Fatigue in multiple sclerosis: Associations with clinical, MRI and CSF parameters

Background: Damage of different brain structures has been related to fatigue. Alternatively, functional alterations of central nervous system (CNS) cells by the inflammatory milieu within the CNS may be responsible for the development of fatigue. Aim: To investigate the effect of structural brain damage and inflammatory cerebrospinal fluid (CSF) changes on fatigue in multiple sclerosis (MS). Methods: We determined the association of different clinical, CSF and magnetic resonance imaging (MRI) parameters with prevalence and severity of fatigue, as measured by the Fatigue Scale for Motor and Cognitive Functions in 68 early MS patients (discovery cohort). We validated our findings in two MS cohorts: the MRI validation cohort (N=233) for the clinical and MRI parameters, and the CSF validation cohort (N=81) for the clinical and CSF parameters. Results: Fatigue was associated with clinical disability. Fatigue did not correlate with any CSF parameter but correlated negatively with total and cortical grey matter volume. However, when controlling for Expanded Disability Status Scale (EDSS) in a multivariate model, these associations lost significance. Conclusion: Disability and disease duration best explain fatigue severity but none of the tested MRI or CSF parameter was reliably associated with fatigue

Complete Epstein-Barr virus seropositivity in a large cohort of patients with early multiple sclerosis

OBJECTIVE: To determine the prevalence of antibodies to Epstein-Barr virus (EBV) in a large cohort of patients with early multiple sclerosis (MS). METHODS: Serum samples were collected from 901 patients with a clinically isolated syndrome (CIS) or early relapsing-remitting multiple sclerosis (RRMS) participating in the German National MS cohort, a prospective cohort of patients with early MS with stringent inclusion criteria. Epstein-Barr nuclear antigen (EBNA)-1 and viral capsid antigen (VCA) antibodies were measured in diluted sera by chemiluminescence immunoassays (CLIAs). Sera of EBNA-1 and VCA antibody-negative patients were retested undiluted by an EBV IgG immunoblot. For comparison, we retrospectively analysed the EBV seroprevalence across different age cohorts, ranging from 0 to >80 years, in a large hospital population (N=16 163) from Berlin/Northern Germany. RESULTS: EBNA-1 antibodies were detected by CLIA in 839 of 901 patients with CIS/RRMS. Of the 62 patients without EBNA-1 antibodies, 45 had antibodies to VCA as detected by CLIA. In all of the remaining 17 patients, antibodies to EBV were detected by immunoblot. Altogether, 901 of 901 (100%) patients with CIS/RRMS were EBV-seropositive. EBV seropositivity increased with age in the hospital population but did not reach 100% in any of the investigated age cohorts. CONCLUSION: The complete EBV seropositivity in this large cohort of patients with early MS strengthens the evidence for a role of EBV in MS. It also suggests that a negative EBV serology in patients with suspected inflammatory central nervous system disease should alert clinicians to consider diagnoses other than MS

Treatment choices and neuropsychological symptoms of a large cohort of early MS

Objective To assess clinical characteristics, distribution of disease-modifying treatments (DMTs), and neuropsychological symptoms in a large cohort of patients with early-stage MS. Methods The German National MS Cohort is a multicenter prospective longitudinal cohort study that has recruited DMT-naive patients with clinically isolated syndrome (CIS) and relapsing-remitting MS (RRMS) since 2010. We evaluated their baseline characteristics and the prevalence of neuropsychological symptoms. Results Of 1,124 patients, with a 2.2: 1 female-to-male ratio and median age at onset of 31.71 years (interquartile range [IQR]: 26.06-40.33), 44.6% and 55.3% had CIS and RRMS, respectively. The median Expanded Disability Status Scale (EDSS) score at baseline was 1.5 (IQR: 1.0-2.0). A proportion of 67.8% of patients started DMT after a median time of 167.0 days (IQR 90.0-377.5) since the first manifestation. A total of 64.7% and 70.4% of the 762 patients receiving early DMT were classified as CIS and RRMS, respectively. Fatigue, depressive symptoms, and cognitive dysfunction were detected in 36.5%, 33.5%, and 14.7% of patients, respectively. Conclusion Baseline characteristics of this large cohort of patients with early, untreated MS corroborated with other cohorts. Most patients received early DMT within the first year after disease onset, irrespective of a CIS or RRMS diagnosis. Despite the low EDSS score, neuropsychological symptoms affected a relevant proportion of patients

Genetic risk and a primary role for cell-mediated immune mechanisms in multiple sclerosis.

