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The PI3K/AKT/mTOR pathway activation plays a central role in glioblastoma multiforme (GBM) development and progression, and in resistance to anti-cancer therapies. Inhibition of the PI3K pathway has been shown to sensitize cultured glioma cells and tumor xenografts to the effects of temozolomide (TMZ) and radiation. Vistusertib is an oral inhibitor of mTORC1/2 complexes. The primary objective of this Canadian Cancer Trials Group phase I study was to determine the recommended phase II dose (RP2D) of vistusertib in patients with GBM receiving TMZ at first progression following primary treatment. Vistusertib was administered at a starting dose of 100 mg bid 2 days on/5 days off weekly with TMZ 150 mg/m2 daily for 5 days/28-days cycle. Dose escalation was according to a 3 + 3 design. Secondary objectives included assessment of vistusertib safety and toxicity profile, and preliminary efficacy. 15 patients were enrolled in the study (median age 66 (range 51–77), females 8). Vistusertib 125 mg BID in combination with TMZ 150 mg/m2 daily for 5 days was well tolerated. Vistusertib treatment-related adverse events were generally grade 1–2, with the most frequently reported being fatigue, gastrointestinal symptoms, and rash. Of 13 response evaluable patients, 1 patient (8%) had a partial response ongoing at 7.6 months of follow-up, and 5 patients had stable disease (38%) as best response (median duration 9.6 months, range 3.7-not yet reached). Six-month progression-free survival (PFS) rate was 26.6%. Combination of vistusertib with TMZ in GBM patients at first recurrence demonstrated a favorable safety profile at the tested dose levels.

A previously healthy 48-year-old female presented to the emergency department with a 2-week history of low back pain, progressive lower extremities weakness, and right leg numbness. There were no bowel or bladder dysfunction symptoms. Spine magnetic resonance imaging (MRI) showed an intradural cystic lesion dorsal to the spinal cord at the level of L1 measuring 1.6 × 2.1 × 4.1 cm, which was T1 hypointense and T2 hyperintense, with a small soft tissue component and no gadolinium enhancement (Figure 1). A small lipomatous component was also noted. There were no associated vertebral anomalies. The patient underwent a T12-L2 laminectomy and cyst resection, which was subtotal due to the cyst adherence to the conus medullaris. Histopathology showed characteristic features of a neurenteric cyst, with respiratory-type epithelium in the cyst wall (Figure 2). Eight months later, follow-up MRI showed no evidence of recurrence. The patient reported improved sensation in the lower extremities; however, there was some residual weakness predominantly in the proximal hip flexors bilaterally.

BACKGROUND Glioblastoma is associated with a poor prognosis in the elderly. Survival has been shown to increase among patients 70 years of age or younger when temozolomide chemotherapy is added to standard radiotherapy (60 Gy over a period of 6 weeks). In elderly patients, more convenient shorter courses of radiotherapy are commonly used, but the benefit of adding temozolomide to a shorter course of radiotherapy is unknown.METHODS We conducted a trial involving patients 65 years of age or older with newly diagnosed glioblastoma. Patients were randomly assigned to receive either radiotherapy alone (40 Gy in 15 fractions) or radiotherapy with concomitant and adjuvant temozolomide.RESULTS A total of 562 patients underwent randomization, 281 to each group. The median age was 73 years (range, 65 to 90). The median overall survival was longer with radiotherapy plus temozolomide than with radiotherapy alone (9.3 months vs. 7.6 months; hazard ratio for death, 0.67; 95% confidence interval [CI], 0.56 to 0.80; PCONCLUSIONS In elderly patients with glioblastoma, the addition of temozolomide to short-course radiotherapy resulted in longer survival than short-course radiotherapy alone. Funded by the Canadian Cancer Society Research Institute and others; ClinicalTrials. gov number, NCT00482677.)

