Latency of herpes simplex virus in absence of neutralizing antibody: model for reactivation.

Mice inoculated with herpes simplex virus (type 1) by the lip or corneal route and then passively immunized with rabbit antibody to herpes simplex virus developed a latent infection in the trigeminal ganglia within 96 hours. Neutralizing antibody to herpes simplex virus was cleared from the circulation and could not be detected in most of these mice after 2 months. Examination of ganglia from the antibody-negative mice revealed latent virus in over 90 percent of the animals, indicating that serum neutralizing antibody is not necessary to maintain the latent state. When the lips or corneas of these mice were traumatized, viral reactivation occurred in up to 90 percent of the mice, as demonstrated by the appearance of neutralizing antibody. This study provides a model for identifying factors that trigger viral reactivation.

Lumbar puncture and subdural hygroma and hematomas in hematopoietic cell transplant patients.

We reviewed records of hematopoietic cell transplantation (HCT) patients seen over the past 10 years who had head scan documentation of subdural fluid collections. A total of 17 patients were identified: 13 with allogeneic and 4 with autologous HCT (0.71% of allogeneic and 0.13% of autologous HCT patients seen in this time interval). Although less than 20% of HCT patients have lumbar puncture, 8 of the 17 subdural patients had lumbar puncture. The lumbar puncture was done 5-112 days (median 46 days) before subdural detection. Acute lymphocytic leukemia was the diagnosis in five of these eight; whereas, either acute myelogenous leukemia or myelodysplasia was the diagnosis in seven of the nine patients without lumbar puncture. In the patient group with lumbar puncture, subdurals were diagnosed earlier after HCT (median 25 days versus 5 months in the patient group without lumbar puncture) and were more often hygromas (37.5 versus 0%). These results support the suggestion of lumbar puncture or intrathecal therapy as a risk factor for subdurals. The presumptive mechanism involves lumbar cerebrospinal leak, low intracranial pressure, downward displacement of the brain, cerebrospinal fluid accumulation into the inner dural layers of the cerebral convexities (hygromas) and bleeding into these fluid collections (hematomas).

Polymyositis as a manifestation of chronic graft-versus-host disease.

A syndrome indistinguishable from idiopathic polymyositis occurred in 11 patients as a manifestation of chronic GVHD. All patients had elevation of creatine phosphokinase (CPK). Immunohistology demonstrated the effector cells in the muscle infiltrates as cytotoxic T cells, a finding similar to idiopathic polymyositis. Polymyositis is a rarely reported complication of chronic graft-versus-host disease (GVHD) with only 8 cases described in the literature. We encountered this syndrome in a small but significant percentage of our patients with chronic GVHD. Polymyositis associated with chronic GVHD does not affect the overall prognosis for the patient. Moreover, polymyositis can be the only manifestation of chronic GVHD. Awareness of this complication is important because it can be confused with other causes of muscle weakness after bone marrow transplantation. Finally, prompt initiation of corticosteroid therapy results in a rapid improvement of the associated symptoms.

Extraction of D-beta-hydroxybutyrate by brain in diabetic rats.

Statistically significant cerebral arteriovenous differences of D-beta-hydroxybutyrate were found in rats made diabetic by administration of streptozotocin. The amount of D-beta-hydroxybutyrate extracted by the brain in diabetic animals increased with increasing arterial concentrations and the extraction ratios were comparable to those found in animals and humans with ketosis due to other causes.

Multiple sclerosis flares associated with recombinant granulocyte colony-stimulating factor.

Four of 10 patients who were enrolled on protocols of high-dose immunosuppression with peripheral blood stem cell rescue for MS experienced neurologic worsening while receiving recombinant human granulocyte colony-stimulating factor. There was improvement when methylprednisolone was given to three of the patients, but one patient died of respiratory failure. The mechanism of the neurologic worsening is uncertain.

Eye movement disorders in bone marrow transplant patients on cyclosporin and ganciclovir.

After 582 allogeneic bone marrow transplants, we have encountered four patients (0.7%) who developed transient unilateral or bilateral sixth nerve palsies. Three of the four patients also had bilateral ptosis. These signs resolved 24-48 h after cyclosporin and ganciclovir were discontinued. One patient had MRI T2 abnormalities compatible with cyclosporin neurotoxicity. We postulate that cyclosporin, possibly together with ganciclovir, can produce transient brain stem or neuromuscular dysfunction with eye movement abnormality in occasional patients.

Immune-mediated myelopathy after allogeneic marrow transplantation.

We describe two patients who developed myelopathy 15 and 27 months after allogeneic marrow transplantation. Exacerbations of the myelopathy occurred, with the development of optic neuropathy in one patient when corticosteroid therapy was tapered. The other patient had two exacerbations, 28 months and 40 months after transplantation, both of which resolved with plasma-pheresis. These case reports suggest that immune-mediated disease after transplantation can affect the central nervous system.

Exacerbation of inflammatory demyelinating polyneuropathy after bone marrow transplantation.

