Unmyelinated nerve fiber degeneration in chronic inflammatory demyelinating polyneuropathy

To determine whether unmyelinated nerve fibers escape degeneration as one might expect in an immune response exclusively directed at myelin, we performed a morphometric examination of unmyelinated axons and myelinated nerve fibers in sural nerve biopsy specimens of 14 patients with a chronic inflammatory demyelinating polyneuropathy (CIDP) and of 12 age-matched normal controls. The numbers of unmyelinated axons, myelinated nerve fibers, denervated Schwann cell units and collagen pockets were quantified and related to the clinical and electrophysiological data of the patients with CIDP. In 4 patients with a rapid onset of the neuropathy and a highly elevated CSF protein, the numbers of both unmyelinated axons and myelinated nerve fibers were decreased equally. In 8 patients we found that the unmyelinated axons were relatively spared compared with the loss of myelinated nerve fibers. In these patients, however, the presence of denervated Schwann cell units and of collagen pockets was increased. We conclude that unmyelinated nerve fibers are affected in patients with CIDP.     

Changes of the ratio between myelin thickness and axon diameter in the human developing sural nerve

Summary Axon caliber and myelin sheath thickness of individual nerve fibers were evaluated in the developing human sural nerve using three different methods of measurement: 1. ocular micrometer evaluation of large fibers, 2. photographic enlargements for evaluating large numbers of nerve fibers of all sizes, and 3. electron microscopic enlargements for more precise measurements in selected nerves. the average axonal diameter doubles from 5 months gestation to about 5 years of age. Large fiber group axons increase, during the same period, by a factor of 3–3.5 with a slight decrease thereafter. The myelin thickness increases more slowly, but continuously, between 5 months gestation until the age of 14. This asynchronous development of axons and myelin sheaths results in a statistically significant change of the ratio between axonal caliber and myelin thickness. The slope of the regression line is steeper in older than in younger individuals, and the correlation coefficient increases during development of the nerve.Presented in part at the VIth Congress of the European Society of Pathology, 11th–17th September, 1977Supported in part by the Deutsche Forschungsgemeinschaft, Bonn-BadGodesberg, Federal Republic of Germany (Schr 195/3)     

Evidence for an early role for myelin-associated glycoprotein in the process of myelination

The expression of myelin-associated glycoprotein (MAG) in purified rat Schwann cells following coculture with dorsal root ganglion neurons was compared with the expression of galactocerebroside (GalC) and Po using immunocytochemistry. In defined serum-free medium, lacking ascorbic acid, in which Schwann cells proliferate but neither ensheathe nor myelinate axons, axonal interaction up-regulated the cell surface expression of MAG and GalC but not of Po. Excision of neuronal cell bodies resulted in a down-regulation of both MAG and GalC from the Schwann cell surface. When cocultures were switched to complete medium (serum plus ascorbic acid) to promote myelination, Schwann cells committed to form myelin continued to express high levels of MAG and GalC on their surface, but nonmyelinating Schwann cells down-regulated MAG and GalC. There was significant MAG immunoreactivity associated with the external aspect of the apparent nodal region of developing myelin sheaths. Permeabilization prior to immunostaining revealed that all of the Schwann cell cytoplasmic processes of nascent internodes were significantly stained with anti-MAG antibodies before the appearance of Po immunoreactivity. The amount of MAG on the surface of mature myelin segments was reduced compared with developing myelin segments, but there was a considerable amount of anti-MAG staining in the paranodes and Schmidt-Lanterman incisures. The time of expression and localization of MAG indicates that it may be a critical molecule in the process by which the Schwann cell engulfs an axon destined to be myelinated and establishes the extent of the future internode.     

