Progressive multifocal leukoencephalopathy--incidental finding in the forensic neuropathological examination.

Progressive Multifocal Leukoencephalopathy (PML) is a fatal demyelinating disease of the central nervous system (CNS) caused by the human virus JC (JCV), a small DNA virus which belongs to the subfamily of polyomaviruses. JVC infection is widely extended in the human population in asymptomatic patients; however, in severely immunocompromised patients the virus is able to replicate itself and reach the brain causing PML. It is an extremely rare disease in patients with a competent immune system and few cases have been described in medical literature. We report the case of an elderly immunocompetent man, with no pathological antecedents, who died of sepsis 50 days after suffering extensive and severe flame burns. In the forensic autopsy, a PML was discovered as an incidental finding in the neuropathological examination that was not detected during his time in hospital. Diagnosis was confirmed by the detection of JCV in the brain by in situ hybridization. Possible pathophysiological mechanisms for the reactivation of the JCV and the rapid evolution to the fatal brain demyelinating lesions are discussed. One of the main clinical implications of this case is that immunocompetence should not be considered as an exclusion criterion for the diagnosis of PML.

Primitive neuroectodermal tumor of the central nervous system with glial differentiation: a FISH study of an adult case.

Primitive neuroectodermal tumors (PNETs) of the central nervous system (CNS), a rare occurrence in adults, may show glial differentiation and can be misinterpreted as pure astrocytic neoplasms. Few fluorescence in situ hybridization (FISH) studies have been carried out on these tumors; isochromosome 17q was found to be the major chromosomal abnormality. We present the case of an adult in which we performed a FISH study of both the glial and neuronal components. A complex array of FISH changes, not including an isochromosome 17q were identified.

Ependymal changes in sudden infant death syndrome.

The ependyma may befall a variety of pathogenic noxae during fetal life, resulting in histological changes which may persist after birth but are without clinical manifestations. Eight of a series of 19 children who died suddenly and unexpectedly, where no explanation as to the cause of death was found at autopsy, were shown to have diverse histological features involving the ependyma. Five micrometer paraffin-embedded brain tissue sections including frontal, temporal, occipital, and ventricular horns as well as the fourth ventricle were stained with hematoxylin-eosin (H&E) and luxol fast blue (LFB). Immunohistochemical stains using antibodies to glial fibrillary acidic protein (GFAP), vimentin and S-100 were also performed. Findings included areas of denuded and/or desquamated ependyma, rosettes in different stages of formation, vacuoles and/or pseudocysts, inflammatory changes consisting in macro- and microglial nodules in the subependymal layer, and gliosis. Chronic brain edema was seen in 4 cases. Our findings indicate that ependymal changes in sudden infant death syndrome (SIDS) cases belong to the prenatal or early postnatal period, thus providing, indirectly, a morphological substrate for the previous existence of a noxa that may also affect other CNS areas, and thus being in the position to produce cardiorespiratory control dysfunction.

Neuronal changes in the substantia nigra with aging: a Golgi study.

In order to recognize substantia nigra neuronal changes occurring in aging, 20 human control brains from 13 males and 7 females with a mean age of 61 years (range 20 to 93 years) without neurological disease were examined using the Golgi method. A quantitative study of dendrites and dendritic spines was performed as well as a statistical analysis of obtained data. Parallel sections to the impregnated material were histologically and immunohistologically studied with the aim to identify possible neuronal cytoskeletal abnormalities. Results were compared to changes of substantia nigra reported in other conditions such as Parkinson's disease (PD) and methyl-4-phenylpyridine (MPTP) experimental toxicity. Three different substantia nigra neuronal types were observed. Morphological changes during aging consisted of distorted profile of the cell body and swelling and beading of dendritic branches. The quantitative assessment of changes observed in neuronal types showed a significant loss of dendrites and dendritic spines, especially in the oldest cases. These findings were similar to those previously described in other cerebral areas during aging, but a specific vulnerability of the largest substantia nigra neuronal type could be observed. Nodulations and beaded aspects of dendrites are reminiscent of those changes previously described in MPTP toxicity. Dendritic varicosities found in the oldest cases have also been found in dendrites of large substantia nigra neurons in PD. Cytoskeletal abnormalities have been described in PD but were not found in the present study. Therefore, other pathophysiological mechanisms different from the cytoskeletal compromise occurring in some neurodegenerative diseases should be involved in aging.

