[Neurological complications of Mediterranean boutonneuse fever. Presentation of a case of acute encephalomeningomyelitis and review of the literature]

Mediterranean spotted fever is an infectious disease due to Rickettsia conorii usually considered as benign; however, 10% of cases may have severe complications. We report a patient with celiac disease who developed encephalomeningomyelitis secondary to Mediterranean spotted fever. Meningoencephalitic involvement occurred during the acute phase, with myelitis appearing early during convalescence, as acute onset paraplegia involving the lumbosacral spinal cord. A magnetic resonance study showed multifocal white matter disturbances, with no lesions in the spinal cord. One month following onset, R. conorii antibodies serum level was 1/640. A cutaneous biopsy performed during the acute phase revealed endothelial hyperplasia, intraluminal thrombosis and lymphocytic perivascular infiltrate. Several immunological disturbances were found (circulating immune complexes, antinuclear antibodies, IgG paraproteinemia). The development of a systemic vasculitis is the major pathogenetic factor in the origin of systemic complications of Mediterranean spotted fever. We review the neurological syndromes reported in association with R. conorii infection. Our case is the second described as acute myelopathy complicating Mediterranean spotted fever.

Fatal Cercopithecine herpesvirus 1 (B virus) infection following a mucocutaneous exposure and interim recommendations for worker protection

On December 10, 1997, a 22-year-old female worker at a primate center died from Cercopithecine herpesvirus 1 (B virus) infection 42 days after biologic material (possibly fecal) from a rhesus macaque (Macaca mulatta) splashed into her right eye. This report summarizes the clinical features of her illness and the subsequent investigation by CDC in response to a technical assistance request from the Occupational Safety and Health Administration (OSHA) and presents interim recommendations to prevent ocular splash exposures. This investigation documented the hazard of ocular splashes and indicated that dendritic corneal lesions, such as herpetic skin vesicles, are not always present in B virus infection.

Blood lead levels in children with neurological disorders

Blood lead levels were measured by atomic absorption spectrometry in 82 children suffering from various neurological disorders (cerebral palsy 42, seizure disorders 35, acute encephalopathy of unknown origin 5) and in 28 healthy children, aged 1 to 12 years. Mean blood lead levels were 11.96 +/- 10.97 micrograms/dl in control children and 19.30 +/- 17.65 micrograms/dl in children with neurological disorders. A significant number of control children as well as those who had neurological disorders were found to have blood lead concentrations of > or = 10 micrograms/dl and > or = 20 micrograms/dl, the cut-off limits for lead poisoning and medical evaluation, respectively. Blood lead levels were, statistically, elevated in children with cerebral palsy compared to controls. Children with pica behaviour exhibited higher blood lead concentrations.

The pathophysiology of paraneoplastic neurological syndromes

Paraneoplastic neurological diseases are a group of neurological disorders associated with neoplastic tumors but not due to tumoral extension, metabolic, infectious, vascular or toxic complications of these tumors or their treatment. In the majority of paraneoplastic neurological disorders, circulating autoantibodies directed against neurons have been found in the serum and/or the CSF suggesting, and in some cases implicating, autoimmunity in the pathophysiology of these diseases. The finding of autoimmune phenomena during the course of paraneoplastic neurological disorders is of importance: from a practical point of view, since the detection of anti-neuronal autoantibodies is of great diagnostic help and should lead to the thorough search of the associated tumor often at an early stage of its development; from a theoretical point of view, these disorders represent a peculiar type of molecular mimicry. Tumoral neontigens having structural homology or identity with neuronal autoantigens elicit autoreactivity. The immunological effector mechanisms involved in the pathophysiology of paraneoplastic syndromes appear to differ according to the disease: autoantibodies are pathogenic in Lambert-Eaton syndrome whereas, in paraneoplastic cerebellar degeneration and in the Hu syndrome, the cellular immune response might play a greater role.

Paraneoplastic encephalomyelitis and seminoma: importance of testicular ultrasonography

We report two patients with paraneoplastic limbic and brainstem encephalitis associated with occult nonmetastatic testicular seminoma. In each patient, the neoplasm was detectable only by testicular ultrasonography. Male patients with this syndrome in whom lung cancer is not found should undergo testicular ultrasonography as part of the search for an extrapulmonary neoplasm. A normal clinical testicular examination is insufficient to exclude an occult seminoma.

