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Shah A, Panchal V, Patel K, Alimohamed Z, Kaka N, Sethi Y, Patel N. Pathogenesis and management of multiple sclerosis revisited. Dis Mon 2023; 69:101497. [PMID: 36280474 DOI: 10.1016/j.disamonth.2022.101497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Multiple sclerosis is an autoimmune chronic inflammatory disease characterized by selective destruction of myelin in the CNS neurons (including optic nerve). It was first described in the 19th century and remained elusive owing to the disease's unique relapsing and remitting course. The widespread and debilitating prevalence of multiple sclerosis (MS) has prompted the development of various treatment modalities for its effective management. METHODS AND OBJECTIVES A literature review was conducted using the electronic databases PubMed and Google Scholar. The main objective of the review was to compile the advances in pathogenesis, classifications, and evolving treatment modalities for MS. RESULTS The understanding of the pathogenesis of MS and the potential drug targets for its precise treatment has evolved significantly over the past decade. The experimental developments are also motivating and present a big change coming up in the next 5 years. Numerous disease-modifying therapies (DMTs) have revolutionized the management of MS: interferon (IFN) preparations, monoclonal antibodies-natalizumab and ocrelizumab, immunomodulatory agents-glatiramer acetate, sphingosine 1-phosphate receptor 1 (S1PR1) modulators (Siponimod) and teriflunomide. The traditional parenteral drugs are now available as oral formulations improving patient acceptability. Repurposing various agents used for related diseases may reinforce the drug reserve to manage MS and are under trials. Although at a nascent phase, strategies to enhance re-myelination by stimulating oligodendrocytes are fascinating and hold promise for better outcomes in patients with MS. CONCLUSIONS The recent past has seen staggering inclusions to the management of multiple sclerosis catalyzing a significant turnabout in our approach to diagnosis, treatment, and prognosis. Since the advent of DMTs various other oral and injectable agents have been approved. The advances in MS therapeutics and diagnostics have laid the ground for further research and development to enhance the quality of life of afflicted patients.
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Affiliation(s)
- Abhi Shah
- Smt NHL MMC, Ahmedabad, Gujarat, 380006, India; PearResearch, India
| | - Viraj Panchal
- Smt NHL MMC, Ahmedabad, Gujarat, 380006, India; PearResearch, India
| | - Kashyap Patel
- Baroda Medical College, Vadodara, India; PearResearch, India
| | - Zainab Alimohamed
- Muhimbili University of Health and Allied Sciences (MUHAS), Tanzania; PearResearch, India
| | - Nirja Kaka
- PearResearch, India; GMERS Medical College, Himmatnagar, India
| | - Yashendra Sethi
- PearResearch, India; Government Doon Medical College, Dehradun, Uttarakhand, India
| | - Neil Patel
- PearResearch, India; GMERS Medical College, Himmatnagar, India.
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Boussamet L, Rajoka MSR, Berthelot L. Microbiota, IgA and Multiple Sclerosis. Microorganisms 2022; 10:microorganisms10030617. [PMID: 35336190 PMCID: PMC8954136 DOI: 10.3390/microorganisms10030617] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 12/16/2022] Open
Abstract
Multiple sclerosis (MS) is a neuroinflammatory disease characterized by immune cell infiltration in the central nervous system and destruction of myelin sheaths. Alterations of gut bacteria abundances are present in MS patients. In mouse models of neuroinflammation, depletion of microbiota results in amelioration of symptoms, and gavage with MS patient microbiota exacerbates the disease and inflammation via Th17 cells. On the other hand, depletion of B cells using anti-CD20 is an efficient therapy in MS, and growing evidence shows an important deleterious role of B cells in MS pathology. However, the failure of TACI-Ig treatment in MS highlighted the potential regulatory role of plasma cells. The mechanism was recently demonstrated involving IgA+ plasma cells, specific for gut microbiota and producing IL-10. IgA-coated bacteria in MS patient gut exhibit also modifications. We will focus our review on IgA interactions with gut microbiota and IgA+ B cells in MS. These recent data emphasize new pathways of neuroinflammation regulation in MS.
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Affiliation(s)
- Léo Boussamet
- Centre for Research in Transplantation and Translation Immunology, Nantes Université, Inserm, CR2TI UMR, 1064 Nantes, France;
| | - Muhammad Shahid Riaz Rajoka
- Laboratory of Animal Food Function, Graduate School of Agricultural Science, Tohoku University, Sendai 980-8572, Japan;
| | - Laureline Berthelot
- Centre for Research in Transplantation and Translation Immunology, Nantes Université, Inserm, CR2TI UMR, 1064 Nantes, France;
- Correspondence:
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Lotan I, Benninger F, Mendel R, Hellmann MA, Steiner I. Does CSF pleocytosis have a predictive value for disease course in MS? NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e584. [PMID: 31355320 PMCID: PMC6624148 DOI: 10.1212/nxi.0000000000000584] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/26/2019] [Indexed: 12/02/2022]
Abstract
Objective MS is a demyelinating CNS disorder with a spectrum of clinical patterns regarding course and prognosis. Although several prognostic factors are considered in the initial evaluation of patients, biological markers defining the disease course and guiding treatments are currently lacking. It is unknown whether patients with CSF pleocytosis differ in regard to symptoms, disease course, and prognosis from those without. The aim of this study was to evaluate whether CSF pleocytosis during the initial presentation has an impact on the clinical course and progression of MS. Methods We retrospectively evaluated patients attending the MS Clinic at Rabin Medical Center between January 1999 and January 2016 who underwent lumbar puncture (LP) at disease presentation, considering CSF cell count, clinical diagnosis (clinically isolated syndrome [CIS] and relapsing-remitting MS [RRMS]), annualized relapse rate (ARR), paraclinical findings (imaging, CSF oligoclonal bands, and evoked potentials), and disease progression, expressed by the Expanded Disability Status Scale (EDSS). Results One hundred fourteen patients (72 females) underwent LP at disease presentation (RRMS: n = 100, CIS: n = 14). Age at diagnosis was 32.4 ± 12.2 years, and the follow-up time was 9.4 ± 3.8 years. Forty-six patients showed a pleocytic CSF (≥5 cells per μL). Compared with patients with <4 cells per μL, patients with pleocytosis had a higher ARR (0.60 ± 0.09 vs 0.48 ± 0.04; p = 0.0267) and a steeper increase (slope) in the EDSS score throughout the follow-up period (correlation coefficient: r2 = 0.04; p = 0.0251). Conclusions CSF pleocytosis may be considered a biological unfavorable predictive factor regarding disease course and progression in MS.
