Acute TNFα levels predict cognitive impairment 6-9 months after COVID-19 infection

BACKGROUND

A neurocognitive phenotype of post-COVID-19 infection has recently been described that is characterized by a lack of awareness of memory impairment (i.e., anosognosia), altered functional connectivity in the brain's default mode and limbic networks, and an elevated monocyte count. However, the relationship between these cognitive and brain functional connectivity alterations in the chronic phase with the level of cytokines during the acute phase has yet to be identified.

AIM

Determine whether acute cytokine type and levels is associated with anosognosia and functional patterns of brain connectivity 6-9 months after infection.

METHODS

We analyzed the predictive value of the concentration of acute cytokines (IL-1RA, IL-1β, IL-6, IL-8, IFNγ, G-CSF, GM-CSF) (cytokine panel by multiplex immunoassay) in the plasma of 39 patients (mean age 59 yrs, 38-78) in relation to their anosognosia scores for memory deficits via stepwise linear regression. Then, associations between the different cytokines and brain functional connectivity patterns were analyzed by MRI and multivariate partial least squares correlations for the whole group.

RESULTS

Stepwise regression modeling allowed us to show that acute TNFα levels predicted (R² = 0.145; β = -0.38; p = .017) and were associated (r = -0.587; p < .001) with scores of anosognosia for memory deficits observed 6-9 months post-infection. Finally, high TNFα levels were associated with hippocampal, temporal pole, accumbens nucleus, amygdala, and cerebellum connectivity.

CONCLUSION

Increased plasma TNFα levels in the acute phase of COVID-19 predict the presence of long-term anosognosia scores and changes in limbic system functional connectivity.

Frequency of Abnormally Low Neuropsychological Scores in Post-COVID-19 Syndrome: the Geneva COVID-COG Cohort

OBJECTIVE

Several studies have reported poor long-term neuropsychological performances in patients following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but none has yet considered the effect of administering multiple intercorrelated neuropsychological tests and assessed the frequency of cognitive deficits in a normative population. Our aim was therefore to assess the presence of cumulative neuropsychological deficits in an actual post-coronavirus disease of 2019 (COVID-19) comparison group versus one simulated using Monte-Carlo methods.

METHOD

Validated neuropsychological Monte-Carlo simulation methods were applied to scores from a battery of neuropsychological tests (memory, executive, attentional, perceptual, logical reasoning, language, and ideomotor praxis) administered to 121 patients who had had mild, moderate, or severe COVID-19 (mean age: 56.70 years; 32% women), 222 ± 43 days post-infection. The cumulative percentages of the three severity subgroups were compared with the results of a false discovery rate-corrected probability analysis based on normative data.

RESULTS

The cumulative percentages of deficits in memory and executive functions among the severe and moderate patients were significantly higher than those estimated for the normative population. Moderate patients also had significantly more deficits in perception and logical reasoning. In contrast, the mild group did not have significantly more cumulative deficits.

CONCLUSIONS

Moderate and severe forms of COVID-19 cause greater long-term neuropsychological deficits than those that would be found in a normative population, reinforcing the hypothesis of long-term effects of SARS-CoV-2 on cognitive function, independent of the severity of the initial infection.

SARS-CoV-2 and Guillain-Barré syndrome: AIDP variant with a favourable outcome

BACKGROUND AND PURPOSE

The spectrum of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2), includes different neurologic manifestations of the central and peripheral nervous system.

METHODS

From March through April 2020, in two university hospitals located in western Switzerland, we examined three patients with Guillain-Barré syndrome (GBS) following SARS-CoV-2.

RESULTS

These cases were characterized by a primary demyelinating electrophysiological pattern (Acute inflammatory demyelinating polyneuropathy or AIDP) and a less severe disease course compared to recently published case series. Clinical improvement was observed in all patients at week five. One patient was discharged from hospital after full recovery with persistence of minor neurological signs (areflexia). Two of the three patients remained hospitalized: one was able to walk and the other could stand up with assistance.

