Clinical and laboratory features of primary progressive and secondary progressive MS

Spinal cord and brain corticospinal tract lesions are associated with motor progression in tumefactive multiple sclerosis

BACKGROUND

Spinal cord lesions have been associated with progressive disease in individuals with typical relapsing remitting MS (RRMS).

OBJECTIVE

In the current study, we aimed to determine if progressive disease is associated with spinal cord lesions in those with tumefactive multiple sclerosis (MS).

METHODS

Retrospective chart review of individuals presenting to Mayo Clinic with tumefactive MS with spinal cord MRIs available (n=159). Clinical data were extracted by chart review. Brain and spinal cord MRIs were reviewed to characterize the tumefactive demyelinating lesion(s) and assess the burden of spinal cord disease.

RESULTS

A total of 69 (43%) had spinal cord lesions. Progressive demyelinating disease was documented in 13 (8%); the majority (11/13) with secondary progressive disease. The method of progression was myelopathic in 8/13 (62%), cognitive in 3/13 (23%), motor from a supratentorial lesion in 2/13 (16%). EDSS at last follow-up was higher in those with progression than those without (median 6.0 (2.0-10.0) vs. 2.5 (0-10.0), p = < 0.001). Progressive demyelinating disease occurred in a minority.

CONCLUSIONS

Patients with progression typically experienced progressive motor impairment, and this occurred exclusively in individuals with lesions in the corticospinal tracts of the brain and/or the spinal cord.

Potential role of indolelactate and butyrate in multiple sclerosis revealed by integrated microbiome-metabolome analysis

Multiple sclerosis (MS) is an immune-mediated disease whose precise etiology is unknown. Several studies found alterations in the microbiome of individuals with MS, but the mechanism by which it may affect MS is poorly understood. Here we analyze the microbiome of 129 individuals with MS and find that they harbor distinct microbial patterns compared with controls. To study the functional consequences of these differences, we measure levels of 1,251 serum metabolites in a subgroup of subjects and unravel a distinct metabolite signature that separates affected individuals from controls nearly perfectly (AUC = 0.97). Individuals with MS are found to be depleted in butyrate-producing bacteria and in bacteria that produce indolelactate, an intermediate in generation of the potent neuroprotective antioxidant indolepropionate, which we found to be lower in their serum. We identify microbial and metabolite candidates that may contribute to MS and should be explored further for their causal role and therapeutic potential.

Profiling serum neurofilament light chain and glial fibrillary acidic protein in primary progressive multiple sclerosis

This study examined the utility of serum neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) as biomarkers in primary progressive multiple sclerosis in context with clinical severity, progression, and treatment. Using a single-molecule array (Quanterix), serum protein concentrations were measured from twenty-five participants semiannually for five years. There was no association between levels of either biomarker and disease severity, disease duration, or treatment group. Enrollment sNfL level was not associated with future clinical worsening. Precedent clinical worsening was not associated with last sGFAP measurement. These results suggest a limited role for these biomarkers in primary progressive disease management.

The influence of sex hormones on cytokines in multiple sclerosis and experimental autoimmune encephalomyelitis: a review

The female predominance of multiple sclerosis (MS) has suggested that hormonal differences between the sexes must confer some protective effect on males or enhance the susceptibility of females to this disease. There has been evidence that gonadal hormones can modulate the immune response regulated by antigen presenting cells and T cells. These cells control the immune response by the production of interacting pro- and anti-inflammatory cytokines. The first include the acute phase pro-inflammatory cytokines of the innate immune response as well as the T-helper 1 (Th1) cytokines, while the later contain the Th2 cytokines as well as the suppressor cytokines. There is some evidence that MS and experimental autoimmune encephalitis (EAE) are Th1 cell-mediated diseases. For this reason many studies have been done to influence the pro-inflammatory cytokine production of these Th1 cells in favour of an anti-inflammatory immune response as mediated by Th2 cells. However the role of the regulatory T cells in this context is not clearly understood. Here we review the studies concerning the role of sex hormones on the cytokine production in relation to the disease course of MS and EAE and in particular in the light of the recent revival of the regulatory T cells and their suppressive cytokines.

Employment among patients with multiple sclerosis-a population study

Objective

To investigate demographic and clinical factors associated with employment in MS.

Methods

The study included 213 (89.9%) of all MS patients in Sogn and Fjordane County, Western Norway at December 31^st 2010. The patients underwent clinical evaluation, structured interviews and completed self-reported questionnaires. Demographic and clinical factors were compared between patients being employed versus patients being unemployed and according to disease course of MS. Logistic regression analysis was used to identify factors independently associated with current employment.

Results

After a mean disease duration of almost 19 years, 45% of the population was currently full-time or part- time employed. Patients with relapsing –remitting MS (RRMS) had higher employment rate than patients with secondary (SPMS) and primary progressive (PPMS). Higher educated MS patients with lower age at onset, shorter disease duration, less severe disability and less fatigue were most likely to be employed.

