NEMO reshapes the α-Synuclein aggregate interface and acts as an autophagy adapter by co-condensation with p62

NEMO is a ubiquitin-binding protein which regulates canonical NF-κB pathway activation in innate immune signaling, cell death regulation and host-pathogen interactions. Here we identify an NF-κB-independent function of NEMO in proteostasis regulation by promoting autophagosomal clearance of protein aggregates. NEMO-deficient cells accumulate misfolded proteins upon proteotoxic stress and are vulnerable to proteostasis challenges. Moreover, a patient with a mutation in the NEMO-encoding IKBKG gene resulting in defective binding of NEMO to linear ubiquitin chains, developed a widespread mixed brain proteinopathy, including α-synuclein, tau and TDP-43 pathology. NEMO amplifies linear ubiquitylation at α-synuclein aggregates and promotes the local concentration of p62 into foci. In vitro, NEMO lowers the threshold concentrations required for ubiquitin-dependent phase transition of p62. In summary, NEMO reshapes the aggregate surface for efficient autophagosomal clearance by providing a mobile phase at the aggregate interphase favoring co-condensation with p62.

Subarachnoid hemorrhages and aneurysms during the SARS-CoV2-pandemia at a tertiary medical center - Analysis of incidence and outcome

Introduction

During the COVID-19-pandemic a significant decrease of up to 13% of all kinds of medical emergencies was reported. Similar trends were expected for aneurysmal subarachnoid hemorrhages (aSAH) and/or symptomatic aneurysms.

Research question

To analyze a correlation of the SARS-CoV2-infection and the incidence of aSAH, and to assess the impact of the pandemic-lockdown on the incidence, the outcome and the course of patients suffering from aSAH and/or aneurysms.

Material and methods

From March 16th, 2020 (first lockdown in Germany) to January 31st, 2021, all patients admitted to our hospital were screened by polymerase-chain-reaction (PCR) test for genetic material of SARS-CoV2. During this period, aSAH and symptomatic cerebral aneurysms were assessed and retrospectively compared to a historic longitudinal case-cohort.

Results

Of 109.927 PCR-tests, 7.856 (7.15%) revealed a SARS-CoV2-infection. None of the patients mentioned above were tested positively. The number of aSAH and symptomatic aneurysms rose by 20.5% (39 vs. 47 cases) (p ​= ​0.93). Poor grade aSAH, as well as extensive bleeding-patterns were more often observed (p ​= ​0.63 and p ​= ​0.40, respectively), with more symptomatic vasospasms diagnosed (5 vs. 9 patients). Mortality rate increased by 8,4%.

Discussion and conclusion

A correlation between SARS-CoV2-infection and the incidence of aSAH could not be established. Still, the overall number and the number of poor-grade aSAHs increased as well as symptomatic aneurysms during the pandemic. Therefore, we might conclude that dedicated neurovascular competence should be retained in designated centers to care for these patients even or especially in special situations affecting the global healthcare system.

Mechanical thrombectomy for acute ischemic stroke in COVID-19 patients: multicenter experience in 111 cases

BACKGROUND

Data on the frequency and outcome of mechanical thrombectomy (MT) for large vessel occlusion (LVO) in patients with COVID-19 is limited. Addressing this subject, we report our multicenter experience.

METHODS

A retrospective cohort study was performed of consecutive acute stroke patients with COVID-19 infection treated with MT at 26 tertiary care centers between January 2020 and November 2021. Baseline demographics, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at discharge and 90 days were noted.

RESULTS

We identified 111 out of 11 365 (1%) patients with acute or subsided COVID-19 infection who underwent MT due to LVO. Cardioembolic events were the most common etiology for LVO (38.7%). Median baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score were 16 (IQR 11.5-20) and 9 (IQR 7-10), respectively. Successful reperfusion (mTICI ≥2b) was achieved in 97/111 (87.4%) patients and 46/111 (41.4%) patients were reperfused completely. The procedure-related complication rate was 12.6% (14/111). Functional independence was achieved in 20/108 (18.5%) patients at discharge and 14/66 (21.2%) at 90 days follow-up. The in-hospital mortality rate was 30.6% (33/108). In the subgroup analysis, patients with severe acute COVID-19 infection requiring intubation had a mortality rate twice as high as patients with mild or moderate acute COVID-19 infection. Acute respiratory failure requiring ventilation and time interval from symptom onset to groin puncture were independent predictors for an unfavorable outcome in a logistic regression analysis.

CONCLUSION

Our study showed a poor clinical outcome and high mortality, especially in patients with severe acute COVID-19 infection undergoing MT due to LVO.

Positive effect of immunomodulatory therapies on disease progression in Huntington's disease? Data from a real-world cohort

Background:

The role of neuroinflammation and autoimmune processes in neurodegenerative diseases is not fully understood. Activation of microglia with expression of proinflammatory cytokines supports the hypothesis that immune processes may play an important role in the pathophysiology of Huntington’s disease (HD) and thus, immunomodulating therapies might have potential neuroprotective properties. Until now, no disease-modifying therapy (DMT) is available for HD.

Objective:

The aim of this research was to characterize a cohort of patients suffering from both HD and autoimmune demyelinating diseases of the central nervous system (classified as G35-37 in ICD-10; ADD-CNS) in comparison to HD cases without ADD-CNS. In particular, we were interested to investigate potential modulating effects on disease manifestation and progression of HD over time of prescribed immunomodulating medications (DMT).

Methods:

We analyzed the course of HD regarding motoric, functional, and cognitive aspects, using longitudinal data of up to 2 years from the worldwide registry study ENROLL-HD. Additional cross-sectional data in the largest cohort worldwide of HD patients was analyzed using demographic and molecular genetic parameters. Data were analyzed using analysis of variance (ANOVA) for cross-sectional and repeated-measures ANOVA for longitudinal parameters in IBM SPSS Statistics V.27.

Results:

Within the ENROLL-HD database, we investigated N = 21,116 participants and identified n = 60 participants suffering from ADD-CNS. Molecular, genetic, and demographic data did not differ between groups. The subgroup of n = 32 participants with motor-manifest HD revealed better cognitive performance in five out of eight cognitive tests at baseline with less progression over time in two tests (all p < 0.05). Differentiation between DMT-treated and untreated patients revealed better cognitive and motor performance in the DMT group; those patients, however, tended to be younger. Pre-manifest HD patients simultaneously diagnosed with ADD-CNS (n = 12) showed lower functional scores and more decline over time when compared with other pre-manifest HD (p < 0.05).

Conclusion:

Patients suffering from motor-manifest HD and simultaneously from ADD-CNS have better cognitive capacities compared with other motor-manifest HD patients. Moreover, DMTs might have beneficial effects on progression of neurodegeneration including the motor phenotype. However, this effect might have been biased by younger age in DMT-treated patients. Pre-manifest HD patients showed more functional impairment as expected due to their additional ADD-CNS disease.

