Exame de dosagem de anticorpo anti-receptor de acetilcolina para diagnóstico da Miastenia Gravis / Examination of anti-receptor antibody dosage acetylcholine for the diagnosis of Myasthenia Gravis

INTRODUÇÃO: A MG é uma doença autoimune da junção neuromuscular que se apresenta com fraqueza muscular localizada ou generalizada. Na maioria dos casos, a doença é causada por anticorpos contra receptores de acetilcolina (anti-AChR), que estão presentes em cerca de 85% e 50% dos pacientes com as formas generalizadas e ocular, respectivamente. O diagnóstico de MG é definido de acordo com manifestações clínicas, além de provas sorológicas ou eletroneuromiográficas, que apresentam sensibilidade e especificidade variadas de acordo com a apresentação da doença. A estimulação nervosa repetitiva é o estudo eletroneuromiográfico complementar atualmente disponível no Sistema Único de Saúde (SUS) para diagnóstico de MG. TECNOLOGIA: Dosagem de anticorpo anti-receptor de acetilcolina. PERGUNTA: o exame diagnóstico de dosagem de anticorpos anti-acetilcolina pode ser uma alternativa à eletroneuromiografia (estimulação nervosa repetitiva ­ ENR) para o diagnóstico da MG? EVIDÊNCIAS CIENTÍFICAS: Uma revisão sistemática (RS) e dois estudos clínicos prospectivos de avaliação de métodos diagnósticos de MG foram incluídos. A RS incluiu sete estudos de avaliação de anticorpos anti-AChR e sete estudos de avaliação da ENR. As estimativas de acurácia do anti-AChR na RS foram agrupadas de acordo com o delineamento dos estudos, evidenciando sensibilidade de 44% a 66% na MG ocular e de 90% a 96% na MG generalizada, sem variação na especificidade (98% a 99% em ambas as apresentações). Os estudos da ENR foram muitos heterogêneos e evidenciaram sensibilidade entre 11% a 39% no diagnóstico da MG ocular, e entre 32% a 98% na MG generalizada, com especificidade elevada em ambos os casos (94% a 97%). Os estudos individuais evidenciaram sensibilidade de 73% a 74% para MG generalizada e de 38% a 70% para MG ocular para o anti-AChR, e sensibilidade de 80% a 83% para MG generalizada e de 45% a 62% para MG ocular. As avaliações do risco de viés dos estudos incluídos demonstraram alto risco de viés para a RS e baixo risco para a maioria dos domínios avaliados nos estudos de coorte. AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO: A estimativa de custo global anual do exame anti-AChR no cenário base foi de aproximadamente 155 mil reais, com impacto cumulativo em 5 anos de 788 mil reais. Considerando que uma parcela dos indivíduos necessitará submeter-se adicionalmente ao exame eletroneuromiográfico, o que implicaria em aproximadamente 15 mil reais a mais por ano, o custo total do diagnóstico da doença foi de cerca de 170 mil reais a mais por ano, e de cerca de 867 mil reais ao final do quinto ano de incorporação. Na análise de sensibilidade, foram observados valores de custo total de 165 mil reais no cenário mais otimista e acima de 2 milhões de reais no cenário mais pessimista, para o diagnóstico de MG no período de 5 anos. A variável de maior impacto nos resultados foi a população inicial, seguida do custo do exame anti-AChR. CONSIDERAÇÕES FINAIS: A dosagem de anticorpos anti-AChR é um exame confirmatório essencial para diagnóstico de MG. De maneira geral, os estudos evidenciam sensibilidade superior à ENR, tanto no diagnóstico da forma ocular quanto generalizada da doença, com elevada especificidade. Os estudos de ENR foram heterogêneos e evidenciaram diferentes níveis de acurácia de acordo com o número e localização dos estímulos avaliados, o que não ocorre no cenário da dosagem de anticorpos. As avaliações do risco de viés dos estudos incluídos demonstraram alto risco de viés para a RS e baixo risco para a maioria dos domínios avaliados nos estudos de coorte. Não foram identificadas recomendações de diagnóstico de MG em agências de ATS, mas diretrizes internacionais recomendam o exame como etapa inicial no diagnóstico da doença. RECOMENDAÇÃO PRELIMINAR: A Conitec, em sua 93ª reunião ordinária, realizada no dia 08 de dezembro de 2020, deliberou que a matéria fosse disponibilizada em consulta pública com recomendação preliminar favorável à incorporação do exame de dosagem de anticorpos anti-acetilcolina para diagnóstico da Miastenia Gravis no Sistema Único de Saúde. Considerouse, entre outros fatores, que, o exame de avaliação de anticorpos anti-AChR possui uma maior sensibilidade diagnóstica em comparação ao exame eletroneuromiográfico, além disso eletroneuromiografia é um exame demorado e requer um treinamento específico para sua realização. Consequentemente, o tratamento precoce da miastenia gravis poderia ser comprometido. CONSULTA PÚBLICA: A consulta pública nº 68 ficou vigente entre os dias 05/01/2021 e 25/01/2021. Foram recebidas nove contribuições, sendo cinco pelo formulário para contribuições técnico-científicas e quatro pelo formulário para contribuições sobre experiência ou opinião. Estas foram provenientes de pacientes, familiares, amigos ou cuidadores de pacientes, profissionais de saúde ou pessoas interessadas no tema. A maioria das contribuições (77,8%) concordou com a recomendação preliminar da Conitec. Uma contribuição foi neutra (nem concorda e nem discorda) e uma contribuição discordou da recomendação preliminar da Conitec, no entanto, ambas estas contribuições não apresentaram justificativa. As contribuições abordaram, principalmente, os pontos positivos da incorporação da dosagem de anticorpos anti-AChR para o diagnóstico de MG. Não foram solicitadas alterações no texto ou apresentadas referências ou anexos. Houve apenas um argumento sobre a possibilidade de inclusão de anti MUSK para melhoria do atendimento dos demais casos negativos do anticorpo anti-receptor de acetilcolina. Porém, como não houve uma demanda ou pergunta de pesquisa priorizada no escopo, a tecnologia não foi avaliada formalmente pela Conitec. RECOMENDAÇÃO FINAL: Os membros da Conitec presentes na 95ª reunião ordinária, no dia 03 de março de 2021, consideraram que o procedimento possui um corpo de evidências que favorece o exame de dosagem de anticorpos antiacetilcolina para diagnóstico da Miastenia Gravis. Considerou-se a maior sensibilidade e facilidade deste exame comparado à eletroneuromiografia. Diante do exposto, o Plenário deliberou por unanimidade recomendar a incorporação do exame de dosagem de anticorpo anti-receptor de acetilcolina para diagnóstico de Miastenia Gravis. Foi assinado o Registro de Deliberação nº 593/2021. DECISÃO: incorporar o exame de dosagem de anticorpo antirreceptor de acetilcolina para diagnóstico de Miastenia Gravis, do Sistema Único de Saúde - SUS, conforme Portaria nº 11, publicada no Diário Oficial da União nº 74, seção 1, página 235, em 19 de abril de 2021.

