Analysis of 21 Patients With Alcoholic Marchiafava-Bignami Disease in Chongqing, China.

OBJECTIVE: This study aimed to investigate the characteristics and prognosis of patients with alcoholic Marchiafava-Bignami disease (MBD), a rare neurological disorder commonly associated with chronic alcoholism, in Chongqing, China. METHODS: We conducted a retrospective analysis of clinical data from 21 alcoholic MBD patients treated at the First Affiliated Hospital of Chongqing University between 2012 and 2022. RESULTS: The study included 21 patients with alcoholic MBD who had a mean age of 59 ± 9.86 years and an average drinking history of 35.48 ± 8.65 years. Acute onset was observed in 14 (66.7%) patients. The primary clinical signs observed were psychiatric disorders (66.7%), altered consciousness (61.9%), cognitive disorders (61.9%), and seizures (42.9%). Magnetic resonance imaging revealed long T1 and long T2 signal changes in the corpus callosum, with lesions predominantly found in the genu (76.2%) and splenium (71.4%) of the corpus callosum. The poor prognosis group demonstrated an increased incidence of altered consciousness (100% vs 50%, P = 0.044), pyramidal signs (80% vs 18.8%, P = 0.011), and pneumonia (100% vs 31.3%, P = 0.007). Patients with a longer drinking history (45.0 ± 10.0 years vs 32.69 ± 5.99 years, p = 0.008) and a lower thiamine dose (p = 0.035) had a poorer prognosis at 1 year. CONCLUSIONS: This study identified altered consciousness, pyramidal signs, and pneumonia as predictors of a poor prognosis in patients with alcoholic MBD. A longer duration of alcohol consumption and inadequate thiamine supplementation were associated with a poorer prognosis.

Clinical and antibodies analysis of anti-GQ1b antibody syndrome: a case series of 15 patients.

OBJECTIVES: To investigate the clinical manifestations, immunity, laboratory test, treatment and prognosis of patients with anti-GQ1b antibody syndrome in Chongqing, China. METHODS: We reviewed 15 patients with positive anti-ganglioside antibodies in the First Affiliated Hospital of Chongqing Medical University from 2016 to 2019. RESULTS: Fifteen patients were included in the study (mean age, 54.4 years; age range, 27 to 80 years; 9 men (60%)). Ten patients presented with a history of preinfection, including flu-like syndrome (n = 6, 60%), upper respiratory tract infection (URTI) (n = 3, 30%), and digestive tract infection (GI) (n = 1, 10%). The most common manifestation was ophthalmoplegia (n = 13, 86.67%), followed by weakness (n = 12, 80%), ataxia (n = 11, 73.3%), paresthesia (n = 8, 53.33%) and hypersomnolence (n = 5, 33.33%). All 15 patients underwent antibody testing. Eight patients (53.33%, 7 men (87.5%)) of whom only have positive immunoglobulin G (IgG) against anti-GQ1b antibody while seven (46.67%, 2 men (28.57%)) were positive for multiple anti-ganglioside antibodies apart from anti-GQ1b antibodies. Nine patients (60%) received intravenous immunoglobulin (IVIG) therapy, four (26.67%) received plasma exchange (PE) and two (13.33%) received steroid therapy. Three patients were lost to follow-up at 6 months, 1 patient (6.67%) had persistent back numbness, and the other 11 patients (73.33%) had fully recovered. CONCLUSION: The clinical subtype of anti-GQ1b antibody syndrome correlates with the type of anti-ganglioside antibody. Patients who test positive for only anti-GQ1b antibody are more likely to be men. Most patients exhibit a unidirectional course with a good prognosis, but anti-GQ1b antibody syndrome is also associated with a risk of recurrence.

Linear porokeratosis of the foot with dermoscopic manifestations: A case report.

BACKGROUND: Porokeratosis (PK) is a common autosomal dominant chronic progressive dyskeratosis with various clinical manifestations. Based on clinical manifestations, porokeratosis can be classified as porokeratosis of mibelli, disseminated superficial porokeratosis, disseminated superficial actinic porokeratosis, linear porokeratosis (LP), porokeratosis palmaris et plantaris disseminata, porokeratosis punctata, popular PK, hyperkeratosis PK, inflammatory PK, verrucous PK, and mixed types. We report a case of LP in a child and describe its dermoscopic findings. CASE SUMMARY: Linear porokeratosis is a rare PK. The patient presented with unilateral keratinizing maculopapular rash of the foot in childhood. The patient underwent skin pathology and dermoscopy, and was treated with liquid nitrogen freezing and topical drugs. CONCLUSION: From this case we take-away that LP is a rare disease, by the dermoscopic we can identify it.

