fiber type disproportion. Brain Dev (Tokyo) 1986;8:526-32. 25. Bove KE, Iannaccone ST, Vogler C. Intramuscular hematopoiesis in hypotonic infants with type 1 muscle fiber dysmaturation. Arch Pathol Lab Med 1986; 110:207-11. 26. Verity MA, Yung-Hua G. Dysmaturation neuromyopathy: correlation with minimal neuropathy in sural nerve biopsies. J Child Neurol 1988; 3:276-91. 27. Bramini M, Carboni P, Giacanelli M, D'Amico A. Su quattro casi di disproporzione congenita dei tipi istochimici di fibre muscolari. RivNeurobioI1981;27:771-5. 28. Dubowitz V, Brooke MH. Histograms. In: Dubowitz V, Brooke MH. Muscle biopsy: a modern approach. London: WB Saunders 1973:98-101. 29. Seay AR, Ziter FA, Petajan JH. Rigid spine syndrome; a type 1 myopathy. Arch Neurol 1977;34: 119-22. 30. Goebel HH, Lenard HG, Gorke W, Kunze K. Fiber type disproportion in rigid spine syndrome. Neuropediatrie 1977; 8:467-77. 31. Argov Z, Gardner-Medwin D, Johnson MA, MastagJia FL. Congenital myotonic dystrophy: fiber type abnormalities in two cases. Arch Neurol 1980;37:693-6. 32. Lieberman DA, Faulkner JA, Craig AB, Maxwell LO. Performance and histochemical composition of guinea pig and
human diaphragm. J Appl Physiol 1973 ;34:233-7. 33. Keens TG, Bryan AC, Levison H, Ianuzzo CD. Developmental pattern of muscle fiber types in human ventilatory muscles. J Appl Physiol 1978;44:909-13. 34. Sanchez J, Derenne JP, Debesse B, Riquet M, Monod H. Typology of the respiratory muscles in normal men and in patients with moderate chronic respiratory disease. Bull Eur Physiopathol Respir 1982; 18:901-14. 35. Isozaki E, Tanabe H, Oda M, Kojima S, Takagi A, Chounabayashi N. Morphological changes in the human diaphragm in respiratory failure (in Japanese). Kokyu (Tokyo) 1988;7: 1170-7. 36. Ricoy JR, Cabello A. Dysmaturative myopathy. Evolution of the morphological picture in 3 cases. Acta Neuropathol 1981 ;(suppJ) :313-6. 37. Brooke MH, Engel WK. The histographic analysis of human muscle biopsies with regard to fiber types. 1. Adult male and female. Neurology 1969; 19:221-33. 38. Hizawa K, Nonaka I. Histopathology and histochemistry of the skeletal muscle. In: Hizawa K, Nonaka I, Ozawa E, eds. Pathology of muscle (in Japanese). Tokyo: Bunkodo 1989: 86-107.
Brain and Liver Pathology in a Patient with Carnitirie Deficiency Seiji Kimura, MD and Fumiaki Amemiya, MD
The ultrastructural brain and liver pathology in an infant, who died of acute encephalopathy due to systemic carnitine deficiency (CD), an important condition mimicking Reye's syndrome (RS), was reported. The major finding in the brain was swelling of astrocyte cytoplasm. Expanded mitochondria in nerve cells and myelin sheath splitting in the white matter, which have been reported to be specific to RS, were not observed. Also in contrast to findings in RS, hepatocytes were filled with macrovesicular fat droplets without expanded mitochondria. These f'mdings suggest significant differences in the pathophysiology of acute encephalopathy in CD and RS, although the clinical and laboratory f'mdings during an episode of acute encephalopathy in the former are usually very similar to those in the latter. Key words: Cornitine deficiency, brain pathology, Reye's syndrome. Kimura S, Amemiya F. Brain and liver pathology in a patient with carnitine deficiency. Brain Dev 1990; 12:436-9
From the Department of Pediatrics, Yokohama City University School of Medicine, Yokohama. Received for publication: February 7,1990. Accepted forpublication: April 13, 1990. Correspondence address: Dr. Seiji Kimura, Department of Pediatrics, Yokohama City University School of Medicine, Urafune-cho 3-46, Minami-ku, Yokohama 232, Japan.
