Human pegivirus identified in severe myelitis and optic neuritis in immunocompromised patients: A pathogenic role for a forgotten virus?

The role of Human pegivirus (HPgV) in patients with encephalitis has been recently questioned. We present cases of 4 patients with similar clinical, biological, and radiological characteristics, including a past history of transplantation with long-term immunosuppression and a progressive course of severe and predominantly myelitis, associated in 3 cases with optic neuropathy causing blindness. Extensive workup was negative but analysis of the CSF by use of pan-microorganism DNA- and RNA-based shotgun metagenomics was positive for HPgV. This case series further supports the hypothesis of HPgV CNS infection and highlights the utility of metagenomic next-generation sequencing of CSF in immunocompromised patients.

MRI characteristics of MOG-Ab associated disease in adults: An update

Our knowledge of the radiological spectrum of myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD) is growing rapidly. An update on the radiological features of the disease, and its evolution is thus necessary. Magnetic resonance imaging (MRI) has an increasingly important role in the differential diagnosis of MOGAD particularly from aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD), and multiple sclerosis (MS). Differentiating these conditions is of prime importance because the management is different between the three inflammatory diseases, and thus could prevent further attack-related disability. Therefore, identifying the MRI features suggestive of MOGAD has diagnostic and prognostic implications. We herein review optic nerve, spinal cord and the brain MRI findings from MOGAD adult patients, and compare them to AQP4-NMOSD and MS.

Advanced multiparametric magnetic resonance imaging of multinodular and vacuolating neuronal tumor

BACKGROUND AND PURPOSE

Multinodular and vacuolating neuronal tumor (MVNT) of the cerebrum is a rare brain lesion with suggestive imaging features. The aim of our study was to report the largest series of MVNTs so far and to evaluate the utility of advanced multiparametric magnetic resonance (MR) techniques.

METHODS

This multicenter retrospective study was approved by our institutional research ethics board. From July 2014 to May 2019, two radiologists read in consensus the MR examinations of patients presenting with a lesion suggestive of an MVNT. They analyzed the lesions' MR characteristics on structural images and advanced multiparametric MR imaging.

RESULTS

A total of 64 patients (29 women and 35 men, mean age 44.2 ± 15.1 years) from 25 centers were included. Lesions were all hyperintense on fluid-attenuated inversion recovery and T2-weighted imaging without post-contrast enhancement. The median relative apparent diffusion coefficient on diffusion-weighted imaging was 1.13 [interquartile range (IQR), 0.2]. Perfusion-weighted imaging showed no increase in perfusion, with a relative cerebral blood volume of 1.02 (IQR, 0.05) and a relative cerebral blood flow of 1.01 (IQR, 0.08). MR spectroscopy showed no abnormal peaks. Median follow-up was 2 (IQR, 1.2) years, without any changes in size.

CONCLUSIONS

A comprehensive characterization protocol including advanced multiparametric magnetic resonance imaging sequences showed no imaging patterns suggestive of malignancy in MVNTs. It might be useful to better characterize MVNTs.

[Optic neuropathy in positive anti-MOG antibody syndrome]

INTRODUCTION

The diagnosis of optic neuritis (ON), or inflammation of the optic nerve, is based on clinical findings: first marked by rapidly progressive visual decline associated with eye pain accentuated by eye movements; abnormalities of color perception and/or contrast sensitivity may also be reported. In this case, inflammatory neuropathies are associated with anti-MOG antibodies. MOGs, oligodendrocytic glycoproteins involved in the production of myelin, were identified nearly three decades ago in association with demyelinating ON. The first series were reported in children following demyelinating neurological manifestations, particularly in ADEM (acute demyelinating encephalomyelitis) or multiple sclerosis (MS) [1]. Anti-MOGs are associated with neuropathies in the phenotypic setting of the neuromyelitis optica (NO) spectrum, and anti-Aquaporin 4 antibodies (AQP4) are negative by definition. Thus, anti-MOG could explain up to 30 % of cases of seronegative optic neuritis; their presence thus represents a significant diagnostic aid for the clinician, especially during a first neurological episode [1]. The first short published series in AQP4-/MOG+populations revealed primarily ophthalmological involvement with a good prognosis for recovery [1]. Knowledge of these antigens is important; it may permit not only an understanding of the physiopathology but also the stratification of patients in terms of prognosis and response to treatment [2]. Thus, the early diagnosis of anti-MOG positive ON must prompt aggressive initial treatment and a more or less maintenance therapy to prevent recurrence. The role of the ophthalmologist remains paramount, since most cases present with purely ocular involvement.

