Passively transferred Lambert-Eaton syndrome in mice receiving purified IgG

Purified IgG antibodies were prepared by ion-exchange chromatography from the plasma of a patient with nonneoplastic form of the Lambert-Eaton myasthenic syndrome (LES). The antibodies were injected into mice with daily doses of 0.15-10 mg for 20-22 days, following which the integrity of neuromuscular transmission was assessed in vitro in phrenic nerve-diaphragm muscle preparations. The injected animals manifested electrophysiologic features of human LES, which were characterized by: dose-dependent reduction in the quantal content of nerve-evoked endplate potentials, an abnormally small increase in the frequency of spontaneous miniature endplate potentials (MEPPs) with elevated [K+]o, and normal MEPP amplitude with no evidence of postjunctional deficiency. Crude immunoglobulins (Igs) from the same patient and two LES patients with associated malignancy similarly transferred the defects in quantal transmitter release. In contrast, animals receiving Igs from control subjects or from a patient with small-cell carcinoma of the lung manifested no functional impairment of neuromuscular transmission. Instead, the evoked release in these animals was significantly enhanced relative to that found in normal untreated mice. These results suggest that an IgG antibody produces the presynaptic impairment that is characteristic of LES and support the concept that LES with and without cancer has an autoimmune pathogenesis.

Suppression of terminal axonal sprouting at the neuromuscular junction by monoclonal antibodies against a muscle-derived antigen of 56,000 daltons

After the partial denervation or paralysis of a muscle, the remaining motor axon terminals may sprout fine, neuritic processes (terminal sprouts) which escape the endplate region of the neuromuscular junction. We previously identified a muscle-derived, protein antigen of 56,000 daltons (56 kD) which plays a necessary role in terminal sprouting. A panel of monoclonal antibodies have been produced against the 56-kD antigen, some of which also partially suppress motor axon terminal sprouting. These monoclonal antibodies define at least two different epitopes upon the surface of the antigen, one of which is necessary for it to effect its biological role in vivo.

Myasthenia gravis: demonstration of membrane attack complex in muscle end-plates

The membrane attack complex (MAC) assembles from C5b-9 complement components and has neoantigenic properties. Antihuman-MAC rabbit immunserum was applied in order to localize the MAC in myasthenic muscles. Using the indirect immunoperoxidase method MAC was demonstrated at the motor end-plates in eleven myasthenic patients who underwent thymectomy. This result provides direct evidence of antibody-dependent complement-mediated injury of acetylcholine receptors in myasthenia gravis.

Myasthenia gravis without acetylcholine-receptor antibody: a distinct disease entity

Immunoglobulin preparations from eight patients with clinical features of myasthenia gravis, in whom no serum antibody against acetylcholine receptor (AChR) could be detected, were injected intraperitoneally into mice. Neuromuscular transmission was significantly impaired compared with mice receiving control human immunoglobulin. No antibody bound to the mouse AChR was detected, but there was a small loss (9.4%) of AChR in the mouse diaphragms. Mice injected with myasthenic AChR-antibody-positive immunoglobulin and mice growing hybridoma cells secreting monoclonal AChR antibody showed similar impairment of neuromuscular transmission, but 75% and 94%, respectively, of their muscle AChR had antibody bound and AChR losses were 47% and 60%. The results suggest that a pathogenetic immunoglobulin antibody interferes with neuromuscular transmission in these AChR-antibody-negative patients by binding to non-AChR determinants at the neuromuscular junction. This form of myasthenia is immunologically and physiologically distinct from the AChR-antibody-positive form.

Region of peptide 125-147 of acetylcholine receptor alpha subunit is exposed at neuromuscular junction and induces experimental autoimmune myasthenia gravis, T-cell immunity, and modulating autoantibodies

A major antigenic region of native nicotinic acetylcholine receptors (AcChoR) has been identified by using a synthetic disulfide-looped peptide corresponding to alpha-subunit residues 125-147 of Torpedo electric organ AcChoR: Lys-Ser-Tyr-Cys-Glu-Ile-Ile-Val-Thr-His-Phe- Pro-Phe-Asp-Gln-Gln-Asn-Cys-Thr-Met-Lys-Leu-Gly. The peptide bound 26-56% of polyclonal antibodies induced in rat, rabbit, and dog by immunization with native AcChoR. Rats inoculated with 50 micrograms of unconjugated peptide developed helper T-cell responses, delayed hypersensitivity, and antibodies to native AcChoR. Anti-peptide antibodies were more reactive with native than denatured AcChoR and bound to the alpha subunit. Some reacted exclusively with mammalian muscle AcChoR, some induced modulation of AcChoR on cultured myotubes, but none inhibited binding of alpha-bungarotoxin to solubilized or membrane-associated AcChoR. Repeated immunization induced experimental autoimmune myasthenia gravis: clinical signs in one rat and electrophysiologic and/or biochemical signs in 10 of 11 rats. Thus, at least part of the corresponding region of the mammalian AcChoR alpha subunit is extracellular at the neuromuscular junction and a potential target for pathogenic autoantibodies in patients with acquired myasthenia gravis.

