1
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Ubogu EE. Animal models of immune-mediated demyelinating polyneuropathies. Autoimmunity 2024; 57:2361745. [PMID: 38850571 DOI: 10.1080/08916934.2024.2361745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/26/2024] [Indexed: 06/10/2024]
Abstract
Immune-mediated demyelinating polyneuropathies (IMDPs) are rare disorders in which dysregulated adaptive immune responses cause peripheral nerve demyelinating inflammation and axonal injury in susceptible individuals. Despite significant advances in understanding IMDP pathogenesis guided by patient data and representative mammalian models, specific therapies are lacking. Significant knowledge gaps in IMDP pathogenesis still exist, e.g. precise antigen(s) and mechanisms that initially trigger immune system activation and identification of large population disease susceptibility factors. The initial directional cues for antigen-specific effector or autoreactive leukocyte trafficking into peripheral nerves are also unknown. An overview of current animal models, with emphasis on the experimental autoimmune neuritis and spontaneous autoimmune peripheral polyneuropathy models, is provided. Insights on the initial directional cues for peripheral nerve tissue specific autoimmunity using a novel Major Histocompatibility Complex class II conditional knockout mouse strain are also discussed, suggesting an essential research tool to study cell- and time-dependent adaptive immunity in autoimmune diseases.
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Affiliation(s)
- Eroboghene E Ubogu
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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2
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Súkeníková L, Mallone A, Schreiner B, Ripellino P, Nilsson J, Stoffel M, Ulbrich SE, Sallusto F, Latorre D. Autoreactive T cells target peripheral nerves in Guillain-Barré syndrome. Nature 2024; 626:160-168. [PMID: 38233524 PMCID: PMC10830418 DOI: 10.1038/s41586-023-06916-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/30/2023] [Indexed: 01/19/2024]
Abstract
Guillain-Barré syndrome (GBS) is a rare heterogenous disorder of the peripheral nervous system, which is usually triggered by a preceding infection, and causes a potentially life-threatening progressive muscle weakness1. Although GBS is considered an autoimmune disease, the mechanisms that underlie its distinct clinical subtypes remain largely unknown. Here, by combining in vitro T cell screening, single-cell RNA sequencing and T cell receptor (TCR) sequencing, we identify autoreactive memory CD4+ cells, that show a cytotoxic T helper 1 (TH1)-like phenotype, and rare CD8+ T cells that target myelin antigens of the peripheral nerves in patients with the demyelinating disease variant. We characterized more than 1,000 autoreactive single T cell clones, which revealed a polyclonal TCR repertoire, short CDR3β lengths, preferential HLA-DR restrictions and recognition of immunodominant epitopes. We found that autoreactive TCRβ clonotypes were expanded in the blood of the same patient at distinct disease stages and, notably, that they were shared in the blood and the cerebrospinal fluid across different patients with GBS, but not in control individuals. Finally, we identified myelin-reactive T cells in the nerve biopsy from one patient, which indicates that these cells contribute directly to disease pathophysiology. Collectively, our data provide clear evidence of autoreactive T cell immunity in a subset of patients with GBS, and open new perspectives in the field of inflammatory peripheral neuropathies, with potential impact for biomedical applications.
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Affiliation(s)
- L Súkeníková
- Institute of Microbiology, ETH Zurich, Zurich, Switzerland
| | - A Mallone
- Institute of Microbiology, ETH Zurich, Zurich, Switzerland
| | - B Schreiner
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - P Ripellino
- Department of Neurology, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - J Nilsson
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - M Stoffel
- Institute of Molecular Health Sciences, ETH Zurich, Zurich, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - S E Ulbrich
- Animal Physiology, Institute of Agricultural Sciences, ETH Zurich, Zurich, Switzerland
| | - F Sallusto
- Institute of Microbiology, ETH Zurich, Zurich, Switzerland
- Institute for Research in Biomedicine, Università della Svizzera Italiana, Bellinzona, Switzerland
| | - D Latorre
- Institute of Microbiology, ETH Zurich, Zurich, Switzerland.
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3
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Ozdag Acarli AN, Tuzun E, Sanli E, Koral G, Akbayir E, Cakar A, Sirin NG, Soysal A, Aysal F, Durmus H, Parman Y, Yilmaz V. Disease activity in chronic inflammatory demyelinating polyneuropathy: association between circulating B-cell subsets, cytokine levels, and clinical outcomes. Clin Exp Immunol 2024; 215:65-78. [PMID: 37638717 PMCID: PMC10776240 DOI: 10.1093/cei/uxad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 08/29/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP), a common and treatable autoimmune neuropathy, is frequently misdiagnosed. The aim of this study is to evaluate the relationship between immunological markers and clinical outcome measures in a mixed cohort of patients with typical CIDP and CIDP variants at different disease stages. Twenty-three typical, 16 multifocal and five distal CIDP patients were included. Twenty-five sex and age-matched healthy controls and 12 patients with Charcot-Marie-Tooth type 1A (CMT1A) disease served as controls. Peripheral B-cell populations were analyzed by flow cytometry. IL6, IL10, TNFA mRNA and mir-21, mir-146a, and mir-155-5p expression levels were evaluated by real-time polymerase chain reaction in peripheral blood mononuclear cells (PBMC) and/or skin biopsy specimens. Results were then assessed for a possible association with clinical disability scores and intraepidermal nerve fiber densities (IENFD) in the distal leg. We detected a significant reduction in naive B cells (P ≤ 0.001), plasma cells (P ≤ 0.001) and regulatory B cells (P < 0.05), and an elevation in switched memory B cells (P ≤ 0.001) in CIDP compared to healthy controls. CMT1A and CIDP patients had comparable B-cell subset distribution. CIDP cases had significantly higher TNFA and IL10 gene expression levels in PBMC compared to healthy controls (P < 0.05 and P ≤ 0.01, respectively). IENFDs in the distal leg showed a moderate negative correlation with switched memory B-cell ratios (r = -0.51, P < 0.05) and a moderate positive correlation with plasma cell ratios (r = 0.46, P < 0.05). INCAT sum scores showed a moderate positive correlation with IL6 gene expression levels in PBMC (r = 0.54, P < 0.05). Altered B-cell homeostasis and IL10 and TNFA gene expression levels imply chronic antigen exposure and overactivity in the humoral immune system, and seem to be a common pathological pathway in both typical CIDP and CIDP variants.
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Affiliation(s)
- Ayse Nur Ozdag Acarli
- Neuromuscular Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erdem Tuzun
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Elif Sanli
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Gizem Koral
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Ece Akbayir
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Arman Cakar
- Neuromuscular Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nermin Gorkem Sirin
- Neuromuscular Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Department of Neurology, Bakirkoy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital, Istanbul, Turkey
| | - Aysun Soysal
- Department of Neurology, Bakirkoy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital, Istanbul, Turkey
| | - Fikret Aysal
- Department of Neurology, Bakirkoy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital, Istanbul, Turkey
| | - Hacer Durmus
- Neuromuscular Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yesim Parman
- Neuromuscular Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Vuslat Yilmaz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
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Seyedsadr M, Bang M, McCarthy E, Zhang S, Chen HC, Mohebbi M, Hugo W, Whitmire JK, Lechner MG, Su MA. A pathologically expanded, clonal lineage of IL-21 producing CD4+ T cells drives Inflammatory neuropathy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.07.574553. [PMID: 38260637 PMCID: PMC10802410 DOI: 10.1101/2024.01.07.574553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Inflammatory neuropathies, which include CIDP (chronic inflammatory demyelinating polyneuropathy) and GBS (Guillain Barre Syndrome), result from autoimmune destruction of the peripheral nervous system (PNS) and are characterized by progressive weakness and sensory loss. CD4+ T cells play a key role in the autoimmune destruction of the PNS. Yet, key properties of pathogenic CD4+ T cells remain incompletely understood. Here, we use paired scRNAseq and scTCRseq of peripheral nerves from an inflammatory neuropathy mouse model to identify IL-21 expressing CD4+ T cells that are clonally expanded and multifunctional. These IL-21-expressing CD4+ T cells are comprised of two transcriptionally distinct expanded populations, which express genes associated with Tfh and Tph subsets. Remarkably, TCR clonotypes are shared between these two IL-21-expressing populations, suggesting a common lineage differentiation pathway. Finally, we demonstrate that IL-21 signaling is required for neuropathy development and pathogenic T cell infiltration into peripheral nerves. IL-21 signaling upregulates CXCR6, a chemokine receptor that promotes CD4+ T cell localization in peripheral nerves. Together, these findings point to IL-21 signaling, Tfh/Tph differentiation, and CXCR6-mediated cellular localization as potential therapeutic targets in inflammatory neuropathies.
