Ryoko Takeuchi

Suppressed Expression of Autophagosomal Protein LC3 in Cortical Tubers of Tuberous Sclerosis Complex

Tuberous sclerosis complex (TSC) is characterized by benign tumors and hamartomas, including cortical tubers. Hamartin and tuberin, encoded by the TSC 1 and 2 genes, respectively, constitute a functional complex that negatively regulates the mammalian target of rapamycin (mTOR) signaling pathway, eventually promoting the induction of autophagy. In the present study, we assessed the induction of autophagy in cortical tubers surgically removed from seven patients with TSC in comparison with five controls of cortical tissue taken from non‐TSC patients with epilepsy. Immunoblotting demonstrated a marked reduction of LC3B‐I and LC3B‐II in tubers relative to the controls. In tubers, strong, diffuse and dot‐like immunoreactivity (IR) for LC3B was observed in dysmorphic neurons and balloon cells, but LC3B‐IR in other neurons with normal morphology was significantly weaker than that in neurons in the controls. Immunoelectron microscopy revealed diffuse distribution of LC3B‐IR within the cytoplasm of balloon cells. The dot‐like pattern may correspond to abnormal aggregation bodies involving LC3. In an autopsy patient with TSC, we observed that LC3B‐IR in neurons located outside of the tubers was preserved. Thus, autophagy is suppressed in tubers presumably through the mTOR pathway, and possibly a pathological autophagy reaction occurs in the dysmorphic neurons and balloon cells.

Maintaining glottic opening in multiple system atrophy: efficacy of serotonergic therapy.

Involuntary muscle contractions began in the right deltoid muscle 2 weeks after onset of pain. Contractions were rhythmic, with sinusoidal and undulating/peristaltic qualities. Both the pain and the deltoid contractions were continuous. The movements continued during sleep, and the patient could not voluntarily stop them. Therapeutic interventions including medications, physical therapy, and surgery did not mitigate the pain or affect the movements. Oral analgesics including oxycodone and antiepileptics including phenytoin and gabapentin all proved ineffective. The patient was treated by chiropractors and physical therapists with no benefit. In 2001, a shoulder spur was removed, and later that year an anterior cervical discectomy with fusion at 3 levels (C4–C5, C5–C6, and C6–C7) was performed. Neither surgery produced benefit. On exam, the patient had no focal motor or sensory deficits. Tendon reflexes were normal. Involuntary movements in the right deltoid were constant, although the amplitude, frequency, and extent of contractions varied. Contraction ‘‘waves’’ were rhythmic and began in the posterior deltoid, swept anteriorly, and gave an ‘‘undulating’’ or peristalsislike appearance. Contraction progression involved more muscle fascicles in the posterior middle-deltoid and was more visible with large amplitude contractions (see Video Supplement). His multiple spine magnetic resonance images revealed progressively worsening cervical spondylosis. Multichannel needle electromyographic (EMG) recording was performed with concentric needle electrodes. Deltoid EMG did not show myokymia or myoclonus. EMG activity underlying the contractions were normal-appearing interference patterns with bursts lasting 400–800 ms. During voluntary shoulder abduction, the bursting temporarily disappeared and was replaced by normal-looking tonic EMG activity. There were no other EMG abnormalities in the upper extremities. The pathophysiology of PLMT is poorly understood and likely heterogeneous. In some cases there is evidence of a lesion in the spinal cord, the cauda equina, the lumbar roots, or the peripheral nerves; the syndrome may also occur after minor limb trauma or without any antecedents. In at least 1 publication on PLMT, it was observed that movements could be suppressed at the patient’s volition. Peripheral nervous injury may produce a spectrum of movement disorders including PLMT, yet such etiology is not always confirmed by routine EMG, similar to our case. In the absence of confirmed peripheral nerve injury, the pathophysiology of these symptoms remains uncertain but likely arises from aberrant spinal cord plasticity. Painful shoulder—moving deltoid syndrome represents a spinal segmental movement disorder possibly analogous to PLMT.

