Cross-reactive epitopes present in campylobacter jejuni serotypes isolated from enteritis patients

Campylobacter jejuni (C. jejuni) infection frequently triggers autoimmune-mediated neuropathies, especially the Guillain-Barre syndrome (GBS). The molecular mimicry between the core oligosaccharides of bacterial lipopolysaccharides (LPSs) and the human gangliosides presumably results in the production of anti-neural cross-reactive antibodies which are likely to be a contributory factor in the induction and pathogenesis of GBS. The aim of our study was to determine the presence of cross-reactive epitopes in C. jejuni LPSs isolated from enteritis patients and to determine their antigen reactivity. For that purpose we collected stool specimens from 21 patients with enteritis and without neurological symptoms. Seven different serotypes of C. jejuni (0:27; 0:6/0:7; 0:38; 0:3; 0:1/0:44; 0:19; 0:37) were detected using the Penner system. Unexpectedly, one serotype from this group was detected as 0:19, a serotype rarely isolated from enteritis patient and in close association with GBS. Binding studies using cholera toxin-B subunit and peanut agglutinin, showed the presence of ganglioside-like epitopes in C. jejuni strains 0:37, 0:19 and 0:27. Reactivity with sera from patient with GBS, with confirmed previous exposure to C. jejuni and with high a titre of anti-ganglioside antibodies, showed that the same three LPSs from C. jejuni serotypes 0:37, 0:19 and 0:27 bear cross-reactive epitopes in their LPSs structures. Our results confirm the results from previous studies that LPSs from certain C. jejuni serotypes bear cross-reactive ganglioside-like epitopes which might be involved in the induction of GBS after C. jejuni infection.

Guidelines for treatment of autoimmune neuromuscular transmission disorders

BACKGROUND

Important progress has been made in our understanding of the autoimmune neuromuscular transmission (NMT) disorders; myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS) and neuromyotonia (Isaacs' syndrome).

METHODS

To prepare consensus guidelines for the treatment of the autoimmune NMT disorders, references retrieved from MEDLINE, EMBASE and the Cochrane Library were considered and statements prepared and agreed on by disease experts.

CONCLUSIONS

Anticholinesterase drugs should be given first in the management of MG, but with some caution in patients with MuSK antibodies (good practice point). Plasma exchange is recommended in severe cases to induce remission and in preparation for surgery (recommendation level B). IvIg and plasma exchange are effective for the treatment of MG exacerbations (recommendation level A). For patients with non-thymomatous MG, thymectomy is recommended as an option to increase the probability of remission or improvement (recommendation level B). Once thymoma is diagnosed, thymectomy is indicated irrespective of MG severity (recommendation level A). Oral corticosteroids are first choice drugs when immunosuppressive drugs are necessary (good practice point). When long-term immunosuppression is necessary, azathioprine is recommended to allow tapering the steroids to the lowest possible dose whilst maintaining azathioprine (recommendation level A). 3,4-Diaminopyridine is recommended as symptomatic treatment and IvIG has a positive short-term effect in LEMS (good practice point). Neuromyotonia patients should be treated with an antiepileptic drug that reduces peripheral nerve hyperexcitability (good practice point). For paraneoplastic LEMS and neuromyotonia optimal treatment of the underlying tumour is essential (good practice point). Immunosuppressive treatment of LEMS and neuromyotonia should be similar to MG (good practice point).

Leptin and the metabolic syndrome in patients with myotonic dystrophy type 1

OBJECTIVES

To evaluate serum leptin concentration and its relation to metabolic syndrome (MSy) in non-diabetic patients with myotonic dystrophy type 1 (DM1).

MATERIALS AND METHODS

This study included 34 DM1 patients, and the same number of healthy subjects matched for age, sex and body mass index (BMI).

RESULTS

DM1 patients had increased BMI and insulin resistance, and increased leptin and insulin concentrations, but the other features of MSy such as diabetes, glucose intolerance and hypertension were not detected in DM1 patients. Serum leptin levels were higher in patients with DM1 than in healthy controls (8.5 +/- 6.6 ng/ml vs 3.6 +/- 2.9 ng/ml in men, and 13.9 +/- 10.0 ng/ml vs 10.9 +/- 6.9 ng/ml in women, respectively). In DM1 patients, leptin levels correlated with BMI, fasting insulin and insulin resistance (HOMA) (P < 0.01).

CONCLUSIONS

The leptin overproduction correlated with insulin resistance in DM1 patients but the significance of this finding remains unclear.

Hereditary motor and sensory neuropathy Lom type in a Serbian family

Hereditary motor and sensory neuropathy Lom type (HMSNL), also called CMT 4D, a hereditary autosomal recessive neuropathy, caused by mutation in N-Myc downstream regulated gene 1 (NDRG1 gene), was first described in a Bulgarian Gypsy population near Lom and later has been found in Gypsy communities in Italy, Spain, Slovenia and Hungary. We present two siblings with HMSNL, female and male, aged 30 and 26, respectively in a Serbian non-consanguineous family of Gypsy ethnic origin. They had normal developmental milestones. Both had symptoms of lower limb muscle weakness and walking difficulties with frequent falls, which began at the age of seven. At the age of 12, they developed hearing problems and at the age of 15 hand muscle weakness. Neurological examination revealed sensorineural hearing loss, dysarthria, severe distal and mild proximal muscle wasting and weakness, areflexia and impairment of all sensory modalities of distal distribution. Electrophysiological study revealed denervation with severe and early axonal loss. Sensorineural hearing loss was confirmed on electrocochleography and brainstem evoked potentials. Molecular genetic testing confirmed homozygote C564t (R148X) mutation in NDRG1 gene.

