Concurrence of multiple sclerosis and Hodgkin's disease

Localised multiple sclerosis-like disease after irradiation of the cervicothoracic spinal cord

BACKGROUND

Radiation has been discussed as a potential causative factor for Multiple Sclerosis (MS). However, it is unresolved whether radiation increases the aggressiveness of the immune system or whether it alters the nervous tissue to become vulnerable to a pre-existing autoimmune attackdisposition. We report a patient with an MS-like disease confined to the irradiated part of his central nervous system (CNS).

CASE REPORT

within the course of a year, a 29 year-old man developed three relapses that were distinguishable regarding their neurological signs and symptoms. Clinically and on MRI, all relapses were localised to the cervico-thoracic spinal cord (sensory level Th6, monoparesis right leg, sign of Lhermitte). Four years before, he had been diagnosed with supradiaphragmatic Hodgkin´s lymphoma stage IIa. Four courses of chemotherapy with the ABVD-protocol and irradiation with 29,5 Gray led to complete tumour remission. Consecutive MR-imaging of the brain and spinal cord revealed fluctuating and partially contrast-enhancing lesions exclusively in those sections of the spinal cord that were localised in the field irradiated four years before. Treatment with pulsed i.v. steroids led to improvement. CSF analysis showed mild pleocytosis and isolated oligoclonal bands. Extensive work-up for differential diagnoses was negative. Genetic sequencing for DNA repair enzymes and in-vitro assays of the patients peripheral blood mononuclear cells for increased sensitivity to irradiation was unrevealing.

CONCLUSION

The fact that this patients MS-like disease was strictly confined to the irradiated parts of the body suggests that the co-occurrence of Hodgkins and MS-like disease was not simple coincidence but that they are pathogenetically linked. An increased aggressiveness of the immune system caused by the radiation is an unlikely explanation as the autoimmune attack would not be expected to spare the non-radiated parts of the CNS. We propose that in our patient the nervous tissue in the radiation clinical target volume was altered by radiation. This alteration of antigenic make-up, in turn, may have enabled an MS-specific autoimmune attack by a pre-existent immunological mechanism. This hypothesis is supported by experimental studies of induction of experimental autoimmune encephalitis (EAE) in irradiated rats.

The association of multiple sclerosis and Hodgkin's disease: the role of Epstein—Barr virus infection

The aetiology of multiple sclerosis (MS) is still an unresolved question. Several recently reported studies are implicating Epstein—Barr virus (EBV) as one of the key players in MS pathogenesis. We present a 21-year-old male patient with a history of EBV-related infectious mononucleosis in puberty and Hodgkin's disease two years previously treated with irradiation and chemotherapy. The patient presented with spastic paraparesis that resolved promptly on corticosteroid treatment. There were no signs of Hodgkin's disease relapse. In the next three years he had three more bouts of the disease and he was diagnosed with relapse—remitting MS. There is evidence of EBV involvement in MS pathogenesis; the association of MS with EBV-related infectious mononucleosis and Hodgkin's disease being just one of them. Although there are many unanswered questions, it is clear that without EBV seropositivity MS in adults is extremely rare. Multiple Sclerosis 2008; 14: 284—287. http://msj.sagepub.com

Urinary tract pathogens and antimicrobial sensitivity patterns in children in Ibadan, Nigeria

A study of bacterial organisms isolated from 65 Nigerian children who had urinary tract infection (UTI) is reported. The predominant isolate in both inpatients and outpatients was Klebsiella species which accounted for 52.8% of cases. Escherichia coli, Pseudomonas spp and Proteus spp accounted for 25.0%, 15.3% and 5.5% of isolates, respectively. All isolates were poorly sensitive to the common first-line drugs used in UTI in our environment, namely, cotrimoxazole and ampicillin, but exhibited good sensitivity to nalidixic acid, nitrofurantoin and ofloxacin. It is recommended that nitrofurantoin and nalidixic acid be used for blind treatment of UTI in Nigerian children in Ibadan while results of culture and sensitivity are awaited. Continuous monitoring of the pattern of organisms isolated in childhood UTI and their antibiotic resistance patterns is recommended as an essential step in guiding blind antibiotic therapy in such cases.