Myasthenic serum selectively blocks acetylcholine receptors with long channel open times at developing rat endplates

We have examined the physiological effects of antibodies from a highly specific myasthenic serum on acetylcholine receptors at developing rat endplates. The antibodies reduced the amplitude of miniature endplate potentials by 60% in 3- to 6-day-old animals but had no effect after day 14. Between days 7 and 12 the antibodies had an intermediate effect. This is the same period during which acetylcholine receptors with long channel open times (slow channels) disappear and receptors with short open times (fast channels) increase in number. Therefore, we examined the effect of the antibodies at endplates with a mixture of channel types more carefully. At all times tested, both noise analysis and analysis of miniature endplate currents showed that the antibodies reduced slow channel activity selectively. Single-channel recordings indicated that acetylcholine receptors that remained active after antibody treatment had normal gating properties. Thus, the antibodies appeared to silence slow channels selectively.

A postnatal change in the immunological properties of the acetylcholine receptor at rat muscle endplates

We have used a myasthenic serum that in adult rat muscle is specific for acetylcholine receptors (AChRs) in the extra-junctional membrane to characterize the AChRs at developing endplates. Immunocytochemical experiments show that AChRs at endplates in the rat diaphragm bind the myasthenic antibodies during the first week after birth but lose their reactivity during the second and third postnatal weeks. AChRs at endplates in adult rat diaphragm do not bind the antibodies even after denervation; in contrast, AChRs at endplates in an adult chicken muscle (anterior latissimus dorsi) are recognized by the antibodies. The loss of immunological reactivity thus may be correlated with a change in the channel properties of the AChR and with the appearance of synaptic folds, two postnatal developmental changes that occur at the endplates of rats, but not of chickens.

Antibodies to motor nerve terminals: an electrophysiological study of a human myasthenic syndrome transferred to mouse

Immunoglobulin G(IgG) prepared from the plasma of patients with a presynaptic disorder of neuromuscular transmission (Lambert-Eaton myasthenic syndrome, l.e.m.s.), or from normal pooled control human plasma, was injected into mice (10 mg daily) for up to 99 days. Micro-electrodes were used to record end-plate potentials from the diaphragm muscle bathed in normal Krebs solution containing tubocurarine (1.0-4.6 microM). At 0.5 Hz nerve stimulation frequency, the quantal content was significantly reduced (P less than 0.01-P less than 0.001) in mice treated with six l.e.m.s. patients' IgG each compared with paired controls. The pooled quantal content was 55 +/- 3 (n = 110 end-plates) for all test animals and 131 +/- 9 (n = 47) for all controls (P less than 0.001). During short trains at 20 or 40 Hz nerve stimulation, control muscles showed marked depression, while test muscles showed either facilitation or less marked depression. Quantal content throughout these trains remained lower than in controls. The results indicate that IgG antibody from l.e.m.s. patients can induce a similar physiologic disorder in injected mice, and they support the view that this antibody interferes with evoked release of transmitter in l.e.m.s. by binding to nerve terminal determinants.

T-lymphocytes in experimental autoimmune myasthenia gravis. Isolation of T-helper cell lines

The role of T-lymphocytes in Experimental Autoimmune Myasthenia Gravis (EAMG) was investigated. We generated highly purified, acetylcholine receptor (AChR)-specific T-cell populations and subsequently characterized these cell lines with respect to their membrane phenotype and their function. Using a series of mouse monoclonal antibodies directed against rat lymphocyte surface differentiation antigens, the vast majority of line cells was shown to express a leucocyte common antigen, a T-common antigen and a T-helper antigen. Small subpopulations were Ia or T suppressor antigen-positive. Adaptive transfer to sublethally irradiated, thymectomized recipients revealed that 1 X 10(6) AChR-specific line cells could cooperate effectively with 10 X 10(6) AChR-primed, complement (C3) receptor-bearing (B-cell enriched) spleen cells in the production of anti-AChR autoantibodies. Recipients of B-cells along with relevant line cells developed an acute myasthenic syndrome 6-7 days after cell transfer. Electron-microscopical examination revealed the typical features of "acute phase" EAMG with heavy mononuclear infiltration. There was, however, no evidence antibody-independent cytotoxic activity exerted by AChR-specific line cells.