Fibronectin is a potential cerebrospinal fluid and serum epilepsy biomarker.

PURPOSE: Previous studies have demonstrated that fibronectin (FN) levels are increased in brain tissues from patients and animals with epilepsy. This study aimed to assess FN levels in cerebrospinal fluid (CSF) and serum samples from patients with epilepsy. METHODS: Fibronectin levels were assessed in CSF and serum samples from 56 patients with epilepsy (27 and 29 individuals with intractable epilepsy and nonintractable epilepsy, respectively) and 25 healthy controls, using sandwich enzyme-linked immunosorbent assays (ELISA). RESULTS: CSF-FN levels were higher in patients with epilepsy (8.07 ± 1.51 mg/l versus 6.20 ± 1.18 mg/l, p<0.05) than in the control group. In addition, serum-FN levels in the group with epilepsy and in the control group were 236.96 ± 65.7 mg/l and 181.43 ± 72.82 mg/l, respectively, indicating a statistically significant difference (p=0.01). Interestingly, serum- and CSF-FN levels in individuals with epilepsy were not affected by antiepileptic drug and duration of epilepsy. Of note, the increase of CSF- and serum-FN levels was more pronounced in subjects with intractable epilepsy than in patients with nonintractable epilepsy. CONCLUSION: Serum- and CSF-FN levels constitute a potential clinical diagnostic biomarker for epilepsy and could also be used for differential diagnosis.

Echinoderm microtubule-associated protein -like protein 5 in anterior temporal neocortex of patients with intractable epilepsy.

OBJECTIVES: EMAP-like Protein 5 (EML5) is a new echinoderm microtubule-associated protein that is expressed in the central nervous system. The aim of this study was to investigate the expression profile of EML5 in the anterior temporal neocortex of patients presenting with intractable epilepsy (IE). MATERIALS AND METHODS: Western blot assays were performed to determine EML5 expression in 36 surgically resected anterior temporal neocortices of patients with IE and eight control tissues. Immunohistochemistry and immunofluorescence were employed to explore protein expression in IE. RESULTS: EML5 was highly expressed in both neurons and glial cells of the anterior temporal neocortex of IE patients, whereas only low levels of EML5 were detected in control brain tissues. Western blotting showed an enhanced expression of EML5 protein in the anterior temporal neocortex of IE (optical density (OD) = 1.8030 ± 0.1335/1.1852 ± 0.2253, P<0.05) compared with normal control tissues. CONCLUSION: The results demonstrate that highly expressed EML5 in the neurons and glial cells of the cortex of patients with epilepsy is associated with microtubular dysfunction after frequent and recurrent seizures.

Is intractable epilepsy a tauopathy?

Tau exists in neuronal axons and glial cells of the central nervous system and contributes to the maintenance of the unique cell morphology. It functions in axon elongation, cell polarity formation and microtubule stabilization. Aggregates and hyper-phosphorylated tau proteins are classical components of neurofibrillary lesions in numerous neurodegenerative disorders, which are called "tauopathies". Recent studies have demonstrated that tau-associated genes and proteins and tau phosphorylation were abnormal in intractable epilepsy. Therefore, the discovery of the dysfunctional tau in intractable epilepsy opens a new window in the study of central tauopathy.

A new hypothesis of drug refractory epilepsy: neural network hypothesis.

Drug refractory is an important clinical problem in epilepsy, affecting a substantial number of patients globally. Mechanisms underlying drug refractory need to be understood to develop rational therapies. Current two prevailing theories on drug refractory epilepsy (DRE) include the target hypothesis and the transporter hypothesis. However, those hypotheses could not be adequate to explain the mechanisms of all the DRE. Thus, we propose another possible mechanism of DRE, which is neural network hypothesis. It is hypothesized that seizure-induced alterations of brain plasticity including axonal sprouting, synaptic reorganization, neurogenesis and gliosis could contribute to the formation of abnormal neural network, which has not only avoided the inhibitory effect of endogenous antiepileptic system but also prevented the traditional antiepileptic drugs from entering their targets, eventually leading to DRE. We will illustrate this hypothesis at molecular and structural level based on our recent studies and other related researches.

