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Chen J, Qin M, Xiang X, Guo X, Nie L, Mao L. Lymphocytes in autoimmune encephalitis: Pathogenesis and therapeutic target. Neurobiol Dis 2024; 200:106632. [PMID: 39117118 DOI: 10.1016/j.nbd.2024.106632] [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: 05/18/2024] [Revised: 08/04/2024] [Accepted: 08/04/2024] [Indexed: 08/10/2024] Open
Abstract
Autoimmune encephalitis (AE) is an inflammatory disease of the central nervous system characterized by the production of various autoimmune antibodies targeting neuronal proteins. The pathogenesis of AE remains elusive. Accumulating evidence suggests that lymphocytes, particularly B and T lymphocytes, play an integral role in the development of AE. In the last two decades, autoimmune neural antibodies have taken center stage in diagnosing AE. Recently, increasing evidence has highlighted the importance of T lymphocytes in the onset of AE. CD4+ T cells are thought to influence disease progression by secreting associated cytokines, whereas CD8+ T cells exert a cytotoxic role, causing irreversible damage to neurons mainly in patients with paraneoplastic AE. Conventionally, the first-line treatments for AE include intravenous steroids, intravenous immunoglobulin, and plasma exchange to remove pathogenic autoantibodies. However, a minority of patients are insensitive to conventional first-line treatment protocols and suffer from disease relapse, a condition referred to as refractory AE. In recent years, new treatments, such as rituximab or CAAR-T, which target pathogenic lymphocytes in patients with AE, have offered new therapeutic options for refractory AE. This review aims to describe the current knowledge about the function of B and T lymphocytes in the pathophysiology of AE and to summarize and update the immunotherapy options for treating this disease.
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Affiliation(s)
- Jiaojiao Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Mengting Qin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xuying Xiang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xiaoqing Guo
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Lei Nie
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ling Mao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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Dalakas MC. Stiff Person Syndrome and GAD Antibody-Spectrum Disorders. Continuum (Minneap Minn) 2024; 30:1110-1135. [PMID: 39088290 DOI: 10.1212/con.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE Antibodies against glutamic acid decarboxylase (GAD), originally associated with stiff person syndrome (SPS), define the GAD antibody-spectrum disorders that also include cerebellar ataxia, autoimmune epilepsy, limbic encephalitis, progressive encephalomyelitis with rigidity and myoclonus (PERM), and eye movement disorders, all of which are characterized by autoimmune neuronal excitability. This article elaborates on the diagnostic criteria for SPS and SPS spectrum disorders, highlights disease mimics and misdiagnoses, describes the electrophysiologic mechanisms and underlying autoimmunity of stiffness and spasms, and provides a step-by-step therapeutic scheme. LATEST DEVELOPMENTS Very-high serum GAD antibody titers are diagnostic for GAD antibody-spectrum disorders and also predict the presence of GAD antibodies in the CSF, increased intrathecal synthesis, and reduced CSF γ-aminobutyric acid (GABA) levels. Low serum GAD antibody titers or the absence of antibodies generates diagnostic challenges that require careful distinction in patients with a variety of painful spasms and stiffness, including functional neurologic disorders. Antibodies against glycine receptors, first found in patients with PERM, are seen in 13% to 15% of patients with SPS, whereas amphiphysin and gephyrin antibodies, seen in 5% of patients with SPS spectrum disorders, predict a paraneoplastic association. GAD-IgG from different SPS spectrum disorders recognizes the same dominant GAD intracellular epitope and, although the pathogenicity is unclear, is an excellent diagnostic marker. The biological basis of muscle stiffness and spasms is related to autoimmune neuronal hyperexcitability caused by impaired reciprocal γ-aminobutyric acid-mediated (GABA-ergic) inhibition, which explains the therapeutic response to GABA-enhancing agents and immunotherapies. ESSENTIAL POINTS It is essential to distinguish SPS spectrum disorders from disease mimics to avoid both overdiagnoses and misdiagnoses, considering that SPS is treatable if managed correctly from the outset to prevent disease progression. A step-by-step, combination therapy of GABA-enhancing medications along with immunotherapies ensures prolonged clinical benefits.
