Clinical profile and HLA-DRB1 genotype of late onset multiple sclerosis in Western Australia

The influence of aging and the microbiome in multiple sclerosis and other neurologic diseases

The human gut microbiome is well-recognized as a key player in maintaining health. However, it is a dynamic entity that changes across the lifespan. How the microbial changes that occur in later decades of life shape host health or impact age-associated inflammatory neurological diseases such as multiple sclerosis (MS) is still unclear. Current understanding of the aging gut microbiome is largely limited to cross-sectional observational studies. Moreover, studies in humans are limited by confounding host-intrinsic and extrinsic factors that are not easily disentangled from aging. This review provides a comprehensive summary of existing literature on the aging gut microbiome and its known relationships with neurological diseases, with a specific focus on MS. We will also discuss preclinical animal models and human studies that shed light on the complex microbiota-host interactions that have the potential to influence disease pathology and progression in aging individuals. Lastly, we propose potential avenues of investigation to deconvolute features of an aging microbiota that contribute to disease, or alternatively promote health in advanced age.

Clinical and radiologic differences between early onset, late onset, and very late onset adult multiple sclerosis

BACKGROUND

Previous studies suggested possible differences in clinical and radiologic characteristics between early-onset multiple sclerosis (EOMS) and late-onset MS (LOMS). However, differences between LOMS and very late onset MS (VLOMS) are largely unknown.

METHODS

We performed a retrospective review of medical records of patients diagnosed with MS between 8/1/2017 and 3/1/2022 at the comprehensive MS center of the Froedtert and Medical College of Wisconsin. We included adult patients with MS diagnosis who were 60 years or older - VLOMS, 50-59 years old at diagnosis - LOMS, or were 18-30 years old at diagnosis - EOMS and had complete imaging and clinical records. Clinical presentation and location of demyelinating lesions at the onset of diagnosis were extracted and compared using the chi-square test, p<0.05.

RESULTS

A total of 246 newly diagnosed patients were identified. Of which 54 were EOMS, 29 were LOMS, and 35 were VLOMS. The sex ratio was not different between groups. EOMS had a higher percentage of patients who self-identified as black, while LOMS had a higher percentage of patients who self-identified as white. LOMS and VLOMS showed significant differences in the presence of tremors and lesion distribution at the onset. Older onset patients were more likely to present with motor symptoms, sphincter dysfunction, fatigue, and tremor. EOMS was more likely to present with cerebellum and occipital lobe lesions, and lesions were more likely to show contrast enhancement on MRI at diagnosis.

CONCLUSION

Our findings revealed novel clinical and imaging characteristics differences between VLOMS and LOMS. The current classification of LOMS may benefit from revision to better align with chronological age classification for old age >60 instead of the current standard in the literature of >50 years.

Radiological features of late-onset multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Late-onset multiple sclerosis (LOMS) is most commonly defined as the onset of the disease's presentations at age 50 or older. There is still much to discover about the radiological features of LOMS. The current study aims to assess the imaging features of LOMS, as well as the correlation between these findings and the clinical characteristics of these patients.

METHOD

This study was conducted following the PRISMA statement. A systematic search was conducted through PubMed, Scopus, and EMBASE databases to identify the studies that have applied magnetic-resonance imaging (MRI) or other imaging methods to investigate the radiological findings, as well as the relationship between them and clinical findings of LOMS patients. The risk of bias was assessed using the Joanna Briggs Institute (JBI) checklists. Meta-analysis was conducted using the third version of the compressive meta-analysis software (CMA3).

RESULTS

Our search identified 753 unique titles. Among them, 15 studies, including seven case-control, five case-series, and three cross-sectional studies, met the eligibility criteria. According to the quantitative synthesis, brain lesions were detected among 72.2% of LOMS patients (4 studies; 95% CI: 67.0% - 93.1%). In the context of spinal lesions, overall spinal cord involvement was 64.0% (8 studies; 95% CI: 42.5% - 81.1%). Based on the available evidence, supratentorial involvement was found in 82.7% of cases (3 studies; 95% CI: 17.4% - 99.1%), juxtacortical involvement in 34.1% (3 studies; 95% CI: 26.4% - 42.7%), infratentorial involvement in 51.3% (4 studies; 95% CI: 32.1% - 70.1%), and cerebellar involvement in 18.5% (3 studies; 95% CI: 13.9% - 24.1%).

