Neuroimmunology 2nd Edition Aaron E.

Miller
Visit to download the full and correct content document:
https://ebookmass.com/product/neuroimmunology-2nd-edition-aaron-e-miller/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Precalculus, 2nd Edition Julie Miller

https://ebookmass.com/product/precalculus-2nd-edition-julie-
miller/

Essential Orthopaedics 2nd Edition Mark D. Miller

https://ebookmass.com/product/essential-orthopaedics-2nd-edition-
mark-d-miller/

The New Humanities Reader 6th Edition Richard E. Miller

https://ebookmass.com/product/the-new-humanities-reader-6th-
edition-richard-e-miller/

Operative Techniques: Knee Surgery 2nd Edition Edition

Mark D. Miller

https://ebookmass.com/product/operative-techniques-knee-
surgery-2nd-edition-edition-mark-d-miller/
Developmental Mathematics: Prealgebra, Beginning
Algebra, & Intermediate Algebra 2nd Edition Julie
Miller

https://ebookmass.com/product/developmental-mathematics-
prealgebra-beginning-algebra-intermediate-algebra-2nd-edition-
julie-miller-2/

Developmental Mathematics: Prealgebra, Beginning

Algebra, & Intermediate Algebra 2nd Edition Julie
Miller

https://ebookmass.com/product/developmental-mathematics-
prealgebra-beginning-algebra-intermediate-algebra-2nd-edition-
julie-miller/

How Scholars Write 1st Edition Aaron Ritzenberg

https://ebookmass.com/product/how-scholars-write-1st-edition-
aaron-ritzenberg/

Sarcopenia 2nd Edition John E. Morley

https://ebookmass.com/product/sarcopenia-2nd-edition-john-e-
morley/

Mayo Clinic Cases in Neuroimmunology (Mayo Clinic

Scientific Press) Andrew Mckeon

https://ebookmass.com/product/mayo-clinic-cases-in-
neuroimmunology-mayo-clinic-scientific-press-andrew-mckeon/
i

Neuroimmunology
ii

What Do I Do Now?

S E R I E S C O -​E D ITORS-​I N-​C HIE F

Lawrence C. Newman, MD
Director of the Headache Division
Professor of Neurology
New York University Langone
New York, New York

Morris Levin, MD
Director of the Headache Center
Professor of Neurology
University of California, San Francisco
San Francisco, California

OT H E R VO L U M E S IN T HE SE RIE S
Headache and Facial Pain
Epilepsy
Neuro-​Ophthalmology
Pain
Emergency Neurology
Neuroinfections
Neurogenetics
Neurotology
Pediatric Neurology, Second Edition
Neurocritical Care, Second Edition
Stroke, Second Edition
Peripheral Nerve and Muscle Disease, Second Edition
Cerebrovascular Disease, Second Edition
Movement Disorders, Second Edition
Women’s Neurology
iii

Neuroimmunology
SECOND EDITION

Edited by
Aaron E. Miller, MD
Medical Director
Corinne Goldsmith Dickinson Center for Multiple Sclerosis
Professor and Vice-​Chair for Education
Department of Neurology
Icahn School of Medicine at Mount Sinai
New York, NY

Tracy M. DeAngelis, MD
Adjunct Assistant Professor of Neurology
The Mount Sinai Hospital
New York, NY

Michelle Fabian, MD
Assistant Professor of Neurology
Corinne Goldsmith Dickinson Center for Multiple Sclerosis
The Mount Sinai Hospital
New York, NY

Ilana Katz Sand, MD

Assistant Professor of Neurology
Icahn School of Medicine at Mount Sinai
Associate Medical Director
Corinne Goldsmith Dickinson Center for Multiple Sclerosis
The Mount Sinai Hospital
New York, NY

1
iv

1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2018
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Miller, Aaron E., author. | DeAngelis, Tracy M., author. |
Fabian, Michelle, author. | Sand, Ilana Katz, author.
Title: Neuroimmunology / by Aaron E. Miller, Tracy M. DeAngelis,
Michelle Fabian, Ilana Katz Sand. Other titles: What do I do now?
Description: Second edition. | Oxford ; New York : Oxford University Press, [2018] |
Series: What do I do now? | Includes bibliographical references and index.
Identifiers: LCCN 2018009729 | ISBN 9780190693190 (paperback : alk. paper)
Subjects: | MESH: Demyelinating Diseases—diagnosis | Demyelinating
Diseases—therapy | Neurologic Manifestations | Vasculitis, Central
Nervous System | Nervous System—immunology | Case Reports
Classification: LCC QP356.47 | NLM WL 141 | DDC 616.97/8—dc23
LC record available at https://lccn.loc.gov/2018009729
This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent on
the individual circumstances. And, while this material is designed to offer accurate information with
respect to the subject matter covered and to be current as of the time it was written, research and
knowledge about medical and health issues is constantly evolving and dose schedules for medications
are being revised continually, with new side effects recognized and accounted for regularly. Readers
must therefore always check the product information and clinical procedures with the most up-​to-​date
published product information and data sheets provided by the manufacturers and the most recent
codes of conduct and safety regulation. The publisher and the authors make no representations or
warranties to readers, express or implied, as to the accuracy or completeness of this material. Without
limiting the foregoing, the publisher and the authors make no representations or warranties as to the
accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do
not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed
or incurred as a consequence of the use and/​or application of any of the contents of this material.