Guidelines for the treatment of autoimmune neuromuscular transmission disorders

Important progress has been made in our understanding of the cellular and molecular processes underlying the autoimmune neuromuscular transmission (NMT) disorders; myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS) and neuromyotonia (peripheral nerve hyperexcitability; Isaacs syndrome). To prepare consensus guidelines for the treatment of the autoimmune NMT disorders. References retrieved from MEDLINE, EMBASE and the Cochrane Library were considered and statements prepared and agreed on by disease experts and a patient representative. The proposed practical treatment guidelines are agreed upon by the Task Force: (i) Anticholinesterase drugs should be the first drug to be given in the management of MG (good practice point). (ii) Plasma exchange is recommended as a short-term treatment in MG, especially in severe cases to induce remission and in preparation for surgery (level B recommendation). (iii) Intravenous immunoglobulin (IvIg) and plasma exchange are equally effective for the treatment of MG exacerbations (level A Recommendation). (iv) For patients with non-thymomatous autoimmune MG, thymectomy (TE) is recommended as an option to increase the probability of remission or improvement (level B recommendation). (v) Once thymoma is diagnosed TE is indicated irrespective of the severity of MG (level A recommendation). (vi) Oral corticosteroids is a first choice drug when immunosuppressive drugs are necessary in MG (good practice point). (vii) In patients where long-term immunosuppression is necessary, azathioprine is recommended together with steroids to allow tapering the steroids to the lowest possible dose whilst maintaining azathioprine (level A recommendation). (viii) 3,4-diaminopyridine is recommended as symptomatic treatment and IvIg has a positive short-term effect in LEMS (good practice point). (ix) All neuromyotonia patients should be treated symptomatically with an anti-epileptic drug that reduces peripheral nerve hyperexcitability (good practice point). (x) Definitive management of paraneoplastic neuromyotonia and LEMS is treatment of the underlying tumour (good practice point). (xi) For immunosuppressive treatment of LEMS and NMT it is reasonable to adopt treatment procedures by analogy with MG (good practice point).

Survival and mortality of myotonic dystrophy type 1 (Steinert's disease) in the population of Belgrade

The purpose of this investigation was to determine survival and mortality in patients with myotonic dystrophy type 1 (DM1) in the Belgrade population within the period from 1983 to 2002. Data of a number of diagnosed DM1 patients with their demographic, clinical and genetic characteristics were gathered from hospital records in all neurologic institutions in Belgrade for the period 1983-2002. Death certificates were reviewed to determine the cause of death. Survival analysis by life table method and Cox proportional hazard model was performed. Within the observed period, in the population of Belgrade, 15 fatal outcomes among 101 patients with DM1 were registered. Average DM1 mortality rate was 0.5/1,000,000 (95% CI 0.3-0.8), and standardized mortality ratio (SMR) was 5.3. A significant inverse correlation was found between age at onset of DM1 and CTG repeats (P=0.023). The cumulative probability of 15-year survival for DM1 patients in Belgrade was 49+/-5% (48+/-2% for males and 50+/-7% for females). Younger age at onset was a significant unfavorable prognostic factor (hazard ratio=4.2; P=0.012).

The features of myasthenia gravis with autoantibodies to MuSK

OBJECTIVES

To determine if myasthenia gravis (MG) with antibodies to MuSK is a distinct subgroup of seronegative MG.

METHODS

We assayed antibodies to muscle specific tyrosine kinase (MuSK) in 55 MG patients who had no antibodies to acetylcholine receptors and looked for the specific phenotype, comparing clinical features of anti-MuSK positive and anti-MuSK negative MG patients.

RESULTS

MG with anti-MuSK antibodies was characterised by a striking prevalence of female patients (15 women, two men). Age at onset ranged from 22 to 52 years, with 70.6% of patients presenting at < 40 years of age. The majority of patients (82.4%) had prevalent involvement of facial and bulbar muscles. One third of them did not respond well to anticholinesterase drugs. Steroid immunosuppression was effective in eight patients (44.4%). Nine patients underwent thymectomy; six of these had no thymus pathology, while three had a hyperplastic thymus. At the end of the observation period, six (35.3%) patients were in remission, five (29.4%) improved, four (23.6%) did not change, and two (11.7%) had died.

CONCLUSIONS

MG patients with antibodies to MuSK have characteristic clinical features that are different from features of the remaining seronegative MG patients. This emphasises the predictive value of anti-MuSK antibody analysis in seronegative MG patients.

Haplotype analysis of the DM1 locus in the Serbian population

OBJECTIVES

Analysis of the CTG-repeat number and three biallelic markers, Alu(+/-), HinfI(+/-), and TaqI(+/-), in the DMPK gene in healthy and myotonic dystrophy type 1 (DM1) Serbian individuals. Also, the consideration of haplotypes in the light of the proposed models of CTG-repeat evolution and origin of the DM1 mutation.

MATERIALS AND METHODS

Markers were analyzed by PCR and haplotypes were obtained on 203 unrelated normal chromosomes and 24 unrelated DM1 chromosomes.

RESULTS

A strong linkage disequilibrium was detected between the three biallelic markers alone (P <0.0001) and between distinct CTG-repeat size classes and reconstructed haplotypes. Greater than 98% of normal chromosomes contain (+++) and (- - -) haplotypes. The (+++) haplotype is the most common, while the (CTG)(9-17) are the most frequent alleles. We found a complete association of (+++) haplotype with (CTG)(> or =18) and mutated alleles.

