Multiple Intracerebral Hemorrhages in an Old Patient with Rheumatoid Arthritis

A 78-year-old Caucasian man was admitted in the Department of Neurology for visual disturbances, started two days before. The next day the patient experienced headache, fever and gait disturbances. He had hypertension, diabetes mellitus, an ischemic stroke 13 years ago, longstanding seronegative rheumatoid arthritis (17 years), polynodular goiter, right ischio-pubian fracture and right femoral vein thrombosis a year ago due to a car accident, since he is treated with oral anticoagulants associated to antiaggregant, hypotensors, statin and oral antidiabetics. The neurologic examination had evidenced nuchal rigidity, left homonymous hemianopsia, left central facial palsy, ataxia of the inferior limbs with wide-based gait, achilean reflexes abolished bilaterally, bilaterally abolished plantar reflexes, ideomotor apraxia, dysarthria, hypoprosexia, and preserved consciousness patient. A non-contrast cerebral CT scan had shown right temporal and parieto-occipital intraparenchymatous hemorrhages, a right frontal sequelar lesion, multiple old lacunar infarets, cortical atrophy. Laboratory findings included an inflammatory syndrome, absence of rheumatoid arthritis positive serology, normal coagulogram, an elevated proteinuria. The cerebral IRM performed on the seventh day of hospitalisation was suggestive for subacute right parietal hemorrhage, old cerebral infarction in the right anterior cerebral artery area, old lacunar infarcts and cerebral atrophy. The anticoagulant and antiaggregant treatment was stopped after a generalized tonic-clonic seizure occurred. Antiedematous, hypotensor, anticonvulsivant, beta-blocker, and symptomatic treatment was started, while the antidiabetic treatment was continued. All symptoms remitted. Arguments for amyloid angiopathy in our patient are previous non-cardioembolic ischemic stroke and a chronic inflammatory disease- rheumatoid arthritis in his personal medical history.

New insight into the rheumatoid vasculitis

Vasculitis in rheumatoid arthritis (rheumatoid vasculitis, RV) has a heterogeneous clinical presentation that includes skin disorders, neuropathy, eye symptoms and systemic inflammation. Rheumatoid vasculitis is an unusual complication of longstanding, severe rheumatoid arthritis (RA). While RA affects the body's joints, vasculitis is a condition in which blood vessels become inflamed. Rheumatoid vasculitis occurs in approximately 2 to 5% of patients who have RA. The blood vessels most often involved are arteries that bring blood to the skin, nerves, and internal organs. Veins can also be involved. Rheumatoid vasculitis is skin condition that is a typical feature of RA, presenting as peripheral vascular lesions that are localized (purpura, cutaneous ulceration, and gangrene of the distal parts of the extremities). The cause of RV is unknown, but given the prominence of immune components and the pathologic changes in involved blood vessels, an autoimmune process is suggested. Compared to other forms of vasculitis, there has been relativejy little research in recent years on the specific entity of RV. There is some evidence that the incidence of RV has decreased over the past several decades, perhaps because of a better treatment of the underlying RA. In the present review, we discuss the clinical features, laboratory tests, the pathogenesis of RV.

The human microbiome in autoimmune diseases

The human microbiome is the collection of all of the genes in all of the microbes in and on our bodies. Recently, the more appropriate term is "microbiota". There are numerous and complex relationships between the microbiome and our immune system. It is also becoming clear that if there is a disruption or disorganization in the microbiome community an inflammatory disease can occur.

Rheumatoid arthritis and ischemic strokes in a young woman. Are these conditions interrelated?

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease which is associated with an increased risk of cardio and cerebrovascular pathology. A 48-year old Caucasian female was admitted for diffuse arthralgias. She was diagnosed eight years before with seropositive RA and she received Methotrexate, Prednisone and anti-inflammatory drugs. A week after the admission the patient presented sudden onset of left hemiplegia. Cerebral CT scan was suggestive for acute infarction in the right middle cerebral artery area and an old sequelar infarction in the left posterior artery area. Laboratory tests revealed: erythrocyte sedimentation rate of 40 mm/hour, fibrinogen 656 mg/dL, C-reactive protein of 20 mg/dL, rheumatoid factor 66.83 U/mL, anti CCP3 IgG 213.54 U/mL, ANA 128.126 U/mL. Also, she had high LDL-cholesterol serum concentration (190 mg/dL). The ECG revealed sinus rhythm, QRS axis-45 degrees, antero-lateral ischemia. Ultrasound examination of cervico-cerebral arteries emphasized occlusion of the left internal carotid artery, large atheromas in both carotid and vertebral arteries. A treatment with anti-aggregant and statin was started, and the former treatment for RA was continued with a raised Prednisone dose. The outcome was favorable, the patient's motor deficit improved (3/5 BMRC at the upper limb and 4/5 at the inferior limb) and she was able to walk with a cane support. She also presented an alleviation in the laboratory test status. Ischemic stroke is a possible complication of RA, presenting as principal risk factor precocious atherosclerosis. A better control of inflammation by new anti-rheumatic treatments will protect the RA patients of deleterious effects of ischemic stroke.

Troponin T changes in acute ischemic stroke

Elevation of cardiac troponin T (cTnT) in serum reflects myocardial injury, but it was also observed in other conditions with cardiac injury including acute ischemic stroke. The objective was to identify the relationship between elevated cTnT and stroke severity, location and outcome, cTnT levels were prospectively performed in 385 patients with different subtypes of acute ischemic stroke admitted in NICU within 72 hours of onset, as TOAST criteria. The patients were divided into two groups: an elevated cTnT (group 1) (n = 42) and a normal cTnT (group 2) (n = 343). The short-term prognosis was assessed by 30-days modified Rankin Scale responder analysis and the NIHSS. Serum cTnT levels were determined using a high sensitive troponin T assay (Roche Elecsys Troponin, Mannheim, Germany), cut-off value of 0.01 ng/ml. Statistical analysis was performed. Serum cTnT level was elevated in 10.91% (42/385) of patients, cTnT positivity on admission is an independent and powerful prognosis predictor in acute ischemic stroke. It was observed a more frequent insular lobe involvement in elevated cTnT group (17/42) (31%) than in group 2 (55/343) (16%) (p = 0.040). Stroke severity was greater in elevated cTnT group. The outcome was worse in elevated cTnT group as compared to group 2 (13/43) (30.95%) vs. (68/343) (19.82%) (p = 0.013). cTnT in acute ischemic stroke is a marker of stroke severity, of insular lobe lesion and of prognosis prediction. cTnT is a highly specific and sensitive marker of myocardial damage in acute ischemic stroke due to insular lesion that induces disturbances of autonomic balance.

The role of heavy metals in autoimmunity

Our understanding of autoimmune diseases has progressed tremendously in the past 20 years. Estimates of the prevalence of autoimmune diseases in the population may be 4% or higher. It is evident that heavy metals present serious risk to human health. Heavy metals are capable of altering the immune response; they have been implicated in influencing autoimmunity. In fact, they are usually inhibitory to immune cell proliferation and activation. This paper reviews the possible mechanisms which may play a role in metal-induced autoimmunity. A better understanding of these interactions remains a priority for the future.

