Experimental axonopathy induced by immunization with Campylobacter jejuni lipopolysaccharide from a...

Abstracts of the 9th Meeting of the Italian Peripheral NerveStudy Group (Joint Meeting with the Italian Association

of Myology)

Taormina, May 6^8, 2004

Organizing Committee: Giuseppe Vita, Paolo Girlanda, Antonio Toscano, Carmelo Rodolico,

Anna Mazzeo, M’hammed Aguennouz; Department of Neuroscience, University of Messina

A CASE OF INSENSITIVITY TO PAIN WITHOUT

ANHIDROSIS: A NEW SYNDROME?

Sandroni P. Department of Neurology, Mayo Clinic,

Rochester, MN, USA.

Case Report: A 20-year-old man presented for evaluation

following an episode of painless injury in which he almost

amputated his thumb. Upon further questioning, the patient

reported he rarely experienced physical (including visceral)

pain and his mother provided support to his history recalling

incidents occurring as a child. He does not experience itching

either. His neurologic and general medical history was other-

wise negative. His neurologic and general examination were

unremarkable except for the inability to perceive painful (pin-

prick, pressure on Achilles’ tendons), hot and cold stimuli over

his entire body, with some relative sparing over his chest, abdo-

men and back. Nerve conduction studies and needle examina-

tions were normal. Quantitative sensory testing revealed

normal threshold to vibration, relatively elevated threshold to

cold and insensitivity to heat and pain. Autonomic reflex screen

and thermoregulatory sweat test were normal. Sural nerve

biopsy showed normal myelinated and unmyelinated fibers.

MRI of head and cervical spine, and extensive laboratory testing

were unremarkable. Conclusion: This patient differs from any

other case described in the literature of pain insensitivity or pain

indifference. Suspecting a central pathology, we prescribed

naltrexone and retested his heat-pain sensation after treatment.

He perceived the probe as hotter. Unfortunately, he suffered

unacceptable dysthymia from the medication and stopped it.

RAT IN VIVO MODELS OF TAXANES’ PERIPHERAL

NEUROTOXICITY FOLLOWING CHRONIC INTRAVENOUS

ADMINISTRATION

Canta A, Lanzani F, Galbiati S, Frigeni B, Giussani G,Marmiroli P,Tredici G,Traebert M*, Mu« ller L*, Cavaletti G.D.N.T.B., Universita di Milano ‘‘Bicocca’’, Monza, Italy,

*Novartis Pharma AG, Basel, Switzerland.

The ‘‘taxanes’’ family includes some widely used antineo-

plastic agents, such as paclitaxel and docetaxel. Treatment

with these microtubule-stabilizing drugs is often associated

with neurotoxicity, a potentially severe side effect limiting the

clinical utility of these agents. To study the pathogenesis of

taxanes’ neurotoxicity and to compare it to the effect of new

agents, the availability of reliable in vivomodels iswarranted. In

this study we developed chronic iv models for the assessment

of ‘‘taxanes’’ peripheral neurotoxicity. Forty-eight adult Wistar

rats were divided into six groups of 8 animals each and treated

as follows: paclitaxel or docetaxel at doses of 5, 10, 12.5mg/kg

1q7d� 4 via a chronic jugular vein implant. The evaluation was

based on the assessment of body weight and survival as a

measure of general tolerability, and on the measurement of tail

nerve conduction velocity, a neurophysiological method pre-

viously used in animalmodels of toxic peripheral neuropathies. The

resultswere comparedwith those obtained in untreated or vehicle-

treated control rats. A clear dose-dependent effect was evident

both on general toxicity, and on neurophysiological changes mea-

sured at the endof the treatment (untreated controls¼ 41,9m/sec,

vehicle¼ 40,3m/sec; paclitaxel 5mg/kg¼ 32,5m/sec, 10mg/

kg¼ 28,5m/sec, 12.5m/kg¼ 27,4m/sec; docetaxel 5mg/

kg¼ 33,6m/sec, 10mg/kg¼ 27,8m/sec, 12.5mg/kg¼ 27,0m/

sec), demonstrating the usefulness of this new model system

to investigate peripheral neurotoxicity mediated by taxanes, and

potentially other drugs, under chronic treatment schedules.

INTRAEPIDERMAL INNERVATION AND TAIL NERVE

CONDUCTION VELOCITY IN NEUROTOXICITY MODELS:

RESULTS OF A CORRELATION STUDY IN NORMAL AND

PATHOLOGICAL CONDITIONS

BorgnaM�, Lombardi R�, Lauria G�00, Grezzi P , Savino C^,Bianchi R^, Oggioni N*, Canta A#, Lanzani F#, Galbiati S#,Frigeni B#, Giussani G#,Tredici G#, Cavaletti G#. �IstitutoNeurologico ‘‘C. Besta’’, Milano, ‘‘ Clinica Neurologica,

Universita di Brescia, ^Lab. Neuroimmunologia, Ist.Ricerche

Farmacologiche ‘‘M. Negri’’, Milano, *CTI Europe, Bresso,#D.N.T.B. Universita di Milano Bicocca, Monza.

Animal models of human diseases affecting the

peripheral nervous system are widely used to assess the

pathogenesis of neurotoxicity and to compare the effect of

Journal of the Peripheral Nervous System 9:104–125 (2004)

� 2004 Peripheral Nerve Society, Inc. 104 Blackwell Publishing

new agents. Several behavioural, pathological and neurophy-

siological methods have been used, and each has advan-

tages and disadvantages. A major goal in the study of

neurotoxicity would be to assess the damage in the same

way in animal models and in humans. In this study we

correlated the neurophysiological results obtained in normal

rats and in rats treated with cisplatin 2mg/kg q3d� 8 with

the density of intraepidermal fibers (IEF) obtained in skin

biopsy specimens. The aim was to investigate the possible

role of a minimally invasive procedure such as skin biopsy as

an alternative method to assess the peripheral neurotoxicity

of antineoplastic drugs. The nerve conduction velocity (NCV)

in the tail nerve was assessed in thirty-six young adult female

Wistar rats which were left untreated, or treated with ery-

thropoietin (EPO), cisplatin (CDDP) or EPOþCDDP. CDDP

and CDDPþEPO-treated rats had a significantly reduced

NCV vs. age-matched untreated rats. At sacrifice, skin speci-

mens were obtained. The density of IEF was calculated by 2

independent blinded examiners and the correlation existing

between NCV and IEF was highly significant (r¼ 0.670,

p< 0.001). This preliminary result suggests that IEF should

be evaluated in other animal models and might represent a

useful tool to study peripheral neurotoxicity also in humans.

TOTAL NEUROPATHY SCALE ITEMS AS EARLY

PREDICTORS OF CHEMOTHERAPY-INDUCED

PERIPHERAL NEUROTOXICITY

Piatti M, Bogliun G*, Marzorati L*, ZinconeA*, Giussani G,Colombo N^, Parma G^, Lissoni A00#, Fei F00#, Cundari S‰,Zanna C‰, Cavaletti G. D.N.T.B., Universita di Milano

‘‘Bicocca’’, Monza, *Clinica Neurologica, A.O. S. Gerardo,

Monza, ^Dipartimento di Ginecologia Oncologica, Istituto Eur-

opeo di Oncologia, Milano, 00Dipartimento di Scienze Chirur-

giche, Universita di Milano ‘‘Bicocca’’, Monza, #Clinica

Ginecologica, A.O. S. Gerardo, Monza, §Sigma-Tau ifr,

Pomezia.

We investigated the possible use of individual Total

Neuropathy Scale (TNS) items to predict the neurological

outcome in patients undergoing cisplatin and paclitaxel com-

bination chemotherapy in a series of thirty-four women

divided, according to the worst TNS score reached during

the period of observation, into three groups, i.e. with a score

<5 (n¼ 14), >5 but <10 (n¼ 5) or >10 (n¼ 15). At the visit

performed before the onset of the worst neuropathy signs,

14 out of the 15 patients with the worst TNS had a change of

2 or more points in the sum of the semiquantitative vibration

score (tuning fork) plus the DTR examination. In 12 of them

the change was due to both vibration perception and DTR

impairment. A change in the combined score was observed

also in 7 out of the 14 patients with the better neurological

outcome, but none of them had any change in the vibration

perception. Early disappearance of DTR in the lower limbs

(i.e. both ankle and patellar reflexes bilaterally) was observed

in 7 out of the 15 patients with a worst outcome, while only 1

patient in the better outcome group had this clinical sign. The

results of the VDT score obtained with a vibrameter did not

improve the accuracy of the neurological assessment. Our

study indicates that the accurate clinical evaluation of the

patients treated with platinum and taxane combination poly-

chemotherapy can be used to predict the final neurological

outcome of the treatment.

THALIDOMIDE SENSORY NEUROTOXICITY: RESULTS OF

A COLLABORATIVE CLINICAL AND NEUROPHYSIOLGICAL

STUDY

Cavaletti G1, BeronioA2, Reni L2, Ghiglione E2, SchenoneA2,Briani C3, Zara G3, Cocito D4, IsoardoG4, Ciaramitaro P4,Plasmati R5, Pastorelli F5, FrigoM6, Piatti M1, CarpoM7. TheItalian Network for the Study of Chemotherapy-Induced Per-

ipheral Neurotoxicity (NETox), 1Universita di Milano Bicocca,

Monza, 2Universita di Genova; 3Universita di Padova, 4Univer-

sita di Torino, 5Ospedale Bellaria, Bologna, 6Ospedale S. Ger-

ardo, Monza, 7Universita di Milano, IRCCS Ospedale Maggiore

Policlinico, Milano.

Despite long-lasting use, several features of thalidomide

neurotoxicity have yet to be resolved. A more detailed know-

ledge of thalidomide-induced sensory neurotoxicity is desir-

able, particularly in view of the future use of thalidomide

derivatives which are currently under investigation. Our

study demonstrates that thalidomide sensory neurotoxicity

is cumulative dose-dependent, but this effect is evident only

when the dose is relatively high (in our study >20 g). In fact,

the risk of developing sensory neuropathy is low (around

10%) below this threshold, while it steadily increases with

increasing cumulative doses. In our series, a discrepancy

between clinical and neurophysiological results was frequent

when a low cumulative dose of thalidomide was adminis-

tered. Regarding the need for thalidomide withdrawal at the

onset of any evidence of peripheral neuropathy, we followed

up the course of seven patients who were clinically and

neurophysiologically normal at baseline, but had treatment-

induced neurotoxicity and a very severe change in their

SAPs. In all these cases the thalidomide dose was reduced

and no clinically-relevant worsening was observed despite a

further marked reduction in their SAPs. This finding suggests

that thalidomide withdrawal is not mandatory even in the

presence of marked abnormalities in sensory neurophysi-

ological parameters, provided that an accurate clinical fol-

low-up is guaranteed and the dose is adjusted.

MULTINEUROPATHY IN A PATIENT WITH HBV

INFECTION, POLYARTERITIS NODOSA AND CELIAC

DISEASE

Squintani G, Ferrari S, Refatti N, Capra F*, Caramaschi P ,RizzutoN,Tonin P.Dipartimento di Scienze Neurologiche e

della Visione, Sezione di Neurologia Clinica, *Medicina

Interna A, ^Medicina Interna B, Policlinico G.B. Rossi,

Verona.

A 53-year-old man came to our observation for impaired

gait and painful paresthesia in his hands and feet. Three

years before he suddenly presented tingling in his hands,

followed, after a few months, by paresthesia in his feet,

IPNS Abstracts Journal of the Peripheral Nervous System 9:104–125 (2004)

105

weakness of the right hand and foot and cutaneous

erythema. Nearly one year after the onset, he presented

left abducens nerve palsy that completely resolved in three

months with steroid therapy. The patient’s conditions pro-

gressively worsened and when he was admitted to our clinic

the neurological examination revealed a stepping gait and

severe muscular atrophy. Sensory abnormalities involved

pin, light touch and vibration perception. In three years he

had severe weight loss. Blood test revealed HBV infection

and high levels of antibodies to transglutaminase, endomy-

sium, and gliadin. EMG showed sensorimotor asymmetric

axonal neuropathy. Nerve biopsy showed fiber loss, axonal

degeneration with asymmetrical distribution and focal ischae-

mia. A duodenal biopsy was consistent with celiac disease.

The patient was treated with high dose steroids, plasma

exchange, immunoglobulin and lamivudine and began a

gluten-free diet. At discharge he could walk unassisted; sen-

sory abnormalities were greatly reduced. One year later a

new duodenal biopsy showed a complete resolution of the

pathological abnormalities. Celiac disease, a chronic inflam-

matory intestinal disease whose pathogenesis involves a

HLA DQ2-DQ8 restricted T-cell immune-reaction, can be

related to a higher risk of autoimmune disorders, such as

insulin-dependent diabetes or thyroid disease. We report the

association of celiac disease, polyarteritis nodosa and HBV

infection in a patient who developed a neuropathy and

discuss the pathogenetic implications.

PRO-INFLAMMATORY CYTOKINES INDUCE

DIFFERENTIATION IN CULTURED SCHWANN CELLS

Conti G, Baron PL, Scarpini E, Bresolin E, De Pol A*. IRCCSOspedale Maggiore Policlinico, Department of Neuro-

logical Sciences, ‘‘Dino Ferrari’’ Centre, University of

Milan, Italy, *Department of Morphological Sciences,

University of Modena, Italy.

During cell-mediated demyelination of the peripheral

nervous system (PNS), pro-inflammatory cytokines have a

predictable pattern of expression and appear to be involved

in damaging the myelin sheath and the axon. However, the

role of these molecules regarding Schwann cell life and

death is still controversial. In fact, some pro-inflammatory

cytokines act synergistically to kill PNS glial cells, but besides

Schwann cell death they can induce cell proliferation, and

both processes are related to cytokine dosage and time of

exposure. In this preliminary study we stimulated Schwann

cell cultures with 10U/ml interleukin-1 beta and 50U/ml

interferon-gamma for 24, 48 and 72 hours. As previously

reported we observed the peak of cell death and proliferation

by 24 hours with both cytokines. At this time point, interest-

ingly, in few Schwann cells belonging to the cytokine treated

cultures and not to the untreated control cultures, we

observed by electron microscopy analysis a cellular differen-

tiation towards a myelin forming phenotype, even though our

cultures were axon free as we have detected by immuno-

cytochemical analysis with neurofilament antibody. In con-

clusion, we think that pro-inflammatory cytokines besides

promoting Schwann cell death and proliferation might be

involved in the processes of cellular differentiation.

INCREASE OF PRO-INFLAMMATORY CYTOKINES IN

CHRONIC SENSORY ATAXIC NEUROPATHIES

Sanvito L*, Santuccio G*, Speciale L‰, Sgandurra M*,Merlino L*, Ceresa L*, Ferrante P‰, Nemni R*. *Department

of Neurology and §Laboratory of Biology, Don Carlo

Gnocchi Foundation, University of Milan.

Chronic sensory ataxic neuropathies (CSAN) are charac-

terised by a predominant involvement of sensory large fibers.

We previously demonstrated the presence of serum anti-

bodies against neuropathy-related antigens in about 50% of

these patients. The aim of our study was to analyse periph-

eral T and B cell subsets and cytokine network in CSAN

patients in order to evaluate their immunological profile. We

studied 10 CSAN patients. ELISA test detected the presence

of neuropathy-related autoantibodies in 5 out of 10 patients.

We evaluated, by flow cytometry, CD3þ, CD3þDRIIþ,

CD4þ, CD8þ, CD16þ and CD19þ cells subset distribution,

and intracellular IL2, INFg, IL1, IL6, IL10 and TNFa production

by CD4þ, CD8þ and CD14þ cells. Results were compared

with healthy controls (HC); statistical analysis was per-

formed. Compared to HC, CSAN patients showed no signifi-

cant difference in lymphocyte subset distribution. We found

a significant increase of IL6 in CD4þ, CD8þ and CD14þcells. INFg and TNFa were increased in CD4þ cells. TNFa

was decreased in CD14þ. Our results show an increase of

pro-inflammatory cytokines not associated with imbalance of

T and B cells subsets. These data support an activation of the

immune system in CSAN, as previously suggested by the

detection of neuropathy-related autoantibodies.

