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Am. J. Trop. Med. Hyg., 78(1), 2008, pp. 20-27
Copyright © 2008 by The American Society of Tropical Medicine and Hygiene

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Association of Matrix Metalloproteinase-9 and Tissue Inhibitors of Metalloproteinase-4 in Cerebrospinal Fluid with Blood-Brain Barrier Dysfunction in Patients with Eosinophilic Meningitis Caused by Angiostrongylus cantonensis

Hung-Chin Tsai, Li-Yu Chung, Eng-Rin Chen, Yung-Ching Liu, Susan Shin-Jung Lee, Yao-Shen Chen, Cheng-Len Sy, Shue-Ren Wann, AND Chuan-Min Yen*
Section of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital 386, Kaohsiung City, Taiwan, Republic of China; National Yang-Ming University, Taipei, Taiwan, Republic of China; Department of Parasitology and Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China


ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
To evaluate possible blood-brain barrier (BBB) dysfunction caused by matrix metalloproteinase-9 (MMP-9) and its regulation by tissue inhibitors of metalloproteinase (TIMPs) in patients with eosinophilic meningitis caused by infection with Angiostrongylus cantonensis, 40 patients and 28 controls were included in this study. Concentrations of MMP-2, MMP-9, TIMP-1, and cerebrospinal fluid (CSF):serum albumin ratios (QAlb values) were significantly increased in patients compared with controls. However, concentrations of TIMP-4 were significantly lower in patients. In contrast to MMP-2, proteolytic activity of MMP-9 detected by gelatin zymography was only observed in patients with eosinophilic meningitis. We detected higher levels of antibodies specific for A. cantonensis and higher QAlb values and MMP-9 concentrations in CSF of patients with eosinophilic meningitis, Furthermore, the increase in the QAlb value was significantly correlated with the increase in MMP-9 in patients. In parallel with CSF MMP-9, patients also showed an increase in CSF leukocyte counts. Gradual decreases in levels of QAlb, MMP-9, and TIMP-1 and increases in levels of TIMP-4 were observed in six patients during recovery from eosinophilic meningitis. These results suggest that the source of MMP-9 in CSF of patients with eosinophilic meningitis was probably associated with leukocytes migrating from peripheral blood to CSF. Activity of MMP-9 in CSF of patients could not be completely inhibited because of the decrease of TIMP-4, which may cause BBB dysfunction, as shown by higher QAlb values in patients.


INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Angiostrongylus cantonensis, a nematode parasite, is the most common cause of eosinophilic meningitis in the Pacific Islands and southeast Asia. Rats serve as the definitive host of this nematode. If an infection occurs in non-permissive hosts, including humans and mice, the development of the parasites will terminate at the young adult worm stage in the brain and cause eosinophilic meningitis or meningoencephalitis.1–4 Several indices, such as an elevated level of cerebrospinal fluid (CSF) total protein, CSF leukocyte count, or CSF:serum IgG ratio have been developed to assess the blood-brain barrier (BBB) integrity in a person with a central nervous system (CNS) infection.5 An elevated CSF:serum albumin ratio (QAlb) is an index of BBB leakage in human immunodeficiency virus–seropositive patients with neurologic diseases.6 In a mouse model of eosinophilic meningitis caused by A. cantonensis infection,7 researchers showed that dysfunction of the BBB occurred in mice infected with A. cantonensis. This was supported by the high concentrations of protein and albumin in CSF, high leukocyte counts in CSF, high ratio of CSF:serum protein and albumin, and high permeability of BBB.7