Multiple sclerosis is a common disease of the central nervous system in which the interplay between inflammatory and neurodegenerative processes typically results in intermittent neurological disturbance followed by progressive accumulation of disability. Epidemiological studies have shown that genetic factors are primarily responsible for the substantially increased frequency of the disease seen in the relatives of affected individuals, and systematic attempts to identify linkage in multiplex families have confirmed that variation within the major histocompatibility complex (MHC) exerts the greatest individual effect on risk. Modestly powered genome-wide association studies (GWAS) have enabled more than 20 additional risk loci to be identified and have shown that multiple variants exerting modest individual effects have a key role in disease susceptibility. Most of the genetic architecture underlying susceptibility to the disease remains to be defined and is anticipated to require the analysis of sample sizes that are beyond the numbers currently available to individual research groups. In a collaborative GWAS involving 9,772 cases of European descent collected by 23 research groups working in 15 different countries, we have replicated almost all of the previously suggested associations and identified at least a further 29 novel susceptibility loci. Within the MHC we have refined the identity of the HLA-DRB1 risk alleles and confirmed that variation in the HLA-A gene underlies the independent protective effect attributable to the class I region. Immunologically relevant genes are significantly overrepresented among those mapping close to the identified loci and particularly implicate T-helper-cell differentiation in the pathogenesis of multiple sclerosis