Acetylcholine receptor-alpha subunit expression in myasthenia gravis: a role for the autoantigen in pathogenesis?

Previous studies have shown increased expression of acetylcholine receptor-alpha (AChR-alpha) subunit transcripts in myasthenia gravis (MG) and experimental MG (EAMG), but none examined the functional properties of this overexpression. In this study we examined the mRNA and protein expression of AChR-alpha as well as the pattern of alpha-bungarotoxin labeling in muscle tissue from EAMG mice with varying disease severity. AChR-alpha expression was increased considerably in endplates from mice with severe EAMG, but it was distinct and greatly in excess of alpha-bungarotoxin labeling. This "aberrant expression" occurred in mice with morphologic endplate damage, and the pattern of complement and immunoglobulin deposition in muscle from these mice appeared to mirror the pattern of AChR-alpha expression. The loss of functional AChR in severe MG increases transcription of AChR-alpha mRNA, but the expressed protein is "functionally inert," failing to compensate for loss of AChR. This enhanced expression of AChR may play a role in driving the ongoing autoimmune response. Muscle Nerve 40: 279-286, 2009.

Identification of agrinSN isoform and muscle-specific receptor tyrosine kinase (MuSK) [corrected] in sperm.

We previously demonstrated several nicotinic acetylcholine receptor (nAChR) subunits and associated proteins in human sperm. Here, we identified in sperm for the first time two additional nAChR-associated molecules: (1) agrin(SN)Z(+) in human sperm localized in the posterior post-acrosomal, neck, and flagellar mid-piece regions; (2) a low-molecular weight isoform of muscle-specific receptor tyrosine kinase in human and mouse sperm localized in the flagellar mid-piece of human sperm.

Novel immunotoxin: a fusion protein consisting of gelonin and an acetylcholine receptor fragment as a potential immunotherapeutic agent for the treatment of Myasthenia gravis.

