L.M Ossege

Changes of the MS functional composite and EDSS during and after treatment of relapses with methylprednisolone in patients with multiple sclerosis

Objectives– The Multiple Sclerosis Functional Composite (MSFC) comprises quantitative functional measures of leg, hand/arm and cognitive function. We examined the responsiveness of the MSFC compared with the Expanded Disability Status Scale (EDSS) during treatment of relapses in patients with multiple sclerosis (MS). Patients and methods– 27 patients received 1000 mg intravenous methylprednisolone (i.v.‐MP) for 5 days, followed by oral methylprednisolone for 14 days. The MSFC and the EDSS‐score were assessed on day 0, before the first corticosteroid treatment, on day 5, after the last course of i.v. MP, and on day 20 after the treatment was finished. Before the first administration of the MSFC, patients were trained for the paced auditory addition test (PASAT) performing three test trials. In order to analyse practice effects, 10 MS patients without an acute exacerbation were tested three times under the same conditions as the treated group. Results– The median EDSS‐score was 2.5 in both groups. On day 5 it remained unchanged in all treated patients, on day 20 a decrease of 0.5 EDSS point occurred in five patients, and in two patients an improvement with a decrease of more than 0.5 point was observed. There was no statistically significant difference between the EDSS‐scores on day 0, 5 and 20. The mean MSFC‐score in the treated group was –0.14 ± 0.63 on day 0, 0.17 ± 0.66 on day 5, and 0.42 ± 0.59 on day 20. On the last study day, 26 patients improved compared with day 0. The differences between the MSFC‐scores at the three points of time were statistically significant for the treated group (P < 0.001), but not for the control group. Conclusion– During and after treatment of relapses in patients with MS, the MSFC appears to be more sensitive in detecting changes in function than the EDSS.

Differential release of β-chemokines in serum and CSF of patients with relapsing–remitting multiple sclerosis

Objective–β‐chemokines were recently demonstrated in active MS‐lesions. We tested whether MCP‐1 and RANTES can also be detected in CSF and serum of patients with MS and whether release is associated with inflammatory disease activity. Materials and methods– CSF and serum from 34 patients with newly diagnosed relapsing–remitting MS (RR‐MS), 17 patients with viral meningitis (VM) and 19 patients with non‐inflammatory neurological diseases (NIND) were investigated by ELISA. RR‐MS patients underwent lumbar puncture and Gd‐enhanced MRI examinations within 2 days. Results– MCP‐1 was strong intrathecally released in all patients. Compared to NIND CSF‐levels were increased in VM (P<0.001) and were decreased in RR‐MS (P<0.05). RANTES was only detected in serum in all patients. Levels were higher in VM and RR‐MS compared to NIND (P<0.05). A total of 14/34 RR‐MS patients exhibited active Gd‐enhancing lesions on MRI. They had lower MCP‐1 levels in CSF (P<0.001) and serum (P<0.05) and higher serum levels of RANTES (P<0.05) as compared to patients without active lesions. Conclusions– MCP‐1 and RANTES are differentially released during acute attacks of RR‐MS, which might reflect different immunregulatory roles of these β‐chemokines in RR‐MS.

Immunomodulatory effects of interferon-β-1b in vivo: induction of the expression of transforming growth factor-β1 and its receptor type II

Abstract The mechanisms by which interferon-beta-1b (IFNβ-1b) acts in the treatment of patients with multiple sclerosis (MS) are not completely known. A total of 10 MS patients were treated with 8 million units of IFNβ-1b every other day. Compared to baseline and control group the expression of TGFβ-1-mRNA by PBMC was persistently increased at week 6, month 3 and month 6 ( p ≤0.04), that of the TGFβ-1 receptor type II from day 5 up to month 6 ( p p p

Expression of tumor necrosis factor-α and transforming growth factor-β1 in cerebrospinal fluid cells in meningitis

Abstract Meningitis is an acute inflammatory disease of the pia and arachnoid and the fluid in the subarachnoid space, in which a participation of cytokines can be expected. While tumor necrosis factor-alpha (TNFα) promotes inflammatory reactions, transforming growth factor-β1 (TGFβ1) has antagonistic effects and suppresses the inflammation in the subarachnoid space. We investigated the protein concentration and mRNA expression of TNFα and TGFβ1 in cerebrospinal fluid (CSF) by ELISA and intracellularly by non-radioactive in situ hybridization in 23 patients with bacterial or viral meningitis. A higher amount of both cytokines on protein and mRNA level, especially of TNFα, could be detected in bacterial infection. While an imbalance of both cytokines with a preponderance of TNFα-compared to TGFβ1-mRNA was visible in CSF cells of patients with bacterial meningitis, a balance of TNFα- and TGFβ1-mRNA or a higher expression of TGFβ1-mRNA could be detected in viral meningitis. In the acute phase of the disease neutrophil granulocytes expressed more TNFα- and TGFβ1-mRNA than lymphocytes and monocytes/macrophages, while these cell types were dominating the cytokine synthesis during the healing phase. These data indicate that immunomodulatory mechanisms take place in the CSF compartment itself, regulated by CSF cells in different but specific ways. In addition, TGFβ1 seems to be involved in the down-regulation of the inflammatory activity and to be one factor in the cytokine network, which could contribute to a lower rate of complications and positive outcomes. Moreover this study favors the possibility to monitor the immunomodulatory mechanisms by non-radioactive in situ hybridization.

