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Metabolic aberrations impact the pathogenesis of multiple sclerosis (MS) and possibly can provide clues for new treatment strategies. Using untargeted metabolomics, we measured serum metabolites from 35 patients with relapsing-remitting multiple sclerosis (RRMS) and 14 healthy age-matched controls. Of 632 known metabolites detected, 60 were significantly altered in RRMS. Bioinformatics analysis identified an altered metabotype in patients with RRMS, represented by four changed metabolic pathways of glycerophospholipid, citrate cycle, sphingolipid, and pyruvate metabolism. Interestingly, the common upstream metabolic pathway feeding these four pathways is the glycolysis pathway. Real-time bioenergetic analysis of the patient-derived peripheral blood mononuclear cells showed enhanced glycolysis, supporting the altered metabolic state of immune cells. Experimental autoimmune encephalomyelitis mice treated with the glycolytic inhibitor 2-deoxy-D-glucose ameliorated the disease progression and inhibited the disease pathology significantly by promoting the antiinflammatory phenotype of monocytes/macrophage in the central nervous system. Our study provided a proof of principle for how a blood-based metabolomic approach using patient samples could lead to the identification of a therapeutic target for developing potential therapy.

Optic neuritis (ON) is an immune-mediated optic neuropathy associated with multiple immune-mediated neurological conditions. Our aim was to characterize the clinical and diagnostic features of first or initial episodes of ON associated with multiple sclerosis (MS)-associated (typical) and antibody-related (atypical) ON.Retrospective, single institution, medical record review. We analyzed demographic, clinical, laboratory, and radiographic findings of 139 patients who presented with first episodes of MS-associated ON (MS-ON), aquaporin 4 antibody-associated ON (AQP4-ON), and myelin oligodendrocyte glycoprotein antibody-associated ON (MOG-ON) between January 2015 and October 2019 without preceding diagnosis. Simple hypothesis testing assessed differences between groups were performed.Of 139 patients (109 [79 %] women; 29 [21 %] men; mean age 47 [SD, 14] years), 106 had MS-ON, 25 had AQP4-ON, and 8 had MOG-ON. Patients with MOG-ON had the highest recurrence rate (88 %) relative to MS-ON (28 %) and AQP4-ON (56 %) patients (P .001). Patients with AQP4-ON had the highest mean visual functional system scores (4.3 [SD, 1.8]) relative to MS-ON (2.0 [SD, 1.9]) and MOG-ON patients (2.8 [SD, 2.0]) (P .001).Patients presenting with initial episodes of ON exhibit a range radiographic and laboratory feature depending on the underlying associated disease. Understanding the variable characteristics of typical (MS-associated) and atypical (antibody-associated) ON may help physicians accurately diagnose and effectively treat ON.

SUMMARYMetabolic aberrations impact the pathogenesis of multiple sclerosis (MS) and possibly can provide clues for new treatment strategies. Using untargeted metabolomics, we measured serum metabolites from 35 relapsing-remitting patients and 14 healthy age-matched controls. Out of 632 known metabolites detected, 60 were significantly altered in relapsing-remitting MS (RRMS). Bioinformatics analysis identified an altered “metabotype” in RRMS patients, represented by 4 changed metabolic pathways of glycerophospholipid, citrate cycle, sphingolipid, and pyruvate metabolism. Interestingly, the common upstream metabolic pathway feeding these 4 pathways is the glycolysis pathway. Real-time bioenergetic analysis of the patient derived peripheral blood mononuclear cells, showed enhanced glycolysis, supporting the altered metabolic state of immune cells. Experimental autoimmune encephalomyelitis mice treated with the glycolytic inhibitor, 2-deoxy-D-glucose ameliorated the disease progression and inhibited the disease pathology significantly by promoting the anti-inflammatory phenotype of monocytes/macrophage in the central nervous system. Our study suggests that targeting glycolysis offers a potential target for MS.

International audience; Background: Ofatumumab, a subcutaneous anti-CD20 monoclonal antibody, selectively depletes B cells. Teriflunomide, an oral inhibitor of pyrimidine synthesis, reduces T-cell and B-cell activation. The relative effects of these two drugs in patients with multiple sclerosis are not known.Methods: In two double-blind, double-dummy, phase 3 trials, we randomly assigned patients with relapsing multiple sclerosis to receive subcutaneous ofatumumab (20 mg every 4 weeks after 20-mg loading doses at days 1, 7, and 14) or oral teriflunomide (14 mg daily) for up to 30 months. The primary end point was the annualized relapse rate. Secondary end points included disability worsening confirmed at 3 months or 6 months, disability improvement confirmed at 6 months, the number of gadolinium-enhancing lesions per T1-weighted magnetic resonance imaging (MRI) scan, the annualized rate of new or enlarging lesions on T2-weighted MRI, serum neurofilament light chain levels at month 3, and change in brain volume.Results: Overall, 946 patients were assigned to receive ofatumumab and 936 to receive teriflunomide; the median follow-up was 1.6 years. The annualized relapse rates in the ofatumumab and teriflunomide groups were 0.11 and 0.22, respectively, in trial 1 (difference, -0.11; 95% confidence interval [CI], -0.16 to -0.06; P

The ongoing pandemic of the novel coronavirus of 2019 (COVID-19) has resulted in over 1 million deaths, primarily affecting older patients with chronic ailments. Multiple sclerosis (MS) patients have been deemed particularly vulnerable given their high rates of disability and increased susceptibility to infections. There have also been concerns regarding disease-modifying therapy (DMT) during the pandemic as many DMTs may increase the risk of infection due to some of their immunosuppressive properties. Furthermore, due to MS-related chronic inflammatory damage within the central nervous system, there have been concerns for worsening neurological injury by COVID-19. This has resulted in an alarmingly high level of anxiety and stress among the MS community leading to a lack of compliance with medications and routine check-ups, and even failure to obtain treatment for relapse. However, there is currently substantial evidence that MS and most DMT usage is not associated with increased COVID-19 severity. MS patients who suffer worse outcomes were more likely to be older and suffer from significant disabilities and comorbid conditions, which would also be expected from those in the general population. Likewise, there is little if any evidence demonstrating an increased susceptibility of MS patients to COVID-19-related neurological complications. Therefore, we aim to summarize the most recent findings related to COVID-19 and MS demonstrating that MS and most DMTs do not appear as risk factors for severe COVID-19.