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Affiliation(s)
- Maryamsadat Seyedsadr
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Madison Bang
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Ethan McCarthy
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Shirley Zhang
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Ho-Chung Chen
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Mahnia Mohebbi
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Willy Hugo
- Department of Medicine, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | | | - Melissa G. Lechner
- Department of Medicine, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
| | - Maureen A. Su
- Department of Microbiology, Immunology, and Molecular Genetics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
- Department of Pediatrics, UCLA David Geffen School of Medicine; Los Angeles, CA 90095
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5
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Ubogu EE, Conner JA, Wang Y, Yadav D, Saunders TL. Development of a major histocompatibility complex class II conditional knockout mouse to study cell-specific and time-dependent adaptive immune responses in peripheral nerves. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.24.550421. [PMID: 37546875 PMCID: PMC10402085 DOI: 10.1101/2023.07.24.550421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Introduction Major histocompatibility complex (MHC) class II professional antigen presenting cell-naïve CD4+ T cell interactions via the T-cell receptor complex are necessary for adaptive immunity. MHC class II upregulation in multiple cell types occurs in human autoimmune polyneuropathy patient biopsies, necessitating studies to ascertain cellular signaling pathways required for tissue-specific autoimmunity. Methods Cryopreserved Guillain-Barré syndrome (GBS) patient sural nerve biopsies and sciatic nerves from the severe murine experimental autoimmune neuritis (sm-EAN) GBS model were studied. Cultured conditional ready MHC Class II antigen A-alpha chain (H2-Aa) embryonic stem cells were used to generate H2-Aa flox/+ C57BL/6 mice. Mice were backcrossed and intercrossed to the SJL background to generate H2-Aa flox/flox SJL mice, bred with hemizygous Tamoxifen-inducible von Willebrand factor Cre recombinase (vWF-iCre/+) SJL mice to generate H2-Aa flox/flox ; vWF-iCre/+ to study microvascular endothelial cell adaptive immune responses. Sm-EAN was induced in adult female SJL Tamoxifen-treated H2-Aa flox/flox ; vWF-iCre/+ mice and H2-Aa flox/flox ; +/+ littermate controls. Neurobehavioral, electrophysiological and histopathological assessments were performed at predefined time points. Results Endoneurial endothelial cell MHC class II expression was observed in normal and inflamed human and mouse peripheral nerves. Adult female Tamoxifen-treated H2-Aa flox/flox ; vWF-iCre/+ did not develop sm-EAN despite extensive MHC class II expression in lymphoid and non-lymphoid tissues. Discussion A conditional MHC class II knockout mouse to study cell- and time-dependent adaptive immune responses in vivo is developed. Initial studies show microvascular endothelial cell MHC class II expression is necessary for peripheral nerve specific autoimmunity, as advocated by human in vitro adaptive immunity and ex vivo transplant rejection studies.
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6
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Relevance of Nerve Biopsy in the Diagnosis of Chronic Inflammatory Demyelinating Polyneuropathy—A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12071691. [PMID: 35885595 PMCID: PMC9315483 DOI: 10.3390/diagnostics12071691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 11/24/2022] Open
Abstract
Chronic Inflammatory Demyelinating Polyneuropathy is an immune-mediated pathology of the peripheral nerves and nerve roots that leads to weakness and sensory symptoms. Given its clinical heterogeneity, often times diagnosis is challenging. Even though nerve conduction studies and clinical features are the main criteria used for diagnosis, supplementary investigations, such as nerve biopsies, cerebral spinal fluid examination and magnetic resonance studies, may be used in order to confirm the diagnosis. Given the fact that the hallmark in CIDP physiopathology is the demyelination process, nerve biopsies are used to demonstrate and assess the magnitude of the phenomenon. The question and the main interest of this review is whether histopathological findings are relevant for the diagnosis and can be useful in disease assessment.
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7
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Chaganti S, Hannaford A, Vucic S. Rituximab in chronic immune mediated neuropathies: a systematic review. Neuromuscul Disord 2022; 32:621-627. [DOI: 10.1016/j.nmd.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/21/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
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8
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Gao Y, Kong L, Liu S, Liu K, Zhu J. Impact of Neurofascin on Chronic Inflammatory Demyelinating Polyneuropathy via Changing the Node of Ranvier Function: A Review. Front Mol Neurosci 2022; 14:779385. [PMID: 34975399 PMCID: PMC8716720 DOI: 10.3389/fnmol.2021.779385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022] Open
Abstract
The effective conduction of action potential in the peripheral nervous system depends on the structural and functional integrity of the node of Ranvier and paranode. Neurofascin (NF) plays an important role in the conduction of action potential in a saltatory manner. Two subtypes of NF, NF186, and NF155, are involved in the structure of the node of Ranvier. In patients with chronic inflammatory demyelinating polyneuropathy (CIDP), anti-NF antibodies are produced when immunomodulatory dysfunction occurs, which interferes with the conduction of action potential and is considered the main pathogenic factor of CIDP. In this study, we describe the assembling mechanism and anatomical structure of the node of Ranvier and the necessary cell adhesion molecules for its physiological function. The main points of this study are that we summarized the recent studies on the role of anti-NF antibodies in the changes in the node of Ranvier function and its impact on clinical manifestations and analyzed the possible mechanisms underlying the pathogenesis of CIDP.
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Affiliation(s)
- Ying Gao
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Lingxin Kong
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Shan Liu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Kangding Liu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Jie Zhu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China.,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Karolinska University Hospital Solna, Stockholm, Sweden
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9
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Dash S, Kamath U, Pai A, Rao P. Serum Inflammatory Markers in Patients with Guillain Barre Syndrome. Neurol India 2022; 70:2082-2085. [DOI: 10.4103/0028-3886.359238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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10
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Latov N. Immune mechanisms, the role of complement, and related therapies in autoimmune neuropathies. Expert Rev Clin Immunol 2021; 17:1269-1281. [PMID: 34751638 DOI: 10.1080/1744666x.2021.2002147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Autoimmune neuropathies have diverse presentations and underlying immune mechanisms. Demonstration of efficacy of therapeutic agents that inhibit the complement cascade would confirm the role of complement activation. AREAS COVERED A review of the pathophysiology of the autoimmune neuropathies, to identify those that are likely to be complement mediated. EXPERT OPINION Complement mediated mechanisms are implicated in the acute and chronic neuropathies associated with IgG or IgM antibodies that target the Myelin Associated Glycoprotein (MAG) or gangliosides in the peripheral nerves. Antibody and complement mechanisms are also suspected in the Guillain-Barré syndrome and chronic inflammatory demyelinating neuropathy, given the therapeutic response to plasmapheresis or intravenous immunoglobulins, even in the absence of an identifiable target antigen. Complement is unlikely to play a role in paraneoplastic sensory neuropathy associated with antibodies to HU/ANNA-1 given its intracellular localization. In chronic demyelinating neuropathy with anti-nodal/paranodal CNTN1, NFS-155, and CASPR1 antibodies, myotonia with anti-VGKC LGI1 or CASPR2 antibodies, or autoimmune autonomic neuropathy with anti-gAChR antibodies, the response to complement inhibitory agents would depend on the extent to which the antibodies exert their effects through complement dependent or independent mechanisms. Complement is also likely to play a role in Sjogren's, vasculitic, and cryoglobulinemic neuropathies.
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Affiliation(s)
- Norman Latov
- Department of Neurology, Weill Cornell Medical College, New York, USA
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11
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Baum P, Toyka KV, Blüher M, Kosacka J, Nowicki M. Inflammatory Mechanisms in the Pathophysiology of Diabetic Peripheral Neuropathy (DN)-New Aspects. Int J Mol Sci 2021; 22:10835. [PMID: 34639176 PMCID: PMC8509236 DOI: 10.3390/ijms221910835] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 12/15/2022] Open
Abstract
The pathogenesis of diabetic neuropathy is complex, and various pathogenic pathways have been proposed. A better understanding of the pathophysiology is warranted for developing novel therapeutic strategies. Here, we summarize recent evidence from experiments using animal models of type 1 and type 2 diabetes showing that low-grade intraneural inflammation is a facet of diabetic neuropathy. Our experimental data suggest that these mild inflammatory processes are a likely common terminal pathway in diabetic neuropathy associated with the degeneration of intraepidermal nerve fibers. In contrast to earlier reports claiming toxic effects of high-iron content, we found the opposite, i.e., nutritional iron deficiency caused low-grade inflammation and fiber degeneration while in normal or high non-heme iron nutrition no or only extremely mild inflammatory signs were identified in nerve tissue. Obesity and dyslipidemia also appear to trigger mild inflammation of peripheral nerves, associated with neuropathy even in the absence of overt diabetes mellitus. Our finding may be the experimental analog of recent observations identifying systemic proinflammatory activity in human sensorimotor diabetic neuropathy. In a rat model of type 1 diabetes, a mild neuropathy with inflammatory components could be induced by insulin treatment causing an abrupt reduction in HbA1c. This is in line with observations in patients with severe diabetes developing a small fiber neuropathy upon treatment-induced rapid HbA1c reduction. If the inflammatory pathogenesis could be further substantiated by data from human tissues and intervention studies, anti-inflammatory compounds with different modes of action may become candidates for the treatment or prevention of diabetic neuropathy.