CONCLUSION

Based on the neuroimaging findings, we found that, given the heterogeneity of MS, LOMS patients have a high rate of spinal cord lesions and supratentorial involvement. The limited available evidence suggests that Barkhof criteria are the best compromise for the diagnosis of LOMS. There is still a need for future studies.

Aging in multiple sclerosis: from childhood to old age, etiopathogenesis, and unmet needs: a narrative review

Multiple sclerosis (MS) primarily affects adult females. However, in the last decades, rising incidence and prevalence have been observed for demographic extremes, such as pediatric-onset MS (POMS; occurring before 18 years of age) and late-onset MS (corresponding to an onset above 50 years). These categories show peculiar clinical-pathogenetic characteristics, aging processes and disease courses, therapeutic options, and unmet needs. Nonetheless, several open questions are still pending. POMS patients display an important contribution of multiple genetic and environmental factors such as EBV, while in LOMS, hormonal changes and pollution may represent disease triggers. In both categories, immunosenescence emerges as a pathogenic driver of the disease, particularly for LOMS. In both populations, patient and caregiver engagement are essential from the diagnosis communication to early treatment of disease-modifying therapy (DMTs), which in the elderly population appears more complex and less proven in terms of efficacy and safety. Digital technologies (e.g., exergames and e-training) have recently emerged with promising results, particularly in treating and following motor and cognitive deficits. However, this offer seems more feasible for POMS, being LOMS less familiar with digital technology. In this narrative review, we discuss how the aging process influences the pathogenesis, disease course, and therapeutic options of both POMS and LOMS. Finally, we evaluate the impact of new digital communication tools, which greatly interest the current and future management of POMS and LOMS patients.

[The development of multiple sclerosis over the age of 50]

Multiple sclerosis (MS) is a common neurological disease among young people of working age, which tends to increase the number of cases registered in the world and in the Russian Federation. However, with improved diagnostics and the emergence of new drugs that change the course of MS (disease-modifying therapy), people's life expectancy increases and the percentage of patients in the older age group increases as well. In this article, we consider the possibility of developing MS among people over 50 years of age, features of the course, diagnosis and treatment.

Clinical and Epidemiological Aspects of Late Onset Multiple Sclerosis in East-Azerbaijan, Iran; A Population-Based Study

BACKGROUND

Late-onset multiple sclerosis (LOMS) is defined as symptoms initiating at an age above 50.

Objective

This study aims to determine the clinical and epidemiological aspects of LOMS in East-Azerbaijan province, Iran.

METHODS

This population-based study recruited nearly all MS patients to the end of 2020, who were diagnosed at age≥50, by referring to the only local MS registry center. We investigated prevalence, sex, age-of-onset, first clinical presentation, family history, and gap of diagnosis. Also, we compared the disease characteristics between male and female cases.

RESULTS

Out of 4905 total cases of MS, 217 cases (4.42%) were LOMS. The mean age of onset was 53.80±3.41 years with a maximum age of 68 years. The most common age group of the patients was 50 to 55 years (69.1%). The frequency by sex of LOMS in females (150) was greater than males (67). Positive family history was seen in 6.17%, and in 41% of the patients, the disease was diagnosed in a timely manner. Early symptoms were motor (31.3%), sensory (24.8%), optic neuritis (23%), cerebellar symptoms (13.8%), and brainstem symptoms (6.9%). The first presentation of the disease was different between male and female cases (P-value<0.01). Motor symptoms were the most prevalent first clinical presentation in female cases (37.6%), while in male cases, cerebellar symptoms (25.8%) were the most common.

CONCLUSION

LOMS is not a rare condition. Increasing knowledge in the diagnosis, as well as increasing awareness of the disease in the general population, leads to early diagnosis of LOMS and prevention of consequences.

