A double-blind controlled trial of high dose methylprednisolone in patients with multiple sclerosis: 2. Laboratory results

Intractable hiccups, nausea, and vomiting, an unnerving cause of vision loss

Acute optic neuritis (ON) is caused by variety of complex disorders that can be differentiated with the help of history, radiology, and serology. Identification of nonneurological symptoms that occur before the demyelinating event aids in timely diagnosis and prevention of further neurological attacks. We describe a case of unilateral ON with a history of intractable hiccups, nausea, and vomiting, wherein the possibility of area postrema syndrome (APS) was overlooked until the development of visual symptoms. APS recently identified as a hallmark of neuromyelitis optica spectrum disorder is a rare neurologic cause of gastrointestinal symptoms. This atypical presentation of APS results from autoantibodies directed against the aquaporin-4 rich sites, such as area postrema. This case brings to light the importance of eliciting history of intractable hiccups, nausea, and vomiting in a patient with ON. Despite being a commonly encountered symptom, it may rarely raise a suspicion for neuromyelitis optica.

The use of transcranial magnetic stimulation in diagnosis, prognostication and treatment evaluation in multiple sclerosis

Despite advances in brain imaging which have revolutionised the diagnosis and monitoring of patients with Multiple Sclerosis (MS), current imaging techniques have limitations, including poor correlation with clinical disability and prognosis. There is growing evidence that electrophysiological techniques may provide complementary functional information which can aid in diagnosis, prognostication and perhaps even monitoring of treatment response in patients with MS. Transcranial magnetic stimulation (TMS) is an underutilised technique with potential to assist diagnosis, predict prognosis and provide an objective surrogate marker of clinical progress and treatment response. This review explores the existing body of evidence relating to the use of TMS in patients with MS, outlines the practical aspects and scope of TMS testing and reviews the current evidence relating to the use of TMS in diagnosis, disease classification, prognostication and response to symptomatic and disease-modifying therapies.

Corticosteroids and plasma exchange in multiple sclerosis

Corticosteroids (CS) remain a mainstay of treatment for relapses in multiple sclerosis (MS) and optic neuritis. Currently, there is not enough evidence that long-term corticosteroid treatment delays progression of long-term disability in patients with MS. Likewise, it is unclear whether there are, in fact, true differences among the various CS agents, doses, and their applications in specific pulse and tapering regimens.In some patients suffering from severe steroid-resistant relapses, the clinical response to CS treatment may be insufficient. Such patients may obtain clinical benefit from subsequent plasma exchange (PE). PE is increasingly considered as an individual treatment decision in patients with severe relapses not properly responding to CS. Because of the lack of appropriate studies, PE is not recommended as a permanent disease-modifying strategy in MS patients.

Corticosteroids or ACTH for acute exacerbations in multiple sclerosis

BACKGROUND

Corticosteroids are often used to improve the rate of recovery from acute exacerbation in multiple sclerosis (MS) patients. However, it is still unclear just how relatively effective these agents are and the type of drug, optimal dose, frequency, duration of treatment and route of administration are unknown.

OBJECTIVES

The object of this review was to determine the efficacy and safety of corticosteroids or ACTH in reducing the short and long term morbidity from MS. Moreover, we wished to examine from indirect comparisons if the effect of corticosteroids is different according to different doses and drugs, routes of administration, length of treatment.

SEARCH STRATEGY

A search strategy developed for the Cochrane MS Group (last searched: June 1999) completed with handsearching and personal contacts with trialists and pharmaceutical companies was used.

SELECTION CRITERIA

All randomised, double-blind, unconfounded trials comparing corticosteroids or ACTH to placebo in patients with MS, treated for acute exacerbations, without any age or severity restrictions, were evaluated.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected articles for inclusion, assessed trials' quality and extracted the data. A third reviewer cross-checked them and disagreements were resolved by a joint discussion.

