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Orrù V, Serra V, Marongiu M, Lai S, Lodde V, Zoledziewska M, Steri M, Loizedda A, Lobina M, Piras MG, Virdis F, Delogu G, Marini MG, Mingoia M, Floris M, Masala M, Castelli MP, Mostallino R, Frau J, Lorefice L, Farina G, Fronza M, Carmagnini D, Carta E, Pilotto S, Chessa P, Devoto M, Castiglia P, Solla P, Zarbo RI, Idda ML, Pitzalis M, Cocco E, Fiorillo E, Cucca F. Implications of disease-modifying therapies for multiple sclerosis on immune cells and response to COVID-19 vaccination. Front Immunol 2024; 15:1416464. [PMID: 39076966 PMCID: PMC11284103 DOI: 10.3389/fimmu.2024.1416464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/27/2024] [Indexed: 07/31/2024] Open
Abstract
Introduction Disease-modifying therapies (DMTs) have been shown to improve disease outcomes in multiple sclerosis (MS) patients. They may also impair the immune response to vaccines, including the SARS-CoV-2 vaccine. However, available data on both the intrinsic immune effects of DMTs and their influence on cellular response to the SARS-CoV-2 vaccine are still incomplete. Methods Here, we evaluated the immune cell effects of 3 DMTs on the response to mRNA SARS-CoV-2 vaccination by comparing MS patients treated with one specific therapy (fingolimod, dimethyl fumarate, or natalizumab) with both healthy controls and untreated patients. We profiled 23 B-cell traits, 57 T-cell traits, and 10 cytokines, both at basal level and after stimulation with a pool of SARS-CoV-2 spike peptides, in 79 MS patients, treated with DMTs or untreated, and 32 healthy controls. Measurements were made before vaccination and at three time points after immunization. Results and Discussion MS patients treated with fingolimod showed the strongest immune cell dysregulation characterized by a reduction in all measured lymphocyte cell classes; the patients also had increased immune cell activation at baseline, accompanied by reduced specific immune cell response to the SARS-CoV-2 vaccine. Also, anti-spike specific B cells progressively increased over the three time points after vaccination, even when antibodies measured from the same samples instead showed a decline. Our findings demonstrate that repeated booster vaccinations in MS patients are crucial to overcoming the immune cell impairment caused by DMTs and achieving an immune response to the SARS-CoV-2 vaccine comparable to that of healthy controls.
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Affiliation(s)
- Valeria Orrù
- Institute for Genetic and Biomedical Research, National Research Council, Lanusei, Italy
| | - Valentina Serra
- Institute for Genetic and Biomedical Research, National Research Council, Lanusei, Italy
| | - Michele Marongiu
- Institute for Genetic and Biomedical Research, National Research Council, Lanusei, Italy
| | - Sandra Lai
- Institute for Genetic and Biomedical Research, National Research Council, Lanusei, Italy
| | - Valeria Lodde
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Magdalena Zoledziewska
- Institute for Genetic and Biomedical Research, National Research Council, Monserrato, Italy
| | - Maristella Steri
- Institute for Genetic and Biomedical Research, National Research Council, Monserrato, Italy
| | - Annalisa Loizedda
- Institute for Genetic and Biomedical Research, National Research Council, Monserrato, Italy
| | - Monia Lobina
- Institute for Genetic and Biomedical Research, National Research Council, Lanusei, Italy
| | - Maria Grazia Piras
- Institute for Genetic and Biomedical Research, National Research Council, Lanusei, Italy
| | - Francesca Virdis
- Institute for Genetic and Biomedical Research, National Research Council, Monserrato, Italy
| | - Giuseppe Delogu
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | | | - Maura Mingoia
- Institute for Genetic and Biomedical Research, National Research Council, Monserrato, Italy
| | - Matteo Floris
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Marco Masala
- Institute for Genetic and Biomedical Research, National Research Council, Monserrato, Italy
| | - M. Paola Castelli
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Rafaela Mostallino
- Department of Biomedical Sciences, University of Cagliari, Monserrato, Italy
| | - Jessica Frau
- Regional Multiple Sclerosis Center, Azienda Sanitaria Locale (ASL) Cagliari, Cagliari, Italy
| | - Lorena Lorefice
- Regional Multiple Sclerosis Center, Azienda Sanitaria Locale (ASL) Cagliari, Cagliari, Italy
| | - Gabriele Farina
- Neurology Unit, Azienza Ospedaliera Universitaria (AOU) Sassari, Sassari, Italy
| | - Marzia Fronza
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Daniele Carmagnini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Elisa Carta
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Silvy Pilotto
- Neurology Unit, Azienza Ospedaliera Universitaria (AOU) Sassari, Sassari, Italy