Heterogeneity of cerebral TDP-43 pathology in sporadic amyotrophic lateral sclerosis: Evidence for clinico-pathologic subtypes

Frontotemporal lobar degeneration (FTLD) and amyotrophic lateral sclerosis (ALS) are types of major TDP-43 (43-kDa TAR DNA-binding protein) proteinopathy. Cortical TDP-43 pathology has been analyzed in detail in cases of FTLD-TDP, but is still unclear in cases of ALS. We attempted to clarify the cortical and subcortical TDP-43 pathology in Japanese cases of sporadic ALS (n = 96) using an antibody specific to phosphorylated TDP-43 (pTDP-43). The cases were divided into two groups: those without pTDP-43-positive neuronal cytoplasmic inclusions in the hippocampal dentate granule cells (Type 1, n = 63), and those with such inclusions (Type 2, n = 33). Furthermore, the Type 2 cases were divided into two subgroups based on semi-quantitative estimation of pTDP-43-positive dystrophic neurites (DNs) in the temporal neocortex: Type 2a (accompanied by no or few DNs, n = 22) and Type 2b (accompanied by abundant DNs, n = 11). Clinico-pathologic analysis revealed that cognitive impairment was a feature in patients with Type 2a and Type 2b, but not in those with Type 1, and that importantly, Type 2b is a distinct subtype characterized by a poor prognosis despite the less severe loss of lower motor neurons, the unusual subcortical dendrospinal pTDP-43 pathology, and more prominent glial involvement in cortical pTDP-43 pathology than other two groups. Considering the patient survival time and severity of motor neuron loss in each group, transition from Type 1 to Type 2, or from Type 2a to Type 2b during the disease course appeared unlikely. Therefore, each of these three groups was regarded as an independent subtype.

Transportin 1 accumulates in FUS inclusions in adult-onset ALS without FUS mutation.

Accumulation of a protein, DNA/RNA binding protein fused in sarcoma (FUS), as cytoplasmic inclusions in neurones and glial cells in the central nervous system (CNS) is the pathological hallmark of amyotrophic lateral sclerosis (ALS) with FUS mutations (ALS-FUS) [1,2] as well as certain subtypes of frontotemporal lobar degeneration (FTLD-FUS) [3,4], the latter being unassociated with FUS mutations. While the inclusions in ALS-FUS contain only FUS, those in FTLD-FUS show co-accumulation of three proteins of the FET protein family, i.e. in addition to FUS, Ewing’s sarcoma (EWS) and TATA-binding proteinassociated factor 15 (TAF15) [5]. These findings strongly suggest that a more complex derangement of transportinmediated nuclear import of proteins accounts for the disease process in FTLD-FUS in comparison to ALS-FUS. Recently, Neumann et al. reported that the inclusions in FTLD-FUS subtypes were strongly labelled for transportin 1 (TRN1) and that, as expected, the inclusions in ALS-FUS were completely unreactive for this protein [6]. Here we report an adult patient who exhibited a clinically pure ALS phenotype without FUS mutations (ALS-FUS) and cytoplasmic inclusions showing coaccumulation of FET and TRN1 proteins, confirming that ALS-FUS and FTLD-FUS represent part of a spectrum of FUS proteinopathy without FUS mutation. A 65-year-old Japanese woman became aware of muscle weakness in her hands. Three years later, she was diagnosed as having ALS. Thereafter, bulbar palsy and respiratory distress progressed gradually; at the age of 70 years, tracheotomy and respirator support became necessary. The patient died of gastrointestinal bleeding at the age of 74 years, about 9 years after disease onset. There was no family history of neurological disorders, including ALS. During the disease course, dementia was not evident. We sequenced and found no mutations in the all coding regions of the FUS gene. The brain was small and weighed 820 g (brainstem and cerebellum, 110 g) before fixation. The spinal cord showed marked atrophy. Histologically, loss of myelinated fibres was observed in the spinal white matter except for the posterior columns; the lateral corticospinal tracts appeared to be only mildly affected (Figure 1a). Neuronal loss and gliosis were also evident in the spinal anterior horns (Figure 1b) and brainstem hypoglossal nucleus. The presence of slightly basophilic round inclusions in the remaining lower motor neurones was a feature (Figure 1c). No Bunina bodies were found. In the cerebral cortex, mild neuronal loss was noted in the motor cortex. Immunostaining with an antibody against FUS (polyclonal, SigmaAldrich, St Louis, USA; 1:50) revealed widely distributed positive neuronal cytoplasmic inclusions (NCIs) in the CNS, including the spinal anterior horn and motor cortex (Figure 1d,e). The distribution and severity of FUS lesions and neuronal loss are shown inTable 1. FUS immunostaining also revealed positive glial cytoplasmic inclusions (GCIs) (Figure 1f). These cytoplasmic inclusions were also labelled by anti-ubiquitin (polyclonal, Dako, Glostrup, Denmark; 1:800) (Figure 1g) and anti-p62 (monoclonal; BD Bioscience, San Jose, CA, USA; 1:1000) antibodies (Figure 1h). No neuronal nuclear inclusions (NIIs) were found.The results of immunostaining for a-internexin and TDP-43 were all negative (data not shown). Immunostaining with an antibody against transportin 1 (TRN1) (monoclonal, Abcam, Cambridge, UK; 1:200) also revealed clearly positive NCIs (Figure 2a) and GCIs. Such inclusions were also labelled with anti-TAF15 (polyclonal, Bethyl Lab, Montgomery, USA; 1:200) (Figure 2b) and anti-EWS (monoclonal, Santa Cruz, Santa Cruz, USA; 1:200) antibodies (Figure 2c). TRN1 and FUS were sometimes fully or partially colocalized in the same neurones (Figure 2d–f,g–i) and glial cells. The ratio of the colocalization (TRN1/FUS) in NCIs was about 50%. FTLD-FUS can be classified into three pathological subtypes, atypical FTLD-U, neuronal intermediate filament inclusion disease (NIFID), and basophilic inclusion body disease (BIBD) on the basis of the morphology and distribution pattern of FUS-positive NCIs and NIIs [3]. Atypical FTLD-U is characterized by compact, round to oval kidneyshaped NCIs and vermiform NIIs in the neocortex, granule cells of the dentate gyrus, striatum and some other brain regions. NIFID is characterized by FUS-positive NCIs and NIIs as well as less predominant type IV interfilament-, a-internexinand neurofilament-positive NCIs. Lastly,