Neurotrauma emergencies during the SARS-CoV2-pandemia at a tertiary medical center – analysis of incidence and outcome

Objective: To assess the impact of the lockdown in Germany due to the COVID-19-pandemic on the incidence and the outcome of neurotrauma emergencies at a tertiary medical center. Material and Methods: From March 16th, 2020 (first lockdown in Germany) to January 31st, 2021, all neurosurgical emergencies were included and compared to a longitudinal case-cohort. Cases were descriptively recorded and retrospectively analyzed with respect to incidence and outcome. Results: All emergencies defined as polytrauma referred to our center decreased by 10% during the pandemic (n=226), whereas neurosurgical emergencies increased by 18.4% (764 vs. 905 cases). Number of specific neurotrauma emergencies increased by 44.4% (63 vs. 91 cases), yet statistically not significant (p=0.245). The duration of treatment in the intensive care unit (ICU) extended from 621 to 1056 days (p=0.34). Conclusion: Reasons for increasing numbers of neurotrauma emergencies were: 1) many surrounding smaller care providers were cancelled during this time, and 2) there was a lack of free intensive care capacities in other hospitals, urging primarily maximum care providers to deal with more referrals. Both these facts and the prolonged treatment on ICUs strenghten the necessity for maximum care providers to keep ICU capacities for non-COVID patients. Specialized neurosurgical expertise should maintain in tertiary medical centers, even or particularly in exceptional circumstances such as the current pandemic.

Non-ischemic neurovascular emergencies at a supra-regional medical center during the SARS-CoV2-pandemia

Objective

To assess the impact of the lockdown in Germany due to the SARS-CoV2-pandemic on the incidence and the outcome of neurovascular emergencies at a tertiary medical center.

Methods

From March 16th, 2020 (first lockdown in Germany) to January 31st, 2021, all neurosurgical emergencies were included and compared to a longitudinal case-cohort. Cases were descriptively recorded and retrospectively analyzed with respect to incidence and outcome.

Results

All emergencies referred to our tertiary medical center decreased by 10% during the pandemic, whereas, neurosurgical emergencies increased by 18.4% (764 vs. 905 cases). Number of specific non-ischemic neurovascular emergencies increased by 29% (95 vs. 123 cases). The difference was not statistically significant (p = 0.53). Mortality rate increased dramatically by 40% during the pandemic throughout all neurovascular cases. As all included patients were negative PCR-tested for SARS-CoV2 the observed increase is unrelated to the virus infection.

Conclusion

Unexpectedly, according to our data neurovascular emergencies raised in number and severity during the pandemic in Germany at our tertiary referral center. Furthermore, the case fatality increased. Even though our data lack proof of evidence for these findings, we might suggest two possible explanations for the absolute increase in numbers: firstly, patients might have refused to seek medical help while suffering only mild symptoms. Furthermore, as numerous lower-level medical centers restricted admissions, the referral times of patients in need of neurosurgical attention increased. We, therefore, suggest that even in a pandemic situation like the SARS-CoV2/COVID-19, it seems of utmost importance to retain dedicated neurovascular competence in designated centers to care for these emergencies.

Germany-wide evaluation of residency in neurological intensive care medicine

BACKGROUND

Neurointensive medicine is an important subspecialization of neurology. Its growing importance can be attributed to factors such as demographic change and the establishment of new therapeutic options. Part of the neurological residency in Germany is a six-month rotation on an intensive care unit (ICU), which has not yet been evaluated nationwide. The aim of this study was to evaluate kind and feasibility of neurointensive care training in Germany and to discover particularly successful training concepts.

METHODS

In a preliminary study, ten residents and ten instructors were interviewed. Using content analysis, two questionnaires were created, which contained questions about specific teaching methods as well as individual satisfaction. The questionnaires were sent to 187 neurological clinics in Germany, and residents and instructors were asked to participate in the study. The data analysis was performed using SPSS and content analysis for the free-text data.

RESULTS

Seventy of the 187 clinics contacted did not offer ICU-rotation. At 59,8% (n = 70) of the remaining hospitals, a total of 154 participants (84 residents, 70 educators) could be recruited. General satisfaction with the neurointensive medical training is high in both groups (residents: 3.34 ± 0.54; instructors: 3.79 ± 0.41, evaluated on the basis of a Likert scale from 1 = "not satisfied" to 5 = "fully satisfied"). Specific teaching methods (e.g. simulation trainings, feedback sessions) are perceived as very useful by residents, but rarely take place. Instructors are interested in educational opportunities such as didactic courses.

CONCLUSION

This study provides an overview of the ICU-rotation as part of the five-year neurological residency. Neurointensive care rotations usually take place at maximum care hospitals and last at least seven months. Despite frequent time and personnel restrictions, motivation of trainers and residents is high. Nevertheless, teaching methods as simulation training and educational opportunities for instructors must be expanded.

Progressive multifocal leukoencephalopathy and immune reconstitution inflammatory syndrome in seven patients with sarcoidosis: a critical discussion of treatment and prognosis

Progressive multifocal leukoencephalopathy (PML) is a subacute brain infection by the opportunistic John Cunningham (JC) virus. Herein, we describe seven patients with PML, lymphopenia, and sarcoidosis, in three of whom PML was the first manifestation of sarcoidosis. At onset, the clinical picture comprised rapidly progressive spastic hemi- or limb pareses as well as disturbances of vision, speech, and orientation. Cerebral magnetic resonance imaging showed T2-hyperintense, confluent, mainly supratentorial lesions. Four patients developed punctate contrast enhancement as a radiological sign of an immune reconstitution inflammatory syndrome (IRIS), three of them having a fatal course. In the cerebrospinal fluid, the initial JC virus load (8–25,787 copies/ml) did not correlate with interindividual severity; however, virus load corresponded to clinical dynamics. Brain biopsies (n = 2), performed 2 months after symptom onset, showed spotted demyelination and microglial activation. All patients had lymphopenia in the range of 270–1150/µl.

To control JC virus, three patients received a combination of mirtazapine and mefloquine, another two patients additionally took cidofovir. One patient was treated with cidofovir only, and one patient had a combined regimen with mirtazapine, mefloquine, cidofovir, intravenous interleukin 2, and JC capsid vaccination. To treat sarcoidosis, the four previously untreated patients received prednisolone. Three patients had taken immunosuppressants prior to PML onset, which were subsequently stopped as a potential accelerator of opportunistic infections. After 6–54 months of follow up, three patients reached an incomplete recovery, one patient progressed, but survived so far, and two patients died. One further patient was additionally diagnosed with lung cancer, which he died from after 24 months. We conclude that the combination of PML and sarcoidosis is a diagnostic and therapeutic challenge. PML can occur as the first sign of sarcoidosis without preceding immunosuppressive treatment. The development of IRIS might be an indicator of poor outcome.