A study on the cerebellar mutants Staggerer, Nervous and Lurcher

Titelblatt Inhaltsverzeichnis 1\. Einführung 1.1 Allgemeine Einleitung 1.2 Das Cerebellum 1.3 Organisation und Projektionsziele corticofugaler Efferenzen 1.4 Cerebelläre Afferenzen 1.5 Histogenese 1.6 Cerebelläre Mutationen bei der Maus 1.7 Calcium-bindende Proteine als selektive Nervenzell-Marker 1.8 Funktionen und Störungen des Cerebellums 1.9 Frühere Untersuchungen als Basis zur Formulierung der Arbeitshypothese 1.10 Arbeitshypothese und Fragestellungen 2\. Material und Methoden 2.1 Versuchstiere 2.2 Antikörper 2.3 Immuncytochemie 2.4 Auswertung und Datenerhebung 3\. Ergebnisse 3.1 Einführende Bemerkungen 3.2 Bestimmung des Purkinje-Zell Verlustes und der Denervation der Kleinhirnkerne anhand von Calbindin D-28k Immuncytochemie 3.3 Parvalbumin in Neuronen der Kleinhirnkerne 3.4 Chronologische Korrelation des Purkinje-Zell Verlustes mit dem Erscheinen Parvalbumin-positiver Neurone in den Kleinhirnkernen 3.5 Bestimmung der Volumina der Kleinhirnkerne 4\. Diskussion 4.1 Technik 4.2 Existenz einer Abhängigkeit zwisachen Purkinje-Zell Verlust und Parvalbumin Expression in den Kleinhirnkernen 4.3 Bedingungen für eine Parvalbumin-Elevation in den Kleinhirnkernen 4.4 Vergleich mit Studien an anderen Mutanten 4.5 Funktionelle Implikationen der Parvalbumin-Expression für die Motorik 4.6 Weitere anterograde Effekte des Purkinje-Zell Verlustes 5\. Zusammenfassung 6\. Literaturverzeichnis 7\. Appendix 8\. DanksagungDiese Arbeit beschreibt morphologische Veränderungen in den Projektionsarealen der PC, den DCN, bei den Mäusemutanten sg, nr und Lc, die sich durch ihren selektiven Neuronenverlust im Cerebellum als Modelle für die Untersuchung von mutationsbedingten Störungen und ihren Folgeerscheinungen eignen. Durch die Auswirkungen der Mutation kommt es zu einer Umorganisation der synaptischen Verbindungen des cerebellären Cortex und damit auch zu einer Veränderung funktioneller Eigenschaften, die sich in einer Alteration motorischer Fähigkeiten äußert. Gegenstand dieser Arbeit war die Frage, inwieweit es bei diesen Mutanten in den DCN zu Veränderungen kommt, die eventuell mit einer Kompensation mutationsbedingter Defizite in Zusammenhang gebracht werden können. Entscheidend ist dabei immer der Vergleich mit dem intakten System. Der Arbeit zugrunde liegen Untersuchungen in den DCN von pcd-Mutanten, die unter einer fast vollständigen Degeneration der PC-Population leiden. Immuncytochemisch konnte in den Neuronen der DCN dieser Mutanten die Expression des Calcium-bindenden Proteins Parv nachgewiesen werden, was in Wildtypen nicht möglich ist. Hieraus wurde die Hypothese abgeleitet, dass die Parv-Expression bei Mutationen mit PC-Verlust eine generelle Antwort als Folge des reduzierten PC-Inputs darstellen könnte. Immuncytochemisch wurde diese These an den DCN der Mutanten sg, nr und Lc überprüft. Die quantitative Reduktion der PC-Population wurde durch Antikörper gegen Calbindin D-28k, einem spezifischen PC-Marker, dokumentiert. In alternierenden Schnitten wurde die Immuncytochemie mit Antikörpern gegen Parvalbumin durchgeführt. Die Ergebnisse zeigten, dass eine Abhängigkeit zwischen der Expression von Parv in den DCN und dem PC-Verlust besteht, wobei das quantitative Ausmaß, die Topographie und Chronologie des PC-Verlustes die entscheidenden Einflussgrößen sind, die über Vorhandensein oder Fehlen von Parv in den DCN entscheiden. Es konnte bewiesen werden, dass 1.) nur ein extremer PC-Input Verlust in den DCN, der eine bestimmte Schwelle überschreitet, zu einer Parv Elevation führt, 2.) Parv genau in den Arealen, in denen es zum PC-Input Verlust kommt, exprimiert wird und 3.) der PC-Terminalien Verlust in den DCN beginnen muss, bevor Parv- positive Neurone in den DCN sichtbar werden, also auch ein chronologischer Zusammenhang zwischen Terminalienverlust und Parv Elevation besteht. Trotz ihres nahezu kompletten PC-Verlustes weisen pcd-Mutanten relativ geringe motorische Defizite auf. Dies ist bei nahezu allen Mutanten, die Parv in Neuronen der DCN exprimieren, zu beobachten. Das Vorhandensein von Parv wird mit erhöhter Aktivität entsprechender Neurone in Verbindung gebracht, und Parv wird vorwiegend in inhibitorischen Neuronen lokalisiert. Möglicherweise kommt es also durch die Expression von Parv in den DCN zur Wiederherstellung verlorengegangener Hemmung, was sich stabilisierend auf die motorischen Fähigkeiten auswirkt. Die Elevation von Parv in den DCN der Mutanten stellt demnach einen Kompensationsmechanismus dar, der von Nutzen für die Motorik ist. Die Bedeutung der Parv-Elevation für die Motorik wurde im Vergleich mit Untersuchungen an anderen Mutanten und mit Transplantationsversuchen embryonaler PC, die über einen anderen Weg die Rekonstituierung verlorener Hemmung erreichen sollen, kritisch diskutiert.The present paper describes morphological changes in the projection areas of the PC, the DCN, with the cerebellar mutant mice sg, nr and Lc, which by their selective loss of cerebellar neurons, are particularly suited to serve as models for the study of disorders caused by mutations and their consequences. The mutation leads to a reorganisation of the synaptic connections of the cerebellar cortex and with it to a change of functional qualities which are expressed by motor impairment. The topic of this paper was to find out to which extent changes in the DCN of these mutants are brought about that could compensate for mutation-caused deficits. The comparison with the wildtype is in this context of crucial importance. The paper is based on studies in the DCN of pcd-mutants which suffer from an almost complete degeneration of the PC-population. By means of immunocytochemical investigations the expression of the calcium-binding protein Parv in neurons of the DCN of these mutants could be shown, which is not possible in wildtypes. From these observations the hypothesis was proposed that the Parv-expression in cerebellar mutants with PC-loss might be a general answer following the reduced PC-input. Immunocytochemically this thesis was tried to be confirmed within the DCN of the mutants sg, nr and Lc. The quantitative reduction of the PC population was proved by means of antibodies against Calbindin D-28 k, a specific PC marker. In alternating sections immunocytochemical investigations with antibodies against Parv were performed. The results show a clear dependence between the expression of Parv in the DCN and the PC-loss. The amount, the topographic localization and the chronology of PC-loss are the key factors deciding wether Parv is expressed in the DCN or not. It could be shown that 1.) only an extreme PC-input loss, which exceeds a certain threshold leads to an elevation of Parv in the DCN, 2.) Parv is expressed exactly in those areas where the PC- input loss takes place and 3.) Parv-positive neurons become visible only after the onset of PC terminal degeneration, indicating a chronolgic order between loss of PC-terminals and Parv-elevation in the DCN. In spite of their almost complete PC-loss pcd-mutants show only slight motor impairment. This is also true for all mutants, that express Parv in DCN neurons. The existence of Parv is a sign for increased activity of corresponding neurons and Parv is localized predominantly in inhibitory neurons. Possibly the expression of Parv indicates the reconstitution of lost inhibition which is a stabilizing factor for the motor activity. Thus the elevation of Parv in the DCN of the mutants could compensate for motor impairment caused by PC input loss. The significance of the elevation of Parv, concerning the motor abilities was critically discussed in context with experiments on other mutants, where embryonic PC were transplanted in order to obtain the reconstitution of lost inhibition