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Affiliation(s)
- Petra Baum
- Department of Neurology, University of Leipzig, Liebigstraße 20, D-04103 Leipzig, Germany;
| | - Klaus V. Toyka
- Department of Neurology, University of Würzburg, Josef-Schneider-Str. 11, D-97080 Würzburg, Germany;
| | - Matthias Blüher
- Department of Medicine, University of Leipzig, Liebigstraße 20, D-04103 Leipzig, Germany;
| | - Joanna Kosacka
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, D-04103 Leipzig, Germany;
| | - Marcin Nowicki
- Institute of Anatomy, University of Leipzig, Liebigstraße 13, D-04103 Leipzig, Germany
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12
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Querol L, Lleixà C. Novel Immunological and Therapeutic Insights in Guillain-Barré Syndrome and CIDP. Neurotherapeutics 2021; 18:2222-2235. [PMID: 34549385 PMCID: PMC8455117 DOI: 10.1007/s13311-021-01117-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 12/22/2022] Open
Abstract
Inflammatory neuropathies are a heterogeneous group of rare diseases of the peripheral nervous system that include acute and chronic diseases, such as Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The etiology and pathophysiological mechanisms of inflammatory neuropathies are only partly known, but are considered autoimmune disorders in which an aberrant immune response, including cellular and humoral components, is directed towards components of the peripheral nerve causing demyelination and axonal damage. Therapy of these disorders includes broad-spectrum immunomodulatory and immunosuppressive treatments, such as intravenous immunoglobulin, corticosteroids, or plasma exchange. However, a significant proportion of patients do not respond to any of these therapies, and treatment selection is not optimized according to disease pathophysiology. Therefore, research on disease pathophysiology aiming to reveal clinically and functionally relevant disease mechanisms and the development of new treatment approaches are needed to optimize disease outcomes in CIDP and GBS. This topical review describes immunological progress that may help guide therapeutic strategies in the future in these two disorders.
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Affiliation(s)
- Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain.
- Centro Para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain.
| | - Cinta Lleixà
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain
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13
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Urbain F, Labeyrie C, Castilla-Llorente C, Cintas P, Puma A, Maubeuge N, Puyade M, Farge D. [Autologous hematopoietic stem cell transplantation for chronic inflammatory demyelinating polyneuropathy]. Rev Med Interne 2021; 42:639-649. [PMID: 33773849 DOI: 10.1016/j.revmed.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/02/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a dysimmune neuropathy with sensory and/or motor symptoms due to destruction of the myelin sheat secondary to an auto-immune attack. A quarter to a third of patients do not respond to immunomodulatory first line recommended therapies. No second line treatment has shown its effectiveness with a sufficient level of evidence. Autologous hematopoietic stem cell transplantation (AHSCT) is a promising therapy for autoimmune disease, especially for CIDP in recent works. We present in this article an update on the diagnosis of CIDP, its conventional treatments as well as the results of AHSCT in this indication, which was the subject of French recommendations under the aegis of the SFGMTC and neuromuscular disease french faculty (FILNEMUS) as a third line therapy after failure of two first-line and one second-line treatments.
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Affiliation(s)
- F Urbain
- Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, service de medecine interne, groupe hospitalier universitaire Paris Sud, hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France.
| | - C Labeyrie
- Assistance Publique-Hôpitaux de Paris, centre de reference maladies rares neuropathies amyloïdes familiales et autres neuropathies peripheriques rares, service de neurologie, groupe hospitalier universitaire Paris Sud, hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - C Castilla-Llorente
- Institut Gustave-Roussy, service d'hématologie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - P Cintas
- Explorations neurophysiologiques, centre SLA, centre de référence de pathologie neuromusculaire, CHU Toulouse, hôpital Pierre-Paul-Riquet, 31059 Toulouse Cedex, France
| | - A Puma
- Maladies du systeme nerveux peripherique et du muscle, Centre SLA, hôpital Pasteur 2-Zone C, CS 51069, 06001 Nice cedex 1, France
| | - N Maubeuge
- CHU de Poitiers, service de neurologie, 2, rue de la Milétrie, 86021 Poitiers cedex, France
| | - M Puyade
- CHU de Poitiers, service de médecine interne et maladies infectieuses, 2, rue de la Milétrie, 86021 Poitiers cedex, France; CHU de Poitiers, CIC-1402, 2, rue de la Milétrie, 86021 Poitiers cedex, France
| | - D Farge
- Unité de médecine interne, maladies auto-immunes et pathologie vasculaire UF04, Centre de référence des maladies auto-immunes systémiques rares d'Île-de-France MATHEC Hôpital Saint-Louis, UF04, Filière 'FAI2R', 1, avenue Claude-Vellefaux, 75475 Paris, France; Université de Paris, EA 3518, Paris, France; Département de Médecine, Université McGill, Montreal, QC, Canada
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14
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Hagen KM, Ousman SS. The immune response and aging in chronic inflammatory demyelinating polyradiculoneuropathy. J Neuroinflammation 2021; 18:78. [PMID: 33752693 PMCID: PMC7983397 DOI: 10.1186/s12974-021-02113-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/16/2021] [Indexed: 12/26/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) consists of various autoimmune subtypes in which the peripheral nervous system (PNS) is attacked. CIDP can follow a relapsing-remitting or progressive course where the resultant demyelination caused by immune cells (e.g., T cells, macrophages) and antibodies can lead to disability in patients. Importantly, the age of CIDP patients has a role in their symptomology and specific variants have been associated with differing ages of onset. Furthermore, older patients have a decreased frequency of functional recovery after CIDP insult. This may be related to perturbations in immune cell populations that could exacerbate the disease with increasing age. In the present review, the immune profile of typical CIDP will be discussed followed by inferences into the potential role of relevant aging immune cell populations. Atypical variants will also be briefly reviewed followed by an examination of the available studies on the immunology underlying them.
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Affiliation(s)
- Kathleen M Hagen
- Department of Neuroscience, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, T2N 4N1, Canada
| | - Shalina S Ousman
- Departments of Clinical Neurosciences and Cell Biology and Anatomy, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, T2N 4N1, Canada.
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15
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Oladiran O, Shi XQ, Yang M, Fournier S, Zhang J. Inhibition of TLR4 signaling protects mice from sensory and motor dysfunction in an animal model of autoimmune peripheral neuropathy. J Neuroinflammation 2021; 18:77. [PMID: 33752705 PMCID: PMC7983271 DOI: 10.1186/s12974-021-02126-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/10/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND While the etiology remains elusive, macrophages and T cells in peripheral nerves are considered as effector cells mediating autoimmune peripheral neuropathy (APN), such as Guillain-Barre syndrome. By recognizing both pathogen-associated molecular patterns (PAMPs) and damage-associated molecular patterns (DAMPs) signals, TLRs play a central role in the initiation of both innate and adaptive immune responses. In this study, we aimed to understand the involvement of TLR4 in the pathogenesis of APN and explore the potential of TLR4 as a drug target for therapeutic use. METHODS APN was induced by a partial ligation on one of the sciatic nerves in B7.2 (L31) transgenic mice which possess a predisposed inflammatory background. APN pathology and neurological function were evaluated on the other non-injured sciatic nerve. RESULTS TLR4 and its endogenous ligand HMGB1 were highly expressed in L31 mice, in circulating immune cells and in peripheral nerves. Enhanced TLR4 signaling was blocked with TAK 242, a selective TLR4 inhibitor, before and after disease onset. Intraperitoneal administration of TAK 242 not only inhibited monocyte, macrophage and CD8+ T cell activation, but also reduced the release of pro-inflammatory cytokines. TAK 242 protected mice from severe myelin and axonal loss, resulting in a remarkable improvement in mouse motor and sensory functions. TAK 242 was effective in alleviating the disease in both preventive and reversal paradigms. CONCLUSION The study identified the critical contribution of TLR4-mediated macrophage activation in disease course and provided strong evidence to support TLR4 as a useful drug target for treating inflammatory autoimmune neuropathy.
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Affiliation(s)
- Oladayo Oladiran
- The Alan Edwards Centre for Research on Pain, McGill University, 740 Docteur Penfield Ave, Suite 3200C, Montreal, QC, H3A0G1, Canada
| | - Xiang Qun Shi
- The Alan Edwards Centre for Research on Pain, McGill University, 740 Docteur Penfield Ave, Suite 3200C, Montreal, QC, H3A0G1, Canada
| | - Mu Yang
- The Alan Edwards Centre for Research on Pain, McGill University, 740 Docteur Penfield Ave, Suite 3200C, Montreal, QC, H3A0G1, Canada
| | - Sylvie Fournier
- Department of Microbiology & Immunology, McGill University, 3775 University Street, Montreal, QC, H3A 2B4, Canada.
| | - Ji Zhang
- The Alan Edwards Centre for Research on Pain, McGill University, 740 Docteur Penfield Ave, Suite 3200C, Montreal, QC, H3A0G1, Canada. .,Department of Microbiology & Immunology, McGill University, 3775 University Street, Montreal, QC, H3A 2B4, Canada. .,Department of Neurology & Neurosurgery, McGill University, Montreal, QC, Canada. .,Faculty of Dentistry, McGill University, Montreal, QC, Canada.
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16
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Hagen KM, Ousman SS. The Neuroimmunology of Guillain-Barré Syndrome and the Potential Role of an Aging Immune System. Front Aging Neurosci 2021; 12:613628. [PMID: 33584245 PMCID: PMC7873882 DOI: 10.3389/fnagi.2020.613628] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/11/2020] [Indexed: 12/15/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is a paralyzing autoimmune condition affecting the peripheral nervous system (PNS). Within GBS there are several variants affecting different aspects of the peripheral nerve. In general, there appears to be a role for T cells, macrophages, B cells, and complement in initiating and perpetuating attacks on gangliosides of Schwann cells and axons. Of note, GBS has an increased prevalence and severity with increasing age. In addition, there are alterations in immune cell functioning that may play a role in differences in GBS with age alongside general age-related declines in reparative processes (e.g., delayed de-differentiation of Schwann cells and decline in phagocytic ability of macrophages). The present review will explore the immune response in GBS as well as in animal models of several variants of the disorder. In addition, the potential involvement of an aging immune system in contributing to the increased prevalence and severity of GBS with age will be theorized.
