Concordance rate between oligoclonal bands and the Kappa index in patients with suspected multiple sclerosis (MS)

BACKGROUND

 Oligoclonal bands (OCBs) and Kappa free light chains (FLCs) in the cerebrospinal fluid (CSF) are sensitive markers of intrathecal immunoglobulin (Ig)G synthesis in patients with multiple sclerosis.

OBJECTIVE

 To evaluate the concordance rate between OCBCs and the Kappa index (KI) in patients with suspected multiple sclerosis (MS).

METHODS

 Patients with suspected MS were referred to a specialized CSF laboratory as part of their diagnostic investigation. Paired CSF and serum samples were collected and submitted to detection of OCBs and determination of the KI. Positive and negative results were determined with both methods, and the percentage of agreement between them was established.

RESULTS

 In total, 171 serum and CSF samples from 171 patients were included in the analysis. The mean age of the patients was of 40 ± 14.2 years; 18.9% of them were male, and 81.1% were female. The OCBs and KI presented concordant results in 161 (94.2%) samples: in 74 (43.3%), both were positive, and in 87 (50.9%), both were negative. In 10 cases, the results were discrepant: KI positive/OCB negative in 8 and OCB positive/KI negative in 2 cases.

CONCLUSION

 The KI and OCBs presented high concordance level. Currently, the detection of OCBs in the CSF is the standard method for MS diagnosis, but it is time-consuming, and its visual interpretation can be difficult. The results suggest that the KI is a good alternative for the detection of intrathecal immunoproduction in cases of suspected MS.

Evaluation of enterovirus concentration, species identification, and cerebrospinal fluid parameters in patients of different ages with aseptic meningitis in São Paulo, Brazil

Human enteroviruses (EV) are the most common cause of aseptic meningitis worldwide. Data on EV viral load in cerebrospinal fluid (CSF) and related epidemiological studies are scarce in Brazil. This study investigated the influence of EV viral load on CSF parameters, as well as identifying the involved species. CSF samples were collected in 2018-2019 from 140 individuals at The Hospital das Clínicas, São Paulo. The EV viral load was determined using real-time quantitative polymerase chain reaction, while EV species were identified by 5'UTR region sequencing. Median viral load was 5.72 log10  copies/mL and did not differ by subjects' age and EV species. Pleocytosis was observed in 94.3% of cases, with the highest white blood cell (WBC) counts in younger individuals. Viral load and WBC count were correlated in children (p = 0.0172). Elevated lactate levels were observed in 60% of cases and correlated with the viral load in preteen-teenagers (p = 0.0120) and adults (p = 0.0184). Most individuals had normal total protein levels (70.7%), with higher in preteen-teenagers and adults (p < 0.0001). By sequencing, 8.2% were identified as EV species A and 91.8% as species B. Age-specific variations in CSF characteristics suggest distinct inflammatory responses in each group.

Cerebrospinal fluid analysis in patients with COVID-19-associated central nervous system manifestations: a systematic review

ABSTRACT Background: Central nervous system (CNS) symptoms may occur in patients with acute COVID-19. The role of CSF examination in these patients remains to be established. Objective: A systematic review of CSF findings relating to COVID-19 was carried out. Methods: CSF parameters, including cytological and biochemical analyses, SARS-CoV-2 RT-PCR and other CSF markers, were recorded and analyzed among patients with acute COVID-19 and one of the following CNS syndromes: stroke, encephalopathy, encephalitis, inflammatory syndromes, seizure, headache and meningitis. Results: Increased white blood cells and/or increased protein concentration were found in 52.7% of the patients with encephalitis, 29.4% of the patients with encephalopathy and 46.7% of the patients with inflammatory syndromes (P < 0.05). CSF RT-PCR for SARS-CoV-2 was positive in 17.35% of the patients with encephalitis and less than 3.5% of the patients with encephalopathy or inflammatory syndromes (P < 0.05). Intrathecal production of immunoglobulins was found in only 8% of the cases. More than 85% of the patients had increased CSF cytokines and chemokines. Increased CSF neurofilament light chain (NfL) and CSF Tau were found in 71% and 36% of the cases, respectively. Conclusion: Non-specific inflammatory CSF abnormalities were frequently found in patients with COVID-19 CNS syndromes. The increase in neurodegeneration biomarkers suggests that neuronal damage occurs, with long-term consequences that are still unknown.

Evaluation of the Utilization of FilmArray Meningitis/Encephalitis in Children With Suspected Central Nervous System Infection: A Retrospective Case Series

BACKGROUND

The etiology of central nervous system infections is often difficult to establish. FilmArray meningitis/encephalitis (ME) panel is a multiplex polymerase chain reaction for rapid identification of 14 pathogens. The aim of this study was to evaluate potential real-life contributions of the use of this method in the pediatric population.

METHODS

We herein report the results obtained with FilmArray ME in a retrospective case series of 367 children with suspected central nervous system infection. We identified viral and bacterial agents by FilmArray, and we evaluated the potential diagnostic contributions of the use of the panel taking into account the cytological, biochemical, and microbiological results of the cerebrospinal fluid (CSF) analysis.

RESULTS

The FilmArray ME panel detected a viral infection in 186 cases (50.7%) and a bacterial infection in 12 cases (3.3%). Fifty-three cases (28.4%) of viral infection had at least 1 CSF finding that could be mistaken for bacterial meningitis. Enterovirus was identified in 2 cases with normal CSF findings. Among 12 bacterial infection cases, only 6 (50%) had a positive result with conventional microbiology analysis (Gram stain and culture). The CSF findings suggestive of bacterial meningitis were found in all 6 cases in which FilmArray was the only method to identify bacterial etiological agent.

