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Liblau RS, Latorre D, Kornum BR, Dauvilliers Y, Mignot EJ. The immunopathogenesis of narcolepsy type 1. Nat Rev Immunol 2024; 24:33-48. [PMID: 37400646 DOI: 10.1038/s41577-023-00902-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/05/2023]
Abstract
Narcolepsy type 1 (NT1) is a chronic sleep disorder resulting from the loss of a small population of hypothalamic neurons that produce wake-promoting hypocretin (HCRT; also known as orexin) peptides. An immune-mediated pathology for NT1 has long been suspected given its exceptionally tight association with the MHC class II allele HLA-DQB1*06:02, as well as recent genetic evidence showing associations with polymorphisms of T cell receptor genes and other immune-relevant loci and the increased incidence of NT1 that has been observed after vaccination with the influenza vaccine Pandemrix. The search for both self-antigens and foreign antigens recognized by the pathogenic T cell response in NT1 is ongoing. Increased T cell reactivity against HCRT has been consistently reported in patients with NT1, but data demonstrating a primary role for T cells in neuronal destruction are currently lacking. Animal models are providing clues regarding the roles of autoreactive CD4+ and CD8+ T cells in the disease. Elucidation of the pathogenesis of NT1 will allow for the development of targeted immunotherapies at disease onset and could serve as a model for other immune-mediated neurological diseases.
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Affiliation(s)
- Roland S Liblau
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, Toulouse, France.
- Department of Immunology, Toulouse University Hospitals, Toulouse, France.
| | | | - Birgitte R Kornum
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Yves Dauvilliers
- National Reference Center for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France
- INSERM Institute for Neurosciences of Montpellier, Montpellier, France
| | - Emmanuel J Mignot
- Stanford University, Center for Narcolepsy, Department of Psychiatry and Behavioral Sciences, Palo Alto, CA, USA.
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2
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Barateau L, Pizza F, Chenini S, Peter-Derex L, Dauvilliers Y. Narcolepsies, update in 2023. Rev Neurol (Paris) 2023; 179:727-740. [PMID: 37634997 DOI: 10.1016/j.neurol.2023.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/29/2023]
Abstract
Narcolepsy type 1 (NT1) and type 2 (NT2), also known as narcolepsy with and without cataplexy, are sleep disorders that benefited from major scientific advances over the last two decades. NT1 is caused by the loss of hypothalamic neurons producing orexin/hypocretin, a neurotransmitter regulating sleep and wake, which can be measured in the cerebrospinal fluid (CSF). A low CSF level of hypocretin-1/orexin-A is a highly specific and sensitive biomarker, sufficient to diagnose NT1. Orexin-deficiency is responsible for the main NT1 symptoms: sleepiness, cataplexy, disrupted nocturnal sleep, sleep-related hallucinations, and sleep paralysis. In the absence of a lumbar puncture, the diagnosis is based on neurophysiological tests (nocturnal and diurnal) and the presence of the pathognomonic symptom cataplexy. In the revised version of the International Classification of sleep Disorders, 3rd edition (ICSD-3-TR), a sleep onset rapid eye movement sleep (REM) period (SOREMP) (i.e. rapid occurrence of REM sleep) during the previous polysomnography may replace the diurnal multiple sleep latency test, when clear-cut cataplexy is present. A nocturnal SOREMP is very specific but not sensitive enough, and the diagnosis of cataplexy is usually based on clinical interview. It is thus of crucial importance to define typical versus atypical cataplectic attacks, and a list of clinical features and related degrees of certainty is proposed in this paper (expert opinion). The time frame of at least three months of evolution of sleepiness to diagnose NT1 was removed in the ICSD-3-TR, when clear-cut cataplexy or orexin-deficiency are established. However, it was kept for NT2 diagnosis, a less well-characterized disorder with unknown clinical course and absence of biolo biomarkers; sleep deprivation, shift working and substances intake being major differential diagnoses. Treatment of narcolepsy is nowadays only symptomatic, but the upcoming arrival of non-peptide orexin receptor-2 agonists should be a revolution in the management of these rare sleep diseases.
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Affiliation(s)
- L Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France.
| | - F Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - S Chenini
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France
| | - L Peter-Derex
- Center for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon 1 University, Lyon, France; Lyon Neuroscience Research Center, PAM Team, Inserm U1028, CNRS UMR 5292, Lyon, France
| | - Y Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France.