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Paola Chessa
- Neurology Unit, Azienza Ospedaliera Universitaria (AOU) Sassari, Sassari, Italy
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Marcella Devoto
- Institute for Genetic and Biomedical Research, National Research Council, Monserrato, Italy
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Paolo Castiglia
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Paolo Solla
- Neurology Unit, Azienza Ospedaliera Universitaria (AOU) Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Roberto Ignazio Zarbo
- Neurology Unit, Azienza Ospedaliera Universitaria (AOU) Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Maria Laura Idda
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Maristella Pitzalis
- Institute for Genetic and Biomedical Research, National Research Council, Monserrato, Italy
| | - Eleonora Cocco
- Regional Multiple Sclerosis Center, Azienda Sanitaria Locale (ASL) Cagliari, Cagliari, Italy
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Edoardo Fiorillo
- Institute for Genetic and Biomedical Research, National Research Council, Lanusei, Italy
| | - Francesco Cucca
- Institute for Genetic and Biomedical Research, National Research Council, Lanusei, Italy
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
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2
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De Biasi S, Lo Tartaro D, Neroni A, Rau M, Paschalidis N, Borella R, Santacroce E, Paolini A, Gibellini L, Ciobanu AL, Cuccorese M, Trenti T, Rubio I, Vitetta F, Cardi M, Argüello RJ, Ferraro D, Cossarizza A. Immunosenescence and vaccine efficacy revealed by immunometabolic analysis of SARS-CoV-2-specific cells in multiple sclerosis patients. Nat Commun 2024; 15:2752. [PMID: 38553477 PMCID: PMC10980723 DOI: 10.1038/s41467-024-47013-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/11/2024] [Indexed: 04/02/2024] Open
Abstract
Disease-modifying therapies (DMT) administered to patients with multiple sclerosis (MS) can influence immune responses to SARS-CoV-2 and vaccine efficacy. However, data on the detailed phenotypic, functional and metabolic characteristics of antigen (Ag)-specific cells following the third dose of mRNA vaccine remain scarce. Here, using flow cytometry and 45-parameter mass cytometry, we broadly investigate the phenotype, function and the single-cell metabolic profile of SARS-CoV-2-specific T and B cells up to 8 months after the third dose of mRNA vaccine in a cohort of 94 patients with MS treated with different DMT, including cladribine, dimethyl fumarate, fingolimod, interferon, natalizumab, teriflunomide, rituximab or ocrelizumab. Almost all patients display functional immune response to SARS-CoV-2. Different metabolic profiles characterize antigen-specific-T and -B cell response in fingolimod- and natalizumab-treated patients, whose immune response differs from all the other MS treatments.
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Affiliation(s)
- Sara De Biasi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy.
| | - Domenico Lo Tartaro
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Anita Neroni
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Moritz Rau
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | | | - Rebecca Borella
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Elena Santacroce
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Annamaria Paolini
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Lara Gibellini
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Alin Liviu Ciobanu
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Michela Cuccorese
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, Azienda Unità Sanitaria Locale AUSL/AOU Policlinico, Modena, Italy
| | - Tommaso Trenti
- Department of Laboratory Medicine and Pathology, Diagnostic Hematology and Clinical Genomics, Azienda Unità Sanitaria Locale AUSL/AOU Policlinico, Modena, Italy
| | - Ignacio Rubio
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Francesca Vitetta
- Neurology Unit, Department of Biomedical, Metabolic and Neurosciences, Nuovo Ospedale Civile Sant'Agostino Estense, University of Modena and Reggio Emilia, Modena, Italy
| | - Martina Cardi
- Neurology Unit, Department of Biomedical, Metabolic and Neurosciences, Nuovo Ospedale Civile Sant'Agostino Estense, University of Modena and Reggio Emilia, Modena, Italy
| | - Rafael José Argüello
- Aix Marseille Univ, CNRS, INSERM, CIML, Centre d'Immunologie de Marseille-Luminy, Marseille, France
| | - Diana Ferraro
- Neurology Unit, Department of Biomedical, Metabolic and Neurosciences, Nuovo Ospedale Civile Sant'Agostino Estense, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cossarizza
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy.
