Myasthenia gravis: T and B cell reactivities to the beta-bungarotoxin binding protein presynaptic membrane receptor

Presynaptic membrane receptor in human brain

Myasthenia gravis (MG) is an autoimmune disease that results from antibody mediated damage of Acetylcholine receptor (AChR) at the neuromuscular junction. The autoimmune character of MG and pathogenic role of AChR antibodies have been established by several workers i.e., the demonstration of anti-AChR antibodies in about 90 % of MG patients. It has been demonstrated that patients with MG also have antibodies against a second protein named presynaptic membrane receptor (PsmR), which is identified by utilizing β-Bgtx, a ligand which binds to PsmR. Using β-Bgtx Sepharose 4B affinity matrix, the PsmR was purified from different regions of human cadaver brain by affinity chromatography. Purified receptor was characterized both by biochemical and immunological procedures. PsmR purified from different regions of the brain shows a specific activity of 0.37 ± 0.01, 0.39 ± 0.02 and 0.43 ± 0.005 nM/ μg of protein in Parietal lobe, Occipital lobe and Frontal lobe respectively. The affinity purified PsmR from the brain of 87 and 68 kd (parietal lobe, occipital lobe and frontal lobe) shows immunoreactivity with myasthenic sera. These findings suggest that PsmR from brain is another antigen against which autoantibodies are developed in Myasthenia gravis patients. Upon treatment with various enzymes we concluded that PsmR from brain is a glycoprotein in which the immunoreactivity resides in the carbohydrate as well as the peptide epitopes. In conclusion the PsmR is another antigen against which autoantibodies are formed in different regions of brain. These can be used as a diagnostic tool for detecting antibodies in the sera or cerebrospinal fluid of MG patients.

The auto-antigen repertoire in myasthenia gravis

Myasthenia Gravis (MG) is an antibody-mediated autoimmune disorder affecting the postsynaptic membrane of the neuromuscular junction (NMJ). MG is characterized by an impaired signal transmission between the motor neuron and the skeletal muscle cell, caused by auto-antibodies directed against NMJ proteins. The auto-antibodies target the nicotinic acetylcholine receptor (nAChR) in about 90% of MG patients. In approximately 5% of MG patients, the muscle specific kinase (MuSK) is the auto-antigen. In the remaining 5% of MG patients, however, antibodies against the nAChR or MuSK are not detectable (idiopathic MG, iMG). Although only the anti-nAChR and anti-MuSK auto-antibodies have been demonstrated to be pathogenic, several other antibodies recognizing self-antigens can also be found in MG patients. Various auto-antibodies associated with thymic abnormalities have been reported, as well as many non-MG-specific auto-antibodies. However, their contribution to the cause, pathology and severity of the disease is still poorly understood. Here, we comprehensively review the reported auto-antibodies in MG patients and discuss their role in the pathology of this autoimmune disease.

Diagnostic difficulties in myasthenia gravis

Four patients with myasthenia gravis presented with severe, largely isolated, bulbar and respiratory muscles weakness. Tensilon tests were positive and antiacetylcholine receptor (anti-AChR) antibody titers were negative in all patients. Only 1 patient had a greater than 10% decremental response during the period of respiratory failure. Although routine nerve conduction studies were normal, all had very low-amplitude diaphragmatic compound muscle action potentials. Three patients had abundant fibrillation potentials and positive sharp waves largely restricted to respiratory muscles. Clinical and electrophysiological findings improved with corticosteroids, and surprisingly, decremental responses became positive in all patients. The assessment of patients with largely isolated bulbar and respiratory muscle weakness due to myasthenia gravis may be difficult and misleading, as anti-AChR antibody titers may be negative, decremental responses may be absent, and electrophysiological assessment atypical. Due consideration of clinical symptomatology, a Tensilon test, and a trial of immunosuppression may be necessary to establish the diagnosis.

A sensitive ELISPOT assay to detect low-frequency human T lymphocytes

We extended the sensitivity of the ELISPOT assay by including an antigen-driven proliferation step prior to a final restimulation with antigen and irradiated antigen presenting cells (APCs). This improved sensitivity made the modified ELISPOT assay better suited to the detection of rare or low frequency T lymphocytes than the standard ELISPOT assay or alternatives such as limiting dilution analysis or in situ hybridization. Use of ELISA-grade plastic or polyvinylidene difluoride (PVDF) plates for the detection of different cytokines improved the signal-to-noise ratio for counting cytokine spots, and use of video computer imaging software improved objective quantitation. Analysis of antigen-reactive peripheral blood mononuclear cells (PBMC) from multiple sclerosis (MS) patients using both the traditional and our modified ELISPOT assay demonstrate a > 10-fold increase in numbers of myelin basic protein (MBP)-responsive T cells detected (an average of less than 1 spot forming cell (SFC) per 2 x 10(5) PBMC with the standard assay compared to 19 SFC per 2 x 10(5) PBMC with the modified assay). In addition, the modified ELISPOT assay could be performed with frozen PBMC, which permitted greater flexibility in sample processing, multiple use of a single sample as an internal standard, and simultaneous analysis of samples collected at different time points. This modified ELISPOT assay has many applications, including analysis of cytokine profiles in rare T cell populations, identification of antigen-responsive individuals as PBMC donors for T lymphocyte cloning or for therapeutic intervention, and assessment of vaccine or therapeutic efficacy as a surrogate clinical marker.

