Pearls & Oy-sters: Gait Instability, Jaw Dystonia, and Horizontal Diplopia in a Woman with Anti-Ri Antibodies and Breast Cancer

A 40-year-old woman was admitted for 6 months of progressive gait disturbance, lower limb-predominant weakness, stiffness, falls, jaw dystonia, horizontal diplopia, and weight loss. Neurologic examination revealed horizontal gaze paresis, limited jaw opening with palpable masseter hypertrophy, and spastic paraparesis with sustained clonus and upgoing plantar responses. MRI revealed T2-hyperintense signal abnormalities in the dorsal pons, medulla, and upper cervical cord central gray matter extending to C3, without gadolinium enhancement. CSF showed mildly elevated protein and immunoglobulin (IgG) index with CSF-specific oligoclonal bands. Neural autoantibody testing was positive for anti-Ri in CSF and serum by mouse brain indirect immunofluorescence and immunoblot. Testing for aquaporin-4 (AQP4)-IgG and myelin oligodendrocyte glycoprotein (MOG)-IgG by cell-based assay was negative. The patient received methylprednisolone 1 g for 5 days and IV immunoglobulin 2 g/kg over 2 days with prednisone taper and botulinum toxin injections for jaw dystonia. PET-CT revealed an enlarged left axillary lymph node with high FDG uptake. Left axillary lymph node biopsy confirmed high-grade, locally invasive breast adenocarcinoma. Neurologic stabilization was documented at 2-week follow-up after hospital discharge before modified radical mastectomy. Our case demonstrates a clinical triad highly suggestive of anti-Ri-associated paraneoplastic neurologic syndrome (Ri-PNS): gait instability, jaw dystonia, and horizontal gaze paresis. The more slowly progressive course and poor response to immunotherapy help distinguish it from AQP4-IgG-seropositive neuromyelitis optica spectrum disorder (NMOSD) and MOG-IgG-associated disease (MOGAD) that share similar radiographic features. Early diagnosis, prompt immunotherapy, and cancer treatment are paramount for disease stabilization

SPARC expression during development and inflammation at the blood-brain barrier

SPARC (secreted protein acidic and rich in cysteine) is a cell-matrix modulating protein involved in angiogenesis and endothelial barrier function, yet a potential role in cerebrovascular repair and inflammatory responses in the central nervous system (CNS) has not previously been characterized. The inflammatory demyelinating disease, multiple sclerosis (MS) is characterized pathologically by inflammatory infiltrates, demyelination and axonal damage/loss and aberrant alterations in blood-brain barrier (BBB) integrity. We hypothesize that SPARC expression may be influenced by inflammatory or repair processes during MS, and that SPARC itself may influence BBB integrity. This study examined SPARC expression in cultured human cerebral microvascular endothelial cell (hCMEC/D3), an in vitro model of the BBB, under steady state conditions or those modeling an inflammatory milieu by immunoblotting and immunocytochemistry. hCMEC/D3s constitutively express SPARC during proliferative growth and downregulate SPARC as cells establish a BBB phenotype. SPARC expression in cerebral endothelia directly correlated with the cell proliferation marker Ki-67, consistent with a role for SPARC in CNS angiogenesis. Proinflammatory cytokines associated with inflammation and immune activation differentially regulate SPARC expression in cerebral endothelia. Tumor necrosis factor alpha (TNF-α) cytokine or lipopolysaccharide (LPS) endotoxin treatment significantly increased SPARC protein levels. TNF-α and interferon gamma (IFN-γ) cotreatment abrogated SPARC induction compared to TNF-α alone, suggesting divergent roles for each cytokine in regulating SPARC expression in cerebral endothelia. Compared to cultures replenished with media lacking exogenously supplied SPARC, addition of a physiological SPARC concentration observed in healthy individuals (0.1μg/ml) increased tight junction protein expression of zonula occludens 1 (ZO-1) and occludin by approximately thirty percent, suggesting a role in BBB maintenance. Paradoxically, functional assays show recombinant human SPARC applied exogenously increased the transendothelial permeability of hCMEC/D3 monolayers. In agreement, barrier hCMEC/D3s exposed to increased SPARC concentrations (1-10 μg/ml) associated with pathological conditions in vivo, reduced ZO-1 and occludin by one-third. Together, these data support a role for SPARC in BBB maintenance under normal physiological conditions and BBB alterations during inflammatory conditions. In this regard, SPARC levels may play a key role in regulating BBB integrity and serve to alter processes of CNS inflammation and repair.Medicine, Faculty ofMedicine, Department ofExperimental Medicine, Division ofGraduat