In continuation of our attempts for antigen-specific suppression of the immune system [I.L. Urbatsch, R.K.M. Sterz, K. Peper, W.E. Trommer, Eur. J. Immunol. 23(1993) 776-779] a novel fusion protein composed of amino acids 4-181 of the extracellular domain of the alpha-subunit of the human muscle acetylcholine receptor and the plant toxin gelonin was expressed in Escherichia coli. The fusion protein formed inclusion bodies but could be solubilized in the presence of guanidinium hydrochloride. After a simple two step purification and refolding procedure, it exhibited a native structure at least in the main immunogenic region as shown by antibodies recognizing a conformational epitope. Half maximal inhibition of translation was achieved at 46 ng/ml as compared to 4.6 ng/ml for native and 2.4 for recombinant gelonin. Its use as therapeutic agent for the treatment of Myasthenia gravis was investigated in an animal model. Female Lewis rats were immunized with complete acetylcholine receptor from the electric ray Torpedo californica and developed thereafter experimental autoimmune M. gravis. Quantitative assessment of the disease was achieved by repetitive stimulation of the Nervus tibialis. Rats showed no symptoms of M. gravis, neither visually nor electrophysiologically after treatment with the fusion protein as determined one and seven weeks after the second application. This approach may also be useful for the therapy of further autoimmune diseases by substituting other autoantigens for the AchR fragment in the fusion protein.

Effects of cytokines on acetylcholine receptor expression: implications for myasthenia gravis.

Myasthenia gravis is an autoimmune disease associated with thymic pathologies, including hyperplasia. In this study, we investigated the processes that may lead to thymic overexpression of the triggering Ag, the acetylcholine receptor (AChR). Using microarray technology, we found that IFN-regulated genes are more highly expressed in these pathological thymic tissues compared with age- and sex-matched normal thymus controls. Therefore, we investigated whether proinflammatory cytokines could locally modify AChR expression in myoid and thymic epithelial cells. We found that AChR transcripts are up-regulated by IFN-gamma, and even more so by IFN-gamma and TNF-alpha, as assessed by real-time RT-PCR, with the alpha-AChR subunit being the most sensitive to this regulation. The expression of AChR protein was increased at the cytoplasmic level in thymic epithelial cells and at the membrane in myoid cells. To examine whether IFN-gamma could influence AChR expression in vivo, we analyzed AChR transcripts in IFN-gamma gene knock-out mice, and found a significant decrease in AChR transcript levels in the thymus but not in the muscle, compared with wild-type mice. However, up-regulation of AChR protein expression was found in the muscles of animals with myasthenic symptoms treated with TNF-alpha. Altogether, these results indicate that proinflammatory cytokines influence the expression of AChR in vitro and in vivo. Because proinflammatory cytokine activity is evidenced in the thymus of myasthenia gravis patients, it could influence AChR expression and thereby contribute to the initiation of the autoimmune anti-AChR response.

Amplification of acetylcholine-binding catenanes from dynamic combinatorial libraries.

Directed chemical synthesis can produce a vast range of molecular structures, but the intended product must be known at the outset. In contrast, evolution in nature can lead to efficient receptors and catalysts whose structures defy prediction. To access such unpredictable structures, we prepared dynamic combinatorial libraries in which reversibly binding building blocks assemble around a receptor target. We selected for an acetylcholine receptor by adding the neurotransmitter to solutions of dipeptide hydrazones [proline-phenylalanine or proline-(cyclohexyl)alanine], which reversibly combine through hydrazone linkages. At thermodynamic equilibrium, the dominant receptor structure was an elaborate [2]-catenane consisting of two interlocked macrocyclic trimers. This complex receptor with a 100 nM affinity for acetylcholine could be isolated on a preparative scale in 67% yield.

Intracellular domains of the delta-subunits of Torpedo and rat acetylcholine receptors--expression, purification, and characterization.

