Multiple sclerosis: correlation between immunoglobulin-G in cerebrospinal fluid and brain.

There is a positive correlation between the concentration of immunoglobulin-G in plaques of demyelination due to multiple sclerosis (as well as in white matter of normal appearance) and the concentration of this globulin in the cerebrospinal fluid. The tentative conclusion drawn from these results was that, in patients with multiple sclerosis, the increase in immuno-globulin-G in the cerebrospinal fluid is a reflection of an excess of this globulin in the brain.

Oligoclonal aspect in the CSF of multiple sclerosis patients: a statistical and physiopathological study.

Oligoclonal aspect (O.A.) is observed in 51 per cent of 468 MS patients investigated. Elevation of gammaglobulins and lymphocytic pleiocytosis increase significantly its frequency. O.A. is more frequent in presence of an inflammatory transsudate. Clinical aggravation and O.A seem significantly connected. In the first years of the MS, when the course is intermittent, the frequency of O.A. is significantly influenced by the proximity of the last bout. No such differences exist in patients with continuous course. In conclusion O.A. appears as intermittent expression of a local and general immunity reaction, in connection with the progression of the disease and as a very probable manifestation of persistant virus. We proposed 3 years ago in Göteborg a physiopathological hypothesis suggesting multiple sclerosis (MS) is a two-phase disease. In this first paper, we demonstrated the existence of two successive immunological reactions: The first one is an intermittent synthesis of IgG obviously linked to a lymphocytic pleiocytosis which is also intermittent. This firs CSF pattern appears in the same time of a bout and disappears quickly like the clinical symptoms. It may represent the manifestation of a brief and only infectious aggression. After a few years (more than 5 in average) a second mechanism progress slowly: The synthesis of IgG appears continuous, in remission as in aggravation, the lymphocyte count becomes normal and the level of albumin increases progressively. This second pattern suggests, contrary to the first, a continuous auto-immune processus with the intervention of the general (systemic) immunity. The purpose of this second paper is an attempt to elucidate the signification of oligoclonal aspect in relation to this schema.

Cerebrospinal fluid immunoglobulins and multiple sclerosis. Correspondence with magnetic resonance imaging and visually evoked potential changes.

The clinical (disability) and paraclinical (visually evoked potential [VEP]/magnetic resonance imaging [MRI]) data of patients with definite or probable multiple sclerosis (MS) were compared with their cerebrospinal fluid (CSF) immunoglobulins taken within the same period of time. For patients with definite diagnosis by the Schumacher criteria (n = 61) we found significant correlations between CSF immunoglobulin content (absolute gamma-globulin value [aggv]) and quantified MRI factors (r = .47), between aggv and the sum of VEP latencies of both eyes (r = .53), and also between MRI and VEP changes (r = .62). This was not true for the patients with a probable MS diagnosis and for patients with first attacks. No correlations were evident between aggv and disability status or duration of the illness. The results give support to recent neuropathologic and experimental findings in animals indicating close pathogenic connections between CSF immunoglobulins and demyelination in MS.

Gamma globulins of CSF and serum in multiple sclerosis: isoelectric focusing on polyacrylamide gel and agar gel electrophoresis.

Cerebrospinal fluid (CSF) and serum from 139 patients with MS were analyzed with electrophoresis on agar gel (AGE) and isoelectric focusing (IEF) on polyacrylamide gel. In both methods, 82 percent of the patients had abnormal patterns of oligoclonal IgG bands in the gamma globulin and alkaline regions. With IEF, 10 percent of the serum samples contained faint bands corresponding to the bands in CSF. Most of the bands were found in the cathodal part of the alkaline IEF region, but there was no correlation with clinical characteristics. Each patient seems to have a special band pattern which does not change throughout the disease. The gamma-trace protein was seen in 77 percent of the patients on IEF and in 29 percent on AGE. On IEF it appeared at two positions, at pH 8.0 and 9.3, but about 10 other bands were seen in the "normal" alkaline CSF region, making the band pattern of IEF more difficult to interpret than that of AGE. This limits the routine clinical value of IEF, even if the high resolution capacity of this method is useful in research.

Unusual demyelinating disease. A form of diffuse-disseminated sclerosis.

A young man, in good health until the age of 22, developed progressive personality changes, lethargy, motor diffuculities, urinary bladder dysfunction, and convulsions. Spinal fluid abnormalities included monocytic pleocytosis and selective increase of gamma globulins. The clinical features and the structural lesions in the central nervous system are reminiscent of disseminated-diffuse sclerosis. Oligodendrocytes appeared normal in number and showed nonspecific abnormalities. Comparison of the structural lesions found in this case with those described in seven reports of demyelination indicates that the separation of this syndrome, as a distinct entity, may not be justified. We suggest that such cases be classified as myelinoclastic disorders, in the same category with multiple sclerosis and its variants.