Carnitine deficiency (CD), whether reflecting a primary and/or secondary etiology, i.e., medium-chain or longchain acyl-CoA dehydrogenase deficiency [1], may closely mimick Reye's syndrome (RS) in its presentation. Both are typically associated with elevation of serum GOT and/ or ammonia. A few studies on the liver pathology but none of the brain in CD have been reported [2,3]. The main purpose of this study is to provide comparison of
Fig 1 Numerous and variably sized fatty droplets in hepatic cells, which displace the nuclei to the periphery. Osmium-embedded epon section, toluidine-blue stain. Bar = 10 J.lm.
Fig 2 Large and small lipid droplets in a hepatocyte and a nucleus, respectively. Bar = 1 J.lm.
Fig 3 Watery swelling of the astrocyte cytoplasm with separated microorganelles. Bar = 1 J.lm.
Fig 4 Marked swelling of the astrocyte cytoplasm around the perivascular area. Bar = 1 J.lm.
Kimura & Amemiya: Pathology in carnitine deficiency
437
the ultrastructural features of the brain in acute encephalopathy in CD and those in RS. CASE REPORT A 4-month-old male was admitted to our hospital in deep coma. He was the third born to nonconsanguineous parents,at 39 weeks gestational age, with a body weight of 2,740 gms. The first son had died of a disease mimicking RS at the age of 4 years. The second son is healthy. He developed uneventfully until the age of 4 months, when he became fretful and anorexic. At around 24 hours after the first symptoms appeared, vomiting and pyrexia began, followed by a convulsion and dyspnea. On admission, he was in deep coma and had irregular respiration. The liver was palpable 8 cm below the right costal margin. The cerebrospinal fluid pressure was high (230 mmH2 0). The cell count and glucose and protein levels in cerebrospinal fluid were within normal ranges. The serum GOT and glucose levels, measured after intravenous glucose infusion, were 84 mU/rnl and 78 mg/dl, respectively. Measurements of urinary organic acids and serum amino acids revealed no abnormality. Serum ammonia was not measured. He died 6 hours after admission and was autopsied 4 hours postmortem. On gross inspection, the liver was found to be markedly swollen and the brain showed severe edema. The levels of medium-chain acylcoA dehydrogenase and urea cycle-related enzyme (car-
bamylphosphate synthetase, ornitine transcarbamylase, argininosuccinate lyase, and arginase) activity in the liver obtained at autopsy were normal. The free and total camitine levels in the liver were decreased; 140 n mol/g wet tissue (control, 1,010) and 299 n mol/g wet tissue (control, 1,205), respectively. The levels of acid soluble and insoluble acyl carnitine in the liver were normal. MATERIALS AND METHODS Tissues from the central and frontal portions of the brain, and from the liver, obtained at autopsy, were fixed in 3% glutaraldehyde and then post-fixed in 2% osmic acid. After dehydration with increasing concentrations of ethanol, the tissues were embedded in an epon mixture. Ultrathin sections were contrasted with uranyl acetate and lead citrate. Other tissues were examined by light microscopy after a routine procedure. Brain tissues obtained at autopsy 2 hours postmortem from a 4-month-old male who died of a non-specific acute encephalopathy were used as an age-matched control.
RESULTS Liver: On light microscopy, hepatocytes were observed to
be filled with macrovesicular lipid droplets which displaced the nuclei to the periphery (Fig I). Electron microscopy revealed numerous and variably sized intracytoplasmic lipid droplets enclosed by thin single limiting membranes (Fig 2). Mitochondria were shrunken and not swollen. There were no evident partial defects of cristae of the sort specific to RS. Brain: On light microscopy, there was no evidence of inflammation. The principal changes observed on HE staining were palor of myelin sheaths and an increased number of swollen astrocytes. On electron microscopy, the dominant feature was swelling of the astrocytic cytoplasm. The microorganelles in astrocytes were separated, which might be a result of the watery swelling of the cytoplasm (Fig 3). In the perivascular area, there was marked swelling of astrocyte cytoplasm (Fig 4). Swelling of astrocytes was observed in every section (Fig 5). The nuclei of nerve cells were pyknotic and the rough endoplasmic reticula were dilated. Neuronal mitochondria showed no expansion or partial defect of cristae. There was no evidence of myelin sheath splitting. These features were also characteristic of the control specimens. Other findings: Mild to mode~ately increased neutral lipid granules were observed in tubular cells of the kidney and pancreas, and heart and skeletal muscles. DISCUSSION
Fig 5 Many astrocytes with a swollen cytoplasms. Bar = 1 j.lm.