Conclusions

Nearly half of all MS patients were still employed after almost two decades of having MS. Lower age at onset, shorter disease duration, higher education, less fatigue and less disability were independently associated with current employment. These key clinical and demographic factors are important to understand the reasons to work ability in MS. The findings highlight the need for environmental adjustments at the workplace to accommodate individual ’s needs in order to improve working ability among MS patients.

Multiple sclerosis

Multiple sclerosis (MS) is a chronic, complex neurological disease with a variable clinical course in which several pathophysiological mechanisms such as axonal/ neuronal damage, demyelination, inflammation, gliosis, remyelination and repair, oxidative injury and excitotoxicity, alteration of the immune system as well as biochemical disturbances and disruption of blood-brain barrier are involved.(1,2) Exacerbations of MS symptoms reflect inflammatory episodes, while the neurodegenerative aspects of gliosis and axonal loss result in the progression of disability. The precise aetiology of MS is not yet known, although epidemiological data indicate that it arises from a complex interactions between genetic susceptibility and environmental factors.(3) In this chapter the brain structures and processes involved in immunopathogenesis of MS are presented. Additionally, clinical phenotypes and biomarkers of MS are showed.

Quantitative measures detect sensory and motor impairments in multiple sclerosis

BACKGROUND

Sensory and motor dysfunction in multiple sclerosis (MS) is often assessed with rating scales which rely heavily on clinical judgment. Quantitative devices may be more precise than rating scales.

OBJECTIVE

To quantify lower extremity sensorimotor measures in individuals with MS, evaluate the extent to which they can detect functional systems impairments, and determine their relationship to global disability measures.

METHODS

We tested 145 MS subjects and 58 controls. Vibration thresholds were quantified using a Vibratron-II device. Strength was quantified by a hand-held dynamometer. We also recorded Expanded Disability Status Scale (EDSS) and Timed 25-Foot Walk (T25FW). t-tests and Wilcoxon-rank sum were used to compare group data. Spearman correlations were used to assess relationships between each measure. We also used a step-wise linear regression model to determine how much the quantitative measures explain the variance in the respective functional systems scores (FSS).

RESULTS

EDSS scores ranged from 0-7.5, mean disease duration was 10.4 ± 9.6 years, and 66% were female. In relapsing-remitting MS, but not progressive MS, poorer vibration sensation correlated with a worse EDSS score, whereas progressive groups' ankle/hip strength changed significantly with EDSS progression. Interestingly, not only did sensorimotor measures significantly correlate with global disability measures (i.e., EDSS), but they had improved sensitivity, as they detected impairments in up to 32% of MS subjects with normal sensory and pyramidal FSS.

CONCLUSIONS

Sensory and motor deficits in MS can be quantified using clinically accessible tools and distinguish differences among MS subtypes. We show that quantitative sensorimotor measures are more sensitive than FSS from the EDSS. These tools have the potential to be used as clinical outcome measures in practice and for future MS clinical trials of neurorehabilitative and neuroreparative interventions.

Gender issues in multiple sclerosis: an update

Although multiple sclerosis (MS) affects both women and men, women are more susceptible to MS than men. Accumulating evidence indicates that the incidence and prevalence of MS is increasing, more so in women than in men. Owing to pregnancy, differing hormonal states and distinct social roles, the impact of MS differs between women and men. Since Patricia K Coyle published a review on gender issues in MS, multiple studies have added to the body of knowledge. This update will summarize the current thinking on gender-related issues in MS and we will address incidence and prevalence, hormonal factors, pregnancy and breastfeeding, genetics, course and prognosis, imaging, treatment and psychosocial aspects. Future progression within this field will help elucidate the cause of and define the treatment of MS.

Multiple sclerosis findings in the spinal cord

The spinal cord is commonly affected by acute demyelinating lesions, chronic tissue loss and atrophy in multiple sclerosis, and is a clinically eloquent site. Historically, however, more attention has been focussed on the analysis and contribution of brain lesions. In this review, we discuss some of the key findings from MRI analysis and histopathological examination of the spinal cord, and how they relate to the clinical characteristics of this common and disabling disease.

Déficit oligodendrocytaire et insuffisance de la remyélinisation au cours de la SEP : étude anatomoclinique et expérimentale comparative

INTRODUCTION

The mechanisms responsible for the failure of remyelination during MS are poorly understood. We have analyzed in which way oligodendrocytes (OL) could be involved.

METHODS

The number of remyelinated fiber per OL has been determined in 18 chronic MS lesions and compared to normal appearing white matter (NAWM), as well as in the center of lysophosphatidyl choline (LPC)-induced lesions in adult rats in which remyelination was accelerated by microinjection of neurotrophin-3 (NT-3).

RESULTS

In chronic MS lesions and in LPC-induced lesions the number of myelinated fibers per OL was strongly decreased compared to NAWM and to animals treated with NT-3 respectively.

