A defect in pyruvate decarboxylase in a child with an intermittent movement disorder.

A patient with an intermittent movement disorder has been found to have an inherited defect in pyruvate decarboxylase ((2-oxo-acid carboxy-lyase, E.C. 4.1.1.1.). The patient is a 9 yr old boy who since infancy has had repeated episodes of a combined cerebellar and choreoathetoid movement disorder. He has an elevated level of pyruvic acid in his blood, an elevated urinary alanine content, and less marked elevations in blood alanine and lactate. Methods were developed to study his metabolic abnormality in dilute suspensions of white blood cells and cultured skin fibroblasts, as well as in cell-free sonicates of fibroblasts. Oxidation of pyruvic acid-1-(14)C and pyruvic acid-2-(14)C by his cells and pyruvate decarboxylase activity in sonicates of his cells were less than 20% of those in cells from control subjects. Oxidation of glutamic acid-U-(14)C, acetate-1-(14)C, and palmitate-1-(14)C was normal, as was incorporation of alanine-U-(14)C into protein. The rate of oxidation of pyruvic acid by the father's cells and the activity of pyruvate decarboxylase in the father's sonicated fibroblasts were intermediate between those of the patient and those of controls. Values for the mother were at or just below the lower limits of the ranges in controls. Kinetic data suggested the posibility of several forms of pyruvate decarboxylase in this family. Possible mechanisms relating the chemical abnormality and the clinical symptoms in this patient are discussed.

An inherited defect affecting the tricarboxylic acid cycle in a patient with congenital lactic acidosis.

Cultured skin fibroblasts from a 3 yr old girl with severe, diffuse neurologic disease and persistant lactic acidosis, oxidized radioactive citrate, palmitate, and pyruvate at less than one-third the rate of control cells. Her fibroblasts oxidized isocitrate and glutamate at rates comparable with controls. In disrupted cells from this patient, the activity of aconitate hydratase appeared normal. The binding of citrate to aconitate hydratase and the activities of the NAD- and NADP-linked isocitrate dehydrogenases were also normal, while the activity of citrate synthase was slightly below control values. A significant defect was, however, apparent in the activity of the pyruvate dehydrogenase complex although not in the thiamine-dependent first enzyme of that complex. This patient appears to have a partial genetic defect affecting the tricarboxylic acid cycle.

Localization of the oxidative defect in phytanic acid degradation in patients with Refsum's disease.

The rate of oxidation of phytanic acid-U-(14)C to (14)CO(2) in three patients with Refsum's disease was less than 5% of that found in normal volunteers. In contrast, the rate of oxidation of alpha-hydroxyphytanic acid-U-(14)C and of pristanic acid-U-(14)C to (14)CO(2), studied in two patients, while somewhat less than that in normal controls, was not grossly impaired. These studies support the conclusion that the defect in phytanic acid oxidation in Refsum's disease is located in the first step of phytanic acid degradation, that is, in the alpha oxidation step leading to formation of alpha-hydroxyphytanic acid. The initial rate of disappearance of plasma free fatty acid radioactivity after intravenous injection of phytanic acid-U-(14)C (t(1/2) = 5.9 min) was slower than that seen with pristanic acid-U-(14)C (t(1/2) = 2.7 min) or palmitic acid-1-(14)C (t(1/2) = 2.5 min). There were no differences between patients and normal controls in these initial rates of free fatty acid disappearance for any of the three substrates tested. There was no detectable lipid radioactivity found in the plasma 7 days after the injection of palmitic acid-1-(14)C or pristanic acid-U-(14)C in either patients or controls. After injection of phytanic acid-U-(14)C, however, the two patients showed only a very slow decline in plasma lipid radioactivity (estimated t(1/2) = 35 days), in contrast to the normals who had no detectable radioactivity after 2 days. Incorporation of radioactivity from phytanic acid-U-(14)C into the major lipid ester classes of plasma was studied in one of the patients; triglycerides accounted for by far the largest fraction of the total present between 1 and 4 hr.