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Affiliation(s)
- Itay Lotan
- Neuro-Immunology Service and Department of Neurology (I.L., M.A.H.), Rabin Medical Center; Department of Neurology (I.L., F.B., R.M., M.A.H., I.S.), Rabin Medical Center; and Sackler Faculty of Medicine (I.L., F.B., R.M., M.A.H., I.S.), Tel Aviv University, Israel
| | - Felix Benninger
- Neuro-Immunology Service and Department of Neurology (I.L., M.A.H.), Rabin Medical Center; Department of Neurology (I.L., F.B., R.M., M.A.H., I.S.), Rabin Medical Center; and Sackler Faculty of Medicine (I.L., F.B., R.M., M.A.H., I.S.), Tel Aviv University, Israel
| | - Rom Mendel
- Neuro-Immunology Service and Department of Neurology (I.L., M.A.H.), Rabin Medical Center; Department of Neurology (I.L., F.B., R.M., M.A.H., I.S.), Rabin Medical Center; and Sackler Faculty of Medicine (I.L., F.B., R.M., M.A.H., I.S.), Tel Aviv University, Israel
| | - Mark A Hellmann
- Neuro-Immunology Service and Department of Neurology (I.L., M.A.H.), Rabin Medical Center; Department of Neurology (I.L., F.B., R.M., M.A.H., I.S.), Rabin Medical Center; and Sackler Faculty of Medicine (I.L., F.B., R.M., M.A.H., I.S.), Tel Aviv University, Israel
| | - Israel Steiner
- Neuro-Immunology Service and Department of Neurology (I.L., M.A.H.), Rabin Medical Center; Department of Neurology (I.L., F.B., R.M., M.A.H., I.S.), Rabin Medical Center; and Sackler Faculty of Medicine (I.L., F.B., R.M., M.A.H., I.S.), Tel Aviv University, Israel
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Issuriya A, Kumarnsit E, Reakkamnuan C, Samerphob N, Sathirapanya P, Cheaha D. Dexamethasone induces alterations of slow wave oscillation, rapid eye movement sleep and high-voltage spindle in rats. Acta Neurobiol Exp (Wars) 2019. [DOI: 10.21307/ane-2019-023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Matute-Blanch C, Montalban X, Comabella M. Multiple sclerosis, and other demyelinating and autoimmune inflammatory diseases of the central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:67-84. [DOI: 10.1016/b978-0-12-804279-3.00005-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Vrethem M, Fernlund I, Ernerudh J, Ohman S. Prognostic value of cerebrospinal fluid IgA and IgG in multiple sclerosis. Mult Scler 2016; 10:469-71. [PMID: 15327048 DOI: 10.1191/1352458504ms1052sr] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IgA antibodies do not activate complement and may compete with and protect against myelin degradation caused by IgM and IgG in multiple sclerosis (MS). We retrospectively evaluated cerebrospinal fluid (CSF) IgA and IgG (as indices and extended indices) from 1980 to 1988 in 68 patients with definitive MS. Sixty-one of them had survived since the time of sampling (11- 19 years). IgA Extended Index was significantly higher for surviving patients (median 0.65) than for the dead patients (median 0.33). CSF IgA or IgG indices did not correlate with disability, walking distance, or time from onset of symptoms to the need of walking aid. The retrospective experimental design allowed an unusually long follow-up time, but it also had the disadvantages of such a study. Thus the results warrant a prospective study to verify the prognostic vale of CSF IgA in MS.
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Affiliation(s)
- Magnus Vrethem
- Divisions of Neurology and Neurophysiology, Department of Neuroscience and Locomotion, Linköping University Hospital, S-581 85 Linköping, Sweden.
