Effect of melatonin intake on postural balance, functional mobility and fall risk in persons with multiple sclerosis: a pilot study

AIM

To assess the safety and the effect of a nocturnal melatonin (MEL) ingestion on postural balance, functional mobility and fall risk the following morning in adults with multiple sclerosis (MS).

METHODS

Fourteen adults with relapsing-remitting MS (RR-MS) (28.36 ± 6.81 years) were evaluated before and after nocturnal ingestion of MEL (6 mg) or placebo (PLA). Evaluations included a posturographic test of static bipedal postural balance with dual-task in eyes open (EO) and eyes closed conditions, and a clinical test of unipedal balance. The physical performance tests were: Timed Up and Go test (TUGT) (mobility), Four Square Step Test (FSST) (fall risk), and Timed 25-foot walk test (T25FWT) (walking speed). Cognitive performance [Montreal Cognitive Assessment (MoCA) and Simple Reaction Time (SRT) tests] and sleep quality [Spiegel's sleep questionnaire (SSQ)] were also assessed.

RESULTS

In EO condition, MEL decreased the posturographic parameters [center of pressure (CoP) sway area (CoPAr), CoP path length (CoPL) and CoPL in the mediolateral axis (CoPLX)] more than PLA by 15.82% (p = 0.0006), 12.48% (p  = 0.0004) and 14.25% (p = 0.0002), respectively. Durations of TUGT and FSST decreased following MEL session more than the PLA one by 14.52% (p = 0.017) and 19.85% (p = 0.0006), respectively. MEL increased the unipedal stance time, SSQ and MoCA scores more than PLA by 49.81% (p = 0.04), 32.21% (p = 0.004) and 11.87% (p = 0.008), respectively.

CONCLUSION

This pilot study showed that acute nocturnal MEL ingestion seems to be safe for enhancing postural balance, fun mobility and fall risk in RR-MS adults probably through improving sleep quality and cognitive function.

Infrequent patterns in cerebrospinal fluid isofocusing test: Clinical significance and contribution of IgG index and Reiber diagram to their interpretation

Cerebrospinal fluid (CSF) isoelectrofocusing (IEF) is considered as the gold standard for detecting an intrathecal synthesis of IgG, which is a hallmark of multiple sclerosis (MS). This corresponds to the presence of CSF-restricted IgG oligoclonal bands (OCB) (typically type 2 pattern). Moreover, this technique can also detect a systemic immune reaction with passive transfer of IgG (type 3 and 4 patterns) for which the clinical relevance is less understood. The aim of our study was to determine the frequency and disease associations of IEF type 3 and 4 patterns and to investigate the potential usefulness of including quantitative data (IgG index and Reiber Diagram) in interpreting such IEF profiles. Among 544 patients who underwent CSF IEF (Hydragel CSF isofocusing kit, Sebia®, France) in our Laboratory during a six-year-period, those who presented type 3 or 4 patterns were selected. Clinical data and results of other immunological tests were analyzed for 27 patients followed in the Neurological Department. Frequencies of type 3 and type 4 patterns were relatively low (2.3 % and 3.4 % respectively). Among patients with type 3 pattern included in our study (n = 10), 5 were diagnosed with MS. For the 5 other patients, the diagnosis was a clinically isolated syndrome (CIS) (2 cases), a probable auto-immune encephalitis (2 cases) and a possible genetic neurodegenerative disease (1 case). MS patients had an IgG index >0.7 and fell into area 4 of Reiber diagram while non-MS patients had an IgG index <0.7 and fell into area 1, except the last case. Regarding type 4 pattern (n = 17), the diagnoses were as follows: MS (3), CIS (4), Neuromyelitis optica spectrum disorders with positive anti-AQP4 antibodies (3) and anti-NMDAR autoimmune encephalitis (1). The remaining cases had central nervous system impairment related to vascular, metabolic or tumoral etiologies (3) or peripheral nervous system impairment (3). In this group (type 4 pattern), IgG index was <0.7 in 15/17 cases. Interpretation using Reiber diagram showed an abnormal blood-brain barrier for 8/17 patients. Type 3 and 4 IEF patterns are infrequently observed in routine neurology practice. It is important for the diagnostic laboratory professional as well as for the neurologist to understand their clinical relevance. Our findings highlight the contribution of quantitative evaluation of CSF (IgG index, Reiber diagram) for the interpretation of such situations. Despite the small size of our study population, our results emphasize the importance of reporting the exact type of IEF pattern and not only the positivity or not of OCB.

