Positive troponin T without cardiac involvement in inclusion body myositis

Cardiac troponin T (cTnT) is considered as a specific marker for acute myocardial infarction. Here, we present a case with elevated cTnT, determined by a third-generation assay, without signs of a myocardial lesion. Routine investigation of a 66-year-old female patient with indolent B-cell lymphoma revealed increased serum levels of creatine kinase (CK), MB fraction of CK (CK-MB), and cTnT, although she did not complain of cardiac symptoms. Electrocardiographic monitoring, echocardiography, magnetic resonance computed angiography, and percutaneous coronary angiography excluded myocardial damage. However, the close follow-up showed a steady increase of CK-MB and cTnT levels and gradual development of weakness in both thighs. A biopsy of the right quadriceps muscle led to the diagnosis of inclusion body myositis. In contrast to cTnT, cardiac troponin I could not be detected retrospectively in any of her serum samples. These results demonstrate for the first time that cTnT is elevated in patients with inclusion body myositis.

Tubulovesicular structures in Creutzfeldt-Jakob disease

By electron microscopy tubulovesicular structures (TVS) have been consistently observed in brain tissue of transmissible spongiform encephalopathies such as natural and experimental scrapie, bovine spongiform encephalopathy and experimentally induced, but not naturally occurring, Creutzfeldt-Jakob disease (CJD). For the first time we report here the presence of TVS in human brains with CJD as detected by transmission electron microscopy. TVS were observed in all three CJD specimens (two biopsies, one autopsy), but they were rare and were found only in one or two location(s) per grid. TVS were seen in distended pre- and postsynaptic terminals and measured approximately 35 nm in diameter; they were smaller and of higher electron density than synaptic vesicles. Their occurrence in all types of transmissible spongiform encephalopathies irrespective of the affected host and the strain of the infectious agent suggests their biological significance.

Cholinergic markers in ALS spinal cord

We analyzed binding sites for quinuclidinyl benzilate (QNB) and hemicholinium-3 (HC-3) by quantitative slice autoradiography and the activities of choline acetyltransferase (ChAT) and acetylcholinesterase (AChE) in spinal cord of 5-7 patients with amyotrophic lateral sclerosis (ALS). In the ventral horn, QNB binding sites were markedly reduced (38% of controls; P less than 0.001), whereas HC-3 binding sites were only moderately affected (76%, P less than 0.01). Losses in cholinergic marker enzymes were inconsistent. The loss of muscarinic binding sites in the ventral horn was the most reliable cholinergic disease marker in ALS.

Amyotrophic lateral sclerosis: changes of noradrenergic and serotonergic transmitter systems in the spinal cord

Noradrenaline (NA), dopamine (DA), serotonin (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA) were measured in discrete subdivisions of cervical, thoracic and lumbar spinal cord segments obtained at autopsy of 4 subjects with amyotrophic lateral sclerosis (ALS) and 7 control patients. NA concentrations in thoracic and lumbar spinal cord of ALS patients were 2- to 4-fold higher compared with values obtained in control patients. 5-HT levels were unchanged at the cervical and thoracic level and slightly above normal in lumbar spinal cord, while the concentration of 5-HIAA was lowered in cervical and thoracic, but within the control range, in lumbar spinal cord. As a result, the molar ratios of 5-HT/5-HIAA were increased at all spinal levels in ALS. No difference in spinal DA concentration was found between ALS and control patients. The changes in the noradrenergic and serotonergic transmitter systems reported here most probably reflect a decreased release of these transmitter substances in ALS spinal cord. Since lack of the facilitatory monoaminergic influence would necessitate an increase in the excitatory, potentially neurotoxic glutamatergic input onto the motoneurones, we hypothesize that this could contribute to the progressive loss of spinal motoneurones in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis: glutamate dehydrogenase and transmitter amino acids in the spinal cord

Measurements were taken of the activity of glutamate dehydrogenase (GDH) and the levels of transmitter amino acids in anatomically dissected regions of cervical and lumbar spinal cord in eight patients dying with amyotrophic lateral sclerosis (ALS) and in 11 neurologically normal controls. GDH activity was considerably increased in lateral and ventral white matter and in the dorsal horn of the ALS cervical spinal cord, but normal in the ventral horn and the dorsal columns. Similar, although less pronounced, GDH changes were found in the lumbar enlargement. The mean concentrations of aspartate and glutamate were reduced in all regions of ALS spinal cord investigated. Taurine concentrations were significantly increased in several subdivisions of cervical spinal cord, but normal in lumbar regions. Glycine levels were significantly reduced in lumbar ventral and dorsal horns. There was no striking change in spinal cord GABA levels in our ALS patients. It is suggested that the reduced levels of glutamate and aspartate as well as the elevated GDH activity in the spinal cord of ALS patients may reflect an overactivity of the neurons releasing these potentially excitotoxic amino acids and thus may be causally related to the spinal neuro-degenerative changes characteristic of ALS.