Clinical and Genetic Analysis in Pediatric Patients with Multiple Sclerosis and Related Conditions: Focus on DR Genes of the Major Histocompatibility Complex

Introduction:

There are several diseases recognized as variants of MS: post-infectious acute disseminated encephalitis, multiple sclerosis (MS), Rasmussen leukoencephalitis and Schilder's leukoencephalitis and related, but separate neuroimmune condition – Neuromyelitis Devic’s. In Kazakhstan diagnosis of such diseases was rare and immune modified treatment was only admitted after the age of 18. Clinical and immunogenetic study of MS spectrum diseases in Kazakhstan would allow to justify early targeted treatment.

Objective:

The aim of the study was to investigate genes of the main complex of human histocompatibility (MHC) associated with diseases of MS spectrum in Kazakhstani population.

Methods:

Complex clinical, neuroimaging and immunogenetic studies were performed in 34 children (24 girls, 10 boys) aged 4 to 18 years. 21 children were diagnosed with MS (11 Kazakh origin and 10 – Russian; 4 boys, 17 girls), 7 with leucoencephalitis (all Kazakh, 5 boys, 2 girls) and 6 with Devic neuromyelitis optica (all Kazakh, 1 boy, 5 girls). Genotyping of HLA DRB1, DQA1, DQB1 genes was performed for all patients.

Results:

MS group was characterized by classical relapsing-remitting MS. Predominant haplotype as a linkage complex was DRB1*15:01~DQA1*01:02~DQB1*06:02 in 20 (47.6%) of 42 DR-alleles, in 16 (76.2%) patients. MS relative risk (RR) was 13,36 for ethnic Kazakhs and RR=5,55 in Russians.

Leukoencephalitis had 7 children, with 28.6% mortality rate. The haplotype DRB1*15:01~DQA1*01:02~DQB1*06:02 as a linkage complex was detected 3 patients (4 alleles), RR=5,88.

Devic’s neuromyelitis optica (NMO) clinical course was characterized by fast and prolonged progression. There was predominance of DRB1*14 allele with RR=3,38.

Conclusion:

Summarizing, in the Kazakh population the haplotype DRB1*15:01∼DQA1*01:02∼DQB1*06:02 as a linkage complex was associated with prediction to MS and leukoencephalitis, but not to Devic’s NMO. Our study highlights the importance of awareness of MS and related disorders diagnosis which allows to implement early admission of disease-modified treatment in pediatric MS in Kazakhstan.

Clinical Features of Late-Onset Multiple Sclerosis: a Systematic Review and Meta-analysis

BACKGROUND

Multiple sclerosis (MS) commonly affects young adults at the ages 20 to 40 years old, but it can onset at each age. Late-onset multiple sclerosis (LOMS) is defined as symptoms initiating after the age of 50. Misdiagnosis and a remarkable gap in diagnosis of LOMS is a challenge of the elderly population so in this article we described the proportion of LOMS and the clinical features and phenotype of the disease in this age group.

METHODS

After registration of the study protocol, an electronic search was performed in 3 databases and for full coverage of the published studies, we also checked the references of each related article. Two independent researchers screened the records in title/abstract and full-text stages and extracted the data using a data extraction table. The risk of bias was assessed using Joanna Briggs Institute checklist and meta-analysis was conducted by CMA 2. Only the studies with 50 years old cut-off and using McDonald or Poser diagnostic criteria were included in the meta-analysis.

