CSF/serum quotient graphs for the evaluation of intrathecal C4 synthesis.

BACKGROUND: Cerebrospinal fluid (CSF)/serum quotient graphs have been used previously to determine local synthesis in brain of immunoglobulins and C3 complement component. The aim of this study was to use the same technique to construct quotient graphs, or Reibergrams, for the beta globulin C4 and to evaluate the method for assessing intrathecal synthesis in neurological disease. METHODS: The constants in the previously-defined Reibergram for immunoglobulin IgA were used to calculate the CSF/serum quotient for C4. CSF and serum were analyzed for C4, IgA and albumin from a total of 12 patients with meningoencephalitis caused by encapsulated microorganisms and 10 subjects without infections or inflammatory neurological disease, some of which had dysfunction of the blood-CSF barrier, RESULTS: The formula and C4 Reibergram with the constants previously found for IgA, determined the intrathecal C4 synthesis in CSF. The intrathecal C4 fraction in CSF (C4 loc in mg/l) was compared to the C4-Index (fraction of CSF: serum for C 4/fraction of CSF: serum for albumin). There was a significant correlation between the two formulae. The CSF/Serum quotient graph was superior for detecting intrathecal synthesis of C4 under variable conditions of blood-CSF barrier permeability. CONCLUSION: The C4 Reibergram can be used to quantify the intrathecal synthesis of this component of the complement system in different infectious diseases of the central nervous system and is especially useful for patients with blood-brain barrier dysfunction.

Intrathecal synthesis of IgE in children with eosinophilic meningoencephalitis caused by Angiostrongylus cantonensis.

BACKGROUND: Eosinophilic meningoencephalitis caused by the helminth Angiostrongylus cantonensis, is an emerging infectious disease in America. The objective of this paper was to determine if the intrathecal synthesis of immunoglobulin E is produced during the acute phase of the disease. METHODS: Thirteen patients, mean age 4.5 years were studied; a diagnostic lumbar puncture was performed and serum samples taken. Immunoglobulin E (IgE) in serum and in cerebrospinal fluid (CSF) was quantified by nephelometry. Control patients had other infections or other neurological diseases. RESULTS: The mean cell count in the CSF was 500 x 10-6 cells/L and of these 23% were eosinophils. In blood the eosinophils were 13%. The chief symptoms of the patients were migraine, vomiting and fever and 50% presented some meningeal signs. IgE intrathecal synthesis analyzed by the corresponding quotient diagram (Reibergram) was observed in all patients. No intrathecal IgE synthesis was seen in control patients. CONCLUSION: Intrathecal synthesis of IgE demonstrates the participation of this immunoglobulin in the destruction of the third stage larvae of the parasite in the CSF. The test should be considered in our environment as a tool to aid diagnosis.

sICAM-1 intrathecal synthesis and release during the acute phase in children suffering from Coxsackie A9 and S. pneumoniae meningoencephalitis.

The intercellular adhesion molecule is a transmembrane glycoprotein belonging to the immunoglobulin superfamily. Serum and cerebrospinal fluid (CSF) soluble intercellular adhesion molecule 1 (sICAM-1) from normal control children as well as from children with Guillain-Barré syndrome (GBS), with Coxsackie A9 virus meningoencephalitis and with Streptococcus pneumoniae meningoencephalitis were studied. sICAM-1 was quantified using an immunoenzimatic assay and albumin using the immunodiffusion technique in both biological fluids. Increased sICAM-1 values in CSF in patients with GBS correspond to an increase of the albumin CSF/serum quotient. In contrast, in inflammatory diseases like S. pneumoniae and Coxsackie A9 virus meningoencephalitis an increased brain-derived fraction was observed. In particular cases these values are 60-65% and 70-75% respectively. The results indicate an additional synthesis of sICAM-1 in subarachnoidal space during central nervous system (CNS) inflammatory process. An important role of sICAM-1 in the transmigration of different cell types into CSF during CNS inflammation in children with S. pneumoniae and Coxsackie A9 meningoencephalitis may be suggested.

