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Coelho FMS. Narcolepsy: an interface among neurology, immunology, sleep, and genetics. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-9. [PMID: 38565187 PMCID: PMC10987254 DOI: 10.1055/s-0044-1779299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/01/2023] [Indexed: 04/04/2024]
Abstract
Narcolepsy is a primary disorder of the central nervous system resulting from genetic, environmental, and immunological interactions defined as excessive daytime sleepiness plus cataplexy, hallucinations, sleep paralysis, and sleep fragmentation. The pathophysiology is not entirely known, but the interaction among genetic predisposition, environmental exposition, and immune component with consequent hypocretin-1 deficiency is the model to explain narcolepsy type I. The mechanism of narcolepsy type II is less understood. There is a delay of over ten years for the diagnosis of narcolepsy around the world. Patients with narcolepsy have many comorbidities with a negative impact on quality of life. The treatment of narcolepsy must contain an educational approach for the family, coworkers, and patients. Scheduled naps and sleep hygiene are essential to minimize the dose of medications. Much progress has been seen in the pharmacological treatment of narcolepsy with new stimulants, different presentations of oxybate, and recent studies with orexin agonists. Narcolepsy is a rare disease that needs to be more understood and highlighted to avoid delayed diagnosis and severe disabilities in patients.
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Zhong X, Yuan Y, Zhan Q, Yin T, Ku C, Liu Y, Wang F, Ding Y, Deng L, Wu W, Xie L. Cell-based vs enzyme-linked immunosorbent assay for detection of anti-Tribbles homolog 2 autoantibodies in Chinese patients with narcolepsy. J Clin Sleep Med 2024; 20:941-946. [PMID: 38318919 PMCID: PMC11145039 DOI: 10.5664/jcsm.11056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 02/07/2024]
Abstract
STUDY OBJECTIVES Narcolepsy type 1 is attributed to a deficiency in cerebrospinal fluid orexin and is considered linked to autoimmunity. The levels of anti-Tribbles homolog 2 (TRIB2) autoantibodies are elevated in the sera of some patients with narcolepsy with cataplexy. Additionally, injecting mice with serum immunoglobulin from patients with narcolepsy with positive anti-TRIB2 antibodies can induce hypothalamic neuron loss and alterations in sleep patterns. Consequently, we hypothesized the existence of a potential association between anti-TRIB2 antibodies and narcolepsy. To test this possibility, we used cell-based assays (CBAs) and enzyme-linked immunosorbent assays (ELISAs) to detect the presence of anti-TRIB2 antibodies in Chinese patients with narcolepsy. METHODS We included 68 patients with narcolepsy type 1, 39 patients with other central disorders of hypersomnolence, and 43 healthy controls. A CBA and a conventional ELISA were used to detect anti-TRIB2 antibody levels in patients' sera. RESULTS CBA was used to detect serum anti-TRIB2 antibodies in Chinese patients with narcolepsy, and the results were negative. However, when the ELISA was used, only 2 patients with narcolepsy type 1 had TRIB2 antibody titers higher than the mean titer plus 2 standard deviations of the healthy controls. CONCLUSIONS In our study, ELISA identified TRIB2 autoantibodies in sera of patients with narcolepsy where CBA failed to demonstrate them. Contrary to our hypothesis, this intriguing finding deserves further research to elucidate the potential association between TRIB2 and narcolepsy type 1. Exploring the implications of TRIB2 autoantibodies in narcolepsy and disparate outcomes between ELISA and CBA could provide crucial insights. CITATION Zhong X, Yuan Y, Zhan Q, et al. Cell-based vs enzyme-linked immunosorbent assay for detection of anti-Tribbles homolog 2 autoantibodies in Chinese patients with narcolepsy. J Clin Sleep Med. 2024;20(6):941-946.
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Affiliation(s)
- Xianhui Zhong
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
| | - Yuqing Yuan
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
| | - Qingqing Zhan
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
| | - Tiantian Yin
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
| | - Chengxin Ku
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
| | - Yuxin Liu
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
| | - Fen Wang
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang, China
| | - Yongmin Ding
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang, China
| | - Liying Deng
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang, China
| | - Wei Wu
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang, China
| | - Liang Xie
- Department of Neurology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, China
- Institute of Neuroscience, Nanchang University, Nanchang, China
- Jiangxi Key Laboratory of Neurological Tumors and Cerebrovascular Diseases, Nanchang, China
- Jiangxi Health Commission Key Laboratory of Neurological Medicine, Nanchang, China
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Gandhi K, Ferdous S. Tetrad of Narcolepsy Type 1: Treatment and Management. Cureus 2024; 16:e55331. [PMID: 38562323 PMCID: PMC10982127 DOI: 10.7759/cureus.55331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 03/01/2024] [Indexed: 04/04/2024] Open
Abstract
Narcolepsy is a chronic condition that brings about excessive daytime sleepiness. It can be classified into two types: narcolepsy type 1 (presence of cataplexy, which is marked by weakness of muscles) and narcolepsy type 2 (without cataplexy). It is generally underdiagnosed, which results in delayed diagnosis of the condition. It has more prevalence in the United States of America as compared to India. The narcoleptic tetrad consists of excessive daytime sleepiness (EDS), cataplexy, sleep paralysis, and hypnagogic hallucinations. Rapid eye movement (REM) sleep behavior disorder is another characteristic feature. Research about narcolepsy has been carried out for about 145-150 years, but it is only in the last 18-20 years that there has been advancement in the underlying pathophysiology, diagnosis, and, thus, availability of better treatment. Both pharmacological and non-pharmacological methods are preferred in treating narcolepsy, yet there is no cure for it. Since the knowledge regarding this condition is very limited, it is often misunderstood, and dealing with it is mentally and socially draining, often causing anxiety in the patients, feeling of social isolation, and other significant impacts on the quality of living. Raising awareness about narcolepsy is vital to prevent further medical attention delays.
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Affiliation(s)
- Kanishka Gandhi
- Physiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Suraiya Ferdous
- Physiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND
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Valizadeh P, Momtazmanesh S, Plazzi G, Rezaei N. Connecting the dots: An updated review of the role of autoimmunity in narcolepsy and emerging immunotherapeutic approaches. Sleep Med 2024; 113:378-396. [PMID: 38128432 DOI: 10.1016/j.sleep.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/08/2023] [Accepted: 12/09/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Narcolepsy type 1 (NT1) is a chronic disorder characterized by pathological daytime sleepiness and cataplexy due to the disappearance of orexin immunoreactive neurons in the hypothalamus. Genetic and environmental factors point towards a potential role for inflammation and autoimmunity in the pathogenesis of the disease. This study aims to comprehensively review the latest evidence on the autoinflammatory mechanisms and immunomodulatory treatments aimed at suspected autoimmune pathways in NT1. METHODS Recent relevant literature in the field of narcolepsy, its autoimmune hypothesis, and purposed immunomodulatory treatments were reviewed. RESULTS Narcolepsy is strongly linked to specific HLA alleles and T-cell receptor polymorphisms. Furthermore, animal studies and autopsies have found infiltration of T cells in the hypothalamus, supporting T cell-mediated immunity. However, the role of autoantibodies has yet to be definitively established. Increased risk of NT1 after H1N1 infection and vaccination supports the autoimmune hypothesis, and the potential role of coronavirus disease 2019 and vaccination in triggering autoimmune neurodegeneration is a recent finding. Alterations in cytokine levels, gut microbiota, and microglial activation indicate a potential role for inflammation in the disease's development. Reports of using immunotherapies in NT1 patients are limited and inconsistent. Early treatment with IVIg, corticosteroids, plasmapheresis, and monoclonal antibodies has seldomly shown some potential benefits in some studies. CONCLUSION The current body of literature supports that narcolepsy is an autoimmune disorder most likely caused by T-cell involvement. However, the potential for immunomodulatory treatments to reverse the autoinflammatory process remains understudied. Further clinical controlled trials may provide valuable insights into this area.
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Affiliation(s)
- Parya Valizadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Sara Momtazmanesh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Giuseppe Plazzi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy; Department of Biomedical, Metabolic, and Neural Sciences, Università Degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Prochazkova P, Sonka K, Roubalova R, Jezkova J, Nevsimalova S, Buskova J, Merkova R, Dvorakova T, Prihodova I, Dostalova S, Tlaskalova-Hogenova H. Investigation of anti-neuronal antibodies and disparity in central hypersomnias. Sleep Med 2024; 113:220-231. [PMID: 38056084 DOI: 10.1016/j.sleep.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/06/2023] [Accepted: 11/25/2023] [Indexed: 12/08/2023]
Abstract
STUDY OBJECTIVES Microbial antigens can elicit an immune response leading to the production of autoantibodies cross-reacting with autoantigens. Still, their clinical significance in human sera in the context of brain diseases is unclear. Therefore, assessment of natural autoantibodies reacting with their neuropeptides may elucidate the autoimmune etiology of central hypersomnias. The study aims to determine whether serum autoantibody levels differ in patients with different types of central hypersomnias (narcolepsy type 1 and 2, NT1 and NT2; idiopathic hypersomnia, IH) and healthy controls and if the differences could suggest the participation of autoantibodies in disease pathogenesis. METHODS Sera from 91 patients with NT1, 27 with NT2, 46 with IH, and 50 healthy controls were examined for autoantibodies against assorted neuropeptides. Participants were screened using questionnaires related to sleep disorders, quality of life, and mental health conditions. In addition, serum biochemical parameters and biomarkers of microbial penetration through the intestinal wall were determined. RESULTS A higher prevalence of autoantibodies against neuropeptides was observed only for alpha-melanocytes-stimulating hormone (α-MSH) and neuropeptide glutamic acid-isoleucine (NEI), which differed slightly among diagnoses. Patients with both types of narcolepsy exhibited signs of microbial translocation through the gut barrier. According to the questionnaires, patients diagnosed with NT2 or IH had subjectively worse life quality than patients with NT1. Patients displayed significantly lower levels of bilirubin and creatinine and slightly higher alkaline phosphatase values than healthy controls. CONCLUSIONS Overall, serum anti-neuronal antibodies prevalence is rare, suggesting that their participation in the pathophysiology of concerned sleep disorders is insignificant. Moreover, their levels vary slightly between diagnoses indicating no major diagnostic significance.
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Affiliation(s)
- Petra Prochazkova
- Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic.
| | - Karel Sonka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Radka Roubalova
- Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic
| | - Janet Jezkova
- Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic; First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Sona Nevsimalova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Jitka Buskova
- National Institute of Mental Health, Klecany, Czech Republic; Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Radana Merkova
- National Institute of Mental Health, Klecany, Czech Republic; Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tereza Dvorakova
- National Institute of Mental Health, Klecany, Czech Republic; Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Iva Prihodova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Simona Dostalova
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Helena Tlaskalova-Hogenova
- Laboratory of Cellular and Molecular Immunology, Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic
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Liblau RS, Latorre D, Kornum BR, Dauvilliers Y, Mignot EJ. The immunopathogenesis of narcolepsy type 1. Nat Rev Immunol 2024; 24:33-48. [PMID: 37400646 DOI: 10.1038/s41577-023-00902-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/05/2023]
Abstract
Narcolepsy type 1 (NT1) is a chronic sleep disorder resulting from the loss of a small population of hypothalamic neurons that produce wake-promoting hypocretin (HCRT; also known as orexin) peptides. An immune-mediated pathology for NT1 has long been suspected given its exceptionally tight association with the MHC class II allele HLA-DQB1*06:02, as well as recent genetic evidence showing associations with polymorphisms of T cell receptor genes and other immune-relevant loci and the increased incidence of NT1 that has been observed after vaccination with the influenza vaccine Pandemrix. The search for both self-antigens and foreign antigens recognized by the pathogenic T cell response in NT1 is ongoing. Increased T cell reactivity against HCRT has been consistently reported in patients with NT1, but data demonstrating a primary role for T cells in neuronal destruction are currently lacking. Animal models are providing clues regarding the roles of autoreactive CD4+ and CD8+ T cells in the disease. Elucidation of the pathogenesis of NT1 will allow for the development of targeted immunotherapies at disease onset and could serve as a model for other immune-mediated neurological diseases.
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Affiliation(s)
- Roland S Liblau
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University of Toulouse, CNRS, INSERM, Toulouse, France.
- Department of Immunology, Toulouse University Hospitals, Toulouse, France.
| | | | - Birgitte R Kornum
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Yves Dauvilliers
- National Reference Center for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France
- INSERM Institute for Neurosciences of Montpellier, Montpellier, France
| | - Emmanuel J Mignot
- Stanford University, Center for Narcolepsy, Department of Psychiatry and Behavioral Sciences, Palo Alto, CA, USA.
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7
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Pintwala SK, Peever J. Brain Circuits Underlying Narcolepsy. Neuroscientist 2023; 29:751-766. [PMID: 34704497 DOI: 10.1177/10738584211052263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Narcolepsy is a sleep disorder manifesting symptoms such as excessive daytime sleepiness and often cataplexy, a sudden and involuntary loss of muscle activity during wakefulness. The underlying neuropathological basis of narcolepsy is the loss of orexin neurons from the lateral hypothalamus. To date numerous animal models of narcolepsy have been produced in the laboratory, being invaluable tools for delineating the brain circuits of narcolepsy. This review will examine the evidence regarding the function of the orexin system, and how loss of this wake-promoting system manifests in excessive daytime sleepiness. This review will also outline the brain circuits controlling cataplexy, focusing on the contribution of orexin signaling loss in narcolepsy. Although our understanding of the brain circuits of narcolepsy has made great progress in recent years, much remains to be understood.