Successful Treatment of Severe Digitoxin Intoxication with CytoSorb® Hemoadsorption

While several intoxications can be successfully treated with specific antidotes, intoxications with the steroid glycoside digitoxin still represent a major challenge. Besides conventional approaches, CytoSorb® hemoadsorption might be another treatment option. We report on an 81-year-old female patient treated in our intensive care unit (ICU) with severe digitoxin intoxication, acute renal failure, and urinary tract infection (UTI). As physiological digitoxin elimination kinetics are known to appear slow, and also in regard to the renal failure, the decision was made to initiate continuous renal replacement therapy combined with CytoSorb hemoadsorption. The patient was hemodynamically stabilized within the first 4 h of treatment and initially required catecholamines to be stopped within 24 h of treatment. Pre- and post-adsorber drug level measurements showed a rapid elimination of digitoxin. Antibiotic treatment with piperacillin/tazobactam was initiated, and despite CytoSorb hemoadsorption therapy and its known potential to reduce plasma concentrations of several drugs, the UTI was successfully treated. After 3 days of CytoSorb treatment, digitoxin plasma levels were stable and almost normalized, and no clinical signs of intoxication were present. Five days after presentation, the patient was transferred from the ICU in a stable condition. CytoSorb hemoadsorption may be an easily available, efficient, and less cost-intensive therapy option than treatment with the Fab fragment, which is the currently recommended therapy for digitalis intoxications. Therefore, the use of CytoSorb might represent an alternative treatment for life-threatening complications of digitoxin intoxications.

Ocrelizumab Treatment in Patients with Primary Progressive Multiple Sclerosis: Short-term Safety Results from a Compassionate Use Programme in Germany

OBJECTIVES

In January 2018, the European Union (EU) approved ocrelizumab in relapsing multiple sclerosis (RMS) and as the first disease-modifying therapy (DMT) for patients with primary progressive multiple sclerosis (PPMS) with efficacy proven in a phase 3 randomised controlled trial. Eleven months prior to the European regulatory approval, a compassionate use programme (CUP) made ocrelizumab available to 489 patients with PPMS in Germany, thereby for the first time providing a therapeutic option to patients with PPMS who could not participate in ocrelizumab studies. Here, we report real-world patient characteristics and short-term safety data of patients with PPMS treated with ocrelizumab in this CUP.

PATIENTS AND METHODS

This CUP was initiated in February 2017 - shortly before US Food and Drug administration approval in March 2017 - and ended in January 2018, following ocrelizumab approval in the EU. Adult patients (age ≥18 years) with PPMS who had a positive benefit/risk ratio according to the treating physician were eligible for inclusion at German treatment centres. The main exclusion criteria were current/recent treatment with other immune therapies and unresolved/chronic/active infections. Patients received methylprednisolone and an antihistamine before treatment with intravenous ocrelizumab in 6-month cycles. The first ocrelizumab dose was a 300 mg infusion followed by a second 300 mg infusion 2 weeks later; subsequent doses were delivered as a single 600 mg infusion. Adverse events were reported immediately.

RESULTS

Of 580 requests received from 104 centres, 525 patients met the eligibility criteria. Thirty-five patients did not participate due to withdrawal by the treating physician, and one due to death prior to treatment. A total of 489 patients received at least one 600 mg dose of ocrelizumab (administered as two 300 mg infusions) and 51 received a second dose. Due to termination of the CUP upon marketing authorisation, the maximum follow-up period was 12 months. Median patient age was 52 years (range: 24-73), and 49% were female. Previous immunomodulatory or immunosuppressive therapies had been received by 41% of patients, with the most commonly used being glucocorticoids, mitoxantrone, interferon-β and glatiramer acetate. Patients with a previous malignancy, serious disease or infection (42 patients, 9%) had recovered from this prior to the CUP. Nine serious adverse events and 70 non-serious adverse events were reported in 40 patients. Adverse event categories were generally consistent with the known safety profile of ocrelizumab; one patient had carry-over progressive multifocal leukoencephalopathy (PML) due to previous natalizumab treatment.

CONCLUSION

This CUP provides first real-world observations of ocrelizumab for the treatment of PPMS in a large patient cohort in Germany, supporting that ocrelizumab is generally well-tolerated in clinical practice. Physicians should be vigilant for early symptoms of PML, as to date, 9 PML cases that were all confounded have been reported in patients treated with ocrelizumab worldwide, with 8 carry-over cases from a prior DMT.

Immunomodulatory and anti-oxidative effect of the direct TRPV1 receptor agonist capsaicin on Schwann cells

Background

Only few studies describe the impact of nutritive factors on chronic inflammatory demyelinating polyneuropathy (CIDP), an inflammatory disease of the peripheral nervous system. The active component of chili pepper, capsaicin, is the direct agonist of the transient receptor potential channel vanilloid subfamily member 1. Its anti-inflammatory effect in the animal model experimental autoimmune neuritis (EAN) has been previously demonstrated.

Methods

In the present study, we describe the anti-inflammatory and anti-oxidative influence of capsaicin on Schwann cells (SCs) in an in vitro setting. Hereby, we analyze the effect of capsaicin on Schwann cells’ gene expression pattern, major histocompatibility complex class II (MHC-II) presentation, and H₂O₂-induced oxidative stress. Furthermore, the effect of capsaicin on myelination was examined in a SC-dorsal root ganglia (DRG) coculture by myelin basic protein staining. Finally, in order to investigate the isolated effect of capsaicin on SCs in EAN pathology, we transplant naïve and capsaicin pre-treated SCs intrathecally in EAN immunized rats and analyzed clinical presentation, electrophysiological parameters, and cytokine expression in the sciatic nerve.

Results

In SC monoculture, incubation with capsaicin significantly reduces interferon gamma-induced MHC-II production as well as toll-like receptor 4 and intercellular adhesion molecule 1 mRNA expression. Calcitonin gene-related peptide mRNA production is significantly upregulated after capsaicin treatment. Capsaicin reduces H₂O₂-induced oxidative stress in SC in a preventive, but not therapeutic setting. In a SC-DRG coculture, capsaicin does not affect myelination rate. After intrathecal transplantation of naïve and capsaicin pre-treated SCs in EAN-immunized rats, naïve, but not capsaicin pre-treated intrathecal SCs, ameliorated EAN pathology in rats.

Conclusions

In conclusion, we were able to demonstrate a direct immunomodulatory and anti-oxidative effect of capsaicin in a SC culture by reduced antigen presentation and expression of an anti-inflammatory profile. Furthermore, capsaicin increases the resistance of SCs against oxidative stress. A primary effect of capsaicin on myelination was not proven. These results are in concordance with previous data showing an anti-inflammatory effect of capsaicin, which might be highly relevant for CIDP patients.

