Diagnosis and treatment of progressive multiple sclerosis: A position paper

Dorsoventral photobiomodulation therapy safely reduces inflammation and sensorimotor deficits in a mouse model of multiple sclerosis

BACKGROUND

Non-invasive photobiomodulation therapy (PBMT), employing specific infrared light wavelengths to stimulate biological tissues, has recently gained attention for its application to treat neurological disorders. Here, we aimed to uncover the cellular targets of PBMT and assess its potential as a therapeutic intervention for multiple sclerosis (MS).

METHODS

We applied daily dorsoventral PBMT in an experimental autoimmune encephalomyelitis (EAE) mouse model, which recapitulates key features of MS, and revealed a strong positive impact of PBMT on the sensorimotor deficits. To understand the cellular mechanisms underlying these striking effects, we used state-of-the-art tools and methods ranging from two-photon longitudinal imaging of triple fluorescent reporter mice to histological investigations and patch-clamp electrophysiological recordings.

RESULTS

We found that PBMT induced anti-inflammatory and neuroprotective effects in the dorsal spinal cord. PBMT prevented peripheral immune cell infiltration, glial reactivity, as well as the EAE-induced hyperexcitability of spinal interneurons, both in dorsal and ventral areas, which likely underlies the behavioral effects of the treatment. Thus, aside from confirming the safety of PBMT in healthy mice, our preclinical investigation suggests that PBMT exerts a systemic and beneficial effect on the physiopathology of EAE, primarily resulting in the modulation of the inflammatory processes.

CONCLUSION

PBMT may therefore represent a new valuable therapeutic option to treat MS symptoms.

Markers of secondary progression in multiple sclerosis

INTRODUCTION

There is no globally accepted definition of Secondary Progressive Multiple Sclerosis (SPMS) or set of unambiguous clinical, radiological, or other criteria that can accurately identify patients who transition to SPMS. Thus, the SPMS diagnosis is almost always a retrospective and frequently delayed process.

OBJECTIVE

The aim of this study was to elucidate the current understanding of phenotypic changes throughout MS course and provide insights into the detection of SPMS from the available literature on this diagnostic landscape.

METHODS

Comprehensive literature review aiming at detecting the transition from RRMS to SPMS. A search for relevant publications was conducted across different databases, scrutinizing studies that investigated tools and biomarkers for an accurate diagnosis of SPMS.

RESULTS

62 studies from the past two decades were included. The EDSS-plus was shown to be more sensitive than the EDSS alone in identifying disability progression. We found some helpful indicators for diagnosing SPMS, including cognitive impairment, particularly on working memory, information processing speed, and verbal fluency; presence of slowly expanding lesions on MRI; thinning of retinal layers on OCT. Also, glial markers as Glial Fibrillary Acidic Protein and Chitinase-3-like protein 1 might be more suitable to identify the conversion to progressive disease than Neurofilament light chain. Certain subjective symptoms seem to be more prevalent in the SPMS phase, although further studies are needed to understand whether patient reported outcomes' measures (PROMs) and which ones could be useful in detecting the transition to a progressive phenotype.

CONCLUSION

Our review highlights the emergence of useful biomarkers in early detection of progression of MS, such as cognitive impairment, MRI, and glial markers. We are getting closer to revolutionising the SPMS diagnosis and clinical management as we get a deeper understanding of these biomarkers.

Active and non-active secondary progressive multiple sclerosis patients exhibit similar disability progression: results of an Italian MS registry study (ASPERA)

'Active' and 'non-active' secondary progressive MS (SPMS) have distinct pathophysiological mechanisms and clinical characteristics, but there is still no consensus regarding the frequency of these MS forms in the real-world setting. We aimed to evaluate the frequency of 'active' and 'non-active' SPMS in a large cohort of Italian MS patients and the differences in terms of clinical and MRI characteristics and disease progression. This multicenter study collected data about MS patients who have transitioned to the SP form in the period between 1st January 2014 and 31st December 2019 and followed by the MS centers contributing to the Italian MS Registry. Patients were divided into 'active SPMS' and 'non-active SPMS', based on both reported MRI data and relapse activity in the year before conversion to SPMS. Out of 68,621, 8,316 (12.1%) patients were diagnosed with SPMS. Out of them, 872 (10.5%) were classified into patients with either 'active' or 'non-active' SPMS. A total of 237 were classified into patients with 'active SPMS' (27.2%) and 635 as 'non-active SPMS' (72.8%). 'Non-active SPMS' patients were older, with a longer disease duration compared to those with 'active SPMS'. The percentages of patients showing progression independent of relapse activity (PIRA) at 24 months were similar between 'active' and 'non-active' SPMS patients (67 [27.4%] vs 188 [29.6%]; p = 0.60). In the 'active' group, 36 (15.2%) patients showed relapse-associated worsening (RAW). Comparison of the survival curves to EDSS 6 and 7 according to disease activity did not show significant differences (p = 0.68 and p = 0.71). 'Active' and 'non-active' SPMS patients had a similar risk of achieving disability milestones, suggesting that progression is primarily attributed to PIRA and only to a small extent to disease activity.