MAIN RESULTS

Six trials contributed to this review; a total of 377 participants (199 treatment, 178 placebo) were randomised. The drugs analysed were methylprednisolone (MP) (four trials, 140 patients) and ACTH (two trials, 237 patients). Overall, MP or ACTH showed a protective effect against the disease getting worse or stable within the first five weeks of treatment (odds ratio[OR]=0.37, 95% confidence interval [CI] 0.24-0.57) with some but non significant greater effect for MP and intravenous administration. Short (five days) or long (15 days) duration of treatment with MP did not show any significant difference. Only one study (with 51 patients) reported data after one year of follow-up: no difference between oral MP and placebo in the prevention of new exacerbations or improvement in long term disability was detected. No data are available beyond one year of follow-up to indicate whether steroids or ACTH have any effect on long-term progression. One study reported that a short term treatment with high dose intravenous MP was not attended by adverse events. On the contrary, gastrointestinal symptoms and psychic disorders were significantly more common in the oral, high-dose MP than in the placebo group. Weight gain and edema were significantly more frequent in the ACTH group than in controls.

REVIEWER'S CONCLUSIONS

We found evidence favouring the corticosteroid MP for acute exacerbation in MS patients. Data are insufficient to reliably estimate effect of corticosteroids on prevention of new exacerbations and reduction of long-term disability. Studies assessing long term risk/benefit and adverse effects of corticosteroids in MS patients are urgently needed.

Measuring evoked responses in multiple sclerosis

Evoked potentials (EPs) have been widely utilised in Multiple Sclerosis (MS) patients to demonstrate the involvement of sensory and motor pathways. Their diagnostic value is based on the ability to reveal clinically silent lesions and to objectivate the central nervous system damage in patients who complain frequently of vague and indefinite disturbances which frequently occurs in the early phases of the disease. The advent of magnetic resonance imaging (MRI) techniques has greatly reduced the clinical utilisation of EPs, which is not fully justifiable, as the information provided by EPs are quite different from those provided by MRI. The abnormalities of evoked responses reflect the global damage of the evoked nervous pathway and are significantly correlated with the clinical findings, while the vast majority of MRI lesions are not associated to symptoms and signs. Transversal and longitudinal studies have demonstrated that EP changes in MS are more strictly related to disability than MRI lesion burden. On the contrary, MRI is more sensitive than EPs in revealing the disease activity. Evoked responses modifications observed in MS are not disease-specific; moreover longitudinal studies showed latency and morphology changes of evoked responses not always related to clinical changes. Such a dissociation can be explained both by technical factors and by subclinical disease activity. To reduce the negative impact of technical aspects, only reproducible parameters of the evoked responses should be used to monitor disease evolution and therapeutic interventions.

Neurophysiological and cognitive markers of disease evolution in multiple sclerosis

Both evoked potentials and cognitive tests may provide useful information which cannot be derived from the clinical observation. For this reason, there have been some attempts to use EPs in monitoring the natural history of the disease and in assessing the efficacy of therapeutic trials. However, no conclusion can be derived from the few available data. Although MRI is more sensitive than EPs in revealing new lesions in brain, cerebellum and brainstem, EPs are more sensitive in revealing optic nerve and spinal cord lesions. Moreover, the poor relationship between brain MRI abnormalities and disability has raised the possibility that cognitive evaluation may be an additional sensitive marker of brain involvement over time. Since the gold standard for the assessment of disease activity is uncertain, it is therefore advisable that frequent MRI, EPs and cognitive assessment may integrate clinical outcomes measured by conventional scales, both in the study of the natural disease course and in monitoring clinical trials.

Effect of annexin-1 on experimental autoimmune encephalomyelitis (EAE) in the rat

Annexin-1, a calcium-dependent phospholipid binding protein, has been shown to act as an endogenous central neuroprotectant, notably against cerebral ischaemic damage. In the present study we extend these findings to an animal model of multiple sclerosis, EAE, and report that endogenous annexin-1 is expressed in ED1+ macrophages and resident astrocytes localized within the lesions in the central nervous system (CNS). Intracerebroventricular (i.c.v.) administration of an NH2-terminal fragment spanning amino acids 1-188 of annexin-1 after the onset of the clinical symptoms significantly reduced both the neurological severity as well as weight loss of mild EAE. Immunoneutralization of endogenous brain annexin-1 failed to exacerbate the clinical features of EAE. Thus, although the role of endogenous annexin-1 in the pathogenesis of EAE remains to be determined, our findings suggest that annexin-1 may be of therapeutic benefit to the treatment of multiple sclerosis.

