Alemtuzumab more effective than interferon ß-1a at 5-year follow-up of CAMMS223 clinical trial.

OBJECTIVE: To report the long-term safety and efficacy results from CAMMS223 comparing alemtuzumab with interferon ß-1a in early, active relapsing-remitting multiple sclerosis (RRMS). What are the long-term effects of alemtuzumab treatment, received 36 to 48 months previously, on relapse and disability in early, active RRMS? This study provides evidence of the effectiveness of alemtuzumab in reducing the relapse rate and accumulation of disability compared with interferon ß-1a (IFNß-1a) through extended follow-up (up to 60 months from baseline). METHODS: Of 334 patients originally randomized, 198 participated in the extension phase (151 [68%] alemtuzumab and 47 [42%] IFNß-1a). Disability, relapses, and safety were assessed as in the original study period. Efficacy outcomes were analyzed from baseline of the original trial period to 60 months. Safety data extended beyond 60 months. RESULTS: Over 5 years, alemtuzumab lowered the risk of sustained accumulation of disability by 72% and the rate of relapse by 69% compared with IFNß-1a (both p < 0.0001). The annualized relapse rate from baseline to month 60 was 0.11 for alemtuzumab and 0.35 for IFNß-1a. Complete safety follow-up reflected 988 and 376 person-years for alemtuzumab and IFNß-1a patients, respectively. Serious infections were seen in 7% of alemtuzumab patients and 3% of IFNß-1a patients, and thyroid disorders were seen in 30% of alemtuzumab patients vs 4% of IFNß-1a patients. Immune thrombocytopenia occurred in 3% of alemtuzumab patients and 0.9% of IFNß-1a patients during the initial study period; no additional events were reported during the extension phase. One alemtuzumab patient developed Goodpasture disease 39 months after the second annual cycle of alemtuzumab. CONCLUSIONS: Through extended follow-up, alemtuzumab remained significantly more efficacious than IFNß-1a, with a safety profile consistent with previous reports. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that alemtuzumab is more effective than interferon ß-1a in reducing relapses and disability in patients with RRMS in a long-term follow-up of a rater-blinded, randomized clinical trial with 59.5% of patients participating in the extended follow-up period.

Productive infection of cerebellar granule cell neurons by JC virus in an HIV+ individual.

BACKGROUND: In the setting of severe immunosuppression, the polyomavirus JC (JCV) can cause a lytic infection of oligodendrocytes. This demyelinating disease of the CNS white matter (WM) is called progressive multifocal leukoencephalopathy (PML). JCV has a very narrow host-cell range and productive infection of neurons has never been demonstrated. Patient, methods, and results: An HIV-1-infected patient presented with signs of pyramidal tract and cerebellar dysfunction. Brain MRI revealed T2 hyperintensities in the WM of both frontal lobes and cerebellar atrophy. His disease progressed despite therapy and he died 6 months later. In addition to classic PML findings in the frontal lobe WM, autopsy revealed scattered foci of tissue destruction in the internal granule cell layer (IGCL) of the cerebellum. In these foci, enlarged granule cell neurons identified by the neuronal markers MAP-2 and NeuN reacted with antibodies specific for the polyomavirus VP1 capsid protein. Electron microscopy showed 40 nm viral particles, consistent with polyomaviruses, in these granule cell neurons. In addition, JCV DNA was detected by PCR after laser capture microdissection of cells from the areas of focal cell loss. Finally, in situ hybridization studies demonstrated that many granule cell neurons were infected with JCV but did not contain viral proteins. Sequence analysis of the JCV regulatory region from cerebellar virions showed a tandem repeat pattern also found in PML lesions of the frontal lobe WM. CONCLUSION: JCV can productively infect granule cell neurons of the IGCL of the cerebellum. This suggests a role for JCV infection of neurons in cerebellar atrophy occurring in HIV-infected individuals.

Stimulation of antiviral antibody response in SHIV-IIIB-infected macaques.

Three macaques infected with SHIV-IIIB and expressing the shared 1F7-idiotypic marker on antibodies against HIV-1 gp120, were injected intravenously with 1F7 monoclonal antibodies (MoAb). As controls, a SHIV-IIIB-infected macaque was injected with a HIV-unrelated mouse monoclonal isotype antibody (TEPC-183) and two healthy, noninfected macaques were injected with MoAb 1F7. 1F7-id-expressing antibodies against gp120-IIIB decreased in two of the three MoAb 1F7-treated macaques and then rebounded. Importantly, antibodies binding to envelope proteins of heterologous HIV-1 strains MN, CM, and SF2, which were low or not detectable before the MoAb 1F7 treatment, increased rapidly following MoAb inoculations in all three 1F7 MoAb treated macaques, but not in the macaque injected with control MoAb TEPC-183. Newly arising antibodies reacting with heterologous virus, i.e. HIV-1 gp120-MN, SF2, and CM did not express 1F7-id. Surprisingly, significant increases of antibodies were also observed in the 1F7-inoculated macaques' antibodies directed to non-HIV antigens (DNP, peptides and BSA). The noninfected control animals did not produce antibodies to these antigens despite MoAb 1F7 treatment. These data show that the MoAb 1F7 injections of chronically SHIV-IIIB-infected macaques resulted in idiotype-specific clonal suppression with broadening the antibody response to HIV envelope proteins.