CONCLUSION

Our results suggest that the capacity of OL to remyelinate axons could be impaired, due to successive relapses, during MS.

The relation between menarche and the age of first symptoms in a multiple sclerosis cohort

BACKGROUND

Previously, multiple sclerosis (MS) has been thought to be associated with changes in hormone levels. This study investigates the association between the age of menarche and the age of onset of the first symptoms of MS.

METHODS

A complete list of patients diagnosed with MS in the province of Newfoundland and Labrador was constructed. The age of menarche for our entire relapsing remitting female MS (RRMS) population was requested by mailout survey. Age of symptom onset was ascertained by chart review.

RESULTS

A 74% rate of return on the survey results was obtained (150 RRMS patients). A linear regression model demonstrated that the age of first symptoms increased by 1.16 years as the age of menarche increased by one year (R2 = 0.69, P = 0.04). Another analysis showed that the average age of first symptoms for women with reported menarche from 10 to 12 years was 28.96 years compared with 31.83 years for a reported menarche from 13 to 15 years, a significant difference (P = 0.047, t-test).

CONCLUSIONS

This study suggests that menarche may be related to the pathogenesis of MS.

Inflammation in white matter: Clinical and pathophysiological aspects

While the central nervous system (CNS) is generally thought of as an immunopriviledged site, immune-mediated CNS white matter damage can occur in both the perinatal period and in adults, and can result in severe and persistent neurological deficits. Periventricular leukomalacia (PVL) is an inflammatory white matter disease of premature infants that frequently results in cerebral palsy (CP). Clinical and experimental studies show that both hypoxic/ischemic and innate immune mechanisms contribute to the destruction of immature oligodendroglia and of axons in the deep cerebral white matter in PVL. No data are yet available as to whether there is any genetic predisposition to PVL or to its neurological sequelae. Multiple sclerosis (MS) is an inflammatory white matter disease that often begins in young adulthood, causes multifocal destruction of mature oligodendroglia and of axons, and eventually leads to substantial cumulative neurological disability. Certain genetic polymorphisms contribute to susceptibility to MS, and adaptive immune responses to myelin-associated self antigens, or to exogenous antigens that mimic these self antigens, play a central role in the pathophysiology of this disease.

P-selectin glycoprotein ligand-1 variable number of tandem repeats (VNTR) polymorphism in patients with multiple sclerosis

P-selectin glycoprotein ligand-1 (PSGL-1) is an important adhesion molecule involved in lymphocyte recruitment into the brain, which represents a crucial step in the pathogenesis of multiple sclerosis (MS). Three hundred twenty-one MS patients and 342 controls were genotyped for the presence of a polymorphism in the PSGL-1 gene, consisting of a variable number of tandem repeats (VNTR) originating three possible alleles: A, B and C, in order to test whether they influence the susceptibility and the course of the disease. No significant differences among allelic frequencies of A, B and C alleles in MS as compared with controls were observed. Stratifying patients according to the course of the disease, a significantly increased frequency of the shortest C allele in PP-MS was found (7.1%), either in comparison with controls (P=0.011) or with all other MS patients, who had acute inflammatory attacks at onset and an initial RR form (P=0.036). Besides, none of SP-MS patients was a carrier of the C allele and B carriers converted later from RR to SP course as compared with A/A subjects (after 15.8 rather than 8.8 years, P=0.01). In conclusion, the C allele of the VNTR polymorphism in PSGL-1 is likely to be associated with PP-MS. As this allele has been demonstrated to have a very low efficiency in mediating lymphocyte binding to brain endothelium during attacks, its high frequency in PP-MS could be related to the absence of exacerbations in such patients.

Is inflammation important in early PPMS? a longitudinal MRI study

BACKGROUND

Magnetic resonance imaging (MRI) studies in primary progressive multiple sclerosis (PPMS) have shown a reduced frequency of enhancement with the contrast agent gadolinium-DTPA (Gd-DTPA), in comparison with relapsing-remitting multiple sclerosis (RRMS), and it has been suggested that there may be a less important role for inflammation in its pathogenesis. However, the earliest clinical stages of PPMS have not been studied and thus it has not been possible to exclude the existence of an early inflammatory phase.

OBJECTIVE

To study the presence, characteristics, and implications of inflammation in early PPMS.

METHODS

45 patients with a mean disease duration of 3.3 years had triple dose Gd enhanced MRI, expanded disability status scale (EDSS), and multiple sclerosis functional composite (MSFC) assessments at baseline. Repeat MRI was done at 1 and 2 months in 24 patients, and at 6 months in 38.

RESULTS

Enhancing brain lesions were present in 42% of patients at baseline but enhancing cord lesions were uncommon (7%); 85% of enhancing lesions enhanced for one month or less. Patients with enhancing lesions had greater disability (EDSS, p = 0.027; MSFC, p = 0.026) and more MRI abnormalities (greater T2 load, p = 0.008; greater T1 hypointensity load, p = 0.001; and reduced partial brain volume, p = 0.012) than those without enhancement. Enhancement at 6 months was seen in 32% of patients and was restricted to a subset of patients who enhanced at baseline.