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Affiliation(s)
| | - John Peever
- Department of Cell and Systems Biology, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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8
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Gagnon K, Rey AE, Guignard-Perret A, Guyon A, Reynaud E, Herbillon V, Lina JM, Carrier J, Franco P, Mazza S. Sleep Stage Transitions and Sleep-Dependent Memory Consolidation in Children with Narcolepsy-Cataplexy. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1702. [PMID: 37892365 PMCID: PMC10605014 DOI: 10.3390/children10101702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023]
Abstract
Electroencephalographic sleep stage transitions and altered first REM sleep period transitions have been identified as biomarkers of type 1 narcolepsy in adults, but not in children. Studies on memory complaints in narcolepsy have not yet investigated sleep-dependent memory consolidation. We aimed to explore stage transitions; more specifically altered REM sleep transition and its relationship with sleep-dependent memory consolidation in children with narcolepsy. Twenty-one children with narcolepsy-cataplexy and twenty-three healthy control children completed overnight polysomnography and sleep-dependent memory consolidation tests. Overnight transition rates (number of transitions per hour), global relative transition frequencies (number of transitions between a stage and all other stages/total number of transitions × 100), overnight transitions to REM sleep (transition from a given stage to REM/total REM transitions × 100), and altered first REM sleep period transitions (transitions from wake or N1 to the first REM period) were computed. Narcoleptic children had a significantly higher overnight transition rate with a higher global relative transition frequencies to wake. A lower sleep-dependent memory consolidation score found in children with narcolepsy was associated with a higher overnight transition frequency. As observed in narcoleptic adults, 90.48% of narcoleptic children exhibited an altered first REM sleep transition. As in adults, the altered sleep stage transition is also present in children with narcolepsy-cataplexy, and a higher transition rate could have an impact on sleep-dependent memory consolidation. These potential biomarkers could help diagnose type 1 narcolepsy in children more quickly; however, further studies with larger cohorts, including of those with type 2 narcolepsy and hypersomnia, are needed.
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Affiliation(s)
- Katia Gagnon
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, FORGETTING, F-69500 Bron, France; (K.G.); (A.E.R.); (E.R.)
| | - Amandine E. Rey
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, FORGETTING, F-69500 Bron, France; (K.G.); (A.E.R.); (E.R.)
| | - Anne Guignard-Perret
- National Reference Center for Narcolepsy in the Service of Epilepsy, Sleep and Neuropediatric Functional Explorations of the Woman Mother Child Hospital of Bron, 59, bd Pinel, F-69677 Bron, France; (A.G.-P.); (A.G.); (V.H.); (P.F.)
| | - Aurore Guyon
- National Reference Center for Narcolepsy in the Service of Epilepsy, Sleep and Neuropediatric Functional Explorations of the Woman Mother Child Hospital of Bron, 59, bd Pinel, F-69677 Bron, France; (A.G.-P.); (A.G.); (V.H.); (P.F.)
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, WAKING, F-69500 Bron, France
| | - Eve Reynaud
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, FORGETTING, F-69500 Bron, France; (K.G.); (A.E.R.); (E.R.)
| | - Vania Herbillon
- National Reference Center for Narcolepsy in the Service of Epilepsy, Sleep and Neuropediatric Functional Explorations of the Woman Mother Child Hospital of Bron, 59, bd Pinel, F-69677 Bron, France; (A.G.-P.); (A.G.); (V.H.); (P.F.)
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, EDUWELL, F-69500 Bron, France
| | - Jean-Marc Lina
- Department of Electrical Engineering, École de Technologie Supérieure, Montréal, QC H3C 1K3, Canada;
| | - Julie Carrier
- Department of Psychology, Université de Montréal, Montréal, QC H3C 3J7, Canada;
| | - Patricia Franco
- National Reference Center for Narcolepsy in the Service of Epilepsy, Sleep and Neuropediatric Functional Explorations of the Woman Mother Child Hospital of Bron, 59, bd Pinel, F-69677 Bron, France; (A.G.-P.); (A.G.); (V.H.); (P.F.)
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, WAKING, F-69500 Bron, France
| | - Stéphanie Mazza
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, FORGETTING, F-69500 Bron, France; (K.G.); (A.E.R.); (E.R.)
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Davis KN, Qu PP, Ma S, Lin L, Plastini M, Dahl N, Plazzi G, Pizza F, O’Hara R, Wong WH, Hallmayer J, Mignot E, Zhang X, Urban AE. Mutations in human DNA methyltransferase DNMT1 induce specific genome-wide epigenomic and transcriptomic changes in neurodevelopment. Hum Mol Genet 2023; 32:3105-3120. [PMID: 37584462 PMCID: PMC10586194 DOI: 10.1093/hmg/ddad123] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 08/17/2023] Open
Abstract
DNA methyltransferase type 1 (DNMT1) is a major enzyme involved in maintaining the methylation pattern after DNA replication. Mutations in DNMT1 have been associated with autosomal dominant cerebellar ataxia, deafness and narcolepsy (ADCA-DN). We used fibroblasts, induced pluripotent stem cells (iPSCs) and induced neurons (iNs) generated from patients with ADCA-DN and controls, to explore the epigenomic and transcriptomic effects of mutations in DNMT1. We show cell type-specific changes in gene expression and DNA methylation patterns. DNA methylation and gene expression changes were negatively correlated in iPSCs and iNs. In addition, we identified a group of genes associated with clinical phenotypes of ADCA-DN, including PDGFB and PRDM8 for cerebellar ataxia, psychosis and dementia and NR2F1 for deafness and optic atrophy. Furthermore, ZFP57, which is required to maintain gene imprinting through DNA methylation during early development, was hypomethylated in promoters and exhibited upregulated expression in patients with ADCA-DN in both iPSC and iNs. Our results provide insight into the functions of DNMT1 and the molecular changes associated with ADCA-DN, with potential implications for genes associated with related phenotypes.
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Affiliation(s)
- Kasey N Davis
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
- Department of Genetics, Stanford University School of Medicine, Palo Alto CA 94304, USA
| | - Ping-Ping Qu
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
- Department of Genetics, Stanford University School of Medicine, Palo Alto CA 94304, USA
| | - Shining Ma
- Department of Statistics, Stanford University, Stanford, CA 94305, USA
| | - Ling Lin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
- Center for Narcolepsy, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Melanie Plastini
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
- Department of Genetics, Stanford University School of Medicine, Palo Alto CA 94304, USA
| | - Niklas Dahl
- Department of Immunology, Genetics and Pathology Sciences for Life Laboratory, Uppsala University BMC, Uppsala 75122, Sweden
| | - Giuseppe Plazzi
- IRCCS—Istituto delle Scienze Neurologiche di Bologna, Bologna 40139, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena 41125, Italy
| | - Fabio Pizza
- IRCCS—Istituto delle Scienze Neurologiche di Bologna, Bologna 40139, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna 40126, Italy
| | - Ruth O’Hara
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Wing Hung Wong
- Department of Statistics, Stanford University, Stanford, CA 94305, USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Joachim Hallmayer
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Emmanuel Mignot
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
- Center for Narcolepsy, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Xianglong Zhang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
- Department of Genetics, Stanford University School of Medicine, Palo Alto CA 94304, USA
| | - Alexander E Urban
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA 94304, USA
- Department of Genetics, Stanford University School of Medicine, Palo Alto CA 94304, USA
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10
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Wang X, Tian R, Zong X, Jeon MS, Luo J, Colditz GA, Wang JS, Tsilidis KK, Ju YES, Govindan R, Puri V, Cao Y. Sleep Behaviors, Genetic Predispositions, and Risk of Esophageal Cancer. Cancer Epidemiol Biomarkers Prev 2023; 32:1079-1086. [PMID: 37195052 PMCID: PMC10525008 DOI: 10.1158/1055-9965.epi-23-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/16/2023] [Accepted: 05/11/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Risk factors contributing to more than 10-fold increase in esophageal cancer in the last 50 years remain underexplored. We aim to examine the associations of sleep behaviors with esophageal adenocarcinoma (EAC) and squamous cell carcinoma (ESCC). METHODS We prospectively assessed the associations between sleep behaviors (chronotype, duration, daytime napping, daytime sleepiness, snoring, and insomnia) and EAC and ESCC risk in 393,114 participants in the UK Biobank (2006-2016). Participants with 0, 1, and ≥2 unhealthy behaviors, including sleep <6 or >9 h/d, daytime napping, and usual daytime sleepiness were classified as having a good, intermediate, and poor sleep. For EAC, we also examined interactions with polygenic risk score (PRS). Cox models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS We documented 294 incident EAC and 95 ESCC. Sleep >9 h/d (HR, 2.05; 95% CI, 1.18-3.57) and sometimes daytime napping (HR, 1.36; 95% CI, 1.06-1.75) were individually associated with increased EAC risk. Compared with individuals with good sleep, those with intermediate sleep had a 47% (HR, 1.47; 95% CI, 1.13-1.91) increased EAC risk, and those with poor sleep showed an 87% (HR, 1.87; 95% CI, 1.24-2.82) higher risk (Ptrend < 0.001). The elevated risks for EAC were similar within strata of PRS (Pinteraction = 0.884). Evening chronotype was associated with elevated risk of ESCC diagnosed after 2 years of enrollment (HR, 2.79; 95% CI, 1.32-5.88). CONCLUSIONS Unhealthy sleep behaviors were associated with an increased risk of EAC, independent of genetic risk. IMPACT Sleep behaviors may serve as modifiable factors for the prevention of EAC.
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Affiliation(s)
- Xiaoyan Wang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, USA
- Brown School, Washington University in St. Louis, St. Louis, USA
| | - Ruiyi Tian
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, USA
- Brown School, Washington University in St. Louis, St. Louis, USA
| | - Xiaoyu Zong
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, USA
| | - Myung Sik Jeon
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, USA
| | - Jingqin Luo
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, USA
| | - Graham A. Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, USA
| | - Jean S. Wang
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, USA
| | - Konstantinos K. Tsilidis
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Yo-El S. Ju
- Center on Biological Rhythms and Sleep (COBRAS), Washington University School of Medicine, St. Louis, USA
- Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, USA
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, USA
| | - Ramaswamy Govindan
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, USA
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, USA
| | - Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, USA
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, USA
- Center on Biological Rhythms and Sleep (COBRAS), Washington University School of Medicine, St. Louis, USA
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11
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Zhang M, Thieux M, Arvis L, Lin JS, Guyon A, Plancoulaine S, Villanueva C, Franco P. Metabolic disturbances in children with narcolepsy: a retrospective study. Sleep 2023; 46:zsad076. [PMID: 36971181 DOI: 10.1093/sleep/zsad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/22/2022] [Indexed: 07/20/2023] Open
Abstract
STUDY OBJECTIVES To determine the prevalence of metabolic syndrome (MS) in children with narcolepsy and to evaluate their clinical and sleep characteristics according to the different components of MS. METHODS This retrospective study consisted of 58 de novo children with narcolepsy (median age: 12.7 years, 48.3% of boys). The recently published MS criteria in a French population of children were used. Clinical and sleep characteristics were compared between groups with different components of MS. RESULTS MS was present in 17.2% of children with narcolepsy, among whom 79.3% presented with high homeostasis model assessment for insulin resistance (HOMA-IR), 25.9% with high body mass index, 24.1% with low high-density lipoprotein cholesterol (HDL-C), and 12.1% with high triglycerides. Patients with at least two MS components had more night eating behaviors and tended to have lower percentage of slow-wave sleep and more fragmented sleep. On multiple sleep latency test, they had shorter mean sleep latencies to rapid eye movement (REM), non-REM sleep and tended to have more sleep onset REM periods (SOREMPs) than those with less than two MS components. CONCLUSIONS Insulin resistance was found to be the core metabolic disturbance in obese as well as in nonobese children with narcolepsy. Children with narcolepsy with at least two MS components presented a more severe daytime sleepiness and a higher prevalence of night-eating behaviors than those with less than two MS components. Such children might benefit from early evaluation and management in order to prevent future complications.