Effects of a nighttime melatonin ingestion on dynamic postural balance and muscle strength the following morning in people living with multiple sclerosis: A preliminary study

BACKGROUND

Decreased endogenous melatonin concentrations in people with multiple sclerosis (PwMS) are associated with fatigue and pain that impair postural balance and muscle strength. Melatonin ingestion had analgesic and anti-fatigue effects. However, the acute effect of exogenous melatonin on dynamic postural stability and muscle strength has not been studied yet in PwMS. This study aimed to investigate the safety and the efficacy of a nighttime melatonin intake on dynamic postural balance and lower-extremity muscle strength the following morning in PwMS.

METHODS

Fourteen PwMS (28.36 ± 6.81 years) were assessed (8 a.m.) pre- and post-acute intake of melatonin or placebo (6mg, 30 minutes before nocturnal bedtime). Evaluated parameters included dynamic postural balance (force platform), lower-extremity muscle strength [Five-Repetition Sit-To-Stand Test (5-STST)], hand dexterity (Nine-Hole Peg Test), nociceptive pain [Visual Analogue Scale (VAS)], neuropathic pain [Neuropathic Pain 4 Questions (DN4)], sleep quality and fatigue perception [Hooper Index (HI)].

RESULTS

In the frontal plane, melatonin reduced the center of pressure (CoP) path length (CoPL), CoPL in the anteroposterior axis (CoPLY) and CoP sway area (CoPAr) compared with placebo by 7.56% (p=0.02, Cohens'd (d)=1.24), 19.27% (p<0.001, d=2.60) and 13.82% (p<0.001, d=2.02), respectively. Melatonin induced a higher decrease in these posturographic parameters compared with placebo in the sagittal plane [CoPL: 9.10% (p=0.005, d=1.02), CoPLY: 4.29% (p=0.025, d=1.07) and CoPAr: 7.45% (p=0.038, d=0.74)]. Melatonin decreased 5-STST duration as well as VAS, DN4, HI-fatigue and HI-sleep scores compared with placebo by 8.19% (p=0.008, d=1.19), 5.74% (p=0.04, d=0.82), 27.30% (p=0.023, d=0.98), 40.15% (p=0.044, d=0.85) and 30.16% (p=0.012, d=1.10), respectively.

CONCLUSION

This preliminary study, among PwMS, showed that acute melatonin ingestion was safe and efficient for improving dynamic postural stability and lower-extremity muscle strength probably through its analgesic and anti-fatigue effects.

Acute-onset chronic inflammatory demyelinating polyneuropathy following AstraZeneca COVID-19 vaccine: a case report

COVID-19 vaccination side effects have been increasingly reported, including new-onset autoimmune diseases such as chronic arthritis, thrombocytopenia, Guillain-Barré syndrome (GBS), and more recently chronic inflammatory demyelinating polyneuropathies (CIDP). Molecular mimicry and vaccine adjuvants appear to be important contributors to immune-mediated neuropathies. However, whether the link between the COVID-19 vaccine and these autoimmune disorders is coincidental or causal remains uncertain. We describe the ever-reported case of acute-onset CIDP following the Oxford/AstraZeneca vaccine in Tunisia. The patient is a 41-year-old man who presented with acute, worsening weakness of the four limbs. The symptoms appeared 15 days after his first dose of the AstraZeneca vaccine. The diagnosis of GBS was initially confirmed according to the clinical features, the albumino-cytological dissociation in the cerebrospinal fluid (CSF), and the electroneuromyography (ENMG) findings. Serum workup for all known infections associated with immune-mediated neuropathy was negative. The patient was treated with plasma exchange without initial improvement followed by aggravation of the symptomatology after an interval of four and a half months. Control ENMG showed signs of CIDP meeting the European Academy of Neurology/Peripheral Nerve Society (EAN/PNS) criteria of 2021. The patient was treated with maintenance intravenous immunoglobulin and oral corticosteroids. Neurological examination 3 months after discharge showed partial improvement. Worldwide, cases of demyelinating polyneuropathies post-COVID-19 vaccination are increasingly reported. The acute onset of CIDP might lead to a misdiagnosis of GBS. Awareness of this complication and distinction from GBS enables early relay with maintenance treatment to prevent relapses and severe complications. Post-COVID neuropathies are found to be more frequently linked to the AstraZeneca vaccine, however, temporal association does not confirm causal association.