CONCLUSIONS

Enhancement is present in some cases of early PPMS and is associated with greater disease impact in terms of both clinical and MRI measures.

Clinical and laboratory features of in-patients with multiple sclerosis in a University Hospital in Tokyo from 1988-2002

OBJECTIVE

The aim of this study was to analyze the clinical and laboratory features of each subtype of multiple sclerosis (MS) (relapsing-remitting, primary progressive, and secondary progressive) in the Tokyo metropolitan area.

METHODS AND PATIENTS

We retrospectively analyzed the medical records of 104 consecutive patients with a diagnosis of MS, who had been admitted to our university hospital from 1988 to 2002. They all met criteria for definite MS, by clinical or laboratory standards.

RESULTS

Eighty-four (80.8%) patients were classified as having relapsing-remitting MS, while 8 patients (7.7%) and 12 patients (11.5%) were classified as having primary progressive MS and secondary progressive MS, respectively. A significant female predominance existed in the relapse-remitting MS (female : male=2.4 : 1) cohort, but this ratio was 1 : 1 in both primary progressive and secondary progressive MS. The age at onset was older in the primary progressive MS (36.6+/-17.1 years of old) population than in either the relapsing-remitting MS (27.9+/-11.1) or the secondary progressive MS (27.8+/-11.5) subjects. Although the duration of illness was similar among the three types of MS, the number of exacerbations in the secondary progressive (5.9+/-4.6) cohort was significantly higher than that in the relapsing-remitting MS subjects (3.2+/-2.6). Patients with primary progressive MS showed a significantly higher rate of gait disturbance (87.5%) as the initial symptom than those with relapsing-remitting MS (23.8%), and this was thought to be due to the higher incidence of brainstem and spinal cord lesions. Visual disturbance as the initial symptom was frequently noted in those with secondary progressive MS (50.0%), while it was noted only in 29.8% and 12.5% in the relapsing-remitting and primary progressive patients, respectively. Primary progressive MS subjects had a higher propensity to be wheelchair-bound (75.0%) than those suffering from relapsing-remitting MS (1.2%). Increased total protein in the cerebrospinal fluid (CSF) of the secondary progressive cohort was statistically significant compared to the relapsing-remitting cohort. The frequency of oligoclonal IgG bands was rather low in each type of MS (17.1-33.3%). Gadolinium enhancement of plaques on MRI was more frequently present in secondary progressive MS (66.7%) than in either relapsing-remitting MS (32.1%) or primary progressive MS (50.0%). Of note, the opticospinal form was found in only 16.3% of the total MS patients, a proportion less than that in previous reports from southern Japan.

CONCLUSION

The present study confirms that while the clinical and laboratory features of the MS patients in the Tokyo metropolitan area are similar to those in Western countries in most regards, features such as proportionally fewer primary and secondary progressive MS patients as well as less oligoclonal IgG bands on CSF analysis are different from those in Western countries.

The presence of glutamic acid at positions 71 or 74 in pocket 4 of the HLA-DRbeta1 chain is associated with the clinical course of multiple sclerosis

BACKGROUND

Primary progressive multiple sclerosis (PP-MS) differs from relapsing-remitting or secondary progressive MS (RR/SP-MS) in ways suggesting differences in the pathogenic pathways. Susceptibility to both PP-MS and RR/SP-MS is linked to carriage of the HLA molecule DRB1*1501. Several serologically defined HLA-DR groups (DR1, DR4, DR6, and DR9) occur less often in RR/SP-MS than in controls. Some or all of the HLA-DR molecules encoded by alleles in these serologically defined groups have a negatively charged glutamic acid at residue 71 or 74 of the beta1 chain (beta1(71)/beta1(74)). Residues at these positions are important in the formation of pocket 4 in the antigen binding site of the HLA-DR molecule.

OBJECTIVES

To investigate whether the presence of alleles encoding HLA-DR molecules containing glutamic acid at beta1(71)/beta1(74) correlates with the course of MS.

METHODS

HLA-DR and HLA-DQ alleles and genotypes were analysed in 121 MS patients (50 with PP-MS) and 109 controls by molecular typing.

RESULTS

Alleles encoding HLA-DR molecules containing a glutamic acid at beta1(71)/beta1(74) occurred less often in patients with RR/SP-MS than in those with PP-MS or controls. In subjects not carrying the DRB1*1501 allele, a much higher proportion of PP-MS patients carried alleles encoding HLA-DR molecules containing a glutamic acid at beta1(71)/beta1(74) than did RR/SP-MS patients or controls.

CONCLUSIONS

The amino acid residues involved in determining the shape and charge of pocket 4 of the HLA-DR beta1 chain could influence the clinical course of MS by determining protection against RR/SP-MS or susceptibility to the development of PP-MS.