Background Cap myopathy is a rare congenital myopathy characterized by cap structures located at the periphery of the muscle fiber. Cap structures consist of disarranged thin filaments with enlarged Z discs. The clinical presentation and natural history of cap myopathy is variable and overlaps with other congenital myopathies. Methods We describe a 10-year-old boy with cap myopathy and contrast him with 20 other individuals reported in the literature. Results Our patient presented at birth with hypotonia and weakness and subsequently developed respiratory failure in infancy. He is ambulatory but has increasing fatigue and requires a wheelchair by midafternoon. His muscle biopsy at 3 months revealed a nemaline myopathy and secondary fiber-type disproportion with type 1 hypotrophy and predominance. A repeat muscle biopsy at age 6 years revealed numerous peripherally located cap-like structures containing nemaline rods and exhibited a spectrum of Z-disk and myofibrillar abnormalities. Molecular genetic testing was performed for NEB , TPM2 , TPM3 , ACTA1 , TNNT1 , SEPN1 , SMN1 , DMPK , FSHMD1A , and mtDNA . A known pathogenic mutation, c.1152+1G>A, and a previously unreported variant, c.1782+4_1782+5delAG, were detected in NEB . Conclusion Our patient has a more severe phenotype than most reported patients and is the first patient with cap myopathy to have a mutation in NEB . Our case supports the identification of cap myopathy as a congenital myopathy with significant overlapping features with nemaline myopathies and further elucidates the phenotype of this disease.

A 37-year-old man presented with a 7-month history of vertigo, nausea, dysphagia, right-sided tinnitus, and hearing loss. He denied headache, paresthesias, change in vision, or problems with cognition. He endorsed a history of progressive fatigue, generalized weakness, and poor libido. His symptoms left him functionally impaired and bedridden.

BACKGROUND: Outcome of low-grade glioma (WHO grade II) is highly variable, reflecting molecular heterogeneity of the disease. We compared two different, single-modality treatment strategies of standard radiotherapy versus primary temozolomide chemotherapy in patients with low-grade glioma, and assessed progression-free survival outcomes and identified predictive molecular factors. METHODS: For this randomised, open-label, phase 3 intergroup study (EORTC 22033-26033), undertaken in 78 clinical centres in 19 countries, we included patients aged 18 years or older who had a low-grade (WHO grade II) glioma (astrocytoma, oligoastrocytoma, or oligodendroglioma) with at least one high-risk feature (aged >40 years, progressive disease, tumour size >5 cm, tumour crossing the midline, or neurological symptoms), and without known HIV infection, chronic hepatitis B or C virus infection, or any condition that could interfere with oral drug administration. Eligible patients were randomly assigned (1:1) to receive either conformal radiotherapy (up to 50·4 Gy; 28 doses of 1·8 Gy once daily, 5 days per week for up to 6·5 weeks) or dose-dense oral temozolomide (75 mg/m(2) once daily for 21 days, repeated every 28 days [one cycle], for a maximum of 12 cycles). Random treatment allocation was done online by a minimisation technique with prospective stratification by institution, 1p deletion (absent vs present vs undetermined), contrast enhancement (yes vs no), age (

Under natural conditions and in some experimental models, rabies virus infection of the central nervous system causes relatively mild histopathological changes, without prominent evidence of neuronal death despite its lethality. In this study, the effects of rabies virus infection on the structure of neurons were investigated with experimentally infected transgenic mice expressing yellow fluorescent protein (YFP) in neuronal subpopulations. Six-week-old mice were inoculated in the hind-limb footpad with the CVS strain of fixed virus or were mock infected with vehicle (phosphate-buffered saline). Brain regions were subsequently examined by light, epifluorescent, and electron microscopy. In moribund CVS-infected mice, histopathological changes were minimal in paraffin-embedded tissue sections, although mild inflammatory changes were present. Terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling and caspase-3 immunostaining showed only a few apoptotic cells in the cerebral cortex and hippocampus. Silver staining demonstrated the preservation of cytoskeletal integrity in the cerebral cortex. However, fluorescence microscopy revealed marked beading and fragmentation of the dendrites and axons of layer V pyramidal neurons in the cerebral cortex, cerebellar mossy fibers, and axons in brainstem tracts. At an earlier time point, when mice displayed hind-limb paralysis, beading was observed in a few axons in the cerebellar commissure. Toluidine blue-stained resin-embedded sections from moribund YFP-expressing animals revealed vacuoles within the perikarya and proximal dendrites of pyramidal neurons in the cerebral cortex and hippocampus. These vacuoles corresponded with swollen mitochondria under electron microscopy. Vacuolation was also observed ultrastructurally in axons and in presynaptic nerve endings. We conclude that the observed structural changes are sufficient to explain the severe clinical disease with a fatal outcome in this experimental model of rabies.