Hemiparesis following influenza vaccination

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Late-onset chronic inflammatory encephalopathy in immune-competent and severe combined immune-deficient (SCID) mice with astrocyte-targeted expression of tumor necrosis factor

To examine the role of tumor necrosis factor (TNF)-alpha in the pathogenesis of degenerative disorders of the central nervous system (CNS), transgenic mice were developed in which expression of murine TNF-alpha was targeted to astrocytes using a glial fibrillary acidic protein (GFAP)-TNF-alpha fusion gene. In two independent GFAP-TNFalpha transgenic lines (termed GT-8 or GT-2) adult (>4 months of age) animals developed a progressive ataxia (GT-8) or total paralysis affecting the lower body (GT-2). Symptomatic mice had prominent meningoencephalitis (GT-8) or encephalomyelitis (GT-2) in which large numbers of B cells and CD4+ and CD8+ T cells accumulated at predominantly perivascular sites. The majority of these lymphocytes displayed a memory cell phenotype (CD44high, CD62Llow, CD25-) and expressed an early activation marker (CD69). Parenchymal lesions contained mostly CD45+ high, MHC class II+, and Mac-1+ cells of the macrophage microglial lineage with lower numbers of neutrophils and few CD4+ and CD8+ T cells. Cerebral expression of the cellular adhesion molecules ICAM-1, VCAM-1, and MAdCAM as well as a number of alpha- and beta-chemokines was induced or upregulated and preceded the development of inflammation, suggesting an important signaling role for these molecules in the CNS leukocyte migration. Degenerative changes in the CNS of the GFAP-TNFalpha mice paralleled the development of the inflammatory lesions and included primary and secondary demyelination and neurodegeneration. Disease exacerbation with more extensive inflammatory lesions that contained activated cells of the macrophage/microglial lineage occurred in GFAP-TNFalpha mice with severe combined immune deficiency. Thus, persistent astrocyte expression of murine TNF-alpha in the CNS induces a late-onset chronic inflammatory encephalopathy in which macrophage/microglial cells but not lymphocytes play a central role in mediating injury.

Neuropathological and aetiological studies of sporadic non-suppurative meningoencephalomyelitis of cattle

Sporadically occurring non-suppurative encephalitis appears to be a frequent condition of Swiss cattle. Fifty-one such cases diagnosed over a period of 10 years were examined retrospectively to investigate whether they constituted one or more distinct diseases, and to search for aetiological agents. Three cases were characterised by periventricular granulomatous encephalitis, and most probably represented a different disease, but the remaining 48 cases had disseminated non-suppurative encephalitis with widespread neuronal changes. Neuronal degeneration was very marked in the hippocampus of 10 cases and in the cerebellar Purkinje cells of 11. It was thought that the latter cases represented morphological variations of the same disease rather than a different disease because of their overlapping morphological features. The 48 cases had the following features in common: the disease had primarily neurological signs affecting mostly adult cattle, it was a sporadic condition, and there was a clear tendency for it to have a subacute to chronic course. Polymerase chain reaction (PCR) amplification for chlamydial DNA was negative except in one of 32 specimens, and immunohistochemistry did not demonstrate the presence of chlamydial antigens either in the one PCR-positive case or in the other cases examined. Immunohistochemistry for rabies virus, Borna disease virus, and central European tickborne encephalitis virus was negative. In four cases, immunolabelled cells were found in the lesions with antibodies against paramyxovirus antigens.

Infection with cytotoxic T-lymphocyte escape mutants results in increased mortality and growth retardation in mice infected with a neurotropic coronavirus

C57BL/6 mice infected with mouse hepatitis virus strain JHM (MHV-JHM) develop a chronic demyelinating encephalomyelitis several weeks after inoculation. Previously, we showed that mutations in the immunodominant CD8 T-cell epitope (S-510-518) could be detected in nearly all samples of RNA and virus isolated from these mice. These mutations abrogated recognition by T cells harvested from the central nervous systems of infected mice in direct ex vivo cytotoxicity assays. These results suggested that cytotoxic T-lymphocyte (CTL) escape mutants contributed to virus amplification and the development of clinical disease in mice infected with wild-type virus. In the present study, the importance of these mutations was further evaluated by infecting naive mice with MHV-JHM variants isolated from infected mice and in which epitope S-510-518 was mutated. Compared to mice infected with wild-type virus, variant virus-infected animals showed higher mortality and morbidity manifested by decreased weight gain and neurological signs. Although a delay in the kinetics of virus clearance has been demonstrated in previous studies of CTL escape mutants, this is the first illustration of significant changes in clinical disease resulting from infection with viruses able to evade the CD8 T-cell immune response.

[Two cases of encephalo-myelo-radiculoneuropathy, triggered by herpes simplex virus type-1 infection]

We report two cases of encephalo-myelo-radiculoneuropathy, triggered by herpes simplex virus type-1 (HSV-1) infection. Patient 1 (a 25-year-old man) and patient 2 (a 52-year-old man) were admitted to the hospital because of fever, headache, abnormal behavior, and loss of consciousness. In each case, cerebrospinal fluid (CSF) showed lymphocytic pleocytosis with protein elevation, and serum and CSF IgG antibody titers to HSV-1 were elevated markedly. Although patient 1 was treated with aciclovir in the early phase of encephalitis, he developed severe quadriparesis as a sequela. Patient 2 was treated with a combination of aciclovir and corticosteroids, and he recovered completely about 4 months after the onset of the disease. There have been only a few reports of encephalo-myelo-radiculoneuropathy triggered by HSV-1 infection. Early corticosteroid therapy was effective in our patients with post-HSV-1 infectious encephalo-myelo-radiculoneuropathy. These two patients were studied with flow cytometry for peripheral blood lymphocyte subsets during the disease course. In the active stage of the disease, the helper-inducer (CD4 + CD29+), activated T cell (CD4 + CD25+), and cytotoxic/NK (CD8 Dull + CD11b Bright+) subsets were increased compared with subsets in controls. An interesting finding was mismatched responses with an increased suppressor-inducer (CD4 + Leu8+) subset and a decreased suppressor-effecter (CD8 Bright+ CD11b Dull+) subset, indicating a possible autoimmune character of encephalo-myelo-radiculoneuropathy triggered by viral infection.