Mild limb girdle muscular dystrophy R9 phenotype caused by novel compound heterozygous FKRP gene mutation

Fukutin-related protein (FKRP) mutations cause a broad spectrum of muscular dystrophies, from a relatively mild limb-girdle muscular dystrophy type 9 (LGMDR9) to severe congenital muscular dystrophy (CMD). This study aims to report two siblings belonging to a non-consanguineous Tunisian family harboring a novel compound heterozygous FKRP variant and presenting a mild LGDMR9 phenotype. For mutation screening, massive parallel sequencing was performed, followed by Sanger sequencing and multiplex ligation-dependent probe amplification (MLPA) to validate the existence of the discovered variants. The absence of alpha-dystroglycan was determined by immunohistochemistry. Brain and thigh magnetic resonance imaging (MRI) were performed to detect thigh and brain abnormalities. The two siblings had a late age at onset and clinical examination showed that the pelvic girdles had a predominantly proximal and symmetrical distribution of weakness without cardiac or respiratory involvement. They both had a modified Gardner-Medwin Walton Scale mGMWS grade of 4 and a modified Rankin Scale (mRS) score of 1. The DNA sequencing revealed a novel deletion of exons 2 and 3 in one allele and a missense mutation c.1364C > A, which has been reported to be responsible for congenital muscular dystrophy and mental retardation on the second allele. The simultaneous presence of the two variations in the two cases suggests that the variants segregate with the pathophysiology.

Dysferlinopathy in Tunisia: clinical spectrum, genetic background and prognostic profile

Dysferlinopathy is a rare group of hereditary muscular dystrophy with an autosomal recessive mode of inheritance caused by a mutation in the DYSF gene. It encodes for the dysferlin protein, which has a crucial role in multiple cellular processes, including muscle fiber membrane repair. This deficit has heterogeneous clinical presentations. In this study, we collected 20 Tunisian patients with a sex ratio of 1 and a median age of 50.5 years old (Interquartile range (IQR) = [36,5-54,75]). They were followed for periods ranging from 5 to 48 years. The median age at onset was 17 years old (IQR = [16,8-28,4]). Five major phenotypes were identified: Limb-girdle muscular dystrophy (LGMDR2) (35%), a proximodistal phenotype (35%), Miyoshi myopathy (10%),  Distal myopathy with anterior tibial onset (DMAT) (10%), and asymptomatic HyperCKemia (10%). At the last evaluation, more than half of patients (55%) were on wheelchair. Loss of ambulation occurred generally during the fourth decade. After 20 years of disease progression, two patients with a proximodistal phenotype (10%) developed dilated cardiomyopathy and mitral valve regurgitation. Restrictive respiratory syndrome was observed in three patients (DMAT: 1 patient, proximodistal phenotype: 1 patient, LGMDR2: 1 patient). Genetic study disclosed five mutations. We observed clinical heterogeneity between families and even within the same family. Disease progression was mainly slow to intermediate regardless of the phenotype.

Vitamin D deficiency in relation with the systemic and central inflammation during multiple sclerosis

Background

During the last decade, vitamin D (VitD) has become a topic of interest in immune regulation, especially in multiple sclerosis (MS) disease. Amongst the wide range of effects reported for this vitamin on the immune system, a regulatory role on cytokines production has been described. Our aim is to analyze the status of VitD and its correlation with the circulating inflammation and the intrathecal humoral response during MS.

