[Mode of action of botulinum neurotoxin: pathological, cellular and molecular aspect]

Optogenetically controlled human functional motor endplate for testing botulinum neurotoxins

Background

The lack of physiologically relevant and predictive cell-based assays is one of the major obstacles for testing and developing botulinum neurotoxins (BoNTs) therapeutics. Human-induced pluripotent stem cells (hiPSCs)-derivatives now offer the opportunity to improve the relevance of cellular models and thus the translational value of preclinical data.

Methods

We investigated the potential of hiPSC-derived motor neurons (hMNs) optical stimulation combined with calcium imaging in cocultured muscle cells activity to investigate BoNT-sensitivity of an in vitro model of human muscle-nerve system.

Results

Functional muscle-nerve coculture system was developed using hMNs and human immortalized skeletal muscle cells. Our results demonstrated that hMNs can innervate myotubes and induce contractions and calcium transient in muscle cells, generating an in vitro human motor endplate showing dose-dependent sensitivity to BoNTs intoxication. The implementation of optogenetics combined with live calcium imaging allows to monitor the impact of BoNTs intoxication on synaptic transmission in human motor endplate model.

Conclusions

Altogether, our findings demonstrate the promise of optogenetically hiPSC-derived controlled muscle-nerve system for pharmaceutical BoNTs testing and development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02665-3.

Emerging Opportunities in Human Pluripotent Stem-Cells Based Assays to Explore the Diversity of Botulinum Neurotoxins as Future Therapeutics

Botulinum neurotoxins (BoNTs) are produced by Clostridium botulinum and are responsible for botulism, a fatal disorder of the nervous system mostly induced by food poisoning. Despite being one of the most potent families of poisonous substances, BoNTs are used for both aesthetic and therapeutic indications from cosmetic reduction of wrinkles to treatment of movement disorders. The increasing understanding of the biology of BoNTs and the availability of distinct toxin serotypes and subtypes offer the prospect of expanding the range of indications for these toxins. Engineering of BoNTs is considered to provide a new avenue for improving safety and clinical benefit from these neurotoxins. Robust, high-throughput, and cost-effective assays for BoNTs activity, yet highly relevant to the human physiology, have become indispensable for a successful translation of engineered BoNTs to the clinic. This review presents an emerging family of cell-based assays that take advantage of newly developed human pluripotent stem cells and neuronal function analyses technologies.

Motion analysis for the evaluation of muscle overactivity: A point of view

Muscle overactivity is a general term for pathological increases in muscle activity such as spasticity. It is caused by damage to the central nervous system at the cortical, subcortical or spinal levels, leading to an upper motor neuron syndrome. In routine clinical practice, muscle overactivity, which induces abnormal muscle tone, is usually evaluated by using the Modified Ashworth Scale or the Tardieu Scale. However, both of these scales involve testing in passive conditions that do not always reflect muscle activity during dynamic tasks such as gait or reaching. To determine appropriate treatment strategies, muscle overactivity should be evaluated by using objective measures in dynamic conditions. Instrumental motion analysis systems that include 3-D motion analysis and electromyography are very useful for this purpose. The method can be used to identify patterns of abnormal muscle activity that can be related to abnormal kinematic patterns. It allows for objective and accurate assessment of the effects of treatments to reduce muscle overactivity on the movement to be improved. The aim of this point-of-view article is to describe the utility of instrumental motion analysis and to outline both its numerous advantages in evaluating muscle overactivity and to present the current limitations for its use (e.g., cost, the need for an engineer, errors relating to marker placement and cross talk between electromyography sensors).

Usefulness of intra-articular botulinum toxin injections. A systematic review

Botulinum toxin is a proven and widely used treatment for numerous conditions characterized by excessive muscular contractions. Recent studies have assessed the analgesic effect of botulinum toxin in joint pain and started to unravel its mechanisms.

LITERATURE-SEARCH-METHODOLOGY

We searched the international literature via the Medline database using the term "intraarticular botulinum toxin injection" combined with any of the following terms: "knee", "ankle", "shoulder", "osteoarthritis", "adhesive capsulitis of the shoulder".