COVID-19 is a highly contagious disease that is caused by novel SARS-CoV-2 virus and has been declared a global pandemic due to its community transmission across several countries. Although it has a profound impact on the respiratory system, it is also associated with severe extrapulmonary manifestations. The variety of neurological symptoms reported in patients with COVID-19 could be attributed to one of the several mechanisms that cause injury to the nervous system and which have been previously postulated to cause similar effects in the context of other viral infections arising from the coronavirus family. However, the ability of SARS-CoV-2 to invade the nervous system remains controversial and unclear. In this chapter, we describe the postulated mechanisms of neuroinvasion and neurological injury in response to SARS-CoV-2 infection, which can be useful for identifying potential drug targets and provide a comprehensive summary of the currently available reports addressing the neuroinvasive potential of SARS-CoV-2.

This chapter addresses COVID-19 in the context of patients with demyelinating disorders of the central nervous system (CNS). Multiple sclerosis (MS) is the most common CNS demyelinating disease, and SARS-CoV-2 infection in patients with MS and other autoimmune demyelinating CNS disorders causes numerous concerns. As with other infectious diseases, COVID-19 may exacerbate pathology in patients with MS. Standard therapies for MS and immunosuppressive treatments for other CNS autoimmune disorders may pose unique risks during severe COVID-19. However, preliminary findings on SARS-CoV-2 infection suggest that some MS therapies may limit the aggressive immune response underlying severe COVID-19 complications. Furthermore, infection with SARS-CoV-2 may have the potential to trigger postinfection autoimmune disorders. Here we review the current understanding of COVID-19 in patients with MS and other CNS disorders and the impact of immunomodulatory therapies on these patients.

Multiple sclerosis (MS) patients have been considered a higher-risk population for COVID-19 due to the high prevalence of disability and disease-modifying therapy use; however, there is little data identifying clinical characteristics of MS associated with worse COVID-19 outcomes. Therefore, we conducted a multicenter prospective cohort study looking at the outcomes of 40 MS patients with confirmed COVID-19. Severity of COVID-19 infection was based on hospital course, where a mild course was defined as the patient not requiring hospital admission, moderate severity was defined as the patient requiring hospital admission to the general floor, and most severe was defined as requiring intensive care unit admission and/or death. 19/40(47.5%) had mild courses, 15/40(37.5%) had moderate courses, and 6/40(15%) had severe courses. Patients with moderate and severe courses were significantly older than those with a mild course (57[50–63] years old and 66[58.8–69.5] years old vs 48[40–51.5] years old, P = 0.0121, P = 0.0373). There was differing prevalence of progressive MS phenotype in those with more severe courses (severe:2/6[33.3%]primary-progressing and 0/6[0%]secondary-progressing, moderate:1/14[7.14%] and 5/14[35.7%] vs mild:0/19[0%] and 1/19[5.26%], P = 0.0075, 1 unknown). Significant disability was found in 1/19(5.26%) mild course-patients, but was in 9/15(60%, P = 0.00435) of moderate course-patients and 2/6(33.3%, P = 0.200) of severe course-patients. Disease-modifying therapy prevalence did not differ among courses (mild:17/19[89.5%], moderate:12/15[80%] and severe:3/6[50%], P = 0.123). MS patients with more severe COVID-19 courses tended to be older, were more likely to suffer from progressive phenotype, and had a higher degree of disability. However, disease-modifying therapy use was not different among courses., Highlights • In a multicenter study of 40 multiple sclerosis (MS) patients, different phenotypes and level of disability were associated with COVID-19 severity. • Poorer outcomes were associated with more severe MS disability. • The use of DMT for MS was not associated with worse outcome.

ImportanceMultiple sclerosis patients have been considered a higher-risk population for COVID-19 due to the high prevalence of disability and disease-modifying therapy use; however, no study has identified clinical characteristics of multiple sclerosis associated with worse COVID-19 outcomes.ObjectiveTo evaluate the clinical characteristics of multiple sclerosis, including staging, degree of disability, and disease-modifying therapy use that are associated with worse outcomes from COVID-19.DesignProspective cohort study looking at the outcomes of multiple sclerosis patients with COVID-19 between March 1stand May 18th2020.SettingThis is a multicenter study of three distinct hospital systems within the U.S.ParticipantsThe study included 40 consecutive patients with nasopharyngeal/oropharyngeal PCR-confirmed COVID-19 infection.ExposuresMultiple sclerosis staging, severe disability (based on baseline-extended disability status scale equal to or greater than 6.0) and disease-modifying therapy.Main Outcomes and MeasureSeverity of COVID-19 infection was based on hospital course, where a mild course was defined as the patient not requiring hospital admission, moderate severity was defined as the patient requiring hospital admission to the general floor only, and most severe was defined as requiring intensive care unit admission and/or death.ResultsFor the 40 patients, the median age was 52(45.5-61) years, 16/40(40%) were male, and 21/40(52.5%) were African American. 19/40(47.5%) had mild courses, 15/40(37.5%) had moderate courses, and 6/40(15%) had severe courses. Patients with moderate and severe courses were significantly older than those with a mild course (57[50-63] years old and 66[58.8-69.5] years old vs 48[40-51.5] years old, P=0.0121, P=0.0373). There was differing prevalence of progressive multiple sclerosis staging in those with more severe courses (severe:2/6[33.3%]primary-progressing and 0/6[0%]secondary-progressing, moderate:1/14[7.14%] and 5/14[35.7%] vs mild:0/19[0%] and 1/19[5.26%], P=0.0075, 1 unknown). Significant disability was found in 1/19(5.26%) mild course-patients, but was in 9/15(60%, P=0.00435) of moderate course-patients and 2/6(33.3%, P=0.200) of severe course-patients. Disease-modifying therapy prevalence did not differ among courses (mild:17/19[89.5%], moderate:12/15[80%] and severe:3/6[50%], P=0.123).Conclusions and RelevanceMultiple sclerosis patients with more severe COVID-19 courses tended to be older, were more likely to suffer from progressive staging, and had a higher degree of disability. However, disease-modifying therapy use was not different among courses.