Methods

We analyzed samples of 318 individuals: 108 MS patients and 210 controls. Determination of 25-(OH) VitD3 level in serum was made using electrochemiluminescence method. Circulating inflammatory cytokines (IL-6, IL-8, IL-10, TNF-a, IL12p70 and IL-1b) were investigated using Cytometer Bead Array Technology. The central humoral response was characterized using CSF isofocusing test and IgG Index calculation.

Results

As expected, mean value of VitD was significantly lower in MS group (26 nmol/L) than in control group (34.75 nmol/L) (p=0.002), with a severe deficiency in 67% of MS patients. Mean value of VitD was significantly lower in MS female patients. Regarding cytokines, mean value of TNFa was significantly higher in MS patients with oligoclonal bands of IgG in the CSF. IL6 was positively correlated with IgG level in serum of MS patients.

Conclusions

Our results support the association of VitD deficiency with MS, especially in female patients of our region. However, the vitamin level seems to not correlate with inflammatory cytokines nor with disability. Interestingly, TNFa and IL6 levels were correlated with the intrathecal synthesis of IgG and the circulating IgG level, respectively.

PTPA variants and impaired PP2A activity in early-onset parkinsonism with intellectual disability

The protein phosphatase 2A complex (PP2A), the major Ser/Thr phosphatase in the brain, is involved in a number of signalling pathways and functions, including the regulation of crucial proteins for neurodegeneration, such as alpha-synuclein, tau and LRRK2. Here, we report the identification of variants in the PTPA/PPP2R4 gene, encoding a major PP2A activator, in two families with early-onset parkinsonism and intellectual disability. We carried out clinical studies and genetic analyses, including genome-wide linkage analysis, whole-exome sequencing, and Sanger sequencing of candidate variants. We next performed functional studies on the disease-associated variants in cultured cells and knock-down of ptpa in Drosophila melanogaster. We first identified a homozygous PTPA variant, c.893T>G (p.Met298Arg), in patients from a South African family with early-onset parkinsonism and intellectual disability. Screening of a large series of additional families yielded a second homozygous variant, c.512C>A (p.Ala171Asp), in a Libyan family with a similar phenotype. Both variants co-segregate with disease in the respective families. The affected subjects display juvenile-onset parkinsonism and intellectual disability. The motor symptoms were responsive to treatment with levodopa and deep brain stimulation of the subthalamic nucleus. In overexpression studies, both the PTPA p.Ala171Asp and p.Met298Arg variants were associated with decreased PTPA RNA stability and decreased PTPA protein levels; the p.Ala171Asp variant additionally displayed decreased PTPA protein stability. Crucially, expression of both variants was associated with decreased PP2A complex levels and impaired PP2A phosphatase activation. PTPA orthologue knock-down in Drosophila neurons induced a significant impairment of locomotion in the climbing test. This defect was age-dependent and fully reversed by L-DOPA treatment. We conclude that bi-allelic missense PTPA variants associated with impaired activation of the PP2A phosphatase cause autosomal recessive early-onset parkinsonism with intellectual disability. Our findings might also provide new insights for understanding the role of the PP2A complex in the pathogenesis of more common forms of neurodegeneration.

Combined effect of gender differences and fatiguing task on postural balance, functional mobility and fall risk in adults with multiple sclerosis: A preliminary study

AIM

To investigate the gender difference effect on postural balance, functional mobility, and fall risk after performing a fatiguing task in adults with multiple sclerosis (MS).

METHODS

Eleven women (30.91 ± 8.19 years) and seven men (30.29 ± 7.99 years) with relapsing-remitting MS performed a fatiguing task: three sets of the Five-repetition Sit-To-Stand Test (5-STST) were performed before and after the six-minute WalkTest (6MWT). Bipedal postural balance in eyes open and eyes closed conditions were assessed prefatigue (T0) and postfatigue (T3) using a force platform. Unipedal balance, functional mobility (Timed Up and Go Test), fall risk (Four Square Step Test) and fatigue [Visual Analogue Scale of Fatigue (VASF)] were assessed at T0 and T3. Heart rate (HR) and Rating of Perceived Exertion (RPE) were recorded before (only for HR), during and after the fatiguing task.