C3c intrathecal synthesis evaluation in patients with multiple sclerosis.

INTRODUCTION: Multiple sclerosis (MS) is a chronic, inflammatory and progressive disease of the central nervous system in which local inflammatory injuries of the brain white matter appears, being the most outstanding feature the myeline loss (demyelination). OBJECTIVE: To determine if the complement system might be involved in the MS immunopathogeny favouring the mechanism intervening in the myelin destruction. METHOD: Samples of sera and CSF from twelve patients with a diagnosis of MS obtained at the moment of the admission to the hospital at the beginning of the break out, were collected. Levels of C3c and albumin in sera and in CSF were quantified using radial immunodiffusion plates. RESULTS: High values over 80% of intrathecal synthesis were obtained except in one of the patients. CONCLUSION: Intrathecal synthesis of C3c and its liberation to the CSF means that the activation of the complement system in any of the two ways has taken place, and that once performed its biological functions, has suffered a degradation process.

[Reibergram for C3c intrathecal synthesis evaluation]. / Reibergrama para la evaluación de la síntesis intratecal de C3c.

INTRODUCTION: Reiber's quotient diagram or reibergram has a growing apply for characterize the intratecal synthesis of proteins. Firstly reibergrama was used for the major classes of immunoglobulins but later it was used to evaluate other proteins based on the theory about molecular flux/cerebrospinal fluid (CSF) flow rate. METHOD: C3c is a degradation product of complement factor C3 with 145 KDa and approaches to IgG molecular characteristics according with Fick's diffusion laws. It was assumed IgG constants and graphic for IgG constants and graphic to evaluate the intrathecal synthesis of C3c. Twenty-seven patients and 27 controls were studied. Serum and CSF C3c and albumin were quantified by immunodiffusion. RESULTS: The patients with the C3c proposed reibergram were evaluated. It has been proved its validity under several CSF blood barrier conditions. CONCLUSION: Reibergram for C3c can be used for the evaluation of the intrathecal synthesis of this protein.

sICAM-1 in meningoencephalitis due to Angiostrongylus cantonensis.

INTRODUCTION: Angiostrongylus cantonensis meningoencephalitis is an emergent disease in the Americas. METHOD: Twelve children suffering from eosinophilic meningoencephalitis due to this parasite aged between 6-10 years were studied. Cerebrospinal fluid (CSF) and serum samples were taken simultaneously in the first diagnostic puncture at admission. RESULTS: All cases showed typical findings on the routine CSF and serum analysis: increased CSF total protein, increased Q (CSF/serum) albumin accompanied by eosinophilia in CSF. No intrathecal synthesis of immunoglobulins was found. Mean serum and CSF sICAM-1 values were 337.4 and 3.97 ng/mL. Qalbumin and QsICAM-1 mean values were 4.1 and 6.2 respectively. In 50% of the patients an increased brain-derived fraction of sICAM-1 was found. CONCLUSION: It may be suggested that a dynamic of the sICAM-1 brain derived fraction is perhaps associated to the immune response in the evolution of the disease.sICAM-1 may be an agent in negative feedback for eosinophils passage through the blood-CSF barrier into the inflammatory brain response.

IgG1,IgG2 and IgE intrathecal synthesis in Angiostrongylus cantonensis meningoencephalitis.

