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Karbian N, Eshed-Eisenbach Y, Zeibak M, Tabib A, Sukhanov N, Vainshtein A, Morgan BP, Fellig Y, Peles E, Mevorach D. Complement-membrane regulatory proteins are absent from the nodes of Ranvier in the peripheral nervous system. J Neuroinflammation 2023; 20:245. [PMID: 37875972 PMCID: PMC10594684 DOI: 10.1186/s12974-023-02920-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Homozygous CD59-deficient patients manifest with recurrent peripheral neuropathy resembling Guillain-Barré syndrome (GBS), hemolytic anemia and recurrent strokes. Variable mutations in CD59 leading to loss of function have been described and, overall, 17/18 of patients with any mutation presented with recurrent GBS. Here we determine the localization and possible role of membrane-bound complement regulators, including CD59, in the peripheral nervous systems (PNS) of mice and humans. METHODS We examined the localization of membrane-bound complement regulators in the peripheral nerves of healthy humans and a CD59-deficient patient, as well as in wild-type (WT) and CD59a-deficient mice. Cross sections of teased sciatic nerves and myelinating dorsal root ganglia (DRG) neuron/Schwann cell cultures were examined by confocal and electron microscopy. RESULTS We demonstrate that CD59a-deficient mice display normal peripheral nerve morphology but develop myelin abnormalities in older age. They normally express myelin protein zero (P0), ankyrin G (AnkG), Caspr, dystroglycan, and neurofascin. Immunolabeling of WT nerves using antibodies to CD59 and myelin basic protein (MBP), P0, and AnkG revealed that CD59 was localized along the internode but was absent from the nodes of Ranvier. CD59 was also detected in blood vessels within the nerve. Finally, we show that the nodes of Ranvier lack other complement-membrane regulatory proteins, including CD46, CD55, CD35, and CR1-related gene-y (Crry), rendering this area highly exposed to complement attack. CONCLUSION The Nodes of Ranvier lack CD59 and are hence not protected from complement terminal attack. The myelin unit in human PNS is protected by CD59 and CD55, but not by CD46 or CD35. This renders the nodes and myelin in the PNS vulnerable to complement attack and demyelination in autoinflammatory Guillain-Barré syndrome, as seen in CD59 deficiency.
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Affiliation(s)
- Netanel Karbian
- Rheumatology and Rare Disease Research Center, The Wohl Institute for Translational Medicine, Hadassah-Hebrew University Medical Center and School of Medicine, Jerusalem, Israel
| | - Yael Eshed-Eisenbach
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
- Department of Molecular Neuroscience, Weizmann Institute of Science, Rehovot, Israel
| | - Marian Zeibak
- Rheumatology and Rare Disease Research Center, The Wohl Institute for Translational Medicine, Hadassah-Hebrew University Medical Center and School of Medicine, Jerusalem, Israel
| | - Adi Tabib
- Rheumatology and Rare Disease Research Center, The Wohl Institute for Translational Medicine, Hadassah-Hebrew University Medical Center and School of Medicine, Jerusalem, Israel
| | - Natasha Sukhanov
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
- Department of Molecular Neuroscience, Weizmann Institute of Science, Rehovot, Israel
| | - Anya Vainshtein
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
- Department of Molecular Neuroscience, Weizmann Institute of Science, Rehovot, Israel
| | - B. Paul Morgan
- Systems Immunity Research Institute, Cardiff University, Cardiff, Wales UK
| | - Yakov Fellig
- Department of Pathology, School of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Elior Peles
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
- Department of Molecular Neuroscience, Weizmann Institute of Science, Rehovot, Israel
| | - Dror Mevorach