Development of a neurologic syndrome in mice with eosinophilic meningitis might be a result of alternations in the BBB that lead to an increased migration of leukocytes into the CNS.7,8 Entry of leukocytes into the CNS is dependent on several factors including the expression of matrix metalloproteinases (MMPs).8,9 The MMPs constitute a family of zinc-binding endopeptidases characterized by their ability to degrade various extracellular matrixes.10 The activity of MMP is highly regulated both at the level of gene expression and by activation of latent pro-MMP to active enzymes.11 In the extracellular milieu, the activity of these enzymes is controlled by four natural tissue inhibitors of matrix metalloproteinases (TIMPs). Changes in the fine balance between MMP and their tissue inhibitors drives extracellular matrix turnover and may be critical to inflammation in infection as well as other pathologic conditions, including neurotoxicity.12 Of these endogenous inhibitors, TIMP-1 primarily complexes with MMP-9 and MMP-2 is bound by TIMP-2 or TIMP-4.13 In addition to their direct MMP-inhibitory activity, TIMP-1 and TIMP-3 are capable of inhibiting a variety of proteases including tumor necosis factor {alpha} (TNF-{alpha})–converting enzyme,14 which is a key mediator of inflammation in meningitis. Expression of TIMP-2 is mainly constitutive,15,16 whereas TIMP-4 shows a highly restricted tissue distribution. cDNA encoding TIMP-4 was first cloned from a human heart cDNA library,17 and TIMP-4 appears to be normally expressed at high levels only in the heart,17,18 but is induced upon vascular injury19 and is an angiogenesis inhibitor.20 TIMP-4 is a 23-kD protein that inhibits MMP-1, MMP-3, MMP-7, and MMP-9, and shows a particular interaction with MMP-2.21

There is little information available on the regulation of the matrix-degrading enzymes in the brain microenvironment by their TIMP inhibitors in patients with eosinophilic meningitis. In the animal study of Chen and others,22 they found that the expression of MMP-9 in CSF was significantly increased in mice with eosinophilic meningitis compared with that in uninfected controls. The protein contents of CSF correlated significantly with MMP-9 intensity and CSF eosinophilia. Given that no human data are currently available on levels of MMP/ TIMP in CSF of patients with eosinophilic meningitis, we investigated the regulation of MMP-2, MMP-9, and TIMPs in the CSF of such patients.


MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients and controls. The CSF samples were obtained from 40 patients with eosinophilic meningitis who came to the Kaohsiung Medical University Hospital, Kaohsiung Veterans General Hospital and several other hospitals in southern Taiwan. All CSF samples were obtained from patients who underwent lumbar puncture immediately at admission and before treatment. The study protocol was reviewed and approved by the Commission on Medical Ethics of the Kaohsiung Veterans General Hospital. Patients were enrolled in the study only if informed consent was obtained. The clinical definition of eosinophilic meningitis was an acute onset of headache and eosinophil pleocytosis in the blood/CSF accompanied by at least of one of the following symptoms: fever, ataxia, visual disturbances, photophobia, nuchal rigidity, neck pain, hyperesthesias, or paresthesias.23–26 Immunodiagnosis for patients was based on presence of antibodies to A. cantonensis in serum and CSF detected by an enzyme-linked immunosorbent assay (ELISA) using young adult worm antigen with a mass of 204 kD that was purified by monoclonal antibody.27 All patients were immediately treated with mebendazole after the first CSF examination. Only six patients were treated with mebendazole and dexamethasone, and CSF was examined weekly until the fourth week after treatment. However, no patients died of this infection and no neurologic sequelae were noted. The CSF control group (n = 28) consisted of patients with headaches or consciousness disturbance who underwent lumbar puncture for exclusion of tumor, subarachnoidal hemorrhage, inflammatory disease, or meningitis. The CSF samples were centrifuged and the supernatants were frozen at –80°C until assayed.

Measurement of QAlb value. Concentrations of albumin in the CSF and serum of all specimens were measured by a commercial kit (BioAssay Systems, Hayward, CA). The ratio of CSF albumin to serum albumin was calculated with their individual concentrations using the formula: QAlb = CSFAlb/serumAlb x 103.

