Suppression of ongoing experimental myasthenia by oral treatment with an acetylcholine receptor recombinant fragment.

Myasthenia gravis (MG) is an autoimmune disorder in which the nicotinic acetylcholine receptor (AChR) is the major autoantigen. In an attempt to develop an antigen-specific therapy for MG, we administered a nonmyasthenogenic recombinant fragment of AChR orally to rats. This fragment, corresponding to the extracellular domain of the human AChR alpha-subunit (Halpha1-205), protected rats from subsequently induced experimental autoimmune myasthenia gravis (EAMG) and suppressed ongoing EAMG when treatment was initiated during either the acute or chronic phases of disease. Prevention and suppression of EAMG were accompanied by a significant decrease in AChR-specific humoral and cellular responses. The underlying mechanism for the Halpha1-205-induced oral tolerance seems to be active suppression, mediated by a shift from a T-helper 1 (Th1) to a Th2/Th3 response. This shift was assessed by changes in the cytokine profile, a deviation of anti-AChR IgG isotypes from IgG2 to IgG1, and a suppressed AChR-specific delayed-type hypersensitivity response. Our results in experimental myasthenia suggest that oral administration of AChR-specific recombinant fragments may be considered for antigen-specific immunotherapy of myasthenia gravis.

Overexpression of amyloid precursor protein reduces epsilon protein kinase C levels.

Alzheimer's disease (AD) is characterized by extracellular deposits of amyloid beta peptide (Abeta), a peptide that is generated upon proteolytic cleavage of amyloid precursor protein (APP). The events leading to the development of AD and their sequence are not yet fully understood. Protein kinase C (PKC) has been suggested to have a significant role in controlling neuronal degeneration and in the aberrant signal transduction taking place in AD. Several studies document a deficit in PKC levels and activity in brains of AD patients when compared with those of normal controls. Such a decrease in PKC could have serious implications since certain PKC isozymes were shown to drive the APP proteolytic cleavage into a non-amyloidogenic pathway. Reduced levels of distinct PKC isozymes could thus contribute to driving APP processing toward an amyloidogenic pathway. The direct cause for the down-regulation of PKC in AD brains is still unknown. In that respect, we tested in this study whether APP may play a role in PKC reduction. We show in three different cell lines (CHO, COS and BOSC) that overexpression of APP leads to decreased PKC levels. This decrease was found to be specific for the epsilon PKC isozyme whereas the levels of delta, alpha and conventional PKC remained unchanged. Furthermore, we observed this decrease for both active, membrane-associated and inactive, cytosolic epsilon PKC. APP-driven decrease in epsilon PKC is most likely mediated by a factor in the culture medium, since transfer of medium from cultured cells overexpressing APP to naïve, non-overexpressing cells, has also led to the selective decrease in epsilon PKC levels. Taken together, our results suggest that APP expression levels may play a role in the decrease of epsilon PKC levels in AD brains and could thus affect the responsiveness of AD brain tissues to growth factors and neurotransmitters.

Peptide modulators of protein-protein interactions in intracellular signaling.

Signal transduction cascades involve multiple enzymes and are orchestrated by selective protein-protein interactions that are essential for the progression of intracellular signaling events. Modulators of these protein-protein interactions have been used to dissect the role of individual components of each signaling cascade. We describe several methods that have been developed for the identification of peptides that inhibit the interaction between signaling proteins and hence selectively modulate their functions. Such peptide modulators provide important tools for basic research and have great potential as leads for the development of new classes of therapeutic drugs.

Suppression of experimental myasthenia gravis, a B cell-mediated autoimmune disease, by blockade of IL-18.

