[How Parkinson's disease patients recognize Parkinson's disease therapeutic guideline?].

The "Parkinson's disease (PD) therapeutic guideline 2002 (PGL)" was published by Societas Neurologica Japonica in Japan. The guideline, which is based on evidence-based medicine (EBM), is a good reference for making medical decisions. Although physicians recognize the usefulness of the guideline, it is unclear whether PD patients know of the its existence. We performed a survey of 42 PD patients to evaluate their thoughts on the guideline. Sixty-seven percent of the patients had no knowledge of the existence of the PGL. However, after informing them of the existence of the PGL, 93% of the patients welcomed its publication. Forty-three percent of the patients wanted to read the PGL, although they expressed reservation that the PGL might be difficult to understand. Ninety-five percent of the patients answered that they would read the PGL if an easy-to read explanation manual were provided. However, none of the patients wanted an excessively strict obedience to the PGL. Eighty-three percent of the patients wanted a flexible application of the PGL to their own therapy. The PGL seems to have been accepted by the patients. A plain-language explanation manual of the PGL for PD patients, if published, would be helpful to the patients' understanding of PD therapy and to building cooperation between patients and physicians.

[Amyotrophic lateral sclerosis associated with extrapyramidal symptoms or signs].

This investigation was conducted to clarify the frequency and characteristics of ALS associated with extrapyramidal symptoms or signs in Wakayama prefecture. The questionnaires to survey ALS cases were mailed to all medical centers in Wakayama prefecture. A total of 252 cases were found to have motor neuron diseases. Among them, 204 cases fulfilled probable or definite according to El Escorial Criteria. In 10 of them, extrapyramidal signs were identified as follows: rigidity 50%, tremor 40% and akinesia 10%. Family history of ALS in these cases (20%) is higher than expected in usual ALS, and all of them are negative for SOD-1 mutation. Dementia and autonomic nervous symptoms were observed in several cases. Incidence of extrapyramidal signs in ALS resulted in 4.8%. The incidence of extrapyramidal signs is more frequent than expected by chance, suggesting that the degeneration of basal ganglia and/or substantia nigra may not be so rare in ALS.

Anti-U3 ribonucleoprotein antibody-positive inflammatory myopathy: a case report.

BACKGROUND: The discovery of myositis-specific autoantibodies and myositis-associated autoantibodies has led to a new serological classification. Human U3 RNP, which consists of the U3 small nucleolar RNA and anti-U3 RNP antibody, is directed against one of the subunits. Anti-U3 RNP antibodies have been detected in 5-8 % of patients with systemic sclerosis, and antibody-positive patients with systemic sclerosis have shown more frequent skeletal muscle involvement than that of antibody-negative patients with systemic sclerosis. CASE PRESENTATION: A 74-year-old Japanese man positive for anti-U3 RNP antibody was referred to our hospital because of gait disturbance and dysphagia. His serum myoglobin and creatine kinase levels were elevated, and myopathic changes were observed in his proximal legs by needle electromyography. A muscle biopsy was performed at the quadriceps femoris muscle, which showed high signal intensity on fat-suppressed and T2-weighted magnetic resonance images. The patient was diagnosed with probable polymyositis because CD8-positive lymphocytes had invaded only the endomysium and not into the muscle fibers. Severe proliferation of the interstitial connective tissue and edematous changes were observed. Oral prednisolone therapy was started, and the patient's muscle weakness of the proximal limbs improved remarkably within 1 month. Dysphagia caused by incomplete function of the cricopharyngeal muscle persisted for 5 years. CONCLUSIONS: Our findings indicate that mild muscle weakness with steroid-resistant dysphagia may be a clinical feature of patients with anti-U3 RNP antibody-positive inflammatory myopathy.

Methotrexate myelopathy after intrathecal chemotherapy: a case report.