Cerebellar cortex delayed maturation in sudden infant death syndrome.

The cerebellum shows afferent and efferent connections with intrinsic bulbar nuclei and plays an important role in respiration and cardiovascular control. Pathological and neurochemical abnormalities of bulbar nuclei including the arcuate nucleus have been postulated in sudden infant death syndrome (SIDS). Most of these abnormalities have been related to impairment in brain development. The cerebellar cortex has a well-documented evolution from fetal life until infancy; thus, it may be a very good model to assess brain maturation in SIDS. The present study was conducted to investigate changes in the cerebellar cortex in 19 SIDS cases compared with 12 age-related controls using morphological, quantitative, and statistical approaches. Five-microns paraffin sections from the midsagittal cerebellar vermis were stained with hematoxylin and eosin (H&E). Immunohistochemical staining was carried out using a polyclonal antiserum to glial fibrillary acidic protein (GFAP). Each case consisted of a 25-microns parallel paraffin section stained with H&E, where the cerebellar external granular layer (EGL) cell density was obtained in one field magnification (x1,000) using an optical dissector procedure on the basis of a stereological method. A statistically significant high EGL cell density, mostly related to the presence of immature bipolar, elongated neuronal cells of the premigratory zone with hyperchromatic, oval or poor differentiated nuclei, was observed in SIDS. In these cases, EGL expressed immunoreactivity for GFAP mainly in the subpial and the postmitotic zone. These findings demonstrate a delayed or slower decline in the number of EGL neurons in SIDS, suggesting either a prolongation of the growth phase related to postnatal cerebellar foliation or a delay in inward migration. These results suggest that in SIDS there is delayed maturation of the cerebellar cortex/EGL, which may support the hypothesized cardiopulmonary control dysfunction, leading to death in a vulnerable period of postnatal development.

Accumulation of wild-type p53 protein in progressive multifocal leukoencephalopathy: a flow of cytometry and DNA sequencing study.

p52 protein accumulation in JC virus (JCV)-infected cells of progressive multifocal leukoencephalopathy (PML) has been previously shown. Since many viral proteins are known to bind and stabilize p53, we are addressing the question of whether p53 protein accumulation in PML is the result of its sequestration by JCV and not the outcome of a p53 gene mutation which would prolong its half-life. We have investigated the status of the p53 gene in frozen autopsy brain samples from five PML patients. After isolating genomic DNA, p53 gene exons 2 through 9 were amplified and sequenced. No discrepancies were found in the DNA sequences of exons 2 through 9 and their intron/exon barriers when compared to those published for wild-type p53. On the other hand, dual (p53/DNA) flow cytometry analysis revealed p53 expression above that of the isotypic controls for each case. No aneuploid populations could be identified, however, which seems at odds with the aneuploid status normally associated with mutation-induced p53 dysfunction. These results indicate that the p53 gene harbors no mutations in PML and provide further evidence of p53 protein accumulation in this condition. Since p53 protein buildup in JCV-infected cells is not the consequence of a mutagenic interaction between JCV and the cell genome, we propose instead that p53 accumulation results from its binding and stabilization by JCV T protein.

April 2003: 55-year-old male with necrotic pontine lesion.