INTRODUCTION: Angiostrongylus cantonensis meningoencephalitis is an emergent zoonotic disease in the Caribbean basin, characterized by the presence of eosinophils and third stage larva of the helmint. OBJECTIVE: To analyze the IgG subclasses and IgE intrathecal synthesis patterns obtained by reibergrams in pediatric patients suffering from eosinophilic meningoencephalitis due to A. cantonensis. PATIENTS AND METHODS: 20 pediatric patients with the disease were studied. During the first diagnostic lumbar puncture an eosinophilic pleocytosis was found. Simultaneously a serum sample was taken. Eight days later, a second lumbar and venous puncture was performed. IgA, IgM, IgG, albumin in serum and cerebrospinal fluid samples were quantified by immunodiffusion in addition to a differential cell count in cerebrospinal fluid. IgG subclasses were quantified in 10 patients by immunodiffusion and IgE in four patients by nephelometry. RESULTS: During the first diagnostic lumbar puncture, all the cases had a blood-cerebrospinal fluid barrier dysfunction with absence of immunoglobulins intrathecal synthesis, a mean of 450 cells/mul and an average of 48% of eosinophils. In the second lumbar puncture 40% of the patients had a dysfunction of the blood-cerebrospinal fluid barrier and an intrathecal synthesis pattern of IgA+IgM+IgG in 50% of the patients. Eight patients had an intrathecal IgA+IgG class response. The synthesis pattern of IgG subclasses was IgG1+IgG2 in six patients, IgG1+IgG2+IgG3 in one patient, IgG1+IgG2+IgG4 in one more patient. Two patients from the second lumbar puncture remained without intrathecal synthesis. IgE intrathecal synthesis was observed in the four analyzed patients in the first diagnostic lumbar puncture. CONCLUSIONS: The IgG1+IgG2 and IgE intrathecal synthesis pattern demonstrated the complexity of the antigenic mosaic of the helmint and it can contribute to diagnosis of eosinophilic meningoencephalitis due to A. cantonensis.

Intrathecal activation as a typical immune response within the central nervous system in angiostrongyliasis.

Angiostrongylus cantonensis is a zoonotic pathogen that occasionally causes human angiostrongyliasis; its main clinical manifestation is eosinophilic meningitis. This report defines the concept of intrathecal activation of complement as evidence of intrathecal synthesis of major immunoglobulins during this disease. Details are presented of the activation of complement system components in cerebrospinal fluid, and their application to our understanding of this tropical disease, which is emerging in the Western hemisphere. Intrathecal synthesis of at least one of the major immunoglobulins and a wide spectrum of patterns may be observed. Although intrathecal synthesis of C3c is always present, C4 intrathecal synthesis does not occur in every patient. The diversity of intrathecal synthesis and activation of the different complement pathways enables their division into three variant groups (A, B, and C). Variant group A includes the classical and/or lectin pathway and involves two or more major immunoglobulins with C3 and C4 intrathecal synthesis. Variant group B involves C4 in cerebrospinal fluid that comes from blood in the intrathecal activation of the classical pathway. Variant group C includes the alternative pathway.

Different intrathecal immunoglobulins synthesis patterns in human host indicate different strains of Angiostrongylus cantonensis.

Eosinophilic meningitis is an emerging disease in western hemisphere produced by Angiostrongylus cantonensis. It was first reported in Cuba in 1981, later was spreading for the Caribbean basin and recently in Ecuador. Ecuadorians have typical intrathecal major immunoglobulins synthesis patterns that are different to Cuban ones. There is a molecular differentiation and phylogenetic relationships of three A. cantonensis geographical isolates. Differentiation in the neuroimmunological patterns found in patients from different countries may be explained by taking into account different strains of the helmint. Here, we discuss that the different between intrathecal synthesis patterns of major immunoglobulins found in patients from different geographical regions not directed linked is due to different circulating strains that produce typical patterns.

Mannan-binding lectin in cerebrospinal fluid: a leptomeningeal protein.

