MS and clinically isolated syndromes: shared specificity but diverging clonal patterns of virus-specific IgG antibodies produced in vivo and by CSF B cells in vitro.

BACKGROUND: Intrathecal synthesis of oligoclonal IgG antibodies against measles virus (MeV), varicella zoster virus (VZV) and herpes simplex virus type-1 (HSV-1) is a characteristic feature multiple sclerosis (MS). METHODS: We have used isoelectric focusing-immunoblot to define the clonal patterns of IgG and of IgG antibodies to MeV, VZV and HSV-1 in supernatants of in vitro cultures of peripheral blood lymphocytes (PBL) and cerebrospinal fluid (CSF) cells and in sera and CSF from three patients with MS and three patients with clinically isolated syndromes (CIS) suspective of demyelinating disease. RESULTS: In vitro synthesis of IgG by PBL was not detected in any patient. In contrast, in vitro synthesis by CSF cells of oligoclonal IgG and oligoclonal IgG antibodies to one or two of the three viruses tested was observed in all six patients. The clonal patterns of the in vitro synthesized IgG and virus specific IgG differed to varying extent from those synthesized intrathecally in vivo. However, in each patient, the in vitro and in vivo intrathecally produced antibodies displayed specificity for the same viruses. The addition of B cell activating factor (BAFF) had no effect on the amounts or clonal patterns of either total IgG or virus-specific IgG produced by CSF cells in vitro. CONCLUSION: Virus specific B cells capable of spontaneous IgG synthesis are clonally expanded in the CSF of patients with MS. The B-cell repertoire in CSF samples is only partially representative of the intrathecal B-cell repertoire.

GAD65 IgG autoantibodies in stiff person syndrome: clonality, avidity and persistence.

BACKGROUND AND PURPOSE: Persistent intrathecal production of IgG autoantibodies against glutamic acid decarboxylase 65 (GAD65 IgG) and oligoclonal IgG of undetermined specificity has been reported in stiff person syndrome (SPS). METHODS: To chart the avidity and clonal patterns of GAD65 IgG, we performed scatchard plot of binding characteristics and isoelectric focusing-immunoblot of cerebrospinal fluid (CSF) and serum from five SPS patients. RESULTS: Oligoclonal GAD65 IgG bands, predominantly restricted to the IgG1 subclass, were detected in CSF and serum in all patients. The distribution of GAD65-specific IgG bands in serum and CSF revealed intrathecal synthesis of oligoclonal GAD65 IgG in all five patients, whilst radioimmunoassay demonstrated intrathecal synthesis of GAD65 IgG in four. The binding avidity of GAD65 IgG from CSF was more than 10 times higher than in serum in two of the patients but did not differ substantially in the remaining three. These differences were not related to symptom severity. The pattern of oligoclonal GAD65 IgG bands in CSF and serum in three patients examined remained unchanged for up to 7 years after symptom debut. CONCLUSION: This study confirms the persistent systemic and intrathecal production of GAD65-specific IgG in SPS, and further shows that this immune response is oligoclonal and mediated by a stable population of affinity maturated B cell clones.

T cells from multiple sclerosis patients recognize immunoglobulin G from cerebrospinal fluid.

Idiotopic sequences are created after V, D and J recombinations and by somatic mutations during affinity maturation of immunoglobulin (Ig) molecules, and may therefore be potential immunogenic epitopes. Idiotope-specific T cells are able to activate and sustain the B cells producing such idiotopes. It is therefore possible that idiotope-specific intrathecal T cells could help maintain the persisting intrathecal synthesis of oligoclonal IgG observed in patients with multiple sclerosis (MS). This study was undertaken to examine T-cell responses to cerebrospinal fluid (CSF) IgG. Peripheral blood mononuclear cells (PBMC) from 14 of 21 MS patients and four of 17 control patients with other neurological diseases proliferated upon stimulation with autologous CSF IgG, while five and three, respectively, responded to serum IgG. By comparison, responses to myelin basic protein were recorded in only four MS and three control patients. Data from a limited number of patients indicate that the CSF IgG responsive cells were CD4+ and human leucocyte antigen DR restricted, that PBMC also respond to CSF IgG from other MS patients and that the CSF may contain T cells responding to autologous CSF IgG. This suggests that CSF IgG, or substances bound to this IgG, may represent T-cell immunogens, which could contribute to the intrathecal immune response in MS.

Diagnostic validity of somatosensory evoked potentials in subgroups of patients with sciatica.