Enzyme-linked immunosorbent assay for MMPs and TIMPs concentrations. Concentrations of MMP-2, MMP-9, TIMP-1, TIMP-2, and TIMP-4 were measured with ELISA Kits (R & D Systems, Minneapolis, MN). The assay was performed according to the manufacturer’s instructions. Wells of the ELISA plate were first coated with antibodies that captured MMP-2, MMP-9, TIMP-1, TIMP-2, and TIMP-4 in CSF specimens after adding the specimens to the wells. Biotinylated detection antibodies and streptavidin-labeled horseradish peroxidase (HRP) were then added to the wells. Substrate (3,3',5,5'-tetramethylbenzidine) solution was used for visualization. Reactions were stopped with 2 N sulfuric acid. Optical density (OD) values were read at 450 nm.

Gelatin zymography. Activity of MMPs was analyzed by modified sodium dodecyl sulfate–polyacrylamide gel electrophoresis. Stacking gels contained 4% polyacryamide and separating gels contained 12.5% polyacrylamide and 0.1% gelatin. The CSF was centrifuged at 10,000 x g for 15 minutes at 4°C to remove debris. Protein contents of supernatants were then mixed with an equal volume of 2x non- reducing sample buffer and 25 µL was loaded per well. The gel was subjected to electrophoresis at 90V and 4°C in running buffer (25 mM Tris, 250 mM glycine, 0.1% sodium dodecyl sulfate) until the bromophenol blue marker dye reached the bottom of the gel. After electrophoresis, the gel was washed twice with gentle agitation (30 min per wash) in 2.5% Triton X-100 at room temperature. After decanting the washing solution, the gel was equilibrated with developing buffer (50 mM Tris-HCl, pH 7.5, 200 mM NaCl, 5 mM CaCl2, 0.02% Brij-35, 0.01% NaN3) for 30 minutes at room temperature with gentle agitation. The gel was then placed in fresh developing buffer and incubated at 37°C for 18 hours. The gel was stained with 0.25% Coomassie Brilliant Blue R-250 (Sigma, St. Louis, MO) for 1 hour and was destained in 15% methanol/7.5% acetic acid. Gelatinase activity was detected as unstained bands on a blue background.

Statistical analysis. Concentrations of MMP-2, MMP-9, TIMP-1, TIMP-2, and TIMP-4 in CSF and QAlb between patients and controls were compared by using the Mann-Whitney U test. Correlations were quantified by using the Pearson correlation test. All results were presented as the mean ± SD. A P value < 0.05 was considered statistically significant.


RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Demography of patients with eosinophilic meningitis and controls. Eosinophilic meningitis caused by the infection with A. cantonensis was diagnosed by clinical manifestations and positive results in immunodiagnosis for A. cantonensis antibody in 40 patients. The CSF control group (n = 28) consisted of patients with headache or consciousness disturbance who underwent lumbar puncture for exclusion of tumor, subarachnoidal hemorrhage, inflammatory disease or meningitis. Their CSF parameters were normal. The CSF antibody level in the patient group (mean ± OD = 0.97 ± 0.38) was significantly higher than the level in the control group (mean ± OD = 0.16 ± 0.06) (P < 0.001, by Mann-Whitney U test). Some of the patients had CSF and peripheral leukocyte counts and percentage eosinophils values available. These patients had peripheral blood leukocyte counts of 10,139 ± 1,770 x 103 cells/µL (range = 6,990–13,600 x 103 cells/µL, n = 13), 26 ± 10% (range = 11–43%, n = 12) eosinophils in peripheral blood, CSF leukocyte counts of 989 ± 570 x 103 cells/µL (range = 139–1,660 103 cells/µL, n = 14), and 37 ± 24% (range = 6–70%, n = 13) eosinophils in CSF.

