Lymphomatous meningitis (LM) represents a severe complication of malignant lymphomas. While clinical suspicion is raised by symptoms ranging from mild disturbances of sensation to severe pain or impaired consciousness, the definite diagnosis of LM is often difficult to obtain. Since B-cell lymphomas are clonally restricted to express either kappa or lambda immunoglobulin light chain, we hypothesised that analysis of free light chain (FLC) ratios might facilitate the diagnosis of LM.Kappa and lambda FLC were measured using a novel nephelometric assay in cerebrospinal fluid (CSF) and serum from 17 patients. 5/17 suffered from LM as demonstrated by cytology, immunocytology, and/or imaging procedures.Measurement of FLC concentrations in CSF was achieved for all 17 patients. FLC levels in CSF were lower than serum FLC levels in samples for the same patient obtained at the same time (p < 0.01). CSF and serum FLC concentrations correlated weakly in all patients irrespective of LM status. Significantly more patients with cytopathologically and immunohistochemically proven LM displayed abnormal kappa/lambda FLC ratios in CSF compared to individuals with no LM (p < 0.01).This is the first report demonstrating that a significant proportion of LM patients display an abnormal kappa/lambda FLC ratio in the CSF. Systemic intermediate- and high-grade Non-Hodgkin's Lymphomas (NHL) carry a substantial risk of central nervous system (CNS) complications, and are sometimes accompanied by lymphomatous meningitis (LM) -4. CytopAssessment of free immunoglobulin light chains in CSF may improve the diagnostic investigation of LM. While most immunoglobulin light chains are bound to immunoglobulin heavy chains to form complete antibody molecules, excess light chains are produced and secreted as free light chains (FLC). Kappa and lambda FLC can be measured quantitatively in serum and urine using a novel nephelometric immunoassay. In normal individuals, serum concentrations of kappa FLC and lambda FLC range from 3.3 to 19.4 mg/l and 5.7 to 26.3 mg/l, respectively. Serum FLC ratios (kappa/lambda) lying outside the normal range  on peripheral blood and CSF samples obtained at the same time. Freelite™ nephelometric assays  use lateDescriptive and comparative statistics were performed by using the SPSS 12 software package. Mann-Whitney-tests were applied for comparisons between groups. Correlations were assessed by using Kendall-Tau-b correlation coefficients. A two-sided p-value less than 0.05 was considered to indicate significance for all tests. Sensitivity and specificity were calculated by using 2 × 2 tables on the basis of the upper reference values of the respective light chain serum values.Between 12/2005 and 08/2006 peripheral blood and CSF samples from 17 patients with lymphomas were assessed. 14/17 experienced clinical symptoms highly suspicious of LM and/or displayed suspect findings on imaging. In the remaining 3 patients, lumbar puncture was indicated according to recent diagnostic guidelines. Those comprised one ocular high-grade B-cell Non-Hodgkin's Lymphoma (B-NHL), one B-NHL with a paravertebral manifestation progressing into the spinal canal, and one high-grade follicular lymphoma of the tonsil .  Also see figure It is of note that no elevations of lambda FLC levels in CSF were detected within the entire study population.8/12 individuals without LM exhibited CSF kappa/lambda FLC ratios within the serum reference range (0.26 to 1.65). In contrast, all (5/5) of the patients with proven LM demonstrated CSF kappa/lambda FLC ratios outside the serum reference range. The CSF kappa/lambda FLC ratios in patients with and without LM was significantly different (p < 0.01). Assessment of the sensitivity and specificity of CSF kappa/lambda FLC ratio for the diagnosis of LM resulted in a sensitivity of 100% and a specificity of 67% Table .Clinical details of the individuals without proven LM but with CSF kappa/lambda FLC ratios outside the serum reference range 4/12) were as follows: Patient 12  in the confirmed LM group. Indeed, all patients (5/5) with proven LM exhibited abnormal CSF kappa/lambda FLC ratios, while most (8/12) patients without definite LM demonstrated normal CSF kappa/lambda ratios. It is of note, however, that 2/4 patients (patient 9 and 12) with abnormal CSF FLC ratios but without LM had definite or very likely intracerebral lymphoma manifestations. LM is far more likely to occur in these patients than in those with systemic NHL without parenchymal involvement of the brain.Finally, it is of note that in our pilot study all patients with definite LM exhibited a kappa light chain restriction. Twice as many B cells in normal peripheral blood produce kappa FLC as produce lambda FLC. It is likely that this ratio will be reflected in there being twice as many B cell NHL producing kappa FLC as lambda FLC. This production ratio and the small number of patients included in this pilot study might explain why we only detected LM in NHL patients with a kappa light chain restriction. The utility of the CSF kappa/lambda FLC ratio for the detection of LM in NHL patients with a lambda light chain restriction will be the subject of a future study involving a larger number of patients.In conclusion, we demonstrate for the first time that the CSF kappa/lambda FLC ratio appears to be a promising parameter for use in diagnosing lymphomatous meningitis. Further research, including the confirmation of these findings in a larger cohort of patients, might establish CSF kappa and lambda FLC analysis as a novel diagnostic tool for patients with suspected lymphomatous meningitis.CNS, central nervous system; CSF, cerebrospinal fluid; FLC, free light chain; LM, lymphomatous meningitis.The author(s) declare that they have no competing interests.BH co-developed the idea of the study, was involved into the provision of patients, performed the statistics and participated in writing the manuscript. CM measured the samples and participated in writing the manuscript. AP was involved into the provision of patients, gave administrative support and participated in writing the manuscript. PTD was involved into the provision of patients, gave administrative support, and participated in writing the manuscript. BD: was involved into the provision of patients, gave administrative support, and participated in writing the manuscript. CS: co-developed the idea of the study, was involved into the provision of patients, and wrote the first draft of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Troponin elevation is usually synonymous with acute coronary syndrome (ACS). Although sensitive for ACS, the elevation of serum troponin, in the absence of clinical evidence of ischemia, should prompt a search for other etiologies of myocardial necrosis. In fact, elevated values of troponin are correlated with myocardial necrosis even though it does not discriminate the mechanism involved. We report a series of seven patients (age range 18-67 years), who presented with complaints of chest discomfort and were found to have regular supraventricular tachycardia (5 patients) and one patient each with atrial fibrillation and ventricular tachycardia. All these patients had elevated troponin I and underwent coronary angiography that revealed normal epicardial coronary arteries. This is first case series in which all patients underwent coronary angiography and none of the patients was hemodynamically unstable at the time of presentation. Patients with elevated troponin due to conditions other  than ACS can receive inappropriate and delayed definitive diagnosis and treatment. Troponin elevation usually signifies some myocardial damage and is associated with significant obstructive coronary artery disease. There are multiple conditions that can cause elevation of troponin besides myocardial ischemia like sepsis, renal failure, decompensated heart failure, pulmonary embolism, coronary vasospasm, prolonged hypotension and tachycardias associated with hypotension to mention few. Although there have been multiple case reports of troponin elevation associated with tachycardias,  coronary artery disease was ruled out either by stress test or by coronary angiography. We report a case series of 7 patients with different kinds of tachycardias and troponin elevation who underwent coronary angiography and were hemodynamically stable.Six patients of supraventricular tachycardias of different duration and one case of sustained ventricular tachycardia were found in our database. All cases presented with palpitations and chest discomfort of different duration. Patients underwent routine laboratory investigations and all of them had two-dimensional echocardiography. All patients were found to have elevated troponin I. There were three cases of accessory pathway mediated tachycardia (AVRT), two cases of atrioventricular-nodal reentrant tachycardia (AVNRT) and one case each of atrial fibrillation (AF) with fast ventricular response and ventricular tachycardia (VT). All patients underwent coronary angiography and had normal coronary arteries. Five patients (3 AVRT and 2 AVNRT) underwent successful radiofrequency ablation. One with atrial fibrillation was subsequently cardioverted after coronary angiography and placed on sotalol. The patient who presented with ventricular tachycardia was placed on amiodarone and had a biventricular ICD implanted for non-ischemic cardiomyopathy. All patients had elevation of Troponin I . Table 1The joint committee of the European Society of Cardiology, the American College of Cardiology, and the American Heart Association has accepted the measurement of troponin T and I in serum as the standard biomarker for the diagnosis of acute myocardial infarction and for diagnosis and management of acute coronary syndromes -3. HowevAll patients in our series underwent coronary angiography and had normal epicardial vessels. None of our patient was hemodynamically unstable and therefore the troponin rise in our series was a direct result of tachycardia.The exact mechanism for troponin elevation during a tachycardia remains unknown. However, the most likely mechanism may be shortening of diastole with subsequent subendocardial ischemia . CoronarThe patients admitted within the framework of tachyarrhythmia without hemodynamic instability, the decision whether to obtain serum markers of myocardial ischemia should cover a comprehensive clinical context. Patients with elevated troponin due to conditions other than ACS can receive inappropriate and delayed definitive diagnosis and treatment.