Clinicopathological characterization of an HIV-2-infected individual with two clonally unrelated primary lymphomas.

Human immunodeficiency virus 2 (HIV-2) is endemic in West Africa and is a causative agent of the acquired immunodeficiency syndrome. Only a small number of HIV-2-infected patients have been described in detail. Non-Hodgkin's lymphoma (NHL) is the second most common neoplasm occurring in HIV-1-infected patients, but its incidence seems to be lower in HIV-2-infected individuals. We report an HIV-2-infected patient from Cape Verde (West Africa) with separate and distinct systemic and primary central nervous system large B-cell lymphomas and review the findings of cases of HIV-2-associated lymphomas reported in the literature. Different clonal rearrangements of the immunoglobulin heavy chain gene could be detected in the two lymphomas of our patient by polymerase chain reaction and sequence analysis. These data indicate the presence of two clonally unrelated large B-cell lymphomas in the same patient, which is an unusual finding. Neither Epstein-Barr virus nor human herpesvirus 8 could be detected in the tumor tissues or the cerebrospinal fluid. HIV-2 infection should be considered in patients with NHL, especially in those from West Africa.

Germline repertoire of the immunoglobulin V(H)3 family in rhesus monkeys.

To facilitate molecular studies of antibody responses in rhesus monkeys (Macaca mulatta), we cloned and sequenced germline segments from its largest and most diverse immunoglobulin heavy-chain gene family, V(H)3. Using a PCR-based approach, we characterized 29 sequences, 20 with open reading frames (ORFs) and 9 pseudogenes. The leader sequences, introns, exons, and recombination signal sequences of M. mulatta V(H)3 gene segments are not strictly identical to those of humans, but the mature coding regions demonstrate, on average, greater than 90% sequence similarity. Although the framework regions are more highly conserved, the complementarity-determining regions (CDRs) also show strong similarities, and their predicted three-dimensional structures resemble those of their human homologues. In one instance, homologous macaque and human CDR1 sequences were 100% identical at the nucleotide level, and some CDR2s shared nucleotide identity as high as 96.5%. However, some rhesus V(H)3 ORFs have unusual structural features, including atypical CDR lengths and uncommon amino acids at structurally crucial positions. The similarity of rhesus and human V(H)3 homologues reinforces the notion that humoral immunity in this nonhuman primate species is an appropriate system for modeling human antibody responses.

Stimulation of HIV-1-neutralizing antibodies in simian HIV-IIIB-infected macaques.

Previously we have discovered a public idiotope, designated 1F7, that is expressed on antibodies against HIV type 1 (HIV-1) in human and nonhuman primates. To test the potential of mouse monoclonal antibody (mAb) 1F7 as a therapeutic anti-clonotypic antibody in HIV-1-infected patients, we used the simian HIV-IIIB macaque infection model, which mimics several immunological and pathological characteristics of HIV-1 infection in humans. Four healthy simian HIV-infected rhesus monkeys (Macaca mulatta) expressing the 1F7 marker on anti-gp120 antibodies were selected for this study. Three monkeys of this group were immunized several times with the murine mAb 1F7 i.v., and one monkey received as control an isotype-matched antibody, TEPC183. No serious side effect or allergic reaction was encountered. Blood collected before and during the immunization and over several months afterward were analyzed for neutralizing antibodies. Significant increases in breadth and potency of HIV-1-neutralizing antibody titers to one or more virus strains were detected in all three of the 1F7-immunized monkeys, but not in the control monkey immunized with TEPC183. These results show that an antibody, recognizing a public idiotope associated with anti-HIV-1 antibodies can function in chronically infected primates as an anti-clonotypic immunogen to boost antibodies that neutralize homologous and heterologous virus strains. This study represents a first step toward the preclinical evaluation of 1F7 as a therapeutic AIDS vaccine.

Immunoglobulin V(H) usage during primary infection of rhesus monkeys with chimeric simian-human immunodeficiency viruses.

It has been suggested that naive immunoglobulins encoded by the V(H)3 gene family interact aberrantly with human immunodeficiency virus type 1 (HIV-1) gp120 via a superantigenic epitope, causing initial expansion and eventual depletion of V(H)3-expressing B cells. However, this possibility has not been prospectively assessed during an AIDS virus infection. We determined V(H) family usage in rhesus monkeys during primary infection with chimeric viruses expressing HIV-1 envelopes on a simian immunodeficiency virus (SIVmac) backbone (SHIVs). Four SHIVs with different envelopes and pathogenicities were studied. V(H) family usage was prospectively assessed in peripheral blood mononuclear cells and lymph node cells of these monkeys by a semiquantitative PCR technique. In the first months following SHIV infection, a period of intense viral antigenemia, representation of various V(H) families increased or decreased for individual monkeys, but no single V(H) family was consistently altered. In particular, the average representation of V(H)3-bearing B lymphocytes did not change. This observation suggests that the envelope glycoprotein of HIV-1 does not selectively expand or deplete the V(H)3 repertoire of primate B cells during acute AIDS virus infection, contrary to predictions of the gp120 superantigen hypothesis.

