1
|
Etemadifar M, Nouri H, Sedaghat N, Ramezani A, Kargaran PK, Salari M, Kaveyee H. Anti-CD20 therapies for pediatric-onset multiple sclerosis: A systematic review. Mult Scler Relat Disord 2024; 91:105849. [PMID: 39243503 DOI: 10.1016/j.msard.2024.105849] [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: 02/04/2024] [Revised: 08/10/2024] [Accepted: 08/26/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Pediatric-onset multiple sclerosis (POMS) cases, defined as multiple sclerosis (MS) with onset before the age of 18, represent between 3 and 5 % of all MS patients. Anti-CD20 drugs mainly rituximab, ocrelizumab, and ofatumumab are being widely used in adult-onset MS. Their use in POMS is also being increasingly considered by experts. OBJECTIVE to review the latest evidence on safety and efficacy of the use of anti-CD20 therapies in POMS. METHODS An extensive search was performed in PubMed, Scopus, and Web of Science databases until the end of July 1st, 2024. Two independent reviewers screened the articles, and collected data. 832 studies were screened using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. RESULTS 12 studies on rituximab (328 patients) and 6 studies on ocrelizumab (106 patients) were synthesized. Using monoclonal antibodies in POMS patients has a noteworthy effect on reducing relapses and lesions and achieving no evidence of disease activity especially in highly active POMS patients. However, anti-CD20 therapies in MS are associated with potential adverse events (AEs). Additional data is required on the effect of anti-CD20 therapy on disability accrual. CONCLUSION Although anti-CD20 therapy is associated with some AEs, it can be provided in several circumstances, especially to patients with highly active disease, or ones resistant to platform therapies.
Collapse
Affiliation(s)
- Masoud Etemadifar
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hosein Nouri
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran; Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Isfahan, Iran
| | - Nahad Sedaghat
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran; Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Isfahan, Iran
| | - Aryana Ramezani
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parisa K Kargaran
- Department of Cardiovascular Medicine, Center for Regenerative Medicine, Mayo Clinic, Rochester, Rochester, MN, USA
| | - Mehri Salari
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hasan Kaveyee
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| |
Collapse
|
2
|
Goyne CE, Fair AE, Sumowski PE, Graves JS. The Impact of Aging on Multiple Sclerosis. Curr Neurol Neurosci Rep 2024; 24:83-93. [PMID: 38416310 DOI: 10.1007/s11910-024-01333-2] [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] [Accepted: 01/17/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE OF REVIEW Multiple sclerosis (MS) is a chronic, immune-mediated demyelinating disorder of the central nervous system. Age is one of the most important factors in determining MS phenotype. This review provides an overview of how age influences MS clinical characteristics, pathology, and treatment. RECENT FINDINGS New methods for measuring aging have improved our understanding of the aging process in MS. New studies have characterized the molecular and cellular composition of chronic active or smoldering plaques in MS. These lesions are important contributors to disability progression in MS. These studies highlight the important role of immunosenescence and the innate immune system in sustaining chronic inflammation. Given these changes in immune function, several studies have assessed optimal treatment strategies in aging individuals with MS. MS phenotype is intimately linked with chronologic age and immunosenescence. While there are many unanswered questions, there has been much progress in understanding this relationship which may lead to more effective treatments for progressive disease.
Collapse
Affiliation(s)
- Christopher E Goyne
- Department of Neurosciences, University of California San Diego, 9452 Medical Center Drive, Ste 4W-222, La Jolla, San Diego, CA, 92037, USA
| | - Ashley E Fair
- Department of Neurosciences, University of California San Diego, 9452 Medical Center Drive, Ste 4W-222, La Jolla, San Diego, CA, 92037, USA
| | - Paige E Sumowski
- Department of Neurosciences, University of California San Diego, 9452 Medical Center Drive, Ste 4W-222, La Jolla, San Diego, CA, 92037, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, 9452 Medical Center Drive, Ste 4W-222, La Jolla, San Diego, CA, 92037, USA.
| |
Collapse
|
3
|
Lioudyno VI, Tsymbalova EA, Chernyavskaya EA, Scripchenko EY, Bisaga GN, Dmitriev AV, Abdurasulova IN. Association of Increased Homocysteine Levels with Impaired Folate Metabolism and Vitamin B Deficiency in Early-Onset Multiple Sclerosis. BIOCHEMISTRY. BIOKHIMIIA 2024; 89:562-573. [PMID: 38648773 DOI: 10.1134/s0006297924030143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/29/2023] [Accepted: 12/08/2023] [Indexed: 04/25/2024]
Abstract
The contents of homocysteine (HCy), cyanocobalamin (vitamin B12), folic acid (vitamin B9), and pyridoxine (vitamin B6) were analyzed and the genotypes of the main gene polymorphisms associated with folate metabolism (C677T and A1298C of the MTHFR gene, A2756G of the MTR gene and A66G of the MTRR gene) were determined in children at the onset of multiple sclerosis (MS) (with disease duration of no more than six months), healthy children under 18 years (control group), healthy adults without neurological pathology, adult patients with MS at the onset of disease, and adult patients with long-term MS. A significant increase in the HCy levels was found in children at the MS onset compared to healthy children of the corresponding age. It was established that the content of HCy in children has a high predictive value. At the same time, an increase in the HCy levels was not accompanied by the deficiency of vitamins B6, B9, and B12 in the blood. The lack of correlation between the laboratory signs of vitamin deficiency and HCy levels may be due to the polymorphic variants of folate cycle genes. An increased HCy level should be considered as a marker of functional disorders of folate metabolism accompanying the development of pathological process in pediatric MS. Our finding can be used to develop new approaches to the prevention of demyelination in children and treatment of pediatric MS.
Collapse
Affiliation(s)
| | | | | | - Elena Y Scripchenko
- Pediatric Research and Clinical Centre for Infectious Diseases, Saint Petersburg, 197022, Russia
| | - Gennadij N Bisaga
- Almazov National Medical Research Center, Saint Petersburg, 197341, Russia
| | | | | |
Collapse
|
4
|
Papetti L, Panella E, Monte G, Ferilli MAN, Tarantino S, Checchi MP, Valeriani M. Pediatric Onset Multiple Sclerosis and Obesity: Defining the Silhouette of Disease Features in Overweight Patients. Nutrients 2023; 15:4880. [PMID: 38068737 PMCID: PMC10707944 DOI: 10.3390/nu15234880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
Obesity has been suggested as an environmental risk factor for multiple sclerosis (MS) and may negatively effect the progression of the disease. The aim of this study is to determine any correlation between overweight/obesity and the clinical and neuroradiological features at the onset of pediatric onset multiple sclerosis (POMS). Were included patients referred to the POMS Unit of the Bambino Gesù Children's Hospital between June 2012 and June 2021. The diagnosis of MS with an onset of less than 18 years was required. For all included subjects, we considered for the analysis the following data at the onset of symptoms: general data (age, sex, functional system compromised by neurological signs, weight and height), brain and spinal magnetic resonance imaging (MRI), cerebrospinal fluid exams. We identified 55 pediatric cases of POMS and divided them into two groups according to the body mass index (BMI): 60% were healthy weight (HW) and 40% were overweight/obese (OW/O). OW/O patients experienced a two-year age difference in disease onset compared to the HW patients (12.7 ± 3.8 years vs. 14.6 ± 4.1 years; p < 0.05). Onset of polyfocal symptoms was seen more frequently in OW/O patients than in HW (72.7% vs. 21.2%; p < 0.05). The pyramidal functions were involved more frequently in the OW/O group than in the HW group (50% vs. 25%; p < 0.005). Black holes were detected more frequently in OW/O patients in onset MRI scans compared to the HW group (50% vs. 15.5%; p < 0.05). Our findings suggest that being overweight/obese affects the risk of developing MS at an earlier age and is associated with an unfavorable clinical-radiological features at onset. Weight control can be considered as a preventive/therapeutic treatment.
Collapse
Affiliation(s)
- Laura Papetti
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Elena Panella
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Hospital of Rome, Tor Vergata University, 00133 Rome, Italy;
| | - Gabriele Monte
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Michela Ada Noris Ferilli
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Samuela Tarantino
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Martina Proietti Checchi
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
| | - Massimiliano Valeriani
- Developmental Neurology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (G.M.); (M.A.N.F.); (S.T.); (M.P.C.); (M.V.)
- Center for Sensory Motor Interaction, Aalborg University, DK-9220 Aalborg, Denmark
| |
Collapse
|
5
|
Huppke B, Reinert MC, Hummel-Abmeier H, Stark W, Gärtner J, Huppke P. Pretreatment Neurofilament Light Chain Serum Levels, Early Disease Severity, and Treatment Response in Pediatric Multiple Sclerosis. Neurology 2023; 101:e1873-e1883. [PMID: 37748882 PMCID: PMC10663003 DOI: 10.1212/wnl.0000000000207791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/12/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES High disease activity and frequent therapy failure in pediatric multiple sclerosis (MS) make prognostic biomarkers urgently needed. We investigated whether serum neurofilament light chain (sNfL) levels in treatment-naive pediatric patients with MS are associated with early disease severity and indicate treatment outcomes. METHODS A retrospective cohort study of patients seen in the Göttingen Center for MS in Childhood and Adolescence, Germany. Inclusion criteria were MS diagnosis according to the McDonald criteria, MS onset <18 years, and available pretreatment serum sample. sNfL levels were analyzed using a single-molecule array assay. Associations with clinical and MRI evidence of disease severity at sampling were evaluated using the Spearman correlations and nonparametric tests for group comparisons. Correlations between pretreatment sNfL and annualized relapse and new T2 lesion rate on first-line therapy, and odd ratios for switch to high-efficacy therapy were assessed. RESULTS A total of 178 patients (116 women [65%]) with a mean sampling age of 14.3 years were included in the study. Pretreatment sNfL levels were above the ≥90th percentile reported for healthy controls in 80% of patients (median 21.1 pg/mL) and correlated negatively with age, but no correlation was seen with sex, oligoclonal band status, or body mass index. High pretreatment sNfL levels correlated significantly with a high number of preceding relapses, a shorter first interattack interval, a high T2 lesion count, and recent gadolinium-enhancing lesions. Of interest, sNfL levels reflected more strongly MRI activity rather than clinical activity. Pretreatment sNfL levels also correlated significantly with the relapse rate and occurrence of new/enlarging T2 lesions while on first-line injectable therapy. Odds of future therapy escalation increased from 0.14 for sNfL below 7.5 pg/mL to 6.38 for sNfL above 15 pg/mL. In patients with a recent relapse, higher sNfL levels were associated with poorer recovery 3 months after attack. DISCUSSION The results of this study have 3 important implications: First, pretreatment sNfL levels are a valuable biomarker for underlying disease activity in pediatric patients with MS. Second, pretreatment sNfL levels in pediatric patients with MS have a predictive value for the response to first-line therapy and the necessity of future therapy escalation. Third, high sNfL levels during a relapse are associated with poor recovery in this age group.
Collapse
Affiliation(s)
- Brenda Huppke
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany.
| | - Marie-Christine Reinert
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany
| | - Hannah Hummel-Abmeier
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany
| | - Wiebke Stark
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany
| | - Jutta Gärtner
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany
| | - Peter Huppke
- From the Department of Pediatric Neurology (B.H.), University Hospital Jena; Department of Pediatrics and Adolescent Medicine (M.-C.R., H.H.-A., W.S., J.G.), Pediatric Neurology, University Medical Center Göttingen, Georg August University Göttingen; and Department of Neuropediatrics (P.H.), University Hospital Jena, Germany.
| |
Collapse
|
6
|
Prajjwal P, M.D.M. M, Natarajan B, Inban P, Gadam S, Sowndarya D, John J, Abbas R, Vaja H, A.D.M. M, Amir Hussin O. Juvenile multiple sclerosis: addressing epidemiology, diagnosis, therapeutic, and prognostic updates along with cognitive dysfunction and quality of life. Ann Med Surg (Lond) 2023; 85:4433-4441. [PMID: 37663711 PMCID: PMC10473341 DOI: 10.1097/ms9.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 09/05/2023] Open
Abstract
Juvenile multiple sclerosis (JMS) is a rare but significant subtype of multiple sclerosis (MS) that affects a small percentage of patients under the age of 10 and 3-5% of all MS patients. Despite its rarity, JMS poses unique challenges in terms of diagnosis, treatment, and management, as it can significantly impact a child or adolescent's physical, cognitive, and emotional development. JMS presents with a varying spectrum of signs and symptoms such as coordination difficulties and permanent cognitive dysfunctions and may include atypical clinical features such as seizures, acute disseminated encephalomyelitis, and optic neuritis, making diagnostic evaluations challenging. Whilst the biology of JMS shares similarities with adult-onset MS, there exist notable distinctions in disease progression, clinical manifestations, and ultimate prognoses. The International Pediatric MS Study Group (IPMSSG) was founded in 2005 to improve understanding of JMS, but there remains a lack of knowledge and guidelines on the management of this condition. This review summarizes the current knowledge on JMS, including its epidemiology, clinical presentations, diagnostic challenges, current treatment options, and outcomes. Current treatment options for JMS include disease-modifying therapies, but JMS can also result in impaired quality of life and psychiatric comorbidity, highlighting the need for comprehensive care for affected children. Through gathering and analyzing scattered studies and recent updates on JMS, the authors aim to address the gaps in current knowledge on JMS and provide an improved understanding of appropriate care for affected children. By doing so, this review hopes to contribute to improving the quality of life and outcomes for JMS patients.