Odontesthes bonariensis (Atherinopsidae), were surgically transplanted into the gonads of sexually mature Patagonian pejerrey O. hatcheri, which have been partially depleted of endogenous GCs by a combination of Busulfan (40 mg/kg) and high water temperature (25°C) treatments. The observation of the donor cells' behavior showed that transplanted spermatogonial cells were able to recolonize the recipients' gonads and resume spermatogenesis within 6 months from the GCT. The presence of donor-derived gametes was confirmed by PCR in 20% of the surrogate O. hatcheri fathers at 6 months and crosses with O. bonariensis mothers produced hybrids and pure O. bonariensis, with donor-derived germline transmission rates of 1.2–13.3%. These findings indicate that transplantation of spermatogonial cells into sexually competent fish can shorten considerably the production time of donor-derived gametes and offspring and could play a vital role in germline conservation and propagation of valued and/or endangered fish species.The transplantation of germ cells into adult recipient gonads is a tool with wide applications in animal breeding and conservation of valuable and/or endangered species; it also provides a means for basic studies involving germ cell (GC) proliferation and differentiation. Here we describe the establishment of a working model for xenogeneic germ cell transplantation (GCT) in sexually competent fish. Spermatogonial cells isolated from juveniles of one species, the pejerrey  Germ cell (GC) transplantation (GCT) is a powerful reproductive technique pioneered by Brinster and colleagues in 1994 The first attempts to perform GCT in fish were performed in rainbow trout and consisted in the grafting of pieces of testes into isogeneic animals, resulting in donor-derived spermatogenesis Odontesthes bonariensis into Patagonian pejerrey O. hatcheri, previously depleted of endogenous germ cells by Busulfan and high water temperature treatments, resulted in recolonization of recipient testes. The transplanted cells successfully developed into functional sperm and were used in artificial fertilization with eggs of the donor species, generating viable progeny of donor origin. These results demonstrate the viability of xenogeneic GCT into sexually mature fish up to the generation of viable offspring.To test the feasibility of this approach in fish, we performed intra-gonadal surgical GCT between two congeneric atherinopsid fishes as models of donor and recipient. Here we report that transplantation of spermatogonia from pejerrey The presence of donor-derived GCs in recipient gonads, as opposed to control (non-transplanted) gonads, was confirmed by tracking CFDA-SE -labeled cells . The proO. bonariensis (donor)-derived spermatozoa in 4 out of 20 (20%) of the GC-transplanted recipients  GCs might sense and respond to molecules released from the blind end of the seminiferous lobules in O. hatcheri (recipient). A series of time-course observations prior to and after the 4–6 week post-GCT period, which was the only period observed in this study, may provide a more comprehensive view of the process of gonadal recolonization by donor-derived germ cell populations.Regardless of the differences in testicular structure between our fish model , other fish species and mammals  We observed that donor-derived spermatozoa from surrogate fathers had similar functional properties as those of control ones in terms of fertilization and hatching rates, and we could not detect any evidence of defective spermatogenesis. Yet, there have been cases of defective transcription of genetic information by donor cells during intertaxa GCT We recorded a donor-derived germline transmission rate in the progeny ranging between 1.2 to 13.3%. In comparison, when primordial germ cells (PGCs) were transplanted into recipient embryos, their contribution to the germline was reported to be between 2–4% In conclusion, the most striking result of our study is the production of pure donor-derived progeny (up to 13.3%) in the span of months when donor germ cells were transplanted into the testes of sexually competent male recipients. This approach offers a workable alternative to PGC or spermatogonia transplantation using embryos and/or young hatchlings, which requires sophisticated equipment, skills, and time to yield donor-derived gametes. It offers a way to preserve and propagate the germplasm from animals that are still sexually immature or that have become senile, which therefore can not provide sperm for cryopreservation, and this may be extremely important in the case of rare, endangered species. Ongoing studies are testing (low-tech) refinements in the proposed approach, such as non-surgical transplantation Odontesthes bonariensis and the Patagonian pejerrey O. hatcheri as donor and recipient, respectively  under a constant light cycle (15L9D). The fish were acclimated for two weeks at 17°C prior to the treatments for depletion of endogenous germ cells. The O. bonariensis used as GC donors were 4–5 months old juveniles and were produced at the rearing facilities of the Tokyo University of Marine Science and Technology at Shinagawa Campus. Both groups of animals were fed pelleted commercial diet four times per day to satiation.In this study, we used two congeneric species of atherinopsid fishes, the pejerrey ectively . These tO. hatcheri intended as recipients were depleted according to the procedure described by Majhi et al. The endogenous GCs of 2+ in PBS (pH 8.2) for 2 hr at 22°C. The dispersed testicular cells were sieved through a nylon screen (mesh size 50 µm) to eliminate the non-dissociated cell clumps. Cells were then suspended in a discontinuous Percoll  gradient of 50%, 25% and 12%, which was prepared by dilution of the stock solution with PBS (pH = 8.2), and centrifuged at 200×g for 20 min at 20°C. The phase containing the largest cells . The testicular tissue was finely minced and incubated in a dissociating solution containing 0.5% Trypsin , 5% Fetal Bovine Serum , and 1 mM Ca2 cells/µl, at a flow rate of approximately 10 µl/min. Trypan blue was added to the injection medium prior to transplantation to allow visualization of the cell suspension inside the needle and inside the gonad after injection. Repeated reentry and readjustment of the needle position were avoided to minimize tissue damage and leakage of cells. The abdominal incision was stitched with nylon surgical thread and topically treated with 10% Isodine , and the fish were resuscitated in clean water.Thirty one recipients were used for surgical GCT. Surgical intervention was used because it allows direct delivery and visualization of the donor cells into the recipient gonad. For this purpose, the fish were anesthetized in 200 ppm phenoxyethanol  and placed on an operation platform under a microscope where they received a constant flow of oxygenated, cool water containing 100 ppm of the anesthetic through the gills. To prevent desiccation, the surface of the fish was moisturized during the entire GCT procedure, which took about 20 min per fish on average. An approximately 1.5 cm-long midline incision was made in abdomen and the gonads were carefully lifted from the coelomic cavity and hold in place with the help of a sterile soft plastic spatula. A micro syringe and fine glass needle were used to inject the cell suspension into the medullar region of each testicular lobe. Each lobe of the testis was injected with 50 µl of cell suspension containing approximately 8×10Post-transplantation analysis of the fate of donor cells was performed first by fluorescent microscopy at 4 and 6 weeks after injection. For this purpose, the testes from three animals chosen randomly on each sampling were removed, washed in PBS (pH 8.2), macroscopically observed for the degree of dispersion of the cell suspension see , and exaO. bonariensis-specific primers  that were designed based on the sequence of the first intron of the amh gene from this species (GenBank accession number #FJ977837) using Genetyx Ver 8.2.1 . Primers for β-actin were used as positive controls . The PCR reactions were run in a Mastercycler EP Gradient S  and consisted of an initial denaturation at 94°C for 3 min, 30 cycles of 94°C for 30 sec, 70°C for 30 sec and 72°C for 1 min, followed by elongation at 72°C for 5 min. PCR products were electrophoresed on an agarose gel (1%), stained with ethidium bromide, and photographed for later analysis.The fate of the donor cells was then examined by sperm density and molecular (PCR) analysis between 6 and 12 months after transplantation. On each occasion, 10–30 µl of sperm was collected from each of 20 transplanted males and 5 control males. Sperm was manually stripped by gentle abdominal pressure after careful removal of urine and wiping of the genital papilla. Ten microliters of sperm were then diluted 1,000 times with PBS and the density of spermatozoa was counted in a hemocytometer  under a microscope. Some of the spreads of sperm used for counting were also observed under the fluorescent microscope for the detection of CFDA-SE labeled donor cells. Sperm samples collected at 6 and 8 months were subjected to PCR analysis for molecular detection of donor-derived cells. DNA was extracted by the standard phenol:chloroform protocol and subjected to PCR analysis with O. bonariensis spermatozoa produced by the surrogate O. hatcheri fathers. About 10 µl of sperm from each of these males was used to fertilize a batch of O. bonariensis eggs, which were then incubated under flowing brackish water at 20°C until hatching. The larvae from each cross were reared separately until sampling for PCR analysis of their genetic background at 8–10 days after hatching. The template DNA was extracted from each sample and subjected to PCR analysis using recipient's (O. hatcheri) specific primers  also designed based on the sequence of the first intron of the amh gene from this species (GenBank accession number #FJ977836) using Genetyx Ver 8.2.1 . The PCR conditions were the same as described above. The genetic information of each individual was used to calculate the donor germline transmission rates as described elsewhere Once the sperm density of transplanted animals have returned to pre-treatment levels and the PCR analysis showed the presence of donor-derived sperm (e.g. after 6 months), we performed artificial insemination using the PCR-positive sperm to assess the viability of the P<0.05.The statistical significance of the differences in sperm production between groups was analyzed by one-way analysis of variance (ANOVA) followed by the Tukey's multiple comparison test using Graphpad Prism ver. 4.00 . Data are presented as mean±SD and differences between groups were considered as statistically significant at Figure S1Sperm density in germ cell transplanted recipients and non-transplanted (negative control) animals between 6 and 12 months after transplantation. Columns with different letters vary significantly .(60.78 MB TIF)Click here for additional data file.Figure S2Histological appearance of the testes of Patagonian pejerrey O. hatcheri in control and Busulfan-high temperature treated groups. A,B) Normal testis showing the thick germinal epithelium, the radially-oriented seminiferous lobules, and large cysts of spermatogonia (arrows) in the blind end of the seminiferous lobule (B is a high magnification of the box shown in A). C,D) Testis from the high temperature (25°C) - Busulfan (two injections of 40 mg/kg 4 weeks apart) treatment group at 8 weeks showing virtual lack of spermatogonia (D is a high magnification of the box shown in C). Scale bars indicates 100 µm  and 20 µm .(5.69 MB TIF)Click here for additional data file.Figure S3Visualization of the dispersal of the cell suspension through the gonad after transplantation. A) Macroscopic appearance of a control testis. B) Appearance of the testis 4 weeks after germ cell transplantation . Scale bars indicate 1 cm.(1.30 MB TIF)Click here for additional data file.