RESULTS

Of 16 selected articles about intraarticular botulinum toxin injections, 7 were randomized controlled trials done in patients with osteoarthritis, adhesive capsulitis of the shoulder, or chronic pain after joint replacement surgery. Proof of anti-nociceptive effects was obtained in some of these indications and the safety and tolerance profile was satisfactory. The studies are heterogeneous. The comparator was usually a glucocorticoid or a placebo; a single study used hyaluronic acid. Pain intensity was the primary outcome measure.

DISCUSSION-CONCLUSION

The number of randomized trials and sample sizes are too small to provide a satisfactory level of scientific evidence or statistical power. Unanswered issues include the effective dosage and the optimal dilution and injection modalities of botulinum toxin.

Solubility of the catalytic domains of Botulinum neurotoxin serotype E subtypes

The Clostridium botulinum neurotoxins (BoNTs) are the most potent protein toxins known to humans. There are seven serotypes of the BoNTs (A-G), among which serotypes A, B, E and F are known to cause natural human intoxication. To date, eleven subtypes of LC/E, termed E1∼E11, have been identified. The LCs of BoNT/E were insoluble, prohibiting studies towards understanding the mechanisms of toxin action and substrate recognition. In this work, the molecular basis of insolubility of the recombinant LCs of two representative subtypes of BoNT/E, E1(Beluga) and E3 (Alaska), was determined. Hydrophobicity profile and structural modeling predicted a C-terminal candidate region responsible for the insolubility of LC/Es. Deletion of C-terminal 19 residues of LC/E(1-400) resulted in enhanced solubility, from 2 to ∼50% for LC/EAlaska and from 16 to ∼95% for LC/EBeluga. In addition, resides 230-236 were found to contribute to a different solubility level of LC/EAlaska when compared to LC/EBeluga. Substituting residues (230)TCI(232) in LC/EAlaska to the corresponding residues of (230)KYT(232) in LC/EBeluga enhanced the solubility of LC/EAlaska to a level approaching that of LC/EBeluga. Among these LC/Es and their derivatives, LC/EBeluga 1-400 was the most soluble and stable protein. Each LC/E derivative possessed similar catalytic activity, suggesting that the C-terminal region of LC/Es contributed to protein solubility, but not catalytic activity. In conclusion, this study generated a soluble and stable recombinant LC/E and provided insight into the structural components that govern the solubility and stability of the LCs of other BoNT serotypes and Tetanus toxin.

Effects of quadriceps muscle fatigue on stiff-knee gait in patients with hemiparesis

The relationship between neuromuscular fatigue and locomotion has never been investigated in hemiparetic patients despite the fact that, in the clinical context, patients report to be more spastic or stiffer after walking a long distance or after a rehabilitation session. The aim of this study was to evaluate the effects of quadriceps muscle fatigue on the biomechanical gait parameters of patients with a stiff-knee gait (SKG). Thirteen patients and eleven healthy controls performed one gait analysis before a protocol of isokinetic quadriceps fatigue and two after (immediately after and after 10 minutes of rest). Spatiotemporal parameters, sagittal knee and hip kinematics, rectus femoris (RF) and vastus lateralis (VL) kinematics and electromyographic (EMG) activity were analyzed. The results showed that quadriceps muscle weakness, produced by repetitive concentric contractions of the knee extensors, induced an improvement of spatiotemporal parameters for patients and healthy subjects. For the patient group, the increase in gait velocity and step length was associated with i) an increase of sagittal hip and knee flexion during the swing phase, ii) an increase of the maximal normalized length of the RF and VL and of the maximal VL lengthening velocity during the pre-swing and swing phases, and iii) a decrease in EMG activity of the RF muscle during the initial pre-swing phase and during the latter 2/3 of the initial swing phase. These results suggest that quadriceps fatigue did not alter the gait of patients with hemiparesis walking with a SKG and that neuromuscular fatigue may play the same functional role as an anti-spastic treatment such as botulinum toxin-A injection. Strength training of knee extensors, although commonly performed in rehabilitation, does not seem to be a priority to improve gait of these patients.

