Autosomal-dominant myopia associated to a novel P4HA2 missense variant and defective collagen hydroxylation

We recently described a complex multisystem syndrome in which mild-moderate myopia segregated as an independent trait. A plethora of genes has been related to sporadic and familial myopia. More recently, in Chinese patients severe myopia (MYP25, OMIM:617238) has been linked to mutations in P4HA2 gene. Seven family members complaining of reduced distance vision especially at dusk underwent complete ophthalmological examination. Whole-exome sequencing was performed to identify the gene responsible for myopia in the pedigree. Moderate myopia was diagnosed in the family which was associated to the novel missense variant c.1147A > G p.(Lys383Glu) in the prolyl 4-hydroxylase,alpha-polypeptide 2 (P4HA2) gene, which catalyzes the formation of 4-hydroxyproline residues in the collagen strands. In vitro studies demonstrated P4HA2 mRNA and protein reduced expression level as well as decreased collagen hydroxylation and deposition in mutated fibroblast primary cultures compared to healthy cell lines. This study suggests that P4HA2 mutations may lead to myopic axial elongation of eyeball as a consequence of quantitative and structural alterations of collagen. This is the first confirmatory study which associates a novel dominant missense variant in P4HA2 with myopia in Caucasian patients. Further studies in larger cohorts are advisable to fully clarify genotype-phenotype correlations.

Autonomic neuropathy in mixed cryoglobulinemia

A retrospective, cross-sectional study was performed on a series of HCV-related mixed cryoglobulinemia (HCV-MC) patients to assess autonomic neuropathy (AN) and its relation to peripheral neuropathy (PN). Thirty consecutive patients affected by HCV-MC underwent clinical, neurological and electrodiagnostic examinations. Autonomic nervous system (ANS) involvement was assessed by functional cardiovascular tests and sympathetic skin response (SSR) evaluation. Sural nerve biopsy was performed in 10 patients with PN. All patients received steroids, 15 also received recombinant interferon-alpha2b (RIfn-alpha2b). PN occurred in 27 patients (90.0%) and AN in 4 (13.3 %) all with signs of PN. SSR was the autonomic test more frequently altered. Biopsy disclosed axonal degeneration more evident in the 4 patients with AN. Three out of 4 patients with AN received steroids and rIFN-alpha2b and 1 steroids alone. In our study on HCV-MC, it was concluded that AN can occur also without dysautonomic symptoms, SSR appears to be one of the optional tests to use together with dysautonomic tests to identify AN and finally PN and AN do not seem to be positively influenced by addition of rIFN-alpha2b to steroid treatment.

Primary cerebral toxoplasmosis: a rare case of ventriculitis and hydrocephalus in AIDS

We describe the clinical, radiological and neuropathological findings in an adult AIDS patient presenting with ventriculitis and hydrocephalus as the primary manifestations of cerebral toxoplasmosis. Clinical symptoms including fever, headache, changes in mental status and focal neurological deficits were non-specific. Cranial computed tomography showed a subtile ventricular dilatation whereas magnetic resonance imaging disclosed triventricular hydrocephalus due to stenosis of the aqueduct and a periventricular nodular rim of high signal intensity on T2- and proton density-weighted images. This rim also showed a slight enhancement on post-contrast T1-weighted images. Focal intracerebral lesions could not be delineated, neither by neuroimaging nor by pathology. Neuropathological examination showed severe ventriculitis with large ependymal and subependymal necrosis as well as dilatation of the lateral and the third ventricle. The only microorganism demonstrated at histology in the central nervous system was Toxoplasma gondii. We conclude that ventriculitis and hydrocephalus without any focal parenchymal lesion may be the only manifestations of CNS toxoplasmosis. It is important to recognize this unusual form of presentation of cerebral toxoplasmosis in order to perform specific therapy.