438 Brain & Development, Vol 12, No 4,1990
CD due to either primary and/or secondary etiology [1] is an important disease which mimicks RS in its presenta-
tion. The liver pathology in CD associated with an RS-like illness has been reported [2,3]. However, to our knowledge, this is the first ultrastructural study on the brain in CD. The illness of this patient was also similar to RS, exception being that the serum GOT level was not elevated to levels more than three times normal. This may have been because the hepatocytes were too severely damaged to maintain enzymatic activtity, as shown in Figs 1 and 2. The brain pathology in this patient comprised marked swelling of the astrocyte cytoplasm, especially in perivascular areas, and dilatation of the endoplasmic reticulum in nerve cells. The above-mentioned changes are almost universally observed in anoxic and ischemic injury, hepatic encephalopathy, intoxication by ammonia and other agents [4] , and also result from poor tissue fixation. There was no evidence of mitochondrial swelling, frequently observed in RS [5,6] and hypoglycemia [7] , and no evidence of myelin splitting, typical of in RS [5,6] and with some kinds of chemical agents [4] . The brain pathology in acute encephalopathy in this CD patient, showing only swelling of the astrocyte cytoplasm without a mitochondrial abnormality in nerve cell bodies or splitting of myelin sheaths. This suggests that the etiology of acute encephalopathy in CD is significantly different from that in RS, despite the fact that CD and RS may resemble each other clinically.
ACKNOWLEDGMENTS The authors with to thank Dr. S. Ohwada, Department of Pediatrics, Nihon University School of Medicine, for kindly providing them with enzymatic assay data. REFERENCES 1. Treem WR, Witzleben CA, Piccoli DA, et al. Medium-chain and long-chain acyl CoA dehydrogenase deficiency: clinical, pathological and ultrastructural differentiation from Reye's syndrome. Hepatology 1986;6: 1270-8. 2. Mikol GBJ, Guillard A, Engel AG. Fatal systemic carnitine deficiency with lipid storage in skeletal muscle, heart, liver and kidney. J Neurol Sci 1976;30:313-25. 3. Ware AJ, Burton WC, McGarry JD, Marks JF, Weinberg AG. Systemic camitine deficiency. Report of a fatal case with multisystemic deficiency. J Pediatr 1978;93:959-64. 4. Sancesario G, Kentzberg GW. Stimulation of astrocyte cytotoxic brain edema. Acta Neuropathol (Bert) 1986; 72: 3-14. 5. Partin JC, Partin JS, Schubert WK, McLaurin RL. Brain ultrastructure in Reye's syndrome (encephalopathy and fatty alteration of the viscera). J Neuropathol Exp Neurol 1975; 34:425-44. 6. Partin JS. McAdams AJ, Partin JC, Schubert WK, McDaurin PL. Brain ultrastructure in Reye's disease. II. Acute injury and recovery processes in three children. J Neuropathol Exp Neurol 1978; 37:796-819. 7. Auer RN, Kalimo H, Olsson Y, Siesj6 K. The temporal evolution of hypoglycemic brain damage. Acta Neuropathol (Berl) 1985 ;67: 13-24.
