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Case Analysis : Multiple System Atrophy

by Drs.Like Wu, Xiaojuan Wang and Bo Cheng


Multiple System Atrophy (MSA)

MSA is a kind of diffusive neurodegenerative disease which usually attacks during the adult period. The clinical manifestations show the autonomic nerve disorder with different degrees, the Parkinson syndrome with poor response to levodopa, cerebellar ataxia, and pyramidal sign and so on. Because the onset successions of the affected 3 systems are different, those clinical manifestations caused are also different. With the development of the disease, the pathological and clinical manifestations of those 3 systems damaged can be occurred finally. The epidemiological survey indicates the MSA annual incidence of the over 50 year-old group is about 3/100,000.

Because of the degeneration of the diffusive substantia nigra with or without the vegetative nerve function disorder and the increase of the usually concomitant clinical and pathological recognization of the Olivopentocerebellar atrophy, the individual performance of the above every symptom are different. The published study on large samples of a few of those complicated syndromes indicated the incidence of the disease and the nature of all kinds of syndromes. 13% of the patients with idiopathic Parkinson's disease are MSA patients, shown in a survey of UK Parkinson's disease association. All the MSA patients had over 1 symptom of vegetative neural insufficiency, which includes postural hypotension, urgent urination or urinary retention, gatism, hoarseness or stridor. Half of the patients have the Babinski syndrome, 1/3 of the patients have cerebellar ataxia. The quantity of the male patients is more than that of the female patients.

The research of MSA patients found that 46% of patients have striatonigral-Parkinson syndrome as the onset symptom, the bilateral affected areas are asymmetric usually; 41% of the patients have the vegetative nerve symptom as the onset symptom; the orthostatic hypotension will appear to all of the patients at last. 5% of the patients have the cerebellar sign as the primary symptom, while the ataxia will occur among over half of the patients in the end; 29% of the patients have a slight tremor as the onset symptom. We should make clear that MSA is more serious than Parkinso's disease because 40% of the patients will live in the wheelchair or gain a serious disability, generally, within the next 5 years. Although striatonigral degeneration, olivopentocerebellar degeneration, and shy-drager syndromes will occur together regularly, every disease can appear independently. The pathological features are: the neuron consumption and the necrosis fragments accumulate inside of the gliacytes (argyrophilia colloid inclusion body). WSCMC thinks it plays a very important role in the pathogenesis that this aggregates inside the cytoplasm of the gliacytes making the onset and development of the degenerative diseases.

Classification of disease

MSA includes Shy-Drager syndrome (SDS), striatonigral degeneration (SND) and Olivopontocerebellar astrophy (OPCA), 3 types. According to the clinical manifestation, it can be classified into 2 kinds of clinical subtypes, 1 clinical subtype, Parkinson syndrome as main clinical manifestation is called MSA-P type, the other clinical subtype, cerebellar ataxia as main clinical manifestation is called MSA-C type.

The cause and Pathogenesis

The cause of the disease is not clear. The pathological symbol of MSA is that the eosinophilic inclusion body can be found in the cytoplasm of the neuroglia cell with the neuron losing and gliacyte hyperplasia.

Recently, it is thought that the pathogenesis of MSA probably has 2 ways: the first is, the pathological changes hypothesis of primary oligodendrocyte, the oligodendrocyte degeneration of a-synuclein positive inclusion body as the feature appears first, which leads to the myelinoclasis and degeneration of the neurons, activates the microglia cells, induces the oxidative stress, then causes the degeneration and death of the neurons. The second is, a-synuclein of the neuron abnormally accumulates, which causes the degeneration and death of the neurons. The cause of a-synuclein accumulation is not clear, although it is probably related to the genetic predisposition and environmental factors.

Clinical Manifestation

Adult-onset, many patients had MSA whose ages are from fifty to sixty years old, the average age of patients at the onset of the disease is 54.2 years old. The morbidity of male is higher than female. The disease onset is slow and progresses gradually. First symptoms of MSA are the autonomic nerve dysfunction, Parkinson's syndrome and cerebellar ataxia. A few patients also have an onset with amyotrophy.

Regardless of the start of the disease, with what kind of nervous system symptoms, when the disease progresses further, there will be two or more systematic neural symptoms group following:

1. Autonomic dysfunction
Autonomic dysfunction is often the first symptoms of MSA disease. Autonomic dysfunction is also one of the most common symptoms. Common clinical manifestations: urinary incontinence, frequent urination, urgent micturition, urinary retention, male erectile dysfunction and postural hypotension. This is accompanied with swallowing difficulty, anisocoria, Horner syndrome, asthma, apnea and breathing difficulty. If the disease is serious, it leads to tracheotomy. Speckled hands and hands that are cold to the tough are caused by autonomic nerve dysfunction, it has characteristics. The earliest symptom for males are erectile dysfunction, the earliest symptom for females is urinary incontinence.