Background Nervous system is affected in 25% of patients with sarcoidosis. Current literature is largely limited to case reports with disproportionate Caucasian population. We aim to evaluate differences in presentation, management and outcomes by race in neurosarcoidosis. Methods Clinical and demographic data on consecutive patients fulfilling Zajicek criteria for neurosarcoidosis from 1995 to 2016 at Henry Ford Hospital were extracted. Disparities in clinical presentation, laboratory values, radiological features, treatment and outcomes, were compared between two groups: African Americans (AA) and non-AA using chi-squared tests, two sample t-test for age and Wilcoxon two sample tests. Results A total of 118 patients were included, of which 58% were female and 73% were AA. The diagnosis of neurosarcoidosis was noted to be definite (25%), probable (64%) and possible (11%). AA patients had a significantly higher rate of elevated erythrocyte sedimentation rate (62% vs 24%, P = .005) and had lower resolution of abnormalities on follow-up imaging (14% vs 41%, P = .017). There was no difference in disability on follow-up (25% vs 33%, P = .43) or mortality (13% vs 9%, P = .6). Conclusions There were no differences in presentation, management and outcomes by race. Discordance in the clinical and radiological data by race has clinical implications and needs further investigation.

Summary The circulating metabolome provides unique insights into multiple sclerosis (MS) pathophysiology, but existing studies are relatively small or characterized limited metabolites. We test for differences in the metabolome between people with MS (PwMS; n = 637 samples) and healthy controls (HC; n = 317 samples) and assess the association between metabolomic profiles and disability in PwMS. We then assess whether metabolic differences correlate with changes in cellular gene expression using publicly available scRNA-seq data and whether identified metabolites affect human immune cell function. In PwMS, we identify striking abnormalities in aromatic amino acid (AAA) metabolites (p = 2.77E−18) that are also strongly associated with disability (p = 1.01E−4). Analysis of scRNA-seq data demonstrates altered AAA metabolism in CSF and blood-derived monocyte cell populations in PwMS. Treatment with AAA-derived metabolites in vitro alters monocytic endocytosis and pro-inflammatory cytokine production. We identify shifts in AAA metabolism resulting in the reduced production of immunomodulatory metabolites and increased production of metabotoxins in PwMS., Graphical abstract, Highlights • Significant alterations in the circulating metabolome are noted in multiple sclerosis • Aromatic amino acid (AAA) metabolite levels are linked to disease severity • Expression of AAA metabolism genes is altered in MS blood and CSF immune cells • AAA metabolites alter human monocyte cytokine production and endocytosis, Fitzgerald et al. identify alterations in circulating aromatic amino acid (AAA) metabolites in multiple sclerosis that are related to disease severity. They also demonstrate changes in AAA metabolism-related gene expression in blood and cerebrospinal fluid immune cells, and that treatment with AAA metabolites alters monocyte pro-inflammatory cytokine production and endocytosis.

The COVID-19 pandemic has reshaped the way healthcare systems operate around the world. The major hurdles faced have been availability of personal protective equipment, intensive care unit beds, ventilators, treatments and medical personnel. Detroit, Michigan has been an epidemic ‘hotspot’ in the USA with Wayne County among the hardest hit counties in the nation. The Department of Neurology at Henry Ford Hospital, in the heart of Detroit, has responded effectively to the pandemic by altering many aspects of its operations. The rapid engagement of the department and enhanced utilisation of teleneurology were two of the pivotal elements in the successful response to the pandemic. In this review, we describe the transformation our department has undergone, as it relates to its infrastructure redesigning, coverage restructuring, redeployment strategies, medical education adaptations and novel research initiatives.

Identification of non-invasive biomarkers of disease progression in multiple sclerosis (MS) is critically needed for monitoring the disease progression and for effective therapeutic interventions. Urine is an attractive source for non-invasive biomarkers because it is easily obtained in the clinic. In search of a urine metabolite signature of progression in chronic experimental autoimmune encephalomyelitis (EAE), we profiled urine at the chronic stage of the disease (day 45 post immunization) by global untargeted metabolomics. Using a combination of high-throughput liquid-and-gas chromatography with mass spectrometry, we found 105 metabolites (P 0.05) significantly altered at the chronic stage, indicating a robust alteration in the urine metabolite profile during disease. Assessment of altered metabolites against the Kyoto Encyclopedia of Genes and Genomes revealed distinct non-overlapping metabolic pathways and revealed phenylalanine-tyrosine and associated metabolism being the most impacted. Combined with previously performed plasma profiling, eight common metabolites were significantly altered in both of the biofluids. Metaboanalyst analysis of these common metabolites revealed that phenylalanine metabolism and Valine, leucine, and isoleucine biosynthetic pathways are central metabolic pathways in both bio-fluids and could be analyzed further, either for the discovery of therapeutics or biomarker development. Overall, our study suggests that urine and plasma metabolomics may contribute to the identification of a distinct metabolic fingerprint of EAE disease discriminating from the healthy control which may aid in the development of an objective non-invasive monitoring method for progressive autoimmune diseases like MS. Graphical Abstract Untargeted urinary metabolomics of a chronic mouse model of multiple sclerosis identified Phenylalanine, tyrosinetryptophan metabolism as the significantly altered metabolic pathway. Eight common metabolites were identified when we combined urinary and plasma metabolic signature, which revealed a perturbation of Phenylalanine metabolism and valine, leucineisoleucine metabolic pathways, involved in CNS dysfunction during diseases. The identified eight metabolic signature of urine and plasma may be of clinical relevance as potential biomarkers and guide towards the identification of specific metabolic pathways as novel drug targets.