CONCLUSIONS

We report three cases of typical GBS (AIDP) occurring after SARS-CoV-2 infection and presenting with a favourable clinical course. Given the interval between COVID-19-related symptoms and neurological manifestations (mean of 15 days) we postulate a secondary immune-mediated mechanism rather than direct viral damage.

Fulminant multifocal relapse in a fingolimod-treated multiple sclerosis patient

BACKGROUND

Fingolimod is the first approved oral disease-modifying treatment for relapsing-remitting multiple sclerosis. Fingolimod targets lymphocytes, exerting a modulator effect on cell-surface sphingosine-1-phosphate receptors and thus blocking lymphocytes egression from secondary lymphoid organs. Recent reports describe fingolimod cessation being followed by severe or pseudo-tumoral relapse, but it usually does not happen on continuous long-term treatment.

CASE PRESENTATION

Here we present the case of a patient on continuous long-term fingolimod treatment who presented with fulminant atypical multifocal relapse involving over 30 new and active lesions.

CONCLUSION

This case is unique since this fulminant multifocal relapse occurred in a patient with grade 3 lymphopenia and irreproachable adherence. This observation should be known as a possible side effect of fingolimod treatment.

Real-life long-term effectiveness of fingolimod in Swiss patients with relapsing-remitting multiple sclerosis

Background and purpose

In 2011, fingolimod was approved in Switzerland for the treatment of relapsing‐remitting multiple sclerosis (RRMS). The aim of the present study was to assess the effectiveness and retention of fingolimod in a real‐life Swiss setting, in which patients can receive fingolimod as both first‐ and second‐line treatment for RRMS.

Methods

This cross‐sectional, observational study with retrospective data collection was performed at 19 sites that comprised both hospitals and office‐based physicians across Switzerland. Sites were asked to document eligible patients in consecutive chronological order to avoid selection bias. Demographic and clinical data from 274 consenting adult patients with RRMS who had received treatment with fingolimod were analyzed.

Results

Mean treatment duration with fingolimod was 32 months. Under fingolimod, 77.7% of patients remained free from relapses and 90.3% did not experience disability progression. The proportion of patients who were free from any clinical disease activity, i.e. without relapses and disability progression, was 72.1%. A total of 28.5% of patients had been RRMS treatment‐naïve prior to fingolimod therapy. High long‐term treatment retention rates ranging between 95.7% at 24 months and 87.8% at 36 months were observed.

Conclusion

In this Swiss cohort of naïve and pre‐treated subjects with RRMS, the majority of patients under fingolimod treatment showed freedom from relapses and disability progression. In addition, treatment retention rate over 2 and 3 years was high, irrespective of previous treatment.

[Dysimmune neuromuscular disorders: diagnostic challenges and new ways of management]

This review describes some dysimmune neuromuscular disorders and their recent management: syndrome of peripheral nerve hyperexcitability (treatment of cramps, immunosuppressors); Guillain-Barré syndrome (new mechanisms and consensus treatment); chronic inflammatory demyelinating polyradiculoneuropathy (new indication for the use of pulse dexamethasone, new scores of activity); importance of subcutaneous immunoglobulin in multifocal motor neuropathy and of infusions of rituximab in myasthenia gravis; new entities in myositis and their treatment.

[Neuropathies associated with paraproteinemia (monoclonal gammopathy)]

Coexistence of neuropathy and paraproteinemia (monoclonal gammopathy) is a common and complex problem seen in clinical practice and requires the distinction of specific syndromes. The clinical courses of these neuropathies are typically chronic and progressive. A precise distinction of the type of haematologic disorder associated (benign or malignant), investigation of other organs manifestations, and assessment of specific markers are mandatory. These steps are important to initiate an appropriate therapy that may include chemotherapy and/or immunosuppressive treatment targeting the neuropathy and the haematological dysfunction.

