Antibodies to acetylcholine receptors in rabbits: immunochemical and electrophysiological studies

Diagnosis and treatment of myasthenia gravis

OBJECTIVE

To describe the clinical presentation, diagnosis, and treatment of myasthenia gravis (MG) while emphasizing the important role of the pharmacist.

DATA SOURCES

English-language articles from MEDLINE pertinent to MG study selection and data extraction: All relevant publications addressing MG management were considered, including prospective comparative trials, epidemiological studies, guideline statements, review articles, and editorials. Particular focus occurred on primary literature published after 1976, but limited amount(s) existed. The American Autoimmune Related Diseases Association, Autoimmune Information Network, Inc., Myasthenia Gravis Foundation of America, Inc. (MGFA), National Institute of Neurological Disorders and Stroke, and National Organization for Rare Disorders.

DATA SYNTHESIS

MG is an autoimmune disorder involving the neuromuscular junction causing characteristic weakness in voluntary muscle groups. To determine appropriate pharmacotherapy, one must characterize the disease based on the degree of function and region of muscles affected. MGFA established a classification system of the disease in order to assess severity. Contemporary treatments include cholinesterase inhibitors, corticosteroids, immodulating/immunosuppressive therapy, intravenous immune globulin, plasmapheresis, and thymectomy. Because of the lack of double-blind, placebo-controlled, randomized clinical trials, treatments are less evidence-based than many other disease states. Clinicians should be aware of the different treatments and recognize the best treatment for the individual.

CONCLUSIONS

The diagnosis and treatment of MG is a therapeutic challenge. Pharmacists play an essential role in the care of these patients by avoiding drugs that exacerbate the disease, promoting optimal pharmacotherapy, monitoring pharmacotherapy, and ensuring compliance with prescribed medications.

How subtle differences in MHC class II affect the severity of experimental myasthenia gravis

Myasthenia gravis is an autoimmune disorder characterized by muscle weakness, due to an antibody-mediated deficit of acetylcholine receptors (AChRs) at neuromuscular junctions. We analyzed the factors that determine the severity of experimental myasthenia gravis (EAMG) induced by immunization with Torpedo AChR, in two congenic strains of mice--B6 mice, which are highly susceptible to EAMG; and bm12 mice, which are relatively resistant, and differ only in a change of three amino acids in MHC Class II. We prepared large numbers of AChR-specific T cell hybridomas from each strain and characterized their epitope specificities and T cell receptor (TCR) gene usage: Half the B6 hybridomas responded to a single AChR peptide (alpha 146-162), and their TCR genes encoded restricted V alpha and V beta chains and CDR3 motifs. bm12 hybridomas had different epitope specificities and different, less restricted TCR genes. APCs were able to present AChR or AChR-derived peptides virtually exclusively to hybridomas of their own strain. Levels of antibodies to Torpedo and autoantibodies to mouse AChR were higher in B6 mice, and were biased toward the IgG2b isotype. We conclude that the "better fit" of MHC II, peptide, and TCR in the B6 mice enhanced cognate interactions of APCs with T cells, and T cells with B cells, resulting in a more abundant and pathogenic AChR antibody response, and thus more severe EAMG.

Oral tolerance in myasthenia gravis

Because of the antibody-mediated pathogenesis of MG, it is of particular interest to understand the effects of oral administration of the autoantigen AChR on the disease process. It is now clear that feeding AChR prior to immunization can prevent clinical manifestation of EAMG. It initially primed, then inhibited, antibody responses to foreign (Torpedo) AChR and self (rat) AChR, with a delayed onset. Cellular responses to AChR, evaluated by lymphocyte proliferation and IL-2 production, were markedly inhibited. The effects were dependent on the dose and purity of the fed antigen. Tolerance to an orally administered unrelated antigen, OVA, was more prompt in development and more profound, illustrating the influence of the nature of the antigen on tolerance. The tolerance induced was antigen specific. Oral administration of AChR after immunization resulted in inhibition of the clinical manifestation of EAMG, concomitant with a paradoxical enhancement of the AChR-antibody responses. Both the clinical benefit and the antibody response appear to be dependent on the feeding protocol. These findings suggest that a molecule with less immunogenic potential than native AChR may be required for safe and effective oral treatment of ongoing disease.