Background: Magnetic resonance imaging (MRI) is widely used in clinical practice, and “abnormal brain MRI” findings often prompt assessment for multiple sclerosis (MS), even when there are no symptoms suggestive of the disease. Despite several studies involving individuals with “radiologically isolated syndrome” (RIS), little is known about what factors might predict future development of MS. The objective of this study was to longitudinally evaluate clinical and MRI characteristics of people who presented to an MS clinic because of incidental abnormal MRI findings but did not have typical symptoms of MS, in order to assess risk factors for developing MS. Methods: Thirty consecutive patients presenting to an MS clinic for evaluation of abnormal MRI findings were enrolled in the study. Clinical and paraclinical data, including MRI results, were reviewed. Magnetic resonance imaging findings of T2 hyperintensities measuring more than 3 mm in diameter and fulfilling at least three out of four Barkhof criteria, with or without gadolinium-enhancing lesions, were considered to be suggestive of MS. Results: The median follow-up time was 5.5 years. No participants without MRI findings suggestive of MS were diagnosed with MS (P = .005). Fifteen participants had MRI findings suggestive of MS. Seven of the 15 (47%) were diagnosed with MS on follow-up. Cerebrospinal fluid (CSF) testing results were available for 15 participants. Abnormal results were found in six participants, of whom five (83%) also had MRI findings suggestive of MS. Only two of the nine (22%) participants with normal CSF results (P = .04) had MRI findings suggestive of MS. Conclusions: In our cohort, none of the participants without MRI findings suggestive of MS developed MS. The participants with MRI findings suggestive of MS were more likely to develop symptoms and MRI changes typical of MS on follow-up.

Objectives Cognitive dysfunction is present in at least half of patients with Multiple Sclerosis. The purpose of this study was to examine functional connectivity abnormalities in patients with multiple sclerosis (MS) using resting state fMRI (rsfMRI). Methods Conventional MRI, rsfMRI and diffusion tensor imaging (DTI) data was acquired from 10 patients with relapsing-remitting multiple sclerosis (RRMS) and 20 healthy controls. Cross-correlation of the resting state average signal among the voxels in each brain region of the five cognitive networks: default mode network (DMN), attention, verbal memory, memory, and visuospatial working memory network, was calculated. Voxelwise analyses were used to investigate fractional anisotropy (FA) of white matter tracts. The normalized gray matter (GM), white matter and thalamus volumes were calculated. Results Compared to controls, significant deficit in MS patients at each of five networks, attention (p=0.026), DMN (p=0.004), verbal memory (p

We performed untargeted metabolomics in plasma of B6 mice with experimental autoimmune encephalitis (EAE) at the chronic phase of the disease in search of an altered metabolic pathway(s). Of 324 metabolites measured, 100 metabolites that mapped to various pathways (mainly lipids) linked to mitochondrial function, inflammation, and membrane stability were observed to be significantly altered between EAE and control (p < 0.05, false discovery rate

To report a case of sporadic Creutzfeldt-Jakob disease (CJD) with bilateral hearing loss at onset and literature review of the scarce cases of CJD with similar audiologic manifestations at presentation.A 67-yr-old man presented to the hospital for evaluation of rapid progression of behavioral decline, unsteady gait, and bilateral hearing loss. Three months before admission, he abruptly developed bilateral hypoacusis without associated tinnitus or vertigo. Shortly after, his family noted an ataxic gait and behavioral changes, for example, paranoid delusions. Initial workup, including a complete autoimmune panel and heavy metals, infectious, toxicology, and paraneoplastic panel (e.g., anti-Hu, anti-VGKC), was conducted. Electroencephalography revealed diffuse generalized slowing without periodic complexes. The presence of distortion product otoacoustic emissions bilaterally was consistent with normal cochlear function, suggesting a retrocochlear origin for symptoms of hearing loss. In the meantime, the patient developed startle myoclonus. The brain magnetic resonance imaging demonstrated asymmetric cortical ribbon along with T2 FLAIR signal hyperintensities of bilateral basal ganglia. Later on, the protein 14-3-3 in the cerebrospinal fluid came back positive, which supported the diagnosis of CJD. Only three cases of CJD with deafness at onset have been published: one sporadic, associated with symptoms suggestive of polyneuropathy; and the other two familial, with the E200K mutation. One presented with symptoms of polyneuropathy and the other with typical features.This case illustrates the phenotypic variability of presentation of CJD in a patient with hearing loss as the initial manifestation. In patients with subacute bilateral hypoacusis and signs of dementia, the differential diagnosis of CJD must be taken into consideration.

