Parkinson's disease with involvement of the parasympathetic ganglia

We report the distribution of Lewy bodies in an 83-year-old man who was diagnosed histopathologically as having Parkinson's disease. Many sections were taken from the brain, spinal cord, spinal dorsal root ganglia and peripheral autonomic systems. In the central nervous system, Lewy bodies were present in many of the areas already reported by previous authors. In the peripheral nervous system, Lewy bodies were present in the sympathetic ganglia, enteric nervous system of the alimentary tract and the submandibular ganglion, which is a peripheral parasympathetic ganglion. The present case indicates that the peripheral parasympathetic ganglia are involved in the disease process of Parkinson's disease.     

Parkinson's disease: the distribution of Lewy bodies in the peripheral autonomic nervous system

The distribution of Lewy bodies (LBs) in the peripheral autonomic nervous system was examined in the following 3 groups: group A, 10 patients with Parkinson's disease (age range, 56-82 years); group B, 5 nonparkinsonian patients with many LBs in the central nervous system (CNS) (range, 26-79 years); group C, 176 nonparkinsonian patients without LBs in the CNS (range, 7-107 years). In group A, LBs were found in the paravertebral and/or celiac sympathetic ganglia in 9 cases, enteric nervous system in all cases, cardiac and pelvic plexuses in 4 cases each, and adrenal medullae in 3 cases. They were almost exclusively intraneural . LBs were also found in group B: sympathetic ganglia in 4 cases, enteric nervous system in 5 cases, and pelvic plexus and adrenal medullae in one case each. Interestingly, both the distribution and the number of LBs in a patient with diffuse Lewy body disease were similar to those in group A. LBs, although definitely fewer in number, were also found in group C: sympathetic ganglia in 5 out of 136 cases; enteric nervous system in 8 out of 40 cases; and cardiac plexus in 2 out of 25 cases. All of these positive cases were over age 60. The wide occurrence of LBs in the peripheral autonomic nervous system in patients with Parkinson's disease may play an important role in causing a variety of autonomic symptoms in the disease. On the other hand, LBs have been occasionally found in nonparkinsonian patients over age 60.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neuropathology of autonomic dysfunction in synucleinopathies

The synucleinopathies—Parkinson's disease, dementia with Lewy bodies, multiple system atrophy, and pure autonomic failure—result from distinct patterns of abnormal α‐synuclein aggregation throughout the nervous system. Autonomic dysfunction in these disorders results from variable involvement of the central and peripheral autonomic networks. The major pathologic hallmark of Parkinson's disease and dementia with Lewy bodies is Lewy bodies and Lewy neurites; of multiple system atrophy, oligodendroglial cytoplasmic inclusions; and of pure autonomic failure, peripheral neuronal cytoplasmic inclusions. Clinical manifestations include orthostatic hypotension, thermoregulatory dysfunction, gastrointestinal dysmotility, and urogenital dysfunction with neurogenic bladder and sexual dysfunction. Strong evidence supports isolated idiopathic rapid eye movement sleep disorder as a significant risk factor for the eventual development of synucleinopathies with autonomic and/or motor involvement. In contrast, some neurologically normal elderly individuals have Lewy‐related pathology. Future work may reveal protective or vulnerability factors that allow some patients to harbor Lewy pathology without overt autonomic dysfunction. © 2018 International Parkinson and Movement Disorder Society     

Autonomic involvement in Parkinson's disease: pathology, pathophysiology, clinical features and possible peripheral biomarkers

Autonomic nervous system involvement occurs at early stages in both Parkinson's disease (PD) and incidental Lewy body disease (ILBD), and affects the sympathetic, parasympathetic, and enteric nervous systems (ENS). It has been proposed that alpha-synuclein (α-SYN) pathology in PD has a distal to proximal progression along autonomic pathways. The ENS is affected before the dorsal motor nucleus of the vagus (DMV), and distal axons of cardiac sympathetic nerves degenerate before there is loss of paravertebral sympathetic ganglion neurons. Consistent with neuropathological findings, some autonomic manifestations such as constipation or impaired cardiac uptake of norepinephrine precursors, occur at early stages of the disease even before the onset of motor symptoms. Biopsy of peripheral tissues may constitute a promising approach to detect α-SYN neuropathology in autonomic nerves and a useful early biomarker of PD.     

