Roland Martin
Department of Clinical Neuroimmunology and MS Research, Neurology Clinic, UniversittsSpital Zrich, University of Zrich
C C
Klinische Bedeutung
Die Abgrenzung von der Multiplen Sklerose ist entscheidend, da die beiden Erkrankungen mit
Eugne Devic (1858-1936)
C C
NMO Diagnosekriterien
= NMO-IgG Aquaporin-4
Immunofluorescence pattern of bound NMO-IgG in mouse CNS
Lennon et al., Lancet 2004
AQP4 transf.
Sehnerv
Kleinhirn
HEK
Aquaporin 4 wird auf Astrozyten-Fen exprimiert und mit einem exzitatorischen Aminosuren-Transporter EAAT2 ko-reguliert.
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
Todesursachen: - in 5 Fllen als NMO-assoziiert eingeschtzt - in 4 Fllen nicht mit der Erkrankung assoziiert
89% relapsierend 11% monophasisch monophasischer Verlauf signifikant hufiger bei seronegativen Pat.
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
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
spinale neurochirurgische Intervention postoperativ EDSS 8 (vs. 4 pr) postoperativ mehrmals Liquorleck Patientin seitdem dauerhaft rollstuhlpflichtig
NEMOS: Konsensusempfehlungen
Acknowledgement: S. Schippling Clinic, USZ, Zrich Dept. Neuroimmunology and MS Research, Neurology
AQP4 transf.
Sehnerv
untransf.
anti-Amphiphysin
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
neurotrope Viren? Paraneoplastische Erkrankung: HSV? Autoantikrper gegen intrazellulre Antigene: Hu, Ma2, CV2/CRMP5, Amphiphysin
Tzn & Dalmau, The Neurologist 2007
Klinische Bedeutung
Hufiger als klassische paraneoplastische Antikrper (Hu, Ma, CV2, Yo, ...). tiologie: Autoimmun > Paraneoplastisch. Gutes Ansprechen der Patienten auf Therapie.
DTX
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 %
VGKC-Antikrper
Neuromyotonie Morvans Syndrom CASPR2 LGI1/CASPR2 LGI1
Limbische Enzephalitis
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
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-NMDAR 38%
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
Monoclonal Antibodies in MS
Natalizumab: approved Alemtuzumab: Phase III Rituximab: Phase III Daclizumab: Phase III Ustekinumab: Phase II gestoppt
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
CD4
CD8
Other cells ?
CD4
B CD8
CD8 CD8
CD8
Monocyte
B
CD4
Neuron
Oligo Neuron
CNS
Oligo
Peripheral blood
CD4
CD8
Other cells ?
CD4
B CD8
CD8 CD8
CD8
Monocyte
B
CD4
Neuron
Oligo Neuron
CNS
Oligo
Peripheral blood
CD4
CD8
Other cells ?
CD8
CD4
Monocyte
CD8 B
Neuron
Oligo Neuron
CNS
Oligo
Peripheral blood
CD4
CD8
Other cells ?
CD8
CD4
CD8 B
Neuron
Oligo Neuron
CNS
Oligo
Peripheral blood
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
CD8
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
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)
PML Pathology
GFAP
JCV
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).
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
Consequence PML-IRIS
CD4
CD8
Other cells ?
CD8
Monocyte
B
CD4
CD4
CD4
CD8 CD8
CD4
PML-IRIS PML-IRIS
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
Patient 1
July 2009 PML Suspicion September 2009 PML-IRIS
Patient 2
January 2010 PML Suspicion March 2010 PML-IRIS
VP1/VLP-specific antibodies
90 60
undiluted CSF
40 30 20 10
30
1/1000 dil
1.0 0.5 0.0 1.0
0.5
Serum
0.0 January-10
Serum
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
CSF
7.5
PBMCs
VLP = virus-like particles, JCV major capsid protein VP1 TTx = tetanus toxin
SI
SI
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
When tested against overlapping peptides of three major myelin proteins there is no response. Brain-infiltrating T cells recognize JCV, but not myelin proteins.
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
Acknowledgements:
Funding: Biogen & Idec, Hertie Foundation JCV viral load determination: Hans Hirsch, University of Basel; Eugene Major, NINDS, NIH