White-matter lesions drive deep gray-matter atrophy in early multiple sclerosis: support from structural MRI

Background: In MS, the relationship between lesions within cerebral white matter (WM) and atrophy within deep gray matter (GM) is unclear. Objective: To investigate the spatial relationship between WM lesions and deep GM atrophy. Methods: We performed a cross-sectional structural magnetic resonance imaging (MRI) study (3 Tesla) in 249 patients with clinically-isolated syndrome or relapsing-remitting MS (Expanded Disability Status Scale score: median, 1.0; range, 0-4) and in 49 healthy controls. Preprocessing of T1-weighted and fluid-attenuated T2-weighted images resulted in normalized GM images and WM lesion probability maps. We performed two voxel-wise analyses: 1. We localized GM atrophy and confirmed that it is most pronounced within deep GM; 2. We searched for a spatial relationship between WM lesions and deep GM atrophy; to this end we analyzed WM lesion probability maps by voxel-wise multiple regression, including four variables derived from maxima of regional deep GM atrophy (caudate and pulvinar, each left and right). Results: Atrophy of each deep GM region was explained by ipsilateral WM lesion probability, in the area most densely connected to the respective deep GM region. Conclusion: We demonstrated that WM lesions and deep GM atrophy are spatially related. Our results are best compatible with the hypothesis that WM lesions contribute to deep GM atrophy through axonal pathology

White-matter lesions drive deep gray-matter atrophy in early multiple sclerosis: support from structural MRI

Background: In MS, the relationship between lesions within cerebral white matter (WM) and atrophy within deep gray matter (GM) is unclear. Objective: To investigate the spatial relationship between WM lesions and deep GM atrophy. Methods: We performed a cross-sectional structural magnetic resonance imaging (MRI) study (3 Tesla) in 249 patients with clinically-isolated syndrome or relapsing-remitting MS (Expanded Disability Status Scale score: median, 1.0; range, 0-4) and in 49 healthy controls. Preprocessing of T1-weighted and fluid-attenuated T2-weighted images resulted in normalized GM images and WM lesion probability maps. We performed two voxel-wise analyses: 1. We localized GM atrophy and confirmed that it is most pronounced within deep GM; 2. We searched for a spatial relationship between WM lesions and deep GM atrophy; to this end we analyzed WM lesion probability maps by voxel-wise multiple regression, including four variables derived from maxima of regional deep GM atrophy (caudate and pulvinar, each left and right). Results: Atrophy of each deep GM region was explained by ipsilateral WM lesion probability, in the area most densely connected to the respective deep GM region. Conclusion: We demonstrated that WM lesions and deep GM atrophy are spatially related. Our results are best compatible with the hypothesis that WM lesions contribute to deep GM atrophy through axonal pathology