CONCLUSIONS

FilmArray ME panel identified an etiological agent in cases in which conventional CSF analysis failed, providing potential clinical contributions to the management of such cases.

Cerebrospinal fluid findings in patients with hematologic neoplasms and meningeal infiltration

Neoplastic cell infiltration into the central nervous system (CNS) is a serious complication of hematological neoplasms. Cytomorphology (CM) and flow cytometry (FC) have been used to detect meningeal infiltration. The association between CSF findings with the results of CM and FC is still poorly understood. We retrospectively evaluated CSF findings in 72 patients with hematological neoplasm and meningeal infiltration detected either by CM or FC. We compared CSF cell count, total protein concentration, and lactate concentration according to the type of hematological neoplasm. We also compared these CSF findings according to the FC and CM results (FC + CM + , FC + CM-, and FC-CM +). The proportion of patients with positive FC was higher than with CM (FC - 91.7%; CM - 63.9%). Thirty-five (48.6%) patients with meningeal infiltration had normal CSF cell count, normal total protein concentration, and normal lactate concentration. The proportion of cases in which these CSF parameters were normal did not differ according to the type of hematological neoplasm. The positivity of CM was significantly higher in patients with > 3 cell/mm³ (P = 0.015) but the positivity of FC was not significantly different between patients with > 3 cell/mm³ or ≤ 3 cells/mm³. Patients with positive CM had more CSF cells (P = 0.0005) and higher lactate concentration (P = 0.0165) than patients with negative CM. The absence of CSF changes in cell count and total protein and lactate concentrations does not exclude the presence of meningeal infiltration. Although CM is considered the gold standard, the probability of positive CM is low in patients without CSF abnormalities in these parameters. Patients with hematological neoplasm with suspected meningeal infiltration should be investigated with both methods.

Cluster headache due to intranasal herpes simplex: a case report

Cluster headache is characterized by pain in the first division of trigeminal nerve along with autonomic features, with attacks last from 15 minutes to 180, up to eight times a day. Albeit considered as a primary headache, it may be mimicked by structural diseases like infections, inflammatory, tumoral and vascular. Intranasal and sinus infectious were also reported. Herpes simplex infections are quite common in the general population, and the nerve ganglia are the natural reservoir of the virus. Intranasal herpes, on the other hand, is exceedingly rare, with only few cases reported in the literature. Our main objective is to describe a case report of a 49-year-old male who was diagnosed with intranasal herpes infection during a bout of cluster headache, evaluated by an otolaryngologist. He got free of symptoms after using valacyclovir and melatonin. Thus, herpes simplex might be involved in the mechanisms of secondary or primary cluster headache.  Further research is necessary to help elucidate this relationship.

Telemedicine use among neurologists before and during COVID-19 pandemic

BACKGROUND

After the public health emergency due to COVID-19 was declared in Brazil, the federal government temporarily regulated and authorized the use of telemedicine services for patient consultation, monitoring, and diagnosis. For more than a decade, neurologists have recognized the benefits of telemedicine in the acute management of stroke patients. However, as the use of telemedicine was restricted until the COVID-19 pandemic, the view of Brazilian neurologists about telemedicine is unknown.

METHODS

All neurologists registered at the Brazilian Academy of Neurology were invited by e-mail to participate in a survey about personal perceptions on telemedicine use.

RESULTS

One hundred sixty-two neurologists from all regions of Brazil answered the online questionnaire. The survey showed that 18.5% of participants worked with telemedicine before the pandemic, while 63.6% reported working with telemedicine during the pandemic. The main telemedicine modalities used during the pandemic were teleorientation and teleconsultation.

DISCUSSION

According to our data, the COVID-19 pandemic deeply influenced the behavior of Brazilian neurologists, who developed a more favorable view about telemedicine and actively searched for information about telemedicine. As there is a need for more training in this area in Brazil, universities and medical societies must strive to improve telemedicine education. Expanding the use of high-quality teleneurology can contribute to a better care for patients with neurological diseases in Brazil.

Telemedicine in neurology: current evidence

BACKGROUND

Telemedicine was first introduced in Neurology as a tool to facilitate access to acute stroke treatment. More recently, evidence has emerged of the use of telemedicine in several other areas of Neurology. With the advent of the COVID-19 pandemic and the need for social isolation, Brazilian authorities have expanded the regulation of the use of telemedicine, thus allowing the treatment of many patients with neurological diseases to be conducted with less risk of SARS-CoV-2 contamination.

OBJECTIVE

This study aimed to critically review the current evidence of the use, efficacy, safety, and usefulness of telemedicine in Neurology.

METHODS

A review of PubMed indexed articles was carried out by searching for the terms "telemedicine AND": "headache", "multiple sclerosis", "vestibular disorders", "cerebrovascular diseases", "epilepsy", "neuromuscular diseases", "dementia", and "movement disorders". The more relevant studies in each of these areas were critically analyzed.

RESULTS

Several articles were found and analyzed in each of these areas of Neurology. The main described contributions of telemedicine in the diagnosis and treatment of such neurological conditions were presented, indicating a great potential of use of this type of assistance in all these fields.

CONCLUSION

Current evidence supports that teleneurology can be a tool to increase care for patients suffering from neurological diseases.