Clinical characteristics of progressive relapsing multiple sclerosis

OBJECTIVE

Patients with progressive relapsing (PR) multiple sclerosis (MS) may accrue disability by incomplete recovery from acute exacerbations and by ongoing deterioration. In primary progressive (PP) MS, disability accumulates solely by continuous decline. Because it is the least common form of MS, there is scant information regarding the clinical characteristics of PRMS, but relapses are reportedly uncommon. The purpose of this study is to describe the clinical features of a cohort of patients with PRMS.

METHODS

A retrospective chart review of 16 patients diagnosed with PRMS at two academic MS centres over a four-year period.

RESULTS

Nine men and seven women had PRMS. The mean age at onset was 35.1+/-11.2 years. The most common presenting symptom was a progressive myelopathy. The mean disease duration was 10.1+/-8.5 years and the average time to first exacerbation was 4.1+/-3.7years. Patients had an average of 2.8+/-2.3 relapses with an annualized relapse rate of 0.6+/-0.8. Time to Expanded Disability Status Scale (EDSS) 6.0 was strongly associated with time to first exacerbation. Although there was no correlation between the number of relapses and time to EDSS 6.0, there was a modest inverse relation between time to EDSS 6.0 and annualized relapse rate.

CONCLUSIONS

Relapses in PRMS may occur more often than previously described and disability may accumulate more rapidly in PRMS than in PPMS. We suggest differentiating between these two forms of MS.

The pathology of primary progressive multiple sclerosis

The pathological hallmark of chronic multiple sclerosis includes focal demyelination, gliosis, inflammation and axonal injury. There is limited information on whether these pathological features differ across the clinical phenotypes of the disease (relapsing-remitting, secondary progressive, and primary progressive). This review will focus on the pathological aspects of PPMS and pathogenic implications. A better understanding of the differences in PPMS pathology and pathogenesis will lead to more effective treatment strategies.

Converting relapsing remitting to secondary progressive experimental allergic encephalomyelitis (EAE) by ultraviolet B irradiation

We induced experimental allergic encephalomyelitis (EAE) in SJL/J mice, an animal model for multiple sclerosis (MS), using myelin oligodendrocyte glycoprotein (MOG)(92-106) peptide, following ultraviolet (UV) irradiation. While all control mice developed relapsing-remitting (RR)-EAE, UV irradiation induced secondary progressive (SP)-EAE in some of the mice. Although mild demyelination was observed with T cell infiltration in RR-EAE, large demyelinating lesions developed in SP-EAE with massive macrophage and neutrophil infiltration and immunoglobulin deposition, but with little T cell infiltration. UV irradiation induced higher anti-MOG antibody responses. In SP-EAE, lymphoproliferative responses and interferon-gamma production were decreased without alteration of interleukin-4.

Primary progressive multiple sclerosis: clinical and paraclinical characteristics with application of the new diagnostic criteria

The aim of our study was to analyse clinical and paraclinical characteristics of patients with multiple sclerosis (MS) with previous diagnosis of primary-progressive (PP) MS according to the Poser's criteria and further investigate if they fulfil the McDonald's diagnostic criteria for this disorder. A total of 561 MS patients were registered in the database at the Institute of Neurology, Belgrade, from 1 January 1997 to 31 December 2000 and 63 of them (11.2%) with previous diagnosis of PPMS were analysed retrospectively. Male/female ratio was 1.3:1 and mean age at onset 33.2 years. Most frequent at onset were pyramidal (in 73% of patients) and sensory symptoms (in 41% of patients); 74.6% of patients had greater than or equal to nine brain magnetic resonance imaging (MRI) lesions. Intrathecal oligoclonal immunoglobulin G (IgG) was detected in 96.7% and prolonged visual evoked potentials (VEP) P100 latency in 82.4% of patients. Of the total study group of 561 patients, 10.2% fulfilled the recently recommended McDonald's diagnostic criteria for the diagnosis of PPMS. Our findings further support the significance of the brain/spinal cord MRI, cerebrospinal fluid and VEP findings for precise diagnostic assessment in patients with suspected PP form of MS.

[Can multiple sclerosis be diagnosed on a first demyelinating event?]

Progression is required. The definition of multiple sclerosis (MS) relies on the notion of temporo-spatial dissemination of inflammatory demyelinating neurological episodes. Until recently, in order to retain the diagnosis of definite MS, two successive neurological episodes had to be observed in two different territories. Since the commercialisation of new immunomodulating treatments, and in particular the recent demonstration of their efficacy in delaying the onset of a second neurological episode, it has been necessary to draw-up new criteria. New criteria have recently been proposed by a group of experts and they emphasize the fundamental role played by magnetic resonance imaging. New priorities. With these new criteria, certain aspects have become front-line. This is the case of the necessity of foreseeing more exhaustive differential diagnoses of MS, so as to avoid the erroneous initiation of a specific treatment. There is also the problem of the selection of patients at high risk of a potentially progressive MS, not all patients necessarily require such treatment at the start. Updating. We successively present the recently revised diagnostic criteria in order to be able to diagnose MS after the first demyelinising episode, we then study the clinical and paraclinical predictive elements that provide supplementary support for MS and, notably, progressive MS. We also discuss the differential diagnoses to be excluded according to the clinical context and, lastly, we will attempt to assess the practical consequences of an early diagnosis, not only with regard to its announcement, but also with regard to the therapeutic decisions to be made.