Measurement of QAlb values and MMP and TIMP concentrations. The QAlb values and concentrations of MMPs and TIMPs in examined specimens are shown in Table 1Go. There were increases in concentrations of MMP-2, MMP-9, and TIMP-1 in the patients group compared with controls. The mean QAlb values of patients were significantly higher than those of controls (P < 0.001). The mean concentration of MMP-2 in CSF of patients with eosinophilic meningitis was significantly higher than that of controls (P < 0.05). We observed only a moderate increase in MMP-2 in CSF of patients (approximately 3 ng/mL). However, the mean concentration of MMP-9 in CSF of patients with eosinophilic meningitis was higher (> 5-fold) than that of controls (P < 0.001). TIMP-1, TIMP-2, and TIMP-4 were detectable in all CSF samples. TIMP-1 increased six-fold in patients with eosinophilic meningitis compared with controls. However, no significant difference was observed in TIMP-2 concentrations between the two groups. In contrast to levels of TIMP-1, TIMP-4 concentrations were significantly decreased in the patient group (392.65 ± 158.04 pg/mL) than in controls (1,311.94 ± 760.39 pg/mL) (P < 0.001, by Mann-Whitney U test).


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TABLE 1
Mean ± SD (ranges) QAlb values and concentrations of MMPs and TIMPs in CSF of patients with eosinophilic meningitis caused by Angiostrongylus cantonensis infection*
 
Relationship between antibody levels and QAlb values or MMP-9 concentrations in patients. Significantly higher antibody levels were observed in CSF of patients than in controls (P < 0.001). We examined the correlation of antibody levels with QAlb value or MMP-9 concentrations in patients with eosinophilic meningitis. Levels of antibodies to A. cantonensis in CSF of patients showed a significant correlation with the levels of QAlb (r = 0.837, P < 0.0001) and MMP-9 (r = 0.870, P < 0.0001). The higher the antibody level in CSF of patients, the higher the QAlb value and MMP-9 concentration, as shown in Figures 1Go and 2Go, respectively.


Figure 1
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  		    FIGURE 1. Relationship between antibody levels and cerebrospi-nal fluid (CSF):serum albumin ratios (QAlb values) in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis infection. Antibodies in the cerebrospinal fluid specific for young adult worm antigen were detected by enzyme-linked immunosorbent assay.

 

Figure 2
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  		    FIGURE 2. Relationship between antibody levels and matrix metalloproteinase-9 in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis infection. Antibodies in the cerebrospinal fluid specific for young adult worm antigen were detected by enzyme-linked immunosorbent assay.

 
Relationship between MMP-9 concentration and QAlb values in patients. The QAlb values and concentrations of MMP-9 in CSF were significantly increased in patients with eosinophilic meningitis. The QAlb values showed a significant positive correlation with MMP-9 concentrations in the CSF of patients (r = 0.834, P < 0.0001). The higher the MMP-9 concentrations in CSF of patients, the higher the QAlb value (Figure 3Go).


Figure 3
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  		    FIGURE 3. Relationship between cerebrospinal fluid (CSF):serum albumin ratios (QAlb values) and matrix metalloproteinase-9 in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis infection.

 
Relationship between concentrations of MMP-9 and TIMP-1 and TIMP-4 in patients. Patients with eosinophilic meningitis showed increases in MMP-9 and TIMP-1 concentrations and decreases in TIMP-4 concentrations in CSF. As shown in Figures 4Go and 5Go, respectively, concentrations of MMP-9 in CSF of patients with eosinophilic meningitis showed a positive correlation with TIMP-1 (r = 0.85, P < 0.0001). However, a negative correlation was observed with TIMP-4 (r = –0.58, P < 0.0001).


Figure 4
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  		    FIGURE 4. Relationship between matrix metalloproteinase-9 and tissue inhibitors of metalloproteinase in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis infection.

 

Figure 5
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  		    FIGURE 5. Relationship between matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-4 in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis infection.