[Neuroborreliosis, tick-borne encephalitis and neurosyphilis]

Infections affecting frequently the nervous system include Lyme disease, tick-borne encephalitis and syphilis. These three most dreaded neuro-infectious diseases observed in Switzerland are discussed, based on diagnostic criteria, screening testing, and treatments modalities. Neuroborreliosis and neurosyphilis are bacterial infectious diseases treatable by antibiotics, whereas the treatment of tick-borne encephalitis, a viral disease, is only based on preventive vaccination.

[New treatment options in multiple sclerosis and their complications]

A new therapeutic era opened for multiple sclerosis (MS) with the appearance of molecules given p.o. and/or molecules with greater efficiency. Early diagnosis is critical, as the time and the choice of therapeutic intervention. The initiation of treatments must be personalized, including the risks associated with MS and those potentially related to the treatment chosen, answering the question <Who, when and how to treat?>>. Monitoring tools that allow to objectively evaluate: I) MS activity and aggressiveness for each patient and 2) the safety of treatments and their risks of complications, must be further investigated.

Adapted timed up and go: a rapid clinical test to assess gait and cognition in multiple sclerosis

BACKGROUND/AIMS

To measure the Timed Up and Go (TUG), imagined TUG (iTUG), and the difference of time between these two tests (delta time) in 20 patients with relapsing-remitting multiple sclerosis (RRMS) and 20 healthy age-matched controls and to examine whether an association with cognitive functions, motor impairment, and behavioral changes can be determined.

METHODS

The mean ± SD of TUG, iTUG and delta time were used as outcomes. Spatiotemporal gait parameters were recorded by a 12-camera optoelectronic system during straight walking at usual self-selected speed. Cognitive functions were assessed by a standardized neuropsychological examination.

RESULTS

Patients performed the TUG slower than the controls (10.00 ± 1.70 s vs. 8.71 ± 1.04 s, p = 0.01, respectively). The TUG was correlated with gait parameters, cognitive functions, and behavior, whereas delta time was correlated only with cognitive functions.

CONCLUSION

TUG represents an interesting test to reveal subtle deficits in RRMS patients with low disability and is related to motor, cognitive, and behavioral functioning. Combining with the TUG, delta time could easily give additional information on specific cognitive functions in the assessment of patients with RRMS.

Hypereosinophilia in patients with multiple sclerosis treated with natalizumab

OBJECTIVE

To report asymptomatic hypereosinophilia as a potential side effect in patients treated with natalizumab, an α-4 integrin blocking agent.

METHODS

A case series of 3 patients treated with natalizumab for relapsing-remitting multiple sclerosis including functional and phenotypic characterization of their peripheral blood lymphocytes and eosinophils is presented.

RESULTS

Marked peripheral blood eosinophilia with more than 2,000 cells/mm(3) emerged in all 3 patients after the fourth natalizumab infusion and was asymptomatic. Hypereosinophilia was associated with enhanced Th2 activity, ceased with drug discontinuation, and in 2 of 3 patients recurred with drug resumption. Despite persistently high eosinophil counts, there were no signs of end-organ damage.

CONCLUSIONS

Hypereosinophilia may occur during treatment with natalizumab. It seems to reflect enhanced Th2 activity and recedes with systemic corticosteroids. If the patient is asymptomatic, natalizumab may be continued, provided that other causes of eosinophilia are excluded and the patient is carefully monitored.

[Biomarkers in neuroimmunology]

Biomarkers of clinical relevance are very important in the workup of patients presenting with neurological autoimmune diseases. Nervous biopsy remains often the "gold standard procedure" but is limited in practice due to the risk of complication and insufficient yield. These biomarkers, most often auto-antibodies, can be the direct cause of the neurological syndrome or be detected as an epiphenomenon of the pathogenic process. The detection of these biomarkers, when performed in well defined clinical conditions, may help the clinician to establish a definite diagnosis which may in turn facilitate the therapeutic decision. The purpose of this article is to review the biomarkers that are available in daily practice to investigate immune-mediated neurological conditions.