CD4 subsets (CD45RA/RO) exhibit differences in proliferative responses, IL-2 and gamma-interferon production during intravenous methylprednisolone treatment of multiple sclerosis

Phytohaemagglutinin (PHA)-induced proliferative responses, interleukin 2 (IL-2) and gamma-interferon production were determined in purified CD4CD45RA and CD4CD45RO lymphocytes isolated by immunomagnetic bead separations from normal subjects and multiple sclerosis (MS) patients. Significantly higher proliferative activities were observed for CD4CD45RA cells compared with the corresponding CD4CD45RO cell population in normal subjects and MS patients. CD4CD45RA lymphocyte proliferative responses declined by 50% 3 h following a single dose (500 mg) of intravenous methylprednisolone (IVMP). At 24 h, levels were similar to those determined pre-therapy, as were the levels observed 24 h after a 5-day course (500 mg daily) of IVMP. In contrast, CD4CD45RO cells were unaffected by IVMP. In vitro incorporation of methylprednisolone (10(-6) M) to cell cultures resulted in a modest reduction in proliferative activities of both CD4 subsets. In MS patients subnormal levels of IL-2 and gamma-interferon were observed in PHA-stimulated cultures of CD4CD45RA and CD4CD45RO cells. Following 5 days of IVMP therapy, IL-2 and gamma-interferon production was similar to that observed in CD4CD45RA and CD4CD45RO cells from normal subjects. IVMP therapy causes selective, but transient, inhibition of CD4CD45RA lymphocyte proliferative responses and enhancement of PHA-induced IL-2 and gamma-interferon production by both CD4CD45RA and CD4CD45RO cells.

Transient immunomodulation by intravenous methylprednisolone treatment of multiple sclerosis

The extent and duration of immunomodulation induced by high-dose corticosteroid treatment of clinical relapse of multiple sclerosis was investigated. Ten patients treated with a 5 day course of intravenous methylprednisolone (IVMP) (500 mg daily) were studied. Circulating lymphocyte subpopulations and mitogen-induced interleukin 2 (IL-2) and gamma-interferon (gamma-IFN) production were determined immediately before initiation of therapy (day 1), during therapy (24 h after first dose, day 2) and at 24 h and 1 week post therapy (days 6 and 12 respectively). T-cell subpopulation (CD3, CD4, CD8, CD4CD45RA, CD4CD45RO) levels fell within 24 h of initiation of therapy, rebounded above pretreatment levels at day 6 and normalised 1 week post therapy. Despite a reduction in total T-cell numbers during treatment, the gamma delta T-cell subpopulation was not significantly altered. HLA-DR expression on B cells and monocytes declined transiently on day 2 to approximately 50% of pretherapy levels. IL-2 and gamma-IFN production were reduced during therapy but returned to baseline levels by 24 h post therapy. The effects of IVMP on lymphocyte distribution and function appear to be short-lived and, therefore, may not be responsible for the rapid improvement associated with this form of treatment.

Serial evoked potentials in multiple sclerosis bouts. Relation to steroid treatment

Serial recordings of multimodal sensory (visual, acoustic and somatosensory) evoked potentials were made in 19 relapsing-remitting Multiple Sclerosis patients enrolled in a clinical trial designed to evaluate the efficacy of dexamethasone versus high- and low-dose methylprednisolone in acute multiple sclerosis bouts. Electrophysiological and clinical evaluations were performed at the onset of therapy and until 6 months after the end of treatment. Using an arbitrary Evoked Potentials score that takes into account both latency and waveform alterations, we found a positive correlation between evoked potentials and clinical disability scores. Furthermore, different electrophysiological profiles were detected in the three therapeutic subgroups. Evoked potentials may be useful for monitoring acute Multiple Sclerosis bouts and evaluating the effect of therapy.

Follow-up study of MS patients treated with high-dose intravenous methylprednisolone