Ischemic strokes in a young patient with dermatomyositis, systemic lupus erythematosus and secondary antiphospholipid syndrome mimicking herpetic encephalitis

A 44-year-old right-handed Caucasian male was initialy diagnosed in 2007 with dermatomyositis (DM) and in 2009 with systemic lupus erythematosus (SLE) (overlap syndrome). He was treated with Methylprednisolone and Hydroxychloroquine. He interrupted the treatment in the last three years. The patient presented with fever (39.8 degrees C), left zoster ophthalmicus, headache and psychomotor agitation. The cerebral CT scan showed left hemispheric hypodense lesions. Herpetic encephalitis was suspected. The patient was referred to the Institute of Infectious Diseases. The patient's neurological status worsened, he presented spastic tetraparesis and aphasia. DW-MRI, ADC, DS and AngioMRI were done, the patient proved to have an ischemic stroke due to acute thrombosis of the left internal carotid artery and multiple watershed infarctions. An infectious pathology, including HSV-1, was excluded by PLEX ID performed from CSF. Acyclovir, anti vitamin K, steroidal intravenous pulse therapy was started. The patient was referred after two weeks to the Department of Neurology. Mild inflammatory syndrome, tests for anti-double stain DNA (dsDNA), anti-Sm, anti-SSA, IgM and IgG anti-cardiolipin antibodies and lupus anticoagulant were positive. He was currently treated with Methylprednisolone (48 mg/d), anti vitamin K, statin, symptomatics. The outcome was favorable, with good laboratory response. Overlap syndrome may be associated with a significant increase in the risk of stroke. Our case presented without clinically susceptible symptoms of stroke but found to have stroke after neurological assessment associated with overlap syndrome (DM and SLE).

Cerebrovascular complications in patients with inflammatory bowel disease

Cerebrovascular complications in 9 patients with inflammatory bowel disease (IBD) are presented, 6 with Crohn's disease (CD) and 3 with ulcerative colitis (UC), 7 men and 2 women, mean age 36.5 +/- 3.5 years, 4 of them during acute disease. Cerebrovascular complications were: cerebral venous thrombosis (CVT)--7 cases (5 CD and 2 UC) and ischemic stroke--2 cases (1 CD and 1 UC). Out of 7 cases with CVT 5 were superior sagittal sinus thrombosis (SSS), 2 SSS and transverse and sigmoid sinus thrombosis. Both ischemic strokes were infarctions in the middle cerebral artery area. No correlation between high doses of corticosteroids or their lowering, IBD activity, duration of the disease, and the appearance of cerebrovascular complications was observed. Tendency to hypercoagulation even in the inactive stage of the IBD was revealed. Investigations for thrombophilia were negative. Significantly high levels of homocysteine were observed in all patients.

CONCLUSION

Neurovascular complications may be observed in IBD, both of venous and arterial type. Pathogenic mechanisms of these vascular complications are complex, low serum folate levels, of vitamin B6 and B12 being associated with elevation of homocysteine levels, high activation of platelets and microvascular endothelial dysfunction. A guide for the orientation of prophylaxis of cerebrovascular complications in IBD patients is necessary.

Could pro-BNP, uric acid, bilirubin, albumin and transferrin be used in making the distinction between stroke subtypes?

To establish the pathogenesis of ischemic strokes is very important in determining an adequate therapy. The objective was to observe if certain plasma parameters could be used as biomarkers in distinguishing between stroke subtypes. Plasma pro-BNP (chemiluminescence), serum uric acid, bilirubin (colorimetric assay), albumin and transferrin (nephelometric assay) levels were performed in 168 admitted patients (mean age 68.7 +/- 11.6 years, 52 men and 116 women) with different subtypes of acute ischemic strokes within 24 hours and at 7 days after stroke onset as TOAST and OCSP criteria, NIHSS and Glasgow Coma Score at baseline and at 7 days were used. The mean value of pro-BNP level was significantly higher in the cardioembolic stroke (CE), in patients, within 24 hours (p < 0.001) and at 7 days (p < 0.001) after stroke onset. A negative correlation between pro-BNP levels and GCS (r = 0.05, p < 0.0002) and a significant difference between pro-BNP levels of NIHSS groups were observed (p < 0.08, respectively (p < 0.01). We observed significantly higher values within 24 hours of uric acid (p < 0.05), significantly lower values within 24 hours of transferrin (p < 0.05), significantly lower values at 7 days of albumin and transferrin (p < 0.001), significantly higher values at 7 days of uric acid and bilirubin (p < 0.001). No significant statistical differences between the values of oxidative stress parameters and stroke subtypes, GCS and NIHSS score were observed. The level of plasma pro-BNP may be useful in distinguishing CE stroke from other stroke subtypes. Oxidative stress is increased in acute ischemic stroke, but oxidative stress parameters could not be used to differentiate stroke subtypes.

ASIA or Shoenfeld's syndrome--an autoimmune syndrome induced by adjuvants

Recently, reports have suggested grouping different autoimmune conditions that are triggered by external stimuli as a single syndrome called autoimmune syndrome induced by adjuvants (ASIA). This syndrome is characterized by the appearance of myalgia, myositis, muscle weakness, arthralgia, arthritis, chronic fatigue, sleep disturbances, cognitive impairment and memory loss, and the possible emergence of a demyelinating autoimmune disease caused by systemic exposure after vaccines and adjuvants. As there are no markers for ASIA, the authors intend to present ASIA, or Shoenfeld's syndrome, as an autoimmune syndrome induced by adjuvants.

Genetic differences between patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common chronic inflammatory joint disease. RA likely develops beginning with genetic risk. Investigating of preclinical period of RA will lead to understanding the relationships between genetic and environmental factors. The recent studies confirm the polygenic contribution of the major histocompatibility complex (MHC) to RA. Various genetic factors involved in the pathogenesis of RA have been discovered. HLA genes contribute only a portion of the genetic susceptibility to RA. There is also evidence for a contribution of non-class II genes to susceptibility. Non-HLA genes are also involved in disease pathogenesis, and identifying them remains a challenge. The association between RA and certain MHC alleles may be important in the pathogenesis of RA. In the future, research into genetic factors correlated with the severity of RA is expected to yield interesting and hopefully clinically relevant results. In this review we present the current data supporting the existence of susceptibility gene for RA.

Evaluation of oxidative stress in patients with acute ischemic stroke

Oxidative stress is involved in the pathogenesis of acute ischemic stroke. Antioxidants are consumed in the reaction with free radicals generated during the oxidative stress. The aim of the study was the to evaluate the oxidative stress in patients with acute ischemic stroke. Malondialdehyde (MDA), plasma glutathione, plasma glutathione peroxidase (GPX), catalase (CAT), uric acid, bilirubin, plasma superoxide dismutase (SOD), red blood cells superoxide dismutase (RBS SOD) (spectrophotometric assay), total antioxidant capacity (TAC) (enhanced chemiluminescence), ceruloplasmin, C-reactive protein (CRP), albumin, transferrin (nephelometric assay) were performed in 57 patients (mean age 73.4 +/- 6.5 years) with acute ischemic stroke within 24 hours and at 7 days after stroke onset as compared to 51 age-and sex-matched controls. Significantly lower values in the first 24 hours were: plasma glutathione, CAT, plasma SOD, RBS SOD (p < 0.001), plasma GPX, TAC, transferrin (p < 0.05). Significantly higher values in the first 24 hours were: CRP (p < 0.001), MDA, uric acid (p < 0.05). Significantly lower values at 7 days were: TAC, albumin, transferrin (p < 0.001), plasma glutathione, plasma SOD, CAT (p < 0.05). Significantly higher values at 7 days were: MDA, plasma GPX, RBC SOD, CRP, uric acid, bilirubin (p < 0.001), ceruloplasmin (p < 0.05). These results indicate that oxidative stress is increased and that the majority of antioxidants are reduced; this suggests the possibility of therapeutic intervention with antioxidant agents.

