Clinical and pathological features affecting cardiac sympathetic denervation in autopsy-confirmed dementia with Lewy bodies.

BACKGROUND AND PURPOSE: The aim was to clarify the features affecting cardiac sympathetic denervation in autopsy-confirmed dementia with Lewy bodies (DLB) patients. METHODS: Fifty-four autopsy-confirmed DLB patients were enrolled. Tissue samples of the left ventricular anterior wall were immunostained with anti-tyrosine hydroxylase antibody to identify catecholaminergic nerve axons. Immunostained areas were quantified as residual cardiac sympathetic nerve (CSN) axons and the relationship between the degree of residual CSN axons and clinical and neuropathological features was examined. RESULTS: Virtually all patients showed small amounts of residual CSN axons (0.87%, range 0.02%-9.98%), with 50 patients (92.6%) showing <2.0% of residual axons. The patients who showed psychological symptoms within the first year of the disease had significantly more residual CSN axons than the remaining patients did (1.50% vs. 0.40%, P < 0.01). Patients with a short disease duration and neocortical-type Lewy body pathology tended to have more preserved CSN axons, although this difference was not statistically significant. Fifty-three patients (98.1%) who had neurofibrillary tangles in the brain and strong concomitant Alzheimer's disease pathology also had statistically significantly more preserved CSN axons. The patient with the most preserved CSN axons showed different characteristics from the results, except for the first symptom. CONCLUSION: Psychological symptoms within the first year of the disease, a short disease duration, neocortical-type Lewy body pathology and strong concomitant Alzheimer's disease pathology may be related to mild CSN degeneration in DLB patients. Thus, DLB patients with broad Lewy body pathology in the brain in the early stages may show mild CSN degeneration.

Unmyelinated axons are more vulnerable to degeneration than myelinated axons of the cardiac nerve in Parkinson's disease.

AIMS: We recently demonstrated accumulation of α-synuclein aggregates of the cardiac sympathetic nerve in Parkinson's disease (PD) and a possible relationship between degeneration of the cardiac sympathetic nerve and α-synuclein aggregates. The aim of this study is to determine whether there is a difference in the degenerative process between unmyelinated and myelinated axons of the cardiac nerve. METHODS: We immunohistochemically examined cardiac tissues from four pathologically verified PD patients, nine patients with incidental Lewy body disease (ILBD) and five control subjects, using antibodies against neurofilament, myelin basic protein (MBP) and α-synuclein. First, we counted the number of neurofilament-immunoreactive axons not surrounded by MBP (unmyelinated axons) and those surrounded by MBP (myelinated axons). Next, we counted the number of unmyelinated and myelinated axons with α-synuclein aggregates. RESULTS: (i) The percentage of unmyelinated axons in PD (77.5 ± 9.14%) was significantly lower compared to that in control subjects (92.2 ± 2.40%). (ii) The ratio of unmyelinated axons with α-synuclein aggregates to total axons with α-synuclein aggregates in ILBD ranged from 94.4 to 100 (98.2 ± 2.18%). Among axons with α-synuclein aggregates, unmyelinated axons were the overwhelming majority, comprising 98.2%. CONCLUSION: These findings suggest that in PD unmyelinated axons are more vulnerable to degeneration than myelinated axons of the cardiac nerve, because α-synuclein aggregates accumulate much more abundantly in unmyelinated axons.

Recruitment of nonexpanded polyglutamine proteins to intranuclear aggregates in neuronal intranuclear hyaline inclusion disease.

Recruitment of polyglutamine-containing proteins into nuclear inclusions (NIs) was investigated in neuronal intranuclear hyaline inclusion disease (NIHID). Some polyglutamine-containing proteins, ataxin-2, ataxin-3, and TATA box binding protein (TBP), as well as unidentified proteins with expanded polyglutamine tracts were recruited into NIs with different frequencies. Ataxin-3 was incorporated into most of the NIs and disappeared from its normal cytoplasmic localization, whereas only a small fraction of NIs contained ataxin-2 and TBP. The consistent presence of ataxin-3 in NIs could reflect a biological feature of wild-type ataxin-3, which is translocated into the nucleus under pathological conditions and participates in the formation of aggregates. Ataxin-2 also accumulated in the nucleus, but was not necessarily incorporated into NIs, suggesting that transport of these cytoplasmic proteins into the nucleus and their recruitment into NIs are not wholly explained by an interaction with a polyglutamine stretch and must be regulated in part by other mechanisms. The prevalence of ubiquitin-immunopositive NIs was inversely correlated to neuronal loss in all cases examined. This correlation could be explained if NI formation is a protective mechanism involving the ubiquitin-proteasome pathway. This hypothesis is supported by the finding that the polyglutamine epitope in the center of NIs was surrounded by ubiquitin.

