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Abraham RS, Albanesi C, Alevizos I, Anguita J, Antiochos B, Aranow C, Atkinson JP, Austin HA, Babu S, Ballow MC, Balow JE, Belmont JW, Berek C, Beukelman T, Bhavsar T, Bird JA, Blutt SE, Boguniewicz M, Bonamichi-Santos R, Boisson B, Borzova E, Boyaka PN, Boyce J, Browne SK, Burks W, Bustamante J, Calder VL, Campbell M, Cardones ARG, Casanova JL, Castells M, Cavacini LA, Chan ES, Chaplin DD, Chatham WW, Chen ES, Chinen J, Christopher-Stine L, Ciancanelli M, Cope AP, Corry DB, Crea F, Cron RQ, Cuellar-Rodriguez JM, Dalakas MC, Dann SM, Diamond B, Du TW, Dupuis-Boisson S, Eagar TN, Elmets CA, Erkan D, Fanning L, Fikrig E, Flego D, Fleisher TA, Fonacier L, Fontenot AP, Freeman AF, Frew AJ, Fujihashi K, Gadina M, Gatt ME, Gershwin ME, Gillespie SL, Goronzy JJ, Goswami S, Grattan CE, Greenspan NS, Gupta S, Gustafson CE, Hall RP, Hamilton RG, Harrington LE, Harrison LC, Hasni SA, Helbling A, Hester J, Holland SM, Hourcade D, Huntington ND, Hwangpo T, Imboden JB, Issa F, Izraeli S, Jaffe ES, Jalkanen S, Jones S, Jouanguy E, Kabbani S, Kaufmann SH, Kheradmand F, Kohn DB, Korngold R, Kovalszki A, Kuhns DB, Kulkarni H, Kuo CY, Lahouti A, Landgren CO, Laurence A, Lee JS, Lemière C, Leung DY, Levinson AI, Levy O, Lewis DE, Lin P, Linkermann A, Liuzzo G, Lockshin MD, Lord AK, Lozier JN, Luong A, Luqmani R, Mackay M, Maltzman JS, Mannon PJ, Manns MP, Martin JG, Maynard CL, McCash S, McDonald DR, Melby PC, Miller SD, Mitchell AL, Mohd-Zaki A, Mold C, Moller DR, Monos DS, Mueller SN, Mulders-Manders CM, Mulligan MJ, Müller UR, Munshi PN, Murata K, Murphy PM, Navasa N, Noel P, Notarangelo LD, Nussbaum RL, Nutman TB, Nutt SL, Oliveira JB, Ortel TL, O'Shea JJ, Pai SY, Pandit L, Paul ME, Pearce SH, Pedicino D, Peterson EJ, Picard C, Pittaluga S, Priel DL, Puck J, Puel A, Radbruch A, Reece ST, Reveille JD, Rich RR, Roifman CM, Rosen A, Rosenbaum JT, Rosenzweig SD, Rouse BT, Rowley SD, Sakaguchi S, Salmi M, Sant AJ, Satola SW, Saw V, Schechter MC, Schroeder HW, Segal BM, Selmi C, Shankar S, Sharma A, Sharma P, Shearer WT, Siegel RM, Simon A, Smith GP, Stephens DS, Stephens R, Straumann A, Teos LY, Timares L, Tonnus W, Torres RM, Uzel G, van der Hilst JC, van der Meer JW, Varga J, Vyas JM, Waldman M, Weiser P, Weller PF, Weyand CM, Wigley FM, Winchester RJ, Wing JB, Wood KJ, Wu X, Xu H, Yee C, Zhang SY. List of Contributors. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00104-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Dalakas MC. Neurological complications of immune checkpoint inhibitors: what happens when you 'take the brakes off' the immune system. Ther Adv Neurol Disord 2018; 11:1756286418799864. [PMID: 30245744 PMCID: PMC6144585 DOI: 10.1177/1756286418799864] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 08/18/2018] [Indexed: 12/13/2022] Open
Abstract
Patients with advanced malignancies treated with immune checkpoint inhibitors are at increased risk for developing immune-related neurological complications. It is a phenomenon of immunological twist when immunotherapy against co-stimulatory molecules activates previously normal T cells to kill tumor cells but, in so doing, the T cells become unrestrained, triggering other autoimmune diseases for which conventional immunotherapy is needed. The most common autoimmune neurological diseases, usually occurring within 2-12 weeks after immune checkpoint inhibitor initiation, include: inflammatory myopathies, myasthenia gravis, acute and chronic demyelinating polyradiculoneuropathies, vasculitic neuropathies, isolated cranial neuropathies, aseptic meningitis, autoimmune encephalitis, multiple sclerosis and hypophysitis. The neurological events can evolve rapidly, necessitating the need for vigilance at all stages of treatment, even after completion, because early immunotherapeutic interventions are