Ocular myasthenia: a protean disorder

Ocular myasthenia is a localized form of myasthenia clinically involving only the extraocular, levator palpebrae superioris, and/or orbicularis oculi muscles. Ocular manifestations can masquerade as a variety of ocular motility disorders, including cranial nerve and gaze palsies. A history of variable and fatiguable muscle weakness suggests this diagnosis, which may be confirmed by the edrophonium (Tensilon) test and acetylcholine receptor antibody titer. Anticholinesterases, corticosteroids and other immunosuppressive agents, and other therapeutic modalities, including thymectomy and plasmapheresis, are used in treatment. As the pathophysiology of myasthenia has been elucidated in recent years, newer treatment strategies have evolved, resulting in a much more favorable prognosis than several decades ago. This review provides historical background, pathophysiology, immuno-genetics, diagnostic testing, and treatment options for ocular myasthenia, as well as a discussion of drug-induced myasthenic syndromes.

Antimuscle and antiacetylcholine receptor antibodies in myasthenia gravis

The sera of 134 patients were examined for antimuscle antibodies by immunofluorescence (IF). These derived from 77 myasthenics, 30 myasthenics with thymoma, 6 patients with thymoma and no clinical evidence of myasthenia, and 21 patients with other autoimmune or neuromuscular diseases. Three separate patterns of antimuscle antibodies could be identified in the myasthenic sera by examination of the relaxed glycerinated myofibrils by both IF and phase-contrast optics: A-band (9 with thymoma, 1 without), I-band (11 with thymoma, 17 without), and a mixed A plus I pattern (5 with thymoma, 3 without). Seventy-seven myasthenic serum samples (24 with thymoma, 53 without) were available for evaluation of antibodies to acetylcholine receptor (anti-AChR) by radioimmunoassay. Ninety-one percent reacted with crude human receptor extract and 80% with receptor extracted from denervated rat muscle. There was no correlation between the titers of anti-AChR and the presence or staining patterns of antimuscle antibodies, but patients without anti-AChR did not have antimuscle antibodies. Myasthenics with thymoma had the highest prevalence of anti-AChR (23/24) and of antimuscle antibodies (25/30), and 15 of the 20 positives stained A-bands alone or with I-band, as compared to 4 of 21 positive reactions in those without tumor. Immunoabsorption, which removed or significantly reduced anti-AChR, did not alter antimuscle reactivity. The discrepancies between anti-AChR levels and the presence and types of antimuscle antibodies suggest that these are independent autoantibodies. Current theories of immunopathogenesis implicate altered thymic antigens or a major breakdown in immune regulation, either of which could explain their production.

Effects of anti-glutamate-binding protein antibodies on synaptic membrane ion flux, glutamate transport and release, and L-glutamate binding activities

Antibodies (Abs) raised against the L-glutamate-binding protein (GBP) purified from bovine brain were used to define the possible physiologic activity of GBP in synaptic membranes. Three processes were examined for their sensitivity to the Abs: the excitatory amino acid stimulation of thiocyanate (SCN-) flux, the transport of L-glutamic acid across the synaptic membrane, and the depolarization-induced release of L-glutamate. Only the amino acid-induced changes in ion flux were inhibited by the anti-GBP Abs. The change in membrane potential produced by exposure of synaptic membranes to excitatory amino acids was measured as the increase in the uptake of the lipophilic anion SCN-. The L-glutamate-induced SCN- influx was 40 times more sensitive to inhibition by the anti-GBP Abs than the stimulation of ion flux by kainate, and 60 times more sensitive than that produced by quisqualate. The anti-GBP Abs did not inhibit the activation of ion flux produced by N-methyl-D-aspartate. The inhibition of glutamate-stimulated ion fluxes by the Abs was complete, whereas the inhibition of L-glutamate binding to either the rat or bovine brain GBP was not. The results obtained indicated that although the majority of the anti-GBP Abs were not directed against the glutamate recognition site of the GBP and of presumed synaptic membrane receptors, they were effective in blocking the activation of receptor-associated ion channels. Thus, the GBP may be considered a component of some excitatory amino acid receptor complexes.