Highly reactive anti-myelin oligodendrocyte glycoprotein antibodies differentiate demyelinating diseases from viral encephalitis in children

Background: Myelin oligodendrocyte glycoprotein (MOG) may be implicated in the immunopathogenesis of multiple sclerosis (MS) inducing demyelination in the animal model of MS. In adults reported anti-MOG antibody frequencies have been variable across a number of studies and can also be detected in controls.

Objective: To measure antibodies against MOG in paediatric patients with demyelinating disorders of the central nervous system and in controls.

Methods: Serum antibodies against MOG and myelin basic protein were measured by ELISA, flow cytometry (FACS) and in the liquid phase in 11 children with acute disseminated encephalomyelitis (ADEM), 22 children with MS, seven children with acute viral encephalitis and 13 healthy controls. The serostatus of Epstein–Barr virus (EBV) infections were assessed.

Results: Anti-MOG antibodies, measured either by ELISA or FACS were exclusively detected in children with demyelination. In ADEM these antibodies were highly reactive. Anti-MBP reactivity was detectable equally in all groups. The presence of either autoantibodies did not associate with EBV serostatus, age, gender or disease course.

Conclusions: This study independently corroborates recently published results of seroprevalence and specificity of the assay. Due to their low sensitivity anti-MOG antibodies will not serve as disease-specific biomarkers, but could help to support the diagnosis of ADEM in difficult cases.

[Viral encephalitis: update]

Suspicion of viral encephalitis should always be considered as a medical emergency and the prognosis depend on both the immune status of the host and the virulence of the virus. Among them, the herpes simplex virus is by far the most important one since it can be associated with severe encephalitis in immunocompetent host, and because a good response to acyclovir can be expected when rapidly initiated. Nevertheless, confirmation of the diagnosis requires exclusion of both metabolic or toxic encephalopathy and inflammatory encephalitis of non-infectious origin. In addition, other germs than viruses can mimic viral encephalitis and must be taken into consideration. The purpose of this review is to update the investigation that should be performed in clinical practice for any patient with suspicion of acute viral encephalitis.

[Autoantibodies in neurological diseases: clinical implications]

Autoantibodies are defined as antibodies directed against self antigens, i.e., against a normal antigenic endogenous tissue constituent. They can be the immediate cause of the neurological syndrome or be detected as an epiphenomenon of the pathogenic process. Autoantibodies are often considered useful biomarkers for the improvement of diagnostic accuracy, for the staging of disease progression or for the follow up of a biological response to a therapeutic intervention. The purpose of this article is to review the autoantibodies that are available to investigate immune-mediated neurological conditions. The detection of some of these autoantibodies may help the clinician to establish a definite diagnosis which may further facilitate the therapeutic decision.

[Neuropathy associated with monoclonal gammopathy (dysglobulinemia)]

Neurological complications of monoclonal gammopathy, or dysglobulinemia, are typically affecting the peripheral nerve. The clinical course is often chronic and progressive and requires a precise diagnosis of the type of plasma cell disorder associated with the neuropathy, to investigate other organs manifestations and to assess the presence of specific markers. These steps are required to initiate an appropriate therapy that may include chemotherapy, immunosuppressive or immunomodulatory treatment.

[Multiple sclerosis and pregnancy]

Mulltiple sclerosis and pregnancy Multiple sclerosis (MS) is diagnosed between the second and fourth decade. More than 2/3 of patients are women and are often in childbearing age. We may ask two main questions: Which implication of pregnancy on the evolution of MS has to be considered ? Which influence of MS on the pregnancy is expected? In other words could the pregnancy worsen MS and could MS represent specific risks for the pregnancy?

