Immune mechanisms in spontaneously occurring CIDP in NOD mice

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an autoimmune disease affecting the peripheral nervous system (PNS) and is thought to involve both cellular and humoral immunity. Although its etiology remains to be fully elucidated, the use of animal models has provided some important information regarding its pathogenetic mechanisms. The development of a spontaneous autoimmune polyneuropathy (SAP) in B7-2 knockout non-obese diabetic (NOD) mice underscores the importance of co-stimulatory pathways such as B7-1/B7-2:CD28/CTLA-4 molecules in inflammatory neuropathies. These co-stimulatory molecules regulate the balance between pathogenic and regulatory T cells (Tregs). In SAP, pathogenic T cells are directed against myelin protein zero (P0), the most prominent PNS myelin protein that is a member of immunoglobulin gene superfamily.     

CD28-B7 costimulation: a critical role for initiation and development of experimental autoimmune neuritis in C57BL/6 mice

CD28 provides a critical costimulatory signal for antigen-specific T cell activation. Because CD28 is an important factor in the development of autoimmune diseases, we investigated its role in T cell-mediated experimental autoimmune neuritis (EAN), an animal model of Guillain-Barré syndrome in humans. CD28-deficient mutant (CD28-/-) C57BL/6 mice and corresponding wild-type mice were immunized with P0 peptide 180-199, a purified component of peripheral nerve myelin, and Freund's complete adjuvant. As a result, all wild-type mice developed severe EAN, in contrast, none of the CD28-/- mice manifested clinical signs of disease. Additionally, CD28-/- mice had fewer IL-12 producing cells in sciatic nerve sections and fewer IFN-gamma secreting splenic cells than wild-type mice on day 24 post immunization, i.e., at the peak of clinical EAN. At that time point, CD28-/- mice had milder infiltration of such inflammatory cells as macrophages, CD4+ T cells and monocytes into sciatic nerve tissues and less demyelination than wild-type mice. Moreover, the CD28-deficiency led to reduced production of specific anti-P0 peptide 180-199 antibodies compared with wild-type mice. Evidently, CD28 is required for interaction with B7 to regulate the activation of T and B cells that initiates development of EAN.     

B cells as therapeutic targets in autoimmune neurological disorders

B cells have a fundamental role in the pathogenesis of various autoimmune neurological disorders, not only as precursors of antibody-producing cells, but also as important regulators of the T-cell activation process through their participation in antigen presentation, cytokine production, and formation of ectopic germinal centers in the intermeningeal spaces. Two B-cell trophic factors-BAFF (B-cell-activating factor) and APRIL (a proliferation-inducing ligand)-and their receptors are strongly upregulated in many immunological disorders of the CNS and PNS, and these molecules contribute to clonal expansion of B cells in situ. The availability of monoclonal antibodies or fusion proteins against B-cell surface molecules and trophic factors provides a rational approach to the treatment of autoimmune neurological diseases. This article reviews the role of B cells in autoimmune neurological disorders and summarizes the experience to date with rituximab, a B-cell-depleting monoclonal antibody against CD20, for the treatment of relapsing-remitting multiple sclerosis, autoimmune neuropathies, neuromyelitis optica, paraneoplastic neurological disorders, myasthenia gravis, and inflammatory myopathies. It is expected that ongoing controlled trials will establish the efficacy and long-term safety profile of anti-B-cell agents in several autoimmune neurological disorders, as well as exploring the possibility of a safe and synergistic effect with other immunosuppressants or immunomodulators.     

Spotlight on anti-CD25: daclizumab in MS

Monoclonal antibodies are a promising new class of therapeutic agents that can be employed to target specific molecules of the immune system or any tissue. They are currently being tested in a number of clinical trials in autoimmune diseases such as multiple sclerosis (MS). One of these, the humanized monoclonal anti-CD25 antibody daclizumab (Zenapax), is directed against the interleukin-2 (IL-2) receptor alpha chain (CD25) that is involved in clonal expansion of autoreactive T-cells by binding of its ligand IL- 2. Several years ago daclizumab was approved for the prevention of renal allograft rejection. Following promising observations in uveitis, daclizumab has since been tested in a number of small clinical trials in MS based on the rationale that blocking CD25 would prevent the expansion of autoreactive T-lymphocytes. Safety and efficacy data from the preliminary clinical exploration as well as findings about the mechanism of action of anti-CD25 treatment are reviewed here.     