CONCLUSIONS

(CTG)(9-17)/(+++) haplotype is the ancestral haplotype and DM1 mutation occurred on (CTG)(18-35)/+++ chromosome.

Cyclosporine in the treatment of myasthenia gravis

Cyclosporine A (CsA) treatment was evaluated in 52 patients with severe generalized myasthenia gravis (MG) whose illness was not controlled by anticholinesterase drugs, thymectomy, corticosteroids, and azathioprine. The efficacy of CsA treatment was expressed by mean disability score quotient (MDSQ), which was obtained by comparing mean disability score (MDS) at the beginning of the treatment with the MDS at the end of the follow-up period. For the entire group of patients MDSQ was 53.3%, indicating moderate improvement. Analyzing individual cases, eight patients (15%) did not improve, 17 (33%) showed moderate improvement, 20 (38%) showed remarkable improvement, and seven patients (14%) achieved complete remission. The most common side effects were rise of serum creatinine (seven), hypertension (two), gingival hyperplasia (two), hypertrichosis (six), myalgia (10), and 'flu-like' symptoms (10 patients). The results of this study suggest that CsA is efficacious and safe treatment in severe and resistant forms of MG.

Monocytoid B cell lymphoma associated with antibodies to myelin-associated glycoprotein and sulphated glucuronyl paragloboside

Monocytoid B cell lymphoma (MBCL) is an immunologically and morphologically well-defined low-grade lymphoma with a predilection for lymph nodes of the parotid region. We describe an association of MBCL with anti-myelin-associated glycoprotein (MAG) polyneuropathy in a 53-year-old male. The diagnosis of stage IV MBCL with nodular bone marrow infiltration, Sjögren's syndrome and sensorimotor polyneuropathy was made in October 1996. Serum immunoelectrophoresis demonstrated IgMkappa paraprotein. This was then cross-reacted with epitopes of MAG and sulphated glucuronyl paragloboside (SGPG) on myelin sheaths, and detected by thin layer chromatography and Western blot. Direct immunofluorescence of a sural nerve biopsy showed loss of myelin fibres, segmental demyelinization and IgM deposits on the myelin sheaths. The cerebrospinal fluid was normal. After six cycles of chemotherapy (ChlVPP protocol), all the patient's haematological parameters normalized accompanied by an improvement in neurological signs. The improvement of the polyneuropathy after chemotherapy indicates that the autoimmune anti-MAG and anti-SGPG antibodies resulted from the neoplastic lymphoid proliferation.

CTG repeat polymorphism in DMPK gene in healthy Yugoslav population

OBJECTIVES

Myotonic dystrophy type 1 (DM1) is caused by large expansions of cytosine-thymine-guanine (CTG)-repeats in myotonic dystrophy protein kinase (DMPK)-gene. This gene is highly polymorphic in healthy individuals. It has been proposed that expanded alleles originated from the group of large sized normal alleles. If this is correct, one should expect a positive correlation between the frequency of large sized normal alleles and a prevalence of this disorder in a population. In this paper we determined the distribution of alleles of DMPK gene in healthy Yugoslav population.

MATERIAL AND METHODS

A sample of 235 healthy individuals of Yugoslav origin have been genotyped for the alleles of DMPK locus.

RESULTS

We found 22 different alleles, ranging in size from 5 to 29 repeats. Among 470 chromosomes studied, 41 chromosomes had more than 18 repeats (8.72%).

CONCLUSIONS

Relatively high frequency of large sized normal alleles found in our population, suggest that prevalence of DM1 in Yugoslavia should not be different from the prevalence in other European populations.

Is the 31 CAG repeat allele of the spinocerebellar ataxia 1 (SCA1) gene locus non-specifically associated with trinucleotide expansion diseases?

A number of human hereditary neuromuscular and neurodegenerative disorders are caused by the expansion of trinucleotide repeats within certain genes. The molecular mechanisms that underlie these expansions are not yet known. We have analyzed six trinucleotide repeat-containing loci [spinocerebellar ataxias (SCA1, SCA3, SCA8), dentatorubral-pallidoluysian atrophy (DRPLA), Huntington chorea (HD) and fragile X syndrome (FRAXA)] in myotonic dystrophy type 1 (DM1) patients (n = 52). As controls, we analyzed two groups of subjects: healthy control subjects (n =133), and a group of patients with non-triplet neuromuscular diseases (n = 68) caused by point mutations, deletions or duplications (spinal muscular atrophy, Charcot-Marie-Tooth disease, type 1A, hereditary neuropathy with liability to pressure palsies, and Duchenne and Becker muscular dystrophy). Allele frequency distributions for all tested loci were similar in these three groups with the exception of the SCA1 locus. In DM1 patients, the SCA1 allele with 31 CAG repeats account for 40.4% of all chromosomes tested, which is significantly higher than in two other groups (11.3% in healthy controls and 6.6% in the group of non-triplet diseased patients; P < 0.001, Fisher's exact test). This is consistent with our previous findings in HD patients. The absence of this association in non-triplet diseases as well as in healthy controls could indicate a possible role of this SCA1 allele with 31 repeats in triplet diseases. Here we discuss a possible role of the SCA1 region in pathological trinucleotide repeat expansions.