effective. The review addresses these complications and the applied therapies, discusses immune pathomechanisms including triggering preexisting autoimmunity, highlights the distinction between paraneoplastic and autoimmune etiologies, and identifies uncertainties regarding risk factors, use of immune checkpoint inhibitors in patients with known immune diseases or restarting therapy after a neurological event. Although the autoimmune neurological complications are not very common, their incidence will likely increase as the use of immune checkpoint inhibitors in metastatic cancer is growing rapidly.
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Hughes R, Dalakas MC, Merkies I, Latov N, Léger JM, Nobile-Orazio E, Sobue G, Genge A, Cornblath D, Merschhemke M, Ervin CM, Agoropoulou C, Hartung HP, Day T, Spies J, Roberts L, Van Damme P, Van den Bergh PYK, Maertens de Noordhout A, Dionne A, Larue S, Massie R, Melanson M, Camu W, De Seze J, Le Masson G, Pouget J, Schmidt J, Kimiskidis VK, Chapman J, Drory VE, Fazio R, Gallia F, Kusunoki S, Mori M, Iijima M, Okamoto T, Baba M, Faber CG, van Schaik IN, Fryze W, Motta E, Selmaj K, Casasnovas C, Sola AG, Illa I, Holt J, Miller JAL, Lunn MP, Brannagan TH, Brown M, Kelemen J, Iyadurai S, Rezania K, Sharma KR, Tandan R, Gudesblatt M, Lawson V, Amato AA. Oral fingolimod for chronic inflammatory demyelinating polyradiculoneuropathy (FORCIDP Trial): a double-blind, multicentre, randomised controlled trial. Lancet Neurol 2018; 17:689-698. [DOI: 10.1016/s1474-4422(18)30202-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/01/2018] [Accepted: 05/14/2018] [Indexed: 12/17/2022]
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Alexopoulos H, Akrivou S, Mastroyanni S, Antonopoulou M, Dinopoulos A, Giorgi M, Konstantinou K, Kouremenos E, Lariou M, Naoumis D, Pavlidou E, Pavlou E, Voudris K, Vlachoyiannopoulos P, Dalakas MC. Postherpes simplex encephalitis: a case series of viral-triggered autoimmunity, synaptic autoantibodies and response to therapy. Ther Adv Neurol Disord 2018; 11:1756286418768778. [PMID: 29774053 PMCID: PMC5949951 DOI: 10.1177/1756286418768778] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/24/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Recent evidence suggests that patients with herpes simplex virus (HSV) encephalitis may relapse because of autoimmunity against the N-methyl-D-aspartate receptor (NMDAR). We present a case series of post-HSV relapsing encephalopathy associated with antibodies to central nervous system (CNS) synaptic antigens. PATIENT/METHODS Sera and cerebrospinal fluid (CSF) from five patients with HSV encephalitis who relapsed after antiviral therapy were tested for anti-NMDAR, gamma-aminobutyric acid b receptor (GABAbR), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), Leucine-rich, glioma inactivated 1 (LGI1), anti -contactin-associated protein-like 2 (CASPR2) and dipeptidyl-peptidase-like protein-6 (DDPX) antibodies using cell-based assays. RESULTS Five patients (two infants, one child and two adults) developed post-HSV autoimmune encephalitis. The infants, aged 9 months and 10 months, after prompt and seemingly successful anti-HSV therapy, were readmitted with typical signs of NMDAR-encephalitis evolving within days, with NMDAR antibodies detected in both serum and CSF. Although they were promptly treated with intravenous immunoglobulin (IVIg) and with IVIg followed by rituximab, respectively, they were both left with psychomotor deficits. A 14-year-old girl with seizures due to HSV encephalitis improved with anti-HSV therapy. Later, she manifested intractable seizures and she was found positive for anti-NMDAR antibodies which persist. The two adults were women, aged 58 and 33 years. The first recovered after anti-HSV therapy and remained asymptomatic for 6 months, until she developed