Peripheral nervous system involvement in Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is a rare congenital malformation of unknown etiology characterized by cutaneous hemangiomas, venous varicosities and bony and soft tissues hypertrophy usually affecting one limb. Several complex anomalies involving various organs and systems have been described, whereas involvement of the peripheral nervous system has rarely been reported in KTS. We describe the case of a 67-year-old woman with KTS and peripheral neuropathy related to the presence of epineurial microscopic arteriovenous anastomoses (AVA) and endoneurial vascular coils in sural nerve biopsy from both hypertrophic and non-hypertrophic limb. The maintenance of AVA has been proposed to be the cause of the hypertrophy. The observation in our patient of AVA in non-hypertrophic limb contrasts with this hypothesis.

Chordomas: a histological and immunohistochemical study of cases with and without recurrent tumors

Chordomas are rare, slow-growing and often recurrent neoplasms being composed of various cell types (physaliferous, epitheloid, chondroid), thus, showing a wide range of histological features. To study the relationship between histological and immunohistochemical pattern and biological behavior according to different cell types, the authors studied 33 specimens of 17 patients with and without recurrent tumors. Additionally, the histological features according to nuclear atypia and mitotic activity of both groups were analyzed and compared with each other. Predominance of one cell type was observed in 19 specimens (10 were composed mainly of physaliferous, 8 of the epitheloid and one of chondroid cell type). In 7 cases, areas of chondroid differentiation were present. MIB proliferation index tended not to be higher in recurrent tumors but in cases with nuclear atypia and nuclear pleomorphism seems to be predictive for recurrency. Immunohistochemically, nearly all cell types (physaliferous, epithelial-like and cells of chondroid differentiation) of both recurrent and non recurrent chordomas stained positive for epithel membrane antigen (EMA), cytokeratins (KL1, AE1/AE3), S100, vimentin and negative for HMB45 and desmin. Positive staining for NSE was observed in 70% of cases, however, the chondroid componente stained negative in every case.

[Peripheral nervous system involvement in HCV-related mixed cryoglobulinemia]

In HCV-related mixed cryoglobulinemia (MC) a peripheral neuropathy (PN) may occur. To evaluate the prevalence and the characteristics of PN, 133 consecutive patients with HCV-MC (117 type II, 16 type III) were studied. Neurologic evaluation was performed according to the guidelines of Italian Group for the Study of Cryoglobulinemias, using a neurological disability score and a neurological symptom score. In 52/133 patients an electrophysiologic study (ENG) of ulnar, peroneal and sural nerves was performed. For 27/52 patients ENG data registered at different times (interval 12-96 months) were available. In 11 patients a sural nerve biopsy was obtained. An overt PN, mostly as sensory asymmetrical or symmetrical nerve impairment, was found in 107/133 patients (80.4%). ENG abnormalities-reduction or absence of sensory and sometimes of motor action potential, normal or slightly impaired nerve conduction velocity, consistent with axonal damage- were detected in 48/52 patients (92.3%). In 26 out of the 27 patients observed at different times an evolution of PN was found. Nerve biopsies showed a prevalent axonal damage, swollen endothelial cells in epi- and perineurial vessels and scarce mononuclear perivascular infiltrates. No leukocytoclastic vasculitis was observed. Immunoglobulins and complement in sub-perineurial vessel wall were detected. CONCLUSIONS: In HCV-MC a PN is frequent. It is mostly a sensory and progressively worsening axonopathy. Different mechanisms may be involved in the pathogenesis of this disorder and a direct role of HCV cannot be excluded.

European surveillance on Creutzfeldt-Jakob disease: a case-control study for medical risk factors

Medical risk factors for Creutzfeldt-Jakob disease (CJD) were analyzed in a prospective ongoing case-control study based on European CJD surveillance. Detailed data on past and recent medical history were analyzed in 405 cases and controls matched by sex, age, and hospital. Data were correlated with polymorphism at codon 129 of the prion protein gene. Our analysis did not support a number of previously reported associations and failed to identify any common medical risk factor for CJD. Although not statistically significant, brain surgery was associated with an increased risk of CJD. A detailed medical history should be obtained in every suspected CJD case in order to identify iatrogenic sources of CJD.

