] [Accepted: 09/06/2022] [Indexed: 11/22/2022] Open
Abstract
Nodding syndrome (NS) is a mostly East African pediatric epileptiform encephalopathy of unknown etiology that shares some clinical features with measles-associated subacute sclerosing panencephalitis (SSPE) and progressive rubella panencephalitis. Two independent studies in northern Uganda identified an association between NS and prior measles infection, while an earlier study in South Sudan found an inverse association. We report preliminary serologic analyses of antibodies to measles (MV), rubella (RV), HSV-1, and CMV viruses in northern Ugandan children with NS and Household (HC) and Community (CC) Controls. Only MV-positive titers were significantly different (3-fold and > 2-fold) in NS relative to HC and HC + CC, respectively. While these results are consistent with greater prior measles infection in Ugandan persons with NS, further studies are needed to determine whether Measles virus (MV) plays any role in the etiology and pathogenesis of NS. Resolving this issue will be invaluable for the thousands of children at risk for this devastating yet often neglected condition. Nodding syndrome (NS) is an enigmatic pediatric epileptiform encephalopathy. We report an association between NS and measles virus (MV)-positive titers. Further studies should assess whether MV plays any role in the etiology of NS.
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