Demonstration of CSF gamma-globulin banding in presenile dementia.

An improved agarose gel electrophoretic technique was used to fractionate serum and cerebrospinal fluid (CSF) proteins in patients with presenile dementia. The CSF electrophoretic patterns demonstrated three abnormal bands in the gamma-globulin region in five out of eight of these patients.

Cerebrospinal fluid proteins in multiple sclerosis.

Various CSF proteins were studied in 255 definite multiple sclerosis patients at various disease stages and compared with corresponding values obtained from 174 controls. The CSF changes in acute multiple sclerosis patients included a significant increase of total proteins and of gamma globulin, IgG, IgA, IgM, alpha-2 ceruloplasmin, 7S-gamma-1, and cytotoxic index for nerve cells in tissue culture, and significant decreases of pre-albumin, alpha-1, and alpha-2 and of the beta/gamma globulin ratio. The CSF levels of IgG, IgA, and IgM remained significantly higher in steroid-treated multiple sclerosis patients than in controls, but the levels often were significantly reduced while patients were on treatment or in remission. During remission or treatment with ACTH and/or steroids, the alpha-2 ceruloplasmin, 7S-gamma-1, and cytotoxic index were significantly reduced and the pre-albumin, alpha-1, and alpha-2 globulin classes and the beta/gamma ratio showed a tendency to return to normal.

Antibodies-restricted heterogeneity in serum and cerebrospinal fluid of chronic relapsing experimental allergic encephalomyelitis.

An animal model which might help to study multiple sclerosis has long been sought. With chronic relapsing experimental allergic encephalitis (EAE), the search seems to have brought hope and evidence of comparable pathology whether concerned with clinical or neuropathological results, but no study of the cerebrospinal fluid (CSF) electrophoretic pattern has been made so far. A new sensitive method enables to study the CSF proteins: unconcentrated CSF proteins after agar gel electrophoresis are stained with silver reagents. The silver technique allows to follow the evolution of the inflammatory reaction in chronic relapsing EAE as well as in the acute form of EAE. This technique provides an additional approach to the study of EAE and an argument in favor of chronic relapsing EAE in guinea pigs as a model for multiple sclerosis.

Diagnostic value of brief microzone electrophoresis of unconcentrated CSF and agar gel electrophoresis of concentrated and unconcentrated CSF.

This paper reports a comparison between brief microzone electrophoresis and agar gel electrophoresis of CSF proteins; 41 different CSFs were examined simultaneously by all three methods. Fractionation of gamma-globulins was found by brief microzone electrophoresis in 53.7% of unconcentrated CSF. This fractionation was found in 63.4% of unconcentrated CSF after agar gel electrophoresis, in 48.8% of concentrated CSF. Serum-like pherogram and the rapid alpha-globulin type were found equally often.

Isotachophoresis in capillary tubes of CSF proteins -- especially gammaglobulins.

Isotachophoresis in polyacrylamide gel tubes (PAG-ITP) and in capillary tubes (Tachophor, LKB) have previously been found by the authors, to be very promising high-separation methods for CSF and serum proteins, especially regarding the diagnosis of MS. PAG-ITP methods for analytical and preparative use have been described by the authors elsewhere, while in this paper proper cationic systems for ITP in capillary tubes for studying gammaglobulins in microliter amounts of CSF and serum are described, i.e. the albumin injection-clog problem is avoided and the preparation time can be forced. By using microdialysis of the CSF samples for desalting, with a technique easy to perform and with high reproducibility, microliter amounts of native CSF can be performed in less than half an hour. The method seems to be even more applicable for clinical and scientific use if the capillary isotachophoretic apparatus is connected to a synchronized equipment (LKB Tachophrac) with a cellulosa acetate strip onto which the separated fractions are ejected for further analysis by immunological tests. The analytical systems used have been especially directed to gammaglobulins in CSF and serum regarding further studies on demyelinating and infectious disorders of the nervous system.

Isotachophoresis of CSF proteins in gel tubes especially gammaglobulins. An analytical and preparative technique for high-separation of CSF proteins.

An isotachophoretic method using polyacrylamide gel (PAG-ITP) in a simple disc electrophoretic equipment with plastic tubes containing the gels, was elaborated and especially designed for studying the gammaglobulins in CSF and serum from control subjects and patients with neurological disorders, especially known or probable MS. The device and the ITP system used, including leading and terminating electrolytes and spacer substances, dividing the gammaglobulins in a reproducible way, are described. No cooling of the gel tubes was needed. The sample volumes varied between 5--500 microliters, and the separation time was 1.5--3.0 h. CSF from patients with verified or probable MS revealed characteristic, increased low-mobility gammaglobulin fractions. Using other ITP systems, such as other spacer compositions, the anodic proteins can also be studied in more detail. PAG-ITP in gel tubes is a simple and inexpensive technique which can be used for both analytical and preparative procedures for biological material such as CSF, serum and extractions from nervous tissues.