INTRODUCTION: Methotrexate is often administered intrathecally or into the cerebral ventricles, particularly in patients with central nervous system tumors. However, in addition to chemical arachnoiditis, methotrexate can induce severe myelopathy. CASE PRESENTATION: A 59-year-old Japanese man with diffuse B-cell lymphoma who underwent systemic chemotherapy including methotrexate and 20 Gy of radiotherapy received intrathecal methotrexate for recurrence. Flaccid paresis of his lower limbs and fecal and urinary incontinence appeared 1 month later. All sensations were impaired below the Th10 dermatome level. Although the clinical symptoms were compatible with transverse myelitis, T2-weighted imaging of his thoracic spinal cord demonstrated signal hyperintensity localized to the posterior and lateral funiculi, which resembled subacute combined degeneration. His serum vitamin B12, folic acid, and total homocysteine levels were within normal limits, but total homocysteine levels in his cerebrospinal fluid were elevated, suggesting spinal cord demyelination. CONCLUSIONS: Little is known of the pathogenesis of methotrexate myelopathy. A possible mechanism of methotrexate myelopathy with demyelination was suggested by the increased homocysteine levels in the cerebrospinal fluid.

Oxidative stress and microglial activation in substantia nigra following striatal MPP+.

The present study aims to study sequential alterations occurring in both dopaminergic neurons and microglia in substantia nigra (SN) following intrastriatal injection of 1-methyl-4-phenylpridium ion (MPP+) in rats. Heme oxygenase-1 (HO-1), a marker of oxidative stress, first appeared in dopaminergic neurons in SN at 1 day post-lesion. Subsequently, microglia in SN exhibited morphological changes indicative of activation. At 7 days post-lesion, those findings increased severity and 7a significant reduction in the number of dopaminergic neurons was observed. The present finding suggests that extensive oxidative stress and secondary-induced neuroinflammation play a relevant role in MPP(+)-induced retrograde dopaminergic neuron degeneration. We hope that this model will be useful in developing a disease modifying therapy of Parkinson's disease.

T2-low signal intensity in the cortex in multiple system atrophy.

To determine the clinical significance of T2-low signal intensity in the cortex of patients presenting parkinsonism, T2-weighted magnetic resonance (MR) images of the cortex of patients with multiple system atrophy (MSA), Parkinson's disease (PD) and progressive supranuclear palsy (PSP), and compared with those of patients with amyotrophic lateral sclerosis (ALS) and age-matched normal controls. The MR images were gathered and presented randomly to three neurologists who were blind to information on the patients. There was a significant increase in the frequency of T2-low signal intensity in the cortex of patients with ALS and MSA. Particularly in those with MSA, the T2-low signal intensity was observed not only in the motor cortex but also in the frontal association cortex. The cortical T2-low signal intensity in MSA might reflect the spread of degenerative processes in the cortex.

Stereotyped behaviors or punding after quetiapine administration in Parkinson's disease.

Quetiapine has been suggested to be useful for the treatment of psychosis in patients with Parkinson's disease without prominent deterioration of motor functions. We present two patients with Parkinson's disease in whom administration of quetiapine for drug-induced psychosis caused characteristic stereotyped behaviors or punding. Since stereotyped behaviors are usually associated with excessive dopaminergic activity, it is clinically important to note that stereotyped behaviors or punding may be induced by an atypical antipsychotic drug for the treatment of psychosis in patients with Parkinson's disease.

[A patient with multiple system atrophy presenting prolonged levodopa-responsive parkinsonism and off-dystonia of the trunk].

A 46-year-old man had a 7-year history of dopa-responsive parkinsonism. Four years after starting levodopa, he had typical motor complications such as wearing-off and peak dose as well as off-period dystonia of his trunk. Brain MRI showed marked atrophy of the brainstem and cerebellum, and the cross sign was present in the pontine base. There was neither abnormal signal intensity nor atrophy in the basal ganglia. Then, he was suspected as having multiple system atrophy (MSA). It is not easy to differentiate MSA from Parkinson diseases, particularly when the patient shows good response to levodopa and motor complications like those seen in Parkinson's disease. If the striatal pathology was not severe and nigral degeneration was prominent, presynaptic parkinsonism might occur in MSA, and putaminal preservation might account for good response to levodopa therapy. In patients with MSA, disproportionate antecollis is common before levodopa treatment, and levodopa induced off-dystonia of his trunk is very rare.