Substance P-like immunoreactivity in developing cranial parasympathetic neurons of the rat

Substance P-like immunoreactivity (SPLI) has been observed in cell bodies of fetal cranial parasympathetic ganglia of rat. It first appears at day 16 of gestation at the same time as in cranial sensory ganglia. From day 17 to 21, SPLI neurons constitute most, if not all, submandibular-sublingual and intralingual ganglia, they form 30–40% of otic and pterygopalatine ganglia and numerous such neurons are found in the myenteric plexus of the esophagus as well as in pharyngeal and buccal walls. The immunoreactive material is thinly granular, and its appearance does not change with prenatal development. The immunoreactivity in cell bodies of parasympathetic ganglia decreases at the end of the gestational period, and cannot be evidenced any more in most cells of normal adult ganglia. However, the corresponding SPLI fibers remain intensely immunoreactive. When grafted to rat irides, which have been chemically depleted of intrinsic SPLI fibers, submandibular, otic and pterygopalatine ganglia from pre- or postnatal rats rapidly produce a large amount of SPLI fibers on the iris mimicking the pattern of sensory innervation. This proves the presence of SPLI neurons in adult parasympathetic ganglia, at least in experimental conditions.This study of fetuses and grafts demonstrates the existence of neurons in SPLI parasympathetic cranial ganglia which has been underestimated or ignored previously as a result of observations on adult ganglia. The very large proportion of SPLI neurons in the ganglia of the salivary gland might be of importance for the interpretation of experimental studies on the control of salivation. The presence of SPLI in all three types of peripheral ganglia, sensory, sympathetic and parasympathetic, raises the question of its functional significance in the different compartments of the peripheral nervous system.     

Neurofilament immunoreactivity in developing rat autonomic and sensory ganglia

Immunoreactivity to neurofilament (NF) antiserum appears early in the development of both the central and peripheral nervous systems of the rat fetus. In 10 somite embryos, positive cell bodies are present in the ventromedial part of anterior rhombencephalic and mesencephalic neural tube. From there the appearance of immunoreactivity spreads cranially to the prosencephalic anlage before closure of the anterior neuropore and caudally following the sequence of neural tube closure. Immunoreactivity increases rapidly in axon bundles of central and peripheral systems, but in immature cell bodies of sensory ganglia the NF material only forms a ring around the nucleus. At 16 days of gestation, some cell bodies are progressively loaded with NF-immunoreactive material as a thick perinuclear network first and then in more excentrically located aggregates. This category of neurons is mainly observed in the distal part of the trigeminal ganglion, in petrous and nodose ganglia and in cervical dorsal root ganglia. In adult ganglia large cell bodies and some small ones present high NF immunoreactivity. In autonomic cell bodies (in superior cervical ganglion and in parasympathetic cranial ganglia) the immunoreactive material only forms a perinuclear ring slowly transformed into a loose perinuciear meshwork at the end of gestation. Intensely reactive nerve fibers are observed in cranial sensory as well as in sympathetic and parasympathetic ganglia and nerves. No positive cell bodies and only a few NF-immunoreactive nerves are observed in the carotid bodies. The NF immunoreactivity is better visualized on sections of fresh frozen material, treated with acetone, than in fixed specimens.These results are compared to previous observations reported for other species and for developing dorsal root ganglia. This immunostaining may be used to detect differentiation of peripheral sensory and autonomic neurons under experimental conditions. The uneven distribution of NF immunoreactivity in sensory neurons from stage 16 days of gestation as specific for precise subpopulations of neurons is discussed.     

VRL-1 immunoreactivity in the rat cranial autonomic ganglia.

Immunohistochemistry for VRL-1, a newly cloned capsaicin-receptor homologue, was performed on the rat cranial autonomic ganglia. The immunoreactivity (ir) was detected in the majority of neurones in the pterygopalatine (66%) and submandibular ganglia (68%). In the tongue and carotid body, parasympathetic neurones contained VRL-I ir. In the superior cervical ganglion, only 2% of postganglionic sympathetic neurones showed the immunoreactivity. VRL-1-ir nerve endings could not be detected in their peripheral tissues. These findings may suggest that VRL-1 has functions within neuronal cell bodies of the cranial autonomic ganglia.     

