Cell-mediated hypersensitivity to neural antigens. Occurrence in human patients and nonhuman primates with neurological diseases

Acute disseminated encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is an acute multifocal demyelinating disease of the central nervous system that typically follows an infectious illness. Its clinical course in most cases is monophasic; however, relapsing ADEM is rarely seen, which poses a diagnostic challenge for distinguishing this disease from multiple sclerosis (MS). Although typically encountered in children, it also occurs in adults with disease characteristics slightly different from the pediatric cases. Formerly, ADEM occurred particularly often in children with measles. However, the illness most often follows a non-descript viral or even bacterial infectious illness. ADEM occurs throughout the world, and may even be more common in less-developed countries, where MS is rare, than in developed ones, where MS is common. Children seldom get MS as opposed to adults, indicating that ADEM constitutes a distinct entity from MS. The prognosis of ADEM is generally good, but severe neurologic sequelae after ADEM are occasionally seen. In this chapter, the etiology, clinical/laboratory/radiologic characteristics, treatment options, and prognosis of ADEM are discussed.

The sad plight of multiple sclerosis research (low on fact, high on fiction): critical data to support it being a neurocristopathy

The literature for evidence of autoimmunity in multiple sclerosis (MS) is analysed critically. In contrast to the accepted theory, the human counterpart of the animal model experimental autoimmune demyelinating disease, experimental allergic encephalomyelitis (EAE), is not MS but a different demyelinating disorder, i.e. acute disseminated encephalomyelitis and acute haemorrhagic leucoencephalitis. Extrapolation of EAE research to MS has been guided largely by faith and a blind acceptance rather than sound, scientific rationale. No specific or sensitive immunological test exists that is diagnostic of MS despite the extensive application of modern technology. Immunosuppression has failed to have any consistent effect on prognosis or disease progression. The available data on MS immunotherapy are conflicting, at times contradictory and are based on findings in animals with EAE. They show predominantly a 30% effect in relapsing/remitting MS which suggests powerful placebo effect. Critical analysis of the epidemiological data shows no association with any specific autoimmune diseases, but does suggest that geographic factors and age at development posit an early onset possibly dependent on environmental influences. Certain neurological diseases are, however, found in association with MS, namely hypertrophic peripheral neuropathy, neurofibromatosis-1, cerebral glioma, glioblastoma multiforme and certain familial forms of narcolepsy. These share a common genetic influence possibly from genes on chromosome 17 affecting cell proliferation. A significant number of these disorders are of neural crest origin, the classical example being abnormalities of the Schwann cell. These and other data allow us to propose that MS is a developmental neural crest disorder, i.e. a cristopathy, implicating glial cell dysfunction with diffuse blood-brain barrier breakdown. The data on transcription factor SOX10 mutations in animals may explain these bizarre clinical associations with MS and the phenotypic variability of such alterations (Cossais et al. 2010). Research directed to the area of neural crest associations is likely to be rewarding.

Multiple sclerosis: cell-mediated immunity to human brain gangliosides

Cell-mediated immunity (CMI) to myelin components has been implicated in Multiple Sclerosis (MS) pathogenesis: two targets were suggested, Myelin Basic Protein with controversial results and, more recently, gangliosides. In order to investigate their possible involvement, we have performed Leukocyte Migration inhibition (LMI) tests in the presence of human brain gangliosides. Thirty nine MS patients (twenty four being "definite", according to McDonald and Halliday's classification), twenty nine patients with Other Neurological Diseases (OND), thirty six patients with Inflammatory diseases (ID) and forty healthy controls were tested. MS patients were divided into two groups, depending on the clinical stage of the disease. The mean migration inhibition percentage of the MS-attack group was found to be significantly different from the four others (p less than 0.01) (24.4 +/- 16.2 versus 10.9 +/- 8.5 in MS without attack, 4.4 +/- 12.9 in OND, 3.9 +/- 13.9 in ID and 11.1 +/- 12.1 in healthy subjects). LMI to gangliosides is therefore significantly increased during the attack stage in MS. These results support the notion of a Delayed Type Hypersensitivity to these glycolipids during the active stage of the disease.

