Laurens Weynants

Localization and Expression of Nuclear Factor of Activated T-Cells 5 in Myoblasts Exposed to Pro-inflammatory Cytokines or Hyperosmolar Stress and in Biopsies from Myositis Patients

Aims: Regeneration in skeletal muscle relies on regulated myoblast migration and differentiation, in which the transcription factor nuclear factor of activated T-cells 5 (NFAT5) participates. Impaired muscle regeneration and chronic inflammation are prevalent in myositis. Little is known about the impact of inflammation on NFAT5 localization and expression in this group of diseases. The goal of this study was to investigate NFAT5 physiology in unaffected myoblasts exposed to cytokine or hyperosmolar stress and in myositis. Methods: NFAT5 intracellular localization and expression were studied in vitro using a cell culture model of myositis. Myoblasts were exposed to DMEM solutions enriched with pro-inflammatory cytokines IFN-γ with IL-1β or hyperosmolar DMEM obtained by NaCl supplementation. NFAT5 localization was visualized using immunohistochemistry (IHC) and Western blotting (WB) in fractionated cell lysates. NFAT5 expression was assessed by WB and RT-qPCR. In vivo localization and expression of NFAT5 were studied in muscle biopsies of patients diagnosed with polymyositis (n = 6), dermatomyositis (n = 10), inclusion body myositis (n = 11) and were compared to NFAT5 localization and expression in non-myopathic controls (n = 13). Muscle biopsies were studied by means of quantitative IHC and WB of total protein extracts. Results: In unaffected myoblasts, hyperosmolar stress ensues in NFAT5 nuclear translocation and increased NFAT5 mRNA and protein expression. In contrast, pro-inflammatory cytokines did not lead to NFAT5 nuclear translocation nor increased expression. Cytokines IL-1β with IFN-γ induced colocalization of NFAT5 with histone deacetylase 6 (HDAC6), involved in cell motility. In muscle biopsies from dermatomyositis and polymyositis patients, NFAT5 colocalized with HDAC6, while in IBM, this was often absent. Conclusions: Our data suggest impaired NFAT5 localization and expression in unaffected myoblasts in response to inflammation. This disturbed myogenic NFAT5 physiology could possibly explain deleterious effects on muscle regeneration in myositis.

Clean Intermittent Self-Catheterization as a Treatment Modality for Urinary Retention: Perceptions of Urologists

Purpose Clean intermittent self-catheterization (CISC) is now considered the gold standard for the management of urinary retention. In the literature, several articles on patients’ perspectives on CISC and adherence to this technique have been published. No studies have yet explored the points of view of professional caregivers, such as nurses and doctors. The aim of this study was to explore the opinions of urologists about CISC and to evaluate the need for dedicated nurses specialized in CISC through a self-administered questionnaire. Methods A questionnaire was developed to explore the opinions of professional caregivers about self-catheterization and to evaluate the need to provide nurses with specialized education in CISC. Questionnaires were sent to 244 urologists through email. We received 101 completed questionnaires. The response rate was 41.4%. Results Hand function, the presence or absence of tremor, and visual acuity were rated as the most important determinants for proposing CISC to a patient. Twenty-five percent of the urologists reported that financial remuneration would give them a greater incentive to propose CISC. The lack of dedicated nurses was reported by half of the urologists as a factor preventing them from proposing CISC. A meaningful number of urologists thought that patients perceive CISC as invasive and unpleasant. Although most urologists would choose CISC as a treatment option for themselves, almost 1 urologist out of 5 would prefer a permanent catheter. Conclusions This questionnaire gave valuable insights into urologists’ perceptions of CISC, and could serve as the basis for a subsequent broader international study. Further research should also focus on the opinions of nurses and other caregivers involved in incontinence management. Apart from financial remuneration, it is also clear that ensuring sufficient expertise and time for high-quality CISC care is important. This could be a potential role for dedicated nurses.