The April Case of the Month (COM). A 55-year-old male with history of diabetes mellitus presented with progressive loss of sensitivity on the left side of the body and horizontal diplopia. Symptoms appeared after a right basal pneumonia one month before admission. A CT scan showed an large inoperable lesion in the pons. The patient was treated with corticoids. One week later, the patient showed general deterioration. The fifth and sixth right cranial nerves were affected. Ataxia and disorders in swallowing were also present. A second CT scan showed that the pontine mass had become larger. The patient died 7 days after his admission and the autopsy was limited to CNS. The right middle cerebellar peduncle showed a 2-cm well-defined white brownish necrotic lesion that extended to the pons and periventricular gray matter. Microscopic examination revealed toxoplasmosis, which was confirmed by immunohistochemical studies. The brain tissue was negative for HIV by PCR. Toxoplasmosis is a well-known complication of AIDS, and has been reported in post-transplant patients as well, but only a few reports of toxoplasmosis in diabetics have been reported.

Correlation between Apolipoprotein-E polymorphism and Alzheimer's disease pathology.

Alzheimer's disease (AD) and small vessel disease dementia (SVDD) are common causes of dementia. The ApoE genotype has been proposed as a risk factor for AD. The frequency of the three ApoE alleles was correlated with the neuropathological changes of AD (senile plaques, neurofibrillary tangles and amyloid angiopathy) and SVDD (status lacunaris, status cribosus, leucoencephalopathy, micronecrosis and vascular fibrohyalinosis) in order to validate previous ApoE genotyping results in AD and to identify pre-clinical AD. Representative cerebral regions (cortex, gyrus cinguli, putamen, hippocampus, white matter) from 28 AD cases, 7 SVDD and 38 non-neurological controls were studied using classical histological techniques and immunohistochemistry for tau protein and amyloid-beta. The frequency of the ApoE allele 4 was significantly increased not only in AD patients but also in aged controls. However, following a detailed histopathological examination was found 62% of this group to exhibit histological changes associated with AD in limited brain areas (entorhinal region, hippocampus and adjacent temporal cortex or entorhinal region and hippocampus, or only in the entorhinal region), but 87% of these cases were found to be ApoE4 positive. The significant differences found in the distribution of ApoE allele frequencies were more marked when these cases were excluded from the control group and included as AD cases. In contrast, the frequency of the ApoE allele 2 is significantly increased in SVDD patients. Using histological techniques we confirmed the clinical diagnoses of all cases and classified the AD patients according to the severity of cortical pathology related to AD, while re-grouping from the control group those cases which had no clinical history of the disease but exhibited typical AD and SVDD histological lessions which could be considered as "pre-clinical" forms of these diseases.

Expression of vascular endothelial growth factor (VEGF) and platelet-derived growth factor receptor-beta (PDGFR-beta) in human gliomas.

The growth of solid tumors is highly dependent on vascular proliferation. Vascular endothelial growth factor (VEGF), the main mediator of angiogenesis, and platelet-derived growth factor receptor-beta (PDGFR-beta), receptor for the potent mitogen PDGF, are two indicators of the angiogenic potential of human gliomas. We studied a series of 57 surgical biopsies of astrocytic neoplasms by immunohistochemistry to elucidate the relationship between tumor proliferation, quantified as Ki67-LI, and the expression of these two proteins. Ki67-LI increases throughout histological malignancy, although staining in endothelial cells has rarely been recorded. Elevated amounts of VEGF-positive tumor cells (VEGF-LI) were found in anaplastic astrocytomas and glioblastomas, mainly around areas of necrosis, cysts, or edema. Endothelium of blood vessels was consistently stained. PDGFR-beta positivity was found in glomeruloid formations and in tumor cells, excluding pilocytic astrocytomas. Multinucleated giant cells and perivascular tumor cells were positive in glioblastomas. In addition, peritumoral microglia-like cells were also stained in some cases. Statistical correlation was only found between PDGFR-beta and Ki67 LIs. In conclusion, VEGF as permeability factor is involved in the development of secondary neoplastic changes, whereas PDGFR-beta is directly correlated to proliferation indexes. Strong expression of VEGF and PDGFR-beta found in endothelium and tumor cells would seem to support a combined role in tumoral neoangiogenesis.