IMMUNOLOGIC PROFILE IN CHRONIC INFLAMMATORY

POLYNEUROPATHIES ASSOCIATED OR NOT

ASSOCIATED WITH MGUS

Santuccio G*, Sanvito L*, Speciale L‰, Merlino L*,Sgandurra M*, Ceresa L*, Ferrante P‰, Nemni R*. *Depart-

ment of Neurology and §Laboratory of Biology, Don Carlo

Gnocchi Foundation, University of Milan.

Chronic inflammatory polyneuropathies (CIP) may be

associated with monoclonal gammopathies (MGUS) directed

or not against neuropathy-related antigens. We analysed per-

ipheral T and B cell subsets and cytokine network in 13

patients with CIP without MGUS (CIP), 10 with CIP with

MGUS anti-MAG (CIP-MAG) and 5 with CIP with MGUS

without anti-MAG activity (CIP-MGUS). We evaluated, by

flow cytometry, CD3þ, CD3þDRIIþ, CD4þ, CD8þ,

CD16þ and CD19þ cells subset distribution, and intracellular

IL2, INFg, IL1, IL6, IL10 and TNFa production by CD4þ,

CD8þ and CD14þ cells. Results were compared with age-

matched healthy controls (HC); statistical analysis was per-

formed. Compared to HC, CIP patients had a significant

decrease of CD3þ and B cells, CIP-MAG patients had an

increase of CD3þ and NK and a decrease of CD3þDRIIþ


106

and B cells. Comparing the different subgroups, we found a

decrease of CD3þDRIIþ and B cells in CIP-MAG versus CIP,

and an increase of CD4þ in CIP-MGUS versus CIP. Com-

pared to HC, CIP showed an increase of INFg in CD4þ and of

IL6 in CD14þ. CIP-MAG showed an increase of IL10 in

CD4þ, IL1 and IL10 in CD8þ, and IL1 in CD14þ, versus HC

and other subgroups. Our results suggest that in CIP-MAG

patients it is possible to identify a distinct immunological

profle.

PHRENIC NERVE CONDUCTION STUDY IN CIDP

Ciaramitaro P1, Poglio F2,Tavella A2, Rota E2, Prolasso I2,Isoardo G3, Baldi S3, Cocito D2. 1Neurofisiologia Clinica,

Ospedale CTO, Torino, 2Neurologia I, A.S.O. San

Giovanni Battista, Torino, 3Neurologia, Ospedale Civile,

Asti, 4Pneumologia, A.S.O. San Giovanni Battista, Torino.

Background: Alterations of the phrenic nerve (FN), as

well as of the pulmonary function tests (PFTs), have been

described in patients with chronic inflammatory demyelinat-

ing polyneuropathy (CIDP). Objective: Our study was aimed

at assessing the relationship between FN conduction study

and respiratory function in 24 CIDP patients without clinical

signs of respiratory failure. Material and Methods: Bilateral

FN and right median nerve conduction studies were accom-

plished, along with emogasanalysis (EGA) and PFTs: maximal

inspiratory pressure (MIP), maximal expiratory pressure

(MEP), forced vital capacity (FVC) and partial CO2 pressure.

Results: The amplitude of the compound muscle action

potential (CMAP) of the FN was altered in 19 (79%) of our

24 patients, the latency in 22 (92%). Eighteen patients (75%)

showed at least one PFT or the pCO2 abnormal. FN

alterations showed a low sensitivity and specificity with

respect to PFTs or pCO2. Discussion: Our results demon-

strated electrophysiological alterations of the FN in a high

percentage of CIDP patients. No significant correlation was

observed between FN and PFTs alterations.

AGREEMENT BETWEEN DIAGNOSTIC HYPOTHESIS AND

RESULTS OF THE ELECTRODIAGNOSTIC TESTS

Tavella A1, Ciaramitaro P2, Costa P2, Paolasso I1, Poglio F1,Duranda E1, Cocito D1. 1Neurologia I, Dipartimento di

Neuroscienze, A.S.O. San Giovanni Battista, Torino,2Neurofisiologia Clinica, UOA Neurochirurgia, Ospedale

CTO, Torino.

Descriptive study will be carried out on patients exam-

ined in the neurophysiology laboratory of Neurological Clinic

of Turin University and in the neurophysiology laboratory of

C.T.O. Hospital of Turin in the period February-April 2004.

Our purpose is to evaluate the following issues: 1) physicians

requiring electrodiagnostic (EDX) test (general and/or specia-

list practitioner), 2) diagnostic hypothesis or the symptoma-

tology reported from the patients that have induced the

doctor to demand the test and 3) the agreement or disagree-

ment with results of EDX test. Moreover, the outcome of

EDX study will be compared with eventual previous EDX

tests. Anagraphic data and the profession of the patient,

eventual presence of concomitant pathologies or therapeutic

use of neurotoxic drugs, possible responsibilities of periph-

eral nervous system diseases, will be also investigated. Our

goal is to evaluate the appropriateness of the EDX test rela-

tive to requiring physicians (general or specialist practitioner).

We would also improve efficiency of the service, optimizing

the economic and human resources, and reducing the

number of inappropriate EDX tests.

PREDICTIVE VALUE OF CLINICAL,

ELECTROPHYSIOLOGICAL AND IMMUNOLOGICAL

FEATURES FOR RESPONSE TO IVIG IN PATIENTS WITH

CIDP

Isoardo G1, Rota E2, Ciaramitaro P3,Tavella A2, Poglio F2,Prolasso I2, Cocito D2. 1Neurologia, Ospedale Civile, Asti,2Neurologia I, Dipartimento di Neuroscienze, A.S.O. San

Giovanni Battista, Torino, 3U.O.A. Neurochirurgia, U.O.

Neurofisiologia Clinica, Ospedale CTO, Torino.

Aims: To investigate the features which are most pre-

dictive of IVIg response in patients with CIDP. Methods: We

included 38 consecutive CIDP diagnosed according to Rotta

et al. (2000). Anti-MAG antibodies (Ab) assay and serum

immunofixation were performed in all. IVIg (0.4 g/Kg/day)

were the first treatment in all patients. Response to IVIg

was defined as increase by at least 1 grade of the Rankin

scale score at 1 month. The following features were consid-

ered: 1) proximal as well as distal weakness, 2) pure clinical

sensory pattern, 3) disease duration lower than 12 months,

4) conduction block in at least 1 motor nerve, 5) mean lower/

upper limbs motor nerve CMAP amplitude lower than 50%

of lower limit of normal, 6)M monoclonal gammopathy, and

7) anti-MAG Ab. Likelihood ratio (LR) of the features signifi-

cantly associated with treatment response was evaluated in

order to determine the increase or decrease of response to

IVIg probability. Results: Twenty-six patients were classified

as responders and 12 as non-responders. Age (60.6� 9.7 vs.

63.6� 9.4 years), disease duration (24 vs. 42 months) and

sex ratio (18 vs. 9 male) were not different among the

groups. Presence of conduction block in at least one motor

nerve was associated significantly with treatment response

(responders 50% vs. non-responders 8.3%, p: 0.02) and

presence of anti-MAG Ab was associated with treatment fail-

ure (non-responders 50% vs. responders 7.6%, p: 0.007).

The remaining features were not significantly associated

with treatment response. LR of presence on conduction

block was 6, whereas LR of anti-MAG Ab was 0.15. Consid-

ering 70% as mean percentage of responders, the finding of

conduction blocks increase the probability of response to

IVIg to 89%, whereas the finding of anti-MAG antibody

decreases this probability to 25%. Conclusion: Presence of

conduction blocks and absence of anti-MAG antibodies seem

to be good predictors of response to IVIg in patients with

CIDP.


107

CIDP ASSOCIATED WITH LUNG CANCER: A

PARANEOPLASTIC DISEASE?

Fazio R, Malaguti MC, Molinari E, Previtali S, Del Carro U,Amadio S, Comi G, Quattrini A. Dept. of Neuroscience,

University Vita e Salute, S. Raffaele Hospital.

We describe a 65-year-old smoker male followed for five

years for a pure motor demyelinating peripheral neuropathy.

The patient had a monthly motor relapse with severe weak-

ness restricting him to a wheelchair, so he needed monthly

high dose IVIg. On EMG the MCV were very slowed (30m/

sec) without evidence of conduction blocks while SCV were

in the normal range. CSF disclosed a high protein level.

Laboratory findings did not reveal any other abnormality

except for the presence of monoclonal gammopathy IgMk

and high titer anti GD1a serum IgM antibodies (1:5000). In

March 2003 he had the most severe relapse with flaccid

tetraplegia and respiratory failure so severe that he required

ventilatory support. A total body CT scan revealed a nodular

lung lesion with diffuse lymphangiitis. Biopsy disclosed a

lung adenocarcinoma with a severe infiltration of CD8 cells.

Surgical eradication of the tumor caused the last severe

relapse. At the moment the patient is relapse-free and no

more treatment was administered. The clinical course of the

motor demyelinating relapsing neuropathy suggests a pos-

sible paraneoplastic pathogenesis of the neurological illness

also supported by the severe inflammatory infiltration of the

tumor.

SOLITARY PLEXIFORM NEUROFIBROMA PRESENTING AS

PURELY MOTOR AXONAL CERVICAL PLEXOPATHY

Terenghi F, Grimoldi N, Costa A, Nobile-Orazio E. Dept.

Neurological Sciences, Milan University, IRCCS

Ospedale Maggiore Policlinico, Milan, Italy.

A 27-year-old male presented with three years of pro-

gressive weakness and atrophy in his right arm. He did not

have sensory complaints or pain but occasional proximal arm

dysesthesias. Neurological examination showed severe right

shoulder girdle atrophy and proximal limb weakness affecting

muscles supplied by the fifth and sixth cervical roots.

Strength was normal distally in the right arm and in the

other limbs. Deep tendon reflexes were normal. Sensation

was normal. Laboratory studies showed increased creatine

kinase levels. Anti-GM1 IgM antibodies were not found.

Electrodiagnostic studies were consistent with either focal

motor neuronopathy or right brachial plexopathy involving the

upper trunk. Nerve conduction studies did not show conduc-

tion blocks or slow conduction velocity. The CMAP amplitude

of the right median nerve was normal. EMG showed chronic

denervation and fibrillation potentials in paraspinal and arm

muscles innervated by right C5–C6. MRI studies revealed

markedly increased signal intensity on T2-weighted images

of the fifth and sixth right cervical roots and upper trunk of

right plexus with contrast-enhanced T1-weighted images. A

provisional diagnosis of motor axonal inflammatory plexopa-

thy was made based on the purely motor focal deficit,

increased creatine kinase levels and enhancing focal hyper-

trophic roots on MRI, as described in CIDP and MMN. The

patient was treated with high dose IVIg 2 g/Kg over four days

with no improvement. Two months later a biopsy of enlarged

cervical root revealed a plexiform neurofibroma. The patient

did not have a family history or other typical abnormalities of

neurofibromatosis (NF1), including cafe-au-lait spots, skin

fold freckling, Lisch nodules in the iris and bone dysplasia.

Solitary plexiform neurofibroma may occur in patients

without other stigmata of NF1 and should be considered in

the differential diagnosis of purely motor focal inflammatory

radiculoplexopathy.

14-3-3 PROTEIN IN THE CSF OF INFLAMMATORY

PERIPHERAL NEUROPATHIES

BersanoA, Allaria S, Nobile-Orazio E. Department of Neu-

rological Sciences, University of Milan, IRCCS Ospedale

Maggiore Policlinico, Milan, Italy.

14-3-3 proteins are a highly conserved protein family of

unknown function, although some authors suggested a role

in cellular proliferation and differentiation, neurotransmitters

biosynthesis and apoptosis. The expression of these proteins

increases during development, in particular, in large projection

neurons such as spinal motor neurons. Recently the protein

was described in cerebrospinal fluid (CSF) of patients with

spongiform encephalopathies, in particular Creutzfeld-Jacob

disease, where the protein is considered a highly sensitive

and specific marker. 14-3-3 protein has been also detected in

CSF of other prion-unrelated dementias and other neurode-

generative (Parkinson disease, stroke and paraneoplastic syn-

dromes) and inflammatory diseases like Multiple Sclerosis.

The aim of our study was to evaluate whether the 14-3-3

protein is also present in the CSF of peripheral nervous system

diseases. We studied by Western Blot the CSF of 120 patients

including 38 with Guillain-Barre syndrome (GBS), 23 with

chronic inflammatory demyelinating polyneuropathy (CIDP),

12 with multifocal motor neuropathies (MMN), 20 motor

neuron disease (MND), 8 paraneoplastic syndrome, 14 other

neuropathies or radiculopathies (OPN), and 5 normal subjects

(NC). We found the 14-3-3 protein in the CSF of 21 (55%)

patients with GBS, 13 (56%) with CIDP, 1 (5%) with MND, 3

(21%) with OPN and none with paraneoplastic syndrome,

MMN or NC. Our results reveal that 14-3-3 protein can be

detected not only in central but also in peripheral nervous

system diseases where it is significantly associated

(p< 0.0001) with GBS and CIDP.

PERIPHERAL NERVOUS SYSTEM INVOLVEMENT AS

PRESENTING SYMPTOM OF SYSTEMIC B-CELL

LYMPHOMA

Casellato C, DiTroia A,Terenghi F, Nobile-Orazio E. Dept.

Neurological Sciences, Milan University, IRCCS

Ospedale Maggiore Policlinico, Milano, Italy.

Peripheral nervous system involvement has been

reported in systemic B or T cell lymphoma and may result

from intraneural localization of lymphoma resulting in

meningo-radiculopathy or mononeuropathies, or manifest as


108

a sensory-motor polyneuropathy sometimes mimicking

chronic inflammatory demyelinating polyneuropathy. We

report two patients with a previously unknown NHL present-

ing in both with a stepwise progressive asymmetric multi-

radiculoneuropathy initially misdiagnosed as inflammatory

radiculopathy. A 58-year-old man presented with a 2 year

history of stepwise progressive peroneal sensory loss,

impotence, and lower limb painful asymmetric neuropathy.

Lumbosacral MRI was normal. Electrophysiological studies

were consistent with an axonal multiradiculoneuropathy

while CSF examinations repeatedly showed increased pro-

tein levels (80–91mg/dl) with slightly increased white cells

(<10mm3) but no malignant cell. The patient repeatedly

failed to respond to steroids although he consistently dete-

riorated at their suspension. An MRI performed 2 years later

when multiple cranial nerve palsies appeared showed bilat-

eral T1 and T2 hyperintensities in the brain and cervical spinal

cord. An extensive investigation for neoplasm was negative.

The patient died from an intracranial hemorrhage during

anticoagulant therapy for deep vein thrombosis. Autoptic

studies revealed a widespread non-Hodgkin’s type B lym-

phoma with massive systemic and neural involvement

including cauda equina and spinal cord. A 54-year-old man

presented with a 1 year history of impotence, urinary incon-

tinence, progressive asymmetric painful distal sensorimotor

impairment at four limbs and prominent weight loss. Four

previous CSF examinations revealed increased protein levels

(80–100mg/dl), and slightly but inconsistently increased

white cells (1–11/mm3) but no malinant cells. Steroids were

repeatedly ineffective although the patient consistently dete-

riorated whenever steroids were discontinued. On admission

electrophysiological studies showed an axonal asymmetric

polyradiculoneuropathy. Brain and spinal MRI was normal

while bone marrow biopsy and aspiration disclosed a B cell

lymphoma.

PARANEOPLASTIC SUBACUTE SENSORY

NEURONOPATHY ASSOCIATED WITH ANTI-RI

ANTIBODIES

Fasolino M, Sabatini P*, CuomoT, Liguori G. U.O. Neuro-

logia – *U.O. Patologia Clinica Ospedali Riuniti delle Tre

Valli – ASL Salerno 1, Nocera Inferiore (SA).

Introduction: Subacute sensory neuronopathy (SSN) is

characterized by degeneration of T cells of dorsal root gang-

lia. This syndrome is associated with autoimmune diseases

(i.e., Sjogren’s Syndrome), tumours (i.e., small-cell lung can-

cer), or idiopathic. Paraneoplastic SSN is frequently asso-

ciated with the presence in the serum of anti-Hu antibodies

(or ANNA 1). Conversely, anti-Ri antibodies (or ANNA 2) have

been associated with paraneoplastic neurological syndromes

as opsoclonus-myoclonus or cerebellar degeneration. Case

Report: A 62-year-old man presented subacute back pain,

gait difficulty, four limbs movement uncoordination and

paresthesias/dysesthesias. Neurological examination also

revealed involuntary pseudoathetoid movements at upper

limbs, loss of vibration sense at lower limbs and diffuse

absence of deep tendon reflexes. Nerve conduction studies

revealed an axonal sensory polyneuropathy. Cerebrospinal

fluid proteins were raised, with increased cell count. Chest

CT disclosed a lung neoplasm. Serum anti-Ri antibodies were

detected using indirect immunofluorescence and confirmed

by Western blotting, while anti-Hu were absent. Conclusion:

We report a case of paraneoplastic subacute sensory neuro-

nopathy associated with serum anti-Ri antibodies. To our

knowledge this is the first description of such an association.