A new de novo mutation of the connexin-32 gene in a patient with X-linked Charcot-Marie-Tooth type 1 disease

We report a 26-year-old Italian man with X-linked Charcot-Marie-Tooth (CMT) disease type 1 (CMT-X1) and a negative family history for neuromuscular diseases. Clinical and electrophysiological examinations of the patient's mother and siblings were normal. Molecular analysis by polymerase chain reaction--single-strand conformation polymorphism (PCR-SSCP) on genomic DNA from the patient and all members of his family revealed a C-to-T transition in codon 8 of exon 2 of the connexin-32 (Cx32) gene on the X chromosome only in the patient. This transition in the 5'-coding region, resulting in a Thr-Ile substitution, is likely to be the cause of CMT phenotype in our patient, and it represents a new de novo mutation of the Cx32 gene.

Lack of sodium channel mutation in an Italian family with paramyotonia congenita

OBJECTIVE

To conduct the genotype-phenotype correlation in a family in which several individuals share clinical and electrophysiologic features of paramyotonia congenita (PC).

BACKGROUND

PC, hyperkalemic periodic paralysis (HyperPP), and potassium-aggravated myotonias form the group of hereditary sodium channelopathies. Each of these disorders is associated with different point mutations in SCN4A, the gene encoding the alpha-subunit of the adult human skeletal muscle sodium channel. However, in HyperPP families, evidence of a causative gene different from SCN4A has been found.

METHODS

We conducted direct clinical examination, electrophysiologic (EMG/electroneurographic) and cardiologic studies, as well as laboratory screening in several affected and nonaffected members of the family. We performed the genotype-phenotype correlation by microsatellite linkage and cDNA-mutation analyses of the SCN4A gene.

RESULTS

Affected members in this family showed clinical and electrophysiologic features typical of PC. The disease phenotype segregated with the chromosomal region that includes the SCN4A gene. Analysis of the entire cDNA sequence of the SCN4A gene in the index case disclosed a G3826A transition, which results in the Val1276Ile substitution. However, PCR-single-stranded confirmation polymorphism and direct sequencing analysis of the segment coding for Val-1276 on genomic DNA confirmed the G3826A transition in the index case but was negative in 11 affected members of the family; however, neither mutations nor aberrant splicings causative of the PC phenotype in this family were found on SCN4A.

CONCLUSION

The existence of a second gene different from SCN4A that can give rise to a clinical PC phenotype can be speculated upon.

Heart mitochondria in rats submitted to chronic hypoxia

The effect of prolonged exposure to normobaric hypoxia on the mitochondria of myocard of rats exposed for several weeks to 8 and 7% O2 has been morphometrically evaluated. Twelve male Wistar rats housed in Nalgene cages (2 per cage) with a batch of six cages placed in plexiglass chambers were maintained in air/N2 mixtures containing different concentrations of O2. Six animals kept in similar cages under normoxia served as controls. When at day 60 the FIO2 was reduced to 8%, the weight increase stagnated and after the 81st test day, on which the hypoxic animals were subdivided into 8% and 7% groups the weight curve showed a decrease in the mean body weight for both groups. The arrest and the following loss of weight beyond the 85th day may be interpreted as the expression of a limit reached in the compensation capacity. In the 8%-group the shape of the mitochondria varied more markedly often with budding and furrowing of the surface. In the 7%-group bizarre shapes and wide variations in size with a decided shift towards larger mitochondria were noteworthy. While rats kept under 8% oxygen exhibited a numerical increase in myocardial mitochondria compared to controls, the mitochondria of the 7%-group were numerically reduced. The results suggest that hypoxia of 8% oxygen is compensatable, if only to some extent, by an increasing surface of mitochondrial membranes, and that further reduction of oxygen causes compensation mechanisms to fail as seen by the severe alterations of the mitochondrial population of the cardiomyocyte in the 7%-group.