9 8 7 6 5 4 3 2 1
Printed by Marquis, Canada
v

This Book Is Dedicated to

Ellen, whose unwavering support makes everything possible and whose

love makes every day a treasure.
—​AEM

To the memory of Dr. Izabella Rozenfeld, dear “Bella,” whose knowledge

and unbridled passion for neurology guide me still.
—​TMD

To my mentors, who have given me the priceless gift of their knowledge

and time; and to my patients who have trusted me to share the journey
of illness with them, and who are so much more than a case in a book.
—​MTF

To my dad, my first and forever mentor, whom I can always count on for
my “what do I do now?” questions.
—​IKS
vi
vi

Contents

Preface ix

Acknowledgments xi

1 A Case of Monocular Blurred Vision 1

2 A Case of Multifocal Neurological Symptoms 9

3 Irritability in a Man with Multiple Sclerosis 15

4 A Case of Myelitis with a Positive Anticardiolipin Antibody 23

5 A Case of Stiffness in the Legs and Gradual Difficulty

Walking 29

6 Family Matters 35

7 Recurrent Ulcers and a Brainstem Lesion 39

8 Ataxia and Orthostasis 45

9 Blurry Vision, Hearing Loss, and Constant Headache 49

10 The Snowball Effect 55

11 A SREATable Encephalopathy 61

12 A Case of Cognitive Impairment and Ataxia 65

13 A Case of Fever and a Wrist Drop 69

14 Double Vision and Droopy Eyelids 75

15 A Case of Personality Change and Seizure 83

16 Drowsiness and Double Vision 89

17 The One-Sided Encephalitis 93

18 Teratoma: “It’s Driving Me Crazy” 97

19 Gad-Awful Spasms 103

20 On the Right Tract 109

21 A Headache Gone Viral 113

22 To CIDP or Not to CIDP 117

23 Extinguishing a “Burning Fire” 121

vi

24 Confusion, Muscle Cramps, and Weight Loss   127

25 The Unforgettable Encephalitis   133

26 The Peppered Brainstem   139

27 A Case of a Fall After a Trip   143

28 A Case of Relapsing Visual Loss   149

29 Checks and Balances   153

30 A Case of Intractable Vomiting   157

31 A Case of Cognitive Change in HIV   163

32 A Case of Progressive Myelopathy   167

33 A Case of Cranial Neuropathies and Leptomeningeal

Enhancement   173

34 A Case of Diabetes Insipidus and Enhancing Brain

Lesions   177

35 A Case of Optic Neuritis and Leg Weakness   183

36 A Man with Multiple Sclerosis and Continuing Disease Activity

on Disease-​Modifying Therapy   189

37 A Case of Syncope and Impaired Micturition   195

38 A Case of Longitudinally Extensive Transverse Myelitis   201

39 A Perplexing Pattern of Weakness   205

40 Progressive Numbness and Tingling   209

Index 215

viii Contents
ix

Preface

In the six years since the publication of the first edition of Neuroimmunology
in the What Do I Do Now? series, novel immunological disorders of the
nervous system have been discovered, and understanding of this fascinating
class of diseases has burgeoned. New therapies based on large clinical trials
for well-​known disorders such as MS have proliferated, whereas treatment
for less common disorders remains anecdotal, albeit based on increasing
experience of experts.
In this second expanded edition of Neuroimmunology, our goal remains
to provide a useful framework for clinicians to use when approaching
challenging immune-​mediated diseases of both the central and periph-
eral nervous systems. Each chapter begins with a very brief case presenta-
tion, including just enough information to challenge your thinking. The
subsequent discussions focus on localization, differential diagnosis, and
treatment specific to the case and disorder itself. We have presented a range
of conditions, including both those frequently encountered such as mul-
tiple sclerosis and those much more rarely seen, such as several unique au-
toimmune encephalopathies. In MS, the availability of new therapies has
created a variety of scenarios, only a few of which could be presented in this
small volume. Our recommendations for diagnostic testing and therapy
rest, whenever possible, on available current evidence, as reflected in the
updated key references for this edition. Key clinical points are highlighted
in the conclusion of each chapter. In select chapters, tables and figures are
provided to illustrate cardinal teaching points such as diagnostic criteria.
We trust this volume will serve as an accessible and practical tool for
neurologists and other clinicians, both those in practice and those still in
training. We hope it will be an important and useful resource for both
clinicians and their patients in helping to facilitate better recognition and
management of an ever-​increasing number of neurological disorders.
Aaron E. Miller, MD
Tracy M. DeAngelis, MD
Michelle Fabian, MD
Ilana Katz Sand, MD
x
xi

Acknowledgments

Many of the cases described in this book have involved challenging

presentations of neuroimmunological disorders requiring the expertise and
support of a multidisciplinary clinical care team at Mount Sinai Hospital
or North Shore University Hospital. These patients have been the subject
of extensive discussion among our colleagues at the Corinne Goldsmith
Dickinson Center for Multiple Sclerosis at Mount Sinai or at Neurological
Associates of Long Island. These consummate professionals have all shared
their wisdom and experience, in addition to their passionate provision of
excellent, compassionate patient care.
In addition, we acknowledge the invaluable collaboration with our
colleagues in the fields of neuroradiology, neuro-​ophthalmology, rheu-
matology, internal medicine, and neuro-​critical care, among others. We
would also like to recognize the residents and fellows at the front lines of
managing such difficult cases for their diligence, commitment, and dedica-
tion that inspire us daily. We especially thank Drs. Bradley Delman, Amit
Aggarwal, and Lara Marcuse for sharing their expertise and providing some
of the images, and Drs. David Podwall, Denis Ostrovsky, Michael Han,
and Vincent DeOrchis for their respective case contributions and neuro-
muscular knowledge.
Finally, we extend our sincerest gratitude to the team at Oxford University
Press, Tiffany Lu and Craig Panner, for their help, support, and persistence
in shepherding this volume to completion.
Aaron E. Miller, MD
Tracy M. DeAngelis, MD
Michelle Fabian, MD
Ilana Katz Sand, MD
xi
xi