Augmented anti-acetylcholine receptor response following long-term penicillamine administration

Because of the association of D-penicillamine (DP) therapy with myasthenia gravis, we have studied long-term DP treatment in five inbred strains of mice with doses comparable to those used in patients with rheumatoid arthritis. No clinical weakness or anti-acetylcholine receptor (AChR) antibody developed with up to 6 months of treatment, but augmented responses did occur to challenge with purified AChR in adjuvant. Anti-AChR antibody titers in C57BL/6 and C3H/He mice were significantly higher after challenge with AChR in DP-treated than in control mice. Augmented anti-AChR titers were not seen in strain A mice, but after 6 months of DP treatment increased susceptibility developed to the induction of experimental autoimmune myasthenia gravis. Nine weeks after challenge with purified AChR, 10 of 11 mice developed clinical weakness, leading to death in 6. Results of edrophonium testing were positive in 5 of 6 mice, and electrophysiological abnormalities were demonstrated in 3 of the surviving mice. Long-term DP treatment is associated with augmented anti-AChR antibody responses in C3H/He and C57BL/6 mice, and increased susceptibility to experimental autoimmune myasthenia gravis in strain A mice.

Immunisation with Torpedo acetylcholine receptor

Acetylcholine mediates the transfer of information between neurons in the electric organ of, for example, Torpedo as well as in vertebrate skeletal muscle. The nicotinic acetylcholine receptor complex translates the binding of acetylcholine into ion permeability changes. This leads to an action potential in the muscle fibre. The nicotinic acetylcholine receptor protein has been purified from Torpedo by use of affinity chromatography. The receptor is an intrinsic membrane glycoprotein composed of five polypeptide chains. When various animals are immunised with the receptor they demonstrate clinical signs of severe muscle weakness coincident with high antibody titres in their sera. The symptoms resemble those found in the autoimmune neuromuscular disease myasthenia gravis in humans. This animal model has constituted a unique model for studying autoimmune diseases. This paper reviews some of the work using Torpedo acetylcholine receptor in order to increase the understanding of the motor nervous system function and myasthenia gravis. It is now known that the nicotinic acetylcholine receptor protein is the antigen involved in myasthenia gravis. The mechanism of immune damage involves a direct block of the receptor function. This depends on the presence of antibodies which crosslink the postsynaptic receptors leading to their degradation. The questions to be answered in the future are; (a) what initiates or triggers the autoimmune response, (b) how do the antibodies cause the symptoms--is there a steric hindrance of the interaction of acetylcholine and the receptor, (c) why is there not a strict relationship between antibody titre and severity of symptoms, and (d) why are some muscles affected and other spared? With help of the experimental model, answers to these questions may result in improved strategies for the treatment of the autoimmune disease myasthenia gravis.

Anti-idiotypic route to anti-acetylcholine receptor antibodies and experimental myasthenia gravis

trans-3,3'-Bis[alpha-(trimethylammonio)methyl]azobenzene bromide (BisQ) is a potent agonist of the acetylcholine receptor (AcChoR) of Electrophorus electricus. BisQ is highly constrained, suggesting that its structure is complementary to the combining site of the AcChoR when the latter is in its activated state. Antibodies produced in rabbits to a conjugate of bovine serum albumin and a derivative of BisQ mimicked the binding characteristics of the AcChoR with respect to the order of binding of a variety of agonists and to the preferred recognition of decamethonium ion (an agonist) over hexamethonium ion (an antagonist). Immunization of three rabbits with purified anti-BisQ yielded antisera having binding characteristics of anti-AcChoR in that, by complement fixation and enzyme immunoassay, crossreactions with receptor preparations from rat, Torpedo, and eel could be demonstrated in sera of all three rabbits immunized. Two of the three rabbits showed signs of muscle weakness similar to that seen after immunization with the AcChoR. One of the rabbits was injected intramuscularly with neostigmine and showed temporary improvement. Another showed post-tetanic exhaustion of hind-limb muscles after stimulation of the sciatic nerve at 50 Hz. Antibodies reactive with the AcChoR, therefore, were elicited by immunization with an antibody to a potent ligand of the AcChoR without the necessity of isolating the receptor itself. A similar mechanism may play a part in the etiology of at least some autoimmune diseases in which antibodies to various other receptors are involved.