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Affiliation(s)
- Min Zhang
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
| | - Marine Thieux
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
- Pediatric Sleep Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon and National Reference Center for Narcolepsy, University of Lyon1, Lyon, France
| | - Laura Arvis
- Pediatric endocrinology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jian-Sheng Lin
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
| | - Aurore Guyon
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
- Pediatric Sleep Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon and National Reference Center for Narcolepsy, University of Lyon1, Lyon, France
| | | | - Carine Villanueva
- Pediatric endocrinology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Patricia Franco
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
- Pediatric Sleep Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon and National Reference Center for Narcolepsy, University of Lyon1, Lyon, France
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12
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Pintwala SK, Fraigne JJ, Belsham DD, Peever JH. Immortal orexin cell transplants restore motor-arousal synchrony during cataplexy. Curr Biol 2023; 33:1550-1564.e5. [PMID: 37044089 DOI: 10.1016/j.cub.2023.03.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/11/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023]
Abstract
Waking behaviors such as sitting or standing require suitable levels of muscle tone. But it is unclear how arousal and motor circuits communicate with one another so that appropriate motor tone occurs during wakefulness. Cataplexy is a peculiar condition in which muscle tone is involuntarily lost during normal periods of wakefulness. Cataplexy therefore provides a unique opportunity for identifying the signaling mechanisms that synchronize motor and arousal behaviors. Cataplexy occurs when hypothalamic orexin neurons are lost in narcolepsy; however, it is unclear if motor-arousal decoupling in cataplexy is directly or indirectly caused by orexin cell loss. Here, we used genomic, proteomic, chemogenetic, electrophysiological, and behavioral assays to determine if grafting orexin cells into the brain of cataplectic (i.e., orexin-/-) mice restores normal motor-arousal behaviors by preventing cataplexy. First, we engineered immortalized orexin cells and found that they not only produce and release orexin but also exhibit a gene profile that mimics native orexin neurons. Second, we show that engineered orexin cells thrive and integrate into host tissue when transplanted into the brain of mice. Next, we found that grafting only 200-300 orexin cells into the dorsal raphe nucleus-a region densely innervated by native orexin neurons-reduces cataplexy. Last, we show that real-time chemogenetic activation of orexin cells restores motor-arousal synchrony by preventing cataplexy. We suggest that orexin signaling is critical for arousal-motor synchrony during wakefulness and that the dorsal raphe plays a pivotal role in coupling arousal and motor behaviors.
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Affiliation(s)
- Sara K Pintwala
- Department of Cell and Systems Biology, University of Toronto, Toronto, ON M5S 3G5, Canada
| | - Jimmy J Fraigne
- Department of Cell and Systems Biology, University of Toronto, Toronto, ON M5S 3G5, Canada
| | - Denise D Belsham
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - John H Peever
- Department of Cell and Systems Biology, University of Toronto, Toronto, ON M5S 3G5, Canada; Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada.
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13
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Kamyab P, Kouchaki H, Motamed M, Boroujeni ST, Akbari H, Tabrizi R. Sleep disturbance and gastrointestinal cancer risk: a literature review. J Investig Med 2023; 71:163-172. [PMID: 36645049 DOI: 10.1177/10815589221140595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Sleep, accounting for roughly one-third of a person's life, plays an important role in human health. Despite the close association between sleep patterns and medical diseases proven by several studies, it has been neglected in recent years. Presently, all societies are facing the most challenging health-threatening disease, cancer. Among all cancer types, gastrointestinal (GI) cancers, especially colorectal type, seem to be one of the most relevant to an individual's lifestyle; thus, they can be prevented by modifying behaviors most of the time. Previous studies have shown that disruption of the 24-h sleep-wake cycle increases the chance of colorectal cancer, which can be due to exposure to artificial light at night and some complex genetic and hormone-mediated mechanisms. There has also been some evidence showing the possible associations between other aspects of sleep such as sleep duration or some sleep disorders and GI cancer risk. This review brings some information together and presents a detailed discussion of the possible role of sleep patterns in GI malignancy initiation.
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Affiliation(s)
- Parnia Kamyab
- Universal Scientific Education and Research Network, Fasa University of Medical Sciences, Fasa, Iran
| | - Hosein Kouchaki
- Universal Scientific Education and Research Network, Fasa University of Medical Sciences, Fasa, Iran
| | - Mahsa Motamed
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hamed Akbari
- Department of Biochemistry, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Tabrizi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran.,Clinical Research Development Unit, Valiasr Hospital, Fasa University of Medical Sciences, Fasa, Iran.,USERN Office, Fasa University of Medical Sciences, Fasa, Iran
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14
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Whole-genome analysis of monozygotic Brazilian twins discordant for type 1 narcolepsy: a case report. BMC Neurol 2022; 22:439. [DOI: 10.1186/s12883-022-02921-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 10/16/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background
Narcolepsy type 1 (NT1) is a rare and chronic neurological disease characterized by sudden sleep attacks, overwhelming daytime drowsiness, and cataplexy. When associated with a sudden loss of muscle tone (cataplexy) narcolepsy is classified as type 1, while the absence of cataplexy indicates type 2. Genetic, degenerative, and immunological hypotheses to explain the pathophysiology of NT1 are still a matter of debate. To contribute to the understanding of NT1 genetic basis, here we describe, for the first time, a whole genome analysis of a monozygotic twin pair discordant for NT1.
Case presentation
We present the case of a pair of 17-year-old male, monozygotic twins discordant for NT1. The affected twin had Epworth Sleepiness Scale (ESS) of 20 (can range from 0 to 24), cataplexy, hypnagogic hallucinations, polysomnography without abnormalities, multiple sleep latency tests (MSLT) positive for narcolepsy, a mean sleep latency of 3 min, sleep-onset REM periods SOREMPs of 5, presence of allele HLA-DQB1*06:02, and Hypocretin-1 level of zero pg/mL (normal values are > 200 pg/mL). The other twin had no narcolepsy symptoms (ESS of 4), normal polysomnography, MSLT without abnormalities, presence of allele HLA-DQB1*06:02, and Hypocretin-1 level of 396,74 pg/mL. To describe the genetic background for the NT1 discordant manifestations in this case, we present the whole-genome analysis of this monozygotic twin pair. The whole-genome comparison revealed that both twins have identical NT1 pathogenic mutations in known genes, such as HLA-DQB1*06:02:01, HLA-DRB1*11:01:02/*15:03:01. The affected twin has the expected clinical manifestation while the unaffected twin has an unexpected phenotype. The unaffected twin has significantly more frameshift mutations as compared to the affected twin (108 versus 75) and mutations that affect stop codons (61 versus 5 in stop gain, 26 versus 2 in start lost).
Conclusions
The differences observed in frameshift and stop codon mutations in the unaffected twin are consistent with loss-of-function effects and protective alleles, that are almost always associated with loss-of-function rare alleles. Also, overrepresentation analysis of genes containing variants with potential clinical relevance in the unaffected twin shows that most mutations are in genes related to immune regulation function, Golgi apparatus, MHC, and olfactory receptor. These observations support the hypothesis that NT1 has an immunological basis although protective mutations in non-HLA alleles might interfere with the expression of the NT1 phenotype and consequently, with the clinical manifestation of the disease.
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15
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Chavda V, Chaurasia B, Umana GE, Tomasi SO, Lu B, Montemurro N. Narcolepsy-A Neuropathological Obscure Sleep Disorder: A Narrative Review of Current Literature. Brain Sci 2022; 12:1473. [PMID: 36358399 PMCID: PMC9688775 DOI: 10.3390/brainsci12111473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/22/2022] [Accepted: 10/28/2022] [Indexed: 08/29/2023] Open
Abstract
Narcolepsy is a chronic, long-term neurological disorder characterized by a decreased ability to regulate sleep-wake cycles. Some clinical symptoms enter into differential diagnosis with other neurological diseases. Excessive daytime sleepiness and brief involuntary sleep episodes are the main clinical symptoms. The majority of people with narcolepsy experience cataplexy, which is a loss of muscle tone. Many people experience neurological complications such as sleep cycle disruption, hallucinations or sleep paralysis. Because of the associated neurological conditions, the exact pathophysiology of narcolepsy is unknown. The differential diagnosis is essential because relatively clinical symptoms of narcolepsy are easy to diagnose when all symptoms are present, but it becomes much more complicated when sleep attacks are isolated and cataplexy is episodic or absent. Treatment is tailored to the patient's symptoms and clinical diagnosis. To facilitate the diagnosis and treatment of sleep disorders and to better understand the neuropathological mechanisms of this sleep disorder, this review summarizes current knowledge on narcolepsy, in particular, genetic and non-genetic associations of narcolepsy, the pathophysiology up to the inflammatory response, the neuromorphological hallmarks of narcolepsy, and possible links with other diseases, such as diabetes, ischemic stroke and Alzheimer's disease. This review also reports all of the most recent updated research and therapeutic advances in narcolepsy. There have been significant advances in highlighting the pathogenesis of narcolepsy, with substantial evidence for an autoimmune response against hypocretin neurons; however, there are some gaps that need to be filled. To treat narcolepsy, more research should be focused on identifying molecular targets and novel autoantigens. In addition to therapeutic advances, standardized criteria for narcolepsy and diagnostic measures are widely accepted, but they may be reviewed and updated in the future with comprehension. Tailored treatment to the patient's symptoms and clinical diagnosis and future treatment modalities with hypocretin agonists, GABA agonists, histamine receptor antagonists and immunomodulatory drugs should be aimed at addressing the underlying cause of narcolepsy.
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Affiliation(s)
- Vishal Chavda
- Department of Pathology, Stanford of School of Medicine, Stanford University Medical Centre, Palo Alto, CA 94305, USA
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj 44300, Nepal
| | - Giuseppe E. Umana
- Department of Neurosurgery, Associate Fellow of American College of Surgeons, Trauma and Gamma-Knife Centre, Cannizzaro Hospital Catania, 95100 Catania, Italy
| | | | - Bingwei Lu
- Department of Pathology, Stanford of School of Medicine, Stanford University Medical Centre, Palo Alto, CA 94305, USA
| | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), University of Pisa, 56100 Pisa, Italy
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16
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Klaus S, Carolan A, O'Rourke D, Kennedy B. What respiratory physicians should know about narcolepsy and other hypersomnias. Breathe (Sheff) 2022; 18:220157. [PMID: 36865656 PMCID: PMC9973529 DOI: 10.1183/20734735.0157-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Narcolepsy and related central disorders of hypersomnolence may present to the sleep clinic with excessive daytime sleepiness. A strong clinical suspicion and awareness of the diagnostic clues, such as cataplexy, are essential to avoid unnecessary diagnostic delay. This review provides an overview of the epidemiology, pathophysiology, clinical features, diagnostic criteria and management of narcolepsy and related disorders, including idiopathic hypersomnia, Kleine-Levin syndrome (recurrent episodic hypersomnia) and secondary central disorders of hypersomnolence.
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Affiliation(s)
- Stephen Klaus
- Department of Sleep Medicine, St James's Hospital, Dublin, Ireland
| | - Aoife Carolan
- Department of Sleep Medicine, St James's Hospital, Dublin, Ireland
| | - Deirdre O'Rourke
- Department of Sleep Medicine, St James's Hospital, Dublin, Ireland
| | - Barry Kennedy
- Department of Sleep Medicine, St James's Hospital, Dublin, Ireland,Corresponding author: Barry Kennedy ()
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17
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Characterization of T cell receptors reactive to HCRT NH2, pHA 273-287, and NP 17-31 in control and narcolepsy patients. Proc Natl Acad Sci U S A 2022; 119:e2205797119. [PMID: 35914171 PMCID: PMC9371724 DOI: 10.1073/pnas.2205797119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Narcolepsy type 1 (NT1), a disorder caused by hypocretin/orexin (HCRT) cell loss, is associated with human leukocyte antigen (HLA)-DQ0602 (98%) and T cell receptor (TCR) polymorphisms. Increased CD4+ T cell reactivity to HCRT, especially DQ0602-presented amidated C-terminal HCRT (HCRTNH2), has been reported, and homology with pHA273-287 flu antigens from pandemic 2009 H1N1, an established trigger of the disease, suggests molecular mimicry. In this work, we extended DQ0602 tetramer and dextramer data to 77 cases and 44 controls, replicating our prior finding and testing 709 TCRs in Jurkat 76 T cells for functional activation. We found that fewer TCRs isolated with HCRTNH2 (∼11%) versus pHA273-287 or NP17-31 antigens (∼50%) were activated by their ligand. Single-cell characterization did not reveal phenotype differences in influenza versus HCRTNH2-reactive T cells, and analysis of TCR CDR3αβ sequences showed TCR clustering by responses to antigens but no cross-peptide class reactivity. Our results do not support the existence of molecular mimicry between HCRT and pHA273-287 or NP17-31.
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18
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Gao XB, Horvath TL. From Molecule to Behavior: Hypocretin/orexin Revisited From a Sex-dependent Perspective. Endocr Rev 2022; 43:743-760. [PMID: 34792130 PMCID: PMC9277634 DOI: 10.1210/endrev/bnab042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Indexed: 11/19/2022]
Abstract
The hypocretin/orexin (Hcrt/Orx) system in the perifornical lateral hypothalamus has been recognized as a critical node in a complex network of neuronal systems controlling both physiology and behavior in vertebrates. Our understanding of the Hcrt/Orx system and its array of functions and actions has grown exponentially in merely 2 decades. This review will examine the latest progress in discerning the roles played by the Hcrt/Orx system in regulating homeostatic functions and in executing instinctive and learned behaviors. Furthermore, the gaps that currently exist in our knowledge of sex-related differences in this field of study are discussed.