Novel variants in a patient with late-onset hyperprolinemia type II: diagnostic key for status epilepticus and lactic acidosis

BACKGROUND

Hyperprolinemia type 2 (HPII) is a rare autosomal recessive disorder of the proline metabolism, that affects the ALDH4A1 gene. So far only four different pathogenic mutations are known. The manifestation is mostly in neonatal age, in early infancy or early childhood.

CASE PRESENTATION

The 64-years female patient had a long history of abdominal pain, and episode of an acute neuritis. Ten years later she was admitted into the neurological intensive-care-unit with acute abdominal pain, multiple generalized epileptic seizures, a vertical gaze palsy accompanied by extensive lactic acidosis in serum 26.0 mmol/l (reference: 0.55-2.2 mmol/l) and CSF 12.01 mmol/l (reference: 1.12-2.47 mmol/l). Due to repeated epileptic seizures and secondary complications a long-term sedation with a ventilation therapy over 20 days was administered. A diagnostic work-up revealed up to 400-times increased prolin-level in urine CSF and blood. Furthermore, a low vitamin-B₆ serum value was found, consistent with a HPII causing secondary pyridoxine deficiency and seizures. The ALDH4A1 gene sequencing confirmed two previously unknown compound heterozygous variants (ALDH4A1 gene (NM_003748.3) Intron 1: c.62 + 1G > A - heterozygous and ALDH4A1 gene (NM_003748.3) Exon 5 c.349G > C, p.(Asp117His) - heterozygous). Under high-dose vitamin-B₆ therapy no further seizures occurred.

CONCLUSION

We describe two novel ALDH4A1-variants in an adult patient with hyperprolinemia type II causing secondary pyridoxine deficiency and seizures. Severe and potentially life-threatening course of this treatable disease emphasizes the importance of diagnostic vigilance and thorough laboratory work-up including gene analysis even in cases with atypical late manifestation.

Brainstem Encephalitis With Low-Titer Acetylcholine Receptor Antibodies Mimicking Myasthenia Gravis

Objective: To report a rare case of brainstem encephalitis with low-titer acetylcholine receptor antibodies mimicking myasthenia gravis.

Methods: The patient was investigated with repeated brain MRI, CSF examination, repetitive nerve stimulation, thoracic CT, and serologic screening. Our patient passed away and finally autopsy revealed a definitive diagnosis. Written informed consent was obtained from the relatives of the patient for access to clinical files for research purposes and publication.

Results: We present a young woman with a subacute bulbar syndrome, who was initially diagnosed with myasthenia gravis based on clinical finding and elevated acetylcholine receptor antibodies. Episodes of numbness in the pharynx and tongue and moderate saccadic horizontal and vertical pursuits were atypical. Despite initial stabilization with intravenous immunoglobulins she developed acute asphyxia after regurgitation of food and had to be resuscitated with ultimately lethal outcome. Autopsy revealed an autoimmune T-cell mediated brainstem encephalitis. Serological screening revealed positive GAD and Ma2 autoantibodies, indicating its probable paraneoplastic nature.

Conclusions: Brainstem encephalitis is an important differential diagnosis even in seropositive bulbar myasthenia gravis, as several autoimmune processes often co-occur. Sudden unexpected death must be taken into account in brainstem encephalitis, requiring prolonged monitoring of the patients.

A protein quality control pathway regulated by linear ubiquitination

Neurodegenerative diseases are characterized by the accumulation of misfolded proteins in the brain. Insights into protein quality control mechanisms to prevent neuronal dysfunction and cell death are crucial in developing causal therapies. Here, we report that various disease-associated protein aggregates are modified by the linear ubiquitin chain assembly complex (LUBAC). HOIP, the catalytic component of LUBAC, is recruited to misfolded Huntingtin in a p97/VCP-dependent manner, resulting in the assembly of linear polyubiquitin. As a consequence, the interactive surface of misfolded Huntingtin species is shielded from unwanted interactions, for example with the low complexity sequence domain-containing transcription factor Sp1, and proteasomal degradation of misfolded Huntingtin is facilitated. Notably, all three core LUBAC components are transcriptionally regulated by Sp1, linking defective LUBAC expression to Huntington's disease. In support of a protective activity of linear ubiquitination, silencing of OTULIN, a deubiquitinase with unique specificity for linear polyubiquitin, decreases proteotoxicity, whereas silencing of HOIP has the opposite effect. These findings identify linear ubiquitination as a protein quality control mechanism and hence a novel target for disease-modifying strategies in proteinopathies.

Tryptophan immunoadsorption during pregnancy and breastfeeding in patients with acute relapse of multiple sclerosis and neuromyelitis optica

BACKGROUND

Up to every fourth woman with multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD) suffers a clinically relevant relapse during pregnancy. High doses of steroids bear some serious risks, especially within the first trimester of pregnancy. Immunoadsorption (IA) is an effective and more selective treatment option in disabling MS relapse than plasma exchange. Data on the use of IA during pregnancy and breastfeeding are scarce.

METHODS

In this retrospective multicenter study, we analyzed the safety and efficacy of IA treatment in acute relapses during pregnancy or breastfeeding. The primary outcome parameter - change of acute relapse-related disability after IA - was assessed using Expanded Disability Status Scale (EDSS) and visual acuity (VA) measurements for patients with optic neuritis (ON).

RESULTS

A total of 24 patients were analyzed, 23 with relapsing-remitting MS, and 1 with NMOSD. Twenty patients were treated with IA during pregnancy. Four patients received IA postnatally during the breastfeeding period. Treatment was started at a mean 22.5 [standard deviation (SD) 13.9] days after onset of relapse. Patients were treated with a series of 5.8 (mean, SD 0.7) IA treatments within 7-10 days. Sixteen patients received IA because of steroid-refractory relapse, eight were treated without preceding steroid pulse therapy. EDSS improved clinically relevant from 3.5 [median, interquartile range (IQR) 2] before IA to 2.5 (median, IQR 1.1) after IA, p < 0.001. In patients with ON, VA improved in four out of five patients. Altogether, in 83% of patients, a rapid and marked improvement of relapse-related symptoms was observed after IA with either a decrease of ⩾1 EDSS grade or improvement in VA ⩾20%. No clinically relevant side effect was reported in 138 IA treatments.

CONCLUSIONS

Tryptophan-IA was found to be effective and well tolerated in MS/NMOSD relapses, both as an escalation option after insufficient response to steroid pulse therapy and as first-line relapse treatment during pregnancy and breastfeeding.

Myotone Dystrophien, nicht dystrophe Myotonien und periodische Paralysen

In der Behandlung der myotonen Dystrophien, nicht dystrophen Myotonien und periodischen Paralysen haben sich in den letzten Jahren einige neue Aspekte ergeben, die in der aktualisierten Leitlinie zu myotonen Dystrophien, nicht dystrophen Myotonien und periodischen Paralysen zusammenfassend dargestellt sind.