Persistent neurogenic bladder dysfunction due to infantile botulism

We present a child, 5 months of age, diagnosed with infantile botulism, showing the signs of neurogenic bladder dysfunction. The patient presented with progressive muscle weakness, hypotonia, suckling and swallowing problems and absent peripheral reflexes at clinical examination. Botulinum neurotoxin type A was detected in her serum, confirming the diagnosis. Starting at day 6, the girl presented with a urinary retention initially necessitating free bladder drainage and subsequently intermittent catheterisation. After 6 weeks in intensive care, the patient recovered but the bladder underactivity persisted. Four months following recovery, a urodynamic evaluation was performed, showing a near normal detrusor activity and normal bladder emptying, and the catheterisation was ceased. At 6 months, the girl was diagnosed with a urinary tract infection and bladder emptying problems, which persisted, and clean intermittent catheterisation was started. The final urodynamic evaluation, a year and a half after her initial presentation, revealed a normal detrusor activity and an adequate bladder emptying.

Effect of botulinum toxin injection on length and lengthening velocity of rectus femoris during gait in hemiparetic patients

BACKGROUND

In hemiparetic patients, rectus femoris spasticity is one of the main causes of reduced knee flexion in swing phase, known as stiff knee gait. Botulinum toxin is often used to reduce rectus femoris spasticity and to increase knee flexion during swing phase. However, the mechanisms behind these improvements remain poorly understood. The aim of this study was (1) to quantify maximal rectus femoris length and lengthening velocity during gait in ten adult hemiparetic subjects with rectus femoris spasticity and stiff knee gait and to compare these parameters with those of ten healthy subjects and (2) to study the effect of botulinum toxin injection in the rectus femoris muscle on the same parameters.

METHODS

10 patients with stiff knee gait and rectus femoris spasticity underwent 3D gait analysis before and one month after botulinum toxin injection of the rectus femoris (200 U Botox, Allergan Inc., Markham, Ontario, CANADA). Rectus femoris length and lengthening velocity were quantified using a musculoskeletal model (SIMM, MusculoGraphics, Inc., Santa Rosa, California, USA).

FINDINGS

Maximal length and lengthening velocity of the rectus femoris were significantly reduced on the paretic side. There was a significant increase in muscle length as well as lengthening velocity during gait following botulinum toxin injection.

INTERPRETATION

This study showed that botulinum toxin injection in the spastic rectus femoris of hemiparetic patients improves muscle kinematics during gait. However maximal rectus femoris length did not reach normal values following injection, suggesting that other mechanisms are likely involved.

Clinical uses of botulinum neurotoxins: current indications, limitations and future developments

Botulinum neurotoxins (BoNTs) cause flaccid paralysis by interfering with vesicle fusion and neurotransmitter release in the neuronal cells. BoNTs are the most widely used therapeutic proteins. BoNT/A was approved by the U.S. FDA to treat strabismus, blepharospam, and hemificial spasm as early as 1989 and then for treatment of cervical dystonia, glabellar facial lines, axillary hyperhidrosis, chronic migraine and for cosmetic use. Due to its high efficacy, longevity of action and satisfactory safety profile, it has been used empirically in a variety of ophthalmological, gastrointestinal, urological, orthopedic, dermatological, secretory, and painful disorders. Currently available BoNT therapies are limited to neuronal indications with the requirement of periodic injections resulting in immune-resistance for some indications. Recent understanding of the structure-function relationship of BoNTs prompted the engineering of novel BoNTs to extend therapeutic interventions in non-neuronal systems and to overcome the immune-resistance issue. Much research still needs to be done to improve and extend the medical uses of BoNTs.

[Botulinum toxin A: analgesic treatment for temporomandibular joint disorders]

INTRODUCTION

Pain, along with clicking, sub-luxation, and blocking, is one of the main symptoms for patients presenting with temporomandibular joint disorders. We assessed the effectiveness of botulinum toxin A (BOTOX(®), Allergan) as analgesic treatment for temporomandibular joint disorders.

PATIENTS AND METHOD

Twenty-six patients with chronic pain linked to temporomandibular joint disorders were prospectively assessed. Botulinum toxin A was injected in masseter and temporalis muscles. Follow-up parameters, at one and three months, were: measuring mouth opening and diduction, muscle tenderness and pain using a visual analogue scale.

