Atypical Prenatal Ultrasound Presentation and Neuropathological Findings in a Neonate With Alpha Thalassemia Major: A Case Report.

Alpha thalassemia major is a hemoglobinopathy caused by the inactivation or deletion of all 4 α-globin alleles. We describe a case of α-thalassemia major with atypical ultrasound and neuropathological findings. The mother had her first prenatal visit at 27 4/7 gestational weeks. Ultrasound revealed a hydropic fetus with multiple anomalies. However, the middle cerebral artery peak systolic velocity (MCA-PSV) suggested that the likelihood of fetal anemia was low. Given the poor prognosis of hydrops fetalis, the parents opted for termination of pregnancy. The neonate died shortly after birth. Autopsy revealed a markedly hydropic female infant with severe limb reduction defects and, in contrast to what was suggested by the prenatal MCA-PSV measurement, unequivocal signs of severe anemia. The brain showed diffuse white matter gliosis. Genetic testing subsequently identified HBA1 and HBA2 deletions, consistent with α-thalassemia major. This case highlights the potential pitfall of MCA-PSV, which is nowadays considered the gold standard for noninvasive detection of fetal anemia. In addition, this is 1 of 2 published case reports detailing neuropathological findings in a fetus or neonate with α-thalassemia major and the first to link α-thalassemia major with diffuse white matter gliosis.

Reduced antiretroviral drug efficacy and concentration in HIV-infected microglia contributes to viral persistence in brain.

BACKGROUND: In patients with HIV/AIDS receiving antiretroviral therapy (ART), HIV-1 persistence in brain tissue is a vital and unanswered question. HIV-1 infects and replicates in resident microglia and trafficking macrophages within the brain although the impact of individual ART drugs on viral infection within these brain myeloid cells is unknown. Herein, the effects of contemporary ART drugs were investigated using in vitro and in vivo models of HIV-1 brain infection. RESULTS: The EC50 values for specific ART drugs in HIV-infected human microglia were significantly higher compared to bone marrow-derived macrophages and peripheral blood mononuclear cells. Intracellular ART drug concentrations in microglia were significantly lower than in human lymphocytes. In vivo brain concentrations of ART drugs in mice were 10 to 100-fold less in brain tissues compared with plasma and liver levels. In brain tissues from untreated HIV-infected BLT mice, HIV-encoded RNA, DNA and p24 were present in human leukocytes while ART eradicated viral RNA and DNA in both brain and plasma. Interruption of ART resulted in detectable viral RNA and DNA and increased human CD68 expression in brains of HIV-infected BLT mice. In aviremic HIV/AIDS patients receiving effective ART, brain tissues that were collected within hours of last ART dosing showed HIV-encoded RNA and DNA with associated neuroinflammatory responses. CONCLUSIONS: ART drugs show variable concentrations and efficacies in brain myeloid cells and tissues in drug-specific manner. Despite low drug concentrations in brain, experimental ART suppressed HIV-1 infection in brain although HIV/AIDS patients receiving effective ART had detectable HIV-1 in brain. These findings suggest that viral suppression in brain is feasible but new approaches to enhancing ART efficacy and concentrations in brain are required for sustained HIV-1 eradication from brain.

Metagenomic and metabolomic characterization of rabies encephalitis: new insights into the treatment of an ancient disease.

Rabies virus (RV) infection is a fatal nervous system disorder. We describe a patient who died of rabies despite a neuroprotective intervention. Neuropathology showed neuronal loss with abundant RV antigen, genome, and Negri bodies, accompanied by intense neuroinflammation, including by CD8(+) T lymphocyte infiltrates. Deep sequencing and real-time reverse-transcription polymerase chain reaction revealed RNA encoding a bat RV strain together with inflammatory gene induction. RV-infected brain demonstrated reduced neuronal metabolites with an anaerobic metabolic profile by nuclear magnetic resonance (NMR) spectroscopy. These multiplatform studies highlight the extent of ongoing viral replication coupled with inflammation in treated rabies, indicative of a neurological immune reconstitution inflammatory syndrome.

Multiple sclerosis: validation of MR imaging for quantification and detection of iron.