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3
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Barateau L, Pizza F, Plazzi G, Dauvilliers Y. 50th anniversary of the ESRS in 2022-JSR special issue. J Sleep Res 2022; 31:e13631. [PMID: 35624073 DOI: 10.1111/jsr.13631] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/21/2023]
Abstract
This article addresses the clinical presentation, diagnosis, pathophysiology and management of narcolepsy type 1 and 2, with a focus on recent findings. A low level of hypocretin-1/orexin-A in the cerebrospinal fluid is sufficient to diagnose narcolepsy type 1, being a highly specific and sensitive biomarker, and the irreversible loss of hypocretin neurons is responsible for the main symptoms of the disease: sleepiness, cataplexy, sleep-related hallucinations and paralysis, and disrupted nocturnal sleep. The process responsible for the destruction of hypocretin neurons is highly suspected to be autoimmune, or dysimmune. Over the last two decades, remarkable progress has been made for the understanding of these mechanisms that were made possible with the development of new techniques. Conversely, narcolepsy type 2 is a less well-defined disorder, with a variable phenotype and evolution, and few reliable biomarkers discovered so far. There is a dearth of knowledge about this disorder, and its aetiology remains unclear and needs to be further explored. Treatment of narcolepsy is still nowadays only symptomatic, targeting sleepiness, cataplexy and disrupted nocturnal sleep. However, new psychostimulants have been recently developed, and the upcoming arrival of non-peptide hypocretin receptor-2 agonists should be a revolution in the management of this rare sleep disease, and maybe also for disorders beyond narcolepsy.
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Affiliation(s)
- Lucie Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France.,Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Yves Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France.,Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
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4
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Latorre D, Federica S, Bassetti CLA, Kallweit U. Narcolepsy: a model interaction between immune system, nervous system, and sleep-wake regulation. Semin Immunopathol 2022; 44:611-623. [PMID: 35445831 PMCID: PMC9519713 DOI: 10.1007/s00281-022-00933-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/22/2022] [Indexed: 12/21/2022]
Abstract
Narcolepsy is a rare chronic neurological disorder characterized by an irresistible excessive daytime sleepiness and cataplexy. The disease is considered to be the result of the selective disruption of neuronal cells in the lateral hypothalamus expressing the neuropeptide hypocretin, which controls the sleep-wake cycle. Diagnosis and management of narcolepsy represent still a substantial medical challenge due to the large heterogeneity in the clinical manifestation of the disease as well as to the lack of understanding of the underlying pathophysiological mechanisms. However, significant advances have been made in the last years, thus opening new perspective in the field. This review describes the current knowledge of clinical presentation and pathology of narcolepsy as well as the existing diagnostic criteria and therapeutic intervention for the disease management. Recent evidence on the potential immune-mediated mechanisms that may underpin the disease establishment and progression are also highlighted.
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Affiliation(s)
| | - Sallusto Federica
- Institute of Microbiology, ETH Zurich, Zurich, Switzerland.,Center of Medical Immunology, Institute for Research in Biomedicine, Università della Svizzera italiana, Bellinzona, Switzerland
| | | | - Ulf Kallweit
- Clinical Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Witten, Germany.,Center for Biomedical Education and Research (ZBAF), University Witten/Herdecke, Witten, Germany
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5
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Olivera GC, Vetter L, Tesoriero C, Del Gallo F, Hedberg G, Basile J, Rottenberg ME. Role of T cells during the cerebral infection with Trypanosoma brucei. PLoS Negl Trop Dis 2021; 15:e0009764. [PMID: 34587172 PMCID: PMC8530334 DOI: 10.1371/journal.pntd.0009764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 10/21/2021] [Accepted: 08/25/2021] [Indexed: 11/18/2022] Open
Abstract
The infection by Trypanosoma brucei brucei (T.b.b.), a protozoan parasite, is characterized by an early-systemic stage followed by a late stage in which parasites invade the brain parenchyma in a T cell-dependent manner. Here we found that early after infection effector-memory T cells were predominant among brain T cells, whereas, during the encephalitic stage T cells acquired a tissue resident memory phenotype (TRM) and expressed PD1. Both CD4 and CD8 T cells were independently redundant for the penetration of T.b.b. and other leukocytes into the brain parenchyma. The role of lymphoid cells during the T.b.b. infection was studied by comparing T- and B-cell deficient rag1-/- and WT mice. Early after infection, parasites located in circumventricular organs, brain structures with increased vascular permeability, particularly in the median eminence (ME), paced closed to the sleep-wake regulatory arcuate nucleus of the hypothalamus (Arc). Whereas parasite levels in the ME were higher in rag1-/- than in WT mice, leukocytes were