Intrathecal synthesis of free immunoglobulin light chains and IgM in initial multiple sclerosis

We studied the intrathecal synthesis of free kappa, free lambda immunoglobulin light chains and of IgM in 33 consecutive patients with possible or probable MS at the time of their first diagnosis. Nineteen patients presented free kappa or lambda light chain bands in CSF after agarose isoelectric focusing, protein transfer to nitrocellulose and immunostaining with specific antisera. Nineteen patients had increased CSF levels of free kappa light chains as measured with a competitive ELISA. Fourteen had an increased IgM index, as evaluated with a sandwich ELISA. Twenty-six patients displayed CSF oligoclonal IgG bands in CSF and 25 had cerebral magnetic resonance imaging lesions suggestive of MS. The local production of free immunoglobulin light chains and IgM is often detected in the CSF of patients with early MS.     

Intrathecal IgG synthesis: marker of progression in multiple sclerosis patients

OBJECTIVES: We study the power of IgG synthesis value as a marker of disease activity in multiple sclerosis (MS). MATERIAL AND METHODS: Link index was calculated in 202 MS patients. Time between first, second and third attack and progression index (PI) were compared in patient with normal (NLI) high (HL) or very high Link index (VHLI). RESULTS: Secondary progressive (SP) patients had a higher LI than relapsing-remitting (RR) and primary progressive (PP) courses (1.10 +/- 0.5 for SP vs 0.86 +/- 0.5 for RR and 0.81 +/- 0.5 for PP, P=0.01 and 0.03, respectively). Having a HLI in MS RR and SP patients has no time effect in the development of the second and third attack. PI was higher in patients with VHIL (0.67 +/- 0.7) vs patients with NLI (0.42 +/- 0.4, P=0.008) and with HLI (0.39 +/- 0.3, P=0.001). CONCLUSIONS: This study confirmed that LI is a good marker of subsequent progression of MS.     

High sensitivity of free lambda and free kappa light chains for detection of intrathecal immunoglobulin synthesis in cerebrospinal fluid

Background – So far, an inflammation of the central nervous system (CNS) is diagnosed by immunoglobulin measurement in cerebrospinal fluid (CSF) and serum as well as by determination of the oligoclonal bands. With the free kappa and lambda light chains, new markers to diagnose intrathecal synthesis are available. Methods – In addition to routine diagnostic tests and the assessment of standard parameters, free immunoglobulin light chains were measured in the CSF of patients with neurological disorders. Results – A significant agreement was found between an increase in free kappa light chain CSF serum quotients and results of the currently widely applied method of oligoclonal band measurement for the detection of intrathecal immunoglobulin synthesis. A sensitivity of 95% and 100% specificity for free kappa light chain concentrations at a cut‐off of 0.41 mg/l was determined for free kappa light chains compared with oligoclonal bands. However, the free lambda light chains in 20 out of the 110 investigated samples were characterized by inconsistent behaviour. These otherwise unremarkable samples yielded increased CSF quotients, leading to the assumption that free lambda light chains represent a highly sensitive measure of intrathecal immunologlobulin synthesis. Thirteen of the 20 samples described above were obtained from patients with cerebral infarction, 4 samples derived from patients with cerebral paresis (primarily facial paresis), one sample was from a patient with multisystem atrophy and two were obtained from patients with migraine and neuralgia. Conclusion – These findings suggest that the high sensitivity of lambda light chains for the detection intrathecal immunoglobulin synthesis may be of benefit in establishing clinical diagnoses.     

Antibodies against light neurofilaments in multiple sclerosis patients

OBJECTIVES: Axonal damage in multiple sclerosis (MS) may be reflected by antibodies against axon-specific proteins - the light subunit of neurofilaments (NFL). MATERIALS AND METHODS: The serum and cerebrospinal fluid obtained from 58 MS patients, 24 normal controls (CN), 49 control patients with miscellaneous diseases (CD) and 31 patients with neurodegenerative disorders (CDEG) were tested for both immunoglobulin G and M antibodies against NFL, using an ELISA. RESULTS: Intrathecal IgG antibodies to NFL were elevated in MS patients compared with that in CD patients (P = 0.001) and were not related to clinical variables. No differences in IgM anti-NFL levels were found between the MS and CN/CD groups. IgM to NFL was higher in the CDEG group than in either the CD group or even the MS group (P < 0.0005). CONCLUSIONS - Intrathecal IgM or IgG antibodies to NFL are not useful surrogate markers for axonal damage or disease subtypes in MS.     