Relapsing-remitting (RRMS), a most common form of MS, is characterized by acute attacks alternated by partial or complete recovery periods. The major focus of our research is to identify the therapeutic target using metabolomics. Metabolomics is a fast emerging field which can provide a direct “functional readout of the physiological state” of an organism. Identification of blood-based metabolic pathway(s) in relapsing-remitting form of MS (RRMS) which could be used for therapy. Using untargeted ultra-performance liquid and gas mass spectrometry, we measured serum metabolites from 33 RRMS patients, and 14 healthy subjects (HS). A total of 621 known metabolites were detected and 60 metabolites were significantly altered in the serum of RRMS compared to HS. Bioinformatics analysis revealed four metabolic pathways altered in RRMS including glycerophospholipid, citrate cycle, sphingolipids, and pyruvate metabolism. PBMCs isolated from RRMS patients exhibited higher glycolysis suggesting altered metabolic state of immune cells. EAE mice treated with glycolytic inhibitor 2-deoxyglucose (2-DG; once daily), resulted in a significantly delayed (P

This study was conducted to evaluate the association of adherence to disease-modifying agents (DMAs) and outcomes among multiple sclerosis (MS) patients in a practice setting. The study had a cross-sectional design. A survey was administered to 214 patients with relapsing-remitting multiple sclerosis (RRMS) to measure quality of life, health status, disability, and employment. Measures of health-care costs and adherence to DMAs were constructed using claims data. The relationship between DMA adherence and outcomes was evaluated using generalized estimating equation methods, adjusting for patient sociodemographic characteristics, comorbidities, medication on hand at the time of the survey, insurance status, prescription copay, and duration of disease. A total of 163 patients (76%) responded to the survey, of whom 111 had been dispensed a DMA. Mean adherence in the 12-month period preceding the survey was 78.1%. Patients with higher adherence had better mental health and pain interference scores. Increasing adherence was also associated with a greater likelihood of employment and lower Expanded Disability Status Scale score. These findings illustrate the potential for improved outcomes among RRMS patients who adhere to DMA regimens and highlight the importance of considering medication adherence when evaluating DMA use and outcomes in practice.

Sexual dimorphism of astrocytes and neurons is well documented in many brain and spinal cord structures. Sexual dimorphism of oligodendrocytes (Olgs) and myelin has received less attention. We recently showed that density of Olgs in corpus callosum, fornix, and spinal cord of wild-type male rodents is more densely packed than in females; myelin proteins and myelin gene expression are likewise greater in males than in female rodents. However, glial cell proliferation and cell death were two times greater in female corpus callosum. Endogenous sex hormones, specifically lack of androgens, produce an Olg female phenotype in castrated male mouse. In vitro studies using Olgs culture also showed differences between males and females Olg survival and signaling pathways in response to sexual hormones. Sexual dimorphism of white matter tracts and glia in rodents indicates the necessity for controlling gender in the experimental studies of neurodegenerative disorders. Most importantly, our studies suggest that hormones may contribute to sexual dimorphism observed in certain human diseases including multiple sclerosis.

Myotonic dystrophy is considered a true dominant condition with no difference in the phenotype between heterozygous and homozygous cases. The homozygous state is very rare and only a few patients have been reported in the literature. We report a 2.5-year-old boy from a nonconsanguineous marriage, with a unique combination of clinical and radiological findings: hypotonia, motor and language developmental delay, ventriculomegaly, subcortical white matter lesions, and craniosynostosis. Mutation analysis revealed 2 copies of expansion mutation of 1260 and 60 cytosine-thymine-guanine repeats in the myotonic dystrophy protein kinase gene. Both the mildly symptomatic (434 repeats) mother and the asymptomatic (37 repeats) father are heterozygous. Craniosynostosis has not been reported previously in myotonic dystrophy. This homozygous case expands the clinical spectrum of myotonic dystrophy type 1 and provides support to the hypothesis that myotonic dystrophy type 1 pathophysiology could be, in part, due to the loss of normal function of the wild-type protein.

The existence of estrogen receptors (ERs) in oligodendrocytes (OLGs) in vivo and in vitro is unresolved, as their presence has been reported in some studies and their absence in others. Using molecular and immunocytochemical techniques, we describe the subcellular localization of ERalpha and ERbeta in OLGs in vivo and in vitro. Both ERalpha and ERbeta are detected in an immortalized OLG cell line and in enriched OLG cultures by RT-PCR and western blot. Immunocytochemistry of OLGs from enriched cultures shows ERalpha receptors are nuclear, whereas ERbeta receptors are cytoplasmic. Confocal and deconvolution microscopy of enriched OLG cultures reveals ERbeta immunoreactivity is concentrated in perikarya and veins of OLG membrane sheets; lesser reactivity is present in their plasma membranes and nuclei. In vivo, we readily detect ERalpha in neurons but not in OLGs, even though we used different fixation procedures and different ERalpha antibodies. The presence of ERalpha in cultured OLGs may be due to culture media that contains factors stimulating ERalpha expression but are reduced in normal brain. In vivo, ERbeta immunoreactivity is readily detectable in OLG cytoplasm and in myelin sheaths. Incubation of glial cultures without or with increasing concentrations of 17beta-estradiol (E2) shows that E2 significantly accelerates OLG process formation.

