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T cell response to two immunodominant proteolipid protein (PLP) peptides in multiple sclerosis patients and healthy controls.

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system in which autoimmune T lymphocytes reacting with myelin antigens are believed to play a pathogenic role. Since HLA binding is involved in the selection of T cell responses, we have examined PLP peptide binding to HLA DR2, an HLA allele frequently found in MS patients. Both PLP 40-60 and PLP 89-106 show significant, high affinity binding to HLA DR2. We then tested whether responses to PLP peptides 40-60 and 89-106 are elevated in multiple sclerosis patients compared to matched controls. We also analysed T cell responses to MBP 87-106, which is considered to be the immunodominant region of MBP in humans. Here we demonstrate heterogenous T cell responses to PLP 40-60, PLP 89-106 and MBP 87-106 in both MS patients and controls. The overall number of TCL and the HLA restriction of those TCL did not vary significantly in the two groups. PLP 40-60 specific cytolytic TCL were increased in MS patients, whereas healthy controls had increased percentages of cytolytic TCL responding to PLP 89-106 and MBP 87-106. Although the data presented here shows heterogenous responses in T cell numbers, differences in numbers and specificity of cytolytic cells could be involved in the pathogenesis of autoimmune demyelinating disease.

Amino Acid Sequence↗

Variation in the vitamin D receptor gene is associated with multiple sclerosis in an Australian population.

Multiple Sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS) resulting in accumulating neurological disability. The disorder is more prevalent at higher latitudes. To investigate VDR gene variation using three intragenic restriction fragment length polymorphisms (Apa I, Taq I and Fok I) in an Australian MS case-control population. One hundred and four Australian MS patients were studied with patients classified clinically as Relapsing Remitting MS (RR-MS), Secondary Progressive MS (SP-MS) or Primary Progressive MS (PP-MS). Also, 104 age-, sex-, and ethnicity-matched controls were investigated as a comparative group. Our results show a significant difference of genotype distribution frequency between the case and control groups for the functional exon 9 VDR marker Taq I (p(Gen) = 0.016) and interestingly, a stronger difference for the allelic frequency (p(All) = 0.0072). The Apa I alleles were also found to be associated with MS (p(All) = 0.04) but genotype frequencies were not significantly different from controls (p(Gen) = 0.1). The Taq and Apa variants are in very strong and significant linkage disequilibrium (D' = 0.96, P < 0.0001). The genotypic associations are strongest for the progressive forms of MS (SP-MS and PP-MS). Our results support a role for the VDR gene increasing the risk of developing multiple sclerosis, particularly the progressive clinical subtypes of MS.

Female↗

Neuroretinitis in patients with multiple sclerosis.

PURPOSE: To present a case series of three patients with neuroretinitis associated with multiple sclerosis. DESIGN: Retrospective, noncomparative, consecutive, interventional case series. PARTICIPANTS: Thirty-five consecutive patients with neuroretinitis. METHODS: The records of 35 consecutive patients with neuroretinitis were reviewed for prior, concurrent, or subsequent development of multiple sclerosis. MAIN OUTCOME MEASURES: Presentation, clinical course, and diagnosis of multiple sclerosis. RESULTS: Three of 35 patients (8.6%) with neuroretinitis were diagnosed with multiple sclerosis by the McDonald criteria. One of the three patients underwent brain biopsy that further confirmed multiple sclerosis. Neuroretinitis in the three patients occurred after the diagnosis of multiple sclerosis. All three patients with multiple sclerosis had been treated with interferon beta before or concurrently with the development of neuroretinitis. CONCLUSIONS: Neuroretinitis can be an associated manifestation of multiple sclerosis. The possible association between neuroretinitis and interferon beta warrants further investigation.

Adult↗

Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis.

