Central Nervous System Autoimmune Diseases/Disorders

Roland Martin
Department of Clinical Neuroimmunology and MS Research, Neurology Clinic, UniversittsSpital Zrich, University of Zrich

CNS autoimmune diseases/disorders

Multiple sclerosis and its subforms Neuromyelitis optica Acute disseminated encephalomyelitis (ADEM) CNS autoimmunity in the context of mixed connective tissue disorders (SLE, Sjgren) Paraneoplastic autoimmune disorders (encephalomyelitides) CNS autoimmunity/damage as a sequel of infection (chronic CNS Lyme disease, progressive multifocal leukoencephalopathy (PML), and PML-immune reconstititution inflammatory syndrome)

CNS autoimmune diseases/disorders

Multiple sclerosis and its subforms Neuromyelitis optica Acute disseminated encephalomyelitis (ADEM) CNS autoimmunity in the context of mixed connective tissue disorders (SLE, Sjgren) Paraneoplastic autoimmune disorders (encephalomyelitides) CNS autoimmunity/damage as a sequel of infection (chronic CNS Lyme disease, progressive multifocal leukoencephalopathy (PML), and PML-immune reconstititution inflammatory syndrome)

Neuromyelitis optica (Devic Syndrom)

C

C C

Eugne Devic (1858-1936)

Kasuistik: 18 jhrige Patientin mit Lhmung beider Arme und Beine

Multiple Sklerose oder NMO?

Klinische Bedeutung
Die Abgrenzung von der Multiplen Sklerose ist entscheidend, da die beiden Erkrankungen mit
Eugne Devic (1858-1936)

C C

unterschiedlichen Medikamenten behandelt werden.

NMO Diagnosekriterien

Wingerchuk et al. Neurology 2006

Hinson, McKeon, Lennon; Neuroscience 168: 1009 (2010)

Identifizierung von Autoantikrpern mit Hilfe der indirekten Immunfluoreszenz

= NMO-IgG Aquaporin-4
Immunofluorescence pattern of bound NMO-IgG in mouse CNS
Lennon et al., Lancet 2004

Serologische Diagnose der NMO

NMO-IgG: Anti-AQP-4:

AQP4 transf.

Sehnerv

Kleinhirn

HEK

Aquaporin 4 wird auf Astrozyten-Fen exprimiert und mit einem exzitatorischen Aminosuren-Transporter EAAT2 ko-reguliert.

Fokus der NEMOS-Auswertung

homogene kaukasische Kohorte auch Spektrum-Erkrankungen bekannter AQP4-Serostatus bei allen Patienten der Kohorte Stratifizierung gemss Serostatus fr AQP4-AK

Fallzahlen

175 kaukasische Flle mit bekanntem AQP4-AK-Serostatus retrospektiv erfasst bis August 2011 119 mit NMO gemss der Wingerchuk 2006 Kriterien: 77% seropositiv 49 mit LETM (Myelitis und Lsionen im sMRT ber >3 WK): 82% seropositiv 7 rekurrierende ON: 71% seropositiv

Geschlechterverteilung

alle Pat.: F:M = 6:1 seropositive Pat.: F:M = 10:1 seronegative Pat.: F:M = 2:1 83% der Frauen seropositiv, jedoch nur 48% der Mnner

Jarius et al., submittiert

Ergebnisse: Demographische Daten

Todesursachen: - in 5 Fllen als NMO-assoziiert eingeschtzt - in 4 Fllen nicht mit der Erkrankung assoziiert

Ergebnisse: Klinische Daten

Ergebnisse: monopasisch vs. schubfrmig

89% relapsierend 11% monophasisch monophasischer Verlauf signifikant hufiger bei seronegativen Pat.

