|
1
|
Al-Diwani A, Theorell J, Damato V, Bull J, McGlashan N, Green E, Kienzler AK, Harrison R, Hassanali T, Campo L, Browne M, Easton A, Soleymani majd H, Tenaka K, Iorio R, Dale RC, Harrison P, Geddes J, Quested D, Sharp D, Lee ST, Nauen DW, Makuch M, Lennox B, Fowler D, Sheerin F, Waters P, Leite MI, Handel AE, Irani SR. Cervical lymph nodes and ovarian teratomas as germinal centres in NMDA receptor-antibody encephalitis. Brain 2022; 145:2742-2754. [PMID: 35680425 PMCID: PMC9486890 DOI: 10.1093/brain/awac088] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/22/2021] [Accepted: 01/24/2022] [Indexed: 01/14/2023] Open
Abstract
Autoantibodies against the extracellular domain of the N-methyl-d-aspartate receptor (NMDAR) NR1 subunit cause a severe and common form of encephalitis. To better understand their generation, we aimed to characterize and identify human germinal centres actively participating in NMDAR-specific autoimmunization by sampling patient blood, CSF, ovarian teratoma tissue and, directly from the putative site of human CNS lymphatic drainage, cervical lymph nodes. From serum, both NR1-IgA and NR1-IgM were detected more frequently in NMDAR-antibody encephalitis patients versus controls (both P < 0.0001). Within patients, ovarian teratoma status was associated with a higher frequency of NR1-IgA positivity in serum (OR = 3.1; P < 0.0001) and CSF (OR = 3.8, P = 0.047), particularly early in disease and before ovarian teratoma resection. Consistent with this immunoglobulin class bias, ovarian teratoma samples showed intratumoral production of both NR1-IgG and NR1-IgA and, by single cell RNA sequencing, contained expanded highly-mutated IgA clones with an ovarian teratoma-restricted B cell population. Multiplex histology suggested tertiary lymphoid architectures in ovarian teratomas with dense B cell foci expressing the germinal centre marker BCL6, CD21+ follicular dendritic cells, and the NR1 subunit, alongside lymphatic vessels and high endothelial vasculature. Cultured teratoma explants and dissociated intratumoral B cells secreted NR1-IgGs in culture. Hence, ovarian teratomas showed structural and functional evidence of NR1-specific germinal centres. On exploring classical secondary lymphoid organs, B cells cultured from cervical lymph nodes of patients with NMDAR-antibody encephalitis produced NR1-IgG in 3/7 cultures, from patients with the highest serum NR1-IgG levels (P < 0.05). By contrast, NR1-IgG secretion was observed neither from cervical lymph nodes in disease controls nor in patients with adequately resected ovarian teratomas. Our multimodal evaluations provide convergent anatomical and functional evidence of NMDAR-autoantibody production from active germinal centres within both intratumoral tertiary lymphoid structures and traditional secondary lymphoid organs, the cervical lymph nodes. Furthermore, we develop a cervical lymph node sampling protocol that can be used to directly explore immune activity in health and disease at this emerging neuroimmune interface.
Collapse
Affiliation(s)
- Adam Al-Diwani
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK,University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jakob Theorell
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK,Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden
| | - Valentina Damato
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK,UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Joshua Bull
- Wolfson Centre for Mathematical Biology, Mathematical Institute, University of Oxford, Oxford, UK
| | - Nicholas McGlashan
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Edward Green
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Anne Kathrin Kienzler
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Ruby Harrison
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Tasneem Hassanali
- Translational Histopathology Laboratory, Department of Oncology, University of Oxford, Oxford, UK
| | - Leticia Campo
- Translational Histopathology Laboratory, Department of Oncology, University of Oxford, Oxford, UK
| | - Molly Browne
- Translational Histopathology Laboratory, Department of Oncology, University of Oxford, Oxford, UK
| | - Alistair Easton
- Translational Histopathology Laboratory, Department of Oncology, University of Oxford, Oxford, UK
| | | | - Keiko Tenaka
- Department of Animal Model Development, Brain Research Institute, Niigata University, Niigata, Japan
| | - Raffaele Iorio
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Russell C Dale
- Kids Neuroscience Centre, Children’s Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Paul Harrison
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - John Geddes
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Digby Quested
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - David Sharp
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, London, UK
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - David W Nauen
- Department of Pathology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mateusz Makuch
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Belinda Lennox
- University Department of Psychiatry, University of Oxford, Oxford, UK
| | - Darren Fowler
- Department of Pathology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Fintan Sheerin
- Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Patrick Waters
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - M Isabel Leite
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK,Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Adam E Handel
- Oxford Autoimmune Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK,Department of Neurology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Sarosh R Irani
- Correspondence to: Professor Sarosh Irani Oxford Autoimmune Neurology Group West Wing, Level 6, John Radcliffe Hospital Oxford OX3 9DU, UK E-mail:
| |
Collapse
|