Immunotherapies for Neurological Manifestations in the Context of Systemic Autoimmunity

Neurological involvement is relatively common in the majority of systemic autoimmune diseases and may lead to severe morbidity and mortality, if not promptly treated. Treatment options vary greatly, depending on the underlying systemic pathophysiology and the associated neurological symptoms. Selecting the appropriate therapeutic scheme is further complicated by the lack of definite therapeutic guidelines, the necessity to differentiate primary neurological syndromes from those related to the underlying systemic disease, and to sort out adverse neurological manifestations caused by immunosuppressants or the biological agents used to treat the primary disease. Immunotherapy is a sine qua non for treating most, if not all, neurological conditions presenting in the context of systemic autoimmunity. Specific agents include classical immune modulators such as corticosteroids, cyclophosphamide, intravenous immunoglobulin, and plasma exchange, as well as numerous biological therapies, for example anti-tumor necrosis factor agents and monoclonal antibodies that target various immune pathways such as B cells, cytokines, and co-stimulatory molecules. However, experience regarding the use of these agents in neurological complications of systemic diseases is mainly empirical or based on small uncontrolled studies and case series. The aim of this review is to present the state-of-the-art therapies applied in various neurological manifestations encountered in the context of systemic autoimmune diseases; evaluate all treatment options on the basis of existing guidelines; and compliment these data with our personal experience derived from a large number of patients.     

Monoclonal antibodies in inflammatory disease of the muscle and peripheral nervous system

Introduction

A significant group of neuromuscular diseases are of autoimmune origin, but the classic immunomodulatory drugs are not often effective. For this reason, there is a need to find new more effective treatments that will lead to better control of these conditions, particularly those that are usually more resistant. In the last few years, the use of monoclonal antibodies against specific antigens of lymphocyte populations or against pro-inflammatory molecules has seen a great expansion, and has been demonstrated to be a useful alternative in autoimmune diseases.An intensive search was made in Medline using the Keywords neuromuscular, myopathy, neuropathy, myasthenia, Lambert-Eaton, monoclonal antibody, rituximab, alemtuzumab, and anti-TNF-α.

Development

Clinical trials performed to evaluate the efficacy of monoclonal antibodies in neuromuscular disease are very limited and of reduced size. Thus, the experience in this field is basically limited to anecdotal cases or short series of patients on open-label treatment. The published data are encouraging, with favourable responses having been observed in patients resistant to classic treatments and in diseases that do not normally respond to the usual immunosuppressant drugs. On the other hand, it has been observed that anti-TNF-α antibodies may trigger the appearance of autoimmune neuromuscular diseases.

Conclusions

Monoclonal antibodies could be an effective alternative treatment in autoimmune neuromuscular diseases, but the favourable responses observed need to be confirmed by means of controlled clinical trials with a sufficient number of patients.     

Treating autoimmune demyelination by augmenting lymphocyte apoptosis in the central nervous system

The elimination of autoreactive T cells from the central nervous system (CNS) by apoptosis plays an important role in switching off autoimmune attack. B-cell apoptosis in the CNS probably also has a key role in downregulating autoimmunity. Augmenting lymphocyte apoptosis in the CNS is a potential strategy for treating autoimmune CNS diseases such as multiple sclerosis. These strategies involve modulation of the physiological pro-apoptotic and anti-apoptotic pathways that control lymphocyte fate in the CNS. In the case of T cells, apoptosis can be augmented by enhancing activation-induced T-cell apoptosis through the CD95 (Fas) pathway and by inhibiting costimulation-induced anti-apoptotic pathways mediated through BCL-2 and BCL-X L.     