Nach wie vor besteht eine europaweit nur sehr eingeschränkte Verfügbarkeit von Mexiletin, welches in Deutschland nur noch über die Auslandsapotheke aus z. B. Japan, den USA oder Kanada in einer Dosierung von 100 mg oder 200 mg bezogen werden kann, wenngleich die Wirksamkeit von Mexiletin bei myotoner Dystrophie Typ 1 in einer amerikanischen Studie erneut bestätigt wurde (Logigian et al., 2010).

In einer rezenten Studie konnte gezeigt werden, dass der Carboanhydrasehemmer Dichlorphenamid sowohl bei hypokaliämischer als auch bei hyperkaliämischer periodischer Paralyse die Attackenfrequenz senkt, allerdings war der Unterschied bei der hyperkaliämischen Lähmung nicht signifikant (Sansone et al., 2016). Bei dieser Studie handelt es sich um die Kombination zweier randomisierter Untersuchungen über 9 Wochen, kombiniert mit einer einjährigen Extensionsphase, bei der alle Teilnehmer Dichlorphenamid erhielten. Die Studie wurde gegen Placebo durchgeführt; der ursprünglich geplante Vergleich mit Acetazolamid wurde abgebrochen, weil die an der Studie teilnehmenden Patienten Dichlorphenamid aufgrund subjektiv besserer Wirksamkeit vorzogen und deshalb keine Gruppe für einen Vergleich Dichlorphenamid/Acetazolamid gebildet werden konnte. Die Hauptnebenwirkungen waren Parästhesien, Nierensteinbildung und eine Verlangsamung des Denkens. Die Studie erlaubte keine Rückschlüsse auf die Beziehung zwischen Wirksamkeit und Genotyp; die häufigste Mutation war T704 M (Nav1.4) bei der hyperkaliämischen Lähmung und R528H (Cav1.1) und R1239H (Cav1.1) bei der hypokaliämischen Lähmung. Ein Patient in der hypokaliämischen Gruppe mit der Mutation pR222 W (Nav1.4) verschlechterte sich. Dichlorphenamid ist inzwischen als Keveyis in den USA im Handel. In der Europäischen Union ist Dichlorphenamid (noch) nicht zugelassen; es hat aber den Status einer „orphan drug“ und ist somit verordnungsfähig.

In einer doppelblinden randomisierten placebokontrollierten Studie mit 22 Patienten mit nicht dystrophen Myotonien konnte gezeigt werden, dass Lamotrigin in einer Dosierung von 300 mg/d die myotone Symptomatik signifikant gegenüber dem Ausgangsbefund verbesserte (Anderson G et al., 2017).

Eine offene Behandlungsstudie mit Ranolazin, einem Piperazinderivat, in einer Dosierung von 2 × 500 mg bei 13 Patienten mit Chloridkanalmyotonie ergab eine signifikant reduzierte EMG-Myotonie, eine nach Patientenangaben signifikant reduzierte Muskelsteifigkeit und geringer auch reduzierte Muskelschwäche und eine reduzierte Myotonie in den klinischen Tests (Arnold WD et al., 2017).

Neuroimmunologische Register in Deutschland

In den letzten 10 Jahren wurden in Deutschland mehrere neuroimmunologische Register aufgebaut. Grundlegendes Ziel ist es, mehr über den Verlauf der entsprechenden Erkrankung, insbesondere unter therapeutischen Bedingungen, oder auch Nebenwirkungen eingesetzter Immuntherapeutika zu erfahren, im besten Fall prädiktive Marker zu identifizieren. Sechs dieser Register möchten wir im folgenden Artikel vorstellen.

Das Deutsche Netzwerk zur Erforschung autoimmuner Enzephalitiden (GENERATE) mit mehr als 40 beteiligten Zentren und 570 dokumentierten Patienten (Stand September 2016) sammelt klinische Daten und Biomaterialien von Patienten mit autoimmunen Enzephalitiden mit bekannten und unbekannten Antikörpern. Es koordiniert und vermittelt die Verbindung zwischen Wissenschaftlern und Klinikern und dient als Plattform zur Entwicklung gemeinsamer Leitlinien und Prozeduren.

Die NeuroMyelitis Optica Studiengruppe (NEMOS) hat ein nationales Register für Patienten mit Neuromyelitis optica und Neuromyelitis optica Spektrum-Erkrankungen aufgebaut. Am Register sind neben 22 Kliniken der Maximalversorgung auch 17 regionale Krankenhäuser und etliche Praxen beteiligt, aktuell sind etwa 250 Patienten erfasst. Mit „NationNMO“ baut NEMOS derzeit innerhalb des Kompetenznetzes Multiple Sklerose eine prospektive Kohorte auf. Die besten Behandlungsstrategien sowohl für akute Schübe als auch deren Prophylaxe stehen im Fokus der aktuellen Forschungsarbeit von NEMOS.

Das Kompetenznetz Multiple Sklerose hat eine multizentrische, prospektive Kohortenstudie für therapienaive Patienten mit klinisch isoliertem Syndrom (KIS) und früher schubförmiger Multipler Sklerose (MS) initiiert (NationMS), mit dem Ziel der langfristigen Beobachtung und klinischer wie paraklinischer Charakterisierung der Patienten. Von August 2010 bis Dezember 2014 wurden in 22 universitären und nicht-universitären Zentren 1212 Patienten in die NationMS-Kohorte eingeschlossen, von denen standardisierte klinische Daten, Biomaterial und MRT-Bilddaten asserviert wurden.

Die Deutsche Multiple Sklerose Gesellschaft, Bundesverband e. V. begann 2001 die Etablierung eines MS-Registers als ein Langzeitprojekt, um eine einheitliche, verlässliche Übersicht über die MS-Erkrankung in Deutschland zu erhalten. Nach einer umfassenden Revision im Jahre 2014 ist nun das primäre Ziel, ein dauerhaftes Datenrepositorium für die Versorgungsforschung zu etablieren, welches die Erfassung, Speicherung und Bereitstellung von Daten von MS-Erkrankten über Jahrzehnte gewährleistet und somit die Darstellung von Langzeitverläufen ermöglicht. In über 170 deutschlandweiten Zentren konnten bisher mehr als 48 000 Patienten eingeschlossen werden.

Ebenfalls vom Kompetenznetz Multiple Sklerose wurde Anfang 2013 das Immuntherapieregister REGIMS initiiert. Primäres Ziel von REGIMS ist die Erfassung der Inzidenz, Art und Eigenschaft von unerwünschten Ereignissen aktueller und zukünftiger Immuntherapeutika in der Behandlung von Patienten mit einer gesicherten MS-Diagnose oder KIS-Patienten. Zum 01.01.2017 umfasste das Register 36 aktive Zentren mit über 700 eingeschlossenen Patienten.