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Vural G, Gumusyayla S, Bektas H, Deniz O, Ergin M, Erel O. Dynamic Thiol-Disulphide Homeostasis in Patients with Multiple Sclerosis. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/wjns.2016.63026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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8
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Modvig S, Degn M, Sander B, Horwitz H, Wanscher B, Sellebjerg F, Frederiksen JL. Cerebrospinal fluid neurofilament light chain levels predict visual outcome after optic neuritis. Mult Scler 2015; 22:590-8. [DOI: 10.1177/1352458515599074] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/26/2015] [Indexed: 12/31/2022]
Abstract
Background: Optic neuritis is a good model for multiple sclerosis relapse, but currently no tests can accurately predict visual outcome. Objective: The purpose of this study was to examine whether cerebrospinal fluid (CSF) biomarkers of tissue damage and remodelling (neurofilament light chain (NF-L), myelin basic protein, osteopontin and chitinase-3-like-1) predict visual outcome after optic neuritis. Methods: We included 47 patients with optic neuritis as a first demyelinating episode. Patients underwent visual tests, optical coherence tomography (OCT), magnetic resonance imaging (MRI) and lumbar puncture. Biomarkers were measured in CSF by enzyme-linked immunosorbent assay (ELISA). Patients were followed up six months after onset and this included visual tests and OCT. Outcome measures were inter-ocular differences in low contrast visual acuity (LCVA), retinal nerve fibre layer (RNFL) and ganglion cell layer+inner plexiform layer (GC-IPL) thicknesses. Results: CSF NF-L levels at onset predicted inter-ocular differences in follow-up LCVA (β=13.8, p=0.0008), RNFL (β=5.6, p=0.0004) and GC-IPL (β=4.0, p=0.0008). The acute-phase GC-IPL thickness also predicted follow-up LCVA (β=12.9, p=0.0021 for NF-L, β=−1.1, p=0.0150 for GC-IPL). Complete/incomplete remission was determined based on LCVA from 30 healthy controls. NF-L had a positive predictive value of 91% and an area under the curve (AUC) of 0.79 for incomplete remission. Conclusion: CSF NF-L is a promising biomarker of visual outcome after optic neuritis. This could aid neuroprotective/regenerative medical advancements.
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Affiliation(s)
- S Modvig
- The MS Clinic, Department of neurology, Glostrup Hospital, University of Copenhagen, Denmark/Department of Clinical Immunology, Rigshospitalet, University of Copenhagen, Denmark
| | - M Degn
- The MS Clinic, Department of Neurology, Glostrup Hospital, University of Copenhagen, Denmark/Department of Diagnostics, Glostrup Hospital, University of Copenhagen, Denmark
| | - B Sander
- Department of Ophthalmology, Glostrup Hospital, University of Copenhagen, Denmark
| | - H Horwitz
- The MS Clinic, Department of Neurology, Glostrup Hospital, University of Copenhagen, Denmark/Department of Clinical Pharmacology, Bispebjerg Hospital, University of Copenhagen, Denmark
| | - B Wanscher
- Department of Clinical Neurophysiology, Glostrup Hospital, University of Copenhagen, Denmark
| | - F Sellebjerg
- Danish MS Research Centre, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | - JL Frederiksen
- The MS Clinic, Department of Neurology, Glostrup Hospital, University of Copenhagen, Denmark
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Fitzner B, Hecker M, Zettl UK. Molecular biomarkers in cerebrospinal fluid of multiple sclerosis patients. Autoimmun Rev 2015; 14:903-13. [PMID: 26071103 DOI: 10.1016/j.autrev.2015.06.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 06/03/2015] [Indexed: 12/15/2022]
Abstract
Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system, usually occurring in young adults and leading to disability. Despite the progress in technology and intensive research work of the last years, diagnosing MS can still be challenging. A heterogenic and complex pathophysiology with various types of disease courses makes MS unique for each patient. There is an urgent need to identify markers facilitating rapid and accurate diagnosis and prognostic assessments with regard to optimal therapy for each MS patient. Cerebrospinal fluid (CSF) is an outstanding source of specific markers related to MS pathology. Molecules reflecting specific pathological processes, such as inflammation, cellular damage, and loss of blood-brain-barrier integrity, are detectable in CSF. Clinically used biomarkers of CSF are oligoclonal bands, IgG-index, measles-rubella-zoster-reaction, anti-aquaporin 4 antibodies, and antibodies against John Cunningham virus. Many other potential biomarkers have been proposed in recent years. In this review we examine the current scientific knowledge on CSF molecular markers that could guide diagnosis and discrimination of different MS forms, support treatment decisions, or be helpful in monitoring and predicting disease progression, therapy response, and complications such as opportunistic infections.
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Affiliation(s)
- Brit Fitzner
- University Medicine Rostock, Department of Neurology, Division of Neuroimmunology, Gehlsheimer Str. 20, 18147 Rostock, Germany; STZ for Proteome Analysis, Schillingallee 69, 18057 Rostock, Germany.
| | - Michael Hecker
- University Medicine Rostock, Department of Neurology, Division of Neuroimmunology, Gehlsheimer Str. 20, 18147 Rostock, Germany; STZ for Proteome Analysis, Schillingallee 69, 18057 Rostock, Germany.
| | - Uwe Klaus Zettl
- STZ for Proteome Analysis, Schillingallee 69, 18057 Rostock, Germany.