A greater appreciation of CSF pressure (CSFP) is being generated by fresh insights on peptidergic regulatory servomechanisms, the role of dysfunctional ependyma and circumventricular organs in causing congenital hydrocephalus, and the clinical use of algorithms to delineate CSFP waveforms for diagnostic and prognostic utility. Increasing attention focuses on CSF flow: how it impacts cerebral metabolism and hemodynamics, neural stem cell progression in the subventricular zone, and catabolite/peptide clearance from the CNS. The pathophysiological significance of changes in CSF volume is assessed from the respective viewpoints of hemodynamics (choroid plexus blood flow and pulsatility), hydrodynamics  and neuroendocrine factors . In aging, normal pressure hydrocephalus and Alzheimer's disease, the expanding CSF space reduces the CSF turnover rate, thus compromising the CSF sink action to clear harmful metabolites  from the CNS. Dwindling CSF dynamics greatly harms the interstitial environment of neurons. Accordingly the altered CSF composition in neurodegenerative diseases and senescence, because of adverse effects on neural processes and cognition, needs more effective clinical management. CSF recycling between subarachnoid space, brain and ventricles promotes interstitial fluid (ISF) convection with both trophic and excretory benefits. Finally, CSF reabsorption via multiple pathways  is likely complemented by fluid clearance across capillary walls (aquaporin 4) and arachnoid villi when CSFP and fluid retention are markedly elevated. A model is presented that links CSF and ISF homeostasis to coordinated fluxes of water and solutes at both the blood-CSF and blood-brain transport interfaces.This review integrates eight aspects of cerebrospinal fluid (CSF) circulatory dynamics: formation rate, pressure, flow, volume, turnover rate, composition, recycling and reabsorption. Novel ways to modulate CSF formation emanate from recent analyses of choroid plexus transcription factors (E2F5), ion transporters (NaHCO1 Overview2 CSF formation2.1 Transcription factors2.2 Ion transporters2.3 Enzymes that modulate transport2.4 Aquaporins or water channels2.5 Receptors for neuropeptides3 CSF pressure3.1 Servomechanism regulatory hypothesis3.2 Ontogeny of CSF pressure generation3.3 Congenital hydrocephalus and periventricular regions3.4 Brain response to elevated CSF pressure3.5 Advances in measuring CSF waveforms4 CSF flow4.1 CSF flow and brain metabolism4.2 Flow effects on fetal germinal matrix4.3 Decreasing CSF flow in aging CNS4.4 Refinement of non-invasive flow measurements5 CSF volume5.1 Hemodynamic factors5.2 Hydrodynamic factors5.3 Neuroendocrine factors6 CSF turnover rate6.1 Adverse effect of ventriculomegaly6.2 Attenuated CSF sink action7 CSF composition7.1 Kidney-like action of CP-CSF system7.2 Altered CSF biochemistry in aging and disease7.3 Importance of clearance transport7.4 Therapeutic manipulation of composition8 CSF recycling in relation to ISF dynamics8.1 CSF exchange with brain interstitium8.2 Components of ISF movement in brain8.3 Compromised ISF/CSF dynamics and amyloid retention9 CSF reabsorption9.1 Arachnoidal outflow resistance9.2 Arachnoid villi vs. olfactory drainage routes9.3 Fluid reabsorption along spinal nerves9.4 Reabsorption across capillary aquaporin channels10 Developing translationally effective models for restoring CSF balance11 Conclusion Free-flowing cerebrospinal fluid (CSF) finely-regulated in composition is vital to brain health ,2. AgingImproved biotechnology and models can now precisely evaluate the role of the CP-CSF in modulating brain development, metabolism and aging -12. AlteCSF assessment should collectively consider physical, biochemical and physiological parameters Table . In addiSeveral CNS regions form CSF or a CSF-like fluid. Although CP tissues generate about two thirds of the total production, extrachoroidal sources make up the balance . The caprd and 4th ventricles. Because CNS metabolism is profoundly affected by CSF transport, it is imperative to delineate the physiological and molecular processes in CP that effect CSF secretion. CSF formation occurs in two stages: passive filtration of fluid across choroidal capillary endothelium [Originating in the ventricular interior of the brain, nascent CSF is continuously produced by the CPs in the lateral, 3othelium , followe-4 ml/min [Fluid is generated at a high capacity by the choroid plexus epithelial (CPe) cells . The CPe4 ml/min . If one 4 ml/min .CSF formation begins as plasma is filtered across permeable choroidal capillaries . Net filTranschoroidal secretion of water, ions and macromolecules drives the volume transmission of CSF Fig.  down the+, Cl-, K+, HCO3- and water from plasma to CP to CSF  and apical (CSF-facing) membranes of the CPe . Because+ and Cl- is the primary step in CSF formation  transfers Na into the choroid cell. This process is inhibited by the diuretic agent amiloride [+-H+ exchanger (NHE3) that normally supports substantial fluid transfer in kidney [--HCO3- exchanger translocates interstitial Cl- into the cytoplasm. Moreover the basolateral Na+-dependent Cl--HCO3- exchanger and the Na+-HCO3- cotransporter in CPe [+ coupling to HCO3- transport is likely integral to nascent CSF generation [+ influx into CPe and subsequently into ventricular CSF [3- transport [3- flux or alter choroid cell pH to modulate fluid formation.At the basolateral membrane, the uptake of Naion Fig. . Inward miloride -38, whicmiloride ,38. Thisn kidney . The Cl-r in CPe -42 may aneration ,44. Systransport ,42 by on+-K+-ATPase, the Na pump, is a workhorse that actively secretes Na into the ventricles  is significant in regard to bidirectional transport capability. The ability of the cotransporter to transfer ions in both the secretory and reabsorptive modes [+ pump [+, Cl- and HCO3- [At the apical membrane Nales Fig.  thereby ve modes  reflectsve modes  or furosve modes . In bothve modes  and aginve modes  disorder [+ pump ), reducend HCO3- , can be +-K+-ATPase and carbonic anhydrase (c.a.) are the two enzymes in the CPe that have been the most extensively analyzed in inhibitory studies of CSF formation. Na+-K+-ATPase, or the Na+ pump, is atypically (amongst epithelia) located on the luminal or CSF face of the CPe. Therefore ouabain inhibits the Na+ pump  when placed intraventricularly, but not intravenously. In addition to interfering with CSF production, the Na+-K+-ATPase inhibition also alters CPe volume, potential difference and ion homeostasis [In experimental settings, Naeostasis ; therefo2 to yield H+ and HCO3-. Acetazolamide, a sulfonamide drug, slows down this reaction [+ availability to basolateral Na+-H+ exchange [3- transporters  to which they supply HCO3- for exchange with interstitial Cl- [Ubiquitous enzymes in the c.a. group integrate cellular acid-base phenomena with CSF formation . One of reaction . Consequexchange ,53,54. Mtial Cl- . It is wtial Cl- -58. Idential Cl-  may helpi increases by 0.3 – 0.4 pH units after acute exposure (1 hr) to acetazolamide [i change. With regard to fluid transfer in the kidney, the crucial importance of Na+-H+ antiport exchange (via NHE3) and pHi stability for maintaining intact AQP2 and NKCC2 systems is revealed in NHE3-knockout analyses [Disruption of cellular acid-base balance by diminishing c.a. activity with acetazolamide provides deductive insights on the function of transporters and aquaporins. CPe pHzolamide ,53. Chrozolamide , includizolamide -64, possanalyses . In the analyses .Yet another potential avenue for regulating CSF formation exploits the expression plasticity of aquaporins (AQP) in CP ,66. AquaOf significance to CSF dynamics, nature performs an experiment in which there is AQP1 deficiency in late life . Thus, ain vitro as well as in vivo. Dark CPe cells have a neuroendocrine role to down -regulate CSF production. Stimulation of V1 vasopressinergic receptors induces dark cells [- efflux from CPe [Neuropeptides in CSF stimulate peptidergic receptors in CP to alter metabolism of 2nd messengers and the associated ion transport coupled to fluid formation . Choroidrk cells , reducesfrom CPe , and decfrom CPe . Moreovefrom CPe  that genfrom CPe  are exprfrom CPe . This infrom CPe  that areAlso supporting this fluid homeostasis model are the observations of substantial plasticity of choroidal receptors for water-regulating neuropeptides when CSF dynamics are imbalanced. There is up-regulated or down-regulated density of CP receptors for ANP in hydrocephalus , dependiCSFP or ICP rises rapidly when there is a significant imbalance between CSF formation and drainage. Augmented ICP reduces cerebral blood flow (CBF) and oxygenation and, at the molecular level, may alter protein expression in neurons and glia. Therefore, because of potentially devastating effects of elevated ICP on brain functions, it is clinically important to assess factors that regulate CSF pressure and devise more effective ways to monitor and manage distorted ICP.2O measured in the lateral recumbent position by lumbar puncture. This pressure is directly proportional to the CSF production rate and outflow resistance, which typically is 70 mm H2O/ml/min and greater in the 8th decade than in young adults [ICP is a complex function of hydrodynamic and hemodynamic parameters. In combination they produce, in adult humans, a CSFP of 100–200 mm Hg adults .On the hydrodynamics side, feedback down regulation of CSF formation can lower CSFP. Homeostatic adjustments to decrease fluid output by CP are critical because sustained CSFP elevation compromises the vascular supply to the CNS . AccordiGrowing evidence supports a ventricular servomechanism to stabilize CSFP. One hypothesis posits pressure-sensitive regulatory elements in the CSF-periventricular nexus that respond by synthesizing/releasing peptides that target the CP . A prime2O, rising to 34 mm H20 at 10 days postnatal and later [+ and Cl- transport into ventricles [Increasing CSFP during development in rodents is temporally associated with the early phases of fluid formation by CP. CSF pressure in pentobarbitone-anesthetized exteriorized fetal rats (18–21 days p.c.) is about 20 mm Hnd later . The 1 –nd later ,106. Thund later -109 fostnd later ,111. Enhntricles . Such inntricles  elevatesntricles . Arteriantricles  and deventricles . Maintaintricles  contribu20 at 10 days after birth to as high as 90 mm H20 by 3 weeks [Untoward effects on brain development, however, result from inordinately elevated CSFP secondary to blockage of the Sylvian aqueduct. Augmented CSFP has been observed in aqueduct-impaired hydrocephalic (H-Tx) rats, increasing 2-fold between 10 and 21 days after birth . In othe 3 weeks ,117. Ele 3 weeks ,119.Transgenic mice lacking ependymal-specific expression of hydin , which fCSFP impacts periventricular protein expression and secretion into the ventricles. An optimally-growing CNS depends on delicately-balanced biophysical and biochemical phenomena in CSF . In congThe interaction between the pressures of the CSF and vascular systems, especially in the onset of hydrocephalus, awaits systematic investigation. Fascinatingly, the elevated arterial pressure in spontaneously hypertensive rats is linked to ventriculomegaly via effects on secretion by the subcommissural organ (SCO) in the aqueductal wall . The SCOIn addition to the pressure effects on the periventricular zone, there are several ways that CSFP impacts the brain globally. Responses to elevated CSFP can be broadly categorized by: i) how neural structure and metabolism are affected by modified CSF dynamics; and ii) how homeostatic transport interfaces that protect the parenchyma respond to neuropeptide up-regulation in CSF hypertension. For the first consideration, there are marked oxidative changes -133 in hIn chronic hydrocephalus, even moderate increments in CSFP can compromise CBF and metabolism. Intermittent changes in CSFP need a thorough analysis, particularly in regard to effects on regional hydrodynamics and hemodynamics. Clearly, prospective as well as retrospective studies  on CSFP CSFP wave analysis provides substantial insight on the state of CSF dynamics and is more reliable than assessments of cerebral perfusion pressure and mean ICP, especially when there are differences in baseline pressure . CSF hasHow