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Affiliation(s)
- Kathleen M. Hagen
- Department of Neuroscience, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Shalina S. Ousman
- Departments of Clinical Neurosciences and Cell Biology and Anatomy, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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17
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Fisse AL, Motte J, Grüter T, Sgodzai M, Pitarokoili K, Gold R. Comprehensive approaches for diagnosis, monitoring and treatment of chronic inflammatory demyelinating polyneuropathy. Neurol Res Pract 2020; 2:42. [PMID: 33324942 PMCID: PMC7722337 DOI: 10.1186/s42466-020-00088-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common chronic inflammatory neuropathy. CIDP is diagnosed according to the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria, which combine clinical features with the electrophysiological evidence of demyelination. However, firstly, diagnosis is challenging, as some patients e.g. with severe early axonal damage do not fulfil the criteria. Secondly, objective and reliable tools to monitor the disease course are lacking. Thirdly, about 25% of CIDP patients do not respond to evidence-based first-line therapy. Recognition of these patients is difficult and treatment beyond first-line therapy is based on observational studies and case series only. Individualized immunomodulatory treatment does not exist due to the lack of understanding of essential aspects of the underlying pathophysiology. Novel diagnostic imaging techniques and molecular approaches can help to solve these problems but do not find enough implementation. This review gives a comprehensive overview of novel diagnostic techniques and monitoring approaches for CIDP and how these can lead to individualized treatment and better understanding of pathophysiology.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Melissa Sgodzai
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
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18
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Rajabally YA, Attarian S, Delmont E. Evolving Immunologic Perspectives in Chronic Inflammatory Demyelinating Polyneuropathy. J Inflamm Res 2020; 13:543-549. [PMID: 32982369 PMCID: PMC7502403 DOI: 10.2147/jir.s224781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/26/2020] [Indexed: 12/17/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is the commonest chronic idiopathic dysimmune neuropathy. Pathophysiologic processes involve both cellular and humoral immunity. There are various known forms of CIDP, likely caused by varying mechanisms. CIDP in its different forms is a treatable disorder in the majority of patients. The diagnosis of CIDP is clinical, supported routinely by electrophysiology. Cerebrospinal fluid analysis may be helpful. Routine immunology currently rarely adds to the diagnostic process but may contribute to the identification of an associated monoclonal gammopathy with or without hematologic malignancy and the consideration of alternative diagnoses, such as POEMS syndrome, anti-myelin associated glycoprotein (MAG) neuropathy or chronic ataxic neuropathy, with ophthalmoplegia, M-protein, cold aglutinins and disialosyl antibodies (CANOMAD). The search for antibodies specific to CIDP has been unsuccessful for many years. Recently, antibodies to paranodal proteins have been identified in a minority of patients with severe CIDP phenotypes, often unresponsive to first-line therapies. In conjunction with reports of high rates of antibody responses to neural structures in CIDP, this entertains the hope that more discoveries are to come. Although still arguably for only a small minority of patients, in view of current knowledge, such progress will enable earlier accurate diagnosis with direct management implications but only if the important, unfortunately and infrequently discussed issues of immunologic technique, test reliability and reproducibility are adequately tackled.
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Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, University Hospitals Birmingham, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
| | - Shahram Attarian
- Reference Centre for Neuromuscular Diseases and ALS, Centre Hospitalier Universitaire La Timone, Marseille 13385, France.,Aix-Marseille University, Inserm, GMGF, Marseille, France
| | - Emilien Delmont
- Reference Centre for Neuromuscular Diseases and ALS, Centre Hospitalier Universitaire La Timone, Marseille 13385, France.,Aix-Marseille University, Inserm, GMGF, Marseille, France
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19
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Biology of the human blood-nerve barrier in health and disease. Exp Neurol 2020; 328:113272. [PMID: 32142802 DOI: 10.1016/j.expneurol.2020.113272] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 12/13/2022]
Abstract
A highly regulated endoneurial microenvironment is required for normal axonal function in peripheral nerves and nerve roots, which structurally consist of an outer collagenous epineurium, inner perineurium consisting of multiple concentric layers of specialized epithelioid myofibroblasts that surround the innermost endoneurium, which consists of myelinated and unmyelinated axons embedded in a looser mesh of collagen fibers. Endoneurial homeostasis is achieved by tight junction-forming endoneurial microvessels that control ion, solute, water, nutrient, macromolecule and leukocyte influx and efflux between the bloodstream and endoneurium, and the innermost layers of the perineurium that control interstitial fluid component flux between the freely permeable epineurium and endoneurium. Strictly speaking, endoneurial microvascular endothelium should be considered the blood-nerve barrier (BNB) due to direct communication with circulating blood. The mammalian BNB is considered the second most restrictive vascular system after the blood-brain barrier (BBB) based on classic in situ permeability studies. Structural alterations in endoneurial microvessels or interactions with hematogenous leukocytes have been described in several human peripheral neuropathies; however major advances in BNB biology in health and disease have been limited over the past 50 years. Guided by transcriptome and proteome studies of normal and pathologic human peripheral nerves, purified primary and immortalized human endoneurial endothelial cells that form the BNB and leukocytes from patients with well-characterized peripheral neuropathies, validated by in situ or ex vivo protein expression studies, data are emerging on the molecular and functional characteristics of the human BNB in health and in specific peripheral neuropathies, as well as chronic neuropathic pain. These early advancements have the potential to not only increase our understanding of how the BNB works and adapts or fails to adapt to varying insult, but provide insights relevant to pathogenic leukocyte trafficking, with translational potential and specific therapeutic application for chronic peripheral neuropathies and neuropathic pain.
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20
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Wolbert J, Cheng MI, Meyer zu Horste G, Su MA. Deciphering immune mechanisms in chronic inflammatory demyelinating polyneuropathies. JCI Insight 2020; 5:132411. [PMID: 32051341 DOI: 10.1172/jci.insight.132411] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disease of the peripheral nerves that presents with either chronic progression or relapsing disease. Recent studies in samples from patients with CIDP and mouse models have delineated how defects in central (thymic) and peripheral (extrathymic) immune tolerance mechanisms can cause PNS autoimmunity. Notably, nerve parenchymal cells actively contribute to local autoimmunity and also control disease outcome. Here, we outline how emerging technologies increasingly enable an integrated view of how immune cells and PNS parenchymal cells communicate in CIDP. We also relate the known heterogeneity of clinical presentation with specific underlying mechanisms. For example, a severe subtype of CIDP with tremor is associated with pathogenic IgG4 autoantibodies against nodal and paranodal proteins. An improved understanding of pathogenic mechanisms in CIDP will form the basis for more effective mechanism-based therapies.
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Affiliation(s)
- Jolien Wolbert
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Mandy I Cheng
- Department of Microbiology Immunology and Medical Genetics and
| | - Gerd Meyer zu Horste
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Maureen A Su
- Department of Microbiology Immunology and Medical Genetics and.,Department of Pediatrics, UCLA, Los Angeles, California, USA
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21
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Murine cytomegalovirus infection in mice results in an acute inflammatory reaction in peripheral nerves. J Neuroimmunol 2019; 335:577017. [PMID: 31430710 DOI: 10.1016/j.jneuroim.2019.577017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 02/08/2023]
Abstract
Human cytomegalovirus (CMV) infection is asymptomatic in immunocompetent individuals. However, it can lead to disease in immunodeficient population. Little is known of the mechanisms underlying the pathogenicity of the virus. We investigated the impact of CMV infection on mouse nervous system. Peripheral nerves but not spinal cord was permissive to MCMV during acute infection. Activated CD8+ T cells, monocytes/macrophages and cytokine expression were increased in the blood and sciatic nerves of infected mice, which exhibited transient sensory dysfunction. This study indicates that systemic MCMV infection leads to a dissemination of MCMV into peripheral nerves, which is associated with a local inflammation but not nerve tissue damage in the acute phase.
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22
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Rodríguez Y, Vatti N, Ramírez-Santana C, Chang C, Mancera-Páez O, Gershwin ME, Anaya JM. Chronic inflammatory demyelinating polyneuropathy as an autoimmune disease. J Autoimmun 2019; 102:8-37. [DOI: 10.1016/j.jaut.2019.04.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/13/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
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23
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Khoo A, Frasca J, Schultz D. Measuring disease activity and predicting response to intravenous immunoglobulin in chronic inflammatory demyelinating polyneuropathy. Biomark Res 2019; 7:3. [PMID: 30805188 PMCID: PMC6373155 DOI: 10.1186/s40364-019-0154-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/28/2019] [Indexed: 12/13/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is characterised by significant clinical heterogeneity and as such reliable biomarkers are required to measure disease activity and assess treatment response. Recent advances in our understanding of disease pathogenesis and the discovery of novel serum-based, electrophysiologic and imaging biomarkers allow clinicians to make more informed decisions regarding individualised treatment regimes. As a chronic immune-mediated process typified by relapse following withdrawal of immunomodulatory therapy, a substantial proportion of patients with CIDP require long term treatment with intravenous immunoglobulin (IVIg), a scarce and expensive donor-derived resource. The required duration and intensity of immunoglobulin treatment vary widely between individuals, highlighting both the heterogeneous nature of the underlying disease process as well as the variable pharmacologic properties of IVIg. This review outlines the use of multimodal biomarkers in the longitudinal evaluation of nerve injury and how recent developments have impacted our ability to predict both response to immunoglobulin administration and its withdrawal.