- Rheumatology and Rare Disease Research Center, The Wohl Institute for Translational Medicine, Hadassah-Hebrew University Medical Center and School of Medicine, Jerusalem, Israel
- The Institute of Rheumatology-Immunology-Allergology, The Wohl Institute for Translational Medicine, Department of Medicine, Hadassah-Hebrew University Medical Center and School of Medicine, POB 12000, 91120 Jerusalem, Israel
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Chai JN, Azad AK, Kuan K, Guo X, Wang Y. A Splice Site Mutation Associated with Congenital CD59 Deficiency. Hematol Rep 2022; 14:172-178. [PMID: 35735736 PMCID: PMC9222317 DOI: 10.3390/hematolrep14020025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/23/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
Congenital CD59 deficiency is a recently described rare autosomal recessive disease associated with CD59 gene mutations that lead to deficient or dysfunctional CD59 protein on the cell surface. The disease is characterized by the early onset of chronic hemolysis, relapsing peripheral demyelinating neuropathy, and recurrent ischemic strokes. To date, there are 14 patients with 4 exon mutations reported globally. A young boy with early onset peripheral neuropathy and atypical hemolytic uremic syndrome is presented. Next-generation sequencing (NGS) identified a homozygous splice site variant in intron 1 of the CD59 gene (c.67 + 1G > T). This variant alters a consensus donor splicing site. Quantitative reverse transcription PCR showed that CD59 mRNA expression in the patient is significantly reduced to 0.017-fold compared to the controls. Flow cytometry showed the lack of CD59 protein on the surface of the patient’s red blood cells. This variant is the first splice site mutation reported to be associated with congenital CD59 deficiency.
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Affiliation(s)
| | | | | | | | - Yanhua Wang
- Correspondence: ; Tel.: +1-718-920-4976; Fax: +1-718-920-7611
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Complement and the prothrombotic state. Blood 2021; 139:1954-1972. [PMID: 34415298 DOI: 10.1182/blood.2020007206] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
In 2007 and 2009 the regulatory approval of the first-in-class complement inhibitor Eculizumab has revolutionized the clinical management of two rare, life-threatening clinical conditions: paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). While being completely distinct diseases affecting blood cells and the glomerulus, PNH and aHUS remarkably share several features in their etiology and clinical presentation. An imbalance between complement activation and regulation at host surfaces underlies both diseases precipitating in severe thrombotic events that are largely resistant to anti-coagulant and/or anti-platelet therapies. Inhibition of the common terminal complement pathway by Eculizumab prevents the frequently occurring thrombotic events responsible for the high mortality and morbidity observed in patients not treated with anti-complement therapy. While many in vitro and ex vivo studies elaborate numerous different molecular interactions between complement activation products and hemostasis, this review focuses on the clinical evidence that links these two fields in humans. Several non-infectious conditions with known complement involvement are scrutinized for common patterns concerning a prothrombotic statues and the occurrence of certain complement activation levels. Next to PNH and aHUS, germline encoded CD59 or CD55 deficiency (the latter causing the disease Complement Hyperactivation, Angiopathic thrombosis, and Protein-Losing Enteropathy; CHAPLE), autoimmune hemolytic anemia (AIHA), (catastrophic) anti-phospholipid syndrome (APS, CAPS) and C3 glomerulopathy are considered. Parallels and distinct features among these conditions are discussed against the background of thrombosis, complement activation, and potential complement diagnostic and therapeutic avenues.