Tubulovesicular structures in human and experimental Creutzfeldt-Jakob disease

Tubulovesicular structures (TVS) have been consistently observed in brain tissue of animals with transmissible spongiform encephalopathies such as natural and experimental scrapie, bovine spongiform encephalopathy, and experimental Creutzfeldt-Jakob disease (CJD). In this communication we demonstrate for the first time the presence of TVS in natural CJD. TVS were detected in all 3 CJD specimens. However, they were rare and were found only in one or two locations per grid. They were seen in distended pre- and postsynaptic terminals and measured approximately 35 nm in diameter, and they were smaller and of higher electron density than synaptic vesicles. Their occurrence in all types of spongiform encephalopathies irrespective of the affected host and the strain of infectious agent emphasizes their biological significance.

Fatal encephalitis in a patient with chronic graft-versus-host disease

A 32-year-old male patient with chronic myelocytic leukemia in accelerated phase received a bone marrow allograft from his 42-year-old HLA/MLC-identical sister. He recovered from acute graft-versus-host disease (GVHD) grade III-IV of skin, liver and gut, but chronic GVHD of progressive onset developed. On day 556 post-graft severe thrombocytopenia was resistant to prednisolone, cyclophosphamide and high dose immunoglobulin. Splenectomy was followed by a normalization of platelet counts. The subsequent clinical course was characterized by progressive muscular atrophy and weight loss. Dysphagia, dysarthria, cachexia and ultimately recurrent pneumonic episodes ensued. The cachectic patient developed a highly abnormal breathing pattern with hypoventilation and intermittent apnea requiring mechanical ventilation. Auditory evoked potentials revealed a considerable dysfunction of the brainstem. The patient died on day 1120 post-graft from pneumonia, aggravated by thoracic muscular insufficiency. Postmortem examination revealed diffuse predominantly lymphoid perivascular infiltration in meninges and CNS tissue; proliferation of activated microglial cells expressing the HLA-DR antigen was prominent in the brainstem. These histologic changes are similar to those observed in the CNS in experimental GVHD. We suggest that this case represents the first documentation of CNS involvement in chronic GVHD.

Diffuse cerebrospinal gliomatosis presenting as motor neuron disease for two years

A patient with symptoms and signs of motor neuron disease for 2 years finally developed sensory disturbances and increased intracranial pressure. MRI and CT showed enlargement of the right side of the cerebellum, the brainstem and parts of the cerebral hemisphere with focal hyperperfusion demonstrated by SPECT. Necropsy revealed a diffuse cerebrospinal gliomatosis with loss of spinal motor neurons in tumour infiltration of the anterior horns. This type of spinal cord involvement is considered responsible for the unusual clinical presentation of the neoplasm.

[Malignant hyperthermia in Austria. II. A comparison of the results of diagnostic test procedures]

During the last 4 years different diagnostic procedures for the detection of malignant hyperthermia (MH) susceptibility have been used at the authors' clinical unit; this study was designed to compare the results of these tests. PATIENTS AND METHODS. Since March 1983, 158 patients have been referred for the following reasons: group A: probands (n = 17) who had had symptoms of MH during anesthesia; group B: patients of probands (n = 48) if the latter were not tested because of age (n = 24) or death (n = 2); group C: relatives from MH families (n = 86); group D: patients (n = 5) who developed fever during stress and/or physical activity (n = 3), had myotonia (n = 1), or developed rhabdomyolysis during intensive care (n = 1); group E: controls (n = 2). Two static halothane and two static caffeine tests according to the European protocol were performed in all patients (n = 158). Histological examinations of skeletal muscle (fixed in glutaraldehyde, stained with hematoxylin-eosin, Gieson, and toluidine blue) were done in the first 100 patients; all specimens were scored by the same investigator (E.S.). Score 0: normal; 1: increased number of sarcolemma cores; 2: 1+cores forming groups; 3: 1+2+fiber degeneration; 4: specific changes-myopathies. Plasma levels of creatine kinase (CK) were determined in the first 50 patients. Complete neurological examinations, including electromyography (EMG), were done in ten patients who had increased CK levels as well as histological scores of 3 or 4 (Table 1).(ABSTRACT TRUNCATED AT 250 WORDS)