A Possible Japanese Male Case of Pelizaeus-Merzbacher Disease Takashi Hayashi, MD, Takashi Ichiyama, MD, Mayumi Koga, MD, Fumiko Okino, MD, Kazuhiko Katayama, MD, and Kunihiko Kobayashi, MD
A boy with an abnormal auditory brain stem response showing only a wave I-II pattern, congenital nystagmus, psychomotor retardation, pyramidal tract signs and muscular hypotonia was reported. The auditory brain stem response, short latency somatosensory-evoked potential, somatosensory-evoked potential and visual-evoked potential indicated an intramedullary disorder of conduction. Magnetic resonance imaging revealed marked high signal intensity of the cerebral white matter in T2-weighted images, suggesting hyporttyelination. A muscle biopsy specimen showed neurogenic changes with mild myogenic changes. Key words: Pelizaeus-Merzbacher disease, congenital nystagmus, MRI, ABR, evoked potential. Hayashi T, Ichiyama T, Koga M, Okino F, Katayama K, Kobayashi K. A possible Japanese male case ofPelizaeus-Merzbacher disease. Brain Dev 1990;12:439-43
human diaphragm. J Appl Physiol 1973 ;34:233-7. 33. Keens TG, Bryan AC, Levison H, Ianuzzo CD. Developmental pattern of muscle fiber types in human ventilatory muscles. J Appl Physiol 1978;44:909-13. 34. Sanchez J, Derenne JP, Debesse B, Riquet M, Monod H. Typology of the respiratory muscles in normal men and in patients with moderate chronic respiratory disease. Bull Eur Physiopathol Respir 1982; 18:901-14. 35. Isozaki E, Tanabe H, Oda M, Kojima S, Takagi A, Chounabayashi N. Morphological changes in the human diaphragm in respiratory failure (in Japanese). Kokyu (Tokyo) 1988;7: 1170-7. 36. Ricoy JR, Cabello A. Dysmaturative myopathy. Evolution of the morphological picture in 3 cases. Acta Neuropathol 1981 ;(suppJ) :313-6. 37. Brooke MH, Engel WK. The histographic analysis of human muscle biopsies with regard to fiber types. 1. Adult male and female. Neurology 1969; 19:221-33. 38. Hizawa K, Nonaka I. Histopathology and histochemistry of the skeletal muscle. In: Hizawa K, Nonaka I, Ozawa E, eds. Pathology of muscle (in Japanese). Tokyo: Bunkodo 1989: 86-107.
Brain and Liver Pathology in a Patient with Carnitirie Deficiency Seiji Kimura, MD and Fumiaki Amemiya, MD
The ultrastructural brain and liver pathology in an infant, who died of acute encephalopathy due to systemic carnitine deficiency (CD), an important condition mimicking Reye's syndrome (RS), was reported. The major finding in the brain was swelling of astrocyte cytoplasm. Expanded mitochondria in nerve cells and myelin sheath splitting in the white matter, which have been reported to be specific to RS, were not observed. Also in contrast to findings in RS, hepatocytes were filled with macrovesicular fat droplets without expanded mitochondria. These f'mdings suggest significant differences in the pathophysiology of acute encephalopathy in CD and RS, although the clinical and laboratory f'mdings during an episode of acute encephalopathy in the former are usually very similar to those in the latter. Key words: Cornitine deficiency, brain pathology, Reye's syndrome. Kimura S, Amemiya F. Brain and liver pathology in a patient with carnitine deficiency. Brain Dev 1990; 12:436-9
From the Department of Pediatrics, Yokohama City University School of Medicine, Yokohama. Received for publication: February 7,1990. Accepted forpublication: April 13, 1990. Correspondence address: Dr. Seiji Kimura, Department of Pediatrics, Yokohama City University School of Medicine, Urafune-cho 3-46, Minami-ku, Yokohama 232, Japan.
Carnitine deficiency (CD), whether reflecting a primary and/or secondary etiology, i.e., medium-chain or longchain acyl-CoA dehydrogenase deficiency [1], may closely mimick Reye's syndrome (RS) in its presentation. Both are typically associated with elevation of serum GOT and/ or ammonia. A few studies on the liver pathology but none of the brain in CD have been reported [2,3]. The main purpose of this study is to provide comparison of
Fig 1 Numerous and variably sized fatty droplets in hepatic cells, which displace the nuclei to the periphery. Osmium-embedded epon section, toluidine-blue stain. Bar = 10 J.lm.