In a longitudinal prospective study, we followed 56 patients (17 men, 29 women) with definite multiple sclerosis (MS), who were treated with high-dose intravenous methylprednisolone (IVMP), 10 consecutive days with 1000 mg IVMP daily. Mean follow-up period after entry was 2.6 years (range 1.7-3.5 yrs). All patients were treated because of a symptomatic deterioration. Independent of the disease courses (RR-relapsing remitting/CP-chronic progressive/CP+RR- mixed course), 65% of the 46 MS patients (30/46) showed a clinical improvement after the first IVMP course, expressed by a decrease in the EDSS rating (1.0 point or more). During the follow-up period 59 additional IVMP courses (range 0-5 courses per patient) were given; 8 patients were treated with a combination of cyclophosphamide and prednisone, because of strong continuous progression. During the follow-up period 19 patients (41%) showed an increase in the EDSS-rating (1.0 point or more) compared with the EDSS level just after the first IVMP; 22 patients (48%) had no changes in the EDSS-rating, and 5 patients (11%) showed a clinical improvement (decrease of 1.0 point or more). In the relapsing MS patients (RR and CP+RR, n = 38) mean relapse rate/patient/year prior to the first IVMP was 2.6, which significantly (p < 0.0001) decreased to 0.8 during the follow-up period. Statistically no significant difference was found between baseline EDSS and EDSS ratings after the follow-up period in relapsing MS patients.(ABSTRACT TRUNCATED AT 250 WORDS)

High-dose glucocorticoids in multiple sclerosis patients exert direct effects on the kidney and skeleton

The effects of acute pharmacologic steroid treatment on skeletal and mineral metabolism were assessed in 56 multiple sclerosis patients who were to receive 1 g intravenous methylprednisolone for 10 days, followed by a 4 day intravenous and 28 day oral glucocorticoid taper. Serum and urine samples were obtained at baseline and then within 3 days, 1, 2, and 3 weeks after beginning steroids. A subset of patients (n = 11) had sampling throughout the 6 weeks of steroid administration and up to 8 weeks afterward. All mean basal biochemistries were normal except 25(OH)D, which was in the "insufficient" range (25-50 nM) at 10 nM. During and after steroid administration, there were no changes in ionized calcium, 25(OH)D, urinary hydroxyproline, or pyridinoline. There was an increase in 1,25(OH)2D and a decrease in serum phosphorus, accompanied by an increase in urinary phosphate clearance, within 3 days of administration (p < 0.006). Serum osteocalcin (BGP) decreased to below assay sensitivity limits within 3 days of steroid administration (p < 0.0002), increasing thereafter but remaining at 50% of baseline by the third week. PTH(1-84) increased to a peak at week 2 (p < 0.02), after both the 1,25(OH)2D peak and the serum phosphorus nadir. Tartrate-resistant acid phosphatase, urinary calcium, and urinary cyclic AMP all increased above baseline (p < 0.05) with a pattern similar to that of PTH. To investigate further the immediate effects of steroid administration, serum samples were obtained at the same four times on both the day before and the day after the first intravenous methylprednisolone dose in a randomly chosen subset of patients (n = 9).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of methylprednisolone on monocyte eicosanoid production in patients with multiple sclerosis

The in vitro effect of methylprednisolone on prostaglandin E2 (PGE2), leukotriene B4 (LTB4) and thromboxane B2 (TXB2) synthesis by adherent monocytes was examined using samples of peripheral blood from 15 patients with multiple sclerosis and 18 normal controls. Eicosanoid production by monocytes was reduced in patients compared with controls and there was a dose-dependent inhibitory effect of methylprednisolone on eicosanoid production in both groups. In vitro production of PGE2 and TXB2 but not LTB4 was reduced in patients with multiple sclerosis following intravenous treatment with methylprednisolone compared with pretreatment samples. In a separate cohort of 20 patients with multiple sclerosis and 15 controls, the in vitro inhibition of PGE2 release by methylprednisolone was not associated with reduced pokeweed-mitogen-stimulated immunoglobulin G synthesis by peripheral blood mononuclear cells. These results suggest that methylprednisolone inhibits monocyte-macrophage function, but this effect is not specific to patients with multiple sclerosis.

High-dose methylprednisolone treatment-induced changes in immunological parameters in progressive MS patients

The effect of High-Dose Methylprednisolone (HD-MP) treatment on Peripheral Blood (PB) and Cerebrospinal Fluid (CSF) immune parameters was investigated in 9 patients with relapsing-progressive Multiple Sclerosis (MS). Short-time effects included reduction of the percentage of CD3+, CD4+ and CD4+CD45RA+ PB lymphocytes and increase in CD3-CD56+ cells. At the end of the treatment, only increase in PB CD19+ and in CSF CD8+, CD8+CD28+ and decrease of CSF CD4+CD45RA- and serum IL2R levels were observed. No changes in CD11a+CD4+, CD18+CD14+ PB cells were observed after treatment. The results further stress the complex and multifaceted action of HD-MP on immune parameters.