The immunopathology of acquired myasthenia gravis

Specific probes (alpha-bungarotoxin for acetylcholine receptor (AChR), staphylococcal protein A for IgG, monospecific antibodies against C3 and C9) labelled with peroxidase were applied to study of the ultrastructure of the MG end plate. In each case of MG there was postsynaptic AChR deficiency, usually greatest at end plates with marked degeneration of junctional folds. Morphometric estimates of postsynaptic AChR correlated linearly with the MEPP amplitude. In each case of MG, IgG was localized on the postsynaptic membrane where AChR is known to be located and on debris in the synaptic space. The abundance of antibody was proportionate to the amount of AChR remaining at the end plate. The localization of C3 was essentially identical with that of IgG. For most cases of MG it can be inferred that binding of IgG and C3 to AChR does not interfere with receptor function. C9, the terminal lytic complement component, was localized on debris in the synaptic space and on remnants of junctional folds. This proves that complement mediated destruction of junctional folds occurs in human MG. Studies in experimental auto-immune MG indicate that antibody-dependent internalization of AChR occurs in subclinical, mild and more severe diseases but increased AChR synthesis can compensate for this in subclinical and mild myasthenia. Complement-mediated injury of the postsynaptic membrane appears to be a requirement for induction of more severe MG.

[Myasthenia gravis. Prototype of an anti-receptor autoaggression disease (author's transl)]

Myasthenia gravis is a classic autoaggression disease in which autoantibodies against the acetylcholine receptors (AChR) of the neuromuscular end-plate have a decisive patho-genetic significance. With sensitive radioimmunoassays anti-AChR antibodies are demonstrable in over 90% of myasthenics and consequently are of great diagnostic significance. The treatment possibilities to date have distinctly improved the prognosis but are either symptomatic or unspecific. More recent knowledge on pathophysiology and pathogenesis and the strategies for development of a specific immunotherapy deducible from this are discussed. X

Immunochemical properties of junctional and extrajunctional acetylcholine receptor

Immunological assays were performed to compare two distinct forms of the nicotinic acetylcholine receptor (AChR): junctional (JR) and extrajunctional receptor (EJR). Antibodies from myasthenia gravis patients' sera inhibited the binding of [125I]alpha-bungarotoxin (BGT), to EJR more effectively than binding to JR. Immunological differences between JR and EJR were confirmed by other assay methods. In all cases, EJR appeared to have antigenic determinants not found on JR. It was established that enzymatic removal of carbohydrates from EJR caused it to more closely resemble JR. Thus differences between JR and EJR may be due, in part, to carbohydrate residues found on EJR that are absent on JR. The extent of antibody binding to EJR was examined by gel filtration methods. Immunochemical studies of bands from SDS gels showed that antibodies are present in myasthenic serum which react with the 3 subunits (42, 53, 64 kdaltons) of AChR to varying degrees.

Myasthenia gravis: passive transfer to mice of antibody to human and mouse acetylcholine receptor

Mice were given intraperitoneal injections of serum from three patients with myasthenia gravis who had different titers of antibody against mouse acetylcholine receptor (AChR). Almost all mice treated with a high titer of serum antigens showed generalized paralysis, reduced amplitudes of miniature endplate potential (MEPP), or reduced numbers of AChRs. The effects were less marked in serum with lower titers of antibody to mouse AChR, when there was no relation to the severity of effects to the titer of antibody to human AChR.

Properties of end-plate channels in rats immunized against acetylcholine receptors