Collapse
Affiliation(s)
| | - Marsool M.D.M.
- University of Baghdad, Al-Kindy College of Medicine, Baghdad, Iraq
| | - Balaganesh Natarajan
- St. George’s University School of Medicine, University Centre Grenada, West Indies
| | - Pugazhendi Inban
- Internal Medicine, Government Medical College, Omandurar, Chennai
| | - Srikanth Gadam
- Internal Medicine, Postdoctoral Research Fellow, Mayo Clinic, USA
| | | | - Jobby John
- Somervell Memorial CSI Medical College and Hospital, Karakonam, Trivandrum
| | - Rahim Abbas
- Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan
| | - HariOm Vaja
- Internal Medicine, BJ Medical College, Ahmedabad, India
| | - Marsool A.D.M.
- University of Baghdad, Al-Kindy College of Medicine, Baghdad, Iraq
| | | |
Collapse
|
7
|
Costa GD, Comi G. Teriflunomide: an oral therapy for first-line treatment of children and adolescents living with relapsing-remitting multiple sclerosis. Expert Rev Neurother 2023; 23:681-687. [PMID: 37382446 DOI: 10.1080/14737175.2023.2229953] [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: 05/03/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Different disease-modifying therapies (DMTs) have been developed to slow down the progression of pediatric multiple sclerosis (MS). Teriflunomide is one such DMT that has recently been approved for use in pediatric MS in the European Union. AREAS COVERED The article provides an introduction to the mechanism of action of teriflunomide, reviews the clinical trials conducted on the safety and efficacy of the drug, and the optimal dosing and monitoring strategies. EXPERT OPINION Teriflunomide is an oral medication that has shown promise in improving outcomes for pediatric MS patients, including reduced relapse rates and improved quality of life. However, more research is needed to determine its long-term safety in pediatric patients. As MS often presents with an aggressive course in children, the choice of disease-modifying treatment should be carefully evaluated, with a preference for second-line therapy. Despite the potential benefits of teriflunomide, changes in clinical practice may be hindered by factors such as cost and physician familiarity with alternative treatments. Longer-term studies and biomarker identification are areas for improvement, but the future of research in this area holds promise for the continued development and refinement of disease-modifying therapies and more personalized, targeted treatments for pediatric MS patients.
Collapse
Affiliation(s)
| | - Giancarlo Comi
- Faculy of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Multiple Sclerosis center, Casa di Cura Igea, Milan, Italy
| |
Collapse
|
8
|
Capasso N, Virgilio E, Covelli A, Giovannini B, Foschi M, Montini F, Nasello M, Nilo A, Prestipino E, Schirò G, Sperandei S, Clerico M, Lanzillo R. Aging in multiple sclerosis: from childhood to old age, etiopathogenesis, and unmet needs: a narrative review. Front Neurol 2023; 14:1207617. [PMID: 37332984 PMCID: PMC10272733 DOI: 10.3389/fneur.2023.1207617] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 06/20/2023] Open
Abstract
Multiple sclerosis (MS) primarily affects adult females. However, in the last decades, rising incidence and prevalence have been observed for demographic extremes, such as pediatric-onset MS (POMS; occurring before 18 years of age) and late-onset MS (corresponding to an onset above 50 years). These categories show peculiar clinical-pathogenetic characteristics, aging processes and disease courses, therapeutic options, and unmet needs. Nonetheless, several open questions are still pending. POMS patients display an important contribution of multiple genetic and environmental factors such as EBV, while in LOMS, hormonal changes and pollution may represent disease triggers. In both categories, immunosenescence emerges as a pathogenic driver of the disease, particularly for LOMS. In both populations, patient and caregiver engagement are essential from the diagnosis communication to early treatment of disease-modifying therapy (DMTs), which in the elderly population appears more complex and less proven in terms of efficacy and safety. Digital technologies (e.g., exergames and e-training) have recently emerged with promising results, particularly in treating and following motor and cognitive deficits. However, this offer seems more feasible for POMS, being LOMS less familiar with digital technology. In this narrative review, we discuss how the aging process influences the pathogenesis, disease course, and therapeutic options of both POMS and LOMS. Finally, we evaluate the impact of new digital communication tools, which greatly interest the current and future management of POMS and LOMS patients.
Collapse
Affiliation(s)
- Nicola Capasso
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
| | - Eleonora Virgilio
- Neurology Unit, Department of Translational Medicine, AOU Maggiore della Carità Novara, University of Eastern Piedmont, Novara, Italy
| | - Antonio Covelli
- Department of Neurology, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Beatrice Giovannini
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Foschi
- Department of Neuroscience, MS Center, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy
| | - Federico Montini
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Nasello
- Neurology Unit, Department of Neurosciences, Mental Health and Sensory organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Elio Prestipino
- UOSC Neuro-Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Giuseppe Schirò
- Section of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Silvia Sperandei
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Roberta Lanzillo
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
| |
Collapse
|
9
|
Klotz L, Antel J, Kuhlmann T. Inflammation in multiple sclerosis: consequences for remyelination and disease progression. Nat Rev Neurol 2023; 19:305-320. [PMID: 37059811 DOI: 10.1038/s41582-023-00801-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 04/16/2023]
Abstract
Despite the large number of immunomodulatory or immunosuppressive treatments available to treat relapsing-remitting multiple sclerosis (MS), treatment of the progressive phase of the disease has not yet been achieved. This lack of successful treatment approaches is caused by our poor understanding of the mechanisms driving disease progression. Emerging concepts suggest that a combination of persisting focal and diffuse inflammation within the CNS and a gradual failure of compensatory mechanisms, including remyelination, result in disease progression. Therefore, promotion of remyelination presents a promising intervention approach. However, despite our increasing knowledge regarding the cellular and molecular mechanisms regulating remyelination in animal models, therapeutic increases in remyelination remain an unmet need in MS, which suggests that mechanisms of remyelination and remyelination failure differ fundamentally between humans and demyelinating animal models. New and emerging technologies now allow us to investigate the cellular and molecular mechanisms underlying remyelination failure in human tissue samples in an unprecedented way. The aim of this Review is to summarize our current knowledge regarding mechanisms of remyelination and remyelination failure in MS and in animal models of the disease, identify open questions, challenge existing concepts, and discuss strategies to overcome the translational roadblock in the field of remyelination-promoting therapies.
Collapse
Affiliation(s)
- Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Jack Antel
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Québec, Canada
| | - Tanja Kuhlmann
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Québec, Canada.
- Institute of Neuropathology, University Hospital Münster, Münster, Germany.
| |
Collapse
|
10
|
Güleç ZEK, Uygunoğlu U, Tütüncü M, Saip S, Siva A, Yalçınkaya C. Analysis of determinants of treatment change in adult paediatric-onset MS patients. Mult Scler Relat Disord 2023; 69:104463. [PMID: 36563594 DOI: 10.1016/j.msard.2022.104463] [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: 06/08/2022] [Revised: 08/24/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Paediatric-onset multiple sclerosis (POMS) is increasing worldwide and represents approximately 5% of all MS cases. Although this patient group has similar characteristics to the adult group, it is important for this patient group to receive effective treatment due to the early onset of cognitive involvement, higher lesion burden, and secondary progression at an earlier age than adults. In this study, we aimed to evaluate the factors that cause treatment change in POMS patients. MATERIAL AND METHOD Adult patients with a first MS attack at age 18 years or younger who were followed up with the diagnosis of MS at the Clinical Neuroimmunology and Demyelinating Diseases outpatient clinic of Cerrahpaşa Medical School between 1987 and 2020 were included in our study. Patient files were reviewed retrospectively, and demographic and clinical characteristics, imaging, first attack characteristics, and treatment change were noted. We included 269 patients with a definite diagnosis of MS in the study, and these patients were evaluated in two groups: negative for treatment change and positive for treatment change. RESULTS Multifocal involvement was detected more frequently in the group with treatment change (p = 0,049). Cerebellar involvement as a first attack symptom was more common in male patients (p = 0,023) The age at first MS attack was found to be younger (p = 0,006), and the disease duration was longer in the positive for treatment change group (p = 0,003). Spinal cord involvement was more common in the positive for treatment change group (p = 0,016). Abnormal VEP findings were observed more frequently in the group without treatment change (p = 0.018). In multivariant analysis, spinal cord involvement, younger age at first attack, and abnormal VEP findings in the group without treatment change were found to be significant. Among the reasons for treatment change, the most common reason was radiological and clinical progression. CONCLUSION The higher inflammatory load in POMS patients compared with adults necessitates early initiation of treatment in this group and timely treatment change to prevent disability. Furthermore, this patient group should be followed closely and receive effective treatment.
Collapse
Affiliation(s)
- Zeynep Ece Kaya Güleç
- Department of Neurology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Uğur Uygunoğlu
- Department of Neurology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Melih Tütüncü
- Department of Neurology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sabahattin Saip
- Department of Neurology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aksel Siva
- Department of Neurology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Cengiz Yalçınkaya
- Department of Neurology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| |
Collapse
|
11
|
Shosha E, Burton JM. Discussing the potential for progression with patients newly diagnosed with multiple sclerosis: When, how, and why? Mult Scler Relat Disord 2022; 68:104230. [PMID: 36240704 DOI: 10.1016/j.msard.2022.104230] [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: 04/20/2022] [Revised: 10/02/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022]
Abstract
Despite convergent evidence that upwards of 50% of patients with MS transition from a relapsing to progressive phase within 20 years of disease onset, and the recent acknowledgement of the commonality of progression independent of relapses, there remains no consensus regarding the nature and timing of a discussion about the possibility of a secondary progressive phase with relapsing-remitting MS patients. Some neurologists prefer to conduct this at the inaugural visit to provide more information about disease behaviour and potential planning that might entail, while others may defer any discussion about this phase, as there is no clear consensus for it and it can be a sensitive topic, with concern that too early a discussion could worsen anxiety and discourage or delay decisions regarding disease modifying treatments. Furthermore, it is unknown at onset which patients will transition to a progressive phenotype. This review and opinion paper will outline some of the opportunities and challenges associated with such a disclosure, and attempt to provide a balanced, patient-centred approach to address this delicate topic.
Collapse
Affiliation(s)
- Eslam Shosha
- Neurology division, Department of Medicine, McMaster University, Hamilton Health Science Center, 237 Barton st, E, Room 436, Hamilton, ON L8L 2X2, Canada.
| | - Jodie M Burton
- Department of clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, Canada
| |
Collapse
|
12
|
Machado-Rivas F, Jaimes C, Scherrer B, Benson LA, Gorman MP, Warfield SK, Afacan O. Evaluation of white matter microstructure in pediatric onset multiple sclerosis with diffusion compartment imaging. J Neuroimaging 2022; 32:1098-1108. [PMID: 36036739 DOI: 10.1111/jon.13038] [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: 03/14/2022] [Revised: 07/20/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Pediatric-onset multiple sclerosis (POMS) shows earlier axonal involvement and greater axonal loss than in adults. We aim to characterize the white matter (WM) microstructural changes in POMS using a diffusion compartment imaging (DCI) model and compare it to standard diffusion tensor imaging (DTI). METHODS Eleven patients (2 males, mean age 18.8 ± 3.9 years) with a diagnosis of relapsing and remitting POMS (mean age at disease onset 13.8 ± 2.9 years, mean duration 5.1 ± 1.9 years) and healthy controls (8 males, mean age 26.4 ± 6.5 years) were recruited and imaged at 3 T. A 90-gradient set Cube and Sphere acquisition and a novel DCI model known as DIstribution of Anisotropic MicrOstructural eNvironments with Diffusion-weighted imaging (DIAMOND) were used to calculate a single anisotropic compartment, an isotropic compartment, and a free diffusion compartment. Lesions and contralateral normal-appearing white matter (NAWM) in patients and whole brain WM for controls were labeled. RESULTS Eleven patients and 11 controls were recruited. When comparing lesions and contralateral NAWM in patients using DCI, compartmental axial diffusivity, radial diffusivity (cRD), and mean diffusivity (cMD) were higher in lesions. Conversely, compartmental fractional anisotropy (cFA) and heterogeneity index were lower in lesions. An analysis of DTI equivalents showed the same trends. In whole-brain NAWM of patients compared to controls, cRD and cMD were higher and cFA was lower in patients. CONCLUSION Lesions in POMS can be accurately characterized by a DCI model. Incipient changes in NAWM seen in DCI may not be readily observable by DTI.