is ICP recorded, and does it matter where sensors are placed, i.e., in the CSF, brain parenchyma or epidural space? Continuous ICP signals have been recorded with sensors such as the Camino OLM ICP and Codman ICP MicroSensor . A studyPulsatile components of CSFP will likely be more helpful than mean CSFP in evaluating intracranial compliance Fig. . Eide inICP/CSF waveform analyses have predictive potential for outcome in adult patients with chronic hydrocephalus. Although patients with idiopathic NPH (iNPH) may have normal mean ICP, it is possible that they have altered single ICP waves. Higher values of mean ICP wave amplitudes were found in iNPH patients who eventually improved after shunting . In one The so-called B waves in CSF, especially in NPH patients, can predict post-surgical outcome in adult chronic hydrocephalus. Slow B waves, however, only weakly correlated with improvement after shunt surgery . An alteA worthy clinical goal is to ascertain absolute CSFP by methodology minimally disruptive to CSF or brain. CSF is contiguous with fluids in the ear, nose and eyes. The orbit vasculature, for example, is exposed to ambient CSFP. This should enable reliable CSFP determination from transocular sonographic and dynamometric data. An empirical index based on ocular arterial (blood flow) and venous (outflow pressure) measurements highly correlates (r = 0.95) with absolute CSFP . TherefoTechnical advances are also being made with directly measured CSFP. A novel technique minimizing CNS invasion utilizes a hollow mandrin. This ventricular probe allows precise cannulation of CSF and determination of opening CSFP without fluid loss along the penetrating catheter . This reTo expedite CSF and hydrocephalus modeling, attention is being devoted to delineating CSFP signals. Highly precise signals for hemodynamic and hydrodynamic parameters facilitate CSFP analyses. Continuous signal inputs to multiple sensors (blood pressure and CSFP during infusions) are integrated by software  to evaluth ventricle and then out through hindbrain foramina into the cisterna magna and the subarachnoid space in basal regions. In addition to this classically-described pathway, new evidence indicates that ventricular CSF also flows by another route to the basal and midbrain cisterns, i.e., into subarachnoid extensions [rd ventricle) and superior medullary velum . Additional evaluation is needed for the limited CSF flow from cisterna magna to cortical subarachnoid regions and arachnoid villi [CSF flow pathways need elucidation for both healthy and diseased brain. Choroidally secreted CSF flows down the neuraxis to the 4tensions  of the vid villi , and forid villi . InsightThere is increasing appreciation that reduced CSF flow adversely affects brain metabolism and fluid balance ,118,119.Interference with CSF flow through the ventricles and aqueduct in fetal life profoundly retards brain development ,119. ThiCSF flow disruption in adult chronic hydrocephalus also devastates cerebral functions. Throughout aging, the ability of CP epithelium to manufacture CSF undergoes continual decline ,3,57,79.Due to previous technological limitations, there has been a paucity of investigations to assess CSF flow in animal models. However several non-invasive studies involving magnetic resonance imaging (MRI) to quantify CSF flow have been carried out in humans. One of the earliest such analyses by Ridgway et al.  demonstret al. [Recent advances have been made in the technology and algorithms for quantifying CSF flow non-invasively. Using phase-contrast MRI to calculate CSF and CBF curves over the cardiac cycle, Stoquart-Elsankari et al.  extracteet al. . PC-bSSFet al. ,185. AppMaintaining normal CSF volume is indispensable to brain health. CSF volume ranges from the greatly reduced spaces in slit ventricle syndrome to the ventriculomegaly of severe hydrocephalus. The dynamics of ventricular contraction and expansion are poorly understood but likely involve the interplay of three main factors: changes in brain tissue properties , CSF dynamics and vascular parameters. CSF volume can be significantly altered iatrogenically by suboptimal rate of CSF flow through shunts. Disorders that rupture the BBB and BCSFB also modify ventricular volume. Understanding CSF volume is important because of the impact on neuronal function exerted by changes in cerebral metabolism and blood flow. Therefore, information is needed on the rate and extent of regional CSF volume adjustments.2 supply and severely compromises the BCSFB and ventricular integrity. Hyperthermia also devastates the CP-ventricle nexus. By way of osmotic and autonomic disruptions between the CP and CSF, hyperthermia causes an edematous expansion of the CNS parenchyma [Maintaining the appropriate size of the ventriculo-cisternal-subarachnoid compartments is biophysically and biochemically complex. CSF volume in adult mammals ranges from about 0.04 ml in mice  to approrenchyma . On the renchyma . TransgeCSF volume importantly adjusts to physiological variations in cerebral blood volume (CBV). Thus an increased amount of blood within the cerebrovascular system leads to a displacement, and to a reduced volume, of CSF. Conversely, a decrease in CBV can result in an augmented volume of CSF. This more-or-less reciprocal relationship between CBV and CSF volume reflects the fact that, according to the Munro-Kelly doctrine , the comPhysical aspects of choroidal hemodynamics also significantly affect CSF volume. There is a brisk, pulsating blood flow of 3–4 ml/g/min to the plexus ,109. ThiHypo-secretion of CSF, presumably occurring consequent to disrupted bicarbonate transport in CP of SLC4 knockout mice, drastically reduces ventricular volume . On the +-K+-2Cl- cotransporter [The spontaneously hypertensive rat model (SHR) also reveals the significance of BCSFB transport and fluid formation in regulating fluid volume within the CNS interior. SHR displays a ventriculomegaly ,195 thatnsporter  which prnsporter ,195. Accnsporter , the larOther injury models of the blood-CSF barrier shed light on dysregulated ventricular volume. Acute arterial hypertension in adult rats transiently opens the BCSFB allowing plasma proteins to leak into the ventricles . PatholoPeptidergically-regulated fluid transfer at the BCSFB and BBB ,201 helpAt the blood-CSF interface in CP, there is a complex interplay among ANP, AVP and FGF2 and their apical membrane receptors to control ion and water secretion into the ventricles. This trio of peptides down-regulates CSF formation via neuroendocrine effects on CPe ,17,81-87in vivo and in vitro reduces CSF formation [Ventricle size is affected by peptide regulation of CSF output from CP. FGF2 has many physiological roles, but a newly appreciated one is fluid regulation. Exogenously administered FGF2 both ormation ,179. Thiormation . FGF2 anormation ,211. It ormation . CollectANP is also regarded as a volume-regulating peptide . SeveralTo construct a global model of CSF-ISF volume homeostasis, more information is needed on how ANP, AVP and FGF2 work in concert to regulate fluid transfer across CP and BBB ,201,209.The brain's ability to turn over or renew CSF is crucially important in maintaining metabolic balance in the CNS. This is because the brain lacks lymphatic capillaries. It therefore relies heavily on continual CSF convection to clear macromolecules and catabolites from the neuronal environment. Such clearance deficiency, as in states of CSF stagnation when turnover rate is severely compromised, results in catastrophic changes in the composition of the interstitium, vessel walls and meninges. Consequently, neurons incur damage. Pharmacotherapeutic strategies to stabilize the aging CNS might well include ways to maintain CSF formation and prevent ventricular enlargement.The CSF turnover rate is defined as the volume of CSF produced in 24 hours divided by the volume of the CSF space. In young adult rats, the total CSF volume is renewed about 11 times daily compared to 4 times/day in control humans . Accordingly, in aging, NPH and AD  is extensively synthesized and secreted by CP into CSF. TTR is a useful CSF marker because it is manufactured mainly by CP  and onlyIn addition to receiving productive secretions from the CP, the CSF is also a repository for catabolites diffusing out of brain. Excessive metabolite efflux from ISF to ventricles can toxify the CSF. Toxic catabolites in CSF, generated by peroxidative phenomena, increase with age and neurodegeneration . GlycateMaintaining ISF and CSF compositional purity is of prime importance and depends upon efficient clearance mechanisms. Because the CNS lacks lymphatic capillaries, the CSF-mediated removal of metabolites and toxins is essential for efficient neuronal function. The CP-CSF system, proximally and distally, plays a major role in removing harmful substances. This occurs three ways. First, reabsorptive transporters in the apical membrane of CP epithelium actively remove organic anions and peptides from ventricular CSF ,17,243. Comprehensive analysis of CSF biochemistry helps to manage NPH, AD and other complications of senescence. Several animal models demonstrate inhibitory effects of neuropeptides and growth factors on CSF formation and reabsorption ,246. A lPharmacological manipulation of CSF and brain ISF composition may prove feasible. One goal is to improve CSF flow and content through actions of drugs delivered across the BCSFB into the brain interior ,17. RepaFunctional interactions between CSF and ISF are plentiful. CSF and ISF move by bulk flow, the former through large cavities and the latter finely through narrow winding pathways in the neuropil and grossly along myelinated fiber tracts. Fluid is convected into and out of the brain parenchyma, depending upon prevailing local hydrostatic pressure gradients. Knowledge of bulk flow pathways is important for: the delivery of micronutrients and peptides to neurons and glia, the conveyance of hormone signals to target cells, the delivery of drugs to receptors, and the removal of catabolic products from CNS. Pathological sequelae ensue when ISF and CSF do not freely percolate. CSF movement via interstitial pathways requires further analysis due to disease implications.CSF and ISF dynamically exchange water and solutes across the ependymal (interior) and pia-glial (exterior) surfaces of brain ,27. BraiMetabolic waste is discarded through ISF and CSF clearance routes. Brain ISF conducts metabolites away from neurons and glia to excretory sites. ISF has multiple input and output components that keep the fluid mixed and delivered to excretory loci. On the input side of ISF volume and flow is a CSF-like fluid likely secreted by the astroglial-endothelial complex in microvessels . The putISF output has at least two components. First, quantitatively substantial reabsorptive fluxes of solutes  occur via LRP-1across endothelial cells into vascular lumina . As LRP-Volume transmission of ISF and CSF is substantially attenuated in aging and dementia ,9. BrainCumulative evidence for dwindling transport and fluid dynamics in aging, NPH, and AD, ,19 pointCSF clearance into lymph and blood involves diverse anatomical sites and physiological mechanisms. Disrupted CSF reabsorption is a common cause of hydrocephalus. The eventual resolution of clinical hydrocephalus depends upon knowledge of outflow sites and their regulation. When CSF is retained in the CNS, compensatory mechanisms stabilize ICP . In addiCSF Ro has been the key hydrodynamic parameter to evaluate reabsorptive phenomena. Methodologically, CSF infusions accompanied by CSFP measurements have generated ample Ro data for humans and animals . In rodein vivo. This new emphasis on drainage via the olfactory route [There has been lively debate regarding the main site of CSF reabsorption. The past decade witnessed a gradual paradigm shift on the preponderant site of CSF drainage in several animal models. Accordingly, drainage/reabsorption of CSF via the olfactory  and optiry route -272, ratUntil recently, CSF drainage models have emphasized a substantial role for the arachnoid villi embedded in the dura mater of the superior sagittal sinus. Each arachnoid villus was thought to have a one-way (CSF outward) valve-like mechanism that opened in response to a positive hydrostatic pressure