generalized seizures with persisting CSF anti-NMDAR antibodies; the second, who continued to be encephalopathic after 2 weeks of anti-HSV therapy, tested positive for anti-NMDAR antibodies in the serum and anti-GABAbR antibodies in the serum and CSF. She recovered fully following IVIg therapy but her serum anti-GABAbR antibodies persist 34 months later. DISCUSSION Infection of the CNS with HSV can trigger CNS autoimmunity associated not only with anti-NMDAR but also with anti-GABAbR antibodies. These antibodies can persist in the serum, even without associated symptoms, but their presence in the CSF is firmly associated with disease development. In contrast to children and adults who responded well to therapies, the infants had an incomplete recovery with severe psychomotor deficits probably due to the interference of anti-NMDAR antibodies with neuro-developmental processes.
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Dalakas MC. Myositis: Are autoantibodies pathogenic in necrotizing myopathy? Nat Rev Rheumatol 2018; 14:251-252. [PMID: 29651118 DOI: 10.1038/nrrheum.2018.54] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Rakocevic G, Martinez-Outschoorn U, Dalakas MC. Obinutuzumab, a potent anti-B-cell agent, for rituximab-unresponsive IgM anti-MAG neuropathy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e460. [PMID: 29629397 PMCID: PMC5886834 DOI: 10.1212/nxi.0000000000000460] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/05/2018] [Indexed: 11/15/2022]
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Dalakas MC. Advances in the diagnosis, immunopathogenesis and therapies of IgM-anti-MAG antibody-mediated neuropathies. Ther Adv Neurol Disord 2018; 11:1756285617746640. [PMID: 29403542 PMCID: PMC5791554 DOI: 10.1177/1756285617746640] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/16/2017] [Indexed: 11/17/2022] Open
Abstract
Polyneuropathy with immunoglobulin M (IgM) monoclonal gammopathy is the most common paraproteinemic neuropathy, comprising a clinicopathologically and immunologically distinct entity. The clinical spectrum spans from distal paresthesias and mild gait imbalance to more severe sensory ataxia, with falls and a varying degree of distal sensorimotor deficits. In approximately 75% of patients, the monoclonal IgM immunoreacts with myelin-associated glycoprotein (MAG) and sulfoglucuronyl glycosphingolipid (SGPG), or other peripheral nerve glycolipids that serve as antigens. These antibodies are considered pathogenic because IgM and complement are deposited on the myelin sheath, splitting the myelin lamellae, while adoptive transfer of patients’ IgM into susceptible host animals causes sensory ataxia and reproduces the human pathology. In spite of the apparently convincing pathogenicity of these antibodies, the response to immunotherapies remains suboptimal. Clorambuscil, cladibrine, cyclophospamide and intravenous immunoglobulin may help some patients but the benefits are minimal and transient. Open-label studies in >200 patients indicate that rituximab is helpful in 30–50% of these patients, even with long-term benefits, probably by suppressing IgM anti-MAG antibodies or inducing immunoregulatory T cells. Two controlled studies with rituximab did not however meet the primary endpoint, mostly because of the poor sensitivity of the scales used; they did however show statistical improvement in secondary endpoints and improved clinical functions in several patients. This review provides an overview of the clinical phenotypes and immunoreactivity of IgM to glycolipids or glycoproteins of peripheral nerve myelin, summarizes the progress on treatment with rituximab as a promising therapy, discusses the pitfalls of scales used, identifies possible biomarkers of response to therapy and highlights the promising new anti-B cell or target-specific immunotherapies.