Effect of high-dose steroid therapy on T-cell subpopulations. A longitudinal study in MS patients

Lymphocyte subpopulations, T cell activation antigens, and serum levels of interleukin 2 (IL-2) and soluble IL-2 receptor (sIL2R), were studied in relapsing-remitting MS (RR-MS) patients before and after high-dose steroid therapy. Prior to therapy, a minority of patients showed increased HLA-DR antigen expression, and an increased number of CD16+ and CD19+ cells. Steroid treatment induced a significant increase in HLA-DR and CD19 expression, a significant reduction in CD16+, CD57+, and CD8+ CD57+ cells, and a slight, non-significant, decrease in IL-2 and sIL-2R levels and CD25 expression on CD4+ T lymphocytes.

T-cell subsets in the cerebrospinal fluid and peripheral blood of multiple sclerosis patients treated with high-dose intravenous methylprednisolone

To determine the effects of high-dose intravenous methylprednisolone (MP) on lymphocytes and lymphocyte subpopulations in the cerebrospinal fluid (CSF) and peripheral blood (PB) in multiple sclerosis (MS) patients, we studied 67 patients with definite MS treated with MP. They were classified according to the disease course: 32 chronic progressive (CP) patients, 25 relapsing-remitting (RR) patients, and 10 patients with a chronic progressive disease course accompanied by relapses and remissions (CP + RR). MS patients were treated with 1000 mgr intravenous MP daily for 10 consecutive days. Before and after MP treatment we simultaneously studied CSF and PB CD3+, CD4+, CD8+, CD20+, and Ia1+ cell subsets. Kurtzke's Expanded Disability Status Scale (EDSS) was used for clinical evaluation. Progression rate was defined as the ratio of EDSS to disease duration. Thirteen patients with lumbar disk herniation were investigated as controls. Before MP, we found in MS patients, especially in the CP group, significantly lower CD4+ T-cell percentages in the PB with respect to controls (p < 0.05). The percentage of CD4+ T-cells in the CSF of MS patients was significantly higher compared with PB (p = 0.0001), and tended to be higher than in controls (p = 0.072). The CSF mononuclear cell counts were significantly correlated with higher percentages of CSF CD3+ (r = 0.40) and CD4+ (r = 0.47) T-cells and lower CSF CD8+ (r = -0.33) T-cell percentages. B-cell percentages in the CSF were significantly elevated compared with controls for all MS groups. No relation could be obtained between T- or B-cell subsets and EDSS or progression rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation of myelin basic protein-like material in cerebrospinal fluid of multiple sclerosis patients with their response to glucocorticoid treatment

Predictors and laboratory correlates of the response of patients with multiple sclerosis to glucocorticoids are not well defined. Our study was undertaken to determine if the levels of myelin basic protein (MBP)-like material in cerebrospinal fluid (CSF) might indicate which patients with multiple sclerosis would show a short-term (5 day) or intermediate-term (40 day) improvement of at least a full-grade Kurtzke disability score after initiating treatment with glucocorticoids. A total of 62 patients received 71 courses of treatment consisting of 5 days of intravenous methylprednisolone (500 mg per day) usually followed by a 4-week tapering dose of oral prednisone. CSF was obtained before initiation of treatment and analyzed for MBP-like material by radioimmunoassay. Results were analyzed by chi 2 tests of association and by logistic regression. Individuals having a CSF MBP-like material level of > or = 0.1 ng/ml overall showed a greater likelihood of continued improvement at day 40 (p = 0.014) or further improvement between days 5 and 40 (p = 0.003). Those in the first 15 days of worsening and with an elevated CSF MBP-like level were more likely to respond by day 5. Relapsing-remitting and relapsing-progressive forms of the disease were more likely to respond at both time points than were patients with primary or secondary chronic progressive patterns. The Kurtzke disability score at entry and the major anatomical site of the central nervous system symptomatically affected were not predictive of outcome at either time.(ABSTRACT TRUNCATED AT 250 WORDS)

CSF myelin basic protein, IgG and IgM levels in 101 MS patients before and after treatment with high-dose intravenous methylprednisolone