Interleukin-18 (IL-18) is a pleiotropic proinflammatory cytokine that plays an important role in interferon gamma (IFN-gamma) production and IL-12-driven Th1 phenotype polarization. Increased expression of IL-18 has been observed in several autoimmune diseases. In this study we have analyzed the role of IL-18 in an antibody-mediated autoimmune disease and elucidated the mechanisms involved in disease suppression mediated by blockade of IL-18, using experimental autoimmune myasthenia gravis (EAMG) as a model. EAMG is a T cell-regulated, antibody-mediated autoimmune disease in which the nicotinic acetylcholine receptor (AChR) is the major autoantigen. Th1- and Th2-type responses are both implicated in EAMG development. We show that treatment by anti-IL-18 during ongoing EAMG suppresses disease progression. The protective effect can be adoptively transferred to naive recipients and is mediated by increased levels of the immunosuppressive Th3-type cytokine TGF-beta and decreased AChR-specific Th1-type cellular responses. Suppression of EAMG is accompanied by down-regulation of the costimulatory factor CD40L and up-regulation of CTLA-4, a key negative immunomodulator. Our results suggest that IL-18 blockade may potentially be applied for immunointervention in myasthenia gravis.

Differences between embryonic and adult Torpedo acetylcholine receptor gamma subunit.

Antibodies to a synthetic peptide corresponding to residues 346-359 of the Torpedo acetylcholine receptor (AChR) gamma subunit, were employed to compare the adult and embryonic receptor. This peptide contains a consensus phosphorylation site for cAMP-dependent protein kinase (PKA). The anti-peptide antibodies discriminated between adult and embryonic AChRs, and reacted preferentially with the adult gamma form. These observed immunological differences did not seem to stem from different phosphorylation states. Our results suggest that the embryonic Torpedo AChR may have a gamma-like subunit that differs from the known adult form of this subunit, at least in the specific region that contains the phosphorylation site for PKA.

An anti-acetylcholine receptor monoclonal antibody cross-reacts with phosvitin.

Rabbit and mouse anti-Torpedo acetylcholine receptor antibodies cross-reacted partially with the highly phosphorylated protein, phosvitin. We have selected an anti-Torpedo acetylcholine receptor monoclonal antibody which binds specifically to phosvitin; this binding is inhibited by acetylcholine receptor. These findings suggest that a phosphorylated amino acid residue may be a part of the determinant on the acetylcholine receptor recognized by this monoclonal antibody.

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

Experimental autoimmune myasthenia gravis (EAMG) was induced in chickens by passive transfer of a monoclonal antibody (mcAb) specific for the cholinergic binding site of the acetylcholine receptor (AChR). Specific anti-idiotypes raised in rabbits against this antisite mcAb (5.5) were demonstrated to prevent the induction of EAMG by a subsequent injection of mcAb 5.5. Also, administration of anti-idiotypes against mcAb 5.5 to chickens in which EAMG has been induced by mcAb 5.5 led to a recovery from myasthenic symptoms. These results suggest that passive transfer of the appropriate anti-idiotypes may have potential in the regulation of myasthenia.

Mechanism of nasal tolerance induced by a recombinant fragment of acetylcholine receptor for treatment of experimental myasthenia gravis.

Acetylcholine receptor (AChR) is the major autoantigen in myasthenia gravis (MG) and experimental autoimmune MG (EAMG). Here we analyze the mechanisms involved in suppression of ongoing EAMG in rats by nasal administration of a recombinant fragment from the human AChR alpha-subunit. We demonstrate that such a fragment, expressed without a fusion partner, confers nasal tolerance that can be adoptively transferred. Our observations suggest that the underlying mechanism of this nasal tolerance is active suppression involving a shift from a Th1 to a Th2/Th3-regulated AChR-specific response which may be mediated by down regulation of costimulatory factors.

Antigenic specificity of acetylcholine receptor in developing muscle. Studies with monoclonal antibodies.

Monoclonal antibodies (mcAbs) elicited against the nicotinic acetylcholine receptor (AChR) from Torpedo, were used to follow antigenic changes in AChR during muscle development. Newborn rat muscle and denervated mouse muscle were used as sources of extrajunctional AChR; adult innervated rat and mouse muscle were used as sources of junctional AChR. Most of the mcAbs tested reacted preferably, but not exclusively with extrajunctional AChR (EJR), as compared to junctional AChR (JR). None was found to react with only one of the two forms of AChR. We conclude that the anti-AChR monoclonal antibodies used in this study detect antigenic determinants which are shared by EJR and JR, but which probably undergo structural changes during muscle development.