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Garred P, Tenner AJ, Mollnes TE. Therapeutic Targeting of the Complement System: From Rare Diseases to Pandemics. Pharmacol Rev 2021; 73:792-827. [PMID: 33687995 PMCID: PMC7956994 DOI: 10.1124/pharmrev.120.000072] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The complement system was discovered at the end of the 19th century as a heat-labile plasma component that "complemented" the antibodies in killing microbes, hence the name "complement." Complement is also part of the innate immune system, protecting the host by recognition of pathogen-associated molecular patterns. However, complement is multifunctional far beyond infectious defense. It contributes to organ development, such as sculpting neuron synapses, promoting tissue regeneration and repair, and rapidly engaging and synergizing with a number of processes, including hemostasis leading to thromboinflammation. Complement is a double-edged sword. Although it usually protects the host, it may cause tissue damage when dysregulated or overactivated, such as in the systemic inflammatory reaction seen in trauma and sepsis and severe coronavirus disease 2019 (COVID-19). Damage-associated molecular patterns generated during ischemia-reperfusion injuries (myocardial infarction, stroke, and transplant dysfunction) and in chronic neurologic and rheumatic disease activate complement, thereby increasing damaging inflammation. Despite the long list of diseases with potential for ameliorating complement modulation, only a few rare diseases are approved for clinical treatment targeting complement. Those currently being efficiently treated include paroxysmal nocturnal hemoglobinuria, atypical hemolytic-uremic syndrome, myasthenia gravis, and neuromyelitis optica spectrum disorders. Rare diseases, unfortunately, preclude robust clinical trials. The increasing evidence for complement as a pathogenetic driver in many more common diseases suggests an opportunity for future complement therapy, which, however, requires robust clinical trials; one ongoing example is COVID-19 disease. The current review aims to discuss complement in disease pathogenesis and discuss future pharmacological strategies to treat these diseases with complement-targeted therapies. SIGNIFICANCE STATEMENT: The complement system is the host's defense friend by protecting it from invading pathogens, promoting tissue repair, and maintaining homeostasis. Complement is a double-edged sword, since when dysregulated or overactivated it becomes the host's enemy, leading to tissue damage, organ failure, and, in worst case, death. A number of acute and chronic diseases are candidates for pharmacological treatment to avoid complement-dependent damage, ranging from the well established treatment for rare diseases to possible future treatment of large patient groups like the pandemic coronavirus disease 2019.
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Affiliation(s)
- Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (P.G.); Departments of Molecular Biology and Biochemistry, Neurobiology and Behavior, and Pathology and Laboratory Medicine, University of California, Irvine, California (A.J.T.); and Research Laboratory, Nordland Hospital, Bodø, Norway, Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway (T.E.M.); Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway (T.E.M.); and Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway (T.E.M.)
| | - Andrea J Tenner
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (P.G.); Departments of Molecular Biology and Biochemistry, Neurobiology and Behavior, and Pathology and Laboratory Medicine, University of California, Irvine, California (A.J.T.); and Research Laboratory, Nordland Hospital, Bodø, Norway, Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway (T.E.M.); Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway (T.E.M.); and Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway (T.E.M.)
| | - Tom E Mollnes
- Laboratory of Molecular Medicine, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (P.G.); Departments of Molecular Biology and Biochemistry, Neurobiology and Behavior, and Pathology and Laboratory Medicine, University of California, Irvine, California (A.J.T.); and Research Laboratory, Nordland Hospital, Bodø, Norway, Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway (T.E.M.); Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway (T.E.M.); and Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway (T.E.M.)
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Yuksel D, Oguz KK, Azapagası E, Kesici S, Cavdarli B, Konuskan B, Topaloglu H. Uncontrolled inflammation of the nervous system: Inherited CD59 deficiency. Neurol Clin Pract 2018; 8:e18-e20. [PMID: 30564502 DOI: 10.1212/cpj.0000000000000511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/29/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Deniz Yuksel