Neuroimmunology
xvi
1

1 A Case of Monocular
Blurred Vision

A 26-​year-​old white woman consults you one month

after she was diagnosed with right optic neuritis by
an ophthalmologist. She reports that initially she
“could not see much out of the right eye.” She denied
pain on eye movement, but she did experience
supraorbital headache. She was treated with three
days of intravenous methylprednisolone, followed
by oral taper of prednisone over the next two weeks.
Her vision markedly improved, though she does not
feel it is quite back to normal. Her past medical and
neurological history is negative.
The patient’s neurological examination is normal
except that she notes that a bright red stimulus
appears less intense with the right eye than with
the left, and she has a right afferent pupillary
defect (APD).

What do you do now?

1
2

MULTIPLE SCLEROSIS

This patient presents with optic neuritis, which may be a monophasic

illness, but is very commonly the initial manifestation of multiple sclerosis
(MS). Most cases of optic neuritis occur in the retrobulbar portion of the
nerve so that, acutely, the fundus appears normal. Eventually some degree
of optic atrophy may become evident as pallor of the optic disk. An APD
is demonstrated by the “swinging flashlight” test. When the flashlight is in-
itially shone in the affected right eye, both direct and consensual pupillary
constriction occur.
The light is then shone in the left eye, and both pupils remain constricted.
However, when the flashlight swings back to the right eye, the pupils both
dilate because the intensity of the light stimulus is now perceived as less in
the eye that had the optic neuritis. This sign often persists even in an eye
with normal visual acuity after recovery from optic neuritis, indicating re-
sidual damage to the optic nerve.
A definite diagnosis of MS depends on the demonstration of clinical
symptoms and signs that indicate a disease process that involves the central
nervous system (CNS; brain, spinal cord, and optic nerves), is disseminated
in space (meaning involvement of two or more non-​contiguous areas of
the CNS) and time (meaning two or more episodes separated by at least a
month), and the absence of a better clinical explanation. It usually presents
in young to middle-​aged adults, but neither young children nor older adults
are completely spared. This patient has had no prior clinical events, but
modern diagnostic criteria allow evidence for dissemination in space or
time (or both) to be obtained with magnetic resonance imaging (MRI).
At this point, therefore, you should order a brain MRI with and without
contrast administration. You should also order dedicated fat-​saturated or-
bital imaging to evaluate the optic nerve, mainly to exclude an alternative
diagnosis. In this patient, the brain MRI showed multiple T2 hyperintense
lesions. In addition, she had many gadolinium-​enhancing (GdE) lesions
(Figure 1.1). Today, the most widely used criteria for making the diagnosis
of MS are known as the “McDonald criteria,” with the most recent revision
in 2017. Although these criteria allow for the traditional clinical diagnosis,
their use often enables an earlier diagnosis to be made by allowing MRI
findings to satisfy criteria for either dissemination in space or time, or both.

2 WHAT DO I DO NOW? Neuroimmunology

3

FIGURE 1.1 This patient met criteria for definite MS by the 2017 revision of the McDonald
criteria because, at the time of his presentation with a clinically isolated syndrome, his MRI
showed both T2 hyperintense lesions (FLAIR sequence, right) and a gadolinium-​enhancing lesion
in the right frontal lobe (left).

The current criteria require the presence of both symptoms suggestive of in-
volvement of the CNS and objective signs on the neurological examination.
Dissemination in space (DIS) could be satisfied by the presence on MRI of
at least one lesion in at least two of the following locations:

• Periventricular
• Juxtacortical or cortical
• Infratentorial
• Spinal cord

Dissemination in time (DIT) can be satisfied by the appearance of any new

lesion on a subsequent MRI performed after a previous MRI. Alternatively,
if both GdE and other non-​enhancing lesions appear on the initial MRI,
the criteria for DIT are met.
Cerebrospinal fluid (CSF) studies are also extremely helpful in confirming
the diagnosis of MS. Routine studies on the CSF are usually normal, or may
show a mild mononuclear pleocytosis (under 50 cells) or a mildly elevated
protein. In most cases (as many as 90% in some published series, but prob-
ably closer to 60–​70% in early cases in routine clinical practice), the CSF
shows evidence of abnormal immunoglobulin production, demonstrated
by either the presence of oligoclonal bands or elevation of the IgG index of
IgG synthesis rate. While these abnormal CSF findings (oligoclonal bands

1 A Case of Monocular Blurred Vision 3

4

are more specific) are not entirely pathognomonic of MS, they usually help
to eliminate alternative diagnoses. In a major change with the 2017 revision
of the McDonald criteria, the presence of two or more oligoclonal bands
in the CSF of a patient who presents with a typical clinically isolated syn-
drome substitutes for DIT, even when criteria for DIT are not met on the
MRI. Therefore, a patient who presents with an initial event typical of MS,
meets MRI criteria for DIS, and has oligoclonal bands in the CSF may be
diagnosed with definite MS. In all cases, however, it is imperative that there
be no better clinical explanation for the patient’s symptoms (Table 1.1).
Optic neuritis is also a major manifestation of neuromyelitis optica
spectrum disorder (NMOSD), a condition discussed in Chapter 30. The
availability of serological testing for anti-​aquaporin4 antibody has greatly
facilitated the diagnosis of this condition and has a sensitivity of more than
70%, with high specificity. Although this patient’s brain MRI is much
more typical of MS than of NMOSD, some experts now routinely order
aquaporin4 antibody testing in anyone presenting with optic neuritis.