Clinical presentation of primary progressive multiple sclerosis 10 years after the incidental finding of typical magnetic resonance imaging brain lesions: the subclinical stage of primary progressive multiple sclerosis may last 10 years

BACKGROUND

Subclinical multiple sclerosis (MS) has been identified incidentally at autopsy; apparently unaffected individuals with an affected twin have demonstrated magnetic resonance imaging (MRI) changes consistent with MS, and 'MRI relapses' are several times more common than clinical relapses.

CASE DESCRIPTION

A 39-year-old, right-handed man underwent MRI and PET scanning in 1986 as a 'normal' control in a Parkinson's disease study, where his father was the proband. MRI indicated multiple areas of abnormal signal intensity in a periventricular and grey-white matter junction distribution. Repeated clinical evaluations over the next 10 years were unchanged until 1996, when he complained of progressive weakness of the right foot and clumsiness in the right hand. MRI now indicated a further area of high signal intensity in the right posterior cord at the level of C5/C6. There was mild pyramidal distribution weakness in the right leg with an extensor plantar response on the same side. Over the next five years there has been mild progression in weakness and fatigue and intermittent Lhermitte's phenomenon. At no stage has there been a history of relapse, cerebrospinal fluid examination was normal and evoked responses (visual and somatosensory) are normal.

CONCLUSION

This case demonstrates the phenomenon of subclinical MS, unusually supported by prolonged clinical and MRI follow-up. The patient eventually became symptomatic nine years after MRI diagnosis and is following a primary progressive course. Although MRI is known to be sensitive in identifying subclinical 'attacks', the pattern illustrated here may actually be quite typical of primary progressive MS and is compatible with the later onset seen in this subgroup of patients.

The diagnosis of primary progressive multiple sclerosis

Primary progressive multiple sclerosis (PPMS) is a rather unique form of the more common relapsing inflammatory demyelinative disease. The absence of attacks that typify relapsing forms of MS imposes special challenges for diagnosis, but also provides an opportunity to study the pathogenesis of the more progressive aspects of the disease process in isolation of confounding transient clinical events. In this review, recent advances in diagnostic approaches are considered in relationship to baseline data from a large multinational study designed to better characterize and treat this clinical phenotype. PPMS subjects with cerebral spinal fluid (CSF) findings consistent with intrathecal immunoglobulin production may have a more tissue destructive disease process than those whose CSF lacks evidence of a B-cell immunopathogenic disease component.

Multiple sclerosis in Finland: incidence trends and differences in relapsing remitting and primary progressive disease courses

OBJECTIVE

To compare the secular trends and geographical differences in the incidence of relapsing-remitting (RRMS) and primary progressive multiple sclerosis (PPMS) in Finland, and to draw inferences about aetiological differences between the two forms of the disease.

METHODS

New multiple sclerosis cases in southern Uusimaa and the western districts Vaasa and Seinäjoki of Finland in 1979-1993 were verified from hospital records and classified into RRMS and PPMS. Patients met the Poser criteria for definite multiple sclerosis or otherwise satisfied the criteria for PPMS. Disease course was categorised by the same neurologist. Crude and age adjusted incidence in 1979-1993 was estimated.

RESULTS

During 1979-1993 the age adjusted incidence was 5.1 per 100 000 person-years in Uusimaa, 5.2 in Vaasa, and 11.6 in Seinäjoki. The rates in Uusimaa remained stable, while a decrease occurred in Vaasa and an increase in Seinäjoki. Between 1979-86 and 1987-93 the incidence of PPMS increased in Seinäjoki from 2.6 to 3.7 per 10(5) and decreased in Vaasa from 1.9 to 0.2 per 10(5); the trends were similar for RRMS.

CONCLUSIONS

There are significant differences in secular trends for multiple sclerosis incidence in Finland by geographical area, but these are similar for PPMS and RRMS. The recent changes point to locally acting environmental factors. The parallel incidence trends for RRMS and PPMS suggest similar environmental triggers for the two clinical presentations of multiple sclerosis.

Issues and practices in multiple sclerosis

The objective of this roundtable discussion of experts in the field of multiple sclerosis (MS) was to summarize the current understanding of MS and its therapeutic options. The experts discussed subjects ranging from the etiology of MS to the current standards for patient care. Specific topics included the subtypes of MS, with a focus on the benign subtype, brain atrophy, the role of magnetic resonance imaging or "neuroimaging studies," disease-modifying therapies, biological markers as indicators of drug efficacy, and combination therapies. In addition, the experts speculated as to what will be available in the near future for the improved diagnosis and management of MS. This review summarizes the main points of this discussion and is intended to serve as a reference for neurologists involved in the care of patients with MS.

