Journal of
J. Neurol. 219, 185--197 (1978)
Neurology © by Springer-Verlag 1978
T and B Lymphocytes in the Cerebrospinal Fluid of Various Neurological Diseases U. Traugott Department of Neurology, University Hospital, Lazarettgasse 14, A-1090 Vienna, Austria
Summary. Cerebrospinal fluids (CSF) from 66 patients with a variety of neurological disorders were studied for total protein content, absolute amount of albumin, IgA, IgG and IgM, as well as their quotients (fraction to total protein ratio), cell numbers and B cell and T cell levels. In addition, the percentage of B cells and T cells in the blood was determined in 34 patients and serum immunoglobulin levels were estimated in 51 patients. In noninflammatory diseases of the CNS, the percentage of B cells was slightly higher and T cell levels were lower in the CSF in comparison to corresponding blood values. The B cell to T cell ratio in viral meningitis was altered in the CSF. An apparent increase in the T cell level led to a decrease of B cell values. Similar changes were also found in optic neuritis. The percentage of T cells was higher in relapsing multiple sclerosis than in the chronic progressive form. There were less striking changes in the B cell to T cell ratios in the CSF of other inflammatory diseases of the CNS. Key words: Cerebrospinal fluid - B cells - T cells - Immunoglobulin levels Multiple sclerosis - Viral meningitis.
Zusammenfassung.Von 66 Patienten wurden im Liquor aul~er Zellzahl, den Bund T-Zellen noch der Gesamteiweil~gehalt sowie die absoluten Werte von Albumin, IgA, IgG, IgM und deren relativer Anteil am Gesamteiweil~ untersucht. Im Blut war die Bestimmung der B- und T-Zellen bei 34 Patienten, die der Immunglobuline bei 51 Patienten m~glich. Bei nicht entziindlichen Erkrankungen des zentralen Nervensystems liegt der prozentuelle Anteil der TZellen im Liquor zumeist etwas niedriger, der der B-Zellen etwas h6her als die entsprechenden Blutwerte. Bei viralen Miningitiden kommt es zn einer deutlichen Verschiebung dieses B:T-Zellen-Verh~iltnisses, und zwar zu einem Ansteigen der T-Zellen bei daraus resultierendem B-Zellen-Abfall. ~hnliche Relationsver~indertingen sind bei retrobulb~iren Neuritiden, die als Erstsymptome einer MS auftreten, zu finden. MS-F~ille mit schubf/Srmiger Verschlechterung weisen einen h6heren Anteil an T-Zellen auf als MS-F~ilIe mit
0340-5354/78/0219/0185/$ 02.60
186
U. Traugott chronisch p r o g r e d i e n t e m Verlauf. Eitrige M e n i n g i t i d e n , Myelitiden u n d Polyn e u r o p a t h i e - S y n d r o m e zeigen die T e n d e n z des T-Zellen-Anstieges u n d BZellen-Abfalles im L i q u o r in geringerer Auspr~igung.
Introduction It has been reported previously [1, 7] that the percentage of B cells a n d T cells in the cerebrospinal fluid (CSF) a n d the b l o o d are similar. T o a p p r o a c h the question whether alterations in the ratio of B cells a n d T cells can be f o u n d d u r i n g n e u r o logical diseases, the present study was performed with samples t a k e n from a variety of conditions.
Materials and Methods CSF samples from 66 patients (29 male, 37 female) with a variety of neurological diseases were studied (Table 1). The patients were between 8 and 72 years of age (mean, 36.5 years). In all CSF samples, the concentration of total protein, the number of white blood cells per mm 3, the percentage of B cells and T cells, and the concentrations of IgA, IgG, IgM and albumin were determined. In addition, the percentage of B cells and T cells in the blood were studied in 34 patients and the levels of IgA, IgG and IgM were examined in the blood of 51 patients. From each patient, 15 ml of heparinized blood was taken by venepuncture. Mononuclear cells were isolated on a Ficoll-Ronpacon gradient by the method of B6yum [2] with slight modifications. Cells from the CSF were recovered by centrifuging at 900 g for 10 min. T cells were determined by the formation of spontaneous non-immune rosettes with sheep erythrocytes. B cells were estimated by direct immunofluorescence using fluorescein isothiocyanateconjugated goat antihuman immunoglobulins. Immunoglobulin levels were tested by radial immunodiffusion [6] using Tri-Partigen diffusion plates for serum and LC Partigen diffusion plates (Behringwerke, West Germany) for CSF samples. The concentration of total protein in the CSF was measured by the method described by Biuret. White blood cells in the CSF were counted using a Fuchs-Rosenthal chamber.
Results The results o b t a i n e d form the b l o o d a n d C S F samples are s h o w n in Tables 2 - - 6 .
Cell Numbers. The m e a n n u m b e r of white b l o o d cells per m m 3 in the C S F was 509 in p u r u l e n t meningitis, 173 in b r a i n abscesses, 58 in viral meningitis, a n d 28 in myelitis. Table 1. Neurological diseases of 66 patients Diagnosis
Number of patients male female
Age (years)
Mean age (years)
Purulent meningitis Myelitis Meningitis Multiple sclerosis Optic neuritis Polyneuropathy Other neurological diseases
4 1 7 4 1 6 6
19--51 28--41 9--57 19--65 20---44 20--72 8--65
34 34 34 36 32 47 38
1 2 6 11 8 3 6
T and B Lymphocytes in the CSF
187
Total Protein. Differences in the concentration of total protein in CSF between the groups of diseases were less apparent. The mean concentration of total protein in purulent meningitis was 100mg/100ml. A mean value of 8 9 m g / 100ml was found in all other groups. CSF Albumin. The absolute concentrations of albumin (mean, 59.2 mg/100ml) were highest in purulent meningitis, corresponding to the levels of total protein. In both other groups, the mean values of albumin were about 45 rag/ 100 ml. The mean albumin to total protein ratio was 0.51 and there were no major decreases. CSF Immunoglobulins. Immunoglobulin levels were elevated in most samples of CSF tested. IgA quotients (the ratio between IgA and total protein) were elevated in all groups. The IgG quotient in purulent meningitis was 0.21--a slightly higher Value than that seen in other groups (mean, 0.18). In a considerable number of CSF samples tested, IgM was also found. IgM could no longer be detected in purulent meningitis after the concentration of total protein had returned to normal values. In contrast, IgM in the CSF was demonstrable for some weeks in myelitis and viral meningitis, even when the total protein values were only slightly elevated. Purulent Meningitis. The percentage of B cells and T cells in the CSF showed no significant differences between purulent meningitis and myelitis.
Myelitis. The levels of B cells (mean = 24%) and T cells (mean = 69%) in myelitis were comparable to those seen in the blood (mean B cell value= 31%, mean T cell value = 66%). However, there was a tendency for T cells to be slightly higher and B cell values somewha t lower in the CSF. There was pleocytosis in the CSF of one patient with myelitis, and B and T cell levels were studied longitudinally. Coinciding with improving neurological signs, B cell values increased gradually while the percentage of T cells remained elevated. No correlation was found between B cell values and immunoglobulin levels in the CSF. The number of white blood cells and the total protein level were normal in chronic progressive myelitis caused by herpes simplex virus. However, the ratio of B cells to T cells was changed. In contrast to the elevation of T cells usually found in the CSF during viral infections, T cells showed significant low values in this case. The percentage of B cells in the CSF was slightly lower than in the blood and the circulating T cell levels were decreased.
Viral Meningoencephalitis. Changes in the ratio of B cells to T cells were more distinct in viral meningoencephalitis. A decrease in the mean value of B cells to 17% and an increase of T cell levels to a mean o f 79%, were found. In the blood, the percentage of B cells (mean = 23%) and T cells (mean = 74%) was within the normal range. In two patients with viral meningitis, lymphocyte values were followed up to one month. Accompanying the improvement of neurological signs, the percentage of B cells stayed low after a transient increase, and T cell levels remained elevated. Immunoglobulin-G levels in the serum were frequently elevated. IgM was increased infrequently. These changes of immunoglobulin concentrations probably indicated that the samples were tested some
188
U. T r a u g o t t
Table 2. Meningitis--Encephalitis Blood values Pat.
Age (years)
Sex
Diagnosis
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg% 170
1
51
m
Abscess
23.2.
27
72
251
1830
2
39
m
Abscess
15.4.
--
--
367
1450
100
3
19
m
Pur. meningitis
6.4. 14.4. 31.5.
-22 28
-67 58
131 159 152
1360 2550 1420
138 439 138
4
23
f
Pur. meningitis
26.2.
--
--
1450
85
5
38
m
SP Pur. meningitis
27.7.
--
.
22 28
58 72
131 367
1420 2550
85 439
26
66
220
1677
178
-35 20 25
-67 71 70
422 347 422 384
1390 1190 1370 1510
216 162 208 190
Range
~om to
Mean value 6
42
m
Myelitis
25.6. 7.7. 21.7. 2.8.
257 .
.
.
7
32
f
Myelitis (Herpes)
20.7.
31
52
106
1690
264
8
28
f
Myelitis
14.5. 31.5.
33 39
66 70
233 233
1120 1740
333 299
20 39
52 71
106 422
1120 1740
162 333
31
66
307
1430
239
Range
from to
Mean value 9
34
f
Meningitis
12.4. 14.5. 28.7.
