Cerebrospinal fluid lipocalin 2 in patients with clinically isolated syndromes and early multiple sclerosis.

BACKGROUND: Lipocalin 2 (LCN2) may be involved in the immunopathogenesis of multiple sclerosis (MS) and might further impact on iron homoeostasis. Brain iron accumulates in MS; however, the association to iron-related proteins is still unsolved. OBJECTIVE: To investigate cerebrospinal fluid (CSF) and serum LCN2, transferrin (Trf) and ferritin in early MS in relation to disease evolution and longitudinal brain iron accumulation. METHODS: We analysed CSF and serum LCN2 by enzyme-linked immunosorbent assay (ELISA) and Trf and ferritin by nephelometry in 55 patients (45 clinically isolated syndrome (CIS), 10 MS, median clinical follow-up 4.8 years) and 63 controls. In patients, we assessed sub-cortical grey matter iron by 3T magnetic resonance imaging (MRI) R2* relaxometry (median imaging follow-up 2.2 years). RESULTS: Compared to controls serum (p < 0.01), CSF (p < 0.001) LCN2 and CSF Trf (p < 0.001) levels were reduced in the patients. CSF LCN2 correlated with CSF Trf (r = 0.5, p < 0.001). In clinically stable patients, CSF LCN2 levels correlated with basal ganglia iron accumulation (r = 0.5, p < 0.05). In CIS, higher CSF LCN2 levels were associated with conversion to clinically definite MS (p < 0.05). CONCLUSION: We demonstrate altered LCN2 regulation in early MS and provide first evidence for this to be possibly linked to both clinical MS activity and iron accumulation in the basal ganglia.

Cerebrospinal fluid transferrin levels are reduced in patients with early multiple sclerosis.

BACKGROUND: Previous magnetic resonance imaging (MRI) studies have demonstrated increased iron deposition in the basal ganglia of multiple sclerosis (MS) patients. However, it is not clear whether these alterations are associated with changes of iron metabolism in body fluids. OBJECTIVES: The purpose of this study was to investigate if iron metabolism markers in cerebrospinal fluid (CSF) and serum of clinically isolated syndrome (CIS) and MS patients differ from controls and how they relate to clinical and imaging parameters. METHODS: We analysed serum ferritin, transferrin and soluble transferrin-receptor and CSF ferritin and transferrin by nephelometry in non-anaemic CIS (n=60) or early MS (n=14) patients and 68 controls. In CIS/MS we additionally assessed the T2 lesion load. RESULTS: CSF transferrin was significantly decreased in CIS/MS compared to controls (p<0.001), while no significant differences were seen in serum. Higher CSF transferrin levels correlated with lower physical disability scores (r= -0.3, p<0.05). CSF transferrin levels did not correlate with other clinical data and the T2 lesion load. CONCLUSION: Our biochemical study provides evidence that altered iron homeostasis within the brain occurs in the very early phases of the disease, and suggests that the transporter protein transferrin may play a role in the increased iron deposition known to occur in the brain of MS patients.

CSF neurofilament and N-acetylaspartate related brain changes in clinically isolated syndrome.

BACKGROUND: Axonal damage is considered a major cause of disability in multiple sclerosis (MS) and may start early in the disease. Specific biomarkers for this process are of great interest. OBJECTIVE: To study if cerebrospinal fluid (CSF) biomarkers for axonal damage reflect and predict disease progression already in the earliest stages of the disease, that is, in clinically isolated syndrome (CIS). METHODS: We assessed CSF levels of neurofilament heavy (NFH), neurofilament light (NFL) and N-acetylaspartate (NAA) in 67 patients with CIS and 18 controls with neuropsychiatric diseases of non-inflammatory aetiology (NC). Patients with CIS underwent baseline magnetic resonance imaging (MRI) at 3T, and a follow-up MRI after 1 year was obtained in 28 of them. RESULTS: Compared with NC, patients with CIS had higher NFH (p=0.05) and NFL (p<0.001) levels. No significant group differences were found for NAA. Patients' NFH levels correlated with physical disability (r=0.304, p<0.05) and with change in brain volume over 1 year of follow-up (r=-0.518, p<0.01) but not with change in T2 lesion load. CONCLUSION: Our results confirm increased neurofilament levels already in CIS being related to the level of physical disability. The association of NFH levels with brain volume but not lesion volume changes supports the association of these markers with axonal damage.

Serum netrin-1 in relation to gadolinium-enhanced magnetic resonance imaging in early multiple sclerosis.