BACKGROUND: Mannan-binding lectin (MBL), a protein of the innate immune response is attracting increasing clinical interest, in particularly in relation to its deficiency. Due to its involvement in brain diseases, identifying the source of MBL in CSF is important. Analysis of cerebrospinal fluid (CSF) can provide data that discriminates between blood-, brain-, and leptomeninges-derived proteins. To detect the source of MBL in CSF we need to consider three variables: the molecular size-dependent concentration gradient between CSF and blood, the variation in transfer between blood and CSF, and the CSF MBL concentration correlation with the albumin CSF/serum quotient (QAlb), i.e., with CSF flow rate. METHODS: MBL was assayed in samples of CSF and serum with an ELISA, coated with anti MBL antibodies. Routine parameters such as albumin-, immunoglobulin- CSF/serum quotients, oligoclonal IgG and cell count were used to characterize the patient groups. Groups comprised firstly, control patients without organic brain disease with normal CSF and normal barrier function and secondly, patients without inflammatory diseases but with increased QAlb, i.e. with a blood CSF barrier dysfunction. RESULTS: MBL concentration in CSF was at least five-fold higher than expected for a molecular-size-dependent passage from blood. Secondly, in a QIgM/QAlb quotient diagram (Reibergram) 9/13 cases showed an intrathecal fraction in some cases over 80% of total CSF MBL concentration 3) The smaller inter-individual variation of MBL concentrations in CSF of the control group (CV = 66%) compared to the MBL concentrations in serum (CV = 146%) indicate an independent source of MBL in CSF. 4) The absolute MBL concentration in CSF increases with increasing QAlb. Among brain-derived proteins in CSF only the leptomeningeal proteins showed a (linear) increase with decreasing CSF flow rate, neuronal and glial proteins are invariant to changes of QAlb. CONCLUSIONS: MBL in CSF is predominantly brain-derived and all results pointed to the leptomeningeal cells as the source of the protein. The evaluation of this protein requires the interpretation of its absolute concentrations in CSF as a function of the albumin quotient, QAlb. This recognition of MBL in brain cells opens a new field of discussion about the function of the innate immune response in CNS in cases of acute and chronic neurological diseases.

Neuroinmunología de la meningoencefalitis por Cryptococcus neoformans. Presentación de un caso / Neuroimmunology of meningoencephalitis by Cryptococcus neoformans. A case report

Introducción: la meningitis/meningoencefalitis criptococócica es una forma infrecuente de infección del sistema nervioso central, producida por Cryptococcus neoformans. Objetivo: mostrar la respuesta neuroinmunológica, a través del reibergrama, en un paciente con meningoencefalitis crónica por Cryptococcus neoformans. Presentación del caso: se cuantificaron los niveles de IgA, IgM, IgG y albúmina en suero y líquido cefalorraquídeo a partir de las cinco punciones lumbares que se le realizó a la paciente y se confeccionó el reibergrama correspondiente. Se comprobó la ocurrencia de síntesis intratecal de, por lo menos, dos clases de inmunoglobulinas mayores, se observó un porciento mayor de síntesis intratecal de IgG. No existió disfunción de la barrera sangre/líquido cefalorraquídeo. Conclusiones: el estudio neuroinmunológico del líquido cefalorraquídeo indica la cronicidad de la entidad. La síntesis intratecal de inmunoglobulinas y el estado de la barrera sangre/líquido cefalorraquídeo constituyen elementos claves en el diagnóstico de la neuroinflamación(AU)

Introduction: Meningitis/meningoencephalitis is a non-frequent central nervous system infection produced by Cryptococcus neoformans. Objective: To show the neuroimmunological response using reibergram in a patient with chronic meningoencephalitis due to Cryptococcus neoformans. Case presentation: Serum and cerebrospinal fluid IgA, IgM, IgG and albumin levels were quantified in a patient suffering from the disease by means of five lumbar punctures during her evolution; the results were plotted in their corresponding reibergram. Syntheses of at least two intrathecal major immunoglobulin were confirmed. A percent bigger of IgG intrathecal synthesis was observed. There is no blood-brain barrier dysfunction. Conclusion: Intrathecal immunoglobulin synthesis and blood-brain barrier situation constitute key element in the neuro-inflammation diagnosis(AU)

Comparison of major immunoglobulins intrathecal synthesis patterns in Ecuadorian and Cuban patients with angiostrongyliasis.