TABLE 1.1 2017 Revised McDonald Criteria for Determination

of Dissemination in Space and Time

Attacks Lesions Additional Requirements

2 or more 2 or more None

2 or more 1 DIS:
❑ Further attack or
❑ MRI* (≥1 T2 lesions in ≥2 of 4 areas1)

1 2 DIT:
❑ Further attack or
❑ MR (presence of GdE and non-​GdE lesions) or
CSF-​OCB

1 1 DIS and DIT

0 1 ❑ >1 year of progression and

❑ 2 of 3 of:
◦ T2 hyperintense lesions in brain—​1 of
3 areas2
◦ T2 hyperintense lesions in spinal
cord—​≥2 areas
◦ CSF-​OCB

4 WHAT DO I DO NOW? Neuroimmunology

5

After the MRI has been completed, you should inform this patient that
she has a diagnosis of definite relapsing-​remitting MS (RRMS). MS is cur-
rently described, according to its temporal profile, as RRMS, secondary
progressive (SPMS), or primary progressive (PPMS). Approximately
80–​85% of patients begin with RRMS, in which they have episodes of
neurological symptoms, typically lasting days to weeks, followed by re-
covery or improvement before the development of another attack (also
called exacerbation or relapse). Conventionally, an attack is considered
new when it occurs at least 30 days after the onset of symptoms in the
previous exacerbation. Most of the remaining 15–​20% of patients have
PPMS, in which symptoms and signs—​ most often those of spastic
paraparesis—​progress gradually without any acute exacerbations. Many
patients—​often estimated at about 50% or even more—​who begin with
RRMS eventually change to a course that is gradually worsening. Such
a course is then labeled SPMS. This insidiously progressive course may
or may not be accompanied by superimposed exacerbations. Recently, an
international committee has recommended that any type of MS be fur-
ther characterized by the presence or absence of activity (by either clinical
or imaging evidence), always placed within a temporal context (e.g., one
year). Progressive forms of MS may plateau, so these phenotypes should be
further modified by the description “with or without progression,” again
within a temporal framework.
When informing the patient of the diagnosis of MS, you should do so
in the most hopeful terms possible, a position currently justified by the
availability of a variety of medications to treat RRMS and the promise
of additional drugs in the near future. You should always inform the pa-
tient in person, rather than in a telephone conversation or message. You
should tell the patient specifically that he or she has MS and avoid the use
of euphemisms, such as “demyelinating disease.” The diagnosis should be
accompanied by an explanation of the condition in terms that the patient
can readily understand.
After giving the patient the diagnosis of MS, you should recommend
initiation of treatment with a disease-​modifying agent. However, generally,
you should defer the discussion of the specific therapeutic options to a sub-
sequent meeting with the patient. Receiving the diagnosis of MS, even if it
was not totally unexpected, is an emotionally upsetting experience, and it