Intrathecal IgG synthesis in multiple sclerosis and other neurological diseases: a comparative evaluation by IgG-index and isoelectric focusing.

Intrathecal IgG synthesis has been investigated by determining the IgG index and by isoelectric focusing in 30 cases of definite multiple sclerosis, in 15 cases of probable multiple sclerosis and in 128 patients affected by other neurological diseases. The blood-brain barrier function was evaluated at the same time by serum albumin/CSF albumin quotient and isoelectric focusing. The IgG index was found elevated in 73.3% of definite multiple sclerosis patients, while oligoclonal IgG bands occurred in 90%. In the other neurological diseases the IgG index was abnormally increased in 35.1% but IgG bands were present only in cerebrospinal fluid (CSF) in 1.5% and both in the CSF and serum in 7% of patients. The high capacity of isoelectric focusing to detect IgG oligoclonal bands in the CSF is pointed out as an extremely useful diagnostic tool in multiple sclerosis.

Biochemical findings in multiple sclerosis IV. Isoelectric focusing of the CSF gamma globulins in multiple sclerosis (262 cases) and other neurological diseases (272 cases).

Despite enormous efforts to find a specific laboratory test for multiple sclerosis, agar gel electrophoresis of the CSF proteins has remained the next to the best one. This study presents evidence that thin layer polyacrylamide isoelectric focusing of the CSF gamma globulins is by far superior for this purpose. In effect, about 91% of the 262 multiple sclerosis patients studied had oligoclonal fractions present in the very alkaline region of the pH gradient. Of the same group of patients only 65% did show pathological results when studied by agar gel electrophoresis. Of the 272 CSF samples from patients suffering from other neurological diseases, only about 7% showed the presence of oligoclonal bands in the same region of the pH gradient, when submitted to isoelectric focusing.

Cerebrospinal fluid in multiple sclerosis: relationships between immunoglobulins, leucocytes and clinical features.

Cerebrospinal fluid (CSF) from 120 patients with multiple sclerosis was analyzed by polyacrylamide gel electrophoresis, as well as routine laboratory microscopy and assays of total protein and immunoglobulin G (IgG). Negative correlations were found between leucocyte counts and patient age, duration of disease and time from last clinical relapse. There was a positive correlation between the leucocyte count and amount of gammaglobulin. A correlation between gammaglobulin content and degree of disability was found. With increasing duration, the gammaglobulin concentration rose only if there was increasing disability. In terms of correlations with clinical features, differences existed depending on whether IgG was assayed immunologically or by electrophoresis and densitometry. Evidence of increased blood: CSF barrier permeability (transudation of high molecular weight proteins) was found in patients with progressive disease. The presence of oligoclonal bands was the CSF abnormality most frequently encountered.

Treatment of HTLV-I-associated myelopathy with high-dose intravenous gammaglobulin.

Fourteen patients with HTLV-1-associated myelopathy were treated with high-dose intravenous gammaglobulin (IVGG). Ten received 10 g/day of IVGG and 4 received 400 mg/kg of body-weight/day of IVGG for 5 consecutive days. Improvement of spastic paraparesis was observed in 10 within 7 days of the commencement of IVGG. The therapeutic effects were sustained for more than 3 weeks in some patients. There were no side effects. Analysis of factors of relevance to the clinical improvement with IVGG showed that the beneficial response was preferentially found in patients having a high CSF titre of anti-HTLV-I antibodies, a high CSF IgG level and a marked brain MRI abnormality.

CSF protein examinations with thin-layer isoelectric focusing in multiple sclerosis.

Thin-layer IEF, due to its extremely high resolving capacity, has been found to be quite valuable for CSF protein examinations, one important advantage of the technique being its excellent capacity for separation of immunoglobulins. The CSF and serum proteins of 230 patients with clinically verified or probable MS and 20 subjects with optic neuritis were examined with thin-layer IEF and the findings were compared with clinical data and results of other CSF examinations. All but 3 of the MS patients and about two thirds of the subjects with optic neuritis inhibited one or combinations of different CSF protein aberrations in the acidic and alkaline range. Oligoclonal bands and/or regional increases of Ig fractions, changes compatible with intrathecal Ig synthesis, were detected in respectively 95 and 80% of patients with clinically verified and probable MS and 30% of subjects with optic neuritis. Other aberrant CSF protein fractions (including transferrin, the taufraction and gamma-trace protein) were found in about half of the cases; some of these fractions had the highest occurrence in patients with the most extensive Ig abnormalities. The diverse CSF protein aberrations seemed to be influenced by the duration and course of the disorder as well as the probable sites of lesions; further factors might be the release of decomposition products from destroyed tissues, the genetically determined reactivity of the individual and the presence of possible agents.

