CDR3 spectratyping analysis of the TCR repertoire in myasthenia gravis.

Because myasthenia gravis (MG) is an autoimmune disease mediated by Abs specific for the acetylcholine receptor, helper T cells play a role in Ab production. In this study, we have performed large-scale cross-sectional and longitudinal TCR studies by CDR3 spectratyping using PBL and thymus tissues from MG patients. We found that there was no preferential usage of any particular TCR beta-chains that was identical among MG patients. However, the longitudinal study clearly demonstrated that one or more TCR Vbeta expansions persisted frequently in MG patients. Importantly, persistent TCR expansions correlated with clinical severity and high anti-acetylcholine receptor Ab titer. Finally, examinations of T cells expressing CXCR5, i.e., follicular B-helper T cells, revealed that spectratype expansions in MG patients were detected mainly in the CD4+ CXCR5+ T cell populations, whereas CD8+ T cells were the major source of clonal expansion in healthy subjects. These findings suggest that persistent clonal expansions of T cells in MG patients are associated with the development and maintenance of MG. Close examination of pathogenic T cells in MG provides useful information to elucidate the pathogenesis and to estimate the disease status.

[Case of CADASIL showing spontaneous subcortical hemorrhage with a novel mutation of Notch3 gene].

The case of a 72-year-old demented woman having episodes of strokes without any risk factors for cardiovascular disease is reported. Her elder brother and sister have also had stroke episodes since their middle age. She experienced hallucinations, delusions, and recurrent headaches since the age of 55. She has gradually developed gait disturbance and cognitive impairment. Brain MRI revealed extensive leukoaraiosis and multiple lacunar infarcts in the deep white matter and brainstem. Repeated MRI incidentally disclosed fresh hemorrhage in the dorsal subcortical temporal lobe, which appeared to be asymptomatic. Anti-platelet agents were not used during disease progression. We detected G975C mutation of the Notch3 gene and diagnosed our patient's disease as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). This report suggests that arteriopathy of CADASIL could cause a hemorrhagic process, indicating that, in such a case, routine administration of anti-platelet agent to prevent recurrent ischemic stroke is not recommended.

Selective adsorption of human CD4 T cells.

The pathogenesis of most autoimmune diseases directly involves CD4(+) helper T cells. To remove CD4(+) T cells selectively from the circulation, we designed a new column in which an anti-CD4 monoclonal antibody was immobilized on the activated substance. Nearly 90% of CD4(+) T cells were selectively adsorbed from whole blood with a single passage through the column in vitro, resulting in depletion of the antigen-specific T cell responses. We conclude that this new column would be potentially useful for treatment of T cell-mediated autoimmune diseases.

Thymic myoid cells as a myasthenogenic antigen and antigen-presenting cells.

We investigated immune property of a myoid cell line, established from Fisher rat thymus. Immunization of syngeneic rats with the myoid cells induced anti-rat acetylcholine receptor (AChR). Implantation of them into the thymus failed to induce typical thymic pathology of human myasthenia gravis (MG) or anti-AChR responses. We also demonstrated that the myoid cells were able to present exogenous antigens to T cells and induce antigen-specific T cell proliferation. These results suggest that myoid cells have the potential antigenicity to induce anti-AChR and the functions of antigen-presenting cells, but their expansion in the thymus may not directly cause MG.

Cytapheresis with a filter for selective removal of CD4+ T cells in experimental autoimmune encephalomyelitis.

Experimental autoimmune encephalomyelitis (EAE) is a major animal model of human multiple sclerosis (MS). CD4+ T cells are thought to play a pivotal role in the pathogenesis of EAE and MS. In order to investigate the depletion of CD4+ T cells from the systemic circulation as an effective strategy for the treatment of MS, we performed extracorporeal CD4+ T cell adsorption, using a filter to which anti-CD4+ antibody is immobilized as a ligand, in adoptively transferred EAE. Rats treated with CD4+ T cell removal filter (CD4RF) exhibited milder clinical signs of EAE and earlier recovery than those receiving sham treatment. Moreover, the thymic cells from EAE rats treated with CD4RF exhibited a suppressed proliferative response and IFN-gamma production to myelin basic protein. These results suggest that depletion of CD4+ T cells from the systemic circulation by extracorporeal treatment is a potentially useful strategy for treatment of acute phase and relapsing MS.

X-linked motor and sensory neuropathy with pyramidal signs and cerebral white matter lesions.

We report two brothers with hereditary motor and sensory neuropathies and pyramidal signs. Electrophysiological evaluation revealed polyneuropathy and involvement of the central motor, somatosensory, and auditory pathways. Brain magnetic resonance imaging studies showed diffuse white matter lesions, and sural nerve biopsy identified a reduction in the large myelinated nerve fibers. The patients' mother and sister exhibited similar, but milder neurologic findings suggesting that the genetic defect may be X-linked; however, a point mutation in the connexin 32 gene was negative.