Identification and characterization of a novel member of the dystrobrevin gene family

A new member of the dystrobrevin gene family was identified using a bioinformatics approach. Sequence analysis indicates that this gene, named DTN-B, is highly homologous to the rabbit A0, the previously described dystrobrevin (DTN), Torpedo 87 kDa and to the C-terminus of dystrophin. The coiled-coil domain, shown to be the site of interaction between dystrobrevins and dystrophin, is highly conserved. Immunostaining studies indicate that DTN-B and DTN expression is absent in affected muscle fibers from DMD patients and carriers.

Cerebral angiogenesis triggered by severe chronic hypoxia displays regional differences

The blood vessels in the brains of adult rats subjected to chronic normobaric hypoxia and control animals housed under normoxic conditions were morphometrically studied. Hypoxic male inbred Wistar rats were exposed over a period of 130 days to decreasing amounts of oxygen starting from 21% down to 7% (15%: 15 days; 12%, 10%, 8%: 22 days, respectively; 7%: 49 days). Areas of cerebral cortex, striatum, hippocampus, cerebellum, and medulla oblongata were investigated. The ratio vessel number per mm2 tissue and the average vessel size were measured using a Quantimet Q570. In the hypoxic animals, cerebral cortex, striatum, and hippocampus showed a significant increase of the vessel density per mm2 tissue (P < 0.01 or P < 0.05). The differences in both groups were highest in the striatum and hippocampus. In the cerebellum and the medulla oblongata of hypoxic animals, only a tendency to higher vessel numbers per mm2 tissue was found. The average blood vessel size differed only in the cerebral cortex and the cerebellum, but not in the other brain regions tested. The results indicate that the adaptation of the brain circulation to hypoxia is achieved by both angiogenesis and dilatation of microvessels, and that the pattern of the microcirculatory changes is not homogenous in all regions.

Phenolic and tyrosyl ring iodothyronine deiodination and thyroid hormone concentrations in the human central nervous system

In the present study we investigated the biochemical properties of in vitro phenolic (5'D) and tyrosyl (5D) ring deiodination and the tissue concentrations of T4, T3, and rT3 in adult human central nervous system (CNS) tissue. All samples were obtained from nontumoral tissue at autopsy (n = 6) or neurosurgical operation (n = 5). Both phenolic and tyrosyl ring deiodinase activities were demonstrable in all samples obtained intraoperatively, whereas only tyrosyl ring deiodination was evident in the tissues obtained postmortem. The phenolic ring deiodination pathway corresponded to the type II 5'-deiodinase isoenzyme with regard to its high affinity for T4 and rT3 (Km = 2.2 and 2.4 nmol/L, respectively), its insensitivity to 6-propyl-n-2-thiouracil (PTU), and the sequential reaction mechanism. No PTU-sensitive 5'-deiodination of rT3 was demonstrable. Tyrosyl ring deiodination of both T4 and T3 showed typical type III 5D kinetics (Ka, 6.5 nmol/L for T4 and 3.4 nmol/L for T3) and was PTU insensitive. Nanomolar concentrations of tissue T4, T3, and rT3 were detected in samples obtained both intraoperatively and postmortem. They were very similar to the absolute values of the apparent Km for T4, T3, and rT3 in the phenolic and tyrosyl ring deiodination pathways. In conclusion, we have demonstrated the coexistence of both phenolic and tyrosyl ring deiodinase activities in the human CNS. Their kinetic characteristics, substrate specificity, and reaction mechanisms are very similar to the corresponding type II 5'- and type III 5-iodothyronine deiodinase activities in rat brain. In contrast to the findings in the rat CNS, no PTU-sensitive phenolic ring deiodinase (i.e. type I 5'D) activity was found in the human CNS. This may explain the relatively high tissue concentrations of rT3.