Immunomodulatory Effects of Anadenanthera colubrina Bark Extract in Experimental Autoimmune Encephalomyelitis

This study aimed to evaluate the efficacy of the ethanolic extract of Anadenanthera colubrina in modulating the immune response in the Experimental Autoimmune Encephalomyelitis (EAE) model. The ethanolic extract of the dried bark was analyzed by ESI (+) Orbitrap-MS to obtain a metabolite profile, demonstrating a wide variety of polyphenols, such as flavonoids and phenolic acids. Various parameters were evaluated, such as clinical signs, cytokines, cellular profile, and histopathology in the central nervous system (CNS). The ethanolic extract of A. colubrina demonstrated significant positive effects attenuating the clinical signs and pathological processes associated with EAE. The beneficial effects of the extract treatment were evidenced by reduced levels of pro-inflammatory cytokines, such as IL1β, IL-6, IL-12, TNF, IFN-γ, and a notable decrease in several cell profiles, including CD8+, CD4+, CD4+IFN-γ, CD4+IL-17+, CD11c+MHC-II+, CD11+CD80+, and CD11+CD86+ in the CNS. In addition, histological analysis revealed fewer inflammatory infiltrates and demyelination sites in the spinal cord of mice treated with the extract compared to the control model group. These results showed, for the first time, that the ethanolic extract of A. colubrina exerts a modulatory effect on inflammatory processes, improving clinical signs in EAE, in the acute phase of the disease, which could be further explored as a possible therapeutic alternative.

The Influence of SARS-CoV-2 Infection on the Development of Selected Neurological Diseases

In 2024, over 775 million cases of COVID-19 were recorded, including approximately 7 million deaths, indicating its widespread and dangerous nature. The disease is caused by the SARS-CoV-2 virus, which can manifest a wide spectrum of symptoms, from mild infection to respiratory failure and even death. Neurological symptoms, such as headaches, confusion, and impaired consciousness, have also been reported in some COVID-19 patients. These observations suggest the potential of SARS-CoV-2 to invade the central nervous system and induce neuroinflammation during infection. This review specifically explores the relationship between SARS-CoV-2 infection and selected neurological diseases such as multiple sclerosis (MS), ischemic stroke (IS), and Alzheimer's disease (AD). It has been observed that the SARS-CoV-2 virus increases the production of cytokines whose action can cause the destruction of the myelin sheaths of nerve cells. Subsequently, the body may synthesize autoantibodies that attack nerve cells, resulting in damage to the brain's anatomical elements, potentially contributing to the onset of multiple sclerosis. Additionally, SARS-CoV-2 exacerbates inflammation, worsening the clinical condition in individuals already suffering from MS. Moreover, the secretion of pro-inflammatory cytokines may lead to an escalation in blood clot formation, which can result in thrombosis, obstructing blood flow to the brain and precipitating an ischemic stroke. AD is characterized by intense inflammation and heightened oxidative stress, both of which are exacerbated during SARS-CoV-2 infection. It has been observed that the SARS-CoV-2 demonstrates enhanced cell entry in the presence of both the ACE2 receptor, which is already elevated in AD and the ApoE ε4 allele. Consequently, the condition worsens and progresses more rapidly, increasing the mortality rate among AD patients. The above information underscores the numerous connections between SARS-CoV-2 infection and neurological diseases.

Kynurenines and Inflammation: A Remarkable Axis for Multiple Sclerosis Treatment

Multiple sclerosis (MS) is a chronic inflammatory autoimmune neurological disease characterized by the recurrent appearance of demyelinating lesions and progressive disability. Currently, there are multiple disease-modifying treatments, however, there is a significant need to develop new therapeutic targets, especially for the progressive forms of the disease. This review article provides an overview of the most recent studies aimed at understanding the inflammatory processes that are activated in response to the accumulation of kynurenine pathway (KP) metabolites, which exacerbate an imbalance between immune system cells (e.g., Th1, Th2, and T reg) and promote the release of pro-inflammatory interleukins that modulate different mechanisms: membrane-receptors function; nuclear factors expression; and cellular signals. Together, these alterations trigger cell death mechanisms in brain cells and promote neuron loss and axon demyelination. This hypothesis could represent a remarkable approach for disease-modifying therapies for MS. Here, we also provide a perspective on the repositioning of some already approved drugs involved in other signaling pathways, which could represent new therapeutic strategies for MS treatment.