Modulation of anti-acetylcholine receptor antibody specificities and of experimental autoimmune myasthenia gravis by synthetic peptides.

Synthetic peptides corresponding to selected sequences from the nicotinic acetylcholine receptor (AChR) were employed to identify possible antigenic determinants within the receptor which can modulate the anti-AChR response and experimental autoimmune myasthenia gravis (EAMG). Immunization of rabbits with peptides T alpha 73-89, T alpha 351-368, T delta 354-367 and H alpha 351-368, prior to AChR inoculation, affected the course of EAMG in six out of eight rabbits. These six protected rabbits survived three inoculations of AChR and survived for at least five months after the third injection with AChR, whereas control rabbits died following one or two injections of AChR. The survival of peptide-preimmunized rabbits injected with AChR seemed to correlate with the antibody specificities in immunoblots. Following AChR inoculation there was a shift in reactivity, from a subunit-restricted response, to reactivity with all subunits of the receptor. This shift was delayed in protected rabbits. This may indicate that the reactivity with the entire Torpedo receptor molecule represents a loss of tolerance to AChR which culminates in the autoimmune disease, EAMG.

Analysis and modulation of the immune response of mice to acetylcholine receptor by anti-idiotypes.

Anti-idiotypes were raised in mice against three well-characterized anti-acetylcholine receptor (AChR) monoclonal antibodies (mcAbs), as well as against polyclonal mouse anti-AChR antibodies. In binding experiments, the anti-idiotypic antibodies inhibited the binding of AChR only to the immunizing idiotype. However, a less restricted specificity was found in in vivo experiments. Mice producing anti-idiotypes were challenged with AChR and the idiotypic composition of their anti-AChR response was analysed using specific rabbit anti-idiotypic antibodies. It was found that preimmunization with a certain idiotype leads to the preferential suppression of this particular idiotype in the polyclonal response to AChR. However, preimmunization with either polyclonal or monoclonal anti-AChR antibodies resulted in a reduction of the overall anti-Torpedo AChR and anti-muscle AChR titers. This reduction was greater than would be expected from the representation of each of the respective idiotypes in the polyclonal anti-AChR serum, and may imply that in addition to the immunizing idiotype other anti-AChR idiotypes are also suppressed. Our results suggest that anti-idiotypes may have a potential for the modulation of the autoimmune response directed against AChR in myasthenia.

Serum ferritin levels in celiac disease.

Of the various common assayed parameters of iron metabolism, serum ferritin levels are the most discriminatory in distinguishing between non-treated celiac disease and other gastrointestinal disorders in the pediatric age group. Patients on normal diets usually have very low ferritin levels that increase at an average rate of 1 microgram/1/month when placed on a gluten-free diet. When the patient returns to a normal diet, however, ferritin levels decrease rapidly at an average rate of about 4 microgram/1/month. There is a relationship between abnormal intestinal changes and low ferritin levels in celiac disease with improvement in both when the patient is on a gluten-free diet. It is suggested that serial blood ferritin evaluations together with the leukocyte migration inhibition factor production assay should eliminate the need for invasive intestinal biopsies for the confirmation and possible follow-up to response to treatment.

Acetylcholine receptor and myogenic factor gene expression in Torpedo embryonic development.

The mRNA levels of acetylcholine receptor (AChR) and myogenic factors were followed during embryonic development of Torpedo skeletal muscle and its homologue, the electric organ. A different developmental pattern of AChR gene expression was found in these two tissues: a slight decrease in the muscle, and a marked increase, concomitant with synapse formation, in the electric organ. However, the developmental pattern of MyoD and MRF4 mRNA levels was similar in both tissues, with no significant changes during development. This is in contrast with the sharp increase in the expression of AChR in the electric organ and may suggest that the burst in the expression of AChR during the differentiation of myotubes into electrocytes is not regulated by changes in the myogenic factor mRNA levels.

The haematologist as watchdog of community health by full blood count.