Hereditary neuropathy with liability to pressure palsies associated with central nervous system myelin lesions

Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal dominant disorder most commonly caused by a 1.5-Mb deletion in chromosome 17p11.2 which contains the peripheral myelin protein-22 (PMP22) gene. Mutations resulting in functional loss of one PMP22 gene copy are less frequent. We present a 51-year-old patient with a l.5-Mb deletion in chromosome 17p11.2 who exhibited signs of peripheral as well as central nervous system lesions. He gave a history of recurrent episodes of limb numbness and weakness with spontaneous but incomplete recovery since age 20. His father and two brothers had similar symptoms. Neurological examination revealed signs of multiple mononeuropathy associated with frontal lobe, corticospinal tract and cerebellar dysfunction, as well as signs of initial cognitive impairment. Electrophysiological investigations showed a demyelinating peripheral nerve disease with multiple conduction blocks and conduction disturbances in both optic nerves. Magnetic resonance imaging of the brain revealed multiple subcortical and periventricular foci of myelin lesions. The association of central and peripheral nervous system lesions in this patient indicates a possible role of PMP22 not only in peripheral but also in central nervous system myelin structure.

Myotonic dystrophy and cardiac disorders

Myotonic dystrophy (MD) is a multisystem disease affecting numerous organs and systems. Cardiac involvement is frequent. Sudden death, due to fatal cardiac rhythm and conduction disturbances occurs in 30% of patients with MD. The aim of this study was to assess the possibilities and methods of early detection of myocardial and conduction system disturbances. ECG, 24-hr Holter monitoring, echocardiography and electrophysiologic studies of the conduction system (electrophysiologic study) were carried out in 45 patients. Analysis of late ventricular potentials was done in 36 patients. Genetic studies revealed multiplication of CTG triplets in all patients. Cardiological abnormalities were detected in 89% of our patients. Disturbances of intraventricular conduction with prolongation of HV interval were most frequent (72%). Electrophysiologic study was the most sensitive method for detecting heart involvement in MD (positive findings in 87% patients). Abnormal findings were also discovered by Holter monitoring (64%), ECG (58%), analysis of late ventricular potentials (55%) and by echocardiography in 46% patients. The results of this study indicate a high rate of cardiac involvement in MD.

Plasma exchange in myasthenia gravis and multiple sclerosis

During the last twenty-year period therapeutic plasma exchange (TPE) was used in the treatment of 68 patients with myasthenia gravis and 61 patients with multiple sclerosis. The therapeutic effects were evaluated on the basis of neurologic deficit changes, electrophysiological findings, necessary laboratory analyses and patient's general conditions. It was shown that the therapeutic effects mosty depended on the nature and stage of the basic disease, adequate selection of the patients and timely applied therapeutic procedure. Significant positive effects of the TPE treatment applied with the anti-inflammatory and immunosuppressive therapy were observed in patients with myasthenia gravis and multiple sclerosis upon clinical findings and some paraclinical tests.

[Diagnostic problems in patients with myasthenia gravis]

Myasthenia gravis (MG) is an antigen-specific autoimmune disease in which antibodies directed against nicotinic acetylcholine receptors of the postsynaptic muscle membrane (nAChR) impair neuromuscular transmission. MG is clinically characterized by abnormal muscle fatigue and weakness. The initial symptoms and signs are often unrecognized. Therefore, we analyzed the diagnostic errors and duration of diagnostic delay in patients affected with MG (n = 444) in a ten-year period (January 1, 1983-December 31, 1992) in Yugoslavia. The initial diagnosis was correct in 44.4% of patients and erroneous in 38.4%; 17.2% of patients were admitted without an initial diagnosis. The average duration of diagnostic delay was 11 months. We present the differential diagnostic difficulties in MG and discuss the principles of diagnostic strategy which may reduce the risk of diagnostic errors in MG.

Epidemiological and clinical characteristics of myasthenia gravis in Belgrade, Yugoslavia (1983-1992)

This is the first epidemiological study of myasthenia gravis (MG) in the area of Belgrade. During the survey period (1983 1992), 124 incidental cases of MG were observed, producing an average annual incidence rate of 7.1 per million population (women, 8.3; men, 5.8). Age and sex specific incidence rates for females demonstrated a bimodal pattern, with the first peak in the age group between 20 and 40, and the second peak in the age group 70-80. The age-specific rates for males showed unimodal pattern, reaching a maximum in the age group between 60 and 80. There was a tendency of more frequent disease appearance in the urban as opposed to the suburban districts. On the prevalence day, December 31, 1992, the point prevalence rate was 121.5 per million (women, 142.5; men, 98.8). Only for incidental cases, the point prevalence rate was 77.1 (women, 83.2; men, 70.4). The average annual mortality rate was 0.47 per million (females, 0.52; males, 0.42), while cumulative lethality was 5.6 (women, 5.6; men, 5.7). Most frequently initial symptoms were ocular, occurring in 58% patients. Through the period of investigation ocular symptoms were generalized in 68%, most frequently in the first 2 years (62.5%). Thymoma was confirmed in 11.3% of patients. In this group there was equal presence of both sexes, older median age at onset, and more severe clinical course of MG. Associated autoimmune disease was found in 17 out of 124 incidental cases (13.7%). The most common were thyroid diseases (7.3%). Family history of MG was recorded in 2 cases belonging to 1 family (1.6%).

Human monoclonal IgM DJ binds to ssDNA and human commensal bacteria

In this study we tried to elucidate further the crossreactivity pattern and binding characteristics of human monoclonal IgM DJ which is an anti-DNA antibody and possesses Y7 natural idiotope. Isolated IgM DJ and its enzymatically obtained fragments Fab' and (Fab')2 were tested for binding to more than 26 antigens and nine bacteria in indirect ELISA. Inhibition of binding studies and examination of the stability of antigen-antibody complexes were also done in ELISA assay. IgM DJ bound to single stranded DNA and human lactic acid bacteria, such as L. acidophyllus, B. bifidum and L. plantarum. This binding was shown to be mediated through IgM DJ Fab' fragment. High avidity and low affinity of interactions was estimated from the binding curves of Fab', (Fab')2 fragments and whole IgM. The common epitopic motif on both antigens were negatively charged phosphodiester moieties. Complexes formed with ssDNA and B. bifidum were resistant to washing with high salt. This suggested that electrostatic attraction was not a strong component of the binding. A novel pattern of natural autoantibody reactivity in a human system related to cross-reactivity with DNA and LAB is described. Possible involvement of LAB in induction of natural anti-DNA antibodies is discussed.