[Ichthyosiform scaling in alpha-1,4-glucosidase deficiency]

In two patients suffering from infantile and juvenile types of alpha-1,4 glucosidase deficiency (Pompe's disease, glycogen storage disease types 2a and 2b) with typical lysosomal glycogen storage, widespread dry "ichthyosiform" scaling skin was observed. The clinical and microscopical findings resembled those of ichthyosis vulgaris. Even in the cytoplasm of keratinocytes vacuolar glycogen accumulation was demonstrated, suggesting a correlation between this pathological storage process and the symptom of "scaling". Therefore, ichthyosiform scaling conditions should be investigated not only for disorders of lipid metabolism but also for a possible disturbance of the carbohydrate-digesting enzymes.

Neurological manifestations of Borrelia burgdorferi-infections: the enlarging clinical spectrum

We report on the clinical symptoms of 50 patients with serologically proven B. burgdorferi infection in stage 2 Lyme disease. Besides the typical pattern of the GBB-syndrom myelitis, encephalitis, cranial nerve neuritis others than Bell's palsy, painful neuritis without CSF-pleocytosis and meningitis without other neurological findings were observed.

High-dose penicillin therapy in meningopolyneuritis Garin-Bujadoux-Bannwarth. Clinical and cerebrospinal fluid data

Clinical data of 19 patients with meningopolyneuritis Garin-Bujadoux-Bannwarth (MPN-GBB), treated with 2 X 10 million units intravenous sodium penicillin for 10 days, were evaluated at the beginning of therapy, 3 weeks thereafter, and 6 months after onset of the neurological disease. Cerebrospinal fluid (CSF) was analysed in 14 patients at the onset of therapy and 3 1/2 weeks thereafter. At the same interval antibodies against B. burgdorferi were measured by enzyme-linked immunosorbent assay (ELISA) in the CSF and sera of 12 patients. Clinical data and all CSF results, with exception of specific antibody titers, were compared with those of patients who had suffered from MPN-GBB between 1979 and 1983, and who had not received antibiotic or corticosteroid therapy. Comparing the clinical data of all treated patients with those of all non-treated controls, no significant difference could be observed. A significant improvement could however be detected in those patients who had their treatment begun 5 weeks within onset of the neurological disease. Changes in CSF 3 1/2 weeks after onset of treatment showed slight differences when compared with controls.

The rigid spine syndrome--a myopathy of uncertain nosological position

Four patients meeting the clinical criteria of the rigid spine syndrome are presented; they are one girl with a positive family history and three boys. Clinical and histological findings are discussed in relation to the 14 cases of rigid spine syndrome reported in the literature. The delineations of the syndrome from other benign myopathies with early contractures are discussed suggesting that the rigid spine syndrome probably does not represent a single nosological entity.

[Apolipoproteins A and B in cerebrovascular diseases]

The present study has proved unequivocally the value of determining apolipoproteins A and B and the APO-L A/B quotient for establishing the risk for cerebrovascular disease. The determination of apolipoproteins should be preferred to the determination of HDL, LDL and VLDL, which has been practised so far. While only 30% of a group of 88 patients suffering from cerebrovascular disease had serum cholesterol levels of more than 250 mg/dl and approx. 57% showed HDL values below 40 mg/dl, a reduced APO-L A/B relation (less than 1.75) was demonstrated in 74%. A reduced APO-L A/B quotient was also observed in more than 70% of 62 CVD patients whose cholesterol level was within the range of normal. Determination of apolipoproteins may, therefore, be regarded as further progress in risk factor diagnostic of arteriosclerotic disease.

[WPW syndrome combined with AV block 2 in an adult with glycogenosis (Type II)]

A 31 year-old female with a five year history of muscle weakness, cardiac palpitations and elevation of activity of some serum enzymes of muscular origin, showed signs of the WPW syndrome on ECG, often in combination with grade 2 A-V block. Type II glycogenosis (Pompe's disease) was diagnosed on the basis of the results of physical examination, laboratory findings--especially subtotal deficiency of acid maltase (a-1,4 glucosidase) activity-and morphological aspects of light and electron microscopy of a quadriceps muscle biopsy specimen. To our knowledge the coincidence of such a rarely encountered arrhythmia with glycogenosis type II in an adult has never been reported so far.