Immunoreactivity of myelin‐associated oligodendrocytic basic protein in Lewy bodies

Myelin‐associated oligodendrocytic basic protein (MOBP) plays a role in structural maintenance of the myelin sheath in the central nervous system. Recent genome analyses have revealed that mutation in MOBP is a risk factor for various neurodegenerative diseases, including Alzheimer's disease (AD), tauopathies and transactivation response DNA‐binding protein 43 kDa proteinopathies. Proteomics analysis has shown that MOBP is a component of cortical Lewy bodies (LBs). However, the immunohistochemical localization of MOBP in the human brain is not known. Using immunohistochemistry, we examined the brain, spinal cord and peripheral ganglia from patients with various neurodegenerative diseases and control subjects. In normal controls, MOBP immunoreactivity was evident in the myelin in the central and peripheral nervous systems (PNS), and neuronal cytoplasm in both the central and PNS. In Parkinson's disease and dementia with LBs, MOBP immunoreactivity was found in the core of LBs in the brainstem, cingulate cortex and sympathetic ganglia. No MOBP immunoreactivity was found in a variety of other neuronal or glial inclusions in other disorders, including multiple system atrophy, AD, Pick's disease, progressive supranuclear palsy, corticobasal degeneration, argyrophilic grain disease, amyotrophic lateral sclerosis and frontotemporal lobar degeneration. Considering that up‐regulation of MOBP has been reported in neurotoxic conditions, accumulation of MOBP in LBs may imply a cytoprotective mechanism in LB disease.     

Multiple organ involvement by alpha‐synuclein pathology in Lewy body disorders

Lewy body (LB) diseases are characterized by alpha‐synuclein (AS) aggregates in the central nervous system (CNS). Involvement of the peripheral autonomic nervous system (pANS) is increasingly recognized, although less studied. The aim of this study was to systematically analyze the distribution and severity of AS pathology in the CNS and pANS. Detailed postmortem histopathological study of brain and peripheral tissues from 28 brain bank donors (10 with Parkinson's disease [PD], 5 with dementia with LB [DLB], and 13 with non‐LB diseases including atypical parkinsonism and non‐LB dementia). AS aggregates were found in the pANS of all 15 LB disease cases (PD, DLB) in stellate and sympathetic ganglia (100%), vagus nerve (86.7%), gastrointestinal tract (86.7%), adrenal gland and/or surrounding fat (53.3%), heart (100%), and genitourinary tract (13.3%), as well as in 1 case of incidental Lewy body disease (iLBD). A craniocaudal gradient of AS burden in sympathetic chain and gastrointestinal tract was observed. DLB cases showed higher amounts of CNS AS aggregates than PD cases, but this was not the case in the pANS. No pANS AS aggregates were detected in Alzheimer's disease (AD) cases with or without CNS AS aggregates. All pathologically confirmed LB disease cases including 1 case of iLBD had AS aggregates in the pANS with a craniocaudal gradient of pathology burden in sympathetic chain and gastrointestinal tract. AS was not detected in the pANS of any AD case. These findings may help in the search of peripheral AS aggregates in vivo for the early diagnosis of PD. © 2014 International Parkinson and Movement Disorder Society     

Latest concept of Lewy body disease

We proposed the term ‘Lewy body disease’ (LBD) in 1980. Subsequently, we classified LBD into three types according to the distribution pattern of Lewy bodies: a brainstem type, a transitional type and a diffuse type. Later, we added the cerebral type. As we have proposed since 1980, LBD has recently been used as a generic term, including Parkinson's disease, Parkinson's disease with dementia and dementia with Lewy bodies. LBD has neuropathological characteristics whereby numerous Lewy bodies are present in the central and sympathetic nervous systems, and it is a type of alpha‐synucleinopathy because the main component of Lewy body is alpha‐synuclein. In this paper we explain the most recent concept of LBD from the historical viewpoint.     