A total of 101 patients (62 women; 39 men) with definite MS were treated with 1000 mg methylprednisolone (MP) intravenously for 10 consecutive days. Immediately before and after MP treatment clinical scoring (Kurtzke's Expanded Disability Status Scale) and CSF analysis were performed. Before MP treatment CSF MBP, IgG and IgM immunoglobulin levels (CSF Ig, index and intrathecal synthesis) were significantly elevated. The mean CSF MBP levels were significantly higher in the relapsing-remitting (RR) and chronic progressive MS patients with relapses (CP + RR) than in the CP group without a RR disease course, respectively 2.1, 2.3 and 1.5 micrograms/l. A weak positive correlation was found between CSF MBP level and EDSS in the RR MS group (r = 0.34). CSF MBP was significantly correlated with IgM index (r = 0.36), IgM synthesis (r = 0.26), but not with the IgG levels. Therefore demyelination seems to be related to intrathecal IgM production. After MP treatment mean (median) EDSS decreased from 4.4 (4.0) to 3.3 (3.0). Except for Q albumin and IgM index, all CSF immunoglobulin levels decreased significantly after MP. The mean CSF MBP returned to reference values. In the RR group the decrease in CSF MBP was significantly correlated with the change in EDSS (r = 0.39). CSF MBP seems to be a good parameter for disease activity in relapsing MS. Following treatment CSF MBP was found to be related with the change in IgM index (r = 0.30). MP treatment reduces CSF MBP and intrathecal IgM in a similar way indicating a relation between these 2 parameters.

Lipocortins (annexins) 1, 2, 4 and 5 are increased in the central nervous system in multiple sclerosis

Western blotting and densitometry have been used to investigate the lipocortin content of post-mortem central nervous system (CNS) tissue samples from multiple sclerosis (MS) patients and normal controls. Lipocortins 1, 2, 4 and 5 were all detected in normal control grey and white matter. In white matter samples from MS patients these lipocortins were found to be significantly increased, a further elevation in lipocortin content was observed in MS plaque tissue. The implications of these findings with respect to the role of these proteins in inflammatory CNS disease and a possible mechanism of steroid action in the therapy of MS are discussed.

High dose steroids in acute relapses of multiple sclerosis: MRI evidence for a possible mechanism of therapeutic effect

The integrity of the blood-brain barrier (BBB) in multiple sclerosis (MS) was monitored by serial gadolinium-(Gd)-DTPA enhanced MRI during and after the treatment of acute relapses with a three day course of high dose intravenous methylprednisolone (IVMP). During treatment there was a rapid reduction of BBB abnormalities in 96% of enhancing lesions. In spite of sustained clinical improvement, many lesions re-enhanced within a few days of stopping IVMP, and new lesions frequently appeared within one month. It is possible that the rapid, albeit transient, reversal of BBB abnormalities contributes to the accelerated recovery from relapses associated with IVMP treatment.

Improvement in motor evoked potentials and clinical course post-steroid therapy in multiple sclerosis

Motor evoked potentials (MEP) were recorded in 23 patients with definite relapsing multiple sclerosis before and after treatment with a short course of high dose of methylprednisolone. MEP were performed together with clinical examination just before treatment, and 6 and 60 days later. The following results were observed: (1) a statistically significant relationship between the corticospinal deficit and the alteration in MEP, (2) a significant improvement in latency of MEP by day 6, (3) a significant correlation between the change in the Kurtzke disability scale rating and the improvement in MEP. The results provide further evidence for the possible effectiveness of short courses of high dose corticosteroids in the treatment of relapses of multiple sclerosis and the usefulness of MEP in its assessment.

Methylprednisolone in multiple sclerosis exacerbation: changes in CSF parameters

Twenty-six patients with multiple sclerosis (MS) received a total of 45 courses of intravenous methylprednisolone daily for seven days, for acute neurological deterioration. Changes in CSF parameters and clinical status following methylprednisolone were determined and first and repeat courses were compared. There were significant reductions in CSF IgG, CSF albumin, serum IgG and serum albumin levels and CSF IgG synthesis rate in the first and repeat treatment groups. CSF IgG index fell significantly with initial methylprednisolone treatment but not with subsequent courses. Oligoclonal bands disappeared in three patients. Definite clinical improvement followed 30 methylprednisolone courses, possible improvement followed six and no change followed seven. Clinical response was not predicted by pre-treatment CSF IgG synthesis status and did not correlate with its degree of reduction.

