A proposed management algorithm for late-onset efavirenz neurotoxicity.

A high proportion of HIV-positive patients in South Africa receive concomitant efavirenz (EFV) and isoniazid (INH) therapy. EFV is metabolised in the liver via CYP2B6, and genetic polymorphism of CYP2B6 is known to result in slowed metabolism of the drug. INH is also metabolised in the liver, causing inhibition of a pathway that plays an important role in slow EFV metabolisers. Concomitant INH use therefore affects plasma levels of EFV. EFV is well known to cause neuropsychiatric side-effects on initiation, and a recent adult case series described late-onset neurotoxicity in the form of subacute ataxia and encephalopathy in patients treated with EFV for a median of 2 years, in association with toxic plasma levels of the drug. We have seen an increase in cases of EFV toxicity presenting to our neurology referral unit. All cases have been in the context of recent initiation of concomitant INH. We therefore conducted a retrospective case record audit to describe these seven cases with the additional advantage of tertiary-level assessment. We outline the clinical features and investigation results, as well as outcomes after EFV was stopped. Our main objectives are to highlight the probable role of concomitant INH use in the development of this syndrome, and to suggest that only limited work-up may be warranted in suspected cases.

Preventive motor training but not progenitor grafting ameliorates cerebellar ataxia and deregulated autophagy in tambaleante mice.

Treatment options for degenerative cerebellar ataxias are currently very limited. A large fraction of such disorders is represented by hereditary cerebellar ataxias, whose familiar transmission facilitates an early diagnosis and may possibly allow to start preventive treatments before the onset of the neurodegeneration and appearance of first symptoms. In spite of the heterogeneous aetiology, histological alterations of ataxias often include the primary degeneration of the cerebellar cortex caused by Purkinje cells (PCs) loss. Thus, approaches aimed at replacing or preserving PCs could represent promising ways of disease management. In the present study, we compared the efficacy of two different preventive strategies, namely cell replacement and motor training. We used tambaleante (tbl) mice as a model for progressive ataxia caused by selective loss of PCs and evaluated the effectiveness of the preventive transplantation of healthy PCs into early postnatal tbl cerebella, in terms of PC replacement and functional preservation. On the other hand, we investigated the effects of motor training on PC survival, cerebellar circuitry and their behavioral correlates. Our results demonstrate that, despite a good survival rate and integration of grafted PCs, the adopted grafting protocol could not alleviate the ataxic symptoms in tbl mice. Conversely, preventive motor training increases PCs survival with a moderate positive impact on the motor phenotype.

Disequilibrium syndrome and prevention in nonhemodialysis patients.

Disequilibrium syndrome (DS) is a central nervous system disorder described in hemodialysis (HD) patients. The authors present 4 cases of elevated blood urea nitrogen (BUN); the first patient passed away from suspected DS, whereas the other 3 patients were identified as having a high risk of developing DS on the basis of their BUN. The authors tried to lower their BUN slowly and prevent rapid correction by different methods. This is the first study in which DS has been studied in patients who are not on HD, and methods are described to identify and prevent DS in such patients. They also review the existing literature on the pathogenesis of DS and highlight the importance of recognizing this syndrome in non-HD patients, while suggesting some innovative ways to prevent it.

Exercise-induced neuroprotection in the spastic Han Wistar rat: the possible role of brain-derived neurotrophic factor.

Moderate aerobic exercise has been shown to enhance motor skills and protect the nervous system from neurodegenerative diseases, like ataxia. Our lab uses the spastic Han Wistar rat as a model of ataxia. Mutant rats develop forelimb tremor and hind limb rigidity and have a decreased lifespan. Our lab has shown that exercise reduced Purkinje cell degeneration and delayed motor dysfunction, significantly increasing lifespan. Our study investigated how moderate exercise may mediate neuroprotection by analyzing brain-derived neurotrophic factor (BDNF) and its receptor TrkB. To link BDNF to exercise-induced neuroprotection, mutant and normal rats were infused with the TrkB antagonist K252a or vehicle into the third ventricle. During infusion, rats were subjected to moderate exercise regimens on a treadmill. Exercised mutants receiving K252a exhibited a 21.4% loss in Purkinje cells compared to their controls. Cerebellar TrkB expression was evaluated using non-drug-treated mutants subjected to various treadmill running regimens. Running animals expressed three times more TrkB than sedentary animals. BDNF was quantified via Sandwich ELISA, and cerebellar expression was found to be 26.6% greater in mutant rats on 7-day treadmill exercise regimen compared to 30 days of treadmill exercise. These results suggest that BDNF is involved in mediating exercise-induced neuroprotection.

Protective effect of IL-18 on kainate- and IL-1 beta-induced cerebellar ataxia in mice.