Cox et al. Lancet Neurology 2005

Ergebnisse: Fehldiagnosen

in 43% initiale Fehldiagnose als MS Fehldiagnosen meist vor der Verfgbarkeit der AQP-Testung vor 2005: 54% nach 2005: 20%

von den initial flschlicherweise als MS diagnostizierten Fllen wurden 53% mindestens einmal mit IFN-beta behandelt vs. 21% in der Gesamtkohorte andere initiale Fehldiagnosen: ADEM, rheumatologische Erkrankungen, Syringomyelie

Ergebnisse: EDSS

Ergebnisse: spinales MRT

Ergebnisse: craniales MRT

Seropositiv vs. seronegativ

hhere Frauenwendigkeit bei seropositiven Patienten mehr seropositive Patienten haben schlechteren Nadir-Visus (<0.1) im ONSchub Paresen bei Myelitis schwerer in seropositiven als in seronegativen Patienten ausgedehnterer Befall des RM bei seropositiven Patienten hherer Anteil von anderen Autoimmunerkrankungen in der seropositiven Gruppe hherer Anteil monophasischer Verlufe bei seronegativen vs. seropositive Pat. seronegative Pat. haben mehr sensible Symptome und hufiger bilaterale ON keine Unterschiede hinsichtlich Schubrate, Remission von Schben und Hirnstammbeteiligung

 damit wenn das MRT so aussieht

 das nicht mehr passiert!

spinale neurochirurgische Intervention postoperativ EDSS 8 (vs. 4 pr) postoperativ mehrmals Liquorleck Patientin seitdem dauerhaft rollstuhlpflichtig

NMO Klinische Befunde

Langstreckige (mehrere Segmente; >3) Rckenmarkslsionen, Myelitis Neuritis nervi optici; ein- oder beidseitig Schwerer Verlauf; schlechtes Ansprechen auf Steroide (und relativ auch auf Plasmapherese) Verschlechterung durch IFN- Hufig keine oligoklonalen Banden im Liquor Aquaporin-4 positiv; nicht alle Patienten; berlappungen mit Erkrankungen des mixed connective tissue disorder Formenkreises

NEMOS: Konsensusempfehlungen

Acknowledgement: S. Schippling Clinic, USZ, Zrich Dept. Neuroimmunology and MS Research, Neurology

CNS autoimmune diseases/disorders

Multiple sclerosis and its subforms Neuromyelitis optica Acute disseminated encephalomyelitis (ADEM) CNS autoimmunity in the context of mixed connective tissue disorders (SLE, Sjgren) Paraneoplastic autoimmune disorders (encephalomyelitides) CNS autoimmunity/damage as a sequel of infection (chronic CNS Lyme disease, progressive multifocal leukoencephalopathy (PML), and PML-immune reconstititution inflammatory syndrome)

Entdeckung neuer Autoantikrper in der Neurologie

2004: Aquaporin-4

2007/8: 2009: 2010: 2010:

NMDA-Rezeptor AMPA-Rezeptor GABAB-Rezeptor LGI1; CASPR2

Anti-CV2 Antikrper bei einem Patienten mit NMO und Prostatakarzinom

Befund 090220-39

AQP4 transf.

Sehnerv

untransf.

Jarius et al., Clin. Neurol. Neurosurg. 2011

Klassische Paraneoplastische Antikrper

Klassische Paraneoplastische Syndrome

Limbische Enzephalitis: anti-Ma, anti-Amphiphysin anti-CV2, anti-Hu anti-Yo anti-Tr anti-Hu

Subakute zerebellre Degeneration: Sensible / autonome Neuropathie: Stiff-person-syndrome:

anti-Amphiphysin

Graus et al., J. Neurol. Neurosurg. 2004

Paraneoplastische Antikrper
anti-Hu (ANNA-1) anti-Yo (PCA-1) anti-Ri (ANNA-2) anti-Amphiphysin anti-CV2 (CRMP5) anti-Ma1 (PNMA1) anti-Ma2/Ta (PNMA2) anti-Recoverin SCLC, Neuroblastom Ovar, Mamma, Uterus Mamma, SCLC Mamma, SCLC SCLC, Thymom Mamma, Various Testis SCLC

Wahrscheinlichkeit fr Tumor bei positivem Befund: >95%

Autoantikrper gegen neuronale Oberflchenantigene

(fakultativ paraneoplastisch)

Enzephalitis ohne Erregernachweis Limbische Enzephalitis

Limbische Enzephalitis: Neugedchtnisstrung Psychische Aufflligkeiten Affektstrung Temporallappenanflle

neurotrope Viren? Paraneoplastische Erkrankung: HSV? Autoantikrper gegen intrazellulre Antigene: Hu, Ma2, CV2/CRMP5, Amphiphysin
Tzn & Dalmau, The Neurologist 2007

Antikrper gegen Neuropil

Zielantigene auf der Zellmembran

- Glutamat-Rezeptoren: (Typ NMDA und AMPA) - GABAB-Rezeptoren - VGKC - LGI1, CASPR2
Vincent et al., Lancet Neurology 2011

Klinische Bedeutung
Hufiger als klassische paraneoplastische Antikrper (Hu, Ma, CV2, Yo, ...). tiologie: Autoimmun > Paraneoplastisch. Gutes Ansprechen der Patienten auf Therapie.