Diminished mitogen-induced calcium uptake by lymphocytes from Alzheimer patients.

Recent studies demonstrate diminished calcium uptake by cultured skin fibroblasts from Alzheimer patients. To determine if altered calcium homeostasis is also present in tissue taken from Alzheimer patients, calcium homeostasis was assessed in mitogen-stimulated lymphocytes. Calcium uptake by lymphocytes from Alzheimer patients was 10%-15% lower (p less than 0.002) than that of lymphocytes from age-matched controls. However, neither superficially bound nor total calcium was altered by Alzheimer's disease. These small differences in uptake may reflect larger differences in cytosolic calcium, in later calcium-mediated events, or in the response of particular subsets of lymphocytes. Their biological significance remains to be determined.

Factors associated with duration of survival in Alzheimer's disease.

With a computerized data base, a data retrieval system, and a computer program using the actuarial method of life-table analysis, we compared survival rates in different subgroups of patients with dementia of the Alzheimer type (DAT; n = 199). Men (n = 71) had a shorter duration of survival than women (n = 128), with 500-day survival (mean +/- SEM) 84 +/- 5% vs. 99 +/- 3%, p less than 0.01; 1000-day survival 49 +/- 10% vs. 96 +/- 8%, p less than 0.001; 50% survival 1000 days vs. 1550 days. Patients younger than 65 years at onset had a decreased relative duration of survival compared with patients over 65 at onset, suggesting a more malignant course. Patients with a longer duration of illness tended to die sooner, but this effect was not statistically significant. The Kahn-Goldfarb mental-status quotient was not a predictor of survival. Patients with high Haycox behavioral score (greater than 20; n = 50), indicating more severe behavioral impairment, had lower survival rates at 500 days than patients with low scores (less than 12; n = 65) (80 +/- 6% vs. 95 +/- 3%, p less than 0.05). Hachinski ischemic score, measuring signs and symptoms of vascular disease, had no correlation with survival. Factors associated with decreased duration of survival in DAT include male sex, presenile onset, and increased severity of behavioral impairment.

Cerebral blood flow decrements in chronic head injury syndrome.

Global and regional cerebral blood flow (CBF) has been reported to be decreased immediately after head injury. Since neuropsychological deficits in patients with chronic head injury syndrome persist long after the initial trauma, we studied CBF, which reflects cerebral metabolism and activity, and evaluated the results of neuropsychological tests in 12 alert, responsive patients aged 18-26, both 2-13 months after head injury and 1-12 months after they regained consciousness. Global CBF was significantly decreased in patients with head injury relative to age-matched normal controls. Four patients had well-localized injury; in three of these, CBF over the affected region was significantly decreased relative to the same region in the opposite hemisphere and relative to the same region in an age-matched normal control. In one patient with right frontal injury, cognitive improvement on repeat testing was associated with a relative increase in right frontal CBF. The remaining eight patients had diffuse bilateral injury. Asymmetry ratios (larger value of mean hemispheric CBF divided by the smaller) were significantly higher for the group with localized dysfunction (1.2 +/- 0.08 vs. 1.0 +/- 0.01, p less than 0.01), suggesting homolateral decrease in CBF in this group. Three patients with diffuse injury underwent repeat studies 5-14 weeks later; all improved on psychological tests, and two had a significant increase in global CBF. These results suggest that the chronic sequelae of head injury include decreased CBF, presumably reflecting decreased cerebral metabolism, which correlates with the neuropsychological impairment.

4-Aminopyridine in the treatment of Alzheimer's disease.