Modeling the relation between neurofibrillary tangles and intellectual status.

The relationship between the neurofibrillary tangles and the intellectual deficit observed in senile dementia of the Alzheimer type was studied in 27 patients over the age of 75. The presence and density of tau positive tangles were assessed in six areas including limbic, paralimbic, and isocortical cortices. In the isocortical areas, the presence [1] or absence [0] of neurofibrillary tangles was better correlated with the Blessed test score than the density of the neurofibrillary tangles profiles. Multivariate analysis showed that the number of areas containing at least one neurofibrillary tangle was the best explanatory variable of the intellectual status. The cortical areas were ranked according to the prevalence of their involvement. The presence of tangles in an area of a given rank took place only if the areas of lower ranks were also involved. It is proposed that the presence of tangles in a given area is a more significant information than the value of their density. These data may lead to new diagnostic procedures.

Vascular and parenchymal Abeta deposition in the aging dog: correlation with behavior.

The behavior of 25 dogs was indirectly assessed by a formal questionnaire (evaluation of Age-Related Cognitive and Affective Disorders-ARCAD), filled out by the owner. The density of diffuse and vascular deposits was evaluated using four anti-Abeta peptide antibodies, in four temporal areas. Parenchymal, diffuse deposits of Abeta42 peptide were found in all aged animals but one. They were Congo red negative and were not immunostained by the anti-Abeta40 antibody, contrary to the vascular deposits. The densities of vascular and parenchymal deposits were not correlated. The ARCAD score was correlated with age, density of Abeta parenchymal and vascular deposits, and with the number of areas containing deposits (extension index). Multivariate analysis showed that the age and the extension index explained most of the variance. Congo red positivity (indicating that the Abeta peptide has the characteristics of an amyloid substance) is limited in the dog to the vascular wall and is associated, as in man, with the deposition of the Abeta 1-40 isoform. Parenchymal Abeta deposition seems to be a common correlate of behavioral problems in aging dogs.

Single-laser three-color immunolabeling of a histological section by laser scanning microscopy: application to senile plaque-related structures in post-mortem human brain tissue.

We describe a method for observing three-color immunofluorescence simultaneously in a histological section under a confocal laser scanning microscope. In this study we investigated the spatial relationship of blood vessels, reactive microglia, and amyloid beta-protein (A beta) deposits in post-mortem brain tissue of patients with Alzheimer's disease. HLA-DR was employed as a marker for activated microglia and von Willebrand factor (vWF) as a marker for vascular endothelial cells. HLA-DR was labeled with R-phycoerythrin (R-PE) and vWF with fluorescein isothiocyanate. A beta-protein was immunostained with the tandem conjugate of R-PE and cyanin 5. Three images were obtained serially by scanning a tissue section with a 488-nm laser beam in combination with an appropriate emission filter for each fluorochrome. Overlaying of these three images permitted simultaneous observation of three distinct structures: activated microglia, blood vessels, and A beta deposits. This technique provides an improved way to study the localization of three different antigens in a single tissue section.

Alzheimer-type pathology in melanin-bleached sections of substantia nigra.

Bleaching of melanin prior to Gallyas staining enabled us to detect an unexpectedly large number of neurofibrillary tangles (NFTs; 62 and 50 NFTs in the upper and the lower substantia nigra, respectively, mostly in the neuronal cytoplasm of the medial zona compacta) in brains of patients who had had Alzheimer's disease. Amyloid-like deposits were quite scarce. In Alzheimer's disease it has been commonly observed that other subcortical nuclei projecting widely to the cerebral cortex also contain a large number of NFTs, although they have few amyloid deposits. In these subcortical nuclei retrograde degeneration may initially affect intraneuronal processes, leading to the preferential development of NFTs in the neuronal cytoplasm.