- National Institute for Cardiovascular Research, Bologna, Italy.
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Vakrakou AG, Brinia ME, Alexaki A, Koumasopoulos E, Stathopoulos P, Evangelopoulos ME, Stefanis L, Stadelmann-Nessler C, Kilidireas C. Multiple faces of multiple sclerosis in the era of highly efficient treatment modalities: Lymphopenia and switching treatment options challenges daily practice. Int Immunopharmacol 2023; 125:111192. [PMID: 37951198 DOI: 10.1016/j.intimp.2023.111192] [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: 09/03/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 11/13/2023]
Abstract
The expanded treatment landscape in relapsing-remitting multiple sclerosis (MS) has resulted in highly effective treatment options and complexity in managing disease- or drug-related events during disease progression. Proper decision-making requires thorough knowledge of the immunobiology of MS itself and an understanding of the main principles behind the mechanisms that lead to secondary autoimmunity affecting organs other than the central nervous system as well as opportunistic infections. The immune system is highly adapted to both environmental and disease-modifying agents. Immune reconstitution following cell depletion or cell entrapment therapies eliminates pathogenic aspects of the disease but can also lead to distorted immune responses with harmful effects. Atypical relapses occur with second-line treatments or after their discontinuation and require appropriate clinical decisions. Lymphopenia is a result of the mechanism of action of many drugs used to treat MS. However, persistent lymphopenia and cell-specific lymphopenia could result in disease exacerbation, secondary autoimmunity, or the emergence of opportunistic infections. Clinicians treating patients with MS should be aware of the multiple faces of MS under novel, efficient treatment modalities and understand the intricate brain-immune cell interactions in the context of an altered immune system. MS relapses and disease progression still occur despite the current treatment modalities and are mediated either by failure to control effector mechanisms inherent to MS pathophysiology or by new drug-related mechanisms. The multiple faces of MS due to the highly adapted immune system of patients impose the need for appropriate switching therapies that safeguard disease remission and further clinical improvement.
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Affiliation(s)
- Aigli G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neuropathology, University of Göttingen Medical Center, Göttingen, Germany.
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Alexaki
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Koumasopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
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4
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Matlak P, Brozmanova H, Sistik P, Kacirova I, Hradilek P, Grundmann M. Liquid chromatography - tandem mass spectrometry method for determination of natalizumab in serum and cerebrospinal fluid of patients with multiple sclerosis. J Pharm Biomed Anal 2023; 234:115542. [PMID: 37364452 DOI: 10.1016/j.jpba.2023.115542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/01/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
Natalizumab is a humanized recombinant monoclonal IgG4 antibody used in the treatment of multiple sclerosis. Commonly used methods for natalizumab and anti-natalizumab antibodies quantification are enzyme-linked immunosorbent assay (ELISA) and radioimmunoassay, respectively. Measurement of therapeutic monoclonal antibodies can be challenging due to the resemblance to human plasma immunoglobulins. Recent developments in mass spectrometry enables to analyze vast variety of large protein molecules. The aim of this study was to develop a LC-MS/MS method for determining natalizumab in human serum and cerebrospinal fluid (CSF) and apply it to clinical settings. For successful quantification, it was necessary to find specific sequences of peptides in natalizumab. This immunoglobulin was treated with dithiothreitol and iodoacetamide, cleaved with trypsin into short specific peptides and determined on a UPLC-MS/MS system. An Acquity UPLC BEH C18 column at 55 °C and gradient elution was used for analysis. Intra- and interassay accuracies and precisions were tested at four concentration levels. Precision was determined by coefficients of variation and was in the range of 0.8-10.2 %, with accuracy in the range of 89.8-106.4 %. The concentration of natalizumab in patient samples ranged from 1.8 to 193.3 μg/mL. The method was validated according to the European Medicines Agency (EMA) guideline, met all acceptance criteria for accuracy and precision, and is suitable for clinical applications. In comparison to immunoassay, which can be elevated by cross-reaction with endogenous immunoglobulins, the results of developed LC-MS/MS method are more accurate and specific.