[Differential diagnosis of ocular myopathies]

While the ocular myopathies were hitherto classified in various syndromes solely on the basis of symptom complexes, biochemical and electron-microscopic studies are leading to new findings in the pathogenesis of these conditions, which are probably enzymopathies. At the same time, with the aid of electron microscopy, a classification of the myopathies is attempted on the basis of the morphological changes seen in the affected cells. However, the occurrence of giant mitochondria is no longer characteristic for myopathies. An acumulation of lipid vacuoles in the cells is currently designated "sudanophilic myopathy", and is frequently found in cases suffering from a carnitine deficiency. However, it is still difficult to demonstrate the enzyme defect responsible for the disease. -- Two cases of "sudanophilic myopathy" are reported. At first, a carnitine deficiency was assumed, but this could not be proved in subsequent follow-ups; the condition was therefore probably due to another type of enzyme deficiency in these two cases.

[Fatal hyperthermic crisis after premedication. Human stress syndrome or trigger effect of promethacine (author's transl)]

A case report of a fatal hyperthermic crisis after premedication and before introduction of anaesthesia is given. Based on the typical clinical course, CK isoenzyme patterns and preliminary results of familial investigation the diagnosis of malignant hyperthermia could be established. According to literature reports, psychic stress and/or phenothiazine medication may be assumed as triggering factors. Until a potential causality between malignant hyperthermia and phenothiazine medication can definitely be ruled out, their use in suspicious cases of susceptibility to malignant hyperthermia should be avoided.

Primary intracranial malignant lymphomas a fine structural cytochemical and CSF immunological study

Cytochemical and electron microscopical studies in six cases of primary intracranial malignant lymphomas, four of which were diagnosed by biopsy, confirmed their ultrastructural identity with extraneural malignant lymphomas classified as immunoblastomas and immunocytomas. Demonstration of transformation of 'blast-like' cells (immunoblasts) toward rough E. R. developing cells in all these tumours argue for the B-dell origin of these types of cerebral lymphomas, previously referred to as reticulum cell sarcomas/microgliomas. CSF studies showed increased levels of B cells with surface IgG in two cases of immunoblastoma, and increased IgG levels with light chains in two cases each immunoblastoma and of pleomorphic immunocytoma, while one case of immunoblastoma showed a normal T cell to B cell ratio with increased monoclonal and surface, IgM suggesting some morphological and immunological heterogeneity of these lymphomas.

[Ocular myopathy with giant mitochondriae (author's transl)]

A case of progressive external ophthalmoplegia and a slight coincident affection of the scapulohumeral muscle group is recorded. Thorough examination including EMG and biopsy from ocular and skeletal muscle tissue confirmed the clinical diagnosis of myopathy. By means of electron microscopy the affection could be identified as a type of myopathy characterized by giant mitochondriae. Causative factors were not detectable. The function of the thyroid and the carnitine level in the muscle tissue and blood serum were normal.

[Myocardial involvement in a special form of Erb's muscular dystrophy (type Becker-Kiener) (author's transl)]

A 22-year-old man with cardiac symptoms had been treated for myocarditis for two years. But the clinical course and special tests, including isoenzyme measurements, electromyography, peripheral muscle and myocardial biopsy, established the diagnosis of X chromosome-linked muscular dystrophy (type Becker-Kiener) with an associated cardiomyopathy (raised left-ventricular end-diastolic pressure). Light- and electron-microscopic studies of the (right ventricular) myocardial biopsy revealed degenerative changes like those seen in peripheral muscle.

[Comparative bioptic and electrophysiological investigations in polyneuropathies (author's transl)]