Familial amyloidotic polyneuropathy: description of an Italian kindred

Familial amyloidotic polyneuropathy (FAP) is a heterogeneous group of genetic disorders characterized by progressive systemic deposition of extracellular amyloid fibrils, mainly affecting the peripheral nervous system (PNS). These disorders, inherited as an autosomal dominant trait, have frequently been described in various ethnic groups, but have rarely been reported in Italy. A 42 year-old man came to our observation for loss of pain and temperature sense in his legs. Clinical and laboratory data pointed to an amyloidotic polyneuropathy. This led us to discover a large italian kindred in which 19 members were affected by FAP. The diagnosis, established in 8 members on the clinical and laboratory findings, was ana-catamnestic in other 11. In this kindred the onset of the disease ranges from 35 to 50 years of age and the course is progressive and often fatal. The early symptoms are mainly related to autonomic disturbances and to peripheral neuropathy. Cardiac and renal involvement occurs frequently and may be life-threatening.

Pathological changes in organs of rats chronically exposed to hypoxia. Development of pulmonary lipidosis

Rats were exposed to chronic normobaric hypoxia of progressively increasing severity; down to 8% or 7% oxygen concentrations. In addition to loss of weight, pathology revealed congestion, haemorrhages, hypertrophy of the heart involving mainly the right ventricle, thickening of arteries, ischaemic changes in the myocardium and extramedullary haematopoiesis in the spleen. Changes not described up until now were: 1) sheets of foam cells in the pulmonary alveoli; 2) foamy and solid storing cells in the spleen; 3) mucoid changes in the atrioventricular valve leaflets; 4) hyperplasia of the juxtaglomerular apparatus; 5) atrophy of the adrenal glomerulosa and hyperplasia of medulla; 6) atrophy of the perifollicular B-cell zone in the spleen; and 7) lipid pigment deposition in various organs. The findings indicate that severe chronic hypoxia induces a significant pulmonary lipidosis similar to that caused by amphiphilic cationic drugs, presumably by inhibiting hydrolytic enzyme activities. The observations are of importance in human hypoxic conditions and open the possibility of their rational treatment.

Morphometrical evaluation of triflusal in brain infarction

MCA occlusion in animals is a common model for experimental stroke. In previous studies we have shown that one of the factors, which influence evolution of an infarct is microthrombosis in the area of infarction and in the surrounding brain tissue. The present study was undertaken for assessment of the number of microthrombi and of the size of brain infarcting in rats treated with the antiaggregatory substance Triflusal. 7 groups of Sprague-Dawley rats, each group consisting of 6 animals, underwent transsphenoidal MCA occlusion. The animals received Triflusal in various amounts from day 2 till day 6. At day 7 animals were decapitated and the brains were fixed in formaldehyde. The brain was dissected at the level of the optic chiasm and embedded in paraffin. Fresh microthrombi were detected py PTAH (Phosphotungstic acid hematoxylin) staining. In each animal the hemisphere with the ischemic lesion as well as the contralateral hemisphere were examined. The area of both hemispheres was calculated by subtraction of the ventricle area from the total brain area of a section. Infarct was defined as the region of necrosis which was sharply demarcated from normal brain. The infarcted area was planimetrically measured to obtain a ratio of infarcted to normal brain. A correlation between the effect of Triflusal, number of microthrombi and size of the infarcted area could be demonstrated. The pathogenetic role of the microthrombi in the evolution of cerebral infarction as well as the effect of Triflusal in different dosages on the number of microthrombi could be clearly assessed by quantitative morphometry.

Blood-brain barrier permeability to micromolecules and edema formation in the early phase of incomplete continuous ischemia

The distribution patterns of ionic Lanthanum (La3+; mol. wt. 139) were evaluated after 15, 30 and 60 min of middle cerebral artery occlusion in perfused-fixed rats. Blood-brain barrier (BBB) permeability to Evans blue (EB) and horseradish peroxidase (HRP; mol. wt. 40,000) in vivo was also evaluated. Brain tissue specific gravity was measured. An increase in brain water content was found as early as 30 min following occlusion. HRP and EB extravasation was not observed. La3+ crossed the interendothelial clefts of venules and capillaries at 30 and 60 min and was seen in both extracellular and intracellular brain compartments at 60 min. La3+ extravasation was seen in nonedematous areas bordering the regions of water accumulation. Our findings suggest that the early phase of incomplete continuous ischemia is accompanied by changes in BBB permeability and the interendothelial clefts of venules and capillaries seem to represent one of the early sites of ischemic damage.