Macrophage procoagulant activity as a measure of cell-mediated immunity to P2 protein of peripheral nerves in the Guillain-Barré syndrome

Cell-mediated and humoral immunity to purified nerve proteins has been assessed in GBS patients and compared with that of patients with other neurological diseases and healthy controls. A strong and specific cell-mediated response to the neuritogenic basic protein P2 occurred in 13/16 GBS patients tested. Extremely low levels of P2 (0.01 micrograms/culture) induced monocyte/macrophage procoagulant activity (MPCA) on peripheral blood mononuclear cells (PBM) from GBS patients (P = 0.007) whereas higher concentrations (2 micrograms/culture) of myelin basic protein (MBP) and sciatic nerve myelin (SNM) were required to stimulate similar levels of activity. These concentrations of nerve antigens failed to induce significant MPCA on peripheral blood mononuclear cells of patients with other neuropathies or healthy controls. Lipopolysaccharide, a non-specific stimulant of macrophage procoagulant activity, induced similar procoagulant levels on PBM from each group. The MPCA assay was a sensitive, quantitative and specific indicator of cell-mediated immunity to the neuritogenic peptide, P2 in GBS patients. Serum antibodies to P2, P0 and SNM were detected by a sensitive solid-phase radioimmunoassay. Naturally occurring antibodies to peripheral nerve antigens were observed in sera of healthy subjects and these levels were not significantly different from patients with GBS or those with other neuropathies. Our results indicate that the autoimmune cell-mediated response to the neuritogenic peptide P2 plays a major role in the pathogenesis of GBS.

Peripheral nervous tissue injury induced by galactocerebroside and galactocerebroside immune complexes

It was demonstrated that New Zealand Albino rabbits sensitized to galactocerebroside had high levels of anti-galactocerebroside antibody and of immune complexes. The rabbits was high titers of immune complexes developed demyelination in the peripheral nerves. Lesion were produced in the peripheral nerves of mice by the i.m. injection of galactocerebroside immune complexes. The lesions were characterized by axonal degeneration, infiltrating macrophages containing myelin debris, and an inflammatory infiltrate of polymorphonuclear and mononuclear cells. Rabbit immunoglobulin and mouse C3 were observed around the endoneural blood vessels. These results suggest that galactocerebroside immune complexes may play a role in the pathogenesis of mouse peripheral nerve lesions, due to the production of vasculomyelinopathy.

Treatment of acute post-infective polyneuropathy by means of plasma exchange

15 patients with acute post-infective polyneuropathy of the Guillain-Barré type have been treated by means of plasma exchange. The clinical course and outcome of these patients is compared to that in a retrospectively matched control series who were treated with supportive therapy only. All patients had severe rapidly evolving muscle weakness and approximately half the patients in each group required ventilatory assistance. Both the duration of muscle weakness and the hospitalisation time was significantly shorter in the patients treated by means of plasma exchange. These results suggest that plasma exchange is of significant benefit in the treatment of patients with the Guillain-Barré syndrome.

Cellular hypersensitivity to gangliosides and myelin basic protein in multiple sclerosis

Peripheral blood lymphocytes from patients with multiple sclerosis (MS), other neurological diseases and healthy controls were investigated for the presence of cell-mediated hypersensitivity to brain gangliosides and myelin basic protein using an active E-rosette assay. Sensitivity to myelin basic protein and gangliosides was found in MS patients in acute relapse and with progressive disease, whereas no sensitivity was found in MS patients in remission. Patients with other neurological diseases showed no response to gangliosides, but sensitization to myelin basic protein was found in a patient with leucoencephalopathy and in 4 of 6 stroke patients. Healthy controls did not respond to either antigen. In MS patients a positive correlation was seen between lymphocyte responses to myelin basic protein and to gangliosides. The data suggest that in comparison to gangliosides, myelin basic protein is a weaker stimulator of active rosette-forming cells. Moreover, cellular hypersensitivity to myelin basic protein is not MS-specific and may be present as a consequence of brain damage. However, cellular hypersensitivity to gangliosides appears to be more specific to MS and may be important in the pathogenesis of the disease.

Late onset of Guillain-Barré syndrome

The Guillain-Barré syndrome (GBS) usually occurs within one month of the precipitating cause. It is the purpose of this paper to show that typical cases may, however, appear weeks to months later. We have reviewed the collected data on these cases and suggest that they provide evidence which is in favour of a humoral, rather than a cell-mediated, aetiology for GBS.