[Effect of zonisamide on resting tremor resistant to antiparkinsonian medication].

The antiparkinsonian effect of zonisamide (ZNS), an antiepileptic agent, has been reported. Generally, resting tremor of patients with Parkinson's disease is not the main therapeutic target in this disease. However, depending on the social situation of the patient, the amelioration of the tremor may be necessary. In this study, we examined the effect of ZNS on tremor in nine patients who desired amelioration of their tremor. Except for tremor, they seemed to be under optimal therapeutic condition based on their daily activities. By the add-on administration of ZNS, the degree of tremor was reduced in seven out of nine patients (p < 0.0017). Although one patient felt sleepiness and two patients had a transient loss of appetite, all the patients tolerated the eight-week ZNS administration period. The final dose of ZNS was 100 mg/day in the majority of the patients. Although the mechanism of the antitremulous effect of ZNS is not yet clear, other than the enhancement of dopaminergic transmission, some specific action of the drug on tremor may exist. A more detailed random examination should be carried out.

[A case of spinocerebellar ataxia 6 accompanied with schizophrenia].

An abnormally expanded CAG repeats (25, normal; 4-20) was identified in the alpha 1A voltage-dependent calcium channel (CACNA1A) gene of a 50-year-old Japanese man with 25 years history of schizophrenia. At age 45, he first noted unsteadiness of standing and gait, which gradually worsened subsequently. In addition to the psychiatric symptoms of schizophrenia, neurological examination revealed marked truncal ataxia and mild limb ataxia. Brain magnetic resonance imaging showed atrophy of the cerebellar vermis. Gene analysis confirmed the diagnosis of spinocerebellar ataxia type 6 (SCA 6). No family members showed similar neuropsychiatric symptoms except that the patient's father had been suffering from an unknown dementing disease. Occurrence of both schizophrenia and SCA 6 in the identical patient may be coincidental. However, growing evidence has shown that various mutations in the CACNA1A gene are associated with phenotypic variability, such as progressive ataxia, episodic ataxia, migraine, coma, epilepsy and mental retardation. Therefore, the schizophrenic symptoms, association of which with SCA 6 has previously reported in a few cases, may represent rare clinical features of the channelopathy associated with the mutation in the CACNA1A gene.

Methylmercury exposure and neurological outcomes in Taiji residents accustomed to consuming whale meat.

Methylmercury (MeHg) is a major environmental neurotoxicant that causes damage to the central nervous system. In Japan, industrial emission of MeHg has resulted in MeHg intoxication in Minamata and Niigata, the so-called Minamata disease. Humans are exposed to MeHg derived from natural sources, primarily fish and fish predators. Therefore, MeHg continues to be an environmental risk to human health, particularly in susceptible populations that frequently consume substantial amounts of fish or fish predators such as whale. This study aimed to investigate the health effects of MeHg exposure in adults. The subjects were 194 residents (117 males, 77 females; age 20-85 years) who resided in the coastal town of Taiji, the birthplace of traditional whaling in Japan. We analyzed hair for mercury content and performed detailed neurological examinations and dietary surveys. Audiometry, magnetic resonance imaging, and electromyography were performed to diagnose neurological defects. Whole blood mercury and selenium (Se) levels were measured in 23 subjects. The geometric mean of the hair mercury levels was 14.9 µg/g. Twelve subjects revealed hair mercury levels >50 µg/g (NOAEL) set by WHO. Hair mercury levels significantly correlated with daily whale meat intake. These results suggested that residents in Taiji were highly exposed to MeHg by ingesting MeHg-contaminated whale meat. Multivariate regression analysis demonstrated no significant correlations between hair mercury levels and neurological outcomes, whereas some of the findings significantly correlated with age. A significantly positive correlation between whole blood mercury and Se levels was observed and the whole blood mercury/Se molar ratios of all subjects were <1. These findings suggested that sufficient Se intake might be one of causes of the absence of adverse effects of MeHg exposure in this study.

Ephrin-A1-mediated dopaminergic neurogenesis and angiogenesis in a rat model of Parkinson's disease.