First case of SARS-COV-2 sequencing in cerebrospinal fluid of a patient with suspected demyelinating disease

The association between coronaviruses and central nervous system (CNS) demyelinating lesions has been previously shown. However, no case has been described of an association between the novel coronavirus (SARS-COV-2) and CNS demyelinating disease so far. SARS-COV-2 was previously detected in cerebrospinal fluid (CSF) sample of a patient with encephalitis. However, the virus identity was not confirmed by deep sequencing of SARS-COV-2 detected in the CSF. Here, we report a case of a patient with mild respiratory symptoms and neurological manifestations compatible with clinically isolated syndrome. The viral genome of SARS-COV-2 was detected and sequenced in CSF with 99.74-100% similarity between the patient virus and worldwide sequences. This report suggests a possible association of SARS-COV-2 infection with neurological symptoms of demyelinating disease, even in the absence of relevant upper respiratory tract infection signs.

Assessment of Work Productivity and Activity Impairment (WPAI) questionnaire for migraine with the help of a smartphone app

BACKGROUND

Migraine is a major cause of disability, which affects many areas of life, including productivity at work. Measuring absenteeism and presenteeism resulting from migraine with the use of appropriate tools is essential for better understanding the impact of this disease.

OBJECTIVE

The aim of the present study was to assess the work impact of migraine using the Brazilian Portuguese version of Work Productivity and Activity Impairment (WPAI) questionnaire.

METHODS

This survey was carried out with the aid of a smartphone app (Dr Cefaleia for Doctors) containing the questionnaires: ID-Migraine, Headache Impact Test (HIT-6), and WPAI. The data were collected during a headache awareness event. Correlations were assessed between migraine impact (HIT-6) with WPAI parameters: a) work time missed (absenteeism), b) impairment at work (presenteeism), c) overall work productivity loss (absenteeism+presenteeism), and d) activity impairment outside work.

RESULTS

Overall, 305 subjects with headache were interviewed and 167 were classified as having migraine. No significant differences in migraine impact according to sex (p=0.8) and modality of work were registered (p=0.8). Females had significantly higher absenteeism score (p<0.001), but presenteeism score was not significantly different between genders (p=0.3). WPAI absenteeism and presenteeism scores significantly correlated with migraine impact (HIT-6).

CONCLUSIONS

The results suggest WPAI Brazilian Portuguese version was efficient in assessing migraine related work impact. The use of an app with validated questionnaires facilitates the conduction of migraine impact research in different populations, allowing a better understanding of the burden of this disease.

Telemedicine in the Management of Primary Headaches: A Critical Review

Telemedicine is a modality of health care services delivery with the use of communication technologies. Its use has grown in several medicine areas. Several studies evaluated the feasibility, acceptance, efficacy, cost-effectiveness, and safety of telemedicine in the diagnosis and management of primary headache disorders. Videoconsultations were shown to be effective, convenient, and safe for primary headache disorders and migraine follow up. Some mobile health devices were show to improve adherence favoring better outcomes. Handling health data is a major concern so that international compliance standards must be adopted in all telemedicine procedures. The impact in the health system and increased access to appropriate primary headache treatments with the use of these technologies has yet to be elucidated.

FilmArray Meningitis/Encephalitis (ME) panel in the diagnosis of bacterial meningitis

The precise diagnosis of bacterial meningitis is essential. Cytological and biochemical examination of cerebrospinal fluid (CSF) are not specific. Conventional methods for bacterial meningitis lack sensitivity or take too long for a final result. Therefore, other methods for rapid and accurate diagnosis of central nervous system infections are required. FilmArray meningitis/encephalitis (ME) panel is a PCR multiplex for simultaneous and rapid identification of 14 pathogens, including 6 bacteria, 7 viruses, and Cryptococcus. We evaluated 436 CSF samples submitted to FilmArray ME Panel. Among them, 25 cases were positive for bacteria, being Streptococcus pneumonia the most frequent (48 %). Among positive cases for bacteria, 60 % were positive only with FilmArray. All the bacterial meningitis cases in which the only positive test was FilmArray had CSF findings suggestive of bacterial meningitis, including neutrophilic pleocytosis, increased CSF protein and lactate, and decreased CSF glucose. These findings suggest that FilmArray may increase the diagnostic sensitivity for bacterial meningitis.

Neurofilament light chain in the assessment of patients with multiple sclerosis

Multiple sclerosis (MS) is an autoimmune, inflammatory, and degenerative disease of the central nervous system. Axonal degeneration is triggered by inflammation and is the pathological substrate of progressive disability in patients with MS. Therapeutic interventions can reduce inflammatory activity, thus delaying neurodegeneration and the progression of disability. Disease activity and neurodegeneration are assessed mainly through clinical evaluation and magnetic resonance imaging. These measures lack sensitivity and accuracy, so new biomarkers are necessary. Several markers have been studied and to date the most promising is neurofilament light (NfL), a component of the axonal cytoskeleton, which is released into cerebrospinal fluid (CSF) following axonal damage. In the present study, we review the current knowledge about CSF NfL determination in MS, clinically isolated syndrome, and radiologically isolated syndrome, and critically discuss how CSF NfL measurement may contribute to therapeutic decision-making in these patients.