RESULTS

After removing duplicated studies, out of 733 results of electronic and hand searching, 31 studies met our inclusion criteria for the systematic review, and 11 of them were included in the quantitative synthesis. With different cut-offs and diagnostic methods 1.1% to 21.3% proportion of LOMS, has been reported in the studies. Meta-analysis reached a 5.01% (95% CI: 3.78% to 6.57%), proportion of LOMS in total MS cases. The female cases were more than males (range between 57.7% to 70.2%) and 64.46% (95% CI: 61.94% to 66.91%) proportion of females has been found in this study. 65.00% (95% CI: 44.71% to 81.02%) proportion of spinal cord involvements and 49.80% (95% CI: 39.28% to 60.24%) proportion of relapsing-remitting multiple sclerosis (RRMS) was also observed in LOMS cases. In 4 of included studies, the progressive form was the predominant phenotype. The most prevalent first disease presentation of LOMS was motor dysfunction (ranges between 100% to 35.4%) followed by sensory problems (ranges between 94% to 5%), visual symptoms (ranges between 22.9% to 5%), and brainstem dysfunction (ranges between 25% to 12.3%). The proportion of positive oligoclonal band (OCB), was varied from 46% to 98% in different studies and positive immunoglobulin G (IgG) index also was seen in 45.04% and 66% of the patients. 2.2% - 12.5% of the LOMS cases had a positive family history.

CONCLUSION

In about 5% of cases, MS can be diagnosed at ages above 50 years old. There is an increasing concern of a more progressive form of MS in LOMS cases. Unlike the adult-onset MS, the first presentation of LOMS is usually motor dysfunction. Understanding the proportion and clinical features of LOMS will help clinicians with the diagnosis of MS in this age group and prevention of wrong management plans and complications in these patients. Although the proportion of females is still more than males in LOMS cases; but there is a trend to increase in male cases with aging.

Distinctive characteristics of early-onset and late-onset neuromyelitis optica spectrum disorders

OBJECTIVES

Little is known about patients with neuromyelitis optica spectrum disorders (NMOSD) as defined by onset age. This study aimed to analyze the different demographic, clinical, laboratory, and magnetic resonance imaging (MRI) characteristics in early-onset (≤50 years) NMOSD (EONMOSD) and late-onset (>50 years) NMOSD (LONMOSD).

MATERIALS AND METHODS

We enrolled 142 patients with NMOSD from Tianjin Medical University General Hospital, Tianjin, China, and categorized them into two groups according to the age of onset: EONMOSD and LONMOSD. Demographic, clinical, laboratory, and MRI characteristics were collected and compared between the two groups. Serum aquaporin-4 (AQP4) antibody levels were determined by cell-based assay and fluorescence immunoprecipitation assays.

RESULTS

Among the patients studied, 83 had early onset (≤50 years) and 59 had late onset (>50 years) of NMOSD. As compared with LONMOSD, EONMOSD patients had more severe visual disability according to functional scores in clinical parameters, significantly lower C3 and C4 serum levels, more frequent cervical lesions, and more lesions around the fourth ventricle, but fewer lesions in hemispheric white matter. LONMOSD patients suffered more motor and sensory disability than EONMOSD patients.

CONCLUSIONS

In NMOSD, the clinical, laboratory, and MRI features differ according to age of onset, suggesting that differences in pathogenesis and treatment should be further investigated.

A role for HLA-DRB1*1101 and DRB1*0801 in cognitive ability and its decline with age

Cognitive abilities (memory, processing speed, vocabulary, and fluid intelligence) are correlated with educational attainment and occupational status, as well as physical and mental health. The variation in cognitive abilities observed within a population has a substantial genetic contribution (heritability ∼50%) and yet the identification of genetic polymorphisms from both genome-wide association and candidate studies have to date only uncovered a limited number of genetic variants that exert small genetic effects. Here we impute human leukocyte antigens (HLA) using existing genome-wide association data from 1,559 non-pathological elderly volunteers who have been followed for changes in cognitive functioning between a 12- and 18-year period. Specifically, we investigate DRB1*05 (*11/*12) and DRB1*01, which have previously been associated with cognitive ability. We also analyze DRB1*0801, which shares close sequence homology with DRB1*1101. Together with DRB1*1101, DRB1*0801 has been associated with several diseases including multiple sclerosis and primary biliary cirrhosis, which themselves are associated with cognitive impairment. We observed that both DRB1*0801 and DRB1*1101 were significantly associated with vocabulary ability (cross-sectional and longitudinal scores) and that the effects were in opposite directions with DRB1*0801 associated with lower score and faster decline. This opposing affect is similar to that reported by other groups in systemic lupus erythematosus, type 1 diabetes, and primary biliary cirrhosis. DRB1*0801 was also significantly associated with reduced memory ability. We observed no associations between cognitive abilities and DRB1*01 or DRB1*12.