 
Correlation between levels of MMP-9 and QAlb, values for leukocytes in CSF The CSF parameters of leukocytes were available in 14 (35%) of 40 patients with eosinophilic meningitis. There was association between QAlb values and leukocyte counts in CSF (r = 0.726, P = 0.003) and between leukocyte counts in CSF and MMP-9 levels (r = 0.680, P < 0.0001). This result suggests that MMP-9 sources are probably derived from the transmigrating leukocytes (Figure 6Go).


Figure 6
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  		    FIGURE 6. Relationship between cerebrospinal fluid (CSF):serum albumin ratios (QAlb values) and leukocytes in the CSF (A), and leukocytes and concentrations of matrix metalloproteinase-9 in the CSF (B) among 14 patients with eosinophilic meningitis.

 
Kinetic changes in QAlb, MMP-9, TIMP-1, and TIMP-4 in patients during recovery from eosinophilic meningitis. The heterogeneity of disease acuity of the study population at the time of hospital admission rendered the collective comparison of kinetic regulation of MMPs, TIMPs, and other parameters inconclusive. We therefore compared concentrations of CSF samples from six patients who had serial lumbar puncture after mebendazole and dexamethasone treatment. These patients showed a rapid kinetic decrease in QAlb values and MMP-9 and TIMP-1 concentrations; TIMP-4 concentrations gradually increased (Figure 7Go). As shown in Table 2Go, decreased QAlb values, decreased levels of MMP-9 and TIMP-1, and increased levels of TIMP-4 showed their greatest changes 2–4 weeks after treatment.


Figure 7
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  		    FIGURE 7. Kinetic changes of cerebrospinal fluid (CSF) concentrations of A, CSF:serum albumin ratios (QAlb values), B, matrix metalloproteinase-9 , C, tissue inhibitor of metalloproteinase-1, and D, tissue inhibitor of metalloproteinase-4 in patients during recovery from eosinophilic meningitis caused by Angiostrongylus cantonensis infection.

 

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TABLE 2
Decrease in rates (%) of QAlb, MMP-9, and TIMP-1 and increase in rates (%) of TIMP-4 in CSF of six patients infected with Angiostrongyus cantonensis after treatment with mebendazole and dexamethasone*
 
Gelatin zymography. The CSF specimens of 4 of 40 patients and 2 of 28 controls were randomly selected for analysis by gelatin zymography. As shown in Figure 8Go, all CSF specimens from patients and controls demonstrated a band with a molecular mass of 72 kD (MMP-2). However, only CSF specimens from patients of eosinophilic meningitis showed MMP-9 activity with a band with a molecular mass of 92 kD.


Figure 8
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  		    FIGURE 8. Gelatin zymography of cerebrospinal fluid (CSF) samples from patients with eosinophilic meningitis caused by Angios-trongylus cantonensis infection. Lanes 1, 3, 4, 6, samples from patients; lanes 2 and 5, controls. Note that only CSF specimens from patients of eosinophilic meningitis showed matrix metalloproteinase-9 activity (band with a molecular mass of 92 kD).

 

DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In this study, high QAlb values and CSF leukocytes counts, which are important BBB dysfunction indices, were observed in patients with eosinophilic meningitis. Significant correlation among QAlb values and CSF MMP-9 concentrations and leukocytes counts were observed in these patients. Furthermore, a positive correlation was seen between MMP-9 values and CSF TIMP-1 concentrations. The TIMP-4 concentrations decreased with high QAlb values. The kinetic changes of QAlb values and MMP-9, TIMP-1, and TIMP-4 concentrations in CSF from six patients with eosinophilic meningitis who underwent serial lumbar punctures showed gradually decreasing QAlb values and MMP-9 and TIMP-1 concentrations and increased levels of TIMP-4. These results demonstrated that concentrations of MMP-9, TIMP-1, and TIMP-4 in the CSF are associated with BBB damage in patients with eosinophilic meningitis caused by infection with A. cantonensis.