There are quite detailed structural data on the extracellular ligand-binding domain and the intramembrane channel-forming domain of the nicotinic acetylcholine receptors (nAChR). However, the structure of the intracellular domain, which has variable amino acid sequences in different nAChR subunits, remains unknown. We expressed in Escherichia coli the intracellular loops (between transmembrane fragments TM3 and TM4) of the delta-subunits from the Torpedo californica and Rattus norvegicus muscle nAChRs. To facilitate purification, (His)6-tags were attached with or without linkers, and the effects of protein truncations at C- or N-termini were examined. The proteins were purified from inclusion bodies under denaturing conditions by Ni-NTA-chromatography. Molecular weight and peptide mass fingerprint was determined by MALDI mass spectrometry. Size-exclusion chromatography revealed that the Torpedo intracellular delta-loop refolded in an aqueous buffer was present in solution as a dimer. Phosphorylation of this protein with protein kinase A and tyrosine kinase (Abl) occurred at the same serine and tyrosine residues as in the native receptor. According to CD spectra, the secondary structure was not sensitive to phosphorylation. The rat intracellular loops could be solubilized only in the presence of non-ionic detergents or lipids. CD spectra indicate that the Torpedo and rat proteins have differences in their secondary structure. In the presence of dodecylphosphocholine, high concentrations (up to 6 mg/ml) of the Torpedo and rat intracellular loops were achieved. The results suggest that the spatial structure of the intracellular loops is dependent on environment and species, but is not changed significantly upon enzymatic phosphorylation.

Development of an assay for modulating anti-acetylcholine receptor autoantibodies using human rhabdomyosarcoma cell line.

Three types of autoantibodies against the acetylcholine receptors (AChR) of skeletal muscle are detectable in patients with myasthenia gravis including binding, blocking, and modulating anti-AChR antibodies. Modulating autoantibodies correlate best with the severity of the disease, but are also technically most difficult to measure because the assay generally requires fresh human muscle cells. We have developed an assay for the modulation of anti-AChR antibodies using a rhabdomyosarcoma (RD) cell line expressing AChR on the cell surface. By decreasing the FetalClone III serum from 10% to 0.5% in Eagles Minimal Essential Medium (EMEM) we were able to increase the number of AChR on RD cells to meet the need of sensitivity of the assay. The extent of modulation was determined as the percent of AChR internalized in the presence or absence of modulating autoantibodies. Less than 6% modulation was found with the normal serum (n = 42). The CVs of both the intra- and day-to-day precision were less than 20%. When clinical samples (n = 105) were assayed in our laboratory and also at Nichols Institute, a correlation coefficient of 0.816 was obtained. The selection of RD cell line, the success of increasing the expression of the AChR on RD cells and the use of 125I alpha-bungarotoxin of high specific activity allowed the establishment of an assay which can be used in routine clinical laboratory for the measurement of modulating anti-AChR autoantibodies for the management of patients with myasthenia gravis.

An improved method for the simultaneous demonstration of mRNA and esterase activity at the human neuromuscular junction.

The aim of this study was to develop a simple means of studying the distribution of mRNA coding for post-synaptic proteins at the human neuromuscular junction. A reliable method by which to identify the junctions in tissue sections after in situ hybridization was essential. A method is described for combining the histochemical demonstration of esterase activity at the neuromuscular junction with autoradiographic localization of mRNA by in situ hybridization in the same cryostat section of skeletal muscle. The indigogenic esterase method of Strum and Hall-Craggs (1982) was modified in such a way that it is able to survive the multiple steps involved in in situ hybridization and autoradiography. The protocol is simple and reproducible and has been used successfully on sections of both rat and human skeletal muscle. To demonstrate the method, sections were reacted to reveal esterase activity and were then processed for in situ hybridization using a 35S-labelled probe specific for the epsilon-subunit of the acetylcholine receptor. The reaction product was retained after the lengthy in situ hybridization and autoradiographic procedures. To our knowledge, this is the first demonstration of acetylcholine receptor mRNA by in situ hybridization at human neuromuscular junctions.

Reverse-phase chromatography isolation and MALDI mass spectrometry of the acetylcholine receptor subunits.

A procedure for purifying the Torpedo californica nicotinic acetylcholine receptor subunits is proposed which involves preparative SDS-PAGE followed by reverse-phase HPLC on a C4 column in an acetonitrile-isopropanol system. By this method, the alpha-subunit can be completely separated from the 43-kDa protein which migrates very close to it on SDS-PAGE, and the delta-subunit can be isolated free from the beta-subunit of Na+, K(+)-ATPase comigrating with it on SDS-PAGE. The purity of all acetylcholine receptor subunits thus obtained was verified by Edman degradation and MALDI mass-spectrometric analysis which could be performed quite easily on the HPLC-purified samples. In general, we observed a good correlation between the experimentally determined molecular masses and those calculated from the amino acid sequences and when known, posttranslational modifications (glycosylation and phosphorylation) of individual receptor subunits. Transfer of the isolated receptor subunits into 1% octyl-beta-D-glucopyranoside generates samples suitable for functional studies and enzymatic proteolysis or deglycosylation.