Pathohistological changes in endomyocardial biopsy specimens in patients with myotonic dystrophy

BACKGROUND

Endomyocardial biopsies in patients with myotonic dystrophy (MD) have, so far, shown changes such as myofibrillar degeneration, mitochondrial abnormalities, focal myocarditis, fibrosis and fatty infiltration of the myocardium and the conduction system.

METHODS

This study presents the results of endomyocardial biopsy in 10 patients with MD. Endomyocardial biopsy was carried out using King's bioptome.

RESULTS

In two patients with servere MD biopsy specimens showed changes compatible with border line myocarditis. In five patients with moderate to severe forms of MD fibrosis and fatty infiltration of the myocardium were found in addition to degenerative changes and hypertrophy of muscle fibers. Three patients with mild MD had non-specific degenerative and hypertrophic myocardial changes. The histological changes described above were present in patients without cardiological symptoms and in those with normal ECG and echocardiographic findings. Only two of the 10 patients in whom endomyocardial biopsy was done complained of fatigue and occasional palpitations while the rest were asymptomatic. One patient with focal myocarditis had ECG signs of left bundle branch block and echocardiographic evidence of reduced left ventricular contractility. Five patients with signs of endomyocardial fibrosis only had an abnormal Q wave on ECG recordings. The remaining five patients with border line myocarditis i.e. with degenerative and hypertrophic myocardial changes had normal ECG and echocardiographic findings.

CONCLUSIONS

These results stress the significance of endomyocardial biopsy in detecting myocardial pathologic changes in patients with MD.

Glutathione peroxidase in amyotrophic lateral sclerosis: the effects of selenium supplementation

The activity of glutathione peroxidase (GSH-Px) as well as the activities of other antioxidative enzymes: CuZn superoxide dismutase (CuZn SOD), catalase (CAT), glutathione reductase (GR) in erythrocytes, as well as the activity of plasma glutathione transferase (GST), and the plasma content of vitamins E and C were evaluated in 35 sporadic amyotrophic lateral sclerosis (sALS) patients. The results revealed significantly decreased activity of both GSH-Px and CuZn SOD in sALS patients compared with the control. These data showed that a disturbed oxidative/antioxidative balance in sALS patients exists not only in motoneurons but also in the blood. The effect of exogenously administered selenium (Se), antioxidants, amino acids, a Ca2+ channel blocker such as nimodipine, and their combination in Alsamin was evaluated by screening parameter levels after 9 weeks of treatment. Only the use of all components together enhanced the activity of GSH-Px and the amount of vitamin E in sALS patients. Judging by the results of clinical trials, this treatment slowed the course of the disease.

[Antiphospholipid antibodies in a female patient with the Sneddon syndrome]

Sneddon was the first one to describe the association of cerebrovascular insult (CVI) and skin changes by livedo reticularis type. Angiography of this patient revealed normal brain blood vessels, occlusive changes or the changes similar to those in moya-moya disease. Computed tomography (CT) of the brain most frequently revealed ischemic lesions and/or diffuse atrophy of the brain, although the normal finding was also possible. Considering the frequent finding of the increased titer of anticardiolipin antibodies (ACA) in those patients, those antibodies could be the most important in the pathogenesis of Sneddon's syndrome. A case of female patient, aged 66 years, with livedo reticularis and recurrent CVI was presented in this study. By panangiography were revealed normal blood vessels of the brain, by scintigraphy two ischemic lesions and by CT ischemic lesions with pronounced cortical and subcortical reductive changes. In laboratory findings were observed increased immunocomplexes and the presence of lupus-like anticoagulants, increased ACA titer, the increase in fibrinogen value associated with increased ESR. The result of bone marrow examination was normal, while the borreliosis test was negative. Vasculitis was excluded by skin biopsy. Solid improvement was noticed after the immunosuppresive therapy was administered, but in the last disease exacerbation with new CVI, the outcome was lethal 3 years since the disease onset.

Unusual association of multiple sclerosis and tomaculous neuropathy

We describe two cases in which multiple sclerosis (MS) occurred in association with tomaculous neuropathy, presenting as chronic, distal sensorimotor polyneuropathy. In Case 1, monoclonal gammopathy of undetermined significance with monoclonal IgG lambda reactive against GM1 ganglioside, was also detected. The diagnosis of tomaculous neuropathy was established after sural nerve biopsy. Teased fibers examination revealed focal 'sausage-like' thickenings of the myelin sheaths in intact fibers and in fibers with segmental demyelination. Electron microscopy showed them to be due, mostly, to multiple windings of redundant myelin and concentric apposition of numerous lamellae, in contact with an intact myelin sheath. These are the first reported cases of tomaculous neuropathy in patients with MS. Whether the combination of the two conditions is purely coincidental or suggests the possible causal relation between MS and tomaculous neuropathy, is not certain.

[Survival in amyotrophic lateral sclerosis]

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder. Median survival from symptom onset is about 3.5 years, but some patients live for longer than 5 years. Because of fatal termination of ALS, searching for the prognostic factors related to the length of illness is very important.