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Zhang L, Zhang Y, Li R, Zhu J, Lin A, Yan Y, Zhang Z, Wang N, Xu G, Fu Y. Anti-neurofascin-155 antibody mediated a distinct phenotype of chronic inflammatory demyelinating polyradiculoneuropathy. J Neurol 2024; 271:4991-5002. [PMID: 38771386 DOI: 10.1007/s00415-024-12443-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND To investigate Ranvier's autoantibodies prevalence and isotypes in various peripheral neuropathy variants, compare clinical features between seronegative and seropositive patients, and elucidate immune mechanisms underlying antibody generation. METHODS Antibodies against anti-neurofascin-155 (NF155), NF186, contactin-1 (CNTN1), CNTN2, contactin-associated protein 1 (CASPR1), and CASPR2 were identified through cell-based assays. Plasma cytokines were analyzed in anti-NF155 antibody-positive chronic inflammatory demyelinating polyneuropathy (NF155+ CIDP) and Ranvier's antibodies-negative CIDP (Ab- CIDP) patients using a multiplexed fluorescent immunoassay, validated in vitro in a cell culture model. RESULTS In 368 plasma samples, 50 Ranvier's autoantibodies were found in 45 individuals, primarily in CIDP cases (25 out of 69 patients) and in 10 out of 122 Guillain-Barré syndrome patients. Anti-NF155 and CNTN1-IgG were exclusive to CIDP. Fourteen samples were NF155-IgG, primarily IgG4 subclass, linked to CIDP features including early onset, tremor, sensory disturbance, elevated CSF protein, prolonged motor latency, conduction block, and poor treatment response. NF155-IgG had low sensitivity (20.28%) but high specificity (100%) for CIDP, rising to 88.88% with tremor and prolonged motor latency. Cytokine profiling in NF155+ CIDP revealed distinct immune responses involving helper T cells, toll-like receptor pathways. Some NF155+ CIDP patients had circulating NF155-specific B cells producing NF155-IgG without antigen presence, suggesting therapeutic potential. CONCLUSION The study emphasizes the high specificity and sensitivity of NF155-IgG for diagnosing CIDP characterized by distinctive features. Further investigation into circulating NF155-specific B cell phenotypes may pave the way for B cell directed therapy.
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Affiliation(s)
- Lijie Zhang
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Yuanyuan Zhang
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Runyun Li
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Jiting Zhu
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Aiyu Lin
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Yaping Yan
- Key Laboratory of the Ministry of Education for Medicinal Resources and Natural Pharmaceutical Chemistry, National Engineering Laboratory for Resource Development of Endangered Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an, 710119, China
| | - Zaiqiang Zhang
- Department of Neurology, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Ning Wang
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
| | - Guorong Xu
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
| | - Ying Fu
- Department of Neurology and Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
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Faissner S, Motte J, Sgodzai M, Geis C, Haghikia A, Mougiakakos D, Borie D, Schroers R, Gold R. Successful use of anti-CD19 CAR T cells in severe treatment-refractory stiff-person syndrome. Proc Natl Acad Sci U S A 2024; 121:e2403227121. [PMID: 38885382 PMCID: PMC11214089 DOI: 10.1073/pnas.2403227121] [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: 02/22/2024] [Accepted: 05/10/2024] [Indexed: 06/20/2024] Open
Abstract
Treatment with autologous chimeric antigen receptor (CAR) T cells has emerged as a highly effective approach in neuroimmunological disorders such as myasthenia gravis. We report a case of successful anti-CD19 CAR T cell use in treatment-refractory stiff-person syndrome (SPS). To investigate clinical and immunological effects of anti-CD19 CAR T cell use in treatment-refractory SPS, a 69-y-old female with a 9-y history of treatment-refractory SPS with deteriorating episodes of stiffness received an infusion of autologous anti-CD19 CAR T cells (KYV-101) and was monitored clinically and immunologically for more than 6 mo. CAR T cell infusion resulted in reduced leg stiffness, drastic improvement in gait, walking speed increase over 100%, and daily walking distance improvement from less than 50 m to over 6 km within 3 mo. GABAergic medication (benzodiazepines) was reduced by 40%. KYV-101 CAR T cells were well tolerated with only low-grade cytokine release syndrome. This report of successful use of anti-CD19 CAR T cells in treatment-refractory SPS supports continued exploration of this approach in SPS and other B cell-related autoimmune disorders.