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Dalakas MC, Rakocevic G, Dambrosia JM, Alexopoulos H, McElroy B. A double-blind, placebo-controlled study of rituximab in patients with stiff person syndrome. Ann Neurol 2017; 82:271-277. [PMID: 28749549 DOI: 10.1002/ana.25002] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 07/18/2017] [Accepted: 07/21/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In stiff person syndrome (SPS), an antibody-mediated impaired γ-aminobutyric acidergic (GABAergic) neurotransmission is believed to cause muscle stiffness and spasms. Most patients improve with GABA-enhancing drugs and intravenous immunoglobulin, but some respond poorly and remain disabled. The need for more effective therapy prompted a trial with the anti-CD20 monoclonal antibody rituximab. METHODS This was a placebo-controlled randomized trial of rituximab (2 biweekly infusions of 1g each). The primary outcome was a change in stiffness scores at 6 months. Secondary outcomes were changes in heightened-sensitivity and quality of life scores. Enrolling 24 patients was calculated to detect 50% change in stiffness scores. RESULTS Randomization was balanced for age, sex, disease duration, and glutamic acid decarboxylase autoantibody titers. No significant changes were noted at 6 months after treatment in all outcomes. Specifically, no differences were noted in the stiffness index, the primary outcome, or sensitivity scores, the secondary outcome, at 3 or 6 months. Quality of life scores improved significantly (p < 0.01) at 3 months in both groups, but not at 6 months, denoting an early placebo effect. Blinded self-assessment rating of the overall stiffness for individual patients revealed improvement in 4 patients in each group. At 6 months, improvement persisted in 1 patient in the placebo group versus 3 of 4 in the rituximab group, where these meaningful improvements were also captured by video recordings. INTERPRETATION This is the largest controlled trial conducted in SPS patients and demonstrates no statistically significant difference in the efficacy measures between rituximab and placebo. Rituximab's lack of efficacy could be due to a considerable placebo effect; insensitivity of scales to quantify stiffness, especially in the less severely affected patients; or drug effectiveness in only a small patient subset. Ann Neurol 2017;82:271-277.