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Affiliation(s)
- Patrik Matlak
- Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic
| | - Hana Brozmanova
- Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic; Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Pavel Sistik
- Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic; Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic.
| | - Ivana Kacirova
- Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic; Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Pavel Hradilek
- Clinic of Neurology, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic; Clinic of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Milan Grundmann
- Department of Clinical Pharmacology, Institute of Laboratory Medicine, University Hospital Ostrava, 17. listopadu 1790, 708 52 Ostrava, Czech Republic; Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
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5
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Hecker M, Fitzner B, Boxberger N, Putscher E, Engelmann R, Bergmann W, Müller M, Ludwig-Portugall I, Schwartz M, Meister S, Dudesek A, Winkelmann A, Koczan D, Zettl UK. Transcriptome alterations in peripheral blood B cells of patients with multiple sclerosis receiving immune reconstitution therapy. J Neuroinflammation 2023; 20:181. [PMID: 37533036 PMCID: PMC10394872 DOI: 10.1186/s12974-023-02859-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 07/25/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic, inflammatory and neurodegenerative disease that leads to irreversible damage to the brain and spinal cord. The goal of so-called "immune reconstitution therapies" (IRTs) is to achieve long-term disease remission by eliminating a pathogenic immune repertoire through intense short-term immune cell depletion. B cells are major targets for effective immunotherapy in MS. OBJECTIVES The aim of this study was to analyze the gene expression pattern of B cells before and during IRT (i.e., before B-cell depletion and after B-cell repopulation) to better understand the therapeutic effects and to identify biomarker candidates of the clinical response to therapy. METHODS B cells were obtained from blood samples of patients with relapsing-remitting MS (n = 50), patients with primary progressive MS (n = 13) as well as healthy controls (n = 28). The patients with relapsing MS received either monthly infusions of natalizumab (n = 29) or a pulsed IRT with alemtuzumab (n = 15) or cladribine (n = 6). B-cell subpopulation frequencies were determined by flow cytometry, and transcriptome profiling was performed using Clariom D arrays. Differentially expressed genes (DEGs) between the patient groups and controls were examined with regard to their functions and interactions. We also tested for differences in gene expression between patients with and without relapse following alemtuzumab administration. RESULTS Patients treated with alemtuzumab or cladribine showed on average a > 20% lower proportion of memory B cells as compared to before IRT. This was paralleled by profound transcriptome shifts, with > 6000 significant DEGs after adjustment for multiple comparisons. The top DEGs were found to regulate apoptosis, cell adhesion and RNA processing, and the most highly connected nodes in the network of encoded proteins were ESR2, PHB and RC3H1. Higher mRNA levels of BCL2, IL13RA1 and SLC38A11 were seen in patients with relapse despite IRT, though these differences did not pass the false discovery rate correction. CONCLUSIONS We show that B cells circulating in the blood of patients with MS undergoing IRT present a distinct gene expression signature, and we delineated the associated biological processes and gene interactions. Moreover, we identified genes whose expression may be an indicator of relapse risk, but further studies are needed to verify their potential value as biomarkers.
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Affiliation(s)
- Michael Hecker
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany.