In vivo demyelinating activity of sera from patients with Guillain-Barré syndrome

The in vivo demyelinating capacity of sera from 27 patients with Guillain-Barré syndrome (GBS) and 47 other individuals was studied by intraneural injection into rat sciatic nerves. The morphological features of the nerves in cross section taken just proximal to the site of needle insertion was assessed 48 hours after injection and the extent of demyelination was quantitated. All 27 GBS serum samples were obtained in the first three weeks of clinical disease. Of these, 11 (41%) produced demyelination. Demyelinative activity of GBS sera correlated only with severity of clinical disease (p less than 0.01). The extent of demyelination after intraneural injection of human sera was less intense on average than that produced by sera from animals with experimental allergic neuritis. Three of 40 (7.5%) sera obtained from normal subjects and patients with other neurological diseases also caused in vivo demyelination, although the activity was weaker and occurred less often than with GBS serum.

The treatment of chronic relapsing and chronic progressive idiopathic inflammatory polyneuropathy by plasma exchange

Observations are reported on the effects of plasma exchange on three patients with chronic relapsing idiopathic inflammatory polyneuropathy and three with the chronic progressive form of this disorder. Substantial temporary improvement occurred in two of the chronic relapsing cases in relation to repeated plasma exchanges, but only slight improvement in the remainder. A striking feature was the rapidity of the effect in the patients that improved. The significance of these observations in relation to pathogenesis and to clinical management of the disorder is discussed.

Treatment of Guillain-Barré syndrome by plasma exchange

Plasma exchange has been used for therapy in eight patients with the Guillain-Barré syndrome. All patients were severely ill. They became tetraplegic and showed cranial nerve involvement. Five patients received assisted respiration, but the others were also at risk of ventilatory insufficiency. Recovery was abrupt in all cases after the first plasma exchanges. Improvement was more marked when plasmapheresis was done on three successive days with plasma exchanges of 2.0-3.01 each in the initial progressive stage of the disease. A considerable advantage of this therapy is the avoidance of continued artificial respiration and nutrition, which both carry the risk of further complications.

The significance of abnormal immune responses in patients with multiple sclerosis

Early diagnosis of multiple sclerosis (MS) may be assisted by tests for the abnormal immune responses of the central nervous system (CNS) including oligoclonal IgG bands in the cerebrospinal fluid (CSF), increased CNS IgG synthesis, increased CNS antibody synthesis against multiple viruses and increased numbers of enlarged lymphoid cells in the CSF. Alterations in immunological responses are important in the pathogenesis of MS. Further studies are needed, however, to identify the antigen(s) and/or antibodies responsible for oligoclonal IgG in the CSF of MS patients. Also, the cause(s) for the other immunological abnormalities with diagnostic importance need to be identified. The increased synthesis of antibodies against multiple unrelated viruses suggests generalized alteration in the immune regulatory system. The etiology of MS might be multifactorial involving abnormal immunological responses, possibly precipitated by infectious agents acquired during childhood by genetically susceptible individuals. The immunological responses including alterations in myelin basic protein concentration, antimyelin antibody and immune complex activities in CSF, and in vitro stimulation, suppression and migration inhibition of blood lymphocytes appear to correlate with stage of MS and severity of CNS damage. Some of the tests may become useful in estimating the prognosis of the disease. Longitudinal studies are needed to clarify the sensitivity of the diagnostic and prognostic immunological tests and etiological significance of these abnormalities in MS.

Lymphocyte transformation in the presence of myelin basic protein in multiple sclerosis and control subjects

The transformation of lymphocytes in vitro in the presence of human myelin basic protein has been investigated in normal people, patients with multiple sclerosis (MS) and controls with other neurological diseases. There was little or no response at low concentrations (1--10 microgram/ml) but significant transformation at higher concentrations (100--1000 microgram/ml) in all three groups. There was no significant difference among the groups as a whole, but those MS patients who had had disease for more than 10 years did show greater responses than normal subjects (P less than 0.05). Increased responses could not be correlated with any other aspect of disease activity: in particular they were not increased in patients with acute relapses. The use of autologous serum instead of homologous AB Rhesus positive serum did not significantly alter lymphocyte responsiveness. The absence of any response in the presence of purified calf thymus histone suggests that the response to myelin basic protein indicates a low level of lymphocyte sensitization to this antigen even in normal subjects. The present evidence does not support a primary pathogenetic role for such a reaction in MS. The increased response in patients with a long duration of disease might merely be an effect of white matter damage or might represent an amplification of the normal immune response contributing to myelin breakdown and leading to the emergence of the progressive stage of the disease. The study of lymphocyte responsiveness over a wide range of concentrations of myelin basic protein is considered to resolve some of the controversy surrounding this subject in the literature.