Clinico-pathological correlations in meningiomas: a DNA and immunohistochemical study.

We have studied 41 meningiomas classified histologically as benign, atypical or anaplastic. There were 26 females and 15 males and the mean age was 53 years. 36 tumours were supratentorial, 4 infratentorial and one spinal. Flow cytometry was performed on paraffin-embedded tissue using a selective staining technique for DNA. The ploidy index of DNA and percentage of cells in the S and G2/M phases were calculated. Results were correlated with clinical, histological and immunohistological data. 16/41 tumours were found to be diploid, 17/41 aneuploid and 8/41 could not be analysed. Significant correlations were found between aneuploid tumours and some qualitative features such as recurrence, pleomorphism, high cellular density, mitotic activity and brain and soft tissue infiltration. A high proliferative index appeared to be associated with clinical aggressiveness. No particular correlation between the expression of cytokeratin and epithelial membrane antigen markers and flow cytometry was found. Our results suggest that DNA flow cytometry in meningiomas may be of value in predicting the behaviour of these neoplasms and confirm that epithelial pattern in meningiomas is not linked to increased anaplasia or poor prognosis.

The value of conjunctival biopsy in childhood cystinosis.

Cystinosis is frequently presented with cystine storage in the cornea and conjunctiva, and the diagnosis can be established by slit-lamp examination. It can also be confirmed by electron microscopy of a conjunctival biopsy. The present paper reports on a 16-month-old boy with Fanconi's syndrome, in whom the slit-lamp examination did not show crystal deposits of cystine in the conjunctiva. The ultrastructural study of the conjunctival biopsy demonstrated polygonal crystals within double membrane-limited organelles located in fibroblasts. Similar crystals were subsequently found in a kidney biopsy. We therefore think that conjunctival biopsy is a valuable diagnostic tool prior to performing renal biopsy, even in cases with negative findings by ophthalmologic examination.

Immunohistological signposts in central nervous system tumours with neuronal differentiation.

25 neuronal tumours with a panel of antibodies were studied and it was found that vimentin was present in 15 tumours. It was also found in a few cells within rosettes. PGP 9.5 showed a somatic pattern of staining with nuclear and perinuclear positivity in 23. Neurofilament reactivity was found in 14. Retinal S-antigen was detected only in one medulloblastoma, 3/4 pineal tumours and 2/2 retinoblastomas. Reactivity, for synaptophysin was present in 2/5 medulloblastomas, 3/10 neuroblastomas and 2/2 retinoblastomas. GFAP was demonstrated in scattered tumour cells in 4/5 medulloblastomas. Two of these were the only tumours featuring bipolar differentiation whilst it was unipolar in the remainder. The significance of these findings in relation to the ontogeny of these tumours is discussed.

Prognostic analysis of astrocytic gliomas correlating histological parameters with the proliferating cell nuclear antigen labelling index (PCNA-LI).

Eighty out of 250 cases of astrocytic glioma collected from a practice served by a single clinical team over a 15-year period were studied using a full complement of clinical, follow up, histopathological analysis and proliferating cell nuclear antigen (PCNA) immunostaining for the obtention of the PCNA-labelling index (LI). A statistical evaluation and discriminant analysis were carried out with the aim of clarifying the importance of various parameters as predictors of tumor behaviour. Data are correlated with survival (with a 10-year follow up). A significant correlation with survival was found when histological grouping and the PCNA-LI were studied with the Cox test. Most significant features were histological as detected using classical techniques including histological grading. The utilization of objective values (mitosis, cellular density and necrosis) appears to be useful in grading astrocytic tumors. Our results emphasize the importance of cytological, histological and PCNA-LI parameters as predictors of tumor behaviour.