| | - Brit Fitzner
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Nina Boxberger
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Elena Putscher
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Robby Engelmann
- Clinic III (Hematology, Oncology and Palliative Medicine), Special Hematology Laboratory, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Wendy Bergmann
- Core Facility for Cell Sorting and Cell Analysis, Rostock University Medical Center, Schillingallee 70, 18057, Rostock, Germany
| | - Michael Müller
- Core Facility for Cell Sorting and Cell Analysis, Rostock University Medical Center, Schillingallee 70, 18057, Rostock, Germany
| | | | - Margit Schwartz
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Stefanie Meister
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Ales Dudesek
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Alexander Winkelmann
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
| | - Dirk Koczan
- Institute of Immunology, Rostock University Medical Center, Schillingallee 70, 18057, Rostock, Germany
| | - Uwe Klaus Zettl
- Division of Neuroimmunology, Department of Neurology, Rostock University Medical Center, Gehlsheimer Str. 20, 18147, Rostock, Germany
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6
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Dyer Z, Tscharke D, Sutton I, Massey J. From bedside to bench: how existing therapies inform the relationship between Epstein-Barr virus and multiple sclerosis. Clin Transl Immunology 2023; 12:e1437. [PMID: 36844913 PMCID: PMC9947628 DOI: 10.1002/cti2.1437] [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: 12/15/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 02/25/2023] Open
Abstract
Therapy for relapsing-remitting multiple sclerosis (MS) has advanced dramatically despite incomplete understanding of the cause of the condition. Current treatment involves inducing broad effects on immune cell populations with consequent off-target side effects, and no treatment can completely prevent disability progression. Further therapeutic advancement will require a better understanding of the pathobiology of MS. Interest in the role of Epstein-Barr virus (EBV) in multiple sclerosis has intensified based on strong epidemiological evidence of an association between EBV seroprevalence and MS. Hypotheses proposed to explain the biological relationship between EBV and MS include molecular mimicry, EBV immortalised autoreactive B cells and infection of glial cells by EBV. Examining the interaction between EBV and immunotherapies that have demonstrated efficacy in MS offers clues to the validity of these hypotheses. The efficacy of B cell depleting therapies could be consistent with a hypothesis that EBV-infected B cells drive MS; however, loss of T cell control of B cells does not exacerbate MS. A number of MS therapies invoke change in EBV-specific T cell populations, but pathogenic EBV-specific T cells with cross-reactivity to CNS antigen have not been identified. Immune reconstitution therapies induce EBV viraemia and expansion of EBV-specific T cell clones, but this does not correlate with relapse. Much remains unknown regarding the role of EBV in MS pathogenesis. We discuss future translational research that could fill important knowledge gaps.
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Affiliation(s)
- Zoe Dyer
- Blood Stem Cell and Cancer Research Group, St Vincent's Centre for Applied Medical ResearchDarlinghurstNSWAustralia,St. Vincent's Clinical School, Faculty of MedicineUniversity of New South Wales (UNSW)DarlinghurstNSWAustralia
| | - David Tscharke
- John Curtin School of Medical ResearchAustralian National UniversityCanberraACTAustralia
| | - Ian Sutton
- St. Vincent's Clinical School, Faculty of MedicineUniversity of New South Wales (UNSW)DarlinghurstNSWAustralia,Department of NeurologySt Vincent's ClinicDarlinghurstNSWAustralia
| | - Jennifer Massey
- Blood Stem Cell and Cancer Research Group, St Vincent's Centre for Applied Medical ResearchDarlinghurstNSWAustralia,St. Vincent's Clinical School, Faculty of MedicineUniversity of New South Wales (UNSW)DarlinghurstNSWAustralia,Department of NeurologySt Vincent's ClinicDarlinghurstNSWAustralia,Department of NeurologySt Vincent's HospitalDarlinghurstNSWAustralia
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7
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Karlowicz JR, Klakegg M, Aarseth JH, Bø L, Myhr KM, Torgauten HM, Torkildsen Ø, Wergeland S. Predictors of hospitalization due to infection in rituximab-treated MS patients. Mult Scler Relat Disord 2023; 71:104556. [PMID: 36842313 DOI: 10.1016/j.msard.2023.104556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/30/2022] [Accepted: 02/07/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Rituximab is extensively used off-label to treat multiple sclerosis (MS), and long-term vigilance for adverse events is needed. This study was conducted to determine frequencies and predictors of hematological adverse events, including hypogammaglobulinemia, severe lymphopenia, neutropenia, and infections leading to hospitalization. METHODS This retrospective cohort study included all patients with MS initiating rituximab treatment at Haukeland University Hospital between January 1st, 2017, and July 1st, 2021. Patients were followed by clinical monitoring and repeated blood sampling every six months. Clinical outcomes and laboratory results were retrieved from the Norwegian MS Registry and Biobank and the patient administrative system at Haukeland University Hospital. RESULTS Five hundred and fifty-six patients were included, 515 with relapsing-remitting MS (RRMS) and 41 with progressive MS. Overall, 33 patients (5.9%) experienced 56 episodes of infections requiring hospital admission. Sixty patients (10.8%) had confirmed hypogammaglobulinemia, 17 (3.1%) had confirmed severe lymphopenia, and 10 (1.8%) had confirmed severe neutropenia. Predictors of infection requiring hospital admission were progressive MS (adjusted OR (aOR): 4.81; 95%CI: 1.25-18.48), duration of treatment with rituximab (aOR: 1.52; 95%CI: 1.11-2.09) and confirmed severe lymphopenia (aOR: 13.58; 95%CI: 3.41-54.06) and neutropenia (aOR: 13.40; 95%CI: 2.93-61.25). Of the hematological abnormalities, only hypogammaglobulinemia was associated with treatment duration (aOR: 1.35; 95%CI: 1.09-1.69). CONCLUSION The risk of hospitalization due to infection is associated with time on rituximab treatment, in patients with lympho- or neutropenia, and in patients with primary progressive MS. We observed a time-dependent decline in IgG values, in contrast to neutrophil and lymphocyte count, suggesting a cumulative dose-dependent response. These predictors can assist clinicians in assessing and monitoring MS patients receiving rituximab.