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Affiliation(s)
- Simon Faissner
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum44791, Germany
| | - Jeremias Motte
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum44791, Germany
| | - Melissa Sgodzai
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum44791, Germany
| | - Christian Geis
- Department of Neurology, Jena University Hospital, Jena07747, Germany
| | - Aiden Haghikia
- Department of Neurology, Medical Faculty, Otto-von-Guericke University, Magdeburg39120, Germany
| | - Dimitrios Mougiakakos
- Department of Hematology, Medical Faculty, Otto-von-Guericke University, Magdeburg39120, Germany
| | | | - Roland Schroers
- Department of Haematology and Oncology, Ruhr-University Bochum, Knappschaftskrankenhaus Bochum, Bochum44892, Germany
| | - Ralf Gold
- Department of Neurology, Ruhr-University Bochum, St. Josef-Hospital, Bochum44791, Germany
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Li S, Hu X, Wang M, Yu L, Zhang Q, Xiao J, Hong Z, Zhou D, Li J. Single-cell RNA sequencing reveals diverse B cell phenotypes in patients with anti-NMDAR encephalitis. Psychiatry Clin Neurosci 2024; 78:197-208. [PMID: 38063052 DOI: 10.1111/pcn.13627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUNDS Anti-N-methyl-D-aspartate receptor encephalitis (NMDAR-E) is a severe autoimmune disorder characterized by prominent psychiatric symptoms. Although the role of NMDAR antibodies in the disease has been extensively studied, the phenotype of B cell subsets is still not fully understood. METHODS We utilized single-cell RNA sequencing, single-cell B cell receptor sequencing (scBCR-seq), bulk BCR sequencing, flow cytometry, and enzyme-linked immunosorbent assay to analyze samples from both NMDAR-E patients and control individuals. RESULTS The cerebrospinal fluid (CSF) of NMDAR-E patients showed significantly increased B cell counts, predominantly memory B (Bm) cells. CSF Bm cells in NMDAR-E patients exhibited upregulated expression of differential expression genes (DEGs) associated with immune regulatory function (TNFRSF13B and ITGB1), whereas peripheral B cells upregulated DEGs related to antigen presentation. Additionally, NMDAR-E patients displayed higher levels of IgD- CD27- double negative (DN) cells and DN3 cells in peripheral blood (PB). In vitro, DN1 cell subsets from NMDAR-E patients differentiated into DN2 and DN3 cells, while CD27+ and/or IgD+ B cells (non-DN) differentiated into antibody-secreting cells (ASCs) and DN cells. NR1-IgG antibodies were found in B cell culture supernatants from patients. Differential expression of B cell IGHV genes in CSF and PB of NMDAR-E patients suggests potential antigen class switching. CONCLUSION B cell subpopulations in the CSF and PB of NMDAR-E patients exhibit distinct compositions and transcriptomic features. In vitro, non-DN cells from NMDAR-E can differentiate into DN cells and ASCs, potentially producing NR1-IgG antibodies. Further research is necessary to investigate the potential contribution of DN cell subpopulations to NR1-IgG antibody production.
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Affiliation(s)
- Sisi Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Department of Breast Cancer, Chongqing University Cancer Hospital, Chongqing, China
| | - Xiang Hu
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Minjin Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Luoting Yu
- State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Qi Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Xiao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinmei Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Vlad B, Wang Y, Newsome SD, Balint B. Stiff Person Spectrum Disorders-An Update and Outlook on Clinical, Pathophysiological and Treatment Perspectives. Biomedicines 2023; 11:2500. [PMID: 37760941 PMCID: PMC10525659 DOI: 10.3390/biomedicines11092500] [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: 08/01/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Stiff person spectrum disorders (SPSD) are paradigm autoimmune movement disorders characterized by stiffness, spasms and hyperekplexia. Though rare, SPSD represent a not-to-miss diagnosis because of the associated disease burden and treatment implications. After decades as an enigmatic orphan disease, major advances in our understanding of the evolving spectrum of diseases have been made along with the identification of multiple associated autoantibodies. However, the most important recent developments relate to the recognition of a wider affection, beyond the classic core motor symptoms, and to further insights into immunomodulatory and symptomatic therapies. In this review, we summarize the recent literature on the clinical and paraclinical spectrum, current pathophysiological understanding, as well as current and possibly future therapeutic strategies.