1 A Case of Monocular Blurred Vision 5

Another random document with
no related content on Scribd:
Penicillium, 122, 123.
Penium, 43, 44.
Pennisetum, 295.
Penny-cress, 401.
Penny-wort, 493.
Pentacyclicæ, 505, 506.
Pentadesma, 414.
Pentapera, 505.
Pentstemon, 524, 527.
Peplis, 47, 483.
Pepper, 361.
Peppermint, 541.
Peperomia, 361, 362.
Pepperwort, 401.
Pereskia, 375, 376.
Perianth, 235.
Perichætium, 192.
Pericarp, 249.
Pericallis, 574.
Peridermium, 147, 148, 153, 154, 155, 156.
Peridinea, 1, 14, 17.
Peridinin, 16.
Peridinium, 17.
Peridiola, 176.
Peridium, 88, 89, 147.
Perigynium, 189.
Perilla, 541.
Periphyses, 88.
Periplasm, 104.
Periploca, 546.
Perisperm, 249.
Perisporiaceæ, 122.
Perisporiales, 95, 116, 118, 119.
Peristome, 195.
Perithecia, 125.
Periwinkle, 543, 544.
Perizonium, 20.
Pernambuco-tree, 468.
Peronocarpic ascocarps, 125.
Peronospora, 101, 104, 105, 107.
Peronosporaceæ, 104.
Persea, 393.
Persica, 461.
Personatæ, 505, 515, 517.
Pertusaria, 140, 142.
Petals, 235.
Petasites, 153, 569, 571.
Petiveria, 372.
Petrocelis, 84.
Petunia, 518, 521.
Peucedaneæ, 496.
Peucedanum, 496.
Peyssonellia, 84.
Peziza, 115, 135, 159.
Pezizaceæ, 135.
Pezizales, 134.
Phacelia, 515.
Phacidiales, 133.
Phacidium, 133.
Phacotus, 48.
Phæophyceæ, 1, 14, 68.
Phæophyl, 68.
Phæosporeæ, 68.
Phæothamnion, 54.
Phagocytes, 41.
Phajus, 332.
Phalarideæ, 295.
Phalaris, 295.
Phallaceæ, 172.
Phalloideæ, 96, 145, 172.
Phallus, 172, 173.
Phanerogams, 3, 234, 236, 249.
Pharbitis, 516.
Pharus, 291, 293.
Phascum, 195.
Phaseoleæ, 470.
Phaseolus, 134, 469, 471, 473.
Phegopteris, 213, 214.
Phellodendron, 437.
Philadephus, 451, 455.
Phillyrea, 547.
Philodendron, 303, 305.
Philonotis, 197.
Phlebia, 163.
Phleum, 290, 294, 296.
Phloëm, 251.
Phlœospora, 70.
Phlomis, 538, 541.
Phlox, 515.
Phœniceæ, 299.
Phœnix, 298, 299, 301, 302.
Pholiota, 171.
Phormium, 312, 313, 314.
Phragmidium, 146, 147, 148, 151, 152.
Phragmites, 113, 131, 291, 294.
Phragmonema, 22, 25.
Phrynium, 327.
Phycocyan, 22, 77.
Phycoerythrin, 22, 77.
Phycomyces, 99.
Phycomycetes, 1, 5, 95, 96.
Phycophæin, 69.
Phycopyrrin, 16.
Phycoxanthin, 69.
Phylica, 448.
Phyllachora, 131.
Phyllactinia, 122.
Phyllactis, 560.
Phyllanthus, 431, 432.
Phyllitis, 70.
Phyllobium, 47, 51.
Phyllocactus, 377.
Phyllocladus, 260.
Phyllodia, 474.
Phyllodoce, 509.
Phylloglossum, 228.
Phyllophora, 83.
Phyllosiphon, 8.
Phyllosiphonaceæ, 47, 61.
Physalis, 521.
Physarum, 6, 8.
Physcia, 139, 143.
Physcomitrium, 188, 197.
Physiological varieties, 41.
Physoderma, 103.
Physostigma, 471, 473.
Phytelephantinæ, 301.
Phytelephas, 299, 301, 302.
Phyteuma, 562.
Phytoamœbæ, 10, 61.
Phytolacca, 372.
Phytolaccaceæ, 372.
Phytomyxa, 8.
Phytophthora, 101, 104, 105, 106.
Piassava, 297.
Picea, 124, 129, 132, 155, 165, 265.
Pichurim, 392.
Picraena, 438.
Picris, 571.
Picrotoxine, 390.
Pilacraceæ, 157.
Pilacre, 157.
Pilea, 353.
Pilobolus, 99, 100.
Pilostyles, 504.
Pilularia, 216, 220.
Pimelea, 449.
Pimenta, 489.
Pimento, 489.
Pimpernel, 513.
Pimpinell, 498.
Pimpinella, 494, 498.
Pine, 127, 153, 161, 165, 255, 263, 266.
Pine-apple, 320.
Pine-shoot Fungus, 152.
Pinellia, 305.
Pinguicula, 334, 528.
Pink, 367.
Pin-mould, 99.
Pinnularia, 19.
Pinus, 129, 132, 153, 155, 165, 264, 265, 266, 267, 272.
Pinoideæ, 256, 258, 259, 262.
Pipe-flower, 500.
Piper, 361, 363.
Piperaceæ, 361.
Pipereæ, 361.
Piptocephalidaceæ, 100.
Piptocephalis, 100.
Pircunia, 372.
Pisonia, 374.
Pistia, 306.
Pistacia, 439.
Pistil, 239.
Pistillaria, 161.
Pistillate, 236.
Pisum, 469, 470, 473.
Pitcairnia, 320.
Pitcher-plant, 409.
Pittosporaceæ, 451, 455.
Pittosporum, 455.
Placenta, 237, 241.
Placochromaticæ, 21.
Plagiochila, 189, 192.
Plagiothecium, 197.
Plagiotropideæ, 21.
Planera, 351.
“Plankton,” 15, 17, 20.
Planogametes, 12.
Plantago, 335, 530, 531, 536, 559.
Plantaginaceæ, 518, 530.
