Plasma exchange of malignant multiple sclerosis

Therapeutic apheresis in multiple sclerosis and other central nervous system disorders

Although the cause of multiple sclerosis (MS) remains unknown, the recent advances in research and the use of immunomodulating therapies have revolutionalized the way this disease is now approached. Apheresis is but one of the various immunomodulating therapies successfully used in MS. Pilot and double-blind randomized controlled studies, long-term follow-up studies, and the possible mechanism of action of therapeutic apheresis in MS are discussed. Based on our current knowledge, as well as on the available published data, it is concluded that apheresis is an effective therapy in severely progressive MS (both acute and chronic) when conventional therapies have failed.

Increased antibody production in peripheral blood mononuclear cells after plasma exchange therapy in multiple sclerosis

It has been difficult to study antibody synthesis in vivo following plasma exchange (PE) because of the intra- and extravascular compartmentation of immunoglobulins, and their altered lymphatic flow and catabolism after the procedure. There is fragmentary experimental and clinical evidence that antibody synthesis may increase due to removal of autoregulatory factors by PE. The present study showed increased in vitro spontaneous immunoglobulin (Ig) G and IgM production, as well as increased spontaneous lymphocytic proliferation, after intensive PE in 10 multiple sclerosis (MS) patients. Cytofluorometric control of cultured mononuclear cell populations revealed no change with treatment except for a small increase in B lymphocytes inadequate to account for the increased immunoglobulin production. These findings indicate an activation of the immune system through PE, and suggest the possible need for adjunctive immunosuppression to control antibody production in autoimmune diseases with subacute, relapsing, or chronic courses when PE is employed as a therapeutic modality.

A double-blind controlled pilot study of plasma exchange versus sham apheresis in chronic progressive multiple sclerosis

Twenty patients with chronically progressive multiple sclerosis (MS) were randomised in a double-blind controlled study to assess the efficacy of plasma exchange therapy. All patients were immunosuppressed with prednisone and azathioprine and underwent either plasma exchange or sham apheresis. The 10 patients in each group were similar in age, sex, duration of disease and degree of disability. Clinical and laboratory responses were assessed immediately following the course of exchange or sham therapy, and 3 to 6 months later, by individuals blinded to the type of therapy administered. Although modest improvement was suggested on clinical examination in 7 of 10 patients exchanged and 3 of the 10 sham treated group, this was transient and was not accompanied by any change in disability status scores. No differences in abnormal laboratory investigations were demonstrable between the two patient groups following therapy. We conclude that plasma exchange therapy using this protocol is unlikely to be of clinical benefit as an adjunct in the management of chronically progressive M.S.

CSF myelin basic protein levels in acute optic neuritis and multiple sclerosis

Normal CSF-MBP levels as determined by a RIA were less than 6.2 ng/ml CSF (mean 3.9). Eighty percent of patients with acute optic neuritis have CSF-MBP levels greater than 6.2 ng/ml (mean 7.6 ng/ml CSF). Five of 7 patients with acute internuclear ophthalmoplegia due to an initial exacerbation of demyelination have CSF-MBP levels above 6.2 ng/ml (mean 6.8 ng/ml). Fifty percent of MS patients with chronic progressive disease have CSF-MBP levels above 6.2 ng/ml (mean 6.7 ng/ml). MS patients experiencing monosymptomatic exacerbations show elevated CSF-MBP levels in 75% in 75% of cases (mean 8.2 ng/ml). MS patients experiencing polysymptomatic exacerbations show significantly higher levels of CSF-MBP (mean 22.3 ng/ml) than the patients with monosymptomatic exacerbations. Ninety-five percent of MS patients experiencing polysymptomatic exacerbations have elevated levels of CSF-MBP.