Downregulation of gephyrin in temporal lobe epilepsy neurons in humans and a rat model.

Gephyrin, which is a postsynaptic scaffolding protein participated in clustering GABA(A) receptors at inhibitory synapses, has been reported to be involved in temporal lobe epilepsy (TLE) recently. Here, we investigate gephyrin protein expression in the temporal lobe epileptic foci in epileptic patients and experimental animals in order to explore the probable relationship between gephyrin expression and TLE. Using immunohistochemistry, immunofluorescence, and western blot analysis, gephyrin expression was examined in 30 human temporal neocortex samples from patients who underwent surgery to treat drug-refractory TLE and 10 histological normal temporal neocortex from the controls. Meanwhile, we investigated the gephyrin expression in the hippocampus and adjacent neocortex from experimental rats on 24 h, 48 h, 1 week, 2 weeks, 1 month, and 2 months postseizure and from control rats. Gephyrin protein was mainly expressed in the membrane and cytoplasm of neurons in temporal lobe epileptic foci in humans and experimental rats. Gephyrin expression was significantly lower in the temporal neocortex of TLE patients compared to the controls. In experimental rats, the expression of gephyrin in temporal lobe was downregulated in epileptic groups compared to the control group. Gephyrin expression gradually decreased during the acute period and the latent period, but then began to increase below the levels seen in controls during the chronic phase. Our findings suggest that gephyrin may be involved in the development of TLE.

Abnormal expression and spatiotemporal change of Slit2 in neurons and astrocytes in temporal lobe epileptic foci: A study of epileptic patients and experimental animals.

Repellent guidance molecules provide targeting information to outgrowing axons along predetermined pathways during development. These molecules may also play a role in synaptic reorganization in the adult brain and thereby promote epileptogenesis. Our aim was to investigate the expression of Slit2, one of repellent guidance molecules, in temporal lobe epileptic foci from epileptic patients and experimental animals. Thirty-five temporal neocortex tissue samples from patients with intractable temporal lobe epilepsy (TLE) and fifteen histological normal temporal lobes from controls were selected. Fifty-four Sprague-Dawley rats were divided randomly into six groups, including five groups with epilepsy induced by lithium-pilocarpine administration and one control group. Temporal lobe tissue samples were taken from rats at 1, 7, 14, 30, and 60 days post-seizure and from controls. Expression of Slit2 was assessed by immunohistochemistry, immunofluorescence, and Western blot analysis. Slit2 was mainly expressed in neurons in human controls and in both neurons and astrocytes in TLE patients. Slit2 expression was significantly higher in TLE patients as compared with the controls. Slit2-positive cells were mainly neurons in the rat temporal lobe tissues of the control group, the acute period group, and the latent period group, while the Slit2-positive cells were mainly astrocytes in chronic phase. Compared with controls, Slit2 expression in animals in the TLE group gradually decreased from days 1 to 14 post-seizure, but then increased over the levels seen in controls, to peak levels at days 30 and 60. These results suggest that Slit2 may play an important role in the pathogenesis of TLE.

Gene expression analysis on anterior temporal neocortex of patients with intractable epilepsy.

To elucidate the molecular basis of intractable epilepsy (IE), we used a whole-genome transcriptomic approach to identify genes involved in the pathogenesis of this disease. Using a complementary DNAs microarray representing 4096 human genes, we analyzed differential gene expression in the anterior temporal neocortex (ATN) of IE patients relative to control patients who had an operation to relieve head trauma-related intracranial pressure. The results were validated by real-time fluorescence-quantitative polymerase chain reaction (FQ-PCR) and reverse transcription-PCR (RT-PCR). The expression of 143 genes (3.5%) was significantly altered in IE patients. Thirty-seven genes (26%) were reduced relative to controls, and 106 (74%) were elevated (more than twofold change vs. controls), including genes involved in immunity, signal transduction, apoptosis, stress, synaptic plasticity, structural, and cellular reorganization, among other processes. Results for 13 of the 14 differentially expressed genes tested by FQ-PCR were consistent with the microarray. Twelve abnormally expressed cytoskeletal genes were confirmed by RT-PCR. Expression of 11 was significantly higher in the ATN of IE patients than in controls. Gene products altered in IE, namely HSPBAP1, TRAP220, glycogen synthase kinase-3beta (GSK-3beta), and cyclin-dependent kinase 5 (CDK5), were tested by immunohistochemistry and immunoblotting. GSK-3beta and CDK5 levels were significantly higher in the ATN of IE patients. Our gene chip data are generally in agreement with the published findings on epilepsy. Thus, gene chips may serve as a screening tool to elucidate the pathophysiology of IE. Investigation of some of these newly identified genes should enhance our understanding of the molecular mechanisms of epileptogenesis.