Performance of lactate in discriminating bacterial meningitis from enteroviral meningitis

The cytological and biochemical examination of cerebrospinal fluid (CSF) has been used for the presumed diagnosis of bacterial meningitis until the final microbiological results are achieved. We assessed the ability of CSF lactate in comparison with other CSF parameters to discriminate bacterial and enteroviral community acquired meningitis. We included 1,187 CSF samples of acute community-acquired meningitis, being 662 cases of bacterial and 525 of enteroviral meningitis. Lactate concentration (mg/dL), leukocyte count/mm³, protein (mg/dL), and glucose (mg/dL) were compared between bacterial and viral meningitis. Receiver operator characteristic (ROC) curves were used to assess diagnostic performance. CSF leukocytes, CSF protein and CSF lactate were significantly higher in bacterial meningitis cases (P<0.0001). CSF glucose was significantly lower in bacterial meningitis cases (P<0.0001). CSF lactate showed the best predictive ability with an area under the curve of 0.944 (95% CI 0.929 – 0.959). Considering a cut off of CSF lactate of 30 mg/dL, the sensitivity and specificity for bacterial meningitis were 84.1% and 99%, respectively. In the cytological and biochemical CSF analysis, CSF lactate was the most accurate marker for bacterial meningitis.

Coexistence of Sunct Syndrome and pituitary tumor: A possible association to be recognized

Case Report

The cerebrospinal fluid in multiple sclerosis: far beyond the bands

The cerebrospinal fluid analysis has been employed for supporting multiple sclerosis diagnosis and ruling out the differential diagnoses. The most classical findings reflect the inflammatory nature of the disease, including mild pleocytosis, mild protein increase, intrathecal synthesis of immunoglobulin G, and, most typically, the presence of oligoclonal bands. In recent years, new biomarkers have emerged in the context of multiple sclerosis. The search for new biomarkers reflect the need of a better evaluation of disease activity, disease progression, and treatment efficiency. A more refined evaluation of disease and therapy status can contribute to better therapeutic choices, particularly in escalation of therapies. This is very relevant taking into account the availability of a greater number of drugs for multiple sclerosis treatment in recent years. In this review, we critically evaluate the current literature regarding the most important cerebrospinal fluid biomarkers in multiple sclerosis. The determination of biomarkers levels, such as chemokine ligand 13, fetuin A, and mainly light neurofilament has shown promising results in the evaluation of this disease, providing information that along with clinical and neuroimaging data may contribute to better therapeutic decisions.

Postpartum Treatment With Immunoglobulin Does Not Prevent Relapses of Multiple Sclerosis in the Mother

Multiple sclerosis (MS) is a chronic, neurological, immune-mediated disease that can worsen in the postpartum period. There is no consensus on the use of immunoglobulin for prevention of disease relapses after delivery. We have shown that the controversial beneficial effect of immunoglobulin given immediately after birth could not be observed in patients with MS.

Nearly one-half of Brazilian patients with multiple sclerosis using natalizumab are DNA-JC virus positive

OBJECTIVE

Natalizumab is a new and efficient treatment for multiple sclerosis (MS). The risk of developing progressive multifocal leukoencephalopathy (PML) during the use of this drug has created the need for better comprehension of JC virus (JCV) infection. The objective of the present study was to assess the prevalence of JCV-DNA in Brazilian patients using natalizumab.

METHOD

Qualitative detection of the JCV in the serum was performed with real-time polymerase chain reaction (PCR).

RESULTS

In a group of 168 patients with MS who were undergoing treatment with natalizumab, JCV-DNA was detectable in 86 (51.2%) patients.

DISCUSSION

Data on JCV-DNA in Brazil add to the worldwide assessment of the prevalence of the JCV in MS patients requiring treatment with natalizumab.

Multiple sclerosis starting before the age of 18 years: the Brazilian experience

Multiple sclerosis (MS) starting in childhood and adolescence poses a challenge for diagnosis and management of the disease. The aim of the present study was to assess the characteristics of early onset MS in Brazilian patients. Methods Retrospective data collection from specialized MS units. Results From 20 MS units in 11 Brazilian states, 117 cases of MS starting before the age of 18 years were collected. These patients had an average of 10 years of disease duration, still typically with low disability and one relapse every 2.5 years. The mean age for disease onset was 13.7 years. Conclusion The present study introduces a large series of Brazilian cases of pediatric MS. Although some patients presented a very severe form of MS, on the whole the group of patients with MS starting in childhood or adolescence presented a relatively mild form of this disease in Brazil.

Viral encephalitis: current treatments and future perspectives

Several viruses may cause central nervous system infections that lead to a broad range of clinical manifestations. The course of the viral encephalitis can be acute, sub acute, or chronic. Some viruses have the ability to enter into the brain and cause direct injury, while others activate inflammatory cells that attack the central nervous system (CNS) secondarily. Some types of viral encephalitis occur in previously healthy individuals, while others affect immunocompromised patients. The epidemiology of viral encephalitis has undergone changes in recent years. Factors such as evolving lifestyles and ecological changes have had a considerable impact on the epidemiology of some types of viral encephalitis. The result is a change in the etiology spectrum of viral encephalitis, with new types of encephalitis arising or returning from time to time. Many scientific achievements in neuroimaging, molecular diagnosis, antiviral therapy, immunomodulatory treatments, and neurointensive care have allowed more precise and earlier diagnoses and more efficient treatments, resulting in improved outcomes. Despite these advances, there is still considerable morbidity and mortality related to these disorders. This aim of this article is to review the current knowledge of the current drugs used in the management of the most important viral encephalitis, focusing on the mechanisms of action, efficacy, and side effects of the drugs. In addition, future perspectives in this area will be addressed. Despite the technological advances, much effort has yet to be undertaken to reduce the impact of these potentially devastating diseases.