Interferon-beta induces brain-derived neurotrophic factor in peripheral blood mononuclear cells of multiple sclerosis patients

Interferon-beta (IFN-beta) achieves its beneficial effect on multiple sclerosis (MS) via anti-inflammatory properties. In this study, we assessed the expression of the brain-derived neurotrophic factor (BDNF) in peripheral blood mononuclear cells (PBMC) from relapsing-remitting multiple sclerosis (RRMS) patients treated or not with IFN-beta. Intracellular BDNF was measured by Western blot and ELISA and compared with serum BDNF. We found higher levels of BDNF in PBMC of IFN-beta-treated versus non-treated patients, whereas serum levels of BDNF were similar. We hypothesize that the increased intracellular BDNF secondary to IFN-beta is not released in the periphery. This release is probably not tissue specific but in MS patients, BDNF could be specifically delivered by PBMC at the site of re-activation, i.e. within the central nervous system.

[Neuromyelitis optica/Devic's syndrome: new perspectives]

Neuromyelitis optica (NMO) or Devic's syndrome is a severe demyelinating disease of the central nervous system involving preferentially the optic nerves and the spinal cord. Until recently, NMO was described as an atypical multiple sclerosis IMS), characterized by an unusual clinical presentation, a severe relapsing progression, and a poor response to usual MS treatments. The recent discovery of the so-called NMO-IgG, a highly NMO-specific antibody directed against the blood brain barrier and the aquaporine-4, allowed to refine diagnostic criteria and to classify this disease as an autoimmune channelopathy. According to this recent advance, early diagnostic and specific treatment targeting the humoral response should be considered.

Inhibition of naive Th1 CD4+ T cells by glatiramer acetate in multiple sclerosis

We investigated whether glatiramer acetate (GA) treatment may affect Th1 differentiation at various T-cell maturation stages. Specifically, we analyzed the effect of in vivo GA treatment on intracellular synthesis of IL-2 and TNF-alpha by naive, memory and effector CD4(+) and CD8(+) T cells by five-colour flow cytometry. Our data indicate that GA treatment downregulates/normalizes an accelerated Th1 differentiation of CD4(+) T cells in RRMS patients at all stages of T-cell maturation. Most notably, we conclude that, by altering naive, unprimed CD4(+) T cells, GA treatment appears to affect T-cell differentiation, at least in part, in an antigen-independent manner.

[Immunity and neurodegeneration: new concepts in multiple sclerosis]

Multiple sclerosis is an autoimmune demyelinating disease of the central nervous system that leads to a progressive deterioration of the neurological functions. The concept of primary myelin and oligodendrocyte damage with axon sparing (axon-myelin dissociation) has been recently reconsidered with the demonstration that neuro-axonal lesions are an early phenomenon, linked to the inflammatory process, observed outside demyelinated areas, and correlated with the progression of the disease. Neurodegeneration in MS, long considered as a late process following recurrent episodes of demyelination, is now accepted as an early and major trigger of MS pathogenesis on which research should focus in the

[Lombosacral radiculopathy (L3-S1) and specificity of multifidus EMG]

AIMS OF THE STUDY

This prospective study tried to establish, in a group of patients with lombosacral radiculopathy, whether the electromyography of the multifidus muscles following the "Paraspinal Mapping" described by Haig and colleagues (1991, 1993, 1995, 1997) allows to specify the exact level of the radiculopathy.

MATERIAL AND METHODS

Twenty-three patients with symptoms of mono or pluriradiculopathy were submitted to an EMG of the lower limbs and multifidus muscles at different levels in accordance to the "Paraspinal Mapping" cartography.

RESULTS AND CONCLUSION

No patient had signs of acute denervation in the multifidus muscles that corresponded exclusively to the suspected levels as determined by clinical and radiological examinations. No patient had signs of acute denervation in the multifidus muscles without associated signs in the lower limb muscles. Conversely, four patients had signs of acute denervation in the lower limb muscles without any signs in the multifidus muscles. In our small series, the EMG of the multifidus muscles was neither sensitive nor specific and did not allow by itself topographical diagnosis.