IFN-beta treatment modulates the CD28/CTLA-4-mediated pathway for IL-2 production in patients with relapsing-remitting multiple sclerosis

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system probably mediated by Th1 lymphocytes. IFN-beta is an established therapy for relapsing MS patients, although the mechanisms underlying its efficacy are yet to be well characterized. We determined IL-2 production, CD25 expression and T-cell proliferation from relapsing-remitting MS patients before and three months after starting therapy. A decrease in the percentage of CD80-induced IL-2-producing cells was observed after in vivo IFN-beta treatment. These data support that one of the immunomodulatory effects of IFN-beta treatment in MS may be a limitation of the autoimmune response modifying the CD80:CD28/CTLA-4 pathway.     

A natural anti-T-cell receptor monoclonal antibody protects against experimental autoimmune encephalomyelitis

The therapeutic potential of natural anti-T-cell receptor (TCR) antibodies is largely unknown. We investigated whether passive administration of C1-19, a novel natural anti-TCRVβ8 monoclonal antibody, could interfere with the development of EAE. Treatment with C1-19 prevented myelin basic protein (MBP)-induced EAE in Vβ8-sufficient B10.PL but not in Vβ8-deficient SJL mice. Furthermore, C1-19 reduced disease severity when administrated shortly after disease onset. These protective effects of C1-19 correlated with a Th2 bias of the cytokine response, in the absence of T-cell deletion or anergy. Together, these findings indicate that natural anti-TCR antibodies could function as therapeutic tools in autoimmune inflammatory diseases.     

Inhibition of experimental autoimmune encephalomyelitis by an antibody to the intercellular adhesion molecule ICAM-1

Experimental autoimmune encephalomyelitis (EAE) was induced in Lewis rats by active immunization with myelin from guinea pig spinal cord by the encephalitogenic myelin basic protein or by adoptive transfer using myelin basic protein-specific CD4-positive T cells. Treatment with purified monoclonal antibody (1A-29) to the intercellular adhesion molecule-1 and its F(ab')₂ fragments efficiently suppressed active EAE. Control treatment with an irrelevant antibody or saline did not alter the course of the disease. Histological sections of the central nervous system showed a pronounced reduction of inflammatory infiltrates during treatment with antibody to intercellular adhesion molecule-1. In the adoptive transfer model of EAE, 1A-29 had only a minor effect. Proliferation assays on lymph node cells ex vivo from 1A-29– and saline-treated animals were performed. Administration of 1A-29 suppressed antigen-specific T-cell proliferation. The differential effects in EAE versus adoptive transfer EAE suggest that 1A-29 acts predominantly on the induction phase of the immune response and, to a lesser extent, on the transendothelial migration of T cells. We conclude that intercellular adhesion molecule-1–dependent pathways are critically involved in the pathogenesis of EAE and that antibodies to leukocyte adhesion molecules could be a novel therapeutic approach to autoimmune disease of the central nervous system.     

Exogenous soluble tumor necrosis factor receptor type I ameliorates murine experimental autoimmune neuritis

Tumor necrosis factor (TNF) and its receptor (TNFR) have been strongly implicated in the pathogenesis of autoimmune disease. Soluble cytokine receptors may be shed naturally from cell membranes to inhibit cytokine activity. Experimental autoimmune neuritis (EAN) is a CD4 Th1 cell-mediated animal model of Guillain-Barré syndrome (GBS) in humans. In the present study, we investigated the effects of soluble TNFR type I (sTNFR I) in EAN induced in mice by P0 peptide 180-199 and Freund's complete adjuvant. Our data from two different therapeutic regimens indicate that the administration of sTNFR I effectively ameliorated the clinical and pathological signs of EAN, i.e., decreased its severity, shortened its duration, and reduced inflammatory cell infiltration into the peripheral nervous system. The suppression of clinical EAN was accompanied in vitro by a marked reduction in antigen-specific T-cell proliferation and IFN-gamma synthesis by spleen cells from sTNFR I-treated mice, compared to control mice treated with PBS. These data directly demonstrate a pivotal role for TNF in the development of EAN and also suggest that sTNFR I may have therapeutic potential for alleviating GBS in humans.     