Antikrper gegen NMDA-Rezeptoren

(Glutamatrezeptoren Typ NMDA)

Anti-NMDA Rezeptor Enzephalitis

Neues (bislang unbekanntes) Krankheitsbild Initial bei jungen Patienten mit Ovarialteratomen beschrieben Auftreten auch bei lteren Patientinnen, Frauen ohne Teratom, Mnnern und Kindern Antikrpernachweis ausschlaggebend fr Diagnose Behandelbare, potentiell heilbare Erkrankung Frhe Therapie entscheidend fr Prognose Krankheit ist unterdiagnostiziert Enzephalitis ohne Erregernachweis; Drogen-induzierte Psychose

Retrospective Analysis of Patients with Encephalitis of unknown origin

Prss et al., Neurology 2010

Anti-NMDA Receptor Encephalitis:

Philadelphia series of 400 patients

Dalmau et al., Lancet Neurology 2011

Antikrper gegen spannungsabhngige Kaliumkanle (VGKC)

DTX

Dendrotoxin (DTX) bindet an Kv1.1, Kv1.2 und Kv1.6

Radioimmun-Przipitations-Assay (RIPA)

VGKC RIA

125I

Substrat: Hirn-Homogenat
Vincent et al., Lancet Neurology 2011

VGKC-Antikrper
Neuromyotonie Morvans Syndrom Limbische Enzephalitis

VGKC RIA

125I

Substrat: Hirn-Homogenat
Vincent et al., Lancet Neurology 2011

VGKC RIA

125I

Substrat: Hirn-Homogenat
Vincent et al., Lancet Neurology 2011

VGKC-Komplex Antikrper
Kv1.1, Kv1.2, Kv1.6 LGI1 CASPR2 ? 3% ? 80 % 17 %

Hauptantigene: LGI1 und CASPR2

Irani et al., Brain 2010

VGKC-Antikrper
Neuromyotonie Morvans Syndrom CASPR2 LGI1/CASPR2 LGI1

Limbische Enzephalitis

Autoantikrper gegen neuronale Oberflchenantigene: Labordiagnostik

Immunohistochemistry
Patient A Patient B Patient C Patient E

Hippocampus

Cerebellum

Neuropil Antibodies Pattern characteristic, but not specific! monospecific assays needed

Tumorassoziation
NMDAR: AMPAR: GABABR: LGI1: CASPR2: 35-40% 70-75% 50-80% 0-10% 0-35% Teratom SCLC SCLC Thymom Thymom

Wandinger et al., J Lab Med 2011

Frequency of Autoantibodies
Neuropil / classical 31% of Results different from initial Antibody Request! (NMDAR + Hu) 1,9% NMDAR + GABAB 0,9% NMDAR + CASPR2 0,9% Anti-CASPR2 11,1% Anti-Ri 9,3% Anti-Ma 1,9% Anti-PCA2 0,9% Anti-CV2 3,7% Anti-Amphiphysin 0,9% classical / classical (Hu + CV2) 2,8% Anti-Hu 5,6% Anti-Yo 8,2%

Neuropil / Neuropil

n=108 patients

Anti-LGI1 11,1%

Anti-GABAB 2,8% Anti-AMPAR 0%

Anti-NMDAR 38%

Take Home Messages

AQP4: Sichere Abgrenzung NMO von MS.

NMDAR, AMPAR, GABABR, LGI1 und CASPR2: neu - wichtig - hufig.

Multiparametrische Testung klinisch notwendig!

VGKC-Hauptantigene: LGI1 und CASPR2 zielgerichtet/zuverlssig untersuchen.