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10
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Modvig S, Degn M, Roed H, Sørensen TL, Larsson HBW, Langkilde AR, Frederiksen JL, Sellebjerg F. Cerebrospinal fluid levels of chitinase 3-like 1 and neurofilament light chain predict multiple sclerosis development and disability after optic neuritis. Mult Scler 2015; 21:1761-70. [PMID: 25698172 DOI: 10.1177/1352458515574148] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 01/31/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) biomarkers have been suggested to predict multiple sclerosis (MS) after clinically isolated syndromes, but studies investigating long-term prognosis are needed. OBJECTIVE To assess the predictive ability of CSF biomarkers with regard to MS development and long-term disability after optic neuritis (ON). METHODS Eighty-six patients with ON as a first demyelinating event were included retrospectively. Magnetic resonance imaging (MRI), CSF leukocytes, immunoglobulin G index and oligoclonal bands were registered. CSF levels of chitinase-3-like-1, osteopontin, neurofilament light-chain, myelin basic protein, CCL2, CXCL10, CXCL13 and matrix metalloproteinase-9 were measured by enzyme-linked immunosorbent assay. Patients were followed up after 13.6 (range 9.6-19.4) years and 81.4% were examined, including Expanded Disability Status Scale and MS functional composite evaluation. 18.6% were interviewed by phone. Cox regression, multiple regression and Spearman correlation analyses were used. RESULTS Forty-six (53.5%) developed clinically definite MS (CDMS) during follow-up. In a multivariate model MRI (p=0.0001), chitinase 3-like 1 (p=0.0033) and age (p=0.0194) combined predicted CDMS best. Neurofilament light-chain predicted long-term disability by the multiple sclerosis severity scale (p=0.0111) and nine-hole-peg-test (p=0.0202). Chitinase-3-like-1 predicted long-term cognitive impairment by the paced auditory serial addition test (p=0.0150). CONCLUSION Neurofilament light-chain and chitinase-3-like-1 were significant predictors of long-term physical and cognitive disability. Furthermore, chitinase-3-like-1 predicted CDMS development. Thus, these molecules hold promise as clinically valuable biomarkers after ON as a first demyelinating event.
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Affiliation(s)
- S Modvig
- The MS Clinic, Department of Neurology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - M Degn
- The MS Clinic, Department of Neurology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - H Roed
- Holbaek municipal eye clinic, Denmark
| | - T L Sørensen
- Clinical Eye Research Unit, Department of Ophthalmology, Copenhagen University Hospital Roskilde and The Faculty of Health Sciences, University of Copenhagen, Denmark
| | - H B W Larsson
- Functional Imaging Unit, Department of Diagnostics, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - A R Langkilde
- Department of Neuroradiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - J L Frederiksen
- The MS Clinic, Department of Neurology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - F Sellebjerg
- Danish MS Research Centre, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Abstract
The cerebrospinal fluid (CSF) is a bodily fluid, which is both easily accessible and the most proximate to the pathological alterations of multiple sclerosis (MS). Consequently, the analysis of this fluid provides an important window into the pathological underpinnings of this disease. For example, for years, it has been known that the CSF of MS patients contains oligoclonal gamma immunoglobulins (IgG), which are synthesized within the central nervous system and presumably relate to the immune dysfunction, which is characteristically found in MS. This insight has lead to the introduction of highly-effective anti-B-cell therapies into the field of MS therapeutics. Moreover, the presence of an oligoclonal IgG response in the CSF, although not specific for MS, is a very sensitive finding and, as a result, its presence can be quite helpful for establishing an MS diagnosis in the right clinical context. In addition, this finding has predictive value. Thus, patients without a definite diagnosis who have CSF IgG bands are significantly more likely to develop definite MS compared to those patients without such a banding pattern. Other biological molecules can also be found in the CSF including neurofiliment, myelin basic protein (MBP), glial fibrillary acidic protein (GFAP), tau, neuronal cell adhesion molecule (NCAM), and the growth associated protein (GAP-43). However, the value of measuring these (and other) CSF constituents for both diagnostic and prognostic purposes and for following response to therapy is still to be determined.
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Affiliation(s)
- Gavin Giovannoni
- Centre for Neuroscience and Trauma, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK.
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Modvig S, Degn M, Horwitz H, Cramer SP, Larsson HBW, Wanscher B, Sellebjerg F, Frederiksen JL. Relationship between cerebrospinal fluid biomarkers for inflammation, demyelination and neurodegeneration in acute optic neuritis. PLoS One 2013; 8:e77163. [PMID: 24116216 PMCID: PMC3792899 DOI: 10.1371/journal.pone.0077163] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 09/07/2013] [Indexed: 12/31/2022] Open
Abstract
Background Various inflammatory biomarkers show prognostic potential for multiple sclerosis (MS)-risk after clinically isolated syndromes. However, biomarkers are often examined singly and their interrelation and precise aspects of their associated pathological processes remain unclear. Clarification of these relationships could aid the appropriate implementation of prognostic biomarkers in clinical practice. Objective To investigate the interrelation between biomarkers of inflammation, demyelination and neurodegeneration in acute optic neuritis and to assess their association to measures of MS risk. Material and Methods A prospective study at a tertiary referral centre from June 2011 to December 2012 of 56 patients with optic neuritis as a first demyelinating symptom and 27 healthy volunteers. Lumbar puncture was performed within 28 (median 16) days of onset. CSF levels of CXCL13, matrix metalloproteinase (MMP)-9, CXCL10, CCL-2, osteopontin and chitinase-3-like-1, myelin basic protein (MBP) and neurofilament light-chain (NF-L) were determined. MS-risk outcome measures were dissemination in space (DIS) of white matter lesions on cerebral MRI, CSF oligoclonal bands and elevated IgG-index. Results In the interrelation analysis the biomarkers showed close correlations within two distinct groups: Biomarkers of leukocyte infiltration (CXCL13, MMP-9 and CXCL10) were strongly associated (p<0.0001 for all). Osteopontin and chitinase-3-like-1 were also tightly associated (p<0.0001) and correlated strongly to tissue damage markers (NF-L and MBP). The biomarkers of leukocyte infiltration all associated strongly with MS-risk parameters, whereas CHI3L1 and MBP correlated with MRI DIS, but not with CSF MS-risk parameters and osteopontin and NF-L did not correlate with any MS-risk parameters. Conclusions Our findings suggest two distinct inflammatory processes: one of leukocyte infiltration, represented by CXCL13, CXCL10 and MMP-9, strongly associated with and potentially predicting MS-risk; the other represented by osteopontin and CHI3L1, suggesting tissue damage-related inflammation, potentially predicting residual disabilities after attack and perhaps cumulative damage over time. These hypotheses should be further addressed in follow-up studies.
