B cells capable of spontaneous IgG secretion in cerebrospinal fluid from patients with multiple sclerosis: dependency on local IL-6 production

B cells as a target of immune modulation

B cells have recently been identified as an integral component of the immune system; they play a part in autoimmunity through antigen presentation, antibody secretion, and complement activation. Animal models of multiple sclerosis (MS) suggest that myelin destruction is partly mediated through B cell activation (and plasmablasts). MS patients with evidence of B cell involvement, as compared to those without, tend to have a worse prognosis. Finally, the significant decrease in new gadolinium-enhancing lesions, new T2 lesions, and relapses in MS patients treated with rituximab (a monoclonal antibody against CD20 on B cells) leads us to the conclusion that B cells play an important role in MS and that immune modulation of these cells may ameliorate the disease. This article will explore the role of B cells in MS and the rationale for the development of B cell-targeted therapeutics. MS is an immune-mediated disease that affects over 2 million people worldwide and is the number one cause of disability in young patients. Most therapeutic targets have focused on T cells; however, recently, the focus has shifted to the role of B cells in the pathogenesis of MS and the potential of B cells as a therapeutic target.

Rituximab (anti-CD20) adjunctive therapy for opsoclonus-myoclonus syndrome

PURPOSE

To determine if rituximab, an anti-CD20 monoclonal antibody, reduces cerebrospinal fluid (CSF) B-cell expansion in opsoclonus-myoclonus syndrome (OMS) and results in clinical improvement.

METHODS

Sixteen children with OMS and increased % CD20 B-cells in CSF received 4 rituximab infusions (375 mg/m IV) as add-on therapy to corticotropin (ACTH), intravenous immunoglobulins, or both, and were reevaluated 6 months later. Outcome measures were clinical (motor function, behavior, sleep) and immunologic (CSF and blood immunophenotype and Ig levels). Controls were 16 age-matched and sex-matched children, who did not have OMS.

RESULTS

After rituximab, 81% of OMS had a lower motor severity score, and 44% improved one severity category. Mean total score decreased by 44% (P = 0.0005). Rituximab reduced rage score, nighttime awakenings, and the number of children with opsoclonus, action myoclonus, drooling, gait ataxia, and rage. Despite a 51% reduction in ACTH dose, 9 of 11 children on ACTH did not relapse. The percentage of CSF CD19 (and CD20) B-cells was lowered in all children (undetectable in 6), with a 90% reduction in the group mean (P = 0.00003). CSF B-cells were no longer expanded compared with controls. In blood, CD19 B-cells decreased (-90%, P = 0.0003), as did the CSF:blood CD19 B-cell ratio (P = 0.00003). Serum IgM fell by 69% (below reference range), with no statistically significant change in IgG or IgA.

CONCLUSIONS

Rituximab seems efficacious and safe as adjunctive therapy for OMS. Selective targeting of CSF B lymphocytes represents a novel and valuable paradigm shift in the therapy for centrally mediated paraneoplastic disorders.

Effects of interferon-β on the cytokine production of astrocytes

The effects of interferon (IFN)-beta used for treatment of multiple sclerosis (MS) on the central nervous system (CNS) have not yet been elucidated. The effect of IFN-beta and IFN-gamma on astrocytes as the major component of the CNS was investigated using murine primary astrocytes and human astrocytoma U251 cell line. IL-1beta, IL-6, TNF-alpha and iNOS were analyzed by RT-PCR. Both protein and mRNA levels of IL-6 were increased by IFN-beta. IFN-gamma augmented the effect of IFN-beta on IL-6 production. These results suggest that IFN-beta has an activity to modulate inflammatory and immune responses by up-regulating IL-6 in the CNS of MS.

CSF B-cell expansion in opsoclonus-myoclonus syndrome: A biomarker of disease activity

Lack of a biomarker of disease activity has hindered the therapy of childhood opsoclonus-myoclonus syndrome (OMS), which is purported to be mediated humorally. To determine if the cerebrospinal fluid (CSF) B lymphocyte, which may traffic into the central nervous system (CNS) to produce antibody locally, is one such biomarker, B lymphocytes were immunophenotyped in the CSF and blood of 56 children with OMS and 26 pediatric controls by dual-laser flow cytometry. Neurological severity was rated blindly from videotapes using a validated 12-item motor evaluation scale. Children with OMS manifested a 4- to 7-fold higher percentage of total B-cells in CSF (P < 0.0001), including CD5(+) (P = 0.001) and CD5(-) (P = 0.0004) B-cell subsets, compared with controls, in whom the percentages were negligible and unchanging with age. CSF expansion of both B-cell subsets increased with disease severity and decreased with disease duration (P </= 0.0001, ANOVA). Previous treatment with conventional immunotherapies, chemotherapy, or tumor resection had not normalized B-cell percentages in those with lingering symptoms. These studies reveal that CSF B-cell expansion in OMS is characteristic and often persistent. Presence of the autoreactive CD5(+) B-cell subset and correlations with neurological severity and disease duration suggest CSF B-cell expansion is a biomarker of disease activity and possible target for B-cell-specific therapy. Immunophenotyping of CSF lymphocytes by flow cytometry yields valuable clinical information missed by routine studies and allows crucial treatment decisions to be made rapidly.