RESULTS

Compared to women, men showed an impairment of posturographic parameters [mean center of pressure (CoP) velocity (CoPVm) in both conditions (p < 0.05); CoP sway area (CoPAr) in both conditions (p < 0.01)], unipedal balance on the dominant leg (p <0.001), mobility (p<0.001) and an increased fall risk (p < 0.05). No gender differences were observed in 6MWT, 5-STST, HR, RPE, and VASF.

CONCLUSION

This preliminary study showed that fatiguing task negatively affected postural control, mobility and fall risk only in men. These gender differences were inconclusive but could be taken into account in postural balance rehabilitation programs for MS persons.

Papillary thyroid carcinoma associated with glioblastoma in a neurofibromatosis 1 patient: An unusual and rare combination of multiple primary malignancies

Introduction

and importance: Papillary Thyroid carcinoma (PTC) is the most common endocrine malignancy and accounts for 1–2% of all cancer cases. Second malignancies in women diagnosed with thyroid cancer are of concern given the young average age at diagnosis. The concurrent occurrence of thyroid cancer and malignant brain tumor such as glioblastoma (GBM) was rarely seen and reported. However, the simultaneous association of these 2 conditions, namely PTC and GBM, in a neurofibromatosis type 1 (NF1) patient, has never been reported before in the literature.

Case presentation

The authors report the first case of an extremely rare association combining papillary thyroid carcinoma, glioblastoma, and a neurofibromatosis 1 in a 34-year-old female patient with primary generalized tonic-clonic seizures.

Clinical discussion

NF1 can be associated with PTC and GBM independently. In this current case, NF1 was accompanied by both PTC and GBM. With the exception of the present case, to our knowledge, there has been no previous case report in the literature in which these 3 entities were associated. The reason for the rarity of this combination of these neoplasms in patients with NF1 remains not clear, but it may be explained by the low incidence of combined occurrence of PTC and GBM.

Conclusion

This is the first reported extremely rare coexistence of GBM and PTC in a female NF1 patient. Further genetic investigations could improve our understanding of this combination and change our therapeutic approaches.

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Papillary Thyroid carcinoma is the most common endocrine malignancy and accounts for 1–2% of all cancer cases.

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Second malignancies in women diagnosed with thyroid cancer are of concern given the young average age at diagnosis.

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The concurrent occurrence of thyroid cancer and malignant brain tumor such as glioblastoma was rarely seen and reported previously.

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Simultaneous association of papillary thyroid carcinoma and glioblastoma in a neurofibromatosis type 1 patient has never been reported before in the literature.

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The rarity of this combination in patients with neurofibromatosis type 1 remains not clear, but it may be explained by the low incidence of combined occurrence of both neoplasms.

Manifestations neurologiques associées à la Covid-19

Introduction

Plusieurs complications neurologiques ont fait suite aux infections par la Covid-19. Les plus fréquentes sont les accidents vasculaires cérébraux, les thromboses veineuses cérébrales (TVC), les encéphalites et le syndrome de Guillain-Barré (SGB)

Objectifs

Faire un récapitulatif des différentes manifestations neurologiques rapportées par nos malades en relevant les particularités épidémiologiques, cliniques et para cliniques de chacune.

Patients et méthodes

Nous avons mené une étude rétrospective comportant 7 patients ayant été suivis pour des manifestations neurologiques faisant suite à une infection à la Covid-19. Les données épidémiologiques, cliniques, biologiques ainsi que les résultats des examens complémentaires de tous les patients ont été collectés afin de relever les particularités de ces complications. Le délai entre le début de l’infection et l’apparition de chaque complication neurologique a été déterminé dans chaque cas.