BACKGROUND: Central pain in multiple sclerosis (MS) is common and often refractory to treatment. METHODS: We conducted a single-center, 5-week (1-week run-in, 4-week treatment), randomized, double-blind, placebo-controlled, parallel-group trial in 66 patients with MS and central pain states (59 dysesthetic, seven painful spasms) of a whole-plant cannabis-based medicine (CBM), containing delta-9-tetrahydrocannabinol:cannabidiol (THC:CBD) delivered via an oromucosal spray, as adjunctive analgesic treatment. Each spray delivered 2.7 mg of THC and 2.5 of CBD, and patients could gradually self-titrate to a maximum of 48 sprays in 24 hours. RESULTS: Sixty-four patients (97%) completed the trial, 34 received CBM. In week 4, the mean number of daily sprays taken of CBM (n = 32) was 9.6 (range 2 to 25, SD = 6.0) and of placebo (n = 31) was 19.1 (range 1 to 47, SD = 12.9). Pain and sleep disturbance were recorded daily on an 11-point numerical rating scale. CBM was superior to placebo in reducing the mean intensity of pain (CBM mean change -2.7, 95% CI: -3.4 to -2.0, placebo -1.4 95% CI: -2.0 to -0.8, comparison between groups, p = 0.005) and sleep disturbance (CBM mean change -2.5, 95% CI: -3.4 to -1.7, placebo -0.8, 95% CI: -1.5 to -0.1, comparison between groups, p = 0.003). CBM was generally well tolerated, although more patients on CBM than placebo reported dizziness, dry mouth, and somnolence. Cognitive side effects were limited to long-term memory storage. CONCLUSIONS: Cannabis-based medicine is effective in reducing pain and sleep disturbance in patients with multiple sclerosis related central neuropathic pain and is mostly well tolerated.

Administration, Oral↗

Quality of life and its relationship to brain lesions and atrophy on magnetic resonance images in 60 patients with multiple sclerosis.

CONTEXT: Disease-modifying multiple sclerosis (MS) therapeutic trials continue to rely on physical disability as the main clinical outcome measure, while the impact of treatment on quality of life (QOL) is poorly understood. Weak correlations exist between physical disability and the disease burden as shown using conventional brain magnetic resonance imaging (MRI), indicating poor sensitivities of these measures alone in defining the clinical course of MS. OBJECTIVES: To investigate the impact of MS on QOL; to determine whether impaired QOL in patients with MS was related to any regional brain abnormalities assessed using conventional MRI sequences; and to determine if the severity of MS as assessed by the Expanded Disability Status Scale (EDSS) and clinical course was associated with worsening QOL. DESIGN, SETTING, AND PATIENTS: Prospective, cross-sectional study of 60 consecutive patients with MS treated in a community-based, university-affiliated MS clinic. MAIN OUTCOME MEASURES: Assessments of QOL using the Multiple Sclerosis Quality of Life-54 Instrument were correlated with the scores of the EDSS, clinical course, and findings on brain MRI. RESULTS: Quality of life was significantly impaired in patients with MS and was worse in patients with secondary-progressive MS compared with those with relapsing-remitting MS. Brain MRI lesions and atrophy were associated with impaired QOL with respect to sexual dysfunction, overall mental health, and limitations due to physical and emotional dysfunction. Correlations between MRI results and QOL assessments were much stronger for hypointense lesions and atrophy on T1-weighted images than for hyperintense lesions on T2-weighted images and were insignificant for lesions on contrast-enhanced images. Higher EDSS scores were associated with impairments in most physical and mental health QOL scales but were weakly correlated with cognitive and sexual dysfunction. CONCLUSIONS: In patients with MS, QOL is impaired and is associated with increasing neurologic disability. Quality of life assessments are related in part to brain lesions and atrophy shown on MRI. Assessments of QOL provide unique information not readily evaluated by EDSS and may be useful as secondary clinical outcome measures. Arch Neurol. 2000;57:1485-1491

Adjuvants, Immunologic↗

Multiple sclerosis, natalizumab therapy, and progressive multifocal leukoencephalopathy.