The circulating level of leptin and blood pressure in patients with multiple system atrophy

Patients with multiple system atrophy (MSA) frequently exhibit orthostatic hypotension (OH). Leptin, an adipose-derived hormone, contributes to the sympathetic control of blood pressure (BP), and loss of leptin may cause OH. We aimed to clarify the relationship between leptin and OH in MSA. Serum leptin levels were measured in 36 patients with MSA, 25 patients with other atypical parkinsonian disorders (APDs), including progressive supranuclear palsy-Richardson syndrome and corticobasal syndrome, and 26 control subjects. Blood samples were obtained after fasting for 12h. In MSA patients, baseline BP was measured in the recumbent position after a 3-min rest, and orthostatic changes in BP were evaluated after 0-3 min of standing. Serum leptin levels did not differ significantly between MSA patients (5.9 ± 0.8 ng/ml), other APD patients (5.2 ± 0.8 ng/ml), and controls (6.1 ± 1.3 ng/ml; P=0.8). In MSA patients, serum leptin levels correlated significantly with body mass index (P=0.01), but not baseline BPs (systolic BP, P=0.20; diastolic BP, P=0.44) or orthostatic drop in BP (systolic BP, P=0.13; diastolic BP, P=0.58). Our observations indicated that the circulating level of leptin was preserved, and OH occurred independent of the leptin level in MSA patients.

Globular Glial Mixed Four Repeat Tau and TDP-43 Proteinopathy with Motor Neuron Disease and Frontotemporal Dementia