Résultats

Trois patients ont présenté une TVC après une infection par la Covid-19. Trois malades ont présenté un SGB dans sa forme démyélinisante, dont la survenue était concomitante à l’infection chez 2 patients, et 2 mois après pour le 3ème. Un patient âgé de 53 ans a présenté un AVC ischémique sylvien profond. Une angéite post infectieuse liée à la Covid-19 a été retenue. L’enquête étiologique était négative chez tous les patients hormis une infection par la Covid-19.

Discussion

Les complications neurologiques de la Covid-19 sont polymorphes. Les manifestations cérébrovasculaires artérielles et veineuses s’expliquent surtout par un état d’hypercoagulabilité pouvant persister après l’infection, expliquant le délai entre celle-ci et l’apparition des symptômes. La survenue du SGB après l’infection par la Covid-19 est expliquée par une réaction inflammatoire et immunitaire suite à un mimétisme moléculaire entre la myéline et le virus.

Conclusion

Les manifestations neurologiques liées aux infections par la Covid-19 ont prouvé sa neuro-virulence. Mais, des associations fortuites en l’absence de relation causale avec la Covid-19 peuvent se voir.

Guillain-Barré syndrome following the first dose of Pfizer-BioNTech COVID-19 vaccine: case report and review of reported cases

Background

Since the SARS-CoV-2 pandemic has started in December 2019, millions of people have been infected all over the world. Vaccination is the most efficient tool to end this pandemic, but vaccine surveillance is necessary to identify side effects. Some studies have shown that neurological complications after COVID-19 vaccination are rare and dominated by demyelinating disease.

Case presentation

We present a case of a 67-year-old man who presented 7 days following his first dose of Pfizer-BioNTech COVID-19 vaccine a rapidly progressive ascending muscle weakness. The diagnosis of Guillain-Barré syndrome (GBS) was confirmed according to the clinical features, the albumino-cytological dissociation in the cerebrospinal fluid, and the electroneuromyography findings. The workup for all known infections associated with immune-mediated GBS was negative. The patient received treatment with intravenous immunoglobulin. Neurological examination 1 month after discharge showed full recovery and he regained his baseline functional status.

Conclusions

As far as we know, this is the first reported case in Tunisia. Although extremely rare, neurologists should remain vigilant for acute inflammatory demyelinating polyradiculoneuropathy after COVID-19 vaccination.

Traditional risk factors and combined genetic markers of recurrent ischemic stroke in adults

BACKGROUND

The involvement of traditional risk factors and combined genetic markers of recurrent arterial ischemic stroke (AIS) in adults remains unclear.

OBJECTIVE

This study aims to determine significant clinical and genetic factors of AIS recurrence, and to investigate the combined effect of genotypes on the occurrence of a second cerebral ischemic attack.

METHODS

We investigated a cohort study of AIS patients (18-50 years old) followed in the neurology department over 5 years. Traditional and genetic risk factors were carried through a multivariable logistic regression model. We used a Cox proportional hazard model for identifying predictors of recurrence.

RESULTS

Two hundred and seventy patients were enrolled in our study. The risk of AIS recurrence was 36.2% within 5 years. The potential risk of recurrence of AIS increased with traditional and genetic risk factors such as hypertension, diabetes mellitus, heart failure, and family history of cerebrovascular diseases. This risk increased with increasing number of genetic factors. The hazard ratio (HR) was 0.66 (95% confidence interval [CI] 0.97-2.67) for the subject with one genetic factor, 1.61 (95% CI 0.97-2.25) for combined methylenetetrahydrofolate reductase (MTHFR) polymorphisms, and 2.57 (95% CI 1.32-4.99) for combined factor V Leiden (FVL) and MTHFR polymorphisms (677 or 1298). The HR for the three polymorphisms combined was 6.04 (95% CI 2.40-15.16).

CONCLUSIONS

Our findings suggest that cumulative effect of both traditional and common genetic risk factors was associated with recurrence of ischemic stroke. We demonstrated for the first time that a combined genotype FVL/MTHFR profile increase the risk of a second cerebral ischemic attack.