gradient between CSF and dural venous blood . It now Johnston and colleagues have implicated the cribriform plate above the nose as a key extracranial site in CSF outflow. Assessments of proportional flow through cribriform and non-cribriform routes indicate that at low ICP the CSF absorption occurs mainly across the plate . Thus anin vitro  has been associated with impaired extracranial venous obstruction . Collecttro Fig. , utilizi. et al. ,277, shoCSF reabsorption also occurs along spinal nerves. Radionuclides injected into the CSF in a cisternography study of human reabsorption revealed a 20% reduction of radioactivity in the spinal subarachnoid space during one hour of testing . This spHydrocephalus impacts and is impacted by CSF egress. When increased Ro causes central fluid overloading, there may be alternate non-arachnoidal mechanisms activated by augmented ICP to prevent further build up of CSF and ISF. Water channel AQPs at the blood-CSF  and blooRestoration of fluid balance perturbed in congenital and adult chronic hydrocephalus remains an enormous challenge. Translational progress is difficult because CSF is complexly interactive with many fluid compartments and interfaces Fig. . In elucThe CPs are more than an appendage of the BBB . Rather,vice versa. The actions and responses at these primary transport interfaces are addressed with in situ and in vivo models allowing concurrent analyses of barriers not possible with in vitro and cell culture preparations. One approach is multi-compartmental analysis [in vivo transport mechanisms.An altered BCSFB can affect the BBB, and analysis  or simulanalysis  of brainanalysis . Anotheranalysis . Systemianalysis  to charaA fascinating advance for CSF modeling is that the BCSFB and BBB can be involved in opposite responses. This happens when the CNS adapts to altered fluxes of water and peptides  in diseases that physically impair distribution pathways. Table CSF integrates a multiplicity of functions for the CNS. From fetal life through adulthood, and extending into terminal stages, CP-CSF actively engages in building, maintaining and repairing the brain . Efficie--HCO3- antiporter; ANP, atrial natriuretic peptide; AQP, aquaporin; AVP, arginine vasopressin; BBB, blood-brain barrier; BCSFB, blood-cerebrospinal fluid barrier (choroid plexus); c.a., carbonic anhydrase; CBF, cerebral blood flow; CBV, cerebral blood volume; cGMP, cyclic guanylyl monophosphate; CNS, central nervous system; CP, choroid plexus; CPe, choroid plexus epithelium; CSF, cerebrospinal fluid; CSFP, cerebrospinal fluid pressure; ELISA, enzyme-linked immunosorbent assay; FGF2, basic fibroblast growth factor; H-Tx, hydrocephalic rat model with a genetic origin and obstruction of the cerebral aqueduct; ICP, intracranial pressure; ISF, interstitial fluid; LRP-1, low-density lipophilic protein receptor related protein (Aβ transporter); MRI, magnetic resonance imaging; NHE1 and NHE3, sodium-hydrogen exchangers; NKCC1, Na-K-Cl cotransporter (secretory form); NPH, normal pressure hydrocephalus; PC-bSSFP, phase contrast balanced steady-state free precession; Pgp, P-glycoprotein transporter; RAGE, receptor for advanced glycation end products (Aβ transporter); RF, Reissner's fiber; Ro, resistance to CSF outflow; RPPC, relative pulse pressure coefficient; SAS, subarachnoid space; SCO, subcommissural organ; SHR, spontaneously hypertensive rat; SLC4, member of the bicarbonate transporter family; TTR, transthyretin.aAMP, arterial pulse amplitude; Aβ, beta-amyloid protein or peptide; AD, Alzheimer's disease; AE2, anion exchanger, e.g., ClThe authors declare that they have no competing interests.CEJ had the main responsibility for organizing and writing the manuscript. JAD aided in developing the material on clinical aspects of pediatric and adult hydrocephalus. PMK and TB contributed perspective on CSF pressure, kaolin hydrocephalus and CSF reabsorption. EGS helped to interpret pathophysiological findings on Alzheimer's disease. GDS provided insight on human and animal BBB transporter expression and CSF dynamics in aging, NPH and dementias; and had a major role in editing. All authors have read and approved the final manuscript.


Granulocyte–macrophage colony-stimulating factor (GM-CSF) has been implicated as an important mediator in the pathogenesis of asthma and chronic obstructive pulmonary disease (COPD). However, the expression of GM-CSF and its receptor in airway samples in asthma and COPD across disease severity needs to be further defined.Sputum GM-CSF was measured in 18 control subjects, 45 subjects with asthma and 47 subjects with COPD. Enumeration of GM-CSF+ cells in the bronchial submucosa and airway smooth muscle bundle was performed in 29 control subjects, 36 subjects with asthma and 10 subjects with COPD.s = 0.41; p = 0.018). The median (interquartile range) GM-CSF+ and GM-CSFR+ cells/mm2 of submucosa was increased in severe asthma (1.4 (3.0) and 2.1 (8.4)) compared with those with mild to moderate asthma (0 (2.5) and 1.1 (5)) and healthy controls (0 (0.5) and 0 (1.6)), .The proportion of subjects with measurable GM-CSF in the sputum was raised in those with moderate (7/14) and severe (11/18) asthma, and in those with COPD GOLD  stage II (7/16), III (8/17) and IV (7/14) compared with controls (1/18) and those with mild asthma (0/13); p = 0.001. The sputum GM-CSF concentration was correlated with the sputum eosinophilia in subjects with moderate to severe asthma (rThe findings support a potential role for GM-CSF in asthma and COPD and suggest that overexpression of GM-CSF in sputum and the bronchial mucosa is a particular feature of severe asthma. Asthma affects 10% of children and 5% of adults, and its prevalence continues to rise.1–Granulocyte–macrophage colony-stimulating factor (GM-CSF) is a major regulator of inflammatory cells of the myeloid lineage and has been implicated in asthma and COPD.12We hypothesised that GM-CSF and GM-CSFR expression is increased in asthma and COPD, and is related to disease severity. To test our hypothesis we have measured the sputum GM-CSF concentration and enumerated in bronchial mucosa the number of GM-CSF+ and GM-CSFR+ cells in asthma and COPD.1) >200 ml, a provocation concentration of methacholine causing a 20% fall in FEV1 (PC20) of <8 mg/ml or a peak flow amplitude percentage mean over 2 weeks of >20%. Asthma severity was classified using the GINA treatment steps.Subjects were recruited from hospital staff, the general respiratory and the ‘Difficult Asthma’ clinics at Glenfield Hospital, Leicester, local primary healthcare and by local advertising. Asthma was defined according to the current Global Initiative for Asthma (GINA) guidelines.Dermatophagoides pteronyssinus, dog, cat and grass pollen. Sputum induction using incremental concentrations of nebulised hypertonic saline 3, 4 and 5% each for 5 min was also performed in all subjects in groups 1 and 2.23For all subjects, demographics and spirometry were recorded. Subjects with asthma and healthy controls in groups 1 and 2 also underwent a methacholine inhalation test using the tidal breathing methodIn group 2, subjects underwent bronchoscopy conducted according to the British Thoracic Society guidelines,25Sputum was selected, dispersed using the mucolytic dithiothreitol (DTT) and processed to generate a sputum differential cell count, and cell-free supernatants were stored at −80°C for later analysis as described previously.26Sputum GM-CSF was measured by ELISA . The lower limit of detection was 10 pg/g sputum. The GM-CSF assay was validated in line with European Respiratory Society recommendations to assess the effect of DTT and the recovery of exogenous spiking with recombinant cytokine.2 of bronchial submucosa or ASM bundle by a blinded observer as described previously.29Sections of 2 μm were cut and stained using monoclonal antibodies against GM-CSF , GM-CSFR , or appropriate isotype controls (rat immunoglobulin G2a (IgG2a)  and mouse IgG1 clone DAK-Go1 , respectively). The number of positive nucleated cells was enumerated per mm2 tests were used to compare categorical data. Correlations were assessed by Spearman rank correlation coefficients.Statistical analysis was performed using PRISM Version 4. Parametric data were expressed as mean (SEM), data that had a normal log distribution were log transformed and described as geometric mean (95% CI) and non-parametric data were described as median (interquartile range (IQR)). One-way analysis of variance  was used for across-group comparisons, with Tukey and Dunn post hoc tests for between-group comparisons. χs = 0.28; p = 0.007), all those with asthma  and moderate and severe disease , but not COPD. There was no association in subjects with asthma or COPD with sputum GM-CSF concentration and percentage predicted FEV1  or the FEV1/FVC  ratio , respectively.Clinical and sputum characteristics for subjects in group 1 are shown in 2 of submucosa was increased in severe asthma (1.4 (3.0)) compared with those with mild to moderate asthma (0 (2.5)) and healthy controls (0 (0.5)),  and 2.4 (5.5)) compared with healthy controls (0 (1.6) and 0 (0.8), but not in those with mild to moderate asthma (1.1 (5) and 1.2 (2.2)) (p = 0.02 and p = 0.049, respectively, Kruskal–Wallis; p<0.05 severe asthma vs control, Examples of GM-CSF and GM-CSFR+ cells in the bronchial submucosa in asthma are as shown in There were no differences in the number of GM-CSF+ or GM-CSFR+ cells within the submucosa or ASM bundle in lung resection tissue from subjects with COPD and controls with and without a significant smoking history .We report here for the first time that the sputum GM-CSF concentration was increased in COPD, independent of disease severity, and confirm that in asthma the sputum GM-CSF concentration is associated with more severe disease. In asthma our sputum findings were supported by increased GM-CSF and GM-CSFR expression in bronchial biopsies in severe disease. Our study therefore supports our hypothesis that GM-CSF and GM-CSFR expression is increased in asthma and COPD, and in asthma is related to disease severity.Several lines of evidence support a role for GM-CSF in COPD. GM-CSF is induced by the presence of airway pathogens–In asthma there is a wealth of data supporting a role for GM-CSF. In particular GM-CSF is pivotal in eosinophil maturation and survival,12Our study design allowed for direct comparison of the sputum GM-CSF concentration in asthma and COPD, but not expression in tissue as samples were obtained using different methods. Comparisons in sputum GM-CSF concentrations were undermined by the relative insensitivity of our assay, with a large number of subjects that had concentrations below the level of detection of our assay. This is likely to reflect the rapid internalisation of GM-CSF. In spite of this limitation we found that sputum GM-CSF was increased in both COPD and moderate to severe asthma, and importantly it was greater in moderate to severe asthma than in COPD. Therefore, whether GM-CSF plays a more important role in severe asthma than in COPD warrants further investigation.Our study has a number of possible criticisms. This is a cross-sectional observational study. We were unable to demonstrate an association between GM-CSF expression and lung function. Whether GM-CSF expression is related to longitudinal clinical outcomes such as disease progression, lung function decline and exacerbations requires further examination. Similarly, we are unable to determine whether differences observed between mild and severe asthma reflect disease severity or are a consequence of differences in treatment. Therefore, the effects of corticosteroids on GM-CSF need to be fully elucidated, although previous work suggests that GM-CSF expression in tissue is attenuated by corticosteroids.In conclusion, we found that the sputum GM-CSF concentration was increased in COPD, independent of disease severity, and in moderate to severe asthma. Increased bronchial submucosal expression of both GM-CSF and its receptor was a particular feature of severe asthma. Our findings therefore do support a potential role for GM-CSF in asthma and possibly COPD. Efficacy studies of therapeutic strategies targeted at GM-CSF are eagerly awaited and will further define the functional importance of GM-CSF in airways disease.