Studies of ischemic brain injury in neonatal rodents have focused upon the pathophysiology of neuronal damage. Much less consideration has been given to white matter injury, even though it is a major contributor to chronic neurological dysfunction in children. In the human neonate, particularly in those born prematurely, periventricular white matter is highly susceptible to hypoxic--ischemic (H--I) injury. To understand the basis for this selective vulnerability, we examined myelin gene expression and cell death in the subventricular layer and the surrounding white matter of neonatal mice following H--I insult. Using an in situ hybridization technique that gives high resolution and is very sensitive, we examined myelin basic protein and proteolipid protein gene expression three and twenty-four hours after a H-I insult. To elicit unilateral forebrain hypoxic and ischemic injury, 9--10-day-old mice underwent right carotid artery ligation followed by timed (40--70 min) exposure to 10% oxygen. Twenty-four hours following H--I, myelin basic protein and proteolipid protein transcripts were markedly reduced in striatum, external capsule, fornix, and corpus callosum in the injured side. Three hours after lesioning (ligation+70 min hypoxic exposure) myelin basic protein gene transcripts were visibly reduced in the ipsilateral white matter tracts. Interestingly, some cells in the subventricular layer expressed proteolipid protein transcripts, and 3 h after a H--I insult they were degenerating in the injured but not contralateral side. TUNEL staining showed an increase in the number of positive cells in the injured subventricular layer and corpus callosum but the adjacent striatum did not show a corresponding change in the number of TUNEL labeled cells. Ultrastructural studies of the subventricular zone and corpus callosum 3 h after H--I revealed that many subventricular cells, glial cells in the corpus callosum, and callosal axons in the injured side had already degenerated. However, the subventricular cells, glia and axons in the contralateral corpus callosum were spared. Many cells in the injured corpus callosum exhibited a apoptotic morphology; yet more mature oligodendrocytes in this region appeared normal. Our results show that a H--I insult causes a surprisingly swift and dramatic degenerative response in the subventricular layer and adjacent white matter. Within 3 h after H--I, the programmed cell death cascade was initiated; internucleosomal DNA degradation took place in subventricular and glial cells; oligodendrocyte progenitors died and axonal degeneration in the ipsilateral corpus callosum was extensive. The swiftness of the subventricular and glial cell degeneration suggests the H--I insult directly targets glia, as well as neurons, and raises the provocative question of whether glia exert damaging effects upon neurons and axons. Since the severity of the H--I insult can be modulated by varying the duration of hypoxia, the model is ideal to study whether oligodendrocyte progenitors are more susceptible to death than mature oligodendrocytes, whether mature oligodendrocytes de-differentiate and then are induced to remyelinate surviving axons, and/or whether oligodendrocyte progenitors in the subventricular layer can be stimulated to proliferate, migrate, and remyelinate the surviving axons.

Point mutations and duplications of proteolipid protein (PLP) gene in mammals cause dysmyelination and oligodendrocyte cell death. The jimpy mouse, which has a lethal Plp point mutation, is the best characterized of the mutants; transgenic mice, which have additional copies of Plp gene, are less characterized. While oligodendrocyte death is a prominent feature in jimpy, the pathways leading to death have not been investigated in jimpy and Plp overexpressors. Using immunohistochemistry and immunobloting, we examined expression of cleaved caspase-3, Poly (ADP-ribose) polymerase (PARP), caspase-12, and mitochondrial apoptotic markers in spinal cord in jimpy males and Plp overexpressors. Compared to controls, cleaved caspase-3 is increased 10× in jimpy white matter spinal cord, and 3× in Plp overexpressor. In jimpy, the number of cleaved caspase-3 cells far exceeds the number of TUNEL+ cells. The majority of cleaved caspase-3+ cells were not TUNEL+ and these cells exhibited staining in perikarya and in processes. Only 30% of the cleaved caspase-3+ cells were TUNEL+ and exhibited both nuclear and perinuclear staining. This observation suggests that activation of caspase-3 begins earlier and overlaps for a period of time with DNA fragmentation. In both Plp mutants, quantitative immunobloting of PARP showed a 45% increase in total as well as cleaved form, indicating that oligodendrocytes die via apoptosis. Most interestingly, cleavage of caspase-12, a caspase associated with unfolded protein response, is dramatically increased in jimpy but not at all in Plp overexpressors. Mitochondrial markers cytochrome c and Bcl-XL are upregulated in both Plp mutants but levels of expression are different between mutants, suggesting that apoptosis in these two Plp mutants follows different pathways. In jimpy, mitochondrial apoptotic markers may play a role in amplifying the apoptotic signal. Our data shows for the first time, in vivo, that mutations in Plp gene increase oligodendrocyte death by activating the caspase cascade but the trigger to upregulate this cascade follows different pathways.

Objective Hemodynamic abnormality and disruption of white matter (WM) integrity are significant components in the pathophysiology of multiple sclerosis (MS) lesions. However, the roles of stratified lesions with distinct degrees of hemodynamic and structural injury in disease states remain to be explored. We tested the hypothesis that hemodynamic and structural impairment, as assessed by cerebral blood volume (CBV) and fractional anisotropy (FA), respectively, characterizes the extent of tissue injury, and the load of lesion with substantial tissue destruction would reflect the disease status and therefore, would be related to clinical disability. Methods Seven relapsing-remitting MS patients and seven healthy controls underwent perfusion, diffusion and conventional MRI scans. Based on T2-FLAIR and T1-weighted image, WM plaques were classified. After image coregistration, values of CBV and FA were estimated in three distinct lesion types (active, T1-hypointense and T1- isointense lesion) and compared with those obtained in WM from controls. A total of 1135 lesions were evaluated. Brain volumetric measurement and correlative analysis between brain atrophy, lesion volume and clinical disability were also performed. Results Compared with normal WM, significantly reduced CBV and FA were present in the T1-hypointense lesion, while insignificant changes in both parameters were exhibited in the T1-isointense lesion. However, increased CBV but significantly decreased FA was detected in the active lesion. A close spatial relationship between active and T1- hypointense lesion was observed. Lesion load represented by T1-hypointense plus active lesion volume significantly correlated with brain atrophy, which, in turn, significantly correlated with the severity of clinical disability. Conclusion A distinct combination of CBV and FA characterizes the status of a specific lesion type. A severe structural impairment does not solely occur in the T1-hypointense lesion, but is also associated with the active lesion. The burden of the lesion with extensive structural damage provides an image index, indicative of disease status.