Collapse
Affiliation(s)
- Fedel Machado-Rivas
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Camilo Jaimes
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benoit Scherrer
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie A Benson
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark P Gorman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Onur Afacan
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Margoni M, Preziosa P, Rocca MA, Filippi M. Pediatric multiple sclerosis: developments in timely diagnosis and prognostication. Expert Rev Neurother 2022; 22:393-403. [PMID: 35400266 DOI: 10.1080/14737175.2022.2064743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Pediatric-onset (PO) multiple sclerosis (MS) accounts for about 2-10% of the total MS cases. Recently, a greater attention has been given to POMS, with substantial improvements in the understanding of its pathophysiology, in the diagnostic work-up and in the identification of reliable prognosticators associated with long-term disability in these patients. AREAS COVERED This review summarizes the most recent updates regarding the pathophysiology of POMS, the current diagnostic criteria and the clinical, neuroradiological and laboratoristic markers that have been associated with disease progression (i.e. occurrence of a second clinical attack at disease onset and accumulation of disability in definite MS). EXPERT OPINION The study of POMS, where the clinical onset is closer to the biological onset of MS, may contribute to better understand how the different pathological processes impact brain maturation and contribute to disease progression, but also how brain plasticity may counterbalance structural damage accumulation. Although rare, POMS is a severe disease, characterized by a prominent clinical and radiological activity at disease onset and by the accumulation of physical and cognitive disability at a younger age compared to the adult counterpart, with significant detrimental consequences at long-term. Early and accurate diagnosis, together with early treatment, is highly warranted.
Collapse
Affiliation(s)
- Monica Margoni
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Multiple Sclerosis Center of the Veneto Region, Department of Neurosciences, University Hospital - School of Medicine, Padua, Italy
| | - Paolo Preziosa
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria A Rocca
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy.,Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| |
Collapse
|
14
|
Wendel EM, Bertolini A, Kousoulos L, Rauchenzauner M, Schanda K, Wegener-Panzer A, Baumann M, Reindl M, Otto M, Rostásy K. Serum neurofilament light-chain levels in children with monophasic myelin oligodendrocyte glycoprotein-associated disease, multiple sclerosis, and other acquired demyelinating syndrome. Mult Scler 2022; 28:1553-1561. [DOI: 10.1177/13524585221081090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To assess the diagnostic and prognostic potential of serum neurofilament light chain (sNfL) in children with first acquired demyelinating syndrome (ADS). Methods: We selected 129 children with first ADS including 19 children with myelin oligodendrocyte glycoprotein (MOG)-antibody associated disease (MOGAD), 36 MOG/AQP4-seronegative ADS, and 74 with multiple sclerosis (MS) from the BIOMARKER study cohort. All children had a complete set of clinical, radiological, laboratory data and serum for NfL measurement using a highly sensitive digital ELISA (SIMOA). A control group of 35 children with non-inflammatory neurological diseases was included. sNfL levels were compared across patient groups according to clinical, laboratory, neuroradiological features and outcome after 2 years. Results: sNfL levels were significantly increased in MOGAD, seronegative ADS and MS compared to controls ( p-value < 0.001), in particular in children with an acute disseminated encephalomyelitis (ADEM)-like magnetic resonance imaging (MRI) pattern ( p < 0.001) or longitudinally extensive myelitis ( p < 0.01). In pediatric MS, elevated sNfL levels were significantly associated with higher numbers of cerebral ( p < 0.001) and presence of spinal ( p < 0.05) MRI lesions at baseline and predicted a higher number of relapses ( p < 0.05). Conclusion: sNfL levels are significantly elevated in all three studied pediatric ADS subtypes indicating neuroaxonal injury. In pediatric MS high levels of sNfL are associated with risk factors for disease progression.
Collapse
Affiliation(s)
- Eva-Maria Wendel
- Department of Pediatrics, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Annikki Bertolini
- Department of Pediatric Neurology, Children’s Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - Lampros Kousoulos
- Department of Pediatric Neurology, Children’s Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - Markus Rauchenzauner
- Department of Pediatrics and Neonatology, Kliniken Ostallgäu-Kaufbeuren, Kaufbeuren, Germany/Division of Pediatric Neurology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Kathrin Schanda
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Wegener-Panzer
- Department of Pediatric Radiology, Children`s Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| | - Matthias Baumann
- Division of Pediatric Neurology, Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Otto
- Department of Neurology, University Hospital of Ulm, Ulm, Germany; Department of Neurology, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Kevin Rostásy
- Department of Pediatric Neurology, Children’s Hospital Datteln, University Witten/Herdecke, Datteln, Germany
| |
Collapse
|
15
|
Gärtner J, Hauser SL, Bar-Or A, Montalban X, Cohen JA, Cross AH, Deiva K, Ganjgahi H, Häring DA, Li B, Pingili R, Ramanathan K, Su W, Willi R, Kieseier B, Kappos L. Efficacy and safety of ofatumumab in recently diagnosed, treatment-naive patients with multiple sclerosis: Results from ASCLEPIOS I and II. Mult Scler 2022; 28:1562-1575. [PMID: 35266417 PMCID: PMC9315184 DOI: 10.1177/13524585221078825] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: In the phase III ASCLEPIOS I and II trials, participants with relapsing
multiple sclerosis receiving ofatumumab had significantly better clinical
and magnetic resonance imaging (MRI) outcomes than those receiving
teriflunomide. Objectives: To assess the efficacy and safety of ofatumumab versus teriflunomide in
recently diagnosed, treatment-naive (RDTN) participants from ASCLEPIOS. Methods: Participants were randomized to receive ofatumumab (20 mg subcutaneously
every 4 weeks) or teriflunomide (14 mg orally once daily) for up to
30 months. Endpoints analysed post hoc in the protocol-defined RDTN
population included annualized relapse rate (ARR), confirmed disability
worsening (CDW), progression independent of relapse activity (PIRA) and
adverse events. Results: Data were analysed from 615 RDTN participants (ofatumumab:
n = 314; teriflunomide: n = 301). Compared
with teriflunomide, ofatumumab reduced ARR by 50% (rate ratio (95%
confidence interval (CI)): 0.50 (0.33, 0.74);
p < 0.001), and delayed 6-month CDW by 46% (hazard ratio
(HR; 95% CI): 0.54 (0.30, 0.98); p = 0.044) and 6-month
PIRA by 56% (HR: 0.44 (0.20, 1.00); p = 0.049). Safety
findings were manageable and consistent with those of the overall ASCLEPIOS
population. Conclusion: The favourable benefit–risk profile of ofatumumab versus teriflunomide
supports its consideration as a first-line therapy in RDTN patients. ASCLEPIOS I and II are registered at ClinicalTrials.gov (NCT02792218 and
NCT02792231).
Collapse
Affiliation(s)
- Jutta Gärtner
- Department of Paediatrics and Adolescent Medicine, Division of Paediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Göttingen, Germany
| | - Stephen L Hauser
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California - San Francisco, San Francisco, CA, USA
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Xavier Montalban
- Department of Neurology-Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jeffrey A Cohen
- Department of Neurology, Mellen MS Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anne H Cross
- Department of Neurology, Section of Neuroimmunology, Washington University School of Medicine, St Louis, MO, USA
| | - Kumaran Deiva
- Department of Pediatric Neurology, University Hospitals Paris Saclay, Hôpital Bicêtre, National Reference Center for Rare Inflammatory Brain and Spinal Diseases, Le Kremlin-Bicêtre, France
| | - Habib Ganjgahi
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK/Statistics Department, University of Oxford, Oxford, UK
| | | | - Bingbing Li
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Wendy Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB) and MS Center, and Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering, University Hospital of Basel, University of Basel, Basel, Switzerland
| |
Collapse
|
16
|
Margoni M, Villani U, Finos L, Franciotta S, Rubin M, Nosadini M, Sartori S, Anglani MG, Causin F, Perini P, Rinaldi F, Bertoldo A, Gallo P. Neurite orientation dispersion and density imaging discloses early changes in the normal-appearing white matter in paediatric multiple sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:332-334. [PMID: 34272345 DOI: 10.1136/jnnp-2021-326355] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/22/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Monica Margoni
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy .,Padova Neuroscience Centre (PNC), University of Padua, Padua, Italy
| | - Umberto Villani
- Padova Neuroscience Centre (PNC), University of Padua, Padua, Italy.,Department of Information Engineering, University of Padua, Padua, Italy
| | - Livio Finos
- Padova Neuroscience Centre (PNC), University of Padua, Padua, Italy.,Department of Developmental Psychology and Socialisation, University of Padua, Padua, Italy
| | - Silvia Franciotta
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Martina Rubin
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Margherita Nosadini
- Department of Women's and Children's Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padua, Italy.,Neuroimmunology Group, Paediatric Research Institute "Città della Speranza", Padua, Italy
| | - Stefano Sartori
- Department of Women's and Children's Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padua, Italy.,Neuroimmunology Group, Paediatric Research Institute "Città della Speranza", Padua, Italy
| | | | | | - Paola Perini
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Francesca Rinaldi
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy
| | - Alessandra Bertoldo
- Padova Neuroscience Centre (PNC), University of Padua, Padua, Italy.,Department of Information Engineering, University of Padua, Padua, Italy
| | - Paolo Gallo
- Multiple Sclerosis Centre of the Veneto Region (CeSMuV), University Hospital of Padua, Padua, Italy.,Department of Neurosciences, Medical School, University of Padua, Padua, Italy
| |
Collapse
|
17
|
Simone M, Palazzo C, Mastrapasqua M, Bollo L, Pompamea F, Gabellone A, Marzulli L, Giordano P, De Giacomo A, Frigeri A, Ruggieri M, Margari L. Serum Neurofilament Light Chain Levels and Myelin Oligodendrocyte Glycoprotein Antibodies in Pediatric Acquired Demyelinating Syndromes. Front Neurol 2021; 12:754518. [PMID: 34867740 PMCID: PMC8635987 DOI: 10.3389/fneur.2021.754518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/07/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: The relationship between serum neurofilament light chain (sNfL) and myelin oligodendrocyte glycoprotein antibody (MOG-Ab) status has not been yet investigated in children with the acquired demyelinating syndrome (ADS). Objective and Methods: The sNfL levels and MOG-Abs were measured by ultrasensitive single-molecule array and cell-based assay in a cohort of 37 children with ADS and negativity for serum anti-aquaporin 4 (AQP4) antibodies. The sNfL levels were compared in MOG-Ab+/MOG-Ab– and in two subgroups MOG-Ab+ with/without encephalopathy. Results: About 40% ADS resulted in MOG-Ab+. MOG-Ab+ were younger at sampling (median = 9.8; range = 2.17–17.5 vs. 14.7/9–17; p = 0.002) with lower frequency of cerebrospinal fluid oligoclonal bands positivity (27% vs. 70%; p = 0.013) compared to MOG-Ab–. About 53% of MOG-Ab+ presented encephalopathy at onset, 1/22 of MOG-Ab– (p = 0.0006). Higher sNfL levels (p = 0.0001) were found in MOG-Ab+ (median/range = 11.11/6.8–1,129) and MOG-Ab– (median/range = 11.6/4.3–788) compared to age-matched controls (median/range = 2.98/1–4.53), without significant difference. MOG-Ab+ with encephalopathy resulted significantly younger at sampling (median/range: 4.5/2.17–11.17 vs. 14.16/9.8–17.5; p = 0.004), had higher sNfL levels (median/range:75.24/9.1–1,129 vs. 10.22/6.83–50.53; p = 0.04), and showed a trend for higher MOG-Ab titer (0.28/0.04–0.69 vs. 0.05/0.04–0.28; p = 0.1) in comparison to those without encephalopathy. Discussion: We confirmed high sNfL levels in pediatric ADS independently from the MOG-Ab status. Encephalopathy at onset is associated more frequently with MOG Ab+ children with higher sNfL levels and MOG titer. These findings suggest a role of acute demyelination in association with axonal damage in the pathogenesis of encephalopathy in pediatric ADS.
Collapse
Affiliation(s)
- Marta Simone
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Claudia Palazzo
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Mariangela Mastrapasqua
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Luca Bollo
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Francesco Pompamea
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Alessandra Gabellone
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Lucia Marzulli
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Paola Giordano
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Andrea De Giacomo
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Antonio Frigeri
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Maddalena Ruggieri
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Lucia Margari
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| |
Collapse
|
18
|
Bonacchi R, Meani A, Pagani E, Marchesi O, Falini A, Filippi M, Rocca MA. Association of Age at Onset With Gray Matter Volume and White Matter Microstructural Abnormalities in People With Multiple Sclerosis. Neurology 2021; 97:e2007-e2019. [PMID: 34607928 DOI: 10.1212/wnl.0000000000012869] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 08/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate whether age at onset influences brain gray matter volume (GMV) and white matter (WM) microstructural abnormalities in adult patients with multiple sclerosis (MS), given its influence on clinical phenotype and disease course. METHODS In this hypothesis-driven cross-sectional study, we enrolled 67 patients with pediatric-onset MS (POMS) and 143 sex- and disease duration (DD)-matched randomly selected patients with adult-onset MS (AOMS), together with 208 healthy controls. All participants underwent neurologic evaluation and 3T MRI acquisition. MRI variables were standardized based on healthy controls, to remove effects of age and sex. Associations with DD in patients with POMS and patients with AOMS were studied with linear models. Time to reach clinical and MRI milestones was assessed with product-limit approach. RESULTS At DD 1 year, GMV and WM fractional anisotropy (FA) were abnormal in AOMS but not in POMS. Significant interaction of age at onset (POMS vs AOMS) into the association with DD was found for GMV and WM FA. The crossing point of regression lines in POMS and AOMS was at 20 years of DD for GMV and 14 for WM FA. For POMS and AOMS, median DD was 29 and 19 years to reach Expanded Disability Status Scale score 3 (p < 0.001), 31 and 26 years to reach abnormal Paced Auditory Serial Addition Task, 3-second version (p = 0.01), 24 and 18 years to reach abnormal GMV (p = 0.04), and 19 and 17 years to reach abnormal WM FA (p = 0.36). DISCUSSION Younger patients are initially resilient to MS-related damage. Then, compensatory mechanisms start failing with loss of WM integrity, followed by GM atrophy and finally disability.