20 23 23
76 72 76
210 202 181
2550 1690 1510
310 228 216
10
48
m
Meningitis
8.7. 16.7. 22.7.
32 ---
65 ---
160 288 205
1160 1390 1200
101 200 169
11
36
m
Meningitis
28.7.
--
--
1000
101
12
34
m
Encephalitis zoster
14.5. 21.5.
---
. .
13
46
f
Meningitis
24.5. 1.6. 25.6.
15 24 26
71 78 71
14
40
m
Meningitis
21.5.
--
15
57
m
Meningitis
2.6. 4.6.
33 --
16
26
f
Meningitis
30.7. 4.8.
Range Mean value
~om to
461 . .
. .
. .
120 126 120
1510 1240 1000
333 368 256
--
398
1280
46
79 --
388 339
1830 1750
228 162
15 21
75 76
389 372
1930 2360
337 347
15 33
65 79
120 461
1000 2520
46 368
23
74
264
1560
227
T and B Lymphocytes in the C S F
189
C S F values B cells %
T cells %
Alb. mg%
IgA mg%
IgG rag%
IgM mg%
26
70
30
69
23 16 23
IgG Quot.
IgM Quot.
42.9
1.3
30.6
--
87.5
185
0.49
49.0
2.6
6.4
--
90.5
856
0.54
0.015
0.35
--
0.029
0.07
77 81 71
50.6 57.6 16.8
1.6 3.1 --
15.4 32.4 8.9
3.7 2.8 --
91.2 122.5 36.2
1520 568 19
--
0.55 0.47 0.47
0.018 0.025 --
0.19 0.26 0.25
0.041 0.023 --
30
60
160.0
7.9
36.5
1.4
213.7
12
79
37.4
1.7
9.2
60.0
4000
0.75
0.037
0.17
0.0066
122
0.62
0.028
0.15
--
12 30
60 81
16.8 160.0
1.3 7.9
6.4 36.5
1.4 3.7
36.2 213.7
19 4000
0.47 0.75
0.015. 0.037
0.07 0.35
0.0066 0.041
23
72
59.2
3.0
19.9
2.6
100.2
1039
0.56
0.025
0.21
0.024
19 24 26 29
72 78 78 75
63.6 52.5 75.9 50.4
9.2 8.9 10.8 6.5
32.8 31.5 27.6 23.1
3.7 3.4 3.7 --
160.0 93.7 135.0 101.2
250 111 102 55
0.40 0.56 0.56 0.50
0.06 0.09 0.08 0.064
0.21 0.34 0.20 0.23
0.023 0.04 0.027 --
24
44
11.7
--
1.6
--
33.7
2
0.35
--
0.05
--
24 24
72 66
30.8 31.6
1.3 0.6
5.8 5.0
---
51.3 47.0
70 7
0.60 0.67
0.028 0.013
0.11 0.11
---
19 29
44 78
11.7 75.9
0.6 10.8
1.6 32.8
3.4 3.7
33.7 160.0
2 250
0.35 0.67
0.013 0.09
0.05 0.34
0.023 0.04
24
69
45.2
6.2
18.2
3.6
88.8
85
0.52
0.056
0.18
0.030
17 29 18
80 75 81
15.1 29.8 22.2
-I. 1 0.1
1.8 3.3 3.0
----
26.5 38.0 37.5
272 84 32
0.57 0.78 0.68
-0.029 0.003
0.07 0.09 0.09
----
17 15 14
82 85 87
94.8 55.0 35.6
1.9 1.9 1.1
20.7 15.6 14.4
2.6 1.9 1.3
121.2 135.0 95.0
290 120 114
0.78 0.60 0.37
0.016 0.02 0.012
0.17 0.17 0.15
0.02 0.02 0.014
14
75
15.9
4.9
20.4
1.9
76.2
56
0.21
0.06
0.27
0.025
19 13
67 76
31.6 61.2
1.9 3.9
18.4 27.6
10.3 0.19
70.0 157.5
125 197
0.45 0.42
0.027 0.024
0.26 0.17
0.14 0.001
15 20 13
83 75 79
163.0 101.2 18.0
2.6 1.9 0.4
41.0 63.0 21.0
8.1 8.2 4.1
265.0 160.0 58.7
750 250 81
0.62 0.63 0.31
0.0098 0.012 0.01
0.16 0.39 0.36
0.031 0.051 0.069 --
--
Tot. Prot. Cell Alb. mg% c o u n t / 3 Quot.
IgA Quot.
14
71
23.0
--
3.9
--
45.0
34
0.51
--
0.09
23
75
39.5
1.6
7.1
3.4
102.5
226
0.39
0.016
0.07
0.03
17
77
29.0
1.3
5.4
0.5
75.0
170
0.39
0.017
0.07
0.007
14 11
84 83
22.2 15.9
1.I --
4.1 2.3
---
31.2 19.0
100 49
0.71 0.84
0.035 --
0.13 0.12
---
11 29
67 87
15.1 163.0
0.1 4.9
1.8 63.0
0.19 10.3
19.0 265.0
32 750
0.21 0.84
0.003 0.035
0.07 0.39
0.001 0.14
17
79
45.5
1.9
16.0
3.9
89.0
174
0.54
0.021
0.17
0.037
190
U. Traugott
Table 2 (continued) Blood values Pat.
Age Sex (years)
Diagnosis
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg%
17 18
65 20
f f
SP Herpes zoster Subacute encephalitis
19
12
m
Encephalitis
20 21
10 9
m f
Encephalitis Meningitis
20.7. 26.6. 6.7. 28.6. 9.7. 6.7. 4.8.
26 14 21 -----
85 78 75 ---.
58 202 199 191 281 191 .
640 1080 1360 1360 1640 2010
121 216 273 80 291 127
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg%
.
.
Table 3. Optic neuritis Blood values Pat.
Age Sex (years)
Diagnosis
1
36
f
Optic neuritis
19.3.
--
--
226
1360
148
2
32
f
Optic neuritis
11.5.
--
--
180
1120
333
3 4
42 36
f f
Optic neuritis Optic neuritis
15.5. 28.5.
---
---
146 153
2040 1330
191 220
5 6
44 25
m f
Optic neuritis Optic neuritis + M S
2.6. 17.3.
-18
-81
226 202
1330 1870
166 344
7
21
f
Optic neuritis + M S
18.6.
--
--
348
2250
200
8 9
33 21
f f
Optic neuritis + M S Neuromyelitis optica
12.5. 16.7.
-22
-74
103 217
2360 1560
228 200
18 22 20
74 81 78
103 348 194
1120 2360 1708
148 344 229
Range Mean value
from to
time after sensitization to the infectious agent. Blood and CSF from one patient suffering from panmyelopathy were studied one month after herpes zoster i n f e c t i o n . T h e u s u a l c h a n g e s o f B cells a n d T cells f o u n d d u r i n g v i r a l inf l a m m a t o r y d i s e a s e s o f t h e C N S w e r e f o u n d in t h e C S F . T h e p e r c e n t a g e o f B cells a n d T cells w a s w i t h i n t h e n o r m a l r a n g e in t h e b l o o d . T h e i m m u n o g l o b u l i n levels w e r e d e c r e a s e d in t h e C S F a n d s e r u m , r e f l e c t i n g t h e p a n m y e l o p a t h y .
Optic Neuritis and Multiple Sclerosis. T h e c o n c e n t r a t i o n o f t o t a l p r o t e i n ( m e a n = 37.2 m g / 1 0 0 m l ) i n o p t i c n e u r i t i s w a s l o w e r t h a n in M S ( m e a n = 4 9 . 5 m g / 1 0 0 ml), a difference possibly due to the greater amount of CNS damage in MS. T h e n u m b e r o f w h i t e b l o o d cells w a s s l i g h t l y e l e v a t e d ( m e a n = 6 ) in o p t i c n e u r i t i s a n d r e l a p s i n g M S . T h e cell n u m b e r ( m e a n = 3) w a s w i t h i n t h e n o r m a l range in chronic progressive MS. The mean values of the albumin quotients
T and B Lymphocytes in the CSF
191
CSF values B cells %
T cells %
Alb. mg%
IgA mg%
IgG rag%
IgM mg%
Tot. Prot. Cell Alb. mg% countJ3 Quot.
IgA Quot.
IgG Quot.
17 32 29
70 65 66
19.6 20.6 23.8
--0.5
0.6 2.7 3.7
----
34.7 30.0 30.0
4 7 8
16 18
65 81
22.2 24.5
-0.3
5.8 4.3
---
50.0 34.8
16
62
17.5
--
3.9
--
59
52
28.8
--
4.3
--
Alb. rag%
IgA mg%
IgG rag%
IgM mg%
IgM Quot.
0.56 0.69 0.79
--0.017
0.017 0.09 0.12
I50 83
0.44 0.70
-0.0086
0.12 0.12
23.7
6
0.74
m
0.16
35.0
87
0.85
--
0.12
Tot. Prot. Cell Alb. mg% count/3 Quot.
IgA Quot.
IgG Quot.
IgM Quot.