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Affiliation(s)
- Signe Modvig
- MS Clinic, Department of Neurology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
- * E-mail:
| | - Matilda Degn
- MS Clinic, Department of Neurology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - Henrik Horwitz
- MS Clinic, Department of Neurology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - Stig P. Cramer
- MS Clinic, Department of Neurology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
- Functional Imaging Unit, Department of Diagnostics, Copenhagen University Hospital, Glostrup, Glostrup, Denmark
| | - Henrik B. W. Larsson
- Functional Imaging Unit, Department of Diagnostics, Copenhagen University Hospital, Glostrup, Glostrup, Denmark
| | - Benedikte Wanscher
- Department of Clinical Neurophysiology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
| | - Finn Sellebjerg
- Danish MS Research Centre, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jette L. Frederiksen
- MS Clinic, Department of Neurology, Copenhagen University Hospital Glostrup, Glostrup, Denmark
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Romme Christensen J, Börnsen L, Khademi M, Olsson T, Jensen PE, Sørensen PS, Sellebjerg F. CSF inflammation and axonal damage are increased and correlate in progressive multiple sclerosis. Mult Scler 2012. [DOI: 10.1177/1352458512466929] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The mechanism underlying disease progression in progressive multiple sclerosis (MS) is uncertain. Pathological studies found widespread inflammation in progressive MS brains correlating with disease progression and axonal damage. Objectives: To study cerebrospinal fluid (CSF) biomarkers and clarify whether inflammation and axonal damage are associated in progressive MS. Methods: Using enzyme-linked immunosorbent assay (ELISA), we analysed CSF from 40 secondary progressive (SPMS), 21 primary progressive (PPMS), and 36 relapsing–remitting (RRMS) and 20 non-inflammatory neurological disease (NIND) patients. Twenty-two of the SPMS patients participated in an MBP8298 peptide clinical trial and had CSF follow-up after one year. Results: Compared to NIND patients, inflammatory biomarkers osteopontin and matrix metalloproteinase-9 (MMP9) were increased in all MS patients while CXCL13 was increased in RRMS and SPMS patients. Biomarkers of axonal damage (NFL) and demyelination (MBP) were increased in all MS patients. In progressive MS patients CSF levels of osteopontin and CXCL13 correlated with NFL while osteopontin and MMP9 correlated with MBP. MBP8298 treatment did not affect the levels of the biomarkers after one year of treatment. All biomarkers were continuously increased after one year of follow-up except MBP, which decreased. Conclusion: CSF biomarkers of inflammation, axonal damage and demyelination are continuously increased in progressive MS patients and correlate. These findings parallel pathology studies, emphasise a relationship between inflammation, axonal damage and demyelination and support the use of CSF biomarkers in progressive MS clinical trials.
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Affiliation(s)
- Jeppe Romme Christensen
- University of Copenhagen and Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Lars Börnsen
- University of Copenhagen and Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Mohsen Khademi
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska University Hospital, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska University Hospital, Sweden
| | - Poul Erik Jensen
- University of Copenhagen and Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Per Soelberg Sørensen
- University of Copenhagen and Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Finn Sellebjerg
- University of Copenhagen and Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark
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Ziemann U, Wahl M, Hattingen E, Tumani H. Development of biomarkers for multiple sclerosis as a neurodegenerative disorder. Prog Neurobiol 2011; 95:670-85. [DOI: 10.1016/j.pneurobio.2011.04.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 04/07/2011] [Accepted: 04/10/2011] [Indexed: 01/24/2023]
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Rammohan KW. Cerebrospinal fluid in multiple sclerosis. Ann Indian Acad Neurol 2011; 12:246-53. [PMID: 20182572 PMCID: PMC2824952 DOI: 10.4103/0972-2327.58282] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 05/31/2009] [Accepted: 07/30/2009] [Indexed: 11/15/2022] Open
Abstract
Background: Technological advances have made it possible to examine the human cerebrospinal fluid (CSF) in a manner that was previously impossible. CSF provides a window into the changes that occur in the central nervous system (CNS) in health and disease. Through analysis of the CSF, we discern indirectly the state of health of the CNS, and correctly or incorrectly, draw conclusions regarding mechanisms of CNS injury and repair. Objective, Materials and Methods: To review the current state of knowledge of changes in the CSF in multiple sclerosis. Discussion: Establishing CSF markers that permit evaluation of the various biological processes in multiple sclerosis remains a challenge. Of all the biological processes, inflammatory markers are probably the best identified. Detection of oligoclonal immunoglobulin bands in the CSF is now established as the single most useful laboratory marker in the CSF to aid in the diagnosis of multiple sclerosis. Markers of demyelination, remyelination, neuro-axonal loss, neural repair and regeneration, and astrogliosis are only now being recognized. A good surrogate for any of these pathophysiological processes has not been defined to date. Conclusion: The goal of future research is not only to define surrogate markers in the CSF for each of the above functions, but also to extend it to other more readily accessible body fluids like blood and urine. A synopsis of the current literature in most of these areas of CSF evaluation pertaining to multiple sclerosis is presented in this article.