- Department of Pediatric Neurology (DY) and Pediatric Intensive Care Unit (EA, SK), University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital; Departments of Radiology (KKO) and Pediatric Neurology (BK, HT), Faculty of Medicine, Hacettepe University; and Ankara Numune Training and Research Hospital (BC), Genetic Diseases Diagnosis Center, Ankara, Turkey
| | - Kader Karli Oguz
- Department of Pediatric Neurology (DY) and Pediatric Intensive Care Unit (EA, SK), University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital; Departments of Radiology (KKO) and Pediatric Neurology (BK, HT), Faculty of Medicine, Hacettepe University; and Ankara Numune Training and Research Hospital (BC), Genetic Diseases Diagnosis Center, Ankara, Turkey
| | - Ebru Azapagası
- Department of Pediatric Neurology (DY) and Pediatric Intensive Care Unit (EA, SK), University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital; Departments of Radiology (KKO) and Pediatric Neurology (BK, HT), Faculty of Medicine, Hacettepe University; and Ankara Numune Training and Research Hospital (BC), Genetic Diseases Diagnosis Center, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Neurology (DY) and Pediatric Intensive Care Unit (EA, SK), University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital; Departments of Radiology (KKO) and Pediatric Neurology (BK, HT), Faculty of Medicine, Hacettepe University; and Ankara Numune Training and Research Hospital (BC), Genetic Diseases Diagnosis Center, Ankara, Turkey
| | - Busranur Cavdarli
- Department of Pediatric Neurology (DY) and Pediatric Intensive Care Unit (EA, SK), University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital; Departments of Radiology (KKO) and Pediatric Neurology (BK, HT), Faculty of Medicine, Hacettepe University; and Ankara Numune Training and Research Hospital (BC), Genetic Diseases Diagnosis Center, Ankara, Turkey
| | - Bahadir Konuskan
- Department of Pediatric Neurology (DY) and Pediatric Intensive Care Unit (EA, SK), University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital; Departments of Radiology (KKO) and Pediatric Neurology (BK, HT), Faculty of Medicine, Hacettepe University; and Ankara Numune Training and Research Hospital (BC), Genetic Diseases Diagnosis Center, Ankara, Turkey
| | - Haluk Topaloglu
- Department of Pediatric Neurology (DY) and Pediatric Intensive Care Unit (EA, SK), University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital; Departments of Radiology (KKO) and Pediatric Neurology (BK, HT), Faculty of Medicine, Hacettepe University; and Ankara Numune Training and Research Hospital (BC), Genetic Diseases Diagnosis Center, Ankara, Turkey
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Karbian N, Eshed-Eisenbach Y, Tabib A, Hoizman H, Morgan BP, Schueler-Furman O, Peles E, Mevorach D. Molecular pathogenesis of human CD59 deficiency. NEUROLOGY-GENETICS 2018; 4:e280. [PMID: 30533526 PMCID: PMC6244018 DOI: 10.1212/nxg.0000000000000280] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/07/2018] [Indexed: 11/15/2022]
Abstract
Objective To characterize all 4 mutations described for CD59 congenital deficiency. Methods The 4 mutations, p.Cys64Tyr, p.Asp24Val, p.Asp24Valfs*, and p.Ala16Alafs*, were described in 13 individuals with CD59 malfunction. All 13 presented with recurrent Guillain-Barré syndrome or chronic inflammatory demyelinating polyneuropathy, recurrent strokes, and chronic hemolysis. Here, we track the molecular consequences of the 4 mutations and their effects on CD59 expression, localization, glycosylation, degradation, secretion, and function. Mutants were cloned and inserted into plasmids to analyze their expression, localization, and functionality. Results Immunolabeling of myc-tagged wild-type (WT) and mutant CD59 proteins revealed cell surface expression of p.Cys64Tyr and p.Asp24Val detected with the myc antibody, but no labeling by anti-CD59 antibodies. In contrast, frameshift mutants p.Asp24Valfs* and p.Ala16Alafs* were detected only intracellularly and did not reach the cell surface. Western blot analysis showed normal glycosylation but mutant-specific secretion patterns. All mutants significantly increased MAC-dependent cell lysis compared with WT. In contrast to CD59 knockout mice previously used to characterize phenotypic effects of CD59 perturbation, all 4 hCD59 mutations generate CD59 proteins that are expressed and may function intracellularly (4) or on the cell membrane (2). None of the 4 CD59 mutants are detected by known anti-CD59 antibodies, including the 2 variants present on the cell membrane. None of the 4 inhibits membrane attack complex (MAC) formation. Conclusions All 4 mutants generate nonfunctional CD59, 2 are expressed as cell surface proteins that may function in non-MAC-related interactions and 2 are expressed only intracellularly. Distinct secretion of soluble CD59 may have also a role in disease pathogenesis.