Chemotherapy Induced neutropenia is a frequent and serious complication of cytotoxic cancer treatment.Granulocyte colony stimulating factors (G-CSF) are frequently used to counter neutropenia, attempt rapid recovery of patients and allow for continuation of treatment without compromise on dose, especially in curative malignancies. Generally regarded as safe, G-CSF use has been very rarely reported to have resulted in serious side effects, such as, splenic rupture.We are reporting a case of a twenty years old man, who was being treated for T cell acute lymphoblastic leukemia and received colony stimulating factors for treatment of severe neutropenia and suffered from splenic rupture, He was treated with splenectomy.Although extremely rare, splenic rupture can be a serious and sometimes life threatening complication of high dose colony stimulating factors therapy. One of the most serious toxicity of chemotherapy is neutropenia, a complication that leads to infection, hospitalization, and even death. Dose reduction in subsequent cycles is also one of the compromise which has to be made in anticipation of troublesome neutropenia. G-CSF tWe here in report a case of a young patient suffering from T-cell lymphoblastic lymphoma, who received G-CSF as secondary prophylaxis and unfortunately suffered from splenic rupture.9/l. A CT scan was obtained in the emergency room (FIG 9/l, and he was discharged uneventfully. He is currently completing his treatment with remaining cycles of hyper-CVAD regimen.A 20 years old gentleman was being treated for Acute T cell lymphoblastic lymphoma with hyper-CVAD regimen, the therapy consists of Cyclophosphomide, vincristine, doxorubicin and dexamethasone alternating with high dose methotraxate and cytarabine. The patroom FIG  which sh9/L[Treatment with G-CSF is commonly practiced in patients undergoing neutropenia secondary to chemotherapy for cancers. It is generally considered safe and effective, while many patients have derived benefits of therapy with G-CSF, developing less infection, less antibiotic use and shorter hospital stay, some suffer from minor self limited side effects as well . Prophyl9/L. There h9/L,9. Case 9/L.To the best of our knowledge this is a rare case where G-CSF induced splenic rupture has been reported in patient suffering from acute lymphoblastic lymphoma. The patient presented with acute onset left sided pain without any history of trauma. He uninterruptedly took G-CSF for about 20 days, with a dose of 5 μg/kg for the first ten days followed by 10 μg/kg during the remaining ten. Splenic rupture can be rationalized on the basis of extramedullary myelopoies leading to parenchymal congestion.Splenomegaly is seen in almost all PBSCT donors receiving G-CSF, regardless of age, sex or race. With a mean size 10.9 ± 2.0 cm before G-CSF to 12.3 ± 2.1 cm on the day of aphaeresis . PBSCT h"Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."The authors declare that they have no competing interests.NM: participated in literature search, manuscript writing and review of document. AJS: participated in manuscript writing, literature search, reviewing the document and coordination with the patient. WAM was the radiologist involved in diagnosis and contributed in literature search. RI was the pathologist involved in diagnosis, reviewing the article and suggesting changes. All authors read the paper and approved the final manuscript.NM and AJS From the section of oncology, department of medicine: the Aga Khan University hospital, Karachi, Pakistan.2. WAM from the department of radiology: the Aga Khan University hospital, Karachi, Pakistan.3. RI from the department of pathology: the Aga Khan University hospital, Karachi, Pakistan.


Staphylococcus lugdunensis is an unusually virulent coagulase-negative staphylococcus that has rarely been implicated in central nervous system infections.Staphylococcus lugdunensis following placement of external ventriculostomy drains. The causative organisms were identified by molecular studies. The patients recovered without significant sequelae after high doses of intrathecal vancomycin.Two children hospitalized in the Neurosurgery Unit developed ventriculitis caused by methicillin-resistant Staphylococcus lugdunensis from other coagulase-negative staphylococcus species is crucial because it carries a substantial risk for severe central nervous system infections displayed by patients with implanted cerebrospinal fluid devices. Clinicians should not underestimate the importance of the isolation of this species from cerebrospinal fluid specimens.Distinguishing  Nucleic acid sequences related to the accessory gene regulator (the major determinant of virulence in S. aureus) have also been demonstrated in S. lugdunensis [First described by Freney patients . It has patients . Its rempatients . Some stdunensis .S. lugdunensis" AND "cerebrospinal fluid (CSF)-shunt infection" OR "central nervous system (CNS) infection" yielded only four cases, which are summarized in Table S. lugdunensis ventriculo-peritoneal shunt (VPS) infections [S. lugdunensis meningitis unrelated to implanted CSF drainage devices [S. lugdunensis infections reported in Table A MEDLINE search conducted with the keywords "fections ,7, and c devices . The othS. lugdunensis CNS infections and summarizes the molecular characteristics of the isolates recovered from CSF and ventricular drain cultures.This report analyzes the management of these patients in light of the few previously reported cases of th day of hospitalization, he had a second operation for partial removal of the tumor (a medulloblastoma). A new EVD was inserted; cultures of the original EVD and CSF yielded no growth. Seven days later, the child developed severe headache, fever (39.5°C), vomiting, lethargy, and signs of EVD malfunction. Shunt puncture yielded cloudy CSF containing 900 leukocytes/mm3 (80% polymorphonuclear cells); 100 mg protein/dl); and 21 mg glucose/dl (blood glucose: 87 mg/dl). Cytocentrifuge Gram staining revealed Gram-positive cocci that were later identified by biochemical and molecular methods as Staphylococcus lugdunensis.A 7-year-old boy was hospitalized in the Pediatric Neurosurgery Unit for headache, vomiting, and right ocular dysmetria. Magnetic resonance imaging (MRI) revealed obstructive hydrocephalus caused by a posterior fossa tumor. The child was taken to the operating room for placement of an external ventriculostomy drain (EVD). CSF cultures yielded no growth. There was no improvement and, on the 10S. lugdunensis. Three blood cultures yielded no growth. Swabs of both inguinal folds and the surgical incision were cultured, but none yielded S. lugdunensis. Defervescence occurred after 2 days of IT vancomycin. After 14 days of vancomycin, the composition of the CSF was normal, and cultures of CSF and EVD were negative. The boy was discharged after 62 days of hospitalization, and no sign of CNS infection was noted at the 6-month follow-up visit.Meanwhile, a presumptive diagnosis of ventriculitis was made , a new E3 (60% were polymorphonuclear cells), and 5 to 10 Gram-positive cocci per microscopic field that were identified in biochemical and molecular assays as S. lugdunensis.A 2-month-old male was admitted to the Pediatric Neurosurgery Unit for rapid head growth with a tense anterior fontanel. He was placed in the same room where Patient 1 was still being cared for. Triventricular hydrocephalus was evident on cranial ultrasonography, and MRI with angiographic sequences disclosed a malformation involving Galen's vein that caused arteriovenous shunting and obstruction of CSF flow through the aqueduct. The malformation was treated successfully with intravascular embolization, but 1 week later, the infant developed seizures. Cerebral angiography confirmed occlusion of the aneurysmal malformation, but computed tomography revealed an intraventricular/subarachnoid hemorrhage. An EVD was placed for continuous intracranial pressure monitoring and collection of CSF specimens. All CSF cultures were negative, including the one obtained during EVD placement. Three days later, the child was febrile (39.2°C) and drowsy. A cloudy CSF specimen collected from the EVD contained 129 mg/dl protein, 20 mg/dl glucose (blood glucose: 113 mg/dl), 800 leukocytes/mmS. lugdunensis. Three blood cultures were negative. Skin cultures  were all negative for S. lugdunensis. The infant's condition rapidly improved after vancomycin was started, and cultures of CSF collected 15 days later and of the second EVD showed no growth. The infant was discharged after 40 days of hospitalization. Six months later, he was well with no evidence of infection and no acute neurological signs.The clinical picture was compatible with ventriculitis , and IT 2) on Columbia and chocolate agars, anaerobic culture (35°C) on Schaedler agar , and 72 hours of aerobic and anaerobic cultures on brain-heart infusion broth supplemented with 5% NaCl.Our routine protocol for suspected CSF shunt infections includes Gram staining of cytocentrifuged CSF, aerobic culture at 35°C on MacConkey agar, microaerobic culture (35°C in room air with 5% COS. lugdunensis by the API ID32 STAPH (bioMérieux) and the VITEK 2  systems.In these two patients, cultures of CSF and EVD tips on Columbia agar produced yellowish beta-hemolytic colonies (diameter: 0.8–2.5 mm) of Gram-positive cocci. Tube coagulase tests with rabbit plasma  were negative. The isolates were positive for catalase, clumping factor, pyrrolidonyl arylamidase, and ornithine decarboxylase. They were identified as S. lugdunensis ATCC 43809 (Z26899). A partial sequence of the rpoB gene of each isolate revealed 99.5% homology with the prototype strain sequence of S. lugdunensis ATCC 43809 (EF173667).Bacterial DNA was extracted from CSF specimens and culture isolates with the QIAmp DNA Mini kit . Species-level identification was confirmed by sequencing of the 16S rRNA gene (using the RIDOM entries) and the RNA polymerase B gene . SequencAntimicrobial susceptibility testing with the E-test  yielded the following MICs (μg/ml): oxacillin, 256; vancomycin, 0.5; erythromycin, 0.03; ciprofloxacin, 0.03; clindamycin, 0.03; rifampicin, 4.0; quinupristin-dalfopristin, 