Myelin basic protein binding cells in active multiple sclerosis

A sensitive, antigen-specific rosetting technique was used to enumerate blood cells that bind myelin basic protein (BP) in MS patients and controls. Sixteen of 23 MS patients in exacerbation but only 7 of 48 in remission formed elevated numbers of rosettes. Five of the latter 7 patients had recovered from an exacerbation within four months of the laboratory evaluation. Eight of 20 patients with progressive MS, all of whom had had disease for more than four years, had BP rosette-forming cells. None of the 16 normal volunteers and 1 of 8 neurological controls had BP rosette-forming cells. These results suggest that BP-binding cells in MS are confined to patients in acute exacerbation or within four months of activity, and those who have had progressive disease for at least four years.

Delayed hypersensitivity to human encephalitogenic protein as assayed by agarose leucocyte migration in multiple sclerosis patients

Using a leucocyte migration test (Clausen's direct agarose gel migration method) hypersensitivity to human encephalitogenic protein has been examined in 50 multiple sclerosis patients (group 1), 50 healthy persons (group 2) and 25 patients with other neurological diseases (group 3). In group 1, 30 MS patients (60%) show an abnormal migration index, manifested either as inhibition or stimulation of migration; 29 controls in group 2 (58%), 11 O.N.D. patients in group 3 (44%) show an abnormal migration index. These results mean that lymphocyte hypersensitivity to myelin basic protein appears neither to be constant nor specific to multiple sclerosis. Three migration index curve types at different antigen concentration are obtained: monophasic curves within the normal index zones; monophasic curves staying in the inhibition or stimulation zone and biphasic curves with dose-effect relationship. Whatever the antigen used, this dose-effect relationship implies that the test must be carried out at different concentrations. The meaning of spontaneous sensitisation in healthy controls is discussed.

Aspects of cellular immunity in multiple sclerosis. Antigen-reactivity of lymphocytes and lymphokine activity

Some new results of cell-mediated immunity in multiple slcerosis (MS) are presented, based on the determination of charge-changing lymphokines as products of antigen sensitive lymphocytes (C PAL), obtained by several forms of the electrophoretic mobility (EM) method. Lymphocytes from MS react to myelin basic protein (BP), the reactivity in other neurological diseases depending on the degree of destruction of nervous parenchyma. Applying a membrane-associated antigen from normal brain (NTA), positive reactivity of MS lymphocytes was obtained. Besides the usual determination of lymphokines in vitro the sensitive EM test allows the demonstration of lymphokine activities in vivo; i.e. in body fluids such as cerebrospinal fluid (CSF) and serum. In CSF of MS a high lymphokine activity was found. The differentiation of lymphokines and comparison between in vitro and in vivo activity were carried out. Moreover, a characteristic lymphokine pattern for MS with high activities in all regions of molecular weight, especially in the CSF, could be detected. On the basis of these findings, important also from the pathogenetic point of view, a diagnostic scheme for MS is suggested, consisting of a program of determination of the immuno-reactive CSF syndrome and some special procedures, including examination of lymphocyte reactivity.

Cell-mediated hypersensitivity in multiple sclerosis and other neurological diseases

Using a direct macrophage migration inhibition test the hypersensitivity against encephalitogenic protein and phytohaemagglubinin in normal persons, multiple sclerosis patients and patients with other diseases of the central nervous system were examined. It proved that the vast majority of patients were sensitised to brain antigen. The percentage of positive tests and the percentage of migration inhibition was related to the activity of the disease. No differences were found between lymphocytes of multiple sclerosis patients and of patients with the other neurological diseases patients. Foetal calf serum was proven to depress the hypersensitivity to phytohaemagglutinin as did multiple sclerosis serum on normal lymphocytes. The results did not support the hypothesis that multiple sclerosis is caused by a cell-mediated auto-immune process.