An HIV-1 infection-related idiotype/clonotype (1F7) is expressed on antibodies directed to envelope glycoprotein in simian immunodeficiency virus- and chimeric simian/human immunodeficiency virus-infected rhesus monkeys.

An antiidiotypic/clonotypic marker, designated 1F7, is restricted to antibodies directed to human immunodeficiency virus type 1 (HIV-1) envelope, core, and reverse transcriptase proteins. 1F7-Id is shared by more than 70% of HIV-infected individuals, arising early and persisting throughout all disease stages. To study the specificity and biological function of this cross-reactive idiotypic marker, and to explore its potential in therapeutics, we have sought an appropriate animal model. 1F7-Id+ antiviral antibodies are found among experimentally HIV-1 IIIB-infected chimpanzees; however, these rare and expensive animals do not develop acquired immunodeficiency syndrome (AIDS), and so are not an appropriate model. We now report the presence in rhesus monkeys of 1F7-Id on antibodies to the external envelope glycoproteins of simian immunodeficiency virus (SIV). This may be surprising, in view of the genetic and serologic differences between SIV and HIV-1, but is in accord with the occurrence of 1F7-Id on antibodies reacting with a broad range of HIV-1 strains. We also found 1F7-Id on anti-gp120 antibodies in rhesus monkeys infected with chimeric immunodeficiency viruses (SHIV) expressing the env, tat, and rev genes of HIV-1 on a backbone of SIV. Both SIV and SHIV cause AIDS in these monkeys. Thus, SIV- and SHIV-infected rhesus monkeys are suitable models for exploring the role of 1F7 in AIDS pathogenesis and prevention. Experiments are underway using MAb 1F7 to test the hypothesis of deceptive imprinting in AIDS.

HIV-1 gp120: a novel viral B cell superantigen.

The envelope glycoprotein of the human immunodeficiency virus (HIV-1), gp120, has recently been characterized as a novel immunoglobulin superantigen (Ig-SAg) [1,2]. Analogous to the interaction of SAgs with T cells, gp120 binds to an unusually large proportion of immunoglobulins (lgs) from HIV-uninfected individuals; most, if not all of these Igs are members of the VH3 family [3]. Functionally, gp120 preferentially stimulates VH3 B cells in vitro. This stimulation correlates with an in vivo VH3 activation during HIV infection. Curiously, this initial activation is followed by a subsequent depletion of VH3-expressing B cells as individuals progress to AIDS. In this article we will review our current understanding of the superantigenic properties of HIV gp120. Specifically we will focus on structural aspects of the binding interaction. on the ontological development of these superantigen-binding antibodies, and on potential roles that this unconventional Ig-pathogen interaction might play in the pathogenesis of HIV-induced disease.

Endogenous opiate reward induced by an enkephalinase inhibitor, thiorphan, injected into the ventral midbrain.

Opiates are known to be reinforcing when injected into the ventral tegmental area (VTA). The present study produced conditioned reinforcement with local injections of exogenous d-ala2-met5-enkephalinamide (DALA), a potent analogue of met-enkephalin, and with thiorphan , an enkephalinase inhibitor which protects endogenous opiates from enzymic degradation. In a conditioned place preference paradigm, rats received injections of DALA (1.0, 3.0, or 8.0 micrograms), thiorphan (60 micrograms), and/or naloxone (10 micrograms), or saline vehicle. Conditioned reinforcement was obtained with 8.0 micrograms of DALA and also with thiorphan but not with thiorphan plus naloxone. This suggests that reward can be generated by endogenous opiates in the VTA. Tests during the light phase and dark phase suggested that diurnal periodicity may play a role in opiate reward. It is concluded that the VTA can generate conditioned reward through transmitter-receptor interaction involving an endogenous opiate substrate which is probably enkephalinergic.

Neurotensin: a new 'reward peptide'.

oeurotensin (NT) is a tridecapeptide which is thought to bind to receptors located on dopamine cells in the ventral tegmental area (VTA). Rats with cannulas implanted in the VTA showed a significant increase in time spent in an environment in which they had received bilateral injections of neurotensin on previous days. This is indicative of conditioned reinforcement in which the neuropeptide was the primary reinforcer. In order to determine the specificity of neurotensin receptor interactions, 3 fragments of the peptide were examined at 2 doses. NT1-8 and NT8-13 were found to be inactive while NT1-11 demonstrated significant activity. The results suggest that NT in the VTA is capable of inducing reinforcing effects. This is the first evidence for a non-opiate 'reward peptide'.