0.5; linezolid, 1.0. Resistance was defined by Clinical Laboratory Standards Institute breakpoints [mecA gene (reflecting methicillin resistance) was detected by PCR, as described by Geha and colleagues [SmaI- and ApaI-digested chromosomal DNA [akpoints . The meclleagues . Pulsed-omal DNA  revealedS. lugdunensis ventriculitis associated with EVDs, which are widely used in neurosurgery for continuous intracranial pressure monitoring, injection of therapeutic agents, and temporary external drainage of CSF [To date, there have been no reports of e of CSF . EVD-asse of CSF . The fore of CSF .Our patients and one of those reported by Elliot and colleagues  had hospStaphylococcus epidermidis.EVD use in critically ill neurosurgical patients is on the rise and reported rates of infection associated with these devices vary widely (from 0 to 45%). The prevailing opinion is that the infecting agent is usually introduced during EVD placement , which iS. lugdunensis is considered part of the resident flora of the human skin and mucous membranes, although the preferred carriage site seems to be the perineum [Like other CoNS species, perineum . In bothS. lugdunensis. However, the staff surveillance cultures were collected after the second child had been infected, not during the time of EVD insertion, so the infection reservoir might have been missed. Environmental cultures and inguinal cultures of providers were not performed.We cannot exclude the possibility that the infections were transmitted during manipulation of the catheters. Healthcare-provider hand cultures (data not shown) and patient skin cultures yielded no growth of S. lugdunensis. The homogeneity they observed among 39 isolates collected over 4 years suggests that S. lugdunensis is either a highly conserved species or that specific clones are more likely to cause invasive infections. Other investigators [SmaI macrorestriction analysis is inappropriate for epidemiological investigations of S. lugdunensis infections only when the strains are β-lactamase-producers, since these isolates usually display a high level of genetic homogeneity. Identification of adequate typing tools for this bacterial population will probably require multimodal molecular characterization of a larger collection of S. lugdunensis strains.Hellbacher and colleagues  recentlytigators , howeverStaphylococcus spp. includes shunt removal and intravenous vancomycin [S. lugdunensis were treated with intravenous vancomycin and/or oxacillin, alone or with rifampicin, and bacteriological and clinical cures were documented in all four [The standard approach to CSF shunt infections caused by a methicillin-resistant ncomycin . The preall four -8. CSF sall four . AlthougS. lugdunensis infections may well be underestimated. The species is likely to escape detection by screening tests or certain automated microbiological systems. Its ability to produce colony variations is well known, described in three of the 11 strains included in the initial description of S. lugdunensis in 1988 [S. lugdunensis phenotype in blood agar cultures.The frequency of  in 1988 . No coloS. lugdunensis can cause severe CNS infections in patients with implanted CSF drainage devices. Accurate species-level identification of isolates causing staphylococcal CSF shunt infections is clearly essential for their successful treatment, but it is also fundamental for epidemiological surveillance and for improving our understanding of the pathophysiological factors affecting the clinical outcome of these infections. With the increasing use of invasive medical devices for management of neurosurgical patients, CSF shunt infections are likely to become more common. Failure to identify their causative agents can be particularly disastrous when the infection is due to S. lugdunensis.Our experience confirms that, unlike other CoNS which usually display low virulence, FM177467 and FM177468, respectively, for the rpoB gene and under accession nos. FM177469 and FM177470, respectively, for the 16 rRNA gene.The sequences of the isolates evaluated in this study have been deposited in the GenBank database under accession nos. CNS: Central nervous system; CoNS: Coagulase-negative staphylococcus; CSF: Cerebrospinal fluid; EVD: External ventriculostomy drain; IT: Intrathecal; VPS: ventriculo-peritoneal shunt; MRI: Magnetic resonance imaging; PFGE: Pulsed-field gel electrophoresis.The authors declare that they have no competing interests.TS and DR participated in the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting of the manuscript and its critical revision. GT and DP managed both children as neurosurgeons. BF, TDI, BP and MS carried out the laboratory studies of patients. GF revised the manuscript. All authors read and approved the final version of the manuscript.Written consent was obtained from each patient's parents for the publication of this report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


In order to evaluate the potential clinical and economic benefits of granulocyte colony-stimulating factor  following peripheral blood progenitor cells (PBPC) rescue after high-dose chemotherapy (HDCT), 23 consecutive patients aged less than 60 years with poor-prognosis, high-grade non-Hodgkin's lymphoma (NHL) were entered into a prospective randomized trial between May 1993 and September 1995. Patients were randomized to receive either PBPC alone (n = 12) or PBPC+G-CSF (n = 11) after HDCT with busulphan and cyclophosphamide. G-CSF (300 microg day[-1]) was given from day +5 until recovery of granulocyte count to greater than 1.0 x 10(9) l(-1) for 2 consecutive days. The mean time to achieve a granulocyte count > 0.5 x 10(9) l(-1) was significantly shorter in the G-CSF arm  as was the median duration of hospital stay . In addition the recovery periods (range 9-12 vs 11-17 days to achieve a count of 1.0 x 10(9) l[-1]) and hospital stays (range 11-14 vs 13-22 days) were significantly less variable in patients receiving G-CSF in whom the values clustered around the median. There were no statistically significant differences between the study arms in terms of days of fever, documented episodes of bacteraemia, antimicrobial drug usage and platelet/red cell transfusion requirements. Taking into account the costs of total occupied-bed days, drugs, growth factor usage and haematological support, the mean expenditure per inpatient stay was pound sterling 6500 (range pound sterling 5465-pound sterling 8101) in the G-CSF group compared with pound sterling 8316  in the group not receiving G-CSF, with an observed mean saving of 1816 per patient  in the G-CSF group. This study suggests that after HDCT and PBPC rescue, the use of G-CSF leads to more rapid haematological recovery periods and is associated with a more predictable and shorter hospital stay. Furthermore, and despite the additional costs for G-CSF, these clinical benefits are not translated into increased health care expenditure.


We investigated the reconstitutive potential of haematopoietic progenitor cells collected in autologous whole blood during multicycle dose-intensified chemotherapy. Forty patients with metastatic solid tumours were treated with up to six cycles of cisplatin and escalating doses of ifosfamide every 14 days. Cisplatin was administered in 3% sodium chloride over 3 h, followed by ifosfamide over 24 h and mesna over 36 h. The first cohort of patients received granulocyte colony-stimulating factor (G-CSF) days 4-14. Once dose-limiting toxicity was reached in cohort 1, the study continued with a second cohort of patients, in whom, in addition to G-CSF on days 4-14, 500 ml of G-CSF and chemotherapy-'primed' whole blood was collected on day 15, i.e. on day 1 of treatment cycles two to six, before cisplatin administration. This volume of blood was kept unprocessed at 4 degrees C and reinfused 20-24 h after the completion of ifosfamide. In cohort 1, dose-limiting toxicity (DLT) was reached at ifosfamide 6.0 g m(-2) with two out of six of the patients developing neutropenic fever. Although in cohort 2 no neutropenic fever was encountered, neither the frequency nor the duration of grade 4 neutropenia and thrombocytopenia were reduced. Cumulative asthenia resulted in DLT at 7.0 g m(-2). The median number of CD34+ cells in 500 ml of whole blood after the first cycle (i.e. at start of cycle 2) was 1.15 x 10(6) kg(-1). This number was significantly greater after the second cycle (2.06 x 10(6) kg(-1), P = 0.01) and then gradually decreased after cycles three to six. After storing whole blood, the number of CD34+ cells had not decreased (median + 10%). We conclude that the method of combined bone marrow support by G-CSF and haematopoietic progenitor cells in autologous whole blood collected before each cycle of a 2-weekly regimen of cisplatin-ifosfamide does not result in clinically measurable reduced bone marrow toxicity compared with what can be expected by the use of G-CSF alone.


Twenty cases of interstitial pneumonia secondary to treatment with granulocyte colony-stimulating factor (G-CSF) were reviewed. Their interstitial pneumonia had the following features: (a) it occurred predominantly in patients aged 60 years or older; (b) it was prevalent among patients with haematological malignancies, particularly non-Hodgkin's lymphoma; (c) in all patients G-CSF was given after anti-cancer agents with potential to affect the lungs; (d) at the onset, many patients had symptoms such as dyspnoea and fever; and (e) the leucocyte (neutrophil) count as well as lactate dehydrogenase (LDH) and C-reactive protein (CRP) levels were usually higher than normal at the onset. These findings indicate that, when G-CSF is used in combination with pneumotoxic anti-cancer agents, respiratory function should be monitored before and during treatment. If the leucocyte (or neutrophil) count and/or LDH and CRP increase suddenly in association with dyspnoea and fever during administration of G-CSF, interstitial pneumonia should be suspected. Accordingly, a chest radiograph and pulmonary functional tests should be performed promptly. If a diagnosis of interstitial pneumonia is made, steroid pulse therapy should be commenced immediately.