CSF values B cells % 27
T cells %
19.6
m
2.7
--
36.5
12
0.54
m
0.07
m
18 16
60 78 74
19.0 18.0
---
6.6 3.0
---
38.8 26.0
35 14
0.49 0.69
---
0.17 0.12
-m
12 19
76 70
16.8 29.0
---
3.3 3.2
---
35.2 42.5
27 8
0.48 0.70
~ --
0.09 0.08
---
21 31
72 71
15.9 35.6
0.2 1.4
4.3 9.2
---
29.0 63.7
15 23
0.55 0.56
"0.007 0.02
0.15 0.14
~ --
32 11
47 84
15.9 56.3
-1.3
3.3 10.2
-2.3
26.2 70.0
9 18
0.61 0.80
-0.018
0.13 0.15
-0.032
12 32
47 78
15.9 35.6
0.2 1.4
2.7 9.2
---
26.0 63.7
8 35
0.48 0.70
0.007 0.02
0.07 0.17
22
69
21.2
0.8
4.5
--
37.2
18
0.58
0.018
0.12
m
m
(0.58) w e r e s l i g h t l y h i g h e r i n o p t i c n e u r i t i s t h a n i n r e l a p s i n g a n d c h r o n i c p r o g r e s s i v e M S (0.50). I g A w a s n o t d e t e c t e d in t h e C S F o f p a t i e n t s w i t h o p t i c neuritis without other neurological signs. It should be mentioned that the lowest concentration of IgA demonstrable with the present method was 0.4 mg/100 ml. IgA was found in relapsing and chronic progressive MS on four occasions with a m e a n q u o t i e n t o f 0.032. T h e m e a n I g G q u o t i e n t (0.11) in o p t i c n e u r i t i s w i t h out other neurological signs was within the normal range. The IgG quotient was elevated (mean=0.22) in 76% of MS patients. IgM was not detected in o p t i c n e u r i t i s o r M S b y t h e m e t h o d s u s e d . S e r u m I g G levels w e r e c o n s i s t e n t l y higher than normal when optic neuritis was accompanied by other neurological signs, but normal when optic neuritis was the only symptom. Serum IgG concent r a t i o n s in M S w e r e m o s t l y w i t h i n t h e n o r m a l r a n g e . T h e r a t i o o f B cells
192
U. T r a u g o t t
Table 4. Multiple sclerosis Blood values Pat.
Age (years)
Sex
Diagnosis
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg%
1
35
f
Relapse
14.7.
25
70
126
1080
169
2
32
m
Relapse
16.7.
27
73
126
1420
169
3
29
f
Relapse
16.7. 2.8.
23 31
79 74
146 191
1200 1780
148 154
4
36
m
Relapse
20.7.
--
--
384
1830
184
5
29
f
Relapse
4.5.
25
70
218
1000
228
6
33
f
Relapse
2.8.
30
68
205
2150
256
7
19
f
Chronic
29.6.
31
82
119
870
190
8
32
f
Chronic
16.7.
--
--
339
1510
96
9
36
f
Chronic
21.5.
33
60
159
1330
166
10
65
f
Chronic
21.5.
28
72
251
1080
249
11
34
f
Chronic
31.5.
31
66
187
1330
157
12
30
m
Chronic
1.6.
--
--
131
820
94
13
35
m
Chronic
29.7.
--
--
126
1420
208
14
52
f
Chronic
24.6.
27
77
408
1740
91
15
45
f
Chroni~
3.6.
14
73
96
1360
107
14 33
60 79
96 408
820 2150
91 256
27
72
201
1370
167
Range
from to
M e a n value
Table 5. P o l y n e u r o p a t h y s y n d r o m e Blood values Pat.
Age (years)
Sex
Diagnosis
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg% 310
1
20
f
Guillain-Barr6
11.5.
--
--
187
1120
2
62
m
Guillain-Barr6
27.7.
16
72
312
1330
148
3
51
m
Guillain-Barr6
2.8.
24
70
321
1600
232
4
28
m
Guillain-Barr6
2.8.
--
--
356
2040
162
5
34
f
Inflammatory
4.6.
--
--
217
1320
157
6
51
m
Inflammatory
12.7. 21.7. 2.8.
-49 --
-52 --
225 169 126
1280 1240 1740
190 80 80
7
48
m
Inflammatory
28.7.
--
--
135
850
122
8
56
m
Degenerative
22.7.
--
--
199
1240
114
9
72
f
Degenerative
2.8.
32
73
241
1510
133
16 49
52 73
126 356
850 2040
80 310
30
67
226
1388
157
Range M e a n value
from to
T and B Lymphocytes
in t h e C S F
193
CSF values B cells %
T cells %
Alb. mg%
IgA mg%
IgG mg%
IgM mg%
T o t . P r o t . Cell Alb. rag% count/3 Quot.
IgA Quot.
IgG Quot.
IgM Quot.
17
77
25.3
--
13.1
--
48.7
7
0.52
--
0.27
--
23
78
27.9
--
7.7
--
41.0
5
0.68
--
0.19
--
15 22
82 84
21.2 21.2
---
8.6 7.9
---
37.5 36.2
25 22
0.59 0.59
---
0.23 0.22
---
12
88
29.0
0.2
10.2
--
54.0
38
0.54
0.004
0.19
--
18
66
24.5
1.0
5.0
--
73.7
10
0.33
0.014
0.07
--
20
85
32.6
--
20.0
--
63.7
25
0.51
--
0.31
--
19
75
24.5
--
2.6
--
37.5
7
0.65
--
0.07
--
16
69
23.0
2.9
12.4
--
51.2
6
0.45
0.06
0.24
--
20
76
33.6
--
11.0
--
66.3
8
0.51
--
0.17
--
24
60
27.9
--
6.9
--
51.0
7
0.55
--
0.14
--
26
76
13.0
--
8.2
--
28.7
13
0.45
--
0.29
--
30
73
34.5
--
6.3
--
56.0
10
0.62
--
0.11
--
24
78
24.5
--
2.8
--
38.7
12
0.63
--
0.07
--
14
77
23.0
2.8
14.6
--
56.2
6
0.41
0.05
0.26
--
18
78
15.9
--
4.1
--
32.5
21
0.49
--
0.13
--
12 30
60 88
13.0 34.5
0.2 2.9
2.6 20.0
---
28.7 73.7
5 38
0.33 0.68
0.004 0.06
0.07 0.31
---
21
76
25.1
1.7
8.8
--
48.3
14
0.53
0.032
0.22
--
IgM mg%
Tot. Prot. Cell mg% count/3
Alb. Quot.
IgA Quot.
IgG Quot.
IgM Quot. --
CSF values B cells %
T cells %
Alb. mg%
IgA mg%
IgG mg%
35
61
94.8
1.7
11.0
--
126.2
6
0.75
0.013
0.09
34
58
72.8
1.4
7.4
--
95.0
11
0.77
0.015
0.08
--
26
71
67.2
2.6
18.0
--
123.7
5
0.54
0.021
0.15
--
88.7
8
0.71
0.011
0.13
--
28
56
63.2
1.0
11.4
--
29
62
21.2
--
2.1
--
38.8
12
0.55
--
0.05
--
24 24 35
68 68 61
39.5 35.6 20.6
-1.1 0.1
6.9 6.7 5.6
-3.2 2.4
63.7 58.0 38.7
356 822 527
0.62 0.61 0.53
-0.019 0.003
0.I1 0.12 0.15
-0.06 0.06
27
72
115.0
0.9
11.0
1.1
145.0
18
0.79
0.006
0.09
0.007
35
54
37.4
0.2
2.6
--
48.7
4
0.77
0.004
0.05
--
32
48
26.4
--
3.3
--
36.2
2
0.73
--
0.09
--
24 35
48 72
20.6 115.0
0.1 2.6
2.1 18.0
1.1 3.2
36.2 126.2
2 822
0.53 0.79
0.003 0.021
0.05 0.15
0.007 0.06
30
61
53.9
7.8
2.1
78.4
161
0.67
0.012
0.10
0.06
1.12
U.Traugott
194 Table 6. Varia
Blood values Pat.
Age Sex (years)
Diagnosis
Date tested
B cells T cells IgA % % mg%
1 2 3 4 5 6 7 8 9 10 11 12
8 58 12 13 42 62 48 34 65 43 32 42
Meningeosis leukemica Stroke Adrenoleucodystrophy Epilepsy ~strocytoma Metastasis Cephalea Cephalea Plexus lesion Discopthy Funic. myelosis Myasthenia
18.3 7.4 15.4. 30.6. 8.4. 4.6. 28.6. 6.8. 21.7. 7.7. 20.7. 22.7.
. -25 ---28 19 -21 -36
f f m m m f f m f f m m
.
. -83 -. -74 76 -77 -77
. 146 172 146 . . 312 342 -181 199 413 264
IgG mg%
IgM mg%
900 4340 1310 . 970 1120 -1280 1000 1460 1780
101 167 154
.
148 283 -127 122 122 148
( m e a n = 1 8 % ) to T cells ( m e a n = 7 2 % ) in the C S F in optic neuritis without other neurological signs was similar to that seen in viral meningitis. W h e n optic neuritis was a c c o m p a n i e d by neurological signs, the m e a n percentage of B cells was 28%, of T cells 60%. A m e a n of 18% B cells a n d 80% Tcells was f o u n d in the C S F in relapsing multiple sclerosis. The m e a n B cell value was 21%, a n d of T cells 74% in chronic progressive MS. After treatment with Synacthen, B cell values in the C S F increased b u t the percentage of T cells was consistently high in one p a t i e n t with relapsing MS. In the same patient, T cell values decreased in the circulation.