Intrathecal levels of vitamin D and IgG in multiple sclerosis

Holmøy T, Lossius A, Gundersen TE, Moen SM, Castellazzi M, Fainardi E, Casetta I. Intrathecal levels of vitamin D and IgG in multiple sclerosis.
Acta Neurol Scand: 2012: 125: e28–e31.
© 2011 John Wiley & Sons A/S. Background – Intrathecal synthesis of IgG is a hallmark of multiple sclerosis (MS). Vitamin D may modulate B‐cell function and dampen the synthesis of IgG. Objective – To investigate the relation between vitamin D levels in cerebrospinal fluid and serum and intrathecal synthesis of IgG. Methods – 25‐hydroxyvitamin D (25(OH)D) and IgG were assessed in cerebrospinal fluid and serum in 40 patients with MS. Results – There was no significant correlation between the IgG index and 25(OH)D levels in cerebrospinal fluid or serum. The levels of 25(OH)D in cerebrospinal fluid and serum did not differ between patients with and without intrathecal synthesis of IgG. There was a non‐significant trend towards a positive correlation between the concentrations of 25(OH)D and IgG in the cerebrospinal fluid, but not in serum. Conclusion – Physiological variation in vitamin D does not exert a major impact on intrathecal synthesis of IgG in MS.     

Intrathecal synthesis of immunoglobulin light chains in a child with late-onset agammaglobulinemia

In a 4-year-old child with late-onset agammaglobulinemia and neurologic disturbances of unknown etiology, immunoglobulin light chains were detected in the cerebrospinal fluid but not in the serum by immunofixation after isoelectric focussing. This finding supports the hypothesis that the central nervous system compartment of the immune system is at least partly capable of autonomous Ig synthesis.     

Intrathecal synthesis of IgG, IgA, IgM and IgD in untreated multiple sclerosis and controls

The intrathecal production (ITP) of the immunoglobulins (Ig) G, A, M and D was examined in untreated patients with multiple sclerosis (MS) and controls. Sensitive sandwich enzyme-linked immunosorbent assay systems were applied to the determination of IgA, IgM and IgD levels in the cerebrospinal fluid and plasma from a group of 61 consecutive MS patients (41 relapsing-remitting and 20 secondary chronic progressive MS). Age-related reference limits for all Ig variables were defined in a group of 57 patients with tension headache. ITP of IgG was demonstrated in 85% of the MS patients, ITP of IgA in 41%, of IgM in 44% and of IgD in 18%. Among 9 MS patients with normal IgG index, 3 displayed ITP of IgA, 3 of IgM and 1 of IgD. Plasma IgA was elevated in 20% and plasma IgM in 24% of the MS cases. No significant variation of Ig ITP was demonstrated in a different group of 27 untreated MS patients examined during exacerbation and remission. Among control patients with other inflammatory nervous system diseases, ITP of IgA, IgM and IgD was found more frequently, and of IgG in a smaller percentage compared with MS patients.     

Intrathecal methylprednisolone acetate in multiple sclerosis treatment: effect on the blood-CSF barrier and on the intrathecal IgG production

28 patients with clinically definite multiple sclerosis were treated with intrathecal injections of Methylprednisolone acetate, 40 mg at 4-day intervals. No modifications in the oligoclonal pattern of the CSF IgG were seen following-treatment in any of the cases, although changes in relative band intensity were observed. After 3 intrathecal injections, 54.8% of the cases showed a decrease of more than 15% in the amount of IgG synthesized daily within the central nervous system (de novo CNS IgG SYN). The IgG SYN rate was significantly decreased in 50.0% of the cases after 4 injections and in 91.7% after 5. With regard to blood-CSF barrier function, an increase of more than 15% of the initial value of the Serum/ CSF albumin quotient was recorded in 48.4% of cases after 3 injections, in 34.6% after 4 and in 58.3% after 5 injections.

---

Sommario 28 pazienti con sclerosi multipla certa in base a criteri clinici sono stati trattati con iniezioni intratecali di Metilprednisolone acetato. Il pattern oligoclonale delle IgG liquorali non subiva modificazioni in seguito alla terapia, anche se in alcuni casi potevano essere osservate modificazioni nella intensità delle singole bande. Dopo tre iniezioni intratecali la quantità di IgG sintetizzata entro il sistema nervoso centrale nelle 24 ore (de novo CNS IgG SYN) era ridotta di più del 15% nel 54.8% dei casi, mentre dopo quattro e cinque iniezioni una riduzione significativa si osservava rispettivamente nel 50% e 91.7% dei casi. Il quoziente Albuminasiero/ Albumina LCS, considerato quale parametro di funzionalità della barriera ematoliquorale, risultava aumentato di più del 15% rispetto al valore iniziale nel 48.4%, 34.6% e 58.3% dei casi rispettivamente dopo tre, quattro e cinque iniezioni intratecali.