RESULTS

There was a significant (P<0.0001) decrease of pain, an increased mouth opening, and diduction at three months. Seventy percent of the patients felt less muscle tenderness. The patient felt his psychological state had improved and so did his family.

DISCUSSION

Botulinum toxin A significantly decreases pain and improves movements of patients presenting with temporomandibular joint disorders. The effects are prolonged three months after the injection.

Molecular mechanisms of substrate recognition and specificity of botulinum neurotoxin serotype F

BoNTs (botulinum neurotoxins) are both deadly neurotoxins and natural toxins that are widely used in protein therapies to treat numerous neurological disorders of dystonia and spinal spasticity. Understanding the mechanism of action and substrate specificity of BoNTs is a prerequisite to develop antitoxin and novel BoNT-derived protein therapy. To date, there is a lack of detailed information with regard to how BoNTs recognize and hydrolyse the substrate VAMP-2 (vesicle-associated membrane protein 2), even though it is known to be cleaved by four of the seven BoNT serotypes, B, D, F, G and TeNT (tetanus neurotoxin). In the present study we dissected the molecular mechanisms of VAMP-2 recognition by BoNT serotype F for the first time. The initial substrate recognition was mediated through sequential binding of VAMP-2 to the B1, B2 and B3 pockets in LC/F (light chain of BoNT serotype F), which directed VAMP-2 to the active site of LC/F and stabilized the active site substrate recognition, where the P2, P1' and P2' sites of VAMP-2 were specifically recognized by the S2, S1' and S2' pockets of LC/F to promote substrate hydrolysis. The understanding of the molecular mechanisms of LC/F substrate recognition provides insights into the development of antitoxins and engineering novel BoNTs to optimize current therapy and extend therapeutic interventions.

Production and characterisation of a neutralising chimeric antibody against botulinum neurotoxin A

Botulinum neurotoxins, produced by Clostridium botulinum bacteria, are the causative agent of botulism. This disease only affects a few hundred people each year, thus ranking it among the orphan diseases. However, botulinum toxin type A (BoNT/A) is the most potent toxin known to man. Due to their potency and ease of production, these toxins were classified by the Centers for Disease Control and Prevention (CDC) as Category A biothreat agents. For several biothreat agents, like BoNT/A, passive immunotherapy remains the only possible effective treatment allowing in vivo neutralization, despite possible major side effects. Recently, several mouse monoclonal antibodies directed against a recombinant fragment of BoNT/A were produced in our laboratory and most efficiently neutralised the neurotoxin. In the present work, the most powerful one, TA12, was selected for chimerisation. The variable regions of this antibody were thus cloned and fused with the constant counterparts of human IgG1 (kappa light and gamma 1 heavy chains). Chimeric antibody production was evaluated in mammalian myeloma cells (SP2/0-Ag14) and insect cells (Sf9). After purifying the recombinant antibody by affinity chromatography, the biochemical properties of chimeric and mouse antibody were compared. Both have the same very low affinity constant (close to 10 pM) and the chimeric antibody exhibited a similar capacity to its parent counterpart in neutralising the toxin in vivo. Its strong affinity and high neutralising potency make this chimeric antibody interesting for immunotherapy treatment in humans in cases of poisoning, particularly as there is a probable limitation of the immunological side effects observed with classical polyclonal antisera from heterologous species.

Different antinociceptive effects of botulinum toxin type A in inflammatory and peripheral polyneuropathic rat models

