Immunological and clinical response to immunosuppressive treatment in paraneoplastic cerebellar degeneration

OBJECTIVE

To report the clinical and immunological response to immunosuppressive treatment with cyclophosphamide in two patients with paraneoplastic cerebellar degeneration.

DESIGN

Case reports. Clinical and immunological follow-up data available for 4 1/2 years in the first patient and for 2 years in the second patient.

SETTING

A 1500-bed university hospital and a 1200-bed university teaching hospital.

INTERVENTION

Cyclophosphamide intermittent treatment.

MAIN OUTCOME MEASURE

Clinical disability.

RESULTS

One of the patients, who was treated from an early stage, recovered completely. The other patient showed a partial clinical response. While the two patients were receiving a maintenance regimen with cyclophosphamide, the conditions of both patients remained stable for at least 2 years. In both patients, intrathecal antibody synthesis declined considerably.

CONCLUSION

Early induction of immunosuppressive therapy with cyclophosphamide should be tried in treating patients with paraneoplastic cerebellar degeneration.

Cyclosporine versus azathioprine in the long-term treatment of multiple sclerosis--results of the German multicenter study

In a double-blind controlled trial of 194 patients with clinically definite active multiple sclerosis, 98 were randomized to treatment with cyclosporine (CyA, 5 mg/kg/day), and 96 to treatment with azathioprine (Aza, 2.5 mg/kg/day). Eighty-five patients in the CyA group and 82 in the Aza group completed a treatment period of 24 to 32 months in accordance with the study protocol. No significant differences could be detected between the two treatment groups at the end of the trial. Assessment was done by serial quantitative neurological examinations and Kurtzke's Expanded Disability Status Scale. Frequency of relapse and patient self-evaluation also failed to show significant differences. Overall deterioration observed in both groups during the trial was only minor. The incidence of side effects in the CyA group was more than two times that in the Aza group. We conclude that CyA as a single agent cannot be the drug of final choice in long-term immunosuppressive treatment of relapsing-remitting and relapsing-progressive multiple sclerosis.

Geographical distribution of mortality rates for cerebrovascular disease in Lower Saxony (Federal Republic of Germany)

Using the official mortality statistics for the 46 districts of Lower Saxony (Federal Republic of Germany) for the years 1975-1977, the geographical distribution of mortality from cerebrovascular disease was studied. Only in women was a slight tendency towards higher rates in rural areas found. There were only moderate correlations with the rates for ischaemic heart disease and no statistically significant correlations with the rates for diseases of peripheral vessels.

Crossreacting idiotypes of kappa-monoclonal immunoglobulins M in sera of patients with Waldenström's macroglobulinemia

Seventeen anti-idiotypic antisera (anti-Id) were prepared against kappa-monoclonal IgM from patients with Waldenström's macroglobulinemia. Their reactivity against homologous and heterologous IgM was tested using an ELISA. Crossreacting idiotypes were only found in two out of 289 investigated antigen-antibody reactions. One anti-Id IgG crossreacted with determinants on polyclonal IgM. These rare crossreactions were observed in Waldenström's macroglobulinemia patients with and without polyneuropathy. The scarcity of common idiotypes on different monoclonal IgM does, however, not constitute a decisive argument against common or related antibody specificities of such monoclonal IgM.

Mollaret's meningitis: CSF-immunocytological examinations

Mollaret's meningitis is a rare clinical entity consisting of recurrent attacks of meningeal irritation, which, after a sudden onset, last for a few days. The prognosis appears to be excellent, although the aetiology has not been established. In the CSF so-called endothelial cells are a typical finding, but their classification is not yet clear. In the present case immunocytological examination of CSF cells revealed that the so-called Mollaret cells are monocytes. The time course of changes in helper/suppressor ratio is similar to that in other infectious diseases of the central nervous system.