Primary progressive multiple sclerosis: increasing clarity but many unanswered questions

Heterogeneity in the clinical course of multiple sclerosis (MS) is well recognised and patients following a primary progressive course, 10-15% of the MS population, have a distinct clinical and paraclinical phenotype. This review examines recent advances in our understanding of this subgroup of patients and examines the new criteria to be applied in diagnosis. It also highlights developments in genetic, immunological, magnetic resonance and pathological aspects of the disease, whilst also outlining the results of recent therapeutic trials.

Immunological indicators of disease activity and prognosis in multiple sclerosis

The need to ensure an accurate diagnosis and proper treatment for multiple sclerosis patients, considering the various clinical and immunopathological subtypes of the disease, requires the identification of biomarkers that measure disease activity and predict the course of disease development in individual patients. Moreover, the identification of effective indicators will lead not only to optimized patient treatment but also to the development of better tools for evaluating clinical trials. Recent studies focusing on the identification of possible immunological markers in multiple sclerosis will be reviewed.

Gender issues and multiple sclerosis

Gender-related issues in multiple sclerosis include the important and widely accepted clinical observations that men are less susceptible to the disease than women and also that disease activity in multiple sclerosis is decreased during late pregnancy. This article reviews mechanisms underlying each of these clinical observations and discusses the role of sex hormones in each. Specifically, the protective role of testosterone in young men and the protective role of the pregnancy hormone estriol in pregnant women are discussed. Rationale for novel therapies in multiple sclerosis based on the protective roles of these sex hormones is presented.

Metabolic differences between multiple sclerosis subtypes measured by quantitative MR spectroscopy

We used quantitative magnetic resonance (MR) spectroscopic imaging with T1-based image segmentation to evaluate the subtypes of multiple sclerosis (MS) (eight patients each group of relapsing-remitting [RR], secondary progressive [SP] and primary progressive [PP]). There was no significant difference in age between the PP group with the RP, SP or control group. We found that the metabolite ratio of choline/NA from the periventricular white matter region was not significantly different between the RR and SP groups. Using an ANOVA, the ratios of periventricular choline/NA or creatine/NA of these combined groups were significantly higher than the PP and control groups. Quantification of these data suggest that the major cause of the elevation of these parameters is due to an increase in choline and creatine in the RR group while NA is decreased in the SP group. Thus, early PP disease appears to be relatively intact with respect to neuronal loss.

The pathology of primary progressive multiple sclerosis

The present review will focus on the current knowledge of the pathology of primary progressive multiple sclerosis lesions. Multiple sclerosis (MS) is an inflammatory demyelinating disease with a broad clinical variability. The main disease courses are relapsing-remitting, secondary progressive and primary progressive MS. Pathological studies examining the specific underlying pathology of a defined clinical subtype are rare. Here, we focus on the pathological characteristics of the MS lesions and summarize the current findings of the pathology of primary progressive MS with respect to inflammation, oligodendrocyte myelin pathology, axon destruction and immunopathology of the lesions.

Pirfenidone for chronic progressive multiple sclerosis

Current treatment of secondary progressive multiple sclerosis is unsatisfactory in stabilizing or reversing the disabilities associated with the disease. Pirfenidone is a new non-peptide drug which has been shown in vitro and in vivo to decrease synthesis of Tumor Necrosis Factor-alpha (TNF-alpha) and block receptors for TNF-alpha. Since TNF-alpha seems to be a key cytokine in demyelination, a pilot study of oral pirfenidone was undertaken in an open-label baseline vs treatment protocol over a 2-year period in 20 patients. Fourteen (14120) patients (70%) remained in the study for 2 years. Three (3/20) patients dropped out early because of gastrointestinal adverse reactions, and another three patients dropped out for personal reasons after 1 year (not because of adverse reactions). The remaining patients did not manifest any other drug-related adverse reactions and complications. Improvement or stabilization occurred in most patients at about 3 months, and it was sustained at 6, 12 and 24 months as evaluated by both primary and secondary outcome measures. Magnetic resonance imaging foiled to reveal any new lesions. Thus, pirfenidone appears to offer protection against the usual slow progression of the disease. Most patients experienced a distinct decrease in their neurological disability. These findings indicate that an extensive multi-center double blind and placebo controlled trial is warranted.