Collapse
Affiliation(s)
- Raffaello Bonacchi
- From the Neuroimaging Research Unit, Division of Neuroscience (R.B., A.M., E.P., O.M., M.F., M.A.R.), Neurology Unit (R.B., M.F., M.A.R.), Neuroradiology Unit (A.F.), Neurorehabilitation Unit (M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute; and Vita-Salute San Raffaele University (A.F., M.F., M.A.R.), Milan, Italy
| | - Alessandro Meani
- From the Neuroimaging Research Unit, Division of Neuroscience (R.B., A.M., E.P., O.M., M.F., M.A.R.), Neurology Unit (R.B., M.F., M.A.R.), Neuroradiology Unit (A.F.), Neurorehabilitation Unit (M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute; and Vita-Salute San Raffaele University (A.F., M.F., M.A.R.), Milan, Italy
| | - Elisabetta Pagani
- From the Neuroimaging Research Unit, Division of Neuroscience (R.B., A.M., E.P., O.M., M.F., M.A.R.), Neurology Unit (R.B., M.F., M.A.R.), Neuroradiology Unit (A.F.), Neurorehabilitation Unit (M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute; and Vita-Salute San Raffaele University (A.F., M.F., M.A.R.), Milan, Italy
| | - Olga Marchesi
- From the Neuroimaging Research Unit, Division of Neuroscience (R.B., A.M., E.P., O.M., M.F., M.A.R.), Neurology Unit (R.B., M.F., M.A.R.), Neuroradiology Unit (A.F.), Neurorehabilitation Unit (M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute; and Vita-Salute San Raffaele University (A.F., M.F., M.A.R.), Milan, Italy
| | - Andrea Falini
- From the Neuroimaging Research Unit, Division of Neuroscience (R.B., A.M., E.P., O.M., M.F., M.A.R.), Neurology Unit (R.B., M.F., M.A.R.), Neuroradiology Unit (A.F.), Neurorehabilitation Unit (M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute; and Vita-Salute San Raffaele University (A.F., M.F., M.A.R.), Milan, Italy
| | - Massimo Filippi
- From the Neuroimaging Research Unit, Division of Neuroscience (R.B., A.M., E.P., O.M., M.F., M.A.R.), Neurology Unit (R.B., M.F., M.A.R.), Neuroradiology Unit (A.F.), Neurorehabilitation Unit (M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute; and Vita-Salute San Raffaele University (A.F., M.F., M.A.R.), Milan, Italy
| | - Maria A Rocca
- From the Neuroimaging Research Unit, Division of Neuroscience (R.B., A.M., E.P., O.M., M.F., M.A.R.), Neurology Unit (R.B., M.F., M.A.R.), Neuroradiology Unit (A.F.), Neurorehabilitation Unit (M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute; and Vita-Salute San Raffaele University (A.F., M.F., M.A.R.), Milan, Italy.
| |
Collapse
|
19
|
Abstract
Teriflunomide (Aubagio®), which was developed by Sanofi, is an oral immunomodulatory agent targeting the mitochondrial enzyme dihydroorotate dehydrogenase and available to adults to treat relapsing-remitting multiple sclerosis (MS). On 18 June 2021, teriflunomide received its first approval in this indication in pediatric patients aged ≥ 10 years in the EU. This article summarizes the milestones in the development of teriflunomide leading to this first pediatric approval for relapsing-remitting MS.
Collapse
Affiliation(s)
- Julia Paik
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| |
Collapse
|
20
|
Kappos L, Wolinsky JS, Giovannoni G, Arnold DL, Wang Q, Bernasconi C, Model F, Koendgen H, Manfrini M, Belachew S, Hauser SL. Contribution of Relapse-Independent Progression vs Relapse-Associated Worsening to Overall Confirmed Disability Accumulation in Typical Relapsing Multiple Sclerosis in a Pooled Analysis of 2 Randomized Clinical Trials. JAMA Neurol 2021; 77:1132-1140. [PMID: 32511687 PMCID: PMC7281382 DOI: 10.1001/jamaneurol.2020.1568] [Citation(s) in RCA: 286] [Impact Index Per Article: 95.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Question What are the relative contributions of progression independent of relapse activity (PIRA) and relapse-associated worsening (RAW) to overall accumulating disability in patients with relapsing multiple sclerosis? Findings Applying a composite outcome measure to a typical population with active relapsing multiple sclerosis, this pooled analysis of 2 randomized clinical trials shows that the most part of confirmed disability accumulation occurs independently of relapse activity. Distinct prognostic factors were associated with PIRA vs RAW, and ocrelizumab had a beneficial outcome in both. Meaning These findings clearly demonstrate underlying progression in this relapsing multiple sclerosis population and challenge the current clinical distinction of relapsing and progressive forms of multiple sclerosis. Importance Accumulation of disability in multiple sclerosis may occur as relapse-associated worsening (RAW) or steady progression independent of relapse activity (PIRA), with PIRA regarded as a feature of primary and secondary progressive multiple sclerosis. Objective To investigate the contributions of relapse-associated worsening vs relapse-independent progression to overall confirmed disability accumulation (CDA) and assess respective baseline prognostic factors and outcomes of 2 treatments. Design, Setting, and Participants Analyses occurred from July 2015 to February 2020 on pooled data from the intention-to-treat population of 2 identical, phase 3, multicenter, double-blind, double-dummy, parallel-group randomized clinical trials (OPERA I and II) conducted between August 2011 and April 2015. In the trials, patients with relapsing multiple sclerosis (RMS), diagnosed using the 2010 revised McDonald criteria, were randomized from 307 trial sites in 56 countries; resulting data were analyzed in the pooled data set. Interventions Participants were randomized 1:1 to receive 600 mg of ocrelizumab by intravenous infusion every 24 weeks or subcutaneous interferon β-1a 3 times a week at a dose of 44 μg throughout a 96-week treatment period. Main Outcomes and Measures Confirmed disability accumulation was defined by an increase in 1 or more of 3 measures (Expanded Disability Status Scale, timed 25-ft walk, or 9-hole peg test), confirmed after 3 or 6 months, and classified per temporal association with confirmed clinical relapses (PIRA or RAW). Results In the pooled OPERA I and II population (1656 of 2096 eligible participants), baseline demographics and disease characteristics were similar for patients randomized to interferon β-1a vs ocrelizumab (mean [SD] age, 37.2 [9.2] vs 37.1 [9.2] years; 552 [66.6%] vs 541 women [65.4%]). After 96 weeks, 12-week composite CDA had occurred in 223 (29.6% by Kaplan-Meier estimate) randomized to interferon β-1a and 167 (21.1%) randomized to ocrelizumab; 24-week composite CDA had occurred in 170 (22.7%) taking interferon β-1a and 129 (16.2%) taking ocrelizumab. The PIRA events were the main contributors to 12-week and 24-week composite CDA after 96 weeks in patients treated with interferon β-1a (174 of 223 [78.0%] and 137 of 170 [80.6%], respectively) and ocrelizumab (147 of 167 [88.0%] and 115 of 129 [89.1%], respectively); a minority had CDA explained by RAW events (69 of 390 [17.7%] and 52 of 299 [17.4%], respectively). Very few patients with composite CDA experienced both RAW and PIRA events (17 of 390 [4.4%] for 12-week and 15 of 299 [5.0%] for 24-week composite CDA). Ocrelizumab (vs interferon β-1a) was associated with reduced risk of composite CDA (hazard ratio [HR], 0.67) and confirmed PIRA (HR, 0.78) and RAW (HR, 0.47) events. Conclusions and Relevance Most disability accumulation in RMS is not associated with overt relapses. This indicates an underlying progression in this typical RMS population and challenges the current clinical distinction of relapsing and progressive forms of multiple sclerosis. Ocrelizumab was superior to interferon β-1a in preventing both RAW and PIRA. Trial Registration ClinicalTrials.gov Identifiers: OPERA I (NCT01247324) and OPERA II (NCT01412333).
Collapse
Affiliation(s)
- Ludwig Kappos
- University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | | | - Douglas L Arnold
- McGill University, Montreal, Quebec, Canada.,NeuroRx Research, Montreal, Quebec, Canada
| | - Qing Wang
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | | | | | | | - Shibeshih Belachew
- F. Hoffmann-La Roche Ltd, Basel, Switzerland.,Now with Biogen, Cambridge, Massachusetts
| | - Stephen L Hauser
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco
| |
Collapse
|
21
|
Palavra F, Figueiroa S, Correia AS, Tapadinhas F, Cerqueira J, Guerreiro RP, de Sá J, Sá MJ, Almeida S, Mota P, Sousa L. TyPed study: Natalizumab for the treatment of pediatric-onset multiple sclerosis in Portugal. Mult Scler Relat Disord 2021; 51:102865. [PMID: 33714125 DOI: 10.1016/j.msard.2021.102865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/08/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A significant proportion of pediatric-onset multiple sclerosis (POMS) patients do not respond to first-line disease-modifying therapies. Clinical trials showed that natalizumab is effective and safe in adults, but there are limited clinical trial data for children. Natalizumab is currently prescribed off-label for POMS. We aimed to characterize the effectiveness, safety and tolerability of natalizumab in all POMS cases treated in Portugal (from 2007 to 2018). METHODS Data from clinical records were retrospectively collected for all POMS cases treated with natalizumab in Portugal. RESULTS Twenty-one patients were included, 14 (67%) of which were female. The median age at POMS diagnosis was 13 years old. The median duration of treatment with natalizumab was 2 years and 3 months. Median Expanded Disability Status Scale score decreased from 1.5 to 1.0 after 24 months. The Annualized Relapse Rate decreased from 1.31 events/patient/year before treatment with natalizumab to 0 after 12 months of treatment and to 0.04 after 24 months. No gadolinium-enhancing lesions or new or enlarged T2 hyperintense lesions were observed in 8/8 patients (100%) after 12 months, and 4/5 (80%) after 24 months. There was one possible serious adverse event, which did not require dose adjustment. Five patients discontinued treatment due to positive anti-JCV (JC virus) antibody JC serostatus. CONCLUSION Natalizumab may be an effective and safe disease-modifying therapy for POMS. Our results are in line with data published for the adult population, as well as with similar observational studies in pediatric populations in other regions.
Collapse
Affiliation(s)
- Filipe Palavra
- Centre for Child Development - Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra; Laboratory of Pharmacology and Experimental Therapeutics, Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | - Sónia Figueiroa
- Neuropediatrics Unit, Centro Materno-Infantil do Norte, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Ana Sofia Correia
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental; CEDOC, Nova Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Fernando Tapadinhas
- Department of Pediatrics, Hospital de Faro, Centro Hospitalar e Universitário do Algarve, Faro, Portugal
| | - João Cerqueira
- Department of Neurology, Hospital de Braga; 2CA - Clinical Academic Centre Braga; School of Medicine, University of Minho, Braga, Portugal
| | - Rui Pedro Guerreiro
- Department of Neurology, Hospital de São Bernardo, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - João de Sá
- Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Maria José Sá
- Department of Neurology, Centro Hospitalar e Universitário de São João; Faculty of Health Sciences, University Fernando Pessoa, Porto, Portugal
| | | | | | - Lívia Sousa
- Department of Neurology, Centro Hospitalar e Universitário de Coimbra; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| |
Collapse
|
22
|
Fadda G, Armangue T, Hacohen Y, Chitnis T, Banwell B. Paediatric multiple sclerosis and antibody-associated demyelination: clinical, imaging, and biological considerations for diagnosis and care. Lancet Neurol 2021; 20:136-149. [PMID: 33484648 DOI: 10.1016/s1474-4422(20)30432-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/28/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
The field of acquired CNS neuroimmune demyelination in children is transforming. Progress in assay development, refinement of diagnostic criteria, increased biological insights provided by advanced neuroimaging techniques, and high-level evidence for the therapeutic efficacy of biological agents are redefining diagnosis and care. Three distinct neuroimmune conditions-multiple sclerosis, myelin-oligodendrocyte glycoprotein antibody-associated disease (MOGAD), and aquaporin-4 antibody-associated neuromyelitis optica spectrum disorder (AQP4-NMOSD)-can now be distinguished, with evidence from humans and animal models supporting distinct pathobiological disease mechanisms. The development of highly effective therapies for adult-onset multiple sclerosis and AQP4-NMOSD that suppress relapse rate by more than 90% has motivated advocacy for trials in children. However, doing clinical trials is challenging because of the rarity of these conditions in the paediatric age group, necessitating new approaches to trial design, including age-based trajectory modelling based on phase 3 studies in adults. Despite these limitations, the future for children and adolescents living with multiple sclerosis, MOGAD, or AQP4-NMOSD is far brighter than in years past, and will be brighter still if successful therapies to promote remyelination, enhance neuroprotection, and remediate cognitive deficits can be further accelerated.
