Claes Martin

Absence of seven human herpesviruses, including HHV-6, by polymerase chain reaction in CSF and blood from patients with multiple sclerosis and optic neuritis

Several members of the herpesvirus family have been implicated in the pathogenesis of multiple sclerosis (MS). Recently, HHV‐6 viral antigen has been demonstrated in association to MS plaques, as well as DNA from human herpesvirus 6 (HHV‐6) in cerebrospinal fluid from a few MS patients by polymerase chain reaction (PCR). In the present study, CSF from patients with MS, optic neuritis and other neurological diseases, as well as consecutive CSF and serum samples from MS patients included in a clinical trial with acyclovir, were analysed by nested PCR for the presence of DNA from herpes simplex virus 1 and 2, Epstein‐Barr virus, varicella zoster virus, cytomegalovirus, human herpesvirus 6 and 7. No virus DNA was found in any CSF (n= 115) or serum (n= 116) sample. These findings argue against a continuous disseminated herpesvirus infection in MS, but do not rule out a lesion‐associated, low‐grade herpesvirus infection within the MS brain.

Indinavir-based treatment of HIV-1 infected patients: efficacy in the central nervous system.

OBJECTIVE To study the pharmacokinetic properties and clinical efficacy of the HIV-1 protease inhibitor (PI) indinavir in the central nervous system (CNS). DESIGN Twenty-five consecutive HIV-1 infected patients on combination therapy that included indinavir, had cerebrospinal fluid (CSF) and plasma samples taken on 32 different occasions, at different times after indinavir administration. CSF and viral load data obtained from these treated patients were compared with those from 36 untreated HIV-1 infected patients of similar immunological and demographic pre-treatment status. METHODS Concentrations of indinavir were measured in CSF and plasma by high-pressure liquid chromatography with ultraviolet light detection and the data were used in pharmacokinetic modelling. RESULTS The concentration of indinavir in plasma varied with time over a dose interval by about two orders of magnitude, whereas the concentration in CSF was relatively stable. The median concentration of indinavir in CSF was 210 nmol/l, which is above the 95% inhibitory concentration in vitro. Findings from the pharmacokinetic modelling indicate that indinavir is actively transported out of the CSF (P <0.001 compared with a passive transport-only model). In the PI-treated group there was a reduction in viral load to below 50 copies/ml in most subjects and a normalization of the CSF cell content and IgG-index. CONCLUSIONS This study has shown that one PI, indinavir, is present in the CSF at therapeutic concentrations, and is likely to contribute to the antiretroviral activities observed within the CNS.

Autologous haematopoietic stem cell transplantation for aggressive multiple sclerosis: the Swedish experience

Background Autologous haematopoietic stem cell transplantation (HSCT) is a viable option for treatment of aggressive multiple sclerosis (MS). No randomised controlled trial has been performed, and thus, experiences from systematic and sustained follow-up of treated patients constitute important information about safety and efficacy. In this observational study, we describe the characteristics and outcome of the Swedish patients treated with HSCT for MS. Methods Neurologists from the major hospitals in Sweden filled out a follow-up form with prospectively collected data. Fifty-two patients were identified in total; 48 were included in the study and evaluated for safety and side effects; 41 patients had at least 1 year of follow-up and were further analysed for clinical and radiological outcome. In this cohort, 34 patients (83%) had relapsing-remitting MS, and mean follow-up time was 47 months. Results At 5 years, relapse-free survival was 87%; MRI event-free survival 85%; expanded disability status scale (EDSS) score progression-free survival 77%; and disease-free survival (no relapses, no new MRI lesions and no EDSS progression) 68%. Presence of gadolinium-enhancing lesions prior to HSCT was associated with a favourable outcome (disease-free survival 79% vs 46%, p=0.028). There was no mortality. The most common long-term side effects were herpes zoster reactivation (15%) and thyroid disease (8.4%). Conclusions HSCT is a very effective treatment of inflammatory active MS and can be performed with a high degree of safety at experienced centres.

Antiretroviral therapy may improve sensory function in HIV-infected patients A pilot study

Objective: To evaluate thermal and nociceptive function in a prospective, longitudinal study of 49 consecutive HIV-1–infected patients before and at 1, 4, and 8 months after initiation of highly active antiretroviral therapy. Methods: Quantitative assessments of thermal perception thresholds for warmth (dWT), cold (dCT), and heat pain (HPT) were performed. CD4+ cell levels in blood and HIV-1 RNA levels in plasma were determined. Depending on the virologic response to treatment, the patients were divided into two groups: responders (37 of 49, 76%) and nonresponders (12 of 49, 24%). Results: Before treatment, impairment of dWT was found in 26 of 49 patients, of dCT in 33 of 49 patients, and of HPT in 19 of 49 patients. Improvements of perception thresholds for dWT (p < 0.0001), dCT (p < 0.001), and HPT (p < 0.01) were observed after 8 months of treatment in the responder group but not in the nonresponders. Within the responder group, improved thermal perception thresholds was associated with higher pretreatment CD4+ levels than in patients without improvement. Conclusions: Virologically successful antiretroviral combination therapy of HIV-1–infected patients has a capacity to improve function of the thermal and nociceptive systems, especially in patients with less advanced immunodeficiency.