instead reduced. Rag1-/- infected mice showed increased levels of meca32 mRNA coding for a blood /hypothalamus endothelial molecule absent in the blood-brain-barrier (BBB). Both immune and metabolic transcripts were elevated in the ME/Arc of WT and rag1-/- mice early after infection, except for ifng mRNA, which levels were only increased in WT mice. Finally, using a non-invasive sleep-wake cycle assessment method we proposed a putative role of lymphocytes in mediating sleep alterations during the infection with T.b.b. Thus, the majority of T cells in the brain during the early stage of T.b.b. infection expressed an effector-memory phenotype while TRM cells developed in the late stage of infection. T cells and parasites invade the ME/Arc altering the metabolic and inflammatory responses during the early stage of infection and modulating sleep disturbances. Trypanosoma brucei (T.b.) causes an early systemic and a late encephalitic infection characterized by sleep alterations. In rodent models, brain invasion by T.b. brucei (T.b.b.) is strictly dependent on T cells. However, an in-depth characterization of T cell functions and phenotypes in the outcome of T.b.b. infection is still lacking. Here we found that during the early stage of infection of mice, most brain T cells differentiated into memory cells, and acquired a tissue-resident memory phenotype during the encephalitic stage. CD4 and CD8 T cells were redundant for the invasion of other T cells and parasites into the brain. Early after infection T.b.b. and leukocytes invade different circumventricular organs (brain areas that lack a blood-brain barrier) including the median eminence (ME) located close to sleep-regulating arcuate nucleus (Arc). T.b.b. infection induced the expression of immune and metabolic molecules in this area. Lymphocytes modulated 1) the levels of invading parasites and leukocytes in the ME; 2) the structure of the blood/ hypothalamus interphase and 3) the expression of IFN-γ in the ME/Arc early after infection. Lymphocytes may also be involved in the regulation of sleep alterations observed in African trypanosomiasis.
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Affiliation(s)
- Gabriela C. Olivera
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Leonie Vetter
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Chiara Tesoriero
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Federico Del Gallo
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Gustav Hedberg
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Juan Basile
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Martin E. Rottenberg
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
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6
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Beltrán E, Gerdes LA, Hansen J, Flierl-Hecht A, Krebs S, Blum H, Ertl-Wagner B, Barkhof F, Kümpfel T, Hohlfeld R, Dornmair K. Early adaptive immune activation detected in monozygotic twins with prodromal multiple sclerosis. J Clin Invest 2020; 129:4758-4768. [PMID: 31566584 DOI: 10.1172/jci128475] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 08/01/2019] [Indexed: 12/31/2022] Open
Abstract
Multiple sclerosis (MS) is a disabling disease of the CNS. Inflammatory features of MS include lymphocyte accumulations in the CNS and cerebrospinal fluid (CSF). The preclinical events leading to established MS are still enigmatic. Here we compared gene expression patterns of CSF cells from MS-discordant monozygotic twin pairs. Six "healthy" co-twins, who carry a maximal familial risk for developing MS, showed subclinical neuroinflammation (SCNI) with small MRI lesions. Four of these subjects had oligoclonal bands (OCBs). By single-cell RNA sequencing of 2752 CSF cells, we identified clonally expanded CD8+ T cells, plasmablasts, and, to a lesser extent, CD4+ T cells not only from MS patients but also from subjects with SCNI. In contrast to nonexpanded T cells, clonally expanded T cells showed characteristics of activated tissue-resident memory T (TRM) cells. The TRM-like phenotype was detectable already in cells from SCNI subjects but more pronounced in cells from patients with definite MS. Expanded plasmablast clones were detected only in MS and SCNI subjects with OCBs. Our data provide evidence for very early concomitant activation of 3 components of the adaptive immune system in MS, with a notable contribution of clonally expanded TRM-like CD8+ cells.
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Affiliation(s)
- Eduardo Beltrán
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital
| | - Lisa Ann Gerdes
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital
| | - Julia Hansen
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital
| | | | - Stefan Krebs
- Laboratory for Functional Genome Analysis (LAFUGA), Gene Center; and
| | - Helmut Blum
- Laboratory for Functional Genome Analysis (LAFUGA), Gene Center; and
| | - Birgit Ertl-Wagner
- Department of Radiology, Grosshadern Medical Campus; Ludwig Maximilian University of Munich, Munich, Germany.,Department of Medical Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, Netherlands.,UCL Institutes of Neurology and Healthcare Engineering, University College London, London, United Kingdom
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital.,Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Klaus Dornmair
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital.,Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
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