Acknowledgements
University of Pennsylvania: University of Oxford: Mayo Clinic, Rochester: J. Dalmau A. Vincent P. Waters V. Lennon S. Pittock C. Klein KP Wandinger W. Stoecker C. Probst K. Borowski C. Klingbeil

Institute for Experimental Immunology:

CNS autoimmune diseases/disorders

Multiple sclerosis and its subforms Neuromyelitis optica Acute disseminated encephalomyelitis (ADEM) CNS autoimmunity in the context of mixed connective tissue disorders (SLE, Sjgren) Paraneoplastic autoimmune disorders (encephalomyelitides) CNS autoimmunity/damage as a sequel of infection (chronic CNS Lyme disease, progressive multifocal leukoencephalopathy (PML), and PML-immune reconstititution inflammatory syndrome)

Monoclonal Antibodies in MS

Natalizumab: approved Alemtuzumab: Phase III Rituximab: Phase III Daclizumab: Phase III Ustekinumab: Phase II gestoppt

Aus Lutterotti & Martin, Lancet Neurol. 2008

Natalizumab Humanized monoclonal antibody against 4 chain (CD49d) of integrins. 4-integrins VLA-4 (4 1) - VCAM (brain endothelium) LPAM-1 (4 7) - MadCAM (gut endothelium)

Highly efficient: blocks disease activity (relapses) in MS by more than 60%. Second line therapy, first line

Peripheral blood

Mechanism of action - natalizumab

Monocyte VLA-4 VCAM-1 ICAM-1 LFA-1

CD4

CD8

Other cells ?

CD4 CD4 CD4

CD4

B CD8

CD8 CD8

CD8

Monocyte

B
CD4

Neuron

Oligo Neuron

CNS

Oligo

Peripheral blood

Mechanism of action - natalizumab

Monocyte VLA-4 VCAM-1 ICAM-1 LFA-1

CD4

CD8

Other cells ?

CD4 CD4 CD4

CD4

B CD8

CD8 CD8

CD8

Monocyte

B
CD4

Neuron

Oligo Neuron

CNS

Oligo

Peripheral blood

Mechanism of action - natalizumab

Monocyte VLA-4 VCAM-1 ICAM-1 LFA-1

CD4

CD8

Other cells ?

CD8
CD4

Monocyte

CD8 B
Neuron

Oligo Neuron

CNS

Oligo

Peripheral blood

Mechanism of action - natalizumab

Monocyte VLA-4 VCAM-1 ICAM-1 LFA-1

CD4

CD8

Other cells ?

CD8
CD4

CD8 B
Neuron

Oligo Neuron

CNS

Oligo

Peripheral blood

Mechanism of action - natalizumab

Monocyte VLA-4 VCAM-1 ICAM-1 LFA-1

CD4

CD8

Other cells ?

CD8
CD4

CD8 B
Neuron

Oligo Neuron

CNS

Oligo

JC Virus and MS

JC virus infection of the brain, i.e. progressive multifocal leukoencephalopathy (PML), recently emerged as a major problem during monoclonal antibody treatment of MS (natalizumab, anti-VLA-4; now > 170 cases), psoriasis (efalizumab; anti-LFA1), rituximab (rheumatoid arthritis, SLE; anti-CD20; > 10 cases). This complication may lead to market withdrawal of the above monoclonal antibodies (efalizumab already withdrawn)

Introduction JC Virus
Monocyte
CD4

JCV
B Other cells ?

VCAM-1

VLA-4 Progressive multifocal LFA-1 ICAM-1 leucoencephalopathy (PML):

CD8

Polyomavirus: non-enveloped, 40 nm icosahedron

Genome: Fatal demyelinating diseases caused by JCV doublestranded , supercoiled DNA, 5130 bp
CD4 Viral Immunocompromised individuals proteins: VP1, VP2, VP3, Large T, small t, Agno PML CD8

CD8

Infection Lytic infection of forming with JCV is myelin highly prevalent in healthy adults, and about 60% of the population carry a Oligo oligodendrocytes
(latent)/persistent infection
CNS
Oligo

Neuron

Neuron Neuron

JC Virus and Disease

Under conditions of immunocompromise (HIV infection/AIDS, immunosuppressive therapies, idiopathic CD4+ T cell lymphopenia, cancer) persistent JCV infection may lead to progressive multifocal leukoencephalopathy (PML)