PURPOSE OF REVIEW: Multiple sclerosis affects many people, often in early adulthood, and causes significant disability. Natalizumab is a novel agent to be evaluated for multiple sclerosis and Crohn's disease that has demonstrated unique efficacy but has unfortunately been implicated in three cases of progressive multifocal leukoencephalopathy. This review covers the mechanism of action of natalizumab and efficacy for multiple sclerosis, the three cases of natalizumab-associated progressive multifocal leukoencephalopathy, our understanding of progressive multifocal leukoencephalopathy, and the mechanisms that may account for these events. RECENT FINDINGS: Natalizumab, an anti-alpha4-integrin antibody, binds to T-cell surface receptors to prevent migration from the circulation into the brain tissue. Phase II and III trials have been completed and demonstrate previously unseen efficacy in preventing relapses and disease progression. The cases of progressive multifocal leukoencephalopathy, two fatal and one disabling, resulted in the voluntary suspension of natalizumab and bring this entire class of agents into doubt. It is important to determine what led to the development of progressive multifocal leukoencephalopathy in the natalizumab-associated cases and to advance understanding and continue to develop therapies for the treatment of multiple sclerosis. SUMMARY: With ongoing safety evaluations, natalizumab is being reevaluated by the US Food and Drug Administration for possible reapproval and return to the market. If natalizumab is reapproved, challenging questions and issues will remain in treating patients with multiple sclerosis.

Adult↗

Visual and motor evoked potentials in the course of multiple sclerosis.

While evoked potentials are sensitive tools for diagnosing multiple sclerosis, little is known about their prognostic value and their role in determining the course of the disease. To validate the visual and motor evoked potentials (VEP and MEP) as measures for the course of multiple sclerosis, we examined prospectively 30 patients with relapsing-remitting or secondary progressive multiple sclerosis. The Expanded Disability Status Scale (EDSS), VEP and MEP were measured at entry and after 6, 12 and 24 months. The Spearman rank correlation was used for statistical analysis. Applying multiple regression in 15 randomized patients allowed derivation of a formula for predicting changes in EDSS score based on changes in MEP and VEP. Validation was done by comparing the predicted with the real changes in EDSS in the other 15 patients. The number of pathological VEP and MEP results correlated at all four measurement points with the EDSS (rho > or = 0.6, P < or = 0.01). When the latencies of VEP and MEP were combined using the sum of their Z scores, correlation with the EDSS was even more significant (rho > or = 0.6, P < 0.001). Changes over time of electrophysiological data and EDSS were also correlated (rho = 0.43, P < 0.05). Moreover, VEP and MEP at baseline correlated with the EDSS after 2 years (rho = 0.43,P = 0.03). Reliable prediction of the course of multiple sclerosis for individual patients is not possible from VEP and MEP data. However, we conclude that, for groups of patients with secondary progressive or relapsing-remitting multiple sclerosis the combined testing of VEP and MEP yields numerical data that allow objective estimation of the course and prognosis of the disease.

Adult↗

Serum IgG and IgM ganglioside GM1 antibodies in patients with multiple sclerosis.

INTRODUCTION: In order to obtain more information concerning the pathogenic significance of ganglioside GM1 in multiple sclerosis serum polyclonal IgG and IgM antibodies to GM1 were evaluated in multiple sclerosis patients with relapsing-remitting and secondary progressive forms of the disease. PATIENTS AND METHODS: The evaluated sera were from 55 patients with clinically definite multiple sclerosis and from 20 healthy subjects. Forty-two of patients were with relapsing-remitting and 13 with secondary progressive multiple sclerosis. Antibodies to GM1 were measured using a modification of the enzyme-linked immunosorbent assay technique of Mizutamari et al (1994). RESULTS: A statistically significant difference of serum IgG antibody titres to GM1 was found between the healthy subjects and the multiple sclerosis patients with relapsing-remitting form of the disease (p = 0.04), as well as of serum IgG antibody titres to GM1 between the patients with relapsing-remitting multiple sclerosis in relapse and in remission (p = 0.01). CONCLUSION: Bearing in mind the heterogeneity of multiple sclerosis, the pathogenic significance of serum antibodies to GM1 should be interpreted concerning the precise clinical form of the disease and not the whole group of MS patients. The findings in this study argue for the possible involvement of ganglioside GM1 in the pathogenesis of demyelination in relapsing-remitting multiple sclerosis.