2. Parkinson syndrome
Parkinson's is an outstanding symptom of MSA-P subtype. Parkinson's is also one of the most common symptoms of other subtypes, as well. The characteristic of MSA'S Parkinsonism is bradykinesia. This is accompanied with myotonia, a tremor involving both sides, but the degree is different. Many patients have an insufficient therapeutic response to L-dopa. This is liable to appear as dyskinesia's and other adverse reactions.

3. Cerebellar ataxia
Cerebellar ataxia is an outstanding symptom of MSA-C subtype. This is also one of the most common symptoms of other subtypes, as well. The clinical manifestation is a progressive gait disorder and limbs ataxia. This is accompanied with obvious dysarthria, nystagmus and cerebellar ataxia.

4. Others
(1) 20% patients have mild cognitive function impairment.
(2) Common with swallowing difficulty, dysphonia and other symptoms.
(3) Sleep disorders, such as sleep apnea, and REM sleep behavior disorder and so on.
(4) Other extrapyramidal systems: dysmyotonia, palatal myoclonus and myoclonus. Stimulus of the hand and the face, the myoclonus is the characteristic performance of MSA.
(5) Some patients have muscle atrophy; later stages have hypermyotonia, tendon hyperreflexia, and optic atrophy. A few patients have ophthalmoplegia, where the eyeballs have gaze palsy up one side or down one side.

Disease prognosis
The prognosis for most patients with MSA are not good. The average time from initial symptom progress to combine dyskinesia (pyramidal system, extrapyramidal system and cerebellar sports disorder) and autonomic nerves system function disorder is 2 years. The average interval from the onset of disease to assistant walk, wheel chair, bed-ridden and failure is 3 years, 5 years, 8 years and 9 years.

The conventional treatment mainly includes symptomatic treatment and rehabilitation therapy but they are not shown to be effective. All kinds of medication therapy cannot hold back the degeneration and necrosis of the neurons and oligodendrocytes. In recent years, WSCMC found that the treatment of supplying neural stem cells, to directly increase the quantity of the neural cells in brain and repair the neural damage partly, while the neural stem cells carry normal genes, they can express normal functions and produce proteome following the proper medication controlling, those proteins with normal structures can replace the functions of abnormal proteins caused by the patients gene mutation, and decrease the quantity of accumulation inside gliacyte cytoplasm. It can partly restore neural functions; slow down the disease progress for MSA, Parkinson's disease, dementia with Lewy bodies, and a series of the degenerative diseases. But it only leads to 10% of the cells survival; the neural stem cells are injected without the proper medication guideline, while the cells location is probably difficult. Based on almost a 10-year research, WSCMC has a unique implanted stem cell location technology and adjusting technology in vivo, which can obviously increase the function level of the location and differentiation and activation of the implanted stem cells in vivo, so that leads to target the effective treatment, improve the patients' life quality and the implanted cells survival period.

Case analysis:

Drs. Xiaojuan Wang and Dr. Like Wu

MSA (Multiple System Atrophy) is a kind of multiple CNS degeneration and atrophy with no clear cause. The following is a case of MSA that we were successful in treating.

Medical history:

Patient is a 65-year-old female; she was presented with progressive motor disturbance of her four limbs and has had difficulty with her speech for more than 2 years, her symptoms have been aggravated for more than half a year. She had walking problems in December of 2006, then the disease progressed quickly, she had severe tremors in her four limbs. Patient has been diagnosed with Parkinson's disease and has received anti-PD treatment, but the treatment effects were not good. Her condition continued to deteriorate and she had slurring of her speech, choking problems, difficulty swallowing, difficulty opening her mouth, and slow movement and balance disturbances that gradually became aggravated. It was hard work for her to get out of bed, roll over, walk and turn around. Patient cannot perform fine motor movements and has to write slowly, but she can walk a few steps slowly with an assistant. Patient was diagnosed with MSA in August, 2007. About a half a year before her treatment, her condition had greatly deteriorated: the disturbance in her movements was much worse, she had severe rigidity in all four of her limbs, she could not completely do any voluntary movements, she could not walk, had difficulty opening her mouth, could not eat any solid food by herself. Patient had hypertension for more than 20 years, and suffers from depression. In February of 2005 the patient received a thyroidectomy because of thyroid cancer. She had a bone fracture in her right arm in 2006 and her arm remains deformed. She received a cholecystectomy in 2007. Patient has no medical history of diabetes, CHD, hepatitis, tuberculosis or other infectious diseases. No history of drug allergies.