Potential role of transforming growth factor-β1 in terminating the immune response in patients with Guillain-Barré syndrome

T-cell activation and proinflammatory cytokines seem to be important in promoting the disease activity in Guillain-Barré syndrome (GBS). Transforming growth factor-β1 (TGF-β1) is a multifunctional peptide with potent immunosuppressive activity, and can therefore be considered a putative disease-limiting cytokine. We determined levels of soluble TGF-β1 in the serum of 12 patients with GBS in serial investigations during the course of the disease, in 12 patients with other non-inflammatory neurological diseases (OND), and in 12 healthy control subjects. Levels of biologically active and total TGF-β1 were significantly increased in patients with GBS compared with patients with OND and healthy controls. During the course of GBS, levels of TGF-β1 peaked in the plateau phase before onset of recovery. During the recovery phase levels of TGF-β1 decreased but still exceeded significantly the levels in patients with OND and healthy controls. The differences were more marked with biologically active than with total TGF-β1. The temporal relationship between increased serum levels of TGF-β1 and the end of the progressive phase indicates that TGF-β1 has a role in terminating the pathological immune response in GBS. These findings suggest that TGF-β1 may be important in recovery from GBS.

Detection of transforming growth factor beta1 mRNA in cerebrospinal fluid cells of patients with meningitis by non-radioactive in situ hybridization

Meningitis is a serious disease mostly caused by viral or bacterial infections. In complicated cases it may lead to brain damage and death. The infection and cell damage result in a cellular and immunological response. Following this, a high secretion of cytokines can be expected. Cytokines, especially tumour necrosis factor alpha (TNF-alpha) and interleukin-1 (IL-1), promote the inflammatory reactions in the subarachnoid space. Transforming growth factor beta1 (TGF-beta1) has antagonistic effects on TNF-alpha and IL-1-mediated processes. Therefore, it suppresses inflammatory reactions. To observe the expression of TGF-betal in transcellular signalling in the inflammatory processes of meningitis, we investigated TGF-betal mRNA in cells in the cerebrospinal fluid of three patients with meningitis by non-radioactive in situ hybridization. All patients fulfilled the usual clinical criteria of meningitis. In one caseNeisseria menigitidis could be identified as the pathogenic agent. In the remainder, no agent could be isolated. In all cytological preparations of the cerebrospinal fluid of these patients a high level of TGF-betal mRNA was detectable in the cell populations. It was possible to distinguish between the different cell types of the cerebrospinal fluid and to attach the mRNA expression to them. On the one hand, this makes it possible to investigate pathogenesis and defence mechanisms in bacterial and aseptic meningitis on a cellular level; on the other hand, it may open new perspectives in the control of disease development, prognosis, diagnosis and supporting therapy.

Neoplastic cells in the cerebrospinal fluid in intravascular lymphomatosis.

Sirs: Intravascular lymphomatosis (IVL) is a rare malignant disorder with characteristic proliferation of neoplastic lymphoid cells within the lumina of small vessels. It was initially reported in 1959 as an endothelial neoplasm and called “angioendotheliomatosis proliferans systemata” [8]. Vascular occlusions in various organs due to the lymphoma may cause a variety of clinical symptoms. Despite many different neurological manifestations the CSF cytology of these patients is usually normal. A 68-year-old man without relevant medical history was admitted because of pain in the back of both legs, paresthesia in both feet, and progressive paresis of the right leg for 4 weeks. Clinical examination revealed a lesion of the first and second motor neuron: proximal paresis of the right leg, pronounced muscle stretch reflexes in the right arm, loss of the reflexes in the lower limbs, positive Babinski sign on the right side, and diminished vibration sense of both legs. Nerve conduction studies (velocity < 35m/s, loss of Fwaves) and CSF examination (elevated protein content (106 mg/dl) without elevated cell count) suggested a polyradiculopathy possibly caused by chronic inflammation. Because of the rapid progression of the neurological deficits treatment with 100 mg prednisolone daily was started before magnetic resonance imaging of the brain and the whole spine had been performed. These investigations demonstrated an area of increased signal intensity on T2weighted images located on the right side of the spinal cord at the level of C2, compatible with an inflammatory or ischemic lesion. Magnetic resonance imaging of the brain was unremarkable. The diagnosis of a paraneoplastic myelitis and polyradiculitis was made and the patient was treated with 1000 mg prednisolone daily over 3 days. No evidence of tumor was shown by any serological tests, computed tomography of thorax, abdomen and pelvis, gastroscopy, colonoscopy, bronchoscopy, or bone marrow aspirate. Six weeks after admission to hospital the patient was tetraplegic, incontinent, and demonstrated psychiatric symptoms in the form of bradyphenia, disorientation, and decreased memory function. Dexamethasone (48 mg per day) was given, without benefit. One week later the patient developed antibioticresistant fever. Repeated blood cultures were negative. CSF was again investigated (elevated protein content at 87 mg/dl, normal total cell count). The CSF cytology then demonstrated malignant lymphoid cells (Fig. 1a). Two days later the patient developed hypoventilation and coma and died 24 h later due to respiratory failure. A complete necropsy revealed no macroscopic abnormalities at the brain or spinal cord. On histological examination many vessels of the spinal roots and leptomeninges contained aggregates of tumor cells (Fig. 1b). These cells were also detectable in the vessels inside the spinal cord, brain, and cerebral leptomeninges. Immunohistochemical staining of the intravascular cells revealed a positivity for LCA (antibody UCHL–1, DAKO, Copenhagen, Denmark) and CD20 (L26, DAKO) demonstrating origin from the B-cell lineage. They were negative for CD3 (DAKO) and CD5 (Novocastra, Newcastle-upon-Tyne, UK) (T-cell markers). The rate of proliferation was 20% (measured by MiB–1 antibody; Dianova, Hamburg, Germany). IsLETTER TO THE EDITORS