Neuromyelitis optica (NMO, also eponymously known as Devic's disease) is an immune-mediated demyelinating disease of the central nervous system that can lead to significant disability. Pediatric NMO is a rare disorder often reported after an infection. The authors report a 16 year-old female patient with pemphigus foliaceus who developed subacute optic neuritis followed by cervical transverse myelitis. Restricted distribution of the lesions in the optic nerve and spinal cord was confirmed by ophthalmological evaluation and magnetic resonance imaging of the brain and spinal cord. She was started on intravenous methylprednisolone and then given a maintenance oral prednisone. Subsequently, she was treated with a nonsteroidal immunosuppressant, mycophenolate mofetil, with a target dose of 1000 mg twice a day. Over the course of months, patient noted significant recovery of previous deficits and resolution of the cervical cord enhancement, expansion and cystic dilatation that was previously seen. This case is noteworthy for being the first patient reported with neuromyelitis optica associated with pemphigus foliaceus.

The aim was to describe the use of and adherence to migraine preventives among insured patients meeting the International Classification of Headache Disorders, 2nd edn (ICHD-II) criteria for migraine headaches. A retrospective, case–control study was conducted using data from a telephone interview linked with health insurance claims data. Subjects were health plan enrollees aged 18–55 years who had incurred at least one encounter between June 2000 and November 2001. Interview responses were used to identify cases meeting the ICHD-II criteria for strict and probable migraine and a random sample of controls. Pharmacy claims data were used to construct measures of use and adherence. Differences in outcomes by adherence status were evaluated using generalized linear models. We identified 2517 cases and 941 controls. Among cases, the prevalence of antidepressant use was 4%, anticonvulsant use was 1.9%, antihypertensive use was 8.9%. Combined use was 13.4% among cases and did not differ significantly from that observed among controls (12.4%). Mean adherence rate between the first and last dispensing during the year was high (88%) and did not differ by migraine status. When the entire 12-month period is considered, adherence was substantially lower (56%). Patients who were adherent between dispensings reported significantly less migraine-related disability and incurred higher prescription drug costs, but did not differ in their total medical care costs. Patients with migraine are unlikely to be users of preventive medications. Among users, few are taking preventive medications continuously. Patients with migraine—especially those without a medical diagnosis for migraine or headaches—are not receiving the benefits available from existing pharmacotherapy options.

Objectives To measure disease-modifying agent adherence and persistence among patients with multiple sclerosis (MS). Design Retrospective cohort study. Setting Multispecialty, salaried group practice in southeast Michigan, between June 1, 2004, and June 30, 2006. Patients 224 insured adult patients with relapsing remitting MS with an outpatient visit. Main outcome measures Medical record–documented receipt of medication recommendation and prescription. Pharmacy claims data–derived measures of dispensing and among patients with two or more dispensings, medication possession ratios (MPRs), and proportion of gap days were estimated. Among those initiating agent use, persistence was estimated. Results Mean cohort age was 47.6 years, while 77% of participants were women and 39% were black. Of patients, 81.8% had a recommendation for a disease-modifying agent, 75.0% had a prescription, and 66.5% had two or more dispensings. Among those with two or more dispensings, mean MPR between the first and last dispensing date was 83.8% (95% CI 80.8–86.8), while mean MPR for the entire 24-month period was 68.0% (64.4–71.7). MPR for the 24-month period decreased with increasing drug copayments and was lower among black patients, while MPR between the first and last dispensing date increased with increasing age. Among those initiating therapy, 43% were nonpersistent with medications within 14 months. Conclusion Medication adherence and persistence among patients with relapsing remitting MS is far from monolithic. Measuring medication adherence and persistence among defined populations is useful for understanding the relationship between medication use and outcomes in practice and for targeting patients and programs to improve medication adherence.

Radiation necrosis of the brain is a well documented adverse effect of radiation therapy. The authors report an unusual case of relapsing multifocal radiation necrosis following whole brain radiation therapy (WBRT) for brain metastases from a systemic germ cell tumor. Anticoagulation with warfarin may have had therapeutic benefit. The patient is alive without a neurological deficit 10 years after the diagnosis of radiation necrosis.

Sexual dimorphism of neurons and astrocytes has been demonstrated in different centers of the brain, but sexual dimorphism of oligodendrocytes and myelin has not been examined. We show, using immunocytochemistry andin situhybridization, that the density of oligodendrocytes in corpus callosum, fornix, and spinal cord is 20–40% greater in males compared with females. These differences are present in young and aged rodents and are independent of strain and species. Proteolipid protein and carbonic anhydrase-II transcripts, measured by real-time PCR, are approximately two to three times greater in males. Myelin basic protein and 2′, 3′-cyclic nucleotide 3′-phosphodiesterase, measured by Western blots, are 20–160% greater in males compared with females. Surprisingly, both generation of new glia and apoptosis of glia, including oligodendrocytes, are approximately two times greater in female corpus callosum. These results indicate that the lifespan of oligodendrocytes is shorter in females than in males. Castration of males produces a female phenotype characterized by fewer oligodendrocytes and increased generation of new glia. These findings indicate that exogenous androgens differentially affect the lifespan of male and female oligodendrocytes, and they can override the endogenous production of neurosteroids. The data imply that turnover of myelin is greater in females than in males. μ-Calpain, a protease upregulated in degeneration of myelin, is dramatically increased at both transcriptional and translational levels in females compared with males. These morphological, molecular, and biochemical data show surprisingly large differences in turnover of oligodendrocytes and myelin between sexes. We discuss the potential significance of these differences to multiple sclerosis, a sexually dimorphic disease, whose progression is altered by exogenous hormones.