IS CARPAL TUNNEL SYNDROME SURGERY USEFUL IN

PATIENTS WITH DIABETES OR AUTOIMMUNE

POLYNEUROPATHIES?

Caliandro P1,Mondelli M3, Aprile I1,2, Pazzaglia C, Sabatelli M1,Tonali P1, Padua L1,2. 1Department of Neuroscience, Institute

of Neurology, Universita Cattolica, L.go F. Vito 1, 00168 Rome,

Italy; 2Fondazione Don C. Gnocchi Roma; 3Servizio di EMG,

ASL 7 Siena.

In the neurological ‘out-patient’ department, focused on

neuropathies, we have to deal with two common diseases:

diabetic neuropathy and autoimmune neuropathies. Carpal

tunnel syndrome is the most frequent neurological syn-

drome. It is difficult to assess if, in a diffuse peripheral

nerve involvement or in systemic condition that may involve

nerves, as diabetes, an entrapment condition is a distinct

entity, a co-morbidity condition, or expression of a ‘‘locus

minor resistentiae.’’ In clinical practice it is difficult to answer

these questions: in autoimmune neuropathy patients and in

diabetic patients, should we surgically treat nerve entrap-

ment? Recently we provided evidence that a mechanical

condition around the nerve, typical of the entrapment region,

does not enhance autoimmune aggression in CIDP. There-

fore, in CIDP patients a true entrapment, neurophysiologi-

cally demonstrated, could be a concomitant pathology and

if a severe and persistent entrapment worsens functional

deficit and symptoms, a surgical decompression could be

useful. There is evidence that diabetic patients operated for

carpal tunnel syndrome have the same post surgery evolu-

tion than non-diabetic patients. In conclusion, in autoimmune

neuropathies and diabetic patients, the physician should

strongly consider the possibility of surgery.

NEW NEUROPHYSIOLOGICAL FINDINGS ON SKIN

RECEPTORS OR INTRADERMAL NERVE ENDINGS AFTER

REPETITIVE CAPSAICIN APPLICATION

Aprile I1,2, Stalberg E3, Caliandro P1, Pazzaglia C1,Tonali P1,Foschini M1,Trotta E1, Padua L1,2. 1Institute of Neurology,

Catholic University, Rome, Italy, 2Don C. Gnocchi

Fondation, Rome, Italy, 3Department of Clinical Neuro-

physiology, University Hospital, Uppsala, Sweden.

Background: The standard sensory nerve conduction

studies evaluate only large myelinated fibres and its sensitiv-

ity may be low in early sensory polyneuropathy where only

skin receptors or intradermal nerve endings are involved.

During conventional sensory nerve conduction studies

through surface electrodes, when we slowly increased the


109

intensity of the stimulus, we occasionally observed a sensory

response characterised by a particular morphology with two

peaks (double peak potential). Some observations suggested

that the first peak was due to stimulation of the nerve fibers

and the second peak was due to the activation of the skin

receptors or intradermal nerve endings. Objective: The aim

of this study is to demonstrate that the second peak is due to

activation of the receptors and epidermal nerve fibres. Pre-

viously, studies showed that repeated topical applications of

capsaicin to human subjects resulted in progressive, almost

complete, degeneration of receptors and epidermal nerve

fibres. In the present study we report the effects of repeated

topical applications of capsaicin to the fingertip of the human

subjects on the double peak potential. Materials and

Methods: Five-healthy symptom-free volunteers participated.

Capsaicin cream (0,075%) was applied topically four times

daily for 4–5 weeks to the fingertip of digit III (on the distal

phalanx). Double peak evaluation and sensory tests were

performed before treatment, at intervals during treatment

and after capsaicin was discontinued. Results: The second

peak obtained using submaximal anodal stimulation disap-

peared after repeated topical applications of capsaicin, and

reappeared one month after interruption of topical applica-

tion. Conclusions: The results of this study confirm our

hypothesis about the neurophysiological meaning of the

two peaks. The double peak potential can have a diagnostic

role in the distal sensory involvement, especially in the

early stage when the distal impairment of nerve endings

cannot be detected by standard evaluation of sensory nerve

conduction.

THE SELF-CARE APPROACH AS A NEW TOOL IN

MODERN HEALTH CARE. CARPAL TUNNEL SYNDROME,

AN IDEAL MODEL TO EVALUATE THE EFFICACY OF AN

INSTRUCTIONAL VIDEO

Conti V1, Pazzaglia C1, Aprile I1,2, Caliandro P1,Tonali P1,Padua L1,2. 1Institute of Neurology, Catholic University –

Roma, 2Ist. Don C. Gnocchi, Fondazione Pro Iuventute,

Roma.

Objective: The proliferation of medical knowledge

(including media attention for health) and this emergence of

chronic disease laid fertile ground for the self-care movement

and revision of the doctor-patient relationship. The growing

emphasis on self-care has led to increasing needs for accu-

rate patient information on alternative approaches to clinical

problems. Carpal tunnel syndrome (CTS) is the most fre-

quent focal neuropathy. Postures are relevant for develop-

ment worsening or improvement of CTS. Hence, CTS

exemplifies a pathology in which patients can be instructed

by the use of a video, avoiding wrong positions that can

worsen the pathology. Materials and Methods: We devel-

oped an instructional video for CTS patients to educate them-

selves on how to avoid postures that could worse the

median nerve entrapment. Furthermore, we performed the

first steps of validation. Results: The first steps of validation

showed that the video is able to transfer the arguments we

believe are relevant to avoid negative posture. To complete

the validation, a randomised controlled trial is ongoing to

evaluate the efficacy of the video. Discussion: We can ima-

gine self-care as a low-cost program for promoting health

self-management, improving elements of health status

while reducing care costs in populations with diverse chronic

diseases. CTS is an ideal model to evaluate the efficacy of

the self-care approach. The developed video was able to

instruct patients about the importance of posture on this

disease and how to avoid/modify daily activities negative for

the entrapment syndrome. Note that the use of the video

was explicitly intended to augment the usual doctor-patient

interaction, not to substitute it.

POEMS SYNDROME: ROLE OF TWO ANGIOGENIC

FACTORS, VEGF AND EPO.

Scarlato M, Carpo M, Previtali S, Pareyson D, Briani C,Casellato C, Nobile-Orazio E, Comi GP, Bresolin N, Quattrini A.Dipartimento di Scienze Neurologiche dell’Universita’ di

Milano; Dipartimento di Neurologia, Istituto San Raffaele,

Milano; Istituto Neurologico ‘‘C.Besta’’, Milano; Dipartimento

di Scienze Neurologiche dell’Universita’ di Padova.

POEMS syndrome is a rare disorder characterized by the

combination of polyneuropathy, organomegaly, endocrinopa-

thy, M-protein and skin changes. The pathogenesis of this

multisystemic disease is not known. Recently, an association

with high levels of serum VEGF (vascular endothelial growth

factor), a multifunctional cytokine that induces angiogenesis

and microvascular hyperpermeability, has been reported.

Both VEGF and erythropoietin (EPO), an acidic glycoprotein

hormone that also promotes endothelial proliferation, are

under the control of a transcription factor called hypoxia-

inducible factor (HIF). To determine whether these angio-

genic factors may have a pathogenic role in POEMS, we

longitudinally evaluated VEGF and EPO serum concentra-

tions by ELISA in ten patients during the clinical course and

in relation to the therapy response. All patients had initially

high levels of VEGF and low EPO concentration and there

was an inverse correlation between VEGF and EPO levels

during the disease progression. We have also analyzed sural

nerve biopsies of seven POEMS patients. The presence of

VEGF/VEGF-R and EPO/EPO-R immunostaining in the endo-

neurial and perineurial vessels has been shown, as well as in

some of the non-myelin forming Schwann cells identified as

glial fibrillary acidic protein (GFAP) positive cells.

PEGYLATED ALPHA-INTERFERONS PERIPHERAL

NEUROTOXICITY: PROSPECTIVE STUDY IN CHRONIC

HEPATITIS C

Briani C, Zara G, Bernardinello L, Cavalletto L, Ermani M,Chemello L. Departments of Neurosciences, Clinical and

Experimental Medicine, University of Padova, Italy.

Objective: To assess whether pegylated interferons

(PEG-IFNs) treatment is associated with occurrence, worsen-

ing or improvement of peripheral neuropathy in HCV patients.


110

Background: Alpha-IFN is associated with central nervous

system side effects. There are reports of both improvement

and worsening of neuropathy during alpha-IFN treatment, but

the possible alpha-IFN peripheral neurotoxicity has never

been consistently investigated. Patients and Methods:

Twenty-six HCV patients (19 male, 7 females, median age

41.5� 9.6 years) have been treated with PEG-IFNs (alpha-2a

180mcg weekly or alpha-2b 1.5mcg, weekly) and ribavirin

for 6–12 months. Eleven patients had neuropathy at recruit-

ment (two diabetic, nine HCV-related neuropathy, one with

cryoglobulins). Before therapy (T0) all patients underwent

quantitative viral RNA determination, HCV genotype analysis,

liver biopsy, neurological and electrophysiological evaluation.

Response amplitude and conduction velocities of median,

ulnar, sural, and peroneal nerves were recorded. During

therapy (T1) (mean follow-up 7,8� 4.0 months), patients

were neurologically and electrophysiologically re-evaluated.

Eighteen HCV patients (11 males, 7 females, median age

47.4� 9.6) with comparable viral load, not in IFN treatment,

were studied as controls. Results: During PEG-IFNs therapy,

no significant differences of all electrophysiological para-

meters were detected between T0 and T1 evaluations

(repeated measures ANOVA) in all 44 treated and non-trea-

ted patients, also in those with neuropathy at recruitment.

No correlations were found between electrophysiological

parameters and length of therapy (Spearman’s Rho). Conclu-

sions: Peripheral neuropathy seems not to complicate PEG-

IFNs therapy in HCV patients. An ongoing follow-up study on

a larger group of patients will help confirm these results.

IS CLINICAL VARIABILITY IN CMT1A RELATED TO

EPIGENETIC FACTORS?

Benedetti L1, Zuccarino R1, Grandis M1, Fiocchi I2, BeronioA1, Ghiglione E1, Bellone E1, Mandich P1, Abruzzese M1,Mancardi GL1, Lamba Doria L2, SchenoneA1. 1Department

of Neuroscience, Ophthalmology and Genetics, Genova,2Department of Child Neurology, Institute G. Gaslini,

Genova.

CMT1A patients bear the same genetic defect but often

present with a wide range of clinical disability. Knowing the

relationship between the phenotypic variability and other

parameters, such as electrophysiological findings, age, gen-

der, disease duration and environmental factors may be

important for understanding the pathogenetic mechanisms

underlying CMT1A. We studied 15 families and 7 sporadic

cases affected by CMT1A (27 adults and 9 children) from the

clinical, neurophysiological and genetic standpoint. A detailed

patient history included: disease onset and progression,

distribution of weakness, additional symptoms, life habits,

genealogical tree, exposure to toxic substances, geographic

provenance, instruction grade, job, use of drugs, and

concurrent diseases. A questionnaire about diet was admi-

nistered. The disability was evaluated by modified Rankin

scale, deambulation index, functional independence measure

and Barthel index. As previously reported, disease onset was

in the first decade in 50% of cases and before the age of 20

years in 70% of cases. Severe disability was rarely observed,

only 2 patients walking with a cane. No clear influence of

gender over clinical severity was observed. Interestingly,

genetic anticipation was observed in all the families. Data

on the influence of environmental factors will also be

presented.

EXPRESSION OF CILIARY NEUROTROPHIC FACTOR

(CNTF) IN CHARCOT-MARIE-TOOTH TYPE 1A (CMT1A)

DISEASE

VigoT*, SchenoneA*, Mancardi G*, Abruzzese M*,TimmermanVy,Van Hummelen P&, Nobbio L*. *Department

of Neuroscience, Ophthalmology and Genetics, Univer-

sity of Genova, yMolecular Genetics Department,

Flanders Interuniversity Institute for Biotechnology,

University of Antwerp, Belgium, &Microarrays Facility,

Flanders Interuniversity Institute for Biotechnology,

University of Antwerp, Belgium.

cDNA microarray experiments on sciatic nerves from

30-day-old PMP22 transgenic (PMP22tg) rats were per-

formed to detect genes modulated in CMT1A. Among the

downregulated genes, CNTF mRNA was significantly

reduced, whereas other neurotrophic factors (BDNF, NT3,

NGF) and cognate receptors (TRKA, TRKB, TRKC) were

unchanged. We further studied CNTF expression in trans-

genic nerves using an ELISA technique. We observed sig-

nificantly (p< 0.001) lower concentrations of the protein in

sciatic nerves from homozygous (59� 7.8 pg/mg of

proteins) and heterozygous (140.8� 17.56 pg/mg of pro-

teins) PMP22tg nerves compared to normal controls

(713.8� 168.7 pg/mg of proteins). Moreover, using real

time PCR, we studied CNTF expression in human sural

nerves from 2 CMT1A patients and in 3 control nerves.

According to the animal results, CNTF mRNA expression

was absent in CMT1A patients whereas it was detectable

in control nerves (1.99� 0.9). Finally, we studied CNTF

mRNA expression in aging PMP22tg rats; preliminary results

show a further decrease of CNTF mRNA in heterozygous

transgenic rats compared to normal age-matched litter-

mates. Our results suggest that reduced CNTF expression

may account for the development of axonal atrophy in

CMT1A.

MUTATIONS DISRUPTING EXTRACELLULAR STRUCTURE

OF MPZ CAUSE EARLY ONSET SEVERE FORMS OF

CMT1B

Grandis M1, Jain M2, La PadulaV1, BalsamoJ3, Lilien J3,Kamholz J2, SchenoneA1, Shy ME1. 1Universita di Genova,

Genova, Italy, 2Wayne State University, Detroit MI, USA,3University of Iowa, Iowa City, IA, USA.

Missense mutations in myelin protein zero (MPZ), an

important molecule for myelin compaction, cause inherited

neuropathies collectively referred to as CMT1B. Depending


111

on the mutation, phenotypes can be severe, or mild. To

determine genotype-phenotype correlations in CMT1B we

evaluated patients from 11 different families seen in our

clinic and 80 reported cases from the literature with respect

to (1) how the mutation affected amino acids known to be

critical for homotypic MPZ interactions; (2) whether the

mutation affected the charge or hydrophobicity of an amino

acid; (3) whether the mutation was likely to affect the

secondary or tertiary structure of the MPZ, or (4) whether it

affected evolutionarily conserved amino acids. We found that

mutations that added a charged residue to the extracellular

domain, introduced a cysteine or altered a conserved

amino acid, caused a severe neuropathy. Mutation of an

amino acid critical for cis or trans homotypic adhesion, how-

ever, had no obvious consequences on disease severity.

We conclude that mutations which significantly disrupt

the secondary or tertiary structure of MPZ are likely to

cause severe, early onset neuropathies, whereas

mutations which do not cause milder disease. Studies on

how mutations disrupt protein trafficking and adhesion are

underway.

GENOTYPE–PHENOTYPE CORRELATION IN SOME

AUTOSOMAL RECESSIVE HEREDITARY SPASTIC

PARAPLEGIAS

Manganelli F, Criscuolo C, ScaranoV, Perretti A, DeMichele G, Filla A, Santoro L. Department of Neurological

Sciences, University of Naples ‘‘Federico II’’.