In addition to inhibition of acetylcholine release in the neuromuscular junction botulinum toxin type A (BoNT-A) also inhibits the release of mediators involved in pain perception. We have investigated the effect of two types of BoNT-A on mechanical hyperalgesia in the rat models of carrageenan-induced hyperalgesia and of paclitaxel-induced peripheral neuropathy. A subplantar (s.p.) injection of BoNT-A in the ipsilateral hindpaw 3 days before carrageenan administration reduced hypersensitivity. Dysport and Botox elicited comparable antihyperalgesic effects. Dysport up to 30 U/kg and Botox up to 20 U/kg did not impair the rat withdrawal nociceptive reflex or the locomotor performance as assessed by the rotarod test. Intraperitoneal administration of the skeletal muscle relaxant dantrolene produced, in contrast to BoNT-A, more motor impairment than analgesia. Paclitaxel treatment resulted in a peripheral neuropathy that affected the two hindpaws. Injection of 20 U/kg (s.p.) Dysport produced a significant antihyperalgesic effect in the injected paw of neuropathic animals 3 days after administration. Unexpectedly, a similar analgesic effect was observed in the contralateral paw. The same results were also observed when Botox was used instead of Dysport. In contrast, a contralateral administration of Dysport in the carrageenan test was ineffective. We conclude that BoNT-A elicits antinociceptive effects independent of the effects on muscular relaxation. Our results suggest that different mechanisms of action are responsible for the effect of BoNT-A in inflammatory and peripheral polyneuropathic rat models.

Engineering botulinum neurotoxin to extend therapeutic intervention

Clostridium botulinum neurotoxins (BoNTs) are effective therapeutics for a variety of neurological disorders, such as strabismus, blepharospam, hemificial spasm, and cervical dystonia, because of the toxin's tropism for neurons and specific cleavage of neuronal soluble N-ethylmaleimide-sensitive fusion protein-attachment protein receptors (SNARE) proteins. Modifying BoNT to bind nonneuronal cells has been attempted to extend therapeutic applications. However, prerequisite to develop nonneuronal therapies requires the retargeting the catalytic activity of BoNTs to nonneuronal SNARE isoforms. Here, we reported the engineering of a BoNT derivative that cleaves SNAP23, a nonneuronal SNARE protein. SNAP23 mediates vesicle-plasma membrane fusion processes, including secretion of airway mucus, antibody, insulin, gastric acids, and ions. This mutated BoNT/E light chain LC/E(K(224)D) showed extended substrate specificity to cleave SNAP23, and the natural substrate, SNAP25, but not SNAP29 or SNAP47. Upon direct protein delivery into cultured human epithelial cells, LC/E(K(224)D) cleaved endogenous SNAP23, which inhibited secretion of mucin and IL-8. These studies show the feasibility of genetically modifying LCs to target a nonneuronal SNARE protein that extends therapeutic potential for treatment of human hypersecretion diseases.

Multiple pocket recognition of SNAP25 by botulinum neurotoxin serotype E

Botulinum neurotoxins (BoNTs) are zinc proteases that cleave SNARE proteins to elicit flaccid paralysis by inhibiting the fusion of neurotransmitter-carrying vesicles to the plasma membrane of peripheral neurons. There are seven serotypes of BoNT, termed A-G. The molecular basis for SNAP25 recognition and cleavage by BoNT serotype E is currently unclear. Here we define the multiple pocket recognition of SNAP25 by LC/E. The initial recognition of SNAP25 is mediated by the binding of the B region of SNAP25 to the substrate-binding (B) region of LC/E comprising Leu166, Arg167, Asp127, Ala128, Ser129, and Ala130. The mutations at these residues affected substrate binding and catalysis. Three additional residues participate in scissile bond cleavage of SNAP25 by LC/E. The P3 site residues, Ile178, of SNAP25 interacted with the S3 pocket in LC/E through hydrophobic interactions. The S3 pocket included Ile47, Ile164, and Ile182 and appeared to align the P1' and P2 residues of SNAP25 with the S1' and S2 pockets of LC/E. The S1' pocket of LC/E included three residues, Phe191, Thr159, and Thr208, which contribute hydrophobic and steric interactions with the SNAP25 P1' residue Ile181. The S2 pocket residue of LC/E, Lys224, binds the P2 residue of SNAP25, Asp179, through ionic interactions. Deletion mapping indicates that main chain interaction(s) of residues 182-186 of SNAP25 contribute to substrate recognition by LC/E. Understanding the mechanism for substrate specificity provides insight for the development of inhibitors against the botulinum neurotoxins.

Cricopharyngeal Botox injection: indications and technique

PURPOSE OF REVIEW

Botulinum injection is a widespread technique for treating oropharyngeal dysphagia although there are no standards or guidelines. Based on the literature review we try to make some recommendations.