Early respiratory evaluation should be carried out systematically in patients with multiple sclerosis

The present study aimed at evaluating respiratory parameters in multiple sclerosis (MS). The sample comprised 30 patients with MS diagnosis and 30 healthy subjects, matched by gender and age. Neurological assessment, expanded disability status scale (EDSS), manovacuometry, and peak flow (PEF) were performed. Patients with MS had lower values of maximum inspiratory (MIP) and expiratory (MEP) pressures and PEF compared to healthy controls. It was shown that respiratory impairment may be present in MS patients with low functional disability by EDSS. The data suggest that manovacuometry and PEF determination should be carried out systematically in patients with MS, and may be a reliable tool for the early detection of respiratory impairment allowing early respiratory rehabilitation.

Cognitive impairment is correlated with reduced quality of life in patients with clinically isolated syndrome

OBJECTIVE

To evaluate the quality of life (QoL) and potential QoL determinants in patients with clinically isolated syndrome (CIS).

METHODS

Eighteen CIS patients and eighteen controls were submitted to QoL evaluation with Functional Assessment of Multiple Sclerosis QoL instrument (FAMS). Cognition was evaluated with specific battery tests; Anxiety and depression with Beck Anxiety (BAI) and Depression (BDI) Inventories and Neurological disability with Guy's Neurological Disability Scale (GNDS).

RESULTS

There was a significant difference in QoL between CIS patients and controls. CIS patients had worse performance in Paced Auditory Serial Addition 2 seconds (p=0.009) and fluency tests (p=0.0038). There was a significant difference in BAI (p=0.003), but no significant difference in BDI between patients and controls. There were significant correlations between QoL measure and verbal fluency and Stroop's test.

CONCLUSIONS

Cognition, but not anxiety, depression and disability, was associated with reduced quality of life.

Cognitive impairment in patients with clinically isolated syndrome

Cognitive abnormalities have been extensively studied in Multiple Sclerosis (MS). However, little is known about the cognitive involvement in patients with Clinically Isolated Syndrome (CIS).

Cognitive impairment in migraine: A systematic review

Patients with migraine often report cognitive complaints, especially regarding attention and memory.

Headache is associated with lower alcohol consumption among medical students

The aim of this study was to investigate the association between headache and alcohol consumption among medical students. 480 medical students were submitted to a questionnaire about headaches and drinking alcohol. Headache was assessed by ID-Migraine and functional disability was evaluated with MIDAS. The evaluation of alcohol consumption was assessed with Alcohol Use Disorders Identification Test (AUDIT). There was significantly lower proportion of students with drinking problem among students with headache. This occurred both among students classified as having migraine and among those who had non-migrainous headache. There was not a correlation between functional disability of headache and AUDIT score. Our data suggest that having headache leads to a reduction in alcohol consumption among medical students regardless the degree of headache functional impact.

Anxiety and depressive symptoms in clinically isolated syndrome and multiple sclerosis

Depression and anxiety have been reported in patients with multiple sclerosis (MS) and in patients with clinically isolated syndrome (CIS). However, the precise mechanisms that lead to depressive and anxiety symptoms in these patients are still unclear. In this study we evaluated with the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) patients with MS and CIS and compared them to controls. We also correlated BDI and BAI scores with clinical parameters. Kruskall-Wallis followed by Dunn's Multiple Comparison Test, Chi-square and Spearman test were used. Patients with MS had higher depressive and anxiety scores than controls. The BDI and BAI scores of patients with CIS were not significantly different from controls. There was a positive correlation between BDI, BAI and EDSS. Our results corroborate the view that MS patients have higher depression and anxiety levels than control subjects. Anxiety and depressive symptoms also seem to progress according to the severity of the disease.

Increased serum levels of brain-derived neurotropic factor during migraine attacks: a pilot study

There is a growing body of evidence implicating inflammatory cytokines and brain-derived neurotropic factor (BDNF) in the generation of migraine pain. No previous study evaluated BNDF levels during migraine attacks and there are conflicting results regarding tumor necrosis factor-alpha (TNF-alpha) serum levels. This study compared serum levels of TNF-alpha, soluble TNF receptors 1 and 2 (sTNF-R1 and sTNF-R2), and BDNF during migraine attacks and in headache-free periods. Nine patients with episodic migraine were clinically evaluated during a migraine attack and in a headache-free period. Blood sample of each patient in both occasions was collected and all serum was submitted to TNF-alpha, sTNF-R1, sTNF-R2, and BDNF determination by ELISA. There was no significant difference in the serum levels of TNF-alpha, sTNF-R1 and sTNF-R2 in migraine attack period and headache-free period. BDNF serum levels were significantly higher during migraine attack than in pain-free period. This is the first report showing that BDNF serum levels increase during migraine attack. This reinforces the view that BDNF may be implicated in the physiopathology of migraine.

Headache and Neuroimmunology: controversies

Headaches are prevalent among patients with neuroimmunological disorders of the central nervous system (CNS). Some autoimmune diseases of the CNS are traditionally recognized as headache causes and therefore are included in the International Headache Disorders Classification. In other conditions, such as systemic lupus erythematosus, multiple sclerosis, and Behçet´s disease, it is uncertain whether there is a causal relationship between headache and the immunologic disease. The presence of a headache history in a patient with an autoimmune disorder of the CNS may be only casual since primary headaches are very prevalent in the general population. In the other hand, CNS inflammatory activity associated with these autoimmune diseases maypotentially provoke headache and may also exacerbate a preexisting primary headache. In this article we make narrativerevision of the literature about this issue, presenting the current evidence of the association of headache and such immunologicdisorders, and critically discuss the potential therapeutic implications in the management of headaches in patients with these autoimmune diseases.