Action myoclonus induced by visually guided movement.

In order to determine what kind of voluntary movement induces action myoclonus, we gave two siblings with sialidosis two kinds of tasks. When the patients were asked to move their index fingers following a smoothly moving target, action myoclonus became prominent. In contrast, when they were asked to perform the same movements with their eyes closed, they could move their index fingers very smoothly. This shows that action myoclonus was induced by visually guided movement, but not by self-paced movement. Our observations might reflect a disorder of the cerebellum, which controls visually guided movement.

Increased CSF tau protein in corticobasal degeneration.

Using a sensitive sandwich enzyme-linked immunosorbent assay (ELISA) method, we measured the concentration of total tau protein in the cerebrospinal fluid (CSF) from nine patients with corticobasal degeneration (CBD) in comparison with 12 normal control subjects in order to assess its diagnostic value. The CSF concentration of tau in patients with CBD (0.69, 0.20 ng/ml; mean, SD) was higher than that in, the normal controls (0.48, 0.14 ng/ml, P = 0.0076 unpaired t test). This increase in CBD patients may reflect widespread tau pathology in CBD, but should be interpreted with reserve as an aid to diagnosis.

Appearance of tau-2 immunoreactivity in glial cells in human brain with cerebral infarction.

Appearance of tau epitopes in ischemic foci was investigated immunohistochemically on a series of autopsied human brains using a panel of anti-tau antibodies. While neurons were immunopositive for Alz-50, microglia and oligodendroglia around ischemic foci abundantly contained tau-2 immunoreactivity. Some astrocytes contained tau-2 immunoreactive granules in their cytoplasm. This difference suggests that neurons and glia react differently to an ischemic insult by exhibiting different tau epitopes. Immunohistochemical visualization tau-2 epitope represents its conformational change, as was reported with neurofibrillary tangles of Alzheimer type. Lack of argyrophilia in any of these tau-immunoreactive cells distinguishes them from tau-immunoreactive structures seen in various neurodegenerative disorders.

ApoE immunoreactivity and microglial cells in Alzheimer's disease brain.

The spatial relationship of apolipoprotein E (apoE)-like immunoreactivity (IR) to amyloid beta-peptide (A beta), astrocytes and microglial cells in the brain of Alzheimer's disease was studied by double immunolabelling. Diffuse apoE-like IR was seen in A beta diffuse deposits, and markedly increased in the core of classic senile plaques. Microglial cells, sometimes immunoreactive for apoE, were frequent in areas of apoE-like IR, where they often grouped into clusters in the core of apoE-labelled senile plaques. Although astrocytic processes were seen within these senile plaques, the cell bodies were always at a distance from the core. None of these astrocytes expressed apoE-like IR. Microglial cells, some of them immunoreactive for apoE, were seen in the center of apoE-labelled senile plaques. These data suggest that microglial cells play a more significant role than astrocytes in apoE deposition in senile plaques of Alzheimer disease.

Neuronal intranuclear inclusions in spinocerebellar ataxia type 2: triple-labeling immunofluorescent study.

Spinocerebellar ataxia type 2 (SCA2) is associated with an expansion of CAG/polyglutamine-repeat of a gene of unknown function. We performed an immunohistochemical study to identify the immunolocalization of the disease protein ataxin-2 in normal and SCA2 patients. Although normal and expanded ataxin-2 were ubiquitously localized to the cytoplasm of neurons, ubiquitinated intranuclear inclusions were observed selectively in 1-2% of neurons of affected brain regions except the cerebellum. Triple-labeling immunofluorescence revealed that ataxin-2, expanded polyglutamine and ubiquitin were colocalized to these neuronal intranuclear inclusions (NIs), indicating that SCA2 shares morphological characteristics common to other neurological disorders associated with an expansion of CAG/polyglutamine-repeat. Lack of NIs in the cerebellar lesion, however, suggests the discrepancy between formation of NIs and neuronal degeneration in SCA2.

Pure progressive clumsiness due to parietal atrophy in a young adult.

Progressive clumsiness developed in the right hand of a 33-year-old man, became bilateral and evolved very slowly for ten years. Another neurological deficit was restricted to a slight impairment of superficial sensations. Magnetic resonance imaging verified an atrophy of bilateral parietal lobes. The cerebral blood flow was markedly decreased in the atrophic area. Pure clumsiness of a very slowly progressive course due to parietal atrophy has never been reported in such a young adult. This clinical picture may suggest another variety of degenerative process.