Neuromyelitis Optica. One
patient with neuromyelitis optica (Devic's disease) was studied 7 m o n t h s after onset of the disease. Changes in the C S F in this case were more similar to those seen in MS t h a n in optic neuritis. Total protein c o n t e n t a n d cell n u m b e r were slightly elevated; the percentage o f T cells was increased a n d B cell values were decreased. Quotients of all three i m m u n o g l o b u l i n classes were elevated. All serum values were within the n o r m a l range.
Guillain-BarrO Syndrome and Polyneuritis. In the C S F samples from the G u i l l a i n Barr~ s y n d r o m e a n d in some from patients with polyneuritis, the total protein c o n t e n t was elevated. In the Guillain-Barr6 syndrome, the quotients of IgA a n d I g G were more frequently elevated t h a n i n polyneuritis, a m a j o r inf l a m m a t o r y disease of the peripheral nervous system. This difference could be related to neuroallergic m e c h a n i s m s which are believed to be operative in the pathogenesis of the Guillain-Barr6 syndrome. I m m u n o g l o b u l i n p r o d u c t i o n leading to an elevation in i m m u n o g l o b u l i n levels in polyneuritis usually was f o u n d n o t to start before 1 to 2 weeks after onset of the disease. I n the C S F of b o t h groups of diseases, the percentage of B cells a n d T cells were within the n o r m a l range. I m m u n o g l o b u l i n levels in the serum were n o r m a l , except one elevated I g G value.
T and B Lymphocytes in the CSF
195
CSF values B cells %
T cells Alb. % rag%
IgA mg%
IgG rag%
IgM mg%
Tot. Prot. Cell Alb. mg% count/3 Quot.
52 30 25 21 31 9 26
6 72 60 63 67 83 69
10.9 19.6 27.9 11.7 73.5 126.5 22.2
--0.15 -3.3 7.7 0.6
0.3 2.1 4.3 1.6 21.7 29.0 3.3
--0.1 -4.2 2.4 --
21.2 27.5 50.0 17.5 122.5 190.0 40.0
382 40 8 6 16 13 14
36 34 21 13 24
58 57 56 72 62
13.8 23.0 25.3 38.5 27.9
---1.3 0.1
1.3 3.1 2.8 4.8 2.8
------
20.2 36.2 41.2 52.5 43.7
2 7 9 3 7
IgA Quot.
IgG Quot.
IgM Quot.
0.51 0.71 0.56 0.67 0.60 0.67 0.56
--0.003 -0.027 0.045 0.015
0.014 0.08 0.09 0.09 0.18 0.15 0.08
--0.002 -0.034 0.012 --
0.68 0.64 0.61 0.73 0.62
---0.025 0.002
0.06 0.09 0.07 0.09 0.06
------
Various Neurological Diseases. T h e results o f the C S F samples f r o m ten adults a n d three children with v a r i o u s n o n - i n f l a m m a t o r y n e u r o l o g i c a l diseases studied, were s u m m a r i z e d in the " v a r i a " group. T o t a l p r o t ei n c o n t e n t an d cell n u m b e r were n o r m a l or slightly elevated a c c o r d i n g to the variety o f disease processes i n c l u d e d in this group. T h e percentage o f B cells in the C S F in meningeosis l e u k e m i ca was a b n o r m a l l y high whereas T cell levels were low. This altered B cell to T cell ratio in the C S F agrees with a previous r e p o r t o n l y m p h o c y t e changes in the b l o o d [3], in which it was s h o w n that p a t h o l o g i c a l cells in l y m p h a t i c l e u k e m i a f r e q u e n t l y originate f r o m B cells. T h e percentage o f T cells in the C S F was elevated once in f u n i c u la r myelosis a n d cerebral metastasis. B cell an d T cell values were within the n o r m a l range in o n e a s t r o c y t o m a studied. All o t h er C S F samples o f the varia g r o u p h a d slightly higher B cell levels an d a l o w er percentage o f T cells when c o m p a r e d with the c o r r e s p o n d i n g b l o o d values. S e r u m i m m u n o globulin levels were within n o r m a l limits in the v ar i a group, except for elevated I g G values in one case o f a d r e n o l e u k o d y s t r o p h y . Discussion In the present study o n the C S F a n d b l o o d o f a variety o f n e u r o l o g i c a l diseases, the p e r c e n t a g e o f B cells and T cells as well as i m m u n o g l o b u l i n levels were studied. Th e B cell to T cell ratio in the C S F was f o u n d to be ch an g ed in viral i n f l a m m a t o r y diseases o f the C N S where the percentage o f B cells was decreased a n d T cells increased when c o m p a r e d with the c o r r e s p o n d i n g values in the blood. S i m i l ar but less m a r k e d changes were f o u n d in optic neuritis an d relapsing multiple sclerosis. I m m u n o g l o b u l i n levels were elevated in i n f l a m m a t o r y diseases o f the C N S . H i g h I g G values were a c o n s t a n t finding in MS, but in optic neuritis the I g G c o n c e n t r a t i o n s were n o r m a l . F o r the diagnosis o f
196
U. Traugott
inflammatory diseases of the CNS, pleocytosis in the CSF is an important criterion. Pleocytosis predominately reflects inflammation of the meninges rather than inflammatory lesions in the parenchyma. This concept was supported by the observation that CSF samples from patients with myelitis with severe clinical signs either had pleocytosis or a normal number of cells. The increased number of T cells in the CSF of viral infections of the CNS might reflect an activation of the cellular immune response. The difference in the percentage of T cells and B cells between the CSF and blood might indicate that there is no strict correlation between the T cell and B cell values in the two compartments. Furthermore, the elevation of CSF T cells might reflect an accentuation of the cellular immune reaction within the subarachnoid space, which could be detected for several weeks. In this regard, Hampe| has shown, that viral diseases of the CNS can only be overcome in the presence of intact T cells. Antibodies produced during a viral infection protect mainly against later disease [5]. In one patient with chronic progressive herpes myelitis, the percentage of T cells in the CSF was abnormally low. In this case it might be regarded that in addition to the quantitative changes in T cells, these might also have been qualitatively insufficient. Both factors might have supported the chronic course of the disease. Similar CSF changes to those seen in viral inflammatory diseases of the CNS were also found in optic neuritis. These consisted of an acute phase reaction (elevation of the quotients of acid a 1 glycoprotein and haptoglobin), slightly increased total protein content and cell number, but IgG quotients were normal. Also, the percentage of CSF T cells was increased leading to a reduced number of B cells. There is usually no acute phase reaction in the CSF of MS, the clinical manifestations of which probably develop many years after initial acquisition, but the IgG quotients are elevated and the increase of T cells is less significant. These differences in the CSF of optic neuritis and MS might not express two basically different types of pathological reactions of the subarachnoid space but could possibly reflect different time points or activities of a similar disease process. To prove this concept, CSF samples from a larger number of patients have yet to be studied longitudinally. The IgM detected in some CSF samples, may be due to several pathological conditions. Since IgM is a macromolecule, (MW about 1,000,000), its presence in the CSF could indicate damage to the b|ood-CSF barrier. In addition, SandbergWolheim has shown that IgM can also be synthesized locally within the CNS as has been shown previously for IgA and IgG. It is known that IgM is the first class of immunoglobulins produced in the serum, after challenge with an antigen. This is followed approximately 1 week later by the production of IgG antibodies following which IgM decreases progressively. Assuming the same relationship of antibody production with time in serum and CSF, the presence of IgM in the CSF for some weeks could be related to the persistence of the infectious agent (Burnet). A correlation between immunoglobulin levels and B cell values was not found in CSF or serum. In conclusion, it has been shown in viral inflammatory diseases of the CNS, t~at in comparison to corresponding blood values, the percentage of T cells in the CSF is elevated and of B cells is decreased. This elevation of T cells and decrease
T and B Lymphocytes in the CSF
197
o f B cells c a n n o t be f o u n d in the C S F o f o t h e r n o n - i n f l a m m a t o r y diseases o f the CNS. W h e t h e r these o b s e r v a t i o n s m a y have d i a g n o s t i c significance m u s t a w a i t the analysis o f larger n u m b e r s o f samples.
References 1. Allen, J., Sheremata, W., Cosgrove, J. B. R., Osterland, K.: Cerebrospinal Fluid T and B lymphocyte kinetics related to exacerbations of multiple sclerosis. J. Neurology 25,352 (1975) 2. Bfyum, A.: Isolation of mononuclear cells and granulocytes from human blood. Scand. J. Lab. Invest. 21, suppl. 97, 77 (1968) 3. Graeves, M. F., Owen, J. J. T., Raft, M. C.: T and B lymphocytes. Origin, properties and roles in immuno-responses. New York: Exc. Med. (Ed. Elsevier) 1974 4. Hapel, A. J.: The protective role of thymus derived lymphocytes in arbovirus induced meningoencephalitis. Scand. J. Immunol. 4, 267 (1975) 5. Humphrey, J. H., White, R. G.: Kurzes Lehrbuch der Immunologie (Ed. E. Macher). Stuttgart: Thieme 1971 6. Mancini, A., Carbonara, A. C., Heremans, J. F.: Immunochemical quantitation of antigens by single radial immunodiffusion. Immunochemistry 2, 235 (1965) 7. Traugott, U., Eibl, M., Weippl, G., Harasek, G.: T und B Lymphozyten in Blut und Liquor bei Mumpsmeningitis. Paed. Paediol. 11,545 (1976) Received April 18, 1977
J. Neurol. 219, 185--197 (1978)
Neurology © by Springer-Verlag 1978
T and B Lymphocytes in the Cerebrospinal Fluid of Various Neurological Diseases U. Traugott Department of Neurology, University Hospital, Lazarettgasse 14, A-1090 Vienna, Austria
Summary. Cerebrospinal fluids (CSF) from 66 patients with a variety of neurological disorders were studied for total protein content, absolute amount of albumin, IgA, IgG and IgM, as well as their quotients (fraction to total protein ratio), cell numbers and B cell and T cell levels. In addition, the percentage of B cells and T cells in the blood was determined in 34 patients and serum immunoglobulin levels were estimated in 51 patients. In noninflammatory diseases of the CNS, the percentage of B cells was slightly higher and T cell levels were lower in the CSF in comparison to corresponding blood values. The B cell to T cell ratio in viral meningitis was altered in the CSF. An apparent increase in the T cell level led to a decrease of B cell values. Similar changes were also found in optic neuritis. The percentage of T cells was higher in relapsing multiple sclerosis than in the chronic progressive form. There were less striking changes in the B cell to T cell ratios in the CSF of other inflammatory diseases of the CNS. Key words: Cerebrospinal fluid - B cells - T cells - Immunoglobulin levels Multiple sclerosis - Viral meningitis.