Acute gastrointestinal hemorrhage from a gastroaortic fistula in the gastric fundoplication pouch is a rare complication of Nissen fundoplication. The present case reports a gastroaortic fistula secondary to gastric ulceration associated with prior Nissen fundoplication and nonsteroidal anti-inflammatory drug use. A 55-year-old man presented with massive hematemesis and died of exsanguination during emergency laparotomy. Recognition of factors that predispose a patient to gastric ulceration after fundoplication, including nonsteroidal anti-inflammatory drug use, is critical to arouse the high index of suspicion required to diagnose and manage this life-threatening complication.

Tumour necrosis factor alpha inhibitors, such as infliximab, and other biologic agents are associated with increased risk of opportunistic infection, including tuberculosis. Tuberculosis infections associated with infliximab tend to present atypically and can be difficult to diagnose, as they are more likely to manifest as extrapulmonary or disseminated disease. The authors report a case involving a 29-year-old male patient who died following 16 days of treatment for undifferentiated sepsis and who was found on autopsy to have widespread disseminated tuberculosis. Prior to the onset of illness, the patient had received infliximab for the treatment of Crohn’s disease. Following discussion of the case, the authors review the definition of adverse events, provide a root cause analysis of the cognitive errors and breakdowns in the health care system that contributed to the reported outcome, and identify opportunities to address these breakdowns and improve patient safety measures for future cases.

There is recent in vitro evidence that human neurons express the innate immune response receptor, Toll-like receptor-3 (TLR-3), and that expression is enhanced in viral infections. The authors examined the immunohistochemical expression of TLR-3 in the cerebellar cortex of postmortem human brains. Purkinje cells were found to express TLR-3 in all cases of rabies (4 of 4) and herpes simplex encephalitis (2 of 2) as well as in cases of amyotrophic lateral sclerosis (1 of 2), stroke (1 of 2), and Alzheimer's disease (3 of 3). In cases of viral infection, direct viral infection was not necessary for enhanced neuronal TLR-3 expression, suggesting that soluble factors likely play an important role in inducing TLR-3 expression. In addition to neurons, occasional Bergmann glia expressed TLR-3 in some cases. This study has provided evidence that human brain neurons can express TLR-3 in vivo and suggests that neurons may play an important role in initiating an inflammatory reaction in a variety of neurological diseases.

Human perinatal hypoxic-ischemic brain injury is an important cause of death and morbidity. One relatively common pattern of perinatal injury involves selective neuronal death in the ventral gray matter of the pons and in the subiculum of the hippocampal formation, classically termed 'pontosubicular neuronal necrosis' (PSN). The vulnerable neurons undergo karyorrhectic condensation of their nuclear chromatin and exhibit in situ end labeling for DNA fragmentation, leading to the recent reclassification of cell death in PSN as apoptotic. Caspase activation plays a central role in apoptosis and caspase-3 appears to be an especially important effector enzyme in neuronal apoptosis. In this study we performed immunohistochemistry on brain sections from six postmortem cases of PSN using two polyclonal antisera; CM1, a specific marker of caspase-3 activation, and fractin, which specifically recognizes a neoepitope at a caspase cleavage site in actin, and is therefore a marker of caspase-like proteolytic activity. Numerous CM1- and fractin-immunolabeled neurons were seen in the nuclei pontis and subiculum in each case, and the great majority showed karyorrhectic morphology. The immunostaining involved the nuclei and cytoplasm of these cells and the proximal portions at least of their neuritic processes. Some neurons exhibited a more extensive pattern of dendritic fractin labeling. Frequent CM1- and fractin-immunoreactive axonal segments were also seen. The identification of caspase-3 activation and caspase-like proteolytic activity in PSN cases in this study suggests that caspase inhibitors may potentially have a therapeutic neuroprotective role in human perinatal hypoxic-ischemic brain injury.