A diagnosis challenge-L4 nerve root compression as the initial presentation of chronic inflammatory demyelinating polyneuropathy

The authors present the case of a 65-year-old woman who was admitted for paraparesis and paresthesias in the inferior limbs. The neurological examination revealed the difficulty in extension of the right foot and of the right toe, accompanied by paresthesias located in the anterolateral area of the right leg, dorsum and plantar area of the foot, the reduction of the right knee jerk, and of the ankle tendon jerk both sides. The vertebro-spinal MRI showed lumbar canal stenosis with L4 intraforaminal compression on the right, and L2-L3 on the left. CSF examination revealed mild increase in protein concentration. The morphological picture of the sural nerve biopsy was compatible with a chronic inflammatory neuropathy and severe muscular lesions of neurogenic origin were observed on right gastrocnemius muscle biopsy. The diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) was established. Solu-medrol (0.5 g/d)-5 days, then medrol (prednisolone) was done, followed by improving of the symptomatology. For the relapse of the disease intravenous immunoglobulins (IVIG)-0.4 g/kg/d-5 days was the elective treatment. Six months later she presented a new relapse. IVIG were administered with the remission of the sensitive symptoms. A chronic treatment with medrol was recommended. The diagnosis of L4 disc herniation was obvious in the studied case, but the electroneurographic examination brought extra data for the associated diagnosis of CIDP whose onset was asymmetrical and initially paucisymptomatic. Neither the electroneurographic examination nor the CSF examination were total relevant for CIDP, imposing the sural nerve biopsy. The diagnosis of CIDP involves a team-work composed of neurologist, electroneurophysiologist and neuropathologist.

The human cathelicidin LL37 peptide has high plasma levels in B and C hepatitis related to viral activity but not to 25-hydroxyvitamin D plasma level

The serum level of the human cathelicidin-LL37, an immunomodulatory vitamin D-induced peptide was less studied in viral hepatitis. The aim of this study was to analyse the cathelicidin-LL37 and vitamin D serum level in hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and their correlations.

METHODS

A total of 52 patients with HBV and HCV hepatitis and 22 controls were selected. ELISA method was used to detect the cahelicidin-LL37 (LL37 human Elisa Hycult Biotech) and 25-hydroxyvitamin D (IDS 25-Hydroxy Vitamin D EIA Immunodiagnostic Systems Ltd) serum level. The positive viral load (obtained following RT-PCR) defined active forms of hepatitis whereas a negative viral load indicated inactive hepatitis. Cathelicidin-LL37 and vitamin D were analysed in each group of hepatitis versus controls and each active hepatitis group versus inactive hepatitis group.

RESULTS

Increased LL37 plasma levels were noted in HCV hepatitis versus controls (p = 0.046), HBV hepatitis versus controls (p = 0.087), active versus inactive HCV hepatitis (p = 0.014) and inactive versus active HBV hepatitis (p = 0.009). Vitamin D deficiency (< 31.80 +/- 8.74 nmol/L) was detected in all the subjects. The Pearson correlation between the vitamin D status and LL37 level was weak.

CONCLUSIONS

Plasma concentrations of cathelicidin-LL37 were significantly higher in active HCV and inactive HBV infection suggesting the LL37 implication in certain HCV and HBV hepatitis forms. Vitamin D deficiency was uniformly observed in all forms of hepatitis but with no significant correlation to the LL37 level.

Changes in plasma matrix metalloproteinase-9 levels in patients with acute ischemic stroke

Matrix metalloproteinases (MMP) have been thought to be involved in stroke pathogenesis. MMP-9 contributes to tissue destruction. Our aim was to analyze the MMP-9 levels in blood within 24 hours of acute ischemic stroke onset to observe the role of MMP-9 in the pathogenesis of atherothrombotic stroke. In this study we investigated prospectively MMP-9 levels in serum from 106 patients (42 men and 64 women, mean age 71.52 +/- 6.32 years) with acute ischemic stroke in the middle cerebral artery area in the first 24 hours from the onset (mean duration 7.8 +/- 4.5 hours) as compared to 112 controls (48 men and 64 women, mean age 70.36 +/- 6.8 years). Serum samples were collected under sterile conditions and stored in aliquots at -70 degrees C until assay. Serum MMP-9 levels were determined by enzyme-linked immunosorbent assay (ELISA) in blood samples obtained on admission. Statistical analysis was performed by Mann-Whitney and Log-Likeliwood Ratio tests. All values reported are expressed as mean (x) +/- SD. Mean serum MMP-9 concentrations were higher in group with ischemic stroke 172 +/- 32.4 ng/mL, range 139.6-204.4 ng/mL vs. controls 57 +/- 9.6 ng/mL, range 47.4-66.6 ng/mL (95% CI, 3.17 to 14.18; p < 0.014). In conclusion, MMP-9 activity is associated with early acute ischemic stroke. The high levels of MMP-9 in acute ischemic stroke document the involvement of this enzyme in the regulation of inflammation in stroke.

Systemic osteoporosis--major complication of psoriatic arthritis

OBJECTIVES

Determination of bone mineral density in patients with psoriatic arthritis and its correlation with the development of the disease.

METHODS

Three groups of patients were recruited: group 1--patients with psoriasis arthritis; group 2--patients with rheumatoid arthritis, group 3--control group. Group 1 was divided into: group 1A--patients with disease duration < 5 years and group 1B--patients with disease duration > 5 years. Bone mineral density was determined for total hip by dual X-ray absorptiometry (DXA).

RESULTS

In the group 1A BMD values of total femur were between -1.32 and -1.68 DS; in the group 1B BMD values of total femur were between 1B -1.58 and - 1.77DS; in the group 2 BMD values of total femur were between -2.51 and -3.41 DS and in the control group BMD values of total femur were between 0.29 and 1.3 DS. In patients with psoriatic arthritis, the duration of arthritis was negatively correlated with BMD values of total femur. In conclusion, psoriatic patients with longer duration of disease may be at a risk for osteoporosis, which can require preventative treatment efforts.

Acute intermittent porphyria--diagnostic and treatment traps

Acute intermittent porphyria (AIP) is a rare metabolic disease defined by mutations coding the deaminaze enzyme of porphobilinogen (PBGD). Porphyrias are somewhat misdiagnosed as a consequence of light symptoms in patients. Acute forms of porphyria can be life-threatening, so a correct diagnosis and an accurate treatment are highly important. The authors presented the case of a 38-years-old patient admitted for persistent abdominal pain that previously presented two generalized convulsive seizures. The diagnosis of AIP was established by the raised concentration of urinary porphyrins. Despite treatment with carbohydrates and hemines, the clinical picture of the patient worsened, with tetraplegia and severe respiratory failure. The patient died seven weeks after the initial presentation of the disease.

Glutathione reductase levels in patients with unstable angina

Experimental evidence suggests that free-radical damage and antioxidant defense may play an important role in the pathogenesis of coronary heart disease. We have examined the association between plasmatic glutathione reductase (GR) levels and the prognosis of patients with unstable angina. We have evaluated 37 patients, under the age of 75, diagnosed with unstable angina and 19 healthy volunteers. The patients were divided into two groups: the first group--10 patients with unstable angina with readmission in the following 6 months--and the second group--27 patients with unstable angina and favourable evolution. GR was measured in dynamics during hospitalization period. After discharge, the patients were monitored and the following data were recorded: months of follow-up, death due to cardiovascular cause and onset of major cardiovascular events. In patients with unstable angina there was a statistically significant higher increase of GR on admission to the values of the control group (p < 0.0001). Subsequently, plasmatic levels begin to decline, so that at discharge, the GR is similar to the control group. Plasmatic levels of GR were statistically significantly lower in patients with unstable angina without cardiovascular event than in patients with readmission in the following months (p < 0.05). In conclusion, patients who experienced unstable angina and without cardiovascular events during follow-up had lower GR plasmatic levels and that GR activity was an independent predictor of cardiovascular events during follow-up.