PURPOSE: To investigate the relationship between iron staining and magnetic resonance (MR) imaging measurements in postmortem subjects with multiple sclerosis (MS). MATERIALS AND METHODS: Institutional ethical approval was obtained, and informed consent was obtained from the subjects and/or their families. Four MR imaging methods based on transverse relaxation (T2 weighting, R2 mapping, and R2* mapping) and phase imaging were performed by using a 4.7-T system in three in situ postmortem patients with MS less than 28 hours after death and in one in vivo patient 1 year before death. Iron staining with the Perls iron reaction was performed after brain extraction. Region-of-interest measurements from six subcortical gray matter structures were obtained from MR imaging and then correlated with corresponding locations on photographs of iron-stained pathologic slices by using a separate linear least-squares regression in each subject. Iron status of white matter lesions, as determined by staining, was compared with appearance on MR images. RESULTS: R2* mapping had the highest intrasubject correlations with iron in subcortical gray matter (R(2) = 0.857, 0.628, and 0.685; all P < .001), while R2 mapping (R(2) = 0.807, 0.615, 0.628, and 0.489; P < .001 and P = .001, .034, and .001, respectively), phase imaging (R(2) = 0.672, 0.441, 0.596, 0.548; all P ≤ .001), and T2-weighted imaging (R(2) = 0.463, 0.582, 0.650, and 0.551; all P < .001) had lower but still strong correlations. Within lesions, hypointense areas on phase images did not always represent iron. A hyperintense rim surrounding lesions on R2* maps was only present with iron staining, yet not all iron-staining lesions had R2* rim hyperintensity. CONCLUSION: All four MR imaging methods had significant linear correlations with iron and could potentially be used to determine iron status of subcortical gray matter structures in MS, with R2* mapping being preferred. A reliable method of determining iron status within MS lesions was not established.

Oligodendroglial neoplasms with ganglioglioma-like maturation: a diagnostic pitfall.

Although oligodendroglial neoplasms are traditionally considered purely glial, increasing evidence suggests that they are capable of neuronal or neurocytic differentiation. Nevertheless, ganglioglioma-like foci (GGLF) have not been previously described. Herein, we report seven examples where the primary differential diagnosis was a ganglioglioma with an oligodendroglial component. These five male and two female patients ranged in age from 29 to 63 (median 44) years at initial presentation and neuroimaging features were those of diffuse gliomas in general. At presentation, the glial component was oligodendroglioma in six and oligoastrocytoma in one; one was low-grade and six were anaplastic. A sharp demarcation from adjacent GGLF was common, although some intermingling was always present. The GGLF included enlarged dysmorphic and occasionally binucleate ganglion cells, Nissl substance, expression of neuronal antigens, GFAP-positive astrocytic elements, and low Ki-67 labeling indices. In contrast to classic ganglioglioma, however, cases lacked eosinophilic granular bodies and CD34-positive tumor cells. Scattered bizarre astrocytes were also common and one case had focal neurocytic differentiation. By FISH analysis, five cases showed 1p/19q codeletion. In the four cases with deletions and ample dysmorphic ganglion cells for analysis, the deletions were found in both components. At last follow-up, two patients suffered recurrences, one developed radiation necrosis mimicking recurrence, and one died of disease 7.5 years after initial surgery. We conclude that GGLF represents yet another form of neuronal differentiation in oligodendroglial neoplasms. Recognition of this pattern will prevent a misdiagnosis of ganglioglioma with its potential for under-treatment.

Identification of PD-L2, B7-H3 and CTLA-4 immune checkpoint proteins in genetic subtypes of meningioma.

Meningioma is the most common brain tumor in adults. Surgical resection remains the primary treatment. No chemotherapy exists. However, gene mutations now could explain ~ 80% of meningioma and targeted therapies based on these are being investigated. Furthermore, with the recent discovery of PD-L1 in malignant meningioma, clinical trials using immunotherapy have commenced. Here, we report for the first time the expression profiles of immune checkpoint proteins PD-L2, B7-H3 and CTLA-4 in meningioma and their association to common gene mutations. PD-L2 and B7-H3 expression was significantly greater than all immune checkpoint proteins studied, and particularly elevated in patients with gene mutations affecting the PI3K/AKT/mTOR pathway. CTLA-4 expressing CD3+ lymphocytes were observed in atypical and malignant meningioma and tumors harboring a PIK3CA or SMO mutation. These results identify novel targets for immunotherapy irrespective of grade and distinguish potential patient populations based on genetic classification for stratification into checkpoint inhibitor clinical trials.