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Affiliation(s)
- Netanel Karbian
- Rheumatology Research Center (N.K., A.T., H.H., D.M.), Center of Rare Diseases, and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem; The Weizmann Institute (Y.E.-E., E.P.), Rehovot, Israel; Systems Immunity Research Institute (B.P.M.), Cardiff University, Cardiff, Wales, UK; and Hebrew University (O.S.-F., D.M.), Jerusalem, Israel
| | - Yael Eshed-Eisenbach
- Rheumatology Research Center (N.K., A.T., H.H., D.M.), Center of Rare Diseases, and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem; The Weizmann Institute (Y.E.-E., E.P.), Rehovot, Israel; Systems Immunity Research Institute (B.P.M.), Cardiff University, Cardiff, Wales, UK; and Hebrew University (O.S.-F., D.M.), Jerusalem, Israel
| | - Adi Tabib
- Rheumatology Research Center (N.K., A.T., H.H., D.M.), Center of Rare Diseases, and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem; The Weizmann Institute (Y.E.-E., E.P.), Rehovot, Israel; Systems Immunity Research Institute (B.P.M.), Cardiff University, Cardiff, Wales, UK; and Hebrew University (O.S.-F., D.M.), Jerusalem, Israel
| | - Hila Hoizman
- Rheumatology Research Center (N.K., A.T., H.H., D.M.), Center of Rare Diseases, and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem; The Weizmann Institute (Y.E.-E., E.P.), Rehovot, Israel; Systems Immunity Research Institute (B.P.M.), Cardiff University, Cardiff, Wales, UK; and Hebrew University (O.S.-F., D.M.), Jerusalem, Israel
| | - B Paul Morgan
- Rheumatology Research Center (N.K., A.T., H.H., D.M.), Center of Rare Diseases, and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem; The Weizmann Institute (Y.E.-E., E.P.), Rehovot, Israel; Systems Immunity Research Institute (B.P.M.), Cardiff University, Cardiff, Wales, UK; and Hebrew University (O.S.-F., D.M.), Jerusalem, Israel
| | - Ora Schueler-Furman
- Rheumatology Research Center (N.K., A.T., H.H., D.M.), Center of Rare Diseases, and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem; The Weizmann Institute (Y.E.-E., E.P.), Rehovot, Israel; Systems Immunity Research Institute (B.P.M.), Cardiff University, Cardiff, Wales, UK; and Hebrew University (O.S.-F., D.M.), Jerusalem, Israel
| | - Elior Peles
- Rheumatology Research Center (N.K., A.T., H.H., D.M.), Center of Rare Diseases, and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem; The Weizmann Institute (Y.E.-E., E.P.), Rehovot, Israel; Systems Immunity Research Institute (B.P.M.), Cardiff University, Cardiff, Wales, UK; and Hebrew University (O.S.-F., D.M.), Jerusalem, Israel
| | - Dror Mevorach
- Rheumatology Research Center (N.K., A.T., H.H., D.M.), Center of Rare Diseases, and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem; The Weizmann Institute (Y.E.-E., E.P.), Rehovot, Israel; Systems Immunity Research Institute (B.P.M.), Cardiff University, Cardiff, Wales, UK; and Hebrew University (O.S.-F., D.M.), Jerusalem, Israel
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Klemann C, Kirschner J, Ammann S, Urbach H, Moske-Eick O, Zieger B, Lorenz MR, Schwarz K, Doostkam S, Ehl S, Korinthenberg R. CD59 deficiency presenting as polyneuropathy and Moyamoya syndrome with endothelial abnormalities of small brain vessels. Eur J Paediatr Neurol 2018; 22:870-877. [PMID: 29843966 DOI: 10.1016/j.ejpn.2018.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 02/17/2018] [Accepted: 04/04/2018] [Indexed: 12/31/2022]
Abstract
CD59 is involved in lymphocyte signal transduction and regulates complement-mediated cell lysis by inhibiting the membrane attack complex. In the cases reported so far, congenital isolated CD59 deficiency was associated with recurrent episodes of hemolytic anemia, peripheral neuropathy, and strokes. Here, we report on a patient from a consanguineous Turkish family, who had a first episode of hemolytic anemia at one month of age and presented at 14 months with acute Guillain-Barré syndrome (GBS). The child suffered repeated infection-triggered relapses leading to the diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP). Although partly steroid-responsive, the polyneuropathy failed to be stabilized by a number of immunosuppressive agents. At the age of 6 years, he developed acute hemiparesis and showed progressive stenosis of proximal cerebral arteries, evolving into Moyamoya syndrome (MMS) with recurrent infarctions leading to death at 8 years of age. Post-mortem genetic analysis revealed a pathogenic p.(Asp49Valfs*31) mutation in CD59. Re-analysis of brain biopsy specimens showed absent CD59 expression and severe endothelial damage. Whereas strokes are a known feature of CD59 deficiency, MMS has not previously been described in this condition. Therefore, we conclude that in MMS combined with hemolysis or neuropathy CD59 deficiency should be considered. Establishing the diagnosis and targeted therapy with eculizumab might have prevented the lethal course in our patient.
