Chronic immune demyelinating neuropathies

During growth of Streptomyces niveus wild-type in the novobiocin production medium CDM the resistance of mycelia to novobiocin rises from about 25 micrograms/ml to over 200 micrograms/ml. (S. lividans, a novobiocin-sensitive strain, is resistant to approx. 10 micrograms/ml novobiocin.) The initial period of low level resistance extends from the time of inoculation of the culture until approx. 70 h when the culture is still in the growth phase. High level resistance is initiated before the start of novobiocin production and rises rapidly to a maximum level beyond the end of the growth phase. The rise in pH of the unbuffered CDM medium which occurs during S. niveus fermentation was shown not to be the cause of the change in novobiocin resistance. However, mycelia-free CDM from S. niveus cultures expressing high level novobiocin resistance was shown to contain a factor which induced high level novobiocin resistance in germinating S. niveus spores. Kinetic studies revealed that the inducer first appears in the culture medium before the switch to high level resistance begins and reaches its highest concentration before resistance reaches its maximum level.     

Influence of elevated expression of rat wild-type PMP22 and its mutant PMP22Trembler on cell growth of NIH3T3 fibroblasts

The peripheral myelin gene PMP22 is the rat and human homologue of the murine growth-arrest-specific gene gas3. The biological function of PMP22 is unknown, but recent progress in the analysis of rat Schwann cells expressing altered levels of PMP22 revealed that one role of PMP22 is as a negative growth modulator. We have investigated the influence of rat PMP22 (rPMP22) and a mutant of PMP22 (rPMP22(Tr)) resembling the murine trembler mutation on cell growth of retrovirus-vector-infected mouse NIH3T3 cells. Transduced cells carrying the two different sense constructs expressed rPMP22 and rPMP22(Tr )mRNAs and proteins. Elevated levels of rPMP22 and rPMP22(Tr )significantly reduced fibroblast growth as judged by proliferation assays. Despite a negative modulatory influence of rPMP22 and rPMP22(Tr )on cell proliferation, cell cycle analyses by flow cytometry did not reveal an influence of rPMP22 or rPMP22(Tr )on the synchronous progression of resting NIH3T3 cells from G0 into S phase. However, cell cycle analyses by flow cytometry of asynchronously dividing cultures demonstrated that the expression of rPMP22 and rPMP22(Tr )increased the fraction of cells in the G1 phase of the cell cycle. Furthermore, cell death analyses revealed that, in contrast to control cells and cells carrying the rPMP22(Tr )construct, a significantly increased fraction of NIH3T3 cells expressing rPMP22 exit the proliferation compartment showing hallmarks of programmed cell death. These results indicate that (i) rPMP22 and rPMP22(Tr )act as negative modulators of proliferation in murine fibroblasts probably through extension of the G1 phase of the cell cycle and (ii) rPMP22 but not rPMP22(Tr )promotes programmed death of these cells.     

Recent advances of immune therapies for demyelinating neuropathies

Most of acquired demyelinating neuropathies are caused by immune-mediated processes. Therefore, we can treat these neuropathies to control underlying immune abnormality. We review the recent therapies and show possible strategies in the future. (1) Recent therapies Guillain-Barré syndrome should be treated quickly and intensively in the first week of the disease with plasmapheresis (PP). Intravenous immunoglobulin (IVIG) is as effective as PP. IVIG is under phase 3 clinical trial in Japan. Chronic inflammatory demyelinating polyneuropathy (CIDP) is treated with corticosteroids, PP or IVIG. Corticosteroids or PP is the first choice. For severe or resistant cases, combined therapy or immunosuppressants, such as cyclophosphamide pulse therapy, should be considered. Polyneuropathy with IgM-MGUS (monoclonal gammopathies of undetermined significance) is treated with PP, immunosuppressants or these combinations to decrease serum IgM, especially for cases with anti-MAG antibody, because the autoantibody induces demyelination by itself. (2) Future strategies Immunopathogenesis may differ among cases with Guillain-Barré syndrome or CIDP. The best therapy will be chosen individually, according to appropriate immunologic tests. In CIDP, immunomodulation therapies, that are similar ones in multiple sclerosis, will be considered to maintain improvement.     

