The treatment of passively transferred experimental myasthenia with anti-idiotypic antibodies

Experimental Autoimmune Myasthenia Gravis (EAMG): from immunochemical characterization to therapeutic approaches

Myasthenia Gravis (MG) is an organ-specific autoimmune disease. In high percentage of patients there are autoantibodies to the nicotinic acetylcholine receptor (AChR) that attack AChR on muscle cells at the neuromuscular junction, resulting in muscle weakness. Experimental Autoimmune Myasthenia Gravis (EAMG) is an experimental model disease for MG. EAMG is induced in several animal species by immunization with acetylcholine receptor (AChR), usually isolated from the electric organ of electric fish, which is a rich source for this antigen. Our lab has been involved for several decades in research of AChR and of EAMG. The availability of an experimental autoimmune disease that mimics in many aspects the human disease, provides an excellent model system for elucidating the immunological nature and origin of MG, for studying various existing treatment modalities and for attempting the development of novel treatment approaches. In this review in honor of Michael Sela and Ruth Arnon, we report first on our early pioneering contributions to research on EAMG. These include the induction of EAMG in several animal species, early attempts for antigen-specific treatment for EAMG, elicitation and characterization of monoclonal antibodies and anti-idiotypic antibodies, measuring humoral and cellular AChR-specific immune responses in MG patient and more. In the second part of the review we discuss more recent studies from our lab towards developing and testing novel treatment approaches for myasthenia. These include antigen-dependent treatments aimed at specifically abrogating the humoral and cellular anti-AChR responses, as well as immunomodulatory approaches that could be used either alone, or in conjunction with antigen-specific treatments, or alternatively, serve as steroid-sparing agents.

Vaccines against myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disease mediated by antibodies to nicotinic acetylcholine receptor (AChR) interfering with the neuromuscular transmission. Experimental autoimmune MG serves as an excellent animal model to study possible therapeutic modalities for MG. This review will focus on the different ways to turn off the autoimmune response to AChR, which results in suppression of myasthenia. This paper will describe the use of fragments or peptides derived from the AChR, antigen-presenting cells and anti-T cell receptor antibodies, and will discuss the underlying mechanisms of action. Finally, the authors propose new promising therapeutic prospects, including treatment based on the modulation of regulatory T cells, which have recently been found to be functionally defective in MG patients.

The role of antibodies in myasthenia gravis

Myasthenia gravis is an autoimmune disease associated with antibodies directed to the postsynaptic acetylcholine receptor. These antibodies reduce the number of receptors. Autoantibodies against AChR and other muscle antigens can be used for the diagnosis of myasthenia gravis and related disorders. The origin and the role of these antibodies in the disease are discussed. Experimental autoimmune myasthenia gravis, an experimental model closely mimicking the disease, has provided answers to many questions about the role of antibodies, complement macrophages and AChR anchor proteins. Genetically modified anti-AChR antibodies may also be used in the future to treat myasthenia.

Anatomy of the antigenic structure of a large membrane autoantigen, the muscle-type nicotinic acetylcholine receptor

The neuromuscular junction nicotinic acetylcholine receptor (AChR), a pentameric membrane glycoprotein, is the autoantigen involved in the autoimmune disease myasthenia gravis (MG). In animals immunized with intact AChR and in human MG, the anti-AChR antibody response is polyclonal. However, a small extracellular region of the AChR alpha-subunit, the main immunogenic region (MIR), seems to be a major target for anti-AChR antibodies. A major loop containing overlapping epitopes for several anti-MIR monoclonal antibodies (mAbs) lies within residues alpha 67-76 at the extreme synaptic end of each alpha-subunit: however, anti-MIR mAbs are functionally and structurally quite heterogeneous. Anti-MIR mAbs do not affect channel gating, but are very effective in the passive transfer of MG to animals; in contrast, their Fab or Fv fragments protect the AChR from the pathogenic effects of the intact antibodies. Antibodies against the cytoplasmic region of the AChR can be elicited by immunization with denatured AChR and the precise epitopes of many such mAbs have been identified; however, it is unlikely that such antibodies are present in significant amounts in human MG. Antibodies to other extracellular epitopes on all AChR subunits are present in both experimental and human MG; these include antibodies to the acetylcholine-binding site which affect AChR function in various ways and also induce acute experimental MG. Finally, anti-AChR antibodies cross-reactive with non-AChR antigens exist, suggesting that MG may result from molecular mimicry. Despite extensive studies, many gaps remain in our understanding of the antigenic structure of the AChR; especially in relation to human MG. A thorough understanding of the antigenic structure of the AChR is required for an in-depth understanding, and for possible specific immunotherapy, of MG.