Thymic abnormalities: antigen or antibody? Response to thymectomy in myasthenia gravis

The therapeutic value of thymectomy for myasthenia is still questioned although it retains an important place among management modalities that strive for sustained remission. Questions derive from uncertainty as to appropriate timing, variable extent of resection and quantitation of response. Forty-seven patients, followed one to seven years, underwent an extended transsternal or combined transcervical-transsternal procedure with anterior mediastinal exenteration. Sixteen have been in complete remission from six months to six years, four are asymptomatic on occasional pyridostigmine and eight are significantly improved. Evaluation of thymic pathology (hyperplasic, involuted areas, and thymoma) included a search for thymic myoid cells by fluorescence cytochemistry. Antibodies to acetylcholine receptor present in 38 of 43, decreased post-operatively to normal in four, by 50% to 80% in 14, by 20 to 50% in three and were unchanged in 14. Most remissions occurred in young women with noninvoluted hyperplastic glands and variably high anti-AChR titers which dropped toward normal in seven of 15. These results encourage us to utilize this procedure routinely.

Recent advances in the molecular mechanisms of human and animal models of myasthenia gravis

The receptor-channel molecule is a dynamic system which exists in multiple conformations and that is the way we should think of it when we study antibody interaction with the molecule. The results presented here suggest that some antibodies may affect receptor function by occupying sites other than the receptor site. Some of these sites may by exposed only in certain conformations, and occupation of some site by antibodies may effect conformational changes. These small but perhaps important differences in cholinergic channel properties of the myasthenic muscle from the normal one are revealed by studying the effect of myasthenic sera on drug interactions with the channel sites. The sera of myasthenics are able to react with certain channel conformations and are able to affect the interaction of channel antagonists such as H12HTX and QNB. The sera appear to act preferentially with the open conformation of the channel. As a consequence of such an effect, important conformational changes of the channel may fail to occur upon activation.

Circulating immune complexes in myasthenia gravis: a study in relation to thymectomy, clinical severity and thymus histology

Circulating immune complexes were assayed employing the method recently described by Barnett and Chia in a group of patients with myasthenia gravis. The subjects were classified according to clinical severity and immune complexes were sought before and after thymectomy. The operated subjects were further divided into those with thymoma or thymic hyperplasia. Antigen-antibody complexes were higher before thymectomy than after, in hyperplasias than in thymomas, and in severe myasthenia gravis than in mild disease. Circulating immune complexes and anti-acetylcholine receptor antibodies did not correlate.

Experimental autoimmune myasthenia gravis

Injection of animals with purified acetylcholine receptor in complete Freund's adjuvant causes development of antibodies which crossreact with receptors in muscle. The crossreacting antibodies impair neuromuscular transmission. Animals with experimental autoimmune myasthenia gravis (EAMG) are excellent models for studying the complex mechanisms by which the autoimmune response to receptor in myasthenia gravis causes muscle weakness. This review first briefly describes the discovery of EAMG. Then, to provide the necessary perspective, receptor structure and function and properties of anti-receptor antibodies are discussed, followed by a brief review of the pathological mechanisms in EAMG.

Inhibition of alpha-bungarotoxin binding to acetylcholine receptors by antisera from animals with experimental autoimmune myasthenia gravis

Conditions are described for an assay that allows the percent inhibition of alpha-bungarotoxin binding to acetylcholine receptors by antisera and monovalent antigen-binding fragments of antibody molecules (Fab) to be determined. Anti-Torpedo californica acetylcholine-receptor antisera, prepared in New Zealand White rabbits and Lewis rats, were tested for the ability to inhibit [125I]-alpha-bungarotoxin binding to membrane-associated and detergent-solubilized T californica acetylcholine receptors. Similar inhibition studies were performed using rabbit antisera and antigen-binding fragments prepared against each of the four acetylcholine receptor subunits. Antisera and antigen-binding fragments prepared against intact receptor could inhibit a maximum of 50% of the alpha-bungarotoxin binding to solubilized receptor. The results using monovalent antigen-binding fragments indicated that the inhibition was not due to antibody-mediated aggregation of receptor molecules. Rabbits and rats immunized with receptor denatured by sodium dodecyl sulfate all produced antisera that could bind to nondenatured receptor, but none of these animals developed experimental autoimmune myasthenia gravis. These results suggest that the antigenic determinants present on acetylcholine receptors responsible for induction of experimental autoimmune myasthenia gravis are lost with sodium dodecyl sulfate denaturation. A strong correlation was also observed between the presence of experimental autoimmune myasthenia gravis in rats and rabbits and the ability of the antisera from these animals to inhibit 50% of alpha-bungarotoxin binding to solubilized acetylcholine receptors.