Is measurement of D-dimer useful in the diagnosis of cerebral venous thrombosis?

BACKGROUND

The diagnosis of cerebral venous thrombosis (CVT) is a challenge because its clinical presentation is variable, brain CT may be normal, and MRI is not always available. Furthermore, early treatment may be effective. As D-dimer (DD) measurement is a sensitive test for the exclusion of venous thromboembolism, the authors studied whether this test could be useful in the diagnosis of CVT.

METHODS

A prospective study of 54 consecutive patients with headaches suggestive of CVT was conducted between October 2000 and September 2002. DD levels were tested for all patients in the emergency room before brain CT or MRI was performed.

RESULTS

Twelve (22%) of the 54 patients had CVT, and 10 (83%) of these 12 patients had DD level of >500 ng/mL (sensitivity of 83% and negative predictive value of 95%). Two patients with confirmed CVT and DD of <500 ng/mL had a history of chronic headache of >30 days' duration. In the 42 patients without confirmed CVT, only 4 patients had DD level of >500 ng/mL (specificity of 90% and positive predictive value of 71%).

CONCLUSIONS

DD test is useful in the diagnosis of acute CVT. A value below 500 ng/mL makes acute thrombosis unlikely.

The role of blood pressure in lacunar strokes preceded by TIAs

Lacunar strokes (LS) are often preceded by repetitive transitory ischaemic attacks (TIAs) known as 'capsular warning syndrome'. The treatment of these symptoms remains controversial. Anticoagulants are often used in this situation, most of the time, however, with no or little benefit. Since it is not rare that these TIAs lead to a definite stroke, the therapeutic approach in the acute phase is very important. We report six patients presenting LS preceded by TIAs. All patients showed intermittent decrease of blood pressure (BP) coinciding with clinical worsening and leading to definite stroke in four of them. All were treated with full-dose intravenous heparin, which did not prevent further clinical deterioration. One patient received noradrenalin, which allowed stabilisation of the blood pressure values and complete resolution of the neurological symptoms. This observation suggests that in lacunar strokes preceded by TIAs monitoring and, if necessary, pharmacological increase of BP may prevent some patients from developing a definite stroke. Thus the 'capsular warning syndrome' could reflect a haemodynamic failure rather than repeated thrombo-embolism within the lumen of a single perforating arteriole.

Endplate dysfunction causing respiratory failure in a patient with prior paralytic poliomyelitis

A 56-year-old man with late amyotrophic sequelae from poliomyelitis experienced progressive dyspnoea requiring intubation and artificial ventilation in the intensive care unit. Repetitive stimulation studies showed a marked decrement of the trapezius muscle response reversible with edrophonium. Ventilatory function considerably and lastingly improved under anticholinesterase treatment. In the absence of biological evidence for autoimmune myasthenia gravis, it is suggested that a mechanism implying endplate dysfunction related to postpolio syndrome. Repetitive stimulation procedure should be considered in postpolio syndrome patients as some of them may benefit from anticholinesterase treatment.

[Recurrent encephalopathy after small bowel resection. Implication of D-lactate]

Recurrent episodes of confusion are most commonly due to transient brain dysfunction related to vascular, epileptic or metabolic abnormalities. We report here a 54-year-old patient who, in the months following an extensive surgery of the small intestine, developed several acute confusional episodes characterized by encephalopathic signs (such as behavioral changes, desorientation and somnolence), ataxia, nystagmus and dysarthria. A number of metabolic changes were demonstrated during the episodes, including metabolic acidosis with increased anion gap and an elevated blood level of D-lactate. Symptoms disappeared after treatment with antibiotics. D-lactate encephalopathy is a rare cause of recurrent confusion which could be suspected based on a characteristic association of clinical signs. Diagnosis is confirmed by appropriate dosages. We discussed the possible mechanisms leading to confusional episodes.