The cognitive and behavioral effect of 4-aminopyridine (4-AP) was examined in Alzheimer's disease (AD) using a dose finding/replication study design. Fourteen inpatients, aged 54-89 years (mean 66.1 +/- 10.6 SD), meeting NINCDS criteria for probable AD, were studied. Three doses of 4-AP--2.5 mg b.i.d., 5 mg b.i.d., and 10 mg b.i.d.--or placebo were administered for 4 consecutive days in random order. Symptomatic assessment was performed on the fourth day of each condition using the Alzheimer Disease Assessment Scale (ADAS). Thereafter, the dose on which the best performance occurred was readministered, as was placebo. Of the 13 patients who completed the dose-finding phase, 7 patients had at least one dose of 4-AP that was associated with less severe symptoms than was placebo, and those patients were included in the replication phase. Results indicated no significant difference in total ADAS scores (p greater than 0.05). Examination of the ADAS subscales revealed no significant 4-AP effect on any particular symptom. Possible explanations of the lack of a drug effect in this study include the unselective release of neurotransmitters by 4-AP, poor penetration into the central nervous system (CNS), and the presenile onset of the disease in these patients.

Regional decline of cerebral blood flow with age in cognitively intact subjects.

Cerebral blood flow was measured by the 133Xenon washout method in 44 cognitively intact subjects. Regression analysis of cerebral blood flow with age was performed on data from 33 subjects without arteriosclerotic cardiovascular disease, hypertension, or chronic obstructive pulmonary disease, factors which have been previously shown to lower cerebral blood flow. Changes with normal aging were significant in the left and right hemispheres with bilateral changes in temporal, parietal, and occipital regions. An additional group of 11 cognitively intact subjects with arteriosclerotic cardiovascular disease but no accompanying dementing disease had lower mean flow values at each detector position than did age- and sex-matched controls, although the differences did not always reach statistical significance. Decreased flows in temporal regions seem to be a concomitant of normal aging, and are not related to the presence of vascular disease.

Human red blood cell choline uptake with age and Alzheimer's disease.

Since previous studies suggested that blood choline homeostasis is altered in aging and in Alzheimer's disease, choline uptake was examined in human red blood cells (RBC) from young adults, intellectually-intact elderly controls and outpatients with Alzheimer's disease. Eadie-Hofstee analysis of uptake by RBC from young controls indicated two components; thus, group comparisons were done with 1 and 50 microM choline in the media. Temperature-dependent choline uptake at low and high choline concentrations increased in RBC from elderly controls (62-66%) or Alzheimer patients (52-54%) compared to young controls. These changes in transport were not directly related to altered RBC choline content, since RBC choline concentrations did not vary significantly between groups. However, plasma choline content was significantly elevated in elderly controls and Alzheimer patients compared to young control values. The RBC to plasma ratio of choline was reduced in elderly compared to young controls, whereas the ratio in Alzheimer patients was between the two other groups. Thus, abnormalities in RBC choline uptake and plasma choline content were not exacerbated in Alzheimer patients, and these results do not support suggestions that Alzheimer's disease is a form of generalized accelerated aging. The striking changes in RBC choline uptake and plasma choline content in elderly subjects do indicate age-related changes in systemic choline homeostasis and these abnormalities may contribute to the predisposition of the elderly to neurological diseases.

Normal replicative lifespan of Alzheimer skin fibroblasts.

Cultured skin fibroblasts from four patients with Alzheimer's disease had life spans comparable to those of six age-sex matched controls, whether measured by passages to phase-out, cumulative population doublings to phase out, or percentage of nuclei incorporating [3H]thymidine (Cristofalo index). These results provide direct experimental evidence that Alzheimer's disease is not simply a form of accelerated aging. They suggest that the abnormalities, described by several groups, in Alzheimer fibroblasts reflect the disease rather than the physiological age of the donor, making the cultured cell a valid tool for studying the cellular pathophysiology of this disorder. Together with other data, these observations raise the possibility that some forms of Alzheimer's disease may represent inborn error(s) of metabolism of late clinical onset.

Thiamin in the elderly--relation to alcoholism and to neurological degenerative disease.