Modulation of the anti-acetylcholine receptor response and experimental autoimmune myasthenia gravis by recombinant fragments of the acetylcholine receptor

Myasthenia gravis (MG) is a neuromuscular disorder of man caused by a humoral response to the acetylcholine receptor (AChR). Most of the antibodies in MG and in experimental autoimmune myasthenia gravis (EAMG) are directed to the extracellular portion of the AChR alpha subunit, and within it, primarily to the main immunogenic region (MIR). We have cloned and expressed recombinant fragments, corresponding to the entire extracellular domain of the AChR alpha subunit (H alpha1-210), and to portions of it that encompass either the MIR (H alpha1-121) or the ligand binding site of AChR (H alpha122-210), and studied their ability to interfere with the immunopathological anti-AChR response in vitro and in vivo. All fragments were expressed as fusion proteins with glutathione S-transferase. Fragments H alpha1-121 and H alpha1-210 protected AChR in TE671 cells against accelerated degradation induced by the anti-MIR monoclonal antibody (mAb)198 in a dose-dependent manner. Moreover, these fragments had a similar effect on the antigenic modulation of AChR by other anti-MIR mAb and by polyclonal rat anti-AChR antibodies. Fragments H alpha1-121 and H alpha1-210 were also able to modulate in vivo muscle AChR loss and development of clinical symptoms of EAMG, passively transferred to rats by mAb 198. Fragment H alpha122-210 did not have such a protective activity. Our results suggest that the appropriate recombinant fragments of the human AChR may be employed in the future for antigen-specific therapy of myasthenia.

Myasthenia gravis as a prototype autoimmune receptor disease

Myasthenia gravis (MG) is an organ-specific autoimmune disease in which autoantibodies against nicotinic acetylcholine receptors (AChR) at the postsynaptic membrane cause loss of functional AChR and disturbed neuromuscular transmission. The immunopathogenic mechanisms responsible for loss of functional AChR include antigenic modulation by anti-AChR antibodies, complement-mediated focal lysis of the postsynaptic membrane, and direct interference with binding of acetylcholine to the AChR or with ion channel function. The loss of AChR and subsequent defective neuromuscular transmission is accompanied by increased expression of the different AChR subunit genes, suggesting a role for the target organ itself in determining susceptibility and severity of disease. Experimental autoimmune myasthenia gravis (EAMG) is an animal model for the disease MG, and is very suitable to study the immunopathogenic mechanisms leading to AChR loss and the response of the AChR to this attack. In this article the current concepts of the structure and function of the AChR and the immunopathological mechanisms in MG and EAMG are reviewed.

Examination of characteristics that may distinguish disease-causing from benign AChR-reactive antibodies in experimental autoimmune myasthenia gravis

In summary, the strategies of the experimentation described above were designed to address the confusion resulting from observations concerning the lack of correlation between antibody titers and disease severity in MG patients. Lessons learned from these studies of EAMG suggest that if the proportion of the total expressed/produced anti-AChR antibody repertoire with disease-causing potential differs from patient-to-patient with MG, then assessment of the total antibody titer becomes meaningless unless a particular patient produces disease-causing reactivities that make up a major portion of the total titer. Not only may disease severity depend on the titer of a small subset of disease-causing antibody(s) reactive with a particular conformation-dependent AChR region, but may also depend on the relative contribution of additional subsets of antibody with functionally irrelevant or potentially protective activity. The key to exploiting the existence of antibody subsets with differing disease-causing potential will be to create probes that would allow the easy monitoring of the relevant reactivities. For instance, carefully selected anti-idiotypic antibodies (such as the 11E10 monoclonal antibody described above) may be of great value when specifically capable of recognizing idiotypes that are selectively associated with disease-causing anti-AChR antibodies and under-represented on antibodies lacking disease-causing capability. If, in addition, characteristics of helper T cells are identified that allow more accurate prediction of D+ Id production, exciting opportunities would become available to more directly evaluate disease mechanisms and to develop more highly efficacious immunotherapeutic strategies.