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Affiliation(s)
| | - Mattias Klakegg
- Department of clinical medicine, University of Bergen, Norway
| | - Jan Harald Aarseth
- Norwegian MS-registry and biobank, Dept of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Lars Bø
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Kjell-Morten Myhr
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Hilde Marie Torgauten
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Øivind Torkildsen
- Department of clinical medicine, University of Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway
| | - Stig Wergeland
- Department of clinical medicine, University of Bergen, Norway; Norwegian MS-registry and biobank, Dept of Neurology, Haukeland University Hospital, Bergen, Norway; Neuro-SysMed, Haukeland University Hospital, Bergen, Norway.
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8
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Breaching Brain Barriers: B Cell Migration in Multiple Sclerosis. Biomolecules 2022; 12:biom12060800. [PMID: 35740925 PMCID: PMC9221446 DOI: 10.3390/biom12060800] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 12/25/2022] Open
Abstract
Multiple sclerosis (MS) is an inflammatory disease of the central nervous system (CNS) known for the manifestation of demyelinated lesions throughout the CNS, leading to neurodegeneration. To date, not all pathological mechanisms that drive disease progression are known, but the clinical benefits of anti-CD20 therapies have put B cells in the spotlight of MS research. Besides their pathological effects in the periphery in MS, B cells gain access to the CNS where they can contribute to disease pathogenesis. Specifically, B cells accumulate in perivascular infiltrates in the brain parenchyma and the subarachnoid spaces of the meninges, but are virtually absent from the choroid plexus. Hence, the possible migration of B cells over the blood-brain-, blood-meningeal-, and blood-cerebrospinal fluid (CSF) barriers appears to be a crucial step to understanding B cell-mediated pathology. To gain more insight into the molecular mechanisms that regulate B cell trafficking into the brain, we here provide a comprehensive overview of the different CNS barriers in health and in MS and how they translate into different routes for B cell migration. In addition, we review the mechanisms of action of diverse therapies that deplete peripheral B cells and/or block B cell migration into the CNS. Importantly, this review shows that studying the different routes of how B cells enter the inflamed CNS should be the next step to understanding this disease.
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9
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Giovannoni G, Popescu V, Wuerfel J, Hellwig K, Iacobaeus E, Jensen MB, García-Domínguez JM, Sousa L, De Rossi N, Hupperts R, Fenu G, Bodini B, Kuusisto HM, Stankoff B, Lycke J, Airas L, Granziera C, Scalfari A. Smouldering multiple sclerosis: the ‘real MS’. Ther Adv Neurol Disord 2022; 15:17562864211066751. [PMID: 35096143 PMCID: PMC8793117 DOI: 10.1177/17562864211066751] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/28/2021] [Indexed: 12/25/2022] Open
Abstract
Using a philosophical approach or deductive reasoning, we challenge the dominant
clinico-radiological worldview that defines multiple sclerosis (MS) as a focal
inflammatory disease of the central nervous system (CNS). We provide a range of
evidence to argue that the ‘real MS’ is in fact driven primarily by a
smouldering pathological disease process. In natural history studies and
clinical trials, relapses and focal activity revealed by magnetic resonance
imaging (MRI) in MS patients on placebo or on disease-modifying therapies (DMTs)
were found to be poor predictors of long-term disease evolution and were
dissociated from disability outcomes. In addition, the progressive accumulation
of disability in MS can occur independently of relapse activity from early in
the disease course. This scenario is underpinned by a more diffuse smouldering
pathological process that may affect the entire CNS. Many putative pathological
drivers of smouldering MS can be potentially modified by specific therapeutic
strategies, an approach that may have major implications for the management of
MS patients. We hypothesise that therapeutically targeting a state of ‘no
evident inflammatory disease activity’ (NEIDA) cannot sufficiently prevent
disability accumulation in MS, meaning that treatment should also focus on other
brain and spinal cord pathological processes contributing to the slow loss of
neurological function. This should also be complemented with a holistic approach
to the management of other systemic disease processes that have been shown to
worsen MS outcomes.