Neurological involvement in Erdheim–Chester disease

Erdheim–Chester disease (ECD) is a rare, non-Langerhans form of histiocytosis of unknown etiology, affecting multiple organs. The disease was first described by Jakob Erdheim and William Chester in 1930 [1]. The most frequent symptom is bone pain, reported by 50 % of the patients, but involvement of the central nervous system, heart, skin, retroperitoneum, kidneys, lungs and pleura is also seen [2–7]. Definite diagnosis of ECD can be made when infiltration by foamy histiocytes expressing CD68, but not CD1a and S-100 protein, is observed in a tissue sample [3, 4, 7]. A 70-year-old male patient presented to a rheumatologist in 2012 with prolonged and diffuse complaints of bone pain, dizziness, unstable gait and increased emotionality. Neurological evaluation objectified the unstable gait and showed a general rigidity and disturbed Romberg test. Recent lab results showed submaximal sedimentation rates and elevated C-reactive protein (CRP). More extensive evaluation of the neurological complaints was performed and identified pseudobulbar affect, slight horizontal nystagmus, wide-based atactic gait, disturbed Romberg test and slight dysmetria of all four limbs. Tendon reflexes were normal and plantar reflexes were flexor. Brain MRI revealed T2 hyperintensity in the pons (Fig. 1a). Cortical and subcortical atrophy was seen in both hemispheres. Technetium Tc 99m bone scintigraphy showed bilateral symmetric elevated tracer uptake in the diaphyses of the long bones, especially in the femorae and tibiae, but also in the humeri (Fig. 1b). To confirm or exclude the diagnosis of Paget’s disease, an X-ray of the long bones and analysis of alkaline phosphatases were performed. The X-ray of the femur showed distal elevated bone sclerosis, which was symmetrical and bilateral (Fig. 1c); in the humeri bone remodeling of the diaphysis was seen (Fig. 1d). This is compatible with Paget’s disease. To exclude systemic pathologies, a PET/CT-scan and thoracic and abdominal CT-scans were performed. No cardiac or vascular abnormalities were seen. The abdominal CT-scan showed a hairy kidney appearance (Fig. 1e). Together with the bone scan, this raised the suspicion of ECD. A bone biopsy of the tibia showed foamy histiocytes and hyperostotic bone. The immunohistochemistry of the histiocytes was CD68 positive and CD1a and S-100 protein negative. Consequently, Langerhans histiocytosis could be excluded and the diagnosis of ECD was confirmed. The patient was started on PEG-IFNa 2a, 180 lg/0.5 ml, once a week. The patient was tested for the BRAF mutation, using exon direct sequencing, but the mutation was not detected. Neither clinical improvement nor deterioration was observed during 6 months of treatment. E. Nys L. Weynants M. Lemmerling J. L. De Bleecker (&) Department of Neurology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium e-mail: jan.debleecker@ugent.be

Cytomegalovirus-induced myeloradiculopathy in an immunocompetent patient.

Cytomegalovirus (CMV) is a member of the herpes viridae family. CMV infection usually occurs early in life and is transmitted through close contact with infected bodily fluids. Like all human herpes viruses, CMV establishes a lifelong latency following primary infection with periodical reactivation and shedding of the virus [1]. In immunocompetent patients, primary CMV infection is usually asymptomatic or manifests itself by a mononucleosis-like syndrome. This syndrome is generally mild but rarely patients develop a severe infection with multi-organ involvement [2]. Severe gastrointestinal tract and neurological diseases may occur [3]. In immunocompromised patients, however, CMV infection can cause encephalitis, pneumonitis and hepatitis with significant morbidity and mortality [3]. A 47-year-old male presented with numbness and increasing loss of strength in both legs, the left more affected than the right. There was no back pain. The diagnosis of active, bilateral polyradiculopathy L5-S1 was made elsewhere on the basis of the clinical examination and the EMG results. A month later, he developed a left foot drop and loss of strength in the upper left limb. Soon thereafter the patient’s condition rapidly deteriorated with a bilateral foot drop and further loss of strength in the lower limbs. Neurological examination showed bilateral Babinski and Hoffman-Trömner signs, distal hypoesthesia in the lower limbs and hyperreflexia of the right leg. Blood tests showed a normal sedimentation, positive CMV IgM and a strongly positive IgG (8.2 IU/ml; normal range 0–0.6), no antibodies against Borrelia Burgdorferi or HIV. ANF and SSA were negative. Cerebrospinal fluid was acellular and IgG oligoclonal bands were observed after iso-electrofocussing. EMG showed normal nerve conduction velocities, low-amplitude CMAPs and absent sensory nerve action potentials in the lower limbs. Myography disclosed fibrillation potentials, positive sharp waves, fasciculations and recruitment of high-amplitude polyphasic motor unit potentials in proximal and distal muscles in all four limbs. These findings were interpreted as being best consistent with combined motor neuron disease and distal sensorimotor axonal neuropathy. Cranial MRI showed no signs of demyelination. MRI full spine showed a mild myelopathy (Fig. 1a, b). The diagnosis of CMV-induced myelopathy and axonal polyradiculoneuropathy was made based on clinical features, lab results and EMG. High-dose intravenous corticosteroids and plasmapheresis were ineffective. In the following 3 months, the patient developed distinct atrophy of the muscles of the forearms and hands, hyperreflexia in the four limbs and a spastic gait. Blood test showed a mildly elevated sedimentation (37 mm; normal range 2–10), transaminases (ALT 111 IU/L; normal range 10–40; AST 91 IU/L; normal range 15–40) and CK (759 U/L; normal range 55–170) which later normalized. CMV IgM remained positive and IgG strongly positive. Positive nuclear ANF (speckled 3 ?), negative cytoplasmatic ANF, SSA ro52 positive, SSA ro60 negative were observed. Based on this serology, the diagnosis of systemic L. Weynants E. Nys J. L. De Bleecker (&) Department of Neurology, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium e-mail: Jan.Debleecker@ugent.be