Fig 2 Large and small lipid droplets in a hepatocyte and a nucleus, respectively. Bar = 1 J.lm.
Fig 3 Watery swelling of the astrocyte cytoplasm with separated microorganelles. Bar = 1 J.lm.
Fig 4 Marked swelling of the astrocyte cytoplasm around the perivascular area. Bar = 1 J.lm.
Kimura & Amemiya: Pathology in carnitine deficiency
437
the ultrastructural features of the brain in acute encephalopathy in CD and those in RS. CASE REPORT A 4-month-old male was admitted to our hospital in deep coma. He was the third born to nonconsanguineous parents,at 39 weeks gestational age, with a body weight of 2,740 gms. The first son had died of a disease mimicking RS at the age of 4 years. The second son is healthy. He developed uneventfully until the age of 4 months, when he became fretful and anorexic. At around 24 hours after the first symptoms appeared, vomiting and pyrexia began, followed by a convulsion and dyspnea. On admission, he was in deep coma and had irregular respiration. The liver was palpable 8 cm below the right costal margin. The cerebrospinal fluid pressure was high (230 mmH2 0). The cell count and glucose and protein levels in cerebrospinal fluid were within normal ranges. The serum GOT and glucose levels, measured after intravenous glucose infusion, were 84 mU/rnl and 78 mg/dl, respectively. Measurements of urinary organic acids and serum amino acids revealed no abnormality. Serum ammonia was not measured. He died 6 hours after admission and was autopsied 4 hours postmortem. On gross inspection, the liver was found to be markedly swollen and the brain showed severe edema. The levels of medium-chain acylcoA dehydrogenase and urea cycle-related enzyme (car-
bamylphosphate synthetase, ornitine transcarbamylase, argininosuccinate lyase, and arginase) activity in the liver obtained at autopsy were normal. The free and total camitine levels in the liver were decreased; 140 n mol/g wet tissue (control, 1,010) and 299 n mol/g wet tissue (control, 1,205), respectively. The levels of acid soluble and insoluble acyl carnitine in the liver were normal. MATERIALS AND METHODS Tissues from the central and frontal portions of the brain, and from the liver, obtained at autopsy, were fixed in 3% glutaraldehyde and then post-fixed in 2% osmic acid. After dehydration with increasing concentrations of ethanol, the tissues were embedded in an epon mixture. Ultrathin sections were contrasted with uranyl acetate and lead citrate. Other tissues were examined by light microscopy after a routine procedure. Brain tissues obtained at autopsy 2 hours postmortem from a 4-month-old male who died of a non-specific acute encephalopathy were used as an age-matched control.
RESULTS Liver: On light microscopy, hepatocytes were observed to
be filled with macrovesicular lipid droplets which displaced the nuclei to the periphery (Fig I). Electron microscopy revealed numerous and variably sized intracytoplasmic lipid droplets enclosed by thin single limiting membranes (Fig 2). Mitochondria were shrunken and not swollen. There were no evident partial defects of cristae of the sort specific to RS. Brain: On light microscopy, there was no evidence of inflammation. The principal changes observed on HE staining were palor of myelin sheaths and an increased number of swollen astrocytes. On electron microscopy, the dominant feature was swelling of the astrocytic cytoplasm. The microorganelles in astrocytes were separated, which might be a result of the watery swelling of the cytoplasm (Fig 3). In the perivascular area, there was marked swelling of astrocyte cytoplasm (Fig 4). Swelling of astrocytes was observed in every section (Fig 5). The nuclei of nerve cells were pyknotic and the rough endoplasmic reticula were dilated. Neuronal mitochondria showed no expansion or partial defect of cristae. There was no evidence of myelin sheath splitting. These features were also characteristic of the control specimens. Other findings: Mild to mode~ately increased neutral lipid granules were observed in tubular cells of the kidney and pancreas, and heart and skeletal muscles. DISCUSSION
Fig 5 Many astrocytes with a swollen cytoplasms. Bar = 1 j.lm.