Satellite glial cells in sympathetic and parasympathetic ganglia: In search of function

Glial cells are established as essential for many functions of the central nervous system, and this seems to hold also for glial cells in the peripheral nervous system. The main type of glial cells in most types of peripheral ganglia - sensory, sympathetic, and parasympathetic - is satellite glial cells (SGCs). These cells usually form envelopes around single neurons, which create a distinct functional unit consisting of a neuron and its attending SGCs. This review presents the knowledge on the morphology of SGCs in sympathetic and parasympathetic ganglia, and the (limited) available information on their physiology and pharmacology. It appears that SGCs carry receptors for ATP and can thus respond to the release of this neurotransmitter by the neurons. There is evidence that SGCs have an uptake mechanism for GABA, and possibly other neurotransmitters, which enables them to control the neuronal microenvironment. Damage to post- or preganglionic nerve fibers influences both the ganglionic neurons and the SGCs. One major consequence of postganglionic nerve section is the detachment of preganglionic nerve terminals, resulting in decline of synaptic transmission. It appears that, at least in sympathetic ganglia, SGCs participate in the detachment process, and possibly in the subsequent recovery of the synaptic connections. Unlike sensory neurons, neurons in autonomic ganglia receive synaptic inputs, and SGCs are in very close contact with synaptic boutons. This places the SGCs in a position to influence synaptic transmission and information processing in autonomic ganglia, but this topic requires much further work.     

Parkinson's disease: an immunohistochemical study of Lewy body-containing neurons in the enteric nervous system

Summary We performed immunohistochemical analysis of specimens from three autopsied patients with Parkinson's disease, using antibodies to tyrosine hydroxylase (TH), vasoactive intestinal polypeptide (VIP), somatostatin, met-enkephalin, leu-enkephalin and substance P in an attempt to reveal the types of neurons that contain Lewy bodies (LBs) in the paravertebral and celiac sympathetic ganglia and in the enteric nervous system of the alimentary tract. In the sympathetic ganglia, almost all LB-containing neuronal cell bodies and processes were immunoreactive for TH. In the alimentary tract, however, most LBs were found in the VIP-immunoreactive (VIP-IR) neuronal cell bodies and processes. In spite of the significant presence of TH-IR neuronal cell bodies and processes in the alimentary tract, LB-containing TH-IR neuronal elements were rarely encountered. These findings indicate that in the alimentary tract, the VIP neuron system is mainly involved in the disease process of Parkinson's disease.Supported in part by a research grant for CNS degenerative diseases from the Ministry of Health and Welfare, Japan     

Alpha‐synuclein in peripheral tissues and body fluids as a biomarker for Parkinson's disease – a systematic review

Parkinson's disease (PD) is neuropathologically characterized as an alpha‐synucleinopathy. Alpha‐synuclein‐containing inclusions are stained as Lewy bodies and Lewy neurites in the brain, which are the pathological hallmark of PD. However, alpha‐synuclein‐containing inclusions in PD are not restricted to the central nervous system, but are also found in peripheral tissues. Alpha‐synuclein levels can also be measured in body fluids. The aim of this study was to conduct a systematic review of available evidence to determine the utility of alpha‐synuclein as a peripheral biomarker of PD. We searched PubMed (1948 to 26 May 2013), Embase (1974 to 26 May 2013), the Cochrane Library (up to 26 May 2013), LILACS (up to 26 May 2013) and CINAHL (up to 26 May 2013) for the studies of alpha‐synuclein in peripheral tissues or body fluids in PD. A total of 49 studies fulfilled the search criteria. Peripheral tissues such as colonic mucosa showed a sensitivity of 42–90% and a specificity of 100%; submandibular salivary glands showed sensitivity and specificity of 100%; skin biopsy showed 19% sensitivity and 80% specificity in detecting alpha‐synuclein pathology. CSF alpha‐synuclein had 71–94% sensitivity and 25–53% specificity for distinguishing PD from controls. Plasma alpha‐synuclein had 48–53% sensitivity and 69–85% specificity. Neither plasma nor CSF alpha‐synuclein is presently a reliable marker of PD. This differs from alpha‐synuclein in solid tissue samples of the enteric and autonomic nervous system, which offer some potential as a surrogate marker of brain synucleinopathy.     