Membranous glomerulonephritis associated with inflammatory demyelinating peripheral neuropathies

A 55-year-old man with chronic inflammatory demyelinating polyradiculoneuropathy developed the nephrotic syndrome. Renal biopsy showed stage I membranous glomerulonephritis. Review of the literature revealed the association of these two rare syndromes, considered to be due to immunologic dysfunction, in two other cases, as well as several cases of the acute form of demyelinating peripheral polyradiculoneuropathy. The nephrotic syndrome appears to be persistent in the chronic form of the peripheral neuropathy but reversible in its acute form following immunosuppressive therapy. The possibility of a common immunopathogenesis in the association of membranous glomerulonephritis and inflammatory demyelinating peripheral neuropathies deserves further scrutiny.     

Childhood chronic inflammatory demyelinating neuropathies: clinical course and long-term follow-up

Chronic inflammatory demyelinating neuropathy (CIDP) is a rare disease in childhood. We reviewed the clinical characteristics, response to therapy, and long-term prognosis in 13 children (1.5 to 16 years of age) diagnosed with CIDP at Washington University Medical Center, St. Louis, and the Royal Children's Hospital, Melbourne, Australia, between 1979 and 1994. The most common presenting symptom (in 11/13 [85%]) was lower extremity weakness associated with difficulty in walking. Preceding events within 1 months of onset, mostly intercurrent infections or vaccinations, occurred in seven children (54%). The disease was monophasic in three children (23%). One relapse occurred in four (30%) and multiple relapses in six (46%). All patients had at least short-term response to steroids. Three children (23%) recovered completely during the first year. Ten children (77%) had residual weakness after an average follow-up of 6 years. There seems to be two populations of children with CIDP. One subgroup, with a favorable prognosis, progressed to peak disability over less than 3 months; these children often have a monophasic course with complete resolution of symptoms and signs and withdrawal from all medications by 1 year after onset. A second subgroup progressed for 3 months or longer; these children all required substantial does of prednisone for prolonged periods and had considerable long-term morbidity with persistent weakness.     

A novel PMP22 point mutation causing HNPP phenotype: studies on nerve xenografts

BACKGROUND: Hereditary neuropathy with liability to pressure palsies (HNPP) in most cases is caused by a deletion in chromosome 17p11.2-12 or, rarely, mutations resulting in a functional loss of one copy of the peripheral myelin protein 22 (PMP22) gene. Point mutations that lie deep within transmembrane (TM) domains causing major structural changes in PMP22 are associated with severe neuropathy. METHODS: A 25-year-old asymptomatic woman with a normal neurologic examination volunteered as a control subject. Electrophysiologic studies showed multiple entrapment neuropathies, prompting a search for a genetic defect. In addition, sural nerve fascicles from the subject were grafted into the cut ends of the sciatic nerve of nude mice and studied at 2, 6, and 8 weeks and compared with controls. RESULTS: Direct sequencing of the PMP22 gene revealed a G-->A transition at position 202 in axon 3 of the PMP22 gene. To determine if this was a causative mutation rather than a polymorphism, 102 DNA samples from controls were studied; none showed a similar base pair change. In the nerve xenografts, there was a marked delay at the onset of myelination and an impairment in the regenerative capacity of the nude mice axons engulfed by the mutant human Schwann cells. The axon tips were enlarged and demonstrated neurofilament density increase. Neurofilament density distribution histograms were bimodal in xenografts as well as in the subject's sural nerve. CONCLUSION: This study provides unequivocal evidence that a base pair change causing a Val30Met substitution at the junction of the first TM domain and the extracellular loop of PMP22 results in the HNPP phenotype.     

Purification of PASII/PMP22--an extremely hydrophobic glycoprotein of PNS myelin membrane

PASII/PMP22 protein (mol. wt 22 kDa, pI 8.8) is an abundant and extremely hydrophobic glycoprotein of PNS myelin which is solubilized effectively by SDS. In humans, this protein is involved in hereditary neuropathies. Here we describe a simple method for purification of PASII/PMP22, suitable for crystallization trials. We usually obtained 10-20 mg PASII/PMP22 from 10 g bovine spinal roots. It is notable, that the original protocol was designated for purification of P0 myelin glycoprotein, and purification of PASII/PMP22 is a bonus. Extensive crystallization trials are in progress.     