The diagnostic utility of scalp-recorded somatosensory evoked potentials (SEP) in patients with sciatica has generally been regarded as low. The purpose of the present study was to determine the validity of sensory nerve SEP in different subgroups of sciatic patients. A total of 65 consecutive patients with sciatica showing disc pathology and/or facet joint hypertrophy on lumbar computed tomography (CT) and/or myelography were studied. Symptomatic myelographically compressed nerve roots were defined as truly compromised roots. Asymptomatic myelographically normal nerve roots were defined as truly normal roots. Bilateral sensory nerve SEP representing nerve roots L4, L5, and S1 were performed in all patients. Evaluation of SEP included the use of P1 latency inter-root comparison. The false-positive rate of SEP was low. Pathological L4, L5, and S1 SEP therefore strongly indicate true compromise of the corresponding nerve roots. The true-positive rate was higher in patients with facet joint hypertrophy with or without additional disc disease than in patients with disc pathology only, and highest if the sciatic sensory symptoms were present during the SEP registration. Diagnostic validity was not influenced by previous episodes of sciatica, the duration of the present episode, or the number of spinal levels with ipsilateral myelographically compressed nerve roots. Pathological SEP strongly indicate sensory radiculopathy in patients with sciatica. Diagnostic efficacy is higher in patients with facet joint hypertrophy than in patients with disc pathology only and highest when the sciatic symptoms are present during registration.

Multiple sclerosis in Oslo, Norway: prevalence on 1 January 1995 and incidence over a 25-year period.

The Oslo Multiple Sclerosis (MS) Registry was established in 1990, and this is the first report on the prevalence and incidence of MS in the city of Oslo, Norway. The prevalence rate of definite MS on 1 January 1995 was 120.4/10(5). Inclusion of patients of native Norwegian ancestry only and exclusion of non-Norwegian immigrants yielded a prevalence rate of 136.0/10(5). A similar prevalence rate (136.5/10(5)) was found when patients and immigrants from the other Nordic countries (Finland, Sweden, Denmark) were included. Segregation of the native Norwegian patients according to the counties where they were born showed no significant differences except for a disproportionate increase of patients born in the inland county of Oppland. A total of 794 cases were resident in Oslo at the time of a diagnosis of definite MS in the period 1972-99. The crude average annual incidence rate for each 5-year period, between 1972 and 1996, increased significantly from 3.7/10(5) in the 1972-76 to 8.7/10(5) in the 1992-96 period. The increase was more marked in relapsing-remitting (RR) than in primary progressive disease and in female cases.

Sex and age at diagnosis are correlated with the HLA-DR2, DQ6 haplotype in multiple sclerosis.

The HLA-DR2, DQ6 (i.e., HLA-DRB1*1501, DQA1*0102, DQB1*0602) haplotype contributes to the risk of developing multiple sclerosis (MS) in Caucasoids of Northern European heritage. A correlation between the clinical expression of MS and the presence of HLA-DR2, DQ6 has, however, not convincingly been shown. In this study conventional bivariate analysis and logistic regression analysis were used to study the relationship between HLA-DR2, DQ6 and four disease variables in a cohort of 286 Norwegian MS patients from the Oslo area. Logistic regression analysis showed that HLA-DR2, DQ6 was significantly more frequent among female than male patients (P=0. 0251), and was negatively correlated with age at diagnosis regardless of sex (P=0.0254). No significant correlation was observed between HLA-DR2, DQ6 and type of disease (relapsing-remitting versus primary chronic progressive MS) or presence/absence of oligoclonal bands in the cerebrospinal fluid.

[Lumbar disk prolapses and radiological spinal intervention. What do the randomized controlled trials say?]. / Lumbale skiveprolapser og radiologisk ryggintervensjon. Hva sier randomiserte kontrollerte studier?

We searched the Medline database and examined 11 randomized controlled trials to evaluate the efficacy of treating lumbar herniated discs by injection with chymopapain or by automated percutaneous discectomy. Our findings show that chemonucleolysis with chymopapain is a documented treatment which is better than placebo, but consistently inferior to surgical discectomy. The two randomized controlled trials to evaluate automated percutaneous discectomy fail to show efficacy that is any better than would be expected from a placebo response. We conclude that surgical discectomy is the best treatment option for a herniated disc when conservative efforts have failed.

Intrathecal immune response in neonatal Flavobacterium meningosepticum meningitis.

Neonates are predisposed to serious infections such as meningitis, probably due to their immature host reaction to the pathogens. We have studied the intrathecal immune response in 2 newborns with Flavobacterium meningosepticum meningitis. They showed a significant elevation of immunoglobulin indices ( >1.10), also after the CSF had become sterile with a normalized cell count. In addition, an intrathecal increase and subsequent decrease of both C3dg and TCC (terminal complement complex) were observed in 1 patient. We conclude that immunoglobulin production and complement activation may occur in neonatal CSF.