Myoclonus with burning sensation in legs that remits with sympathetic blockade.

Two patients with hitherto unrecognized spells of involuntary movements in legs are described. They occurred on dropping off to sleep, were preceded by a burning sensation and resembled myoclonus. Subcutaneous injection of epinephrine reproduced the spells. Neurogenic bladder of uninhibited type was noted on cystometry. Epidural or sympathetic nerve block of the lumbar region relieved all the symptoms including the neurogenic bladder. A few minutes before the spells, a rise in blood pressure and pulse rate was observed in one of the cases. Pathophysiological resemblance to painful legs and moving toes was pointed out, but more widespread involvement of the spinal cord was suspected.

Successful treatment of atypical mycobacterial meningitis by fluoroquinolone.

We report a case of restricted meningeal infection by atypical mycobacteria, identified by the polymerase chain reaction, in a non-immunocompromised adult successfully treated by multiple antibiotics including fluoroquinolone. New quinolones should be considered as a therapeutic option for such mycobacterial meningitis.

Compression of brachial plexus as a diagnostic test of cervical cord lesion.

STUDY DESIGN: This study evaluated the clinical significance of radicular signs around the neck in relation to mechanical lesions of the cervical spine and cord. SUMMARY OF BACKGROUND DATA: Classical radicular signs around the neck, such as Jackson's sign or Spurling's sign, are not sensitive enough to detect corresponding lesions. OBJECTIVES: Compression of the brachial plexus elicits radiating pain (BP) in patients with cervical lesions. The clinical significance of this new sign as a potential indicator of the cervical lesion compared with other classical signs was evaluated. METHODS: Sixty-five patients who underwent magnetic resonance imaging of the cervical spine were prospectively evaluated for these clinical signs that elicit radiating pain around the neck. Clinical signs were correlated to deformity of the cervical spine and cord and to final diagnosis. RESULTS: Classical radicular signs often were lacking, even in patients with mechanical lesions around the cervical spine. However, BP was often observed in these patients. CONCLUSIONS: Compared with the classical radicular signs, BP is highly sensitive and reasonably specific in detecting mechanical lesions around the cervical spine, and suggests radicular involvement.

Myoclonic activity associated with cefmetazole, with a review of neurotoxicity of cephalosporins.

We reported a case of a 66-year-old female with uremia who developed myoclonic activity after administration of cefmetazole (4g/2 days). Curiously, the level of the antibiotics (236 micrograms/ml) in the cerebrospinal fluid (CSF) was higher than that in the blood (103 micrograms/ml). Myoclonic activity faded away after cessation of the antibiotics. This is the first case reported developing neurotoxicity associated with intravenous administration of cefmetazole. In addition, the curious pharmacokinetic dynamics of cephalosporin in uremia is discussed.

Spontaneous resolution of an acute spontaneous spinal epidural hematoma without neurological deficits.

A 46-year-old woman presented with sudden severe pain in the interscapular region. Physical examination, including detailed neurological evaluation, did not disclose any abnormalities. However, magnetic resonance imaging revealed an epidural hematoma anterior to the thoracic spinal cord and its spontaneous resolution thirty days after onset. Her hospital course was uneventful. To our knowledge, this report documents the first case of a spontaneous spinal spidural hematoma without neurological deficits. Spinal epidural hematoma may be more common than previously thought because some cases have probably been misdiagnosed as transient back pain of unknown etiology.

Marked elevation of carcinoembryonic antigen and carbohydrate antigen 19-9 in the peripheral blood as an initial manifestation of meningeal carcinomatosis.

Marked elevation of tumor markers in the peripheral blood was initially a sole manifestation of meningeal carcinomatosis in a man with gastric carcinoma. In addition to extensive meningeal carcinomatosis, no metastatic lesions were found at autopsy other than microscopic infiltration into a tiny paraaortic lymph node. Elevation of these markers in the peripheral blood is best explained by meningeal carcinomatosis. When elevation of these markers is otherwise unexplainable, meningeal carcinomatosis should be considered as a diagnostic possibility even in the absence of neurological symptoms.