Two patients with hematologic malignancy and quiescent inflammatory demyelinating polyneuropathy developed severe exacerbations of polyneuropathy at the time of bone marrow transplantation. The clinical course in both patients was progressive despite therapy with immuno-suppressive agents, plasmapheresis, and high dose immunoglobulin. The polyneuropathy resulted in quadriplegia which contributed to the patients' deaths 175 and 48 days after transplantation. Sections of multiple peripheral nerves sampled post mortem in the first case revealed prominent demyelination with heavy infiltration of macrophages and lymphocytes. Immunohistochemical studies demonstrated that most of the lymphocytes were of the CD8+, cytotoxic/suppressor cell class and that many of the Schwann cells expressed class II (HLA-DR) antigen. This report suggests that bone marrow transplantation can exacerbate inflammatory demyelinating polyneuropathy.

Hematopoietic stem cell transplantation for multiple sclerosis. A retrospective multicenter study.

RATIONALE: Phase I/II studies of autologous hematopoietic stem cell transplantation (HSCT) for multiple sclerosis ( MS) were initiated, based on results of experimental transplantation in animal models of multiple sclerosis and clinical observations in patients treated concomitantly for malignant disease. PATIENTS: Eighty-five patients with progressive MS were treated with autologous HSCT in 20 centers and reported to the autoimmune disease working party of the European Group for Blood and Marrow Transplantation (EBMT). 52 (61 %) were female, median age was 39 [20-58] years. The median interval from diagnosis to transplant was 7 [1-26] years. Patients suffered from severe disease with a median EDSS score of 6.5 [4.5-8.5]. Active disease prior to transplant was documented in 79 of 82 evaluable cases. RESULTS: The stem cell source was bone marrow in 6 and peripheral blood in 79, and stem cells were mobilized into peripheral blood using either cyclophosphamide combined with growth factors or growth factors alone. Three patients experienced transient neurological complications during the mobilization phase. The high dose regimen included combination chemotherapy, with or without anti-lymphocyte antibodies or, with or without, total body irradiation. The stem cell transplants were purged of lymphocytes in 52 patients. Median follow-up was 16 [3-59] months. There were 7 deaths, 5 due to toxicity and infectious complications, 2 with neurological deterioration. The risk of death of any cause at 3 years was 10 (+/-7)% (95 % confidence interval). Neurological deterioration during transplant was observed in 22 patients; this was transient in most but was associated with MS progression in 6 patients. Neurological improvement by > or = 1 point in the EDSS score was seen in 18 (21 %) patients. Confirmed progression-free survival was 74 (+/-12)% at 3 years being 66 (+/-23)% in patients with primary progressive MS but higher in patients with secondary progressive or relapsing-remitting MS, 78 (+/-13)%; p = 0.59. The probability of confirmed disease progression was 20 (+/-11)%. MRI data were available in 78 patients before transplant showing disease activity (gadolinium enhancing, new or enlarging lesions) in 33 %. Posttransplant MRI showed activity at any time in 5/61 (8 %) evaluable cases. CONCLUSION: Autologous HSCT suggest positive early results in the management of progressive MS and is feasible. These multicentre data suggest an association with significant mortality risks especially in some patient groups and are being utilised in the planning of future trials to reduce transplant related mortality.

Immunocytochemical localization of herpes simplex virus antigen in the trigeminal ganglia of experimentally infected mice.

The peroxidase anti-peroxidase (PAP) technique was used to study the distribution of herpes simplex virus (HSV) antigens in mouse ganglia during the acute infection and the transition into the latent infection. At 2 days after HSV inoculation by the corneal route, immunoperoxidase staining was present in occasional isolated neurons of the trigeminal ganglion and also in scattered satellite cells. By 4 days, more cells were stained with the infection centered in the medial portion of the ganglion. Inflammatory cells were present around PAP-labeled fragments from lysed cells. Stained satellite cells often with a hypertrophic appearance surrounded labeled or unlabeled neurons in a ring-like array. At 6 days after HSV inoculation, there was a decrease both in the number of cells stained and in the intensity of staining. By 8 days, HSV antigens could be detected by weak PAP staining only in neurons. Otherwise, these neurons appeared morphologically normal. No immunoperoxidase staining was present after the 8th day. These results are compatible with retrograde axoplasmic transport of HSV and cell to cell spread of virus in ganglia. Also the appearance of infected ganglion cells during the transition to latency suggests that neurons can be switched from an HSV-permissive to a non-permissive (latent) state.

Cerebrospinal fluid interleukin 6 in amyotrophic lateral sclerosis: immunological parameter and comparison with inflammatory and non-inflammatory central nervous system diseases.