Cerebrospinal fluid mononuclear cell counts influence CSF HIV-1 RNA levels.

This study evaluated the relation between cerebrospinal fluid (CSF) mononuclear cells (MNC) and CSF HIV-1 RNA levels. HIV-1 RNA levels in plasma and CSF were analyzed by reverse transcription-polymerase chain reaction (RT-PCR) in 58 consecutive patients with neurologic symptoms and late HIV-1 infection. The majority of the patients had no central nervous system (CNS) complication (n = 36), 11 had AIDS dementia complex (ADC) and 11 had CNS opportunistic infection (CNS OI). CSF cell counts were analyzed using a method that also evaluated hypocellular CSF (i.e., from 0.1 x 10(6) cells/L). A strong correlation was found between CSF MNC and CD4+ lymphocyte counts in blood (r = 0.58; p < .0001). HIV-1 RNA was detected in all plasma samples and in 38 of 58 (66%) of the cell-free CSF samples. CSF HIV-1 RNA was less frequently detected in patients with hypocellular CSF than in patients with normocellular or pleocytic CSF (13 of 28 patients [46%] versus 10 of 14 patients [71%] versus 15 of 16 patients [94%], respectively). The levels of CSF HIV-1 RNA correlated with the CSF MNC count (r = 0.61; p < .0001). The correlation also remained strong within the clinical subgroups of CNS asymptomatic patients (r = 0.55; p < .001) and ADC patients (r = 0.79; p < .001), but not among CNS OI patients (r = 0.19). Patients with CNS OI were found to have higher CSF HIV-1 RNA levels than the patients without evidence of CNS complication. Thus, a close relation was found between CSF HIV-1 RNA levels and CSF MNC counts. These data support the hypothesis that a substantial part of the virus in the CSF of HIV-1-infected patients is locally produced by CSF MNC.

Painful and non-painful neuropathy in HIV-infected patients: an analysis of somatosensory nerve function

Fifteen to 50% of AIDS‐patients suffer from distal predominantly sensory neuropathy (DSP), which is commonly associated with painful symptoms. In the present study, we have focused on the function of fine calibre nerve channels, in 36 consecutive HIV‐1‐infected patients with painful (PPN) (n=20; 54%) and non‐painful (PN) (n=16) sensory neuropathy, assessed by clinical, quantitative thermal testing (QTT) (31/36), and peripheral nerve conduction examination (32/36). Control QTT data were obtained from 49 healthy subjects with a corresponding age‐ and sex distribution. Demographics, antiviral treatment, immunological status, and nerve conduction examination did not differ between patients with and without painful symptoms. Hypoaesthesia to warmth, cold, and heat pain was observed in both neuropathy groups when compared to healthy controls. However, the perception threshold to warmth was more often impaired (p<0.01) and the level of impairment was more pronounced (p<0.001) in patients with painful neuropathy. Furthermore, increased pain sensitivity to cold was found only in patients with painful symptoms (p<0.05). An abnormal outcome of any QTT parameter was found in all patients with pain, but only among 62% of patients without pain, p<0.01, and the cumulative frequency of abnormalities in any of the four thermal percepts (warmth, cold, heat pain, and cold pain) was higher in patients with painful symptoms, p<0.0001. This study demonstrates a more pronounced impairment of C‐fibre‐mediated innocuous warm perception in patients with painful neuropathy, which in the setting of impaired or absent heat pain perception suggests a more generalised loss of function in somatosensory C‐fibre channels.

Time to secondary progression in patients with multiple sclerosis who were treated with first generation immunomodulating drugs

Background: It is currently unknown whether early immunomodulatory treatment in relapsing–remitting MS (RRMS) can delay the transition to secondary progression (SP). Objective: To compare the time interval from onset to SP in patients with RRMS between a contemporary cohort, treated with first generation disease modifying drugs (DMDs), and a historical control cohort. Methods: We included a cohort of contemporary RRMS patients treated with DMDs, obtained from the Swedish National MS Registry (disease onset between 1995–2004, n = 730) and a historical population-based incidence cohort (onset 1950–64, n = 186). We retrospectively analyzed the difference in time to SP, termed the “period effect” within a 12-year survival analysis, using Kaplan-Meier and Cox regression analysis. Results: We found that the “period” affected the entire severity spectrum. After adjusting for onset features, which were weaker in the contemporary material, as well as the therapy initiation time, the DMD-treated patients still exhibited a longer time to SP than the controls (hazard ratios: men, 0.32; women, 0.53). Conclusion: Our results showed there was a longer time to SP in the contemporary subjects given DMD. Our analyses suggested that this effect was not solely driven by the inclusion of benign cases, and it was at least partly due to the long-term immunomodulating therapy given.