HLA-DRB1, -DQA1, -DQB1, -DPA1 and -DPB1 genes in Japanese multiple sclerosis patients.

Japanese MS patients and controls were examined for the distribution of HLA-DRB1, -DQA1, -DQB1, -DPA1 and -DPB1 alleles using in vitro amplification of genomic DNA and probing with sequence-specific oligonucleotides. No significant difference in frequency of the examined alleles was observed among the two groups. This is in contrast to Norwegian MS patients, where an association to a combination of certain DQA1 and DQB1 alleles has previously been demonstrated.

HLA-DQA1 and HLA-DQB1 genes may jointly determine susceptibility to develop multiple sclerosis.

Serologic DR typing and genomic DRB1, DQA1, DQB1, DPA1, and DPB1 typing using sequence-specific oligonucleotides were performed in 69 multiple sclerosis (MS) patients and 181 healthy controls on in vitro amplified DNA. The frequencies of DR2 as well as the DR2-associated DQA1*0102 and DQB1*0602 alleles were increased whereas DR7 was decreased among MS patients. The distribution of DR4 subtypes as well as DP alleles were similar in patients and healthy controls. All but one of 23 DR4-positive MS patients carried the DQB1*0302 allele, whereas five of five DR7-positive MS patients carried the DQB1*0303 allele. Of the MS patients, 99% compared to 79% of the controls carried DQA1 alleles encoding glutamine at residue 34, while 97% of the MS patients compared to 72% of the controls carried DQB1 alleles encoding DQ beta chains sharing long polymorphic stretches. A combination of such DQA1 and DQB1 alleles was carried by 96% of the MS patients and 60% of the controls, suggesting an association between MS and a combination of particular DQA1 alleles and DQB1 alleles. The corresponding DQ alpha beta heterodimers may have in common an ability to bind a particular peptide.

Cerebral vasculopathy associated with primary varicella infection.

A previously healthy 5-year-old boy developed cerebral vasculopathy, presenting as two episodes of acute hemiparesis 3 and 9 months, respectively, after a primary varicella infection (chickenpox). This association has not been reported before, to our knowledge, although cerebral vasculopathy is a well-known complication of herpes zoster ophthalmicus. The diagnosis was based on the presence of oligoclonal varicella-specific IgG in the cerebrospinal fluid and angiographic findings. Clinical and angiographic follow-up, and serial thymidine kinase activity levels in the cerebrospinal fluid suggested a self-limiting course of the virus-induced vasculopathy. Varicella zoster virus seems to be another potential causative agent to be considered in acute childhood hemiplegia.

Quantitation of immunoglobulins produced by donor lymphocytes in transplant patients and the possible identification of donor cell-produced antiviral antibodies by imprint immunofixation.

In the present study two patients were studied in detail to estimate the quantity of IgG of donor lymphocyte origin. Using IgG subclass quantitation and Gm haemagglutination inhibition titre, we estimated that up to 3% of IgG found after transplantation may be of donor lymphocyte origin. Analysis of viral antibody patterns by imprint immunofixation suggested polyclonal production of donor-derived antibodies.

Patients with multiple sclerosis carry DQB1 genes which encode shared polymorphic amino acid sequences.

Of 61 Norwegian multiple sclerosis patients tested, 59, i.e., 97%, were positive for at least one of the HLA specificities DR2, DR4, or DRw6. Typing with sequence-specific oligonucleotide probes revealed that the same 59 patients carried DR2-, DR4-, or DRw6-associated HLA-DQB1 genes which encode shared polymorphic amino acid sequences in the membrane-distal part of their HLA-DQ beta chains. This shared DQ beta polymorphism may explain previously reported DR associations and could thus be the primary HLA association in MS.

Multiple sclerosis patients have a high frequency of an HLA-DQ beta epitope defined by a human-human hybridoma antibody.

Epstein-Barr virus (EBV) transformed B-cells from patients with multiple sclerosis (MS) and healthy controls were analysed for reactivity with the HLA-DQ-specific human-human hybridoma Ab TrB12 (anti-DQw6 + DQw8 + DQw9) by indirect immunofluorescence (IIF). Positive results were obtained with 34 out of 35 MS patients (97.1%) and 79 out of 106 controls (74.5%) (p less than 0.005, RR = 11.6). Thus, DQ molecules that express the TrB12 epitope may contribute to the susceptibility to develop MS.

Paramyxovirus SV5 and multiple sclerosis.