Adipose-derived stem cells differentiate into a Schwann cell phenotype and promote neurite outgrowth in vitro

Experimentally, peripheral nerve repair can be enhanced by Schwann cell transplantation but the clinical application is limited by donor site morbidity and the inability to generate a sufficient number of cells quickly. We have investigated whether adult stem cells, isolated from adipose tissue, can be differentiated into functional Schwann cells. Rat visceral fat was enzymatically digested to yield rapidly proliferating fibroblast-like cells, a proportion of which expressed the mesenchymal stem cell marker, stro-1, and nestin, a neural progenitor protein. Cells treated with a mixture of glial growth factors (GGF-2, bFGF, PDGF and forskolin) adopted a spindle-like morphology similar to Schwann cells. Immunocytochemical staining and western blotting indicated that the treated cells expressed the glial markers, GFAP, S100 and p75, indicative of differentiation. When co-cultured with NG108-15 motor neuron-like cells, the differentiated stem cells enhanced the number of NG108-15 cells expressing neurites, the number of neurites per cell and the mean length of the longest neurite extended. Schwann cells evoked a similar response whilst undifferentiated stem cells had no effect. These results indicate adipose tissue contains a pool of regenerative stem cells which can be differentiated to a Schwann cell phenotype and may be of benefit for treatment of peripheral nerve injuries.     

Calmodulin distribution in peripheral nerve: an EM immunocytochemical study

We used electron microscopic immunocytochemistry to study the distribution of calmodulin in rat sciatic nerve. Calmodulin immunoreactivity was found throughout the axoplasmic matrix, but particularly along microtubules. Schwann cell cytoplasm and nuclei demonstrated immunoreactivity, while compact myelin did not. There was particularly intense immuno-gold deposition within Schmidt Lanterman clefts. At the nodes of Ranvier, calmodulin appeared preferentially in the paranodal region, along the apposition of the axolemma to the paranodal loops of myelin and extending into the paranodal loops. The presence of calmodulin immunoreactivity along microtubules supports biochemical and pharmacological evidence of calmodulin involvement in regulating the assembly and phosphorylation of microtubules, and in fast axonal transport along microtubules. The co-localization of paranodal calmodulin immunoreactivity with Ca-ATPase activity demonstrated cytochemically (Mata et al.,Brain Research, in press) supports the notion that the paranodal Ca-ATPase activity may be regulated by calmodulin, and agrees with the in vitro biochemical evidence for Ca-ATPase of other cells.     

Acute inflammatory demyelinating polyneuropathy in a diabetic patient: Predominance of vesicular disruption in myelin sheaths

Summary A diabetic woman underwent an incision of the right big toe for an abscess and developed a typical Guillain-Barré syndrome 48 h later. A biopsy of a peripheral nerve, performed 10 days later, showed modifications usually seen in diabetic patients, as well as the characteristic ultrastructural modifications of the Guillain-Barré syndrome (GBS). Moreover, 22% of myelinated fibers exhibited vesicular disruption of the myelin sheaths. This lesion is rarely encountered on the biopsies of peripheral nerve in GBS and concerns only a few myelinated fibers. Such a prominence of myelinic vesicular disruption and its occurrence in a diabetic patient are discussed.     

Mifepristone (RU 38486) influences expression of glycoprotein Po and morphological parameters at the level of rat sciatic nerve: in vivo observations

The observations here reported indicate that, in vivo, the expression of an important protein of peripheral myelin, the glycoprotein Po, is influenced by mifespristone (RU 38486), that is, an antagonist of progesterone (PR) and glucocorticoid (GR) receptor. In our experimental model, male rats have been treated at the first day of life with this antagonist and after repeated treatments, we have analyzed in the sciatic nerve of 20- (20d) and 30-day-old rats (30d) the mRNA and protein levels of Po. Moreover, expression of Po has also been analyzed in the sciatic nerve of animals treated during the first 30 days of postnatal life and then sacrificed at 90th day of life (90d). The results obtained have indicated that both mRNA and protein levels of Po decrease at 20d. Apparently, these effects seem to be transient because no changes are evident at the other two times of analysis. As shown by morphometric analysis, the treatment with RU 38486 is also able to induce morphological changes at the level of sciatic nerve. However, at variance to what is expected by an alteration of an important component of the myelin membranes like Po, no changes are evident at the level of the myelin compartment. On the contrary, a significant reduction of axon diameter in parallel to an increase in neurofilament (NF) density occurs since 30d. In conclusion, the present data seem to suggest that progestin and/or glucocorticoid signals are not only involved in the control of myelin compartment but also on the axon maintenance.     