MATERIAL AND METHODS

The aim of this study was to determine the mean duration of the disease and statistical probability of survival in our ALS population. In a 7-year-survey period (1985-1991), 58 patients with ALS were discovered in the Belgrade district. The outcome in 54 cases was determined by directly contacting patients or their families. Four patients (2 men and 2 women) could not be reached for follow-up and dropped out of the study after diagnostic hospitalization. The differences between the two arithmetic means were tested by Student's t-test. The probability of survival was obtained bythe life table method]. Differences in survival between subpopulations were evaluated by long-rank test.

RESULTS

Over the period from 1985 to 1991, fifty-eight patients were diagnosed as new cases of ALS in Belgrade. Our series comprised 35 men and 23 women. The mean age at onset of symptoms was 56.2 +/- 9.8 (55.9 +/- 7.6 in male and 56.6 +/- 12.5 in female group). Although female patients were somewhat older than male subjects at onset of the disease, this difference was not statistically significant (t = 0.805; p > 0.05). The clinical manifestation at the onset of the disease was bulbar in nine (15.5%) and spinal in 49 (84.5%) patients. The mean age at onset was 56.0 +/- 9.5 in the group with spinal ALS. The patients with bulbar ALS were older at onset (57.3 +/- 9.8), but this difference was not statistically significant (t = 0.49; p > 0.05). In order to gain better insight into the natural course of ALS in our population, we focused special attention on 32 patients who died during the survey period. The mean duration of ALS in our population was 27.7 +/- 18.2 months (approximately 2 years and 4 months). The cumulative probabilities of survival of a two-, five- and seven-year period were 62%, 27% and 27%, respectively. These findings refer to the total population. We also analyzed survival in relation to sex, age and clinical form of ALS. There was a difference of survival according to sex. A five-year survival was 22% in males and 36% in females; the same was noted after a seven-year survey period. The long-rank test detected no statistically significant difference (chi2 = 2.65; p > 0.05). Survival was compared between subgroups of patients with different forms of the disease (spinal and bulbar ALS). At the end of a four-year period no patient with bulbar ALS was in live, while 38.4% patients with spinal ALS were still alive (Fig. 1). This difference was statistically highly significant (long-rank test; chi2 = 3.44; k = 1; p < 0.01). There was a significant difference in survival between patients under and over 49 years (Fig. 2). A two-year survival for patients under 49 years was 88% and 57% for those over 49 years old. At the end of a five-year period these figures were 53% and 23%, respectively. More than 50% of the patients under 49 and only 19% of those over 49 years were alive at the end of the survey period (chi2 = 21.87; k=1; p < 0.01).

DISCUSSION

Advanced age and bulbar signs at onset indicated poorer prognosis in our population. The patients under 49 years had significantly higher survival rates than the older patients. The more benign course of ALS in younger patients was also confirmed by the other authors. The bulbar form of ALS had a significantly lower survival rate in comparison to the spinal form. These findings are also consistent with findings in other populations. Some possible explanations for different survivals of ALS patients are also discussed, including the hypothesis that the apolipoprotein Eepsilon 4 allele may influence the pattern of motor neuron loss.

[Amyotrophic lateral sclerosis in a defined population in Belgrade--an epidemiologic study]

The paper shows the results of the first epidemiological study of ALS in Belgrade. The incidence, prevalence and natural course of ALS were determined for the period 1985 through 1991. The distribution of 58 newly discovered cases in a 7-year survey period showed that the average annual incidence rate was 0.54 per 100000 population (95% confidence interval, 0.23-1.06), and age-adjusted incidence rate was 0.42 per 100000 population (95% confidence interval, 0.18-0.83). The rate for males was 1.5 times higher than the rate for females. The greatest age-specific average incidence rate was observed in patients between 60 and 64 (3.66 per 100000 population: 95% confidence interval, 2.17-5.78). The actual age-adjusted prevalence rate on December 31, 1991 was 1.07 per 100000 (95% confidence interval, 0.71-1.71). The mean age at the onset of the disease was 56.2 +/- 9.8 and it ranged from 24 to 74. The average interval between the onset of symptoms and the establishing of the diagnosis was 14.38 +/- 17.26 months. The mean duration of the disease was 27.7 +/- 18.2 months. The cumulative probability of survival was 27% for the whole population in a 5-year interval. Elderly patients and those with bulbar signs at the onset had a poorer prognosis.

[Treatment of diabetic amyotrophy with steroids]

The cause of diabetic neuropathies has not yet been fully elucidated. In severe forms of proximal diabetic neuropathy, the role of ischaemia caused by inflammatory microvasculopathy has been recently implicated, suggesting the use of anti-inflammatory and immunosuppressive therapeutic agents. We present a 70-year-old man with non-insulin-dependent diabetes mellitus, who developed diabetic amyotrophy responsive to steroids. Pain preceded the development of severe, asymmetric, lower extremities weakness, with amyotrophy, areflexia and fasciculations. Weakness gradually worsened over a 15-month period. The electrophysiologic study revealed predominant motor and axonal polyneuropathies. Laboratory analyses showed elevated erythrocyte sedimentation rate (130/h), moderately elevated cerebrospinal fluid (CSF) protein level and mildly elevated CSF cell content. Therapy with methylprednisolone (120 mg dailu, i.m., with slow tapering) was administered with beneficial effect. Pain subsided immediately after starting the therapy, and strength gradually improved. In conclusion, immunosuppressive treatment should be considered in selected patients with diabetic amyotrophy who develop severe and disabling weakness of the lower extremities.