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Affiliation(s)
- Anthony Khoo
- 1Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia 5042 Australia.,2College of Medicine and Public Health, Flinders University, Adelaide, South Australia
| | - Joseph Frasca
- 1Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia 5042 Australia.,2College of Medicine and Public Health, Flinders University, Adelaide, South Australia
| | - David Schultz
- 1Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia 5042 Australia.,2College of Medicine and Public Health, Flinders University, Adelaide, South Australia
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24
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Allard DE, Wang Y, Li JJ, Conley B, Xu EW, Sailer D, Kimpston C, Notini R, Smith CJ, Koseoglu E, Starmer J, Zeng XL, Howard JF, Hoke A, Scherer SS, Su MA. Schwann cell-derived periostin promotes autoimmune peripheral polyneuropathy via macrophage recruitment. J Clin Invest 2018; 128:4727-4741. [PMID: 30222134 DOI: 10.1172/jci99308] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/31/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) and Guillain-Barre syndrome (GBS) are inflammatory neuropathies that affect humans and are characterized by peripheral nerve myelin destruction and macrophage-containing immune infiltrates. In contrast to the traditional view that the peripheral nerve is simply the target of autoimmunity, we report here that peripheral nerve Schwann cells exacerbate the autoimmune process through extracellular matrix (ECM) protein induction. In a spontaneous autoimmune peripheral polyneuropathy (SAPP) mouse model of inflammatory neuropathy and CIDP nerve biopsies, the ECM protein periostin (POSTN) was upregulated in affected sciatic nerves and was primarily expressed by Schwann cells. Postn deficiency delayed the onset and reduced the extent of neuropathy, as well as decreased the number of macrophages infiltrating the sciatic nerve. In an in vitro assay, POSTN promoted macrophage chemotaxis in an integrin-AM (ITGAM) and ITGAV-dependent manner. The PNS-infiltrating macrophages in SAPP-affected nerves were pathogenic, since depletion of macrophages protected against the development of neuropathy. Our findings show that Schwann cells promote macrophage infiltration by upregulating Postn and suggest that POSTN is a novel target for the treatment of macrophage-associated inflammatory neuropathies.
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Affiliation(s)
| | - Yan Wang
- Department of Pediatrics, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
| | - Jian Joel Li
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bridget Conley
- Department of Pediatrics, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
| | - Erin W Xu
- Department of Pediatrics, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Department of Microbiology, Immunology, and Molecular Genetics, UCLA, Los Angeles, California, USA
| | - David Sailer
- Department of Pediatrics, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
| | - Caellaigh Kimpston
- Department of Pediatrics, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
| | - Rebecca Notini
- Department of Pediatrics, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
| | | | - Emel Koseoglu
- Neurology Department, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Joshua Starmer
- Department of Genetics and 7Department of Neurology, UNC-CH, Chapel Hill, North Carolina, USA
| | - Xiaopei L Zeng
- Department of Pediatrics, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
| | - James F Howard
- Department of Neurology, UNC-CH, Chapel Hill, North Carolina, USA
| | - Ahmet Hoke
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Steven S Scherer
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maureen A Su
- Department of Microbiology and Immunology and.,Department of Pediatrics, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA.,Department of Microbiology, Immunology, and Molecular Genetics, UCLA, Los Angeles, California, USA.,Department of Pediatrics, UCLA, Los Angeles, California, USA
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25
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Debnath M, Nagappa M, Talukdar PM, Subbanna M, Sundaravadivel P, Shivakumar V, Dutta D, Wahatule R, Sinha S, Bindu PS, Periyavan S, Umamaheswara Rao GS, Taly AB. Comprehensive cytokine profiling provides evidence for a multi-lineage Th responses in Guillain Barré Syndrome. Cytokine 2018; 110:58-62. [PMID: 29704819 DOI: 10.1016/j.cyto.2018.04.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/03/2018] [Accepted: 04/20/2018] [Indexed: 12/21/2022]
Abstract
Guillain Barré Syndrome (GBS) is one of the commonest acquired immune-mediated neuropathies, often preceded by infections. Although cellular immune responses are shown to substantially account for the pathophysiology of GBS, the precise mechanistic basis of risk and disease course remains enigmatic till date. Cytokines are best known for their abilities to drive cellular immunity and inflammation through their co-ordinated actions. Data obtained from clinical and animal model studies suggest important implications of some of the cytokines in the progression and recovery of GBS. However, these studies were performed on few cytokines and small set of GBS patients, thereby lacking a complete understanding of the patterns of association of cytokines representing Th1, Th2, and Th17 responses with GBS. We studied 65 well-characterized GBS patients and 73 age- and sex-matched healthy controls. A panel of 15 cytokines representing Th1, Th2 and Th17 pathways was assayed using Multiplex Suspension Array platform. Plasma levels of five cytokines were found to be altered in GBS patients compared to healthy control subjects: (i) IL-1β exhibited reduced levels, and (ii) IFN-γ, IL-4, IL-21 and IL-33 were elevated in GBS patients. The most important finding of this study was up-regulated expression of IL-21 and IL-33 in patients with GBS. Given the role of IL-33 as an alarmin, the elevated level of this cytokine provides important indication about a much broader role of cytokines in GBS. This study also provides evidence towards a multi-lineage Th cells (Th1, Th2 and Th17) associated cytokine responses in the pathophysiology of GBS.
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Affiliation(s)
- Monojit Debnath
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Bangalore, India.
| | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Pinku Mani Talukdar
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Manjula Subbanna
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - P Sundaravadivel
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Venkataram Shivakumar
- Translational Psychiatry Laboratory, Neurobiology Research Centre, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Debprasad Dutta
- Department of Human Genetics, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Rahul Wahatule
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Parayil Sankaran Bindu
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Sundar Periyavan
- Department of Transfusion Medicine and Haematology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - G S Umamaheswara Rao
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
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26
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Smith CJ, Allard DE, Wang Y, Howard JF, Montgomery SA, Su MA. IL-10 Paradoxically Promotes Autoimmune Neuropathy through S1PR1-Dependent CD4 + T Cell Migration. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2018; 200:1580-1592. [PMID: 29367208 PMCID: PMC5821539 DOI: 10.4049/jimmunol.1701280] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/28/2017] [Indexed: 01/13/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a debilitating condition caused by autoimmune demyelination of peripheral nerves. CIDP is associated with increased IL-10, a cytokine with well-described anti-inflammatory effects. However, the role of IL-10 in CIDP is unclear. In this study, we demonstrate that IL-10 paradoxically exacerbates autoimmunity against peripheral nerves. In IL-10-deficient mice, protection from neuropathy was associated with an accrual of highly activated CD4+ T cells in draining lymph nodes and absence of infiltrating immune cells in peripheral nerves. Accumulated CD4+ T cells in draining lymph nodes of IL-10-deficient mice expressed lower sphingosine-1-phosphate receptor 1 (S1pr1), a protein important in lymphocyte egress. Additionally, IL-10 stimulation in vitro induced S1pr1 expression in lymph node cells in a STAT3-dependent manner. Together, these results delineate a novel mechanism in which IL-10-induced STAT3 increases S1pr1 expression and CD4+ T cell migration to accelerate T cell-mediated destruction of peripheral nerves.
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Affiliation(s)
- Collin-Jamal Smith
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Denise E Allard
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Yan Wang
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - James F Howard
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Stephanie A Montgomery
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599; and
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
| | - Maureen A Su
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599;
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599
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Axonal damage in central and peripheral nervous system inflammatory demyelinating diseases: common and divergent pathways of tissue damage. Curr Opin Neurol 2018; 29:213-21. [PMID: 27058223 DOI: 10.1097/wco.0000000000000334] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Axonal injury is the pathological correlate of fixed disability in the inflammatory demyelinating disorders of the central and peripheral nervous system. The mechanisms that initiate and propagate neurodegeneration in these conditions are poorly understood, and a lack of available neuroprotective and proreparative therapies represent a significant unmet clinical need. In this article, we review new data pertaining to the convergent and divergent immunological, cellular, and molecular mechanisms that underpin neurodegeneration in multiple sclerosis and the chronic inflammatory demyelinating neuropathies that will inform the development of targeted therapies. RECENT FINDINGS New insights have been gained from recognition of the axon as an integral component of the axon-myelin unit, identification of defects in axonal transport, elucidation of mechanisms of Wallerian degeneration and, in the central nervous system, the appreciation of trans-synaptic axonal degeneration, and widespread cortical synaptopathy. Concurrently, specific immune triggers of axonal injury, particularly in the peripheral immune system; and inhibitors of repair and regrowth, have been identified. SUMMARY Neurodegeneration is a critical determinant of disability in the inflammatory demyelinating diseases of both the central nervous system and peripheral nervous system. Current therapies are restricted to agents that (effectively) treat the inflammatory components of these conditions. Although propagated, and in some instances triggered, by inflammation, axon damage will in future years be treated or prevented with adjuvant, targeted therapies that exploit emerging pathways to neurodegeneration.