Adult↗

Zinc in multiple sclerosis.

Zinc profiles were examined in 68 patients with multiple sclerosis, 62 normal volunteers, and 13 patients with other neurological diseases. Plasma zinc levels were slightly increased in patients with multiple sclerosis and significantly increased in those with other neurological impairments (p less than 0.01), compared with control subjects. Albumin-bound as well as protein-bound zinc levels were normal in all groups tested. The alpha 2 macroglobulin-bound zinc level was significantly lower (p less than 0.01) in patients with multiple sclerosis than in control subjects. Erythrocyte-bound zinc levels were significantly increased (p less than 0.05) in patients with multiple sclerosis when compared with control subjects. Erythrocyte-bound zinc was normal in patients with other neurological impairments. Because erythrocyte-bound zinc levels are relatively independent of daily fluctuations in dietary zinc intake, an increase in these values may suggest alterations in the control mechanisms governing zinc compartmentalization in patients with multiple sclerosis.

Blood Proteins↗

Use and misuse of statistics for epidemiological studies of multiple sclerosis.

Despite a vast literature on the epidemiology of multiple sclerosis, the cause of this disease remains elusive. The majority of the studies have focused on prevalence, so that a worldwide distribution of multiple sclerosis can now be mapped. Tantalizing apparent differences in prevalence have resulted in an abundance of hypotheses about risk factors for multiple sclerosis, none of which have been firmly established. This article reviews the difficulties inherent in the use of any type of descriptive study to investigate etiology of disease and provides an update of appropriate statistical methodology to analyze study results. The major focus is on the use of analytical study design, specifically the case-control study, to investigate a specific hypothesis about association between a risk factor and multiple sclerosis. An update on new epidemiological and statistical methodology to enhance the design of future case-control studies is presented. Future opportunities to study multiple sclerosis in new ways, such as in cohort studies or nested case-control studies, using large medical insurance and other types of health-related data bases, are discussed.

Case-Control Studies↗

Use of the Pulfrich pendulum for detecting abnormal delay in the visual pathway in multiple sclerosis.

(1) Pulfrich's pendulum has been developed as a method for detecting abnormal delay in the visual pathway of patients with suspected multiple sclerosis. (2) Forty-one normal subjects gave a mean interocular latency difference of 2-4 +/- 1-8 msec on Pulfrich's pendulum. This mean +2 SD (6 msec) was taken as the limit of normal interocular latency difference by this method. (3) The test was assessed on 58 patients. Eighteen of these had definite multiple sclerosis, 9 had probable multiple sclerosis, and 8 had possible multiple sclerosis, according to clinical criteria. The remaining 23 patients did not conform with clinical criteria for multiple sclerosis, and served as neurological controls. Thirteen of these 23 patients had abnormal signs in the visual system. All the 58 patients also had visual evoked responses (VERs) recorded. (4) Interocular latency difference was outside the normal range in 9/18 with definite multiple sclerosis, in 3/9 with probably multiple sclerosis and in 2/8 with possible multiple sclerosis. (5) Interocular latency difference was outside the normal range in 2/23 patients with other neurological disorders. (6) There was a strong correlation between abnormality on the Pulfrich pendulum and on the VER for the multiple sclerosis group. (7) Individual results are compared with those from the VER. There was no significant correlation of the size and direction of the interocular latency difference obtained from the Pulfrich pendulum with that obtained from the VER, for any group. Possible reasons for this are discussed. (8) It is concluded that Pulfrich's pendulum is an easily performed and potentially useful subjective test for detecting abnormal dealy in the visual pathway in multiple sclerosis.