We assayed IL-6 in 105 cerebrospinal fluid (CSF) samples from patients with ALS, MS, HTLV-1 associated myelopathy (HAM), and controls. There was considerable overlap in IL-6 levels in all patient groups. The mean IL-6 in 27 patients with ALS was significantly higher than in 21 patients in the other neurological disease (OND) group (P=0.0075). There were no significant differences in MS or HAM and the OND control group. Overall, CSF IL-6 correlated with protein concentration but not with percentage IgG or IgG-albumin index. Patients with CSF oligoclonal bands were no more likely to have detectable IL-6 than patients without oligoclonal bands. Similarly, IL-6 did not correlate with clinical disease activity in MS when subgroups of patients were compared or when an individual patient was followed over time. The elevated IL-6 in ALS may reflect an ongoing humoral immune response, or IL-6 may be non-specifically expressed in these patients as a putative neurotrophic factor in response to nerve cell degeneration.

Ocular acyclovir delivery by collagen discs: a mouse model to screen anti-viral agents.

Discs 1.6 mm in diameter trephined from corneal collagen shields were used to deliver acyclovir (ACV) to the cornea of mice inoculated with herpes simplex virus type 1 (HSV-1). In the first minute after application to the cornea, there was a 23% decrease of ACV in the discs. After the first minute, ACV clearance from the discs appeared to be exponential with a half-life of 21 minutes. Treatment given 3 times a day reduced HSV-1 titer in tear film, corneal tissue, and trigeminal ganglia. This animal model should be useful to conserve novel potential anti-viral drugs undergoing initial screening.

Detection of herpes simplex virus DNA sequences in corneal transplant recipients by polymerase chain reaction assays.

Polymerase chain reaction (PCR) assays were used to amplify herpes simplex virus type 1 (HSV-1) thymidine kinase (TK) sequences in DNA extracted from formalin-fixed, paraffin embedded corneas of patients undergoing corneal transplantation. PCR reamplification with an internal (nested) set of primers was required for detection in 10 of the 12 positive corneas indicating very low abundance of viral sequences. Three of the positive corneal samples were from failed corneal grafts. Overall, TK sequences were detected in 8 of 11 corneas from subjects with a past history of herpes keratitis and in 4 of 11 corneas from subjects with no past history of herpetic eye disease.

Antiviral effects of herpes simplex virus specific anti-sense nucleic acids.

We have targeted mRNA sequences encompassing the translation initiation codon of the essential herpes simplex virus type 1 (HSV-1) IE3 gene with three kinds of anti-sense molecule. Addition of a 15mer oligodeoxyribonucleoside methylphosphonate to tissue culture cells resulted in suppression of viral replication. HSV-1 replication was also inhibited in cultured cells containing anti-sense vectors expressing transcripts complementary to the IE3 mRNA. We have also constructed a ribozyme which upon base pairing with the target IE3 mRNA induces cleavage at the predicted GUC site. A major obstacle to anti-sense studies in animals is drug delivery of preformed antisense molecules to ganglionic neurons, the site of HSV latency and reactivation. We speculate as to how this may be accomplished through carrier compounds which are taken up by nerve terminals and transported by retrograde axoplasmic flow. By the same route, HSV itself may be used as an anti-sense vector.

Autologous hematopoietic cell transplantation following high-dose immunosuppressive therapy for advanced multiple sclerosis: long-term results.

The purpose of the study was to determine the long-term safety and effectiveness of high-dose immunosuppressive therapy (HDIT) followed by autologous hematopoietic cell transplantation (AHCT) in advanced multiple sclerosis (MS). TBI, CY and antithymocyte globulin were followed by transplantation of autologous, CD34-selected PBSCs. Neurological examinations, brain magnetic resonance imaging and cerebrospinal fluid (CSF) for oligoclonal bands (OCB) were serially evaluated. Patients (n=26, mean Expanded Disability Status Scale (EDSS)=7.0, 17 secondary progressive, 8 primary progressive, 1 relapsing/remitting) were followed for a median of 48 months after HDIT followed by AHCT. The 72-month probability of worsening ≥1.0 EDSS point was 0.52 (95% confidence interval, 0.30-0.75). Five patients had an EDSS at baseline of ≤6.0; four of them had not failed treatment at last study visit. OCB in CSF persisted with minor changes in the banding pattern. Four new or enhancing lesions were seen on MRI, all within 13 months of treatment. In this population with high baseline EDSS, a significant proportion of patients with advanced MS remained stable for as long as 7 years after transplant. Non-inflammatory events may have contributed to neurological worsening after treatment. HDIT/AHCT may be more effective in patients with less advanced relapsing/remitting MS.

Multiple sclerosis conference synopsis and discussion: cellular therapy for treatment of autoimmune diseases (October 2005).

At a conference held in October 2005, participants presented studies on high dose immunosuppression with hematopoietic cell transplant (HCT) for multiple sclerosis (MS), including neuroimmunological and magnetic resonance imaging (MRI) mechanistic approaches, clinical registry reports, and ongoing or newly-designed protocols. A discussion panel considered questions on how to define success, timing of controlled clinical trials, difficulty in patient recruitment, and future direction of high dose therapy.