Oligoclonal gamma-globulin banding of cerebrospinal fluid in patients with subacute sclerosing panencephalitis. Comparison of the electrophoretic pattern with that in multiple sclerosis and congenital infections.

Lumbar cerebrospinal fluid (CSF) of 8 patients with subacute sclerosing panencephalitis (SSPE) was examined by agarose gel electrophoresis. In comparison with normal controls and children with different neurological diseases (including infections, tumours and degenerative diseases) the quantitative evaluation of the pherograms by an analog computer revealed an extreme change of the gamma-globulin profile. All cases showed 6-7 abnormal subfractions consisting of 2-4 tall, markedly protruding spikes and several small intermediate fractions. The oligoclonal gamma-globulin contributed 20.1-42.5% to total protein. This particular gamma-globulin profile seems to be highly indicative of the diagnosis of SSPE. It can be distinguished from the oligoclonal pattern in patients suffering from multiple sclerosis (MS) and congenital infections. The CSF protein profile of 13 patients with MS was different from that in SSPE in that it showed 1-5 monoclonal gamma-fractions in every case with none or only one peak protuding more markedly. The percentage of all subfractions amounted to 4.5-23.8% of total protein. As in MS, the aspect of oligoclonality in 9 children with congenital infections (cytomegalic inclusion body disease, toxoplasmosis and rubella) was quite variable, as again 1-5 abnormal subfractions were detected. Their relative concentrations, on the whole ranging from 0.6-12% of total protein, was considerably lower than in SSPE.

Spastic paraplegia-paraparesis. A reappraisal.

During a 16-year period 672 patients were admitted to the Columbia Presbyterian Medical Center with spastic paraplegia-paraparesis (SPP) as a prominent finding. Group I. 520 patients (77.3%) had either a familial disorder, sensory findings, other neurological signs, or a diagnosis obvious on admission by history, examination or plain spine roentgenograms. Group II. In 108 patients (16.2%) diagnosis was reached after more extensive investigation. In 78 of these a cause other than multiple sclerosis was found including spinal cord tumor, arteriovenous malformation and cervical spondylotic myelopathy. Thirteen patients had probable multiple sclerosis on the basis of additional signs emerging, and 17 were considered to have possible multiple sclerosis on the basis of elevated CSF gamma-globulin. Group III. In 44 patients (6.5%) no cause for SPP could be found. Diagnostic considerations for this group included amyotrophic lateral sclerosis, multiple sclerosis, unappreciated structural lesions, hereditary disease, and "primary lateral sclerosis".

Isoelectric focusing and electrophoresis of the CSF proteins in tremor of different origins.

The CSF proteins have previously been very little investigated in the cerebellar syndrome of chronic alcoholism and in essential tremor. Such studies have been carried out more thoroughly by electrophoretic methods in Parkinson's disease but generally with normal results. In the present investigation the CSF proteins were examined by isoelectric focusing and quantitative paper electrophoresis in 10 patients with the cerebellar syndrome of chronic alcoholsm, 12 patients with Parkinson's disease and 16 subjects with essential tremor. Abnormal CSF proteins of very similar appearance were found on isoelectric focusing in the acidic pH interval 5.6-5.8 in 80% of the patients with the cerebellar syndrome of chronic alcoholism. In Parkinson's disease the most common aberration was evidence of nonspecific blood-CSF-barrier damage which occurred in half of the patients. In only 17% of these cases did other alterations appear, situated in the pH range alkaline to pH 5.8. Abnormal CSF proteins were found in 94% of the patients with essential tremor. The aberrant proteins appeared in both the acidic and alkaline pH regions, most frequently with anisoelectric point at pH 5.9, 7.2 and 9.3. There was a considerably higher frequency of CSF protein abnormalities in different pH ranges in patients with tremor of more pronounced degree as compared to those with only mild symptoms. The electrophoretic examinations failed to show any conclusive alterations. Barrier-damage patterns of mild or moderate degree or slightly increased levels of CSF beta1-globulin were occasionally found in all 3 diseases. The results indicate that isoelectric focusing of the CSF proteins may be of diagnostic value in the cerebellar syndrome of chronic alcoholism and in essential tremor but does not reveal any characteristic abnormalities in Parkinson's disease.

Evidence for heterogeneous or incomplete immunoglobulins in oligoclonal CSF studied by electroimmunofixation.

10 oligoclonal CSF have been studied by electroimmunofixation techniques on Cellogel RS. The gammaglobulin bands are either homogeneous or heterogeneous. The heterogeneous bands migrate preferentially in the cathodic part of the gamma zone. The light chain type of many homogeneous bands is lambda. Some oligoclonal bands may be composed of free homogeneous light chains. The free lambda chains have a more anodic migration than the free kappa chains. Furthermore, our results suggest the presence of free heavy chains in some instances.