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Affiliation(s)
- Xiao-Bing Gao
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Tamas L Horvath
- Department of Comparative Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
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19
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Zhang M, Thieux M, Inocente CO, Vieux N, Arvis L, Villanueva C, Lin J, Plancoulaine S, Guyon A, Franco P. Characterization of rapid weight gain phenotype in children with narcolepsy. CNS Neurosci Ther 2022; 28:829-841. [PMID: 35212159 PMCID: PMC9062543 DOI: 10.1111/cns.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To characterize the rapid weight gain (RWG) phenotype associated with the onset of childhood narcolepsy and to determine whether it could constitute a marker of severity of the disease. METHODS RWG was defined using the BMI z-score slope reported to one year (>0.67 SD) from symptom onset to disease diagnosis. We compared the clinical, metabolic, and sleep characteristics between patients with or without RWG at diagnosis. Pharmacological management, anthropometric, and clinical progression were also evaluated during the follow-up. RESULTS A total of 84 de novo narcoleptic pediatric patients were included; their median age at diagnosis was 12.0 years; 59.5% boys, 90.5% cataplexy, and 98.7% HLA-DQB1*06:02, 57% had RWG profile. RWG patients were younger at diagnosis than non-RWG patients, despite a shorter diagnostic delay. They had a higher BMI z-score and a higher prevalence of obesity at diagnosis, but not at symptom onset, and higher adapted Epworth Sleepiness Scale and Insomnia Severity Index scores than non-RWG patients. No differences on nocturnal polysomnography and multiple sleep latency tests were found between groups at disease diagnosis. After a median follow-up of 5 years, RWG patients still had a higher BMI z-score and a higher prevalence of obesity despite benefiting from the same therapeutic management and displaying improvement in sleepiness and school difficulties. CONCLUSIONS Narcoleptic RWG patients were younger, sleepier, and the prevalence of obesity was higher at diagnosis despite a shorter diagnostic delay than that of non-RWG patients. These patients had also a higher risk of developing a long-term obesity, despite a positive progression of their narcoleptic symptoms. RGW could then represent a maker of a more severe phenotype of childhood narcolepsy, which should inspire a prompt and more offensive management to prevent obesity and its complications.
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Affiliation(s)
- Min Zhang
- Integrative Physiology of the Brain Arousal SystemsCRNLINSERM U1028CNRS UMR5292Université Claude Bernard Lyon 1LyonFrance
| | - Marine Thieux
- Integrative Physiology of the Brain Arousal SystemsCRNLINSERM U1028CNRS UMR5292Université Claude Bernard Lyon 1LyonFrance
- Pediatric Sleep UnitHôpital Femme Mère EnfantHospices Civils de Lyon & National Reference Center for NarcolepsyUniversité Claude Bernard Lyon 1LyonFrance
| | - Clara Odilia Inocente
- Integrative Physiology of the Brain Arousal SystemsCRNLINSERM U1028CNRS UMR5292Université Claude Bernard Lyon 1LyonFrance
| | - Noemie Vieux
- Pediatric Sleep UnitHôpital Femme Mère EnfantHospices Civils de Lyon & National Reference Center for NarcolepsyUniversité Claude Bernard Lyon 1LyonFrance
| | - Laura Arvis
- Pediatric Endocrinology UnitHôpital Femme Mère EnfantHospices Civils de LyonUniversité Claude Bernard Lyon 1LyonFrance
| | - Carine Villanueva
- Pediatric Endocrinology UnitHôpital Femme Mère EnfantHospices Civils de LyonUniversité Claude Bernard Lyon 1LyonFrance
| | - Jian‐Sheng Lin
- Integrative Physiology of the Brain Arousal SystemsCRNLINSERM U1028CNRS UMR5292Université Claude Bernard Lyon 1LyonFrance
| | | | - Aurore Guyon
- Pediatric Sleep UnitHôpital Femme Mère EnfantHospices Civils de Lyon & National Reference Center for NarcolepsyUniversité Claude Bernard Lyon 1LyonFrance
| | - Patricia Franco
- Integrative Physiology of the Brain Arousal SystemsCRNLINSERM U1028CNRS UMR5292Université Claude Bernard Lyon 1LyonFrance
- Pediatric Sleep UnitHôpital Femme Mère EnfantHospices Civils de Lyon & National Reference Center for NarcolepsyUniversité Claude Bernard Lyon 1LyonFrance
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20
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Latorre D, Federica S, Bassetti CLA, Kallweit U. Narcolepsy: a model interaction between immune system, nervous system, and sleep-wake regulation. Semin Immunopathol 2022; 44:611-623. [PMID: 35445831 PMCID: PMC9519713 DOI: 10.1007/s00281-022-00933-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/22/2022] [Indexed: 12/21/2022]
Abstract
Narcolepsy is a rare chronic neurological disorder characterized by an irresistible excessive daytime sleepiness and cataplexy. The disease is considered to be the result of the selective disruption of neuronal cells in the lateral hypothalamus expressing the neuropeptide hypocretin, which controls the sleep-wake cycle. Diagnosis and management of narcolepsy represent still a substantial medical challenge due to the large heterogeneity in the clinical manifestation of the disease as well as to the lack of understanding of the underlying pathophysiological mechanisms. However, significant advances have been made in the last years, thus opening new perspective in the field. This review describes the current knowledge of clinical presentation and pathology of narcolepsy as well as the existing diagnostic criteria and therapeutic intervention for the disease management. Recent evidence on the potential immune-mediated mechanisms that may underpin the disease establishment and progression are also highlighted.
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Affiliation(s)
| | - Sallusto Federica
- Institute of Microbiology, ETH Zurich, Zurich, Switzerland.,Center of Medical Immunology, Institute for Research in Biomedicine, Università della Svizzera italiana, Bellinzona, Switzerland
| | | | - Ulf Kallweit
- Clinical Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Witten, Germany.,Center for Biomedical Education and Research (ZBAF), University Witten/Herdecke, Witten, Germany
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21
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Dale NC, Hoyer D, Jacobson LH, Pfleger KDG, Johnstone EKM. Orexin Signaling: A Complex, Multifaceted Process. Front Cell Neurosci 2022; 16:812359. [PMID: 35496914 PMCID: PMC9044999 DOI: 10.3389/fncel.2022.812359] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/07/2022] [Indexed: 11/15/2022] Open
Abstract
The orexin system comprises two G protein-coupled receptors, OX1 and OX2 receptors (OX1R and OX2R, respectively), along with two endogenous agonists cleaved from a common precursor (prepro-orexin), orexin-A (OX-A) and orexin-B (OX-B). For the receptors, a complex array of signaling behaviors has been reported. In particular, it becomes obvious that orexin receptor coupling is very diverse and can be tissue-, cell- and context-dependent. Here, the early signal transduction interactions of the orexin receptors will be discussed in depth, with particular emphasis on the direct G protein interactions of each receptor. In doing so, it is evident that ligands, additional receptor-protein interactions and cellular environment all play important roles in the G protein coupling profiles of the orexin receptors. This has potential implications for our understanding of the orexin system's function in vivo in both central and peripheral environments, as well as the development of novel agonists, antagonists and possibly allosteric modulators targeting the orexin system.
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Affiliation(s)
- Natasha C. Dale
- Molecular Endocrinology and Pharmacology, Harry Perkins Institute of Medical Research and Centre for Medical Research, The University of Western Australia, Nedlands, WA, Australia
- Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, VIC, Australia
- Australian Research Council Centre for Personalised Therapeutics Technologies, Perth, WA, Australia
| | - Daniel Hoyer
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, United States
| | - Laura H. Jacobson
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
- Department of Biochemistry and Pharmacology, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Melbourne Dementia Research Centre, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Kevin D. G. Pfleger
- Molecular Endocrinology and Pharmacology, Harry Perkins Institute of Medical Research and Centre for Medical Research, The University of Western Australia, Nedlands, WA, Australia
- Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, VIC, Australia
- Australian Research Council Centre for Personalised Therapeutics Technologies, Perth, WA, Australia
- Dimerix Limited, Nedlands, WA, Australia
| | - Elizabeth K. M. Johnstone
- Molecular Endocrinology and Pharmacology, Harry Perkins Institute of Medical Research and Centre for Medical Research, The University of Western Australia, Nedlands, WA, Australia
- Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, VIC, Australia
- Australian Research Council Centre for Personalised Therapeutics Technologies, Perth, WA, Australia
- School of Biomedical Sciences, The University of Western Australia, Nedlands, WA, Australia
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22
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Melzi S, Morel AL, Scoté-Blachon C, Liblau R, Dauvilliers Y, Peyron C. Histamine in murine narcolepsy: What do genetic and immune models tell us? Brain Pathol 2021; 32:e13027. [PMID: 34672414 PMCID: PMC8877734 DOI: 10.1111/bpa.13027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/14/2021] [Accepted: 09/27/2021] [Indexed: 12/20/2022] Open
Abstract
An increased number of histaminergic neurons, identified by labeling histidine‐decarboxylase (HDC) its synthesis enzyme, was unexpectedly found in patients with narcolepsy type 1 (NT1). In quest for enlightenment, we evaluate whether an increase in HDC cell number and expression level would be detected in mouse models of the disease, in order to provide proof of concepts reveling possible mechanisms of compensation for the loss of orexin neurons, and/or of induced expression as a consequence of local neuroinflammation, a state that likely accompanies NT1. To further explore the compensatory hypothesis, we also study the noradrenergic wake‐promoting system. Immunohistochemistry for HDC, orexin, and melanin‐concentrating hormone (MCH) was used to count neurons. Quantitative‐PCR of HDC, orexin, MCH, and tyrosine‐hydroxylase was performed to evaluate levels of mRNA expression in the hypothalamus or the dorsal pons. Both quantifications were achieved in genetic and neuroinflammatory models of narcolepsy with major orexin impairment, namely the orexin‐deficient (Orex‐KO) and orexin‐hemagglutinin (Orex‐HA) mice respectively. The number of HDC neurons and mRNA expression level were unchanged in Orex‐KO mice compared to controls. Similarly, we found no change in tyrosine‐hydroxylase mRNA expression in the dorsal pons between groups. Further, despite the presence of protracted local neuroinflammation as witnessed by the presence of reactive microglia, we found no change in the number of neurons nor the expression of HDC in Orex‐HA mice compared to controls. Importantly, no correlation was found in all conditions between HDC and orexin. Our findings indicate that, in mice, the expression of histamine and noradrenalin, two wake‐promoting systems, are not modulated by orexin level whether the lack of orexin is constitutive or induced at adult age, showing thus no compensation. They also show no recruitment of histamine by local neuroinflammation. Further studies will be needed to further define the role of histamine in the pathophysiology of NT1.
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Affiliation(s)
- Silvia Melzi
- Sleep Team, Center for Research in Neuroscience of LYON, CNRS UMR5292, INSERM U1028, University of Lyon1, Bron, France
| | - Anne-Laure Morel
- Sleep Team, Center for Research in Neuroscience of LYON, CNRS UMR5292, INSERM U1028, University of Lyon1, Bron, France
| | - Céline Scoté-Blachon
- Functional Neurogenetics platform, Center for Research in Neuroscience of LYON, CNRS UMR5292, INSERM U1028, University of Lyon1, Bron, France
| | - Roland Liblau
- Toulouse Institute for Infectious and Inflammatory diseases, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, UPS, University of Toulouse, Toulouse, France
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases, Narcolepsy - Rare hypersomnia, Sleep Unit, Department of Neurology, CHU Montpellier, Institute for Neuroscience of Montpellier INM, INSERM U1298, University of Montpellier, Montpellier, France
| | - Christelle Peyron
- Sleep Team, Center for Research in Neuroscience of LYON, CNRS UMR5292, INSERM U1028, University of Lyon1, Bron, France
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23
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Viste R, Lie BA, Viken MK, Rootwelt T, Knudsen-Heier S, Kornum BR. Narcolepsy type 1 patients have lower levels of effector memory CD4 + T cells compared to their siblings when controlling for H1N1-(Pandemrix™)-vaccination and HLA DQB1∗06:02 status. Sleep Med 2021; 85:271-279. [PMID: 34388506 DOI: 10.1016/j.sleep.2021.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/15/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVES Evidence suggests a cell-mediated autoimmune pathogenesis for narcolepsy type 1 (NT1), but it is not clear whether the disease is associated with overall changes in T cell subsets. The increase in NT1 incidence after H1N1 vaccination campaign with the Pandemrix™ vaccine suggests that disease-relevant changes in the immune system following this vaccination were important. In this study, we aimed to investigate differentiated T cell subsets and levels of CD25 and CD69 activation markers in a cohort of mainly Pandemrix™-vaccinated NT1 patients compared with their vaccinated and unvaccinated siblings. METHODS Peripheral blood mononuclear cells were collected in parallel and analysed with flow cytometry in 31 NT1 patients with disease onset after the 2009 influenza A (H1N1) pandemic and/or Pandemrix™ vaccination and 45 of their non-narcoleptic siblings (29/31 and 34/45 vaccinated, respectively). RESULTS We observed significantly lower effector memory CD4+ T cell levels in NT1 patients compared to their siblings, when controlling for HLA DQB1∗06:02 and vaccination status. Further, within the sibling group, vaccination status significantly affected frequencies of central memory and CD8+CD25+ T cells, and HLA DQB1∗06:02 status significantly affected frequencies of CD4+CD25+ T cells. CONCLUSION We confirm that NT1 is associated with lower levels of effector memory CD4+ T cells in peripheral blood. Importantly, this finding was only significant when controlling for vaccination and HLA status in both patients and controls. We thus demonstrate the importance of characterizing such factors (eg HLA and vaccination) when studying T cell subsets in NT1. This might explain earlier conflicting results.
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Affiliation(s)
- Rannveig Viste
- Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias (NevSom), Department of Rare Disorders, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Benedicte A Lie
- Department of Immunology, University of Oslo and Oslo University Hospital, Norway; Department of Medical Genetics, University of Oslo and Oslo University Hospital, Norway
| | - Marte K Viken
- Department of Immunology, University of Oslo and Oslo University Hospital, Norway; Department of Medical Genetics, University of Oslo and Oslo University Hospital, Norway
| | - Terje Rootwelt
- Institute of Clinical Medicine, University of Oslo, Norway; Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Norway
| | - Stine Knudsen-Heier
- Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias (NevSom), Department of Rare Disorders, Oslo University Hospital, Norway
| | - Birgitte R Kornum
- Kornum Laboratory, Department of Neuroscience, University of Copenhagen, Denmark.