Identification of a hexapeptide that mimics a conformation-dependent binding site of acetylcholine receptor by use of a phage-epitope library

Monoclonal antibody (mAb) 5.5 is directed against the ligand-binding site of the nicotinic acetylcholine receptor. The epitope for this antibody is conformation-dependent, and the antibody does not react with synthetic peptides derived from the receptor sequence. We have identified a ligand peptide that mimics this conformation-dependent epitope from a phage-epitope library composed of filamentous phage displaying random hexapeptides. Among 38 positive phage clones, individually selected from the library, 34 positive clones carried the sequence Asp-Leu-Val-Trp-Leu-Leu (DLVWLL), 1 positive clone had the sequence Asp-Ile-Val-Trp-Leu-Leu (DIVWLL), and 3 positive clones expressed the sequence Leu-Ile-Glu-Trp-Leu-Leu (LIEWLL), none of which are significantly homologous with the nicotinic acetylcholine receptor alpha subunit sequence. All of these phages bind specifically to mAb 5.5. The synthetic peptide DLVWLL inhibits binding of mAb 5.5 to the related peptide-presenting phage and to the nicotinic acetylcholine receptor in a concentration-dependent manner; the IC50 value is of the order of 10(-4) M. Bioactivity of the peptide "mimotope" DLVWLL was demonstrated in vivo in hatched chickens by inhibition of the mAb 5.5 effect by the peptide. The neuromuscular block and myasthenia gravis-like symptoms that are induced in chicken by passive transfer of mAb 5.5 were specifically abolished by DLVWLL. This study shows the potential of a random peptide phage-epitope library for selecting a mimotope for an antibody that recognizes a folded form of the protein, where peptides from the linear amino acid sequence of the protein are not applicable.

Fab fragments of monoclonal antibodies protect the human acetylcholine receptor against antigenic modulation caused by myasthenic sera

The human cell line TE671 produces large amounts of muscle nicotinic acetylcholine receptor (AChR). TE671 cells were used to determine the specificity of antibodies which can increase the internalization rate of AChR (antigenic modulation) and to test procedures for protecting AChR against this mechanism. The half-life of AChR both in the absence and the presence of anti-AChR antibodies was very similar to that of AChR on human muscle cell cultures. The relative contribution of different anti-AChR antibody fractions to the total antigenic modulation capacity of human myasthenic sera was investigated by competition experiments between Fab fragments of anti-AChR monoclonal antibodies (MoAbs) and intact antibodies (MoAb or myasthenic sera). Fab fragments, which do not induce antigenic modulation, were allowed to shield the corresponding regions of the AChR. Intact antibodies were subsequently added. It was found that protection of the main immunogenic region (MIR), but not of a region on the beta-subunit, essentially blocked the modulatory effect of the intact anti-MIR MoAbs, and approximately 80% of that of myasthenic sera. These data suggest that anti-MIR antibodies are mainly responsible for the loss of human AChR via antigenic modulation. Furthermore the observation that Fab fragments of anti-MIR MoAbs can efficiently protect AChR against antigenic modulation may have therapeutic implications.

Theoretical mechanisms by which immunoglobulin therapy might benefit myasthenia gravis

The mechanisms underlying any clinical improvement observed in some patients with myasthenia gravis (MG) treated with normal immunoglobulin (Ig) are not defined. The pathologic alterations in the postsynaptic motor end plate in MG are likely due at least in part to one or more actions of antibodies against epitopes on the nicotinic acetylcholine receptor (anti-AChR Ab). Such anti-AChR Ab are secreted by B lymphocytes and are increased in the serum of MG patients but not of controls. The stimulus for anti-AChR Ab production in MG is unknown with evidence for a role of thymic abnormalities, immunoregulatory disturbances, and some possible molecular mimicry of exogenous antigens (microbial?). Postulated mechanisms underlying Ig effects in MG include: (i) competing with anti-AChR for binding to AChR; (ii) preventing attachment of Fc receptor-positive inflammatory cells to the anti-AChR Ab bound to the motor end plate; (iii) decreasing synthesis of anti-AChR Ab; and (iv) exerting an anti-idiotypic effect. Evidence for these mechanisms are discussed.