The clinical significance of MIBG myocardial scintigraphy in Parkinson disease

Meta-iodobenzylguanidine (MIBG) myocardial scintigraphy can assess postganglionic presynaptic cardiac sympathetic nerve endings. Reduced cardiac MIBG uptake on MIBG myocardial scintigraphy has been reported in patients with Parkinson disease (PD), dementia with Lewy bodies (DLB), pure autonomic failure (PAF), and familial PD linked to SNCA duplication. This imaging procedure is a sensitive diagnostic tool that might differentiate PD and DLB from other movement disorders from Alzheimer disease (AD). We recently reported cardiac sympathetic denervation in PD, DLB, PAF, and familial PD linked to SNCA duplication which accounts for the reduced cardiac MIBG uptake in these disorders. The patients with PD, DLB, PAF and familial PD linked to SNCA duplication have Lewy bodies in the nervous system, whereas patients with multiple system atrophy (MSA), progressive supranuclear palsy (PSP), corticobasal degeneration, AD, and parkin-associated PD do not. However, in patients with MSA or PSP, cardiac sympathetic denervation was associated with the presence of Lewy bodies in the nervous system. Therefore, cardiac sympathetic denervation is closely related to the presence of Lewy bodies in the wide range of neurodegenerative processes. Thus, we conclude that reduced cardiac MIBG uptake is a potential biomarker for the presence of Lewy bodies in the nervous system. We infer that MIBG myocardial scintigraphy is a noninvasive tool for detecting Lewy bodies during life.     

The distribution of Lewy bodies in pure autonomic failure: autopsy findings and review of the literature

Pure autonomic failure (PAF; also known as idiopathic orthostatic hypotension or Bradbury-Eggleston syndrome) is an uncommon sporadic disorder, characterized by autonomic failure without other neurological deficits and histopathologically by cell loss in intermediolateral columns and sympathetic ganglia. Few postmortem studies of patients with PAF have been reported in the literature, and none have demonstrated Lewy bodies in distal axons, although this has been described as a feature in Parkinson’s disease with autonomic failure. We report a patient with PAF who had orthostatic hypotension and urinary symptoms for 15 years prior to death at the age of 63 years. Postmortem findings included typical and atypical Lewy bodies in the substantia nigra, locus ceruleus, substantia innominata, and sympathetic ganglia, as well as in autonomic axons in the epicardial fat, autonomic nerve fascicles in periadrenal adipose tissue, and autonomic nerves in the muscularis of the urinary bladder. Sites of autonomic nerve involvement correlated with clinical symptomatology, and thus were a valuable observation in the complete autopsy. Systemic autopsy results should be reviewed carefully in patients with PAF, as Lewy bodies in this disease may be seen in distal axons at a great length from their primary cell bodies. Received: 23 September 1996 / Revised, accepted: 30 January 1997     

Review: Sporadic Parkinson's disease: development and distribution of α‐synuclein pathology

The development of α‐synuclein immunoreactive aggregates in selectively vulnerable neuronal types of the human central, peripheral, and enteric nervous systems is crucial for the pathogenesis of sporadic Parkinson's disease. The presence of these lesions persists into the end phase of the disease, a process that is not subject to remission. The initial induction of α‐synuclein misfolding and subsequent aggregation probably occurs in the olfactory bulb and/or the enteric nervous system. Each of these sites is exposed to potentially hostile environmental factors. Once formed, the aggregates appear to be capable of propagating trans‐synaptically from nerve cell to nerve cell in a virtually self‐promoting pathological process. A regional distribution pattern of aggregated α‐synuclein emerges that entails the involvement of only a few types of susceptible and axonally interconnected projection neurons within the human nervous system. One major route of disease progression may originate in the enteric nervous system and retrogradely reach the dorsal motor nucleus of the vagal nerve in the lower brainstem. From there, the disease process proceeds chiefly in a caudo‐rostral direction through visceromotor and somatomotor brainstem centres to the midbrain, forebrain, and cerebral cortex. Spinal cord centres may become involved by means of descending projections from involved lower brainstem nuclei as well as by sympathetic projections connecting the enteric nervous system with postganglionic peripheral ganglia and preganglionic nuclei of the spinal cord. The development of experimental cellular and animal models is helping to explain the mechanisms of how abnormal α‐synuclein can undergo aggregation and how transmission along axonal connectivities can occur, thereby encouraging the initiation of potential disease‐modifying therapeutic strategies for sporadic Parkinson's disease.     