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Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Yujie Wang
- Department of Neurology, University of Washington, Seattle, WA 98195, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Scott D. Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Bettina Balint
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
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Tröscher AR, Mair KM, Verdú de Juan L, Köck U, Steinmaurer A, Baier H, Becker A, Blümcke I, Finzel M, Geis C, Höftberger R, Mawrin C, von Oertzen TJ, Pitsch J, Surges R, Voges B, Weis S, Winklehner M, Woermann F, Bauer J, Bien CG. Temporal lobe epilepsy with GAD antibodies: neurons killed by T cells not by complement membrane attack complex. Brain 2023; 146:1436-1452. [PMID: 36314080 PMCID: PMC10115353 DOI: 10.1093/brain/awac404] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/22/2022] [Accepted: 10/03/2022] [Indexed: 11/14/2022] Open
Abstract
Temporal lobe epilepsy (TLE) is one of the syndromes linked to antibodies against glutamic acid decarboxylase (GAD). It has been questioned whether 'limbic encephalitis with GAD antibodies' is a meaningful diagnostic entity. The immunopathogenesis of GAD-TLE has remained enigmatic. Improvement of immunological treatability is an urgent clinical concern. We retrospectively assessed the clinical, MRI and CSF course as well as brain tissue of 15 adult patients with GAD-TLE who underwent temporal lobe surgery. Brain tissue was studied by means of immunohistochemistry, multiplex fluorescent microscopy and transcriptomic analysis for inflammatory mediators and neuronal degeneration. In 10 patients, there was a period of mediotemporal swelling and T2 signal increase; in nine cases this occurred within the first 6 years after symptom onset. This resulted in unilateral or bilateral hippocampal sclerosis; three cases developed hippocampal sclerosis within the first 2 years. All CSF studies done within the first year (n = 6) revealed intrathecal synthesis of immunoglobulin G. Temporal lobe surgeries were done after a median disease duration of 9 years (range 3 weeks to 60 years). Only two patients became seizure-free. Brain parenchyma collected during surgery in the first 6 years revealed high numbers of plasma cells but no signs of antibody-mediated tissue damage. Even more dense was the infiltration by CD8+ cytotoxic T lymphocytes (CTLs) that were seen to locally proliferate. Further, a portion of these cells revealed an antigen-specific resident memory T cell phenotype. Finally, CTLs with cytotoxic granzyme B+ granules were also seen in microglial nodules and attached to neurons, suggesting a CTL-mediated destruction of these cells. With longer disease duration, the density of all lymphocytes decreased. Whole transcriptome analysis in early/active cases (but not in late/inactive stages) revealed 'T cell immunity' and 'Regulation of immune processes' as the largest overrepresented clusters. To a lesser extent, pathways associated with B cells and neuronal degeneration also showed increased representation. Surgically treated patients with GAD-TLE go through an early active inflammatory, 'encephalitic' stage (≤6 years) with CTL-mediated, antigen-driven neuronal loss and antibody-producing plasma cells but without signs of complement-mediated cell death. Subsequently, patients enter an apparently immunologically inactive or low-active stage with ongoing seizures, probably caused by the structural damage to the temporal lobe. 'Limbic encephalitis' with GAD antibodies should be subsumed under GAD-TLE. The early tissue damage explains why immunotherapy does not usually lead to freedom from seizures.
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Affiliation(s)
- Anna R Tröscher
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
- Department of Neurology I, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Katharina M Mair
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Laia Verdú de Juan
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Ulrike Köck
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Anja Steinmaurer
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | | | - Albert Becker
- Section for Translational Epilepsy Research Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Ingmar Blümcke
- Department of Neuropathology, Universitätsklinikum Erlangen, Erlangen, Germany
| | | | - Christian Geis
- Section Translational Neuroimmunology, Department of Neurology, University Hospital Jena, Jena, Germany
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christian Mawrin
- Department of Neuropathology, University Hospital Magdeburg, Magdeburg, Germany
| | - Tim J von Oertzen
- Department of Neurology I, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Julika Pitsch
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Berthold Voges
- Hamburg Epilepsy Centre, Protestant Hospital Alsterdorf, Department of Neurology and Epileptology, Hamburg, Germany
| | - Serge Weis
- Division of Neuropathology, Department of Pathology and Molecular Pathology, Neuromed Campus, Kepler University Hospital Linz, Linz, Austria
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Friedrich Woermann
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
- Epilepsy Centre Bodensee, Ravensburg, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Centre for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Campus Bielefeld-Bethel, Bielefeld University, Bielefeld, Germany
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Biljecki M, Eisenhut K, Beltrán E, Winklmeier S, Mader S, Thaller A, Eichhorn P, Steininger P, Flierl-Hecht A, Lewerenz J, Kümpfel T, Kerschensteiner M, Meinl E, Thaler FS. Antibodies Against Glutamic Acid Decarboxylase 65 Are Locally Produced in the CSF and Arise During Affinity Maturation. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/3/e200090. [PMID: 36823135 PMCID: PMC9969496 DOI: 10.1212/nxi.0000000000200090] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/12/2022] [Indexed: 02/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Antibodies (Abs) against the cytoplasmic protein glutamic acid decarboxylase 65 (GAD65) are detected in patients with neurologic syndromes together referred to as GAD65-Ab spectrum disorders. The response of some of these patients to plasma exchange or immunoglobulins indicates that GAD65-Abs could contribute to disease pathogenesis at least at some stages of disease. However, the involvement of GAD65-reactive B cells in the CNS is incompletely understood. METHODS We studied 7 patients with high levels of GAD65-Abs and generated monoclonal Abs (mAbs) derived from single cells in the CSF. Sequence characteristics, reactivity to GAD65, and the role of somatic hypermutations of the mAbs were analyzed. RESULTS Twelve CSF-derived mAbs were generated originating from 3 patients with short disease duration, and 7/12 of these mAbs (58%) were GAD65 reactive in at least 1 detection assay. Four of 12 (33%) were definitely positive in all 3 detection assays. The intrathecal anti-GAD65 response was polyclonal. GAD65-Abs were mostly of the IgG1 subtype and had undergone affinity maturation. Reversion of 2 GAD65-reactive mAbs to their corresponding germline-encoded unmutated common ancestors abolished GAD65 reactivity. DISCUSSION GAD65-specific B cells are present in the CNS and represent a sizable fraction of CSF B cells early in the disease course. The anti-GAD65 response in the CSF is polyclonal and shows evidence of antigen-driven affinity maturation required for GAD65 recognition. Our data support the hypothesis that the accumulation of GAD65-specific B cells and plasma cells in the CSF is an important feature of early disease stages.