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Dalakas MC. Gene therapy for Duchenne muscular dystrophy: balancing good science, marginal efficacy, high emotions and excessive cost. Ther Adv Neurol Disord 2017; 10:293-296. [PMID: 28781610 PMCID: PMC5518962 DOI: 10.1177/1756285617717155] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 05/30/2017] [Indexed: 01/16/2023] Open
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Dalakas MC. Rituximab in anti-MAG neuropathy: More evidence for efficacy and more predictive factors. J Neurol Sci 2017; 377:224-226. [DOI: 10.1016/j.jns.2017.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 12/14/2022]
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Fouka P, Alexopoulos H, Chatzi I, Dedos SG, Samiotaki M, Panayotou G, Politis P, Tzioufas A, Dalakas MC. Antibodies to inositol 1,4,5-triphosphate receptor 1 in patients with cerebellar disease. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2016; 4:e306. [PMID: 27957507 PMCID: PMC5141524 DOI: 10.1212/nxi.0000000000000306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 10/10/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe newly identified autoantibodies associated with cerebellar disorders. DESIGN/METHODS We first screened the sera of 15 patients with cerebellar ataxia, without any known associated autoantibodies, with immunocytochemistry on mouse brain. After characterization and validation of a newly identified antibody, 85 additional patients with suspected autoimmune cerebellar disease were screened using a cell-based assay. RESULTS Immunoglobulin G from one of the first 15 patients demonstrated a distinct staining pattern on Purkinje neurons. This autoantibody, as characterized further by immunoprecipitation and mass spectrometry, was binding inositol 1,4,5-triphosphate receptor 1 (IP3R1), an intracellular channel that mediates the release of Ca2+ from intracellular stores. Anti-IP3R1 specificity was then validated with a cell-based assay. On this basis, screening of 85 other patients with cerebellar disease revealed 2 additional IP3R1-positive patients. All 3 patients presented with cerebellar ataxia; the first was eventually diagnosed with primary progressive multiple sclerosis, the second had a homozygous CAG insertion at the gene TBP, and the third was thought to have a neurodegenerative disease. CONCLUSIONS We independently identified an autoantibody against IP3R1, a protein highly expressed in Purkinje neurons, confirming an earlier report. Because a mouse knockout model for IP3R1 exhibits ataxia and epilepsy, this autoantibody may have a functional role. The heterogeneity of the antibody-positive patients suggests that this antibody may either have a direct involvement in disease pathogenesis or it is a surrogate marker secondary to cerebellar injury. Anti-IP3R1 antibodies should be further explored in various ataxic and epileptic syndromes as they may denote a marker of response to immunotherapies.
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Dalakas MC. Necrotising autoimmune myopathy (NAM): antibodies seem to be specific markers in aiding diagnosis. J Neurol Neurosurg Psychiatry 2016; 87:1037. [PMID: 27151962 DOI: 10.1136/jnnp-2016-313418] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/03/2016] [Indexed: 11/04/2022]
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Kampylafka EI, Alexopoulos H, Fouka P, Moutsopoulos HM, Dalakas MC, Tzioufas AG. Epileptic syndrome in systemic lupus erythematosus and neuronal autoantibody associations. Lupus 2016; 25:1260-5. [DOI: 10.1177/0961203316636473] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/25/2016] [Indexed: 11/15/2022]
Abstract
We investigated systemic lupus erythematosus (SLE) patients with epilepsy, a major and organic neurological symptom. Our aim was to test patients for the autoimmune epilepsy-associated antibodies anti-GAD, anti-NMDAR, anti-AMPAR1/2, anti-GABABR and anti-VGKC. We tested sera from ten SLE patients with current or previous episodes of epileptic seizures. In addition, sera were tested for staining on primary hippocampal neurons. The patients’ clinical and neuroimaging profile, disease activity and accumulated damage scores and therapeutic regimens administered were recorded, and correlations were evaluated. Patients were negative for all anti-neuronal autoantibodies tested, and showed no staining on primary hippocampal cells, which suggests the absence of autoantibodies against neuronal cell surface antigens. Epileptic seizures were all tonic–clonic, and all patients had high disease activity (mean SLE Damage Acticity Index score 19.3 ± 7.3). Six patients had minor or no brain magnetic resonance imaging findings, and three had major findings. 9/10 patients received immunosuppression for 5 ± 4 months, while anti-convulsive treatment was administered to all patients (4.2 ± 3 years). Our results suggest that the majority of SLE-related epileptic seizures cannot be attributed to the action of a single antibody against neuronal antigens. Studies with larger neuropsychiatric SLE populations and stricter inclusion criteria are necessary to verify these findings.