Analysis of the adrenal gland is useful for evaluating pathology of the peripheral autonomic nervous system in lewy body disease

Lewy body disease is defined as Lewy body-related neuronal degeneration involving the nigrostriatal system, limbic-neocortical system, and peripheral autonomic nervous system (PANS). We investigated whether the adrenal gland, which is evolutionarily related to sympathetic ganglia and is routinely examined in general autopsy, could be used to assess pathology of the PANS in Lewy body disease. Brains, spinal cords, and adrenal glands from 783 consecutive autopsy cases from a general geriatric hospital were examined immunohistochemically with antiphosphorylated alpha-synuclein antibodies and routine staining. Parkinson disease (PD) with dementia and dementia with Lewy bodies (DLB) were defined using 1996 Consensus Guidelines for DLB and the secondary Lewy body-related alpha-synucleinopathy or amygdala variants using previously established criteria. Lewy body-related alpha-synucleinopathy was found in 207 (26.4%) of 783 cases, with 1 case solely in the adrenal gland. In all 18 PD cases with or without dementia and in 33 of 38 DLB cases, the adrenal gland was involved, but it was spared in all cases of amygdala variants. Our results indicate that the adrenal gland can provide useful information for evaluation of the PANS in Lewy body disease.     

Wpływ głębokiej stymulacji mózgowej jądra niskowzgórzowego na objawy autonomiczne obserwowane w chorobie Parkinsona

Dysfunctions of the autonomic nervous system (DA) are common in Parkinson's disease (PD). DA appear in the premotor phase of PD and may antedate cardinal motor symptoms by years or decades. DA significantly impair quality of life in the majority of PD patients. DA are related to accumulation of Lewy bodies in the central and peripheral nervous system. Progression of neurodegeneration and chronic dopaminergic therapy may increase DA as well. It is accepted that bilateral deep brain stimulation of the subthalamic nucleus (STN DBS) improves motor symptoms in PD. The effect of STN DBS on DA, such as cardiovascular symptoms and urinary, gastrointestinal and sexual dysfunction in PD, is not clear. STN DBS ameliorates some DA, but others might deteriorate at the same time.     

Involvement of the peripheral nervous system in synucleinopathies, tauopathies and other neurodegenerative proteinopathies of the brain

Involvement of the peripheral nervous system (PNS) is relatively common in some neurodegenerative proteinopathies of the brain and may be pathogenetically and diagnostically important. In Parkinson’s disease, neuronal α-synuclein aggregates are distributed throughout the nervous system, including the central nervous system (CNS), sympathetic ganglia, enteric nervous system, cardiac and pelvic plexuses, submandibular gland, adrenal medulla and skin. The pathological process may target the PNS and CNS at the same time. In multiple system atrophy, numerous glial cytoplasmic inclusions composed of filamentous α-synuclein are widely distributed in the CNS, while α-synuclein accumulation is minimal in the sympathetic ganglia and is restricted to neurons. Neurofibrillary tangles can occur in the sympathetic and spinal ganglia in tauopathy, although they appear to develop independently of cerebral Alzheimer’s disease pathology. In amyotrophic lateral sclerosis, neuronal loss with TDP-43-positive neuronal cytoplasmic inclusions in the spinal ganglia is more frequent than previously thought. Peripheral ganglia and visceral organs are also involved in polyglutamine diseases. Further elucidation and characterization of PNS lesions will have implications for intravital biopsy diagnosis in neurodegenerative proteinopathy, particularly in Parkinson’s disease.     

Autonomic functions in the early stages of Parkinson's disease.

Disturbances of autonomic nervous functions are common in patients with Parkinson's disease (PD) and may develop as a result of pathological changes in centers of autonomic regulation such as the hypothalamus, brainstem, and sympathetic ganglia. We examined cardiovascular reflexes using bedside, noninvasive procedures in 20 unmedicated PD patients with early stages of the disease (stages 1 and 2 on the Hoehn and Yahr's scale). Sixteen patients (80%) exhibited some degree of autonomic nervous system dysfunction. These included predominantly cardiovascular functions mediated via the parasympathetic system. Our findings demonstrate: (a) a high prevalence of autonomic disturbances in early stage PD, and (b) that dysregulation of parasympathetic cardiovascular control mechanisms is a major feature of dysautonomia in early, unmedicated PD patients.