Multiple sclerosis is commonly associated with a local humoral immune response within the central nervous system. A hallmark of this intrathecal response is the presence of electrophoretically demonstrable oligoclonal bands of IgG in the cerebrospinal fluid (CSF) of up to 95% of patients. Observations indicating that a major part of the CSF IgG in some patients may represent antibodies to SV5, a simian virus closely related to human parainfluenza type 2 virus, were recently reported by Goswami et al. We have studied thirty patients with multiple sclerosis, but although we find intrathecal synthesis of IgG antibodies reacting with SV5 in seven of these, the antibodies were not associated with oligoclonal CSF IgG bands and could in each case be explained as potentially cross-reacting antibodies to other paramyxoviruses known to be human pathogens. We have therefore been unable to confirm that SV5 may be a major intrathecal immunogen in multiple sclerosis.

Human immunodeficiency virus infection of the brain. II. Detection of intrathecally synthesized antibodies by enzyme linked immunosorbent assay and imprint immunofixation.

Sera and CSF from 29 patients in early and late stages of HIV infection were analysed for intrathecal antibody production. Elevated CSF-IgG indices indicating intrathecal IgG synthesis were demonstrated in 9 patients while 4 of 18 patients tested had oligoclonal IgG bands in the CSF. Analysis of HIV-specific antibodies by enzyme-linked immunosorbent assay (whole antigen and site-directed ELISA) and calculation of "antibody indices" (CSF/serum antibody quotient divided by CSF/serum albumin quotient) indicated intrathecal HIV antibody synthesis in 19 patients. Analysis of serum and CSF antibodies by an imprint immunofixation (IIF) method showed intrathecal synthesis of predominantly polyclonal HIV-IgG antibodies in 11 of 13 patients examined. IIF analysis of antibodies to six other infectious agents showed no intrathecal antibody production except in one patient who had minor fractions of intrathecally synthesized IgG antibodies to varicella zoster virus. The present results demonstrate that an intrathecal HIV-specific antibody response may be present in both early and late stages of HIV infection, and indicates that HIV may reach the brain at an early stage of infection.

The intrathecal immune response in the early stage of multiple sclerosis.

Sequential pairs of cerebrospinal fluid (CSF) and serum samples from 10 patients followed for 2.5-12 years after onset of unilateral optic neuritis (ON) were studied. Eight patients developed definite multiple sclerosis (MS) during the observation period. All patients had normal CSF protein patterns on agar or agarose gel electrophoresis at onset. Six patients developed oligoclonal immunoglobulin (Ig) bands in the CSF during the observation period. Imprint immunofixation of electrofocused specimens disclosed intrathecal synthesis of oligoclonal IgG antibodies to 1 or more of 6 viruses (measles, herpes simplex type 1, varicella-zoster, cytomegalo, mumps, rota) during the observation period in 8 patients. Changes in patterns of intrathecally synthesized viral antibodies, characterized by the appearance of "new" antibody populations and the waxing or waning of others were observed in 6 patients. The results suggest that the early stage of MS in some patients is associated with transient as well as permanent recruitment of B cell clones producing viral antibodies of different specificities.

Intrathecal complement activation in neurological diseases evaluated by analysis of the terminal complement complex.

The terminal complement complex (TCC) was determined in plasma and cerebrospinal fluid (CSF) from 208 neurological patients. Elevated CSF TCC levels were observed in higher frequencies in patients with infectious diseases (80%), radiculoneuritis (62%), multiple sclerosis (30%), and miscellaneous autoimmune diseases (27%) than in patients with miscellaneous non-inflammatory diseases (2-13%). The plasma level of TCC was significantly increased only in the infectious group. No positive correlation was observed between the plasma and the CSF TCC concentration in the whole patient population nor in subgroups divided according to blood-brain barrier function. Furthermore, the CSF TCC concentration did not correlate with the serum/CSF albumin ratio or with CSF total protein concentration when this was below 1.0 g/l. It is concluded that an elevated TCC concentration in CSF reflects intrathecal complement activation and that quantification of TCC in CSF may be a valuable supplement in the examination of neurological diseases.

Immunofluorescence staining of agarose-embedded cells. A new technique developed for immunological characterization of markers on a small number of cells.

A simple new method for the immunofluorescence staining of small numbers of cells is described: cell suspensions are mixed with low-temperature-gelling agarose at 37 degrees C and 2 microliter samples of agarose containing cells are dispensed onto multitest microslides precoated with agarose. The cells are subsequently stained by immunofluorescence techniques. Alternatively, the cell slides can be stored in liquid nitrogen until immunofluorescence staining is carried out. Since cells are entrapped within the agarose matrix, cell loss is prevented during staining and washing procedures. The method permits staining of as few as 250 cells for each marker, thus enabling simultaneous characterization of several separate cell markers in cerebrospinal fluid or other body compartments from which comparatively few cells are obtainable.