Hereditary spastic paraplegias (HSPs) are a group of

clinically and genetically inherited disorders. Spastic parapar-

esis (SP), the main clinical feature of all HSPs can occur in

relative isolation in the ‘‘pure’’ form or in combination with

other neurological deficits in ‘‘complicated’’ forms. Autoso-

mal dominant, autosomal recessive (AR) and X-linked reces-

sive inheritance pattern of HSPs have been reported. At

present, among AR-HSPs, three genes, paraplegin (SPG7),

spartin (SPG20 – Troyer syndrome) and maspardin (SPG21)

have been identified and six genetic loci have been mapped

(SPG5, SPG11, SPG14, SPG15, SPG24, SPG25). We have

evaluated 11 patients belonging to six AR-HSP families

genetically identified as SPG5, SPG7, SPG11 and SPG15.

In all patients electromyography, nerve conduction velocity

studies, visual (VEPs), somatosensory (SSEPs), brainstem

auditory (BAEPs) and magnetic motor (MMEPs) evoked

potentials were performed. All 4 SPG5 patients, affected by

a pure form of SP, showed abnormalities of both MMEPs

and SSEPs, and two of them also VEP alterations. In the two

SPG7 patients with complicated SP, MMEP abnormalities

only were discovered. Among the three SPG11 patients

affected by SP, complicated by mental retardation and thin

corpus callosum, electrophysiological studies revealed

MMEP abnormalities and signs of motor neuropathy in one

of them. Finally, in the SPG15 family, presenting with SP

associated with mental retardation and neurosensorial deaf-

ness, MMEP and BAEP alterations were found.

SCREENING FOR MUTATIONS IN THE

LIPOPOLYSACCHARIDE-INDUCED TUMOR NECROSIS

FACTOR-ALPHA FACTOR (LITAF) GENE IN ITALIAN

PATIENTS WITH CHARCOT-MARIE-TOOTH DISEASE.

Bellone E, Balestra P, Di Maria E, Pigullo S, Gulli R, Ajmar F,Mandich P.Dipartimento di Neuroscienze, Oftalmologia e

Genetica, Sezione di Genetica Medica, Universita di

Genova.

Mutations in LITAF (lipopolysaccharide-induced tumor

necrosis factor-alpha factor), also referred to as SIMPLE, are

associated with one of the dominantly inherited demyelinating

forms of Charcot-Marie-Tooth disease (CMT1C). LITAF is a

widely expressed gene, which maps on chromosome

16p13.1-p12.3 and encodes a 161-amino acid protein that may

play a role in the degradation of proteins critical to peripheral

nerve function. A cohort of 46 unrelated Italian patients affected

with demyelinating peripheral neuropathy with dominant inheri-

tance was screened for mutations in the LITAF gene. The three

coding exons (2, 3 and 4) and flanking intron nucleotide

sequence was examined by single strand conformation poly-

morphism (SSCP) and direct sequencing. All patients were

negative for the 17p11.2 duplication and for mutations in the

MPZ, PMP22 and EGR2 genes. SSCP analysis showed several

electrophoretic variants in all exons. Direct sequencing demon-

strated the presence of few single nucleotide substitutions. All

of them were demonstrated to be common polymorphisms:

one of them was non-synonymous, two were synonymous

and two were intronic. Based on the present analysis, LITAF

mutations are not a frequent cause of autosomal dominant

demyelinating neuropathies in our population.

CLINICAL HISTORY AND NEW PROGNOSTIC INDICATORS

IN METACHROMATIC LEUKODYSTROPHY

Del Carro U*, Biffi A�, Baldoli C^, Gerevini S^, Amadio S*,Fumagalli F*, Roncarolo MG�, Sessa M*� Department of

*Neurology and ^Neuroradiology, Scientific Institute San

Raffaele and �TIGET-HSR, Milan.

Objective: To study clinical phenotypes and to increase

knowledge of natural history of different variants of metachro-

matic leukodystrophy (MLD). Background: Little is known

about factors influencing age of onset, progression rate and

peripheral nerve involvement in MLD due to its rarity, hetero-

geneity and paucity of serial clinical and instrumental reports.

Methods: 15 biochemically and molecularly characterized

MLD patients were evaluated along a two-year follow-up per-

iod with clinical, electroneurographic (ENG) and brain MRI

recordings. Results: Late infantile patients had a progressive

and rapid course, whereas juvenile form showed marked

variability. Different clinical presentations were associated

with similar levels of ARSA activity; mutation screening indi-

cated a high prevalence of rare or private mutations. In all late

infantile and in the adult patient, ENG revealed a severe poly-

neuropathy. In juvenile patients a milder polyneuropathy or

even normal tests were found. The earliest MRI change was

periventricular white matter signal alterations, with initial invol-

vement of posterior regions in a majority of late infantile

patients, while in juvenile forms white matter lesions were


112

mainly anterior. Conclusions: MLD course is highly variable

and only partially influenced by age of onset, especially

among juvenile patients. No clear-cut correlations exist

between clinical phenotype and biochemical or molecular

characterization. The presence of peripheral neuropathy at

onset seems a strong indicator of a poorer clinical outcome.

PERIPHERAL NERVE REGENERATION IN THE ABSENCE

OF GLIAL FIBRILLARY ACIDIC PROTEIN

Previtali SC, Dina G, Galizia G, Malaguti C, Amadio S, DelCarro U, Messing A, Quattrini A. S. Raffaele Scientific

Institute, Dept. Neurology, Milano, Italy, Waisman

Center, Univ. Wisconsin, MA, USA.

Axonal loss is a consistent and undesirable event even in

primary demyelinating neuropathies, and is responsible for

most disabling and permanent deficits. In fact, in several

peripheral neuropathies the physiological ability of nerve to

regenerate is lost or dramatically reduced. Schwann cells

play a central role in nerve regeneration and the laminin-

laminin receptor-cytoskeleton pathway is fundamental to

control numerous Schwann cell functions and Schwann

cell-axon interaction. A model to reproduce the events

involved in axonal degeneration and regeneration is recapitu-

lated in the stereotyped model of crush injury of the sciatic

nerve in rodents. With this tool, we investigated the effi-

ciency of nerve regeneration in mice lacking the glial fibrillary

acidic protein (GFAP) intermediate filament, a Schwann cell

specific cytoskeleton constituent. The peripheral nerves of

GFAP null mice normally develop and function, and we did

not detect gross differences in laminin and laminin receptor

expression. However, after injury, the GFAP null mice

showed a delay in the early phase of nerve regeneration.

DOMINANT LAMIN A/C GENE MUTATIONS CAN BE

ASSOCIATED WITH MUSCULAR DYSTROPHY AND

PERIPHERAL NEUROPATHY

Benedetti S, Previtali S,Toniolo D, Iannaccone S,Sferrazza B, Comi G, Carrera P, Ferrari M, Quattrini A,Bertini E. San Raffaele Scientific Institute, Milan, Italy.

The coexistence of neurogenic and myogenic etiology in

scapuloperoneal syndrome was not previously ascribed to a

single gene. Defects in the lamin A/C gene (LMNA) have

been associated with a variety of pathologies, affecting

mainly muscular and adipose tissues, although recently

reported also in autosomal recessive CMT2. We describe

here two patients associating features of myopathy and

neuropathy linked to dominant LMNA mutations. Patient 1

presented with distal weakness at lower limbs and elevated

serum CK. Neurophysiological studies revealed a sensorimo-

tor axonal neuropathy, whereas muscle biopsy showed signs

of both neurogenic and myogenic features. Molecular

analysis of LMNA gene revealed a heterozygous R571C sub-

stitution. Patient 2 presented with mild proximal weakness

and fatigability. She was carrying a pacemaker for cardiac

arrhythmia and had a family history of sudden death. Electron-

myography showed mild myopathic changes. A muscle

biopsy revealed chronic myogenic and neurogenic features

including atrophic angular fibers and type grouping. Analysis

of the LMNA gene showed a heterozygous four nucleotides

deletion in exon 5 (864del4), leading to premature protein

truncation. The same mutation was found in the asympto-

matic younger brother. This report describes for the first

time dominantly-inherited alterations of the nuclear lamins

affecting both muscle and peripheral nerve, and the clinical

heterogeneity of LMNA mutations.

ELECTROPHYSIOLOGICAL FEATURES IN THE

DISTINCTION BETWEEN HEREDITARY DEMYELINATING

AND CHRONIC ACQUIRED DEMYELINATING

NEUROPATHIES

Poglio F1,Tavella A1, Ciaramitaro P2, Prolasso I1,Vercelli L3,MonginiT3, Palmucci L3, Cocito D1. 1Neurologia I, A.S.O.

San Giovanni Battista, Torino, 2Neurofisiologia Clinica,

Ospedale CTO, Torino, 3Neurologia II, A.S.O. San

Giovanni Battista, Torino.

We carried out an electrophysiological retrospective study

in 55 patients with chronic demyelinating acquired and heredi-

tary neuropathies. Alterations of motor nerve conduction velo-

cities (MNCV), distal motor latencies (DML), conduction blocks

(CB) and compound muscle action potential (CMAP) were

compared, considering the whole number of nerves for each

disease. MNCV, DML, CB and CMAP were considered

suggestive of demyelination when meeting the American

Academy of Neurology (AAN) criteria. Abnormally slow

MNCV was found respectively in the 46% of all the CMTX

female nerves studied, in the 56.5% of CMTX males, 84% of

CMT1A, 74% CIDP and 70% of MAG-PNP. Prolonged DML

was observed in the 25% of the CMTX female nerves studied,

in the 49.5% of CMTX males, 81% of CMT1A, 63% of CIDP

and 71% of MAG-PNP. Moreover, CB were quite often evi-

denced in CIDP and MAG-PNP nerves (respectively in 48%

and 29%) and rarely in hereditary neuropathies. Finally, we

observed CMAP reduction in the 45% of all the CMTX female

nerves studied, in the 50% of CMTX males, 63% of CMT1A,

49% of CIDP and 60% of MAG-PNP. A well-characterized

pattern generally allows an electrophysiological distinction

between CMT1A, CMTX males, MAG-PNP on one side and

CIDP and CMTX females on the other side. A clear electro-

diagnostic distinction result is often hard between CMTX

males and MAG-PNP and between CIDP and CMTX females.

CORRECTION OF METACHROMATIC

LEUKODYSTROPHIES (MLD) IN THE MOUSE MODEL BY

TRANSPLANTATION OF GENETICALLY MODIFIED

HEMATOPOIETIC STEM CELLS

Quattrini A, Biffi A, Amadio S, Bertani I, Dina G, Del Carro U,Previtali S, Bordignon C, Naldini L. Neurology Dept. San

Raffaele-TIGET, Milan, Italy.

MLD is inborn lipidosis caused by the deficiency of the

lysosomal enzymes arylsulfatase A (ARSA), which results in


113

storage of undergraded sulfatides in the CNS and PNS, leading

to progressive demyelination. Bone marrow transplant pro-

vides a clinically feasible method for permanently replacing

deficient lysosomal enzyme activity. Using Lentiviral Vectors

(LV), we efficiently transduced hematopoietic stem cells (HSC)

ex vivo and evaluated the potential of their progeny to target

therapeutic genes to the CNS and PNS of transplanted mice,

and correct MLD phenotype in the mouse model. We proved

extensive repopulation of CNS microglia and PNS endoneurial

macrophages by transgene-expressing cells. By transplanting

HSC transduced with the ARSA gene, we reconstituted

enzyme activity in the hematopoietic system of MLD mice at

supranormal levels and prevented major disease manifesta-

tions: the complete protection from the development of the

motor conduction impairment and of the neuropathological

abnormalities (prevention of sulfatide accumulation and

demyelination in CNS and PNS) typical of the disease. Remark-

ably, ex vivo gene therapy had a significantly higher therapeutic

impact than wild-type HSC transplantation on all examined

parameters, highlighting the crucial role of enzyme over-

expression and indicating the likely occurrence of in vivo

cross-correction.

STANDARD DEVIATION OF THE DISTANCES BETWEEN

CONSECUTIVE EPIDERMAL NERVE FIBERS AS A

PARAMETER TO STUDY THEIR DISTRIBUTION IN HUMAN

SKIN

ProviteraV, Nolano M, Stancanelli A, Lullo F, Santoro L*.‘‘Salvatore Maugeri’’ Foundation – Medical Centre of

Telese T. (BN) Italy, *Dept. of Neurological Sciences,

University of Naples ‘‘Federico II’’.

Evaluation of epidermal nerve fiber (ENF) density by skin

biopsy is nowadays considered as the gold standard for the

diagnosis of small fiber neuropathies. ENFs show in normal

subjects quite a regular distribution between the keratino-

cytes while in patients with small fiber neuropathies we

can find, besides a loss of ENFs, evident anomalies of their

distribution. Different patterns of nerve fiber dispersion can

express different pathophysiological processes. The aim of

this study was to define a tool capable of describing the

distribution of ENF in the epidermis. For this purpose, we

measured the distance between subsequent epidermal

fibers on skin samples of healthy and diabetic subjects. We

calculated the standard deviation of the interfiber length as a

parameter (the dispersion index – DI) to evaluate the varia-

bility of the distance between consecutive ENFs. We

selected thigh skin samples from five healthy subjects (age

range 30–50 years) and five age and sex matched diabetic

patients. Samples were processed using immunohistochem-

ical techniques. Sections were PGP 9.5 and Collagen IV

double stained to show nerve fibers and basement mem-

brane. One randomly selected section for each subject was

acquired for its entire length (usually seven 20x confocal

images obtained from a z-stack of 16 two micron optical

sections) using a confocal microscope (CARV, Atto Bios-

ciences, Rockville MD, USA). We measured the distance

between consecutive ENFs along the entire epidermal

length, using dedicated software (ScionImage, Scion Cor-

poration Frederick, Maryland USA). In diabetic patients the

DI resulted significantly higher than in normal subjects. We

suggest that DI along with the ENF density can be useful to

better characterize epidermal innervation.

CUTANEOUS INNERVATION IN ROSS SYNDROME: A

FUNCTIONAL AND MORPHOLOGICAL STUDY IN 8

PATIENTS

Nolano M, ProviteraV, Perretti A*, Saltalamacchia AM,TugnoliV‰, DonadioV#, Manganelli F*, Santoro L*. ‘‘Salva-tore Maugeri’’ Foundation – Medical Centre of Telese T.

(BN) Italy, *Dept. of Neurological Sciences, University of

Naples ‘‘Federico II’’, §Department of Neurology,

‘S. Anna’ Hospital, Ferrara, Italy, #Department of Neuro-

logical Sciences, University of Bologna, Italy.

Ross syndrome is described as a very rare disorder

characterized by segmental anhydrosis, hyporeflexia and

tonic pupils. We observed 8 subjects (6 males and 2 females;

age range 31–57 years) affected by Ross syndrome in the

last 4 years. They had suffered heat intolerance for at least 7

years with severe impairment of thermoregulation before

diagnosis of Ross syndrome was defined. All patients under-

went neurological examination, electrophysiological study,

quantitative sensory testing, Minor test, silastic imprint

test, sympathetic skin response, cardiovascular reflexes

and 3mm punch biopsies from fingertip, thigh, leg and

from residual hyperhydrotic areas. Skin samples were cut in

80-micron sections and incubated with a panel of primary

antibodies and then with secondary antibodies conjugated

with fluorophores Cy2, Cy3, Cy5 to visualize neural and vascu-

lar structures. Different primary antibodies were used to dis-

tinguish myelinated and sensory and autonomic unmyelinated

fibers. Digital images were obtained using a non-laser confocal

microscope (CARV, Atto Biosciences, Rockville MD, USA) and

analyzed by dedicated image analysis software (Neurolucida,

Microbrightfield, Willistone VT, USA). As we previously

described in 3 patients (Perretti et al., Clin Neurophysiol,

2003), besides a lack of cholinergic sudomotor fibers we

found a milder involvement of unmyelinated and myelinated

sensory fibers. These morphological findings were in keeping

with a moderate subclinical impairment of tactile and thermal

thresholds and mechanical pain detection. Sensory nerve con-

duction study was normal indicating a very distal involvement

of sensory nerve endings. This study confirms our previous

observation that Ross syndrome is a degenerative process

involving progressively, besides cholinergic autonomic fibers,

sensory unmyelinated and myelinated nerve fibers.

EXPERIMENTAL AXONOPATHY INDUCED BY

IMMUNIZATION WITH CAMPYLOBACTER JEJUNI

LIPOPOLYSACCHARIDE FROM A PATIENT WITH

GUILLAIN-BARRE SYNDROME

Caporale CM1, Capasso M1, Lucani M2, Gandolfi P2,DeAngelis MV1, Di MuzioA1, CaporaleV2, Uncini A1.1Neuromuscular Diseases Unit, Ce.S.I., Foundation

University ‘‘G. d’Annunzio’’, Chieti, 2Experimental

Zooprophylactic Institute ‘‘G. Caporale’’, Teramo, Italy.