Laboratory investigation of cerebrospinal fluid proteins

Analysis of CSF proteins is useful in the diagnosis and management of neurological diseases in the following situations: 1. In inflammatory conditions when there is breakdown of blood-CSF barrier integrity. Meningitis is a medical emergency, with CSF total protein measurement being only a screening test. 2. In the detection of immune responses within the CNS. This is by far the most important application in a routine clinical setting, as it is now a firmly established criterion in the diagnosis of multiple sclerosis. Oligoclonal bands restricted to the CSF are the only reliable indicators of intrathecal immunoglobulin G synthesis and are practically always associated with inflammatory disease of the CNS. The method fo choice for detecting oligoclonal bands is isoelectric focusing with immunofixation. Quantitative measurement of IgG in the CSF is of no value in diagnostic pathology. 3. In destructive brain diseases when brain-specific proteins are released into the CSF, measurement of these proteins can give prognostic information.

The effect of methylprednisolone on lymphocyte phenotype and function in patients with multiple sclerosis

The extent to which symptomatic improvement in patients with multiple sclerosis treated with intravenous methylprednisolone depends on immunological actions of corticosteroids is unknown. In this study the effect of methylprednisolone on circulating T and B cell function has been assessed in vitro and in vivo. Low molar concentrations of methylprednisolone increased pokeweed mitogen-stimulated IgG synthesis by unfractionated lymphocytes in 20 patients with multiple sclerosis and 15 controls. Treatment with methylprednisolone was associated with increased IgG synthesis in a further cohort of 26 affected individuals although dose responsiveness to methylprednisolone was uninfluenced in these patients. Sequential concanavalin A-pokeweed mitogen-induced IgG synthesis by mononuclear cells was also stimulated by methylprednisolone. Phenotypic analysis of paired samples from 12 patients with multiple sclerosis, taken before and after treatment showed no alteration in CD4 or CD8 cells, their suppressor inducer or suppressor subpopulations or activated lymphocytes.

T-lymphocyte subpopulations in acute unilateral optic neuritis

The authors prospectively analyzed T-lymphocyte subpopulations in the peripheral blood of nine patients with acute unilateral optic neuritis and compared them with 25 controls without neurologic disease. The presence or absence of alterations in circulating T-cell subsets has not been examined previously in patients with isolated optic neuritis. The authors found the mean ratio of inducer (CD4) to suppressor (CD8) T-lymphocytes was 2.07 +/- 0.51 for the group with optic neuritis, statistically indistinguishable from a value of 1.78 +/- 1.04 for the control group. Multiple sclerosis (MS) subsequently developed in one patient. Her inducer/suppressor T-cell ratio was initially 2.66, but progressively increased to 3.68 concomitant with the clinical manifestation of focal neurologic signs. Although optic neuritis may be the initial clinical sign of MS, the periodic alteration of circulating T-lymphocytes increasing the inducer/suppressor T-cell ratio in MS was not observed in those with isolated optic neuritis.

Cyclosporin A curtails the progression of free light chain synthesis in the CSF of patients with multiple sclerosis

Free light chains in the cerebrospinal fluid of patients with multiple sclerosis correlate closely with disease activity. As part of a double-blind placebo controlled trial of immunosuppression using cyclosporin A in patients with multiple sclerosis, light chain analysis was performed on pre- and post-treatment CSF samples in 19 patients, nine having received cyclosporin A and 10 placebo. The placebo treated patients showed continued immunological activity, as evidenced by an increase in both free kappa and lambda chains, but cyclosporin A treatment resulted in no change or an improvement in light chain response, indicative of suppression of continued activity. As cyclosporin A does not enter the CSF, this implies that systemic stimulation is at least partly responsible for continued disease activity in multiple sclerosis. Cyclosporin A may thus be effective in preventing the deterioration of patients with multiple sclerosis.

