Case Report: A Case of Severe Clinical Deterioration in a Patient With Multiple Sclerosis

Tumefactive multiple sclerosis (MS) is a rare variant of MS that may lead to a rapidly progressive clinical deterioration requiring a multidisciplinary diagnostic workup. Our report describes the diagnostic and therapeutic approach of a rare and extremely severe course of MS. A 51-year-old man with an 8-year history of relapsing-remitting MS (RRMS) was admitted with a subacute progressive left lower limb weakness and deterioration of walking ability. After extensive investigations including repeated MRI, microbiological, serological, cerebrospinal fluid (CSF) studies, and finally brain biopsy, the diagnosis of a tumefactive MS lesion was confirmed. Despite repeated intravenous (IV) steroids as well as plasma exchanges and IV foscarnet and ganciclovir owing to low copy numbers of human herpesvirus 6 (HHV-6) DNA in polymerase chain reaction (PCR) analysis, the patient did not recover. The clinical presentation of tumefactive MS is rare and variable. Brain biopsy for histopathological workup should be considered in immunocompromised patients with rapidly progressive clinical deterioration with brain lesions of uncertain cause

Incidence of Invasive Fungal Infections in Liver Transplant Recipients under Targeted Echinocandin Prophylaxis

Invasive fungal infections (IFIs) are one of the most important infectious complications after liver transplantation, determining morbidity and mortality. Antimycotic prophylaxis may impede IFI, but a consensus on indication, agent, or duration is still missing. Therefore, this study aimed to investigate the incidence of IFIs under targeted echinocandin antimycotic prophylaxis in adult high-risk liver transplant recipients. We retrospectively reviewed all patients undergoing a deceased donor liver transplantation at the Medical University of Innsbruck in the period from 2017 to 2020. Of 299 patients, 224 met the inclusion criteria. We defined patients as being at high risk for IFI if they had two or more prespecified risk factors and these patients received prophylaxis. In total, 85% (190/224) of the patients were correctly classified according to the developed algorithm, being able to predict an IFI with a sensitivity of 89%. Although 83% (90/109) so defined high-risk recipients received echinocandin prophylaxis, 21% (23/109) still developed an IFI. The multivariate analysis identified the age of the recipient (hazard ratio—HR = 0.97, p = 0.027), split liver transplantation (HR = 5.18, p = 0.014), massive intraoperative blood transfusion (HR = 24.08, p = 0.004), donor-derived infection (HR = 9.70, p p = 0.003) as variables with increased hazard ratios for an IFI within 90 days. The fungal colonization at baseline, high-urgency transplantation, posttransplant dialysis, bile leak, and early transplantation showed significance only in a univariate model. Notably, 57% (12/21) of the invasive Candida infections were caused by a non-albicans species, entailing a markedly reduced one-year survival. The attributable 90-day mortality rate of an IFI after a liver transplant was 53% (9/17). None of the patients with invasive aspergillosis survived. Despite targeted echinocandin prophylaxis, there is still a notable risk for IFI. Consequently, the prophylactic use of echinocandins must be critically questioned regarding the high rate of breakthrough infections, the increased occurrence of fluconazole-resistant pathogens, and the higher mortality rate in non-albicans Candida species. Adherence to the internal prophylaxis algorithms is of immense importance, bearing in mind the high IFI rates in case algorithms are not followed

The nucleic acid binding protein YB-1-controlled expression of CXCL-1 modulates kidney damage in liver fibrosis

Acute kidney injury is a common complication of advanced liver disease and increased mortality of these patients. Here, we analyzed the role of Y-box protein-1 (YB-1), a nucleic acid binding protein, in the bile duct ligation model of liver fibrosis and monitored liver and subsequent kidney damage. Following bile duct ligation, both serum levels of liver enzymes and expression of hepatic extracellular matrix components such as type I collagen were significantly reduced in mice with half-maximal YB-1 expression (Yb1(-/-)) as compared to their wild-type littermates. By contrast, expression of the chemokine CXCL1 was significantly augmented in these Yb1(-/-) mice. YB-1 was identified as a potent transcriptional repressor of the Cxc/1 gene. Precision-cut kidney slices from Yb1(-/-) mice revealed higher expression of the CXCL1 receptor CXCR2 as well as enhanced responsivity to CXCL1 compared to those from wild-type mice. Increased CXCL1 content in Yb1(-/-) mice led to pronounced bile duct ligation-induced damage of the kidneys monitored as parameters of tubular epithelial injury and immune cell infiltration. Pharmacological blockade of CXCR2 as well as application of an inhibitory anti-CXCL1 antibody significantly mitigated early systemic effects on the kidneys following bile duct ligation whereas it had only a modest impact on hepatic inflammation and function. Thus, our analyses provide direct evidence that YB-1 crucially contributes to hepatic fibrosis and modulates liver-kidney crosstalk by maintaining tight control over chemokine CXCL1 expression

The nucleic acid binding protein YB-1-controlled expression of CXCL-1 modulates kidney damage in liver fibrosis