[Clinical characteristics and LGI1 gene mutation analysis on an autosomal dominant lateral temporal lobe epilepsy].

OBJECTIVE: To report the clinical and genetic study of a new Chinese family with autosomal dominant lateral temporal lobe epilepsy (ADLTE). METHODS: The living affected members underwent a full clinical, neurophysiological, electroencephalogram (EEG), and magnetic resonance imaging (MRI) study. Genetic analysis was performed by LGI1 DNA sequence analysis. RESULTS: The clinical feature of the patients was coincidence wall with the definition of ADLTE by International League Against Epilepsy in 2001. The living affected members had an adult or children onset of drug-responsive tonic-clonic seizures or complex partial seizures constantly preceded by auditory or visionary aura. Routine EEG revealed no focal abnormalities over both temporal regions. MRI detected no structural abnormality. Analysis of LGI1 gene showed no mutation in all affected members. CONCLUSION: This kindred has typical clinical manifestations of ADLTE. The pathogenesis has no association with mutation of the exons of LGI1 gene.

Up-regulation of epithelial membrane protein-1 in the temporal neocortex of patients with intractable epilepsy.

Epithelial membrane protein-1 (EMP-1), called Tumor-associated membrane protein, is the marker of a drug-resistant tumor and take part in the drug-resistant mechanism of tumor, with the relationship of epidermal growth factor receptor (EGFR). Because there are some similarities between the pathogenesis and the drug resistance mechanism of tumor and the drug resistance mechanisms in epilepsy. EMP1 expression may be connected with the drug-resistance mechanism of epilepsy. We detected EMP-1 by gene scanning and immunohistochemistry staining, comparing the IE group and the control group, and we investigated the relationship between EMP-1 and EGFR by double-label immunofluorescence staining in the IE group. We found expression of EMP-1 mRNA was higher in IE per the gene scanning, EMP-1 immunoreactivity was apparent in neurons of IE patients but not in the control group, and the expression of EMP-1 and EGFR occurred in the same neuron. We confirm EMP-1 is abnormally expressed in IE and suggest the interaction of EGFR and EMP-1 plays a role in the mechanism of drug resistance in epilepsy and may be a new gene for drug resistance.

Efficacy and safety of levetiracetam (3,000 mg/Day) as an adjunctive therapy in Chinese patients with refractory partial seizures.

AIM: To evaluate the efficacy and safety of 3,000 mg daily levetiracetam (LEV; Keppra) as an adjunctive therapy for Chinese patients with refractory partial seizures. METHODS: This randomized, placebo-controlled trial consisted of an 8-week baseline period followed by a 4-week titration interval and a 12-week maintenance period, and concluded with a 4-week medication withdrawal period or entered an open-label study. LEV was compared with placebo. RESULTS: The 50% responder rate (the proportion of patients with a minimum of 50% reduction in partial seizure frequency) occurred in 46.4% of the LEV group, compared with 39.3% of the placebo group (p = 0.590). The median of the absolute weekly frequency reduction from baseline of partial seizures was 0.66 per week for LEV versus 0.48 per week for placebo (p = 0.187). The most common treatment-emergent adverse events, mostly mild to moderate in severity, were somnolence, dizziness and agitation. CONCLUSION: In this study, adjunctive therapy with LEV 3,000 mg daily was well tolerated but not as effective as expected in controlling partial seizures in this study population. Considering the lower mean weight of this study population, we suggest the dosage of LEV 3,000 mg daily may contribute to the results.

Altered expression of synaptotagmin I in temporal lobe tissue of patients with refractory epilepsy.