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Dalakas MC. Treating myasthenia on consensus guide: Helpful and challenging but still unfinished business. Neurology 2016; 87:350-1. [DOI: 10.1212/wnl.0000000000002796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Schmidt K, Kleinschnitz K, Rakocevic G, Dalakas MC, Schmidt J. Molecular treatment effects of alemtuzumab in skeletal muscles of patients with IBM. BMC Neurol 2016; 16:48. [PMID: 27083892 PMCID: PMC4833914 DOI: 10.1186/s12883-016-0568-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 04/06/2016] [Indexed: 11/25/2022] Open
Abstract
Background Mechanisms of inflammation and protein accumulation are crucial in inclusion body myositis (IBM). Recent evidence demonstrated that intravenous immunoglobulin failed to suppress cell-stress mediators in IBM. Here we studied the molecular changes in skeletal muscle biopsies from patients with IBM before and after treatment with alemtuzumab. Methods Relevant inflammatory and degeneration-associated markers were assessed by quantitative-PCR and immunohistochemistry in repeated muscle biopsy specimens from patients with IBM, which had been treated in a previously published uncontrolled proof-of-concept trial with alemtuzumab. Results There were no significant changes of the mRNA expression levels of the pro-inflammatory chemokines CXCL-9, CCL-4, and the cytokines IFN-γ, TGF-β, TNF-α, and IL-1β. Similarly, the degeneration-associated molecules ubiquitin, APP and αB-crystallin did not substantially change. Although no overall beneficial treatment effect was noted except for a 6-month stabilization, some patients experienced a transient improvement in muscle strength. In such responders, a trend towards reduced expression of inflammatory markers was noted. In contrast, the expression remained unchanged in the others who did not experience any change. The expression levels of IL-1β and MHC-I correlated with the positive clinical effect. By immunohistochemistry, some inflammatory mediators like CD8, CXCL-9, and MHC-I were downmodulated. However, no consistent changes were noted for ubiquitin, nitrotyrosin and β-amyloid. Conclusions Alemtuzumab showed a trend towards downregulation of the expression of some inflammatory molecules in skeletal muscle of IBM patients but has no effect on several crucial markers of cell stress and degeneration. The data are helpful to explain the molecular treatment effects of future lymphocyte-targeted immunotherapies in IBM.
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Dalakas MC, Gooch C. Close to the node but far enough: What nodal antibodies tell us about CIDP and its therapies. Neurology 2016; 86:796-7. [PMID: 26843563 DOI: 10.1212/wnl.0000000000002427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Magira EE, Alexopoulos H, Charitatos E, Michas D, Dalakas MC. Progressive encephalomyelitis with rigidity and myoclonus (PERM): brucellosis as a possible triggering factor and long-term follow-up therapy with rituximab. Ther Adv Neurol Disord 2016; 9:69-73. [PMID: 26788132 DOI: 10.1177/1756285615614812] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Lünemann JD, Quast I, Dalakas MC. Efficacy of Intravenous Immunoglobulin in Neurological Diseases. Neurotherapeutics 2016; 13:34-46. [PMID: 26400261 PMCID: PMC4720677 DOI: 10.1007/s13311-015-0391-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Owing to its anti-inflammatory efficacy in various autoimmune disease conditions, intravenous immunoglobulin (IVIG)-pooled IgG obtained from the plasma of several thousands individuals-has been used for nearly three decades and is proving to be efficient in a growing number of neurological diseases. IVIG therapy has been firmly established for the treatment of Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy, either as first-line therapy or adjunctive treatment. IVIG is also recommended as rescue therapy in patients with worsening myasthenia gravis and is beneficial as a second-line therapy for dermatomyositis and stiff-person syndrome. Subcutaneous rather than intravenous administration of IgG is gaining momentum because of its effectiveness in patients with primary immunodeficiency and the ease with which it can be administered independently from hospital-based infusions. The demand for IVIG therapy is growing, resulting in rising costs and supply shortages. Strategies to replace IVIG with recombinant products have been developed based on proposed mechanisms that confer the anti-inflammatory activity of IVIG, but their efficacy has not been tested in clinical trials. This review covers new developments in the immunobiology and clinical applications of IVIG in neurological diseases.