Multiple sclerosis in older adults: the clinical profile and impact of interferon Beta treatment

Background. We examined (1) patient characteristics and disease-modifying drug (DMD) exposure in late-onset (LOMS, ≥50 years at symptom onset) versus adult-onset (AOMS, 18–<50 years) MS and (2) the association between interferon-beta (IFNβ) and disability progression in older relapsing-onset MS adults (≥50 years). Methods. This retrospective study (1980–2004, British Columbia, Canada) included 358 LOMS and 5627 AOMS patients. IFNβ-treated relapsing-onset MS patients aged ≥50 (regardless of onset age, 90) were compared with 171 contemporary and 106 historical controls. Times to EDSS 6 from onset and from IFNβ eligibility were examined using survival analyses. Results. LOMS patients (6%) were more likely to be male, with motor onset and a primary-progressive course, and exhibit faster progression and were less likely to take DMDs. Nonetheless, 57% were relapsing-onset, of which 31% were prescribed DMDs, most commonly IFNβ. Among older relapsing-onset MS adults, no significant association between IFNβ exposure and disability progression was found when either the contemporary (hazard ratio [HR]: 0.46; 95% CI: 0.18–1.22) or historical controls (HR: 0.54; 95% CI: 0.20–1.42) were considered. Conclusion. LOMS differed clinically from AOMS. One-third of older relapsing-onset MS patients were prescribed a DMD. IFNβ exposure was not significantly associated with reduced disability in older MS patients.

The Role of HLA in MS Susceptibility and Phenotype

One of the most consistent findings in multiple sclerosis (MS) is that development of MS is linked with carriage of the class II human leucocyte antigen (HLA) molecule HLA-DRB1*15:01; around 60 % of Caucasian MS patients carry this allele compared to 25-30 % of ethnically matched healthy individuals. However, other HLA molecules have also been linked to the development of MS. In this chapter, the association between different HLA types and susceptibility to MS will be reviewed, and other linkages between the carriage of specific HLA molecules and clinical and experimental findings in MS will be considered.

Genetics of primary progressive multiple sclerosis

Multiple sclerosis (MS) patients are classified as either having relapsing onset or progressive onset disease, also known as primary progressive MS (PPMS). Relative to relapsing onset patients, PPMS patients are older at disease onset, are equally likely to be men or women, and have more rapid accumulation of disability that does not respond well to treatments used in relapsing onset MS. Although estimates vary, 5-15% of all MS patients have a PPMS disease course. Genetic variance is a proposed determinant of MS disease course. If distinct genes associated with PPMS were identified study of these genes might lead to an understanding of the biology underlying disease progression and neural degeneration that are the hallmarks of PPMS. These genes and their biological pathways might also represent therapeutic targets. This chapter systematically reviews the PPMS genetic literature. Despite the intuitively appealing notion that differences between PPMS and relapsing onset MS are due to genetics, definite differences associated with these phenotypes at the major histocompatibility complex or elsewhere in the genome have not been found. Recent large-scale genome wide screens identified multiple genes associated with MS susceptibility outside the MHC. The genetic variants identified thus far make only weak individual contributions to MS susceptibility. If the genetic effects that contribute to the differences between PPMS and relapsing MS are similar in magnitude to those that distinguish MS from healthy controls then, given the relative scarcity of the PPMS phenotype, very large datasets will be needed to identify PPMS associated genes. International collaborative efforts could provide the means to identify such genes. Alternately, it is possible that factors other than genetics underlie the differences between these clinical phenotypes.

The importance of HLA DRB1 gene allele to clinical features and disability in patients with multiple sclerosis in Lithuania

BACKGROUND

The association of HLA DRB1 alleles with susceptibility to multiple sclerosis (MS) has been consistently reported although its effect on the clinical features and disability is still unclear probably due to diversity in ethnicity and geographic location of the studied populations. The aim of the present study was to investigate the influence of HLA DRB1 alleles on the clinical features and disability of the patients with MS in Lithuania.