Metalloproteinases have also been identified in a variety of helminthes including Brugia malayi,28 Toxocara canis,29 Strongyloides stercoralis,30 Nippostrongylus brasiliensis,31 Dirofilaria immitis,32 Trichuris suis,33 Ancylostoma caninum,34 Caenorhabditis elegans,35 and Gnathostoma spinigerum.36 Metalloproteinase-mediated degradation of extra-cellular matrix components is also a feature of some helminthes.28 Metalloproteinase secreted in the infective larvae of A. cantonensis was associated with parasite dissemination or pathogenesis.37

Conflicting results have been reported with regards to the relationship between CSF pleocytosis and MMP-9 levels. A relationship between increased MMP-9 levels in CSF and the number of leukocytes in various neurologic disorders was first reported by Gijbels and others.38 In contrast, Paemen and others39 studied inflammatory neurologic diseases such as optical neuritis and multiple sclerosis and did not find a significant correlation of MMP-9 with CSF leukocyte counts. Leppert and others40 described a correlation between MMP-and CSF pleocytosis but not with QAlb in multiple sclerosis. Sporer and others41 found MMP-9 in CSF of patients infected with human immunodeficiency virus associated with leukocyte counts and QAlb values but not with total protein. Perides and others42 and Kolb and others43 found a correlation between MMP-9 concentration in CSF with leukocyte counts in Lyme borreliosis and viral meningitis, respectively. In this study, a highly significant correlation was found between CSF MMP-9 concentrations and CSF leukocyte counts. We did not measure the CSF:serum ratio of MMP-9. It is probable, at least in some patients, that increased concentrations of MMP-9 in CSF were derived from the serum because of damage to the BBB. These results suggest that increased MMP-9 levels are associated with BBB dysfunction and are dependent on CSF pleocytosis.

Corticosteroids have been shown to suppress expression of MMP-9 in CSF during acute CNS inflammation.44,45 Thus, there has been an attempt to use corticosteroids as an adjunctive therapy in eosinophilic meningitis. In the clinical study of Chotmongkol and others,46 a two-week course of predisolone was beneficial in relieving headaches in patients with eosinophilic meningitis. In another study, Sawanyawisuth and others47 showed that a one-week course of corticosteroid had the same beneficial effect in relieving headaches as a two-week course. The beneficial effect of corticosteroid for patients with eosinophilic meningitis may be the result of their down-regulating effects on MMP-9 expression. In this present study, we had only CSF samples from patients from several hospitals but none of the clinical features of these patients. The MMP-9 levels and the index of BBB dysfunction decreased more than 50% in six patients two weeks after treatment with mebendazole and dexamathasone.

A significant increase in TIMP-1 concentrations in patients with eosinophilic meningitis was observed in this study. We hypothesized that increased TIMP-1 concentrations in CSF of patients might bind or neutralize MMP-9, as reported by Welgus and others.48 Foerster and others49 provided direct evidence that corticosteroids increase TIMP-1 concentrations in the murine brain endothelial cell line cEND, prevent alterations in microvascular integrin-{alpha}1 subunit expression, and help maintain endothelial barrier function in response to pro-inflammatory stimuli (TNF administration). They concluded that corticosteroid-induced up-regulation of TIMP-1 expression by the CNS vascular endothelium may play a role in preservation of endothelial basal lamina and maintain integrin 1 expression important for vessel wall integrity. However, TIMP-1 concentrations significantly decreased in CSF of six patients infected with A. cantonensis two weeks after treatment with mebendazole and dexamathasone in this study. Worms in the brain of patients may have been dead after treatment with mebendazole, which abated the stimulator to induce production of TIMP-1 in spite of dexamathasone used for combined therapy.

Rosenberg and others50 showed in an animal model that active MMP-2, which is constitutively expressed in human and animal CSF, is also able to open the BBB. However, up-regulation of MMP-2 in various types of meningitis has not been reported.43,51–53 Lee and others54 showed that the persistent increase of MMP-2 levels in patients with tuberculous meningitis was associated with development of complications. Patients with late neurologic complications had higher MMP-2 levels than those without neurologic complications. In this study, we also found higher MMP-2 levels in the patients than in controls. The BBB damage in patients with eosinophilic meningitis caused by infection with A. cantonensis might be caused by MMP-2. However, it may not play a major role because the increase of MMP-2 was only slight.