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Kampylafka EI, Alexopoulos H, Dalakas MC, Tzioufas AG. Immunotherapies for Neurological Manifestations in the Context of Systemic Autoimmunity. Neurotherapeutics 2016; 13:163-78. [PMID: 26510559 PMCID: PMC4720664 DOI: 10.1007/s13311-015-0393-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Neurological involvement is relatively common in the majority of systemic autoimmune diseases and may lead to severe morbidity and mortality, if not promptly treated. Treatment options vary greatly, depending on the underlying systemic pathophysiology and the associated neurological symptoms. Selecting the appropriate therapeutic scheme is further complicated by the lack of definite therapeutic guidelines, the necessity to differentiate primary neurological syndromes from those related to the underlying systemic disease, and to sort out adverse neurological manifestations caused by immunosuppressants or the biological agents used to treat the primary disease. Immunotherapy is a sine qua non for treating most, if not all, neurological conditions presenting in the context of systemic autoimmunity. Specific agents include classical immune modulators such as corticosteroids, cyclophosphamide, intravenous immunoglobulin, and plasma exchange, as well as numerous biological therapies, for example anti-tumor necrosis factor agents and monoclonal antibodies that target various immune pathways such as B cells, cytokines, and co-stimulatory molecules. However, experience regarding the use of these agents in neurological complications of systemic diseases is mainly empirical or based on small uncontrolled studies and case series. The aim of this review is to present the state-of-the-art therapies applied in various neurological manifestations encountered in the context of systemic autoimmune diseases; evaluate all treatment options on the basis of existing guidelines; and compliment these data with our personal experience derived from a large number of patients.
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Dalakas MC. Neuro-Immunotherapies: A 30-year Retrospective of an Overwhelming Success and a Brighter Future. Neurotherapeutics 2016; 13:1-3. [PMID: 26684870 PMCID: PMC4720665 DOI: 10.1007/s13311-015-0414-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Alexopoulos H, Biba A, Dalakas MC. Anti-B-Cell Therapies in Autoimmune Neurological Diseases: Rationale and Efficacy Trials. Neurotherapeutics 2016; 13:20-33. [PMID: 26566961 PMCID: PMC4720683 DOI: 10.1007/s13311-015-0402-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
B cells have an ever-increasing role in the etiopathology of a number of autoimmune neurological disorders, acting as antibody-producing cells and, most importantly, as sensors, coordinators, and regulators of the immune response. B cells, among other functions, regulate the T-cell activation process through their participation in antigen presentation and production of cytokines. The availability of monoclonal antibodies or fusion proteins against B-cell surface molecules or B-cell trophic factors bestows a rational approach for treating autoimmune neurological disorders, even when T cells are the main effector cells. This review summarizes basic aspects of B-cell biology, discusses the role(s) of B cells in neurological autoimmunity, and presents anti-B-cell drugs that are either currently on the market or are expected to be available in the near future for treating neurological autoimmune disorders.
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Dalakas MC. Future perspectives in target-specific immunotherapies of myasthenia gravis. Ther Adv Neurol Disord 2015; 8:316-27. [PMID: 26600875 PMCID: PMC4643871 DOI: 10.1177/1756285615605700] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by complement-fixing antibodies against acetylcholine receptors (AChR); antigen-specific CD4+ T cells, regulatory T cells (Tregs) and T helper (Th) 17+ cells are essential in antibody production. Target-specific therapeutic interventions should therefore be directed against antibodies, B cells, complement and molecules associated with T cell signaling. Even though the progress in the immunopathogenesis of the disease probably exceeds any other autoimmune disorder, MG is still treated with traditional drugs or procedures that exert a non-antigen specific immunosuppression or immunomodulation. Novel biological agents currently on the market, directed against the following molecular pathways, are relevant and specific therapeutic targets that can be tested in MG: (a) T cell intracellular signaling molecules, such as anti-CD52, anti-interleukin (IL) 2 receptors, anti- costimulatory molecules, and anti-Janus tyrosine kinases (JAK1, JAK3) that block the intracellular cascade associated with T-cell activation; (b) B cells and their trophic factors, directed against key B-cell molecules; (c) complement C3 or C5, intercepting the destructive effect of complement-fixing antibodies; (d) cytokines and cytokine receptors, such as those targeting IL-6 which promotes antibody production and IL-17, or the p40 subunit of IL-12/1L-23 that affect regulatory T cells; and (e) T and B cell transmigration molecules associated with lymphocyte egress from the lymphoid organs. All drugs against these molecular pathways require testing in controlled trials, although some have already been tried in small case series. Construction of recombinant AChR antibodies that block binding of the pathogenic antibodies, thereby eliminating complement and antibody-depended-cell-mediated cytotoxicity, are additional novel molecular tools that require exploration in experimental MG.