Collapse
Affiliation(s)
- Giulia Fadda
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Thais Armangue
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Spain; Pediatric Neuroimmunology Unit, Neurology Department, Sant Joan de Déu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Yael Hacohen
- Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK; Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - Tanuja Chitnis
- Department of Neurology, Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital, Boston, MA, USA
| | - Brenda Banwell
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| |
Collapse
|
23
|
Jäckle K, Zeis T, Schaeren-Wiemers N, Junker A, van der Meer F, Kramann N, Stadelmann C, Brück W. Molecular signature of slowly expanding lesions in progressive multiple sclerosis. Brain 2020; 143:2073-2088. [PMID: 32577755 DOI: 10.1093/brain/awaa158] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/04/2020] [Accepted: 03/30/2020] [Indexed: 01/08/2023] Open
Abstract
Multiple sclerosis is an immune-mediated chronic inflammatory disease of the CNS that leads to demyelinated lesions in the grey and white matter. Inflammatory, active demyelinating white matter lesions predominate in the relapsing-remitting disease stages, whereas in the progressive stage the so-called slowly expanding lesion is characteristic. These lesions show an accumulation of macrophages/microglia at their borders, mediating the ongoing myelin breakdown and axonal degeneration. The exact pathogenetic mechanisms of lesion progression in chronic multiple sclerosis are still not clear. In the present study, we performed a detailed immunological and molecular profiling of slowly expanding lesions (n = 21) from 13 patients aged between 30 to 74 years (five females and eight males), focusing on macrophage/microglia differentiation. By applying the microglia-specific marker TMEM119, we demonstrate that cells accumulating at the lesion edge almost exclusively belonged to the microglia lineage. Macrophages/microglia can be subdivided into the M1 type, which are associated with inflammatory and degenerative processes, and M2 type, with protective properties, whereby also intermediate polarization phenotypes can be observed. By using a panel of markers characterizing M1- or M2-type macrophages/microglia, we observed a preferential accumulation of M1-type differentiated cells at the lesion edge, indicating a crucial role of these cells in lesion progression. Additionally, unbiased RNA microarray analyses of macrodissected lesion edges from slowly expanding and chronic inactive lesions as well as normal-appearing white matter were performed. In slowly expanding lesions, we identified a total of 165 genes that were upregulated and 35 genes that were downregulated. The upregulated genes included macrophage/microglia-associated genes involved in immune defence and inflammatory processes. Among the upregulated genes were ALOX15B, MME and TNFRSF25. We confirmed increased expression of ALOX15B by quantitative PCR, and of all three genes on the protein level by immunohistochemistry. In conclusion, the present study characterized in detail slowly expanding lesions in progressive multiple sclerosis and demonstrated a preferential accumulation of resident microglia with M1 differentiation at the lesion edge. Microarray analysis showed an increased expression of genes related to immune function, metabolic processes as well as transcription/translation. Thus, these genes may serve as future therapeutic targets to impede lesion progression.
Collapse
Affiliation(s)
- Katharina Jäckle
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas Zeis
- Neurobiology, Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicole Schaeren-Wiemers
- Neurobiology, Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Junker
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Neuropathology, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
| | | | - Nadine Kramann
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Christine Stadelmann
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| |
Collapse
|
24
|
Paediatric onset of multiple sclerosis: Analysis of chemokine and cytokine levels in the context of the early clinical course. Mult Scler Relat Disord 2020; 46:102467. [PMID: 32889374 DOI: 10.1016/j.msard.2020.102467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/19/2020] [Accepted: 08/23/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Inflammatory activity in children with paediatric onset multiple sclerosis (POMS) is higher than that in adults with MS. Chemokine/cytokine profiling in children may provide new insights into the disease pathogenesis and clinical course. The levels of chemokines/cytokines and their roles in POMS remain largely unknown. OBJECTIVE To identify the possible utility of chemokines/cytokines in children with POMS, we analysed their levels at the time of disease diagnosis and in the context of subsequent clinical relapse. METHODS CC and CXC motif ligand chemokines (CCL2, CXCL8, CXCL10, and CXCL13), interleukin (IL)-4, IL-17A, interferon gamma and B cell-activating factor in the blood and cerebrospinal fluid (CSF) of 34 POMS patients and 20 age-related controls were measured using Luminex multiplex bead and enzyme-linked immunosorbent assay techniques. Nonparametric tests were used for statistical analyses. RESULTS The CSF levels of CXCL8 (p = 0.002), CXCL10 (p = 0.001), and CXCL13 (p<0.0001) were higher in POMS than in controls; CXCL10 and CXCL13 correlated with pleocytosis and oligoclonal bands. A subsequent clinical relapse occurred in 17/34 of the children; the median time from the diagnosis of POMS was 6 months (range, 2-64 months). The follow-up period of patients who did not experience a clinical relapse was significantly longer than the time to first relapse (p = 0.003). The initial CCL2 level was lower in relapsing than in non-relapsing patients (p = 0.063) and correlated negatively with the CSF/serum albumin ratio and positively with the time to relapse (p<0.04). CONCLUSIONS Elevated CSF levels of CXL10 and CXCL13 in children with POMS at the time of disease diagnosis reflect inflammatory activity and suggest the involvement of adaptive immunity; elevated CXCL8 levels further indicate the involvement of innate immunity. An initial low CSF level of CCL2 may be associated with an unfavourable early MS course.
Collapse
|
25
|
Reinert MC, Benkert P, Wuerfel J, Michalak Z, Ruberte E, Barro C, Huppke P, Stark W, Kropshofer H, Tomic D, Leppert D, Kuhle J, Brück W, Gärtner J. Serum neurofilament light chain is a useful biomarker in pediatric multiple sclerosis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/4/e749. [PMID: 32404429 PMCID: PMC7238898 DOI: 10.1212/nxi.0000000000000749] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 04/09/2020] [Indexed: 12/13/2022]
Abstract
Objective To investigate serum neurofilament light chain (sNfL) as a potential biomarker for disease activity and treatment response in pediatric patients with multiple sclerosis (MS). Methods In this retrospective cohort study, sNfL levels were measured in a pediatric MS cohort (n = 55, follow-up 12–105 months) and in a non-neurologic pediatric control cohort (n = 301) using a high-sensitivity single-molecule array assay. Association of sNfL levels and treatment and clinical and MRI parameters were calculated. Results Untreated patients had higher sNfL levels than controls (median 19.0 vs 4.6 pg/mL; CI [4.732, 6.911]), p < 0.001). sNfL levels were significantly associated with MRI activity (+9.1% per contrast-enhancing lesion, CI [1.045, 1.138], p < 0.001; +0.6% per T2-weighted lesion, CI [1.001, 1.010], p = 0.015). Higher values were associated with a relapse <90 days ago (+51.1%; CI [1.184, 1.929], p < 0.001) and a higher Expanded Disability Status Scale score (CI [1.001, 1.240], p = 0.048). In patients treated with interferon beta-1a/b (n = 27), sNfL levels declined from 14.7 to 7.9 pg/mL after 6 ± 2 months (CI [0.339, 0.603], p < 0.001). Patients with insufficient control of clinical or MRI disease activity under treatment with interferon beta-1a/b or glatiramer acetate who switched to fingolimod (n = 18) showed a reduction of sNfL levels from 16.5 to 10.0 pg/mL 6 ± 2 months after switch (CI [0.481, 0.701], p < 0.001). Conclusions sNfL is a useful biomarker for monitoring disease activity and treatment response in pediatric MS. It is most likely helpful to predict disease severity and to guide treatment decisions in patients with pediatric MS. This study provides Class III evidence that sNfL levels are associated with disease activity in pediatric MS.
Collapse
Affiliation(s)
- Marie-Christine Reinert
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany.
| | - Pascal Benkert
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Jens Wuerfel
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Zuzanna Michalak
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Esther Ruberte
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Christian Barro
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Peter Huppke
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Wiebke Stark
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Harald Kropshofer
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Davorka Tomic
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - David Leppert
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Jens Kuhle
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Wolfgang Brück
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| | - Jutta Gärtner
- From the Department of Pediatrics and Adolescent Medicine (M.-C.R., P.H., W.S., J.G.), Division of Pediatric Neurology, University Medical Centre Göttingen, Georg August University Göttingen, Germany; Clinical Trial Unit (P.B.), Department of Clinical Research, University Hospital Basel, University of Basel; Medical Image Analysis Centre Basel (MIAC AG) (J.W., E.R.); Department of Biomedical Engineering (J.W.), University Basel; Neurologic Clinic and Policlinic (Z.M., C.B., D.L., J.K.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel; Novartis Pharma AG (H.K., D.T.), Basel, Switzerland; and Institute of Neuropathology (W.B.), University Medical Centre Göttingen, Georg August University Göttingen, Germany
| |
Collapse
|
26
|
Kopp TI, Blinkenberg M, Petersen T, Sorensen PS, Magyari M. Long term effect of delayed treatment on disability in patients with paediatric onset multiple sclerosis: A prospective Danish cohort study. Mult Scler Relat Disord 2020; 40:101956. [DOI: 10.1016/j.msard.2020.101956] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/20/2019] [Accepted: 01/17/2020] [Indexed: 01/03/2023]
|
27
|
Deiva K, Huppke P, Banwell B, Chitnis T, Gärtner J, Krupp L, Waubant E, Stites T, Pearce GL, Merschhemke M. Consistent control of disease activity with fingolimod versus IFN β-1a in paediatric-onset multiple sclerosis: further insights from PARADIG MS. J Neurol Neurosurg Psychiatry 2020; 91:58-66. [PMID: 31467033 PMCID: PMC6952840 DOI: 10.1136/jnnp-2019-321124] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND In PARADIGMS, a double-blind phase III trial in 215 paediatric patients with multiple sclerosis (MS) (10 to <18 years), fingolimod administered for up to 2 years significantly reduced the annualised relapse rate (ARR) and rate of new/newly enlarged T2 (n/neT2) lesions compared with interferon (IFN) β-1a. OBJECTIVES To investigate (1) differences between treatment groups across subpopulations (treatment-naïve, younger/prepubertal patients); (2) disability progression. METHODS ARRs at 10, 11 and 12 years were estimated based on predefined modelling extrapolations. Changes in Expanded Disability Status Scale (EDSS), and in 3 month (3M) and 6 month (6M) confirmed disability progression (CDP) were evaluated post hoc. RESULTS In the treatment-naïve subpopulation, fingolimod reduced ARR and n/neT2 lesions by 85.8% and 53.4%, respectively versus INF β-1a (both p<0.001), compared with 81.9% and 52.6% in the overall population. Model-based ARR reductions in younger patients (≤12 years) were 91.9%-94.6%. Twice as many IFN β-1a-treated than fingolimod-treated patients had worse EDSS scores at study end (20.6% vs 10.5%, p=0.043). Risk reductions in 3M-CDP and 6M-CDP were 77.2% (p=0.007) and 80.2% (p=0.040), respectively. CONCLUSIONS Fingolimod in paediatric MS was associated with consistent control of disease activity versus IFN β-1a (including treatment-naïve and younger patients) and resulted in less disability progression for up to 2 years. TRIAL REGISTRATION NUMBER NCT01892722.
Collapse
Affiliation(s)
- Kumaran Deiva
- Department of Pediatric Neurology, National Referral Center for Rare Inflammatory Brain and Spinal Diseases, Hopitaux Universitaires Paris-Sud, Le Kremlin-Bicetre, France .,Immunology of Viral Infections and Autoimmune Diseases, Universite Paris 11 Faculte de Medecine, Le Kremlin-Bicetre, France
| | - Peter Huppke
- Department of Pediatrics and Adolescent Medicine, German Center for Multiple Sclerosis in Childhood and Adolescence, University Medical Center Göttingen, Gottingen, Germany
| | - Brenda Banwell
- Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jutta Gärtner
- Department of Pediatrics and Adolescent Medicine, German Center for Multiple Sclerosis in Childhood and Adolescence, University Medical Center Göttingen, Gottingen, Germany
| | - Lauren Krupp
- Pediatric MS Center, NYU Langone Health, New York City, New York, USA
| | - Emmanuelle Waubant
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Tracy Stites
- Neuroscience Department, Novartis Pharmaceuticals Corp, East Hanover, New Jersey, USA
| | | | | |
Collapse
|
28
|
Ghezzi A, Chitnis T, K-Laflamme A, Meinert R, Häring DA, Pohl D. Long-Term Effect of Immediate Versus Delayed Fingolimod Treatment in Young Adult Patients with Relapsing-Remitting Multiple Sclerosis: Pooled Analysis from the FREEDOMS/FREEDOMS II Trials. Neurol Ther 2019; 8:461-475. [PMID: 31325110 PMCID: PMC6858894 DOI: 10.1007/s40120-019-0146-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Fingolimod has demonstrated clinical and MRI benefits versus placebo/interferon β-1a in young adults with multiple sclerosis (MS). Here we report the long-term effects of fingolimod 0.5 mg on clinical and MRI outcomes in young adults with MS aged ≤ 30 years followed up for up to 8 years (96 months). METHODS This post hoc analysis of pooled FREEDOMS/FREEDOMS II studies included patients who either received fingolimod 0.5 mg from randomization (immediate; N = 163) or switched from placebo to fingolimod at month (M) 24 (delayed; N = 147). The 6-month confirmed disability improvement [6m-CDI: based on Expanded Disability Status Scale (EDSS)], 6m-CDI-plus (6m-CDI+; EDSS, 9-Hole Peg Test, Timed 25-Foot Walk Test), 6-month confirmed disability progression (6m-CDP), time to EDSS score ≥ 4, annualized relapse rates (ARRs), new/newly enlarging T2 (neT2) lesions, and annual rate of brain volume loss (BVL) were analyzed from baseline to M24, M48, and M96. Cox regression and negative binomial regression models were used to analyze measured outcomes. RESULTS At baseline, more than two-thirds of young adult patients were treatment naïve, had more than two relapses in the previous 2 years, and EDSS score < 2. From M0 to M96, a significantly higher proportion of young adult patients in the immediate group (vs. delayed group) achieved 6m-CDI (58.2% vs. 30.5%, p = 0.0206) and 6m-CDI+ (70.6% vs. 42.3%, p = 0.0149); significantly fewer patients reached 6m-CDP (20.1% vs. 34.7%, p = 0.0058) and EDSS ≥ 4 (24.1% vs. 34.1%, p = 0.0041). Up to M96, young adults in the immediate versus delayed group had lower ARRs (0.16 vs. 0.38, p < 0.0001) and a higher proportion of patients were free of neT2 lesions at M48 (31.0% vs. 5.0%, p = 0.0011). CONCLUSION In young adult patients with MS, immediate versus delayed fingolimod treatment was associated with improved disease outcomes and greater long-term benefits in both disease activity and disability progression. FUNDING Novartis Pharma AG.