Plantain, 530.
Plasmodia, 4, 5, 7.
Plasmodiophora, 8.
Plasmodiophorales, 6.
Platanaceæ, 455.
Platanus, 456.
Platanthera, 332, 333.
Plate-cultures, 33.
Platonia, 414.
Platycerium, 213.
Platycodon, 562.
Platystemon, 395.
Plectonema, 24.
Plectranthus, 541.
Pleospora, 130.
Pleosporaceæ, 130.
Pleurandra, 413.
Pleuridium, 195.
Pleurocarpi, 197.
Pleurococcaceæ, 47, 51.
Pleurococcus, 10, 51, 138.
Pleurorhizæ. 400.
Pleurotænium, 44.
Pleurothallis, 332.
Pleurotus, 171.
Plocamium, 83.
Plum, 117, 164, 461, 462.
Plumbaginaceæ, 514.
Plumbago, 514.
Plumeria, 544.
Plumule, 247.
Pneumathodia, 267.
Poa, 287, 290, 294, 296.
“Pocket-plum,” 85.
“Pockets,” 117.
Pod, 466.
Pod-pepper, 522.
Podalyrieæ, 469.
Podocarpeæ, 260.
Podocarpus, 251, 255, 261, 272.
Podophyllum, 390.
Podosphæra, 120.
Podospora, 129.
Podostemaceæ, 451, 456.
Pogostemon, 541.
Poinciana, 468.
Point Caraway, 498.
Polanisia, 406.
Polemoniaceæ, 509, 515.
Polemonium, 515.
Polianthes, 318.
Pollinarium, 332.
Pollinia, 329.
Pollinodium, 100, 120.
Pollen-chamber, 251.
Pollen-grain, 240, 244, 245.
Pollen-sac, 235, 237, 240.
Pollen-tube, 244, 249.
Polycarpicæ, 377.
Polycystis, 24.
Polydinida, 16, 17, 18.
Polyembryony, 247.
Polygala, 442, 443.
Polygalaceæ, 442.
Polygamous, 236.
Polygonaceæ, 239, 359.
Polygonatum, 314, 316.
Polygonifloræ, 358.
Polygonum, 359, 360, 361.
Polyides, 84.
Polykrikos, 17.
Polypetalæ, 336.
Polyphagus, 103, 104.
Polypodiaceæ, 202, 205, 206, 209, 210, 212.
Polypodium, 207, 213.
Polyporaceæ, 163.
Polyporus, 163, 164, 165.
Polysiphonia, 79, 83.
Polystachya, 332.
Polystigma, 125, 127.
Polytrichaceæ, 197.
Polytrichum, 197.
Pomaceæ, 456, 462.
Pomaderris, 448.
Pomalo, 438.
Pomegranate, 488, 489.
Pomona-fungus, 171.
Pond-weed, 279.
Pontederia, 316.
Pontederiaceæ, 308, 316.
Poplar, 124, 164, 338.
Poppies, 394.
Populus, 152, 338.
Pore-fungus, 163.
Porogames, 273.
Poronia, 131.
Porphyra, 10, 78.
Porphyraceæ, 78.
Portulaca, 373.
Portulacaceæ, 373.
Posidonia, 281.
Potamogeton, 47, 278, 279.
Potamogetonaceæ, 278, 279.
Potato-fungus, 104, 107.
Potato-plant, 521, 522.
Potentilla, 458, 460.
Potentilleæ, 458.
Poterium, 460.
Pothos, 304.
Pottia, 196.
Pottiaceæ, 196.
Pouzolzia, 353.
Prasiola, 53.
Preissia, 191.
Preslia, 539.
Primrose, 512.
Primula, 511, 512, 513.
Primulaceæ, 239, 512, 514.
Primulinæ, 505, 511.
Pringsheimia, 54.
Prionium, 284.
Pritchardia, 298.
Priva, 535.
Privet, 547.
Procarpium, 81.
Proembryo, 64.
Profichi, 355.
Promycelium, 94, 146.
Pronucleus, 245.
Prorocentrum, 17, 18.
Protea, 450.
Proteaceæ, 450.
Prothallium, 198, 244, 248.
Secondary, 233.
Protistæ, 5.
Protium, 438.
Protobasidia, 144.
Protobasidiomycetes, 96, 145.
Protococcaceæ, 47, 48, 51.
Protococcoideæ, 8, 47.
Protomyces, 108.
Protomycetaceæ, 108.
Protonema, 181.
Provence oil, 547.
Prunella, 539.
Prunus, 117, 118, 127, 130, 152, 461, 462.
Psalliota, 167, 168, 169, 171.
Psamma, 295, 296.
Pseudophacidiaceæ, 133.
Pseudopodium, 10, 193.
Pseudotsuga, 264, 265, 266.
Psidium, 488, 489.
Psilotaceæ, 228.
Psilotum, 201, 228.
Psychotria, 550.
Ptelea, 437.
Pteridium, 131, 207, 213, 214.
Pteridophyta, 2, 198, 234.
Pterigynandrum, 197.
Pteris, 199, 203, 213, 214.
Pterisanthes, 445.
Pterocarpus, 473.
Pterocarya, 350.
Pterocephalus, 560.
Pterogoniaceæ, 197.
Pterogyne, 468.
Pterostegia, 360.
Pterygophyllum, 197.
Ptilidium, 192.
Ptilota, 84.
Ptychogaster, 166.
Puccinia, 147, 148, 149, 150.
Puff-ball, 174.
Pulmonaria, 533, 534.
Pulque, 318.
Pulsatilla, 384.
Pumpkin, 480, 481.
Punctaria, 70.
Punica, 483, 488, 489, 490.
Puniceæ, 488.
Puschkinia, 312.
Putrefaction, 32.
Puya, 319.
Pycnidia, 89.
Pylaiella, 70.
Pyrenoid, 46.
Pyrenolichenes, 142.
Pyrenomycetes, 95, 116, 118, 125.
Pyrenula, 142.
Pyrethrum, 572, 574.
Pyrola, 334, 506, 507.
Pyrolaceæ, 506.
Pyrrophyl, 16.
Pyrus, 152, 463.
Pythium, 101, 106.