438 Brain & Development, Vol 12, No 4,1990
CD due to either primary and/or secondary etiology [1] is an important disease which mimicks RS in its presenta-
tion. The liver pathology in CD associated with an RS-like illness has been reported [2,3]. However, to our knowledge, this is the first ultrastructural study on the brain in CD. The illness of this patient was also similar to RS, exception being that the serum GOT level was not elevated to levels more than three times normal. This may have been because the hepatocytes were too severely damaged to maintain enzymatic activtity, as shown in Figs 1 and 2. The brain pathology in this patient comprised marked swelling of the astrocyte cytoplasm, especially in perivascular areas, and dilatation of the endoplasmic reticulum in nerve cells. The above-mentioned changes are almost universally observed in anoxic and ischemic injury, hepatic encephalopathy, intoxication by ammonia and other agents [4] , and also result from poor tissue fixation. There was no evidence of mitochondrial swelling, frequently observed in RS [5,6] and hypoglycemia [7] , and no evidence of myelin splitting, typical of in RS [5,6] and with some kinds of chemical agents [4] . The brain pathology in acute encephalopathy in this CD patient, showing only swelling of the astrocyte cytoplasm without a mitochondrial abnormality in nerve cell bodies or splitting of myelin sheaths. This suggests that the etiology of acute encephalopathy in CD is significantly different from that in RS, despite the fact that CD and RS may resemble each other clinically.
ACKNOWLEDGMENTS The authors with to thank Dr. S. Ohwada, Department of Pediatrics, Nihon University School of Medicine, for kindly providing them with enzymatic assay data. REFERENCES 1. Treem WR, Witzleben CA, Piccoli DA, et al. Medium-chain and long-chain acyl CoA dehydrogenase deficiency: clinical, pathological and ultrastructural differentiation from Reye's syndrome. Hepatology 1986;6: 1270-8. 2. Mikol GBJ, Guillard A, Engel AG. Fatal systemic carnitine deficiency with lipid storage in skeletal muscle, heart, liver and kidney. J Neurol Sci 1976;30:313-25. 3. Ware AJ, Burton WC, McGarry JD, Marks JF, Weinberg AG. Systemic camitine deficiency. Report of a fatal case with multisystemic deficiency. J Pediatr 1978;93:959-64. 4. Sancesario G, Kentzberg GW. Stimulation of astrocyte cytotoxic brain edema. Acta Neuropathol (Bert) 1986; 72: 3-14. 5. Partin JC, Partin JS, Schubert WK, McLaurin RL. Brain ultrastructure in Reye's syndrome (encephalopathy and fatty alteration of the viscera). J Neuropathol Exp Neurol 1975; 34:425-44. 6. Partin JS. McAdams AJ, Partin JC, Schubert WK, McDaurin PL. Brain ultrastructure in Reye's disease. II. Acute injury and recovery processes in three children. J Neuropathol Exp Neurol 1978; 37:796-819. 7. Auer RN, Kalimo H, Olsson Y, Siesj6 K. The temporal evolution of hypoglycemic brain damage. Acta Neuropathol (Berl) 1985 ;67: 13-24.
A Possible Japanese Male Case of Pelizaeus-Merzbacher Disease Takashi Hayashi, MD, Takashi Ichiyama, MD, Mayumi Koga, MD, Fumiko Okino, MD, Kazuhiko Katayama, MD, and Kunihiko Kobayashi, MD
A boy with an abnormal auditory brain stem response showing only a wave I-II pattern, congenital nystagmus, psychomotor retardation, pyramidal tract signs and muscular hypotonia was reported. The auditory brain stem response, short latency somatosensory-evoked potential, somatosensory-evoked potential and visual-evoked potential indicated an intramedullary disorder of conduction. Magnetic resonance imaging revealed marked high signal intensity of the cerebral white matter in T2-weighted images, suggesting hyporttyelination. A muscle biopsy specimen showed neurogenic changes with mild myogenic changes. Key words: Pelizaeus-Merzbacher disease, congenital nystagmus, MRI, ABR, evoked potential. Hayashi T, Ichiyama T, Koga M, Okino F, Katayama K, Kobayashi K. A possible Japanese male case ofPelizaeus-Merzbacher disease. Brain Dev 1990;12:439-43