Determination of gene dosage at the PMP22 and androgen receptor loci by quantitative PCR

Although many genetic diseases are caused by the presence of point mutations in respective genes, an increasing number of diseases are known to be caused by gene copy number changes. We report the development of a rapid and reliable PCR-based method for quantitation of gene copy number with sufficient sensitivity to detect single copy changes without the use of radioactive or fluorescent labeling. The sensitivity of this technique has been demonstrated by the detection of the DNA duplication or deletion occurring in two inherited peripheral neuropathies, Charcot-Marie-Tooth type 1A (CMT1A) and hereditary neuropathy with liability to pressure palsies (HNPP), that are caused by a reciprocal duplication or deletion event on chromosome 17p11.2-12. This method relies on the comparison of the amount of PCR product generated from a potentially duplicated or deleted target sequence with the amount of product generated from a disomic reference gene. The value of this ratio (target PCR product:reference PCR product) indicates whether the target sequence is duplicated, deleted, or unchanged. Using primers from within a duplicated or deleted region (PMP22 gene and EW401) and from within a reference region (NF1 gene), we tested 50 CMT1A, 30 HNPP, and 50 unaffected individuals for the presence of a DNA duplication or deletion. Target:reference ratios of 1.58, 1.02, and 0.56 were detected for the CMT1A, unaffected, and HNPP groups, respectively. Thus, differentiation of the three groups of individuals was on the basis of gene copy number. This technique was successfully used to detect the difference in the X chromosome copy number between males and females (target:reference ratios of 1.1 and 2.3, respectively). This approach to the detection of DNA duplications and deletions is sensitive, accurate, and has potential applications in the quantitation of changes in gene copy number associated with diseases characterized by such chromosomal alterations.     

Protein zero (P0)-deficient mice show myelin degeneration in peripheral nerves characteristic of inherited human neuropathies

Mutations in the human gene for the myelin recognition molecule protein zero (P0) give rise to severe and progressive forms of dominantly inherited peripheral neuropathies. We have previously reported that mice homozygous for a null mutation in P0 have severely hypomyelinated nerves ten weeks after birth. Here we show hypomyelination already exists at day four with subsequent demyelination and impaired nerve conduction. Furthermore, heterozygous mutants show normal myelination, but develop progressive demyelination after four months of age. Thus, the pathology of homo- and heterozygous P0 mutants resembles that of the severely affected Déjérine-Sottas and the more mildly affected Charcot-Marie-Tooth type 1B patients, respectively.     

A new point mutation affecting the fourth transmembrane domain of PMP22 results in severe de novo Charcot-Marie-Tooth disease

OBJECTIVE: Fiji is a Pacific nation with roughly equal numbers of indigenous Fijians and Indians. Previous studies, using police and medical records, have suggested significant racial, regional, age and gender differences in suicidal behaviour. The objective of the present study is to use a unique data set (autopsy reports) in the evaluation of earlier reports and to identify groups at greater risk. METHOD: Hanging and poisoning autopsy reports from two distinct regions were examined. RESULTS: The rate of autopsy (per 100000 population per year) among Indians (19.5) is significantly greater (p < 0.0001) than among Fijians (1.53). In the north, among the Indians, there are more autopsies in females (21.2) than males (16.8), and hanging constitutes 85% of total suicides, while in the Central and Eastern Divisions hanging constitutes only 58% of the total. These are regional influences. Among Fijians, the rates of hanging autopsy are significantly greater (p < 0.001) in males (1.98) than females (0.40); however, among Indians there is no significant difference. This is a racial difference. Hanging remains the preferred option for all groups. The mean age at autopsy is 31.7. There is no significant difference between the mean ages of the races, the sexes or the regions. There is no significant difference between the mean age of poisoning (31.5) and hanging (31.8). CONCLUSION: There is a significant racial difference in rates of suicide but the influences of region, age and method are relatively slight.     