     

Elevated intrathecal antibodies against the medium neurofilament subunit in multiple sclerosis

Neurofilaments are cytoskeletal proteins localized within axons, which may interact with the immune system during and following tissue destruction in multiple sclerosis (MS). Antibodies against the medium neurofilament subunit synthesized intrathecally may reflect axonal damage in MS patients. Both immunoglobulin G (IgG) and M (IgM) responses against the purified native medium subunit of neurofilaments (NFM) using enzyme-linked immunosorbent assay (ELISA) were determined in paired serum and cerebrospinal fluid samples obtained from 49 MS patients, 16 normal controls (CN), 21 control patients with miscellaneous diseases (CD) and 14 patients with neurodegenerative disorders (CDEG). Intrathecal production of IgM and IgG antibodies to NFM were elevated in MS patients compared with the CN or CD groups (p < 0.04 for IgM, p < 0.01 for IgG). The increase was present in all the MS courses (relapsing-remitting, primary and secondary progressive). Similar local anti-NFM IgG and IgM synthesis occurred in the MS and CDEG groups. MS patients with short and long disease duration did not differ in terms of their anti-NFM IgM and IgG responses. Repeated examinations showed stable intrathecal anti-NFM production. Intrathecal IgG and IgM antibodies against NFM were increased in MS patients and may serve as a potential marker for axonal pathology. The extent of anti-NFM levels did not correspond to any individualized clinical profiles of MS patients.     

Elevated levels of kappa free light chains in CSF support the diagnosis of multiple sclerosis

Background   Numerous studies have demonstrated elevated kappa free light chains (KFLCs) in CSF of multiple sclerosis (MS) patients. However, so far only small cohorts have been examined, and generally only through qualitative KFLCs analysis. Using a recently developed free light chain (FLC) immunoassay, it is now possible to quantitatively measure KFLCs by automated nephelometry. Our objective was to determine the extent to which KFLC levels in CSF correlated with the diagnosis of MS and CISSMS (clinically isolated syndrome suggestive of MS) compared to oligoclonal banding (OCB) and the immunoglobulin G (IgG) index. Methods   CSF and serum samples from 438 unselected patients, including a MS group of 70 patients (41 MS, 29 CISSMS), were analysed using nephelometry and isoelectric focusing. We then retrospectively correlated results with patients’ diagnoses. Results   Of the MS group (n = 70), 67 patients had elevated KFLCs using the KFLC index (≥ 5.9), 64 patients showed OCB and 56 patients presented with an elevated IgG index (≥ 0.6). Sensitivities were 0.96 for the KFLC index, 0.91 for OCB and 0.80 for the IgG index. The specificity of the KFLC index for the MS group (0.86) was lower than that of OCB (0.92) but distinctly higher compared to the IgG index (0.77). Conclusion   In this study, an elevated KFLC-index represented the most sensitive and specific quantitative diagnostic parameter for MS. As it is measured by automated, routinely available laboratory methods, KFLC quantitation can provide a rapid and reproduceable indication of intrathecal immunological processes supporting current MS diagnostic criteria. The study was performed in accordance with the ethical standards. An erratum to this article can be found at     

Intrathecal synthesis of beta-2-microglobulin in multiple sclerosis and aseptic meningo-encephalitis

Beta-2-microglobulin (beta 2m) levels were studied in the cerebrospinal fluid (CSF) and plasma of 52 patients with clinically definite multiple sclerosis (MS) and of 14 with aseptic meningo-encephalitis (AM). Reference values for beta 2m were defined in 72 subjects of different age groups with tension headache (TH). Plasma levels of beta 2m increased with age in TH controls, particularly in the older age group, while no significant age variation could be detected for CSF beta 2m. Increased levels of beta 2m were found in the CSF and plasma of AM patients and in the CSF in MS. Calculations of CSF/plasma beta 2m ratios showed higher values in AM, reflecting intrathecal beta 2m synthesis, while only borderline alterations were evident in MS. Demonstration of intrathecal production of beta 2m is an additional CSF finding that may be useful in evaluating, among others, inflammatory nervous system disorders, but it has limited importance in the study of MS patients.     