The Spectrum of Psychiatric Pathology in a Patient with Genetically Verified Huntington’s Disease

Psychiatric and behavioral disturbances are common in Huntington’s disease (HD) and contribute significantly to its morbidity and mortality. We herein present the case of a 43-year-old woman with genetically verified HD, whose deteriorating psychiatric condition necessitated multiple inpatient psychiatric hospitalizations and featured a clinical spectrum of neuropsychiatric disturbances classically associated with HD. This paper reviews the literature concerning Huntington’s psychopathology and provides an illustrative case example of its clinical nature

SPARC expression by cerebral microvascular endothelial cells in vitro and its influence on blood-brain barrier properties

Background: SPARC (secreted protein acidic and rich in cysteine) is a nonstructural, cell-matrix modulating protein involved in angiogenesis and endothelial barrier function, yet its potential role in cerebrovascular development, inflammation, and repair in the central nervous system (CNS) remains undetermined. Methods This study examines SPARC expression in cultured human cerebral microvascular endothelial cells (hCMEC/D3)—an in vitro model of the blood-brain barrier (BBB)—as they transition between proliferative and barrier phenotypes and encounter pro-inflammatory stimuli. SPARC protein levels were quantified by Western blotting and immunocytochemistry and messenger RNA (mRNA) by RT-PCR. Results Constitutive SPARC expression by proliferating hCMEC/D3s is reduced as cells mature and establish a confluent monolayer. SPARC expression positively correlated with the proliferation marker Ki-67 suggesting a role for SPARC in cerebrovascular development. The pro-inflammatory molecules tumor necrosis factor-α (TNF-α) and endotoxin lipopolysaccharide (LPS) increased SPARC expression in cerebral endothelia. Interferon gamma (IFN-γ) abrogated SPARC induction observed with TNF-α alone. Barrier function assays show recombinant human (rh)-SPARC increased paracellular permeability and decreased transendothelial electrical resistance (TEER). This was paralleled by reduced zonula occludens-1 (ZO-1) and occludin expression in hCMEC/D3s exposed to rh-SPARC (1–10 μg/ml) compared with cells in media containing a physiological dose of SPARC. Conclusions Together, these findings define a role for SPARC in influencing cerebral microvascular properties and function during development and inflammation at the BBB such that it may mediate processes of CNS inflammation and repair.Medicine, Faculty ofScience, Faculty ofNon UBCMedicine, Department ofPathology and Laboratory Medicine, Department ofZoology, Department ofReviewedFacult

Metastatic Adenocarcinoma of Unknown Origin Presenting as Small Bowel Perforation

Metastatic malignant tumors that originate from occult primaries are defined as “cancers of unknown origin.” We herein present the case of a 59-year-old man who presented with small bowel perforation secondary to metastatic adenocarcinoma of an unknown primary site. Imaging exhibited two pulmonary nodules, neither of which was dominant, along with mediastinal and retroperitoneal lymphadenopathy. Immunohistochemical profiling of the small bowel biopsy specimens revealed the tumor was most likely pulmonary in origin

Additional file 1: Figure S1. of SPARC expression by cerebral microvascular endothelial cells in vitro and its influence on blood-brain barrier properties

Subconfluent hCMEC/D3 regions exhibit more intense SPARC expression than confluent regions by regional immunocytochemistry analysis. SPARC intensity was measured in mean pixel intensity (MPI ± SD) for selected cell-covered regions. SPARC staining in the subconfluent cultures (3.85 ± 0.49, n = 21 images, 7 from each triplicate well) was greater than that in the confluent cultures (2.83 ± 0.43, n = 14 images, 7 from each duplicate well). Bars represent the average of results from n = 21 and n = 14 images, respectively. Error bars represent SD. Data were analyzed for regional SPARC MPI in one experiment. Mann-Whitney comparison test, ***P < 0.0001. (TIF 40 kb