[Angiostrongylosis in infants in Reunion and Mayotte. Apropos of 3 cases of eosinophilic meningitis including 1 fatal radiculo-myeloencephalitis with hydrocephalus]

BACKGROUND

Eosinophilic meningitis caused by Angiostrongylus cantonensis is widespread in Southeast Asia and Pacific islands. Adults develop a transient meningitis with a benign course but severe or fatal disease may occur in pediatric patients.

CASE REPORT

Case 1. A 11-month-old boy living in Mayotte island was hospitalized a few days with fever and skin rash following by seizure, coma, flaccid quadraplegia, absence of deep tendon reflexes, urinary retention and anal incontinence. Eosinophilia was observed in peripheral blood and cerebrospinal fluid. He further developed a triventricular hydrocephalus treated by ventriculoperitoneal shunt. The child died 3 weeks later. A serodiagnosis of angiostrongylus infestation was restrospectively established. Case reports 2 and 3.-Two infants, 10 and 11-month-old-boys, living in Reunion island, developed fever and vomitings, irritability and, for one of them, unilateral sixth cranial nerve palsy. There was eosinophilia in the peripheral blood and in the cerebrospinal fluid. All symptoms progressively disappeared with complete recovery. The suspected diagnosis of angiostrongylus infestation was confirmed by the serology.

CONCLUSION

We report the first case of Angiostrongylus cantonensis infection in the French island of Mayone (Comoro Islands) and we confirm the presence of this disease in Reunion island. In this Indian Ocean area, eosinophilic meningitis occurs most of the time in infants with sometimes severe radiculomyeloencephalitic forms.

[Paraneoplastic encephalomyeloneuritis with anti-Hu antibodies and cancer of the rectum]

We report the case of a 62-year-old man affected by anti-Hu-associated paraneoplastic encephalomyelitis. The underlying tumor was a neuroendocrine cancer of the rectum expressing Hu antigen. The neurologic presentation was limited to moderate sensitive neuropathy associated with two complex partial seizures (dreamy state) without any further signs of limbic encephalopathy. A paraneoplastic etiology should be considered in patients with moderate symptomatology. Paraneoplastic encephalomyelitis with anti-Hu antibodies is not always associated with small-cell lung cancer.

Paraneoplastic syndromes associated with small cell lung cancer

The term paraneoplastic syndrome refers to the ability of some tumors to produce signs and symptoms at a distance from the site of the primary tumor or its metastases. Paraneoplastic syndromes may develop before the diagnosis of carcinoma is made. Paraneoplastic syndromes associated with small cell lung cancer (SCLC) include endocrinologic abnormalities secondary to peptide hormone production, and neurologic sequelae due to autoantibody production. This article reviews the common paraneoplastic syndromes that may occur in patients with SCLC.

Encephalitogenic potential of myelin basic protein-specific T cells isolated from normal rhesus macaques

Myelin basic protein (MBP)-specific T cells are implicated in the pathogenesis of multiple sclerosis and are targets of selective immunotherapies. However, autoantigen-specific T cells can also be isolated from healthy individuals. Their functional potential is unknown and obviously cannot be tested in humans. We approached this question in a closely related primate species, the rhesus monkey. CD4+ T cell lines specific for MBP were isolated from normal rhesus monkeys using the same primary limiting dilution technique that is now widely used to generate human autoreactive T cell clones in vitro. Three different epitopes were recognized by three rhesus T cell lines isolated from three different monkeys. Upon activation, all lines produced interferon-gamma, interleukin-2, tumor necrosis factor-alpha, and granulocyte/macrophage colony-stimulating factor but neither interleukin-4 nor transforming growth factor-beta. The MBP-specific T cells were injected intravenously without adjuvant into the nonirradiated autologous monkey. One of the three rhesus monkeys developed an encephalomyelitis with a pleocytosis in the spinal fluid and perivascular infiltrates in the leptomeninges, spinal nerve roots and cerebral cortex. The data demonstrate that the normal immune repertoire of a primate species contains MBP-specific CD4+ T cells that are able to induce an autoimmune encephalomyelitis upon transfer into the nonirradiated autologous recipient.

Lymphocytic encephalomyeloneuritis as a neurologic complication of ulcerative colitis

Ulcerative colitis (UC) is a chronic relapsing inflammatory bowel disease (IBD) showing immunologic abnormalities and association with autoimmune states (Snook et al., 1989). Extraintestinal manifestation of UC affect various organ systems (Podolsky, 1991). We describe morphologically documented encephalomyeloneuritis in a 58-year-old white male with UC in full remission providing support for the concept that ulcerative colitis may be complicated by neurologic manifestations affecting both the central and peripheral nervous system.