Freeze-fracture observations on normal and abnormal human perineurial tight junctions: alterations in diabetic polyneuropathy

Summary Perineurial cells in the human sural nerve possess tight junctions which in freeze-fracture replicas are seen to be composed of networks of branching and anastomosing P face strands and E face grooves. Isolated circular tight junctions (maculae occludentes) may represent attachment devices between adjacent perineurial lamellae. At the overlapping margins of the cells, a beltlike tight junction (zonula occludens) encircles the cells and is believed to comprise a paracellular diffusion barrier. As the permeability of the perineurium has been found to be altered in diabetic polyneuropathy, the zonulae occludentes have been studied. In freeze-fracture replicas from cases of diabetic polyneuropathy a mixed population of structurally normal and abnormal junctions was observed. In some, the strands were abnormally curved with reduced numbers of intersections, the intervening plasma membrane displaying prominent P face concavities and E face convexities. At other sites, the junctions were severely disorganized and represented by fragmented and isolated strands with few intersections and numerous free ends. These abnormalities resemble changes that have been produced experimentally in epithelial tight junctions by osmotic damage. The possibility is considered that similar mechanisms could result in the alterations of the perineurial tight junctions in diabetic polyneuropathy and account for its impaired permeability barrier properties.Supported by the Medical Research Council and Joint Standing Research Committee of St. Mary's Hospital     

Nerve ultrasound in diabetic polyneuropathy: Correlation with clinical characteristics and electrodiagnostic testing

Introduction: Diabetic polyneuropathy (DPN) is increasingly prevalent in the USA, but nerve ultrasound (US) findings have not been assessed systematically. Our aim was to establish the sonographic characteristics of lower extremity nerves in DPN and correlate them with electrodiagnostic (EDx) findings. Methods: Consecutive patients (n = 25) with evidence of DPN and 25 patient controls without DPN underwent blinded US imaging of the fibular and sural nerves. Nerve cross‐sectional area (CSA), diameter and echogenicity were recorded. Results: There were no differences in fibular or sural nerve CSA, diameter, or echogenicity between the 2 groups. No correlations between nerve CSA and EDx studies were found. In DPN, there were moderate inverse correlations with age (r = ?0.44 sural ankle, r = ?0.39 sural leg, r = ?0.45 fibular ankle). Conclusions: US measurements of lower extremity nerves in DPN do not differ from controls or correlate with EDx findings. Novel US techniques and/or pedal nerve US may be necessary to detect differences. Muscle Nerve 47:379‐384, 2013     

Peripheral nerve regeneration through silicone chambers in streptozocin-induced diabetic rats

The silicone chamber model was used to evaluate peripheral nerve regeneration (PNR) in streptozocin (STZ)-induced diabetic rats. Diabetic and control animals underwent sciatic nerve transection and silicone chamber implantation establishing gaps of various lengths between the transected nerve ends. In animals with 5 and 10 mm gaps, diabetes was induced in experimental rats 1 week before surgery, and the animals were sacrificed 3 weeks after surgery. In animals with 8 mm gaps, diabetes induction occurred 3 days after surgery, and they were sacrificed after 7 weeks. Diabetic rats with 10 mm gaps demonstrated an impaired ability to form bridging cables, the initial step of regeneration through chambers. Morphometric studies of bridging cables between transected nerve ends demonstrated a significant reduction in the mean endoneurial area in diabetic animals with 5 and 8 mm gaps compared to controls. The number of regenerated myelinated axons in the chamber was significantly decreased in diabetic rats with 8 and 10 mm gaps. The mean myelinated fiber area in the regenerated cables of the diabetic group was significantly decreased with 5 mm gaps and significantly increased with 8 mm gaps compared to controls. Size-frequency histograms of regenerated myelinated fiber areas suggest a delay in the maturation of small caliber axons. Schwann cell migration across 5 mm gaps was examined with S-100 immunohistochemistry. The total distance of Schwann cell migration into cables from both proximal and distal ends was significantly reduced in diabetic animals. Characterization of PNR across gaps through silicone chambers in diabetic rats showed impairment in multiple aspects of the regenerative process, including cable formation, Schwann cell migration, and axonal regeneration.     