Polyneuropathy in Waldenström's macroglobulinaemia. Passive transfer from man to mouse

To support the hypothesis of an immunopathogenesis of polyneuropathy in Waldenström's macroglobulinaemia (MW), serum IgM fractions of MW patients were applied intraperitoneally to mice for 17 days. Sections of liver, kidney, M. glutaeus maximus, central nervous system (CNS) and both Nn. ischiadici were examined for IgM, IgG, C3 and as control IgD with PAP-immunostaining. IgM deposits were found in every organ except the CNS. In peripheral nerves larger amounts were visualized in perineurium and endoneural space, whereas myelin lamellae and periaxon did not stain. Therefore, perhaps our investigation reveals a greater permeability of the blood-nerve barrier (BNB) compared with the blood-brain barrier (BBB). The involvement of the monoclonal IgM of MW, which has been shown to react in vitro with peripheral nerve constituents, appears possible in the pathogenesis of polyneuropathy.

[Familial polyneuropathy with a disposition to pressure paralyses. A contribution to the differential diagnosis of mononeuropathies]

When a young woman admitted for recurrent peripheral nerve palsies was suspected to suffer from hereditary polyneuropathy with liability to pressure palsies, 8 members of her family were examined diagnostically. Only one of these had a history of a transient mononeuropathy. A neurophysiological examination demonstrated peripheral nerve lesions not only in the patients father but also in 5 of her brothers and sisters. In presenting the data for this family the characteristics of hereditary polyneuropathy with liability to pressure palsies and the most important differential diagnostic aspects are discussed.

[Mycotic intracranial aneurysm in infective endocarditis of the mitral valve]

A 20-year-old woman suffering from mitral valve endocarditis due to streptococcus faecalis infection after blunt trauma and splenectomy complained of severe headache 18 days later. Cerebral angiography showed a left posterior artery aneurysm. A craniotomy was performed and the aneurysm could be successfully removed. The postoperative neurological status showed a mild transient right hemiparesis. The patient underwent mitral valve replacement with a St. Jude-Medical prosthesis 14 days after brain surgery. The patient was in stable neurologic and hemodynamic conditions at the time of discharge 3 weeks after valve replacement.

Primary germinoma of the brain. Immunocytochemical demonstration of tumour cells in the cerebrospinal fluid

A patient is presented, who developed a suprasellar tumour. Stereotactical biopsy of the tumour revealed the diagnosis of a dysgerminoma. Immunocytochemical examination of the CSF showed neoplastic cells staining for human chorionic gonadotropin and for alpha-fetoprotein. The authors stress the possibility to diagnose primary intracranial germ cell tumours without operation.

Tobacco-alcohol amblyopia neuro-ophthalmological findings and clinical course

The clinical picture of 40 patients with tobacco-alcohol amblyopia (TAA) is described. In 15 patients the course of the disease was studied longitudinally over a period of 31 months. In addition in six patients the acute development of the disease was studied during a period of four weeks in-patient treatment. TAA is characterised by distinct bilateral visual disturbances, symmetric scotomas, acquired disturbances of colour vision and mostly normal fundi. Visual acuity is usually grossly diminished. Central scotomas were present in 80% of the cases while the centrocecal from prevailed in the rest. The acquired disturbances of colour vision usually concerned the red-green sense (84%). The amplitudes of the visual evoked potentials were always reduced and deformed. In 33% we could not detect a P-100. In 5% the latency of the P-100 was prolonged. Full field stimulation was the best method of defining the P-100. By foveal stimulation the deformations of the amplitudes were more evident. The prognosis of the visual disturbances was unpredictable. The abnormalities improved in one half of the patients, but complete recovery was never reached despite substitution with vitamins.