Cuprizone and piperonyl butoxide, proposed inhibitors of T-cell function, attenuate experimental allergic encephalomyelitis in SJL mice

Multiple sclerosis (MS) and its animal model, experimental allergic encephalomyelitis (EAE), are autoimmune demyelinating diseases with autoreactive T-cells acting as important mediators of pathogenesis. Cuprizone, a copper chelator, and piperonyl butoxide (PBO), a pesticide synergist, are implicated to inhibit T-cell activation and function. The purpose of this study was to assess whether either of these agents would suppress PLP-peptide-induced EAE in the SJL mouse. Indeed, treatment with cuprizone beginning 1 week prior to disease induction, and PBO administration from days 1 to 9 of EAE, significantly attenuated EAE clinical severity. Furthermore, both agents decreased blood CD4+/CD8+ ratios, and reduced signs of chronic graft vs. host disease (GVHD) indicating attenuation of an immune T-cell response. These results suggest that cuprizone and PBO suppress EAE and use of these agents will provide insights into the mechanisms of T-cell mediated diseases.     

Neurological autoimmune disease and the trimolecular complex of T-lymphocytes

T-lymphocytes recognize antigen in a trimolecular complex: The T-cell receptor binds to a processed fragment of antigen that itself is bound to a major histocompatibility complex (MHC) molecule on the surface of an antigen-presenting cell. The trimolecular complex controls antigen-specific T-cell activation in normal and abnormal immune reactions. Recent progress in myasthenia gravis (MG) and experimental autoimmune encephalomyelitis (EAE) exemplifies this, leading to the following conclusions: (1) Autoimmune T cells may act by interfering with immunoregulation (as in MG) or by directly mediating autoimmune damage (as in EAE), or both. (2) In both diseases, the autoimmune T cells are clonally heterogeneous but recognize only a limited number of epitopes on the autoantigen (acetylcholine receptor in MG; myelin basic protein in EAE). Many of these epitopes can be defined as short peptide fragments of antigen, bound to a particular type of MHC molecule. (3) The MHC determines which peptides are recognized by autoimmune T cells in a given patient or inbred animal strain. (4) The discovery of the limited repertoire of autoimmune T cells has allowed considerable progress in the immunotherapy of EAE, using either monoclonal antibodies or cytotoxic T cells directed against clonotypic determinants on the autoaggressive T cells. (5) One obstacle to this approach in human disease is the polymorphism of the MHC in the species and the commensurate heterogeneity of autoimmune T cells.     

Natalizumab: targeting alpha4-integrins in multiple sclerosis

In 1992, it was shown that monoclonal antibodies blocking alpha(4)-integrins prevent the development of experimental autoimmune encephalomyelitis, an animal model for multiple sclerosis (MS). As alpha(4)beta(1)-integrin was demonstrated to mediate the attachment of immune-competent cells to inflamed brain endothelium in experimental autoimmune encephalomyelitis, the therapeutic effect was attributed to the inhibition of immune cell extravasation and inflammation in the central nervous system. This novel therapeutic approach was rapidly and successfully translated into the clinic. The humanized anti-alpha(4)-integrin antibody natalizumab demonstrated an unequivocal therapeutic effect in preventing relapses and slowing down the pace of neurological deterioration in patients with relapsing-remitting MS in phase II and phase III clinical trials. The occurrence of 3 cases of progressive multifocal leukoencephalopathy in patients treated with natalizumab led to the voluntary withdrawal of the drug from the market. After a thorough safety evaluation of all patients receiving this drug in past and ongoing studies for MS and Crohn's disease, natalizumab again obtained approval in the US and the European Community. A treatment targeting leukocyte trafficking in MS has now re-entered the clinic. Further thorough evaluation is necessary for a better understanding of the risk-benefit balance of this new treatment option for relapsing MS. In this review, we discuss the basic mechanism of action, key clinical results of clinical trials and the emerging indication of natalizumab in MS.     