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Quast I, Keller CW, Maurer MA, Giddens JP, Tackenberg B, Wang LX, Münz C, Nimmerjahn F, Dalakas MC, Lünemann JD. Sialylation of IgG Fc domain impairs complement-dependent cytotoxicity. J Clin Invest 2015; 125:4160-70. [PMID: 26436649 DOI: 10.1172/jci82695] [Citation(s) in RCA: 199] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/25/2015] [Indexed: 12/19/2022] Open
Abstract
IgG molecules exert both pro- and antiinflammatory effector functions based on the composition of the fragment crystallizable (Fc) domain glycan. Sialylated IgG Fc domains have antiinflammatory properties that are attributed to their ability to increase the activation threshold of innate effector cells to immune complexes by stimulating the upregulation of the inhibitory Fcγ receptor IIB (FcγRIIB). Here, we report that IgG Fc sialylation of human monoclonal IgG1 molecules impairs their efficacy to induce complement-mediated cytotoxicity (CDC). Fc sialylation of a CD20-targeting antibody had no impact on antibody-dependent cellular cytotoxicity and did not change the affinity of the antibody for activating Fcγ receptors. In contrast, the presence of sialic acid abrogated the increased binding of C1q to Fc-galactosylated IgG1 and resulted in decreased levels of C3b deposition on the cell surface. Similar to monoclonal antibodies, sialic acid inhibited the increased C1q binding to galactosylated Fc fragments in human polyclonal IgG. In sera derived from patients with chronic inflammatory demyelinating polyneuropathy, an autoimmune disease of the peripheral nervous system in which humoral immune responses mediate tissue damage, induction of IgG Fc sialylation was associated with clinical disease remission. Thus, impairment of CDC represents an FcγR-independent mechanism by which Fc-sialylated glycovariants might limit proinflammatory IgG effector functions.
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MESH Headings
- Animals
- Antibody-Dependent Cell Cytotoxicity
- Antigens, CD20/immunology
- B-Lymphocytes/immunology
- Burkitt Lymphoma/pathology
- Cell Line, Tumor
- Complement C1q/immunology
- Complement C1q/metabolism
- Complement Pathway, Classical
- Complement System Proteins/immunology
- Cytotoxicity, Immunologic
- Glycosylation
- Humans
- Immunoglobulin G/chemistry
- Immunoglobulin G/immunology
- Immunoglobulin gamma-Chains/chemistry
- Immunoglobulin gamma-Chains/immunology
- Immunoglobulins, Intravenous/therapeutic use
- Killer Cells, Natural/immunology
- Lymphocyte Depletion
- Mice
- Myelin-Oligodendrocyte Glycoprotein/immunology
- N-Acetylneuraminic Acid/chemistry
- Polyradiculoneuropathy, Chronic Inflammatory Demyelinating/immunology
- Polyradiculoneuropathy, Chronic Inflammatory Demyelinating/therapy
- Protein Processing, Post-Translational
- Receptors, IgG/immunology
- Rituximab/chemistry
- Rituximab/immunology
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