New-onset refractory status epilepticus (NORSE) is a recently defined clinical entity which describes patients who present with severe generalized seizures of unclear etiology that occur in the context of a preceding febrile illness.1–3 These seizures are typically unresponsive to antiepileptic medications. ### Case report. A 26-year-old otherwise healthy right-handed man presented with generalized tonic-clonic seizures after a 1-week history of headache, fever, and myalgias. He was admitted to our intensive care unit for treatment and underwent continuous EEG monitoring for 77 days. On admission to our intensive care unit, the CSF contained 92 × 106 white blood cells (96% lymphocytes). Consistent with previous reports of NORSE, an exhaustive structural, infectious, toxic/metabolic, autoimmune, neoplastic, and paraneoplastic workup did not identify a clear underlying etiology (figure, A). IV infusions of propofol or thiopental were used to maintain the patient in either an electrographic burst suppression pattern or electrographic silence, while enteral antiepileptic medications were titrated to therapeutic doses (e.g., phenytoin, valproic acid, clobazam, topiramate, vigabatrin, phenobarbital, and levetiracetam) (figure, B). Attempts to wean IV antiepileptic drugs were met with recurrence of electrographic multifocal sharp transients, originating from either temporal lobe, which evolved into clinical and electrographic seizures. Figure Laboratory investigations, imaging, and pathologic findings in a case of new-onset refractory status epilepticus (A) Table of investigations performed to identify the underlying etiology of the …

Hirano bodies are eosinophilic rod-like inclusions that are found predominantly in neuronal processes in the hippocampal CA1 sector with increasing age and are particularly numerous in Alzheimer's disease. They contain a variety of cytoskeletal epitopes, especially actin and actin-binding proteins. Actin cleavage by cysteinyl aspartate-specific proteases (caspases) is a feature of apoptosis. Cleavage at aspartate 244 generates N-terminal 32 kDa and C-terminal 15 kDa actin fragments. This has led to the development of a rabbit polyclonal antibody specific for caspase-cleaved actin, directed to the last five C-terminal amino acids of the 32 kDa fragment of actin ('fractin'). Fractin immunohistochemistry was performed on hippocampal sections from Alzheimer's disease and control cases containing numerous Hirano bodies, in addition to immunolabelling with CM1 antiserum which recognizes activated caspase-3. The Hirano bodies showed strong diffuse fractin immunoreactivity. They did not label with CM1 antiserum, perhaps reflecting too low a level of activated caspase-3 for immunodetection, or involvement of a different member of the caspase family. The finding of fractin immunoreactivity of Hirano bodies suggests that caspase-like cleavage of actin may play a role in their formation and further supports caspase-like activity in neuronal processes, distinct from that associated with acute perikaryal apoptosis.

A polyclonal antibody intended to recognize c-Jun (Oncogene Science, c-jun/AP-1, Ab-2) has previously been shown to recognize an apparently novel "apoptosis-specific protein" (ASP) in the cytoplasm of cells undergoing apoptotic cell death in vitro. We have investigated whether this antibody would also serve as a reliable marker for apoptotic motoneurons in vivo. Following transection of the left facial nerve in anesthetized neonatal rat pups, which results in over 90% death of the facial motoneurons, we performed immunohistochemistry on frozen brain stem sections with Oncogene Science Ab-1 and Ab-2 antibodies which are raised against different peptide fragments of c-Jun. While Ab-1/c-Jun labelling was seen in the nuclei of the majority of axotomized motoneurons, Ab-2/ASP immunoreactivity was present only in scattered cells, all of which had characteristic apoptotic morphology. Furthermore, Ab-2/ASP immunoreactivity was cytoplasmic and frequently included the dendrites and axons of dying neurons. Some cerebellar granule cells undergoing postnatal developmental cell death were also Ab-2/ASP positive. The time course of the number of Ab-2/ASP-labelled motoneurons corresponded relatively closely with our previous data on DNA fragmentation in these cells, as assessed by an in situ end labelling (ISEL) technique. When facial nerve axotomy was performed at 7 and 14 days postnatum, resulting in reduced cell death, the number of Ab-2/ASP immunoreactive cells decreased correspondingly. Although the exact identity of the epitope recognized by Ab-2 is unclear, we conclude that, by labelling the cytoplasmic and neuritic components of apoptotic motoneurons, Ab-2/ASP immunohistochemistry is a valuable complementary technique to existing in situ methods based on the detection of fragmented DNA in the cell nucleus.