Adolescent↗

Loss of functional suppression is linked to decreases in circulating suppressor inducer (CD4+ 2H4+) T cells in multiple sclerosis.

A consistent immunological finding in patients with progressive multiple sclerosis is a loss of functional suppression. We have recently found decreases in suppressor inducer T cells in progressive multiple sclerosis as measured by two-color immunofluorescence using differentiation markers CD4 and 2H4. In the present study, we examined the relationship between functional suppression and circulating CD4+ 2H4+ T cells using a two-stage assay. (1) T cells were stimulated for 7 days with irradiated non-T cells (autologous mixed lymphocyte reaction [AMLR]) and harvested. It has previously been shown that suppressor T cells are generated during the course of the AMLR. (2) The AMLR-generated suppressor T cells were then incubated with mononuclear cells plus pokeweed mitogen, and immunoglobulin (Ig) synthesis was measured. There was less AMLR-induced suppression of IgG synthesis in patients with progressive multiple sclerosis as compared with normal subjects and patients with other neurological diseases. More importantly, there were significant correlations between decreases in circulating CD4+ 2H4+ cells and the AMLR (p = 0.009). Thus, the decreases in functional suppression and the decreases in the AMLR in multiple sclerosis appear tightly linked to CD4+ 2H4+ cells, and their measurement provides a means to monitor suppressor function phenotypically. Decreases in suppressor inducer T cells may in part explain immunoregulatory abnormalities observed in multiple sclerosis.

Biological Assay↗

Is the frequency of abnormalities on magnetic resonance imaging in isolated optic neuritis related to the prevalence of multiple sclerosis? A global comparison.

The link between optic neuritis and multiple sclerosis is well established, as is the increased risk of conversion to multiple sclerosis, with lesions seen at presentation on the magnetic resonance imaging (MRI) scan of the brain. One or more asymptomatic lesions were present in 77% of the optic neuritis cohort from London, UK, a higher proportion than that reported in other large cohorts studied elsewhere, where generally lower prevalence rates for multiple sclerosis are also reported. These observations may support the hypothesis that optic neuritis is more likely to be associated with abnormalities on MRI and to be due to multiple sclerosis in geographical regions where multiple sclerosis is more common.

Adolescent↗

Epidemiological study of multiple sclerosis in Hong Kong Chinese: questionnaire survey.

OBJECTIVE: To study the epidemiology of multiple sclerosis in Hong Kong Chinese. DESIGN: Cross-sectional questionnaire survey. SETTING: Neurology and paediatric neurology departments in Hong Kong from January through June 1999. PARTICIPANTS: All confirmed multiple sclerosis patients. MAIN OUTCOME MEASURES: Demographic data, investigation results, Kurtzke's Expanded Disability Status Scale during the last follow-up visit, number of relapses between 1997 and 1998, and treatments used/currently in use. RESULTS: Fifty-three Chinese multiple sclerosis patients were identified. The prevalence was thus estimated to be 0.77 per 100,000 population. This low prevalence was also noted in other multiple sclerosis studies from South-East Asia (range, 0.8-4 per 100,000 population). The female to male ratio among the Chinese multiple sclerosis sufferers was 9.6:1, a figure somewhat higher than that reported in the other studies from South-East Asia (range, 3.2-6.6:1). The Chinese multiple sclerosis patients in this study also had a high spinal cord involvement (66%) and a low presence of cerebrospinal fluid oligoclonal banding (40%). These findings were different from those in Caucasian multiple sclerosis patients. CONCLUSION: Multiple sclerosis in Hong Kong Chinese has a low prevalence, a high female to male ratio, and a low cerebrospinal fluid oligoclonal banding presence.

Adult↗

Depressive symptoms and severity of illness in multiple sclerosis: epidemiologic study of a large community sample.