Peripheral blood in Sjögren's syndrome does not contain increased levels of T lymphocytes reactive with the recombinant Ro/SS-A 52 kD and La/SS-B 48 kD autoantigens

Patients with Sjögren's syndrome (SS) frequently have anti-Ro/SS-A and anti-La/SS-B autoantibodies. The aim of this study was to investigate if these patients have peripheral blood lymphocytes (PBL) secreting IFN-gamma after short-term cultivation in the presence of Ro/SS-A and La/SS-B antigens. The frequency of PBL secreting IFN-gamma was examined in 12 SS patients and 11 healthy controls. The enzyme-linked immunospot (ELISPOT) assay was performed after 48 hours cultivation of PBL in the presence of recombinant Ro 52 kD protein or recombinant La 48 kD protein. The number of unstimulated IFN-gamma secreting cells in the SS patient group was not significantly different from that of the control group. Moreover, no increase in the number of IFN-gamma secreting cells after Ro/SS-A and La/SS-B stimulation was detected in the two groups. Thus, T cells reactive with the recombinant Ro 52 kD and La 48 kD proteins do not occur with any increased frequency in peripheral blood of SS patients.

Selective inhibition of the slow K+ current at motor nerve ending by plasma from a myasthenia gravis patient

The effect of plasma from a myasthenia gravis (MG) patient, containing anti-presynaptic membrane receptor (PsmR) antibody on the membrane currents of motor nerve ending was investigated in mouse intercostal nerve triangularis sterni preparations by perineurial recording. After inhibition of both the fast K+ current and Ca(2+)-dependent K+ current by 30 mM Tetraethyl-ammonium (TEA) unmasked the voltage dependent fast Ca2+ current and the "Ca plateau", which was contributed by the voltage-dependent slow Ca2+ current and slow K+ current. Application of the MG plasma caused further prolongation and increase of the Ca plateau, due to blockage of the slow K+ current. This effect was observed immediately after the application and could be partially reversed by washing, whereas no change was found by addition of the plasma from healthy persons. When K+ current was completely blocked by 30 mM TEA and 300 microM 3,4-diaminopyridine (3,4-DAP), the fast Ca2+ current and the slow Ca2+ current were revealed. Neither the fast nor the slow Ca2+ current could be affected by the MG plasma; It was also shown that the MG plasma was devoid of noticeable effect on the voltage dependent Na+ current, fast K+ current as well as the Ca(2+)-dependent K+ current. So the effect of the MG plasma with antibody to PsmR was concluded to inhibit the slow K+ current selectively. As we knew, the beta-bungarotoxin binding protein was a kind of K+ channel, these results further confirmed that the beta-bungarotoxin binding protein should be the target of the antibody to PsmR found in the plasma of some patients suffering from MG.

Antibody-secreting cells to acetylcholine receptor and to presynaptic membrane receptor in seronegative myasthenia gravis

Peripheral blood and bone marrow from seronegative and seropositive myasthenics were evaluated for antibody-secreting cells (ASC). Cells secreting antibody to acetylcholine receptor (AchR) and to presynaptic membrane receptor (prsmR) were counted using an immunospot assay. Immunoglobulin G (IgG) anti-AchR ASC were present in peripheral blood lymphocytes (PBL) from nine of 13 seronegative and nine of 12 seropositive myasthenics and in bone marrow lymphocytes (BML) from nine of 13 seronegative and eight of 12 seropositive myasthenics. The mean number of IgG anti-AchR ASC was lower for seronegative than for seropositive patients (P < 0.01 for PBL and P < 0.0001 for BML). In seropositive patients the mean number of IgG anti-AchR ASC was higher for BML than for PBL (P < 0.01); in seronegative patients it was not. IgG anti-prsmR ASC were detected in PBL from four of eight seronegative and six of eight seropositive myasthenics and in BML from three of eight seronegative and five of eight seropositive patients. The mean number of IgG-anti-prsmR ASC did not differ between seronegative and seropositive patients for PBL but for BML the value was higher for seropositive than for seronegative patients (P < 0.01). We conclude that seronegative myasthenia gravis is an autoimmune disease and that ASC to AchR and to prsmR are present both in the blood and the bone marrow in seronegative patients as in seropositive ones. A major difference between the groups lies in the significantly greater number of ASC found in the bone marrow in the seropositive cohort.