Although full blood counts (FBC) are among the most commonly performed laboratory tests, the contribution of routine FBCs to the diagnosis of new problems is controversial. This study represents a unique linkage of a consultant haematology team, reviewing all abnormal blood counts, to an organization providing ambulatory health care to 350,000 patients. The objective was to establish the underlying clinical disorders responsible for all abnormal FBCs during a 2-month period, and to estimate the impact of the haematology team on the diagnostic work-up and management of newly identified problems. 572 (2.55%) of the 22,454 FBCs were abnormal. Of these, 357 showed microcytosis, caused by iron deficiency (58%), thalassaemia minor (35%), inflammation (6%) or chronic renal failure (1%). The most common causes of normocytic anaemia (25 patients) were disseminated malignancy and acute blood loss; of macrocytosis (27 patients), chronic liver disease and cancer; of erythrocytosis (16 patients), chronic hypoxia; of thrombocytopaenia (48 patients), chronic liver disease and ITP; of thrombocytosis (47 patients), iron deficiency and inflammation; of leukopaenia or pancytopaenia (20 patients), cirrhosis and disseminated malignancy; and of leukocytosis (26 patients), chronic leukaemias in the elderly and infection in children. Major new haematological abnormalities were encountered in 0.24% of all blood counts, representing about one new diagnosis per day. Routine blood counts do contribute to the health care of a population. Screening for haematological disease through a central clinical laboratory covering a large high-risk ambulatory population offers a cost-effective way of searching for serious clinical problems, alerting the primary physicians of their existence, and offering advice in continued evaluation and problem management.

Antibodies to spiroperidol and their anti-idiotypes as probes for studying dopamine receptors.

Spiroperidol was covalently conjugated to bovine serum albumin (BSA). Conjugated spiroperidol was almost as efficient as free spiroperidol in its binding capacity to dopamine receptor. Antibodies to spiroperidol were produced in rabbits following repeated immunizations with the conjugate of spiroperidol and BSA. The obtained antibodies have an apparent KD of 0.02 nM for [3H]-spiroperidol. These antibodies bind also to other butyrophenones with IC50 values three to four orders of magnitude higher than the IC50 obtained with unlabeled spiroperidol. Antibodies were purified from anti-spiroperidol sera by affinity chromatography. Anti-idiotypic antibodies were raised in rabbits by immunization with the purified anti-spiroperidol antibodies. Some rabbits produced anti-idiotypic antibodies which bind to rat and calf striatum.

Development of novel therapies for MG: Studies in animal models.

Experimental myasthenia gravis (MG) in animals, and in particular experimental autoimmune MG in rodents, serves as excellent models to study possible novel therapeutic modalities for MG. The current treatments for MG are based on cholinesterase inhibitors, general immunosuppressants, and corticosteroids, broad immunomodulatory therapies such as plasma exchange or intravenous immunoglobulins (IVIGs), and thymectomy for selected patients. This stresses the need for immunotherapies that would specifically or preferentially suppress the undesirable autoimmune response without widely affecting the entire immune system as most available treatments do. The available animal models for MG enable to perform preclinical studies in which novel therapeutic approaches can be tested. In this review, we describe the different therapeutic approaches that were so far tested in experimental models of MG and discuss their underlying mechanisms of action. These include antigen - acetylcholine receptor (AChR)-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. The antigen-specific treatments are based on fragments or peptides derived from the acetylcholine receptor (AChR) that would theoretically deviate the anti-AChR autoimmune response away from the muscle target or on ways to target AChR-specific T- and B- cell responses or antibodies. The immunomodulatory modalities include cell-based and non-cell-based ways to affect or manipulate key players in the autoimmune process such as regulatory T cells, dendritic cells, cytokine networks, and chemokine and costimulatory signaling as well as complement pathways. We also describe approaches that attempt to affect the cholinergic balance, which is impaired at the neuromuscular junction. In addition to enabling to test the feasibility of novel approaches, experimental MG enables to perform analyses of existing treatment modalities, which cannot be performed in human MG patients. These include studies on the mode of action of various immunosuppressants and on IVIGs. Hopefully, the vast repertoire of therapeutic approaches that are studied in experimental models of MG will pave the way to clinical studies that will eventually improve the management of MG.