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Décard BF, Pham M, Grimm A. Ultrasound and MRI of nerves for monitoring disease activity and treatment effects in chronic dysimmune neuropathies – Current concepts and future directions. Clin Neurophysiol 2018; 129:155-167. [DOI: 10.1016/j.clinph.2017.10.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/03/2017] [Accepted: 10/07/2017] [Indexed: 02/07/2023]
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Rajabally YA, Stettner M, Kieseier BC, Hartung HP, Malik RA. CIDP and other inflammatory neuropathies in diabetes — diagnosis and management. Nat Rev Neurol 2017; 13:599-611. [DOI: 10.1038/nrneurol.2017.123] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Muller S, Brun S, René F, de Sèze J, Loeffler JP, Jeltsch-David H. Autophagy in neuroinflammatory diseases. Autoimmun Rev 2017; 16:856-874. [DOI: 10.1016/j.autrev.2017.05.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 05/20/2017] [Indexed: 12/12/2022]
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Leal de Araujo J, Tizard I, Guo J, Heatley JJ, Rodrigues Hoffmann A, Rech RR. Are anti-ganglioside antibodies associated with proventricular dilatation disease in birds? PeerJ 2017; 5:e3144. [PMID: 28413724 PMCID: PMC5390765 DOI: 10.7717/peerj.3144] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 03/04/2017] [Indexed: 11/20/2022] Open
Abstract
The identification of Parrot bornaviruses (PaBV) in psittacine birds with proventricular dilatation disease (PDD) has not been sufficient to explain the pathogenesis of this fatal disease, since not all infected birds develop clinical signs. Although the most accepted theory indicates that PaBV directly triggers an inflammatory response in this disease, another hypothesis suggests the disease is triggered by autoantibodies targeting neuronal gangliosides, and PDD might therefore resemble Guillain-Barré Syndrome (GBS) in its pathogenesis. Experimental inoculation of pure gangliosides and brain-derived ganglioside extracts were used in two different immunization studies. The first study was performed on 17 healthy chickens (Gallus gallus domesticus): 11 chickens were inoculated with a brain ganglioside extract in Freund’s complete adjuvant (FCA) and six chickens inoculated with phosphate-buffered saline. A second study was performed five healthy quaker parrots (Myiopsitta monachus) that were divided into three groups: Two quaker parrots received purified gangliosides in FCA, two received a crude brain extract in FCA, and one control quaker parrot received FCA alone. One chicken developed difficult in walking. Histologically, only a mild perivascular and perineural lymphocytic infiltrate in the proventriculus. Two quaker parrots (one from each treatment group) had mild lymphoplasmacytic encephalitis and myelitis. However, none of the quaker parrots developed myenteric ganglioneuritis, suggesting that autoantibodies against gangliosides in birds are not associated with a condition resembling PDD.
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Affiliation(s)
- Jeann Leal de Araujo
- Department of Veterinary Pathobiology, Texas A&M University, College Station, TX, United States
| | - Ian Tizard
- Department of Veterinary Pathobiology, Texas A&M University, College Station, TX, United States
| | - Jianhua Guo
- Department of Veterinary Pathobiology, Texas A&M University, College Station, TX, United States
| | - J Jill Heatley
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, TX, United States
| | | | - Raquel R Rech
- Department of Veterinary Pathobiology, Texas A&M University, College Station, TX, United States
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Dong C, Greathouse KM, Beacham RL, Palladino SP, Helton ES, Ubogu EE. Fibronectin connecting segment-1 peptide inhibits pathogenic leukocyte trafficking and inflammatory demyelination in experimental models of chronic inflammatory demyelinating polyradiculoneuropathy. Exp Neurol 2017; 292:35-45. [PMID: 28215575 DOI: 10.1016/j.expneurol.2017.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/25/2017] [Accepted: 02/14/2017] [Indexed: 11/30/2022]
Abstract
The molecular determinants of pathogenic leukocyte migration across the blood-nerve barrier (BNB) in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are unknown. Specific disease modifying therapies for CIDP are also lacking. Fibronectin connecting segment-1 (FNCS1), an alternatively spliced fibronectin variant expressed by microvascular endothelial cells at sites of inflammation in vitro and in situ, is a counterligand for leukocyte α4 integrin (also known as CD49d) implicated in pathogenic leukocyte trafficking in multiple sclerosis and inflammatory bowel disease. We sought to determine the role of FNCS1 in CIDP patient leukocyte trafficking across the BNB in vitro and in severe chronic demyelinating neuritis in vivo using a representative spontaneous murine CIDP model. Peripheral blood mononuclear leukocytes from 7 untreated CIDP patients were independently infused into a cytokine-treated, flow-dependent in vitro BNB model system. Time-lapse digital video microscopy was performed to visualize and quantify leukocyte trafficking, comparing FNCS1 peptide blockade to relevant controls. Fifty 24-week old female B7-2 deficient non-obese diabetic mice with spontaneous autoimmune peripheral polyneuropathy (SAPP) were treated daily with 2mg/kg FNCS1 peptide for 5days via intraperitoneal injection with appropriate controls. Neurobehavioral measures of disease severity, motor nerve electrophysiology assessments and histopathological quantification of inflammation and morphometric assessment of demyelination were performed to determine in vivo efficacy. The biological relevance of FNCS1 and CD49d in CIDP was evaluated by immunohistochemical detection in affected patient sural nerve biopsies. 25μM FNCS1 peptide maximally inhibited CIDP leukocyte trafficking at the human BNB in vitro. FNCS1 peptide treatment resulted in significant improvements in disease severity, motor electrophysiological parameters of demyelination and histological measures of inflammatory demyelination. Microvessels demonstrating FNCS1 expression and CD49d+ leukocytes were seen within the endoneurium of patient nerve biopsies. Taken together, these results imply a role for FNCS1 in pathogenic leukocyte trafficking in CIDP, providing a potential target for therapeutic modulation.
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Affiliation(s)
- Chaoling Dong
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kelsey M Greathouse
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rebecca L Beacham
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Steven P Palladino
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - E Scott Helton
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Eroboghene E Ubogu
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States.
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The pathogenic relevance of α M-integrin in Guillain-Barré syndrome. Acta Neuropathol 2016; 132:739-752. [PMID: 27460017 DOI: 10.1007/s00401-016-1599-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 01/08/2023]
Abstract
The molecular determinants and mechanisms involved in leukocyte trafficking across the blood-nerve barrier (BNB) in the acute inflammatory demyelinating polyradiculoneuropathy (AIDP) variant of Guillain-Barré syndrome are incompletely understood. Prior work using a flow-dependent in vitro human BNB model demonstrated a crucial role for αM-integrin (CD11b)-intercellular adhesion molecule-1 interactions in AIDP patient leukocyte trafficking. The aim of this study is to directly investigate the biological relevance of CD11b in AIDP pathogenesis. Immunohistochemistry was performed on three AIDP patient sural nerve biopsies to evaluate endoneurial leukocyte CD11b expression. A severe murine experimental autoimmune neuritis (sm-EAN) model was utilized to determine the functional role of CD11b in leukocyte trafficking in vivo and determine its effect on neurobehavioral measures of disease severity, electrophysiological assessments of axonal integrity and myelination and histopathological measures of peripheral nerve inflammatory demyelination. Time-lapse video microscopy and electron microscopy were employed to observe structural alterations at the BNB during AIDP patient leukocyte trafficking in vitro and in situ, respectively. Large clusters of endoneurial CD11b+ leukocytes associated with demyelinating axons were observed in AIDP patient sural nerves. Leukocyte CD11b expression was upregulated during sm-EAN. 5 mg/kg of a function-neutralizing monoclonal rat anti-mouse CD11b antibody administered after sm-EAN disease onset significantly ameliorated disease severity, as well as electrophysiological and histopathological parameters of inflammatory demyelination compared to vehicle- and isotype antibody-treated mice. Consistent with in vitro observations of leukocyte trafficking at the BNB, electron micrographs of AIDP patient sural nerves demonstrated intact electron-dense endoneurial microvascular intercellular junctions during paracellular mononuclear leukocyte transmigration. Our data support a crucial pathogenic role of CD11b in AIDP leukocyte trafficking, providing a potential therapeutic target for demyelinating variants of Guillain-Barré syndrome.
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Hu MY, Stathopoulos P, O'connor KC, Pittock SJ, Nowak RJ. Current and future immunotherapy targets in autoimmune neurology. HANDBOOK OF CLINICAL NEUROLOGY 2016; 133:511-36. [PMID: 27112694 DOI: 10.1016/b978-0-444-63432-0.00027-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Randomized controlled treatment trials of autoimmune neurologic disorders are generally lacking and data pertaining to treatment are mostly derived from expert opinion, large case series, and anecdotal reports. The treatment of autoimmune neurologic disorders comprises oncologic therapy (where appropriate) and immunotherapy. In this chapter, we first describe the standard acute and chronic immunotherapies and provide a practical overview of their use in the clinic (mechanisms of action, dosing, monitoring, and side effects). Novel approaches to treatment of autoimmune neurologic disorders, through new drug discovery or repurposing, are dependent on improved mechanistic understanding of immunopathology. Such approaches, with emphasis on monoclonal antibodies, are discussed using the paradigm of three autoimmune neurologic disorders whose immunopathogenesis is better understood, specifically myasthenia gravis, neuromyelitis optica, and chronic inflammatory demyelinating polyradiculoneuropathy. It is important to realize that the treatment strategy and management plan must be individualized for each patient. In general these are influenced by the following: clinical severity, antibody type, presence or absence of cancer, and prior treatment response, if known.