BACKGROUND: Netrin-1, a secreted laminin-related protein, is known to regulate not only axonal guidance and neuronal cell migration, but also blood-brain barrier integrity and inflammation. Two preliminary studies reported altered serum netrin-1 levels in multiple sclerosis; however, associations with longitudinal clinical and magnetic resonance imaging activity have not been investigated. OBJECTIVES: We aimed to assess serum netrin-1 in multiple sclerosis and controls with respect to disease activity and its temporal dynamics. METHODS: Serum netrin-1 was assessed by enzyme-linked immunosorbent assay in 79 patients with clinically isolated syndrome or multiple sclerosis, and 30 non-inflammatory neurological disease controls. In patients, serum samples were collected immediately prior to gadolinium-enhanced 3 T magnetic resonance imaging at two time points (initial contrast-enhancing gadolinium+ n = 47, non-enhancing gadolinium- n = 32; reference gadolinium- n = 70; median time-lag 1.4, interquartile range 1.0-2.3 years). RESULTS: Serum netrin-1 levels were similar in clinically isolated syndrome, multiple sclerosis and controls, and gadolinium+ and gadolinium- patients. Among gadolinium+ patients, serum netrin-1 was decreased in clinically active (n = 8) vs non-active patients (n = 39; p = 0.041). Serum netrin-1 showed no temporal dynamics in multiple sclerosis and was unrelated to clinical data. CONCLUSIONS: Serum netrin-1 levels show no multiple sclerosis specific changes and are not sensitive for detection of subclinical disease activity. Netrin-1 changes during relapses may deserve further examination.

Pathogenetic role of autoantibodies in neurological diseases.

Autoreactive B cells and antibodies can be detected in a variety of neurological diseases. Their causative role has been established in some disorders and they are obviously involved in the pathogenesis of others. Some mechanisms engendering B-cell autoimmunity in animal models have been shown to operate in humans. Factors that determine B-cell immune-response patterns and the effector pathways have been identified. B-cell responses to CNS-restricted autoantigens are governed by distinctive immune reactions. Evidence has accumulated that the CNS is a permissive and, under inflammatory conditions, even a B-cell-supporting micro-environment. Data from human and animal experiments have enhanced our understanding of B-cell physiology in health and neurological disease, which has relevant diagnostic and therapeutic implications.

The role of integrins in immune-mediated diseases of the nervous system.

Immune-mediated diseases of the CNS and PNS, such as multiple sclerosis and Guillain-Barré syndrome, respectively, constitute a major cause of transient and permanent neurological disability in the adult. The aetiology and pathogenesis of these disorders are only partially understood. On a cellular level, focal mononuclear-cell infiltration with demyelination and eventual axonal loss is a crucial pathogenetic event that leads to inflammation and subsequent dysfunction. Here, the evidence that integrins, a family of cell adhesion molecules, expressed on neural and immune cells might play a central role in immune cell recruitment to the CNS and PNS, and probably in tissue repair is reviewed. Distinct integrin expression patterns are observed in multiple sclerosis and Guillain-Barré syndrome. Therapeutic targeting of integrins has been very successful in the corresponding animal models and holds promise as a novel treatment strategy to combat human immune-mediated disorders of the nervous system.

Role of integrins in the peripheral nervous system.

Integrins, a subgroup of adhesion receptors, are transmembrane glycoproteins that mediate interactions between cytoplasm and the extracellular environment. These interactions influence, among others, events such as cell migration, proliferation, and differentiation. Differential expression of integrins is developmentally regulated in the peripheral nervous system (PNS) and is associated with crucial events in both physiological and pathological processes. Preliminary studies suggest that integrin expression influences neural crest cell migration, axonal outgrowth, and Schwann cell differentiation. Similarly, the abnormal expression of integrins or their ligands, is associated with degenerative, inflammatory, and malignant disorders of the PNS. Finally, integrins participate in the complex interactions that promote repair of the PNS. A better comprehension of the role of integrins in the PNS, their protein interactions and transducing signals is being achieved by selected biochemical and genetic experiments. Here we review a large bias of evidence suggesting the key functions for integrins in the PNS.

Mechanisms of immune regulation in the peripheral nervous system.