Haemangioblastoma: histological and immunohistological study of an enigmatic cerebellar tumour.

Paraffin-embedded blocks of 36 cerebellar haemangioblastomas were reacted with a panel of antibodies including glial fibrillary acidic protein, vimentin, epithelial membrane antigen, cytokeratin, Factor VIII, a neuroendocrine marker and with Ulex europaeus. agglutinin The main histological features, apart from the characteristic large abnormal vessels, were a prominent reticulin network, a cystic architecture and cellular and nuclear polymorphism. Two cell types were identified: endothelial and stromal. Twenty tumours were positive for glial fibrillary acidic protein because of included or reactive astrocytes as well as positive stromal cells. Vimentin was positive in all tumours with a diffuse distribution and a somatic pattern; blood vessels, stromal cells and reactive astrocytes were strongly positive. Factor VIII and Ulex europaeus agglutinin reactivity were present in a similar pattern of staining in endothelium and in five cases there were stromal cells that were positive with the latter. We were not able to ascertain the histogenesis of the stromal cell, which remains enigmatic.

Argyrophilic nucleolar organizer region (AgNOR) counting in astrocytic gliomas: prognostic value.

In 87 astrocytic gliomas the number of AgNORs/nucleus was retrospectively studied and data correlated with the histological type of the tumors and survival. All patients were treated by the same surgical team and with uniform criteria. Statistically significant differences (p < 0.01) were found in relation with the AgNOR averages among the histological types of tumors. A statistically significant linear correlation (p < 0.05) between the AgNOR values and survival of the patients was also found. Patients with mean AgNOR values higher than 2.23 and lower than 2.9 survived an average of 11.5 +/- 9.1 months vs. a survival in average of 24.4 +/- 34.1 months with mean AgNOR values under 2.23 (p < 0.05). Patients with AgNOR values higher than 2.9 survived, on average, 7.7 +/- 3.9 months. AgNOR counting in astrocytic gliomas is a reproducible, easy, quick method with prognostic value. AgNORs may be successfully applied in routine material to assess the growth potential of astrocytic gliomas.

Brain-derived neurotrophic factor and neurotrophin 3 in schizophrenic psychoses.

Disturbed neural development has been postulated as a crucial factor in the pathophysiology of schizophrenic psychoses. The neurobiochemical basis for such changes of cytoarchitecture and changed neural plasticity could involve an alteration in the regulation of neurotrophic factors. In order to test this hypothesis, BDNF and NT-3 levels in post-mortem brain tissue from schizophrenic patients were determined by ELISA. There was a significant increase in BDNF concentrations in cortical areas and a significant decrease of this neurotrophin in hippocampus of patients when compared with controls. NT-3 concentrations of frontal and parietal cortical areas were significantly lower in patients than in controls. These findings lend further evidence to the neurotrophin hypothesis of schizophrenic psychoses which proposes that alterations in expression of neurotrophic factors could be responsible for neural maldevelopment and disturbed neural plasticity, thus being an important event in the etiopathogenesis of schizophrenic psychoses.

Apolipoprotein E genotype in Spanish schizophrenic patients.

Apolipoprotein E (ApoE) is a lipoprotein that, in the central nervous system, is thought to play a role in neuronal growth and repair. ApoE has three isoforms (ApoE2, ApoE3 and ApoE4) coded by three different alleles (epsilon2, epsilon3 and epsilon4). Evidence from family, twin and adoption studies suggest that there is an important genetic contribution to the etiology of schizophrenia. Schizophrenia is in some cases associated with cognitive impairment similar to that of Alzheimer patients; therefore, one may postulate that the ApoE gene, whose role in the dementia of Alzheimer's type has been clearly demonstrated, may also be involved in schizophrenia. In the present study, we have genotyped 114 schizophrenic Spanish patients and 94 healthy matched controls, and found no association between the ApoE genotype and schizophrenia. Subdivision of patients in clinical subgroups showed a slight increase of ApoE4 in early-age onset of the disease and a slight decrease in positive family history for psychiatric diseases; the group with a poor response to neuroleptic drugs had a lower ApoE2 allele frequency. However, as the differences did not reach statistical significance, we cannot draw evidence of an association. Our negative data do not support an involvement of ApoE in schizophrenia, and suggest that the underlying mechanism for the cognitive impairment found in schizophrenic patients is not related to that of Alzheimer's patients nor to a higher prevalence of the ApoE allele 4.