Angiostrongylus cantonensis meningitis was first reported in Cuba in 1981, and it was recently reported in South America. The aim of this paper is to evaluate the intrathecal immunoglobulin synthesis patterns from Cuba's and Ecuador's patients with angiostrongyliasis; 8 Ecuadorian patients from two different outbreaks and 28 Cuban patients were studied. Simultaneous blood and cerebrospinal fluid samples were taken. Immunoglobulin (Ig) A, IgM, IgG, and albumin were quantified by radial immunodiffusion. Corresponding Reibergrams were applied. A three-Ig pattern was the most frequent in the two groups, but IgM was presented in all Ecuadorian young mature patients; however, in the Cuban children, only 12 of 28 patients had intrathecal IgM, but about 90% had an IgA and IgG synthesis at time of later puncture. This indicates that, with a larger amount of parasites ingested, clinical symptoms are more severe, and a higher frequency of intrathecal IgM synthesis could be observed. This is discussed as a similarity with the intrathecal IgM synthesis in African trypanosomiasis.

Mannose-binding lectin deficiency with eosinophilic meningoencephalitis due to Angiostrongylus cantonensis in children: a case series.

INTRODUCTION: Eosinophilic meningitis, a potentially fatal disease caused by Angiostrongylus cantonensis, is considered an emerging infectious disease. CASE PRESENTATION: Three Caucasian boys (aged five-years-old, 10-years-old and six-years-old) with a diagnosis of eosinophilic meningoencephalitis caused by Angiostrongylus cantonensis were studied. Serum immunoglobulin A (IgA), IgM, IgG, and complements C3c and C4 levels were quantified by using an immunodiffusion technique. Immunoglobulin E in serum was quantified by nephelometry and mannose-binding lectin by time-resolved fluorometry. Mannose-binding lectin deficiency was observed in the three patients. The first patient showed a reduction in the levels of IgA and IgM and an increase in the values of IgE and C4. The second patient showed a reduction in mannose-binding lectin level with increased IgG, C4 and IgE levels, and the third patient showed a decrease in mannose-binding lectin level and increased levels of IgM and complement C3c as well as a low level of C4. CONCLUSIONS: To the best of our knowledge, this is the first report of mannose-binding lectin deficiency associated with Angiostrongylus cantonensis meningoencephalitis in children, and it may contribute to the understanding of the participation of this component of the lectin pathway in the development of the disease.

Neuroimmunological findings of Angiostrongylus cantonensis meningitis in Ecuadorian patients.

UNLABELLED: Meningitis caused by Angiostrongylus cantonensis has recently been reported in patients resulting from the first outbreaks in subtropical regions of Ecuador. METHOD: Eight young adult patients from the two outbreaks were studied. IgA, IgM, IgG and albumin in cerebrospinal fluid and serum were quantified and plotted in cerebrospinal fluid/serum quotient diagrams (Reibergrams). The anamnesis on the patients included asking about any consumption of raw snails, symptoms and harm caused. RESULTS: Mean eosinophilia of 7.5% and 26% in serum and cerebrospinal fluid respectively was observed, as well as a moderate increase in total proteins. The most frequent pattern of intrathecal synthesis was observed in three classes of immunoglobulins. Intrathecal synthesis of IgM was observed in all cases two weeks after the first symptoms appeared. CONCLUSION: The intrathecal synthesis patterns of eosinophilic meningitis due to Angiostrongylus cantonensis, facilitated by cerebrospinal fluid analysis, were similar to those of previous cases from abroad.

Reibergram of intrathecal synthesis of C4 in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis.

Angiostrongylus cantonensis produces eosinophilic meningitis in humans and is endemic in Thailand, Taiwan, China, and the Caribbean region. During infection with this parasite, it is important to know if the complement system may be activated by the classical or lectin pathway. Cerebrospinal fluid and serum samples from 20 patients with meningitic angiostrongyliasis were used to quantify C4 levels and albumin. Results were plotted on a C4 CSF/serum quotient diagram or Reibergram. Twelve patients showed intrathecal synthesis of C4. Antibody-dependent complement cytotoxicity should be considered as a possible mechanism that destroys third-stage larvae of this helminth in cerebrospinal fluid of affected patients.

Clinical behavior of Streptococcus pneumoniae meningoencephalitis.