The peripheral nervous system (PNS) is a target for heterogenous immune attacks mediated by different components of the systemic immune compartment. T cells, B cells, and macrophages can interact with endogenous, partially immune-competent glial cells and contribute to local inflammation. Cellular and humoral immune functions of Schwann cells have been well characterized in vitro. In addition, the interaction of the humoral and cellular immune system with the cellular and extracellular components in the PNS may determine the extent of tissue inflammation and repair processes such as remyelination and neuronal outgrowth. The animal model experimental autoimmune neuritis (EAN) allows direct monitoring of these immune responses in vivo. In EAN contributions to regulate autoimmunity in the PNS are made by adhesion molecules and by cytokines that orchestrate cellular interactions. The PNS has a significant potential to eliminate T cell inflammation via apoptosis, which is almost lacking in other tissues such as muscle and skin. In vitro experiments suggest different scenarios how specific cellular and humoral elements in the PNS may sensitize autoreactive T cells for apoptosis in vivo. Interestingly several conventional and novel immunotherapeutic approaches like glucocorticosteroids and high-dose antigen therapy induce T cell apoptosis in situ in EAN. A better understanding of immune regulation and its failure in the PNS may help to develop improved, more specific immunotherapies.

Soluble ICAM-1 serum levels in multiple sclerosis and viral encephalitis.

Intercellular adhesion molecule ICAM-1 has a crucial role in the induction of an immune response and is instrumental in migration of T cells into inflamed tissue. We studied soluble ICAM-1 concentrations in patients with multiple sclerosis (MS), viral encephalitis, and other immunologic diseases, and compared results with those in other noninflammatory, nondemyelinating neurologic disorders as well as in healthy controls. MS patients with clinically active disease or enhancing lesions on MRI had elevated serum levels of soluble ICAM-1. Concentrations of soluble ICAM-1 were also increased in some patients with viral encephalitis. These findings raise the possibility that circulating ICAM-1 serves as a marker of acute inflammatory events in the brain and add to evidence implicating this adhesion molecule in the pathogenesis of MS.

Statins as immunomodulators: comparison with interferon-beta 1b in MS.

BACKGROUND: Recent data suggest that statins may be potent immunomodulatory agents. In order to evaluate the potential role of statins as immunomodulators in MS, the authors studied their immunologic effects in vitro and compared them to interferon (IFN)beta-1b. METHODS: Peripheral blood mononuclear cells (PBMC) obtained from untreated or IFN beta-1-treated patients with relapsing-remitting MS or from healthy donors (HD) and T cells were stimulated with concanavalin A, phytohemagglutinin, or antibody to CD3 in the presence of lovastatin, simvastatin, mevastatin, IFN beta-1b, or statins plus IFN beta-1b. The authors analyzed proliferative activity of T cells and B cells, cytokine production and release, activity of matrix metalloproteinases (MMP), and surface expression of activation markers, adhesion molecules, and chemokine receptors on both T and B cells. RESULTS: All three statins inhibited proliferation of stimulated PBMC in a dose-dependent manner, with simvastatin being the most potent, followed by lovastatin and mevastatin. IFN beta-1b showed a similar effect; statins and IFN beta-1b together added their inhibitory potentials. Furthermore, statins reduced the expression of activation-induced adhesion molecules on T cells, modified the T helper 1/T helper 2 cytokine balance, reduced MMP-9, and downregulated chemokine receptors on both B and T cells. Besides strong anti-inflammatory properties, statins also exhibited some proinflammatory effects. CONCLUSIONS: Statins are effective immunomodulators in vitro that merit evaluation as treatment for MS.

Circulating adhesion molecules and inflammatory mediators in demyelination: a review.

Accumulating evidence shows that adhesion molecules are critically involved in inflammatory demyelination in the focusing of systemic immune responses into the target tissue, the nervous system. Adhesion molecules are upregulated through the action of cytokines. Tumor necrosis factor alpha appears to be of prime importance. Circulating adhesion molecules probably reflect acute inflammatory episodes in the central and peripheral nervous system, but may also function to modulate ongoing inflammatory responses. Cytokines released by TH1 cells render resident and immigrant macrophages, as well as microglia, activated to synthesize and release increased amounts of inflammatory mediators, such as oxygen radicals, nitric oxide metabolites, and components of the complement system. A more detailed understanding of the sequence of immunopathologic events that culminate in myelin damage in the central and peripheral nervous systems has revealed several sites to which more specific and effective immunointervention can be targeted.

Inflammatory mediators in demyelinating disorders of the CNS and PNS.