Expression of TIMP-2 is mainly constitutive.15,16 In our study, we did not find any significant difference in levels of CSF TIMP-2 between patients and controls. TIMP-2 is both an activator and an inhibitor of MMP-2 at lower and higher concentrations, respectively. TIMP-2 functions in connection with MT1-MMP to activate MMP-2.55 It is possible that TIMP-2 may not play a major role in eosinophilic meningitis or selective sampling time points did not reflect changes in MMP-2 or TIMP-2 expression in CSF because they are measured in specimens from patients beginning on the day they were hospitalized.

Interestingly, the TIMP-4 concentration in CSF was substantially down-regulated during the acute phase of infection with A. cantonensis. This change may be caused by alteration of the cytokine milieu and other biologic factors that are major modulators of TIMP expression56 and may reflect greater roles of these proteins in eosinophilic meningitis. The detailed mechanism for this process is still unknown. In parallel with MMP-9 in CSF of patients, although TIMP-1 was also significantly increased, eosinophilic meningitis still persisted until TIMP-4 concentrations increased. TIMP-4 in the CSF may play an important role in the proteolytic balance of BBB damage in patients with eosinophilic meningitis.

In conclusion, BBB dysfunction may occur in patients with eosinophilic meningitis caused by infection with A. cantonen-sis because patients show significantly higher QAlb values that show a significant correlation with concentrations of MMP-9 in CSF. The increase in MMP-9 in CSF of patients is probably caused by leukocytes because they were present in large numbers in CSF. Although TIMP-1 increased in CSF of patients and neutralized MMP-9, high levels of proteolytic activity of MMP-9 still remained. The reason why TIMP-4 in CSF of patients suddenly decreased in the acute phase of eosinophilic meningitis and its role in BBB dysfunction of this parasitic disease should be clarified in further studies.

Received June 28, 2007. Accepted for publication October 15, 2007.

Acknowledgments: We thank Min-Hon Shi for assistance with zymography.

Financial support: This work is supported by grant VGHKS96-027 from Kaohsiung Veterans General Hospital, and grant NSC-96-2320-B-075B-002 from the National Science Council, Republic of China.

* Address correspondence to Chuan-Min Yen, Department of Parasitology, Kaohsiung Medical University, #100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan, Republic of China. E-mail: hctsai1011 @yahoo.com.tw Back

Authors’ addresses: Hung-Chin Tsai, Section of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital 386, Ta-Chung 1st Road, Kaohsiung City, 813, Taiwan, Republic of China, National Yang-Ming University, Taipei, Taiwan, Republic of China, and Department of Parasitology and Graduate Institute of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan, Republic of China. Eng-Rin Chen, Li-Yu Chung, and Chuan-Min Yen, Department of Parasitology and Graduate Institute of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan, Republic of China. Yung-Ching Liu, Susan Shin-Jung Lee, Yao-Shen Chen, Cheng-Len Sy, and Shue-Ren Wann, Section of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital 386, Ta-Chung 1st Road, Kaohsiung City, 813, Taiwan and National Yang-Ming University, Taipei, Taiwan, Republic of China.


REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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H.-C. Tsai, Y.-L. Huang, Y.-C. Liu, S.-R. Wann, S. S.-J. Lee, E.-R. Chen, C.-M. Yen, M.-H. Tai, M.-H. Shi, and Y.-S. Chen
Dynamic Changes of Hepatocyte Growth Factor in Eosinophilic Meningitis Caused by Angiostrongylus cantonensis Infection
Am J Trop Med Hyg, June 1, 2009; 80(6): 980 - 982.
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