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Affiliation(s)
- Michelle Biljecki
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Katharina Eisenhut
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Eduardo Beltrán
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Stephan Winklmeier
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Simone Mader
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Anna Thaller
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Peter Eichhorn
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Philipp Steininger
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Andrea Flierl-Hecht
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Jan Lewerenz
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Tania Kümpfel
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Martin Kerschensteiner
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Edgar Meinl
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany
| | - Franziska S Thaler
- From the Institute of Clinical Neuroimmunology (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), University Hospital, Ludwig-Maximilians-Universität Munich; Biomedical Center (BMC) (M.B., K.E., E.B., S.W., S.M., A.T., A.F.-H., T.K., M.K., E.M., F.S.T.), Medical Faculty, Ludwig-Maximilians-Universität Munich, Martinsried; Graduate School of Systemic Neurosciences Ludwig-Maximilians-Universität Munich (M.B., K.E.); Munich Cluster for Systems Neurology (SyNergy) (E.B., M.K., F.S.T.); Innate Immunity Unit (A.T.), Institut Pasteur, Inserm U1223, Paris, France; Université de Paris (A.T.), Sorbonne Paris Cité, France; Institute of Laboratory Medicine (P.E.), University Hospital, LMU Munich; Institute of Clinical and Molecular Virology (P.S.), University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; and Department of Neurology (J.L.), University Hospital Ulm, Germany.
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9
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Stathopoulos P, Dalakas MC. Evolution of Anti-B Cell Therapeutics in Autoimmune Neurological Diseases. Neurotherapeutics 2022; 19:691-710. [PMID: 35182380 PMCID: PMC9294112 DOI: 10.1007/s13311-022-01196-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 02/08/2023] Open
Abstract
B cells have an ever-increasing role in the etiopathology of a number of autoimmune neurological disorders, acting as antigen-presenting cells facilitating antibody production but also as sensors, coordinators, and regulators of the immune response. In particular, B cells can regulate the T cell activation process through their participation in antigen presentation, production of proinflammatory cytokines (bystander activation or suppression), and contribution to ectopic lymphoid aggregates. Such an important interplay between B and T cells makes therapeutic depletion of B cells an attractive treatment strategy. The last decade, anti-B cell therapies using monoclonal antibodies against B cell surface molecules have evolved into a rational approach for successfully treating autoimmune neurological disorders, even when T cells seem to be the main effector cells. The paper summarizes basic aspects of B cell biology, discusses the roles of B cells in neurological autoimmunities, and highlights how the currently available or under development anti-B cell therapeutics exert their action in the wide spectrum and immunologically diverse neurological disorders. The efficacy of the various anti-B cell therapies and practical issues on induction and maintenance therapy is specifically detailed for the treatment of patients with multiple sclerosis, neuromyelitis-spectrum disorders, autoimmune encephalitis and hyperexcitability CNS disorders, autoimmune neuropathies, myasthenia gravis, and inflammatory myopathies. The success of anti-B cell therapies in inducing long-term remission in IgG4 neuroautoimmunities is also highlighted pointing out potential biomarkers for follow-up infusions.
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Affiliation(s)
- Panos Stathopoulos
- 1st Department of Neurology, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece.