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Affiliation(s)
- Kottil W Rammohan
- Clinical and Experimental Neuroimmunology, Department of Neurology, The Ohio State University, Columbus, Ohio 43221 USA
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16
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Gout O, Bouchareine A, Moulignier A, Deschamps R, Papeix C, Gorochov G, Héran F, Bastuji-Garin S. Prognostic value of cerebrospinal fluid analysis at the time of a first demyelinating event. Mult Scler 2010; 17:164-72. [PMID: 20965960 DOI: 10.1177/1352458510385506] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE This study aimed to assess the value of cerebrospinal fluid (CSF) findings for predicting conversion to clinically definite multiple sclerosis (CDMS). METHODS From a database of 447 patients with a first demyelinating event, the records of 208 patients less than 51 years old who had baseline magnetic resonance imaging (MRI) and CSF examinations and a follow-up of at least 1 year were included. A multivariable Cox model was used to assess the short-term risk of CDMS according to baseline CSF findings after adjustment for prognostic factors (including brain MRI) and to provide a simple classification for predicting CDMS. RESULTS During a median follow-up of 3.5 years, 141 (67.8%) patients converted to CDMS. In multivariate analysis, younger age (hazard ratio [HR]: 1.44 [95% CI 1.02-2.01]), spatial dissemination on brain MRI (HR: 2.07 [95% CI 1.47-2.91]) and more than 4 WBC/mm³ in CSF (HR: 1.44 [95% CI 1.03-2.02]) were independently associated with CDMS. The Cox score obtained from these three predictors enabled patients to be divided into three groups with significant increased risks of CDMS at 1, 2 and 3 years; groups were classified as high-risk (64.7%, 77.4%, 96.1%), intermediate-risk (33.3%, 51.5%, 61.5%), and low-risk (11.1%, 18.3%, 40.3%). CONCLUSIONS Age at onset, spatial dissemination on brain MRI and CSF white blood cell count are independently associated with short-term conversion to CDMS. The three proposed risk group classifications could be a useful tool to select patients for early therapeutic intervention.
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Affiliation(s)
- Olivier Gout
- Department of Neurology, Fondation Ophtalmologique A de Rothschild, France.
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17
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Kempuraj D, Tagen M, Iliopoulou BP, Clemons A, Vasiadi M, Boucher W, House M, Wolfberg A, Theoharides TC. Luteolin inhibits myelin basic protein-induced human mast cell activation and mast cell-dependent stimulation of Jurkat T cells. Br J Pharmacol 2008; 155:1076-84. [PMID: 18806808 DOI: 10.1038/bjp.2008.356] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Allergic inflammation and autoimmune diseases, such as atopic dermatitis, psoriasis and multiple sclerosis (MS), involve both mast cell and T-cell activation. However, possible interactions between the two and the mechanism of such activations are largely unknown. EXPERIMENTAL APPROACH Human umbilical cord blood-derived cultured mast cells (hCBMCs) and Jurkat T cells were incubated separately or together, following activation with myelin basic protein (MBP), as well as with or without pretreatment with the flavonoid luteolin for 15 min. The supernatant fluid was assayed for inflammatory mediators released from mast cells and interleukin (IL)-2 release from Jurkat cells. KEY RESULTS MBP (10 microM) stimulates hCBMCs to release IL-6, IL-8, transforming growth factor (TGF)-beta1, tumour necrosis factor-alpha (TNF-alpha), vascular endothelial growth factor (VEGF), histamine and tryptase (n=6, P<0.05). Addition of mast cells to Jurkat cells activated by anti-CD3/anti-CD28 increases IL-2 release by 30-fold (n=3, P<0.05). MBP-stimulated mast cells and their supernatant fluid further increase Jurkat cell IL-2 release (n=3, P<0.05). Separation of mast cells and activated Jurkat cells by a Transwell permeable membrane inhibits Jurkat cell stimulation by 60%. Pretreatment of Jurkat cells with a TNF-neutralizing antibody reduces IL-2 release by another 40%. Luteolin pretreatment inhibits mast cell activation (n=3-6, P<0.05), Jurkat cell activation and mast cell-dependent Jurkat cell stimulation (n=3, P<0.05). CONCLUSIONS AND IMPLICATIONS Mast cells can stimulate activated Jurkat cells. This interaction is inhibited by luteolin, suggesting that this flavonoid may be useful in the treatment of autoimmune diseases.