METHODS

This was a prospective study of 120 patients with MS. HLA DRB1 alleles were genotyped using the polymerase chain reaction.

RESULTS

The first symptoms of MS in patients with HLA DRB1*15 allele manifested at younger age than in those without this allele (28.32 +/- 5.49 yrs vs. 30.94 +/- 8.43 yrs, respectively, p = 0.043). HLA DRB1*08 allele was more prevalent among relapsing-remitting (RR) MS patients than among patients with progressive course of MS (25.0% vs. 8.3%, respectively, chi^2 = 6.000, p = 0.05). MS patients with this allele had lower relapse rate than those without this allele (1.00 +/- 0.97 and 1.44 +/- 0.85, respectively, p = 0.043). Degree of disability during the last visit was lower among the patients with HLA DRB1*08 allele (EDSS score 3.15 +/- 1.95 vs. 4.49 +/- 1.96, p = 0.006), and higher among those with HLA DRB1*15 allele (EDSS score 4.60 +/- 2.10 vs.4.05 +/- 1.94, p = 0.047) compared to patients without these alleles but there were no significant associations between these alleles and the duration of the disease to disability. HLA DRB1*08 allele (OR = 0.18, 95% CI 0,039-0,8, p = 0.029) was demonstradet to be independent factor to take a longer time to reach an EDSS of 6, while HLA DRB1*01 allele (OR = 5.92, 95% CI 1,30-26,8, p = 0.021) was related in a shorter time to reach and EDSS of 6. Patients with HLA DRB1*08 allele had lower IgG index compared to patients without this allele (0.58 +/- 0.17 and 0.73 +/- 0.31, respectively, p = 0.04), and HLA DRB1*15 allele was more often found among MS patients with oligoclonal bands (OCBs) in cerebrospinal fluid than among those without OCBs (OR 2.3, CI 95% 1.017-5.301; p = 0.043).

CONCLUSIONS

HLA DRB1*15 allele was related with an earlier manifestation of the first MS symptoms, progressive course of the disease and higher degree of disability. HLA DRB1*08 allele was more prevalent among the RR MS patients and was associated with the lower rate of relapse, degree of disability and IgG index.

Spinal cord involvement in multiple sclerosis: a correlative MRI and high-resolution HLA-DRB1 genotyping study

BACKGROUND

There have been few magnetic resonance imaging (MRI) studies of the spinal cord in large multiple sclerosis (MS) patient cohorts and little is known about correlations between cord lesions and human leukocyte antigen (HLA) alleles.

OBJECTIVE

To investigate the spectrum of MRI changes in the spinal cord in MS and associations with the HLA-DRB1 genotype.

METHODS

Two hundred and fifty two consecutive MS patients from the Perth Demyelinating Diseases Database had MRI of the spinal cord and brain and high-resolution HLA-DRB1 genotyping. The numbers, locations, shape and segmental extent of cord lesions were analysed and were correlated with carriage of individual HLA-DRB1 alleles and diplotypes.

RESULTS

Focal cord lesions were present in 82.9% of cases, with numbers being maximal in the cervical cord and increasing with disease duration. Focal lesions were usually round or oval in shape but in 35% of cases subpial wedge-shaped lesions were present. Diffuse cord involvement was present in 10% of cases and correlated with carriage of HLA-DRB1*1501 and with higher disability. Carriage of the minor allele HLA-DRB1*0701 was significantly associated with numbers of wedge-shaped lesions and lesions in the cervical cord, while HLA-DRB1*1104 and DRB1*0103 were significantly associated respectively with higher and lower numbers of thoracic cord lesions. HLA-DRB1*1501 and the HLA-DRB1*11 sub-alleles DRB1*1101 and DRB1*1104 were significantly associated with the segmental length of cord lesions.

CONCLUSIONS

Our study is the first to investigate the frequency of subpial wedge-shaped lesions in the cord in vivo and has provided preliminary evidence that HLA-DRB1 alleles may play a role in determining the severity and extent of spinal cord involvement in MS.