Highly purified oligo-His tagged human recombinant alpha(1)-AChR is immunogenic in vivo and suitable for T cell stimulation in vitro in experimental and human myasthenia gravis.

Using recombinantly expressed proteins for selection of antigen-specific T cell lines carries a high risk of selecting T cells specific for contaminating proteins. This risk is especially high for very hydrophobic proteins which are notoriously difficult to purify, such as the integral membrane protein acetylcholine receptor (AChR). We prepared a highly purified recombinant AChR by adding an oligo-histidine affinity-tag to the human alpha(1)-AChR and expressing it in E. coli. This allowed purification by Ni-NTA chromatography and subsequent electroelution from preparative SDS gel as purification steps, resulting in complete purity as assessed by silver stain on SDS-PAGE. This protein preparation induced fatal experimental allergic myasthenia gravis in Lewis rats. Furthermore, the protein could be used to select T cell lines from immunized Lewis rats and patients with myasthenia gravis. However, even with this highly purified protein, one of 8 Lewis rat T cell lines and 3 of 7 human T cell lines cross-reacted to E. coli control proteins. The results show that oligo-histidine tagged, highly purified human alpha(1)-AChR is highly immunogenic in vivo and in vitro.

Distribution of alpha-dystroglycan during embryonic nerve-muscle synaptogenesis.

The distribution of alpha-dystroglycan (alpha DG) relative to acetylcholine receptors (AChRs) and neural agrin was examined by immunofluorescent staining with mAb IIH6 in cultures of nerve and muscle cells derived from Xenopus embryos. In Western blots probed with mAb IIH6, alpha DG was evident in membrane extracts of Xenopus muscle but not brain. alpha DG immunofluorescence was present at virtually all synaptic clusters of AChRs and neural agrin. Even microclusters of AChRs and agrin at synapses no older than 1-2 h (the earliest examined) had alpha DG associated with them. alpha DG was also colocalized at the submicrometer level with AChRs at nonsynaptic clusters that have little or no agrin. The number of large (> 4 microns) nonsynaptic clusters of alpha DG, like the number of large nonsynaptic clusters of AChRs, was much lower on innervated than on noninnervated cells. When mAb IIH6 was included in the culture medium, the large nonsynaptic clusters appeared fragmented and less compact, but the accumulation of agrin and AChRs along nerve-muscle contacts was not prevented. It is concluded that during nerve-muscle synaptogenesis, alpha DG undergoes the same nerve-induced changes in distribution as AChRs. We propose a diffusion trap model in which the alpha DG-transmembrane complex participates in the anchoring and recruitment of AChRs and alpha DG during the formation of synaptic as well as nonsynaptic AChR clusters.

Suppression of experimental autoimmune myasthenia gravis by nasal administration of acetylcholine receptor.

Experimental autoimmune myasthenia gravis (EAMG) is a well established animal model, which can be induced in various animal species and strains with acetylcholine receptor (AChR) and represents an experimental counterpart of human myasthenia gravis (MG). Current immunotherapies of both EAMG and MG are non-specific and limited by their toxicity. Tolerance to EAMG has been achieved by oral administration of milligram quantities of Torpedo AChR. In the present report we demonstrate that nasal administration of microgram doses of Torpedo AChR to female Lewis rats prior to immunization with Torpedo AChR and complete Freund's adjuvant resulted in the prevention of subsequently induced EAMG, the suppression of serum anti-AChR antibody levels, the decrease of delayed-type hypersensitivity responses to AChR, as well as the suppression of AChR-specific immunoglobulin G-secreting cells, AChR-reactive interferon-gamma-secreting cells and T cell proliferation in peripheral lymphoid organs, particularly in popliteal and inguinal lymph nodes regional to immunization. We conclude that clinical signs of EAMG can be efficiently prevented by nasal administration of AChR in parallel with the downregulation of both B and T cell responses specific to AChR.

Use of complementary peptides and their antibodies in B-cell-mediated autoimmune disease: prevention of experimental autoimmune myasthenia gravis with a peptide vaccine.