Das Deutsche Multiple Sklerose und Kinderwunschregister (DMSKW) hat das Ziel, Sicherheitsinformationen zur Exposition mit immunmodulierenden Therapien in der Schwangerschaft zu gewinnen. Neben Sicherheitsaspekten interessieren auch der Verlauf der MS in der Schwangerschaft und postpartum, sowie die Identifikation modifizierbarer Schubrisikofaktoren. In das DMSKW konnten bisher 1500 Schwangerschaften eingeschlossen werden, pro Jahr kommen mindestens 250 prospektiv verfolgte Schwangerschaften hinzu.

Alle in diesem Artikel vorgestellten Register leisten einen wichtigen Beitrag zur Erforschung verschiedener neuroimmunologischer Erkrankungen. Viele Kollegen, sowohl in der Klinik als auch in der Praxis, unterstützen die hier vorgestellten Register. Ziel ist es, den Verlauf und den Einfluss therapeutischer Entscheidungen besser zu verstehen, aber auch die Beratung und Versorgung dieser Patienten zu verbessern.

Insight into Metabolic 1H-MRS Changes in Natalizumab Induced Progressive Multifocal Leukoencephalopathy Brain Lesions

Background

Progressive multifocal leukoencephalopathy (PML) is a severe complication of immunosuppressive therapies, especially of natalizumab in relapsing–remitting multiple sclerosis (MS). Metabolic changes within PML lesions have not yet been described in natalizumab-associated PML in MS patients.

Objective

To study metabolic profiles in natalizumab-associated PML lesions of MS patients by ¹H magnetic resonance spectroscopy (¹H-MRS) at different stages during the PML course. To assess changes associated with the occurrence of the immune reconstitution inflammatory syndrome (IRIS).

Methods

20 patients received ¹H-MRS and imaging at 3 T either in the pre-IRIS, IRIS, early-post-PML, or late post-PML setting. Five of these patients received individual follow-up examinations, including the pre-IRIS or IRIS phase. Clinical worsening was described by changes in the Karnofsky Performance Scale (KPS) and the expanded disability status scale (EDSS) 1 year before PML and scoring at the time of ¹H-MRS.

Results

In PML lesions, increased levels of the Lip/Cr ratio, driven by rising of lipid and reduction of Creatine, were found before the occurrence of IRIS (p = 0.014) with a maximum in the PML–IRIS group (p = 0.004). By contrast, marked rises of Cho/Cr in PML lesions were detected exclusively during the IRIS phase (p = 0.003). The Lip/Cr ratio decreased to above-normal levels in early-post-PML (p = 0.007, compared to normal appearing white matter (NAWM)) and to normal levels in the late-post-PML group. NAA/Cho was reduced compared to NAWM in the pre-IRIS, IRIS, and early-post-PML group. In NAA/Cr, the same effect was seen in the pre-IRIS and early-post-PML group. These cross-sectional results were confirmed by the individual follow-up examinations of four patients. NAA/Cho, Cho/Cr, and the lipid rise relative to NAWM in PML lesions were significantly correlated with the residual clinical worsening (KPS change) in post-PML patients (Spearman correlations ρ = 0.481, p = 0.018; ρ = −0.505, p = 0.014; and ρ = −0.488, p = 0.020).

Conclusion

¹H-MRS detected clinically significant dynamic changes of metabolic patterns in PML lesions during the course of natalizumab-associated PML in MS patients. Lip/Cr and Cho/Cr may provide additional information for detecting the onset of the IRIS phase in the course of the PML disease.

Metabolic profiles by 1H-magnetic resonance spectroscopy in natalizumab-associated post-PML lesions of multiple sclerosis patients who survived progressive multifocal leukoencephalopathy (PML)

PURPOSE

Early diagnosis and treatment of multiple sclerosis-related progressive multifocal leukoencephalopathy (PML) significantly improve clinical outcomes. However, there is a lack of information regarding the restart of immunomodulatory therapy in the post-PML setting, when multiple sclerosis activity reappears. We aimed at the examination of metabolic differences using 1H-magnetic resonance spectroscopy (1H-MRS) in multiple sclerosis patients at various post-PML stages and at the exploration of differences according to their disease and JC virus (JCV) status.

METHODS

1H-MRS of PML lesions was carried out on 15 relapsing-remitting multiple sclerosis patients with natalizumab-associated PML. Patients were grouped according to their stage after PML infection as early post-PML, less than 19 months after PML onset (n = 5), or late post-PML group, more than 23 months after PML onset (n = 10). The latter group was further categorized according to persisting JCV load in the cerebrospinal fluid.

RESULTS

Early post-PML patients showed significantly higher Lipid/Creatine ratios within PML lesions than late post-PML (p = 0.036). Furthermore, N-Acetyl-Aspartate/Creatine and N-Acetyl-Aspartate/Choline were significantly reduced in early post-PML and late post-PML lesions relative to normal-appearing white matter. In late post-PML, virus-positive patients showed significantly higher ratios of Choline/Creatine (p = 0.019) and consequently a reduced N-Acetyl- Aspartate/Choline ratio (p = 0.010) in contrast to virus-negative patients. In late post-PML patients with persisting viral load, an elevated Choline/Creatine ratio correlated significantly with higher disability.

CONCLUSIONS

1H-MRS may provide additional information related to underlying PML disease activity in various post-PML stages. In particular, Choline/Creatine levels, Lipid levels, and N-Acetyl- Aspartate/Choline are relevant markers in the post-PML setting, taking also the JCV status into account.

Inhibition of Huntingtin Exon-1 Aggregation by the Molecular Tweezer CLR01

Huntington's disease is a neurodegenerative disorder associated with the expansion of the polyglutamine tract in the exon-1 domain of the huntingtin protein (htt^e1). Above a threshold of 37 glutamine residues, htt^e1 starts to aggregate in a nucleation-dependent manner. A 17-residue N-terminal fragment of htt^e1 (N17) has been suggested to play a crucial role in modulating the aggregation propensity and toxicity of htt^e1. Here we identify N17 as a potential target for novel therapeutic intervention using the molecular tweezer CLR01. A combination of biochemical experiments and computer simulations shows that binding of CLR01 induces structural rearrangements within the htt^e1 monomer and inhibits htt^e1 aggregation, underpinning the key role of N17 in modulating htt^e1 toxicity.

Two years' long-term follow up in chronic inflammatory demyelinating polyradiculoneuropathy: efficacy of intravenous immunoglobulin treatment

BACKGROUND

Administration of intravenous immunoglobulins (IVIgs) is established for long-term treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Prevention of secondary axonal loss going along with permanent clinical disability and muscular atrophy is a major aim in CIDP therapy. To assess long-term clinical efficacy of IVIg treatment despite heterogenous disease course and variable complaints reported by the patients, long-term electrophysiological monitoring was performed for systematic evaluation of therapeutic efficacy of IVIg.