The aim of this study was to use the same technique to construct quotient graphs, or Reibergrams, for the beta globulin C4 and to evaluate the method for assessing intrathecal synthesis in neurological disease.Cerebrospinal fluid (CSF)/serum quotient graphs have been used previously to determine local synthesis in brain of immunoglobulins and C4. CSF and serum were analyzed for C4, IgA and albumin from a total of 12 patients with meningoencephalitis caused by encapsulated microorganisms and 10 subjects without infections or inflammatory neurological disease, some of which had dysfunction of the blood-CSF barrier,The constants in the previously-defined Reibergram for immunoglobulin IgA were used to calculate the CSF/serum quotient for C4 Reibergram with the constants previously found for IgA, determined the intrathecal C4 synthesis in CSF. The intrathecal C4 fraction in CSF (C4 loc in mg/l) was compared to the C4-Index . There was a significant correlation between the two formulae. The CSF/Serum quotient graph was superior for detecting intrathecal synthesis of C4 under variable conditions of blood-CSF barrier permeability.The formula and C4 Reibergram can be used to quantify the intrathecal synthesis of this component of the complement system in different infectious diseases of the central nervous system and is especially useful for patients with blood-brain barrier dysfunction.The C Raised levels of Cphalitis ,9, in prphalitis  and othephalitis  such as phalitis , schizopphalitis , cerebraphalitis , meningophalitis  and braiphalitis . Cytokinphalitis ,18. Somephalitis , althoug4 protein is a beta globulin with a sedimentation coefficient of 18.7, molecular weight 200 kDa and a serum concentration of 430 μg/mL. It is activated by the complement system and is a C2 receptor. C4a acts as anaphylatoxin similar to C3abut is weaker, while C4b acts as an opsonin promoting phagocytosis by binding to complement receptors. It is important to assess C4 intrathecal synthesis if the classical complement pathway has been activated in infectious and autoimmune neurological diseases. Combined with analysis of C3c intrathecal synthesis [Cynthesis , this kn4 and to determine the intrathecal synthesis of C4 in patients with bacterial meningoencephalitis. To do this we used IgA which has molecular characteristic similar to the C4 molecule and its previously-defined CSF/serum quotient graph, to create the formula and Reibergram for C4.The aim of this paper was to construct quotient graphs (Reibergrams) for the beta globulin CStreptococcus pneumoniae and three with Haemophilus influenzae . A control group consisted of ten subjects without infections or inflammatory neurological disease and that did or did not have dysfunction of the blood-CSF barrier , The research was approved by the Committee on Bioethics Research of the Faculty of Medical Sciences, Dr. Miguel Enriquez Superior Institute of Medical Sciences of Havana, Havana City, Cuba. All patients and persons whose samples were used as controls, and parents or tutors of the children gave their informed consent to carry out a diagnostic lumbar puncture.Twelve patients with meningoencephalitis caused by encapsulated microorganisms were studied: nine patients suffering from CSF samples were obtained by lumbar puncture and simultaneous blood samples were taken to obtain serum. Cells were removed from CSF by centrifugation and samples with blood contamination were eliminated. Control samples were from CSF and serum collections held in our laboratory from patients with suspicion of meningoencephalitis but were subsequently found to have febrile convulsions without biological agents or verified autoimmune causes. Aliquots of both patient and control samples were kept at -70°C for up to 30 days after the puncture date before analysis.4, IgA and albumin were quantified by radial immunodiffusion with NOR PARTIGEN© and LC PARTIGEN© plates  for serum and CSF, respectively. Radial immunodiffusion detects the reaction of antigen and antibody by a precipitation reaction based on the principle that a quantitative relationship exists between the amount of antigen placed in a well cut in the agar-antibody plate and the resulting ring of precipitation. This end point method requires that the precipitation rings reach the maximal possible size, which often requires 48–72 h of diffusion. A standard curve was experimentally determined with known standards and used for the determination of protein concentration corresponding to any diameter size.C4 was created taking into consideration the molecular characteristics of this protein. In addition, the C4-Index was calculated using the following formula [The CSF/Serum quotient graph or Reibergram for C formula :4-Index, we used C4-Index = 0.46As a cut off for discrimination between a normal and pathological C4 is most similar to IgA in terms of molecular characteristics  is the upper discrimination line of the reference range, Q C4 = C4 (CSF)/C4 (Serum), a = intercept hyperbole value on the y axis, b = x value to asymptotic hyperbole line, c = constant and a/b = hyperbole slope. The following values previously obtained for IgA were used: a/b = 0.77, b2 = 23 × 10-6, c = 3.1 × 10-3.Where Q C4 in the CSF or C4 (loc) is:Thus the formula for the amount of locally-synthesized CThe program MEDCALC version 6.0 was used to perform the statistical comparison.4 quotient graph for the patients and controls under study with a range of values of Q albumin (QAlb) is shown in figure 4 values for all twelve patients with meningoencephalitis are above the lower thin hyperbolic line. For nine of these twelve patients Q C4 was located above the upper solid line showing that these patients synthesized C4 intrathecally. The Q C4 for all control patients is in the area between the thick hyperbolic line and the lower thin line, indicating that there is no CNS synthesis of this component. Also included is the QIgA of the patients with inflammatory meningoencephalitis and only five of these are in the region that indicates intrathecal synthesis. Another two patients had no detectable IgA in CSF. Hence the pattern of intrathecal synthesis of IgA is not the same as for C4, suggesting that IgA has a different role in the immune response, despite the similar molecular flux from blood to CSF according to the molecular size. Mean values, range and coefficient of variation for C4 and IgA in serum and CSF are shown in Table The Q C4 complement has been the C4-Index [4-Index values. Using C4-Index, among the non-inflammatory controls, there were 2 false positives, although intrathecal complement synthesis should not occur in such cases. With C4-Index > 0.46 we find in 10/12 case of meningoencephalitis a pathological increase, i.e. an intrathecal synthesis  was found to be superior in sensitivity, specificity and predictive values.There was a positive correlation between the C3 and C4 are associated with specific immune-mediated diseases. In patients with immune-mediated diseases in the CNS, it is essential to measure complement activation in CSF and the intrathecal synthesis of complement proteins.The complement system consists of more than thirty proteins and has three types of activation pathways: classical, lectin and alternative pathways. The complement system not only has a role in innate immunity but also works as an antibody-dependent effector to eliminate pathogens. In serum, normal or decreased levels of C3c is associated with infectious [The immune response within the CNS has specific characteristics associated with a reduced immunological environment, being a unique and special compartment without much peripheral regulation. The CNS humoral immune response is different from the immune response observed in blood, mainly because there is no switch from the IgM class response to IgG or IgA class response in the CSF in the course of inflammatory neurological disease. The pattern of intrathecal IgG/IgA/IgM synthesis remains fairly constant and depends on the cause, pathophysiology and localization of the disease process ,4. In adfectious  and autofectious .4 concentration in blood was larger than in CSF in controls and in patients with meningoencephalitis. In the patient group, the CV in CSF was larger than in serum but in the control group, the CV was not larger in CSF than in blood. This suggests that although C4 is a blood-derived protein, during the inflammation process there was an increased amount produced in brain. This study showed that 75% of patients with meningoencephalitis had intrathecal C4 synthesis with or without dysfunction of the blood-CSF barrier as indicated by its QAlb value which varies according to age. In addition, the control group with variable QAlb values was in the normal range, indicating no intrathecal synthesis, which is consistent with the absence of cerebral inflammation in this group [Studies carried out on the passage of different blood proteins into the CSF have established different models that tried to explain their differential diffusion into the cerebral compartment. The theory of protein flux/CSF flow ,24 suggeis group . Also no4-Index to study intrathecal C4synthesis has disadvantages over the quotient method. The index is a linear formula whereas the distribution of proteins from blood to cerebral compartments follows a hyperbolic curve [4-Index may produce false results [Using the previously-used Cic curve , thus th results . In addi results . However results ,25,27.4 Reibergram were compared to those of the index since there is no other known gold standard. There was a positive significant statistical correlation between both methods. Nevertheless, these results demonstrated the superior diagnostic value of Reibergram.Despite these limitations, the results of the C4 synthesis. It can quantify the C4 fraction which is locally produced in the CNS and differentiate from C4 that may have entered the CSF from blood. On the other hand, the C4-Index should not be used in patients with low QAlb and in particular with high QAlb, i.e. with blood-CSF barrier dysfunction.Under all conditions of the blood-CSF barrier, the CSF/Serum quotient graph can identify the occurrence of intrathecal CThe authors declare that they have no competing interests.BPD and AJDC designed and coordinated the study and drafted the manuscript. RBCF participated in its design and reviewed the clinical profiles of patients. ARR helped with protein analysis and in drafting the manuscript. All authors read and approved the final version of the manuscript.


Persistent mullerian duct syndrome is a rare disorder characterized by the presence of uterus and fallopian tube in 46XY phenotypic males and is ascribed to defects in the synthesis or action of anti-mullerian hormone. We report a rare case of hernia uterine inguinale, transverse testicular ectopia associated with mixed germ cell tumor of the testis with metastasis. Transverse testicular ectopia should be suspected preoperatively in patients who have unilateral inguinal hernia associated with contralateral nonpalpable testis. In such cases ultrasonography should be done prior to repair of hernia to evaluate the possible presence of mullerian structures and testicular malignancy, for better management. Persistent mullerian duct syndrome (PMDS) is a rare autosomal recessive disorder, characterized by the persistence of mullerian duct derivatives  in otherwise normally differentiated 46 XY males. During embryogenesis, regression of mullerian structures in normal males is mediated by antimullerian hormone (AMH), also called mullerian inhibiting substance (MIS), produced by fetal sertoli cells. This internal pseudohermaphroditism is caused by deficient AMH or abnormal AMH Type II receptor. These patients often present with cryptoirchidism or an inguinal hernia. Presence of uterus in the hernial sac is known as ‘hernia uterine inguinale’.Transverse testicular ectopia (TTE) is a rare form of testicular ectopia in which both testes are located on one inguinal side. One testis crosses midline to meet its opposite mate. As with undescended testis, these gonads are at increased risk of malignant transformation. Persistent mullerian duct syndrome exists with one-third cases of transverse testicular ectopia. We report a rare case of right side hernia uterine inguinale with TTE and advanced metastatic mixed germ cell tumor.A 35-year-old male patient came with a history of right-sided inguinal hernia for the past 15 years, which became irreducible and painful since six days. He complained of severe back pain since three months. He was married for 15 years and had no sexual dysfunction. He had two children. There was no history of any drug intake by his mother during the first trimester of pregnancy. There was no family history of such disorder.On physical examination, secondary male sexual characters were found to be well developed and had a normal penis. Right inguinal swelling was 8×6cm in size, tender and irreducible. The scrotum was well developed on the right side with soft testis in it and left side was poorly developed without a palpable testis. Rest of the physical examination was unremarkable. Clinical diagnosis of right-sided irreducible inguinal hernia with left cryptoirchidism was made.Patient was operated upon under spinal anesthesia. Peroperatively, the hernial sac contained a uterus-like mass with a tubular structure on each side . One sidHistology revealed normal hypoplastic uterine tissue with attached fallopian tube. The mass was of malignant germ cell tumor with predominance of yolk sac elements. Additional components of embryonal carcinoma and teratoma were seen. Tumor was found to infiltrate spermatic cord. Few vascular emboli were also seen in the capsule. There was no ovarian tissue. Chromosomal analysis revealed 46 XY. Scan of the abdomen revealed multiple liver secondaries with multiple para-aortic and bilateral para-ileac lymph node involvement. There was thrombosis in the infrarenal aspect of the IVC and bilateral common ileac veins. Associated left side hydronephrosis was found. Right scrotal testis was normal. Chest X-ray was normal. In view of raised AFP, bHCG and LDH and nonpulmonary visceral metastasis, tumor was graded as poor risk Stage III. Even with anticoagulant therapy, DVT progressed relentlessly and he died of pulmonary embolism before the first cycle of BEP chemotherapy could be completed.Müllerian (paramesonephric) ducts and wolffian (mesonephric) ducts are the anlagen of the female and male reproductive tracts, respectively. In the XY fetus, the testis differentiates by the end of the seventh gestational week. Sertoli cells begin to secrete AMH, which is responsible for the regression of the Müllerian ducts. The AMH binds to a specific Type II serine-threonine kinase transmembrane receptor (AMHR-II). Human AMH gene localized near the tip of Chromosome 19, AMHR2 gene is located on 12q13. The type of persistent Mullerian duct syndrome caused by mutation in the AMH gene will be referred to as Type I, that which forms due to mutation in the AMH receptor (AMHR) will be designated as Type II.[et al reported development of mixed germ cell tumor 18 years after bilateral orchidopexy.[It is not necessary to perform testicular biopsy to detect tumor in the scrotal testis, because an impalpable tumor can be localized by ultrasonography. Orchidectomy of ectopic testis should be done, because orchidopexy offers only limited protection against future malignancy if performed after two years of age. Manasserhidopexy. Most arehidopexy. Testis, Many diagnostic mistakes are made which could be prevented by performing abdominopelvic ultrasonography before surgical treatment of inguinal hernia with contralateral nonpalpable testis for better management. The patient or his relatives should be educated to come early in the course of such conditions so that malignant change can be prevented by early surgery or detected in early stages and prognosis can be improved.