Fourier transform infrared spectromicroscopy and hierarchical cluster analysis of human meningiomas.

Limitations of conventional light microscopy in pathological diagnosis of brain tumors include subjective bias in interpretation and discordance of nomenclature. A study using mid-infrared (IR) spectromicroscopy was undertaken to determine whether meningiomas, a group of brain tumors prone to recurrence, could be identified by the unique spectral 'fingerprints' of their chemical composition. Paired, thin (5-microm) cryosections of snap-frozen human meningioma tumor samples removed at elective surgery were mounted on glass (hematoxylin and eosin-stained tissue section) and infrared (unstained tissue section) reflectance slides, respectively. Concordance of the tumor-bearing areas identified in the stained section by a pathologist with the unstained IR tissue section was ensured using a novel digital grid and tumor-mapping system developed in our laboratory. Compared with the normal control, tumor samples from four meningioma patients revealed a marked decrease in bands associated with unsaturated fatty acids, particularly in the bands at 3010, 2920, 2850, and 1735 cm(-1). Spectral datasets were subjected to hierarchical cluster analyses (HCA) using Ward's algorithm for comparison and grouping of similar data groups, and were converted into color-coded digital maps for matching spectra with their respective clusters. False color images of 5 and 6 clusters obtained by HCA identified dominant clusters corresponding to tumor tissue. Corroboration of these findings in a larger number of meningiomas may allow for more precise identification of these and other types of brain tumors.

GNE Myopathy With Novel Mutations and Pronounced Paraspinal Muscle Atrophy.

GNE myopathy is characterized by distal muscle weakness, and caused by recessive mutations in GNE. Its onset is characteristically in young adulthood, although a broad spectrum of onset age is known to exist. A large number of mutations in GNE are pathogenic and this clinical phenotype can be difficult to differentiate clinically from other late-onset myopathies. We describe two families with novel mutations in GNE, and describe their clinical and MRI features. We also describe the presence of striking paraspinal muscle involvement on MRI of the lumbar spine, which is an under-recognized feature of GNE myopathy.

Precocious synapses in 13.5-week fetal holoprosencephalic cortex and cyclopean retina.

BACKGROUND: Genetic programming of cerebral development involves tissue morphogenesis and also timing of developmental processes. Precocious synaptogenesis in the neocortical plate was previously demonstrated in 5 of 6 fetuses of 20-31 weeks gestation. MATERIALS AND METHODS: Neuropathological examination was performed of a 13-week-5-day fetus with trisomy-13, a lobar holoprosencephaly, hydrocephalus, cyclopia and absence of ears. Immunocytochemical demonstration of the synaptic vesicle protein synaptophysin was performed in the brain and retina, along with other neuronal markers. RESULTS: Synaptophysin reactivity in the cortical plate was patchy and precocious. Radial glial fibres, demonstrated by vimentin, were oriented parallel to the cortical plate rather than perpendicular, probably because of hydrocephalus. A corpus striatum was not identified, but the poorly formed thalamus exhibited synaptophysin reactivity around many neurones. The cyclopean eye had ocular features of maturational delay including persistent hyaloid artery; ganglion cells were reduced in number, but retinal synaptophysin reactivity was paradoxically precocious. CONCLUSIONS: Holoprosencephaly exhibits abnormal patchy synapse distribution in the neocortex and retina; synaptogenesis was precocious, as we previously described in older fetuses. Too soon an onset of synapse formation may promote early epileptic circuitry, leading to severe infantile epilepsies postnatally. The visual system is the last of the special sensory systems to mature, yet in this case showed too early synapse formation. In HPE, cyclopia and in trisomy 13, total absence of external ears has not been reported; it results from faulty craniofacial induction by neural crest.