Local administration of vasoactive intestinal peptide after nerve transection accelerates early myelination and growth of regenerating axons

Our goal was to determine whether local injections of vasoactive intestinal peptide (VIP) promote early stages of regeneration after nerve transection. Sciatic nerves were transected bilaterally in 2 groups of 10 adult mice. In the first group, 15 microg (20 microL) of VIP were injected twice daily into the gap between transected ends of the right sciatic nerve for 7 days (4 mice) or 14 days (6 mice). The same number of mice in the second group received placebo injections (20 microL of 0.9% sterile saline) in the same site, twice daily, for the same periods. After 7 days, axon sizes, relationships with Schwann cells and degree of myelination were compared in electron micrographs of transversely sectioned distal ends of proximal stumps. Fourteen days after transection, light and electron microscopy were used to compare and measure axons and myelin sheaths in the transection gap, 2-mm distal to the ends of proximal stumps. Distal ends of VIP-treated proximal stumps contained larger axons 7 days after transection. More axons were in 1:1 relationships with Schwann cells and some of them were surrounded by thin myelin sheaths. In placebo-treated proximal stumps, axons were smaller, few were in 1:1 relationships with Schwann cells and no myelin sheaths were observed. In VIP-treated transection gaps, measurements 14 days after transection showed that larger axons were more numerous and their myelin sheaths were thicker. Our results suggest that in this nerve transection model, local administration of VIP promotes and accelerates early myelination and growth of regenerating axons.     

Evaluation of carpal tunnel syndrome in patients with polyneuropathy

The difference between the median nerve latency to the second lumbrical muscle and the ulnar nerve latency to the second interosseous muscle (L-I DIFF) was tested in a prospective study to discriminate whether prolonged distal motor latency of the median nerve in patients with polyneuropathy (PNP) reflects an additional carpal tunnel syndrome (CTS). We investigated 92 patients (107 hands) with CTS, 30 patients (34 hands) with PNP, 22 patients (27 hands) with CTS and coexisting PNP (PNP+CTS), and 77 controls (87 hands). L-I DIFF was significantly prolonged in both the CTS and PNP+CTS patients as compared to PNP patients and controls. It proved to be the most specific test to differentiate between diffuse (PNP) and focal (entrapment) nerve disorder. © 1997 John Wiley & Sons, Inc. Muscle Nerve, 20, 153–157, 1997.     

Severe axonal polyneuropathy with onset in the postpartum period

We report two patients who presented severe polyneuropathy in the postpartum period. Electrophysiological studies evidenced an axonal process which was associated with proximal demyelination in the second patient. In both cases, a peripheral nerve biopsy showed severe axonal Wallerian-like degeneration and no feature of demyelination. The first patient had a dramatic loss of myelinated fibres, and severe disability persisted for several months. These two patients are different from cases of acute or chronic inflammatory demyelinating polyradiculoneuropathy previously reported in relation with pregnancy.     