OBJECTIVE: Previous research has shown high prevalence rates of depression in multiple sclerosis patients seen in specialty clinics. The relationships among depressive symptoms and severity, duration, and course of multiple sclerosis are controversial. METHOD: A survey was mailed to members of the Multiple Sclerosis Association of King County (Wash.). Of the 1,374 eligible participants, 739 returned the survey, a response rate of 53.8%. Data about demographic characteristics, employment, and duration and course of multiple sclerosis were collected. Severity of multiple sclerosis was determined by the Expanded Disability Status Scale, self-report version. Severity of depressive symptoms was evaluated with the Center for Epidemiologic Studies Depression Scale (CES-D Scale). Analysis of covariance was used to compare mean CES-D Scale scores across categories of multiple sclerosis, and logistic regression was used to identify variables associated with clinically significant depression. RESULTS: Clinically significant depressive symptoms (CES-D Scale score > or =16) were found in 41.8% of the subjects, and 29.1% of the subjects had moderate to severe depression (score > or =21). Subjects with advanced multiple sclerosis were much more likely to experience clinically significant depressive symptoms than subjects with minimal disease. Shorter duration of multiple sclerosis was associated with a greater likelihood of significant depressive symptoms, but the pattern of illness progression was not. CONCLUSIONS: In this large community sample, the severity of multiple sclerosis was more strongly associated with depressive symptoms than was pattern of illness. Clinicians should evaluate depression in patients with recent diagnoses of multiple sclerosis, major changes in functioning, or limited social support.

Activities of Daily Living↗

Event-related brain potential evidence for a verbal working memory deficit in multiple sclerosis.

Memory deficits are frequently identified in patients with multiple sclerosis. Both working (short-term) and long-term memory appear affected, particularly on free-recall tasks. The focus of our study was to examine neurophysiological correlates of working memory processes and to identify the specific components responsible for the working memory deficits reported in multiple sclerosis. Event-related brain potentials (ERPs) were recorded from the scalp of mildly afflicted multiple sclerosis patients and their matched normal controls during the performance of phonological and visuo-spatial working memory tasks. Neuropsychological test, behavioural performance and ERP data all indicated that verbal working memory is especially susceptible to impairment by multiple sclerosis, while visuospatial working memory is less susceptible. The pattern of results further indicated that the verbal working memory dysfunction in multiple sclerosis is at least partially due to impairment in the phonological loop, a rehearsal mechanism for retaining verbal information in working memory.

Adult↗

Serum measles antibodies in multiple sclerosis.

Serum haemagglutination inhibition/HI/antibody titres to measles virus were examined in 80 multiple sclerosis patients, their 20 sibs, in 990 healthy controls, and 25 control patients. The measles HI titres were significantly raised in the serum of multiple sclerosis patients compared with healthy controls. There was no statistical difference between the levels of HI antibody titres in multiple sclerosis patients and their sibs. The measles HI titres decreased significantly in older age groups of healthy controls, whereas an analogous drop was not found in the multiple sclerosis group. The levels of serum HI antibody titres did not correlate with the sex of patients with multiple sclerosis or the activity of the disease. In the CSF of six multiple sclerosis patients low titres of HI antibodies were detected, whereas none of eight control patients had measurable traces of measles antibodies in the CSF. The significance of these findings in the aetiology of multiple sclerosis is briefly discussed.

Adolescent↗

[Diagnostic criteria of borderline forms of multiple sclerosis].

Border forms of multiple sclerosis (MS) can be separated in two groups: either they are variants of MS or they are distinct from MS but they share several characteristics with MS thus representing for some of them a continuum with MS. All these entities are central nervous system demyelinating diseases. Here we describe, for the first group, MS in childhood, MS in elderly subjects, Balò's concentric sclerosis, Schilder's myelinoclastic diffuse sclerosis and MS simulating a mass lesion, and for the second group, acute disseminated encephalomyelitis and Devic's neuromyelitis optica.

Adolescent↗