MATERIALS AND METHODS

We report herein the clinical, ophthalmological, laboratory and radiological data for 25 patients (45 eyes) managed between February 2011 and January 2017. All of our patients had optic neuritis associated with anti-MOG antibodies. All patients underwent the following testing: - Visual acuity; - Humphrey and/or Goldmann visual field; - Non-mydriatic fundus photography; - Optic disc OCT; - 3 Tesla orbital-cerebral MRI with and without contrast; - Standard and immunological laboratory testing for anti-MOG and anti AQP4 antibodies by Western Blot and ELISA.

RESULTS

The male: female ratio of the population was 0.92 (13 women and 12 men). The average age at onset was 35.68 years (15 to 60 years); 40 % of the subjects were between 31 and 40 years old. The initial symptoms leading to consultation were mostly visual acuity (80 %) and pain (88 %). Involvement was bilateral in 80 % of cases (5 unilateral). Initial visual acuity was poor; 52 % of eyes were less than or equal to count fingers. The course was favorable however, with visual acuity returning to 10-12/10 after 6 months of follow-up (84 % of eyes). Orbital/cerebral MRI with attention to the visual pathways revealed involvement of the anterior visual pathways with gadolinium uptake in 92 % of cases. Of the 35 eyes initially considered affected, the main initial diagnoses were: - 36 % retro-bulbar optic neuritis (RBON); - 40 % anterior optic neuritis (AON); - 24 % other; of which 16 % were initially diagnosed as acute anterior ischemic optic neuropathy (AAION). 96 % of patients received corticosteroid treatment in the acute phase. 16 % required plasma exchange sessions. Maintenance therapy was proposed for only 36 % of the population.

CONCLUSION

Optic neuritis is a pathology frequently encountered in ophthalmology; a good knowledge of symptoms and clinical signs is essential for early diagnosis and optimal management. The identification of autoantibodies, including anti-MOG antibodies, is important for patient management and is part of the required testing for all cases of optic neuritis, in order to adapt the treatment of the acute episode and to provide maintenance therapy to avoid recurrence.

Multinodular and Vacuolating Posterior Fossa Lesions of Unknown Significance

Multinodular and vacuolating neuronal tumor of the cerebrum is a rare supratentorial brain tumor described for the first time in 2013. Here, we report 11 cases of infratentorial lesions showing similar striking imaging features consisting of a cluster of low T1-weighted imaging and high T2-FLAIR signal intensity nodules, which we referred to as multinodular and vacuolating posterior fossa lesions of unknown significance. No relationship was found between the location of the lesion and clinical symptoms. A T2-FLAIR hypointense central dot sign was present in images of 9/11 (82%) patients. Cortical involvement was present in 2/11 (18%) of patients. Only 1 nodule of 1 multinodular and vacuolating posterior fossa lesion of unknown significance showed enhancement on postcontrast T1WI. DWI, SWI, MRS, and PWI showed no malignant pattern. Lesions did not change in size or signal during a median follow-up of 3 years, suggesting that multinodular and vacuolating posterior fossa lesions of unknown significance are benign malformative lesions that do not require surgical intervention or removal.

Diagnosis and Prediction of Relapses in Susac Syndrome: A New Use for MR Postcontrast FLAIR Leptomeningeal Enhancement

BACKGROUND AND PURPOSE

Leptomeningeal enhancement can be found in a variety of neurologic diseases such as Susac Syndrome. Our aim was to assess its prevalence and significance of leptomeningeal enhancement in Susac syndrome using 3T postcontrast fluid-attenuated inversion recovery MR imaging.

MATERIALS AND METHODS

From January 2011 to December 2017, nine consecutive patients with Susac syndrome and a control group of 73 patients with multiple sclerosis or clinically isolated syndrome were included. Two neuroradiologists blinded to the clinical and ophthalmologic data independently reviewed MRIs and assessed leptomeningeal enhancement and parenchymal abnormalities. Follow-up MRIs (5.9 MRIs is the mean number per patient over a median period of 46 months) of patients with Susac syndrome were reviewed and compared with clinical and retinal fluorescein angiographic data evaluated by an independent ophthalmologist. Fisher tests were used to compare the 2 groups, and mixed-effects logistic models were used for analysis of clinical and imaging follow-up of patients with Susac syndrome.