Immunomodulatory effects of interferon-β-1b in patients with multiple sclerosis

The mechanisms by which IFN beta-1b acts in the treatment of patients with multiple sclerosis (MS) are not completely known. Immunomodulatory effects of IFN beta-1b were investigated in patients with relapsing-remitting (RR) MS in vivo and in vitro. Compared to baseline and controls, defined as patients with RR-MS without immunomodulatory therapy, the expression of TGF beta-1-mRNA by peripheral blood mononuclear cells (PBMC) was persistently increased at week 6, month 3 and month 6 (p < or = 0.05), that of the TGF beta-1 receptor type II from day 5 up to month 6 (p < 0.01). The expression of TNF alpha-mRNA decreased from day 1 to month 3 compared to day 0 and the controls (p < 0.01). The in vitro investigations performed on isolated peripheral blood lymphocytes demonstrated that these effects were dose-dependent. The mRNA and protein expression of TNF alpha-R-I (55 kD-receptor) was only temporarily elevated at the beginning of the therapy in vivo. The expression of TNF alpha-R-I-mRNA increased dose-dependently after stimulation with IFN beta-1b for 24 h in vitro. Serum levels of soluble vascular cell adhesion molecule (sVCAM) were increased during the whole time of in vivo treatment (p < 0.01). The CD8CD38 lymphocyte subpopulation was continuously elevated from day 5 up to month 6 (p < 0.01) in the MS patients treated with IFN beta-1b in vivo. No persistent, significant changes were demonstrable concerning the percentage of total CD4, CD8, CD19 nor in CD4 subpopulations (CD4CD29, CD4CD45RA). The present data suggest that IFN beta-1b induces the mRNA expression of TGF beta-1 and TGF beta-R-II by PBMC, decreases that of TNF alpha and increases levels of sVCAM-1 and of circulating activated CD8 cells (CD8CD38) in blood. These might be other mechanisms by which IFN beta-1b mediates its positive effects in the treatment of MS patients.

Expression of TNFα and TGFβ1 in Guillain–Barré syndrome: correlation of a low TNFα‐/TGFβ1‐mRNA ratio with good recovery and signs for immunoregulation within the cerebrospinal fluid compartment

In the pathogenesis of Guillain–Barré syndrome (GBS) a dysregulation of cytokines is supposed. The protein concentration and mRNA expression of TNFα and TGFβ1 were investigated in cerebrospinal fluid (CSF) and blood in 10 patients with GBS. TNFα‐mRNA was increased at the beginning of the disease and demonstrated a decline during the time course (P = 0.001). The level of TNFα protein was elevated in only a few patients. TGFβ1‐mRNA (P = 0.001) and the active TGFβ1 protein (P < 0.05) increased during the course of GBS, and the level of total TGFβ1 protein was temporarily elevated (P = 0.005). A low ratio of TNFα‐/TGFβ‐mRNA expression correlated to a good clinical course (P < 0.05). The results indicate an association of TNFα with disease activity. TGFβ1 seems to terminate and limit the inflammatory reactions and to promote the healing course of GBS. In addition the investigations show that in GBS immunoregulatory mechanisms also take place in the CSF compartment itself and that CSF cells are involved in the production of pro‐inflammatory as well as immunosuppressive cytokines.

Corticosteroids induce expression of transforming-growth-factor-beta1 mRNA in peripheral blood mononuclear cells of patients with multiple sclerosis

The mechanisms by which corticosteroids act in the treatment of an acute relapse in multiple sclerosis (MS) are not completely known. We investigated the mRNA and protein expression of transforming-growth-factor-beta1 (TGFbeta1), a cytokine with anti-inflammatory and immunosuppressive potentials, in peripheral blood mononuclear cells (PBMC) and serum of 10 patients with an acute relapse of MS before, during and after the treatment with 500 mg prednisolone daily over 5 days. The expression of TGFbeta1-mRNA increased at day 3-5 and declined at day 8-10. Serum levels of TGFbeta1 demonstrated a comparable course. The present data suggest that corticosteroids induce the expression of TGFbeta1 in vivo. This is might be an other mechanism by which corticosteroids mediate immunosuppression.