Brain changes in experimental chronic hypoxia

A model of normobaric hypoxia was developed in which adult female cats were exposed to decreasing amounts of oxygen (21, 15, 10, 8, 7, and 5 vol.%) over a period of 320 days. Blood flow as well as the blood flow responses to changes of pCO2 were depressed in both cerebrum and cerebellum. These decreases were more severe in the cerebellum. The metabolic rate for oxygen was also depressed. A decrease in the Purkinje cell number was evident. A different degree of damage was observed in the top, the intermediate and the bottom region of the cerebellar gyri. Microvascular proliferation occurred in the whole brain.

Altered glial fibrillary acidic protein immunoreactivity in rat brain following chronic hypoxia

Glial fibrillary acidic immunoreactivity in brain was examined in normal animals and in rats subjected to chronic hypoxia. Animals were exposed to a chronic normobaric adaptive hypoxia with decreasing amounts of oxygen (finally 6%) for a period of 59 and 114 days, respectively. In paraffin-embedded sections the glial fibrillary acidic protein immunoreactivity in normal and hypoxic animals was examined at three coronal levels. A mild glial fibrillary acidic protein immunoreactivity in the perivascular glial layer, external glial limitans membrane and periventricular astrocytes, as well as in some areas of hippocampus and cerebellum, was noted in normal animals. Chronic hypoxia for 114 days resulted in a marked increase of glial fibrillary acidic protein immunoreactivity in dentate gyrus of hippocampus, Bergmann glia of the cerebellum, internal capsule and pyramidal tract. On the other hand, the glial fibrillary acidic protein activity following 59 days hypoxic exposure was almost the same as controls. These results show that systemic deep chronic hypoxia (depending on the intensity and the duration) activates the endogenous expression of glial fibrillary acidic protein in astrocytes of specific brain regions. The probable significance of this finding is discussed.

Paramedian hourglass epidermoid extending above and below the tentorium

The case of a 22-year-old woman with a large hourglass epidermoid tumor extending both below and above the tentorium is presented. The tumor was located in the suprasellar region, left middle cranial fossa, and posterior fossa on the left side. Conventional computerized tomographic (CT) scanning was inconclusive as to the actual extension of the tumor, whereas air encephalography was more helpful. The subtemporal transtentorial approach made it possible to achieve a seemingly radical excision of the tumor. Nevertheless, the CT scan one year later showed the presence of a small tumor mass. The diagnostic and surgical implications are discussed in light of few similar cases reported in the literature.

Neuroradiological findings in multiloculated hydrocephalus

The characteristic neuroradiological features of multiloculated hydrocephalus following neonatal meningitis and ventriculitis in five infants are presented. The role of ventriculography and computerized tomography in detecting multiloculated and enlarged ventricles and paraventricular cavities, as well as complete and incomplete septa, is emphasized for early diagnosis and surgical management. CT scan also provides clues indicating the presence of thin but not visualized septa. It is suggested that post-meningitic hydrocephalus should be repeatedly followed-up for detection of multiloculated transformation. Probably this entity occurs less uncommonly than was thought in the past. The CT scan appears the most helpful and safe procedure for the serial evaluation, but ventriculography may be usefully combined with it in order to plan the most suitable operative approach for fenestration of membranes.

Multiloculated hydrocephalus in infants

The clinical features and the neuroradiological appearance of multiloculated hydrocephalus that followed meningitis and ventriculitis in five newborn infants are presented. Several factors probably involved in the pathogenesis are discussed. Computed tomography is particularly helpful in the recognition of this entity and in the evaluation of its course. However, ventriculograms are advised to document the communication of the septated cavities. Of four infants treated by ventriculoatrial shunting, two died and two are mentally and neurologically disabled. Another infant, who underwent craniotomy and fenestration of the ventricular membranes, died accidentally 3 months after operation. In light of similar cases reported in the literature, the prognosis seems very poor. Craniotomy with fenestration of the ventricular septa seems a promising procedure, although further supportive evidence is needed.