114

Campylobacter jejuni (C. jejunj) infection is the most

common antecedent in the axonal variant of Guillain-Barre

syndrome (GBS). Antibodies against nerve gangliosides

found in GBS patients recognize cross-reactive epitopes in

the lipopolysaccharide (LPS) of C. jejuni. This led to the

molecular mimicry hypothesis of GBS. We immunized eleven

rabbits with a LPS extracted from HS:19 C. jejuni strain

isolated from a patient with GBS and complete Freund’s

adjuvant (CFA) (group I). In a second experiment we immu-

nized seven rabbits with LPS, CFA and keyhole limpet hemo-

cyanin (KLH) (group II). All group I rabbits developed high

titers of anti-LPS, anti-GM1, anti-GD1b antibodies and lower

titers of anti-GD1a. One rabbit, 50 days after initial inocula-

tion, showed tremor and weakness. All rabbits of group II

developed high titres of antiganglioside antibodies and six

animals showed weakness 59–113 days after initial inocula-

tion. Two rabbits died. Pathology showed mild to moderate,

tendentially grouped, axonal degeneration in sciatic nerves of

four out of five animals. Control rabbits of group I (immunized

with CFA only) did not develop antibodies, controls of group

II (immunized with CFAþKLH) developed low titers of IgG

anti-GM1. None developed neurological signs or showed

axonal degeneration. C. jejuni LPS is a potent B-cell stimula-

tor capable to induce a strong antiganglioside response in

rabbits. However, to induce the neuropathy is crucial to

employ KLH, a glycoprotein known to stimulate both humoral

and cellular responses. This animal model reproduces the

pathogenetic process hypothesized in axonal GBS with

antiganglioside antibodies post C. jejuni infection.

DEMYELINATING MOTOR GUILLAIN-BARRE SYNDROME

FOLLOWING RUBELLA

Capasso M, Caporale CM, DeAngelis MV, Cantarella C, DiMuzioA, Lugaresi A, Uncini A. Center for Neuromuscular

Diseases, University ‘‘G. d’Annunzio’’, Chieti.

A 20-year-old man developed weakness without sensory

complaints ten days after rubella. Examination showed limb

weakness and brisk tendon reflexes but no sensory

abnormalities. Laboratory investigations revealed IgG and

IgM anti-Rubella and increased CSF protein content (0,8 g/

L). Electrophysiological examination showed partial motor

conduction blocks in eight nerves and normal sensory con-

ductions even across the sites of CB. Brain and spinal cord

MRI and SEPs were normal. The patient was treated with

four plasmaphereses and fully recovered in six months. Con-

duction blocks gradually improved with increasing duration

and abnormal temporal dispersion in proximal CMAPs. GBS

has been rarely reported after rubella. Anti-myelin basic pro-

tein antibodies have been found in a patient with a relapsing

motor neuropathy following rubella vaccination. As antibo-

dies cross-reacted with a viral protein, molecular mimicry

has been proposed as a pathophysiological mechanism. In

our patient we did not find anti-MBP antibodies and antibo-

dies to-glycolipids (GM1, GM2, GA1, GD1a, GD1b, GQ1b,

sulfatides, galactocerebroside) were also negative. Indirect

immunofluorescence after incubation of patient’s serum on

rabbit sciatic nerve and human sural nerve and roots was

negative. Our patient confirms the occurrence of GBS follow-

ing Rubella and shows some uncommon features: 1) hyper-

active deep tendon reflexes; 2) demyelination selectively

involving motor fibres; and 3) widespread early conduction

blocks in intermediate nerve segments.

ACUTE DEMYELINATING SENSORIMOTOR

POLYNEUROPATHY IN B-CELL LYMPHOMA WITH IGM

AUTOANTIBODIES AGAINST GLYCOLIPID GD1B

Marfia GA, Pachatz C,Terracciano C, Leone G, Massa R.Clinica Neurologica, Universita di Roma Tor Vergata,

Roma.

We report the case of an acute demyelinating sensor-

imotor polyneuropathy in a patient with IgM autoantibody

against peripheral nerve myelin glycolipid GD1b produced

by a B-cell lymphoma. A 76-year-old woman presented with

one month history of weight loss, paresthesias at the distal

extremities of the four limbs followed by progressive and

diffuse motor weakness. Neurological examination showed

sensory ataxia, marked motor deficit (4 at MRC scale in

proximal and distal muscle districts of limbs), superficial and

proprioceptive sensory deficit with a stocking-glove distribu-

tion, areflexia at lower limbs. Electroneurography documen-

ted absent sensory action potentials, prolonged distal

latencies of motor action potentials, markedly slowed motor

conduction velocities and evidence of conduction block and

temporal dispersion of motor action potentials. Diagnosis of

acute demyelinating sensorimotor polyneuropathy was estab-

lished. CSF examination showed a slight increase of protein

concentration. Haematological screening revealed a monoclo-

nal gammopathy with high serum IgM (1151mg/dL) and light

chain kappa proteinuria. A total body CT scan evidenced a

pelvic mass identified as low grade B-cell lymphoma by rectal

biopsy. Research for antiganglioside autoantibodies evidenced

the presence of IgM antibodies against glycolipid GD1b.

Autoantibodies anti-Mag, anti-Hu, anti-Yo and anti-Ri were

negative. The pathogenetic role of serum autoantibodies

against glycolipid GD1b in the development of demyelinization

in the peripheral nervous system has already been documen-

ted either clinically in post-infective polyneuropathies or

experimentally in animal research. This is the first report of

selective positivity of anti-GD1b in polyneuropathy associated

to B-cell lymphoma supporting the possible paraneoplastic

significance of these serum autoantibodies.

CHRONIC RELAPSING POLYNEUROPATHY ASSOCIATED

WITH HEPATITIS B VIRUS INFECTION

Lus G,Vincitorio CM, Di Palma A, Carpo M*, Allaria S*,Cotrufo R. Department of Neurological Sciences, Second

University of Naples, *Department of Neurological

Sciences, University of Milan, IRCCS Ospedale Maggiore

Policlinico University, Italy.

We report the case of a 50-year-old woman affected by

a chronic latent Hepatitis B (H.B.V.) virus infection since


115

the age of 35, who complained of several relapses of

sub-acute sensorimotor inflammatory polyneuropathy with

albumino-cytological dissociation, successfully treated with

IVIg pulse therapy during acute phase and with chronic pre-

dnisone therapy. An exacerbation of H.B.V. infection, likely

induced by corticosteroid administration, associated with

marked increase in serum of hepatic enzymes and high

H.B.V. DNA levels in blood, coincided with a severe worsen-

ing of the neuropathy. Laboratory investigations revealed,

among others, elements of renal involvement (hypoalbumi-

nemia, proteinuria). Immunofixation electrophoresis revealed

an IgM (k) monoclonal gammopathy, antibody testing

high level of IgM to GD1a (1/81920). Lamivudina, rituximab

and IVIg were administered: renal and liver indexes

re-entered within the ranges, sensorimotor deficits had

slow and incomplete remission. In this case, polyneuropathy

could be an expression of systemic H.B.V. illness mediated

by a specific immunogenic attack in the phase of chronic

latent infection, mediated by immune-complexes precipita-

tion in the reactivation phase, as the renal involvement

seems to suggest. The pathological mechanism is under

discussion.

THALIDOMIDE-ASSOCIATED NEUROPATHY IN MULTIPLE

MYELOMA

Morino S, Petrucci MT*, Gragnani F, CeschinV, Clemenzi A,Di PasqualeA, Antonimi G. II Faculty of Medicine, *I

Faculty of Medicine, University of Rome ‘‘La Sapienza,’’

Italy.

Thalidomide is a neurotoxic immunomodulating agent

currently used in Multiple Myeloma (MM). We prospectively

evaluated the frequency and characteristics of peripheral

neuropathy in a continuous series of 25 patients (13 M,

12 F; age 38–60, median 55 yrs) treated with thalidomide

for MM. Patients underwent a neurological and neurophysio-

logical evaluation before starting thalidomide therapy and

monthly throughout duration of treatment. Sixteen patients

(5 M, 11 F) developed neurophysiological characteristics of

axonal sensitive damage and/or clinical peripheral neuropathy

with distal sensory symptoms; treatment duration ranged

between 95 and 572 days (median 298) in patients with

neuropathy, and 49–264 days (median 162) in patients

without neuropathy; the total amount of thalidomide taken

ranged between 26 and 169g (median 83 g) for patients with

neuropathy and 13–170 g (median 51 g) for those without. In

four patients, ENG alterations appeared before clinical

symptoms, while in two patients they were not followed by

clinical symptoms. In the remaining three patients, clinical

symptoms preceded neurophysiological alterations. Age at

onset of MM, disease duration before thalidomide therapy

was started, total dose, duration of therapy and previous

treatments were not correlated with neuropathy (multivariate

logistic regression analysis). Female gender was a risk factor

for developing neuropathy (OR 7.7).

MYOGENESIS CONTRIBUTES TO FUNCTIONAL

ELECTRICAL STIMULATION (FES)-INDUCED RECOVERY

OF MYOFIBER EXCITABILITY AND MASS OF HUMAN

LONG-TERM DENERVATED MUSCLES IN SPINAL CORD

INJURY (SCI)

Kern H1, Boncompagni S2, Rossigni K3, MayrW4, Protasi F2,Carraro U3. 1Ludwig Boltzmann Institute of Electrosti-

mulation and Physical Rehabilitation, Department of

Physical Medicine, Wilhelminenspital, Vienna, Austria,2CeSI, University G. d’Annunzio, Chieti, Italy, 3Labora-

tory of Applied Myology, University of Padova, Italy,4Biomedical Engineering and Physics, University of

Vienna, Austria.

Many months after SCI, when an irreversible injury

involves lower motoneurons, severe atrophy of human mus-

cle is complicated by fibrosis and fat substitution (dener-

vated, degenerated muscle, DDM). We will describe the

effects of long-term lower motoneuron denervation on

human muscle and present the structural results of muscle

trained using FES. Antibody for embryonic myosin demon-

strates that sustained myogenesis occurs in human DDM.

By electron microscopy we studied: a) the overall structure

of fibers and myofibrils in long-term DDM, including the

effects of FES, and b) the structure and localization of

calcium release units, or triads, the structure deputed to

activate muscle contraction during excitation-contraction

coupling (ECC). The poor excitability of human long-term

DDM fibers during the first stages of FES training could be

explained in terms of spatial disorder of both the ECC and

contractile apparati. The structural studies are extremely

encouraging since they demonstrate that FES training is

effective in reverting long-term DDM atrophy and in

maintaining the trophic state of the recovered myofibers.

NEUROMUSCULAR COMPLICATIONS OF JEJUNOILEAL

SHUNT FOR MORBID OBESITY: CASE REPORT AND

LITERATURE REVIEW

Ariatti A, Cappelli G�, Suozzi R, Galassi G. Department of

Neurology and �Nephrology, Modena, Italy.

Intestinal malabsorption by jejunoileal bypass has been

used to treat morbid obesity. Although the procedure is

considered safe, several long-term neurological complica-

tions have been described. A 47-year-old man was evaluated

because of increasing gait difficulties five years after jejunoi-

leal bypass at age 42. Neurological examination showed

upper, lower extremities proximal weakness, distal sensory

loss for touch, pin-prick, vibration and position. Deep jerks

were absent. Electrophysiology was consistent with axonal

neuropathy. Blood tests revealed microcitic anemia (Hb 9 g/

dl), normal thyroid function, tumor marker titer, and viral

screenings. Vitamin A was 1.12 umol/l (n.v. 0.56–4.25) and

vitamin E was 10.7 umol/l (n.v. 11.5–31). B12, folate levels

were within normal range. A 42-year-old obese man had a

similar surgery. Two years later he developed an acute epi-

sode of confusion and unsteadiness due to lactic acidosis,

from which he recovered. He was first evaluated neurologi-

cally fifteen years after jejunoileostomy because of muscle


116

cramps, paraesthesias, and progressive imbalance. On

examination there were trunk, extremity ataxia, proximal

and distal muscle weakness, distal atrophy, loss of reflexes,

and severe loss of all sensory modalities. Electrophysiology

confirmed a sensorimotor neuropathy. Blood tests showed

macrocitic anemia, low free calcium (3.7mEq/l, n.v. 4–5),

increased PTH (75 pg/ml, n.v. 10–65), and low serum level

of vitamins A and E. Brachial biceps biopsy showed neuro-

genic changes. General conditions progressively deteriorated

because of repeated episodes of dehydration leading to

terminal uremia within 27 years.

CMTX: HETEROZYGOSITY FOR A GJB1/CX32 MUTATION

IN A XXY MALE RESULTS IN A MILD PHENOTYPE

Milani M, Pareyson D,Taroni F. Istituto Nazionale Neurolo-

gico ‘‘C. Besta’’, Milan, Italy.

Mutations in the GJB1/Cx32 gene (Xq13.1) cause the

most common X-linked form of CMT (CMTX1) and are the

most frequent cause of CMT disease after the CMT1A dupli-

cation. The disorder is characterized by a moderate-to-severe

neuropathy in affected males and mild-to-no symptoms in

carrier females. We report here a CMT1A-negative family in

which 4 females and 2 males were affected, exhibiting dif-

ferent disease severity. Molecular analysis of the GJB1/Cx32

gene uncovered a nonsense mutation (Arg22stop) in exon 2.

The mutation, which had been previously described by

others and observed by us in numerous other families,

occurred in heterozygous form in the 4 females. However,

while one of the two male patients was severely affected

and shown to be hemizygous, as expected, the other

was mildly affected and found to carry the mutation in het-

erozygous form. Genotyping at the SRY (Yp11.3) and DMD

(Xp21) loci suggested the occurrence of the XXY genotype

associated with Klinefelter syndrome. Microsatellite analysis

indicated that the nondysjunctional error was of paternal

origin, as it is usually observed in about half the cases. The

patient had no children. At clinical examination, he exhibited a

very mild neurologic phenotype and showed signs of

hypogonadism (mild gynecomastia and small testes) as

well as moderate cognitive impairment. Electrophysiologic,

cytogenetic and endocrinologic investigations are in

progress in order to define the unusual phenotype in this

patient.

AN UNUSUAL COSEGREGATION OF CMT1A

DUPLICATION AND HNPP PMP22 POINT MUTATION IN A

FAMILY WITH CMT1 DISEASE

Milani M, Pareyson D,Taroni F. Istituto Nazionale Neurolo-

gico ‘‘C. Besta’’, Milan, Italy.

The common CMT1A duplication and HNPP deletion

arise from unequal crossing over and homologous recombi-

nation during meiosis between flanking repeats (CMT1A-

REP). CMT1A and HNPP thus result from an altered copy

number of the dosage-sensitive myelin gene PMP22 which

is included in the duplicated/deleted tract. However, both

diseases can also be caused by rare PMP22 point mutations.

We report here a unique family carrying both the CMT1A

duplication and an HNPP PMP22 point mutation. A CMT1

child (III-1), the only affected member of her family, was

found to carry the duplication. Surprisingly, the mutation

was also found in the mother (II-2) who had normal clinical

and electrophysiologic phenotype. PMP22 sequence

analysis in both individuals uncovered a truncating frameshift

mutation (Leu145fs) in the healthy mother but not in the

affected child. In the mother, this mutation, which had

been previously identified by us in 3 other HNPP

families, would inactivate the extra copy of the PMP22

gene, functionally compensating the effects of the duplica-

tion. Further investigations in the family demonstrated that

the healthy maternal grandmother (I-1) also carried both the

duplication and the point mutation, while her other son (II-1)

had neither of them, which indicates that both mutations

were harbored by the same chromosome. Microsatellite

analysis suggests that a meiotic homologous recombination

event has occurred in the affected child, replacing the

mutated PMP22 copy with a functional one and resulting in

CMT1 phenotype.

MOLECULAR ANALYSIS OF THE LITAF/SIMPLE AND

PRX GENES IN PATIENTS WITH DEMYELINATING

CHARCOT-MARIE-TOOTH (CMT) DISEASE

Milani M, Cesari M, Baratta S, Caccia C, Balestrini MR, RivaD, Pareyson D,Taroni F. Istituto Nazionale Neurologico

‘‘C. Besta’’, Milan, Italy.