Demyelination in allergic and Marek's disease virus induced neuritis. Comparative electron microscopic studies

Patterns of demyelination were studied in sciatic nerves, spinal roots and ganglia of chickens afflicted with either Marek's disease (MD) or experimental allergic neuritis (EAN). MD was induced in susceptible chicks after hatching by inoculation of the JM strain of MD Herpes virus. Tissues from these chickens were examined 7-83 days after infection. EAN was studied 10-21 days after sensitization of 4 week old chickens to emulsions containing human peripheral nerve with complete Freund's adjuvant. In both conditions lesions were encountered which consisted of perivenular infiltrates of mononuclear cells that penetrated the basal lamina of the neurolemmal sheath, displaced Schwann cells, lysed and stripped myelin lamellae without damage to axons. Other lesions in MD were characterized by lymphomatous infiltrates that contained necrotic cells and disintegrating axons. The similarity of the demyelinating process in MD to that seen in EAN suggests that MD virus infection activates lymphocytes sensitized to peripheral nerve myelin. The findings are discussed with reference to acute idiopathic polyneuritis (Guillain-Barré syndrome) in patients with preceding or concurrent Herpes virus infections including those known to cause lymphoproliferative disorders.

Biochemical findings in multiple sclerosis. V. Transformation of lymphocytes from patients with multiple sclerosis by human basic protein

Lymphocyte stimulation tests with human basic protein of myelin were performed on patients with multiple sclerosis, with other neurological diseases and on normal subjects. In both MS and OND group, a hypersensitization to basic protein was seen in about one third of the cases. All normal subjects, except one, had negative responses. In the MS group, a positive correlation could be found with some features of the disease: significantly more positive responses were found in independent patients with a short duration of illness and in those with an oligoclonal distribution in the CSF. The authors compare their results with those of the literature. The possible role of BP in pathogeny of MS and OND is discussed.

Tissue culture studies of demyelinating disease: a critical review

Tissue culture studies of human and experimental demyelinating diseases have demonstrated that sera from patients with multiple sclerosis reversibly demyelinate central nervous system cultures. Similar changes are evoked by sera from animals with experimental allergic encephalomyelitis induced by inoculation with whole central nervous system tissue but not by encephalitogenic myelin basic protein. Sera and buffy coat or lymph node cells from humans with idiopathic polyneuritis and animals with experimental allergic neuritis demyelinate cultures of peripheral nervous system tissue. While these studies have contributed to speculations about pathogenetic mechanisms of demyelinating diseases, including the role of both circulating antibodies and delayed hypersensitivity factors, a number of important questions remain unanswered. Among these are the identity of the antigens that evoke antimyelin antibodies and the precise relationship of serum or cellular antimyelin factors to the pathogenesis or clinical course of the demyelinating diseases. Further studies with this technique may provide more complete information about the role of immunological events in induction of disease.

Tetanus antibody production in serum and cerebrospinal fluid in the rabbit and correlated histopathological features of the central nervous system

The histopathological features in the central nervous system (CNS) developing during the active phase of tetanus antibody formation in the cerebrospinal fluid (CSF) as induced in 15 rabbits were studied. The measurement of antibody titres in serum and CSF by electroimmunodiffusion and histological examination were done sequentially at the 1st, 3rd, 5th, 7th and 9th days after cisternal secondary inoculation with fluid tetanus toxoid. Tetanus antibodies appeared in serum after the 1st and in CSF after the 5th day. Decreasing values of CSF total protein were found. The meaning of an elevated Q ratio as observed in this situation of strong antibody formation in the CSF was enhanced. The histopathological features in the central nervous system consisted of perivascular inflammatory infiltration, at first polymorphic and then composed almost exclusively of mononuclear cells with a predominantly leptomeningeal and subpial localization, which might represent the origin of CSF tetanus antibodies. The localization was related to the contact zone between the antigen- and antibody-containing compartments, respectively the subarachnoid space and vascularized structures of the brain and spinal cord. Four control rabbits presented neither tetanus antibodies in the CSF nor perivascular inflammatory infiltration in the CNS. Similarity between the present experimental results and the immunopathological features of the primary demyelinating diseases provides some useful information about the immunological inflammatory events in these diseases.