RESULTS

Patients with Susac syndrome were significantly more likely to present with leptomeningeal enhancement: 5/9 (56%) versus 6/73 (8%) in the control group (P = .002). They had a significantly higher leptomeningeal enhancement burden with ≥3 lesions in 5/9 patients versus 0/73 (P < .001). Regions of leptomeningeal enhancement were significantly more likely to be located in the posterior fossa: 5/9 versus 0/73 (P < .001). Interobserver agreement for leptomeningeal enhancement was good (κ = 0.79). There was a significant association between clinical relapses and increase of both leptomeningeal enhancement and parenchymal lesion load: OR = 6.15 (P = .01) and OR = 5 (P = .02), respectively.

CONCLUSIONS

Leptomeningeal enhancement occurs frequently in Susac syndrome and could be helpful for diagnosis and in predicting clinical relapse.

A 3T Phase-Sensitive Inversion Recovery MRI Sequence Improves Detection of Cervical Spinal Cord Lesions and Shows Active Lesions in Patients with Multiple Sclerosis

BACKGROUND AND PURPOSE

Magnetic Resonance Imaging is the modality of choice to detect spinal cord lesions in patients with Multiple Sclerosis (MS). However, this imaging is challenging. New sequences such as phase-sensitive inversion recovery have been developed to improve detection. Our aim was to compare a 3D phase-sensitive inversion recovery and a conventional imaging dataset including postcontrast T2WI and T1WI to detect MS spinal cord lesions.

MATERIALS AND METHODS

This retrospective single-center study included 100 consecutive patients with MS (mean age, 41 years) from January 2015 to June 2016. One senior neuroradiologist and 1 junior radiologist blinded to clinical data checked for new spinal cord lesions, individually analyzing conventional and 3D phase-sensitive inversion recovery datasets separately, placing a 3-week delay between the 2 readings. A consensus reading was done with a third senior neuroradiologist. A Wilcoxon test was used to compare the 2 imaging datasets. Intra- and interobserver agreement was assessed by the κ coefficient.

RESULTS

3D phase-sensitive inversion recovery detected significantly more lesions than conventional imaging (480 versus 168, P < .001). Eleven patients had no detected lesions on T2WI, whereas 3D phase-sensitive inversion recovery detected at least 1 lesion. All postcontrast T1WI enhancing lesions were also visible on 3D phase-sensitive inversion recovery. The signal-to-noise ratio was significantly higher using 3D phase-sensitive inversion recovery (0.63 versus 0.46, P = .03). Mean reading confidence was significantly higher using 3D phase-sensitive inversion recovery. Inter- and intraobserver agreement was good for both datasets.

CONCLUSIONS

Our study showed that 3D phase-sensitive inversion recovery significantly improved detection of cervical spinal cord lesions, including both enhancing and nonenhancing lesions in patients with MS.

Inaugural tumor-like multiple sclerosis: clinical presentation and medium-term outcome in 87 patients

BACKGROUND

Tumefactive demyelinating lesions of the central nervous system can be the initial presentation in various pathological entities [multiple sclerosis (the most common), Balo's concentric sclerosis, Schilder's disease and acute disseminated encephalomyelitis] with overlapping clinical presentation. The aim of our study was to better characterize these patients.

METHODS

Eighty-seven patients (62 women and 25 men) from different MS centers in France were studied retrospectively. Inclusion criteria were (1) a first clinical event (2) MRI showing one or more large demyelinating lesions (20 mm or more in diameter) with mass-like features. Patients with a previous demyelinating event (i.e. confirmed multiple sclerosis) were excluded.

RESULTS

Mean age at onset was 26 years. The most common initial symptoms (67% of the patients) were hemiparesis or hemiplegia. Aphasia, headache and cognitive disturbances (i.e. atypical symptoms for demyelinating diseases) were observed in 15, 18 and 15% of patients, respectively. The mean largest diameter of the tumefactive lesions was 26.9 mm, with gadolinium enhancement in 66 patients (81%). Twenty-one patients (24%) had a single tumefactive lesion. During follow-up (median time 5.7 years) 4 patients died, 70 patients improved or remained stable and 12 worsened. 86% of patients received initial corticosteroid treatment, and 73% received disease-modifying therapy subsequently. EDSS at the end of the follow-up was 2.4 ± 2.6 (mean ± SD).

CONCLUSION

This study provides further evidence that the clinical course of MS presenting with large focal tumor-like lesions does not differ from that of classical relapsing-remitting MS, once the noisy first relapsing occurred.