Work in both experimental models and human disorders of the central and peripheral nervous system has delineated multiple effector mechanisms that operate to produce inflammatory demyelination. The role of various soluble inflammatory mediators generated and released by both blood-borne and resident cells in this process will be reviewed. Cytokines such as interleukin (IL)-1, interferon (IFN)-gamma, and tumor necrosis factor (TNF)-alpha are pivotal in orchestrating immune and inflammatory cell-cell interactions and represent potentially noxious molecules to the myelin sheath, Schwann cells, and/or oligodendrocytes. Arachidonic acid metabolites, synthesized by and liberated from astrocytes, microglial cells and macrophages, are intimately involved in the inflammatory process by enhancing vascular permeability, providing chemotactic signals and modulating inflammatory cell activities. Reactive oxygen species can damage myelin by lipid peroxidation and may be cytotoxic to myelin-producing cells. They are released from macrophages and microglial cells in response to inflammatory cytokines. Activation of complement yields a number of inflammatory mediators and results in the assembly of the membrane attack complex that inserts into the myelin sheath-creating pores. Activated complement may contribute both to functional disturbance of neural impulse propagation, and to full-blown demyelination. Proteases, abundantly present at inflammatory foci, can degrade myelin. Vasoactive amines may play an important role in breaching of the blood-brain/blood-nerve barrier. The importance of nitric oxide metabolites in inflammatory demyelination merits investigation. A better understanding of the multiple effector mechanisms operating in inflammatory demyelination may help to devise more efficacious antigen non-specific therapy.

Partial inhibition of AT-EAE by an antibody to ICAM-1: clinico-histological and MRI studies.

The role of quantitative proton magnetic resonance imaging (MRI) for the evaluation of immunopathological lesions in the CNS was studied in adoptively transferred experimental allergic encephalomyelitis (AT-EAE). We utilized a recently established treatment model, inhibition of the cell adhesion molecule ICAM-1 by the monoclonal antibody 1A-29. The animals were scanned on days 3, 5 and 7 after injection of encephalitogenic T-cells, before and after bolus injection of Gd-DTPA by performing T1-measurements to assess the integrity of the blood-brain barrier (BBB). On day 7, immunohistochemistry was performed looking for T-cells, activated macrophages, and albumin staining. There was clinical evidence of partial inhibition of AT-EAE in rats treated with antibodies against ICAM-1. This finding was in line with a significantly reduced number of T-cells in the medulla. However, the number of activated macrophages and the distribution of albumin did not differ from untreated AT-EAE animals. The histological findings are in agreement with the MRI data before and after Gd-DTPA injection which were similar in treated and untreated AT-EAE rats on day 3 and 5. On day 7 after Gd-DTPA injection there was evidence of a delayed breakdown of the BBB in the treated rats. The observation of a dissociation of clinical and MRI findings, especially evidence of Gd-enhancement despite clinical improvement, may be important in the context of interpreting MRI studies in MS patients in treatment trials.

The monoclonal antibody 23E9 defines a novel developmentally-regulated Schwann cell surface antigen.

The present study describes the identification and partial characterization of a novel Schwann cell surface molecule by means of a monoclonal antibody (23E9). The 23E9 antigen was found in association with Schwann cells of the peripheral nerve but not with sensory neurons and satellite cells of the dorsal root ganglion. The expression of the antigen in the sciatic nerve starts after birth, is high around postnatal day 8 and becomes down-regulated towards the adult stage. This suggests that it may be involved in the induction of myelin formation. On Western blots, the antibody identified two major bands of approximately 27 and 42 kDa. Treatment of cultured Schwann cells with forskolin, an agent known to mimic neuronal contact in vitro, stimulated the up-regulation of the antigen. This implies that the expression of 23E9 is induced and maintained by axon-derived signals in vivo. Comparison of the presented data with the literature suggests that we have identified a novel cell surface molecule not previously characterized in the context of Schwann cell biology. To clarify the molecular identity of the antigen and define its physiological relevance, the antibody will be used in future studies for immunoprecipitation and functional in vitro assays.

Attenuation of experimental autoimmune neuritis in the Lewis rat by treatment with an antibody to L-selectin.

The leukocyte adhesion molecule L-selectin plays a key role in the initial steps of transendothelial migration of T cells and monocytes. In this study we investigated the role of L-selectin in the pathogenesis of experimental autoimmune neuritis (EAN) an animal model of the Guillain-Barré syndrome. EAN was induced in Lewis rats by sensitization with peripheral nerve myelin. Treatment with HRL3, a monoclonal antibody to L-selectin, efficiently suppressed clinical signs of EAN. Histological examination of the peripheral nervous system (PNS) revealed a marked reduction of inflammatory infiltrates and demyelination during treatment with HRL3. We conclude that L-selectin-dependent mechanisms are of pathophysiological relevance in EAN. Modulation of L-selectin in vivo could be a novel therapeutic approach to autoimmune diseases of the PNS.