JCV genome

JC Virus Strains

The archetypic JCV strains and the neurotropic, PMLcausing strain (Mad1) only differ by a tandem repeat in the viral regulatory region; there are only minor differences in the structural proteins. However, certain mutations in VP1 occur (aa 55, 269, and others)

CNS Manifestations of JCV Infection

PML Clinical Findings

Clinical symptoms: PML versus MS

From: Weber, T. Neurol Clin 26 (2008) 833854

PML MRI Findings

Confluent T2hyperintense lesions in the CNS white matter

From: Weber, T. Neurol Clin 26 (2008) 833854

PML Pathology

GFAP

JCV

Courtesy: Carlos Pardo, JHU

Monocyte VLA-4 VCAM-1 ICAM-1 LFA-1

CD4

CD8

Other cells ?

CD4

CD8

PML PML
B
Oligo

CD8

Neuron

Neuron Neuron

CNS

Oligo

JCV infection of oligodendrocytes leads to direct cell lysis and release of infectious virus; infection of astrocytes is nonproductive = progressive multifocal leukoencephalopathy (PML).

Natalizumab in MS PML Risk

Natalizumab in MS PML Risk

In JCV seronegative patients without prior immunosuppression < 1:10.000 In JCV seropositive patients without prior immunosuppression = 1:1.000 In JCV seropositive patients with prior immunosuppression and greater 2 years treatment = 1:100 Rate of infection approximately 60% (based on seropositivity); 40-50% excrete viral DNA in the urine; serum is usually JCV DNA negative.

PML Diagnosis

Clinical neurocognitive/-psychiatric abnormalities, speech problems, seizures, other neurological deficits MRI: confluent T2-hyperintense lesions in the CNS white matter; absence of inflammation Pathology: demyelinated plaques with irregular borders; enlarged oligodendrocytes with intranuclear inclusions, bizarre appearing astrocytes with multiple nuclei, detection of JCV by immunohistochemistry or in situ hybridization; usually supratentorial Laboratory: PCR for JCV DNA positive in the CSF; intrathecal JCV-specific antibodies

PML-immune reconstitution inflammatory syndrome (PML-IRIS) PML-IRIS occurs as soon as the compromised immune system is reconstituted, e.g. in AIDS patients under HAART therapy or in natalizumab-treated MS patients, when the antibody has been washed out by plasmapheresis.

PML-IRIS

HIV and HAART Therapy

MS and Natalizumab Therapy

Consequence PML-IRIS

Monocyte VLA-4 VCAM-1 ICAM-1 LFA-1

CD4

CD8

Other cells ?

CD8

Monocyte

B
CD4

CD4

CD4

CD8 CD8 CD8

CD8 CD8
CD4

PML-IRIS PML-IRIS

Neuron

CD8 CD8 Monocyte

Neuron

CNS

The strong inflammatory response against JC virus-infected cells leads to their elimination; JC viral load drops; substantial collateral brain damage and often fatal outcome

Monocyte

CD4

VCAM-1

B Inflammatory PML -Immune Reconstitution Other cells ? PML-Immune Reconstitution Inflammatory VLA-4 LFA-1 ICAM-1 Syndrome IRIS): Syndrome(PML(PML-IRIS):

CD8

CD8

CD8

CD4 CD8 CD4 High inflammation B High inflammation CD8 CD8 Monocyte CD4 Low/negative JCV CSF CD8 Low/negative JCVviral viralload load CSF B PML-IRIS PML-IRIS CD4 No/few oligodendrocytes and astrocytes No/fewinfected infected CD8 oligodendrocytes and astrocytes May be fatal due May dueto tobrain brainswelling swelling Monocyte Neuron CD8 be fatal

Neuron

CNS

Summary

Background

MS and natalizumab therapy

Polyomavirus JC and PML Immune control of JC virus and therapeutic considerations

Background JCV-specific immunity:

91% of PML survivors show CD8+ T cells, but only 9% of those with fatal outcome, Koralnik et al, 2002. Restoration of CD4+ response leads to elimination of JCV from the CNS of AIDS patients, Gasnault et al, 2003. PML is normally seen in the context of AIDS (loss of CD4+ T cells), malignancies, transplant therapy, idiopathic CD4+ lymphopenia). PML patients show high intrathecal antibody titers against JCV, and JCV antibody seropositivity is considered a sign of exposure (they are probably relevant as well).