The pathogenesis of sporadic cerebellar ataxia remains unknown. In this study, we demonstrate that proinflammatory cytokines, IL-18 and IL-1beta, reciprocally regulate kainate-induced cerebellar ataxia in mice. We show that systemic administration of kainate activated IL-1beta and IL-18 predominantly in the cerebellum of mice, which was accompanied with ataxia. Mice deficient in caspase-1, IL-1R type I, or MyD88 were resistant to kainate-induced ataxia, while IL-18- or IL-18R alpha-deficient mice displayed significant delay of recovery from ataxia. A direct intracerebellar injection of IL-1beta-induced ataxia and intracerebellar coinjection of IL-18 counteracted the effect of IL-1beta. Our data firstly show that IL-18 and IL-1beta display differential direct regulation in kainate-induced ataxia in mice. Our results might contribute toward the development of a new therapeutic strategy for cerebellar ataxia in humans.

Endogenous estrogen formation is neuroprotective in model of cerebellar ataxia.

The expression of aromatase, the enzyme that transforms testosterone into estradiol, was analyzed by reverse transcriptase polymerase chain reaction in the inferior olive of adult male rats. The expression of this messenger in the inferior olive suggests that this brain area may be able to synthesize estradiol. The neuroprotective role of estradiol in the inferior olive was then assessed in a model of cerebellar ataxia, achieved by the ip administration of 3-acetylpyridine (3-AP). In a first experiment, male Wistar rats were orchidectomized to diminish the plasmatic levels of testosterone, the direct precursor of estradiol. Immediately after castration, animals were implanted with a silicone tube that was either empty or filled with estradiol. One week later, animals were injected with 3-AP. Estradiol treatment resulted in a significant reduction in neuronal death in the olive. In a second experiment, animals were treated with fadrozole, an aromatase inhibitor, to assess the role of endogenous estradiol formation in neuroprotection. The results show that the inhibition of aromatase activity, and therefore the decrease in endogenous estrogen formation, increases the death in inferior olive. In conclusion, this study indicates that the inferior olive is a steroidogenic tissue and that olivary neurons are protected by exogenous and endogenous estradiol.

Mapping the gene for acetazolamide responsive hereditary paryoxysmal cerebellar ataxia to chromosome 19p.

Acetazolamide responsive hereditary paroxysmal cerebellar ataxia (APCA) is a rare autosomal dominant disorder characterized by attacks of cerebellar ataxia and dysarthria with normal or near normal neurologic function between attacks. A genome-wide search using polymorphic di- and tri-nucleotide repeats was initiated and the APCA locus was found to be linked to the short arm of chromosome 19 in two large kindreds. The microsatellite marker UT705 was found to be linked to the APCA locus with two point analysis yielding a maximum lod score of 8.20 at theta max = 0.000 in a five generation pedigree. Linkage to this region was confirmed in a second kindred. The absence of known candidate genes in the region may necessitate a positional cloning approach in order to identify the gene for this disorder.

Investigation of an epidemic of seasonal ataxia in Ikare, western Nigeria.

Seasonal outbreaks of an acute ataxic syndrome occur annually in parts of South-Western Nigeria, characterized by cerebellar ataxia, nystagmus and varying levels of impaired consciousness following consumption of the roasted larvae of Anaphe venata Butler (Lepidoptera, Notodontidae). An investigation of an epidemic in Ikare, headquarters of the Akoko north-east local Government in Western Nigeria (pop. 60,000) in the 1993 disease season is reported. The diagnosis of seasonal ataxia was verified in 34 consecutive new admissions (M:F 1:3.25, median age 29 years, range 2-70 years). All were of low socio-economic status, and had consumed the larvae of Anaphe venata prior to the onset of disease. There were 1,126 admissions for the seasonal ataxic syndrome in Ikare in the 1993 season, with an estimated attack rate of 1.87%. The peak incidence was in August, when patients with the syndrome accounted for 71% of all hospital admissions. There was no mortality. Control measures included therapy with high-potency multivitamins and health education.

The effect of neonatal thymectomy on Tamiami virus-induced central nervous system disease.

Tamiami virus, a member of the arenavirus group, produces an acute CNS disease in suckling mice manifested primarily by cerebellar ataxia, paralysis, convulsions, and death. Animals that survive are left with an asymptomatic cerebellar heterotopia. Neonatal thymectomy prevents both acute CNS disease and the resultant cerebellar heterotopia despite equivalent titers of virus and concentrations of viral antigen in the brains of both thymectomized and nonthymectomized infected mice. Inflammatory CNS disease and cerebellar germinal cell necrosis do not develop in thymectomized mice examined more than three months after infection. Viremia and complement-fixing antibody occur in both groups of mice with slightly higher antibody titers in nonthymectomized mice. Tamiami virus-induced cerebellar heterotopia appears to be immunologically-mediated, but the immunopathologic cerebellar lesion differs from the frank necrosis of the brain produced by both Tacaribe and LCM virus in newborn mice.