Improved Detection of New MS Lesions during Follow-Up Using an Automated MR Coregistration-Fusion Method

BACKGROUND AND PURPOSE

MR imaging is the key examination in the follow-up of patients with MS, by identification of new high-signal T2 brain lesions. However, identifying new lesions when scrolling through 2 follow-up MR images can be difficult and time-consuming. Our aim was to compare an automated coregistration-fusion reading approach with the standard approach by identifying new high-signal T2 brain lesions in patients with multiple sclerosis during follow-up MR imaging.

MATERIALS AND METHODS

This prospective monocenter study included 94 patients (mean age, 38.9 years) treated for MS with dimethyl fumarate from January 2014 to August 2016. One senior neuroradiologist and 1 junior radiologist checked for new high-signal T2 brain lesions, independently analyzing blinded image datasets with automated coregistration-fusion or the standard scroll-through approach with a 3-week delay between the 2 readings. A consensus reading with a second senior neuroradiologist served as a criterion standard for analyses. A Poisson regression and logistic and γ regressions were used to compare the 2 methods. Intra- and interobserver agreement was assessed by the κ coefficient.

RESULTS

There were significantly more new high-signal T2 lesions per patient detected with the coregistration-fusion method (7 versus 4, P < .001). The coregistration-fusion method detected significantly more patients with at least 1 new high-signal T2 lesion (59% versus 46%, P = .02) and was associated with significantly faster overall reading time (86 seconds faster, P < .001) and higher reader confidence (91% versus 40%, P < 1 × 10^-4). Inter- and intraobserver agreement was excellent for counting new high-signal T2 lesions.

CONCLUSIONS

Our study showed that an automated coregistration-fusion method was more sensitive for detecting new high-signal T2 lesions in patients with MS and reducing reading time. This method could help to improve follow-up care.

Different HLA class II (DRB1 and DQB1) alleles determine either susceptibility or resistance to NMO and multiple sclerosis among the French Afro-Caribbean population

BACKGROUND

Despite similarities, neuromyelitis optica (NMO) can be distinguished from multiple sclerosis (MS) by clinical, radiological and serological findings.

OBJECTIVE

This case-control study aimed to determine whether patients with NMO or with MS in an Afro-Caribbean population originating from French West Indies shared the same or different HLA class I and II pattern distribution.

METHODS

The association with HLA class II (DRB1 and DQB1) alleles was tested in 42 NMO patients, 163 MS patients and 150 healthy controls. HLA-DRB1 and DQB1 typing was undertaken on genomic DNA extracted from peripheral blood leucocytes.

RESULTS

By comparison with healthy controls, significantly increased frequency of HLA-DRB1 03 (26.2% vs. 13%, odds ratio 2.4, 95% confidence interval 1.31-4.28, p after correction, cp 0.045) was observed in patients with NMO. By contrast, in MS patients, HLA-DRB1 15 (24.8% vs. 13%, odds ratio 2.21, 95% CI 1.45-3.36, cp < 0.0015), but not DRB1 03 allele, was positively associated with the disease. Moreover, a modest protective effect of HLA-DRB1 11 in the MS group, independently of DRB1 15 association, was found (13.7% vs. 7% in controls, odds ratio 0.48, p 0.006), but did not survive Bonferroni correction.

CONCLUSION

In conclusion, comparison of the HLA-DRB1 and DQB1 distribution in NMO and MS in this Afro-Caribbean population shows important differences in the HLA associations among NMO and MS.

[Bilateral papilledema: prospective study of fifty patients]

In this prospective study, we report fifty consecutive cases of bilateral papilledema without neurosurgical or obvious ophthalmologic etiology, referred to our institution between January 2005 and March 2007. Lumbar puncture with opening CSF pressure measurement distinguished two groups of patients: Group 1 (n=39) with and Group 2 (n=11) without intracranial hypertension. In Group 1, 9/39 patients presented secondary intracranial hypertension mainly due to cerebral venous thrombosis. In 30 patients, after complete investigations, a diagnosis of idiopathic intracranial hypertension was made: as commonly reported, patients were predominantly overweight (96.7% with body mass index>25kg/m2) young (mean age=27.6 years) and women (96.7%). Eleven patients with intracranial hypertension had no headaches. In Group 2, the most common diagnosis was bilateral non-arteritic anterior ischemic optic neuropathy, but rare causes have been identified.