Acute kidney injury is a common complication of advanced liver disease and increased mortality of these patients. Here, we analyzed the role of Y-box protein-1 (YB-1), a nucleic acid binding protein, in the bile duct ligation model of liver fibrosis and monitored liver and subsequent kidney damage. Following bile duct ligation, both serum levels of liver enzymes and expression of hepatic extracellular matrix components such as type I collagen were significantly reduced in mice with half-maximal YB-1 expression (Yb1(-/-)) as compared to their wild-type littermates. By contrast, expression of the chemokine CXCL1 was significantly augmented in these Yb1(-/-) mice. YB-1 was identified as a potent transcriptional repressor of the Cxc/1 gene. Precision-cut kidney slices from Yb1(-/-) mice revealed higher expression of the CXCL1 receptor CXCR2 as well as enhanced responsivity to CXCL1 compared to those from wild-type mice. Increased CXCL1 content in Yb1(-/-) mice led to pronounced bile duct ligation-induced damage of the kidneys monitored as parameters of tubular epithelial injury and immune cell infiltration. Pharmacological blockade of CXCR2 as well as application of an inhibitory anti-CXCL1 antibody significantly mitigated early systemic effects on the kidneys following bile duct ligation whereas it had only a modest impact on hepatic inflammation and function. Thus, our analyses provide direct evidence that YB-1 crucially contributes to hepatic fibrosis and modulates liver-kidney crosstalk by maintaining tight control over chemokine CXCL1 expression

In vitro generation of functional liver organoid-like structures using adult human cells

In this study we used differentiated adult human upcyte1 cells for the in vitro generation of liver organoids. Upcyte1 cells are genetically engineered cell strains derived from primary human cells by lenti-viral transduction of genes or gene combinations inducing transient proliferation capacity (upcyte1 process). Proliferating upcyte1 cells undergo a finite number of cell divisions, i.e., 20 to 40 population doublings, but upon withdrawal of proliferation stimulating factors, they regain most of the cell specific characteristics of primary cells. When a defined mixture of differentiated human upcyte1 cells (hepatocytes, liver sinusoidal endothelial cells (LSECs) and mesenchymal stem cells (MSCs)) was cultured in vitro on a thick layer of Matrigel™, they self-organized to form liver organoid-like structures within 24 hours. When further cultured for 10 days in a bioreactor, these liver organoids show typical functional characteristics of liver parenchyma including activity of cytochromes P450, CYP3A4, CYP2B6 and CYP2C9 as well as mRNA expression of several marker genes and other enzymes. In summary, we hereby describe that 3D functional hepatic structures composed of primary human cell strains can be generated in vitro. They can be cultured for a prolonged period of time and are potentially useful ex vivo models to study liver functions

Generation of liver organoids <i>in vitro</i>.

<p>(A) Time-dependent formation of liver organoids in 24-well plates. Long-term culture (>48h) was performed in a dynamic system, e.g. the quasi vivo system from kirkstall^® (B) or the Live-box 1 system, generated by the group of Prof. Arti Ahluwalia, Faculty of Engineering, University of Pisa, Italy (C).</p

Immunostainings of a 10-day liver organoid in comparison with adult human liver.

<p><b>A)</b> Immunofluorescent staining for the epithelial marker protein E-Cadherin (green) and the functional marker protein albumin (red) in a 10-day LO on the left and a cross-section of adult human liver on the right. The scale bar equals 10 μm. <b>B)</b> Immunohistochemical stainings for E-Cadherin and the proliferation marker Ki67 in a 10-day liver organoid (left panel). Human liver sections were used as control (right panel). The arrows point to Ki67-positive cells in the liver. Scale bars equal 100 μm (original magnification: 400x). <b>C)</b> The expression levels of the hepatocyte polarization markers E-Cadherin and ZO–1 as well as albumin were further analyzed by real-time PCR in samples from 10-day LOs (the average value of 4 different LOs +/-SD is shown). For comparison samples from four different donors were analyzed in parallel. Expression of the house-keeping gene HPRT–1 was used for normalization. pHC = primary hepatocytes (non-cultured).</p

Expression and activity of drug metabolizing enzymes. Comparison of 10-day LOs with human liver.

<p><b>A)</b> The basal activities of Cyps 3A4, 2B6 and 2C9 were measured (average of n = 4 +/-SD) in 10-day liver organoids (LOs). LOs were formed as shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0139345#pone.0139345.g002" target="_blank">Fig 2</a> inside a bioreactor (Quasi-vivo^® System from Kirkstall). Substrate incubation was performed for 60 min on day 10 of culture. CYP-activity was normalized to total protein content of the organoids. Paired pHC are the same primary hepatocytes which had been upcyted® and used to form the organoids. Basal CYP activity levels of primary cells shown in the figure were provided by the manufacturer. For CYP2C9 no value was given (ND, not determined). <b>B)</b> Three more CYPs as well as Sult1a1 and Ugt1a3 were investigated on the mRNA expression level by real-time PCR. The average values of 4 different LOs +/-SD is shown. For comparison RNA samples from 4 donors were analyzed in parallel. The samples from donor 1–3 were RNAs from hepatocytes which were isolated, frozen down without primary culture and directly lysed after thawing (pHC; non-cultured cells). The sample from donor 4 represents the total RNA isolated from a piece of whole liver. Expression of the house-keeping gene HPRT–1 was used for normalization. <b>C)</b> Cross-sections of a 10-day LO (on the left) in direct comparison to adult human liver (on the right; stained against cytokeratins plus haematoxylin). The rectangles mark representative cells showing the typical cuboidal shape of polarized hepatocytes. The circles highlight areas where hepatocytes have arranged around circular openings. The scale bar equals 100 μm.</p