Zusammenfassung.Von 66 Patienten wurden im Liquor aul~er Zellzahl, den Bund T-Zellen noch der Gesamteiweil~gehalt sowie die absoluten Werte von Albumin, IgA, IgG, IgM und deren relativer Anteil am Gesamteiweil~ untersucht. Im Blut war die Bestimmung der B- und T-Zellen bei 34 Patienten, die der Immunglobuline bei 51 Patienten m~glich. Bei nicht entziindlichen Erkrankungen des zentralen Nervensystems liegt der prozentuelle Anteil der TZellen im Liquor zumeist etwas niedriger, der der B-Zellen etwas h6her als die entsprechenden Blutwerte. Bei viralen Miningitiden kommt es zn einer deutlichen Verschiebung dieses B:T-Zellen-Verh~iltnisses, und zwar zu einem Ansteigen der T-Zellen bei daraus resultierendem B-Zellen-Abfall. ~hnliche Relationsver~indertingen sind bei retrobulb~iren Neuritiden, die als Erstsymptome einer MS auftreten, zu finden. MS-F~ille mit schubf/Srmiger Verschlechterung weisen einen h6heren Anteil an T-Zellen auf als MS-F~ilIe mit
0340-5354/78/0219/0185/$ 02.60
186
U. Traugott chronisch p r o g r e d i e n t e m Verlauf. Eitrige M e n i n g i t i d e n , Myelitiden u n d Polyn e u r o p a t h i e - S y n d r o m e zeigen die T e n d e n z des T-Zellen-Anstieges u n d BZellen-Abfalles im L i q u o r in geringerer Auspr~igung.
Introduction It has been reported previously [1, 7] that the percentage of B cells a n d T cells in the cerebrospinal fluid (CSF) a n d the b l o o d are similar. T o a p p r o a c h the question whether alterations in the ratio of B cells a n d T cells can be f o u n d d u r i n g n e u r o logical diseases, the present study was performed with samples t a k e n from a variety of conditions.
Materials and Methods CSF samples from 66 patients (29 male, 37 female) with a variety of neurological diseases were studied (Table 1). The patients were between 8 and 72 years of age (mean, 36.5 years). In all CSF samples, the concentration of total protein, the number of white blood cells per mm 3, the percentage of B cells and T cells, and the concentrations of IgA, IgG, IgM and albumin were determined. In addition, the percentage of B cells and T cells in the blood were studied in 34 patients and the levels of IgA, IgG and IgM were examined in the blood of 51 patients. From each patient, 15 ml of heparinized blood was taken by venepuncture. Mononuclear cells were isolated on a Ficoll-Ronpacon gradient by the method of B6yum [2] with slight modifications. Cells from the CSF were recovered by centrifuging at 900 g for 10 min. T cells were determined by the formation of spontaneous non-immune rosettes with sheep erythrocytes. B cells were estimated by direct immunofluorescence using fluorescein isothiocyanateconjugated goat antihuman immunoglobulins. Immunoglobulin levels were tested by radial immunodiffusion [6] using Tri-Partigen diffusion plates for serum and LC Partigen diffusion plates (Behringwerke, West Germany) for CSF samples. The concentration of total protein in the CSF was measured by the method described by Biuret. White blood cells in the CSF were counted using a Fuchs-Rosenthal chamber.
Results The results o b t a i n e d form the b l o o d a n d C S F samples are s h o w n in Tables 2 - - 6 .
Cell Numbers. The m e a n n u m b e r of white b l o o d cells per m m 3 in the C S F was 509 in p u r u l e n t meningitis, 173 in b r a i n abscesses, 58 in viral meningitis, a n d 28 in myelitis. Table 1. Neurological diseases of 66 patients Diagnosis
Number of patients male female
Age (years)
Mean age (years)
Purulent meningitis Myelitis Meningitis Multiple sclerosis Optic neuritis Polyneuropathy Other neurological diseases
4 1 7 4 1 6 6
19--51 28--41 9--57 19--65 20---44 20--72 8--65
34 34 34 36 32 47 38
1 2 6 11 8 3 6
T and B Lymphocytes in the CSF
187
Total Protein. Differences in the concentration of total protein in CSF between the groups of diseases were less apparent. The mean concentration of total protein in purulent meningitis was 100mg/100ml. A mean value of 8 9 m g / 100ml was found in all other groups. CSF Albumin. The absolute concentrations of albumin (mean, 59.2 mg/100ml) were highest in purulent meningitis, corresponding to the levels of total protein. In both other groups, the mean values of albumin were about 45 rag/ 100 ml. The mean albumin to total protein ratio was 0.51 and there were no major decreases. CSF Immunoglobulins. Immunoglobulin levels were elevated in most samples of CSF tested. IgA quotients (the ratio between IgA and total protein) were elevated in all groups. The IgG quotient in purulent meningitis was 0.21--a slightly higher Value than that seen in other groups (mean, 0.18). In a considerable number of CSF samples tested, IgM was also found. IgM could no longer be detected in purulent meningitis after the concentration of total protein had returned to normal values. In contrast, IgM in the CSF was demonstrable for some weeks in myelitis and viral meningitis, even when the total protein values were only slightly elevated. Purulent Meningitis. The percentage of B cells and T cells in the CSF showed no significant differences between purulent meningitis and myelitis.
Myelitis. The levels of B cells (mean = 24%) and T cells (mean = 69%) in myelitis were comparable to those seen in the blood (mean B cell value= 31%, mean T cell value = 66%). However, there was a tendency for T cells to be slightly higher and B cell values somewha t lower in the CSF. There was pleocytosis in the CSF of one patient with myelitis, and B and T cell levels were studied longitudinally. Coinciding with improving neurological signs, B cell values increased gradually while the percentage of T cells remained elevated. No correlation was found between B cell values and immunoglobulin levels in the CSF. The number of white blood cells and the total protein level were normal in chronic progressive myelitis caused by herpes simplex virus. However, the ratio of B cells to T cells was changed. In contrast to the elevation of T cells usually found in the CSF during viral infections, T cells showed significant low values in this case. The percentage of B cells in the CSF was slightly lower than in the blood and the circulating T cell levels were decreased.
Viral Meningoencephalitis. Changes in the ratio of B cells to T cells were more distinct in viral meningoencephalitis. A decrease in the mean value of B cells to 17% and an increase of T cell levels to a mean o f 79%, were found. In the blood, the percentage of B cells (mean = 23%) and T cells (mean = 74%) was within the normal range. In two patients with viral meningitis, lymphocyte values were followed up to one month. Accompanying the improvement of neurological signs, the percentage of B cells stayed low after a transient increase, and T cell levels remained elevated. Immunoglobulin-G levels in the serum were frequently elevated. IgM was increased infrequently. These changes of immunoglobulin concentrations probably indicated that the samples were tested some
188
U. T r a u g o t t
Table 2. Meningitis--Encephalitis Blood values Pat.
Age (years)
Sex
Diagnosis
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg% 170
1
51
m
Abscess
23.2.
27
72
251
1830
2
39
m
Abscess
15.4.
--
--
367
1450
100
3
19
m
Pur. meningitis
6.4. 14.4. 31.5.
-22 28
-67 58
131 159 152
1360 2550 1420
138 439 138
4
23
f
Pur. meningitis
26.2.
--
--
1450
85
5
38
m
SP Pur. meningitis
27.7.
--
.
22 28
58 72
131 367
1420 2550
85 439
26
66
220
1677
178
-35 20 25
-67 71 70
422 347 422 384
1390 1190 1370 1510
216 162 208 190
Range
~om to
Mean value 6
42
m
Myelitis
25.6. 7.7. 21.7. 2.8.
257 .
.
.
7
32
f
Myelitis (Herpes)
20.7.
31
52
106
1690
264
8
28
f
Myelitis
14.5. 31.5.
33 39
66 70
233 233
1120 1740
333 299
20 39
52 71
106 422
1120 1740
162 333
31
66
307
1430
239
Range
from to
Mean value 9
34
f
Meningitis
12.4. 14.5. 28.7.
20 23 23
76 72 76
210 202 181
2550 1690 1510
310 228 216
10
48
m
Meningitis
8.7. 16.7. 22.7.