Management of acute viral encephalitis in Brazil

The appropriate management of acute viral encephalitis is a challenge. Clinical picture includes general symptoms and a wide range of neurological signs. Etiological diagnosis cannot be performed only by clinical means and depends on neuroimaging studies and cerebrospinal fluid molecular analyses. It is recommended since some of these viruses are treatable and that the prognoses of these infections depend on the prompt administration of antiviral and/or immunomodulatory drugs. The management of acute viral encephalitis in Brazil has some peculiarities. First, the etiological distribution of the viral encephalitis may differ from what is found in other countries. Some viruses, such as dengue virus, are more common in Brazil than in developed countries while others, like West Nile virus, are not found here. Second, there are some regions in Brazil where neuroimaging and laboratorial methods are not available, and a clinical-based decision is the only therapeutic approach. As most of the guidelines in the literature are based on complimentary methods, it is relevant to establish an alternative approach compatible with the Brazilian health system reality. The goal of this study was to review the recent advances in the field of the acute viral encephalitis, to discuss the diagnosis and the treatment of the main etiologies of acute viral encephalitis found in Brazil, and to propose a viable guideline for the evaluation of the suspected acute viral encephalitis cases in the emergence room in Brazil.

Cognitive impairment in clinically isolated syndrome: A systematic review

The pattern of cognitive abnormalities in multiple sclerosis (MS) has been extensively studied and well characterized. However, little is known about the cognitive involvement in patients with the clinically isolated syndrome (CIS).

Treatment of viral encephalitis

Several viruses may cause central nervous system diseases with a broad range of clinical manifestations. The time course of the viral encephalitis can be acute, subacute, or chronic. Pathologically there are encephalitis with direct viral entry into the CNS in which brain parenchyma exhibits neuronal damaging and viral antigens and there are postinfectious autoimmune encephalitis associated with systemic viral infections with brain tissue presenting perivascular aggregation of immune cells and myelin damaging. Some virus affect previously healthy individuals while others produce encephalitis among imunocompromised ones. Factors such evolving lifestyles and ecological changes have had a considerable impact on the epidemiology of some viral encephalitis [e.g. West-Nile virus, and Japanese B virus]. Citomegalovirus and JC virus are examples of infections of the brain that have been seen more frequently because they occur in immunocompromised patients. In the other hand many scientific achievements in neuroimaging, molecular diagnosis, antiviral therapy, immunomodulatory treatments, and neurointensive care have allowed more precise and earlier diagnoses and more efficient treatments, resulting in improved outcomes. In this article, we will present the current drug options in the management of the main acute and chronic viral infection of the central nervous system of immunocompetent and immunocompromised adults, focusing on drugs mechanisms of action, efficacy, and side effects. The early diagnosis and correct management of such diseases can reduce mortality and neurological sequelae; however, even with recent treatment advances, potentially devastating outcomes are still possible.

Prevalence and impact of headache and migraine among Brazilian Tupiniquim natives

This is the first study to evaluate the prevalence of headache and migraine among Tupiniquim Brazilian natives. A high prevalence of headache was found and the most prevalent headache was migraine. Women were more commonly affected than men. A high impact of headache was found, especially among migraineurs. Half of the headache sufferers were under medical assistance for headache given by the government Family Health Program (PSF). Most of them declared to use common analgesics. None of them was taking prophylactic therapy for this medical problem.

Correlation between migraine subtipes and depression

This study has evaluated depression in patients with episodic migraine (n=98), chronic migraine without medication overuse (n=23), and chronic migraine with medication overuse (n=57). The Beck Depression Inventory (BDI) was used to evaluate depressive symptoms in these three groups. The mean BDI score obtained in all patients was higher than that observed in asymptomatic subjects (episodic migraine=16.09±11.79, chronic migraine with medication overuse=18.91±12.53, chronic migraine without medication overuse=19.83±14.79). This finding corroborates previous studies suggesting a co-morbid association between migraine and depression. Depression did not seem to be crucial in the transformation of migraine as the median BDI scores did not differ significantly between patients with episodic and chronic migraine. The median BDI scores of the patients with chronic migraine with medication overuse and that patients with chronic migraine without medication overuse were similar as well. Therefore, medication overuse behavior may not be related with depression.

Treatment of trigeminal neuralgia with low doses of topiramate

Topiramate was administered to eight patients with classical trigeminal neuralgia with or without previous symptomatic therapy with other antiepileptic drugs. The topiramate doses ranged from 50 to 100 mg a day, according to the clinical response and the reported side effects. Three patients had complete symptoms remission, three reported moderate improvement, and the treatment was not effective in two. The most frequently registered side effects were dizziness, somnolence and weight loss. Topiramate can be considered an alternative treatment for patients with trigeminal neuralgia.

Headache features in patients with dengue virus infection

The aim of this study was to describe the frequency and features of headache among patients with confirmed dengue virus infection and to compare the headache features in patients with dengue fever and dengue haemorrhagic fever, primary and secondary dengue infection, and patients with and without neurological involvement. Patients with classic dengue fever had a more intense headache than those with the more severe form of the disease, dengue haemorrhagic fever.