Epidemiological and clinical characteristics of ALS in Belgrade, Yugoslavia

We present the results of the first epidemiological study of ALS in Belgrade. The distribution of 58 newly discovered cases in a 7-year survey period (1985-1991) showed that the average annual age-adjusted incidence rate was 0.42 per 100,000 population (95% confidence interval, 0.18-0.83). The rate for males was 1.5 times higher than the rate for females. The greatest age-specific average incidence rate was observed in patients between 60 and 64 (3.66 per 100,000 population; 95% confidence interval, 2.17-5.78). The actual age-adjusted prevalence rate on December 31, 1991 was 1.07 per 100,000 (95% confidence interval, 0.71-1.71). The mean age at onset of the disease was 56.2 +/- 9.8 and it ranged from 24 to 74. We studied the natural course of the disease through the mean duration and cumulative probability of survival. The mean duration of the disease was 27.7 +/- 18.2 months. The cumulative probability of survival was 27% for the whole population in a 5-year interval. Elderly patients and those with bulbar signs at onset had a poorer prognosis. Patients under 49 at onset and those with the spinal form of the disease survived longer.

[Guillain-Barre syndrome and antibodies to ganglioside GM1. Case report]

A sudden onset of the syndrome Guillain-Barré in 48-year-old woman presenting as an acute motor neuropathy was associated with antibodies against ganglioside GM1 detected by ELISA. The neurological examination revealed flaccid quadriplegia without affection of the sensory system, and the additional investigation showed mild increase of the CSF protein content, demyelination of the peripheral motor nerves and significantly increased titer of the serum and CSF anti-GM1 antibodies. Several copruculture for Campylobacter jejuni gave negative results. There was a significant correlation between the severity of the clinical picture and the titer of the serum anti-GM1 antibodies. The patient completely and spontaneously recovered after five weeks. According to the clinical and laboratory parameters the patient could be classified as an axonal, and according to electromyographic findings and the course of the disease as the classical form of the syndrome Guillain-Barré.

[Cerebrospinal fluid findings in patients with acute and chronic inflammatory demyelinating polyradiculoneuropathies]

We studied the cerebrospinal fluid (CSF) in patients with acute (AIDP) and chronic inflammatory demyelinating poliradiculoneuropathy (CIDP). In order to assess its possible contribution in establishing the diagnostic approach, we analyzed the cell content, concentrations of total proteins, albumin and IgG, CSF/serum albumin quotient and the qualitative study of IgG. Sixteen patients with AIDP and 16 patients with CIDP, fulfilling the accepted diagnostic criteria, were included in this study. CSF features were not used as exclusion criteria. The cell count and concentration of total proteins were determined by standard procedures. CSF albumin was performed and IgG were done by single radial immunodiffusion, and the qualitative analysis of IgG by agarose isoelectric focusing of unconcentrated CSF. The incidence of elevated levels of total CSF proteins was identical in patients with AIDP and CIDP, reaching 94%. The mean level of CSF protein was similar in patients with AIDP and CIDP, 1100 and 1150 mg/l, respectively. The cell count was elevated in 3 (19%) patients with AIDP and normal in patients with CIDP. There were no significant differences in the mean level of any of CSF parameters between patients with AIDP and CIDP. Local synthesis of CSF oligoclonal IgG was found in 2 patients with CIDP and was not detected in patients with AIDP. No association between CSF and clinical parameters was recorded. The results of this study confirm that an elevated CSF protein and low CSF cell count are features highly supportive of the diagnosis of both AIDP and CIDP. The most intriguing finding is the detection of locally produced CSF oligoclonal IgG which may suggest the associated inflammation within the central nervous system in a number of patients with CIDP, and furthermore a pathogenic link between CIDP and multiple sclerosis.

[Frontal lobe dysfunction in ALS]

We present the facts on kind and frequency of disorder of high cortical functions in amyotrophic lateral sclerosis. It was considered for a long time that this disease affects selectively motor neurons. The signs of degeneration found in other structures and associated signs of other neurological disorders brought the diagnosis of amyotrophic lateral sclerosis under suspicion. However, the specific type of degenerative dementia is nowadays more frequently discovered in patients with amyotrophic lateral sclerosis. The nosological status of motor neuron disease with dementia is still controversial. There is a possibility of a new clinical entity or a variant of motor neuron disease. Taking into account the fact that pathological changes of motor neurons and the natural history of amyotrophic lateral sclerosis and amyotrophic lateral sclerosis with dementia are not essentially different, as well as the fact that frontal dysfunction is detected in non-demented patients with amyotrophic lateral sclerosis, the authors consider that we are facing a variant of well-known disease of motor neuron.

[Frequency of electrocardiographic changes in patients with myotonic dystrophy]

Cardiac abnormalities are frequently associated with myotonic dystrophy (MD), and electrocardiographic (ECG) changes are not rare in these patients. The most common ECG abnormalities are PQ or QT interval prolongation, low P wave amplitude, ST elevation or depression, negative T waves, conduction and rhythm abnormalities. We analysed ECG changes in 42 patients with MD. ECG abnormalities were obvious in 24 (57%) patients. The most prevalent ECG changes were sinus bradycardia and low P wave amplitude, occurring in 23 (55%) patients. Nineteen (45%) patients had QTc prolongation. PQ prolongation occurred in 16 (38%) patients, abnormal Q waves in 9 (21%), intraventricular conduction defects in 7 (16%) and QRS prolongation or T wave changes in 4 (9%) patients. We found no ST alterations. ECG changes were more frequent in patients with severe disease, but it was not statistically significant. There was no correlation between age and ECG abnormalities in our patients.