Apoptosis in neurones exposed to cerebrospinal fluid from patients with multiple sclerosis or acute polyradiculoneuropathy

Primary cultures of murine cerebellar granule neurones were exposed to cerebrospinal fluid from patients with subtypes of multiple sclerosis or acute polyradiculoneuropathy (Guillain-Barré syndrome) for 2 days. Cells were then stained with Hoechst 33342 or terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling (TUNEL) to detect apoptotic bodies. The results were compared with control cultures exposed to cerebrospinal fluid from patients with no known neurological disease or deficit. There was no significant difference in the level of apoptosis induced between these controls and cultures not exposed to cerebrospinal fluid at all. Cultures exposed to cerebrospinal fluid samples from patients with relapsing-remitting multiple sclerosis did not have higher levels of apoptosis than cells exposed to controls, regardless of whether the sample was taken during relapse or remission. However, a significant increase in apoptosis was observed in cultures exposed to cerebrospinal fluid from patients with primary progressive multiple sclerosis, and apoptosis correlated with disease severity. This supports the existence of biochemical differences between subgroups of multiple sclerosis. A significant increase in apoptosis was also induced by cerebrospinal fluid samples from patients with acute polyradiculoneuropathy, suggesting the presence of neurotoxic factor(s) here also. The relevance to disease pathology is unclear.

["Multiple sclerosis plus": leukoencephalopathies at the frontiers of internal medicine]

INTRODUCTION

Multiple sclerosis (MS) is an inflammatory, demyelinating and probably autoimmune disease affecting the white matter of the central nervous system (CNS). Due to the absence of specific clinical and laboratory markers, diagnosis remains difficult.

CURRENT KNOWLEDGE AND KEY POINTS

In particular, no clinical or paraclinical investigation is satisfactory to distinguish definite MS from other autoimmune or inflammatory diseases, especially when they predominantly affect the CNS. Moreover, previous studies have reported that patients with definite MS could present clinical systemic signs suggestive of other inflammatory or autoimmune diseases, and that MS could be associated with other autoimmune diseases. On the other hand, the presence of biological autoimmune abnormalities, including antinuclear antibodies and antiphospholipid antibodies, has been observed, with a high frequency in patients with MS in comparison to control populations. These clinical and laboratory features could therefore represent a new nosological entity characterized by a systemic immune dysregulation more extensive than the CSN target, or a distinct subgroup of MS patients with a classical course of the disease. Because of the impact of the new therapeutic approach to MS, an important issue concerning this aspect that should be addressed is the use of immunomodulatory therapy, especially with interferon beta. It appears necessary to consider these abnormalities before treating MS patients with preventive therapy, in particular in the perspective of new strategies, such as treatment at an early stage of the disease or combination therapies.

Chronic fatigue syndrome: sociodemographic subtypes in a community-based sample

Most chronic fatigue syndrome (CFS) studies are based on information about patients from primary or tertiary care settings. These patients might not be typical of patients in the general population. This investigation involved examinations of individuals with CFS from a community-based study. A random sample of 18,675 in Chicago was interviewed by telephone. Individuals with chronic fatigue and at least four minor symptoms associated with CFS were given medical and psychiatric examinations. A group of physicians then diagnosed individuals with CFS, who were then subclassified based on three sociodemographic categories--gender, ethnicity, and work status. Sociodemographic subgroups were analyzed in terms of symptom severity, functional disability, coping, optimism, perceived stress, and psychiatric comorbidity. Women, minorities, and nonworking individuals with CFS reported greater levels of functional disability, symptom severity, and poorer psychosocial functioning than men, Caucasians, and working individuals, suggesting sociodemographic characteristics may be associated with poorer outcomes in urban, community-based samples of CFS individuals.

p-Cresol sulfate is the dominant component of urinary myelin basic protein like material

Multiple sclerosis (MS) is clinically heterogeneous and has an uncertain natural history. A high priority for more effective treatment of MS is an objective and feasible laboratory test for predicting the disease's course and response to treatments. Urinary myelin basic protein (MBP)-like material (MBPLM), so designated because it is immunoreactive as a cryptic epitope in peptide 83-89 of the human MBP molecule of 170 amino acids, is present in normal adults, remains normal in relapsing-remitting, but increases in progressive MS. In the present investigation, MBPLM was purified from urine and characterized. p-Cresol sulfate is the major component of urinary MBPLM. This conclusion is based on the following: (1) MBPLM and p-cresol sulfate both have a mass of 187 on negative scans by electrospray ionization mass spectrometry, the same fragments on tandem mass spectrometry of 80 (SO(-)(3)) and 107 (methylphenol), and similar profiles on multiple reaction monitoring; (2) (1)H and (13)C nuclear magnetic resonance spectroscopy revealed identical spectra for MBPLM and p-cresol sulfate; (3) purified p-cresol sulfate reacted in parallel with MBP peptide 83-89 in the same radioimmunoassay for MBPLM; and (4) p-cresol sulfate has the same behavior on preparative HPLC columns as urinary MBPLM. The unexpected immunochemical degeneracy permitting a cross-reaction between p-cresol sulfate and a peptide of an encephalitogenic myelin protein is postulated to be based on shared conformational features. The mechanisms by which urinary p-cresol sulfate, possibly derived from tyrosine-SO(4), reflects progressive worsening that is disabling in MS are unknown.