Synaptotagmin I is a key synaptic protein involved in both exocytosis and endocytosis. We aimed to investigate Synaptotagmin I expression in the anterior temporal neocortex of epilepsy patients, and to explore the possible role of Synaptotagmin I in refractory epilepsy. In the present study, 30 epilepsy patients were divided into refractory epilepsy and non-refractory epilepsy groups, another 15 histologically normal anterior temporal lobes from head trauma patients were used as control group. The results were compared among different groups. The findings were consistently observed using immunohistochemistry, immunofluorescence, and Western blotting technique. Synaptotagmin I was mainly expressed in the cytoplasm and cytomembrane of neurons. The expression of Synaptotagmin I in refractory epilepsy group was significantly higher than that in the control and non-refractory epilepsy groups. These findings provide new information in the epileptogenesis of refractory epilepsy, and suggest that Synaptotagmin I might be involved in human refractory epilepsy. Further studies will be required to elucidate the mechanism by which Synaptotagmin I plays role in refractory epilepsy.

Proteomic analysis of cerebrospinal fluid from patients with idiopathic temporal lobe epilepsy.

Proteomic analysis of cerebrospinal fluid (CSF) from patients with temporal lobe epilepsy (TLE) and controls was carried out using two-dimensional gel electrophoresis followed by liquid chromatography electrospray ionization tandem mass spectrometry. Five protein spots showed significant differential expression (p<0.05): vitamin D-binding protein (DBP) was elevated in the CSF of TLE patients whereas cathepsin D, apolipoprotein J, Fam3c, and superoxide dismutase 1 (SOD1) were decreased in the CSF of TLE patients. Additional six protein spots presented only in the CSF of epilepsy patients were identified as tetranectin (TN), talin-2, apolipoprotein E, immunoglobulin lambda light chain (IGL@), immunoglobulin kappa variable light chain 1-5 (IGKV1-5), and procollagen C-endopeptidase enhancer 1 (PCOLCE). Expression of DBP, SOD1 and talin-2 was validated by western blot. Our results may provide better understanding of the pathophysiologic mechanisms underlying epileptogenesis and possible epilepsy biomarkers.

[Epidemiologic study on patients with invasive fungal infections].

OBJECTIVE: To investigate the epidemiological features of patients with nosocomial invasive fungal infection. METHODS: Fungi in blood were identified by BacT ALERT 3D, other clinical samples were cultured by Sabouraud's dextrose agar (SDA) medium. Candidas were isolated and identified by CHRO Magar candida color medium. Fungus-cultured positive cases from Jan. 2004 to Nov. 2007 were analyzed on items as patients' age, underlying disease, sample, strain, and species distribution. All statistical analyses were carried out by SPSS 13.0. RESULTS: The overall incidence rate of invasive fungal infections was 4.12%. The average age of patients was 7 - 96 with most patients were male, with geriatric problems and different kinds of underlying diseases. Lower respiratory tract infection was the most frequent infection site, followed by urinary tract, gastrointestinal tract. The main pathogens of invasive fungal infections were Candidas (93.80%). Strains of Candida albicans were the most frequent organisms which accounted for 67.29% of all the isolates. Mould fungus infections accounted for only 6.20%. During the 4 years of observation, the detection rate of fungi, specimen sources and the distribution of species and compartment were different with significant differences (P < 0.0083). CONCLUSION: The epidemiological properties such as the source of specimen, the distribution of species and composition sections of invasive fungal infections were changing. Candida spp. were still the main pathogens of invasive fungal infections but the sections of fungi changed. The incidence of Aspergillus infections had been increasing recently.

Expression of laminin beta1 in hippocampi of patients with intractable epilepsy.

We investigated laminin beta1 expression in the hippocampi of patients with intractable epilepsy and explored the role of laminin beta1 in the pathogenesis of this condition. Fluorescence quantitative PCR, immunofluorescence, immunohistochemistry and Western blotting were used to measure laminin beta1 expression in surgically removed hippocampi of patients with intractable epilepsy, and the results were compared with control hippocampi. Fluorescence quantitative PCR showed increased expression of laminin beta1 mRNA in patient hippocampi compared with control tissues. Immunohistochemical staining demonstrated that laminin beta1 protein expression was significantly increased in patient hippocampi, and immunofluorescence microscopy showed accumulation of laminin beta1 in the cell membrane and cytoplasm of patient hippocampi. These findings were confirmed by Western blotting of protein preparations from patient hippocampi. Elevated expression of laminin beta1 mRNA and protein in the hippocampus suggests that laminin beta1 may play a role in the development of epileptic seizures in patients with intractable epilepsy.