Study of interleukin-6 production in Alzheimer's disease

There is a growing body of evidence which supports the hypothesis of faulty immune regulation and autoimmunity or inflammatory processes as viable mechanisms of the pathogenesis of Alzheimer's disease. The aim of this study was to evaluate the IL-6 level in serum of patients with AD and to analyze the correlation between IL-6 and this disease. Serum samples from 47 patients with clinically diagnosed Alzheimer's disease (27 women and 20 men, mean age 70.43 +/- 10.82 years, range 40-89 years) as compared to 47 controls (25 women and 22 men, mean age 70.17 +/- 10.64 years, range 40-89 years) were analyzed for IL-6 by ELISA (R&D Systems). The interleukin-6 levels were significantly higher in AD patients (234 pg/ml, range 85-567 pg/ml) as compared to control group (67 pg/ml, range 38-181 pg/ml); p < 0.001. It was evident from the study that increased production of IL-6 cytokine is found in AD patients, suggesting abnormal cellular immunity in these patients. Interleukin-6 plays a role in the pathogenesis of Alzheimer's disease. Our results suggest that high peripheral IL-6 secretion levels may be responsible for acute-phase proteins observed in the serum of AD patients. We find these results very promising for the consideration of future treatment of AD patients.

Gastrointestinal manifestations in systemic autoimmune diseases

In an autoimmune disease, the immune system attacks and harms the body's own tissues. The systemic autoimmune diseases include collagen vascular diseases, the systemic vasculitides, Wegener granulomatosis, and Churg-Strauss syndrome. These disorders can involve any part of the gastrointestinal tract, hepatobiliary system and pancreas. They can cause a variety of gastrointestinal manifestations that are influenced by the pathophysiologic characteristics of the underlying disease process. There is a wide variation of gastrointestinal manifestations from these autoimmune disorders including, but not limited to: oral ulcers, dysphagia, gastroesophageal reflux disease, abdominal pain, constipation, diarrhea, fecal incontinence, pseudo-obstruction, perforation and gastrointestinal bleeding. Clinical workup should be initiated by the patient's subjective complaints. In this review, we analyze the effects of autoimmune diseases on the gastrointestinal tract.

Primary Sjögren's syndrome or multiple sclerosis? Our experience concerning the dilemma of clinically isolated syndrome

The authors present the case of a 50 years old woman who during 3 years had a transient right limbs palsy, and numerous episodes of unilateral/bilateral optic neuropathy. The CSF and MRI examinations did not sustain the diagnosis of multiple sclerosis (MS). After 2 years from the onset, she presented bilateral trigeminal neuropathy, and after 9 months the anti-SS-A and anti SS-B antibodies were positive. The sialography and the minor salivary ducts biopsy (in the absence of xerostomia and xerophthalmia) have established the diagnosis of primary Sjögren's syndrome (pSS). Subsequently, the patient presented spastic paraparesis, the clinical and imagistical features have suggested the diagnosis of acute transverse myelitis C4-T4. The treatment administered (corticosteroids and IGIV) improved the clinical state. The authors analyse then cases with SLE and cases with pSS, whose initial diagnosis was MS possibly with no evidence of collagen tissue disorders (CD) for many years. In conclusion, screening for biomarkers of SLE or pSS should be systematically performed in a case of acute or chronic myelopathy. Some laboratory tests as CSF examination, the antibodies type, cranial and spinal MRI, are useful for the differential diagnosis with MS. In a neurological clinically isolated syndrome (CIS) the diagnosis of MS should be precautiously established; the close follow-up of patients is always necessary, those with atypical neurological symptoms for MS, relapsing-remitting form, or lack of response to the common treatment for MS, should be examined for CD.

Multiple autoimmune syndrome

The co-occurrence of autoimmune diseases has been epidemiologically studied and has aided in our understanding of autoimmunity. The combination of at least three autoimmune diseases in the same patient has defined as multiple autoimmune syndrome (MAS). About 25 percent of patients with autoimmune diseases have a tendency to develop additional autoimmune diseases. MAS is recognized with increasing frequency. Several associations have been proposed as a form of MAS. Multiple autoimmune syndrome can be classified into three groups according to the prevalence of their associations with one another: type 1, type 2 and type 3. Genetic, infectious, immunologic and psychological factors have all been implicated in the development of MAS. In MAS, patients often have at least one dermatological condition, usually vitiligo or alopecia areata. The pathogenesis of multiple autoimmune disorders is not known yet, perhaps environmental triggers and genetic susceptibility are involved. Abnormalities of both humoral and cell-mediated immunity have been described. However, as new perspectives develop on the pathogenesis and natural history of autoimmune diseases, a refinement in the methodology for the study of the co-occurrence of disease is warranted in order to maximize the information that one may realize from such studies. This paper presents some recent results of studies in light of current understanding of the natural history of autoimmune diseases.

Plasma myeloperoxidase levels in patients with acute ischemic stroke

Myeloperoxidase (MPO) is a glycoprotein released by activated polymorphonuclear neutrophils, which takes part in the defence of the organism through production of hypochlorous acid (HOCl), a potent oxidant. MPO has a role in pathogenesis of atherosclerosis. The aim of the study was to evaluate the time course of MPO plasma levels in the early stage of ischemic stroke. The study included 78 patients with acute ischemic stroke, 46 females and 32 males, mean age 74.3 +/- 6.8 years. Blood samples for MPO measurement were taken within 24 hours after the onset of ischemic stroke. Seventy-two patients served as matched controls 43 females and 29 males, mean age 71.3 +/- 6.4 years. MPO was measured in plasma using the Abbott Architect platform (Abbott Diagnostics Inc., Abbott Parck IL). Comparisons between patients and controls and patients group were expressed as relative risk with its 95% confidence interval (RR [95% CI]), where a lower limit > 1.0 was considered significant. All p values were determined by Fischer's exact test. A value of p < 0.05 was considered statistically significant. Mean plasma MPO level was in patients with acute ischemic stroke 583 +/- 48 pmol/L. Seventy-one patients out of seventy-eight patients with ischemic stroke presented mean plasma MPO levels greater than the upper of normal (425 +/- 36 pmol/L, p < 0.0001, (RR 8.188, [95% CI 4.038 to 16.600]). Twelve controls presented mean plasma MPO level greater than the upper of normal. In conclusion, plasma MPO levels were statistically significantly higher in patients after ischemic stroke as compared to controls. MPO has been associated with acute ischemic stroke but its direct role in its pathogenesis has not been established. MPO could be proposed as a potential prognostic marker of such lesions rather than a marker of diagnosis. MPO is a new biomarker and a possible future therapeutic target.

Detection of serum of IgG anti-neuronal antibodies in systemic lupus erythematosus patients with central nervous system manifestations

The objective of the study was to assess the frequence of serum IgG anti-neuronal antibodies (NA) in SLE patints with CNS manifestations. Serum anti-NA antibodies were measured in 47 patients with SLE with CNS manifestations (CNS-SLE), age 33-52 years, mean age 38.6 years, 18 men and 29 women, as compared to 31 patients with SLE without CNS manifestations, age 28-56 years, mean age 41.2 years, 13 men and 18 women and 56 healthy subjects. Serum IgG antineuronal antibodies were measured by indirect immunofluorescent assay. Thirty-five of out 47 CNS-SLE patients presented anti-NA (74.6%). Anti-NA were observed in 15 out of 15 patients with acute confusional state (100%), in 8 of 8 patients with cerebrovascular disease (100%), in 5 out of 7 patients with seizure disorder (76.3%), and in 4 out of 5 patients in intractable headache (86.8%). Out of 31 nonCNS-SLE patients 1 patient presented anti-NA (3.9%). Serum anti-NA were more frequently observed in CNS-SLE patients as compared to controls (p < 0.000001). The frequence of serum anti-NA was significantly higher in CNS-SLE patients as compared to non CNS-SLE patients (p < 0.00001). In conclusion, serum anti-neuronal antibodies are associated with CNS-SLE. These antibodies are more frequent in CNS-SLE than in nonCNS-SLE patients, demonstrating a strong association between serum anti-NA and CNS involvement of SLE. The presence of serum anti-NA could be a useful diagnostic tool for CNS-SLE, the test could help to distinguish SLE from other diseases with similar symptoms. Further studies are needed to evaluate the predictive value of anti-NA in SLE.