METHODS

A total of 21 patients with CIDP treated with IVIg 1 g/kg bodyweight every 3-6 weeks were examined electrophysiologically every 12 months over a period of 2 years.

RESULTS

Assessment of clinical symptoms, using the Inflammatory Neuropathy Cause and Treatment (INCAT) and Hughes functional grading score (F-score) revealed improvement of motor and sensory symptoms over a period of 2 years. As electrophysiological results remained stable, IVIg treatment seems to be suitable to prevent axonal loss in CIDP.

CONCLUSIONS

This study confirms efficacy of IVIg as firstline therapy in CIDP. Doses and frequency of IVIg application should be adapted based on clinical evaluation and analysis of long-term electrophysiological findings.

[Radiation-Induced Radiculopathy with Paresis of the Neck and Autochthonous Back Muscles with Additional Myopathy]

Radiation-induced tissue damage is caused by ionizing radiation mainly affecting the skin, vascular, neuronal or muscle tissue. Early damages occur within weeks and months while late damages may occur months or even decades after radiation.Radiation-induced paresis of the spine or the trunk muscles with camptocormia or dropped-head syndrome are rare but have already been described as long-term sequelae after treatment of Hodgkin's lymphoma. The differential diagnosis includes limb-girdle muscular dystrophy, fascioscapulohumeral muscular dystrophy (FSHD) or lysosomal storage diseases (e. g. Acid Maltase Deficiency). We present the case of a patient with long lasting diagnostics over many months due to different inconclusive results.

Tumefactive multiple sclerosis lesions in two patients after cessation of fingolimod treatment

BACKGROUND

Fingolimod (FTY) is the first oral medication approved for multiple sclerosis therapy. Until now, little has been known about the effects of FTY withdrawal regarding disease activity and development of tumefactive demyelinating lesions (TDLs), as already described in patients who discontinue natalizumab.

METHODS

In this study we present the clinical and radiological findings of two patients who had a severe rebound after FTY withdrawal and compare these with patients identified by a PubMed data bank analysis using the search term 'fingolimod rebound'. In total, 10 patients, of whom three developed TDLs, are presented.

RESULTS

Patients suffering from TDLs were free of clinical and radiological signs of disease activity under FTY therapy (100% versus 57%, compared with patients without TDLs) and had rebounds after a mean of 14.6 weeks (standard deviation 11.5) [patients without TDLs 11.7 (standard deviation 3.4)].

CONCLUSION

We propose that a good therapeutic response to FTY might be predisposing for a severe rebound after withdrawal. Consequently, therapy switches should be planned carefully with a short therapy free interval.

Echogenicity of basal ganglia structures in different Huntington's disease phenotypes

In Huntington's disease (HD), a neurodegenerative-inherited disease, chorea as the typical kind of movement disorder is described. Beside chorea, however, all other kinds of movement disturbances, such as bradykinesia, dystonia, tremor or myoclonus can occur. Aim of the current study was to investigate alterations in the echogenicity of basal ganglia structures in different Huntington's disease phenotypes. 47 patients with manifest and genetically confirmed HD were recruited. All participants underwent a thorough neurological examination. According to a previously described method, classification into predominantly choreatic, mixed or bradykinetic-rigid motor phenotypes was performed depending on subscores of the Unified Huntington's Disease Rating Scale. In addition, findings in juvenile HD were compared to adult HD. Transcranial sonography was performed by investigators blinded to clinical classification. There were no significant differences in basal ganglia echogenicities between the three phenotypes. Size of echogenic area of substantia nigra (SN) correlated positively with CAG repeat and bradykinesia subscore, and negatively with age of onset and chorea subscore. Comparing juvenile and adult HD subtypes, SN hyperechogenicity was significantly more often detectable in the juvenile form (100 vs. 29.3 %, p = 0.002). Regarding echogenicity of caudate or lentiform nuclei, no significant differences were detected. HD patients with the juvenile variant exhibit marked hyperechogenicity of substantia nigra. No significant differences in basal ganglia echogenicities between predominantly choreatic, mixed or bradykinetic-rigid motor phenotypes were detected.

Increase of angiotensin II type 1 receptor auto-antibodies in Huntington's disease

Background

In the recent years, a role of the immune system in Huntington’s disease (HD) is increasingly recognized. Here we investigate the presence of T cell activating auto-antibodies against angiotensin II type 1 receptors (AT1R) in all stages of the disease as compared to healthy controls and patients suffering from multiple sclerosis (MS) as a prototype neurologic autoimmune disease.

Results

As compared to controls, MS patients show higher titers of anti-AT1R antibodies, especially in individuals with active disease. In HD, anti-AT1R antibodies are more frequent than in healthy controls or even MS and occur in 37.9% of patients with relevant titers ≥ 20 U/ml. In a correlation analysis with clinical parameters, the presence of AT1R antibodies in the sera of HD individuals inversely correlated with the age of onset and positively with the disease burden score as well as with smoking and infection.

Conclusions

These data suggest a dysfunction of the adaptive immune system in HD which may be triggered by different stimuli including autoimmune responses, infection and possibly also smoking.

Fumarate treatment in progressive forms of multiple sclerosis: first results of a single-center observational study

OBJECTIVES

Therapeutic options in progressive forms of multiple sclerosis (MS) are still limited. Dimethyl fumarate (DMF) has immunomodulatory properties but may also exert antioxidative cytoprotective effects. Hence, it may be a therapeutic option for progressive MS. The aim of this observational study was to evaluate safety, adherence and efficacy of fumarates in patients with primary progressive MS (PPMS) or secondary progressive MS.

METHODS

Patients with progressive MS whose condition had failed to respond to standard therapies and had worsened received the fumarate mixture Fumaderm, licensed for psoriasis therapy in Germany, or DMF by pharmaceutical preparation (Bochum ethics approval no. 4797-13). At regular follow-up visits, tolerability and disease course were assessed.

RESULTS

Twenty-six patients [age 54 ± 7.8 years; female = 13 (50%); PPMS = 12 (46.2%); Expanded Disability Status Scale (EDSS) = 6.0 ± 0.4 (range 3.5-8.0); disease duration = 14.1 ± 8.7 years] were initiated on treatment with Fumaderm (n = 18) or pharmacy-prepared DMF (n=8). During a mean follow-up period of 13.2 ± 7.5 months (range 6-30) only five patients (19.2%) reported minor complaints. In 15 patients (57.7%) EDSS remained stable. In five cases (19.2%) there was even a decrease in EDSS while in six patients (23.1%) there was an increase in EDSS of more than 0.5 points, reflecting deterioration. Laboratory values were controlled for lymphopenia, renal and hepatic values, without any safety problems. We observed no significant differences between the two pharmaceutical forms.