1. Rats injected with purified acetylcholine receptors (AChR) extracted from electric organs of Torpedo marmorata showed clinical symptoms consistent with the development of experimental myasthenia gravis.2. Sera of rats with this disease contain high levels of anti-AChR antibodies. However, no simple correlation was found between antibody titre and miniature end-plate current (m.e.p.c.) amplitude.3. M.e.p.c.s. at the end-plates of rats injected with AChR (Anti-R), emulsified in complete Freund Adjuvant (CFA), were reduced to about one third the size of controls taken from rats injected only with CFA (Anti-CFA). Mean m.e.p.c. (Anti-R) = 0.73 +/- 0.06 nA; mean m.e.p.c. (Anti-CFA) = 2.43 +/- 0.12 nA (V(m) = -80 mV, T = 20 degrees C).4. The m.e.p.c. decay time constant, tau(m.e.p.c.), is similar at immunized and control rat end-plates. tau(m.e.p.c.) (Anti-R) = 1.32 +/- 0.06 msec; tau(m.e.p.c.) (Anti-CFA) = 1.31 +/- 0.06 msec (V(m) = -80 mV, T = 20 degrees C).5. The end-plate current decay time constant, tau(e.p.c.), is similar at immunized and control end-plates and in both cases depends exponentially on membrane potential. The change in membrane potential required to produce an e-fold change in tau(e.p.c.) is 102.0 +/- 5.72 mV at immunized (Anti-R) end-plates and 92.3 +/- 6.14 mV at control (Anti-CFA) end-plates at T = 10 degrees C.6. Acetylcholine noise was examined at immunized and control rat end-plates at 10 degrees C. Analysis of noise indicates that the single channel conductance, gamma, and mean channel life-time, tau(noise), are essentially unchanged by immunization against AChR. gamma (Anti-R) = 13.15 +/- 0.53 pS; gamma (Anti-CFA) = 12.50 +/- 0.50 pS; tau(noise) (Anti-R) = 2.9 +/- 0.18 msec; tau(noise) (Anti-CFA) = 2.68 +/- 0.14 msec (V(m) = -80 mV, T = 10 degrees C).7. Mean quantal content and Ca(2+) dependence of the end-plate potential are unchanged at immunized end-plates.8. It is concluded that at immunized end-plates the number of activated receptor-channel complexes is reduced without modification of single channel properties. In this respect the immunized rat end-plate is a good model for myasthenia gravis affected human end-plates.

Passively transferred myasthenia gravis: protection of mouse endplates by Fab fragments from human myasthenic IgG

Using the mouse passive transfer model, the effects of purified human myasthenic immunoglobulin G and of the monovalent Fab fragment on neuromuscular junctions were investigated. Treatment with IgG markedly reduced amplitudes of miniature endplate potentials. When Fab fragments were transferred alone or with subsequent addition of IgG no neuromuscular transmission block was induced. Myasthentic IgG and Fab were specifically demonstrated at the neuromuscular junctions by immunohistochemistry. On electronmicroscopy endplate structure was normal in transfer experiments using IgG for up to 30 days. It is suggested that Fab fragments bind to acetylcholine receptors without affecting transmission and protect them from the attack of complete IgG antibodies.

Anti-acetylcholine receptor antibodies

Early suggestions that a humoral factor might be implicated in the disorder of neuromuscular transmission in myasthenia gravis have been confirmed by the detection of anti-AChR antibody in 85-90% of the patients with generalised disease and in 75% of cases with restricted ocular myasthenia. Plasma exchange reveals that serum anti-AChR usually has an inverse relationship to muscle strength and present evidence indicates that patients responding to thymectomy and immunosuppressive drug treatment usually show a consistent decline in serum anti-AChR titres. The antibody is heterogeneous and can lead to a loss of muscle AChR by several mechanisms. Anti-AChR is produced in the thymus in relatively small amounts. Anti-AChR antibody synthesis by thymic lymphocytes and pokeweed stimulated peripheral lymphocytes in culture provides a means of studying the effect of different lymphocyte populations in vitro. Analysis of clinical, immunological and HLA antigen characteristics in MG suggest that more than one mechanism may underlie the breakdown in tolerance to AChR, leading to the production of anti-AChR antibodies.

Ultrastructural localization of the terminal and lytic ninth complement component (C9) at the motor end-plate in myasthenia gravis

The terminal and lytic complement component (C9) was localized at the motor end-plate in acquired autoimmune myasthenia gravis (MG) by the immunoperoxidase method, with adequate preservation of fine structure and negligible background staining. C9 was localized on short segments of the postsynaptic membrane on degenerated fragments of the junctional folds shed into the synaptic space, and on disintegrating junctional folds. An inverse relationship was noted between the structural integrity of the junctional folds and the abundance of C9 at a given end-plate region. Destruction of junctional folds by complement may induce relocation of the nerve terminal and increased spatial separation of end-plate regions on the muscle fiber. Destruction of junctional folds by the complement membrane attack complex is a cause of the acetylcholine receptor deficiency at the MG end-plate, but antibody-dependent modulation of the receptor may also contribute to deficiency of the receptor. In certain disorders other than autoimmune MG, pathological mechanisms other than complement-mediated lysis may affect the structural integrity of the postsynaptic region.

Antibodies to acetylcholine receptor in patients with thymoma but without myasthenia gravis

Antibodies to acetylcholine receptor were found in 3 of 11 patients with a thymoma removed by operation but without myasthenia gravis. Because masthenia gravis may appear after removal of the thymoma, detection of antiacetylcholine receptor antibodies may have predictive value.