Overexpression of N-WASP in the brain of human epilepsy.

Neuronal circuit remodeling is the most critical pathological characteristic closely associated with the initiation and maintenance of epilepsy; however, the exact mechanisms of neuronal remodeling need further elucidation. Neuronal Wiskott-Aldrich syndrome protein (N-WASP) is a key regulator of the actin cytoskeleton that causes actin polymerization and thus neurite extension. Our previous research demonstrated that the upstream regulator of N-WASP, cell division cycle 42 GTP-binding protein (Cdc42), is significantly upregulated in the brains of patients with intractable epilepsy (IE). In addition, cDNA microarray analysis has shown that gene expression of N-WASP is notably enhanced in the epileptic brain, suggesting a possible role for N-WASP in epileptogenesis. Here, we investigated the expression of N-WASP and its downstream effector, actin-related protein 2/3 (Arp2/3), at the protein level in the temporal lobe of IE patient brains to explore its possible role in the genesis of IE. Forty surgical samples from brains of patients with IE and 20 control brain tissues were obtained for this study. The expression of N-WASP in the anterior temporal neocortex was detected using immunohistochemistry, immunofluorescence and western blotting; Arp2/3 expression was detected by western blotting. Compared with controls, N-WASP expression in brains of IE patients was significantly higher; similarly, Arp2/3 level was markedly increased in the IE patient group. These results suggest that increased expression of N-WASP in the human brain may be associated with human IE.

[Overexpression of the Cdc42 in the brain tissue of human with intractable temporal epilepsy].

OBJECTIVE: To investigate the expression of cell division cycle 42 GTP-binding protein (Cdc42) in the brain tissue of patients with intractable temporal epilepsy and discuss its effect on epileptogenesis. METHODS: Twenty samples brain tissues were collected from the brain tissue bank of intractable temporal epilepsy established by Epilepsy Preventive and Therapeutic Center of Chongqing. The expression of Cdc42 was determined by immunohistochemistry and fluoroimmunoassay. Twenty brain tissue samples were collected from autopsy on 20 sex and age-matched persons who died from accident were used as controls. RESULTS: The absorption values of Cdc42 in the temporal lobe of the patients was 0.038 +/- 0.016, significantly higher than that of the controls (0.020 +/- 0.005, t = 14.59, P < 0.01). The absorption values of Cdc42 in the hippocampus of the patients was 0.049 +/- 0.009, t = 12.01, P < 0.01). Fluoroimmunoassay showed that the fluorescence intensity of Cdc42 in the temporal lobe of the patients was 18.3 +/- 2.5, significantly higher than that of the controls (11.8 +/- 2.9, t = 33.77, P < 0.01), and the Fluorescence intensity of Cdc42 in the hippocampus of the patients was and control hippocampus were 23.8 +/- 3.3, significantly higher than that of the controls (10.1 +/- 2.6, t = 12.01, P < 0.01). CONCLUSION: The overexpression of Cdc42 in the cortex of temporal lobe and hippocampus may play an important role in the epileptogenic mechanisms of intractable epilepsy.

TDAG51 in the anterior temporal neocortex of patients with intractable epilepsy.

TDAG51 (T cell death-associated gene 51) is an apoptosis-associated protein. Our aim was to investigate TDAG51 expression in the anterior temporal neocortex of patients with intractable epilepsy (IE), and then to discuss the possible role of TDAG51 in IE. Tissue samples from the anterior temporal neocortex of 33 patients who had surgery for IE were used to detect TDAG51 expression by immunohistochemistry, immunofluorescence, and Western blotting. We compared these tissues with nine histologically normal anterior temporal lobes from intracranial hypertension patients who had decompression procedures. TDAG51 was mainly expressed in the cytoplasm of neurons and glial cells. TDAG51 in IE was significantly higher than that in the controls. These findings were consistently observed using Western blotting, immunofluorescence, and immunohistochemistry techniques. TDAG51 in patients with IE was significantly higher when compared with levels in the controls. This finding suggests TDAG51 is consistent with a possible role of this gene in the evolution of the pathology in IE.