Immunoserological changes in the cerebro-spinal fluid and serum in systemic lupus erythematosus patients with demyelinating syndrome and multiple sclerosis

The aim of the present study was to investigate the role of antinuclear and antiphospholipid antibodies in the pathogenesis of systemic lupus erythematosus (SLE) with demyelinating syndrome and several forms of multiple sclerosis (MS). Paired samples of serum and cerebrospinal fluid (CSF) were investigated using laser nephalometric and enzyme linked immunosorbant assay (ELISA) methods, and the parameters of intrathecal synthesis were calculated. Elevation of the concentrations of antiribosomal P protein antibodies in the CSF and serum, and intrathecal synthesis anticardiolipin (aCL) antibodies were characteristic in all patient groups. The immunoserological changes were more pronounced in the SLE patients. A similar pathogenetic role of antiphospholipid antibodies in central nervous system (CNS) damage in SLE patients with demyelinating syndrome and of MS patients can be assumed.

Longitudinal study of antimyelin T-cell reactivity in relapsing-remitting multiple sclerosis: association with clinical and MRI activity

In multiple sclerosis (MS), T-cells are considered to be critical in coordinating an immunopathological cascade that results in myelin damage. We investigated whether clinical disease activity or brain inflammatory activity as measured by magnetic resonance imaging (MRI) was associated with changes in autoreactive T-cell reactivities in MS patients. To this end, a longitudinal study was performed in which T-cell-related immune parameters and clinical parameters (including MRI) were monitored in seven relapsing-remitting (RR) MS patients and two healthy controls with bimonthly intervals over a period of 18 months. The serial evaluation of antimyelin (MBP, PLP, MOG) T-cell responses revealed highly dynamic shifts and fluctuations from one pattern to another in a patient-dependent manner. In some of the patients, changes in T-cell-related immune variables were found to concur with MRI activity and generally preceded clinical relapses. These alterations include: increased number of myelin-reactive IFN-gamma secreting T-cells, detection of clonally expanded myelin-reactive T-cells, elevated proinflammatory and decreased antiinflammatory cytokine production, upregulation of ICAM-1 membrane expression and highly increased serum levels of soluble VCAM-1. However, not all exacerbations and MRI changes were associated with changes in antimyelin reactivity. Some of the observed immune alterations were also detected in the healthy controls, indicating that additional regulatory mechanisms-which may be defective in MS-play a role in the downregulation of potentially pathological T-cell responses. In conclusion, this study provides further support for an important role of myelin-reactive T-cells in the pathogenesis of MS. In addition, the observed dynamic changes in the antimyelin T-cell reactivity pattern may be a major obstacle for the development of antigen-specific immunotherapies.

Intrathecal IgG synthesis and autoantibody-secreting cells in multiple sclerosis

We studied intrathecal IgG synthesis and autoantibody-secreting cells in 148 patients with possible onset symptoms of MS (POSMS) or clinically definite MS (CDMS). In POSMS intrathecal synthesis of IgG oligoclonal bands and abnormalities on T2-weighted magnetic resonance imaging were associated but the former were more prevalent. The cerebrospinal fluid (CSF) leukocyte count and the number of anti-protelipid protein antibody-secreting cells in cerebrospinal fluid (CSF) correlated with disease activity in POSMS. Intrathecal IgG synthesis levels and the number of anti-myelin basic protein antibody-secreting cells in CSF correlated with disease activity in CDMS. Our results support recent reports of pathogenetic heterogeneity and a pathogenetic role of the antibody response in MS.

Cytokines in multiple sclerosis: pro-inflammation or pro-remyelination?

The targets of the inflammatory response in multiple sclerosis (MS) are myelin and the myelin producing cells, oligodendrocytes. The infiltration of activated immune cells and recruitment of endogenous glia lead to the destruction of myelin and oligodendrocytes, a process that is compounded by the release of cytokines by infiltrating cells. Recent evidence suggests that key cytokines that are responsible for the destruction of myelin may also mediate the process of remyelination and repair. It appears that both inflammatory and repair processes are governed by the temporal and spatial relation of cytokines to their targets.