A null mutation allele in the CNTF gene and schizophrenic psychoses.

The maldevelopmental theory postulates disturbances in neural development as crucial factors in the aetiopathogenesis of schizophrenia. Neurotrophic factors, including ciliary neurotrophic factor (CNTF), play a central role in the regulation of such development. A mutation has been described for the CNTF gene, whereby subjects homozygous for the mutation lack CNTF. The polymerase chain reaction was used to amplify the CNTF gene region containing this mutation in whole blood genomic DNA. The mutation was detected by analysis of restriction fragment length polymorphisms. Patients suffering from schizophrenic psychosis (ICD-10 criteria) (51 from Würzburg, 83 from Barcelona), and healthy controls (62 from Würzburg, 50 from Barcelona) were investigated. In the Würzburg group, the frequency of subjects homozygous or heterozygous for the mutation was significantly higher among schizophrenic patients than in controls. However, no difference could be detected in the Spanish sample; the possible reasons for the different allele distribution in the two patient groups is discussed. It is concluded that the CNTF null mutation may be relevant to the aetiopathogenesis of schizophrenia in some patients, but further work is required to identify specifically the patient group for which it is important.

Brain-derived neurotrophic factor and neurotrophin-3 levels in Alzheimer's disease brains.

In the present study, we investigated the levels of brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) in post-mortem brain tissue of Alzheimer's disease (AD) patients, and we observed a significant increase of BDNF concentration in hippocampus and parietal cortex of AD patients, as well as a negative correlation between NT-3 levels and age in hippocampus and putamen of control subjects, and for BDNF in frontal cortex. A defining feature of AD is the post-mortem identification of neuritic plaques and neurofibrillary tangles in the brain, however, a more significant neuropathological finding is the degeneration of cholinergic neurones of the basal forebrain, critically involved in memory and cognition. Neurotrophic factors are partly responsible for the maintenance of neuronal function and structural integrity in the adult brain. Our results provide, therefore, evidence that, under conditions of progressive neurodegeneration the brain stimulates the over expression of certain neurotrophic factors as a possible mechanisms of compensation, and that during senescence the expression of these molecules is regulated.

Clinical and pathological study of two patients with progressive supranuclear palsy and Alzheimer's changes. Antigenic determinants that distinguish cortical and subcortical neurofibrillary tangles.

Two cases with classical clinical manifestations of progressive supranuclear palsy (PSP) showed severe progressive dementia as an additional clinical feature. Neuropathological study demonstrated typical features of PSP in the brainstem. Additionally, histological criteria of Alzheimer's disease (AD) were observed. A topographic and immunohistological study (with neurofilament subunit and Tau and Ubiquitin antibodies) of the distribution of neurofibrillary tangles (NFTs) was performed in order to compare the characteristics of NFTs from cortex and brainstem. NFTs from cortex were positive with all antibodies used and were predominantly distributed in cortical layers III and V and affected medium size neurons. Brainstem NFTs were positive only for neurofilament subunits and Tau. Cortical and brainstem NFTs showed immunohistological differences. Cortical NFTs in our two cases had a similar distribution as in control AD cases. On the basis of our observations we believe (1) that cortical tangles in our PSP cases are related to Alzheimer's disease and (2) that the cortical NFTs of PSP and AD are morphologically and immunohistologically distinct. Mechanisms concerned with the production of cortical and brainstem NFTs in PSP and AD are discussed.