Intrathecal IgM-synthesis does not correlate with the risk of relapse in patients with a primary demyelinating event

The objective of this study was to investigate, whether the presence of oligoclonal immunoglobulin M bands (IgM-OCB) in cerebrospinal fluid (CSF) from patients with a clinically isolated syndrome (CIS), which is suggestive for the first clinical manifestation of multiple sclerosis (MS), anticipates the risk of a relapse during a retrospective study period of 21–106 months (mean 60 ± 25). A relapse would lead to the diagnosis of clinically definite MS. Paired CSF and serum samples from 42 patients with a CIS and positive intrathecal IgG-synthesis were tested retrospectively for IgM-OCB, which are exclusively present in CSF, but not in the corresponding serum. Isoelectric focusing and affinity blot were used and clinical follow-up was based on telephone interviews. IgM-OCB were found in the CSF from 31 of 42 patients (74%). There was no correlation between the presence of IgM-OCB, the number of such bands or the IgM-Index on the one hand and the risk of a relapse during the follow-up in the cohort studied, on the other hand. These data do not support the idea that the presence of IgM-OCB in CSF might predict an unfavourable course in MS.     

Free light chains in the CSF in multiple sclerosis

Summary The presence of free light chains (FLC) was investigated in 32 patients with clinically definite or laboratory supported definite multiple sclerosis (MS), 2 patients with neurosyphilis and 10 normal controls. The detection of FLC in unconcentrated cerebrospinal fluid (CSF) was performed by means of agarose isoelectric focusing, followed by transfer of proteins to nitrocellulose membranes, double immunofixation, avidin-biotin amplification and peroxidase staining. Bands due to FLC were clearly demonstrated in the CSF of 28 MS patients; 3 of them showed only kappa FLC, 10 only lambda FLC, while 15 had both kappa and lambda FLC. The CSF of 4 MS patients was FLC negative. In both cases of neurosyphilis FLC bands were observed. FLC were never found in normal CSF. Among the indexes of intrathecal immunological activity (IgG oligoclonal bands, FLC, IgG index, intra-blood-brain barrier IgG synthesis rate, pleocytosis) the FLC proved to be the second most frequent abnormality in MS CSF, the presence of IgG oligoclonal bands being the first. In one MS case an FLC band was found, while all the other indexes of intrathecal IgG production were negative. A high correlation was found between an elevated number of FLC and pleocytosis. The presence of FLC in MS CSF seems to indicate a recent immunological stimulation leading to increased synthesis of FLC within the CNS.     

Intrathecal polyspecific immune response to neurotropic viruses in multiple sclerosis: a comparative report from Cuban patients

OBJECTIVE: Intrathecal measles(M)- rubella(R)- and varicella zoster(Z)-antibody synthesis in German and Cuban multiple sclerosis (MS) patients are compared considering the different rubella epidemiology in the tropics. PATIENTS AND METHODS: Twenty-three Cuban MS patients with a representative age distribution and gender ratio like the group of 177 German MS patients were analysed for albumin, IgG, IgA IgM, oligoclonal IgG and MRZ- antibodies in cerebrospinal fluid (CSF) and serum. RESULTS: Cuban MS patients show similar CSF data patterns like German patients and high frequencies of intrathecal measles- (78/78%) and varicella zoster- (59/55%) antibody synthesis correspondingly. A lower frequency of intrathecal rubella antibody synthesis (rubella-AI >or= 1.5) in Cuban patients (30%, gender ratio of increased rubella - AI m:f = 1:6) compared with German patients (60%, m:f = 1:1.8) is explained by low incidence of rubella infections in Cuba. Only about 10% of the male population (not immunized before 1986, in contrast to females) had rubella antibodies compared to at least 60% in a European male population, representing the relation of increased rubella-AI in male MS patients. CONCLUSION: In MS the frequency of intrathecal antibody synthesis is limited by the fraction of seropositives in the population. Natural infection or vaccination are a necessary and equivalent precondition contributing to the arguments against microorganisms as a cause of MS.     

Cerebrospinal fluid IgG profiles and oligoclonal bands in Chinese patients with multiple sclerosis

OBJECTIVES: To investigate the significance of oligoclonal bands (OCBs) and intrathecal IgG fractions (IgGIF) for the diagnosis of multiple sclerosis (MS) in northern China. MATERIALS AND METHODS: OCBs in cerebrospinal fluid from 30 patients with MS, 34 with other inflammatory neurological diseases (IND) and 22 with non-inflammatory neurological diseases (NIND) were detected using isoelectric focusing. IgGIF was calculated based on corresponding formula. RESULTS: There was no significant difference in the frequencies of positive OCBs and elevated IgGIF between the MS group and the IND group. Compared with NIND, the MS and IND groups had a significantly higher incidence of OCBs and elevated IgGIF. The sensitivity, specificity and positive result likelihood ratio of OCBs for the diagnosis of MS were 63.3%, 74.2% and 2.5 respectively; those of IgGIF were 36.7%, 84.5% and 2.4. CONCLUSIONS: The two parameters, OCBs and IgGIF are of less diagnostic value for MS in China.     