At least 20 genetic loci and 12 genes have been asso-

ciated with the demyelinating form of CMT disease and

related disorders. Mutations in the LITAF/SIMPLE gene

(CMT1C; 16p13.3) have been recently suggested to be a

relatively common cause of CMT1 after the CMT1A duplica-

tion and GJB1/Cx32 mutations (Saifi et al., ASHG 2003). We

have screened for LITAF mutations a group of 120 CMT1

patients negative for CMT1A-dup, MPZ, PMP22 and GJB1/

Cx32. We have so far identified two relatively frequent poly-

morphisms and 3 severely affected patients who exhibited

unique abnormal DHPLC profiles in ex2 and ex3. Unlike the

dominant forms, only a limited number of loci have been

linked to the rare recessive forms (AR-CMT). The 4.9-kb

coding region of the periaxin gene (PRX, CMT4F) was

scanned for mutations by DHPLC and sequence analysis in

a group of 30 CMT1A/MPZ/PMP22/Cx32-negative patients

with severe demyelinating neuropathy. Three novel frame-

shift and nonsense mutations were identified in two AR

families. Interestingly, in one family, two siblings exhibited

different disease severity and were found to be compound

heterozygotes for two mutations affecting the long (L-peri-

axin) but not the short (S-periaxin) variant of the protein,

suggesting that S-periaxin expression may account for clin-

ical variability in these patients.


117

IDIOPATHIC CIDP (I-CIDP) AND CIDP ASSOCIATED WITH

DIABETES MELLITUS OR MONOCLONAL GAMMOPATHY

OF UNDETERMINED SIGNIFICANCE HAVE DIFFERENT

CLINICAL COURSE AND RESPONSE TO TREATMENT

Jann S, Beretta S**, Bramerio M*. Department of Neurol-

ogy and *Pathology, Niguarda Hospital, Milan, **Dept of

Neurology, Vimercate Hospital, Vimercate (MI) Italy.

CIDP can occur with other systemic diseases such as

diabetes mellitus (CIDP-DM) and non-malignant monoclonal

gammopathy (CIDP-MGUS). Whether I-CIDP, CIDP-DM and

CIDP-MGUS differ in clinical presentation, response to treat-

ment and long-term outcome is unclear, as well as the rela-

tionship of these concurrent diseases to CIDP. Eight patients

with I-CIDP, 16 patients with CIDP-DM and 7 patients with

CIDP-MGUS were included in this study and sural nerve

biopsies were taken. Clinical conditions were evaluated

using a Neurologic Disability Scale (NDS) and a modified

Rankin Scale (MRS). All patients were treated with at least

1 course of intravenous immunoglobulins (IVIg) at a dosage

of 2 g/Kg administered over 5 days and classified as treat-

ment responders or non responders according to clinical

improvement. Improvement was defined as a decrease of 4

points in the NDS score. Patients were retreated in case of

relapses. Relapse was defined as worsening after improve-

ment with an increase of 4 points or more in NDS score.

Sural nerve pathology was assessed on semithin sections.

No differences were detected among the three groups

according to age and sex. On neurologic examination the

CIDP-DM group had a significantly more severe disease

based on the NDS and MRS score. In all the three groups

there was an improvement after treatment but this is statis-

tically significant only in the CIDP-DM group. At the end of

the follow-up there is no difference in clinical conditions

among the three groups but there is a significant difference

according to the number of IVIg administrations and thus

with the number of relapses. In conclusion CIDP-DM is a

more severe disease compared to the other 2 groups, but

with a significant better response to IVIg and less number of

relapses.

INFLUENCE OF GENDER AND PREGNANCY ON CMT1A

Pareyson D, Dell’Anna E, DiMondaT, ScaioliV, Ciano C,Sghirlanzoni A, Lauria G, Morbin M, Laura' M, Solari A,Taroni F. Istituto Nazionale Neurologico ‘‘C. Besta’’,

Milan, Italy.

Progesterone increases PMP22 expression. Transgenic

rats overexpressing PMP22, a model of Charcot-Marie-Tooth

type 1A (CMT1A), improve when treated with the progester-

one antagonist, onapristone, and worsen with progesterone

administration. CMT worsening during pregnancy (when pro-

gesterone secretion increases dramatically) has been occa-

sionally reported. We investigated whether gender and

pregnancy influence disease severity and course in CMT1A.

We analyzed clinical and electrophysiological data of 94

CMT1A patients. Data in males and females were compared.

We also determined disease severity in female patients in

the fertile age as compared to males of the same age group.

We retrospectively assessed influence of gestation on dis-

ease course in 20 CMT1A females through a comprehensive

interview. There was no significant difference in disease

severity in females as compared to males. Skeletal deformi-

ties, abnormalities of gait and deep tendon jerks, wasting,

weakness, and sensory impairment were similar in the two

genders. Nerve conduction abnormalities and decrease of

sensory and motor evoked response amplitudes were com-

parable in the two groups. We found no difference in disease

severity even when considering 15 to 50-year-old patients.

Symptom worsening during pregnancy was reported by 4/20

CMT1A females. The effect of sex hormones on PMP22

does not result in a relevant difference in disease severity

between the two genders. A few patients reported some

worsening during pregnancy. Disease and normal controls

need to be evaluated to establish whether this is a CMT1A-

related phenomenon.

ENDOTHELIN AND ENDOTHELIN-CONVERTING-ENZYME-

1 IN INFLAMMATORY NEUROPATHIES: AN

IMMUNOHISTOLOGICAL STUDY

Volpi N, Carbotti P, Greco G*, Bibbo' G*, Alessandrini C,Giannini F*. Dip. Scienze Anatomiche e Biomediche,

*Dip. Neuroscienze (Sezione Neurologia), Universita di

Siena, Italy.

Endothelin (ET), a vasoconstrictive peptide, has a role in

different biological processes. The isoform ET1, the most

active in inflammation, is expressed by endothelial and glial

cells, macrophages, leukocytes, fibroblasts and myocardio-

cytes. ET1 works as pro-inflammatory cytokine in infectious

vasculitis and myocarditis, and experimental myocardial

infarction where antagonists of ET-receptors are effective.

Endothelin-Converting-Enzyme-1 (ECE1), a zinc-dependent

metalloprotease, cleaves inactive precursors into mature

ETs. ECE1 up-regulation has been shown in experimental

hypoglossal nerve axotomy and diabetic neuropathy. Interac-

tions among cytokines, active mediators and matrix metallo-

proteases are currently being investigated in inflammatory

neuropathies. We carried out immunohistochemical analysis

of ET1 and ECE1 on sural nerves from nine patients with

peripheral nerve vasculitis (NV), CIDP and CIDP-diabetic neu-

ropathy. NVs showed a clear ET1 up-regulation on vessel

walls of endoneurium and epineurium, notably in smooth

muscle cells, and in inflammatory cells. ECE1 was expressed

by endoneurial macrophages and Schwann cells. Both immu-

nolocalizations were weaker in CIDP specimens, whereas

CIDP-diabetic neuropathy showed an intermediate pattern.

Endothelin system may have a dual role in NV, as a vasocon-

strictive agent contributing to fascicle ischaemia and as a pro-

inflammatory cytokine. Highest ECE1 expression in fascicles

with severe axonal loss is possibly also due to its wider

peptidase activity. In CIDP-diabetic neuropathy, up-regulation

of ET1 and ECE1 is likely to depend on increase of ET-

receptors induced by hyperglycaemia.


118

AQUADYNIA. A MANIFESTATION OF SMALL FIBER

SENSORY NEUROPATHY?

Brindani F, Gemignani F, Zinno L, Marbini A. Department of

Neurosciences, University of Parma.

Aquadynia is a rare phenomenon of water-induced pain

through presumed neural mechanisms. We describe two

women in whom bathing was regularly followed by pain in

the lower limbs, as a unique symptom (case 1) and, respec-

tively, in the clinical context of an axonal polyneuropathy

(case 2). Case 1: A 71-year-old woman complained, by age

69, of pruritus and pinprick-like pain in the extremities that

lasted about 20 minutes following bathing. Neurological

examination and electroneurography were negative, as well

as investigations for systemic diseases. Quantitative sensory

testing (QST) showed abnormal cold-pain sensation. Treat-

ment with gabapentin was not effective. Case 2: A 69-year-

old woman affected with HCV-related cryoglobulinemia had

numbness and aquadynia in the distal lower limbs and rest-

less legs syndrome, in the last few months. Neurological

examination showed absent ankle jerks, and decreased

touch and vibration sense in the feet. Electroneurography

demonstrated an axonal neuropathy. Aquadynia likely repre-

sents a manifestation of small fiber neuropathy. It is unclear

whether it has to be viewed as a primary sensory phenom-

enon similar to allodynia, or a type of noradrenergic pain

primarily due to autonomic dysfunction. Alteration of QST in

case 1, and the association with obvious features of sensory

neuropathy in case 2, may favour the sensory hypothesis.

FREQUENCY OF CLINICALLY DIAGNOSED SMALL FIBER

NEUROPATHY IN A NEUROPATHY POPULATION

Gemignani F, Brindani F, Zinno L, Allegri I, Alfieri S, MarbiniA. Department of Neurosciences, University of Parma,

Italy.

We reviewed the files of outpatients with polyneuropa-

thy or multiple mononeuropathy over a two-year period

(2002–2003), to assess the relative incidence of small fiber

sensory neuropathy (SFSN), diagnosed with clinical criteria.

The cohort included a total of 97 patients (41 men, 56

women), age 11–85 years (median 64), 91 with polyneuro-

pathy and 6 with multiple mononeuropathy. Twenty-seven

patients with SFSN (27.8%) were identified (7 men, 20

women), age 11–76 years (median 62). SFSN was idiopathic

in 8 cases, and secondary to other diseases in 19 cases,

mainly diabetes or glucose intolerance (8 cases) and mixed

cryoglobulinemia (6 cases). The most frequent manifesta-

tions of SFSN were burning feet (12 cases) and restless

legs syndrome (12 cases). Duration of neuropathy was

2.2þ 2.06 years, whereas in the other patients with poly-

neuropathy was 9.02þ 13.6 (p¼ 0.011). Treatment with

drugs for neuropathic pain was effective in 9 out of 16

cases (56.2%). In this series, SFSN diagnosed by minimal

clinical criteria showed an unexpectedly high relative inci-

dence among miscellaneous peripheral neuropathies. This

can be due to overdiagnosis of SFSN, as we included

patients diagnosed using minimal clinical criteria; on the

other hand, the diagnostic sensitivity of additional tests

(quantitative sensory examination and skin biopsy) is not

definitive, thus diagnosis of SFSN is actually a frequent diag-

nostic challenge. The efficacy of treatment with drugs for

neuropathic pain in many patients may provide further sup-

port for diagnosis.

CHRONIC ATAXIC NEUROPATHY INITIALLY DIAGNOSED

AS ATAXIC VARIANT OF GUILLAIN BARRE SYNDROME

Galassi G, Ruggeri A, Leone M�, Cappelli G. Department of

Neurology and �Nephrology, Modena, Italy.

Acute ataxic neuropathy is characterized by cerebellar-

like ataxia, insignificant weakness, areflexia, and mildly

impaired sensation. Patients usually experience antecedent

infections as in typical Guillain Barre syndrome. Clinical

course is usually monophasic or relapsing with high titer of

antiganglioside antibodies. A 40-year-old mildly hypertensive

man was admitted because of acral paraesthesias, dysar-

thria, swallowing difficulties, and imbalance. On admission,

the patient exhibited inconstant diplopia on lateral gaze,

scanned speech, facial diplegia, cerebellar–like ataxia, tre-

mor, areflexia, mild deep sensory loss, and nearly normal

muscle weakness. Brain and spinal cord MRI was normal.

Electrophysiology showed delayed F waves. Normal labora-

tory results included extensive hematologic tests, search for

IgM paraprotein, antiganglioside antibodies, namely GT1a,

GQ1b IgG, and cold agglutinins. CSF revealed albuminocyto-

logic dissociation. A remote malignancy was excluded.

Patient was treated with plasmaphoresis (PE) with transient

benefit. Four weeks later, because of progression of cerebel-

lar signs, the patient was newly admitted. Electrophysiology

confirmed axonal and demyelinating features. CSF protein

were 330mg/dl (normal <45). PE, IVIG, methylprednisolone

e.v. (1 g daily for 3 days, 500mg for 2 days switched to oral

regimen) and oral chlorambucil gave transient improvement.

Nine months after first onset, the patient suffered new

relapse. Renal biopsy was performed showing focal glomer-

ular changes. In conclusion, the patient exhibited a chronic

relapsing ataxic neuropathy without ophthalmoparesis or

significant deep sensory disturbances, accompanied during

acute phase by bifacial weakness in absence of antiganglio-

side antibody activity.

PAINFUL DIABETIC NEUROPATHY (PDN): A

MORPHOLOGICAL STUDY OF CAPSAICIN RECEPTOR

DISTRIBUTION

Morbin M*, Capobianco R*, Borgna M*, Lombardi R*,Geppetti P , Davis JB�, Pareyson D*, Lauria G*#. *Istitutodi Ricerche Farmacologiche Mario Negri, Milano,#Department of Clinical Neurosciences, University of

Brescia, Brescia, �Neurology Centre of Excellence for

Drug Discovery, GlaxoSmithKline, Harlow, ^Department

of Experimental Medicine and Clinical Medicine,

Pharmacology Unit, University of Ferrara, Firenze, Italy.

Capsaicin receptor TRPV1 is a non-selective ligand-gated

channel activated by different noxious stimuli. Previous


119

studies suggested that an increased density of TRPV1 posi-

tive axons in the skin could be involved in the pathogenesis

of neuropathic pain. To investigate the expression of TRPV1

in PDN patients, skin biopsies from 6 patients with PDN and

10 controls, and sural nerve biopsies from 2 patients with

PDN and 2 controls were studied using the polyclonal

anti-human TRPV1 antibody. Skin nerve fibers widely

expressed TRPV1 immunoreactivity. The density of TRPV1

positive dermal and intra-epidermal nerve fibers (IENF) did

not differ from that obtained using the PGP 9.5 antibody (the

standard marker for IEFN recognition). Confocal analysis

demonstrated that TRPV1 and anti unique-tubulin-1 antibody

(TuJ1) co-localized in all axons. In PDN patients IENF density

was significantly reduced, but no difference in immunostain-

ing was detectable using TRPV1, PGP 9.5 and TuJ1 antibo-

dies. Sural nerve unmyelinated fibers and few small-

myelinated fibers were intensely stained by TRPV1. DPN

patients disclosed a severe reduction in unmyelinated fiber

density, but residual fibers were recognized by TRPV1.

These data suggest that TRPV1 is widely expressed in skin

and sural nerve unmyelinated axons, but its expression is not

increased in PDN. Other mechanisms, such as changes

in proximal axon or neuron excitability, are more likely

involved in the pathogenesis of neuropathic pain in diabetic

neuropathy.

CLINICAL OPEN-LABEL STUDY FOR EVALUATION OF

EFFICACY AND TOLERABILITY OF OXCARBAZEPINE IN

THE TREATMENT OF NEUROPATHIC PAIN

Cafforio G, D’Avino C, Calabrese R, Siciliano G. Department

of Neuroscience, University of Pisa, Italy.

Oxcarbazepine (OXC) is a keto-10-analogue of carbama-

zepine (CBZ) with linear pharmacokinetics and a better toler-

ability profile compared to CBZ. For this reason, OXC has been

used in some studies in the treatment of neuropathic pain of

various genesis, with administration doses ranging from 300

to 2400mg/day. In this study we have assessed the efficacy

and tolerability of OXC 600mg/day, a dose considered, based

on previous data, the minimal therapeutic dose in the treat-

ment of neuropathic pain in some neuropathies, such as dia-

betic neuropathy. We have studied 11 patients affected by

predominant sensitive painful neuropathy, of metabolic, com-

pressive, inflammatory or dysimmune genesis, clinically char-

acterized by paresthesias, dysesthesias and neuralgic pain not

responding to other pharmacologic therapies. At the follow-up

analysis, 7 patients have referred an improvement of painful

symptoms, as evidenced by Visual Analogue Scale score, the

reduction of which ranged from 20 to 60% compared to base-

line values. One patient interrupted the trial for incompliance,

two patients for collateral events (excessive sleepiness) and

another one for a worsening of clinical picture. In conclusion,

our study suggests that OXC can be considered as a valid

alternative in the treatment of painful neuropathies owing

to its characteristics of tolerability and efficacy in such

conditions.