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24
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Tisdale RK, Yamanaka A, Kilduff TS. Animal models of narcolepsy and the hypocretin/orexin system: Past, present, and future. Sleep 2021; 44:6031626. [PMID: 33313880 DOI: 10.1093/sleep/zsaa278] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/04/2020] [Indexed: 11/12/2022] Open
Abstract
Animal models have advanced not only our understanding of the etiology and phenotype of the sleep disorder narcolepsy but have also informed sleep/wake regulation more generally. The identification of an inheritable narcolepsy phenotype in dogs in the 1970s allowed the establishment of a breeding colony at Stanford University, resulting in studies that provided the first insights into the genetics and neurotransmitter systems that underlie cataplexy and rapid-eye movement sleep atonia. Although the discovery of the hypocretin/orexin neuropeptides in 1998 initially seemed unrelated to sleep/wake control, the description of the phenotype of the prepro-orexin knockout (KO) mouse as strongly resembling cataplexy, the pathognomonic symptom of narcolepsy, along with identification of a mutation in hypocretin receptor-2 gene as the source of canine narcolepsy, unequivocally established the relationship between this system and narcolepsy. The subsequent discovery of hypocretin neuron degeneration in human narcolepsy demystified a disorder whose etiology had been unknown since its initial description 120 years earlier. These breakthroughs prompted the development of numerous other animal models that have allowed manipulation of the hypocretin/orexin system, thereby advancing our understanding of sleep/wake circuitry. While animal models have greatly informed understanding of this fascinating disorder and the role of the hypocretin/orexin system in sleep/wake control, the question of why these neurons degenerate in human narcolepsy is only beginning to be understood. The development of new immune-mediated narcolepsy models are likely to further inform the etiology of this sleep disorder and animal models will undoubtedly play a critical role in the development of novel narcolepsy therapeutics.
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Affiliation(s)
- Ryan K Tisdale
- Center for Neuroscience, Biosciences Division, SRI International
| | - Akihiro Yamanaka
- Department of Neuroscience II, Research Institute of Environmental Medicine, Nagoya University, Japan.,Department of Neural Regulation, Nagoya University Graduate School of Medicine, Japan
| | - Thomas S Kilduff
- Center for Neuroscience, Biosciences Division, SRI International
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25
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Bassetti CLA, Kallweit U, Vignatelli L, Plazzi G, Lecendreux M, Baldin E, Dolenc-Groselj L, Jennum P, Khatami R, Manconi M, Mayer G, Partinen M, Pollmächer T, Reading P, Santamaria J, Sonka K, Dauvilliers Y, Lammers GJ. European guideline and expert statements on the management of narcolepsy in adults and children. J Sleep Res 2021; 30:e13387. [PMID: 34173288 DOI: 10.1111/jsr.13387] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Narcolepsy is an uncommon hypothalamic disorder of presumed autoimmune origin that usually requires lifelong treatment. This paper aims to provide evidence-based guidelines for the management of narcolepsy in both adults and children. METHODS The European Academy of Neurology (EAN), European Sleep Research Society (ESRS), and European Narcolepsy Network (EU-NN) nominated a task force of 18 narcolepsy specialists. According to the EAN recommendations, 10 relevant clinical questions were formulated in PICO format. Following a systematic review of the literature (performed in Fall 2018 and updated in July 2020) recommendations were developed according to the GRADE approach. RESULTS A total of 10,247 references were evaluated, 308 studies were assessed and 155 finally included. The main recommendations can be summarized as follows: (i) excessive daytime sleepiness (EDS) in adults-scheduled naps, modafinil, pitolisant, sodium oxybate (SXB), solriamfetol (all strong); methylphenidate, amphetamine derivatives (both weak); (ii) cataplexy in adults-SXB, venlafaxine, clomipramine (all strong) and pitolisant (weak); (iii) EDS in children-scheduled naps, SXB (both strong), modafinil, methylphenidate, pitolisant, amphetamine derivatives (all weak); (iv) cataplexy in children-SXB (strong), antidepressants (weak). Treatment choices should be tailored to each patient's symptoms, comorbidities, tolerance and risk of potential drug interactions. CONCLUSION The management of narcolepsy involves non-pharmacological and pharmacological approaches with an increasing number of symptomatic treatment options for adults and children that have been studied in some detail.
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Affiliation(s)
- Claudio L A Bassetti
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Ulf Kallweit
- Center for Narcolepsy/Hypersomnias, Clin. Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Witten, Germany
| | - Luca Vignatelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Michel Lecendreux
- AP-HP, Pediatric Sleep Center, CHU Robert-Debré, Paris, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome (CNR narcolepsie-hypersomnie), Paris, France
| | - Elisa Baldin
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Leja Dolenc-Groselj
- Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Neurology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Faculty of Health Sciences, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ramin Khatami
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Center of Sleep Medicine, Sleep Research and Epileptology, Clinic Barmelweid, Barmelweid, Switzerland
| | - Mauro Manconi
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Sleep Center, Faculty of Biomedical Sciences, Neurocenter of Southern Switzerland, Università della Svizzera Italiana, Lugano, Switzerland
| | - Geert Mayer
- Neurology Department, Hephata Klinik, Schwalmstadt, Germany.,Department of Neurology, Philipps-Universität Marburg, Marburg, Germany
| | - Markku Partinen
- Department of Clinial Neurosciences, Clinicum, Helsinki Sleep Clinic, Vitalmed Research Center, Terveystalo Biobank and Clinical Research, University of Helsinki, Helsinki, Finland
| | | | - Paul Reading
- Department of Neurology, James Cook University Hospital, Middlesbrough, UK
| | - Joan Santamaria
- Neurology Service, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Karel Sonka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, Sleep Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, University of Montpellier, INM INSERM, Montpellier, France
| | - Gert J Lammers
- Sleep Wake Centre SEIN, Heemstede, The Netherlands.,Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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26
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Bassetti CLA, Kallweit U, Vignatelli L, Plazzi G, Lecendreux M, Baldin E, Dolenc-Groselj L, Jennum P, Khatami R, Manconi M, Mayer G, Partinen M, Pollmächer T, Reading P, Santamaria J, Sonka K, Dauvilliers Y, Lammers GJ. European guideline and expert statements on the management of narcolepsy in adults and children. Eur J Neurol 2021; 28:2815-2830. [PMID: 34173695 DOI: 10.1111/ene.14888] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIM Narcolepsy is an uncommon hypothalamic disorder of presumed autoimmune origin that usually requires lifelong treatment. This paper aims to provide evidence-based guidelines for the management of narcolepsy in both adults and children. METHODS The European Academy of Neurology (EAN), European Sleep Research Society (ESRS) and European Narcolepsy Network (EU-NN) nominated a task force of 18 narcolepsy specialists. According to the EAN recommendations, 10 relevant clinical questions were formulated in PICO format. Following a systematic review of the literature (performed in Fall 2018 and updated in July 2020) recommendations were developed according to the GRADE approach. RESULTS A total of 10,247 references were evaluated, 308 studies were assessed and 155 finally included. The main recommendations can be summarized as follows: (i) excessive daytime sleepiness in adults-scheduled naps, modafinil, pitolisant, sodium oxybate (SXB), solriamfetol (all strong), methylphenidate, amphetamine derivates (both weak); (ii) cataplexy in adults-SXB, venlafaxine, clomipramine (all strong) and pitolisant (weak); (iii) excessive daytime sleepiness in children-scheduled naps, SXB (both strong), modafinil, methylphenidate, pitolisant, amphetamine derivates (all weak); (iv) cataplexy in children-SXB (strong), antidepressants (weak). Treatment choices should be tailored to each patient's symptoms, comorbidities, tolerance and risk of potential drug interactions. CONCLUSION The management of narcolepsy involves non-pharmacological and pharmacological approaches with an increasing number of symptomatic treatment options for adults and children that have been studied in some detail.
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Affiliation(s)
- Claudio L A Bassetti
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Ulf Kallweit
- Center for Narcolepsy/Hypersomnias, Clin. Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Witten, Germany
| | - Luca Vignatelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Michel Lecendreux
- AP-HP, Pediatric Sleep Center, CHU Robert-Debré, Paris, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia and Kleine-Levin Syndrome (CNR narcolepsie-hypersomnie), Paris, France
| | - Elisa Baldin
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Leja Dolenc-Groselj
- Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Neurology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Faculty of Health Sciences, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ramin Khatami
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Center of Sleep Medicine, Sleep Research and Epileptology. Clinic Barmelweid, Barmelweid, Switzerland
| | - Mauro Manconi
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.,Sleep Center, Faculty of Biomedical Sciences, Neurocenter of Southern Switzerland, Università della Svizzera Italiana, Lugano, Switzerland
| | - Geert Mayer
- Neurology Department, Hephata Klinik, Schwalmstadt, Germany.,Department of Neurology, Philipps-Universität Marburg, Marburg, Germany
| | - Markku Partinen
- Department of Clinial Neurosciences, Clinicum, Helsinki Sleep Clinic, Vitalmed Research Center, Terveystalo Biobank and Clinical Research, University of Helsinki, Helsinki, Finland
| | | | - Paul Reading
- Department of Neurology, James Cook University Hospital, Middlesbrough, UK
| | - Joan Santamaria
- Neurology Service, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Karel Sonka
- Department of Neurology and Center of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, Sleep Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, University of Montpellier, INM INSERM, Montpellier, France
| | - Gert J Lammers
- Sleep Wake Centre SEIN, Heemstede, The Netherlands.,Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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27
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Luo G, Yogeshwar S, Lin L, Mignot EJM. T cell reactivity to regulatory factor X4 in type 1 narcolepsy. Sci Rep 2021; 11:7841. [PMID: 33837283 PMCID: PMC8035403 DOI: 10.1038/s41598-021-87481-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/23/2021] [Indexed: 11/11/2022] Open
Abstract
Type 1 narcolepsy is strongly (98%) associated with human leukocyte antigen (HLA) class II DQA1*01:02/DQB1*06:02 (DQ0602) and highly associated with T cell receptor (TCR) alpha locus polymorphism as well as other immune regulatory loci. Increased incidence of narcolepsy was detected following the 2009 H1N1 pandemic and linked to Pandemrix vaccination, strongly supporting that narcolepsy is an autoimmune disorder. Although recent results suggest CD4+ T cell reactivity to neuropeptide hypocretin/orexin and cross-reactive flu peptide is involved, identification of other autoantigens has remained elusive. Here we study whether autoimmunity directed against Regulatory Factor X4 (RFX4), a protein co-localized with hypocretin, is involved in some cases of narcolepsy. Studying human serum, we found that autoantibodies against RFX4 were rare. Using RFX4 peptides bound to DQ0602 tetramers, antigen RFX4-86, -95, and -60 specific human CD4+ T cells were detected in 4/10 patients and 2 unaffected siblings, but not in others. Following culture with each cognate peptide, enriched autoreactive TCRαβ clones were isolated by single-cell sorting and TCR sequenced. Homologous clones bearing TRBV4-2 and recognizing RFX4-86 in patients and one twin control of patient were identified. These results suggest the involvement of RFX4 CD4+ T cell autoreactivity in some cases of narcolepsy, but also in healthy donors.
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Affiliation(s)
- Guo Luo
- Department of Psychiatry and Behavioral Sciences, Stanford University Center for Sleep Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Selina Yogeshwar
- Department of Psychiatry and Behavioral Sciences, Stanford University Center for Sleep Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Biosciences, Department of Cell and Developmental Biology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Ling Lin
- Department of Psychiatry and Behavioral Sciences, Stanford University Center for Sleep Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Emmanuel Jean-Marie Mignot
- Department of Psychiatry and Behavioral Sciences, Stanford University Center for Sleep Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.
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28
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Sunwoo JS. Narcolepsy, autoimmunity, and influenza A H1N1 vaccination. ENCEPHALITIS 2021; 1:31-35. [PMID: 37469760 PMCID: PMC10295885 DOI: 10.47936/encephalitis.2021.00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 07/21/2023] Open
Abstract
Narcolepsy is a rare neurological disorder characterized by excessive daytime sleepiness (EDS) with or without cataplexy. A main pathophysiology of narcolepsy is hypocretin deficiency in the central nervous system resulting from a selective loss of hypocretin neurons in the lateral hypothalamus. To date, the pathogenesis of hypocretin neuron loss in narcolepsy is the most commonly accepted autoimmune hypothesis which is supported by genetic risk factors for narcolepsy such as HLA‑DQB1*06:02 allele and T-cell receptor alpha polymorphisms. Other evidence supporting the immune-mediated mechanisms include the presence of anti-Tribbles homolog 2 (TRIB2) and anti-streptococcal antibodies in patients with narcolepsy, seasonal patterns of narcolepsy onset, and increased incidence of narcolepsy after the H1N1 pandemic influenza A infections and vaccinations. Among several types of vaccines, the AS03-adjuvanted vaccine Pandemrix (GlaxoSmithKline) was the only vaccine found to increase the risk of narcolepsy. However, the comprehensive results of several epidemiological studies indicate the adjuvant AS03 alone cannot cause the disease. The genetic predisposition, environmental triggers, molecular mimicry of specific H1N1 antigens, and bystander immune activation caused by the adjuvant AS03 may have combined to contribute to autoimmunity against hypocretin neurons and development of narcolepsy.