Integrated analyses of single-cell transcriptome and Mendelian randomization reveal the protective role of FCRL3 in multiple sclerosis

Background

Multiple sclerosis (MS) represents a multifaceted autoimmune ailment, prompting the development and widespread utilization of numerous therapeutic interventions. However, extant medications for MS have proven inadequate in mitigating relapses and halting disease progression. Innovative drug targets for preventing multiple sclerosis are still required. The objective of this study is to discover novel therapeutic targets for MS by integrating single-cell transcriptomics and Mendelian randomization analysis.

Methods

The study integrated MS genome-wide association study (GWAS) data, single-cell transcriptomics (scRNA-seq), expression quantitative trait loci (eQTL), and protein quantitative trait loci (pQTL) data for analysis and utilized two-sample Mendelian randomization study to comprehend the causal relationship between proteins and MS. Sequential analyses involving colocalization and Phenome-wide association studies (PheWAS) were conducted to validate the causal role of candidate genes.

Results

Following stringent quality control preprocessing of scRNA-seq data, 1,123 expression changes across seven peripheral cell types were identified. Among the seven most prevalent cell types, 97 genes exhibiting at least one eQTL were discerned. Examination of MR associations between 28 proteins with available index pQTL signals and the risk of MS outcomes was conducted. Co-localization analyses and PheWAS indicated that FCRL3 may exert influence on MS.

Conclusion

The integration of scRNA-seq and MR analysis facilitated the identification of potential therapeutic targets for MS. Notably, FCRL3, implicated in immune function, emerged as a significant drug target in the deCODE databases. This research underscores the importance of FCRL3 in MS therapy and advocates for further investigation and clinical trials targeting FCRL3.

Molecular Mechanisms in the Design of Novel Targeted Therapies for Neurodegenerative Diseases

Neurodegenerative diseases are a diverse group of diseases characterized by a progressive loss of neurological function due to damage to nerve cells in the central nervous system. In recent years, there has been a worldwide increase in the expanding associated with increasing human life expectancy. Molecular mechanisms control many of the essential life processes of cells, such as replication, transcription, translation, protein synthesis and gene regulation. These are complex interactions that form the basis for understanding numerous processes in the organism and developing new diagnostic and therapeutic approaches. In the context of neurodegenerative diseases, molecular basis refers to changes at the molecular level that cause damage to or degeneration of nerve cells. These may include protein aggregates leading to pathological structures in brain cells, impaired protein transport in nerve cells, mitochondrial dysfunction, inflammatory processes or genetic mutations that impair nerve cell function. New medical therapies are based on these mechanisms and include gene therapies, reduction in inflammation and oxidative stress, and the use of miRNAs and regenerative medicine. The aim of this study was to bring together the current state of knowledge regarding selected neurodegenerative diseases, presenting the underlying molecular mechanisms involved, which could be potential targets for new forms of treatment.

Optic Neuritis in a Pediatric Patient with Kikuchi-Fujimoto Disease: A Case Report and Review of the Literature

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare, benign, and self-limiting condition characterized by lymph node inflammation. While KFD is rarely associated with ocular manifestations, our case report highlights bilateral optic neuritis in a 13-year-old male patient with KFD. We also provide a comprehensive review of similar cases in the literature.

CNS Resident Innate Immune Cells: Guardians of CNS Homeostasis

Although the CNS has been considered for a long time an immune-privileged organ, it is now well known that both the parenchyma and non-parenchymal tissue (meninges, perivascular space, and choroid plexus) are richly populated in resident immune cells. The advent of more powerful tools for multiplex immunophenotyping, such as single-cell RNA sequencing technique and upscale multiparametric flow and mass spectrometry, helped in discriminating between resident and infiltrating cells and, above all, the different spectrum of phenotypes distinguishing border-associated macrophages. Here, we focus our attention on resident innate immune players and their primary role in both CNS homeostasis and pathological neuroinflammation and neurodegeneration, two key interconnected aspects of the immunopathology of multiple sclerosis.