Pain in ambulatory HIV-infected patients with and without intravenous drug use

The prevalence of pain in 211 HIV‐infected patients with and without intravenous drug use was assessed and the prognostic information inherent in pain reporting was evaluated, using a questionnaire on pain and HIV‐related symptoms combined with data on disease classification, route of HIV transmission, CD4+ lymphocyte counts in blood (CD4) and mortality rates at 15 months after completing the questionnaire. The pain prevalence was significantly higher among intravenous drug users (IDUs) compared with non‐IDUs [76/89 (85%) vs 87/122 (71%);p<0.05], especially among the patients classified as asymptomatic [43/53 (81%) vs 35/59 (59%);p = 0.01]. No significant difference was found among AIDS patients. In non‐IDUs, a strong correlation was found between HIV disease stages according to the Centers for Disease Control classification (CDC) and pain prevalence (CDC A: 59%vs B: 74%vs C: 96%, p<0.001), and between the number of concurrent pain sites and both the CD4 levels (no pains: CD4 0.26 × 109/l vs 1–2 pain sites: CD4 0.22 vs>2 pain sites: CD4 0.09;r = 0.35, p<0.001), and the mortality rate [no pains: 2/35 (6%) vs 1–2 pain sites: 8/45 (18%) vs> 2 pain sites: 12/42 (29%), p<0.01]. In IDUs, no such correlations were found. Our data demonstrates differences in the development, prevalence and prognostic value of pain among HIV‐infected patients, with and without intravenous drug use, clearly indicating the need to differentiate risk groups in pain related studies.

Prevalence and risk factors for HTLV-II infection in 913 injecting drug users in Stockholm, 1994

The prevalence and risk factors for acquisition of human T-cell lymphotropic virus type I and II (HTLV-I and II) were investigated in a prospective study of 913 injecting drug users (IDUs) in Stockholm in 1994. Epidemiologic data were recorded, and blood samples were tested for antibodies against HTLV-I and HTLV-II; human immunodeficiency virus (HIV) types 1 and 2; and hepatitis A (HAV), B (HBV), C (HCV), and D (HDV). Positive serologic results for HTLV were confirmed by Western blot (WB) and polymerase chain reaction (PCR). Of the 905 participants with conclusive HTLV-II status, 29 (3.2%) were HTLV-II positive, and all but three were of Nordic descent. None was HTLV-I infected. One person was infected as early as 1981, before HIV had reached the IDU population in Sweden. The prevalence of HTLV-II infection was 12% among HIV-1-seropositive and 1.8% among HIV-1-seronegative participants. The overall seroprevalences were 14% for HIV-1, 0% for HIV-2, 41% for HAV, 75% for HBV, 92% for HCV, and 8% for HDV. Although amphetamine has been the main injecting drug in Sweden for several decades, heroin abuse combined with a debut of injecting drugs before 1975 was identified as the most important risk factor associated with HTLV-II infection. HAV and HIV seropositivity were also independent risk factors.

The 'Immunomodulation and Multiple Sclerosis Epidemiology' (IMSE) study : a Swedish nationwide pharmaco-epidemiological and genetic study focused on long-term safety and efficacy of natalizumab (Tysabri)

cancelled P2035 Epigenetic mechanisms in a rare case of monozygotic twins discordant for Alzheimer’s disease C. D’Addario1, B. Arosio2, A. Di Francesco1, C. Abbate2, A. Casè3, L. Bergamaschini3,4, D. Mari2, M. Maccarrone1,5 1Biomedical Sciences, University of Teramo, Teramo, 2Geriatric Unit, Department of Clinical Sciences and Community, 3A.S.P. Pio Albergo Trivulzio, 4Medical Sciences, University of Milan, Milan, 5European Center for Brain Research (CERC)/Santa Lucia Foundation, Rome, Italy Case report: Target genes in Alzheimer’s disease (AD) have been identified. The study of rare monozygotic (MZ) twins discordant for AD provides a unique opportunity to evaluate the role of environmental factors in the etiology of the disease. Since epigenetic differences could contribute to phenotypic differences, we investigated either global changes in selected chromatin modifications as well as DNA methylation in peripheral blood mononuclear cells of a couple of these MZ twins. Moreover, we analysed the gene expression of DNA methyltransferases (DNMTs) and histone deacetylases (HDACs) directly recruited by DNMTs. We observed, in the AD twin, markers of transcriptional activation namely a strong reduction in DNA methylation, revealed by higher levels of [3H]methyl group incorporated into DNA (AD twin=2.86±0.23 fold over healthy twin =1±0.16), as well as a clear reduction in histone 3 acetylation at lysine 9 (AD twin=34% versus healthy twin=100%). Consistently, we observed increases in the gene expression of few HDACs isoforms in the AD twin (HDAC2 (3,39), HDAC6 (2,08) HDAC9 (4,16) versus healthy twin =1) and no changes in all the others. Finally, slightly changes were observed in the other histone modifications investigated (Histone 3 Lysine 4 trimethylation, Histone 3 Lysine27 trimethylation) and in all the DNMTs isoforms mRNA levels. Our results unravel epigenetic differences potentially helpful in the understanding of environmental factors and phenotypic differences in MZ twins. We also confirm the use of peripheral blood cells as useful model for the study of gene regulation that mirrors the alterations within the brain.