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Affiliation(s)
- Christian Klemann
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Center for Pediatrics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Department of Pediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.
| | - Janbernd Kirschner
- Center for Pediatrics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Center for Pediatrics, Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Sandra Ammann
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Cambridge Institute for Medical Research, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Olaf Moske-Eick
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Center for Pediatrics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany
| | | | - Klaus Schwarz
- Institute for Transfusion Medicine, University of Ulm, Ulm, Germany; Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Service, Baden-Württemberg - Hessen, Ulm, Germany
| | - Soroush Doostkam
- Institute for Neuropathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Stephan Ehl
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Center for Pediatrics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Rudolf Korinthenberg
- Center for Pediatrics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Center for Pediatrics, Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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Kinoshita T. Congenital Defects in the Expression of the Glycosylphosphatidylinositol-Anchored Complement Regulatory Proteins CD59 and Decay-Accelerating Factor. Semin Hematol 2018; 55:136-140. [DOI: 10.1053/j.seminhematol.2018.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/10/2018] [Indexed: 12/29/2022]
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9
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Tabib A, Hindi I, Karbian N, Zelig O, Falach B, Mevorach D. Prothrombotic mechanisms in patients with congenital p.Cys89Tyr mutation in CD59. Thromb Res 2018; 168:67-77. [PMID: 29929138 DOI: 10.1016/j.thromres.2018.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 06/03/2018] [Accepted: 06/08/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Thrombosis is the prognostic factor with the greatest effect on survival in patients with paroxysmal nocturnal hemoglobinuria (PNH), who lack dozens of membrane surface proteins. We recently described a primary homozygous Cys89Tyr congenital nonfunctioning CD59 in humans with clinical manifestation in infancy, associated with chronic hemolysis, recurrent strokes, and relapsing peripheral demyelinating neuropathy. Here we investigated hypercoagulability mechanisms characterizing the syndrome. METHODS Membrane attack complex (MAC) deposition (anti-SC5b-9) and free hemoglobin (colorimetric assay) were assessed. Platelet activation was identified (anti-CD61, anti-CD62P), and microparticles (MPs) of 0.5-0.9 μm, were characterized (Annexin V, anti-human GlyA, anti-CD15, anti-CD14, anti-CD61). Platelet-monocyte aggregation was assessed with FlowSight. FINDINGS 2/7 patients (29%) with homozygosity for Cys89Tyr and 6/12 (50%) with any of four described CD59 mutations had recurrent strokes. In plasma samples from four patients carrying identical mutations, MAC deposition was increased on RBCs (p < 0.0003), neutrophils (p < 0.009), and platelets (p < 0.0003). Free-plasma hemoglobin levels were abnormally high, up to 100 mg/dl. Patients with CD59 mutation had RBC-derived MP levels 9-fold higher than those in healthy controls (p < 0.01), and 2-2.5 fold higher than PNH patients (p < 0.09). Leukocyte-activated platelet aggregation was increased (p < 0.0062). Loss of CD59 was shown in the endothelium of these patients. INTERPRETATION Nonfunctioning CD59 is a major risk factor for stroke and hypercoagulability. Uncontrolled hemolysis causes massive MP release and endothelial heme damage. MAC attack on unprotected endothelium and platelet activation and aggregation with leukocytes mediate additional mechanisms leading to vascular occlusion. It is suggested that CD59 loss represents a major arterial prothrombotic factor in PNH and additional diseases.