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Affiliation(s)
- Jun-Sang Sunwoo
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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29
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Abstract
Narcolepsy Type 1 (NT1) is hypothesized to be an autoimmune disease targeting the hypocretin/orexin neurons in the lateral hypothalamus. Ample genetic and epidemiologic evidence point in the direction of a pathogenesis involving the immune system. Many autoantibodies have been detected in blood samples from NT1 patients, but none in a consistent manner. Importantly, T cells directed toward hypocretin/orexin neurons have been detected in samples from NT1 patients. However, it remains to be seen if these potentially autoreactive T cells are also present in the hypothalamus and if they are pathogenic. For this reason, NT1 does still not fully meet the criteria for being classified as a genuine autoimmune disease, even though more and more results are pointing in that direction as will be described in this chapter. The autoimmune hypothesis has led to many attempts at slowing or stopping disease progression with immunomodulatory treatment, but so far the overall results have not been very encouraging. It is clear that more research into the pathogenesis of NT1 is needed to establish the precise role of the immune system in disease development.
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30
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Giannoccaro MP, Liguori R, Plazzi G, Pizza F. Reviewing the Clinical Implications of Treating Narcolepsy as an Autoimmune Disorder. Nat Sci Sleep 2021; 13:557-577. [PMID: 34007229 PMCID: PMC8123964 DOI: 10.2147/nss.s275931] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/19/2021] [Indexed: 11/23/2022] Open
Abstract
Narcolepsy type 1 (NT1) is a lifelong sleep disorder, primarily characterized clinically by excessive daytime sleepiness and cataplexy and pathologically by the loss of hypocretinergic neurons in the lateral hypothalamus. Despite being a rare disorder, the NT1-related burden for patients and society is relevant due to the early onset and chronic nature of this condition. Although the etiology of narcolepsy is still unknown, mounting evidence supports a central role of autoimmunity. To date, no cure is available for this disorder and current treatment is symptomatic. Based on the hypothesis of the autoimmune etiology of this disease, immunotherapy could possibly represent a valid therapeutic option. However, contrasting and limited results have been provided so far. This review discusses the evidence supporting the use of immunotherapy in narcolepsy, the outcomes obtained so far, current issues and future directions.
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Affiliation(s)
- Maria Pia Giannoccaro
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Rocco Liguori
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Pizza
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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31
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Sagi D, de Lecea L, Appelbaum L. Heterogeneity of Hypocretin/Orexin Neurons. FRONTIERS OF NEUROLOGY AND NEUROSCIENCE 2021; 45:61-74. [PMID: 34052814 PMCID: PMC8961008 DOI: 10.1159/000514964] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 02/02/2021] [Indexed: 01/21/2023]
Abstract
The multifunctional, hypothalamic hypocretin/orexin (HCRT)-producing neurons regulate an array of physiological and behavioral states including arousal, sleep, feeding, emotions, stress, and reward. How a presumably uniform HCRT neuron population regulates such a diverse set of functions is not clear. The role of the HCRT neuropeptides may vary depending on the timing and localization of secretion and neuronal activity. Moreover, HCRT neuropeptides may not mediate all functions ascribed to HCRT neurons. Some could be orchestrated by additional neurotransmitters and neuropeptides that are expressed in HCRT neurons. We hypothesize that HCRT neurons are segregated into genetically, anatomically and functionally distinct subpopulations. We discuss accumulating data that suggest the existence of such HCRT neuron subpopulations that may effectuate the diverse functions of these neurons in mammals and fish.
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Affiliation(s)
- Dana Sagi
- The Faculty of Life Sciences and the Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat-Gan, Israel
| | - Luis de Lecea
- Dept of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Lior Appelbaum
- The Faculty of Life Sciences and the Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat-Gan, Israel.,Corresponding author: Lior Appelbaum, Bar-Ilan University, Ramat-Gan 5290002, Israel. Telephone: +972-3-7384536,
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32
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Blackburn KM, Wang C. Post-infectious neurological disorders. Ther Adv Neurol Disord 2020; 13:1756286420952901. [PMID: 32944082 PMCID: PMC7466892 DOI: 10.1177/1756286420952901] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/08/2020] [Indexed: 12/18/2022] Open
Abstract
A multitude of environmental factors can result in breakdown of immune tolerance in susceptible hosts. Infectious pathogens are among the most important environmental triggers in the pathogenesis of autoimmunity. Certain autoimmune disorders have a strong association with specific infections. Several neurological autoimmune disorders are thought to occur through post-infectious mechanisms. In this review, we discuss the proposed mechanisms underlying pathogen-induced autoimmunity, and highlight the clinical presentation and treatment of several post-infectious autoimmune neurological disorders. We also highlight post-infectious neurological disorders in the setting of recent outbreaks.
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Affiliation(s)
- Kyle M. Blackburn
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Cynthia Wang
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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33
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Dietmann A, Horn MP, Schinkelshoek MS, Fronczek R, Salmen A, Bargiotas P, Lammers GJ, Khatami R, Bassetti CLA. Conventional autoantibodies against brain antigens are not routinely detectable in serum and CSF of narcolepsy type 1 and 2 patients. Sleep Med 2020; 75:188-191. [PMID: 32858359 DOI: 10.1016/j.sleep.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/15/2020] [Accepted: 08/01/2020] [Indexed: 11/24/2022]
Abstract
Narcolepsy with cataplexy (NT1) is a chronic hypothalamic disorder with a presumed immune-mediated etiology leading to a loss of hypocretin neurons. Previous studies reported conflicting results in terms of presence of auto-antibodies involved in narcolepsy pathophysiology. A total of 86 patients with primary/idiopathic narcolepsy (74 NT1, 12 NT2) and 23 control patients with excessive daytime sleepiness due to other causes were tested for the presence of a wide range of anti-neuronal antibodies in both serum and cerebrospinal fluid (CSF). Anti-neuronal antibodies were rarely found in patients with narcolepsy (n = 2) and in controls (n = 1). Our results are in line with previous reports. We can therefore support the current evidence, that conventional anti-neuronal antibodies are not routinely detected during the workup of NT1 and other CDH patients.
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Affiliation(s)
- Anelia Dietmann
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
| | - Michael P Horn
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Mink S Schinkelshoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Sleep-wake Centre SEIN, Heemstede, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Sleep-wake Centre SEIN, Heemstede, the Netherlands
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Panagiotis Bargiotas
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland; Department of Neurology, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Gert J Lammers
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Sleep-wake Centre SEIN, Heemstede, the Netherlands
| | - Ramin Khatami
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland; Center for Sleep Medicine and Sleep Research, Clinic Barmelweid, Barmelweid, Switzerland
| | - Claudio L A Bassetti
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland; Neurology Department, Sechenov First Moscow State Medical University, Moscow, Russia
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34
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Zhang M, Inocente CO, Villanueva C, Lecendreux M, Dauvilliers Y, Lin JS, Arnulf I, Gustin MP, Thieux M, Franco P. Narcolepsy with cataplexy: Does age at diagnosis change the clinical picture? CNS Neurosci Ther 2020; 26:1092-1102. [PMID: 32761857 PMCID: PMC7539846 DOI: 10.1111/cns.13438] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/06/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022] Open
Abstract
Objective To compare symptoms and sleep characteristics in patients diagnosed with narcolepsy‐cataplexy (NC) before and after the age of 18 years. Methods De novo patients with NC diagnosis completed a standardized questionnaire and interview, followed by a sleep study. The clinical and sleep measures were compared between patients diagnosed before (46 children, median age: 12 year old) and after (46 adults, median age: 28.5 year old) 18 years of age. Results The frequency of obesity (54% vs 17%), night eating (29% vs 7%), parasomnia (89% vs 43%), sleep talking (80% vs 34%), and sleep drunkenness (69% vs 24%) were higher in children than in adults, the frequency of sleep paralysis was lower (20% vs 55%) but the frequency of cataplexy and the severity of sleepiness were not different. Children scored higher than adults at the attention‐deficit/hyperactivity disorder (ADHD) scale. Depressive feelings affected not differently children (24%) and adults (32%). However, adults had lower quality of life than children. There was no difference between groups for insomnia and fatigue scores. Quality of life was essentially impacted by depressive feelings in both children and adults. Obstructive apnea‐hypopnea index (OAHI) was lower in children with higher mean and minimal oxygen saturation than in adults. No between‐group differences were found at the multiple sleep latency test. The body mass index (z‐score) was correlated with OAHI (r = .32). Conclusion At time of NC diagnosis, children have more frequent obesity, night eating, parasomnia, sleep talking, drunkenness, and ADHD symptoms than adults, even if sleepiness and cataplexy do not differ. These differences should be considered to ensure a prompt diagnosis.
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Affiliation(s)
- Min Zhang
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
| | - Clara Odilia Inocente
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
| | - Carine Villanueva
- Endocrinology Pediatric Unit, Woman Mother Child Hospital, Civil Hospices of Lyon, Lyon, France
| | - Michel Lecendreux
- Pediatric Sleep Centre, Hospital Robert-Debre, Paris, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Paris, France
| | - Yves Dauvilliers
- National Reference Network for Narcolepsy, Sleep-Wake Disorder Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,Inserm U1061, University of Montpellier, Neuropsychiatry: Epidemiological and Clinical Research, Montpellier, France
| | - Jian-Sheng Lin
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
| | - Isabelle Arnulf
- AP-HP, Pitié-Salpêtrière Hospital, Sleep Disorder Unit & Sorbonne University, Paris, France
| | - Marie-Paule Gustin
- Emerging Pathogens Laboratory-Fondation Mérieux, International Center for Infectiology Research (CIRI), Inserm U1111, CNRS UMR5308, ENS de Lyon, Lyon, France.,Institute of Pharmaceutic and Biological Sciences, Public Health Department, Biostatistics, University Claude Bernard Lyon 1, Villeurbanne, France
| | - Marine Thieux
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France.,Sleep Pediatric Unit, Woman Mother Child Hospital, Civil Hospices of Lyon, Lyon, France
| | - Patricia Franco
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France.,Sleep Pediatric Unit, Woman Mother Child Hospital, Civil Hospices of Lyon, Lyon, France
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35
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Freitag TL, Leffler DA. Inside the Mind of a Cereal Killer: New Insights Into the Effect of Celiac Disease on Central Nervous Systems Function. Gastroenterology 2020; 158:2043-2045. [PMID: 32247693 DOI: 10.1053/j.gastro.2020.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/27/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Tobias L Freitag
- Translational Immunology Research Program, Department of Bacteriology and Immunology, University of Helsinki, Finland
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School.
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36
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Melén K, Jalkanen P, Kukkonen JP, Partinen M, Nohynek H, Vuorela A, Vaarala O, Freitag TL, Meri S, Julkunen I. No evidence of autoimmunity to human OX 1 or OX 2 orexin receptors in Pandemrix-vaccinated narcoleptic children. J Transl Autoimmun 2020; 3:100055. [PMID: 32743535 PMCID: PMC7388359 DOI: 10.1016/j.jtauto.2020.100055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 04/15/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022] Open
Abstract
Narcolepsy type 1, likely an immune-mediated disease, is characterized by excessive daytime sleepiness and cataplexy. The disease is strongly associated with human leukocyte antigen (HLA) DQB1∗06:02. A significant increase in the incidence of childhood and adolescent narcolepsy was observed after a vaccination campaign with AS03-adjuvanted Pandemrix influenza vaccine in Nordic and several other countries in 2010 and 2011. Previously, it has been suggested that a surface-exposed region of influenza A nucleoprotein, a structural component of the Pandemrix vaccine, shares amino acid residues with the first extracellular domain of the human OX2 orexin/hypocretin receptor eliciting the development of autoantibodies. Here, we analyzed, whether H1N1pdm09 infection or Pandemrix vaccination contributed to the development of autoantibodies to the orexin precursor protein or the OX1 or OX2 receptors. The analysis was based on the presence or absence of autoantibody responses against analyzed proteins. Entire OX1 and OX2 receptors or just their extracellular N-termini were transiently expressed in HuH7 cells to determine specific antibody responses in human sera. Based on our immunofluorescence analysis, none of the 56 Pandemrix-vaccinated narcoleptic patients, 28 patients who suffered from a laboratory-confirmed H1N1pdm09 infection or 19 Pandemrix-vaccinated controls showed specific autoantibody responses to prepro-orexin, orexin receptors or the isolated extracellular N-termini of orexin receptors. We also did not find any evidence for cell-mediated immunity against the N-terminal epitopes of OX2. Our findings do not support the hypothesis that the surface-exposed region of the influenza nucleoprotein A would elicit the development of an immune response against orexin receptors. No evidence of humoral immunity against human OX1 or OX2 orexin receptors. No cross-reactive antibodies between influenza virus NP and orexin receptors. No evidence for cell-mediated immunity against the N-terminal epitopes of OX2.