Cells of the neural stem cell lineage in the adult subventricular zone (SVZ) respond to brain insult by increasing their numbers and migrating through the rostral migratory stream. However, in most areas of the brain other than the SVZ and the subgranular zone of the dentate gyrus, such a regenerative response is extremely weak. Even these two neurogenic regions do not show extensive regenerative responses to repair tissue damage, suggesting the presence of an intrinsic inhibitory microenvironment (niche) for stem cells. In the present study, we assessed the effects of injection of clustered ephrin-A1-Fc into the lateral ventricle of rats with unilateral nigrostriatal dopamine depletion. Ephrin-A1-Fc clustered by anti-IgG(Fc) antibody was injected stereotaxically into the ipsilateral lateral ventricle of rats with unilateral nigrostriatal lesions induced by 6-hydroxydopamine, and histologic analysis and behavioral tests were performed. Clustered ephrin-A1-Fc transformed the subventricular niche, increasing bromodeoxyuridine-positive cells in the subventricular area, and the cells then migrated to the striatum and differentiated to dopaminergic neurons and astrocytes. In addition, clustered ephrin-A1-Fc enhanced angiogenesis in the striatum on the injected side. Along with histologic improvements, behavioral derangement improved dramatically. These findings indicate that the subventricular niche possesses a mechanism for regulating both stem cell and angiogenic responses via an EphA-mediated signal. We conclude that activation of EphA receptor-mediated signaling by clustered ephrin-A1-Fc from within the lateral ventricle could potentially be utilized in the treatment of neurodegenerative diseases such as Parkinson's disease.

Transcranial sonography of the substantia nigra in Japanese patients with Parkinson's disease or atypical parkinsonism: clinical potential and limitations.

OBJECTIVE: There is growing interest in the use of transcranial sonography (TCS) of the substantia nigra (SN) in patients with Parkinson's disease (PD), as it has been reported that SN hyperechogenicity may be present in about 90% of PD patients. However, TCS of the SN has not been applied in Japanese patients, and its clinical potential has not been determined. PATIENTS AND METHODS: TCS of the SN was performed in patients with PD, progressive supranuclear palsy (PSP), multiple system atrophy (MSA), and essential tremor (ET), and age-matched controls. Ultrasound images of the SN were assessed using semi-qualitative estimation criteria by two investigators unaware of clinical diagnosis. RESULTS: SN hyperechogenicity was observed in approximately 83% of accessible SNs in Japanese PD patients. In comparison, SN hyperechogenicity was less frequently observed in healthy subjects or in patients with PSP, MSA, and ET. However, the rate of successful recording of the SN by TCS decreased prominently with advancing age, particularly in females. CONCLUSION: The present study confirmed that TCS of the SN is potentially useful in the investigation of Japanese patients, and it provides a better differential diagnosis between PD and atypical parkinsonism. The recording failure of TCS in aged, particularly female subjects, may limit the clinical potential of TCS of the SN in Japanese patients.

Cerebellar atrophy in a patient with anorexia nervosa.

UNLABELLED: Reversible cerebral atrophy (pseudoatrophy) is observable in patients with anorexia nervosa. However, it is extremely rare to see marked cerebellar atrophy. OBJECTIVES: We report on a patient who developed cerebellar atrophy after the severe deterioration of cardiac and respiratory functions resulting from undernutririon. RESULTS: A 30-year-old Japanese woman was admitted to the Wakayama Medical University Hospital (Wakayama, Japan) because of unsteadiness of gait. She had a 7-year history of anorexia nervosa and had been admitted to an emergency hospital because of asthenic shock resulting from severe undernutrition at the age of 28. On admission to our hospital, neurologic examination revealed dysarthria and cerebellar ataxia of the trunk and lower extremities without nystagmus. A brain magnetic resonance imaging scan demonstrated marked atrophy of the cerebellum. DISCUSSION: Because her cerebellar ataxia appeared during severe deterioration of her general condition, and there has been no subsequent progression, it is possible that her cerebellar atrophy was induced by undernutrition.