OBJECTIVE: There was an increased number of cases of meningoencephalitis caused by Streptococcus pneumoniae, after the successful vaccination campaigns against Neisseria meningitidis and Haemophilus influenzae. This paper aims at describing the clinical characteristics, the laboratory findings, the complications, and the therapeutic management of these patients, who have been suffering from this disease since 1993 to 2006. METHOD: Twelve children with Streptococcus pneumoniae meningoencephalitis admitted to the pediatric hospital of San Miguel del Padron, City of Havana in this period were assessed. RESULTS: Children under one year are the most frequently affected. Septic shock and brain edema were the most severe complications. Three patients died, implying that this disease has a serious course. Early treatment of brain edema is very important to reduce mortality. The elective drugs for treatment of these cases of Streptococcus pneumoniae meningoencephalitis were vancomycin combined with cephalosporin, cefotaxime or ceftriaxone type. CONCLUSION: Patients with Streptococcus pneumoniae meningoencephalitis show clinical characteristics, complications, and sequels that are different to other bacterial meningoencephalitis, meaning that they could be helpful for physicians considering the differential diagnosis of meningoencephalitis.

Reibergrama para evaluar la síntesis intratecal de Lectina de unión a Manosa / Reibergram to evaluate the Mannan binding Lectin intrathecal synthesis

INTRODUCCIÓN: la dinámica particular de las proteínas derivadas del cerebro en el líquido cefalorraquídeo es diferente a la dinámica de las proteínas derivadas de la sangre. OBJETIVO: describir los datos empíricos de la lectina de unión a manosa y brindar una interpretación teórica de la dinámica de esta proteína a través de la confección un nuevo reibergrama. MÉTODOS: la lectina de unión a manosa en suero y líquido cfalorraquídeo, fue medida en 40 adultos normales a través de un ensayo inmunofluorométrico. El criterio diagnóstico estuvo basado en; muestras controles (pacientes normales) y muestras de pacientes con enfermedades que cursaron con disfunción de barrera sangre-líquido cefalorraquídeo. RESULTADOS: el coeficiente de correlación entre la lectina de unión a manosa en el líquido cefalorraquídeo y en el suero, fue muy bajo. El reibergrama de la lectina de unión a manosa se diseñó de acuerdo con procedimientos previos. CONCLUSIONES: bajo cualquier condición de barrera sangre-líquido cefalorraquídeo, el reibergrama puede identificar la ocurrencia de síntesis intratecal de lectina de unión a manosa.

BACKGROUND: The dynamics of brain derived proteins in cerebrospinal fluid is different from the dynamics of blood-derived proteins. Aim: To describe the empirical data for mannan binding lectin and gives a theoretical interpretation of the dynamics of this protein in cerebrospinal fluid through a new reibergram. METHODS: Serum and cerebrospinal fluid mannan binding lectin were measured in 40 normal adults by immunofluorometric assays. The diagnostic criteria were based in; normal control samples defined clinically and diseases with blood-cerebrospinal fluid barrier dysfunction. RESULTS: Correlation coefficient between cerebrospinal fluid MBL and serum MBL was very low. Mannan binding lectin reibergram was designed according with previous procedures. CONCLUSION: Under all conditions of the blood-cerebrospinal fluid barrier, the reibergram can identify the occurrence of intrathecal mannan binding lectin synthesis.

Seasonal distribution and evolving forms of multiple sclerosis patients diagnosed from April 2004 to November 2007.

BACKGROUND: Multiple sclerosis (MS) was first reported in Cuba in 1965. The most frequent appearance is observed in the first six months of the year. OBJECTIVE: To determine the seasonal distribution and evolving forms of MS patients diagnosed with the disease between April 2004 and November 2007. METHOD: Twenty-one patients with suspected MS and 42 outbreaks were studied. Patients were classified according to Lublin and Revingold's criteria for clinical forms and according to McDonald. RESULTS: Most patients were classified in outbreak and remission and only two patients classified as primary-progressive multiple sclerosis. The higher number of outbreaks occurred in the first two quarters of the year. CONCLUSION: It is recommended to study further weather variables that may be related to the emergence of these outbreaks in our environment.