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Affiliation(s)
- Krister Melén
- Institute of Biomedicine, University of Turku, Kiinamyllynkatu 10, 20520, Turku, Finland.,Expert Microbiology Unit, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00300, Helsinki, Finland
| | - Pinja Jalkanen
- Institute of Biomedicine, University of Turku, Kiinamyllynkatu 10, 20520, Turku, Finland
| | - Jyrki P Kukkonen
- Department of Physiology and Department of Pharmacology, Institute of Biomedicine, Faculty of Medicine and Biochemistry and Cell Biology, Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Markku Partinen
- Helsinki Sleep Clinic, Vitalmed Research Centre Helsinki and Medicum, Faculty of Medicine, University of Helsinki, Finland
| | - Hanna Nohynek
- Infectious Disease Control and Vaccination Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Arja Vuorela
- Reseach Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki
| | - Outi Vaarala
- Reseach Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki
| | - Tobias L Freitag
- Department of Bacteriology and Immunology and Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Seppo Meri
- Department of Bacteriology and Immunology and Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Ilkka Julkunen
- Institute of Biomedicine, University of Turku, Kiinamyllynkatu 10, 20520, Turku, Finland.,Turku University Hospital, Clinical Microbiology, Kiinamyllynkatu 10, 20520, Turku, Finland
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37
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Kornum BR. Narcolepsy type 1: what have we learned from immunology? Sleep 2020; 43:5813740. [DOI: 10.1093/sleep/zsaa055] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/19/2020] [Indexed: 12/31/2022] Open
Abstract
Abstract
Narcolepsy type 1 is hypothesized to be an autoimmune disease targeting the hypocretin/orexin neurons in the hypothalamus. Ample genetic and epidemiological evidence points in the direction of a pathogenesis involving the immune system, but this is not considered proof of autoimmunity. In fact, it remains a matter of debate how to prove that a given disease is indeed an autoimmune disease. In this review, a set of commonly used criteria for autoimmunity is described and applied to narcolepsy type 1. In favor of the autoimmune hypothesis are data showing that in narcolepsy type 1 a specific adaptive immune response is directed to hypocretin/orexin neurons. Autoreactive T cells and autoantibodies have been detected in blood samples from patients, but it remains to be seen if these T cells or antibodies are in fact present in the hypothalamus. It is also unclear if the autoreactive T cells and/or autoantibodies can transfer the disease to healthy individuals or animals or if immunization with the proposed autoantigens can induce the disease in animal models. Most importantly, it is still controversial whether suppression of the autoimmune response can prevent disease progression. In conclusion, narcolepsy type 1 does still not fully meet the criteria for being classified as a genuine autoimmune disease, but more and more results are pointing in that direction.
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Affiliation(s)
- Birgitte R Kornum
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
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38
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Lind A, Eriksson D, Akel O, Ramelius A, Palm L, Lernmark Å, Kämpe O, Elding Larsson H, Landegren N. Screening for autoantibody targets in post-vaccination narcolepsy using proteome arrays. Scand J Immunol 2020; 91:e12864. [PMID: 32056243 DOI: 10.1111/sji.12864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 01/01/2023]
Abstract
Narcolepsy type 1 (NT1) is a chronic sleep disorder caused by a specific loss of hypocretin-producing neurons. The incidence of NT1 increased in Sweden, Finland and Norway following Pandemrix®-vaccination, initiated to prevent the 2009 influenza pandemic. The pathogenesis of NT1 is poorly understood, and causal links to vaccination are yet to be clarified. The strong association with Human leukocyte antigen (HLA) DQB1*06:02 suggests an autoimmune pathogenesis, but proposed autoantigens remain controversial. We used a two-step approach to identify autoantigens in patients that acquired NT1 after Pandemrix®-vaccination. Using arrays of more than 9000 full-length human proteins, we screened the sera of 10 patients and 24 healthy subjects for autoantibodies. Identified candidate antigens were expressed in vitro to enable validation studies with radiobinding assays (RBA). The validation cohort included NT1 patients (n = 39), their first-degree relatives (FDR) (n = 66), population controls (n = 188), and disease controls representing multiple sclerosis (n = 100) and FDR to type 1 diabetes patients (n = 41). Reactivity towards previously suggested NT1 autoantigen candidates including Tribbles homolog 2, Prostaglandin D2 receptor, Hypocretin receptor 2 and α-MSH/proopiomelanocortin was not replicated in the protein array screen. By comparing case to control signals, three novel candidate autoantigens were identified in the protein array screen; LOC401464, PARP3 and FAM63B. However, the RBA did not confirm elevated reactivity towards either of these proteins. In summary, three putative autoantigens in NT1 were identified by protein array screening. Autoantibodies against these candidates could not be verified with independent methods. Further studies are warranted to identify hypothetical autoantigens related to the pathogenesis of Pandemrix®-induced NT1.
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Affiliation(s)
- Alexander Lind
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS, Malmö, Sweden
| | - Daniel Eriksson
- Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Omar Akel
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS, Malmö, Sweden
| | - Anita Ramelius
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS, Malmö, Sweden
| | - Lars Palm
- Section for Paediatric Neurology, Department of Paediatrics, Skåne University Hospital SUS, Malmö, Sweden
| | - Åke Lernmark
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS, Malmö, Sweden
| | - Olle Kämpe
- Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Science for Life Laboratory, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Helena Elding Larsson
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS, Malmö, Sweden
| | - Nils Landegren
- Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,K.G. Jebsen Center for Autoimmune Disorders, Bergen, Norway
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39
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Giannoccaro MP, Sallemi G, Liguori R, Plazzi G, Pizza F. Immunotherapy in Narcolepsy. Curr Treat Options Neurol 2020; 22:2. [PMID: 31997035 DOI: 10.1007/s11940-020-0609-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Narcolepsy type 1 (NT1) is a chronic and disabling sleep disorder due to the loss of hypocretinergic neurons in the lateral hypothalamus pathophysiologically linked to an autoimmune process. Current treatment is symptomatic, and no cure is available to date. Immunotherapy is considered a promising future therapeutic option, and this review discusses the rationale for immunotherapy in narcolepsy, current evidences of its effects, outcome measures, and future directions. RECENT FINDINGS A limited number of case reports and uncontrolled small case series have reported the effect of different immunotherapies in patients with NT1. These studies were mainly based on the use of intravenous immunoglobulin (IVig), followed by corticosteroids, plasmapheresis, and monoclonal antibodies. Although initial reports showed an improvement of symptoms, particularly when patients were treated close to disease onset, other observations have not confirmed these results. Inadequate timing of treatment, placebo effects, and spontaneous improvement due to the natural disease course can account for these contrasting findings. Moreover, clear endpoints and standardized outcome measures have not been used and are currently missing in the pediatric population. On the basis of the available data, there are no enough evidences to support the use of immunotherapy in NT1. Randomized, controlled studies using clear endpoints and new outcome measures are needed to achieve a definitive answer about the usefulness of these treatments in narcolepsy.
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Affiliation(s)
- Maria Pia Giannoccaro
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Ospedale Bellaria, Padiglione G, piano 1, Via Altura 3, 40139 Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giombattista Sallemi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Ospedale Bellaria, Padiglione G, piano 1, Via Altura 3, 40139 Bologna, Italy
| | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Ospedale Bellaria, Padiglione G, piano 1, Via Altura 3, 40139 Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Ospedale Bellaria, Padiglione G, piano 1, Via Altura 3, 40139 Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Ospedale Bellaria, Padiglione G, piano 1, Via Altura 3, 40139 Bologna, Italy. .,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
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40
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Ravel JM, Mignot EJM. [Narcolepsy: From the discovery of a wake promoting peptide to autoimmune T cell biology and molecular mimicry with flu epitopes]. Biol Aujourdhui 2019; 213:87-108. [PMID: 31829930 DOI: 10.1051/jbio/2019026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Indexed: 11/14/2022]
Abstract
Narcolepsy-cataplexy was first described in the late 19th century in Germany and France. Prevalence was established to be 0.05 % and a canine model was discovered in the 1970s. In 1983, a Japanese study found that all patients carried HLA-DR2, suggesting autoimmunity as the cause of the disease. Studies in the canine model established that dopaminergic stimulation underlies anti-narcoleptic action of psychostimulants, while antidepressants were found to suppress cataplexy through adrenergic reuptake inhibition. No HLA association was found in canines. A linkage study initiated in 1988 revealed in hypocretin (orexin) receptor two mutations as the cause of canine narcolepsy in 1999. In 1992, studies on African Americans showed that DQ0602 was a better marker than DR2 across all ethnic groups. In 2000, hypocretin-1/orexin A levels were measured in the cerebrospinal fluid (CSF) and found to be undetectable in most patients, establishing hypocretin deficiency as the cause of narcolepsy. Decreased CSF hypocretin-1 was then found to be secondary to the loss of the 70,000 neurons producing hypocretin in the hypothalamus, suggesting immune destruction of these cells as the cause of the disease. Additional genetic studies, notably genome wide associations (GWAS), found multiple genetic predisposing factors for narcolepsy. These were almost all involved in other autoimmune diseases, although a strong and unique association with T cell receptor (TCR) alpha and beta loci were observed. Nonetheless, all attempts to demonstrate presence of autoantibodies against hypocretin cells in narcolepsy failed, and the presumed autoimmune cause remained unproven. In 2009, association with strep throat infections were found, and narcolepsy onsets were found to occur more frequently in spring and summer, suggesting upper away infections as triggers. Following reports that narcolepsy cases were triggered by vaccinations and infections against influenza A 2009 pH1N1, a new pandemic strain that erupted in 2009, molecular mimicry with influenza A virus was suggested in 2010. This hypothesis was later confirmed by peptide screening showing higher activity of CD4+ T cell reactivity to a specific post-translationally amidated segment of hypocretin (HCRT-NH2) and cross-reactivity of specific TCRs with a pH1N1-specific segment of hemagglutinin that shares homology with HCRT-NH2. Strikingly, the most frequent TCR recognizing these antigens was found to carry sequences containing TRAJ24 or TRVB4-2, segments modulated by narcolepsy-associated genetic polymorphisms. Cross-reactive CD4+ T cells with these cross-reactive TCRs likely subsequently recruit CD8+ T cells that are then involved in hypocretin cell destruction. Additional flu mimics are also likely to be discovered since narcolepsy existed prior to 2009. The work that has been conducted over the years on narcolepsy offers a unique perspective on the conduct of research on the etiopathogeny of a specific disease.
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Affiliation(s)
- Jean-Marie Ravel
- Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Medicine, Stanford University, 3615 Porter Drive, Palo Alto, CA, USA
| | - Emmanuel J M Mignot
- Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Medicine, Stanford University, 3615 Porter Drive, Palo Alto, CA, USA
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In vivo clonal expansion and phenotypes of hypocretin-specific CD4 + T cells in narcolepsy patients and controls. Nat Commun 2019; 10:5247. [PMID: 31748512 PMCID: PMC6868281 DOI: 10.1038/s41467-019-13234-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/29/2019] [Indexed: 01/15/2023] Open
Abstract
Individuals with narcolepsy suffer from abnormal sleep patterns due to loss of neurons that uniquely supply hypocretin (HCRT). Previous studies found associations of narcolepsy with the human leukocyte antigen (HLA)-DQ6 allele and T-cell receptor α (TRA) J24 gene segment and also suggested that in vitro-stimulated T cells can target HCRT. Here, we present evidence of in vivo expansion of DQ6-HCRT tetramer+/TRAJ24+/CD4+ T cells in DQ6+ individuals with and without narcolepsy. We identify related TRAJ24+ TCRαβ clonotypes encoded by identical α/β gene regions from two patients and two controls. TRAJ24-G allele+ clonotypes only expand in the two patients, whereas a TRAJ24-C allele+ clonotype expands in a control. A representative tetramer+/G-allele+ TCR shows signaling reactivity to the epitope HCRT87–97. Clonally expanded G-allele+ T cells exhibit an unconventional effector phenotype. Our analysis of in vivo expansion of HCRT-reactive TRAJ24+ cells opens an avenue for further investigation of the autoimmune contribution to narcolepsy development. T cells from narcolepsy patients were recently reported to recognize hypocretin, a wakefulness-promoting neurohormone, suggesting autoimmune origin of the disease. Here the authors show that hypocretin-specific T cells expand both in healthy controls and in narcolepsy patients, and identify preliminary features that may distinguish them.
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Chin J, Bearison C, Silverberg N, Lee Wong M. Concomitant atopic dermatitis and narcolepsy type 1: psychiatric implications and challenges in management. Gen Psychiatr 2019; 32:e100094. [PMID: 31673678 PMCID: PMC6802969 DOI: 10.1136/gpsych-2019-100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/12/2019] [Accepted: 09/06/2019] [Indexed: 11/03/2022] Open
Abstract
Atopic dermatitis (AD) and narcolepsy type 1 (NT1) are two distinct diseases that have not been classically shown to be related. The potential connection between the known immunological aetiology of AD and the proposed autoimmune pathophysiology of dysregulation in NT1; however, is the subject of ongoing speculation and debate with advances in gene sequencing and technology. Here, we present a case of a patient with concomitant refractory AD and NT1 and review the current research on their immunological relationship and the challenges in management relative to disease burden and psychiatric comorbidities.
