Chronic granulomatous disease involving the central nervous system

Endoscopic scoring system for extraparenchymal neurocysticercosis

OBJECTIVE

To propose a scoring system using endoscopy for assessment of the inflammatory alterations caused by neurocysticercosis (NCC) inside the ventricular cavities and the basal subarachnoid space.

METHODS

Video recordings of the endoscopic procedures in patients with hydrocephalus secondary to NCC were assessed in a two-phase study. In the first phase (n = 10), the assigned score of each patient was correlated with the cerebrospinal fluid values obtained by lumbar and ventricular puncture. Reproducibility was determined using an intraclass correlation coefficient. In the second phase (n = 30), the prognostic value of the score was tested by comparing it with the patient's Karnofsky performance score (KPS) 3 months after endoscopy.

RESULTS

The score included four main components: ependymal findings, number of involved sites, abnormalities in the subarachnoid space, and other alterations. These values were summed to produce a total score, which correlated strongly with both protein and cell counts from ventricular cerebrospinal fluid. The intraclass correlation coefficient of the global score was 0.85. In the second phase, the scores were divided into mild, moderate, and severe categories (6, 15, and 9 patients). The initial KPS was similar between the groups (P = 0.56); however, when measured 3 months later, there were significant differences (P = 0.02). The logistic regression analysis of patients with a score in the severe range (odds ratio = 0.09; 95% confidence interval, 0.06-0.64) showed a reduced chance for achieving a good outcome (KPS ≥90) after 3 months.

CONCLUSIONS

Our scoring system enables endoscopic classification of the damage caused by NCC in the ventricular and basal subarachnoid space. The score has a biologic basis and a good internal reproducibility. The score seems to be useful for determining the short-term prognosis, and patients with high scores require additional therapeutic measures to improve their outcomes.

Chronic granulomatous disease: a review of the infectious and inflammatory complications

Chronic Granulomatous Disease is the most commonly encountered immunodeficiency involving the phagocyte, and is characterized by repeated infections with bacterial and fungal pathogens, as well as the formation of granulomas in tissue. The disease is the result of a disorder of the NADPH oxidase system, culminating in an inability of the phagocyte to generate superoxide, leading to the defective killing of pathogenic organisms. This can lead to infections with Staphylococcus aureus, Psedomonas species, Nocardia species, and fungi (such as Aspergillus species and Candida albicans). Involvement of vital or large organs can contribute to morbidity and/or mortality in the affected patients. Major advances have occurred in the diagnosis and treatment of this disease, with the potential for gene therapy or stem cell transplantation looming on the horizon.

Gastrointestinal complications of chronic granulomatous disease: case report and literature review

Chronic granulomatous disease (CGD), an inherited disorder of phagocytic leukocyte function, is characterized by recurrent infections with catalase-positive organisms. Gastrointestinal (GI) tract involvement, present in the majority of affected individuals, may be present initially and recurrently, mimics other entities such as inflammatory bowel disease, and causes substantive morbidity and mortality. Disorders of motility, ulceration, obstruction, and infection (e.g., abscesses) occur from the mouth to the anus and stereotypically manifest with vomiting, diarrhea, abdominal pain, weight loss, and fever. Careful physical examination, in concert with appropriate diagnostic studies, is necessary to delineate intraabdominal pathologic processes. Abdominal radiographs, ultrasonography, computerized tomography, and endoscopy are useful ancillary diagnostic procedures. Drainage of accessible abscesses, antimicrobial therapy based on organisms cultured from blood and tissue, and interferon gamma may lead to suppression or eradication of infections and resolution of symptoms. Corticosteroids are useful for gastric outlet obstruction and sulfasalazine and cyclosporine for large bowel disease. Gallbladder dysfunction may be ameliorated, as in our patient, with administration of cholestyramine.

Brain lesions in chronic granulomatous disease

In chronic granulomatous disease (CGD) enzyme-deficient neutrophils and mononuclear cells lack the respiratory burst required for biocidal activity. Recurrent infections lead to granulomas in various organs but brain lesions are rare. In the present case, a 23-year-old male with numerous infections since early childhood died of overwhelming pulmonary aspergillosis. He first began to experience neurological deficits at the age of 17. Computerized tomography and magnetic resonance imaging revealed fleeting white matter lesions that were interpreted as multiple sclerosis (MS). At post mortem, three types of brain lesions were found: (1) Pigmented macrophages in perivascular spaces and the leptomeninges similar to those reported previously. They contained fine, golden-brown, lipofuscin-like material whose chemical composition included a sulfur peak by X-ray analysis. (2) Focal, well-demarcated, "burnt out" white matter lesions with loss of both myelin and axons and intense sclerosis. (3) Diffuse areas of mild pallor in the centrum ovale which spared the U fibers. The pigmented macrophages are characteristic of those seen in the periphery in CGD. The origin of the discrete, destructive white matter lesions is unclear. They may have resulted from: (i) earlier activity by CGD macrophages; (ii) previous infections due to sepsis or embolism; or (iii) possibly post-infectious encephalomyelitis. The more diffuse, mild, white matter lesions are attributed to edema. Evidence for MS, progressive multifocal leukoencephalopathy, or human immunodeficiency virus encephalitis was lacking. This case is presented to alert us to look more carefully for brain lesions in CGD, characterize them and to help determine their cause.

Enhancement of normal neutrophil chemiluminescence by chronic granulomatous disease neutrophils

Neutrophils and other phagocytic cells from patients with chronic granulomatous disease (CGD) lack the ability to generate reactive oxygen intermediates (ROI), although other phagocytic functions appear to be intact. The effects of CGD neutrophils on the ability of normal neutrophils to produce ROI as measured by luminol-enhanced chemiluminescence (CL) were examined. Normal neutrophils (2 x 10(5)) had a peak CL response to phorbol myristate acetate (PMA; 20 ng/ml) of 6.5 +/- 0.9 mV, while the CL response to CGD neutrophils was completely absent. However, the addition of CGD neutrophils (8 x 10(5)) to normal neutrophils (2 x 10(5)) markedly increased the peak CL response to PMA to 11.0 +/- 1.1 mV (P less than 0.001). The peak response of normal neutrophils (2 x 10(5)) alone to the peptide N-formyl-methionyl-leucyl-phenylalanine (FMLP; 10(-6) M) was 9.0 +/- 1.1 mV, and this increased to 22.2 +/- 3.5 mV (P less than 0.001) when 8 x 10(5) CGD neutrophils were added and to 18.9 +/- 3.6 mV (P less than 0.005) when 4 x 10(5) CGD neutrophils were added. Thus, CGD neutrophils increase the release of ROI from normal cells, suggesting nonoxidative regulatory factors in ROI production.

Pigmented, lipid-laden histiocytes in the central nervous system in chronic granulomatous disease of childhood

In addition to granulomas, infiltrates of pigmented, lipid-laden histiocytes are a consistent morphologic finding in visceral organs of the reticuloendothelial system in patients with chronic granulomatous disease. We report a case with widespread meningeal and focal brain stem infiltrates of these distinctive histiocytes. The noninfectious involvement of the central nervous system in chronic granulomatous disease may be greater than previously recognized and related to the role of the CNS in the reticuloendothelial system.