Amyotrophic lateral sclerosis (ALS) may be accompanied by frontotemporal dementia (FTD). We report a case of glial mixed tau and TDP‐43 proteinopathies in a Japanese patient diagnosed clinically as having ALS‐D. Autopsy revealed loss of lower motor neurons and degeneration of the pyramidal tracts in the spinal cord and brain stem. The brain showed frontotemporal lobar degeneration (FTLD), the most severe neuronal loss and gliosis being evident in the precentral gyrus. Although less severe, such changes were also observed in other brain regions, including the basal ganglia and substantia nigra. AT8 immunostaining revealed that predominant occurrence of astrocytic tau lesions termed globular astrocytic inclusions (GAIs) was a feature of the affected regions. These GAIs were Gallyas‐Braak negative. Neuronal and oligodendrocytic tau lesions were comparatively scarce. pS409/410 immunostaining also revealed similar neuronal and glial TDP‐43 lesions. Interestingly, occasional co‐localization of tau and TDP‐43 was evident in the GAIs. Immunoblot analyses revealed band patterns characteristic of a 4‐repeat (4R) tauopathy, corticobasal degeneration and a TDP‐43 proteinopathy, ALS/FTLD‐TDP Type B. No mutations were found in the MAPT or TDP‐43 genes. We consider that this patient harbored a distinct, sporadic globular glial mixed 4R tau and TDP‐43 proteinopathy associated with motor neuron disease and FTD.

Multifocal hits for propagation of prion protein in sporadic Creutzfeldt-Jakob disease

A 60-year-old woman presented with discomfort during respiration and anxiety. One month later, she developed dysarthria and unsteadiness of gait that gradually progressed over 3 months. She was referred to our affiliated hospital. A neurologist noted muscle rigidity, parkinsonian gait, and bradyphrenia, but her general cognitive function was preserved, with a Mini-Mental State Examination (MMSE) score of 29/30. At this time, diffusion-weighted imaging (DWI) demonstrated multifocal spotty hyperintense signals in the cerebral cortex (figure, A). Six months later, she became unable to stand or walk because of limb and truncal ataxia, and she was admitted to our hospital. On admission, she showed marked cognitive decline (MMSE score of 14/30) and apathy. Neurologic examination revealed cerebellar ataxia and parkinsonism such as rigidity and akinesia, but myoclonus was not present. Laboratory findings were all normal except for those of the serologic tests for syphilis (STS) and the Treponema pallidum latex agglutination (TPLA) test. Both the STS and the TPLA test showed positivity for syphilis with a low titer, whereas the TPLA test of CSF showed negative results, indicating self-limited syphilis. DWI findings were not significantly different from those 5 months ago (figure, B). EEG showed 5-Hz slow waves but not periodic sharp wave complexes. Two months after admission, she developed urinary tract infection and subsequently severe inspiratory stridor with a high-pitched sound. Laryngeal fiberscope showed that the bilateral vocal cords were fixed in the midline position. After tracheostomy, her stridor disappeared. However, her condition deteriorated rapidly. She became mute and subsequently developed myoclonus. At this time, CSF analysis revealed a total tau protein level of 246 pg/mL (cutoff for the diagnosis of sporadic Creutzfeldt-Jakob disease [CJD] >1,300). The 14-3-3 protein was not detected in the CSF. However, RT-QUIC (real-time quaking-induced conversion) assay, which has a sensitivity of 83.3% for CJD,1 showed positivity for CJD. EEG showed 1-Hz periodic sharp wave complexes. DWI revealed hyperintense signals slightly spread (figure, C) and extended throughout the cerebral cortex and basal ganglia 4 months later (figure, D). The diagnosis of sporadic CJD was made on the basis of progressive dementia and myoclonus, EEG findings, and hyperintense lesions detected by DWI. Analysis of the prion protein gene PRNP showed no mutations. The polymorphic codon 129 was homozygous for methionine and codon 219 was homozygous for glutamate.

Patient with insidious hypoactive delirium associated with pregabalin

Pregabalin has favorable effects on several types of neurological pain, but can cause side‐effects including dizziness, somnolence and delirium. Delirium presents as two variants in terms of psychomotor disturbance: the hyperactive type, showing agitation and vigilance; and the hypoactive type, showing lethargy and decreased motor activity. Patients with delirium associated with pregabalin therapy have been reported to experience hyperactive delirium. Here, we report the case of a 68‐year‐old patient with insidious hypoactive delirium caused by pregabalin therapy for postherpetic neuralgia. Delirium improved after discontinuation of pregabalin. Hypoactive delirium is considered to be more common than the hyperactive type in older adults, and is likely to be overlooked. Attention should thus be paid to latent cases of hypoactive delirium associated with pregabalin therapy in elderly individuals.