CONCLUSION

Our pilot data indicate that fumarate therapy appears to be safe and well tolerated by patients with progressive MS. In more than 75% of cases no further disease progression was evident. However, controlled studies are warranted to evaluate the detailed therapeutic potential of fumarates and their long-term effects in progressive MS.

Serum anti-Müllerian hormone levels in reproductive-age women with relapsing–remitting multiple sclerosis

Background:

Fertility might be reduced in women with multiple sclerosis (MS), although only few studies exist and the underlying reasons are not well understood. Similar to other autoimmune diseases, a decreased ovarian reserve may contribute to impaired fertility in women with MS. Anti-Müllerian hormone (AMH) is an established marker of the ovarian reserve and an objective indicator of ovarian function, which is independent of the hypothalamus-pituitary-gonadal axis function.

Objective:

The purpose of this study was to determine AMH levels in females with relapsing–remitting MS (RRMS) in combination with other reproduction and lifestyle factors.

Methods:

A total of 76 reproductive-age females with RRMS and 58 healthy controls were included in this case control study. An enzymatically amplified two-site immunoassay was used to measure serum AMH level.

Results:

Mean AMH level was significantly decreased in females with RRMS ( p<0.04), and a higher proportion of females with RRMS showed very low AMH values (<0.4 ng/ml) compared to healthy controls ( p<0.05). The majority of these women were currently without any disease modifying treatment.

Conclusions:

Our data contribute to our understanding of impaired fertility in women with MS. The unexpected finding that the majority of MS subjects with very low AMH levels were currently without medication requires further evaluation.

Neuroprotective dimethyl fumarate synergizes with immunomodulatory interferon beta to provide enhanced axon protection in autoimmune neuroinflammation

INTRODUCTION

Despite recent advances in development of treatments for multiple sclerosis, there is still an unmet need for more effective and also safe therapies. Based on the modes of action of interferon-beta (IFN-β) and dimethyl fumarate (DMF), we hypothesized that anti-inflammatory and neuroprotective effects may synergize in experimental autoimmune encephalomyelitis (EAE).

METHODS

EAE was induced in C57BL/6 mice by immunization with MOG35-55-peptide. Murine IFN-β was injected s.c. every other day at 10.000IU, and DMF was provided at 15mg/kg by oral gavage twice daily. Control mice received PBS injections and were treated by oral gavage with the vehicle methylcellulose. Mice were scored daily by blinded observers and histological, FACS and cytokine studies were performed to further elucidate the underlying mechanism of action.

RESULTS

Combination therapy significantly ameliorated EAE disease course in comparison to controls and monotherapy with IFN-β. Histological analyses showed a significant effect on axon preservation with almost twice as much axons present in inflamed lesions as compared to control. Remarkably, the effect on axonal preservation was more pronounced under combination therapy than with both monotherapies. Neither monotherapy nor combination therapy demonstrated modulation of cytokines and frequency of antigen presenting cells.

DISCUSSION

Combination of IFN-β and DMF resulted in greater beneficial effects with improved tissue protection as compared to the respective monotherapies. Further combination studies of these safe therapies in human disease are warranted.

The role of the immune system in Huntington's disease

Huntington's disease (HD) is characterized by a progressive course of disease until death 15-20 years after the first symptoms occur and is caused by a mutation with expanded CAG repeats in the huntingtin (htt) protein. Mutant htt (mhtt) in the striatum is assumed to be the main reason for neurodegeneration. Knowledge about pathophysiology has rapidly improved discussing influences of excitotoxicity, mitochondrial damage, free radicals, and inflammatory mechanisms. Both innate and adaptive immune systems may play an important role in HD. Activation of microglia with expression of proinflammatory cytokines, impaired migration of macrophages, and deposition of complement factors in the striatum indicate an activation of the innate immune system. As part of the adaptive immune system, dendritic cells (DCs) prime T-cell responses secreting inflammatory mediators. In HD, DCs may contain mhtt which brings the adaptive immune system into the focus of interest. These data underline an increasing interest in the peripheral immune system for pathomechanisms of HD. It is still unclear if neuroinflammation is a reactive process or if there is an active influence on disease progression. Further understanding the influence of inflammation in HD using mouse models may open various avenues for promising therapeutic approaches aiming at slowing disease progression or forestalling onset of disease.

Oral available agents in the treatment of relapsing remitting multiple sclerosis: an overview of merits and culprits

Multiple sclerosis (MS) is a chronic immunological disease of the central nervous system characterized by early inflammatory demyelination and subsequent neurodegeneration. Major therapeutic progress has occurred during the past decade, in particular since the introduction of immunomodulatory agents, however, MS is still an incurable disease. In addition, parenteral application of the currently licensed drugs is associated with injection-related adverse events (AEs) and low patient compliance. Thus, there remains an unmet need for the development of more effective and well tolerated oral therapies for the treatment of MS. A number of new orally administered agents including fingolimod, laquinimod, teriflunomide, cladribine, and BG-12 have been licensed recently or are currently under investigation in relapsing remitting MS patients. In multi-center, randomized, placebo-controlled phase III clinical studies, all of these agents have already shown their efficacy on both clinical disease parameters and magnetic resonance imaging-based measures of disease activity in patients with relapsing remitting MS. However, there are essential differences concerning their clinical efficacy and side-effect profiles. Additionally, the mechanisms by which these substances exert clinical efficacy have not been fully elucidated. In this article, we review the pharmaceutical properties of fingolimod, laquinimod, teriflunomide, cladribine, and BG-12; and their suggested mechanisms of action, clinical efficacy, and side-effect profiles.

Anti-inflammatory effects of levetiracetam in experimental autoimmune encephalomyelitis

Levetiracetam (LEV) is an established anticonvulsant with numerous mechanisms of action. Apart from its anti-epileptic effects, recent experimental studies suggest anti-inflammatory properties via modulation of interleukin (IL)-1β and transforming-growth-factor (TGF)-β1. However, its anti-inflammatory properties have not yet been examined in an autoimmune inflammatory disease of the central nervous system (CNS). We investigated LEV anti-inflammatory properties in experimental autoimmune encephalomyelitis, an established mouse model of multiple sclerosis. FACS analyses, ELISA, histology and rt-PCR experiments were done to explore potential anti-inflammatory effects. In line with prior studies, we demonstrate that LEV modulates both the relative gene expression and secretion of IL-1β and TGF-1β. However, these changes were not sufficient to alter the disease course or histological parameters. Additionally, LEV showed no effects on the absolute number of different immune cell subsets. In summary, LEV showed only minor anti-inflammatory effects not sufficient to ameliorate disease course in an autoimmune inflammatory disease of CNS.