32 ---
65 ---
160 288 205
1160 1390 1200
101 200 169
11
36
m
Meningitis
28.7.
--
--
1000
101
12
34
m
Encephalitis zoster
14.5. 21.5.
---
. .
13
46
f
Meningitis
24.5. 1.6. 25.6.
15 24 26
71 78 71
14
40
m
Meningitis
21.5.
--
15
57
m
Meningitis
2.6. 4.6.
33 --
16
26
f
Meningitis
30.7. 4.8.
Range Mean value
~om to
461 . .
. .
. .
120 126 120
1510 1240 1000
333 368 256
--
398
1280
46
79 --
388 339
1830 1750
228 162
15 21
75 76
389 372
1930 2360
337 347
15 33
65 79
120 461
1000 2520
46 368
23
74
264
1560
227
T and B Lymphocytes in the C S F
189
C S F values B cells %
T cells %
Alb. mg%
IgA mg%
IgG rag%
IgM mg%
26
70
30
69
23 16 23
IgG Quot.
IgM Quot.
42.9
1.3
30.6
--
87.5
185
0.49
49.0
2.6
6.4
--
90.5
856
0.54
0.015
0.35
--
0.029
0.07
77 81 71
50.6 57.6 16.8
1.6 3.1 --
15.4 32.4 8.9
3.7 2.8 --
91.2 122.5 36.2
1520 568 19
--
0.55 0.47 0.47
0.018 0.025 --
0.19 0.26 0.25
0.041 0.023 --
30
60
160.0
7.9
36.5
1.4
213.7
12
79
37.4
1.7
9.2
60.0
4000
0.75
0.037
0.17
0.0066
122
0.62
0.028
0.15
--
12 30
60 81
16.8 160.0
1.3 7.9
6.4 36.5
1.4 3.7
36.2 213.7
19 4000
0.47 0.75
0.015. 0.037
0.07 0.35
0.0066 0.041
23
72
59.2
3.0
19.9
2.6
100.2
1039
0.56
0.025
0.21
0.024
19 24 26 29
72 78 78 75
63.6 52.5 75.9 50.4
9.2 8.9 10.8 6.5
32.8 31.5 27.6 23.1
3.7 3.4 3.7 --
160.0 93.7 135.0 101.2
250 111 102 55
0.40 0.56 0.56 0.50
0.06 0.09 0.08 0.064
0.21 0.34 0.20 0.23
0.023 0.04 0.027 --
24
44
11.7
--
1.6
--
33.7
2
0.35
--
0.05
--
24 24
72 66
30.8 31.6
1.3 0.6
5.8 5.0
---
51.3 47.0
70 7
0.60 0.67
0.028 0.013
0.11 0.11
---
19 29
44 78
11.7 75.9
0.6 10.8
1.6 32.8
3.4 3.7
33.7 160.0
2 250
0.35 0.67
0.013 0.09
0.05 0.34
0.023 0.04
24
69
45.2
6.2
18.2
3.6
88.8
85
0.52
0.056
0.18
0.030
17 29 18
80 75 81
15.1 29.8 22.2
-I. 1 0.1
1.8 3.3 3.0
----
26.5 38.0 37.5
272 84 32
0.57 0.78 0.68
-0.029 0.003
0.07 0.09 0.09
----
17 15 14
82 85 87
94.8 55.0 35.6
1.9 1.9 1.1
20.7 15.6 14.4
2.6 1.9 1.3
121.2 135.0 95.0
290 120 114
0.78 0.60 0.37
0.016 0.02 0.012
0.17 0.17 0.15
0.02 0.02 0.014
14
75
15.9
4.9
20.4
1.9
76.2
56
0.21
0.06
0.27
0.025
19 13
67 76
31.6 61.2
1.9 3.9
18.4 27.6
10.3 0.19
70.0 157.5
125 197
0.45 0.42
0.027 0.024
0.26 0.17
0.14 0.001
15 20 13
83 75 79
163.0 101.2 18.0
2.6 1.9 0.4
41.0 63.0 21.0
8.1 8.2 4.1
265.0 160.0 58.7
750 250 81
0.62 0.63 0.31
0.0098 0.012 0.01
0.16 0.39 0.36
0.031 0.051 0.069 --
--
Tot. Prot. Cell Alb. mg% c o u n t / 3 Quot.
IgA Quot.
14
71
23.0
--
3.9
--
45.0
34
0.51
--
0.09
23
75
39.5
1.6
7.1
3.4
102.5
226
0.39
0.016
0.07
0.03
17
77
29.0
1.3
5.4
0.5
75.0
170
0.39
0.017
0.07
0.007
14 11
84 83
22.2 15.9
1.I --
4.1 2.3
---
31.2 19.0
100 49
0.71 0.84
0.035 --
0.13 0.12
---
11 29
67 87
15.1 163.0
0.1 4.9
1.8 63.0
0.19 10.3
19.0 265.0
32 750
0.21 0.84
0.003 0.035
0.07 0.39
0.001 0.14
17
79
45.5
1.9
16.0
3.9
89.0
174
0.54
0.021
0.17
0.037
190
U. Traugott
Table 2 (continued) Blood values Pat.
Age Sex (years)
Diagnosis
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg%
17 18
65 20
f f
SP Herpes zoster Subacute encephalitis
19
12
m
Encephalitis
20 21
10 9
m f
Encephalitis Meningitis
20.7. 26.6. 6.7. 28.6. 9.7. 6.7. 4.8.
26 14 21 -----
85 78 75 ---.
58 202 199 191 281 191 .
640 1080 1360 1360 1640 2010
121 216 273 80 291 127
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg%
.
.
Table 3. Optic neuritis Blood values Pat.
Age Sex (years)
Diagnosis
1
36
f
Optic neuritis
19.3.
--
--
226
1360
148
2
32
f
Optic neuritis
11.5.
--
--
180
1120
333
3 4
42 36
f f
Optic neuritis Optic neuritis
15.5. 28.5.
---
---
146 153
2040 1330
191 220
5 6
44 25
m f
Optic neuritis Optic neuritis + M S
2.6. 17.3.
-18
-81
226 202
1330 1870
166 344
7
21
f
Optic neuritis + M S
18.6.
--
--
348
2250
200
8 9
33 21
f f
Optic neuritis + M S Neuromyelitis optica
12.5. 16.7.
-22
-74
103 217
2360 1560
228 200
18 22 20
74 81 78
103 348 194
1120 2360 1708
148 344 229
Range Mean value
from to
time after sensitization to the infectious agent. Blood and CSF from one patient suffering from panmyelopathy were studied one month after herpes zoster i n f e c t i o n . T h e u s u a l c h a n g e s o f B cells a n d T cells f o u n d d u r i n g v i r a l inf l a m m a t o r y d i s e a s e s o f t h e C N S w e r e f o u n d in t h e C S F . T h e p e r c e n t a g e o f B cells a n d T cells w a s w i t h i n t h e n o r m a l r a n g e in t h e b l o o d . T h e i m m u n o g l o b u l i n levels w e r e d e c r e a s e d in t h e C S F a n d s e r u m , r e f l e c t i n g t h e p a n m y e l o p a t h y .
Optic Neuritis and Multiple Sclerosis. T h e c o n c e n t r a t i o n o f t o t a l p r o t e i n ( m e a n = 37.2 m g / 1 0 0 m l ) i n o p t i c n e u r i t i s w a s l o w e r t h a n in M S ( m e a n = 4 9 . 5 m g / 1 0 0 ml), a difference possibly due to the greater amount of CNS damage in MS. T h e n u m b e r o f w h i t e b l o o d cells w a s s l i g h t l y e l e v a t e d ( m e a n = 6 ) in o p t i c n e u r i t i s a n d r e l a p s i n g M S . T h e cell n u m b e r ( m e a n = 3) w a s w i t h i n t h e n o r m a l range in chronic progressive MS. The mean values of the albumin quotients
T and B Lymphocytes in the CSF
191
CSF values B cells %
T cells %
Alb. mg%
IgA mg%
IgG rag%
IgM mg%
Tot. Prot. Cell Alb. mg% countJ3 Quot.
IgA Quot.
IgG Quot.
17 32 29
70 65 66
19.6 20.6 23.8
--0.5
0.6 2.7 3.7
----
34.7 30.0 30.0
4 7 8
16 18
65 81
22.2 24.5
-0.3
5.8 4.3
---
50.0 34.8
16
62
17.5
--
3.9
--
59
52
28.8
--
4.3
--
Alb. rag%
IgA mg%
IgG rag%
IgM mg%
IgM Quot.
0.56 0.69 0.79
--0.017
0.017 0.09 0.12
I50 83
0.44 0.70
-0.0086
0.12 0.12
23.7
6
0.74
m
0.16
35.0
87
0.85
--
0.12
Tot. Prot. Cell Alb. mg% count/3 Quot.
IgA Quot.
IgG Quot.
IgM Quot.