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Affiliation(s)
| | - Veronica Popescu
- Universitair MS Centrum, Hasselt, Belgium;
Noorderhart Hospital, Pelt, Belgium; Hasselt University, Hasselt,
Belgium
| | - Jens Wuerfel
- MIAC AG, Department of Biomedical Engineering,
University of Basel, Basel, Switzerland; Charité – University Medicine
Berlin, Berlin, Germany
| | - Kerstin Hellwig
- Katholisches Klinikum Bochum, Klinikum der
Ruhr-Universität, Bochum, Germany
| | | | | | | | - Livia Sousa
- Centro Hospitalar e Universitário de Coimbra,
Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | | | - Raymond Hupperts
- Zuyderland Medisch Centrum, Sittard-Geleen,
The Netherlands; Maastricht University Medical Center, Maastricht, The
Netherlands
| | - Giuseppe Fenu
- Department of Neurology, Brotzu Hospital,
Cagliari, Italy
| | - Benedetta Bodini
- Paris Brain Institute, Sorbonne University,
Paris, France; Department of Neurology, APHP, Saint-Antoine Hospital, Paris,
France
| | - Hanna-Maija Kuusisto
- Department of Neurology, Tampere University
Hospital, Tampere, Finland; Department of Customer and Patient Safety,
University of Eastern Finland, Kuopio, Finland
| | - Bruno Stankoff
- Paris Brain Institute, Sorbonne University,
ICM, CNRS, Inserm, Paris, France; APHP, Saint-Antoine Hospital, Paris,
France
| | - Jan Lycke
- Institute of Neuroscience and Physiology,
University of Gothenburg, Gothenburg, Sweden
| | | | - Cristina Granziera
- Neurologic Clinic and Policlinic, Departments
of Medicine, Clinical Research and Biomedical Engineering, University
Hospital Basel and University of Basel, Basel, Switzerland
- Translational Imaging in Neurology (ThINk)
Basel, Department of Biomedical Engineering, University Hospital Basel and
University of Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology
and Neuroscience Basel (RC2NB), University Hospital Basel and University of
Basel, Basel, Switzerland
| | - Antonio Scalfari
- Centre for Neuroscience, Department of
Medicine, Charing Cross Hospital, Imperial College London, London, UK
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10
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Natalizumab Induces Changes of Cerebrospinal Fluid Measures in Multiple Sclerosis. Diagnostics (Basel) 2021; 11:diagnostics11122230. [PMID: 34943468 PMCID: PMC8699923 DOI: 10.3390/diagnostics11122230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background: There is a lack of knowledge about the evolution of cerebrospinal fluid (CSF) markers in multiple sclerosis (MS) patients undergoing natalizumab treatment. Aim: We aimed to evaluate the effect of natalizumab on basic inflammatory CSF and MRI measures. Methods: Together, 411 patients were screened for eligibility and 93 subjects with ≥2 CSF examinations ≤6 months before and ≥12 months after natalizumab initiation were recruited. The effect of natalizumab on CSF as well as clinical and paraclinical measures was analyzed using adjusted mixed models. Results: Natalizumab induced a decrease in CSF leukocytes (p < 1 × 10−15), CSF protein (p = 0.00007), the albumin quotient (p = 0.007), the IgG quotient (p = 6 × 10−15), the IgM quotient (p = 0.0002), the IgG index (p = 0.0004), the IgM index (p = 0.003) and the number of CSF-restricted oligoclonal bands (OCBs) (p = 0.0005). CSF-restricted OCBs positivity dropped from 94.6% to 86% but 26 patients (28%) had an increased number of OCBs at the follow-up. The baseline to follow-up EDSS and T2-LV were stable; a decrease in the relapse rate was consistent with a decrease in the CSF inflammatory markers and previous knowledge about the effectiveness of natalizumab. The average annualized brain volume loss during the follow-up was −0.50% (IQR = −0.96, −0.16) and was predicted by the baseline IgM index (B = −0.37; p = 0.003). Conclusions: Natalizumab is associated with a reduction of basic CSF inflammatory measures supporting its strong anti-inflammatory properties. The IgM index at the baseline predicted future brain volume loss during the course of natalizumab treatment.