Study of anti-endothelial cell antibodies in SLE patients with acute ischemic stroke

Endothelial dysfunction is the predominant manifestation of SLE. Anti-endothelial cell antibodies (AECA) are a heterogeneous group of autoantibodies directed against different antigens in endothelial cells. The objective of this study was to assess the possible correlation between the presence of AECA and ischemic stroke manifestations in SLE. The AECA titers in serum from 34 patients with SLE and acute ischemic stroke (8 men and 26 women, mean age 38.37 +/- 3.25 years) and in 32 controls (11 men and 21 women, mean age 37.52 +/- 3.86 years) were tested. The method used was ELISA. The data were expressed as mean +/- SD from indicated number of patients. Comparison between patients and controls was expressed as relative risk with its 95% confidence interval (RR[95% CI]), where lower limit > 1.0 was considered significant. All p values were determined by Fisher's exact test. A value of p < 0.05 was considered statistically significant. AECA were positive in 31 out of 34 patients, mean value 19.2 +/- 16.3 U/mL and in 8 out of 32 controls, mean value 5.5 +/- 2.6 U/mL (RR 7.154 [95% CI 2.801 to 18.274]), p < 0.0001. Patients with SLE and acute ischemic stroke tended to have higher mean values of AECA. AECA play a pivotal role in the pathogenesis of neurologic complications of SLE. AECA titers in SLE patients with acute ischemic stroke support a role for AECA as potential diagnostic marker possibly associated to cerebral manifestations of SLE patients. Further study is needed in order to clarify if AECA presence is related to systemic diseases severity and to situate their importance among other markers of endothelial dysfunction.

Study of endothelin-1 in acute ischemic stroke

Endothelins (ETs) are potent vasoconstrictor and may play a role in the pathophysiology of several cardiovascular diseases. Endothelin-mediated vasoconstriction may enhance ischemic neuronal damage. The study aimed to find out whether the plasma ET-1 levels may serve as marker of early ischemic stroke. Plasma ET-1 levels were tested in 20 patients with acute ischemic stroke, mean age 63.7 +/- 5.03 years, 12 men and 8 women, within 24 hours of stroke onset as compared to 10 sex- and age-matched control subjects; only the patients with normal CT-scan at admission were included in the study. Plasma ET-1 was measured by ELISA. The results were statistically analyzed by Student test and a p < 0.05 (95% CI) was considered statistically significant. ET-1 levels in patients with hemiplegia and normal CT-scan at admission were significantly higher as compared to control group (0.0910 +/- 0.0256 pg/mL vs. 0.0490 +/- 0.0185 pg/mL, p < 0.0001) (95% CI). Ischemic stroke is associated with acute and marked increased levels of ET-1 in plasma. This may reflect enhanced production by damaged endothelial cells within the infarcted lesion. ET-1 may be used as additional marker of cerebral ischemia in selected cases to distinguish between the onset of an ischemic stroke and other non-vascular diseases presenting similar symptoms.

Lack of association between ACE ID polymorphism and colorectal cancer in Romanian patients

BACKGROUND

The insertion/deletion polymorphism of the angiotensin I-converting enzyme (ACE) gene has recently been linked to the pathogenesis of human cancers. The goal of this study was to analyze the possible association between ACE gene I/D polymorphism and colorectal cancer in Romanian patients.

METHODS

Blood samples were obtained, after informed consent, from individuals with colorectal cancer (n=108, M:W = 64:44), and healthy persons (n=150, M:W = 84:66). Genomic DNA was extracted from peripheral blood leucocytes using commercial kits and the insertion (I) / deletion (D) polymorphism was assessed by PCR. Statistical analysis was done using the chi2 test. We determined the odds ratio using the genotype II as risk factor. A p value < 0.05 was considered statistically significant.

RESULTS

The distribution of ACE II: ID: DD genotypes was 23.1%: 46.3%: 30.6% in patients and respectively 20%: 48.7%: 31.3% in controls. The distribution of genotype (chi2 0.37, p = 0.54) and alleles (chi2 0.19, p = 0.65) did not differ significantly between cancer patients and control.

CONCLUSIONS

Study results do not demonstrate an association between ACE ID polymorphism and colorectal cancer in our patients.

Expression of IL-6 activity in patients with acute ischemic stroke

Cerebral ischemia initiates an inflammatory response in the brain and periphery. Inflammatory mechanisms, including IL-6, are suspected to play a role in arterial thrombogenesis. Their presence in the periphery is still controversial. The question arises as to whether IL-6 might directly contribute to cerebral infarct pathogenesis. IL-6 has several pro-inflammatory effects which may contribute to the induction and evolution of early inflammatory injury in the brain and its vasculature. The objective of this study was to test the hypothesis that there is a relationship between inflammation and the ischemic stroke measuring the levels of IL-6 in the blood of acute ischemic stroke patients. Plasma IL-6 was measured in 46 patients in the first 24 hours after acute ischemic stroke and in 98 controls matched for sex and age. Forty-five out of 46 acute ischemic stroke patients presented high IL-6 values. Fourteen out of 98 controls presented IL-6 values higher than normal. Mean level of circulating IL-6 was in acute ischemic stroke patients 26.5 +/- 2.3 pg/mL (range 6.4-161.3 pg/mL), significantly higher as compared to that in controls 3.9 +/- 1.5 pg/mL (range 2.3-5.9 pg/mL) [p < 0.0001, 95% CI (9.186 to 457.53)]. In our study, IL-6 levels were significantly elevated in the first 24 hours after ischemic stroke. This observation supports the hypothesis that IL-6 production is an inflammatory response to acute hypoxic-ischemic injury. IL-6 may serve as warning sign, because it increases early in inflammation.

Inflammatory, degenerative and vascular lesions in long-term dialysed patients

No other medical field but nephrology showed so important achievements as a result of concerted efforts of doctors, biologists and technicians. Considering that in renal insufficiency, regardless of its aetiology, the common path is represented by the transitory or definite damage of the "renal filter", many attempts have been made in order to reproduce the process of blood cleaning by the kidney.

AIM

The high prevalence of cardiovascular diseases in hemodialysed population suggested that the disease could begin before or during the stage of chronic renal insufficiency. We investigated the vascular lesions, especially the immunologic features of patients involved in hemodialysis programs. Our study reflects a general picture of the immunologic status of hemodialysed patients, helping to understand the special profile ofa hemodialysed patient.

MATERIAL AND METHODS

Two groups have been selected and analyzed: one of 15 patients from the Hemodialysis Department in "Sfântul Ioan" Hospital, and another one composed of 30 patients with other diseases (the control group), from the Medical Department. The detection of specific antibodies against some HCV proteins corresponding to the most conserved regions of the viral genome has been done using the immune test LiaTEK HCV III. In the hemodialysed group, a blood sample has been drawn before and after the hemodialysis session, at 15-20 minutes, while in the other group the blood sample has been drawn together with the other tests. A flow cytometry examination was made at the Center of Immunology, in order to determine simultaneously several physical and chemical parameters. We analyzed the two groups of patients (HD/n=15; the reference group/n=30) regarding immunophenotyping, all types of lymphocytes and interleukin 2 (IL-2).