Heterozygous peripheral myelin protein 22-deficient mice are affected by a progressive demyelinating tomaculous neuropathy

Hereditary neuropathy with liability to pressure palsy (HNPP) is associated with a heterozygous 1.5 megabase deletion on chromosome 17 that includes the peripheral myelin protein (PMP) gene PMP22. We show that heterozygous PMP22 knock-out mice, which carry only one functional pmp22 allele and thus genetically mimic HNPP closely, display similar morphological and electrophysiological features as observed in HNPP nerves. As reported previously, focal hypermyelinating structures called tomacula, the pathological hallmarks of HNPP, develop progressively in young PMP22(+/0) mice. By following the fate of tomacula during aging, we demonstrate now that these mutant animals are also interesting models for examining HNPP disease mechanisms. Subtle electrophysiological abnormalities are detected in PMP22(+/0) mice >1 year old, and a significant number of abnormally swollen and degenerating tomacula are present. Thinly myelinated axons and supernumerary Schwann cells forming onion bulbs as fingerprints of repeated cycles of demyelination and remyelination are also encountered frequently. Quantitative analyses using electron microscopy on cross sections and light microscopy on single teased nerve fibers suggest that tomacula are intrinsically unstable structures that are prone to degeneration; however, the severity of morphological and electrophysiological abnormalities in PMP22(+/0) mice is variable. These combined findings are reminiscent of the disease progression in HNPP and offer a possible explanation about why some HNPP patients develop a chronic motor and sensory neuropathy later in life that resembles demyelinating forms of Charcot-Marie-Tooth disease by both morphological and clinical criteria.     

Peripheral neuropathies in diabetes

Peripheral neuropathy in diabetes remains a difficult management dilemma. The clinical manifestations may vary widely. Polyneuropathies develop with increasing duration of disease, and a thorough understanding of the clinical manifestations, including sensory, motor, and autonomic deficiencies, helps guide diagnosis and treatment. A multidisciplinary approach emphasizing preventive care and timely intervention can decrease morbidity significantly and improve the quality of life for the patient. Properly fitting shoes and avoidance of foot trauma are cornerstones of preventive management. Strict control of serum glucose can alter the course of peripheral neuropathies. This control can be accomplished with a strict insulin regimen or pancreatic transplant. Further research is needed to increase knowledge about peripheral neuropathies in diabetes and aid the physician with new treatment options.     

Acute and chronic neuropathies: new aspects of Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy, an overview and an update

During the last 15 years new information about clinical, electrophysiological, immunological and histopathological features of acute and chronic inflammatory neuropathies have emerged. Thus, the Guillain-Barré syndrome (GBS) is no longer considered a simple entity. Subtypes of the disorder besides the typical predominant motor manifestation, are recognized, i.e. a cranial nerve variant with ophthalmoplegia, ataxia and areflexia, an immune-mediated primary motor axonal neuropathy (AMAN), and a motor-sensory syndrome (AMSAN). Also, the clinical pattern of GBS is related to preceding viral or bacterial infections. Two types of acute motor paralysis have been described, one with slow and incomplete recovery, another with recovery times identical with acute inflammatory demyelinating polyneuropathy (AIDP). Histologically, the first is characterized by Wallerian degeneration of motor roots and peripheral motor nerve fibres. In the latter anti-GM antibodies bind to the nodes of Ranvier producing a failure of impulse transmission. Motor-point biopsies have shown denervated neuromuscular junctions and a reduced number of intramuscular nerve fibres. Molecular mimicry has been postulated as a possible mechanism triggering GBS. Thus, in the cranial variant antibodies to ganglioside GQ1b recognizes similar epitopes on Campylobacter jejuni strains and similar observations apply to anti-GM1 antibodies. Chronic inflammatory demyelinating polyneuropathy (CIDP) also has several different clinical presentations such as a pure motor syndrome, a sensory ataxic variant, a mononeuritis multiplex pattern, relapsing GBS, and a paraparetic subtype. Each of the acute and the subtypes have different, more or less distinct, electrophysiologic and pathological findings. Instructive patient stories are presented together with there electrophysiologic and biopsy findings.     

Local synthesis of immunoglobulins in neuropathies

It is essential to know how the immune system acts in different neurological diseases, some of them non very well known or of unknown etiology at all. It was applied Reiber and Felgenhauer's formula in 56 patients with different diseases. IgA, IgM, IgG and albumin were quantified in sera and cerebrospinal fluid by simple immunodiffusion. It was observed more frequent IgG local synthesis and IgA in this sample.