DOWN-REGULATION OF RECEPTORS FOR

SEMAPHORINS AND VEGF IN A TRANSGENIC MODEL OF

CMT1A

Panico MB*, Palumbo C�,VigoT , Nobbio L^ , PisaniV*,Terracciano C*, SchenoneA^ , Modesti A�, Massa R*.Dipartimenti di *Neuroscienze e �Medicina Sperimentale,

Universita di Roma-Tor Vergata, ^Dipartimento di Scienze

Neurologiche, Universita di Genova, Italy.

Charcot-Marie-Tooth type 1 disease (CMT1) encom-

passes a group of primary demyelinating polyneuropathies

caused by molecular defects of the Schwann cells (SC).

Beside myelin damage, axonal atrophy and degeneration

are invariably present and correlate with clinical severity.

This is expected, since signals derived from SC regulate

several axonal properties in myelinated fibers. However, the

molecular mechanisms leading to axonal loss in CMT1 are

still obscure. An important role in promoting axonal growth,

guidance and fasciculation in peripheral nerve (PN) is played

by semaphorins and the vascular endothelial growth factor

(VEGF), by binding with specific receptors, the neuropilins

(NP) and VEGF receptors (VEGFR). These molecules are

expressed by peripheral neurons and SC, and induced in

these cells during Wallerian degeneration. We have utilized

a transgenic rat model of CMT1A to assess the immunor-

eactivity for NP and VEGFR in PN affected by PMP22 over-

dosage. These rats, in the hemizygote condition, show hypo/

demyelination and axonal atrophy in PN. In the sciatic nerve

of young hemizygotes we observed a substantial decrease of

immunoreactivity for NP1 and VEGFR2, both in myelinated

axons and SC, as compared to controls. Conversely, NP2

expression was slightly reduced. These data show that a

down-regulation of the semaphorin/neuropilin and VEGF sig-

nalling pathways may take place in CMT1. Such event may

play a causative role in the axonal atrophy observed in this

group of disorders.

LEPROUS NEUROPATHY: A CLINICAL AND

NEUROPHYSIOLOGICAL STUDY

Ghiglione E, BeronioA, Reni L, Abruzzese M. Department

of Neurosciences, Ophthalmology and Genetics, Univer-

sity of Genoa, Italy.

Leprosy is one of the most common treatable causes of

neuropathy in the world. Peripheral nerves and skin are com-

monly affected. We reported the clinical features and elec-

trophysiological findings in 46 patients with leprosy. The aim

of our study was to evaluate the nature of damage in the

nerve fibres, especially in the first phase of disease. Forty-six

patients (mean age: 44.8� 17.8) with diagnosed leprosy

were studied by neurological examination and nerve conduc-

tion studies (NCS). Twenty-eight patients were examined for

a mean period of 34.8 months. The number of tests for

patients varied from 1 to 13 controls. Amplitude of sensory

and motor action potentials (SNAP and MAP), sensory-motor

conduction velocity of median, ulnar, tibialis, peroneal and

sural nerves were evaluated. Abnormalities were found in

282 of 647 nerves investigated (37.56%), sensory nerve

abnormalities being more frequent than motor (50.16%


120

29.45). Of 282 nerves with neurophysiological abnormalities,

123 were clinically asymptomatic (43.62%). A statistically

significant correlation between duration of disease and num-

ber of electrophysiological abnormalities was demonstrated.

In 19 nerves partial ‘‘conduction-block’’ (reduction of

cMAP> 50% in the proximal response) was individuated.

The first electrophysiological alteration, suggesting segmen-

tal demyelination, was detected in 41 nerves of 21 patients

(33.3 %). According to this view, our data support the

hypothesis that leprosy induces a neuropathy of demyelinat-

ing nature in the first phase.

PAINFUL SENSORY NEUROPATHY AND DYSIMMUNITY:

IS THERE A RELATION?

Carpo M, Scarlato M, Bardella MT,Terrani C, Peracchi M,Allaria S, Nobile-Orazio E, Bresolin N. Dept. Neurological

Sciences, Dept. Medical Sciences, Ospedale Maggiore

Policlinico-IRCCS, Milan, Italy.

Painful sensory neuropathies consist of a wide range of

neuropathies that can involve large as well as small nerve

fibres. Even if most cases remain of unknown cause, some

of them may be associated with an underlying disorder such

as diabetes, HIV, infections, amyloidosis, and Sjogren’s syn-

drome. Since in some cases an autoimmune mechanism has

been postulated, we investigated a panel of circulating auto-

antibodies including anti-gliadin (AGA), anti-endomysium

(EmA), anti-transglutaminase (tTGA) and anti-nuclear (ANA)

antibodies in the sera of patients with unexplained painful

sensory neuropathies in order to identify other potentially

treatable disorders. We tested the sera of 10 patients (4M;

6F) previously investigated for other causes of neuropathies,

including anti-nerve, onconeural, anti-extractable nuclear,

anti-neutrophil cytoplasmic, anti-thyroglobulin (TgA) and anti-

peroxidase (TPOA) antibodies. We found the presence of

AGA positivity in 4 patients (40%), ANA in 7 (70%) and

AGAþANA in 4 (40%), two of whom were negative for

celiac disease by gastrointestinal biopsy. None of the

patients had EmA positivity. Three (30%) had TgA and

TPOA and none had anti-nerve or onconeural antibodies.

Whether the presence of circulating autoantibodies in

patients with unexplained painful neuropathy reflects an

autoimmune involvement which may be amenable to

immune therapy and not only to symptomatic treatment

remains to be established.

MYELIN THICKENINGS IN VAL 102/FS NULL MUTATION

OF MPZ GENE

DeAngelis MV1, Capasso M1, Anghiari C2, CavallaroT2, DiMuzioA1, Fabrizi GM2, Uncini A1. 1Center for Neuromus-

cular Diseases, University G. d’Annunzio, Chieti; 2Sec-

tion of Clinical Neurology, Department of Neurological

and Visual Sciences, University of Verona, Italy.

Myelin thickenings, abnormal myelin foldings and toma-

cula have been rarely described in CMT1B. In two unrelated

patients of different age (patient 1: 29 years old; patient 2: 65

years old) with CMT1B and Val 102/fs null mutation of MPZ

gene we performed morphometric analysis, teased fibers

and ultrastructural examination of sural nerve. We found: 1)

markedly decreased fiber density with prevalent loss of large

diameter fibers (patient 1: 4419 fibers/mm2; patient 2: 1326

fibers/mm2); 2) evidence of de-remyelination; and 3) parano-

dal and internodal myelin thickenings in virtually all fibers.

Patient 1 has myelin thickenings measuring more than 50%

of the fiber diameter in 14% of fibers and thickenings greater

than 30% in 33% of fibers. Patients 2 presents myelin thick-

enings measuring more than 50% of fiber diameter in 23%

of fibers and thickening greater than 30% in 49% of fibers.

When considering the absolute measure of myelin thicken-

ings and their number over 100 internodes, patient 1 pre-

sents 150 small myelin thickenings (<8mm of diameter)

whereas patient 2 has 57. The number of globules (8–12mm

of diameter) is 56 in patient 1 and 45 in patient 2.

The number of myelin thickenings greater than 12mm is 33

in patient 1 and 45 in patient 2. Ultrathin sections showed

myelin infoldings, outfoldings and uncompacted myelin.

CMT1B with a heterozygous null mutation of MPZ gene is

characterized by abundant focal myelin thickenings. Similar

findings have been described in the P0 deficient heterozy-

gous mice.

ATYPICAL RAT CEREBELLAR IMMUNOREACTIVITY IN A

PATIENT WITH FAMILIAL AMYLOID POLYNEUROPATHY

MazzeoA, Laura' M, *Giometto B, ‰Ferlini A, Musumeci O,Autunno M,Vita G, Messina C. Dept. of Neurosciences,

Psychiatry and Anaesthesiology, University of Messina,

*Dept. of Neurological and Psychiatric Sciences,

University of Padua, §Unit of Medical Genetics, Dept. of

Experimental and Diagnostic Medicine, University of

Ferrara, Italy.

Objective: To describe an atypical immunoreactivity

against Purkinje cells and glia of rat cerebellum in a case of

transthyretin (TTR)-related familial amyloid polyneuropathy

(FAP). Background: TTR-FAP is an autosomal dominant dis-

ease, usually presenting as a progressive sensory or sensor-

imotor polyneuropathy with autonomic disturbances. Case

report: A 68-year-old man complained of a two-year history

of severe orthostatic hypotension, diarrhea and progressive

sensorimotor polyneuropathy. The neurological examination

showed a severe distal weakness at the four limbs, areflexia

and distal impairment of pin-prick sensation and propriocep-

tion. The patient was bed-ridden because of the severe

hypotension. Routine laboratory studies, autoantibodies,

neoplastic markers and immunoelectrophoresis were nega-

tive; thyroid function was impaired with reduced levels of

TSH, T3 and high level of anti-tireoglobulin antibodies. An

unusual reactivity against Purkinje cell membrane and glial

cells of rat cerebellum white matter was found on immuno-

histochemistry. Western blot for the detection of onconeural

antibodies (Hu, Ri, Yo and Amphiphysin) was negative. Elec-

trophysiological studies showed a severe axonal sensorimo-

tor polyneuropathy. Chest x-ray and chest and abdomen CT

scans did not reveal any malignancies. Genetic analysis


121

revealed a Phe 64 Leu mutation on TTR gene. Discussion: The

unusual immunoreactivity found in our patient has not been

previously described. Our case report may be a warning to

clinicians to suspect a genetic origin in patients with poly-

neuropathy and atypical pattern of neuronal immunoreactivity.

FATAL LAMIVUDINE-INDUCED EXACERBATION OF

PERIPHERAL NEUROPATHY IN A PATIENT WITH HBV AND

HCV POSITIVITY: EVIDENCE FOR IATROGENIC

MITOCHONDRIAL DAMAGE

MazzeoA, FodaleV, Aguennouz M, Pratico' C, SantamariaLB,Vita G,ToscanoA. Department of Neuroscience, Psy-

chiatric and Anesthesiological Sciences, University of

Messina, Italy.

A 57-year-old man with diabetes, HBV and HCV positiv-

ity, cryoglobulinemia and mild neuropathy was treated by the

nucleoside reverse transcriptase inhibitor (NRTI), Lamivudine

(300mg/daily). Three months later he presented dysphonia,

progressive muscle weakness at lower limb with mild upper

limb involvement. Three weeks later, he was unable to walk

and developed acute tetraparesis followed by an acute

respiratory failure and cardiac arrest that required assisted

ventilation. Electrophysiological studies evidenced a worsen-

ing of a sensorimotor axonal neuropathy. Nerve biopsy

showed complete lack of myelinated fibers with vasculitic

features whereas muscle biopsy presented denervation and

reinnervation with diffuse type grouping. Mitochondrial

respiratory chain enzyme activities demonstrated a marked

reduction of complex I and IV, whereas Southern and dot blot

analyses evidenced a �60% depletion of mtDNA. Lamivu-

dine administration was discontinued. One week later the

patient was awake and able to move his fingertips and his

respiratory drive resumed with partial mechanical support,

but he died a few days later. Lamivudine is often adminis-

tered in HBV treatment. In the last few years, it has been

considered neurotoxic and capable of exacerbating a

peripheral neuropathy. Its NRTI mechanism may cause mito-

chondrial toxicity and cellular polymerase inhibition. In our

patient, polyneuropathy worsened after lamivudine treat-

ment; biochemical and molecular results of our studies

suggest possible diffuse iatrogenic mitochondrial damage.

THE SPECTRUM OF TRANSTHYRETIN GENE MUTATIONS

IN ITALY: A REPORT

Ravani A1, Salvi F2, Rimessi P1, Lauria G3,Vita G4,ToscanoA4, MazzeoA4, Rappezzi C5, Leone O6,Tassinari CA2,Calzolai E1, Ferlini A1. 1Dipartimento di Medicina

Sperimentale-Sezione di Genetica Medica, Ferrara

University, 2Cattedra di Neurologia, Bologna University,3Istituto Neurologico Besta, Milano, 4Clinica Neurologica

II, Azienda Ospedaliera Universitaria, Policlinico di

Messina; 5Istituto di Cardiologia, 6Istituto di Anatomia

Patologica, Bologna University, Italy.

Transthyretin gene mutations causing autosomal domi-

nant familial amyloidotic polyneuropathy (FAP) are often

associated with cardiomyopathy. More than 80 amino acid

variations have been described until now, showing a high

allelic heterogeneity. We screened for TTR mutations 55

patients with mixed polyneuropathy with variable cardiac invol-

vement. By means of direct sequencing of the full coding

region we identified the following 26 genotypes: 2 Ser6 (poly-

morphism), 3 Met30, 4 Gln89, 2 Leu64 (TTT> TTG) and 7

Leu64 (TTT>CTT), 2 Ala49, 2 Leu68, 1 Thr34, 1 Arg50, 1

Glu53 and 1 Asn90. Interestingly, two Leu64 variants were

due to a novel nucleotide variation TTT to TTG in codon 64 and

1 Asn90 mutation was found to co-segregate with a FAP

phenotype. Transthyretin mutations in hereditary amyloidosis

deserve to be investigated in all cases of mixed polyneuropa-

thy with cardiomyopathy both familial and sporadic. A marked

allelic heterogeneity in Italy has been further confirmed by this

study and PCR and direct sequencing seems to represent the

more appropriate diagnostic tool for this pathology.

CHARCOT-MARIE-TOOTH DISEASE TYPE 1: NOVEL

CASES AND NOVEL MUTATIONS DETECTED BY DHPLC

Angiari C, Ferrarini M,Taioli F, CavallaroT, Fabrizi GM,Rizzuto N. Department of Neurological and Visual

Sciences, Section of Clinical Neurology, University of

Verona, Italy.

Background: Charcot-Marie-Tooth disease type 1 (CMT1)

and related Dejerine-Sottas syndrome (DSS) and Hereditary

Neuropathy with liability to Pressure Palsy (HNPP) have a high

degree of genetic heterogeneity; mutation analysis performed

by direct nucleotide sequencing is highly sensitive but time-

consuming and expensive. Objective: To evaluate the sensi-

tivity of denaturing high performance liquid chromatography

(DHPLC), a recently developed technology for fast mutational

analysis. Methods: Optimal conditions for analysing Cx32, P0

and PMP22 genes by DHPLC were developed on the basis of

39 mutations (Cx32¼ 21; P0¼ 10; PMP22¼ 8) detected in the

period 1997–2002. Patients: During 2003, 44 patients fitting

the clinical and electrophysiological criteria of CMT1, DSS or

HNPP who were negative for the 17p11.2 duplication/deletion

were analysed either by nucleotide sequencing or by DHPLC.

Results: In the last year we identified a total of 3 mutations in

Cx32, 3 mutations in MP0 (2 novels mutations, one recessive)

and 2 mutations in PMP22 (2 novels nonsense mutations).

Conclusions: DHPLC was capable of detecting all mutations

identified by sequencing, thus appearing as a reliable approach

for the mutational analysis of CMT1.

DISTAL HEREDITARY MOTOR NEUROPATHY (DHMN): A

NEW LOCUS FOR AN AUTOSOMAL RECESSIVE FORM

Mostacciuolo ML1, Crestanello E1, Boaretto F1, Boscolo E1,Liguori M2,Tessarolo D2,Vettori A1,Vazza G1. 1Department

of Biology, University of Padua, 2Department of Neu-

roscience, S. Camillo Hospital, Rome, Italy.

Distal hereditary motor neuropathy (dHMN), also known

as the spinal form of Charcot-Marie-Tooth (spinal CMT) disease

or as distal spinal muscular atrophy (dSMA), is an exclusively


122

motor disorder of the peripheral nervous system. Seven differ-

ent variants of distal HMN have been clinically identified and 5

loci have so far been mapped, of which two for the recessive

forms (HMN type 3 and type 6). We collected the DNA of a

family in which some cases of HMN have been clinically diag-

nosed. This family lives in a small and geographically isolated

village of southern Italy. Due to the presence of a high fre-

quency of inbreeding evident from several consanguinity loops,

an autosomal recessive inheritance has been postulated and

the involvement of a single gene responsible can be assumed.