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10
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Dalakas MC. Stiff-person Syndrome and GAD Antibody-spectrum Disorders: GABAergic Neuronal Excitability, Immunopathogenesis and Update on Antibody Therapies. Neurotherapeutics 2022; 19:832-847. [PMID: 35084720 PMCID: PMC9294130 DOI: 10.1007/s13311-022-01188-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 01/10/2023] Open
Abstract
Although antibodies against Glutamic Acid Decarboxylase (GAD) were originally associated with Stiff Person Syndrome (SPS), they now denote the "GAD antibody-spectrum disorders (GAD-SD)" that include Cerebellar Ataxia, Autoimmune Epilepsy, Limbic Encephalitis, PERM and eye movement disorder. In spite of the unique clinical phenotype that each of these disorders has, there is significant overlapping symptomatology characterized by autoimmune neuronal excitability. In addition to GAD, three other autoantibodies, against glycine receptors, amphiphysin and gephyrin, are less frequently or rarely associated with SPS-SD. Very high serum anti-GAD antibody titers are a key diagnostic feature for all GAD-SD, commonly associated with the presence of GAD antibodies in the CSF, a reduced CSF GABA level and increased anti-GAD-specific IgG intrathecal synthesis denoting stimulation of B-cell clones in the CNS. Because anti-GAD antibodies from the various hyperexcitability syndromes recognize the same dominant GAD epitope, the clinical heterogeneity among GAD-SD patients remains unexplained. The paper highlights the biologic basis of autoimmune hyperexcitability connected with the phenomenon of reciprocal inhibition as the fundamental mechanism of the patients' muscle stiffness and spasms; addresses the importance of high-GAD antibody titers in diagnosis, pinpointing the diagnostic challenges in patients with low-GAD titers or their distinction from functional disorders; and discusses whether high GAD-antibodies are disease markers or pathogenic in the context of their association with reduced GABA level in the brain and CSF. Finally, it focuses on therapies providing details on symptomatic GABA-enhancing drugs and the currently available immunotherapies in a step-by-step approach. The prospects of future immunotherapeutic options with antibody therapies are also summarized.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit National and Kapodistrian University of Athens Medical School, Athens, Greece.
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11
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Winklmeier S, Eisenhut K, Taskin D, Rübsamen H, Gerhards R, Schneider C, Wratil PR, Stern M, Eichhorn P, Keppler OT, Klein M, Mader S, Kümpfel T, Meinl E. Persistence of functional memory B cells recognizing SARS-CoV-2 variants despite loss of specific IgG. iScience 2022; 25:103659. [PMID: 34957380 PMCID: PMC8686444 DOI: 10.1016/j.isci.2021.103659] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/17/2021] [Accepted: 12/15/2021] [Indexed: 01/22/2023] Open
Abstract
Although some COVID-19 patients maintain SARS-CoV-2-specific serum immunoglobulin G (IgG) for more than 6 months postinfection, others eventually lose IgG levels. We assessed the persistence of SARS-CoV-2-specific B cells in 17 patients, 5 of whom had lost specific IgGs after 5-8 months. Differentiation of blood-derived B cells in vitro revealed persistent SARS-CoV-2-specific IgG B cells in all patients, whereas IgA B cells were maintained in 11. Antibodies derived from cultured B cells blocked binding of viral receptor-binding domain (RBD) to the cellular receptor ACE-2, had neutralizing activity to authentic virus, and recognized the RBD of the variant of concern Alpha similarly to the wild type, whereas reactivity to Beta and Gamma were decreased. Thus, differentiation of memory B cells could be more sensitive for detecting previous infection than measuring serum antibodies. Understanding the persistence of SARS-CoV-2-specific B cells even in the absence of specific serum IgG will help to promote long-term immunity.
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Affiliation(s)
- Stephan Winklmeier
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
| | - Katharina Eisenhut
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
| | - Damla Taskin
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
| | - Heike Rübsamen
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
| | - Ramona Gerhards
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
| | - Celine Schneider
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
| | - Paul R. Wratil
- Max von Pettenkofer Institute & GeneCenter, Virology, LMU Munich, 80336 Munich, Germany
| | - Marcel Stern
- Max von Pettenkofer Institute & GeneCenter, Virology, LMU Munich, 80336 Munich, Germany
| | - Peter Eichhorn
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Oliver T. Keppler
- Max von Pettenkofer Institute & GeneCenter, Virology, LMU Munich, 80336 Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Simone Mader
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
| | - Edgar Meinl
- Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, 81377 Munich, Germany
- Biomedical Center (BMC), Faculty of Medicine, LMU Munich, 82152 Martinsried, Germany
- Corresponding author
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12
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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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13
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Novel insights into pathophysiology and therapeutic possibilities reveal further differences between AQP4-IgG- and MOG-IgG-associated diseases. Curr Opin Neurol 2021; 33:362-371. [PMID: 32304439 DOI: 10.1097/wco.0000000000000813] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW This review summarizes recent insights into the pathogenesis and therapeutic options for patients with MOG- or AQP4-antibodies. RECENT FINDINGS Although AQP4-IgG are linked to NMOSD, MOG-IgG-associated diseases (MOGAD) include a broader clinical spectrum of autoimmune diseases of the central nervous system (CNS). Details of membrane assembly of AQP4-IgG required for complement activation have been uncovered. Affinity-purified MOG-IgG from patients were shown to be pathogenic by induction of demyelination when the blood--brain barrier (BBB) was breached and by enhancement of activation of cognate T cells. A high-affinity AQP4-IgG, given peripherally, could induce NMOSD-like lesions in rats in the absence of BBB breach. Circulating AQP4-specific and MOG-specific B cells were identified and suggest differences in origin of MOG-antibodies or AQP4-antibodies. Patients with MOG-IgG show a dichotomy concerning circulating MOG-specific B cells; whether this is related to differences in clinical response of anti-CD20 therapy remains to be analyzed. Clinical trials of AQP4-IgG-positive NMOSD patients showed success with eculizumab (preventing cleavage of complement factor C5, thereby blocking formation of chemotactic C5a and membrane attack complex C9neo), inebilizumab (depleting CD19 + B cells), and satralizumab (anti-IL-6R blocking IL-6 actions). SUMMARY New insights into pathological mechanisms and therapeutic responses argue to consider NMOSD with AQP4-IgG and MOGAD as separate disease entities.