Complications following transjugular intrahepatic portosystemic shunt: a retrospective analysis

Transjugular intrahepatic portosystemic shunt (TIPS) has been the therapeutic option for severe decompensation of chronic liver disease and as a bridge to liver transplantation. The aim of this study was to analyze the complications of this procedure. The records of 47 patients (39 men) of mean age 48 years underwent TIPS procedures from 1998 to 2003 were reviewed. Forty-one patients received 45 successful TIPS; it failed in six patients. Improvement was observed in 20 of 28 patients with upper gastrointestinal bleeding (71%); 9 of 11 with ascites (82%); and 5 of 8 with impaired renal function (62%). The Child-Pugh scores improved in 6 of the 47 patients (13%). Transplantation was performed in 11 patients (23%). The complications were: encephalopathy (49%); infection (19%); renal failure (17%); TIPS migration to the portal vein (4%) and to the right atrium (4%). Mortality was 32% (15/47) over 3 months. Eight patients developed active bleeding during TIPS installation requiring mechanical ventilation and intensive care, and died within the first week. Other causes of death were sepsis (n = 2), liver failure (n = 1), accidental puncture of the Glisson's capsule leading to intra-abdominal bleeding (n = 1) and refractory upper gastrointestinal bleeding (n = 3). The latter four patients had TIPS placement failure. In conclusion, TIPS produced clinical improvement among 51% of patients with complications in 49%. The main complications were encephalopathy (49%), infection (19%), and renal failure (17%). The 3-month mortality rate after TIPS placement was 32%.

Headache epidemiology in Vitória, Espírito Santo

This is the first headache survey in the region of Vitória, ES Brazil. A high prevalence of headache sufferers was found (52.8%). Headache was more common among women (63.9%) and less common among people older than 55 years old. The type of professional activity was not related with the headache prevalence. The most frequent causal attribution was stress. Most headache sufferers are not under regular medical treatment (9%), and most of them use analgesic drugs without proper orientation. The most used compounds are combinations with caffeine (33%) and simple analgesics (52.3%).

[Alternative diagnoses among suspected herpes simplex encephalitis patients with negative polymerase chain reaction]

The aim of this study was to analyze the diagnosis found in a series of patients in which the diagnosis of Herpes simplex encephalitis (HSE) was ruled out by a negative polymerase chain reaction (PCR) result for HSV DNA in cerebrospinal fluid (CSF) samples. Forty three out of 61 HSE suspected patients had negative PCR. An alternative diagnosis was established in 41.9% of these patients. These patients were diagnosed as having viral (2 cases-11.1%) and non viral (5 cases-27.2%) CNS infections, vascular (4 cases-22.2%) and demyelinating diseases (3 cases-16.7%), metabolic disturbances (3 cases-16.7%), and CNS tumor (1 case-5.6%). The non specific clinical presentation of this disease and the availability of an efficient treatment for HSE explain why several patients with other diseases were initially treated with acyclovir. The early use of PCR in CSF was considered essential for the evaluation of the acute encephalitis cases in this study.

Application of competitive PCR to cerebrospinal fluid samples from patients with herpes simplex encephalitis

The purpose of the present study was to determine if the quantity of herpes simplex virus (HSV) DNA in the cerebrospinal fluid (CSF) of patients with herpes encephalitis would be useful in establishing the prognosis of the disease and to determine the effect of antiviral therapy on the clearance of viral DNA from the CSF. Quantitation of HSV DNA was done by constructing an internal standard (IS) from the glycoprotein B amplicon which had a 25-bp deletion between primer annealing sites. Each CSF specimen was coamplified with the IS and the ratio of the amount of HSV/amount of IS was compared to the ratios on a standard curve constructed with the same IS plus known amounts of HSV DNA. CSF specimens were available from 16 patients who were treated with intravenous acyclovir, and the amount of HSV DNA ranged from < 25 to 18,000 copies per microliter in CSF obtained before or within 4 days of the initiation of acyclovir therapy. Patients with > 100 copies of HSV DNA per microliter were older, were found by computed tomography to have lesions, and had poorer outcomes than patients with < 100 copies. Follow-up CSF specimens were available from seven patients. In six of these seven patients, the HSV DNA levels decreased during therapy. One patient had a twofold increase in HSV DNA levels after 1 week of therapy and died on day 8. The application of this assay may be helpful in establishing the prognosis and in the monitoring of patients with herpes simplex encephalitis.

Diagnosis of herpes simplex encephalitis by magnetic resonance imaging and polymerase chain reaction assay of cerebrospinal fluid

The early diagnosis of herpes simplex encephalitis (HSE) is essential because early introduction of antiviral therapy can significantly reduce the mortality of this disease. Herpes simplex virus (HSV) DNA detection in cerebrospinal fluid (CSF) samples is a rapid, noninvasive, specific, and highly sensitive method for HSE diagnosis. Neurodiagnostic methods have also been studied for noninvasive diagnosis of HSE. Magnetic resonance imaging (MRI) seems to be the most sensitive of them but it has not been compared to PCR in terms of efficacy for HSE diagnosis. In this study, 17 patients with focal encephalitis were prospectively evaluated by PCR analysis of CSF samples and MRI examination. MRI lesions involving the inferomedial region of one or both temporal lobes were observed in all PCR-positive patients but one. No PCR-negative patient presented with the same pattern of MRI lesions. MRI was also important for the establishment of an alternative diagnosis in three of eight PCR-negative patients. Both methods should be routinely applied in the evaluation of presumed HSE cases.