Admission PE:

Bp 130/70mmHg, Hr 83/min. No remarkable signs of problems with her heart, lungs and abdomen. There is mild pitting edema of her lower limbs.

Neural system examination: alert, mask face, slurred speech, anarthria, her memory, calculation and orientation abilities are all normal. Bilateral pupils are equal and round, diameter is about 2mm. Both eyes have slow reflex to light. The bilateral pupils move slowly, with limitation and mild nystagmus. She had tremors in the muscles of her tongue. Muscle force of upper limbs is 4 degrees, of the left lower limb is 2 degrees, of the right lower limb is 1 degree. Muscle tone increased, and her lower extremities had severe cogwheel rigidity. Tendon reflexes are weaker than normal. Sucking reflex is negative, palmental reflex is positive, Hoffmann sign of both sides is positive, Babinski sign in right side is positive. Sensory system is ok. She cannot participate successfully with the medical examination of her coordinate movements because of her high muscle tone. She suffers from neck rigidity and has to maintain a special posture as a result. Kerning sign is negative, and Brudzinski sign is negative.

Assistant examination:

Brain MRI: Bilateral frontal lobe, pons and cerebellum atrophy.

Diagnosis: MSA

Treatment procedure:

Patient was given treatment to control blood pressure, expand blood vessels, anti-free radicals, nourish neurons, stabilize the cell membrane. This was combined with the neural stem cells activation treatment. After 7 weeks of treatment, the patient's condition greatly improved, her muscle tone decreased quickly, she could lift her head and turn her head to both sides. The movement ability of all her limbs improved noticeably. Muscle force of the upper limbs is 5 degrees, she can do some voluntary movement, and she can lift her arm to her head. Muscle force of the left lower limb recovered to 4 degrees, muscle force of the right lower limb is 3+ degrees. Patient can open her mouth and speak, she still speaks slowly, but her voice is stronger than before. She can chew food by herself, and now she can eat normally.

Case analysis:

MSA is the aggregation of alpha-synuclein, mybe accompany with vegetative nerve functional disturbance.There is a series of symptoms associated with clinical pathological change which includes OPCA (oliva-pons-cerebella atrophy), sporadic degeneration of the nigrostriatal system, accompanied with vegetative nerve functional disturbance: Parkinson's symptoms (tremors, rigidity, walking difficulty); vegetative nerve functional damage (it is related to the loss of lateral horn cells and brain stem pigment group cells. The clinical symptoms are orthostatic hypotension, swoon, impotence, adiapneustia, thirst, urinary retention,fecal incontinence. In general, paralysis of the vocal cords is the most important and earliest symptom of vegetative nerve functional disturbance, (patient always experiences hoarseness); cerebella symptoms and pyramidal signs. The symptoms will be different for every patient, so in 1969, Dr. Graham and Dr. Oppenheimer proposed naming this complicated disease MSA. But currently doctors still cannot find an effective solution.

MSA is a kind of neurodegenerative disorder, through the causal mechanisms research performed on the molecular level; we can see that the amyloidal change of the CNS lead by the aggregation and aggradation of hemoprotein is the most important mechanism. That means in the affected neurons, and in the spongiocyte cells, those high soluble proteins can turn into insoluble fibrous polymers, which can transfer into fibrous amyloid deposits which will deposit in the endochylema, cell nucleus and the spatium of extracellulars. These degenerated proteins/ polymers have great neurotoxicity, and they can lead to the damage and death of neurons.

According to recent research, neural stem cells can improve the patient's vegetative nerve, cerebellar extrapyramidal symptoms and movement disturbances effectively. On the one side, these stem cells (neural stem cells and bone marrow mesenchymal stem cells) have a complicated and elaborate self controlling system; they can prevent the protein's malconstruction and aggregation: molecular chaperone can help the proper protein folding, and prevent the accumulation of non-natural proteins. We can use medication to accelerate the degradation of these malconstructed proteins and endocytose through the ubiquitin-protease bodies system. It can block the development of the disease effectively. On another side, these stem cells can locate in the damaged area of the neural system, repair the damage and help the patient regain more neural functioning.

For these cases, we have a comprehensive treatment for the patient:

1. Improve the internal microenvironment.

2. Stem cells implantation and treatment to help these stem cells locate in the damaged area.

3. Rebuild the neural system; improve the patient's neural functioning.

After the 3 steps of treatment were completed, the patient's condition had obvious improvements. In general, the MSA patient will still have nonreversible neurodegeneration, while the treatment results showed that neural stem cells implantation treatment can be effective for MSA patients. Now we still need further observation and randomized controlled research to verify our findings.

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