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14
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Gerhards R, Pfeffer LK, Lorenz J, Starost L, Nowack L, Thaler FS, Schlüter M, Rübsamen H, Macrini C, Winklmeier S, Mader S, Bronge M, Grönlund H, Feederle R, Hsia HE, Lichtenthaler SF, Merl-Pham J, Hauck SM, Kuhlmann T, Bauer IJ, Beltran E, Gerdes LA, Mezydlo A, Bar-Or A, Banwell B, Khademi M, Olsson T, Hohlfeld R, Lassmann H, Kümpfel T, Kawakami N, Meinl E. Oligodendrocyte myelin glycoprotein as a novel target for pathogenic autoimmunity in the CNS. Acta Neuropathol Commun 2020; 8:207. [PMID: 33256847 PMCID: PMC7706210 DOI: 10.1186/s40478-020-01086-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022] Open
Abstract
Autoimmune disorders of the central nervous system (CNS) comprise a broad spectrum of clinical entities. The stratification of patients based on the recognized autoantigen is of great importance for therapy optimization and for concepts of pathogenicity, but for most of these patients, the actual target of their autoimmune response is unknown. Here we investigated oligodendrocyte myelin glycoprotein (OMGP) as autoimmune target, because OMGP is expressed specifically in the CNS and there on oligodendrocytes and neurons. Using a stringent cell-based assay, we detected autoantibodies to OMGP in serum of 8/352 patients with multiple sclerosis, 1/28 children with acute disseminated encephalomyelitis and unexpectedly, also in one patient with psychosis, but in none of 114 healthy controls. Since OMGP is GPI-anchored, we validated its recognition also in GPI-anchored form. The autoantibodies to OMGP were largely IgG1 with a contribution of IgG4, indicating cognate T cell help. We found high levels of soluble OMGP in human spinal fluid, presumably due to shedding of the GPI-linked OMGP. Analyzing the pathogenic relevance of autoimmunity to OMGP in an animal model, we found that OMGP-specific T cells induce a novel type of experimental autoimmune encephalomyelitis dominated by meningitis above the cortical convexities. This unusual localization may be directed by intrathecal uptake and presentation of OMGP by meningeal phagocytes. Together, OMGP-directed autoimmunity provides a new element of heterogeneity, helping to improve the stratification of patients for diagnostic and therapeutic purposes.
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15
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Sun B, Ramberger M, O'Connor KC, Bashford-Rogers RJM, Irani SR. The B cell immunobiology that underlies CNS autoantibody-mediated diseases. Nat Rev Neurol 2020; 16:481-492. [PMID: 32724223 PMCID: PMC9364389 DOI: 10.1038/s41582-020-0381-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 12/17/2022]
Abstract
A rapidly expanding and clinically distinct group of CNS diseases are caused by pathogenic autoantibodies that target neuroglial surface proteins. Despite immunotherapy, patients with these neuroglial surface autoantibody (NSAb)-mediated diseases often experience clinical relapse, high rates of long-term morbidity and adverse effects from the available medications. Fundamentally, the autoantigen-specific B cell lineage leads to production of the pathogenic autoantibodies. These autoantigen-specific B cells have been consistently identified in the circulation of patients with NSAb-mediated diseases, accompanied by high serum levels of autoantigen-specific antibodies. Early evidence suggests that these cells evade well-characterized B cell tolerance checkpoints. Nearer to the site of pathology, cerebrospinal fluid from patients with NSAb-mediated diseases contains high levels of autoantigen-specific B cells that are likely to account for the intrathecal synthesis of these autoantibodies. The characteristics of their immunoglobulin genes offer insights into the underlying immunobiology. In this Review, we summarize the emerging knowledge of B cells across the NSAb-mediated diseases. We review the evidence for the relative contributions of germinal centres and long-lived plasma cells as sources of autoantibodies, discuss data that indicate migration of B cells into the CNS and summarize insights into the underlying B cell pathogenesis that are provided by therapeutic effects.