RESULTS

The results have classified the HD patients into three subgroups, depending on the mean of the results from flow cytometry exam, referred to normal values. The assessment of the patients with or without HD to each group was made on the basis of the similar behavior of the markers investigated. The most affected age group in patients with HD was 31-40 years, followed by the age group 41-50 years (26%). The majority patients of the control group were of the same age 31-40 years old (40%), while 33% of them were between 41 and 50 years old. One subgroup (A) of HD patients showed the improvement of the total number of T lymphocytes (CD3+/CD19-) after the session, while the total number of B lymphocytes was stable. The number ofT lymphocytes with receptors for interleukin 2 (CD25) improved after hemodialysis. The second group (B) presented from the beginning a low number of total T lymphocytes (CD3+/CD19-). We found that the value of B lymphocytes (CD19+/CD3-) decreased after hemodialysis. Activated T lymphocytes (CD25), with receptors for interleukin 2, achieved greater values (3.66%), which cannot be found in the other groups. The third group (C) showed normal values for total T lymphocytes (CD3+/CD19-) before HD, which did not modify significantly after the session. The patients had the same decreased values for B lymphocytes, which have continued to decrease after the HD (7.98%).

CONCLUSIONS

Post dialytic immunologic changes of the mononuclear cells represent the hallmark of the complexity of the immune response generally and especially too, in hemodialysed patients. We have noticed patients that presented an increase of the total number of T lymphocytes after the dialysis, but only T and NK lymphocytes and not B lymphocytes as well, suggesting the susceptibility to infections. The evaluation of the immune response using flow cytometry has confirmed the presence of high variations of the immune profile in hemodialysed patients, the decrease of T-cells activation but, it does not support the data regarding intrinsic functions of T and B cells. The high diversity of the immune response in hemodialysed patients is a consequence of the genetic individuality of each patient and also of the associated pathology or equipment used (viral infection, membrane type).

Study of antiphospholipid antibodies in type 2 diabetes mellitus with and without diabetic retinopathy

Antiphospholipid antibodies (aPL) are considered to be contributory factors in the development of thrombotic events. The objective of the study was to determine if aPL are involved in the pathogenesis of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus. IgG anticardiolipin antibodies (IgG aCL), lupus anticoagulant (LA), and anti-IgG beta2-glycoprotein I antibodies (anti-beta2-GPI) were prospectively tested in 34 patients with DR (group 1), 20 males and 14 females, range of age 52-79 years, mean age 57 +/- 4.6 years, duration of diabetes 8-15 years, as compared to 29 type 2 diabetic patients without DR (group 2), 19 males and 10 females, range of age 54-77 years, mean age 58 +/- 4.8 years, duration of diabetes 10-13 years, and to 31 controls matched for age and sex (group 3). IgG aCL and anti-beta2-GPI were detected by enzyme-linked immunosorbent assay (ELISA) and LA was detected by activated partial thromboplastin time, kaolin clotting time, dilute Russell's viper venom time, dilute prothrombin time. Comparison between patients and controls and patients group were expressed as relative risk with its 95% confidence interval (RR [95%/CI], where a lower limit > 1.0 was considered significant. All values were determined by Fischer's exact test. A value of p < 0.05 was considered statistically significant. The incidence of IgG aCL positive (low 4-15 GPL U IgG aCL titers) in group 1 was 21/34 (62%) vs. 12/29 (41%) in group 2 (RR 1.460 95% CI [0.9052 to 2.382]), p = 0.1330. The incidence of LA positive in group 1 was 27/34 (79%) vs. 8/29 (28%) in group 2 (RR 3.086 95% CI [1.584 to 6.010]), p < 0.0001. The incidence of anti-IgG beta2-GPI positive in group 1 was 29/34 (85%) vs. 6/29 (21%) in group 2 (RR 4.640 95% CI [2.067-10.418]), p < 0.0001. The results suggest the possible participation of anti-beta2-GPI and LA in the pathogenesis of DR, shifting the hemostatic balance toward a pro-thrombotic state increasing the risk of developing thrombosis.

Changes of magnesium serum levels in patients with acute ischemic stroke and acute infections

Magnesium (Mg) deficiency seems to be implicated in immune dysfunction, including acute and chronic infections. Magnesium serum levels in 53 patients with acute ischemic stroke and acute bacterial (37 patients) and acute viral infections (16 patients) (29 men and 24 women, mean age 68.6+/-4.7 years) were analyzed as compared to 36 healthy subjects. As Mg is mainly an intracellular ion, assessment of Mg status is difficult. Mg serum levels were determined by the colorimetric method. Data were statistically analyzed. In patients with acute bacterial infections (sepsis, bronchopneumonia, urinary tract infections) a statistically significant decrease of Mg serum concentrations was found (1.26+/-0.12 mEq/L vs 1.69+/-0.14 mEq/L, p<0.001). In patients with acute viral infections, the decrease of Mg serum levels was significantly less (1.64+/-0.13 mEq/L vs 1.69+/-0.14 mEq/L, p<0.05). The change onset of Mg occurred within a few days and persisted for several weeks. These changes seemed to be non-specific and were independent of the agent causing bacterial infection. Patients with sepsis having a high degree of inflammation did not show a positive correlation between the severity of the disease and the changes of Mg. In conclusion, the measurement of Mg serum in bacterial infections is useful and physicians should maintain a high index of suspicion for hypomagnesemia and implement Mg therapy.

Phospholipase A2 in patients with noncardioembolic ischemic stroke and severe inflammatory reaction

The inflammatory reaction is characterized by increased circulatory levels of various indicators of the severity of inflammation. The objective was to investigate the value of lipoprotein-associated phospholipase A2 (Lp-PLA2) in patients with noncardioembolic ischemic stroke and severe proinflammatory reaction. There were investigated prospectively Lp-PLA2 levels in sera from 47 patients with ischemic stroke and severe inflammatory reaction (32 men and 15 women, mean age 63 +/- 4.23 years) as compared to 38 patients with ischemic stroke without inflammatory reaction (21 men and 17 women, mean age 61 +/- 5.52 years) and 114 healthy elderly controls. Lp-PLA2 levels were assessed using the diaDexus PLAC test (a noncompetitive ELISA). Out of 47 patients with ischemic stroke and severe inflammatory reaction 36 presented Lp-PLA2 high levels (79%). Lp-PLA2 was detected with high levels in 17 out of 30 patients with ischemic stroke without inflammatory reaction (45%). Patients with ischemic stroke and severe inflammatory reaction presented Lp-PLA2 with high levels more frequently than the healthy controls (RR 12.1 [95% CI. 6.22 to 19.333], p<0.0001). Levels of Lp-PLA2 were higher in subjects who experienced a stroke as compared to controls. Lp-PLA2 is a strong predictor of recurrent stroke risk and of increased risk of dying. The determination of Lp-PLA2 should be used to predict patient risk of cardiovascular disease and stroke; it does provide additional risk of inflammation when used in conjunction with the traditional markers. Lp-PLA2 might be used not only for risk stratification of stroke patients, but also as target for treatment.