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Affiliation(s)
- D Kempuraj
- Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Pharmacology and Experimental Therapeutics, Tufts University School of Medicine and Tufts Medical Center, Boston, MA 02111, USA
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18
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Lim ET, Sellebjerg F, Jensen CV, Altmann DR, Grant D, Keir G, Thompson EJ, Giovannoni G. Acute axonal damage predicts clinical outcome in patients with multiple sclerosis. Mult Scler 2005; 11:532-6. [PMID: 16193890 DOI: 10.1191/1352458505ms1218oa] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The objectives of this study were (1) to determine how cerebrospinal fluid (CSF) neurofilament heavy chain (NfH(SM134) and NfH(SM135)) levels relate to clinical outcome in optic neuritis (ON) and multiple sclerosis (MS) relapse patients treated with high dose oral methylprednisolone; and (2) to correlate neurofilament and myelin basic protein (MBP) concentrations, particularly as the latter was previously associated with clinical disability. Fifty subjects participated in two double-blind, randomized, placebo-controlled clinical trials. Eight/18 patients in the ON trial and 15/32 subjects in the MS attack trial were treated with oral methylprednisolone. In the MS attack trial group, CSF NfH(SM134) and NfH(SM135) measured at week 3 and deltaCSF NfH(SMI34) levels from baseline to week 3 were predictive of clinical outcome at week 8 and 52. In the ON group, no such association was seen. When both groups were combined, baseline CSF NfH(SHM134) and NfH(SM135) correlated positively with baseline enhancing lesion volume (ELV) (r(s) =0.50, P <0.01 and rS =0.53, P <0.01, respectively). Levels of NfH(SM135) at baseline and week 3 also strongly correlated with the MBP concentration. This study supports the view that acute inflammation in ON and MS results in axonal pathology and that the latter has a role in determining functional impairment.
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Affiliation(s)
- E T Lim
- Department of Neuroinflammation, Institute of Neurology, University College London, Queen Square, London WC1N 3BG, UK.
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Sellebjerg F, Jensen CV, Larsson HBW, Frederiksen JL. Gadolinium-enhanced magnetic resonance imaging predicts response to methylprednisolone in multiple sclerosis. Mult Scler 2003; 9:102-7. [PMID: 12617276 DOI: 10.1191/1352458503ms880sr] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Oral high-dose methylprednisolone treatment is efficacious in acute optic neuritis (ON) and attacks of multiple sclerosis (MS). The responses to treatment in subgroups of patients participating in two randomized, controlled trials were assessed. Fifty-eight patients with ON and 51 patients with attacks of MS were treated with placebo or oral methylprednisolone (500 mg daily for five days with a 10-day tapering period). A gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) scan was obtained at baseline in 66 patients, and 29 patients underwent repeated MRI studies. Seventy-four patients underwent lumbar puncture before treatment. The odds ratio (OR) of improvement after methylprednisolone treatment (a one point change in the visual function system score of the Kurtzke Expanded Disability Status Scale (EDSS) in ON or in the EDSS score in attacks of MS) was higher in patients with enhancing lesions on baseline MRI (one week: OR 15, P = 0.02; eight weeks: OR 4.6, P = 0.02). Methylprednisolone treatment suppressed Gd-enhancement after one week (P < 0.001) and three weeks (P = 0.001). Cerebrospinal fluid measures of intrathecal inflammation correlated with the area of Gd-enhancement but did not correlate as closely with the treatment response as did the results of Gd-enhanced MRI. These findings suggest that the resolution of intrathecal inflammation as assessed by Gd-enhanced MRI is a major effect of oral high-dose methylprednisolone.
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Affiliation(s)
- F Sellebjerg
- The MS Clinic, Department of Neurology, University of Copenhagen, Glostrup Hospital, DK-2600 Glostrup, Denmark.
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20
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Abstract
Radioimmunoassay for myelin basic protein in cerebrospinal fluid is commonly used as a biochemical marker of demyelination in multiple sclerosis patients. A sensitive enzyme-linked immunosorbent assay for myelin basic protein has been recently developed, which can make a clinical evaluation of myelin basic protein in cerebrospinal fluid of patients with multiple sclerosis and other neurological diseases. Most multiple sclerosis patients with acute exacerbation had markedly high myelin basic protein. Longitudinal studies of multiple sclerosis patients showed that myelin basic protein in CSF increases rapidly in agreement with acute relapse and then rapidly declines and disappears. Significantly higher cerebrospinal fluid myelin basic protein levels in human T-cell lymphotropic virus Type I-associated myelopathy/tropical spastic paraparesis patients were also detected. This enzyme-linked immunosorbent assay system can be used routinely to measure myelin basic protein in cerebrospinal fluid as a useful diagnostic indicator, not only for central active demyelination as in multiple sclerosis but, also for spinal cord demyelination as in human T-cell lymphotropic virus Type I-associated myelopathy/tropical spastic paraparesis.
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Affiliation(s)
- Mitsuhiro Ohta
- Department of Clinical Chemistry, Kobe Pharmaceutical University, Higashinadu-ku, Kobe 658-8558, Japan.
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21
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Abstract
PURPOSE To review the clinical features, natural history, potential pathogenic mechanisms, differential diagnosis, and management of optic neuritis in multiple sclerosis. METHODS Relevant literature regarding optic neuritis in multiple sclerosis from 1970 to the present was reviewed. RESULTS Optic neuritis is an acute inflammatory optic neuropathy. It is the most common type of optic neuropathy causing acute visual loss in young adults (peak age at 30-40 years), especially among women. Patients usually present with an acute reduction of visual acuity, orbital pain exacerbated by eye movements, dyschromatopsia, and an afferent papillary defect, with or without swelling of the optic nerve head. Visual field testing most often reveals central defects, but others, such as centrocecal, can also occur. Magnetic resonance image (MRI) scanning of the brain should be undertaken in all cases of acute optic neuritis for diagnostic and prognostic purposes. The brain lesions of multiple sclerosis are commonly seen as T2 ovoid high-signal white matter lesions on MRI scans of the brain located in perivenular regions perpendicular to ventricles with variable enhancement. For atypical presentations of optic neuritis, additional laboratory tests, such as cerebrospinal fluid analysis, serologic tests, and visual evoked potentials, prove to be useful in the diagnosis and subsequent management of the patient. The recommended treatment for optic neuritis is intravenous steroids, as shown in the Optic Neuritis Treatment Trial (ONTT). CONCLUSION Optic neuritis is often the initial presentation of multiple sclerosis. Recent advances in the understanding of the immune basis for multiple sclerosis has led to earlier and more effective treatment of this disease.