Mice develop a fatal encephalomyelitis after infection with the Trinidad donkey strain of Venezuelan equine encephalitis (VEE) virus. Adult mice were inoculated intraperitoneally with VEE virus and the brains were examined at different time points. Morphological changes were assessed by histological staining. VEE virus antigen was detected with immunoperoxidase staining, and DNA fragmentation was evaluated in situ using the terminal deoxynucleotidyl transferase-mediated dUTP-digoxigenin nick end labeling (TUNEL) method. VEE antigen was found in many areas of the brain and it was prominent in neurons. There were mild associated inflammatory changes. DNA fragmentation was demonstrated in many of these areas using TUNEL. In areas with TUNEL staining, morphological neuronal changes ranged from nuclear chromatin condensations to nuclear and cellular fragmentation, which are characteristic of apoptosis. There is strong morphological and biochemical evidence of apoptotic cell death in this experimental model of VEE virus infection.

A young adult man with neurofibromatosis type 1 (NF1) presented with a several-month history of an increasingly painful mass in the posteroinferior region of the right thigh. Imaging studies (Figure) showed a relatively well-circumscribed mass, 15 cm in length and 7 cm in diameter, arising on a background of very extensive involvement of the peripheral nervous system by plexiform neurofibromas. A biopsy specimen of the mass showed a high-grade (World Health Organization grade IV) malignant peripheral nerve sheath tumor (MPNST). An above-knee amputation was subsequently performed and the MPNST (Figure, inset A) was found to arise in continuity with one of the many preexisting low-grade (World Health Organization grade I) plexiform neurofibromas (Figure, inset B shows an example of such in the leg). For approximately 3.5 years following surgery and radiotherapy, there was no evidence of local tumor recurrence. The patient then was seen with a large left-sided retroperitoneal mass that was histopathologically confirmed to also be an MPNST, possibly a metastasis from the original thigh tumor but more likely a de novo primary tumor. He subsequently underwent several major debulking surgeries, radiotherapy, and rounds of chemotherapy, including palliative doxorubicin, for increasingly disseminated metastatic disease. He died approximately 7 years after his initial presentation.

For over 140 years, pathological studies of human and animal material have continued to provide important insights towards a better understanding of the complex pathogenesis of rabies. As a highly neurotropic infection of the central nervous system, rabies shares a spectrum of histopathological changes with other viral encephalitides, including leptomeningeal and perivascular mononuclear inflammatory cell infiltrates, microglial activation, and neuronophagia. The presence of Negri bodies, eosinophilic inclusions in the cytoplasm of infected neurons, is a unique and pathognomonic finding in many cases of ‘street’ rabies virus infection. Although naturally occurring rabies infection is almost invariably lethal, inflammatory changes and neuronal cell death are minimal in some cases. Data from experimental models suggest that structural changes in neuronal processes, including vacuolation of presynaptic nerve endings, may be sufficient to account for the fatal outcome of rabies. Neuronal apoptosis does not play an important pathogenetic role in human rabies encephalitis. Immunohistochemical studies of rabies virus antigen distribution in humans and in naturally occurring and experimental rabies in animals have been particularly important in elucidating rabies pathogenesis, including centripetal and centrifugal viral spread through the peripheral nervous system and involvement of extraneural organs, including salivary glands and the heart.

The involvement of dorsal root ganglia was studied in an in vivo model of experimental rabies virus infection using the challenge virus standard (CVS-11) strain. Dorsal root ganglia neurons infected with CVS in vitro show prolonged survival and few morphological changes, and are commonly used to study the infection. It has been established that after peripheral inoculation of mice with CVS the brain and spinal cord show relatively few neurodegenerative changes, but detailed studies of pathological changes in dorsal root ganglia have not previously been performed in this in vivo experimental model. In this study, adult ICR mice were inoculated in the right hindlimb footpad with CVS. Spinal cords and dorsal root ganglia were evaluated at serial time points for histopathological and ultrastructural changes and for biochemical markers of cell death. Light microscopy showed multifocal mononuclear inflammatory cell infiltrates in the sensory ganglia and a spectrum of degenerative neuronal changes. Ultrastructural changes in gangliocytes included features characteristic of the axotomy response, the appearance of numerous autophagic compartments, and aggregation of intermediate filaments, while the neurons retained relatively intact mitochondria and plasma membranes. Later in the process, there were more extensive degenerative neuronal changes without typical features of either apoptosis or necrosis. The degree of degenerative neuronal changes in gangliocytes contrasts with observations in CNS neurons in experimental rabies. Hence, gangliocytes exhibit selective vulnerability in this animal model. This contrasts markedly with the fact that they are, unlike CNS neurons, highly permissive to CVS infection in vitro. Further study is needed to determine mechanisms for this selective vulnerability, which will give us a better understanding of the pathogenesis of rabies.