Myasthenia in frogs immunized against cholinergic-receptor protein

Frogs immunized with cholinergic-receptor protein developed myasthenia in 116--175 days. The muscular weakness was overcome by subcutaneous administration of 20 microgram of neostigmine. Electromyograms showed a decline in action potential amplitude during a 2-Hz train. Nerve stimulation evoked subthreshold end-plate potentials (EPPs) averaging 10.4 +/- 7.4 mV, but at many junctions no EPP was obtained. Miniature EPP amplitude had a modal value of 0.15 mV compared with 0.35 mV for the controls. The corresponding means were 0.24 +/- 0.23 mV and 0.48 +/- 0.23 mV. Microperfusion with edrophonium (5 mg/l) increased the amplitude of EPPs and miniature end-plate potentials (MEPPS). Postjunctional response tested with 20 muM carbamylcholine was 56% of control. Postjunctional response by carbamylcholine iontophoresis gave 19 +/- 22 mV/nC compared with 76 +/- 50 mV/nC for the controls. The data indicate that the neuromuscular transmission deficits in receptor-immunized frogs are mainly postsynaptic in origin, but there may be additional presynaptic contributions. This amphibian model of myasthenia gravis offers many opportunities and advantages in the study of receptor-immunized animals.

Study of two different subpopulations of anti-acetylcholine receptor antibodies in a rabbit with experimental auto-immune myasthenia gravis

Two different subpopulations of anti-acetylcholine receptor antibodies were studied during the evolution of experimental autoimmune myasthenia in one rabbit immunized with Torpedo acetylcholine receptor. The results show that the subpopulation of antibodies directed against the toxin-binding site of the receptor might play a role in the appearance of the paralysis observed in this particular case.

Studies of human myasthenia gravis: electrophysiological and ultrastructural evidence compatible with antibody attachment to acetylcholine receptor complex

Neuromuscular junctions from patients with early onset and chronic myasthenia gravis were examined by electrophysiological and ultrastructural techniques. Acetylcholine (AcCh) sensitivities were reduced by 34-63% in early onset myasthenia and 60-80% in chronic myasthenia. Ultrastructural analysis revealed that virtually all junctional folds of the early onset patients were intact but that the AcCh-receptor-rich crests of these folds were uniformly covered by an attached layer of 30 X 70 A particles arranged in small tufts or rosettes. In chronic myasthenic endplates, however, junctional fold crests were destroyed, apparently being replaced by vesicular membrane debris similarly labeled by tufts of 30 X 70 A particles. Thus, the initial reduction in junctional AcCh sensitivity observed in early onset myasthenia gravis may be attributed at least in part to in situ masking or inactivation of AcCh receptors, whereas the marked decrease in AcCh sensitivity observed in the chronic myasthenic patient may represent a combination of two factors: (a) in situ masking of AcCh receptors and (b) destruction of the receptor-containing crests of the junctional folds. These observations are compatible with an autoimmune etiology of myasthenia gravis initially involving an apparent antibody attachment to one or more components of the functional AcCh receptor complex, followed by systematic destruction and removal of junctional folds by both humoral and cell-mediated autoimmune responses.

Dynamic properties of isolated acetylcholine receptor proteins: release of calcium ions caused by acetylcholine binding

Interaction of Ca and acetylcholine (AcCh) ions with purified acetylcholine receptor (AcChR) from Torpedo californica and Electrophorus electricus has been investigated in view of these ions' role proposed in bioelectricity. Spectrophotometric Ca titration using murexide as an indicator and an ultrafiltration method with 45Ca show that AcChR proteins have a high binding capacity for Ca ions. Per macromolecule of 260,000 daltons, up to 60 Ca ions can be bound with at least three Ca dissociation constants. A linear inhibition of AcCh binding to AcChR by Ca was observed in the 0.1-1 mM Ca range, indicating competition of AcCh and Ca for AcChR. The addition of AcCh to a Ca-AcChR solution at 1.2 mM Ca causes release of four to six bound Ca ions from AcChR when a maximum of two AcCh ions are bound per 260,000 dalton macromolecule. The subsequent addition of alpha-bungarotoxin causes reuptake of up to six Ca ions by AcChR. These results suggest that the neural activator AcCh and the inhibitor alpha-bungarotoxin induce opposing shifts between different conformational states of isolated AcChR.