Status of thiamin in the elderly North American population is reviewed. Most Americans eat sufficient thiamin but about 5% of those over 60 yr old show impaired thiamin status. This is more marked in the poor, those confined in institutions, or those with illness. Thiamin responsive heart disease and Wernicke Korsakoff CNS syndromes occur in the elderly but there is no increased prevalence. Minor heart or neurological syndromes related to thiamin deficiency cannot be identified. The Recommended Dietary Allowance of thiamin provides at least 50% excess thiamin for those over 60 yr old--this amount is adequate. There is no known toxicity for thiamin.

Cultured cells as a screen for novel treatments of Alzheimer's disease.

Two easily measured abnormal properties of fibroblasts from patients with Alzheimer's disease have been utilized to develop an in vitro test system for screening novel therapeutic agents for Alzheimer's disease. The abnormal properties selected for study were increased isoproterenol-stimulated cyclic adenosine monophosphate production and decreased pH (measured by the weak-acid distribution method). L-Carnitine was tested as a potential therapeutic agent, since it has been used to treat a variety of experimental metabolic encephalopathies. The addition of L-carnitine normalized both of these properties in the Alzheimer cells. Tissue culture may aid as a preliminary screen for identifying novel approaches to the treatment of Alzheimer's disease.

Thiamine and Alzheimer's disease. A pilot study.

As a test of the significance of previously described biochemical abnormalities in thiamine-dependent enzymes in brains and other tissues in patients with Alzheimer's disease, a double-blind, placebo-controlled, crossover, outpatient pilot study compared the effects of 3 g/d of oral thiamine hydrochloride for three months with those of a niacinamide placebo. Eleven moderately impaired patients with "probable Alzheimer's disease" by the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria completed the study. All patients were well nourished and had no stigmata of dietary thiamine deficiency. Their initial mean +/- SEM Mini-Mental State Examination score was 14.2 +/- 1.4, and the mean age was 72 years. Global cognitive rating by the Mini-Mental State Examination was higher during three months with 3 g/d of oral thiamine hydrochloride than with niacinamide placebo. Behavioral ratings, however, did not differ significantly, nor did clinical state when it was judged subjectively.

Induction of Alzheimer antigens by an uncoupler of oxidative phosphorylation.

Since previous studies have suggested that the coupling of oxidation to phosphorylation is impaired in Alzheimer brain and fibroblasts, the effects of carbonyl cyanide m-chlorophenylhydrazone, a hydrazone known to uncouple mitochondrial oxidative phosphorylation, were tested on the development of immunoreactivity with antibodies to "Alzheimer antigens" in cultured fibroblasts from cognitively intact subjects. The fibroblasts were exposed for 10 to 14 days to a medium (DMd) modeled on media that favor neuronal differentiation in fetal brain cultures. The addition of a 10-microns concentration of carbonyl cyanide m-chlorophenylhydrazone to the DMd culture medium increased by more than 10-fold the proportion of cells reacting immunocytochemically with antibodies to paired helical filaments and by 157-fold the proportion of cells reacting with the Alz-50 monoclonal antibody. These observations suggest that the oxidative abnormalities previously described in tissues from patients with Alzheimer's disease may contribute to the accumulation of abnormal cytoskeletal materials in this disorder.

A trial of thiamine in Alzheimer's disease.

Because a previous short-term study demonstrated a statistically significant, but not clinically important, improvement in cognitive test scores during thiamine treatment in patients with dementia of the Alzheimer's type, a 12-month, double-blind, parallel-group study was conducted to examine whether long-term administration of thiamine at 3 g/d might slow the progression of dementia of the Alzheimer's type. Fifteen subjects were enrolled and 10 completed the 1-year study. Data are available for two additional subjects through the first 9 months of study. No significant differences were found between the placebo and thiamine groups at any point during the study. In both groups, overall means for the Mini-Mental State Examination, verbal learning, and naming scores decreased significantly over the 12-month study period. These results do not support the hypothesis that long-term administration of thiamine at 3 g/d might slow the progression of dementia of the Alzheimer's type.