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Affiliation(s)
- Jane W Chan
- Department of Internal Medicine, Division of Neurology, University of Nevada School of Medicine, 2040 W. Charleston Boulevard, Suite 300, Las Vegas, NV 89102, USA
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22
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Ohta M, Ohta K, Ma J, Takeuchi J, Saida T, Nishimura M, Itoh N. Clinical and Analytical Evaluation of an Enzyme Immunoassay for Myelin Basic Protein in Cerebrospinal Fluid. Clin Chem 2000. [DOI: 10.1093/clinchem/46.9.1326] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractBackground: RIA of myelin basic protein (MBP) in cerebrospinal fluid (CSF) is commonly used as a biochemical marker of demyelination in patients with multiple sclerosis (MS). Our aim was to develop a sufficiently sensitive ELISA for MBP and evaluate it clinically in patients with MS.Methods: The ELISA used anti-bovine MBP antibody coated on plates and biotinylated anti-MBP antibody. The bound antibody complex was quantified with streptavidin-horseradish peroxidase. MBP was determined in CSF from 84 MS patients and 55 patients with other neurological diseases.Results: The respective within- and between-assay CVs were 4.7% and 7.2% at 200 ng/L, and 6.3% and 8.8% at 2000 ng/L. The detection limit was 30 ng/L. Most of the MS patients with acute exacerbations had markedly increased MBP in the CSF. Longitudinal studies of six MS patients with recurrent exacerbation confirmed this observation. MBP concentrations from 78 MS patients, as tested with our ELISA, correlated well with those obtained by RIA (r = 0.9; P <0.01), but the detection limit of the ELISA was much lower than that of the RIA.Conclusions: This convenient ELISA with higher sensitivity than the existing assays is a suitable routine assay that provides a diagnostic indicator of myelin breakdown in the central nervous system; moreover, it is an excellent indicator of MS disease activity.
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Affiliation(s)
- Mitsuhiro Ohta
- Clinical Research Center, Utano National Hospital, Narutaki, Ukyo-ku, Kyoto 616-8255, Japan
- Department of Clinical Chemistry, Kobe Pharmaceutical University, Higashinada-ku, Kobe 658-8558, Japan
| | - Kiyoe Ohta
- Clinical Research Center, Utano National Hospital, Narutaki, Ukyo-ku, Kyoto 616-8255, Japan
| | - Jie Ma
- Clinical Research Center, Utano National Hospital, Narutaki, Ukyo-ku, Kyoto 616-8255, Japan
| | - Juji Takeuchi
- Clinical Research Center, Utano National Hospital, Narutaki, Ukyo-ku, Kyoto 616-8255, Japan
| | - Takahiko Saida
- Clinical Research Center, Utano National Hospital, Narutaki, Ukyo-ku, Kyoto 616-8255, Japan
| | - Masataka Nishimura
- Clinical Research Center, Utano National Hospital, Narutaki, Ukyo-ku, Kyoto 616-8255, Japan
| | - Nobuyuki Itoh
- Department of Genetic Biochemistry, Kyoto University Graduate School of Pharmaceutical Science, Sakyo-ku, Kyoto 606-8304, Japan
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Sellebjerg F, Jensen CV, Christiansen M. Intrathecal IgG synthesis and autoantibody-secreting cells in multiple sclerosis. J Neuroimmunol 2000; 108:207-15. [PMID: 10900355 DOI: 10.1016/s0165-5728(00)00292-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- F Sellebjerg
- Department of Neurology, University of Copenhagen, Glostrup Hospital, 57 Nordre Ringvej, DK-2600 Glostrup, Copenhagen, Denmark.
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Sellebjerg F, Madsen HO, Jensen CV, Jensen J, Garred P. CCR5 delta32, matrix metalloproteinase-9 and disease activity in multiple sclerosis. J Neuroimmunol 2000; 102:98-106. [PMID: 10626673 DOI: 10.1016/s0165-5728(99)00166-6] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Chemokines and matrix metalloproteinases (MMPs) appear to be crucial in leukocyte recruitment to the central nervous system in multiple sclerosis (MS). CCR5 delta32, a truncated allele of the CC chemokine receptor CCR5 gene encoding a non-functional receptor, did not confer protection from MS. CCR5 delta32 was, however, associated with a lower risk of recurrent clinical disease activity. High CSF levels of MMP-9 activity were also associated with recurrent disease activity. These results directly link intrathecal inflammation to disease activity in patients with MS, suggesting that treatments targeting CCR5 or treatment with MMP inhibitors may attenuate disease activity in MS.
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Affiliation(s)
- F Sellebjerg
- Department of Neurology, University of Copenhagen, Glostrup Hospital, Denmark.
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