Antiglycolipid antibodies and peripheral neuropathies: links to pathogenesis

Immunoglobulin (Ig) M antibody against myelin associated glycoprotein (MAG): A comparison of methods

The presence of immunoglobulin (Ig)M antibody against myelin associated glycoprotein (MAG) has been associated with autoimmune demyelinating, sensorimotor neuropathies. Approximately 50% of patients with IgM paraproteinemia and associated peripheral neuropathy possess antibodies against MAG. These autoantibodies are thought to interfere with the process of myelination, myelin maintenance, or axon-Schwann cell interaction. The detection of these autoantibodies is useful to the clinician and is suggestive of active demyelination in a peripheral neuropathy. Our objective in this study was to compare the results obtained using three different methods (dual enzyme immunoassay [EIA], immunofluorescent antibody [IFA] and Western blot [WB]) for detecting IgM antibody against MAG in patients suspected of having autoimmune demyelinating neuropathies. Since the dual EIA utilized two different antigens, results from this assay were separated into two groups: MAG and sulfate-3-glucuronyl paragloboside (SGPG). When compared to WB (gold standard), percent agreement, sensitivity, and specificity for EIA and IFA are as follows: MAG EIA (68.3, 100.0, and 60.6); SGPG EIA (95.1, 100.0, and 93.9); and myelin IFA (97.6, 100.0, and 97.0). The authors conclude that the SGPG EIA and myelin IFA compared well with the standard WB method when detecting IgM antibody against MAG (100 kD). Many sera demonstrated reactivity on the MAG EIA that were negative by WB (100 kD glycoprotein). The authors recommend screening for MAG IgM in suspected patient sera by SGPG EIA or myelin IFA and utilizing these same methods to titer sera confirmed positive by WB.

Immunotherapy in autoimmune neuromuscular disorders

Important progress has been made in our understanding of the cellular and molecular processes underlying autoimmune neuromuscular diseases that has led us to identify targets for rational therapeutic intervention. Although antigen-specific immunotherapy is not yet available, old and new immunomodulatory treatments, alone or in combination, provide effective immunotherapy for most autoimmune disorders. In parallel, the achievements of molecular medicine provide more specific yet largely experimental therapeutic tools that need to be tested in the human diseases. Here we review the principles and targets of immunotherapy for autoimmune neuromuscular disorders, address applications and practical guidelines, and give an outlook on future developments.

Variability in immunohistochemistries of IgM M-proteins binding to sulfated glucuronyl paragloboside

Serum IgMs from 4 of 12 patients with polyneuropathy and IgM M-proteins that bind to sulfated glucuronyl paragloboside (SGPG) strongly immunostained the human peripheral nerve myelin (group A), whereas those from the other eight patients strongly immunostained the cytoplasm of the Schwann cells surrounding the myelin sheath with only weak staining of the myelin (group B). Strong immunostaining of peripheral myelin by IgMs from group A patients may be due to the strong cross-reactivities against P0 and peripheral myelin protein-22 (PMP-22), which are localized in compact myelin. Only three patients (all in group B) showed some response to the immunotherapies. Weak reactivities to P0 and and PMP-22 might indicate the possibility of improvement after the immunotherapies.

Binding of cholera toxin B subunit: a surface marker for murine microglia but not oligodendrocytes or astrocytes

GM1 ganglioside is a receptor for the B subunit of cholera toxin. In lymphocytes, B subunit elicits an influx of extracellular Ca++ (Dixon et al., 1987). To investigate this signaling pathway in glia, we assessed the presence of GM1 ganglioside on the surface of cultured murine central nervous system (CNS) glia by binding of fluorescein-labeled B subunit. B subunit binding was compared to binding of peanut agglutinin, wheat germ agglutinin, and Bandeiraea (Griffonia) simplicifolia lectin (BSL)I, a microglial marker. Antibodies to glial fibrillary acidic protein, A007/O4 antigens, and galactocerebroside were used to identify astrocytes, immature oligodendrocytes (OLs) and mature OLs, respectively. Binding patterns differed based on cell type and developmental stage. Wheat germ and peanut agglutinins bound to the surface of microglia, astrocytes, and immature OLs; neither lectin bound to any significant extent to the surface of membrane sheets of mature OLs, although wheat germ agglutinin was rapidly endocytosed. Cells identified as microglia by BSL I binding and morphology were the only cells to stain brightly on the surface with B subunit. Thus, surface GM1 ganglioside appears to be a highly enriched marker for microglia in these mixed glial cultures. The effects of B subunit on intracellular Ca++ were examined by laser cytometry in glial cultures loaded with Indo-1. No Ca++ responses were observed in microglia. Mature OLs were examined for Ca++ responses to B subunit before and after surface levels of GM1 ganglioside were increased by incubation with exogenous GM1 ganglioside. Again, no Ca++ responses were observed. Thus, cultured microglia and mature OLs do not have the GM1-mediated signal transduction pathway seen in lymphocytes. However, the presence of GM1 ganglioside on microglia may play a role in giving rise to antibodies to this glycolipid in some CNS inflammatory diseases.

A somatically mutated human antiganglioside IgM antibody that induces experimental neuropathy in mice is encoded by the variable region heavy chain gene, V1-18

IgM paraproteins associated with autoimmune peripheral neuropathy and anti-Pr cold agglutinins react with sialic acid epitopes present on disialylated gangliosides including GD1b, GT1b, GQ1b, and GD3. A causal relationship between the paraprotein and the neuropathy has never been proven experimentally. From peripheral blood B cells of an affected patient, we have cloned a human hybridoma secreting an antidisialosyl IgM mAb, termed Ha1, that shows identical structural and functional characteristics to its serum counterpart. Variable region analysis shows Ha1 is encoded by the same VH1 family heavy chain gene, V1-18, as the only other known anti-Pr antibody sequence and is somatically mutated, suggesting that it [correction of is] arose in vivo in response to antigenic stimulation. In the rodent peripheral nervous system, Ha1 immunolocalizes to dorsal root ganglia, motor nerve terminals, muscle spindles, myelinated axons, and nodes of Ranvier. After intraperitoneal injection of affinity-purified antibody into mice for 10 d, electrophysiological recordings from the phrenic nerve-hemidiaphragm preparation demonstrated impairment of nerve excitability and a reduction in quantal release of neurotransmitter. These data unequivocally establish that an antidisialosyl antibody can exert pathophysiological effects on the peripheral nervous system and strongly support the view that the antibody contributes to the associated human disease.

Neuropathies associated with monoclonal gammopathies

Approximately 10% of patients with idiopathic peripheral neuropathy have an associated serum monoclonal gammopathy or M-protein. This represents six times the incidence of M-proteins found in the general population. In 5% of idiopathic peripheral neuropathy patients the M-protein is associated with an identifiable plasma cell dyscrasia. Sclerotic myeloma is particularly important to recognize because treatment may result in amelioration of the neuropathy and remission of the tumor. Patients with primary systemic amyloidosis often have preferential small fiber involvement with a dissociated sensory loss and autonomic dysfunction. The nerve root infiltration of lymphoproliferative disorders may simulate a polyradiculoneuropathy. In cases without an identifiable cause for the M-protein, referred to as monoclonal gammopathy of undetermined significance (MGUS), the pathophysiologic basis for the neuropathy is poorly defined in most cases. A role for M-proteins with antibody activity to myelin-associated glycoprotein is provocative. This review summarizes current knowledge of this important group of disorders.