Accident vasculaire cérébral chez le jeune Afro-Caribéen en Martinique : étude prospective épidémiologique et étiologique

Few data are available regarding stroke among young black patients. We have conducted, in Martinique, a prospective study among young Afro-Caribbeans aged 15 to 45 Years, from June 1994 through May 1999. We identified 60 cerebral infarcts (CI) and 20 cases of intracerebral hemorrhage (ICH). Annual incidence and case fatality rate at 30 days were 7.6/100000/Year (95p.cent confidence interval, 3.13 to 11.35) and 8.3p.cent respectively for CI, and 2.42/100000/Year (95p.cent confidence interval, 0.06 to 4.7) and 25p.cent for ICH. Hypertension was the most prevalent stroke risk factor: 35p.cent in CI and 68p.cent in ICH. According to the TOAST criteria, a probable cause of ischemic stroke was identified in 61.3p.cent. Atherosclerosis, lacunar infarcts and cardioembolism were the main causes of CI (13.3p.cent for each etiology). Spontaneous cervical arterial dissection was found in only 6.7p.cent. Hypertensive ICH (60p.cent) was the most common subtype of ICH. In Martinique, high frequencies of ICH and lacunar infarcts are characteristic of stroke in young Afro-Carribeans. These suggest the role of the high prevalence of hypertension in the black population. We confirm the heterogeneity of stroke etiologies and the low prevalence of cervical arterial dissection in black people.

Acute stroke in the very elderly: epidemiological features, stroke subtypes, management, and outcome in Martinique, French West Indies

BACKGROUND AND PURPOSE

Stroke incidence increases with increasing age and has an impact on daily living in many areas. With increasing life expectancy, old people will constitute the majority of stroke victims. We present the first stroke study focusing on very old patients in a black Caribbean population (Martinique, French West Indies).

METHODS

All Martinican patients suffering from their first-ever stroke during 1 calendar year between June 1, 1998, and May 31, 1999, were included. Epidemiological, clinical, neuroimaging, management, and outcome data during the first month were collected and compared between very old patients (>or=85 years) and patients aged <85 years.

RESULTS

One hundred patients aged >or=85 years and 480 patients aged <85 years were included (sex ratio, women/men, 2.84 and 0.85, respectively; mean+/-SD age, 88.8+/-3.6 and 65.8+/-13.3 years, respectively). The incidence of first-ever stroke was 1.64/1000 per year in the Martinique population and 18.2/1000 per year in patients aged >or=85 years. Elderly patients showed a significantly lower proportion of diabetes (19.1% versus 32.2%; P=0.012) and smoking (0% versus 8.4%; P=0.004) and a higher proportion of peripheral artery disease (23.4% versus 11.4%; P=0.002). Prevalence of hypertension was identical in the 2 groups (70%). There were no significant differences in stroke types or ischemic stroke subtypes between the 2 groups. Active medical care was poorer in older than in younger patients (hospitalization rate, 89% versus 94.4%; admission to neurological ward, 8% versus 23.8%; rate of performance of a CT scan, 82% versus 94%). The 30-day case fatality rate was approximately twice as high in elderly patients (31% versus 16.7%; P=0.0009), and disability (Rankin Scale score >or=3) in survivors was markedly higher (78% versus 48%; P<0.0001).

CONCLUSIONS

In Martinique, the incidence of first-ever stroke in very old black Caribbean patients seems similar to that in white patients. They have the same pathological type and subtype of stroke as do young patients. The poorer stroke outcome found in the elderly during the first month may be related in large part to less active management than in younger patients.

[Neutropenia in a patient treated with clozapine in combination with other psychotropic drugs]