Collapse
Affiliation(s)
| | - Tanuja Chitnis
- Partners Pediatric Multiple Sclerosis Centre, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Daniela Pohl
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| |
Collapse
|
29
|
An J, Yin JJ, He Y, Sui RX, Miao Q, Wang Q, Yu JZ, Yu JW, Shi FD, Ma CG, Xiao BG. Temporal and Spatial Dynamics of Astroglial Reaction and Immune Response in Cuprizone-Induced Demyelination. Neurotox Res 2019; 37:587-601. [DOI: 10.1007/s12640-019-00129-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/03/2019] [Accepted: 10/25/2019] [Indexed: 12/14/2022]
|
30
|
Abstract
PURPOSE OF REVIEW With the recognition that pediatric-onset multiple sclerosis (POMS) is characterized by more prominent disease activity, earlier age at onset of disability milestones, and more prominent cognitive impairment compared with physical disability earlier in the disease course compared with adult-onset multiple sclerosis (AOMS), there has been increasing interest in identifying optimal and safe treatment approaches to achieve better disease control in this group. Injectable therapies have been traditionally used as first line in this population, although not formally approved. This review focuses on current treatment and monitoring approaches in POMS. RECENT FINDINGS In the past few years, and despite the paucity of FDA-approved medications for use in POMS, an increasing trend toward using newer disease-modifying therapies (DMTs) in this group is observed. However, escalation (as opposed to induction) remains the most frequent approach, and many children continue to be untreated before age 18, particularly before age 12. The only FDA- and EMA-approved disease-modifying therapy in POMS is fingolimod; however, dimethyl fumarate, teriflunomide, natalizumab, ocrelizumab, and alemtuzumab either have been evaluated in observational studies or are being currently investigated in formal randomized controlled trials for use in POMS and appear to be safe in this group. Autologous hematopoietic stem cell transplantation has also been evaluated in a small series. Clinical outcome measures and MS biomarkers have been poorly studied in POMS; however, the use of composite functional scores, neurofilament light chain, optical coherence tomography, and imaging findings is being increasingly investigated to improve early diagnosis and efficient monitoring of POMS. Off-label use of newer DMTs in POMS is increasing, and based on retrospective data, and phase 2 trials, this approach appears to be safe in children. Results from ongoing trials will help clarify the safety and efficacy of these therapies in the future. Fingolimod is the only FDA-approved medication for use in POMS. Outcome measures and biomarkers used in AOMS are being studied in POMS and are greatly needed to quantify treatment response in this group.
Collapse
|
31
|
McKay KA, Manouchehrinia A, Berrigan L, Fisk JD, Olsson T, Hillert J. Long-term Cognitive Outcomes in Patients With Pediatric-Onset vs Adult-Onset Multiple Sclerosis. JAMA Neurol 2019; 76:1028-1034. [PMID: 31206130 DOI: 10.1001/jamaneurol.2019.1546] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance Cognitive impairment in multiple sclerosis (MS) can lead to reduced quality of life, social functioning, and employment. Few studies have investigated cognitive outcomes among patients with pediatric-onset MS (POMS) over the long term. Objective To compare long-term information-processing efficiency between patients with POMS and adult-onset MS (AOMS). Design, Setting, and Participants This population-based longitudinal cohort study accessed the Swedish MS Registry (SMSreg), which collates information from all 64 neurology clinics in Sweden. Registered cases with definite MS in the SMSreg with an onset before April 15, 2018, and at least 2 Symbol Digit Modalities Test (SDMT) scores recorded were included. Only persons aged 18 to 55 years and with duration of disease of less than 30 years at the time of SDMT administration were included, to ensure comparable ranges between patients with POMS and AOMS. Of 8247 persons with an SDMT recorded in the SMSreg, 5704 met inclusion criteria, 300 (5.3%) of whom had POMS. Data were collected from April 1, 2006, through April 15, 2018 and analyzed from April through August 2018. Exposures Pediatric-onset MS (onset <18 years of age) vs AOMS (onset ≥18 years of age). Main Outcomes and Measures Information-processing efficiency measured every 6 or 12 months by the SDMT. Linear mixed-effects models were used to compare all available SDMT scores between patients with POMS and those with AOMS. Persons with cognitive impairment (ever vs never) were identified using regression-based norms and compared between POMS and AOMS groups using logistic regression. Results Of the 5704 participants, 4015 were female (70.4%), and 5569 had a relapsing-onset disease course (97.6%). Most participants were exposed to a disease-modifying therapy (DMT) during follow-up (98.8%). Median age at baseline for the POMS group was 25.6 years (interquartile range, 21.0-31.7 years) and for the AOMS group, 38.3 years (interquartile range, 31.4-45.2 years). A total of 46 429 unique SDMT scores were analyzed. After adjustment for sex, age, disease duration, disease course, total number of SDMTs completed, oral or visual SDMT form, and DMT exposure, the SDMT score for patients with POMS was significantly lower than that of patients with AOMS (β coefficient, -3.59 [95% CI, -5.56 to -1.54]). The SDMT score for patients with POMS declined faster than that of patients with AOMS (β coefficient, -0.30 [95% CI, -0.42 tp -0.17]). The odds of cognitive impairment were also significantly elevated in the POMS group (odds ratio, 1.44; 95% CI, 1.06-1.98). Conclusions and Relevance In adulthood, patients with POMS demonstrated a more rapid reduction in information-processing efficiency over time and were more likely to experience cognitive impairment than patients with AOMS, independent of age or disease duration. Further investigation is required to understand the mechanisms by which early MS onset influences cognitive outcomes.
Collapse
Affiliation(s)
- Kyla A McKay
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ali Manouchehrinia
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Centre for Molecular Medicine, Karolinska Hospital, Stockholm, Sweden
| | - Lindsay Berrigan
- Department of Psychology, St Francis Xavier University, Antigonish, Nova Scotia, Canada.,Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John D Fisk
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Centre for Molecular Medicine, Karolinska Hospital, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Centre for Molecular Medicine, Karolinska Hospital, Stockholm, Sweden
| |
Collapse
|
32
|
Hebert D, Geisthardt C, Hoffman H. Insights and Recommendations From Parents Receiving a Diagnosis of Pediatric Multiple Sclerosis for Their Child. J Child Neurol 2019; 34:464-471. [PMID: 31012369 DOI: 10.1177/0883073819842420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Forty-two parents of 41 children reported on their experiences receiving a diagnosis of pediatric-onset multiple sclerosis for their child through semistructured phone interviews. Time to diagnosis ranged from 8 hours to 16 years, with the mean age at diagnosis of 13.7 years. The most common initial symptoms included visual disturbances and numbness. The mean number of medical visits to receive a diagnosis was 3.6. Parents reported feeling frustrated and overwhelmed during the diagnosis process, as well as shocked when told their child had multiple sclerosis. Parents emphasized the need for more awareness of pediatric-onset multiple sclerosis. Numerous parents reported encountering physicians who believed multiple sclerosis did not occur in childhood, contributing to a longer time to diagnosis. Parents preferred physicians first share the diagnosis with the parents without the child present. Finally, parents appreciated when physicians provided a variety of resources to help them cope with the diagnosis.
Collapse
Affiliation(s)
- Danielle Hebert
- 1 Central Michigan University College of Medicine, Mount Pleasant, MI, USA
| | - Cheryl Geisthardt
- 2 College of Education and Human Services, Central Michigan University, Mount Pleasant, MI, USA
| | - Holly Hoffman
- 2 College of Education and Human Services, Central Michigan University, Mount Pleasant, MI, USA
| |
Collapse
|
33
|
|
34
|
Rensel M. Long-Term Treatment Strategies of Pediatric Multiple Sclerosis, Including the use of Disease Modifying Therapies. CHILDREN-BASEL 2019; 6:children6060073. [PMID: 31159312 PMCID: PMC6617229 DOI: 10.3390/children6060073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/02/2019] [Accepted: 05/14/2019] [Indexed: 01/20/2023]
Abstract
Multiple sclerosis (MS) presenting in the pediatric years can lead to landmark disability levels younger in life than adult onset MS and so therefore early and effective treatment remains paramount for long-term outcomes. The goals of MS therapeutics in adults have widened to address multiple mechanisms: anti-inflammatory, neuroprotective, and myelin repair, yet the optimal paradigm for MS therapies in the pediatric population is not known. Pediatric onset MS add complexities due to the ongoing development of the central nervous system and the immune system. Clinical trials have led to an increasing number of pharmaceutical therapies for adult onset MS (AOMS), one POMS randomized controlled trial is completed and other trials are ongoing, yet due to the low prevalence of POMS, the dynamic landscape and risk management of the MS disease modifying therapies (DMT) it remains more difficult to complete trials in POMS. There is consensus that controlled clinical trials leading to appropriate and safe therapies for POMS are important for a multitude of reasons that include unique pediatric pharmacokinetics, short and long-term safety, developmental issues, clinical benefits, and regulatory approval. This review will focus on new treatment goals, paradigm, strategies, monitoring, compliance, and products in the long-term treatment of POMS. The discussion will focus on these new concepts and the published data related to DMT use in POMS. This review provides significant insight into new concepts of treatment goals and current approaches to enhance the lives of the POMS patients now and in the future.
Collapse
Affiliation(s)
- Mary Rensel
- The Mellen Center, Department of Neurology, Cleveland Clinic, Cleveland, OH 44195, USA.
| |
Collapse
|
35
|
McKay KA, Hillert J, Manouchehrinia A. Long-term disability progression of pediatric-onset multiple sclerosis. Neurology 2019; 92:e2764-e2773. [PMID: 31092624 PMCID: PMC6598792 DOI: 10.1212/wnl.0000000000007647] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/05/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To evaluate long-term disability progression in pediatric-onset multiple sclerosis (POMS) and compare to adult-onset multiple sclerosis (AOMS). METHODS This was a retrospective cohort study using prospectively collected clinical information from the Swedish MS Registry. Clinical features were compared and Kaplan-Meier and Cox proportional hazards regression were used to assess the risk of reaching sustained Expanded Disability Status Scale (EDSS) 3, 4, and 6 in POMS (multiple sclerosis [MS] onset <18 years) and AOMS (MS onset ≥18 years). RESULTS A total of 12,482 persons were included; 549 (4.4%) were classified as POMS. The POMS cohort took longer to reach all 3 disability milestones from their MS onset, but did so at a younger age than the AOMS cohort. Primary progressive course (hazard ratio [HR] 4.63; 95% confidence interval [CI] 1.46-14.7), higher relapse rate in the first 5 years of disease (HR 5.35; 95% CI 3.37-8.49), and complete remission from the initial relapse (HR 0.41; 95% CI 0.18-0.94) were associated with an altered risk of progression to EDSS 4 among POMS cases. The same pattern emerged for the risk of reaching EDSS 3 and 6. CONCLUSIONS Patients with pediatric-onset MS follow a distinctive clinical course, which should be considered in the treatment and management of the disease.