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Affiliation(s)
- Melody Y Hu
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | | | - Kevin C O'connor
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Sean J Pittock
- Departments of Laboratory Medicine/Pathology and Neurology, Mayo Clinic, College of Medicine, Rochester, MN, USA
| | - Richard J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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Yang M, Peyret C, Shi XQ, Siron N, Jang JH, Wu S, Fournier S, Zhang J. Evidence from Human and Animal Studies: Pathological Roles of CD8(+) T Cells in Autoimmune Peripheral Neuropathies. Front Immunol 2015; 6:532. [PMID: 26528293 PMCID: PMC4606118 DOI: 10.3389/fimmu.2015.00532] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/30/2015] [Indexed: 01/28/2023] Open
Abstract
Autoimmune peripheral neuropathies such as Guillain-Barre Syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) affect millions of people worldwide. Despite significant advances in understanding the pathology, the molecular and cellular mechanisms of immune-mediated neuropathies remain elusive. T lymphocytes definitely play an important role in disease pathogenesis and CD4+ T cells have been the main area of research for decades. This is partly due to the fact that the most frequent animal model to study autoimmune peripheral neuropathy is experimental allergic neuritis (EAN). As it is induced commonly by immunization with peripheral nerve proteins, EAN is driven mainly by CD4+ T cells. However, similarly to what has been reported for patients suffering from multiple sclerosis, a significant body of evidence indicates that CD8+ T cells may play a pathogenic role in GBS and CIDP disease development and/or progression. Here, we summarize clinical studies pertaining to the presence and potential role of CD8+ T cells in autoimmune peripheral neuropathies. We also discuss the findings from our most recent studies using a transgenic mouse line (L31 mice) in which the T cell co-stimulator molecule B7.2 (CD86) is constitutively expressed in antigen presenting cells of the nervous tissues. L31 mice spontaneously develop peripheral neuropathy, and CD8+ T cells are found accumulating in peripheral nerves of symptomatic animals. Interestingly, depletion of CD4+ T cells accelerates disease onset and increases disease prevalence. Finally, we point out some unanswered questions for future research to dissect the critical roles of CD8+ T cells in autoimmune peripheral neuropathies.
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Affiliation(s)
- Mu Yang
- Department of Neurology and Neurosurgery, McGill University , Montreal, QC , Canada ; The Alan Edwards Centre for Research on Pain, McGill University , Montreal, QC , Canada
| | - Corentin Peyret
- Department of Microbiology and Immunology, McGill University , Montreal, QC , Canada
| | - Xiang Qun Shi
- The Alan Edwards Centre for Research on Pain, McGill University , Montreal, QC , Canada
| | - Nicolas Siron
- The Alan Edwards Centre for Research on Pain, McGill University , Montreal, QC , Canada
| | - Jeong Ho Jang
- The Alan Edwards Centre for Research on Pain, McGill University , Montreal, QC , Canada
| | - Sonia Wu
- The Alan Edwards Centre for Research on Pain, McGill University , Montreal, QC , Canada
| | - Sylvie Fournier
- Department of Microbiology and Immunology, McGill University , Montreal, QC , Canada
| | - Ji Zhang
- Department of Neurology and Neurosurgery, McGill University , Montreal, QC , Canada ; The Alan Edwards Centre for Research on Pain, McGill University , Montreal, QC , Canada ; Department of Microbiology and Immunology, McGill University , Montreal, QC , Canada ; Faculty of Dentistry, McGill University , Montreal, QC , Canada
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Inflammatory neuropathies: pathology, molecular markers and targets for specific therapeutic intervention. Acta Neuropathol 2015; 130:445-68. [PMID: 26264608 DOI: 10.1007/s00401-015-1466-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 08/01/2015] [Accepted: 08/02/2015] [Indexed: 12/21/2022]
Abstract
Inflammatory neuropathies encompass groups of heterogeneous disorders characterized by pathogenic immune-mediated hematogenous leukocyte infiltration of peripheral nerves, nerve roots or both, with resultant demyelination or axonal degeneration or both. Inflammatory neuropathies may be divided into three major disease categories: Guillain-Barré syndrome (particularly the acute inflammatory demyelinating polyradiculoneuropathy variant), chronic inflammatory demyelinating polyradiculoneuropathy and nonsystemic vasculitic neuropathy (or peripheral nerve vasculitis). Despite major advances in molecular biology, pathology and genetics, the pathogenesis of these disorders remains elusive. There is insufficient knowledge on the mechanisms of hematogenous leukocyte trafficking into the peripheral nervous system to guide the development of specific molecular therapies for immune-mediated inflammatory neuropathies compared to disorders such as psoriasis, inflammatory bowel disease, rheumatoid arthritis or multiple sclerosis. The recent isolation and characterization of human endoneurial endothelial cells that form the blood-nerve barrier provides an opportunity to elucidate leukocyte-endothelial cell interactions critical to the pathogenesis of inflammatory neuropathies at the interface between the systemic circulation and peripheral nerve endoneurium. This review discusses our current knowledge of the classic pathological features of inflammatory neuropathies, attempts at molecular classification and genetic determinants, the utilization of in vitro and in vivo animal models to determine pathogenic mechanisms at the interface between the systemic circulation and the peripheral nervous system relevant to these disorders and prospects for future potential molecular pathology biomarkers and targets for specific therapeutic intervention.
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Mathey EK, Park SB, Hughes RAC, Pollard JD, Armati PJ, Barnett MH, Taylor BV, Dyck PJB, Kiernan MC, Lin CSY. Chronic inflammatory demyelinating polyradiculoneuropathy: from pathology to phenotype. J Neurol Neurosurg Psychiatry 2015; 86:973-85. [PMID: 25677463 PMCID: PMC4552934 DOI: 10.1136/jnnp-2014-309697] [Citation(s) in RCA: 259] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/09/2014] [Accepted: 12/11/2014] [Indexed: 11/04/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory neuropathy, classically characterised by a slowly progressive onset and symmetrical, sensorimotor involvement. However, there are many phenotypic variants, suggesting that CIDP may not be a discrete disease entity but rather a spectrum of related conditions. While the abiding theory of CIDP pathogenesis is that cell-mediated and humoral mechanisms act together in an aberrant immune response to cause damage to peripheral nerves, the relative contributions of T cell and autoantibody responses remain largely undefined. In animal models of spontaneous inflammatory neuropathy, T cell responses to defined myelin antigens are responsible. In other human inflammatory neuropathies, there is evidence of antibody responses to Schwann cell, compact myelin or nodal antigens. In this review, the roles of the cellular and humoral immune systems in the pathogenesis of CIDP will be discussed. In time, it is anticipated that delineation of clinical phenotypes and the underlying disease mechanisms might help guide diagnostic and individualised treatment strategies for CIDP.
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Affiliation(s)
- Emily K Mathey
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Susanna B Park
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia Neuroscience Research Australia & Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - Richard A C Hughes
- MRC Centre for Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
| | - John D Pollard
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Patricia J Armati
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Michael H Barnett
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce V Taylor
- Menzies Research Institute, University of Tasmania, Sydney, New South Wales, Australia
| | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew C Kiernan
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Cindy S-Y Lin
- Faculty of Medicine, Department of Physiology, Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales, Randwick, New South Wales, Australia
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Abstract
Peripheral nervous system axons and myelin have unique potential protein, proteolipid, and ganglioside antigenic determinants. Despite the existence of a blood-nerve barrier, both humoral and cellular immunity can be directed against peripheral axons and myelin. Molecular mimicry may be triggered at the systemic level, as was best demonstrated in the case of bacterial oligosaccharides. The classification of immune neuropathy has been expanded to take into account specific syndromes that share unique clinical, electrophysiological, prognostic and serological features. Guillain-Barré syndrome encompasses a classical syndrome of acute demyelinating polyradiculoneuropathy and many variants: axonal motor and sensory, axonal motor, Miller-Fisher, autonomic, and sensory. Similarly, chronic immune neuropathy is composed of classic chronic inflammatory demyelinating polyradiculoneuropathy and variants characterized as multifocal (motor or sensorimotor), sensory, distal symmetric, and syndromes associated with monoclonal gammopathy. Among putative biomarkers, myelin associated glycoprotein and several anti-ganglioside autoantibodies have shown statistically significant associations with specific neuropathic syndromes. Currently, the strongest biomarker associations are those linking Miller-Fisher syndrome with anti-GQ1b, multifocal motor neuropathy with anti-GM1, and distal acquired symmetric neuropathy with anti-MAG antibodies. Many other autoantibody associations have been proposed, but presently lack sufficient specificity and sensitivity to qualify as biomarkers. This field of research has contributed to the antigenic characterization of motor and sensory functional systems, as well as helping to define immune neuropathic syndromes with widely different clinical presentation, prognosis and response to therapy. Serologic biomarkers are likely to become even more relevant with the advent of new targeted forms of immunotherapy, such as monoclonal antibodies.
