Tubular inclusions in macrophages in the brain of a patient with acute hemorrhagic leukoencephalitis (Weston-Hurst syndrome)

Mycoplasma pneumoniae, a trigger for Weston Hurst syndrome

Objective:

We report a case of Mycoplasma pneumoniae infection as one possible trigger for Weston Hurst syndrome (acute hemorrhagic leukoencephalitis), a rare disorder of microvascular injury often described as a postinfectious complication of an upper respiratory illness.

Methods:

This is a case of a 27-year-old man presenting with a Glasgow Coma Scale score of 3 and an acute head CT revealing extensive vasogenic edema in the right hemisphere associated with mass effect in the context of a recent upper respiratory illness. Right frontal biopsy was performed on day 2, which showed acute cerebritis, and the patient was aggressively treated with antibiotics. However, over the next 5 days from presentation, the vasogenic edema increased, leading ultimately to brain herniation and death.

Results:

A full autopsy was performed at 5 days from presentation, which showed areas of vessel wall fibrinoid necrosis throughout the right hemisphere as well as, but less so, in the left frontal lobe and pons. Chest x-ray on presentation revealed atypical pneumonia, blood tests were positive for cold agglutinins, and at full autopsy, there was myocarditis, all in keeping with recent M pneumoniae infection. DNA obtained from lung and diseased brain (postmortem) was positive for Mycoplasma providing more direct evidence for brain invasion by this organism as the ultimate trigger for Weston Hurst syndrome.

Conclusions:

This is a rare case report of Weston Hurst syndrome having both initial brain biopsy on day 2 and full autopsy results on day 5 of presentation revealing important clinical clues about the pathogenesis of this often fatal disorder.

Disorders that mimic central nervous system infections

Many noninfectious diseases can cause signs, symptoms, and cerebrospinal fluid (CSF) abnormalities simulating central nervous system (CNS) infection. Infection usually can be excluded in these cases by the judicious use of serologic tests and CSF stains and cultures. Then, the correct diagnosis is typically suggested by the history and the concomitant presence of clinical and laboratory evidence of disease in other organ systems. Occasionally, particularly when such evidence is absent, the distinction requires meningeal or brain biopsy.

Morphologic evidence for a preferential storage of tissue plasminogen activator (t-PA) in perivascular axons of the rat uvea

The uveal layer is thought to hold the largest stores of tissue plasminogen activator (t-PA) within the eye. However, the uveal cell types that contain and could release t-PA to contiguous tissues and fluids have not been clearly identified. In the present study the general distribution pattern of t-PA antigen in fresh rat iris and choroid tissue was determined by immunofluorescence in preliminary light microscopic (LM) cryosections. Transmission electron microscopic (TEM) immunogold localization was then used to detect specific cellular and subcellular sites of t-PA antigen. The primary antibody was rabbit anti-mouse t-PA IgG. The immunofluorescence in preliminary LM cryosections of both tissues was most intense over discrete linear and cross-sectioned structures that resembled the contours of axon bundles. This impression was strengthened when silver impregnation highlighted similar structures in separate sections of the same tissue samples. TEM immunogold labeling of thin sections then confirmed that the t-PA antigen was confined to the axoplasm of both myelinated and unmyelinated perivascular nerve fibers in both the iris and choroid. Gold particles were not observed over axonal membranes, myelin sheaths, Schwann cells, retinal pigment epithelium or vascular endothelial cells. Ultrathin TEM cryosections of the iris showed a localization of some particles over structures that resembled tubules and vesicles within the axoplasm, but not over mitochondria. The axonal location of t-PA was shown by the co-localization of t-PA with an antibody against rat neurofilaments. The typical axon morphology that enclosed the t-PA particle markers in all TEM sections also indicated an axonal location. Separate TEM sections were processed with conventional fixatives and stains to highlight the typical uveal axon morphology, which also confirmed the identity of perivascular axons as the sites of t-PA localization. Affinity of the primary antibody for rat t-PA was shown by an inhibition ELISA against rat uveal tissue extracts and by the inhibition of t-PA activity in aqueous humor. An amidolytic assay was used to quantify t-PA activity. Possible explanations for the preferential immunolocalization of t-PA antigen to the axoplasm of uveal nerve terminals and the need for additional functional studies to confirm a putative neural t-PA synthesis are discussed.