Landry-Guillain-Barré-Strohl syndrome. A study of 302 cases

Three hundred and two cases of Landry-Guillain-Barré-Strohl syndrome (LGBSS) are studied and relevant literature is reviewed. The existing diagnostic criteria appear not in keeping with the histopathological and immunological findings of this condition, hence some modifications have been suggested. The role of steroids in the treatment of this disorder is critically examined, and no benefit is found to be gained from their use.

Polyradiculoneuropathy accompanying procainamide-induced lupus erythematosus: evidence for drug-induced enhanced sensitization to peripheral nerve myelin

Factors involved in the development of an insidious polyradiculoneuropathy in association with a procainamide-induced, lupuslike syndrome were explored. A 73-year-old man with this clinical syndrome had sural nerve changes consisting of loss of large myelinated fibers with evidence of remyelination and Schwann cell proliferation. The patient's lymphocytes showed marked incorporation of tritiated thymidine when cultured with either procainamide or extracts of human peripheral nerve myelin, and there was an enhanced response with the combination. We also found that procainamide-treated rats showed acceleration of lymphocyte sensitization to peripheral nerve myelin as judged by the early development of inhibition of macrophage migration and positive skin tests to extracts of peripheral nerve myelin. These studies suggest that procainamide can enhance lymphocyte sensitization to peripheral nerve myelin and may have predisposed this individual to development of a polyradiculoneuropathy.

Effect of encephalitogenic protein on migration in agarose of leukocytes from patients with multiple sclerosis. Variable effect of the antigen in a large dose range, with a literature review

The literature on in vitro test of sensitivity to brain antigen in multiple sclerosis is summarized in the tables. A study is presented using leukocyte migration in agarose as test system and a wide range of concentration of bovine encephalitogenic protein as antigen. Definite reactivity was seen in 12 out of 28 patients with MS. Some occurred in patients who had had no signs of disease activity for at least 5 years. Reactivity occurred more often in patients with active disease studied within 5 days after a relapse. The significance of the in vitro reactivity is briefly discussed.

Multiple sclerosis and cell-mediated hypersensitivity to myelin A1 protein

Cellular hypersensitivity to myelin basic (A1) protein was evaluated using the MIF assay in 246 subjects. Of 100 with multiple sclerosis positive results are seen in relationship to acute exacerbations of illness. Normal control subjects gave a mean value of 100 +/- 9% whereas patients studied within 4 weeks of onset of illness gave a result of 59 +/- 12.5%. A convalescent group studied between 5 and 12 weeks after an attack gave results of 86 +/- 22.2%. A chronic group gave a mean of 91 +/- 8.2%. Positive values were also seen in a number of other patients with central or peripheral nervous system disease especially those with "autoimmune disease". However, results of this study clearly establish a temporal relationship between in vitro evidence of hypersensitivity to A1 protein and clinical expression of disease.

Optic neuritis in the Landry-Guillain-Barré-Strohl syndrome

A patient with typical Landry-Guillain-Barré-Strohl syndrome (LG-BS) developed bilateral optic neuritis. Laboratory studies showed hypersensitivity to both central and peripheral nervous tissue myelin. The occurrence of optic neuritis is presumably due to autohypersensitivity to central nervous tissue myelin. The initial lesions of the LG-BS syndrome in the peripheral nerves might have liberated sequestered antigens that cross-reacted with central nervous system myelin.

Cellular hypersensitivity to basic myelin (P2) protein in the Guillain-Barré syndrome

Lymphocytes of 29 subjects were assayed for MIF production in response to P2 peripheral nerve protein, crude human peripheral nerve and human central nervous system Al basic myelin protein. Seven were performed in normal control subjects, 12 in Guillain-Barre patients (GB), 5 with other polyneuropathies and 5 in patients with multiple sclerosis (MS). Only GB patients with acute illness produced MIF in response to neuritogenic P2 protein and crude human nerve. Two MS patients in the acute phase of an exacerbation and one GB patient produced MIF in Response to Al protein. The results of this study demonstrate cellular hypersensitivity to a neuritogenic consituent in peripheral nervous tissue and support the concept that this may be important in the pathogenesis of GB.