Some clinico-immunological aspects in patients with ocular myasthenia gravis associated with inflammatory bowel disease

The link between inflammatory bowel disease (IBD) and ocular myasthenia gravis (OMG) is thought to be related to the production of autoantibodies. The aim of this study was to determine the incidence of some antibodies in OMG patients with IBD. Sixty-four patients with IBD and neurological symptoms were examined neurologically and immunologically (41 men and 23 women, mean age 43-5.4 years); mean duration of IBD before the diagnosis of OMG was 7.5 years. The following immunological investigations were performed: anti-acetylcholine receptor antibodies (AChR Abs) (ELISA), anti-smooth muscle antibodies (ASMA) (indirect immunofluorescence), perinuclear anti-neutrophilic cytoplasmic antibodies (p-ANCA) (indirect immunofluorescence), carcinoembryonic antigen (CEA) (ELISA), Saccharomyces cerevisiae antibodies IgA and IgG (ASCA) (ELISA), peripheral lymphocyte counts, immature CD4, CD4/CD8 ratio. Five patients out of 64 with IBD presented OMG. The following antibodies were observed: anti-AChR in 4 OMG patients, ASMA in 4 OMG patients, p-ANCA in 4 OMG patients, CEA in 5 OMG patients, ASCA IgA and IgG in 3 OMG patients. Of 5 OMG patients 4 were positive for >3 antibodies. The peripheral lymphocytic counts were reduced in 5 OMG patients, a decline in CD8 cells and an increase in immature CD4 cells in 5 OMG patients, an increased CD4/CD8 ratio in 5 OMG patients were observed. The association of IBD with OMG was rare. Autoimmune dysregulation is the central defect in both MG and IBD. Further studies are required to define the nature of this association.

Detection of autoantibodies to ribosome P in lupus patients with neurological involvement

Autoantibodies to ribosome P react with the cytoplasmic ribosomes and are specific for the diagnostic of lupus with neurological involvement. The objective of this study was to assess prevalence of serum autoantibodies to ribosome P as a biomarker for lupus with neurological involvement. We measured serum autoantibodies in 47 lupus patients with neurological involvement (range 31-52 years, mean age 38.6 years) as compared to 31 patients with lupus without neurological involvement (range 28-56 years, mean age 41.2 years) and 56 healthy subjects matching with both groups with regard to sex and age. Serum autoantibodies to ribosome P were measured by means of ELISA test. The results were statistically analyzed using the Student t-test. A value of p < 0.05 was considered significant. Autoantibodies to ribosome P were detected in 43 (91%) oflupus patients with neurological involvement and in 7 (15%) lupus patients without neurological involvement (p < 0.001). The results confirm that these autoantibodies are released into the blood, they can be easily measured, and they correlate with outcome including neurological involvement. This study provides additional information with regard to autoantibodies to ribosome P in Romanian lupus population with neurological involvement. Detection of autoantibodies to ribosome P appears useful for diagnostic purpose. Higher peak of serum autoantibodies to ribosome P levels correlated well with neurological involvement (highly specific).

Detecting anti-prothrombin antibodies in young women with acute ischemic stroke

Prothrombin (PT) is a target for antibodies with lupus anticoagulant (LA) activity. Anti-prothrombin antibodies (aPT) were recently identified as antibodies directed toward a phospholipid-binding protein. aPT are a new serologic marker of antiphospholipid syndrome. The objective was to detect aPT in a group of 46 patients with acute ischemic stroke in order to correlate their presence with clinical diagnosis, laboratory and neuroradiological findings. We tested aPT, lupus anticoagulant (LA), anticardiolipin (aCL), and anti-beta2-glycoprotein I antibodies (anti-bbeta2-GPI) in 46 young women with acute ischemic stroke aged 34-45 years and 43 patients with nonischemic neurologic diseases and 141 normal controls. Anti-prothrombin antibodies were detected by calcium-containing aPT ELISA, aCL and anti-beta2-GPI by ELISA. All samples were screened using the activated partial thromboplastin time (aPTT); the dilute Russell viper venous time (dRVV) coagulation test was performed. The results were statistically analyzed. Anti-prothrombin antibodies were found in 26 (57%) of 46 stroke patients. Out of 43 patients with nonischemic neurological disorders, 2 (4.18%) were positive for aPT. aPT were detected in one (0.70%) of the normal controls. Ten stroke patients (21%) were positive for IgG aPT only, 9 stroke patients (18.2%) for IgM aPT only, and 8 stroke patients (16.9%) for both IgG and IgM isotypes of aPT. Two nonischemic neurological disorders patients (4.18%) presented IgM isotype of aPT. Patients with ischemic stroke presented aPT much more frequently than the healthy controls (OR 182.00 [95% CI 23.382-1416.6]. p < 0.0001). Patients with ischemic stroke presented aPT much frequently than the nonischemic neurological disorders patients (OR 26.650 [95% CI 5.743-123.66], p < 0.0001). When IgG or IgM aPT were considered separately, they were more frequently found in patients with ischemic stroke than in healthy control group (OR 38.889 [95% CI 4.817-313.95], p < 0.0001) and (OR 34.054 [95% CI 4.178-277.5], p < 0.0001), respectively. Simultaneous positive titers for both isotypes of aPT (IgG and IgM) were more frequently found in patients with ischemic stroke than in healthy control group (OR 29.474 [95% CI 3.573-243.12], p < 0.0001). Eleven stroke patients (43%) were negative for aCL, LA and anti-beta2-GPI, but positive for aPT (OR 0.03287 [95% CI 0.001794-0.6022], p < 0.001). aCL, LA and anti-beta2-GPI were not found both in nonischemic neurological disorders patients and in healthy controls.

Changes in plasma levels of complement in patients with acute ischemic stroke

Inflammatory processes are involved in cerebral ischemia. Patients with ischemic stroke may be predisposed to marked activation of the inflammatory system. The objective was to analyze the association between the level of complement at different stages after stroke and outcome. We collected blood samples from 179 patients (81 men and 98 women, mean age 73 +/- 5.6 years) within 24 hours after ischemic stroke, within 48 to 72 hours and at hospital discharge (16 +/- 7 days) as compared to 156 healthy controls, matching ischemic stroke patients with regard to sex and age. We measured levels of total hemolytic activity of serum complement (EIA method) and of C3, C4 (nephelometric measurements). The data were evaluated using chi 2 test. Within 24 hours after ischemic stroke in 38% patients mean value of CH50 was 148.4 +/- 57 CH50 U Eq/mL (p<0.05), of C3 was 1.49 +/- 0.24 mg/L (p<0.05) and of C4 was 0.32 +/- 0.08 mg/L (p<0.05). Within 48-72 hours after ischemic stroke in 34% patients mean value of CH50 was 167 +/- 5.9 CH50 U Eq/mL (p<0.01), of C3 was 1.58 +/- 0.27 mg/L (p<0.01) and of C4 was 0.38 +/- 0.08 mg/L (p<0.01). At hospital discharge in 31% patients mean value of CH50 was 192.8 +/- 64 CH50 U Eq/mL (p<0.001), of C3 was 1.66 +/- 0.28 mg/L (p<0.001) and of C4 was 0.49 +/- 0.07 mg/L (p<0.001). Patients with ischemic stroke who had elevated complement levels (inflammatory marker) at discharge had a worse neurological disability; complement might directly contribute to vascular damage.

Detection of neopterin as parameter of potential monocyte activation in patients with acute ischemic stroke

The mechanisms by which inflammation may induce endothelial dysfunction are not fully understood. It was analyzed if neopterin (a by-product of activated macrophage metabolism) is elevated in patients with systemic inflammatory insult at the time of ischemic stroke. There were investigated 86 consecutive patients with mean age 67 +/- 7.8 years who were admitted within 24 h after ischemic stroke. A control group of 37 patients with mean age 58 +/- 4.9 years without ischemic stroke was also tested. Measurements of serum neopterin levels were performed using enzyme linked immunosorbent assay. Patients with acute ischemic stroke had significantly higher serum levels of neopterin (mean value +/- SD) than controls: 9.6 +/- 1.2 vs. 7 +/- 0.8 nmol/L (p < 0.01). Immune mechanisms contribute to cerebral ischemic injury. The finding of higher serum levels of neopterin, which is regarded as a humoral component of the immune-mediated inflammatory response, sustains the hypothesis that patients with ischemic stroke may show higher levels of inflammatory markers like neopterin. Our results indicate increased monocyte activation after ischemic stroke. In patients with stroke it has been shown that neopterin was determinant of endothelium-dependent vascular dysfunction. However, these preliminary results need to be confirmed by controlled studies.

