He had been taking methotrexate (20 mg/week) for RA for 1 year, a

He had been taking methotrexate (20 mg/week) for RA for 1 year, and continued until his demise. The patient had a past history of myocardial infarction, spontaneous deep vein thrombosis and pulmonary embolus. Examination revealed an afebrile, alert, cachectic man oriented to time and person but not to place. The patient displayed moderate paratonia, mild reduction of vibration sense in big toes, drifting of the left arm up and down when eyes were closed, dysdiadochokinesis and striking bilateral dysmetria in the arms and legs, left worse than right. He had an ataxic gait with marked

truncal instability and inconsistent stimulus-sensitive myoclonus. Laboratory investigations INCB024360 were negative for Pexidartinib anti-neuronal nuclear antibody 1 (ANNA-1), ANNA-2 and Purkinje cell antibodies, as well as for Lyme disease and HIV. Levels of serum gamma globulins were normal. CSF glucose, WBC and protein levels were within normal limits. The CSF was negative for JCV and BK viruses but was positive for 14-3-3 protein, raising the suspicion of CJD. Brain

MRI revealed non-enhancing white matter hyperintensities in the left cerebellar hemisphere. A repeat MRI scan 12 days later revealed “progressive vasogenic edema” suggestive of an acute progressive demyelinating disease. A CT scan of the chest, abdomen and pelvis Inositol monophosphatase 1 was noncontributory. Due to his advanced age and the possibility of CJD, no further aggressive diagnostic procedure or treatment was undertaken. He continued to deteriorate and died at home 2 months after presentation. Standard set of neuropathology sections from all brain areas as well as samples

of grossly described abnormalities were removed for microscopic examination. The sections were processed to paraffin embedding and stained with HE, and in luxol fast blue with PAS methods. Selected sections were routinely immunostained for the following tissue antigens with commercially available primary antibodies (all from DAKO, Carpenteria, CA, USA): GFAP (polyclonal, 1:3000 dilution), ferritin (polyclonal 1:500), P53 (clone DO-7, 1:50) and neurofilament (NF, monoclonal, 1:4000, clone 2F11). Monoclonal antibodies against SV-40 T antigen (Calbiochem, 1:400) were used for initial detection of the virus. For the identification of inflammatory cells, monoclonal antibodies against CD3, CD4, CD8, CD45 and CD68 (Novocastra, Newcastle-upon-Tyne, UK; 1:50) were also applied. The streptovidin/biotin detection system (Invitrogen, Carlsbad, CA, US; “Histostatin Plus”) was used for visualization of the immune reactions and followed by a light hematoxylin counterstain. Immunohistochemistry was performed using LabVision autostainer.

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