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Affiliation(s)
- Justin Chin
- Department of Primary Care, Touro College of Osteopathic Medicine, New York City, New York, USA
| | - Craig Bearison
- Department of Internal Medicine, Beth Israel Medical Center, New York City, New York, USA
| | - Nanette Silverberg
- Department of Pediatric Dermatology, Mount Sinai Health System, New York City, New York, USA
| | - Mary Lee Wong
- Department of Allergy and Immunology, Beth Israel Medical Center, New York City, New York, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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43
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Wasling P, Malmeström C, Blennow K. CSF orexin-A levels after rituximab treatment in recent onset narcolepsy type 1. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:6/6/e613. [PMID: 31484686 PMCID: PMC6745716 DOI: 10.1212/nxi.0000000000000613] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/05/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Pontus Wasling
- From the Department of Clinical Neuroscience (P.W., C.M.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; and Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.
| | - Clas Malmeström
- From the Department of Clinical Neuroscience (P.W., C.M.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; and Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Kaj Blennow
- From the Department of Clinical Neuroscience (P.W., C.M.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; and Department of Psychiatry and Neurochemistry (K.B.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
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44
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Molecular codes and in vitro generation of hypocretin and melanin concentrating hormone neurons. Proc Natl Acad Sci U S A 2019; 116:17061-17070. [PMID: 31375626 PMCID: PMC6708384 DOI: 10.1073/pnas.1902148116] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hypocretin/orexin (HCRT) and melanin concentrating hormone (MCH) neuropeptides are exclusively produced by the lateral hypothalamus and play important roles in sleep, metabolism, reward, and motivation. Loss of HCRT (ligands or receptors) causes the sleep disorder narcolepsy with cataplexy in humans and in animal models. How these neuropeptides are produced and involved in diverse functions remain unknown. Here, we developed methods to sort and purify HCRT and MCH neurons from the mouse late embryonic hypothalamus. RNA sequencing revealed key factors of fate determination for HCRT (Peg3, Ahr1, Six6, Nr2f2, and Prrx1) and MCH (Lmx1, Gbx2, and Peg3) neurons. Loss of Peg3 in mice significantly reduces HCRT and MCH cell numbers, while knock-down of a Peg3 ortholog in zebrafish completely abolishes their expression, resulting in a 2-fold increase in sleep amount. We also found that loss of HCRT neurons in Hcrt-ataxin-3 mice results in a specific 50% decrease in another orexigenic neuropeptide, QRFP, that might explain the metabolic syndrome in narcolepsy. The transcriptome results were used to develop protocols for the production of HCRT and MCH neurons from induced pluripotent stem cells and ascorbic acid was found necessary for HCRT and BMP7 for MCH cell differentiation. Our results provide a platform to understand the development and expression of HCRT and MCH and their multiple functions in health and disease.
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45
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Wallenius M, Lind A, Akel O, Karlsson E, Svensson M, Arvidsson E, Ramelius A, Törn C, Palm L, Lernmark Å, Elding Larsson H. Autoantibodies in Pandemrix ®-induced narcolepsy: Nine candidate autoantigens fail the conformational autoantibody test. Autoimmunity 2019; 52:185-191. [PMID: 31328572 DOI: 10.1080/08916934.2019.1643843] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Study objectives: Narcolepsy type 1 (NT1) is a chronic sleep disorder characterized by loss of hypocretin-producing neurons. Increased NT1 incidence was observed in Sweden following mass-vaccination with Pandemrix®. Genetic association to HLA DQB1*06:02 implies an autoimmune origin, but target autoantigen remains unknown. Candidate autoantigens for NT1 have previously been identified in solid-phase immunoassays, while autoantibodies against conformation-dependent epitopes are better detected in radiobinding assays. The aims are to determine autoantibody levels against nine candidate autoantigens representing (1) proteins of the hypocretin transmitter system; Preprohypocretin (ppHypocretin), Hypocretin peptides 1 and 2 (HCRT1 and HCRT2) and Hypocretin receptor 2 (HCRTR2); (2) proteins previously associated with NT1; Tribbles homologue 2 (TRIB2), Pro-opiomelanocortin/alpha-melanocyte-stimulating-hormone (POMC/α-MSH) and Prostaglandin D2 Receptor DP1 (DP1); (3) proteins suggested as autoantigens for multiple sclerosis (another HLA DQB1*06:02-associated neurological disease); ATP-dependent Inwardly Rectifying Potassium Channel Kir4.1 (KIR4.1) and Calcium-activated chloride channel Anoctamin 2 (ANO2). Methods: Serum from post-Pandemrix® NT1 patients (n = 31) and their healthy first-degree relatives (n = 66) were tested for autoantibody levels in radiobinding assays separating autoantibody bound from free labelled antigen with Protein A-Sepharose. 125I-labelled HCRT1 and HCRT2 were commercially available while 35S-methionine-labelled ppHypocretin, HCRTR2, TRIB2, α-MSH/POMC, DP1, KIR4.1 or ANO2 was prepared by in vitro transcription translation of respective cDNA. In-house standards were used to express data in arbitrary Units/ml (U/ml). Results: All radiolabelled autoantigens were detected in a concentration-dependent manner by respective standard sera. Levels of autoantibodies in the NT1 patients did not differ from healthy first-degree relatives in any of the nine candidate autoantigens. Conclusions: None of the nine labelled proteins proposed to be autoantigens were detected in the radiobinding assays for conformation-dependent autoantibodies. The results emphasise the need of further studies to identify autoantigen(s) and clarify the mechanisms in Pandemrix®-induced NT1.
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Affiliation(s)
- Madeleine Wallenius
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Alexander Lind
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Omar Akel
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Emma Karlsson
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Markus Svensson
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Elin Arvidsson
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Anita Ramelius
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Carina Törn
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Lars Palm
- Section for Paediatric Neurology, Department of Paediatrics, Skåne University Hospital SUS , Malmö , Sweden
| | - Åke Lernmark
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
| | - Helena Elding Larsson
- Department of Clinical Sciences Malmö, Lund University/CRC, Skåne University Hospital SUS , Malmö , Sweden
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46
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Narcolepsy — clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol 2019; 15:519-539. [DOI: 10.1038/s41582-019-0226-9] [Citation(s) in RCA: 204] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2019] [Indexed: 12/15/2022]
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47
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Mané-Damas M, Hoffmann C, Zong S, Tan A, Molenaar PC, Losen M, Martinez-Martinez P. Autoimmunity in psychotic disorders. Where we stand, challenges and opportunities. Autoimmun Rev 2019; 18:102348. [PMID: 31323365 DOI: 10.1016/j.autrev.2019.102348] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 12/24/2022]
Abstract
Psychotic disorders are debilitating mental illnesses associated with abnormalities in various neurotransmitter systems. The development of disease-modifing therapies has been hampered by the mostly unknown etiologies and pathophysiologies. Autoantibodies against several neuronal antigens are responsible for autoimmune encephalitis. These autoantibodies disrupt neurotransmission within the brain, resulting in a wide range of psychiatric and neurologic manifestations, including psychosis. The overlap of symptoms of autoimmune encephalitis with psychotic disorders raised the question as to whether autoantibodies against a number of receptors, ion channel and associated proteins could ultimately be responsible for some forms of psychosis. Here we review our current knowledge, on antibody mediated autoimmunity in psychotic disorders, the different diagnostic methods and their limitations, as well as on varying therapeutic approaches targeting the immune system.
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Affiliation(s)
- Marina Mané-Damas
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Carolin Hoffmann
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Shenghua Zong
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Amanda Tan
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Peter C Molenaar
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Mario Losen
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
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48
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Pedersen NW, Holm A, Kristensen NP, Bjerregaard AM, Bentzen AK, Marquard AM, Tamhane T, Burgdorf KS, Ullum H, Jennum P, Knudsen S, Hadrup SR, Kornum BR. CD8 + T cells from patients with narcolepsy and healthy controls recognize hypocretin neuron-specific antigens. Nat Commun 2019; 10:837. [PMID: 30783092 PMCID: PMC6381094 DOI: 10.1038/s41467-019-08774-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/28/2019] [Indexed: 12/19/2022] Open
Abstract
Narcolepsy Type 1 (NT1) is a neurological sleep disorder, characterized by the loss of hypocretin/orexin signaling in the brain. Genetic, epidemiological and experimental data support the hypothesis that NT1 is a T-cell-mediated autoimmune disease targeting the hypocretin producing neurons. While autoreactive CD4+ T cells have been detected in patients, CD8+ T cells have only been examined to a minor extent. Here we detect CD8+ T cells specific toward narcolepsy-relevant peptides presented primarily by NT1-associated HLA types in the blood of 20 patients with NT1 as well as in 52 healthy controls, using peptide-MHC-I multimers labeled with DNA barcodes. In healthy controls carrying the disease-predisposing HLA-DQB1*06:02 allele, the frequency of autoreactive CD8+ T cells was lower as compared with both NT1 patients and HLA-DQB1*06:02-negative healthy individuals. These findings suggest that a certain level of CD8+ T-cell reactivity combined with HLA-DQB1*06:02 expression is important for NT1 development.
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Affiliation(s)
- Natasja Wulff Pedersen
- Department of Health Technology, Section of Experimental and Translational Immunology, Technical University of Denmark, 2800 Kgs Lyngby, Denmark
| | - Anja Holm
- Department of Clinical Biochemistry, Molecular Sleep Laboratory, Rigshospitalet, 2600 Glostrup, Denmark
| | - Nikolaj Pagh Kristensen
- Department of Health Technology, Section of Experimental and Translational Immunology, Technical University of Denmark, 2800 Kgs Lyngby, Denmark
| | - Anne-Mette Bjerregaard
- Department of Health Technology, Section of Experimental and Translational Immunology, Technical University of Denmark, 2800 Kgs Lyngby, Denmark
| | - Amalie Kai Bentzen
- Department of Health Technology, Section of Experimental and Translational Immunology, Technical University of Denmark, 2800 Kgs Lyngby, Denmark
| | - Andrea Marion Marquard
- Department of Health Technology, Section of Experimental and Translational Immunology, Technical University of Denmark, 2800 Kgs Lyngby, Denmark
| | - Tripti Tamhane
- Department of Health Technology, Section of Experimental and Translational Immunology, Technical University of Denmark, 2800 Kgs Lyngby, Denmark
| | - Kristoffer Sølvsten Burgdorf
- Department of Clinical Immunology 2034, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Henrik Ullum
- Department of Clinical Immunology 2034, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Poul Jennum
- Department of Clinical Neurophysiology, Danish Center for Sleep Medicine, Rigshospitalet, 2600 Glostrup, Denmark
| | - Stine Knudsen
- Department of Clinical Neurophysiology, Danish Center for Sleep Medicine, Rigshospitalet, 2600 Glostrup, Denmark
- Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias (Nevsom), Department of Rare Disorders, Oslo University Hospital, Ullevål, 0424 Oslo, Norway
| | - Sine Reker Hadrup
- Department of Health Technology, Section of Experimental and Translational Immunology, Technical University of Denmark, 2800 Kgs Lyngby, Denmark.
| | - Birgitte Rahbek Kornum
- Department of Clinical Biochemistry, Molecular Sleep Laboratory, Rigshospitalet, 2600 Glostrup, Denmark.
- Department of Clinical Neurophysiology, Danish Center for Sleep Medicine, Rigshospitalet, 2600 Glostrup, Denmark.
- Department of Neuroscience, University of Copenhagen, 2200 Copenhagen, Denmark.
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49
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Abstract
Narcolepsy is the most common neurological cause of chronic sleepiness. The discovery about 20 years ago that narcolepsy is caused by selective loss of the neurons producing orexins (also known as hypocretins) sparked great advances in the field. Here, we review the current understanding of how orexin neurons regulate sleep-wake behaviour and the consequences of the loss of orexin neurons. We also summarize the developing evidence that narcolepsy is an autoimmune disorder that may be caused by a T cell-mediated attack on the orexin neurons and explain how these new perspectives can inform better therapeutic approaches.
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Affiliation(s)
- Carrie E Mahoney
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Andrew Cogswell
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Igor J Koralnik
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Thomas E Scammell
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
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50
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Miyagawa T, Tokunaga K. Genetics of narcolepsy. Hum Genome Var 2019; 6:4. [PMID: 30652006 PMCID: PMC6325123 DOI: 10.1038/s41439-018-0033-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 11/15/2018] [Accepted: 11/18/2018] [Indexed: 11/09/2022] Open
Abstract
Narcolepsy is a term that was initially coined by Gélineáu in 1880 and is a chronic neurological sleep disorder that manifests as a difficulty in maintaining wakefulness and sleep for long periods. Currently, narcolepsy is subdivided into two types according to the International Classification of Sleep Disorders, 3rd edition: narcolepsy type 1 (NT1) and narcolepsy type 2 (NT2). NT1 is characterized by excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis and is caused by a marked reduction in neurons in the hypothalamus that produce orexin (hypocretin), which is a wakefulness-associated neuropeptide. Except for cataplexy, NT2 exhibits most of the same symptoms as NT1. NT1 is a multifactorial disease, and genetic variations at multiple loci are associated with NT1. Almost all patients with NT1 carry the specific human leukocyte antigen (HLA) allele HLA-DQB1 * 06:02. Genome-wide association studies have uncovered >10 genomic variations associated with NT1. Rare variants associated with NT1 have also been identified by DNA genome sequencing. NT2 is also a complex disorder, but its underlying genetic architecture is poorly understood. However, several studies have revealed loci that increase susceptibility to NT2. The currently identified loci cannot explain the heritability of narcolepsy (NT1 and NT2). We expect that future genomic research will provide important contributions to our understanding of the genetic basis and pathogenesis of narcolepsy.
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Affiliation(s)
- Taku Miyagawa
- 1Sleep Disorders Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.,2Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsushi Tokunaga
- 2Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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