Comparative bioptic and electrophysiological investigations were performed in 30 cases of polyneuropathy of varying aetiology. Axonal and demyelinating neuropathies were distinguishable concordantly on the basis of both investigations. Maximum motor nerve conduction velocity (NCV) and compound potential (CP) were regularly examined in several nerves of each patient. Low (NCV) values (critical limit 25 m/sec) and long-standing high CP values were characteristic of demyelinating processes, whereas axonal neuropathies showed a slight to moderate decrease in NCV with early decrease in CP, often rapidly followed by loss of nerve excitability. Nonclassifiable stages and diseases are discussed. In biopsies, ultrastructural examination in particular, not only allowed the differentiation of primary axonal and primary demyelinating lesions and the respective neuropathic syndromes, but permitted moreover, further classification of these heterogenous groups of neuropathies. According to the sequence of lesions of the nerve fibre classes on the one hand, and to the nature of the primary lesion of the nerve fibres on the other hand, the following types of neuropathies were distinguished: in axonal neuropathies of the myelinated fibres, dystrophic and disintegrative forms were differentiated; axonal neuropathies of unmyelinated fibres correlated with sensory neuropathies. Demyelinating neuropathies were represented by hypertrophic, leucodystrophic and paraproteinaemic forms. The correlation of these types of neuropathies to the different clinical and aetiological forms of polyneuropathies is diagrammatically shown. The connection between the electrophysiological data and the basic nerve fibre alterations of the different neuropathies is discussed.

Spastic paraplegia associated with Addison's disease: adult variant of adreno-leukodystrophy

Clinical and pathological features of an adult variant of adreno-leukodystrophy (ALD) are presented. A male with clinical and laboratory signs of Addison's disease (AD) developed at age 22 a slowly progressing paraplegia with slight sensory deficits in both legs and bladder and sphincter dysfunctions; he died at age 24 in an AD crisis. Autopsy revealed hyperplasia of lymphatic tissues, lymphocytic infiltrates in various organs including the CNS and adrenocortical atrophy with prominence of large ballooned, sometimes bizarre and occassionally striated cortical cells. CNS lesions consisted in incomplete demyelination of long tracts of brain stem and spinal cord with accentuation in the pyramical tracts; in these areas, perivascular cuffs of "epitheloid" histiocytic cells contained a strongly PAS-positive non-sudanophilic material. Electron microscopy demonstrated massive stroge of leaflet structures in perivascular histiocytes identical to the lamellar profiles previously described as specific for ALD. Some leaflets were found in close contact with compact lamellar arrays and with an electron-dense fingerprint material within astrocytes. In our case, the spastic paraplegia-AD syndrome which has been described previously in several clinical observations could be neuropathologically classified as an adult variant of ALD. Several differences to "classical" ALD occurring in young boys are stressed: the predominance of the endocrine disorder probably accounting for some of the perivascular lymphocyte infiltrates within the CNS; the absence of both clinical and pathological signs of diffuse cerebral involvement and the peculiar topistic pattern of CNS lesions and the very slow evolution of neurological signs paralleled by the absence of active sudanophilic demyelinating lesions. The possible mechanism of demyelination and the nature of the suggested metabolic defect in ALD are discussed. The ultrastructurally prominent leaflet structures may originate from myelin remnants, thus relating ALD to pathological storage of a myelin degradation product.

[Slow-virus "encephalitis" following measles in a child with cytostatically-treated leukaemia (author's transl)]

A child with acute infantile lymphoblastic leukaemia in remission after cytostatic therapy contracted apparently uncomplicated measles. 8 weeks later, an acute neurological syndrome developed, which led to death within 2 weeks. At autopsy, a peculiar type of inclusion body "encephalitis" almost without signs of inflammatory infiltration was found. Electron microscopic examination showed changes of paramyxovirus infection, which were attributable to slow measles virus disease of the CNS. There was evidence of disturbed nucleocapside synthesis, which is considered to be one of the basic defects in the development of slow-virus processes and their altered viral maturation. Possible pathogenetic factors are discussed in the light of our case.

SSPE-like inclusion body disorder in treated childhood leukemia

Clinico-pathological report on a boy with cytostatically treated leukemia, dying with cerebral symptoms after passing clinical measles 10 weeks before death. At autopsy, numerous nuclear inclusion bodies in glial and nerve cells were found. By electron microscopy, nuclear inclusions appeared as loosely arranged smooth tubules, corresponding to paramyxovirus nucleocapsids. Frequently, cytoplasmic changes appeared too, consisting of incomplete tubular structures and an abundant dense "fuzzy" material. No regular tubuli of the coated granular type were present, as in common measles virus infection, nor any mature viral structures or differentiation of the surface membrane. The lack of maturation in cytoplasm together with a predominance of nuclear changes suggested a slow type of measles virus infection, while the particular cytoplasmic changes suggested a defect in synthesis of granular nucleocapsids, possibly a basic factor for the slow type of the viral infection. Possible pathogenetic factors are discussed.