Development of a device for selective removal of CD4+ T cells.

To control antigen (Ag)-specific immune cells is important in the treatment of autoimmune diseases. In particular, controlling the immune response of autoimmune T cells is effective in the treatment of these diseases. The development of a device that can remove CD4+ T cells specifically by extracorporeal circulation is now in progress, with the aim to deplete autoimmune T cells. We developed a removal material made of polypropylene non-woven fabrics with anti human CD4 monoclonal antibody immobilized on the surface. Using a column packed with the removal material, we succeeded in removing CD4+ T cells specifically from peripheral whole blood by direct perfusion. Moreover, CD4+ T cells can be specifically removed even from blood with lower surface antigen density by in vitro activation.

Paramyotonia congenita due to a de novo mutation: a case report.

A Japanese man with a negative family history of paramyotonia congenita (PMC) was evaluated for symptoms of cold-induced weakness and stiffness. Exercise testing revealed findings characteristic of PMC, and a genetic analysis was therefore performed. A well-known sodium channel mutation for PMC (T1313M) was identified in the patient, but was absent in his biological parents. These data demonstrate the occurrence of a de novo mutation, suggesting that evaluation for PMC should be performed in patients with typical symptoms even if the family history is negative.

[Medical care and long-term care insurance and clinical practice guideline for neurological disorders].

Society in 21st century is a global community, and undergoes a paradigm shift to a new value. This is about the significance of clinical practice guideline for neurological disorders as a new paradigm in information technology society and global community. Medical care is required to be "safer, more effective, more efficient and more transparent" in 21st century. In order to improve the quality of medical care, not only the improvement of the quality in manpower but also the betterment of the response to patients based on proper balance between quality and efficiency of medicine is required and clinical practice guideline for patients and medical doctors should be actively utilized. Guidelines are socially positioned following regulations, directives and recommendations and it is not restriction upon practitioner and patient decisions about appropriate health care. In the definitions of Institute of Medicine and Medline-MeSH, a word "assist" is used and it is said that guidelines are "means to realize EBM assisting decision making" for medical doctors to expertise their specialties. It has a significant meaning in connection with doctors' discretion. When clinical practice guidelines clarify the intended purpose and are applied as suggestion instead of obligation, they would not invade doctors' discretion.

Miller Fisher syndrome and plasmapheresis.

Treatment for Miller Fisher syndrome (MFS) is controversial, and even the natural history and prognosis are not fully understood. We retrospectively reviewed our cases of MFS for the last 3 years. The analysis of 4 MFS cases revealed that we had performed plasmapheresis or additional immunotherapy to each of 4 patients, and their symptoms resolved for up to 50 days after the onset (ataxia improved 20-35 days and ophthalmoplegia for 25-50 days) except for 1 patient, and that Guillain-Barré syndrome had been diagnosed in 1 patient who had developed profound muscle weakness. We also discovered that MFS patients had a deviated T-helper Type-1 (Th1)/T-helper Type-2 (Th2) polarization and that plasmapheresis can shift Th2-dominant status to Th1-dominant status in patients with MFS. Although plasmapheresis may remove humoral factors, including anti-GQ1b, and may induce a shift of the Th1/Th2 cytokine-producing cell balance in peripheral blood, the therapeutic rationale has not yet been established. Therefore, controlled clinical trials are required to show whether plasmapheresis leads to earlier recovery with fewer neurologic deficits in patients with MFS.

[The effects of repetitive transcranial magnetic stimulation (rTMS) in the patients with Parkinson's disease].

The 1-Hz rTMS of 320 stimuli with an intensity of 90% of motor threshold was applied over the vertex of the skull using a round coil in a day. The effects of short-term (treated in 5 successive days) treatment was examined in 6 patients and long-term (treated in every one or two weeks for six months) treatment was examined in five. Unified Parkinson's Disease Rating Scale (UPDRS), motor evoked potential threshold (MT) and cortical silent period (SP) were recorded before and one day after the short-term treatment. In the long-term treatment, same recordings were obtained in every two months. After the short-term treatment, the total UPDRS scores was reduced from 37 +/- 3.3 (mean +/- S.E.) to 31 +/- 3.1 and the SP duration was prolonged from 98.9 +/- 24.7 to 106 +/- 22.0 significantly (P < 0.05 by Wilcoxon Matched Pairs Teat). After the long-term treatment, both total UPDRS scores and MEP threshold was reduced from 33 +/- 5.8 to 30 +/- 5.3 and from 75 +/- 7.2 to 69 +/- 5.7, respectively two months after the initiation of the treatment. Both values reduced continuously until the end of treatment, and a significant linear correlation was noted (r = 0.98) between them. Our results show the beneficial effects of rTMS and suggest the possible mechanism that the alteration of brain excitability induced by rTMS mediate therapeutic effects in patients with Parkinson's disease.