CSF values B cells % 27
T cells %
19.6
m
2.7
--
36.5
12
0.54
m
0.07
m
18 16
60 78 74
19.0 18.0
---
6.6 3.0
---
38.8 26.0
35 14
0.49 0.69
---
0.17 0.12
-m
12 19
76 70
16.8 29.0
---
3.3 3.2
---
35.2 42.5
27 8
0.48 0.70
~ --
0.09 0.08
---
21 31
72 71
15.9 35.6
0.2 1.4
4.3 9.2
---
29.0 63.7
15 23
0.55 0.56
"0.007 0.02
0.15 0.14
~ --
32 11
47 84
15.9 56.3
-1.3
3.3 10.2
-2.3
26.2 70.0
9 18
0.61 0.80
-0.018
0.13 0.15
-0.032
12 32
47 78
15.9 35.6
0.2 1.4
2.7 9.2
---
26.0 63.7
8 35
0.48 0.70
0.007 0.02
0.07 0.17
22
69
21.2
0.8
4.5
--
37.2
18
0.58
0.018
0.12
m
m
(0.58) w e r e s l i g h t l y h i g h e r i n o p t i c n e u r i t i s t h a n i n r e l a p s i n g a n d c h r o n i c p r o g r e s s i v e M S (0.50). I g A w a s n o t d e t e c t e d in t h e C S F o f p a t i e n t s w i t h o p t i c neuritis without other neurological signs. It should be mentioned that the lowest concentration of IgA demonstrable with the present method was 0.4 mg/100 ml. IgA was found in relapsing and chronic progressive MS on four occasions with a m e a n q u o t i e n t o f 0.032. T h e m e a n I g G q u o t i e n t (0.11) in o p t i c n e u r i t i s w i t h out other neurological signs was within the normal range. The IgG quotient was elevated (mean=0.22) in 76% of MS patients. IgM was not detected in o p t i c n e u r i t i s o r M S b y t h e m e t h o d s u s e d . S e r u m I g G levels w e r e c o n s i s t e n t l y higher than normal when optic neuritis was accompanied by other neurological signs, but normal when optic neuritis was the only symptom. Serum IgG concent r a t i o n s in M S w e r e m o s t l y w i t h i n t h e n o r m a l r a n g e . T h e r a t i o o f B cells
192
U. T r a u g o t t
Table 4. Multiple sclerosis Blood values Pat.
Age (years)
Sex
Diagnosis
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg%
1
35
f
Relapse
14.7.
25
70
126
1080
169
2
32
m
Relapse
16.7.
27
73
126
1420
169
3
29
f
Relapse
16.7. 2.8.
23 31
79 74
146 191
1200 1780
148 154
4
36
m
Relapse
20.7.
--
--
384
1830
184
5
29
f
Relapse
4.5.
25
70
218
1000
228
6
33
f
Relapse
2.8.
30
68
205
2150
256
7
19
f
Chronic
29.6.
31
82
119
870
190
8
32
f
Chronic
16.7.
--
--
339
1510
96
9
36
f
Chronic
21.5.
33
60
159
1330
166
10
65
f
Chronic
21.5.
28
72
251
1080
249
11
34
f
Chronic
31.5.
31
66
187
1330
157
12
30
m
Chronic
1.6.
--
--
131
820
94
13
35
m
Chronic
29.7.
--
--
126
1420
208
14
52
f
Chronic
24.6.
27
77
408
1740
91
15
45
f
Chroni~
3.6.
14
73
96
1360
107
14 33
60 79
96 408
820 2150
91 256
27
72
201
1370
167
Range
from to
M e a n value
Table 5. P o l y n e u r o p a t h y s y n d r o m e Blood values Pat.
Age (years)
Sex
Diagnosis
Date tested
B cells %
T cells %
IgA mg%
IgG mg%
IgM mg% 310
1
20
f
Guillain-Barr6
11.5.
--
--
187
1120
2
62
m
Guillain-Barr6
27.7.
16
72
312
1330
148
3
51
m
Guillain-Barr6
2.8.
24
70
321
1600
232
4
28
m
Guillain-Barr6
2.8.
--
--
356
2040
162
5
34
f
Inflammatory
4.6.
--
--
217
1320
157
6
51
m
Inflammatory
12.7. 21.7. 2.8.
-49 --
-52 --
225 169 126
1280 1240 1740
190 80 80
7
48
m
Inflammatory
28.7.
--
--
135
850
122
8
56
m
Degenerative
22.7.
--
--
199
1240
114
9
72
f
Degenerative
2.8.
32
73
241
1510
133
16 49
52 73
126 356
850 2040
80 310
30
67
226
1388
157
Range M e a n value
from to
T and B Lymphocytes
in t h e C S F
193
CSF values B cells %
T cells %
Alb. mg%
IgA mg%
IgG mg%
IgM mg%
T o t . P r o t . Cell Alb. rag% count/3 Quot.
IgA Quot.
IgG Quot.
IgM Quot.
17
77
25.3
--
13.1
--
48.7
7
0.52
--
0.27
--
23
78
27.9
--
7.7
--
41.0
5
0.68
--
0.19
--
15 22
82 84
21.2 21.2
---
8.6 7.9
---
37.5 36.2
25 22
0.59 0.59
---
0.23 0.22
---
12
88
29.0
0.2
10.2
--
54.0
38
0.54
0.004
0.19
--
18
66
24.5
1.0
5.0
--
73.7
10
0.33
0.014
0.07
--
20
85
32.6
--
20.0
--
63.7
25
0.51
--
0.31
--
19
75
24.5
--
2.6
--
37.5
7
0.65
--
0.07
--
16
69
23.0
2.9
12.4
--
51.2
6
0.45
0.06
0.24
--
20
76
33.6
--
11.0
--
66.3
8
0.51
--
0.17
--
24
60
27.9
--
6.9
--
51.0
7
0.55
--
0.14
--
26
76
13.0
--
8.2
--
28.7
13
0.45
--
0.29
--
30
73
34.5
--
6.3
--
56.0
10
0.62
--
0.11
--
24
78
24.5
--
2.8
--
38.7
12
0.63
--
0.07
--
14
77
23.0
2.8
14.6
--
56.2
6
0.41
0.05
0.26
--
18
78
15.9
--
4.1
--
32.5
21
0.49
--
0.13
--
12 30
60 88
13.0 34.5
0.2 2.9
2.6 20.0
---
28.7 73.7
5 38
0.33 0.68
0.004 0.06
0.07 0.31
---
21
76
25.1
1.7
8.8
--
48.3
14
0.53
0.032
0.22
--
IgM mg%
Tot. Prot. Cell mg% count/3
Alb. Quot.
IgA Quot.
IgG Quot.
IgM Quot. --
CSF values B cells %
T cells %
Alb. mg%
IgA mg%
IgG mg%
35
61
94.8
1.7
11.0
--
126.2
6
0.75
0.013
0.09
34
58
72.8
1.4
7.4
--
95.0
11
0.77
0.015
0.08
--
26
71
67.2
2.6
18.0
--
123.7
5
0.54
0.021
0.15
--
88.7
8
0.71
0.011
0.13
--
28
56
63.2
1.0
11.4
--
29
62
21.2
--
2.1
--
38.8
12
0.55
--
0.05
--
24 24 35
68 68 61
39.5 35.6 20.6
-1.1 0.1
6.9 6.7 5.6
-3.2 2.4
63.7 58.0 38.7
356 822 527
0.62 0.61 0.53
-0.019 0.003
0.I1 0.12 0.15
-0.06 0.06
27
72
115.0
0.9
11.0
1.1
145.0
18
0.79
0.006
0.09
0.007
35
54
37.4
0.2
2.6
--
48.7
4
0.77
0.004
0.05
--
32
48
26.4
--
3.3
--
36.2
2
0.73
--
0.09
--
24 35
48 72
20.6 115.0
0.1 2.6
2.1 18.0
1.1 3.2
36.2 126.2
2 822
0.53 0.79
0.003 0.021
0.05 0.15
0.007 0.06
30
61
53.9
7.8
2.1
78.4
161
0.67
0.012
0.10
0.06
1.12
U.Traugott
194 Table 6. Varia
Blood values Pat.
Age Sex (years)
Diagnosis
Date tested
B cells T cells IgA % % mg%
1 2 3 4 5 6 7 8 9 10 11 12
8 58 12 13 42 62 48 34 65 43 32 42
Meningeosis leukemica Stroke Adrenoleucodystrophy Epilepsy ~strocytoma Metastasis Cephalea Cephalea Plexus lesion Discopthy Funic. myelosis Myasthenia
18.3 7.4 15.4. 30.6. 8.4. 4.6. 28.6. 6.8. 21.7. 7.7. 20.7. 22.7.
. -25 ---28 19 -21 -36
f f m m m f f m f f m m
.
. -83 -. -74 76 -77 -77
. 146 172 146 . . 312 342 -181 199 413 264
IgG mg%
IgM mg%
900 4340 1310 . 970 1120 -1280 1000 1460 1780
101 167 154
.
148 283 -127 122 122 148
( m e a n = 1 8 % ) to T cells ( m e a n = 7 2 % ) in the C S F in optic neuritis without other neurological signs was similar to that seen in viral meningitis. W h e n optic neuritis was a c c o m p a n i e d by neurological signs, the m e a n percentage of B cells was 28%, of T cells 60%. A m e a n of 18% B cells a n d 80% Tcells was f o u n d in the C S F in relapsing multiple sclerosis. The m e a n B cell value was 21%, a n d of T cells 74% in chronic progressive MS. After treatment with Synacthen, B cell values in the C S F increased b u t the percentage of T cells was consistently high in one p a t i e n t with relapsing MS. In the same patient, T cell values decreased in the circulation.