Reactivity of sera and isolated monoclonal IgM from patients with Waldenström's macroglobulinaemia with peripheral nerve myelin

Sera of 23 patients with Waldenström's macroglobulinaemia and six monoclonal IgM paraproteins, which had been isolated from these sera, were examined for reactivity against peripheral nerve tissue. Of these 23 patients, 12 had clinical signs of peripheral polyneuropathy (PN). Using an indirect immunofluorescence method, all sera and monoclonal IgM preparations reacted with peripheral nerve structures, displaying a distinct granular fluorescence pattern with anti-IgM sera. The Waldenström sera reacted mainly with structures at the border of the myelin sheath, as well as between myelin and axon, and occasionally with the axon itself. There was no difference between sera of patients with PN and those without. Negative results were obtained in a complement fixation assay. Of the 23 sera, 15 reacted in an antibody-dependent lymphocyte-mediated cytotoxicity reaction (ADLC) with peripheral nerve myelin, and to a much lesser extent with myelin basic protein from CNS. Five of the six isolated monoclonal IgM preparations also gave positive ADLC reactions. These results constitute additional evidence for an immunological mechanism in the pathogenesis of PN in Waldenström's macroglobulinaemia.

[Tobacco-alcohol amblyopia. Clinical course in 33 patients]

The clinical data of 33 patients with tobacco-alcohol-amblyopia are described. Usually, the visual disturbance concerned both eyes and was not associated neither with headache nor with painful eye movements. The fundus was very often normal. In the static perimetry mostly relative or absolute central scotomas were found, sometimes centrocoecal scotomas and very seldom paracentral scotomas. The colour vision was very often disturbed, usually the red-green discrimination. In the rule the amplitudes of the visual evoked potentials were diminished, the P-100 latency was delayed in 39%. A follow-up of 25 patients revealed that the visus and the results of the static perimetry improved in 72% during vitamin substitution (B1, B2, B6, B12, folic acid). In a few cases this improvement could be observed even though the alcohol drinking was not ceased. In most cases the disturbance of the colour vision and the pathologic visual evoked potentials, however, did not change.

[Boeck's disease with unilateral optic nerve involvement]

A rare symptom of Boeck's disease is involvement of the fasciculus opticus. This paper reports on a patient with sarcoidosis who developed cerebral symptoms during the course of the disease; some months later he suffered an acute deterioration of vision in his right eye, with central scotoma but without papilledema. The difficulty of distinguishing this condition from bulbar neuritis in cases of multiple sclerosis is discussed.

The influence of disease activity on the number of blood cells of multiple sclerosis patients

The influence of disease activity on blood cell counts was studied in over 100 multiple sclerosis patients examined at regular intervals of 4-8 weeks over an 18-month period. T-lymphocytes were assessed by the cytochemical alpha-naphthyl-acetate-esterase (ANAE) stain in addition to conventional differentials. In all patients as a group as well as in individual patients studied sequentially, an exacerbation was marked by a striking reduction in both the relative and absolute numbers of ANAE-positive cells. Simultaneously, a strong increase in granulocytes and a slight augmentation of ANAE-negative cells occurred. Similar changes related to disease activity in leucocytes and lymphocytes were also detected in conventional blood smears. Fluctuations in the number of blood cells with disease activity persisted under therapy with corticosteroids and to a lesser degree also with azathioprine.

Azathioprine in treatment of multiple sclerosis. Final results of a 41/2-year controlled study of its effectiveness covering 115 patients

In an open, randomised, controlled follow-up study the effectiveness of continuous azathioprine therapy of multiple sclerosis with a dosage of 2 mg/kg/day was tested against a control group that was not treated with cytostatics. In the treated group the disease progressed less rapidly than in the untreated group. Statistically significant differences were only seen in patients having an intermittent-progressive course. The effect of azathioprine on the course was not dependent on the period or severity of illness nor on the patient's sex. In chronically progressive disease and with an intermittent disease course no influence of azathioprine was observed.