Expression of intercellular adhesion molecule-1 on rat microglial cells.

Microglial cells isolated from newborn rat brain displayed a baseline immunoreactivity for intercellular adhesion molecule-1 (ICAM-1) after 10-20 days in culture. ICAM-1 immunoreactivity was enhanced in a time-dependent fashion by exposing the microglial cells to recombinant rat gamma-interferon (gamma-IFN; 100 U/ml) or tumor necrosis factor-alpha (TNF-alpha; 1000 U/ml). We conclude that rat brain macrophages/microglial cells can be induced by gamma-IFN and TNF-alpha to express ICAM-1. This may be relevant in the interaction of microglial cells with other brain cells during inflammation of the central nervous system.

Role of the leukocyte-adhesion molecule L-selectin in experimental autoimmune encephalomyelitis.

L-selectin is an adhesion molecule expressed on T cells and monocytes. It mediates rolling--the initial step of transendothelial migration. In this study, we investigated the role of L-selectin in the pathogenesis of experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis. EAE was induced in Lewis rats by active sensitization with myelin basic protein (MBP-EAE), or by adoptive transfer using MBP specific T cells (AT-EAE). Treatment with HRL3, a monoclonal antibody to L-selectin, and its F(ab')2 fragments efficiently suppressed MBP-EAE, and had a mild inhibitory effect on AT-EAE. Histological examination revealed a marked reduction of inflammatory infiltrates after treatment with HRL3. Administration of the control antibody HRL4 did not significantly alter the course of the disease. HRL3 caused T-cell depletion in the draining lymph nodes and spleen and a downregulation of L-selectin expression on T cells. We conclude that L-selectin-dependent mechanisms are involved in the pathogenesis of EAE. Modulation of L-selectin in vivo by antibodies or by competitive antagonists could be a novel therapeutic approach to autoimmune diseases of the central nervous system.

Detection and quantification of antibodies to the extracellular domain of P0 during experimental allergic neuritis.

Quantification of the peripheral nerve myelin glycoprotein P0 and antibodies to P0 is difficult due to insolubility of P0 in physiological solutions. We have overcome this problem by using the water-soluble recombinant form of the extracellular domain of P0 (P0-ED) and describe newly developed assays which allow detection and quantitation of P0 and antibodies to P0, in serum and cerebrospinal fluid (CSF). These sensitive and specific assays based on the ELISA technique were used to study humoral immune responses to P0 during experimental autoimmune ("allergic") neuritis (EAN). In order to establish these tests, monoclonal antibodies to different epitopes of rodent and human P0-ED were produced. A two-antibody sandwich-ELISA allowing quantitation of P0 (lower detection limit of 0.5 ng/ml or 30 fmol/ml) and an antibody-capture ELISA (lower detection limit 1 ng specific antibody/ml) to detect antibodies to P0 in serum and CSF were developed. EAN was induced in rats by active immunization with bovine myelin or the neuritogenic protein P2 or by adoptive transfer using P2 specific CD4 positive T cells. Serum and CSF were assayed for the presence of P0-ED and antibodies to P0-ED or P2. Antibodies to P0-ED were detected during active myelin-induced EAN, but not during P2-induced or adoptive transfer EAN. The anti-P0-ED antibodies in the CSF showed a correlation with disease activity. In contrast, in the same model antibodies to P2 persisted long after the disease ceased. No soluble P0-like fragments could be found in serum or CSF during any of the three types of EAN. We conclude that P0 may be a B-cell epitope in EAN. These findings warrant a screen for antibodies to P0-ED in human immune neuropathies.

The immunopathogenesis of multiple sclerosis. A survey of recent advances and implications for future therapy.

The etiology of multiple sclerosis (MS) still remains elusive. However, the association of the disease with relevant genes, the characteristic white matter infiltrates, similarities with animal models, and the fact that MS can be treated with immunomodulatory and immunosuppressive therapies support the notion that this disorder is autoimmune in nature. During the last few years the knowledge about the mechanisms involved in the pathogenesis of MS increased rapidly. In this review, recent advances in our understanding about relevant pathomechanisms in inflammatory demyelinating diseases of the central nervous system will be discussed and the rational of some novel immunotherapies is explained in context of the current understanding of immunological principles.