Evaluation of antiphospholipid antibodies in young women with ischemic stroke

There is an association between antiphospholipid antibodies (aPL) and ischemic stroke. The detection of aPL in young women is to characterize a subset of patients with venous or/and arterial thrombotic complications, to describe whether aPL are a cause, a consequence, or an accompanying event. Cerebral ischemia is the most common arterial thrombotic manifestation associated with the presence of aPL. In patients with ischemic stroke, diagnostic value of aPL can be increased by patient testing for antibodies against cardiolipin. The aim of the study was to assess the prevalence of IgG-aCL in young women with ischemic stroke. IgG-aCL were screened by ELISA in 34 young women, under the age of 45 (mean age 36.7 years) with ischemic stroke without the common stroke risk factors: hypertension, diabetes, hyperlipidemia, vasculitis or arterial fibrillation, smoking. Other 20 healthy, age and sex matched adults with no evidence of disease were also included as a control group. Twelve of the 34 (35%) patients were found to have aCL of the IgG isotype. The present study confirmed that IgG-aCL may be associated with ischemic stroke; this phenomenon is however relevant only in a small subgroup of young women. They should be sought in all stroke patients under the age of 45, especially those with previous histories of deep venous thrombosis, spontaneous abortion or thrombocytopenia.

Ischemic stroke accompanied by anti-PR3 antibody-related cerebral vasculitis and hepatitis C virus infection

BACKGROUND

Hepatitis C virus (HCV) infection has been found to be strikingly associated with autoimmune phenomena. Autoantibodies are commonly found in patients with HCV infection.

PURPOSE

The aim of the present study was to investigate the presence of anti-neutrophil cytoplasmic antibody (ANCA) in patients with ischemic stroke and HCV infection.

MATERIAL AND METHODS

ANCA were determined in sera from 36 patients with ischemic stroke and HCV infection (18 females, 18 males, mean age 75+/-10 years) and 44 healthy controls. Assays employed were indirect immunofluorescence for detection of ANCA and ELISA for anti-proteinase 3 (anti-PR3-ANCA). No one of the patients studied received IFN-alpha treatment before blood collection.

RESULTS

ANCA were positive in 21 out of 36 (58 %) patients with ischemic stroke and HCV infection. All sera with ANCA showed cANCA patterns and contained anti-PR3 specificity. HCV patients with ANCA showed a higher prevalence of cerebral vasculitis.

CONCLUSION

HCV may be regarded as a possible causative factor in ANCA-related vasculitis.

Serum magnesium in patients with acute ischemic stroke

Magnesium (Mg) has important effects within the vascular system. Magnesium deficiency was shown to trigger vasoconstriction and enhance vascular endothelial injury, thus promoting the development and progression of atherosclerosis. However, it is still not completely understood whether low serum Mg also promotes the occurrence of stroke. We hereby intended to investigate Mg levels in serum in the early stage of ischemic stroke and to evaluate the relationship between serum Mg concentration and the development of neurological deficits. The study included forty patients with acute ischemic stroke (26 women and 14 men), mean age 56 +/- 4 years, without any other serious injuries. Twenty-one healthy subjects, sex- and age-matched were selected as controls. The serum Mg concentrations were measured colorimetrically on a Hitachi 917 autoanalyzer. Serum levels of Mg were checked on admission, and at 48 hours after the onset of ischemic stroke. Using NIHSS, the neurological deficit was assessed on the 1st day, and 48 hours later. Statistical analysis was performed using the Student t test. The results confirm that there is a relationship between a low Mg concentration in serum at 48 hours after onset of ischemic stroke and the intensity of the neurological deficit. Mean value was 1.39 +/- 0.213 mmol/L (on admission), 1.47 +/- 0.181 mmol/L (at 48 hours after the onset of stroke) versus 1.66 +/- 0.138 mmol/L (in controls). Severity of paresis degree was higher in the patients with low Mg levels (p < 0.05). The serum Mg concentration has been suggested to possibly affect the neurologic state. A decrease in the serum Mg concentration indicates the severity of the injury. A magnesium substitution therapy may be useful.

Prevalence of anti-neutrophil cytoplasmic antibodies in patients with chronic hepatitis C infection associated mixed cryoglobulinemia

Chronic hepatitis C virus (HCV) has been linked to extrahepatic autoimmune phenomena. In addition, a variety of autoantibodies are found in patients with HCV. Anti-neutrophil cytoplasmic antibodies (ANCA) have been considered to be highly specific for systemic small vessel vasculitides with renal involvement. The prevalence, nature, a clinical significance of anti-neutrophil cytoplasmic antibodies (ANCA) in serum samples of patients with HCV were therefore investigated. A prospective study of 67 consecutive patients with chronic HCV with no evidence of previous hepatitis B virus (HBV) infection or any other autoimmune disorder. Twenty-seven patients with HBV and 35 healthy volunteers matched for age and sex served as control groups. Anti-neutrophil cytoplasmic antibodies in the serum samples were measured by indirect immunofluorescence assay. The group of patients with HCV and ANCA in their serum showed significantly higher total IgG levels, a higher incidence of antinuclear antibodies, and viraemia (HCV RNA) than the ANCA negative patients. None of the patients with HCV and ANCA showed any clinical manifestations related to those autoantibodies. This study clearly shows a high prevalence of ANCA in the serum of patients with HCV. The role of these autoantibodies on the course of HCV infection and their clinical significance has not been determined yet. In conclusion, ANCA are not only markers of small vessel vasculitides, but can also be (false?) positive in patients with HCV infection. A hepatitis C associated vasculitis should be considered in the differential diagnosis. Determination of target antigens for ANCA is indispensable. Interpretation and therapeutic decisions concerning ANCA associated HCV should only be performed within the clinical context.

The effect of magnesium deficit on serum immunoglobulin concentrations in type 1 diabetes mellitus

The aim of this study was to evaluate the correlation between changes in the concentration of serum magnesium and serum immunoglobulin concentrations in type 1 diabetes mellitus. In this study were included 110 patients with type 1 diabetes mellitus (64 men and 46 women) with ages ranging from 19 to 54 years (mean age 41.6+/-6.8 years). The mean duration of the disease was 8.7+/-7.5 years. Thirty-six healthy subjects served as a control group. The serum magnesium concentrations were evaluated by VITROS 750 XRC, Johnson & Johnson kit, (Ortho Clinical Diagnostics). Total serum IgA, IgG and IgM were determined by laser nephelometry (MININEPH The Binding Site kit). Values are means (x) + standard deviations (SD). Serum magnesium concentrations confirmed the magnesium deficit in patients with type 1 diabetes mellitus (1.8+/-0.11 mg/dL, range 1.73-2.47 mg/dL vs 2.2+/-0.2 mg/dL, range 1.6-2.4 mg/dL). In patients with type 1 diabetes mellitus, IgA levels are mildly elevated (4.03+/-0.51 g/L vs 3.43+/-0.48 g/L; p<0.05), while IgG levels are decreased (7.38+/-0.76 g/L vs 9.92+/-1.32 g/L; p<0.001) and IgM levels are almost constantly normal (1.18+/-0.16 g/L vs 1.22+/-0.15 g/L; p>0.05). Therefore, magnesium deficit has profound immunosuppressive capabilities in patients with type 1 diabetes mellitus by significantly reducing the number of IgG synthesizing cells and serum IgG concentrations.