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11
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Walo-Delgado PE, Monreal E, Medina S, Quintana E, Sainz de la Maza S, Fernández-Velasco JI, Lapuente P, Comabella M, Ramió-Torrentà L, Montalban X, Midaglia L, Villarrubia N, Carrasco-Sayalero A, Rodríguez-Martín E, Roldán E, Meca-Lallana J, Alvarez-Lafuente R, Masjuan J, Costa-Frossard L, Villar LM. Role of B Cell Profile for Predicting Secondary Autoimmunity in Patients Treated With Alemtuzumab. Front Immunol 2021; 12:760546. [PMID: 34691084 PMCID: PMC8531491 DOI: 10.3389/fimmu.2021.760546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective To explore if baseline blood lymphocyte profile could identify relapsing remitting multiple sclerosis (RRMS) patients at higher risk of developing secondary autoimmune adverse events (AIAEs) after alemtuzumab treatment. Methods Multicenter prospective study including 57 RRMS patients treated with alemtuzumab followed for 3.25 [3.5-4.21] years, (median [interquartile range]). Blood samples were collected at baseline, and leukocyte subsets determined by flow cytometry. We had additional samples one year after the first cycle of alemtuzumab treatment in 39 cases. Results Twenty-two patients (38.6%) developed AIAEs during follow-up. They had higher B-cell percentages at baseline (p=0.0014), being differences mainly due to plasmablasts/plasma cells (PB/PC, p=0.0011). Those with no AIAEs had higher percentages of CD4+ T cells (p=0.013), mainly due to terminally differentiated (TD) (p=0.034) and effector memory (EM) (p=0.031) phenotypes. AIAEs- patients also showed higher values of TNF-alpha-producing CD8+ T cells (p=0.029). The percentage of PB/PC was the best variable to differentiate both groups of patients. Baseline values >0.10% closely associated with higher AIAE risk (Odds ratio [OR]: 5.91, 95% CI: 1.83-19.10, p=0.004). When excluding the 12 patients with natalizumab, which decreases blood PB/PC percentages, being the last treatment before alemtuzumab, baseline PB/PC >0.1% even predicted more accurately the risk of AIAEs (OR: 11.67, 95% CI: 2.62-51.89, p=0.0007). The AIAEs+ group continued having high percentages of PB/PC after a year of alemtuzumab treatment (p=0.0058). Conclusions A PB/PC percentage <0.1% at baseline identifies MS patients at low risk of secondary autoimmunity during alemtuzumab treatment.
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Affiliation(s)
- Paulette Esperanza Walo-Delgado
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Enric Monreal
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Silvia Medina
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Ester Quintana
- Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Neurodegeneration and Neuroinflammation Research Group, Biomedical Research Institute (IDIBGI), Red Española de Esclerosis Múltiple (REEM), Girona, Spain
| | - Susana Sainz de la Maza
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - José Ignacio Fernández-Velasco
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Paloma Lapuente
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Manuel Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Lluis Ramió-Torrentà
- Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Neurodegeneration and Neuroinflammation Research Group, Biomedical Research Institute (IDIBGI), Red Española de Esclerosis Múltiple (REEM), Girona, Spain
| | - Xavier Montalban
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Luciana Midaglia
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Institut de Recerca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Red Española de Esclerosis Múltiple (REEM), Barcelona, Spain
| | - Noelia Villarrubia
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Angela Carrasco-Sayalero
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Eulalia Rodríguez-Martín
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Ernesto Roldán
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - José Meca-Lallana
- Department of Neurology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Roberto Alvarez-Lafuente
- Grupo de Investigación de Factores Ambientales en Enfermedades Degenerativas, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Hospital Clínico San Carlos, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Jaime Masjuan
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Lucienne Costa-Frossard
- Department of Neurology, Ramón y Cajal University Hospital, IRYCIS, Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
| | - Luisa Maria Villar
- Department of Immunology, Ramón y Cajal University Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Red Española de Esclerosis Múltiple (REEM), Madrid, Spain
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