Neuromyelitis Optica. One
patient with neuromyelitis optica (Devic's disease) was studied 7 m o n t h s after onset of the disease. Changes in the C S F in this case were more similar to those seen in MS t h a n in optic neuritis. Total protein c o n t e n t a n d cell n u m b e r were slightly elevated; the percentage o f T cells was increased a n d B cell values were decreased. Quotients of all three i m m u n o g l o b u l i n classes were elevated. All serum values were within the n o r m a l range.
Guillain-BarrO Syndrome and Polyneuritis. In the C S F samples from the G u i l l a i n Barr~ s y n d r o m e a n d in some from patients with polyneuritis, the total protein c o n t e n t was elevated. In the Guillain-Barr6 syndrome, the quotients of IgA a n d I g G were more frequently elevated t h a n i n polyneuritis, a m a j o r inf l a m m a t o r y disease of the peripheral nervous system. This difference could be related to neuroallergic m e c h a n i s m s which are believed to be operative in the pathogenesis of the Guillain-Barr6 syndrome. I m m u n o g l o b u l i n p r o d u c t i o n leading to an elevation in i m m u n o g l o b u l i n levels in polyneuritis usually was f o u n d n o t to start before 1 to 2 weeks after onset of the disease. I n the C S F of b o t h groups of diseases, the percentage of B cells a n d T cells were within the n o r m a l range. I m m u n o g l o b u l i n levels in the serum were n o r m a l , except one elevated I g G value.
T and B Lymphocytes in the CSF
195
CSF values B cells %
T cells Alb. % rag%
IgA mg%
IgG rag%
IgM mg%
Tot. Prot. Cell Alb. mg% count/3 Quot.
52 30 25 21 31 9 26
6 72 60 63 67 83 69
10.9 19.6 27.9 11.7 73.5 126.5 22.2
--0.15 -3.3 7.7 0.6
0.3 2.1 4.3 1.6 21.7 29.0 3.3
--0.1 -4.2 2.4 --
21.2 27.5 50.0 17.5 122.5 190.0 40.0
382 40 8 6 16 13 14
36 34 21 13 24
58 57 56 72 62
13.8 23.0 25.3 38.5 27.9
---1.3 0.1
1.3 3.1 2.8 4.8 2.8
------
20.2 36.2 41.2 52.5 43.7
2 7 9 3 7
IgA Quot.
IgG Quot.
IgM Quot.
0.51 0.71 0.56 0.67 0.60 0.67 0.56
--0.003 -0.027 0.045 0.015
0.014 0.08 0.09 0.09 0.18 0.15 0.08
--0.002 -0.034 0.012 --
0.68 0.64 0.61 0.73 0.62
---0.025 0.002
0.06 0.09 0.07 0.09 0.06
------
Various Neurological Diseases. T h e results o f the C S F samples f r o m ten adults a n d three children with v a r i o u s n o n - i n f l a m m a t o r y n e u r o l o g i c a l diseases studied, were s u m m a r i z e d in the " v a r i a " group. T o t a l p r o t ei n c o n t e n t an d cell n u m b e r were n o r m a l or slightly elevated a c c o r d i n g to the variety o f disease processes i n c l u d e d in this group. T h e percentage o f B cells in the C S F in meningeosis l e u k e m i ca was a b n o r m a l l y high whereas T cell levels were low. This altered B cell to T cell ratio in the C S F agrees with a previous r e p o r t o n l y m p h o c y t e changes in the b l o o d [3], in which it was s h o w n that p a t h o l o g i c a l cells in l y m p h a t i c l e u k e m i a f r e q u e n t l y originate f r o m B cells. T h e percentage o f T cells in the C S F was elevated once in f u n i c u la r myelosis a n d cerebral metastasis. B cell an d T cell values were within the n o r m a l range in o n e a s t r o c y t o m a studied. All o t h er C S F samples o f the varia g r o u p h a d slightly higher B cell levels an d a l o w er percentage o f T cells when c o m p a r e d with the c o r r e s p o n d i n g b l o o d values. S e r u m i m m u n o globulin levels were within n o r m a l limits in the v ar i a group, except for elevated I g G values in one case o f a d r e n o l e u k o d y s t r o p h y . Discussion In the present study o n the C S F a n d b l o o d o f a variety o f n e u r o l o g i c a l diseases, the p e r c e n t a g e o f B cells and T cells as well as i m m u n o g l o b u l i n levels were studied. Th e B cell to T cell ratio in the C S F was f o u n d to be ch an g ed in viral i n f l a m m a t o r y diseases o f the C N S where the percentage o f B cells was decreased a n d T cells increased when c o m p a r e d with the c o r r e s p o n d i n g values in the blood. S i m i l ar but less m a r k e d changes were f o u n d in optic neuritis an d relapsing multiple sclerosis. I m m u n o g l o b u l i n levels were elevated in i n f l a m m a t o r y diseases o f the C N S . H i g h I g G values were a c o n s t a n t finding in MS, but in optic neuritis the I g G c o n c e n t r a t i o n s were n o r m a l . F o r the diagnosis o f
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inflammatory diseases of the CNS, pleocytosis in the CSF is an important criterion. Pleocytosis predominately reflects inflammation of the meninges rather than inflammatory lesions in the parenchyma. This concept was supported by the observation that CSF samples from patients with myelitis with severe clinical signs either had pleocytosis or a normal number of cells. The increased number of T cells in the CSF of viral infections of the CNS might reflect an activation of the cellular immune response. The difference in the percentage of T cells and B cells between the CSF and blood might indicate that there is no strict correlation between the T cell and B cell values in the two compartments. Furthermore, the elevation of CSF T cells might reflect an accentuation of the cellular immune reaction within the subarachnoid space, which could be detected for several weeks. In this regard, Hampe| has shown, that viral diseases of the CNS can only be overcome in the presence of intact T cells. Antibodies produced during a viral infection protect mainly against later disease [5]. In one patient with chronic progressive herpes myelitis, the percentage of T cells in the CSF was abnormally low. In this case it might be regarded that in addition to the quantitative changes in T cells, these might also have been qualitatively insufficient. Both factors might have supported the chronic course of the disease. Similar CSF changes to those seen in viral inflammatory diseases of the CNS were also found in optic neuritis. These consisted of an acute phase reaction (elevation of the quotients of acid a 1 glycoprotein and haptoglobin), slightly increased total protein content and cell number, but IgG quotients were normal. Also, the percentage of CSF T cells was increased leading to a reduced number of B cells. There is usually no acute phase reaction in the CSF of MS, the clinical manifestations of which probably develop many years after initial acquisition, but the IgG quotients are elevated and the increase of T cells is less significant. These differences in the CSF of optic neuritis and MS might not express two basically different types of pathological reactions of the subarachnoid space but could possibly reflect different time points or activities of a similar disease process. To prove this concept, CSF samples from a larger number of patients have yet to be studied longitudinally. The IgM detected in some CSF samples, may be due to several pathological conditions. Since IgM is a macromolecule, (MW about 1,000,000), its presence in the CSF could indicate damage to the b|ood-CSF barrier. In addition, SandbergWolheim has shown that IgM can also be synthesized locally within the CNS as has been shown previously for IgA and IgG. It is known that IgM is the first class of immunoglobulins produced in the serum, after challenge with an antigen. This is followed approximately 1 week later by the production of IgG antibodies following which IgM decreases progressively. Assuming the same relationship of antibody production with time in serum and CSF, the presence of IgM in the CSF for some weeks could be related to the persistence of the infectious agent (Burnet). A correlation between immunoglobulin levels and B cell values was not found in CSF or serum. In conclusion, it has been shown in viral inflammatory diseases of the CNS, t~at in comparison to corresponding blood values, the percentage of T cells in the CSF is elevated and of B cells is decreased. This elevation of T cells and decrease
T and B Lymphocytes in the CSF
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o f B cells c a n n o t be f o u n d in the C S F o f o t h e r n o n - i n f l a m m a t o r y diseases o f the CNS. W h e t h e r these o b s e r v a t i o n s m a y have d i a g n o s t i c significance m u s t a w a i t the analysis o f larger n u m b e r s o f samples.
References 1. Allen, J., Sheremata, W., Cosgrove, J. B. R., Osterland, K.: Cerebrospinal Fluid T and B lymphocyte kinetics related to exacerbations of multiple sclerosis. J. Neurology 25,352 (1975) 2. Bfyum, A.: Isolation of mononuclear cells and granulocytes from human blood. Scand. J. Lab. Invest. 21, suppl. 97, 77 (1968) 3. Graeves, M. F., Owen, J. J. T., Raft, M. C.: T and B lymphocytes. Origin, properties and roles in immuno-responses. New York: Exc. Med. (Ed. Elsevier) 1974 4. Hapel, A. J.: The protective role of thymus derived lymphocytes in arbovirus induced meningoencephalitis. Scand. J. Immunol. 4, 267 (1975) 5. Humphrey, J. H., White, R. G.: Kurzes Lehrbuch der Immunologie (Ed. E. Macher). Stuttgart: Thieme 1971 6. Mancini, A., Carbonara, A. C., Heremans, J. F.: Immunochemical quantitation of antigens by single radial immunodiffusion. Immunochemistry 2, 235 (1965) 7. Traugott, U., Eibl, M., Weippl, G., Harasek, G.: T und B Lymphozyten in Blut und Liquor bei Mumpsmeningitis. Paed. Paediol. 11,545 (1976) Received April 18, 1977