Collapse
Affiliation(s)
- Kyla A McKay
- From the Department of Clinical Neuroscience (K.A.M., J.H., A.M.), Karolinska Institutet; and Centre for Molecular Medicine (A.M.), Karolinska Hospital, Stockholm, Sweden
| | - Jan Hillert
- From the Department of Clinical Neuroscience (K.A.M., J.H., A.M.), Karolinska Institutet; and Centre for Molecular Medicine (A.M.), Karolinska Hospital, Stockholm, Sweden
| | - Ali Manouchehrinia
- From the Department of Clinical Neuroscience (K.A.M., J.H., A.M.), Karolinska Institutet; and Centre for Molecular Medicine (A.M.), Karolinska Hospital, Stockholm, Sweden.
| |
Collapse
|
36
|
Waubant E, Banwell B, Wassmer E, Sormani MP, Amato MP, Hintzen R, Krupp L, Rostásy K, Tenembaum S, Chitnis T. Clinical trials of disease-modifying agents in pediatric MS: Opportunities, challenges, and recommendations from the IPMSSG. Neurology 2019; 92:e2538-e2549. [PMID: 31043474 PMCID: PMC6556085 DOI: 10.1212/wnl.0000000000007572] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/31/2019] [Indexed: 11/17/2022] Open
Abstract
Objective The impetus for this consensus discussion was to recommend clinical trial designs that can deliver high-quality data for effective therapies for pediatric patients, in a reasonable timeframe, with a key focus on short- and long-term safety. Methods The International Pediatric Multiple Sclerosis Study Group convened a meeting of experts to review the advances in the understanding of pediatric-onset multiple sclerosis (MS) and the advent of clinical trials for this population. Results In the last few years, convincing evidence has emerged that the biological processes involved in MS are largely shared across the age span. As such, treatments proven efficacious for the care of adults with MS have a biological rationale for use in pediatric MS given the relapsing-remitting course at onset and high relapse frequency. There are also ethical considerations on conducting clinical trials in this age group including the use of placebo owing to highly active disease. It is imperative to reconsider study design and implementation based on what information is needed. Are studies needed for efficacy or should safety be the primary goal? Further, there have been major recruitment challenges in recently completed and ongoing pediatric MS trials. Phase 3 trials for every newly approved therapy for adult MS in the pediatric MS population are simply not feasible. Conclusions A primary goal is to ensure high-quality evidence-based treatment for children and adolescents with MS, which will improve our understanding of the safety of these agents and remove regulatory or insurance-based limitations in access to treatment.
Collapse
Affiliation(s)
- Emmanuelle Waubant
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston.
| | - Brenda Banwell
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Evangeline Wassmer
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Maria-Pia Sormani
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Maria-Pia Amato
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Rogier Hintzen
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Lauren Krupp
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Kevin Rostásy
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Silvia Tenembaum
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | - Tanuja Chitnis
- From the UCSF MS Center (E.W.), San Francisco, CA; The Children's Hospital of Philadelphia (B.B.), Perelman School of Medicine, University of Pennsylvania; Birmingham Children's Hospital (E.W.), UK; Department of Health Sciences (M.-P. S.), University of Genova and Ospedale Policlinico San Martino IRCCS; Department NEUROFARBA (M.-P.A.), University of Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi (M.-P.A.), Florence, Italy; Department of Neurology (R.H.), Erasmus MC, Rotterdam, the Netherlands; MS Comprehensive Care Center at NYU Langone (L.K.), New York, NY; Division of Paediatric Neurology (K.R.), Children's Hospital Datteln, University Witten/Herdecke, Datteln, Germany; Pediatric MS Center (S.T.), Department of Neurology, National Pediatric Hospital Dr. Garrahan, Buenos Aires, Argentina; and Partners Pediatric MS Center (T.C.), Massachusetts General Hospital, Boston
| | | |
Collapse
|
37
|
Sa M, Green L, Abdel-Mannan O, Chong WKK, Jacques T, Clarke A, Childs AM, Lim M, Hemingway C, Hacohen Y. Is chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) in children the same condition as in adults? Dev Med Child Neurol 2019; 61:490-496. [PMID: 30146710 DOI: 10.1111/dmcn.13997] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 02/04/2023]
Abstract
This case series describes three children with chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS), an inflammatory condition characterized by a relapsing-remitting disease course responsive to steroids. The patients (two males, age 3y and 13y; one female, age 14y) presented with ataxia, dysarthria, and multiple cranial neuropathies. All patients demonstrated bilateral nodular lesions with contrast enhancement in the brainstem and cerebellum on magnetic resonance imaging, and perivascular lymphocytes and macrophages infiltrates on brain biopsies. Despite an initially good response to corticosteroids, all patients eventually became steroid-dependent or -resistant, with frequent relapses on maintenance immunosuppressive therapy. Natalizumab and intravenous immunoglobulin stopped neurological disease progression in Patient 1 but he died at 17 years from respiratory complications. Patient 2 went into remission on infliximab and intravenous methylprednisolone for several months but was then diagnosed with Epstein-Barr virus driven B-cell lymphoma 3 years after symptom onset. Patient 3 failed to respond to treatment and died 4 years after diagnosis. CLIPPERS disease in children is aggressive, with poor response to immunotherapy. Earlier use of newer immunotherapeutic agents such as natalizumab may be beneficial. Potential side effects need to be considered carefully. WHAT THIS PAPER ADDS: Paediatric chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) appears a more severe condition than previously reported in adults. Aggressive treatment before neuroaxonal loss may be required for a better outcome.
Collapse
Affiliation(s)
- Mario Sa
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Lydia Green
- Department of Paediatric Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Omar Abdel-Mannan
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - W K Kling Chong
- Neuroradiology Department, Great Ormond Street Hospital for Children, London, UK
| | - Thomas Jacques
- Department of Histopathology, Great Ormond Street Hospital for Children, London, UK
| | - Antonia Clarke
- Department of Paediatric Neurology, St Georges Healthcare NHS Trust, London, UK
| | - Anne-Marie Childs
- Department of Paediatric Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Cheryl Hemingway
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Yael Hacohen
- Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, London, UK
| |
Collapse
|
38
|
Nishioka C, Liang HF, Barsamian B, Sun SW. Sequential phases of RGC axonal and somatic injury in EAE mice examined using DTI and OCT. Mult Scler Relat Disord 2018; 27:315-323. [PMID: 30469023 DOI: 10.1016/j.msard.2018.11.010] [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: 05/20/2018] [Revised: 11/10/2018] [Accepted: 11/12/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Clinical imaging modalities including optical coherence tomography (OCT) and diffusion tensor imaging (DTI) are vital in Multiple Sclerosis (MS), but their relationships during the different phases of Retinal ganglion cell (RGC) degeneration are not clear. We hypothesize that initial injury in optic nerve causes axonal degeneration leading to RGC loss in retina, which can be characterized by a combination of DTI and OCT. Our objective was to examine the correlation between noninvasive and histological data to chronicle the degeneration profile of RGCs in the retina and optic nerve in a mouse model of MS. MATERIALS AND METHODS Experimental Autoimmune Encephalomyelitis (EAE) was induced in 11 C57Bl/6 mice, with 8 mice reserved as controls. OCT and DTI was conducted 2-8 weeks after induction of EAE. The thickness of the retinal ganglion cell complex (GCC) was measured using OCT and compared to DTI indices measured in optic nerves. End-stage histology was used to quantify axon/myelin loss in the optic nerve and retinal thinning/RGC loss in the retina. RESULTS Significant changes in DTI-derived Axial Diffusivity (AD, -17.2%) and Trace Diffusivity (TR, -18.3%) began after 2 weeks of EAE. Later significant reductions in Fractional Anisotropy (FA) and AD, with increases in Radial Diffusion (RD) were apparent after 4 and 8 weeks. OCT-derived measures of GCC thickness were reduced after 4 weeks, and reached significant reduction after 8 weeks. Among EAE mice, DTI (FA, AD and RD measures) and OCT measures were all significantly correlated after 4 and 8 weeks. Among histology measures, RGC density (-23%), RGC size (-27%), and the number of SMI31+ axons (-54%) were reduced significantly. DTI measures of FA and AD along with GCC thinning were the best independent predictors of axon loss. CONCLUSIONS DTI and OCT measures are tightly correlated during the chronic phase of axonal degeneration (4-8 weeks) in EAE mice. After 8 weeks of EAE, both OCT and DTI measures are strong predictors of axon loss in the Optic Nerve.
Collapse
Affiliation(s)
- Christopher Nishioka
- Basic Sciences, School of Medicine, Loma Linda University, CA, United States; Neuroscience Graduate Program, University of California, Riverside, United States
| | - Hsiao-Fang Liang
- Basic Sciences, School of Medicine, Loma Linda University, CA, United States; Pharmaceutical Science, School of Pharmacy, Loma Linda University, CA, United States
| | - Barsam Barsamian
- Basic Sciences, School of Medicine, Loma Linda University, CA, United States; Neuroscience Graduate Program, University of California, Riverside, United States
| | - Shu-Wei Sun
- Basic Sciences, School of Medicine, Loma Linda University, CA, United States; Neuroscience Graduate Program, University of California, Riverside, United States; Pharmaceutical Science, School of Pharmacy, Loma Linda University, CA, United States.
| |
Collapse
|
39
|
|
40
|
Fenu G, Lorefice L, Loi L, Sechi V, Contu F, Coghe G, Frau J, Spinicci G, Barracciu M, Marrosu M, Cocco E. Adult brain volume in multiple sclerosis: The impact of paediatric onset. Mult Scler Relat Disord 2018; 21:103-107. [DOI: 10.1016/j.msard.2018.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/22/2018] [Accepted: 03/01/2018] [Indexed: 11/17/2022]
|
41
|
Yuan XL, Zhao YP, Huang J, Liu JC, Mao WQ, Yin J, Peng BW, Liu WH, Han S, He XH. A Kv1.3 channel-specific blocker alleviates neurological impairment through inhibiting T-cell activation in experimental autoimmune encephalomyelitis. CNS Neurosci Ther 2018; 24:967-977. [PMID: 29577640 DOI: 10.1111/cns.12848] [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: 12/22/2017] [Revised: 02/21/2018] [Accepted: 02/23/2018] [Indexed: 12/18/2022] Open
Abstract
AIM Multiple sclerosis (MS) is a neurological autoimmune disorder characterized by mistaken attacks of inflammatory cells against the central nervous system (CNS), resulting in demyelination and axonal damage. Kv1.3 channel blockers can inhibit T-cell activation and have been designed for MS therapy. However, little is known about the effects of Kv1.3 blockers on protecting myelin sheaths/axons in MS. This study aimed at investigating the neuroprotection efficacy of a selective Kv1.3 channel blocker ImKTx88 (ImK) in MS animal model. METHODS Experimental autoimmune encephalomyelitis (EAE) rat model was established. The neuroprotective effect of ImK was assessed by immunohistochemistry and transmission electron microscopy (TEM). In addition, the antiinflammatory effect of ImK by suppressing T-cell activation was assessed by flow cytometry and ELISA in vitro. RESULTS Our results demonstrated that ImK administration ameliorated EAE clinical severity. Moreover, ImK increased oligodendrocytes survival, preserved axons, and myelin integrity and reduced the infiltration of activated T cells into the CNS. This protective effect of the peptide may be related to its suppression of autoantigen-specific T-cell activation via calcium influx inhibition. CONCLUSION ImK prevents neurological damage by suppressing T-cell activation, suggesting the applicability of this peptide in MS therapy.
Collapse
Affiliation(s)
- Xiao-Lu Yuan
- Department of Pathophysiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Yi-Peng Zhao
- Department of Pathophysiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Jie Huang
- Department of Pathophysiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Jun-Chen Liu
- Department of Pathophysiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Wen-Qian Mao
- Department of Pathophysiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Jun Yin
- Department of Pathophysiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Bi-Wen Peng
- Hubei Provincial Key Laboratory of Developmentally Originated Disease, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Wan-Hong Liu
- Hubei Province Key Laboratory of Allergy and Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Song Han
- Department of Pathophysiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| | - Xiao-Hua He
- Department of Pathophysiology, School of Basic Medical Sciences, Wuhan University, Wuhan, China
| |
Collapse
|
42
|
Abstract
BACKGROUND Pediatric-onset multiple sclerosis (POMS) prevalence and incidence rates are increasing globally. No disease-modifying therapy are approved for MS pediatric population. Hence, we aim to review the literature on POMS to guide treating physicians on the current understanding of diagnosis and management of pediatric MS. METHODS The authors performed a literature search and reviewed the current understanding on risk factors and disease parameters in order to discuss the challenges in assessing and implementing diagnosis and therapy in clinical practice. RESULTS The revised International Pediatric MS group diagnostic criteria improved the accuracy of diagnosis. Identification of red flags and mimickers (e.g. acute disseminated encephalomyelitis and neuromyelitis optica) are vital before establishing a definitive diagnosis. Possible etiology and mechanisms including both environmental and genetic risk factors are highlighted. Pediatric MS patients tend to have active inflammatory disease course with a tendency to have brainstem / cerebellar presentations at onset. Due to efficient repair mechanisms at early life, pediatric MS patients tend to have longer time to reach EDSS 6 but reach it at earlier age. Although no therapeutic randomized clinical trials were conducted in pediatric cohorts, open-label multi-center studies reported efficacy and safety results with beta interferons, glatiramer acetate and natalizumab in similar adult cohorts. Several randomized clinical trials assessing the efficacy and safety of oral disease-modifying therapies are ongoing in pediatric MS patients. CONCLUSION Pediatric MS has been increasingly recognized to have a more inflammatory course with frequent infratentorial presentations at onset, which would have important implications in the future management of pediatric cohorts while awaiting the results of ongoing clinical trials.
Collapse
Affiliation(s)
- Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Arabian Gulf Street, 13041, Sharq, Kuwait.
| | - Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetic of the Pirogov's Russian National Research Medical University and MS Clinic at the Usupov's Hospital, Ostrovitianov str. 1, Moscow, 117997, Russia
| |
Collapse
|
43
|
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.