It is generally accepted that there are not prominent features of neuronal cell death in rabies encephalitis. However, Hemachudha and coworkers recently reported widespread apoptosis in the central nervous system of several human rabies cases (BMC Infect Dis 5: 104, 2005). In this study we have evaluated morphological features and markers of neuronal apoptosis in postmortem brain tissue from 12 cases of human rabies who died in four different countries. Histopathological analysis, TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling) staining, and immunostaining for cleaved (activated) caspase-3 were performed on paraffin-embedded tissues from the cerebral cortex, hippocampus, and brainstem, and additional regional areas from one of the cases. We did not find morphological evidence of neuronal apoptosis or TUNEL staining in any of the cases of rabies encephalitis. Similarly, immunostained cleaved caspase-3 was not seen in neurons, but prominent staining was observed in microglial processes. We conclude that neuronal apoptosis does not play an important pathogenetic role in human rabies encephalitis.

Alpha-synuclein protein aggregates are a major component of Lewy bodies, the intracytoplasmic inclusions found in dopaminergic neurons that are a defining characteristic of Parkinson's disease. Other "synucleopathies" include dementia with Lewy bodies and multisystem atrophy. In vitro, the formation of these deposits can be induced by a number of substances, including metal ions. Fish provide a useful model to study the long-term biological effects of metal ion exposure, but to date no studies have been reported concerning such exposures with respect to alpha-synuclein aggregation. Mature white sucker fish (Catostomus commersoni; aged 5-8 years) were sampled from two sites within the Red Lake area of Northwestern Ontario, a region highly contaminated by metal ions due to mining activity. Individual fish were characterized with respect to liver metal ion uptake and metallothionein levels. Central nervous system (CNS) tissues of fish from test sites representing high and low metal ion contamination were examined immunohistochemically using a polyclonal antibody recognising alpha-synuclein protein. We demonstrate here that the CNS of fish exposed to elevated metal ion environments had increased alpha-synuclein-like immunoreactive aggregates, potentially reflecting metal ion exposure leading to CNS toxicity. These findings demonstrate that fish may be an important new model for studying environmental risk factors and the pathology associated with Parkinson's disease.

Minocycline is a tetracycline derivative with antiapoptotic and anti-inflammatory properties, and the drug has been shown to have beneficial effects in a variety of models of neurological disorders. The potentially neuroprotective role of minocycline was assessed in experimental in vitro and in vivo models of rabies virus infection. In this study, 5 nM minocycline did not improve the viability of embryonic mouse cortical and hippocampal neurons infected in vitro with the attenuated SAD-D29 strain of rabies virus, based on assessments using trypan blue exclusion. Two-day-old ICR mice were inoculated in the right hind limb thigh muscle with SAD-D29, and they received daily subcutaneous injections of either 50 mg/kg minocycline or vehicle (phosphate-buffered saline). Infected minocycline-treated mice experienced an earlier onset of neurologic signs and greater mortality (83% versus 50%) than those receiving vehicle (log rank test, P = 0.002 and P = 0.003, respectively). Immunohistochemical analysis of rabies virus antigen distribution was performed at early time points and in moribund mice. There were greater numbers of infected neurons in the regional brain areas of minocycline-treated mice than in vehicle-treated mice, which was significant in the CA1 region of the hippocampus. There was less apoptosis ( P = 0.01) and caspase 3 immunostaining ( P = 0.0008) in the midbrains of mice treated with minocycline than in mice treated with vehicle, consistent with a neuroprotective role of neuronal apoptosis that may have had a mild effect of inhibiting viral spread. Reduced infiltration of CD3 + T cells was observed in the pons/medulla of moribund mice that received minocycline therapy ( P = 0.008), suggesting that the anti-inflammatory actions of minocycline may intensify the neurologic disease. These findings indicate that minocycline has important detrimental effects in the therapy of experimental rabies. Empirical therapy with minocycline should therefore be approached with caution in cases of human rabies and possibly other viral encephalitides until more experimental data become available.