Molecular detection and isolation of human T-cell lymphotropic virus type I (HTLV-I) from patients with HAM/TSP in São Paulo, Brazil

BACKGROUND

Infection with HTLV-I is etiologically linked with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP). However some patients with chronic progressive paraparesis resembling HAM/TSP have been shown to be infected with HTLV-II.

OBJECTIVE

To clarify the role of each of these human retroviruses in the etiology of HAM/TSP in São Paulo, Brazil.

STUDY DESIGN

A detailed serological and molecular analysis of HTLV-I/II infection was performed in a cohort of 19 patients with HAM/TSP attending a neurological clinic.

RESULTS

Plasma samples analyzed for anti-HTLV-I/II antibodies using a Western blot assay, comprising HTLV-I (rgp46I)- and HTLV-II (rgp46II)-specific recombinant env epitopes, demonstrated reactivity to rgp46I and hence were typed as seropositive for HTLV-I. Presence of HTLV genomic sequences in peripheral blood mononuclear cells (PBMC) was sought after by PCR using consensus primers SK 110 and SK 111 for the pol region of HTLV proviral DNA followed by hybridization with type-specific probes--SK 112 (HTLV-I) and SK 188 (HTLV-II). Southern blots from all individuals hybridized with SK 112 but not with SK 188, further confirming HTLV-I infection. Cocultivation of PBMC from eight of these patients with activated lymphocytes from normal individuals resulted in active viral production, detected as presence of soluble p24gag antigen in culture supernatants. Investigation of risk factors for HTLV-I infection in these individuals revealed that five out of 19 patients studied (26.3%) had received blood transfusions previous to disease onset.

Human T cell lymphotropic virus type-1-associated myelopathy/tropical spastic paraparesis in Sao Paulo, Brazil: association with blood transfusion

Human T cell lymphotropic virus type-1 (HTLV-1) associated myelopathy/tropical spastic paraparesis (HAM/TSP) has been epidemiologically linked to prior blood transfusion. The prevalence of transfusion as a risk factor for infection varies among endemic areas. Here we report the relative frequency of reported history of blood transfusion among 52 patients evaluated in Sao Paulo, Brazil. A patient reported history of blood transfusion prior to the onset of symptoms, found in 15 (28.8%) of the patients, was the most important risk factor identified in this group of patients when compared with a history of sexually transmitted diseases, homo/bisexuality, sexual promiscuity (three or more sexual partners a year), and intravenous drug use. The mean time between reported transfusions and the onset of symptoms was longer than previously reported. There was no trend toward a more severe evolution to motor inability among the HAM/TSP patients with a history of previous transfusion.

Evaluation of the range of clinical presentations of herpes simplex encephalitis by using polymerase chain reaction assay of cerebrospinal fluid samples

Detection of DNA from herpes simplex virus in cerebrospinal fluid (CSF) samples by polymerase chain reaction (PCR) analysis has been shown to be more sensitive and specific for the diagnosis of herpes simplex encephalitis than isolation of herpes simplex virus from biopsy specimens of brain tissue. Because of the invasiveness of brain biopsy, it has been suggested that PCR analysis of CSF may reveal a wider spectrum of the disease than has been previously recognized by brain biopsy studies. In this study, PCR assay of CSF samples obtained from 29, 12, and 8 patients with focal, mild, and diffuse encephalitis, respectively, was performed. PCR assay was positive for 15 (51.7%) of 29 patients with focal encephalitis and three (25%) of 12 patients with mild encephalitis. The correlation between temporal abnormalities shown by electroencephalography, computed tomography of the brain, or cranial magnetic resonance imaging and a positive PCR assay was high. PCR analysis has revealed that atypical and less severe forms of encephalitis are caused by herpes simplex virus.

Advantage of polymerase chain reaction in the diagnosis of herpes simplex encephalitis: presentation of 5 atypical cases

Four case of herpes encephalitis (HSVE) are described. The diagnosis was established by polymerase chain reaction (PCR) assay of cerebrospinal fluid (CSF). These reports illustrate different situations in the clinical management of this disease. PCR was considered useful in confirming the HSVE diagnosis in 3 atypical cases, and in the differentiation between virologic failure and postinfectious encephalitis in a patient with recurrence of symptoms. A case with typical HSVE clinical findings is also reported where PCR was negative and a temporal lobe lymphoma was diagnosed at autopsy. This last case is representative of the utility of PCR in the management of other diseases mimicking HSVE.

Human T lymphotropic virus type I-associated myelopathy/tropical spastic paraparesis in São Paulo, Brazil

We conducted a prospective clinical and epidemiologic evaluation of 45 cases of human T lymphotropic virus type I (HTLV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) in São Paulo, Brazil. All enrolled patients had progressive chronic myelopathy and high titers of HTLV-I and HTLV-II antibodies, as determined by enzyme immunoassay and western blot. In 24 cases, the polymerase chain reaction (PCR) was performed so that HTLV-I could be distinguished from HLTV-II. The clinical and epidemiologic features of the patients from our study were similar to those of patients with HAM/TSP from other areas of endemicity for HTLV-I except that more patients in our study had received a blood transfusion prior to their illness. Despite the presence of HTLV-II virus in Brazil, all patients whose serum was tested by PCR were found to be infected with the HTLV-I virus.