We have developed and describe a new method of altering B-cell-mediated autoimmune diseases by induction of anti-idiotypic (Id) antibodies (Abs) by immunization with complementary peptides. Specifically, a peptide denoted RhCA 67-16 encoded by RNA complementary to RNA for the Torpedo acetylcholine receptor (AChR) main immunogenic region, AChR 61-76, was tested in the Lewis rat model of experimental autoimmune myasthenia gravis (EAMG). Immunization with RhCA 67-16 induced monoclonal and polyclonal anti-Id Ab against Abs to Torpedo AChR 61-76. RhCA 67-16 antisera inhibited AChR binding by AChR-specific Abs. In addition, a mAb to RhCA 67-16 (denoted TCM 240) recognized two well known EAMG-causing mAbs, 6 and 35. TCM 240, but not a control mAb F28C, inhibited mAb 6 binding to Torpedo AChR 67-76 peptide. mAb 35 binding to TCM 240 was inhibited by native Torpedo AChR as well as by RhCA 67-16. In in vivo experiments, immunization with a RhCA 67-16 keyhole limpet hemacyanin (KLH) conjugate blocked the development of EAMG after challenge with native Torpedo AChR (25% disease incidence versus 90% in the controls). This new approach may provide a novel therapy for MG and perhaps other B-cell-mediated autoimmune disorders through the induction of anti-Id Abs with complementary peptide antigens.

Interleukin-2 secreting cells in multiple sclerosis and controls.

To evaluate systemic T cell activation and reactivity against putative autoantigens in multiple sclerosis (MS), numbers of interleukin-2 (IL-2) secreting cells were determined in peripheral blood of 32 patients with MS, 7 patients with acute aseptic meningitis (AM) and 12 patients with tension headache (TH). Numbers of IL-2 secreting cells were higher in MS patients compared to patients with AM + TH after stimulation with myelin proteolipid protein (PLP), myelin associated glycoprotein (MAG) and myelin oligodendrocyte glycoprotein (MOG), but not after stimulation with myelin basic protein (MBP). In response to MAG, MOG and acetylcholine receptor (AChR) the frequencies of IL-2 secreting cells were higher in patients with MS than TH, while there were no differences between AM and TH to any of the tested antigens. Between patients with MS and AM there was no difference regarding frequency of IL-2 secreting cells in response to any of the tested antigens except MAG to which the response was higher in MS patients. Six of 10 MS patients had IL-2 secreting cells in response to all four myelin antigens (MBP + PLP + MAG + MOG) or to three antigens, while this broad reactivity was not found in any control patient. There was no correlation between numbers of IL-2 secreting cells in MS patients and clinical variables, including exacerbation versus remission, disability and duration of disease. The results suggest that the systemic T cell response in patients with MS is directed to several antigens.

Clustering and immobilization of acetylcholine receptors by the 43-kD protein: a possible role for dystrophin-related protein.

Recombinant acetylcholine receptors (AChRs) expressed on the surface of cultured fibroblasts become organized into discrete membrane domains when the 43-kD postsynaptic protein (43k) is co-expressed in the same cells (Froehner, S.C., C. W. Luetje, P. B. Scotland, and J. Patrick, 1990. Neuron. 5:403-410; Phillips, W. D., M. C. Kopta, P. Blount, P. D. Gardner, J. H. Steinbach, and J. P. Merlie. 1991. Science (Wash. DC). 251:568-570). Here we show that AChRs present on the fibroblast cell surface prior to transfection of 43k are recruited into 43k-rich membrane domains. Aggregated AChRs show increased resistance to extraction with Triton X-100, suggesting a 43k-dependent linkage to the cytoskeleton. Myotubes of the mouse cell line C2 spontaneously display occasional AChR/43k-rich membrane domains that ranged in diameter up to 15 microns, but expressed many more when 43k was overexpressed following transfection of 43k cDNA. However, the membrane domains induced by recombinant 43k were predominantly small (< or = 2 microns). We were then interested in whether the cytoskeletal component, dystrophin related protein (DRP; Tinsley, J. M., D. J. Blake, A. Roche, U. Fairbrother, J. Riss, B. C. Byth, A. E. Knight, J. Kendrick-Jones, G. K. Suthers, D. R. Love, Y. H. Edwards, and K. E. Davis, 1992. Nature (Lond.). 360:591-593) contributed to the development of AChR clusters. Immunofluorescent anti-DRP staining was present at the earliest stages of AChR clustering at the neuromuscular synapse in mouse embryos and was also concentrated at the large AChR-rich domains on nontransfected C2 myotubes. Surprisingly, anti-DRP staining was concentrated mainly at the large, but not the small AChR clusters on C2 myotubes suggesting that DRP may be principally involved in permitting the growth of AChR clusters.