Idiopathic Intracranial Hypertension Preceding Tumefactive Multiple Sclerosis

Idiopathic intracranial hypertension (IIH) and multiple sclerosis (MS) are rare neurological disorders that largely affect females within the reproductive age group. The clinical pictures of both diseases can overlap, which therefore places great importance on accurately studying and reporting their concurrence. Therein, we report a case of IIH presenting and progressing simultaneously with MS. This young, previously healthy female presented with the primary complaint of a severe right-sided headache associated with blurred vision and a finding of papilledema. The initial investigations including a lumbar puncture (LP) that revealed high opening pressure (more than 25 mm H2O) with normal cerebrospinal fluid (CSF) analysis led to an impression of idiopathic intracranial hypertension, and she was treated accordingly with acetazolamide and scheduled for regular follow-ups with both neurology and neuro-ophthalmology. However, about two months after the initial presentation, she complained of unusual headaches, and a neuro-ophthalmology clinical evaluation revealed complete right homonymous hemianopia, suggesting a lesion in the left temporo-parietal occipital region. The patient was thus admitted as a case of cerebral edema following an urgent brain magnetic resonance imaging (MRI). After obtaining thorough imaging and workup, the patient was given steroids and markedly improved, favoring a diagnosis of tumefactive MS with IIH.

Key Components of Qigong for People With Multiple Sclerosis: A Survey of Clinicians, Researchers, and Instructors

Background

Preliminary evidence suggests that Qigong (QG), a mind-body therapy, may help address symptoms of multiple sclerosis (MS), but the heterogeneity of QG content and delivery may affect its feasibility, acceptability, and efficacy.

Objective

To survey researchers, clinicians, and QG instructors with experience working with people with MS to identify key components of MS-specific QG guidelines and protocols.

Methods

We conducted an online survey to identify QG forms and movements considered helpful for MS, reasons for selection, characteristics of effective learning environments, and recommended dosage and frequency of practice. Quantitative data were analyzed using summary statistics. Qualitative data were analyzed using reflexive thematic analysis.

Results

Forty-seven experts, including QG instructors, clinicians, and QG and MS researchers, completed the survey. Respondents had a mean (SD) of 20 (11) years of QG teaching experience, 26 (12) years of clinical practice, 24 (9) years of QG research experience, 13 (5) years of MS research experience, and worked with at least 3 (2) people with MS. Approximately 125 QG forms/movements were recommended. Some forms were specifically recommended to address MS symptoms (e.g., emotional regulation, balance and coordination, muscle strength and flexibility, immune regulation, and circulation). Some respondents felt that any QG form could be beneficial if basic principles were met (e.g., intentional movement, posture, focused awareness, rhythmic breathing/movement, and a relaxed mind and body). Instructor qualities included the ability to convey information clearly, being caring and compassionate, proficient in QG, and having basic knowledge of MS. To promote confidence in learning QG, recommendations included having simple, easy-to-learn movements with modifications based on physical ability. We provide a sample protocol based on these recommendations.

Conclusions

This study provides expert guidance for developing a QG protocol for an MS population, including content and delivery recommendations.

Natural compounds as potential therapeutic candidates for multiple sclerosis: Emerging preclinical evidence

BACKGROUND

Multiple sclerosis is a chronic neurodegenerative disease, with main characteristics of pathological inflammation, neural damage and axonal demyelination. Current mainstream treatments demonstrate more or less side effects, which limit their extensive use.

PURPOSE

Increasing studies indicate that natural compounds benefit multiple sclerosis without remarkable side effects. Given the needs to explore the potential effects of natural compounds of plant origin on multiple sclerosis and their mechanisms, we review publications involving the role of natural compounds in animal models of multiple sclerosis, excluding controlled trials.

STUDY DESIGN AND METHODS

Articles were conducted on PubMed and Web of Science databases using the keywords ``multiple sclerosis'' and ``natural compounds'' published from January 1, 2008, to September 1, 2023.

RESULTS

This review summarized the effects of natural ingredients (flavonoids, terpenoids, polyphenols, alkaloids, glycosides, and others) from three aspects: immune regulation, oxidative stress suppression, and myelin protection and regeneration in multiple sclerosis.

CONCLUSION

Overall, we concluded 80 studies to show the preclinical evidence that natural compounds may attenuate multiple sclerosis progression via suppressing immune attacks and/or promoting myelin protection or endogenous repair processes. It would pave the roads for the future development of effective therapeutic regiments of multiple sclerosis.