Mutations of the myelin proteolipid protein gene (Plp) are associated with excessive programmed cell death (PCD) of oligodendrocytes. We show for the first time that PLP is a molecule ubiquitously expressed in non-neural tissues during normal development, and that the level of native PLP modulates the level of PCD. We analyze three non-neural tissues, and show that native PLP is expressed in trophoblasts, spermatogonia, and cells of interdigital webbing. The non-neural cells that express high levels of native PLP also undergo PCD. The level of PLP expression modulates the level of PCD because mice that overexpress native PLP have increased PCD and mice deficient in PLP have decreased PCD. We show that overexpression of native PLP causes a dramatic acidification of extracellular fluid that, in turn, causes increased PCD. These studies show that the level of native PLP modulates the amount of PCD during normal development via a pH-dependent mechanism.

Oligodendrocytes, the myelin-forming cells in the central nervous system, were visualized with excellent resolution at the light microscopic level using in situ hybridization (ISH). Digoxigenin (Dig)-tagged probes were synthesized and efficiently labeled by PCR. Specific probes to myelin genes were made by RT from brain total RNAs, followed by PCR with designed specific primers in the presence of Dig-11-dUTP. Probes specific to proteolipid protein (PLP), PLP and its isoform DM20 (PLP/DM20), and myelin oligodendrocyte glycoprotein (MOG) were synthesized and labeled. ISH was then applied on vibratomed tissue sections from mouse brains. Despite a low expression of MOG-specific and PLP-specific mRNAs in adult and newborn mouse brains, an oligodendrocyte population was detected. The specificity of Dig-labeled probes was confirmed with the double labeling of carbonic anhydrase II (CA II) and glial fibrillary acidic protein (GFAP) immunocytochemistry and ISH. This versatile and easy method for synthesis and labeling of specific probes to oligodendrocytes can be also applied to detect many other mRNAs in the nervous system and in other tissues.

Objective: To investigate changes in spontaneous brain activity in patients with relapsing-remitting multiple sclerosis (RRMS) and compare with resting-state network of healthy controls. Background Resting State connectivity using fMRI of the default-mode network (DMN) has been recently shown to be altered in patients with secondary and primary progressive MS. Dysfunction of DMN has been hypothesized to be the factor responsible for accumulation of cognitive deficits in patients with progressive MS. Design/Methods: Six patients with RRMS and 15 normal controls were scanned. fMRI images were acquired on a GE 3.0-T whole-body magnet using a gradient echo EPI sequence for whole-brain BOLD fMRI. For the resting state image set, 150 volumes were recorded while the subjects were lying quietly with eyes open. High resolution (IRSPGR) images were also acquired for brain segmentation. The brain was segmented into 104 regions using the high resolution 3D IRSPGR image and the HAMMER software and the temporal fMRI signals from all voxels in each segmented region were averaged to represent one signal for each region. Results: Resting state networks of different cognitive circuits (DMN, attention, language, memory, visual-spatial memory) were assessed in patients with MS and controls. Cross correlation of the resting state fMRI signals between every two nodes in each network was calculated for the patients and compared to the data from controls. All the pairs that had cross-correlation values outside the normal range were tagged and summed among all the patients. DMN analysis showed decreased correlation in cingulate region and lateral parietal cortices in patients with cognitive impairment, similar with a recent report in literature. Moreover, all or almost all assessed cognitive circuits showed decreased correlation in patients with MS with known cognitive deficit. Conclusions: Dysfunction of resting-state is seen in RRMS patients not only in DMN but also in other subsystems involved in cognitive process. Supported by: Henry Ford Hospital. Disclosure: Dr. Cerghet has nothing to disclose. Dr. Nejad-Davarani has nothing to disclose. Dr. Li has nothing to disclose. Dr. Jiang has nothing to disclose.

Objective: To describe the clinical and radiologic manifestations of spinal cord NS. Background Neurological involvement precedes the diagnosis of sarcoidosis in up to 74% and it is the only manifestation in up to 17% of patients. A definitive diagnosis requires histologic confirmation, which rarely is obtained. Our current knowledge for diagnosis and treatment relies on case reports. In our previous study of 71 cases with neurosarcoidosis (NS), transverse myelitis was the most common initial presentation (28%). Design/Methods: From the institutional approved NS database, 26 patients of spinal cord NS seen between 1995-2011 were selected. All patients met criteria for possible, probable or definitive NS (Zajicek et al., 1999). Neurological symptoms, socio-demographic, laboratory, radiographic and treatment data were collected. Descriptive statistics were used to characterize the NS cases. Results: Of the 26 patients, 14 (56%) had extensive intramedullary lesion, 3 (12%) had patchy intramedullary lesion(s) and 11 (44%) had leptomeningeal involvement. Patients with patchy lesion and/or leptomeningeal involvement were more likely to have elevated IgG and protein level in CSF (p=0.048; p=0.013, chi-square test). Multi-organ involvement was seen at a higher rate with leptomeningeal involvement than extensive lesions (88% vs 65%). 77% of patients had associated degenerative disease of spine, which did not appear to be associated with age. 19/26 had Gad-enhancing lesion at presentation and majority 18/21 continued to have abnormal MRI with 13/19 having enhancing lesion despite immunosuppressant treatment. 10 (40%) had a monophasic disease, 8 (32%) had relapses and 7 (28%) had a progressive disease. Conclusions: Three types of radiological presentation were seen in spinal cord NS and those are frequently associated with degenerative disease. Extensive intramedullary lesion is the most common presentation and is less likely associated with abnormal findings in CSF. Despite treatment with immunosuppression radiologic resolution is not common. Disclosure: Dr. Rai has nothing to disclose. Dr. Cerghet has nothing to disclose. Dr. Grover has nothing to disclose. Dr. Shultz has nothing to disclose. Dr. Elias has nothing to disclose.