[Myasthenia gravis: treatment with thymectomy, corticoids and plasmapheresis]

This paper reviews a 12 year experience with myasthenia gravis management (surgical and drug therapy). A total of 27 patients were submitted to thymectomy, and 12 out of 13 showed fairly good results with this only form of therapy (15.3% with complete remission, 46.15% with marked improvement and 30.7% with moderate improvement). The other 14 need either a combination of surgery and plasmapheresis or corticosteroids with the cummulative results of: 14.8% of remission (4 out of 27), 74% of improvement (20 out of 27), 7.4% of worsening (2 out of 27) and 3.7% without change (1 out of 27). Two other patients not submitted to surgery showed either a stable state of their symptoms or a mildly worsening. Another eight patients not submitted to surgery could not be bollowed up. The authors also conclude by the validity of the use of plasmapheresis in myasthenic crises leading to a transient relief of the symptoms and suggest the use of corticosteroids as a second choice, due to their undesirable side effects and difficulty in their reduction and elimination without worsening the symptoms. Other immunosuppressive drugs could be used in cases in which those above cited therapies showed unsuitable results.

Selective elimination of autoreactive lymphocytes with immunotoxins

A variety of diseases are the result of identifiable cell types entering an abnormal state of development in which they escape existing mechanisms that regulate their growth or other functional activities. A variety of investigators interested in eliminating cells that have undergone malignant transformation have devised immunotherapeutic approaches based on the construction of hybrid molecules composed of highly toxic biological poisons covalently coupled with antibodies specific for membrane antigens expressed selectively by tumor cell targets. This strategy can be further exploited to eliminate any target cell with defined, selectively expressed membrane antigens. The following discussion describes possible uses of such an approach for achieving selective cytotoxicity of lymphocytes with undesirable immunoreactivities, such as those found in autoimmune disease and graft-versus-host disease.

[Myasthenia gravis. Clinical and therapeutic evaluation of 55 cases]

It is reported the study of 55 myasthenia gravis cases, with a review of the symptoms and signals, comparing initial symptoms ant those found at the time of the first evaluation. The mean age of the patients was 31.05 +/- 18.46 and the mean time of follow-up 5.88 +/- 5.47 years. Also the results of the diagnostic tests is reported, as well as the results of the treatment. The patients were treated with anticholinesterasics, corticosteroids, azathioprine, plasma-exchange and thymectomy. A statistical analysis with the chi-square test was unable to show a difference between the above procedures, regarding the definitive resolution of the disease. From the 55 cases, 9 (16.6%) had total remission, 41 (74.5%) remained with symptoms and need some kind of treatment, and 5 (9.09%) died (three patients with thymoma, one patient with congenital myasthenia gravis, severe kyphoscoliosis and pulmonary restriction, and one patient during the thymectomy procedure). It was found a relation between the signs of respiratory insufficiency, myasthenic crisis and thymoma only in the group of patients who died. A review about the diagnostic methods and treatment in the current days is made.

Anti-idiotypic antibodies to anti-acetylcholine receptor antibody: characterization by ELISA and immunoprecipitation assays

The idiotype network is important both as a means of autoregulation of immune mechanisms and a potential tool for manipulation of abnormal responses. In the autoimmune disease myasthenia gravis the acetylcholine receptor (AChR) is the target of an aberrant immune response. In this study we compare 2 widely used methods of antibody determination--immunoprecipitation radioimmunoassay (IPRA) and enzyme-linked immunoassay (ELISA)--for their ability to detect both anti-AChR antibodies (polyclonal and monoclonal) and anti-idiotypic antibodies raised against polyclonal anti-AChR antibodies. Although the IPRA is considerably more sensitive for the detection of monoclonal anti-AChR antibodies, the 2 methods produce similar results in the detection of anti-idiotypic antibodies to the anti-AChR immune response. The 2 techniques also demonstrated specificity of the reagents for idiotypes associated with the anti-AChR response and absence of effect on an idiotype associated with the control antigen, ovalbumin. The results demonstrate that the idiotypic repertoire of the polyclonal anti-AChR response in C57B1/6 mice is sufficiently restricted that antigen-specific blocking anti-idiotypic antibodies can be raised in rabbits by immunization with anti-AChR antibodies.