A, An autopsy of an adult patient who underwent remote enucleation revealed optic atrophy (arrowhead). Compared with control magnocellular and parvocellular layers (ie, layers 1, 2, and 3-6) (B), the patient’s lateral geniculate nuclei showed degeneration of layers 2, 3, and 5 on the right side (C) and of layers 1, 4, and 6 on the left side (D) (cresyl-violet, original magnification ×12 [insets: cresyl-violet, original magnification ×40]). IL indicates intercalated layer. ARTICLE INFORMATION Correction: This article was corrected on January 21, 2015, to fix an error in the figure. JAMA Ophthalmol. 2015;133(1):e141789. doi:10.1001/jamaophthalmol.2014.1789

A 28-year-old woman presented with a one day history of high fever and partial seizures with secondary generalization. This was preceded by a three week history of headache, ataxia, and fatigue. An initial computed tomogram head scan showed a low density mass lesion in the right frontal operculum without enhancement. On the next day, a repeat scan showed a new frontopolar, expansile, low density cortical lesion (Figure 1A) suggestive of encephalitis. Cerebrospinal fluid showed a pleocytosis of 311 mononuclear white blood cell count per μL and an elevated protein of 1.57 g/L. She received intravenous acyclovir and antibiotics. She remained febrile and became mute. A magnetic resonance (MR) scan under general anesthesia on her fourth hospital day showed frontal and perisylvian lesions with restricted diffusion (Figure 1B - D and Figure 2). A right frontal brain biopsy showed meningoencephalitis and immunohistochemical staining was positive for herpes simplex virus (HSV) antigen (Figure 3). Subsequently, HSV-1 DNA was demonstrated in both cerebrospinal fluid and brain tissue with polymerase chain amplification. She improved after a course of intravenous therapy with acyclovir with residual frontal lobe signs, including marked executive dysfunction, and her speech became normal.

Recent reports have suggested that rabies virus phosphoprotein (P) interaction with dynein minus-end-directed microtubule motor proteins may be of fundamental importance in the axonal transport of rabies virus. A deletion of 11 amino acids was introduced into recombinant rabies virus SAD-L16 (L16) that modified the dynein light chain (LC8) binding site of the rabies virus P, producing mutant L-DeltaP11. This mutant is a useful tool for determining the role of P-LC8 interaction in viral spread and pathogenesis. Seven-day-old ICR mice were inoculated into a hindlimb thigh muscle with L16 or L-DeltaP11. Histopathological and immunohistochemical analyses of their brains were performed at serial time points in order to determine the pattern of viral spread. L16 spread to the brain and caused a severe encephalitis with apoptotic neuronal changes. L-DeltaP11 infected specific brain areas (brainstem and hippocampus) 1-2 days later than L16 and involved a smaller number of neurons in some brain regions. However, the neuronal apoptotic changes produced by both viruses were similar in most brain regions. Following peripheral inoculation, deletions modifying the LC8 binding site had an effect on delaying viral spread, but did not significantly alter the pattern of rabies virus encephalitis. The precise role of the rabies virus P-dynein interaction in the axonal transport of rabies virus, particularly the importance of this interaction during natural infection, merits further study.

The purpose of this study was to develop a guinea pig model of chorioamnionitis to study the mechanisms that lead to fetal brain injury. Study design Pregnant guinea pigs at 70% gestation were inoculated intracervically with 1000 to 2500 colony-forming units of Escherichia coli. Guinea pigs were killed 2 to 3 days after bacterial inoculation. Maternal blood and fetal amniotic fluid samples were analyzed for proinflammatory cytokine tumor necrosis factor-alpha, interleukin-1beta, and interleukin-6 levels with the use of enzyme-linked immunosorbent assay kits. Fetal brains were stained for evidence of cell death with NeuroTacs stain.Of 34 maternal guinea pigs that were given an intracervical inoculation of E coli, 8 guinea pigs showed microbiologic evidence of chorioamnionitis in the amniotic fluid. Tumor necrosis factor-alpha and interleukin-6 were significantly higher (P.05) in amniotic fluid samples that were obtained from sows that were subjected to intracervical inoculation with bacteria as compared with control animals (n=6 control maternal animals). These results were observed even if no bacteria were found subsequently on culture of the amniotic fluid from inoculated animals, which indicated that indirect exposure to infectious agents was sufficient to cause an elevated inflammatory response in the fetus. Levels of white matter injury were greater in fetuses that were exposed to bacterial infection in utero, as compared with control animals (P.05). This result was found in the staining of periventricular and cortical white matter for the immunolabeling of activated caspase 3 and NeuroTacs staining for cells that exhibited evidence of apoptotic cell death (positive stain with evidence of karyorrhexis).Intracervical inoculation with E coli results in chorioamnionitis in guinea pigs that is associated with fetal brain injury.