Quantitative magnetic resonance imaging in multiple sclerosis: the effect of high dose intravenous methylprednisolone

Magnetic resonance imaging was performed on 50 patients with clinically definite or probable multiple sclerosis before and 15 days after starting treatment with intravenous methylprednisolone (0.5 g daily for 5 days). Scans were abnormal in 49 patients. New lesions had appeared on the second scan in nine individuals and in seven a single pre-existing lesion appeared to have become smaller but in no case were lesions seen to disappear. Two patients showed both reduction in the size of an abnormal area and development of a single new lesion indicating that corticosteroids do not appear rapidly to alter the process underlying plaque formation. Measurements of relaxation times were performed in 12 randomly selected patients. All showed elevated values in normal appearing white matter but not cortex before treatment compared with 18 healthy controls. After treatment a significant decrease of T1 and T2 was observed in cortex, and of T1 alone in normal appearing white matter. No significant change could be detected within lesions, a finding attributed to the wide range of relaxation values observed at these sites before treatment. Since brain water content is increased in normal appearing white matter of multiple sclerosis patients, and is significantly reduced by high-dose methylprednisolone, resolution of oedema may contribute to the rapid spontaneous or corticosteroid induced symptomatic recovery that characterises the disease in its early stages.

Multiple sclerosis: an overview

Demyelinating lesions of MS are infiltrated by activated T-lymphocytes and macrophages with secretion of soluble factors. This results in the synthesis of oligoclonal immunoglobulin (IgG) by plasma cells. The activated T-lymphocytes migrate from the peripheral blood to the CNS. This hyperactive state is linked to a selective loss of the suppressor/inducer T-cell subset. Administration of a soluble factor--interferon gamma--enhances the immune response by promoting class II antigen expression on macrophages or astrocytes, resulting in a relapse. However, the reason for T-cell activation in peripheral blood is not known, nor is the antigen. Myelin basic protein (MBP) has been considered to be the target since MBP is able to induce chronic relapsing allergic encephalomyelitis (CRAE) in an animal model of MS. Yet other myelin antigens have succeeded in inducing CRAE in animal models, and anti-MBP antibodies have been found in healthy individuals. The possibility that the hyperimmune state results from a viral infection has not yet been proven. It is known that in Caucasians, a genetic susceptibility factor is linked to class II MHC. Using MRI it has been found that the presence of new plaques was not regularly correlated with relapses, which indicates that MS is an ongoing pathology process. Most drugs used in MS influence the immune response but have potential toxicity. Monoclonal antibodies offer the opportunity of specific targeting of T-cells and are promising for the future.

Immunotherapy of multiple sclerosis

Based on the assumption that multiple sclerosis is an autoimmune disease, a number of clinical trials designed to suppress the immune system or to restore immune balance in multiple sclerosis have been attempted. Depending on the disease category, the clinical goals of immunotherapy differ. Therapeutic goals include improving recovery from acute attacks, preventing or decreasing the number of relapses, and halting the disease in its progressive stage. The ultimate goal of multiple sclerosis therapy is the early treatment of patients in an attempt to halt the onset of progression. Specific strategies of immunotherapy include generation of a suppressor influence, removal of helper/inducer cells, manipulation of activated T cells, manipulation of class II major histocompatibility complex-bearing cells, alteration of lymphocyte traffic, extracorporeal removal of serum factors or cells, and manipulation of antigen-specific cells. Present treatment modalities are beginning to show some efficacy of nonspecific immunosuppression, but these treatments are limited by their toxicities. As the immunotherapy of multiple sclerosis moves to the next stage in the coming years, patients at an earlier stage of their disease will have to be treated, nontoxic forms of therapy developed, clinical trials lengthened, and a laboratory monitor of the disease developed. Given the positive effects of immunotherapy seen thus far in the disease, it is possible that appropriate immunotherapeutic intervention may provide effective treatment for the disease in the future.

A double-blind controlled trial of high dose methylprednisolone in patients with multiple sclerosis: 1. Clinical effects

A randomised double-blind, placebo-controlled trial of high-dose, pulsed intravenous methylprednisolone was carried out in 50 individuals with multiple sclerosis; 22 patients were in acute relapse and 28 had chronic progressive disease. After a baseline assessment using the Kurtzke functional and expanded disability status scales each patient was randomly allocated to intravenous treatment with methylprednisolone (500 mg) or a saline placebo administered as a single daily dose for 5 days. Clinical assessments were repeated at 1 and 4 weeks after starting treatment. The results from all 50 patients showed a highly significant effect in favour of methylprednisolone treatment (p less than 0.001). In patients with relapse, there was a significant decrease in clinical disability scores at 1 and 4 weeks in the methylprednisolone treated group compared with controls (p less than 0.05 for each comparison). In the chronic progressive group, disability scores at 4 weeks only were significantly lower after treatment with methylprednisolone (p less than 0.01), mainly attributable to improvement in pyramidal function.