Clozapine is an atypical antipsychotic known for its efficacy in refractory schizophrenia. However, according to different epidemiological studies clozapine can induce neutropenia in less than 3% of patients and may represent a major problem for the management of treatment-resistant patients not responding to conventional or other atypical antipsychotics. Recently, a few case of neutropenia have been reported following the addition of other medications to clozapine, notably paroxetine, risperidone, trimethoprim-sulfamethoxazole and erythromycin. In our report we present the case of Mr A., a 40-year-old Caucasian patient with a 20-year history of paranoid schizophrenia. After numerous trials with conventional antipsychotics, partial remission of psychotic symptoms was obtained with clozapine. Over the past eight years during his treatment with clozapine, the patient presented 2 episodes of neutropenia. The first episode came five years after starting clozapine and was attributed to the addition 6 weeks earlier of haloperidol (2 mg/day) to clozapine (250 mg/day) and divalproex (1,500 mg/day). Recently, one week after the addition of risperidone (2 mg/day) to clozapine (550 mg/day), leukocytes count dropped from 12 100/mm(3) to 5 700/mm(3) and neutrophils from 7 400/mm(3) to 900/mm(3). The patient was also taking haloperidol (4 mg/day), methotrimeprazine (35 mg/day), procyclidine (5 mg/day) and valproic acid (1,500 mg/day). Twelve days after discontinuation of risperidone, leukocytes and neutrophils count increased to 11,100/mm(3) and 6,300/mm(3) respectively while the treatment with clozapine was continued. The first eighteen weeks of treatment represent the period where the risk of neutropenia is the highest. In our patient neutropenia occurred 5 and 7 years after starting clozapine. It is proposed that the two neutropenic episode were precipitated by adding respectively haloperidol and risperidone to clozapine. Also, divalproex can potentially cause a decrease in white blood cell count and may have contributed to the two neutropenic episode. It is suggested that drug interactions may be responsible for neutropenia in clozapine treated patients and that clozapine should not necessarily be discontinued in the presence of neutropenia. Also we propose that hematological surveillance should be done on a weekly basis for 4 to 6 weeks following the addition of psychotropic drugs known for their potential to cause neutropenia when associated with clozapine. Therefore polypharmacy may contribute to cause neutropenia in clozapine treated patients and that discontinuation of an antipsychotic should be done before introducing another one.

[The concept of frontotemporal lobar degeneration]

Consensus criteria have been recently proposed to improve clinical identification of frontotemporal dementia, non fluent progressive aphasia and semantic dementia (Neary et al., 1998). However, clinical observations show that these syndromes may overlap, underlying the value of the more generic entity of frontotemporal lobar degeneration.

[Inflammatory optic neuropathy and multiple sclerosis]

The diagnosis of inflammatory optic neuritis remains essentially clinical, and may be improved by complementary investigations. The prognosis is related to the evolution of visual acuity and the risk of development of multiple sclerosis. The treatment of acute episodes is better precised but remains a matter of debate. Long term treatment has benefited from the results of recent MRI studies.

[Acute optic neuritis: clinical and MRI prognostic factors. Study of fifty patients]

The objective of this study was to evaluate the risk of visual outcome after acute optic neuritis (ON) in relation to clinical and MRI findings. Fifty cases of acute ON within one month were retrospectively studied. MRI with Short Tau Inversion Recovery (STIR) sequence of the optic nerve were obtained with a median time onset of 9 days after ON. Mean age of patients was 32.8 years, mean initial visual acuity was 3/10 and orbital pain was present in 86 percent100 of patients. The STIR sequence revealed lesion in 88 percent 100 of acutely symptomatic optic nerves. An initial low visual acuity (less than 2/10), the absence of orbital pain and involvement of the intracanalicular portion of the optic nerve on STIR sequence were statistically correlated with a poorer visual outcome (respectively p=0.0041, p=0.035 and p=0.011).

[Spinal cord infections]

Although infectious myelopathies are rare, appropriate aetiological diagnosis is of crucial importance to improve outcome. Lyme disease causes a myelomeningoradiculitis during the second stages and a progressive encephalomyelitis during the third stage. Serum and cerebrospinal fluid antibody tests are the basis of diagnosis. Myelopathy usually responds to treatment with ceftriaxone or doxycycline. Vacuole myelopathy occurs in patients with human immunodeficiency virus infection. It is characterised by a progressive spastic and ataxic paraparesis. About half of patients have symptoms of dementia. No specific treatment is available. Human T-cell lymphotropic virus type I is endemic in tropical areas and particularly in French West Indies. It causes a chronic spastic paraparesis with sexual and bladder dysfunction. Diagnosis depends on the positive antibody response in both serum and cerebrospinal fluid, and on the exclusion of other causes of spinal cord disease. There is no specific treatment.

Magnetic resonance imaging using FLAIR pulse sequence in white matter diseases

Fifty six patients among whom 39 had white matter diseases had MRI of the brain comparing FLAIR sequence to a conventional proton density sequence. Flair sequence allowed to detect 18 additional hypersignal (HS) that were not present on T2 sequence. These HS were located in the periventricular areas for 5 of them, near the cortical sulci in 10, and in the centrum semi-ovale for 3. FLAIR sequence permitted analyze 41 other lesions that were not obvious on proton density sequences. Thirty five of them were thus confirmed to be HS : 31 in the paracortical areas, 3 in the paraventricular regions and one in the internal capsule, whereas the remaining 6 were normal sulci of the brain. FLAIR sequence increases the sensitivity of MRI in white matter diseases.