Specificity and cross-reactivity of anti-galactocerebroside antibodies

Anti-galactocerebroside (GalC) antibodies have been reported to inhibit myelin formation, cause demyelination, and block HIV-I infection of neural cells. We examined the binding of 3 monoclonal and polyclonal anti-GalC antibodies to a panel of purified glycolipids by ELISA and by an immunospot assay on nitrocellulose blots. All 3 antibodies bound strongly to GM1 ganglioside, monogalactosyl diglyceride, and asialo-GM1, and 2 of the antibodies bound to GD1b and psychosine. The anti-GalC antibodies also bound to 3 glycoprotein bands in human neuroblastoma cells on Western blot, and binding to the proteins was abolished by pre-treatment with pronase or with periodate which oxidizes the terminal carbohydrate residues. These results indicate that anti-GalC antibodies cross react with oligosaccharide determinants of other glycolipids and glycoproteins, and that these cross-reactivities may be responsible for some of the biological effects of the anti-GalC antibodies.

[Treatment of myasthenia gravis with intravenous immunoglobulin G (IVIG)]

In the two past years 25 patients with generalized myasthenia gravis (MG) were treated with high-dose intravenous immunoglobulin G (IVIG) at the Institute of Neurology in Belgrade. The patients were affected with severe forms of MG (IIB, III and IV according to Osserman's classification) refractory to all previous treatment. All patients received IVIG, 250-350 mg/kg during five consecutive days. An immediate positive effect was mild and recorded 12-15 days later in only 37.5% patients. On the contrary, 92% patients showed delayed improvement which was effective for over six months. Distribution and severety of the disease decreased as expressed by reduced Besinger mean clinical score from 12.3 to 5.7 after six months. Immunologic parameters before and after IVIG treatment did not differ significantly. An increase of IgG was observed in 88% of patients. IVIG side effects were infrequent, usually mild, and qualitatively different from those induced by other therapies (azathioprine, corticosteroids). The authors emphasize the beneficial delayed effect of IVIG on the course of MG which resulted in significant reduction of the dose of additional immunosuppressive agents. The absance of immediate therapeutic effect of IVIG does not justify this mode of treatment in acute deterioration and crisis of MG.

Leflunomide prevents the development of experimentally induced myasthenia gravis

Myasthenia gravis is an autoimmune disease in which autoantibodies specific to the acetylcholine receptor (AChR) are formed, leading to a gradual destruction of the receptors in muscles that are responsible for picking up nerve impulses, and results in weakness and eventual loss of muscle function. The novel immunomodulating drug leflunomide (HWA 486) has been shown to be very effective in preventing and halting ongoing disease in an array of experimental autoimmune disorders and reactions leading to organ graft rejection. Further, recent data from phase II clinical trials indicate that this drug is efficacious and is safe in humans with rheumatoid arthritis. In the studies reported here, we found that rats immunized with AChR-protein and not receiving leflunomide developed experimental myasthenia gravis (EMG) between day 7 and 11 post-immunization, and about 79% of these animals expressed clinical signs of disease. Treatment of AChR-protein immunized rats with leflunomide, from the day of disease induction, totally suppressed the development of EMG. Thus, the results we have obtained using leflunomide in EMG indicate that this drug could be beneficial in combating myasthenia gravis in humans.

Motor neuron disease and monoclonal gammopathy

In a study to determine the prevalence of monoclonal gammopathy (MG) among patients with motor neuron disease (MND), 6 out of 56 (10.7%) were found to have a monoclonal paraprotein. Of these 6 patients, 4 had an IgG and 2 had an IgA paraprotein. The clinical syndromes consisted of amyotrophic lateral sclerosis in 2 patients, lower motor neuron syndrome with preserved reflexes in at least one limb in 3 patients, and motor neuropathy with multifocal conduction block in 1 patient. The presence of gammopathy appears to correlate with the absence of marked upper motor neuron involvement and with elevated CSF protein concentration. An underlying malignant disorder was ruled out in all 6 patients, and they were considered to have MG of undetermined significance (MGUS). In a control group of 121 age-matched patients with other neuroimmunological disorders, 5 patients (4.13%) had MG. Four of these had gammopathy associated with malignant myeloma, and 1 had MGUS. These results support previous reports of increased prevalence of MGUS in patients with MND and suggest that an autoimmune mechanism may play a role in the disease.

Identification of Gal(beta 1-3)GalNAc bearing glycoproteins at the nodes of Ranvier in peripheral nerve

A subset of human anti-GM1 ganglioside antibodies cross-reacts with Gal(beta 1-3)GalNAc bearing glycoproteins in peripheral nerve and spinal cord. The same oligosaccharide determinant is recognized by the lectin peanut agglutinin (PNA) which binds at the nodes of Ranvier in intact peripheral nerve. The Gal(beta 1-3)GalNAc bearing glycoproteins were isolated using PNA lectin affinity chromatography followed by separation on Western blot, and the proteins were subjected to partial amino acid sequence analysis. Two major PNA binding glycoproteins were identified in peripheral nerve and spinal cord; one had an approximate molecular weight of 120 kD and had sequence homology to the oligodendrocyte-myelin glycoprotein (OMgp). The other migrated between 70 and 80 kD and had sequence homology to the hyaluronate binding domain of versican, which has been reported to share sequence homology with the 70 kD proteins hyaluronectin and the glial hyaluronic acid binding protein (GHAP). By immunocytochemistry, OMgp was localized to the paranodal region of myelin, and the protein homologous to the hyaluronate binding domain of versican was localized to the nodal gap in peripheral nerve. These PNA binding glycoproteins might be target antigens for autoantibodies in peripheral nerve.