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Affiliation(s)
- Adi Tabib
- Rheumatology Research Center and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Issam Hindi
- Rheumatology Research Center and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Netanel Karbian
- Rheumatology Research Center and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Orly Zelig
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Batla Falach
- Rheumatology Research Center and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Dror Mevorach
- Rheumatology Research Center and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Tabib A, Karbian N, Mevorach D. Demyelination, strokes, and eculizumab: Lessons from the congenital CD59 gene mutations. Mol Immunol 2017. [PMID: 28622911 DOI: 10.1016/j.molimm.2017.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Neurological symptoms of patients with p.Cys89Tyr mutation in the CD59 gene include recurrent peripheral neuropathy resembling Guillain-Barré syndrome, characterized by sensory-motor demyelinating neuropathy with secondary axonal damage and moderate enhancement of the nerve roots on spine MRI, together with recurrent strokes and retinal involvement. Three additional mutations in CD59, leading to loss of function, have been described, and overall, 12/12 (100%) of patients with any mutation presented with neurological symptoms; 11/12 (92%) patients presented with recurrent peripheral neuropathy, 6/12 (50%) with recurrent strokes, and 1/12 (8%) with retinal involvement. We review the possible thrombophilic profile associated with the mutations. In these patients, excessive intravascular hemolysis saturates scavenger mechanisms resulting in free hemoglobin in plasma that irreversibly reacts with nitric oxide to form nitrate and methemoglobin, leading to arterial thrombosis. CD59 loss of function is also one of the major thrombophilic mechanisms in patients with paroxysmal nocturnal hemoglobinuria. We then describe the relationship with demyelination. The lack of CD59 allows uncontrolled complement amplification following low-level spontaneous-, viral-, or post viral-induced complement activation, resulting in severe demyelination in the peripheral nervous system. It is interesting, and certainly encouraging, that after 3 years, following 4 patients with Cys89Tyr mutations who are treated with eculizumab, no strokes occurred and non-permanent neurological insults underwent resolution without any new neurological exacerbations.
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Affiliation(s)
- Adi Tabib
- Rheumatology Research Center and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Netanel Karbian
- Rheumatology Research Center and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Dror Mevorach
- Rheumatology Research Center and Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Mevorach D, Reiner I, Grau A, Ilan U, Berkun Y, Ta-Shma A, Elpeleg O, Shorer Z, Edvardson S, Tabib A. Therapy with eculizumab for patients with CD59 p.Cys89Tyr mutation. Ann Neurol 2016; 80:708-717. [DOI: 10.1002/ana.24770] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 08/22/2016] [Accepted: 08/24/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Dror Mevorach
- Rheumatology Research Center and Department of Medicine; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Inna Reiner
- Rheumatology Research Center and Department of Medicine; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Amir Grau
- Rheumatology Research Center and Department of Medicine; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Uri Ilan
- Department of Pediatrics; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Yackov Berkun
- Department of Pediatrics; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Asaf Ta-Shma
- Monique and Jacques Roboh Department of Genetic Research; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Orly Elpeleg
- Monique and Jacques Roboh Department of Genetic Research; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Zamir Shorer
- Neuropediatric Unit, Soroka Medical Center; Beer Sheba Israel
| | - Simon Edvardson
- Neuropediatric Unit; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Adi Tabib
- Rheumatology Research Center and Department of Medicine; Hadassah-Hebrew University Medical Center; Jerusalem Israel
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