Quaking-grass, 294, 296.

Quassia, 438, 439.
Quassine, 438.
Quercifloræ, 337, 340.
Quercitron-wood, 348.
Quercus, 341, 346, 347, 348, 504.
Quillaja, 457, 460.
Quillajeæ, 457.
Quill-wort, 230.
Quince, 464, 465.
Quinchamalium, 500.
Quinine, 550, 553.

Racomitrium, 197.
Radiatæ, 571.
Radicle, 247.
Radiola, 418.
Radiolarias, 9.
Radish, 403, 404, 405.
Radula, 192.
Rafflesia, 504.
Rafflesiaceæ, 499, 504.
Raisins, 447.
Rajania, 323.
Ralfsia, 71.
Ralfsiaceæ, 71.
Ramalina, 143.
Ramenta, 209.
Ramié, 353.
Rampion, 562.
Randia, 550.
Ranunculaceæ, 278, 378.
Ranunculeæ, 383.
Ranunculus, 151, 378, 379, 380, 382, 383, 384.
Rapateaceæ, 308.
Rape, 404.
Raphanus, 400, 403.
Raphia, 301.
Raphidium, 51.
Raphiolepis, 463, 465.
Raspberry, 459, 460, 461.
Ravenala, 325.
Ray-flowers, 567.
Reboulia, 191.
Receptacle, 210.
Red Algæ, 1.
Red-beet, 372.
Red-cabbage, 405.
Red-clover, 466, 517.
Red-currant, 455.
Red-pine, 264, 266.
“Red-rot,” 164, 166.
Red Sandalwood, 473.
Red Seaweeds, 4, 77.
Red Snow, 48.
Red-strip, 165.
Red-tree, 468.
Reed, 151, 294.
Reed-mace, 303.
Reindeer Moss, 141.
Reineckea, 314.
Remijia, 550, 553.
Renealmia, 326.
Replum, 398.
Reseda, 407.
Resedaceæ, 406.
Resin, 266.
Rest-harrow, 471.
Restiaceæ, 309.
Restio, 309.
Restrepia, 332.
Retama, 472.
Reticularia, 8.
Retinospora, 268.
Rhamnaceæ, 447, 449.
Rhamnus, 151, 448.
Rhaphidophora, 305.
Rhatany, 468.
Rheum, 151, 359, 360.
Rhinanthaceæ, 153.
Rhinantheæ, 525, 526.
Rhinanthus, 526.
Rhingia, 320.
Rhipidium, 320.
Rhipsalis, 375, 376, 377.
Rhizidiaceæ, 103.
Rhizoboleæ, 415.
Rhizocarpeæ, 205, 215.
Rhizoclonium, 58.
Rhizoids, 4, 10.
Rhizomorpha, 169, 170.
Rhizopaceæ, 99.
Rhizophora, 482, 486, 487, 513.
Rhizophoraceæ, 482, 486.
Rhizophyllidaceæ, 84.
Rhizophyllis, 84.
Rhizopods, 5.
Rhizopogon, 175, 176.
Rhizopus, 99.
Rhizosolenia, 20.
Rhodanthe, 573.
Rhodiola, 451, 452.
Rhodochiton, 525.
Rhododendron, 161, 508.
Rhodomela, 83.
Rhodomelaceæ, 83.
Rhodophyceæ, 1, 14, 77.
Rhodophyll, 77.
Rhodophyllidaceæ, 83.
Rhodophyllis, 83.
Rhodoraceæ, 335, 508.
Rhodotypus, 457.
Rhodymenia, 83, 84.
Rhodymeniaceæ, 83.
Rhodymeniales, 82, 84.
Rhœadinæ, 393.
Rhopographus, 131.
Rhubarb, 359.
Rhus, 439.
Rhynchosia, 471.
Rhynchospora, 285, 286.
Rhytisma, 132.
Ribbon-grass, 296, 296.
Ribes, 121, 152, 153, 241, 454, 455.
Ribesiaceæ, 454.
Rib-grass, 530.
Riccia, 186, 189, 190.
Ricciaceæ, 190.
Rice, 291, 293, 296.
Richardia, 305.
Richardsonia, 550.
Ricinus, 431.
Riella, 192, 231.
Ringworm, 180.
Rivina, 372.
Rivularia, 10, 25.
Rivulariaceæ, 22, 24, 25.
Robinia, 470, 473.
Roccella, 142.
Rock-cress, 402.
Rock-rose, 412.
Rod-bacteria, 39.
Roestelia, 147, 148, 151, 152, 153.
Roman spinach, 372.
Roots, 4.
“Ropiness,” 35.
Rosa, 148, 459, 460.
Rosaceæ, 451, 457.
Rose, 121.
Rose-mallow, 428.
Rose of Jericho, 401, 574.
Roseæ, 459.
Rosellinia, 130.
Rosemary, 540.
Oil of, 541.
Rosifloræ, 456, 466.
Rosmarinus, 536, 540, 541.
Rostellum, 329, 332.
Rotang, 298.
Royal-fern, 209, 215.
Rubeæ, 458.
Rubia, 551, 552, 553.
Rubiaceæ, 542, 546, 548, 549, 553.
Rubiales, 490, 505, 548, 556, 564.
Rubus, 458, 460, 461.
Rudbeckia, 572.
Ruellia, 530.
Rulingia, 422.
Rumex, 151, 359, 360.
Ruppia, 278, 279.
Ruscus, 316.
Rush, 283, 284.
Russula, 171.
Russulei, 171.
Rust of Wheat, 148.
Rusts, 146.
“Rust spots,” 130.
Ruta, 436.
Rutaceæ, 436.
Ruteæ, 436.
Rye, 125, 151.
Rye-grass, 295, 296.
Rye-stem blight, 113.