RECENT FINDINGS

In the last 12 months molecular and pharmacological research has reported the working mechanism of the various botulinum toxin types which tries to explain former clinical observations such as variable response rate and therefore dosage, and toxin type specific resistance. Recent dose-ranging studies or comparisons of different toxin preparations or types rarely focus on oropharyngeal dysphagia.

SUMMARY

Injection of botulinum toxin A should be considered in cases of relative hypertonicity of the cricopharyngeal muscle and has an onset around day 7 and an offset of at least 4 months. The technique is simple and the complication rate is extremely low (7/100). There are some conditions for success: injection in the horizontal part of the cricopharyngeal muscle, and a high enough start dose. Botulinum injection may be preferred over surgical myotomy because of the low risk, low cost and effectiveness of the procedure. Only in cases of BoNT/A resistance should other toxin types be used.

Mechanism of substrate recognition by botulinum neurotoxin serotype A

Botulinum neurotoxins (BoNTs) are zinc proteases that cleave SNARE proteins to elicit flaccid paralysis by inhibiting neurotransmitter-carrying vesicle fusion to the plasma membrane of peripheral neurons. Unlike other zinc proteases, BoNTs recognize extended regions of SNAP25 for cleavage; however, the molecular basis for this extended substrate recognition is unclear. Here, we define a multistep mechanism for recognition and cleavage of SNAP25 by BoNT/A. SNAP25 initially binds along the belt region of BoNT/A, which aligns the P5 residue to the S5 pocket at the periphery of the active site. Although the exact order of each step of recognition of SNAP25 by BoNT/A at the active site is not clear, the initial binding could subsequently orient the P4'-residue of SNAP25 to form a salt bridge with the S4'-residue, which opens the active site allowing the P1'-residue access to the S1'-pocket. Subsequent hydrophobic interactions between the P3 residue of SNAP25 and the S3 pocket optimize alignment of the scissile bond for cleavage. This explains how the BoNTs recognize and cleave specific coiled SNARE substrates and provides insight into the development of inhibitors to prevent botulism.

New indications for botulinum toxin in rheumatology

Previously known only as a deadly bacterial poison responsible for severe paralysis, botulinum toxin is now a well-recognized therapeutic agent used to relieve involuntary movements, dystonia-related functional impairments, spasticity, and autonomic disorders such as hyperhidrosis. Musculoskeletal pain in patients with rheumatic disorders is among the emerging indications for botulinum toxin therapy. Preliminary data have been obtained in patients with cervical or thoracolumbar myofascial pain syndrome, chronic low back pain, piriformis muscle syndrome, tennis elbow, and stiff person syndrome. At present, the effects of botulinum toxin and its use for pain relief remain controversial. Carefully designed prospective trials are needed to investigate the efficacy and safety of botulinum toxin in pain disorders.

Unique Substrate Recognition by Botulinum Neurotoxins Serotypes A and E

Botulinum neurotoxins (BoNTs) are zinc proteases that cleave SNARE proteins to elicit flaccid paralysis by inhibiting the fusion of neurotransmitter-carrying vesicles to the plasma membrane of peripheral neurons. There are seven serotypes of BoNT, termed A-G. BoNT serotype A and serotype E cleave SNAP25 at residues 197-198 and 180-181, respectively. Unlike other zinc proteases, the BoNTs recognize extended regions of SNAP25 for cleavage. The basis for this extended substrate recognition and specificity is unclear. Saturation mutagenesis and deletion mapping identified residues 156-202 of SNAP25 as the optimal cleavage domain for BoNT/A, whereas the optimal cleavage domain for BoNT/E was shorter, comprising residues 167-186 of SNAP25. Two sub-sites were resolved within each optimal cleavage domain, which included a recognition or active site (AS) domain that contained the site of cleavage and a binding (B) domain, which contributed to substrate affinity. Within the AS domains, the P1', P3, and P5 sites of SNAP25 contributed to scissile bond cleavage by LC/A, whereas the P1' and P2 sites of SNAP25 contributed to scissile bond cleavage by LC/E. These studies provide insight into the development of strategies for small molecule inhibitors of the BoNTs.