Expression of 'Alzheimer antigens' in cultured skin fibroblasts.

When cultured skin fibroblasts were exposed to culture conditions designed to favor the expression of neuronal antigens, cells from each of 19 patients with Alzheimer's disease reacted immunocytochemically with antibodies to paired helical filaments, Alz-50, or both compared with only a small fraction of cells from 19 identically treated age-matched control cultures. Immunoblots confirmed the presence of soluble material reacting with Alz-50 antibody in the Alzheimer fibroblasts. Ultrastructurally, fascicles of 10-nm filaments were seen that occasionally twisted around each other, but no structures were seen that were identical to paired helical filaments. Thus, cultured skin fibroblasts from patients with Alzheimer's disease developed greater immunocytochemical reactivity with antibodies raised to paired helical filaments than did fibroblasts from control subjects, when cultured under the specified conditions.

Reduced activities of thiamine-dependent enzymes in the brains and peripheral tissues of patients with Alzheimer's disease.

A report of cell loss in the nucleus basalis of Meynert in patients with Wernicke-Korsakoff disease prompted the examination of thiamine pyrophosphate (TPP)-dependent enzymes in the brain and peripheral tissues of patients with Alzheimer's disease. In these brains, the activities of the 2-ketoglutarate dehydrogenase complex were reduced more than 75% and those of transketolase more than 45%. Decreases occurred in histologically damaged and in relatively undamaged areas. Small but statistically significant abnormalities of transketolase, but not of 2-ketoglutarate dehydrogenase complex, were identified in red blood cells and cultured fibroblasts. Previous studies have shown deficiencies in the brain and variable effects in peripheral tissues on another TPP-dependent enzyme--the pyruvate dehydrogenase complex. Activities of TPP-dependent enzymes appear to be deficient in the brain and perhaps in some peripheral tissues in patients with Alzheimer's disease.

Studies of transketolase abnormality in Alzheimer's disease.

The partially purified transketolase from each of eight well-nourished patients with Alzheimer's disease contained significantly less heat-stable component with a significantly longer half-life of heat inactivation than that from eight controls. Immunochemical studies utilizing antibodies to the purified human liver transketolase did not distinguish between red blood cell transketolases of patients with Alzheimer's disease and those of controls. However, three brains from patients with Alzheimer's disease that were deficient in transketolase activity lacked a 69-kilodalton form on immunoblots. Subtle structural abnormalities of transketolase appear to occur in a high proportion of patients with Alzheimer's disease.

Pyruvate dehydrogenase phosphate (PDHb) phosphatase activity in fibroblasts from Leigh's disease.

The defective activation of pyruvate dehydrogenase complex (PDHC) in Leigh's disease (subacute necrotizing encephalomyelopathy) could be due to deficiency of pyruvate dehydrogenase phosphate (PDHb) phosphatase (EC 3.1.3.43). This enzyme catalyzes the dephosphorylation and activation of phospho-PDHC. In cultured skin fibroblasts, we assayed this enzyme by measuring the rate of activation of the exogenously added, purified phospho-PDHC (bovine kidney). PDHb phosphatase activity did not differ significantly among normal control cells, Leigh's lines, spinocerebellar ataxias, or other neurologic disorders. The results do not support the idea that PDHb phosphatase is deficient in Leigh's disease.

Abnormal activation of pyruvate dehydrogenase in Leigh disease fibroblasts.

Incubation with dichloroacetate increased activity of the pyruvate dehydrogenase complex (PDHC) in disrupted fibroblasts from controls but not from two patients with autopsy-proved Leigh disease. These results are consistent with a genetically determined aberration of the regulation of PDHC in this disorder, although further studies are necessary to define the aberration.