Getting specific: monoclonal antibodies in multiple sclerosis

For more than a decade the only therapies that were available for multiple sclerosis (MS) were two immunomodulatory drugs-interferon beta and glatiramer acetate-and the immunosuppressant mitoxantrone. Natalizumab, a monoclonal antibody against alpha4 integrin, has been approved by the US Food and Drug Administration and the European Medicines Agency on the basis of its higher efficacy than the available treatments and its good safety profile. Monoclonal antibodies that are already licensed to treat other diseases, such as cancer and autoimmune diseases, are being tested for the treatment of MS. Additionally, novel targets are currently being investigated for MS. The therapeutic use of monoclonal antibodies was initially viewed with great scepticism owing to the high rates of sensitisation against mouse proteins, their pharmacokinetic properties, and the difficulties in their production. However, most of these problems have been overcome, and monoclonal antibodies are now among the most promising therapies for MS.     

The role of CD4+ T-cells in the development of MS

OBJECTIVE: Multiple sclerosis (MS) is a chronic, progressive central nervous system (CNS) disease with unknown cause. Considerable evidence supports an autoimmune origin with an important role for cellular immune responses in its pathogenesis. METHODS: We have reviewed the current literature dealing with lymphocyte responses and their interactions as it relates to MS and present supporting evidence from animal models. RESULTS: Issues regarding CD4+ T-cell subpopulations, their functional differentiation and regulatory interactions as they relate to their presumed role in MS-related pathology have been updated with references to the current literature. DISCUSSION: The evidence reviewed supports an important role of CD4+ T-cells in the immunopathogenesis of MS. The successful outcome of blocking CD4 cells entry into the CNS of animals with experimental demyelinating disease and humans with MS is a strong support for other evidence of an important role of these cell populations in the pathogenesis of MS. The understanding of the specific roles of CD4+ T-cells in the development of MS is crucial for better disease management and the prevention of neurological disability.     

Regulation of human peripheral blood lymphocytes IL-10 BY SMS 201-995

The somatostatin analog SMS 201-995 inhibits human peripheral blood lymphocytes (PBL) proliferation and here we demonstrate that it induces a significant increase in T cells IL-10 release as is evidenced in double fluorescence experiments. Seizing IL-10 by monoclonal antibody, SMS does not affect lymphocyte proliferation, suggesting that this cytokine is involved in the antiproliferative effect of these analog. We previously demonstrated that SMS inhibits T cells acting on the CD28 rather than the CD3-mediated signal in exactly the same way as does IL-10. Thus SMS inhibits human PBL activation by inducing IL-10 release and the consequent inhibition of the CD28 co-stimulatory pathway providing new perspectives on developing immunosuppressive strategies.     

Differentiated regulation of allo-antigen presentation by different types of murine microglial cell lines

We established granulocyte-macrophage colony-stimulating factor (GM-CSF)-dependent murine microglial clones and investigated the immune properties of four individual clones. All four clones expressed MHC class I and CD54 (ICAM-1) at similar levels. The 5-2, Ra2, and 6-3 clones expressed CD80 (B7-1), CD86 (B7-2), and MHC class II at low, medium, and high levels, respectively. Only the 6-3 clone expressed CD40. Generally, the levels of co-stimulation and CD 40 signals had a profound effect on the response to antigens. The 5-2, Ra2, and 6-3 clones, however, stimulated allogenic T-cell proliferation to the same extent or less compared to spleen cells. Although the 6-1 clone expressed co-stimulatory and MHC molecules at levels similar to Ra2, it suppressed allogenic T-cell proliferation, unlike Ra2. Thus, allo-antigen presentation by microglial clones was not correlated with the expression of CD40 and co-stimulatory molecules. When microglial clones were fixed with paraformaldehyde, they enhanced IL-2-dependent T-cell proliferation according to the level of their expression of co-stimulatory molecules. Furthermore, conditioned medium from the 6-1 clone inhibited the T-cell response to allo-antigen. This indicates that some factor(s) derived from a microglial subtype may play an important role in the regulation of T-cell proliferation in addition to the molecules involved in antigen presentation. Moreover, these results also suggest that there may be specialized subtypes of microglia that regulate the immune response in the CNS.