Characterization of the systemic disease and ocular signs induced by experimental infection with Chlamydia psittaci in cats

In addition to the commonly reported ocular signs, Chlamydia psittaci infection of kittens resulted in fever, lethargy, lameness and reduction in weight gain following ocular instillation of virulent organisms. The appearance of these systemic signs was late with respect to the appearance of ocular symptoms and occurred simultaneously with increasing levels of chlamydia-specific IgG. Measurement of acute phase reactants and IL-6 in plasma indicated that both became elevated concurrent with or slightly after the appearance of fever and remained elevated after the fever began to resolve. Preliminary data also indicated that infectious C. psittaci was present in the blood stream during this time period. The results of ocular instillation of three different levels of C. psittaci (10(3.8), 10(2.8) and 10(1.5) TCID50) indicated that the frequency of infection and the severity of ocular signs were diminished in the group receiving the lowest dose. However, the magnitude of systemic disease was similar in all animals which exhibited clinical signs, irrespective of the dose administered. The immune response to infection included elementary body (EB)-specific lymphocyte proliferation as well as the development of EB-specific IgG and IgM antibodies. The predominant antibody response was to a 45 kDa protein, the major outer membrane protein (MOMP), lipopolysaccharide (LPS), a 58 kDa doublet and 32 and 16-19 kDa proteins.

Modulation of hypothalamic-pituitary-adrenal function by transgenic expression of interleukin-6 in the CNS of mice

Interleukin-6 (IL-6) and IL-6 receptor mRNA and protein have been reported in different brain regions under normal and pathophysiological conditions. Although much is known about the hypothalamic-pituitary-adrenal (HPA) axis stimulation after acute administration, less is known about the chronic effects of IL-6 on the function of the HPA axis. In the present study, we examined the function of the HPA axis in transgenic mice in which constitutive expression of IL-6 under the control of the glial fibrillary acidic protein (GFAP) promoter was targeted to astrocytes in the CNS. GFAP-IL6 mice heterozygous or homozygous for the IL-6 transgene had normal basal plasma corticosterone levels but, after restraint stress, showed abnormally increased levels in a gene dose-dependent manner. The increased plasma corticosterone levels in the IL-6 transgenic mice were associated with increased adrenal corticosterone content and hyperplasia of both adrenal cortex and medulla. Notably, plasma adrenocorticotrophic hormone (ACTH) levels and pituitary ACTH content were either not changed or decreased in these mice, whereas plasma arginine vasopressin (AVP) was increased, supporting a role for AVP in response to acute immobilization stress. The reduced ACTH response together with the adrenal hyperplasia in the IL-6 transgenic mice suggests direct activation at the level of the adrenal gland that may be directly activated by AVP or sensitized to ACTH. A similar mechanism may play a role in the blunted ACTH response and elevated corticosterone levels under pathophysiological conditions observed in humans with high brain levels of IL-6.

Modulation of hypothalamic-pituitary-adrenal function by transgenic expression of interleukin-6 in the CNS of mice

Interleukin-6 (IL-6) and IL-6 receptor mRNA and protein have been reported in different brain regions under normal and pathophysiological conditions. Although much is known about the hypothalamic-pituitary-adrenal (HPA) axis stimulation after acute administration, less is known about the chronic effects of IL-6 on the function of the HPA axis. In the present study, we examined the function of the HPA axis in transgenic mice in which constitutive expression of IL-6 under the control of the glial fibrillary acidic protein (GFAP) promoter was targeted to astrocytes in the CNS. GFAP-IL6 mice heterozygous or homozygous for the IL-6 transgene had normal basal plasma corticosterone levels but, after restraint stress, showed abnormally increased levels in a gene dose-dependent manner. The increased plasma corticosterone levels in the IL-6 transgenic mice were associated with increased adrenal corticosterone content and hyperplasia of both adrenal cortex and medulla. Notably, plasma adrenocorticotrophic hormone (ACTH) levels and pituitary ACTH content were either not changed or decreased in these mice, whereas plasma arginine vasopressin (AVP) was increased, supporting a role for AVP in response to acute immobilization stress. The reduced ACTH response together with the adrenal hyperplasia in the IL-6 transgenic mice suggests direct activation at the level of the adrenal gland that may be directly activated by AVP or sensitized to ACTH. A similar mechanism may play a role in the blunted ACTH response and elevated corticosterone levels under pathophysiological conditions observed in humans with high brain levels of IL-6.