The occurrence and significance of myelin with unusually large periodicity

Summary The occurrence of myelin with an unusually large periodicity has been noted in a variety of human and animal diseases by many authors. It has also proved possible to create regular alterations in periodicity by various treatments of fresh unfixed nerve. We have quantified the changes found in material from a variety of sources and conclude that they are compatible with the occurrence of physicochemical changes in the myelin membranes, leading to overhydration.A preliminary account of these findings was presented at a meeting of the Peripheral Nerve Study Group in Fontevraud, France, in July 1983Financially supported by the Medical Research Council and the National Fund for Research into Crippling Diseases     

Topiramate and physiologic measures of nerve function in polyneuropathy

OBJECTIVE: To evaluate topiramate treatment on nerve function using electrophysiologic methods and a non-inferiority clinical trial design. METHODS: A double-blind, multicenter, placebo-controlled trial was conducted in patients with painful diabetic polyneuropathy (n = 67). Change in peroneal motor nerve conduction velocity (NCV) was the primary outcome. NCVs of sural sensory and ulnar nerves, and amplitude and latency changes were measured secondarily. Peripheral nerve function was also evaluated in a patient subgroup reporting treatment-emergent paresthesias. RESULT: Least squares mean decrease in NCV was greater for placebo (-0.2 m/s) than for topiramate treatment (-0.1 m/s) (95% CI: -1.30, 1.42). Secondary measures showed no decrease in nerve function for topiramate-treated patients. Neurophysiologic measures were similar in patients with and without paresthesias. The most common adverse events with topiramate were paresthesias, anorexia, weight decrease, and taste perversion. CONCLUSION: This nerve conduction study found no evidence that topiramate is associated with deterioration of nerve function.     

Nerve conduction and biopsy correlation in over 100 consecutive patients with suspected polyneuropathy

Neuropathy was classified physiologically and histologically as normal, axonal, demyelinative, or indeterminate using specific motor nerve conduction (NC) and sural sensory nerve biopsy (NB) criteria. Physiological and histological diagnoses were concordant in 63%, and minimally discordant in 14% of patients. The most important discordant patients were 6 with demyelinative neuropathy, 4 by NC, of which 2 were pure motor syndromes, and 2 by NB, both predominantly sensory syndromes. In the 55 patients with predominant axonal degeneration on biopsy, the extent of NC slowing was determined. As compound motor and sensory nerve action potential (CMAP and SNAP) amplitude declined, distal motor latency increased, whereas motor and sensory conduction velocity (CV) did not. Minimum F response latency increased as motor CV decreased, more in lower than upper extremity nerves. We conclude that: (1) except for sensory neuropathy, routine motor NC studies generally suffice in identifying demyelinative neuropathy; (2) NC slowing in axonal neuropathy is usually slight but may result in significantly prolonged distal motor latencies when CMAP amplitude is very low, and prolonged F wave latency when motor CV is slightly low; and (3) The physiologic criteria employed in this study rarely misclassifies neuropathy as demyelinative in patients with predominant axon loss on biopsy. © 1994 John Wiley & Sons, Inc.     

Quantitative sensory testing in patients with polyneuropathy and healthy individuals

Aims –  Elderly individuals and patients with polyneuropathy often feel heat pain or burning sensation on quantitative sensory testing (QST) of warm perception distally in the lower limbs. We therefore studied heat pain threshold (HPT), warm perception threshold (WPT) and the difference between heat pain and warm perception thresholds in 48 patients with symptoms and signs of polyneuropathy matched according to age and gender with 48 healthy persons.
Methods –  QST (using method of limits) was performed on the distal calf and the dorsal foot.
Results –  Particularly in the neuropathy group several individuals (58%) had an unpleasant feeling, often burning, when the thresholds according to the WPT algorithm were recorded. Difference between heat pain and warm perception thresholds in the lower calf of the patients was 3.9 ± 3.5 and 5.8 ± 3.4°C in the controls ( P  = 0.012), and on the foot 3.8 ± 2.8 vs 5.3 ± 3.6°C ( P  = 0.02).
Conclusions –  When performing QST it is important to assess also quality features of warm perception, such as burning and heat pain sensation.