A male infant was born with severe hydrocephalus, bilateral cleft lip/palate, left anophthalmos and right microphthalmos, and an equino-varus foot deformity. Imaging studies showed enlarged lateral ventricles, apparent absence of the corpus callosum and a midline density in the third ventricular region. He had a normal male karyotype. He was severely mentally retarded and died suddenly at 7 years of age. Neuropathological examination of the brain revealed enlarged and polygyric cerebral hemispheres, due to congenital obstructive hydrocephalus, and secondary thinning of the corpus callosum. An unusually large neuronal hamartoma filled the interpeduncular fossa and third ventricle. It was continuous posteriorly with the left thalamus and so was classified as diencephalic rather than as hypothalamic. The right optic nerve merged with the hamartoma, whereas the left nerve was absent. Microscopically the hamartoma consisted of mature grey matter interspersed with narrow bands of white matter. No immature or non-neural elements were identified. This combination of diencephalic neuronal hamartoma, hydrocephalus, ocular and craniofacial abnormalities has not, to our knowledge, previously been described.

Cultured rat prostatic adenocarcinoma (AT3) cells infected with the challenge virus standard (CVS) strain of fixed rabies virus showed characteristic morphologic features of apoptosis, evidence of oligonucleosomal DNA fragmentation, and expression of the Bax protein. CVS-infected Bcl-2-transfected AT3 cells did not demonstrate these features. Adult ICR mice inoculated intracerebrally with CVS showed morphologic changes of apoptosis, DNA fragmentation, and increased Bax expression in neurons, with changes most marked in the hippocampus and cerebral cortex. Ultrastructurally, some neurons demonstrated morphologic features more typical of necrosis. These studies provide evidence that apoptosis plays an important role in the pathogenesis of rabies virus infection.

A case of fulminant myocarditis in a young man is described. Bedside hand-held focused cardiac ultrasound demonstrated severe systolic dysfunction with hypertrophied myocardium. Echocardiogram showed a speckled texture of the myocardium and a "velvet-like" appearance. Unfortunately, the patient developed cardiogenic shock and despite aggressive management, he died. The autopsy showed multifocal lymphohistiocytic infiltration and myocyte injury. We propose that the "velvet" myocardial ultrasonic appearance with ventricular hypertrophy is an indicator of rapid clinical demise.

Hirano bodies are eosinophilic rod-like inclusions that are found predominantly in neuronal processes in the hippocampal CA1 sector with increasing age and are particularly numerous in Alzheimer's disease. They contain a variety of cytoskeletal epitopes, especially actin and actin-binding proteins. Actin cleavage by cysteinyl aspartate-specific proteases (caspases) is a feature of apoptosis. Cleavage at aspartate 244 generates N-terminal 32 kDa and C-terminal 15 kDa actin fragments. This has led to the development of a rabbit polyclonal antibody specific for caspase-cleaved actin, directed to the last five C-terminal amino acids of the 32 kDa fragment of actin ('fractin'). Fractin immunohistochemistry was performed on hippocampal sections from Alzheimer's disease and control cases containing numerous Hirano bodies, in addition to immunolabelling with CM1 antiserum which recognizes activated caspase-3. The Hirano bodies showed strong diffuse fractin immunoreactivity. They did not label with CM1 antiserum, perhaps reflecting too low a level of activated caspase-3 for immunodetection, or involvement of a different member of the caspase family. The finding of fractin immunoreactivity of Hirano bodies suggests that caspase-like cleavage of actin may play a role in their formation and further supports caspase-like activity in neuronal processes, distinct from that associated with acute perikaryal apoptosis.