Patient 1
July 2009 PML Suspicion September 2009 PML-IRIS

Patient 2
January 2010 PML Suspicion March 2010 PML-IRIS

JCV-viral load urine JCV-viral load serum JCV-viral load CSF

85,250 copies/ml 0 copies/ml < 100 copies/ml

JCV-viral load urine JCV-viral load serum JCV-viral load CSF

7,744,255 copies/ml 58 copies/ml 12 copies/ml

VP1/VLP-specific antibodies
90 60

undiluted CSF

40 30 20 10

undiluted CSF 1/1000 dil

30

1/1000 dil
1.0 0.5 0.0 1.0

undiluted 1/1000 dil

August-09 September-09

0.5

Serum
0.0 January-10

undiluted 1/1000 dil

May-10

Serum

Aly, Yousef, et al., Brain, 2011

Workflow and steps of biopsy characterization

Brain Biopsy

Characterization
Specificity Phenotype Transcription factors TCR expression

Pathology

FACS

Characterization
Limiting dilution T cell cloning Fine specificity Phenotype Transcription factors Restriction TCR V , CDR3 characterization

Brain biopsy of patient 2 PML-IRIS

Aly, Yousef, et al., Brain, 2011

Antigen specificity of PHA-expanded cells from different compartments: Biopsy

700 600 500 20 5.0 30

CSF
7.5

PBMCs

VLP = virus-like particles, JCV major capsid protein VP1 TTx = tetanus toxin

SI

SI

300 200 100 0 0 10

SI
2.5 0.0

400

VLP TTx

VLP TTx

VLP TTx

Tissue/brain-infiltrating T cells are highly specific for JCV, whereas CSF-infiltrating- and peripheral blood T cells respond only weakly.
Aly, Yousef, et al., Brain, 2011

Antigen specificity of brain-infiltrating T cells:

When tested against overlapping peptides of three major myelin proteins there is no response. Brain-infiltrating T cells recognize JCV, but not myelin proteins.

Aly, Yousef, et al., Brain, 2011

Antigen specificity of brain-infiltrating CD4+ T cells (bulk-expanded)

CD8+ JCV-specific T cells

Both JCV-specific CD4+ and CD8+ T cells are found in the biopsy; very high frequency of CD4+ VP1-specific T cells. Aly, Yousef, et al.,
Brain, 2011

Conclusions PML-IRIS
The vigorous CNS immune response in PML-IRIS is characterized by: T cell-, B cell and monocyte/macrophage infiltrate; VP1-specific antibodies in the CSF. CNS cell destruction is directed against virus-infected cells; there is collateral damage of tissue, but the response is not an autoimmune response. Since PML-IRIS may run a very acute course and lead to fatal outcome, transient immunosuppression is critical.

Contributions
PML-IRIS
Lilian Aly* - inims Sara Yousef*- inims Sven Schippling - inims Petra Breiden- inims Mireia Sospedra - inims, Hamburg Ilijas Jelcic, inims, USZ, Zrich Michael Linnebank USZ, Zrich Rosina Girones UB, Barcelona Silvia Bofill-Mas - UB, Barcelona Robert Schulz Neurology, HH Jacob Matschke Pathology, HH Thomas Weber Marienkrankenhaus, HH Viktorya Demina LSI, Bonn Graham Ogg Univ. Oxford

JCV epitope mapping

Lilian Aly*, inims Ilijas Jelcic*, inims, USZ, Zrich Sven Schippling, inims Petra Breiden, inims Raquel Planas, inims Mireia Sospedra, inims Thomas Weber, Marienkrankenhaus, HH Viktorya Demina, LSI, Bonn Thomas Binder, Dept. Transfusion Medicine, UKE, Hamburg Thomas Eiermann, Dept. Transfusion Medicine, UKE, Hamburg Silvia Bofill-Mas, UB, Barcelona Rosine Girones, UB, Barcelona 1 investigator each from Wrzburg, Bochum, Rostock, Dresden, Regensburg (PML cases)

Acknowledgements:
Funding: Biogen & Idec, Hertie Foundation JCV viral load determination: Hans Hirsch, University of Basel; Eugene Major, NINDS, NIH