Heightened intrathecal release of soluble CD137 in patients with multiple sclerosis

Human CD137 (ILA/4-1BB), a member of the tumour necrosis factor (TNF) receptor family, regulates the activation and proliferation of immune cells, and may induce apoptosis (programmed cell death) of activated lymphocytes. A soluble form of CD137 (sCD137) released by activated lymphocytes may interfere with the activities of the membrane-bound CD137. This study reports the detection of significantly high intrathecal and systemic levels of sCD137 in patients with clinically active multiple sclerosis (MS) when compared with corresponding levels from patients with clinically stable MS or those with inflammatory and non-inflammatory neurological disorders, or from healthy individuals. Intrathecal concentrations of sCD137 in patients with active MS correlate with the intrathecal release of the soluble death receptor protein Fas, but not with the release of interleukin-2, TNF or the synthesis of immunoglobulins G and M. Results presented here suggest that heightened release of sCD137 is a feature of clinically active MS.     

Transferrin in patients with multiple sclerosis: a comparison among various subgroups of multiple sclerosis patients

OBJECTIVES: To compare cerebrospinal fluid (CSF) and serum transferrin (Tf) concentrations, transferrin quotient and index in various subgroups of MS patients. MATERIAL AND METHODS: CSF and serum transferrin concentrations, transferrin quotient QTf (i.e. CSF transferrin/serum transferrin x 10(3)) and index (QTf/Qalbumin) were determined in a group of 51 patients with clinically definite or probable multiple sclerosis (MS). Patients were subdivided according to the disease form (relapsing-remitting = RR, secondary progressive = SP, primary progressive = PP; patients with RR form were further subdivided into those in the attack and those in remission), disease severity (EDSS 0-5.5, EDSS 6.0-10.0), its treatment (non-treated - including patients treated with vitamins and/ or vasodilators only, treated - i.e. glucocorticoids and/or immunosuppressants and/or (exceptionally) beta-interferon), disease duration (0-2 years, >2-10 years, > 10 years) and sex. Correlation of transferrin values with age was also performed. RESULTS: Serum transferrin was somewhat lower and significantly more frequently subnormal in PP patients in comparison with the SP form and the RR form in remission. Transferrin index was significantly higher in the PP form than in the RR as well as the SP form. Transferrin quotient was significantly more frequently subnormal in patients in remission compared to those in the attack of the RR disease. CSF transferrin as well as transferrin quotient were more frequently subnormal in patients with short disease duration (0-2 years) than in patients with longer disease duration; these parameters, however, correlated also significantly with age. CSF transferrin and transferrin quotient were higher in male than in female patients. CONCLUSION: The authors conclude that evaluation of transferrin in MS patients - along with albumin - may help to differentiate among various MS subgroups, since there are significant differences among RR, SP and PP forms. For this purpose, however, other CSF protein fractions should be evaluated in parallel in order to obtain more complex information and to establish a panel of examinations enabling multiple statistical analyses. Transferrin evaluation in MS may also be of significant theoretical interest, since transferrin is known to be involved in the regulation of iron metabolism and it may have a protective role against the oxidative stress. Moreover, transferrin is a growth factor important for proliferation of activated T lymphocytes. By means of the use of transferrin quotient and especially transferrin index, it may be possible to estimate the proportion of intra-CNS-synthesized transferrin and/or rate of specific transferrin transport across the blood-CSF barrier. Further studies are, however, needed for such an evaluation.     

Visual evoked responses and immunoglobulin abnormalities in the diagnosis of multiple sclerosis

Visually evoked responses (VERs), CSF IgG/albumin ratio and CSF oligoclonal IgG were examined in 136 patients with multiple sclerosis (MS) admitted to hospital for investigation, and compared to the CSF findings in 87 patients with other neurological diseases (OND). 33% of patients with OND had abnormal CSF IgG/albumin ratios but only 9% had CSF oligoclonal IgG banding. In clinically definite MS, VERs were abnormal in 87% and CSF oligoclonal banding was found in 80% of patients, but CSF oligoclonal banding was found significantly more frequently than abnormal VERs in patients with suspected MS. We were unable to show any relationship between benign MS and the absence or presence of CSF oligoclonal IgG. The significance of CSF oligoclonal IgG in the less clinically definite forms of MS will only emerge with prolonged follow-up.