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Affiliation(s)
- Bo Sun
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Melanie Ramberger
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kevin C O'Connor
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, USA
| | | | - Sarosh R Irani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
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16
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Olberg HK, Eide GE, Vedeler CA. Can serum GAD65 antibody levels predict neurological disease or cancer? J Neuroimmunol 2019; 336:577025. [PMID: 31472399 DOI: 10.1016/j.jneuroim.2019.577025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 01/04/2023]
Abstract
The clinical relevance of antibodies that bind to glutamic acid decarboxylase 65 (GAD65) is controversial regarding diagnostic utility in screening for neurological disease or cancer. We did a retrospective study of 3152 GAD65 antibody-positive patients to examine whether analysis of the antibody levels could predict neurological disease or cancer. Serum GAD65 antibody levels were not associated with any of the following groups: neurological disease, neurological disease and diabetes, diabetes only, no neurological diagnosis and no diabetes mellitus, or cancer. Analysis of serum GAD65 antibody levels had no prognostic value in neurological disease or cancer. GAD65 antibodies should therefore be measured in selective cases of autoimmune neurological diseases.
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Affiliation(s)
- Henning K Olberg
- Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Geir E Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Christian A Vedeler
- Department of Neurology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway; Neuro-SysMed - Centre of Excellence for Experimental Therapy in Neurology, Departments of Neurology and Clinical Medicine, Bergen, Norway.
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17
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B cells in autoimmune and neurodegenerative central nervous system diseases. Nat Rev Neurosci 2019; 20:728-745. [DOI: 10.1038/s41583-019-0233-2] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
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Winklmeier S, Schlüter M, Spadaro M, Thaler FS, Vural A, Gerhards R, Macrini C, Mader S, Kurne A, Inan B, Karabudak R, Özbay FG, Esendagli G, Hohlfeld R, Kümpfel T, Meinl E. Identification of circulating MOG-specific B cells in patients with MOG antibodies. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:625. [PMID: 31611268 PMCID: PMC6857907 DOI: 10.1212/nxi.0000000000000625] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify circulating myelin oligodendrocyte glycoprotein (MOG)-specific B cells in the blood of patients with MOG antibodies (Abs) and to determine whether circulating MOG-specific B cells are linked to levels and epitope specificity of serum anti-MOG-Abs. METHODS We compared peripheral blood from 21 patients with MOG-Abs and 26 controls for the presence of MOG-specific B cells. We differentiated blood-derived B cells in vitro in separate culture wells to Ab-producing cells via engagement of Toll-like receptors 7 and 8. We quantified the anti-MOG reactivity with a live cell-based assay by flow cytometry. We determined the recognition of MOG epitopes with a panel of mutated variants of MOG. RESULTS MOG-Ab-positive patients had a higher frequency of MOG-specific B cells in blood than controls, but MOG-specific B cells were only detected in about 60% of these patients. MOG-specific B cells in blood showed no correlation with anti-MOG Ab levels in serum, neither in the whole group nor in the untreated patients. Epitope analysis of MOG-Abs secreted from MOG-specific B cells cultured in different wells revealed an intraindividual heterogeneity of the anti-MOG autoimmunity. CONCLUSIONS This study shows that patients with MOG-Abs greatly differ in the abundance of circulating MOG-specific B cells, which are not linked to levels of MOG-Abs in serum suggesting different sources of MOG-Abs. Identification of MOG-specific B cells in blood could be of future relevance for selecting patients with MOG-Abs for B cell-directed therapy.
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Affiliation(s)
- Stephan Winklmeier
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Miriam Schlüter
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Melania Spadaro
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Franziska S Thaler
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Atay Vural
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Ramona Gerhards
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Caterina Macrini
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Simone Mader
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Aslı Kurne
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Berin Inan
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Rana Karabudak
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Feyza Gül Özbay
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Gunes Esendagli
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Reinhard Hohlfeld
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Tania Kümpfel
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany
| | - Edgar Meinl
- From the Institute of Clinical Neuroimmunology (S.W., M. Schlüter, M. Spadaro, F.S.T., A.V., R.G., C.M., S.M., R.H., T.K., E.M.), Biomedical Center and University Hospitals, Ludwig Maximilian University Munich, Germany; Research Center for Translational Medicine (A.V.), Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, (A.K., B.I., R.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey; Department of Basic Oncology (F.G.Ö., G.E.), Hacettepe University Cancer Institute, Ankara Turkey; and Munich Cluster for Systems Neurology (SyNergy) (R.H.), Germany.
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