Collapse
|
44
|
The influence and impact of ageing and immunosenescence (ISC) on adaptive immunity during multiple sclerosis (MS) and the animal counterpart experimental autoimmune encephalomyelitis (EAE). Ageing Res Rev 2018; 41:64-81. [PMID: 29101043 DOI: 10.1016/j.arr.2017.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/21/2022]
Abstract
The human ageing process encompasses mechanisms that effect a decline in homeostasis with increased susceptibility to disease and the development of chronic life-threatening illness. Increasing age affects the immune system which undergoes a progressive loss of efficiency, termed immunosenescence (ISC), to impact on quantitative and functional aspects of innate and adaptive immunity. The human demyelinating disease multiple sclerosis (MS) and the corresponding animal model experimental autoimmune encephalomyelitis (EAE) are strongly governed by immunological events that primarily involve the adaptive arm of the immune response. MS and EAE are frequently characterised by a chronic pathology and a protracted disease course which thereby creates the potential for exposure to the inherent, on-going effects and consequences of ISC. Collective evidence is presented to confirm the occurrence of established and unendorsed biological markers of ISC during the development of both diseases. Moreover, results are discussed from studies during the course of MS and EAE that reveal a premature upregulation of ISC-related biomarkers which indicates untimely alterations to the adaptive immune system. The effects of ISC and a prematurely aged immune system on autoimmune-associated neurodegenerative conditions such as MS and EAE are largely unknown but current evaluation of data justifies and encourages further investigation.
Collapse
|
45
|
Giorgio A, Zhang J, Stromillo ML, Rossi F, Battaglini M, Nichelli L, Mortilla M, Portaccio E, Hakiki B, Amato MP, De Stefano N. Pronounced Structural and Functional Damage in Early Adult Pediatric-Onset Multiple Sclerosis with No or Minimal Clinical Disability. Front Neurol 2017; 8:608. [PMID: 29184534 PMCID: PMC5694464 DOI: 10.3389/fneur.2017.00608] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 10/31/2017] [Indexed: 12/29/2022] Open
Abstract
Pediatric-onset multiple sclerosis (POMS) may represent a model of vulnerability to damage occurring during a period of active maturation of the human brain. Whereas adaptive mechanisms seem to take place in the POMS brain in the short-medium term, natural history studies have shown that these patients reach irreversible disability, despite slower progression, at a significantly younger age than adult-onset MS (AOMS) patients. We tested for the first time whether significant brain alterations already occurred in POMS patients in their early adulthood and with no or minimal disability (n = 15) in comparison with age- and disability-matched AOMS patients (n = 14) and to normal controls (NC, n = 20). We used a multimodal MRI approach by modeling, using FSL, voxelwise measures of microstructural integrity of white matter tracts and gray matter volumes with those of intra- and internetwork functional connectivity (FC) (analysis of variance, p ≤ 0.01, corrected for multiple comparisons across space). POMS patients showed, when compared with both NC and AOMS patients, altered measures of diffusion tensor imaging (reduced fractional anisotropy and/or increased diffusivities) and higher probability of lesion occurrence in a clinically eloquent region for physical disability such as the posterior corona radiata. In addition, POMS patients showed, compared with the other two groups, reduced long-range FC, assessed from resting functional MRI, between default mode network and secondary visual network, whose interaction subserves important cognitive functions such as spatial attention and visual learning. Overall, this pattern of structural damage and brain connectivity disruption in early adult POMS patients with no or minimal clinical disability might explain their unfavorable clinical outcome in the long term.
Collapse
Affiliation(s)
- Antonio Giorgio
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Jian Zhang
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Francesca Rossi
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Marco Battaglini
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Lucia Nichelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | | | - Bahia Hakiki
- Department of Neurology, University of Florence, Florence, Italy
| | - Maria Pia Amato
- Department of Neurology, University of Florence, Florence, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| |
Collapse
|
46
|
McGinley M, Rossman IT. Bringing the HEET: The Argument for High-Efficacy Early Treatment for Pediatric-Onset Multiple Sclerosis. Neurotherapeutics 2017; 14:985-998. [PMID: 28895071 PMCID: PMC5722772 DOI: 10.1007/s13311-017-0568-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Pediatric-onset multiple sclerosis (POMS) is rarer than adult-onset disease, and represents a different diagnostic and treatment challenge to clinicians. We review POMS clinical and radiographic presentations, and explore important differences between POMS and adult-onset MS natural histories and long-term outcomes. Despite having more active disease, current treatment guidelines for patients with POMS endorse the off-label use of lower-efficacy disease-modifying therapies (DMTs) as first line. We review the available MS DMTs, their evidence for use in POMS, and the contrasting treatment strategies of high-efficacy early treatment and escalation therapy. We introduce a new treatment approach, the "high-efficacy early treatment", or HEET strategy, based on using directly observed, high-efficacy intravenously infused DMTs as first-line therapies. Like other proposed POMS treatment strategies, HEET will need to be prospectively studied, and all treatment decisions should be determined by an experienced neurologist, the patient, and his/her parents.
Collapse
Affiliation(s)
- Marisa McGinley
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, 9500 Euclid Avenue U10, Cleveland, OH, 44195, USA
| | - Ian T Rossman
- NeuroDevelopmental Science Center, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308, USA.
| |
Collapse
|
47
|
Rüther BJ, Scheld M, Dreymueller D, Clarner T, Kress E, Brandenburg LO, Swartenbroekx T, Hoornaert C, Ponsaerts P, Fallier-Becker P, Beyer C, Rohr SO, Schmitz C, Chrzanowski U, Hochstrasser T, Nyamoya S, Kipp M. Combination of cuprizone and experimental autoimmune encephalomyelitis to study inflammatory brain lesion formation and progression. Glia 2017; 65:1900-1913. [PMID: 28836302 DOI: 10.1002/glia.23202] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/21/2017] [Accepted: 07/24/2017] [Indexed: 12/13/2022]
Abstract
Brain-intrinsic degenerative cascades are a proposed factor driving inflammatory lesion formation in multiple sclerosis (MS) patients. We recently described a model combining noninflammatory cytodegeneration (via cuprizone) with the classic active experimental autoimmune encephalomyelitis (Cup/EAE model), which exhibits inflammatory forebrain lesions. Here, we describe the histopathological characteristics and progression of these Cup/EAE lesions. We show that inflammatory lesions develop at various topographical sites in the forebrain, including white matter tracts and cortical and subcortical grey matter areas. The lesions are characterized by focal demyelination, discontinuation of the perivascular glia limitans, focal axonal damage, and neutrophil granulocyte extravasation. Transgenic mice with enhanced green fluorescent protein-expressing microglia and red fluorescent protein-expressing monocytes reveal that both myeloid cell populations contribute to forebrain inflammatory infiltrates. EAE-triggered inflammatory cerebellar lesions were augmented in mice pre-intoxicated with cuprizone. Gene expression studies suggest roles of the chemokines Cxcl10, Ccl2, and Ccl3 in inflammatory lesion formation. Finally, follow-up experiments in Cup/EAE mice with chronic disease revealed that forebrain, but not spinal cord, lesions undergo spontaneous reorganization and repair. This study underpins the significance of brain-intrinsic degenerative cascades for immune cell recruitment and, in consequence, MS lesion formation.
Collapse
Affiliation(s)
- Bernhard Josef Rüther
- Institute of Neuroanatomy and JARA-BRAIN, Faculty of Medicine, RWTH Aachen University, Aachen, 52074, Germany
| | - Miriam Scheld
- Institute of Neuroanatomy and JARA-BRAIN, Faculty of Medicine, RWTH Aachen University, Aachen, 52074, Germany
| | - Daniela Dreymueller
- Institute of Pharmacology and Toxicology, Faculty of Medicine, RWTH Aachen University, Aachen, 52074, Germany
| | - Tim Clarner
- Institute of Neuroanatomy and JARA-BRAIN, Faculty of Medicine, RWTH Aachen University, Aachen, 52074, Germany
| | - Eugenia Kress
- Department of Anatomy and Cell Biology, RWTH Aachen University, Aachen, 52074, Germany
| | - Lars-Ove Brandenburg
- Department of Anatomy and Cell Biology, RWTH Aachen University, Aachen, 52074, Germany
| | - Tine Swartenbroekx
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, 2610, Belgium
| | - Chloé Hoornaert
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, 2610, Belgium
| | - Peter Ponsaerts
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, 2610, Belgium
| | - Petra Fallier-Becker
- Institute of Pathology and Neuropathology, University of Tuebingen, Tuebingen, 72076, Germany
| | - Cordian Beyer
- Institute of Neuroanatomy and JARA-BRAIN, Faculty of Medicine, RWTH Aachen University, Aachen, 52074, Germany
| | - Sven Olaf Rohr
- Department of Anatomy II, Ludwig-Maximilians-University of Munich, Munich, 80336, Germany
| | - Christoph Schmitz
- Department of Anatomy II, Ludwig-Maximilians-University of Munich, Munich, 80336, Germany
| | - Uta Chrzanowski
- Department of Anatomy II, Ludwig-Maximilians-University of Munich, Munich, 80336, Germany
| | - Tanja Hochstrasser
- Department of Anatomy II, Ludwig-Maximilians-University of Munich, Munich, 80336, Germany
| | - Stella Nyamoya
- Institute of Neuroanatomy and JARA-BRAIN, Faculty of Medicine, RWTH Aachen University, Aachen, 52074, Germany.,Department of Anatomy II, Ludwig-Maximilians-University of Munich, Munich, 80336, Germany
| | - Markus Kipp
- Department of Anatomy II, Ludwig-Maximilians-University of Munich, Munich, 80336, Germany
| |
Collapse
|
48
|
Paediatric Multiple Sclerosis: Update on Diagnostic Criteria, Imaging, Histopathology and Treatment Choices. Curr Neurol Neurosci Rep 2017; 16:68. [PMID: 27271748 PMCID: PMC4894922 DOI: 10.1007/s11910-016-0663-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Paediatric multiple sclerosis (MS) represents less than 5 % of the MS population, but patients with paediatric-onset disease reach permanent disability at a younger age than adult-onset patients. Accurate diagnosis at presentation and optimal long-term treatment are vital to mitigate ongoing neuroinflammation and irreversible neurodegeneration. However, it may be difficult to early differentiate paediatric MS from acute disseminated encephalomyelitis (ADEM) and neuromyelitis optica spectrum disorders (NMOSD), as they often have atypical presentation that differs from that of adult-onset MS. The purpose of this review is to summarize the updated views on diagnostic criteria, imaging, histopathology and treatment choices.
Collapse
|
49
|
Beard H, Hassiotis S, Gai WP, Parkinson-Lawrence E, Hopwood JJ, Hemsley KM. Axonal dystrophy in the brain of mice with Sanfilippo syndrome. Exp Neurol 2017; 295:243-255. [PMID: 28601604 DOI: 10.1016/j.expneurol.2017.06.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 04/16/2017] [Accepted: 06/06/2017] [Indexed: 01/29/2023]
Abstract
Axonal dystrophy has been described as an early pathological feature of neurodegenerative disorders including Alzheimer's disease and amyotrophic lateral sclerosis. Axonal inclusions have also been reported to occur in several neurodegenerative lysosomal storage disorders including Mucopolysaccharidosis type IIIA (MPS IIIA; Sanfilippo syndrome). This disorder results from a mutation in the gene encoding the lysosomal sulphatase sulphamidase, and as a consequence heparan sulphate accumulates, accompanied by secondarily-stored gangliosides. The precise basis of symptom generation in MPS IIIA has not been elucidated, however axonal dystrophy may conceivably lead to impaired vesicular trafficking, neuronal dysfunction and/or death. We have utilised a faithful murine model of MPS IIIA to determine the spatio-temporal profile of neuronal inclusion formation and determine the effect of restoring normal lysosomal function. Dopaminergic (tyrosine hydroxylase-positive), cholinergic (choline acetyltransferase-positive) and GABAergic (glutamic acid decarboxylase65/67-positive) neurons were found to exhibit axonal dystrophy in MPS IIIA mouse brain. Axonal lesions present by ~seven weeks of age were Rab5-positive but lysosomal integral membrane protein-2 negative, suggesting early endosomal involvement. By 9-12-weeks of age, immunoreactivity for the autophagosome-related proteins LC3 and p62 and the proteasomal subunit 19S was noted in the spheroidal structures, together with wildtype α-synuclein, phosphorylated Thr-181 Tau and amyloid precursor protein, indicative of impaired axonal trafficking. Sulphamidase replacement reduced but did not abrogate the axonal lesions. Therefore, if axonal dystrophy impairs neuronal activity and ultimately, neuronal function, its incomplete resolution warrants further investigation.
Collapse
Affiliation(s)
- Helen Beard
- Lysosomal Diseases Research Unit, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5001, Australia
| | - Sofia Hassiotis
- Lysosomal Diseases Research Unit, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5001, Australia
| | - Wei-Ping Gai
- Dept Human Physiology, The Flinders University of SA, Bedford Park, SA 5052, Australia
| | - Emma Parkinson-Lawrence
- School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - John J Hopwood
- Lysosomal Diseases Research Unit, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5001, Australia
| | - Kim M Hemsley
- Lysosomal Diseases Research Unit, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5001, Australia.
| |
Collapse
|
50
|
Ghezzi A, Baroncini D, Zaffaroni M, Comi G. Pediatric versus adult MS: similar or different? ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40893-017-0022-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|