Course of multiple sclerosis. First results of a prospective study carried out of 102 MS patients from 1976-1980

The course of multiple sclerosis was monitored by means of a long-term prospective study. This paper reports on first results from this study, covering 102 patients who were monitored for 2 years or more and examined regularly. It is attempted to quantify the extent of the worsening or improvement in the patients' clinical status over the period of observation using regression analysis techniques. The severity of the disease did not correlate to the period of observation in 15% of the cases, these displaying no progression with regard to the clinical signs. In most cases (32%) a description of the disease progression was possible by means of a linear regression line, 21% had a parabolic and 23.5% an increasingly progressive course. For nine patients a second or third degree polynomial regression curve could be used to describe the course of the disease. The individual progression of the disease as estimated using the linear regression coefficient did not correlate with the individual relapse rate (on average 1.1 per year), nor with the age of the patient, the severity of the multiple sclerosis, the duration of the illness or with the previous course of the disease.

Azathioprine in multiple sclerosis--a 3 year controlled study of its effectiveness

The results of a prospective, long-term controlled study on the treatment of multiple sclerosis with azathioprine are reported. The effect of a daily 2 mg/kg body weight dosage on 56 randomly chosen patients with multiple sclerosis is compared with a non-treated control group of 51 randomly selected multiple sclerosis patients. The azathioprine therapy was continued in all cases for more than one year, on average for 732 days. To assess the effect of therapy, the course of the disease was followed by regular examinations evaluating the severity of the disease by use of an objective weighting-scale covering the whole range of neurological signs. The individual course of the disease within the observation period was determined by means of regression analysis. On average, the disease deteriorated less rapidly for those undergoing azathioprine therapy, this being most marked for patients who had had the disease for less than two years. For those who had been affected for longer, no significant differences in the progression of the disease could be detected. The annual relapse rate was the same for both categories.

Immune complexes in multiple sclerosis: relation to clinical pattern

Using a C1q binding test, circulating immune complexes (IC) were detected in 33.3% of sera from 138 patients and in 19.4% of 124 spinal fluid samples from patients with multiple sclerosis. Most often they occur in sera alone. As a rule their detectable amount is small in sera as well as in spinal fluids. IC were observed with equal frequency during acute exacerbations and in stable phases of the disease. In patients with early MS of less than 3 months duration, IC were detected only rarely, whereas their frequency increased up to 50% in patients with longer standing disease. Immunosuppressive therapy has no influence on IC formation. Patients with immune complexes exhibited a more rapid clinical deterioration if compared as a group with IC-negativ ones. No correlations were found between immune complex formation and the CSF-IgG index or the rate of pleocytosis in spinal fluids. Neither the complement factors C3, C4, C3A nor total hemolytic complement activities (CH50) in serum were significantly decreased in patients with IC formation in serum as compared with the IC-negative group. The results demonstrate that IC formation probably is of no importance in the pathogenesis of multiple sclerosis.

Cerebrospinal fluid immune complexes in multiple sclerosis

Using a C1q binding test, immune complexes have been detected in one half of cerebrospinal fluid samples from patients with multiple sclerosis. These results provide additional evidence for the participation of an immune reaction in the disease process.

[Optic neuritis in childhood (author's transl)]

The symptoms and signs of twenty-one children under 15 years of age with optic neuritis are presented here. The optic neuritis often was bilateral and accompanied by papilledema. In the acute stage there was however no typical central scotoma in every case. Some children had only peripheral visual field defects. The visual disorder will not improve so much as is general assumed: a slight decrease of visus and visual field defects in static perimetry usually persist. Half of the children developed signs of multiple sclerosis within a few years.

[Adie's syndrome from a neurological standpoint (author's transl)]

The findings in 22 examinations of tonic pupils, 15 of which presented Adie's syndrome, are described. The neurological and chemical as well as liquor analyses are normal except for the well known tendon reflex anomalies. Neurophysiologically, in 7 of 10 examinations mild disruptions in the sensory nerve conduction velocity were observed. The literature of the last 10 years, where it is of interest from a neurological standpoint and where it relates to the site of damage or to the origin of the tendon reflex abnormalities in Adie's syndrome, is discussed. Adie's syndrome is interpreted as damage to the peripheral nervous system in a polyneuropathic form.