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Berger M, Allen JA. Optimizing IgG therapy in chronic autoimmune neuropathies: a hypothesis driven approach. Muscle Nerve 2015; 51:315-26. [PMID: 25418426 PMCID: PMC4357394 DOI: 10.1002/mus.24526] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 12/22/2022]
Abstract
Prolonged intravenous immunoglobulin (IVIG) therapy is used for the chronic autoimmune neuropathies chronic idiopathic demyelinating polyneuropathy and multifocal motor neuropathy, but the doses and treatment intervals are usually chosen empirically due to a paucity of data from dose-response studies. Recent studies of the electrophysiology and immunology of these diseases suggest that antibody-induced reversible dysfunction of nodes of Ranvier may play a role in conduction block and disability which responds to immunotherapy more rapidly than would be expected for demyelination or axonal damage per se. Clinical reports suggest that in some cases, the effects of each dose of IVIG may be transient, wearing-off before the next dose is due. These observations lead us to hypothesize that that therapeutic IgG acts by competing with pathologic autoantibodies and that individual patients may require different IgG levels for optimal therapeutic effects. Frequent IVIG dosing and weekly subcutaneous IgG have been tried as ways of continuously maintaining high serum IgG levels, resulting in stabilization of neuromuscular function in small case series. Frequent grip strength and disability measurements, performed by the patient at home and reported electronically, can be used to assess the extent and duration of responses to IgG doses. Individualization of IgG treatment regimens may optimize efficacy, minimize disability, and identify nonresponders.
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Affiliation(s)
- Melvin Berger
- CSL Behring, LLC., 1040 First Avenue, King of PrussiaPennsylvania, USA 19406
| | - Jeffrey A Allen
- University of MinnesotaMinneapolis, Minnesota, USA
- Northwestern UniversityChicago, Illinois, USA
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Plasmacytosis is a common immune signature in patients with MMN and CIDP and responds to treatment with IVIg. J Neuroimmunol 2015; 278:60-8. [DOI: 10.1016/j.jneuroim.2014.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/08/2014] [Accepted: 11/10/2014] [Indexed: 11/21/2022]
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Blum S, McCombe PA. Genetics of Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP): current knowledge and future directions. J Peripher Nerv Syst 2014; 19:88-103. [DOI: 10.1111/jns5.12074] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/04/2014] [Accepted: 04/09/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Stefan Blum
- The University of Queensland Centre for Clinical Research; UQ CCR; Queensland Australia
| | - Pamela A. McCombe
- The University of Queensland Centre for Clinical Research; UQ CCR; Queensland Australia
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Bekircan-Kurt CE, Üçeyler N, Sommer C. Cutaneous activation of rage in nonsystemic vasculitic and diabetic neuropathy. Muscle Nerve 2014; 50:377-83. [DOI: 10.1002/mus.24164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 12/20/2013] [Accepted: 01/02/2014] [Indexed: 12/25/2022]
Affiliation(s)
- Can Ebru Bekircan-Kurt
- Department of Neurology; University of Würzburg; Josef-Schneider-Str. 11 97080 Würzburg Germany
| | - Nurcan Üçeyler
- Department of Neurology; University of Würzburg; Josef-Schneider-Str. 11 97080 Würzburg Germany
| | - Claudia Sommer
- Department of Neurology; University of Würzburg; Josef-Schneider-Str. 11 97080 Würzburg Germany
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Odaka M. Chronic inflammatory demyelinating polyneuropathy: a treatment protocol proposal. Expert Rev Neurother 2014; 6:365-79. [PMID: 16533141 DOI: 10.1586/14737175.6.3.365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Guidelines for diagnostic criteria and treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) have been proposed by a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society, based on available evidence and expert consensus. These should prove practical for the clinical management of CIDP. Intravenous immunoglobulin followed by corticosteroids should be considered as the initial treatment, however no clear second drug of choice for patients who do not respond to the initial treatment is given. The author reports the long-term therapeutic efficacy of ciclosporin for patients with CIDP who did not show sustained improvement under steroid therapy. Ciclosporin should be tried for patients with intractable CIDP who require repeated intravenous immunoglobulin. An adequate initial dose of ciclosporin is 3 mg/kg/day, with plasma trough concentrations between 100 and 150 ng/ml. If patients respond to ciclosporin, remission can be maintained for 2 years, after which the dose can be slowly reduced over 1 year. Eventual withdrawal should be considered. This review proposes a treatment strategy that includes long-term maintenance therapy for CIDP based on published clinical trials and the author's clinical experience. Current concepts concerning the clinical spectrum of CIDP and diagnostic approaches are also considered.
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Affiliation(s)
- Masaaki Odaka
- Department of Neurology, Dokkyo University School of Medicine, Kitakobayashi 880, Mibu, Shimotsuga, Tochigi 321-0293, Japan.
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Abstract
Guillain-Barre syndrome is a postinfectious disorder caused by an aberrant immune response to an infectious pathogen, resulting in an autoimmune disease. As with other autoimmune diseases of infectious nature, the intricate balance of the numerous factors involved in the immune response may determine the outcome of the interaction between the microbe and host. Recent studies focusing on the role of cytokines and its network of related mediators and receptors suggest that any imbalance may make a significant contribution to the outcome of the infectious disease process. Better understanding of the pathogenesis of Guillain-Barre syndrome may lead to the discovery of newer therapeutics and may also serve as a model for studying other autoimmune diseases.
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Affiliation(s)
- Raymond Sw Tsang
- CNS Infection and Vaccine Preventable Bacterial Diseases, National Microbiology Laboratory, Health Canada, 1015 Arlington Street, Winnipeg, Manitoba, R3E 3R2, USA.
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Kaida K, Kusunoki S. Guillain–Barré syndrome: update on immunobiology and treatment. Expert Rev Neurother 2014; 9:1307-19. [DOI: 10.1586/ern.09.77] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Faivre-Sarrailh C, Devaux JJ. Neuro-glial interactions at the nodes of Ranvier: implication in health and diseases. Front Cell Neurosci 2013; 7:196. [PMID: 24194699 PMCID: PMC3810605 DOI: 10.3389/fncel.2013.00196] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 10/08/2013] [Indexed: 01/06/2023] Open
Abstract
Specific cell adhesion molecules (CAMs) are dedicated to the formation of axo-glial contacts at the nodes of Ranvier of myelinated axons. They play a central role in the organization and maintenance of the axonal domains: the node, paranode, and juxtaparanode. In particular, CAMs are essential for the accumulation of voltage-gated sodium channels at the nodal gap that ensures the rapid and saltatory propagation of the action potentials (APs). The mechanisms regulating node formation are distinct in the central and peripheral nervous systems, and recent studies have highlighted the relative contribution of paranodal junctions and nodal extracellular matrix. In addition, CAMs at the juxtaparanodal domains mediate the clustering of voltage-gated potassium channels which regulate the axonal excitability. In several human pathologies, the axo-glial contacts are altered leading to disruption of the nodes of Ranvier or mis-localization of the ion channels along the axons. Node alterations and the failure of APs to propagate correctly from nodes to nodes along the axons both contribute to the disabilities in demyelinating diseases. This article reviews the mechanisms regulating the association of the axo-glial complexes and the role of CAMs in inherited and acquired neurological diseases.
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Mathey EK, Pollard JD. Chronic inflammatory demyelinating polyneuropathy. J Neurol Sci 2013; 333:37-42. [DOI: 10.1016/j.jns.2012.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 10/14/2012] [Accepted: 10/22/2012] [Indexed: 12/12/2022]
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Abstract
Endoneurial fibroblast-like cells (EFLCs) have been described for more than 60 years, but the embryology, functions, and pathology of these cells are not well defined. Several hypotheses of their origin have been proposed. A previous study suggesting that they were of neural crest origin is supported by our data in humans. This lineage might account for EFLCs having multiple biologic functions and involvement in pathological processes. Here, we review what is known about the origin; functions in collagen synthesis, phagocytosis, inflammatory responses, and immune surveillance; and the pathological alterations of EFLCs based on the literature and on our personal observations.
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Abstract
The latest estimation for the frequency of Guillain-Barré syndrome (GBS) is 1.1 to 1.8 per 100000 persons per year. Guillain-Barré syndrome is today divided into two major subtypes: acute inflammatory demyelinating polyneuropathy (AIDP) and the axonal subtypes, acute motor axonal neuropathy (AMAN) and acute motor and sensory axonal neuropathy (AMSAN). The axonal forms of GBS are caused by certain autoimmune mechanisms, due to a molecular mimicry between antecedent bacterial infection (particularly Campylobacter jejuni) and human peripheral nerve gangliosides. Improvements in patient management in intensive care units has permitted a dramatic drop in mortality rates. Immunotherapy, including plasma exchange (PE) or intravenous immunoglobulin (IVIg), seems to shorten the time to recovery, but their effect remains limited. Further clinical investigations are needed to assess the effect of PE or IVIg on the GBS patients with mild affection, no response, or relapse.
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Affiliation(s)
- Harutoshi Fujimura
- Department of Neurology, Toneyama National Hospital, Toneyama, Toyonaka, Japan.
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