To exclude possible involvement of genes causing similar

pathological phenotypes, a preliminary mutational screening

for the genes PMP22 and P0, involved in CMT1, and SMN1

gene, responsible for the SMA, has been carried out: no muta-

tions were found. Furthermore, a linkage analysis has been

made for the HMN 3 and 6, obtaining negative LOD score

values (less than -2). On the bases of such data and considering

the high informativity of this pedigree (simulated max LOD

score¼ 4.24 at a recombination frequency of 0.0), we per-

formed a genomewide analysis using 483 fluorescent-labelled

microsatellite markers. Preliminary results allow us to identify a

critical region cosegregating with the disease in the affected

subjects on chromosome 11p.

A NOVEL 9BP INSERTION IN GJB1 GENE CAUSING LATE

ONSET, INTERMEDIATE CMT IN AN ITALIAN PATIENT

Zortea M1,2, Merlini L3, Mostacciolo ML1. 1Department of

Biology and 2Department of Neurologic and Psychiatric

Sciences, University of Padua, 3Neuromuscular Unit,

Orthopaedic Institute ‘‘Rizzoli’’, Bologna, Italy.

Charcot-Marie-Tooth disease constitutes a clinically and

genetically heterogeneous group of hereditary motor and

sensory peripheral neuropathies. On the basis of electrophy-

siologic properties and histopathology, CMT has been

divided into demyelinating (type 1) and axonal (type 2) neu-

ropathies. The form of Charcot-Marie-Tooth neuropathy that

maps to Xq13 may present mild electrophysiological changes

(NCV> 40M/s), mixed neuropathy (NCV: Intermediate (30–

40M/s), or demyelinating neuropathy (NCV: Slow (<37M/s).

On molecular grounds, CMTX is caused by mutations in

GJB1 gene, coding for Connexin 32 protein. A 42-year-old

man, with no other affected family members, was clinically

evaluated for CMT. Three years ago he noticed thumb abduc-

tor atrophy and then leg muscle atrophy. He presented with

hand and leg muscle atrophy, bilateral pes cavus, areflexia,

and apallesthesia. The median and ulnar motor NVC were

35–38m/s, and the median sensory NVC was 35m/s. Both

motor and sensory nerve action potentials were markedly

reduced. After exclusion of CMT1A and 1B, analysis for

CMTX was performed. The mutation screening of GJB1

gene showed a 9bp insertion upstream the 194ATG codon

(Met194) with preservation of the downstream sequence.

The three new amino acids (Thr-Val-Phe) inserted are loca-

lized between the end of the second extracellular domain

and the beginning of the fourth transmembrane domain.

This is the first 9bp insertion found in GJB1 gene; a

genotype-phenotype correlation may be deduced.

PERIPHERAL NEUROPATHY AS INITIAL SIGN OF

MITOCHONDRIAL DISORDER

Manneschi L, Battisti C*, Pesci I, Malandrini A, SantorelliFM‰, Scaglioni A, FedericoA*, Montanari E. U.O. Neurolo-

gia, Ospedale Civile, Fidenza (PR), *Dipartimento di

Scienze Neurologiche e del Comportamento, Universita

di Siena, §Ospedale Bambin Gesu, Roma, Italy.

Peripheral neuropathy is one of the clinical manifesta-

tions of mitochondrial disorders such as MELAS, MERRF,

MNGIE, NARP, Leigh’s syndrome, and Kearne-Sayre syn-

drome. However, the prevalence of the neuropathy and its

pathogenesis in mitochondrial diseases are not yet comple-

tely clarified. We describe the clinical case of a 40-year-old

woman who, at 35 years of age, developed a progressive

peripheral neuropathy that was the only and first clinical sign

of disease for several years. In the family history a preva-

lence of severe cardiomyopathy in paternal lineage (the

father and two brothers) is referred. Four years after the

onset of the disease, our patient developed secondary thyr-

oid hypothyroidism with multinodular gland and recently,

bilateral cataract. Routinely laboratory investigations and neu-

roimaging study were normal. A mild increase of serum lactic

acid was present (1.7mmol/l, n.v. 0.3–1.3). Electrophysiolo-

gical examination showed a sensorimotor neuropathy, with a

prevalence of demyelinating pattern. Nerve biopsy confirmed

myelin and axonal degeneration. Muscle biopsy showed

80% of negative cytochrome C oxidase fibres and mitochon-

dria with paracrystalline inclusions. Biochemical analysis con-

firmed COX deficiency. Molecular genetic analysis excluded

multiple deletions of mtDNA. The sequence of mitochondria

DNA is being performed. In the literature there are a few

cases of mitochondrial disorder with peripheral neuropathy

at onset, usually juvenile cases. Our clinical case shows that

a mitochondrial pathogenesis should be considered in the

differential diagnosis of neuropathies.

PAINFUL NEUROPATHY VASCULITIS IN HIV INFECTION

Ferrari S1, CavallaroT1, Lanzafame M2, Malena M3, RizzutoN1. 1Sezione di Neurologia Clinica Dipartimento di

Scienze Neurologiche e della Visione, 2Malattie Infettive,

Universita di Verona, and 3Centro Screening HIV,

ULSS20, Verona, Italy.

The clinical picture of painful neuropathy is generally

related to direct HIV involvement in the peripheral nervous

system (PNS) or to neurotoxic effect of drugs contained in

high activity antiretroviral therapy (HAART). We describe 2

patients with long-standing HIV infection treated with

HAART. Both patients developed a subacute distal painful

symmetric neuropathy not influenced by analgesics and

anti-inflammatory drugs. Sural nerve biopsy revealed focal

axonal loss, degeneration of myelinated fibers and epineurial

necrotizing vasculitis with T-cell infiltration of vessel wall. In

both cases steroid therapy led to improvement of symptoms.

Vasculitic neuropathy with a clinical picture of painful neuro-

pathy is most unusual, the common clinical expression of

vasculitis being mononeuritis multiplex. Our cases indicate

that isolated vasculitis of peripheral nerve can occur in


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long-standing HIV-1 infection and the clinical presentation

with distal symmetric polyneuropathy does not rule out

such a diagnosis. High activity antiretroviral therapy is unable

to prevent vasculitis in peripheral nerves; similar to a pre-

vious reported case of Guillain-Barre syndrome, an immune

reconstitution phenomenon plays a role in the induction of a

vasculitic autoimmune process. In conclusion, in cases of

DSPN with intense and persistent symptoms, a nerve biopsy

is necessary for a differential diagnosis to be made and an

appropriate and effective therapy given.

ARE GIANT AXONS A PATHOLOGICAL MARKER OF

CHARCOT-MARIE-TOOTH NEUROPATHY TYPE 2E?

CavallaroT, Fabrizi GM, Angiari C, Lus G*, Cabrini I, CotrufoR*, Rizzuto N. Department of Neurological and Visual

Sciences, Section of Clinical Neurology, University of

Verona, *Department of Neurological Sciences. Second

University of Naples, Italy.

Background: According to electrophysiological and

pathological criteria Charcot Marie Tooth (CMT) disease

includes primary demyelinating forms (CMT1) and neuropa-

thies with primary axonal loss (CMT2). In CMT1, genetic

analysis provided some associations between characteristic

lesions and different proteins. In CMT2, four genes were

identified recently (CMT2A, B, D, E); the molecular diagnosis

is complex and phenotypical hallmarks are lacking. Objec-

tives: To describe the nerve biopsy in three pedigrees with

CMT2E caused by mutations of the neurofilament-light chain

gene (NF-L): two pedigrees from Campania sharing a Pro22-

Ser substitution in the head domain of protein and one pedi-

gree from Apulia with a novel Leu268Prol substitution in the

central rod domain. In all three pedigrees electrophysiology

was consistent with a mixed, demyelinating and axonal neu-

ropathy. Results: The three patients analysed revealed a

primary axonopathy characterized by giant axonal swelling

filled with densely packed neurofilaments and some atrophic

axons. Conclusions: We propose that, in the diagnostic work

up of CMT2, giant axons may orientate towards CMT2E. The

pathological alterations detected correlate intuitively with an

altered function of the neurofilaments which constitute the

axonal cytoskeleton and are critical for radial growth and for

axonal transport.

A SPLICE-JUNCTION MUTATION IN SBF2 GENE CAUSES

AUTOSOMAL RECESSIVE CHARCOT-MARIE-TOOTH

DISEASE (CMT4B2) IN A FAMILY FROM SOUTHERN ITALY

Conforti FL1, Muglia M1, Mazzei R1,Valentino P2, PatitucciA1, Bono F2, MagarielloA2, Sprovieri T1, Senderek J3,Bergmann C3, Nistico' R2, GabrieleAL1, Peluso G1,QuattroneA1,2. 1Institute of Neurological Sciences,

National Research Council, Piano Lago di Mangone,

Cosenza, 2Institute of Neurology, University Magna

Graecia, Catanzaro, Italy, 3Department of Human Genet-

ics, Aachen University of Technology, Aachen, Germany.

Autosomal recessive Charcot-Marie-Tooth disease type

4 (CMT4) comprises a group of clinically and genetically

heterogeneous disorders of the peripheral nervous system.

At least 10 loci are responsible for autosomal recessive CMT

and six genes have been identified so far. In this study, we

report a small pedigree with a recessive form of CMT

(CMT4B) from Southern Italy. There were six individuals in

two generations with two affected subjects. We performed

haplotype analysis using highly polymorphic microsatellite

markers located on chromosome 11p15. Subsequently, the

coding region of the Sbf2 gene was sequenced by using

primers flanking intron-exon boundaries. Mutational screen-

ing of Sbf2 revealed a homozygous mutation in the splice-

junction donor-acceptor site of intron 32 (þ1G!C) in the

affected patients. The variation was also confirmed by diges-

tion with restriction enzyme Alu I and it was absent in 100

control chromosomes examined. This is the first finding of a

mutation in the Sbf2 gene that alters the correct splicing of

the gene. Furthermore, these data confirm that mutations in

the Sbf2 gene are causative of CMT4B2.

NARROWING OF THE CRITICAL REGION IN AUTOSOMAL

RECESSIVE SPASTIC PARAPLEGIA LINKED TO THE SPG5

LOCUS

Muglia M1, Criscuolo C2, MagarielloA1, De Michele G2,ScaranoV2, D’Adamo P3, Ambrosio G2, GabrieleAL1,Patitucci A1, Mazzei R1, Conforti FL1, Sprovieri T1, MorganteL4, EpifanioA4, La Spina P4,Valentino P5, Gasparini P3, FillaA2, QuattroneA1^5. 1Institute of Neurological Sciences,

National Research Council, Mangone-Cosenza, 2Depart-

ment of Neurological Sciences, Federico II University,

Napoli, 3Telethon Institute of Genetics and Medicine

(TIGEM), Napoli, 4Department of Neurology, University

of Messina, Messina, 5Institute of Neurology, University

‘‘Magna Graecia’’, Catanzaro, Italy.

Hereditary spastic paraplegias are neurodegenerative

disorders characterized clinically by progressive spasticity of

the lower limbs; they are inherited as autosomal dominant,

autosomal recessive and X-linked traits. We have analyzed

four autosomal recessive HSP families gathered from south-

ern Italy. We performed genetic analysis using microsatellite

markers associated with SPG5, SPG7, SPG11 and SPG14.

Positive lod scores were obtained with markers located on

chromosome 8. The lod scores for the four combined

families were significantly higher than 3 for D8S509,

D8S1102, D8S1723 and D8S260 with a maximum two-

point lod score at �¼ 0 of 3.99 for the marker D8S260. In

one of the examined families, the haplotype analysis sug-

gests two key recombination events demonstrating that the

gene is localized in the 11 cM region flanked by markers

D8S285 and D8S544, refining the ARHSP region by approxi-

mately 22 cm. We also analyzed five candidate genes loca-

lized within the HSP region: TOX, syndecan-binding-protein

(SDCBP), RAB2, CA8 and PENK, but we did not find disease

causing mutations.


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FURTHER EVIDENCE OF GENETIC HETEROGENEITY IN

AUTOSOMAL DOMINANT DISTAL MOTOR

NEURONOPATHY

MagarielloA1, Muglia M1, Passamonti L2, Bellesi M2,Conforti FL1, Mazzei R1, Patitucci A1, GabrieleAL1, SprovieriT1, Peluso G1, Caracciolo M1, Medici E2, Logullo F2,Provinciali L2, QuattroneA1^3. 1Institute of Neurological

Sciences, National Research Council, Piano Lago di

Mangone, Cosenza, 2Institute of Neurological Sciences,

Ospedale Regionale ‘‘Torrette’’, University Ancona,3Institute of Neurology, University ‘‘Magna Graecia’’,

Catanzaro, Italy.

Distal hereditary motor neuronopathy (distal HMN) is a

genetically and clinically heterogeneous disorder. To date

three loci have been identified on chromosomes 7p14, 9q34

and 12q24. We describe a four generation Italian family with

distal HMN starting at around 30 years of age with weakness

and atrophy of distal leg muscles and pyramidal features. We

performed genetic linkage analysis with microsatellites on

chromosomes 7p14, 9q34 and 12q24. Negative LOD scores

excluded any evidence of linkage to the above-mentioned

chromosomes in the family. Moreover, because of pyramidal

features in our patients, we performed the linkage analysis to

all the known loci for autosomal dominant hereditary spastic

paraparesis (ADHSP). The analysis was negative thus exclud-

ing that our patients were affected by a complicated form of

ADHSP. These data further confirm a genetic heterogeneity

within inherited motor neuronopathy disorders.

UNRAVELLING THE MOLECULAR BASIS OF CMT4B

PATHOLOGY

Bolis A1, Previtali S2, Bussini S1, Dina G2, Dati G3, Feltri ML3,Quattrini A2,Wrabetz L3, BolinoA1. 1Dulbecco Telethon

Institute, DIBIT, San Raffaele Scientific Institute, Via

Olgettina, 58, 20132 Milano, 2Neuropathology Unit,

Dept. of Neurology, and 3DIBIT, San Raffaele Scientific

Institute, 20132 Milano, Italy.

Charcot-Marie-Tooth type 4B (CMT4B) disease is a

severe autosomal recessive peripheral neuropathy with child-

hood onset, characterised by progressive muscular atrophy

and weakness in the distal extremities, sensory loss,

severely decreased nerve conduction velocities, and demye-

lination with myelin outfoldings in the peripheral nerve. We

demonstrated that CMT4B is caused by loss of function

mutations in the Myotubularin-related 2 gene, MTMR2, on

chromosome 11q22 (Bolino et al., Nat Genet 25:17–19,

2000). MTMR2 belongs to the myotubularin family of protein

phosphatases, of which, myotubularin (MTM), mutated in

the X-linked myotubular myopathy (XLMTM) is the founder

member. MTMR2 shows specific activity towards phospha-

tidylinositol 3-phosphate and 3,5-biphosphate, PI(3)P and

PI(3,5)P2, respectively. However, how abrogation of this

lipid phosphatase activity is leading to the specific disease

phenotype has not yet been demonstrated. To elucidate the

biological role of MTMR2 in the nerve, we performed an

extensive expression analysis of this protein in the peripheral

nervous system. Since MTMR2 was demonstrated to be

ubiquitously expressed also within the nerve, we sought

nerve-specific interactors using the yeast two-hybrid

approach. The neurofilament light chain protein, NF-L,

mutated in various CMTs including axonal type CMT2E, and

demyelinating Dejerine-Sottas syndrome, was found to inter-

act with MTMR2 in Schwann cells as well as in neurons.

Since NF-L is specifically expressed in the nervous system,

the interaction between MTMR2 and NF-L would

explain why loss of a ubiquitously expressed phosphatase

affects specifically the nerve (Previtali and Bolino, Hum Mol

Genet 12:1713–1723, 2003). To model the CMT4B pathol-

ogy, we generated a general knock-out mouse arising

from inactivation f Mtmr2 in all cells. The characterisation of

this animal model is underway. Overall, Mtmr2 null mice

display a milder phenotype with respect to the human dis-

order. The morphological analysis of the peripheral nerve of

this mouse line performed at P28 revealed the presence

of myelin outfoldings, which are the hallmark of CMT4B

pathology.


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