Anti-NMDA receptor encephalitis. The disorder, the diagnosis and the immunobiology.

Anti-NMDAR encephalitis is a newly characterized syndrome with a progressive, predictable clinical course and the possibility of effective treatment. Accurate and timely diagnosis is critical to selection and implementation of treatments, and optimal patient outcomes. Outcomes are improved with early diagnosis via indirect immunofluorescence or cell-based assays, and the rapid and appropriate administration of immunosuppressant and anti-psychotic therapies. Three possible scenarios accounting for the immunopathogenesis of anti-NMDAR encephalitis are presented, with the most probable one being that of paraneoplastic autoimmunity. Future efforts in this disorder should focus on elucidating the mechanisms that contribute to initiation of this antibody response, as well as exploring the role of tumors, infectious triggers and immune-reactivation. Finally, accessible tools need to be developed that allow for reliable identification of specific antibody markers against synaptic proteins.

Syphilitic myositis: a case-based review.

To present the clinical and pathological findings in patients presenting with myositis caused by syphilis. The literature is reviewed, and pathophysiologic factors discussed. A 49-year-old Caucasian heterosexual male with a known history of stable human immunodeficiency virus (HIV) and hepatitis C (HCV) co-infection, developed progressive muscle weakness over 10 weeks. He discontinued his medications; however, he had on-going muscle symptoms. A muscle biopsy was performed, consistent with mild myositis. While on prednisone therapy, he developed panuveitis and vertigo. CSF studies were positive for syphilis (Treponema pallidum). He was started on appropriate antibiotic therapy with complete clinical resolution. This patient presented with myositis and panuveitis as a manifestation of acute onset of syphilis. Syphilis is an uncommon cause of myositis. In patients with HIV and/or HCV, the disease itself and side effects of the medications must be considered. As patients with HIV may have co-infections, syphilis must be considered, especially when unresponsive to traditional management.

Temporal artery biopsy for giant cell arteritis.

OBJECTIVE: To evaluate the influence of temporal artery biopsy (TAB) techniques on establishing a diagnosis of giant cell arteritis (GCA). METHODS: A retrospective review of 141 TAB pathology records from 1996 to 2002 was conducted. Histopathology slides on 136 TAB were reviewed by a single, independent, blinded pathologist. RESULTS: The population included 101 (71.6%) women, mean age 75.8 years (range 45-92), and 40 men, mean age 73.9 years (range 47-90). The mean length of a TAB sample after formalin fixation was 1.76 cm (range 0.1-5.3). Surgeons performing the TAB represented 6 disciplines. Ophthalmologists had the largest volume, at 78 biopsies (55.3%), and the longest segments of artery, with a mean length of 2.37 cm (range 0.4-5.3) (p < 0.001). Comparison of biopsy interpretation provided a kappa coefficient of 0.8 (95% CI 0.69, 0.91). The 38 (27%) positive biopsies had a mean length of 2.07 cm (SD 1.1), and the 98 negative biopsies a mean length of 1.69 cm (SD 1.04) (p = 0.058). Biopsies < 1.0 cm length (n = 35, 25.7%) were less likely to be positive than those > or = 1.0 cm (p = 0.037). No significant differences in surgical discipline, hospital site, number of slides, or cross-sections/cm artery were found between the positive and negative biopsies. CONCLUSION: Biopsy specimens reported positive for GCA tended to be longer than those reported as negative. A "threshold" size of 1.0 cm is associated with increased diagnostic yield. Lack of standardization of biopsy harvesting and processing techniques may contribute to variable sensitivity of TAB.

Expression of N-myristoyltransferase in human brain tumors.

N-myristoylation is a process of covalent irreversible protein modification that promotes association of proteins with membranes. Based on our previous findings of elevated N-myristoyltransferase (NMT) activity in colonic epithelial neoplasms that appears at an early stage in colonic carcinogenesis, together with elevated NMT expression in human colorectal and gallbladder carcinomas, we investigated NMT activity and protein expression of NMT1 and NMT2 in human brain tumors and documented elevated NMT activity and higher protein expressions. For the first time, we have demonstrated that NMT has the potential to be used as a marker of human brain tumors. However, further studies with larger number of patients are required to establish its role as a complementary diagnostic tool. This finding has significant implications for further understanding of biological mechanisms involved in tumorigenesis, as well as for diagnosis and therapy of human brain tumors.