Sabal, 300.
Sabaleæ, 299.
Saccharomyces, 177, 178.
Saccharomyces-forms, 176.
Saccharum, 293.
Safflower, 574.
Saffron, 321.
Sagina, 364, 365, 366.
Sagittaria, 281, 282.
Sago, 254.
Sago-palm, 298.
Sainfoin, 472, 473.
“Salep,” 333.
Salicaceæ, 338.
Salicin, 339.
Salicifloræ, 337.
Salicornia, 369, 371, 503.
Salicornieæ, 371.
Salisburia, 259.
Salix, 122, 337, 338.
Salpiglossis, 521.
Salsafy, 574.
Salsola, 370, 371, 372.
Salsoleæ, 370.
Saltpetre formation, 35.
Saltwort, 370.
Salvadora, 547.
Salvadoraceæ, 542, 547.
Salvia, 536, 540, 541.
Salvinia, 201, 216, 217, 218, 245.
Salviniaceæ, 210, 218.
Sambuceæ, 555, 557.
Sambucus, 156, 553, 555.
Samolus, 513.
Samydaceæ, 476.
Sandalwood, 473, 500.
Sandarack resin, 269.
Sand-box tree, 432.
Sand-star, 287.
Sanguinaria, 395.
Sanguisorba, 460.
Sanicula, 493.
Sannicle, 493.
Sanseviera, 320.
Santalaceæ, 500.
Santalum, 500.
Santolina, 572.
Sapindaceæ, 440.
Sapindus, 441.
Saponaria, 368.
Saponin, 460.
Sapotaceæ, 510.
Saprolegnia, 102, 107, 108.
Saprolegniaceæ, 107.
Saprophytes, 5.
Sapucaia-nuts, 489.
Saranthe, 327.
Sarcina, 27, 28, 38.
Sarcophyte, 504.
Sargassum, 4, 10, 73, 75.
Sarothamnus, 472.
Sarracenia, 409.
Sarraceniaceæ, 408.
Sarsaparilla, 316.
Sassafras, 392.
Satureia, 540, 541.
Satureieæ, 539.
Saurureæ, 362.
Saururus, 362.
Saussurea, 570.
Sauvagesieæ, 411.
Saw-wort, 570.
Saxifraga, 161, 452.
Saxifragaceæ, 451, 452.
Saxifrage, 452.
Saxifraginæ, 451, 555.
Scabiosa, 558, 559, 560.
Scævola, 564.
Scale-leaves, 235.
Scammony, 517.
Scandiceæ, 495.
Scandix, 495.
Scapania, 192.
Scarlet-runner, 473.
Scenedesmus, 51.
Scheuchzeria, 278.
Schistostega, 196, 197.
Schistostegaceæ, 197.
Schizæa, 215.
Schizæaceæ, 210, 215.
Schizanthus, 521.
Schizocarp, 492.
Schizocarpeæ, 195.
Schizochlamys, 51.
Schizomeris, 53.
Schizomycetes, 26, 33.
Schizopetaleæ, 404.
Schizopetalum, 402.
Schizophyceæ, 8, 10, 23, 26.
Schizophyllum, 171.
Schizophyta, 1, 14, 19, 22, 24.
Schœnocaulon, 310.
Schœnoxiphium, 287.
Schœnus, 286.
Schwendenerian Theory, 139.
Sciadium, 51.
Sciadopitys, 267.
Scilla, 312, 314.
Scirpeæ, 285.
Scirpus, 285, 286, 287.
Scirrhia, 131.
Scitamineæ, 276, 278, 323, 328.
Scitonemaceæ, 22, 24, 25, 27.
Scleranthus, 365, 367.
Scleria, 286.
Scleroderma, 175.
Sclerodermataceæ, 175.
Sclerotinia, 116, 134, 135.
Sclerotium, 87, 127.
Scolopendrium, 213, 214.
Scoparia, 525.
Scopolia, 519, 521.
Scorodosma, 496.
Scorzonera, 571, 574.
Scotch Fir, 259, 266.
Scotinosphæra, 47, 51.
Screw Pine, 302.
Scrophularia, 524, 526.
Scrophulariaceæ, 518, 521, 522, 527.
Scutellaria, 536, 539.
Scutellum, 293.
Scyballium, 504.
Scytonema, 22, 26, 176.
Scytonemaceæ, 25.
Sea-holly, 493.
Sea-kale, 403, 405.
Sea-lavender, 514.
Sea-milkwort, 513.
Seaweed, 4.
Sea-wormwood, 574.
Sebacina, 156.
Secale, 127, 295, 296.
cornutum, 127.
Sechium, 481.
“Sedimentary-yeast,” 178.
Sedum, 451, 452.
Seed, 247, 248, 249.
Seguieria, 372.
Selaginaceæ, 532, 541.
Selaginella, 200, 203, 228, 229, 230, 232, 233, 245, 254.
Selaginellaceæ, 231.
Selaginelleæ, 205, 228.
Selago, 541.
Selenastrum, 51.
Selenipedilum, 329, 330.
Seligeria, 196.
Seligeriaceæ, 196.
Semele, 316.
Sempervivum, 151, 451, 452.
Senebiera, 400, 401.
Senecio, 566, 569, 572, 573.
Senecioneæ, 572.
Senna, 468.
Sepals, 235.
Sequoia, 267, 272.
Serapias, 332.
Serjania, 441.
Serratula, 570, 574.
Serum, 33.
Service-tree, 465.