Hypothalamic neurocytoma with vasopressin immunoreactivity: Immunohistochemical and ultrastructural observations.

Hypothalamic tumors of neuronal derivation are rare. We describe the case of a 55-year-old woman with visual disturbances who was found by magnetic resonance imaging (MRI) to have a sellar and suprasellar tumor. She underwent subtotal surgical resection by a transsphe-noidal approach. By light microscopy the tumor displayed a uniform population of short spindle cells with round to oval nuclei, separated by an abundant fibrillary stroma containing axonal processes as shown by the Bodian stain. The neoplastic cells were immunoreactive for neuron-specific enolase (NSE), synaptophysin, and vasopressin, and nonimmunoreactive for glial fibrillary acidic protein (GFAP), vasoactive intestinal peptide (VIP), bombesin, chromogranin, neurofilament, cytokeratins (high and low molecular weight), vimentin, S100 protein, somatostatin, ß-endorphin, galactosamine, growth hormone-releasing hormone (GRH), neurophysin, serotonin, adrenaline and noradrenaline, and corticotropin-releasing hormone (CRH). Ultrastructural features included an abundance of neurosecretory granules within neurites and perinuclear cytoplasm. Synapses and glial stroma were not demonstrable. The term hypothalamic neurocytoma delineates this neuronal tumor with distinctive histologic, immunohistochemical, and ultrastructural features. The identification of vasopressin within the tumor provides evidence of neuroendocrine function.

Coxiella burnetii seropositivity in parturient women is associated with adverse pregnancy outcomes.

OBJECTIVE: We conducted a cohort study of parturient women in an area with endemic Q fever infection to determine whether those seropositive for Coxiella burnetii had evidence of adverse birth outcomes. STUDY DESIGN: From June 1997 to November 1998, the cord blood of all women delivered at our health center was tested for antibodies to C burnetii by indirect immunofluorescence antibody test by using purified whole cell strain Nine Mile antigens. A titer of 1:8 or greater to either phase I or phase II antigens was considered seropositive. Placentas of a sample of cases and seronegative controls had polymerase chain reaction and culture performed. RESULTS: Evidence of prior infection with C burnetii was found in 3.8% (291/7658) of all parturient women. In a multivariate logistic regression, an association was seen between seropositivity (phase I titer >or= 1:8 or phase II titer >or= 1:32) and newborn gestational age >or=36 weeks (phase I antibody, odds ratio [OR] 2.4, 95% CI 1.3-4.3, P =.005; phase II antibody, OR 1.9, 95% CI 1.02-3.7, P =.04). Women with phase I antibody were more likely to have a prior or current neonatal death (phase I OR 3.2, 95% CI 1.09-9.3, P =.03). No placental samples from 153 seropositive or 93 seronegative women had Q fever by polymerase chain reaction or culture. CONCLUSION: About 4% of parturient women in this endemic area have evidence of previous exposure to C burnetii and this exposure is associated with adverse pregnancy outcomes. The pathogenesis of this association remains to be determined.

T-cell/periodic acid-Schiff stain: a useful tool in the evaluation of tubulointerstitial infiltrates as a component of renal allograft rejection.

Distinguishing between tubulitis and tubulointerstitial mononuclear cell infiltrates and determining the severity of tubulitis are critical components of diagnosing and grading renal allograft rejection using the 1993 Banff schema, the revised 1997 Banff schema, or the Cooperative Clinical Trials in Transplantation grading system. We describe a novel staining method, the T-PAS stain (CD3 and periodic acid-Schiff), which removes some of the subjectivity in the evaluation of tubulointerstitial infiltrates in renal allograft biopsies. The method simply combines two routine stains, immunoperoxidase staining for T cells (CD3) and periodic acid-Schiff (PAS) staining for tubular basement membrane, on the same section.