Antibodies to sulfatide and to chondroitin sulfate C in patients with chronic sensory neuropathy

Sera from eight of 25 patients with chronic sensory neuropathy had high titers of antibodies to sulfatide and chondroitin sulfate C or both. Preclearing of patients' sera with either sulfatide or chondroitin sulfate C revealed that in four patients the antisulfatide antibodies crossreacted with chondroitin sulfate C. By indirect immunohistochemistry sera reactive to sulfatide only had a different staining pattern from those reactive to both sulfatide and chondroitin sulfate C. By direct immunohistochemistry we found immunoglobulins bound to nerve fibers only in patients with serum antibodies against both sulfatide and chondroitin sulfate C. Our study provides evidence that antibodies to sulfatide and to chondroitin sulfate C differ in their fine specificity and are present in 30% of patients with chronic sensory neuropathy.     

Anti-MAG IgM paraproteins from some patients with polyneuropathy associated with IgM paraproteinemia also react with sulfatide

Sera from five of 11 patients with neuropathy associated with IgM paraproteinemia (NAIgMPP) and reactivity against myelin-associated glycoprotein (MAG) also had elevated levels of IgM against sulfatide. Although three patients had anti-sulfatide IgM titers of less than or equal to 1:1000, two patients had titers of greater than or equal to 1:50,000. Absorption of patient serum with sulfatide revealed that anti-MAG IgM paraproteins in two patients with high titer anti-sulfatide IgM crossreacted with sulfatide. Our study is the first to show that some anti-MAG IgM paraproteins crossreact with sulfatide, a major acidic glycolipid of myelin. Moreover, some patients with NAIgMPP have polyclonal anti-sulfatide IgM in addition to anti-MAG IgM paraproteins. Therefore, sulfatide may be a target antigen in some patients with NAIgMPP.     

Frequency and clinical correlates of anti–neural IgM antibodies in neuropathy associated with IgM monoclonal gammopathy

We studied the frequency and clinical correlates of different IgM specificities in 75 patients with neuropathy associated with IgM monoclonal gammopathy. Patients were tested for IgM reactivity with the myelin-associated glycoprotein, PO, neurofilaments, and tubulin by immunoblot; with GM1, asialo-GM1, GM2, GD1a, GD1b, sulfatide, and chondroitin sulfate C by enzyme-linked immunosorbent assay; and with brain and nerve glycolipids by overlay highperformance thin-layer chromatography. Forty-two patients (56%) had high titers of IgM antibodies to MAG; 4 (5%), to sulfatide (1 also to myelin-associated glycoprotein); 4 (5%), to the 200-kd neurofilament (2 also to myelin-associated protein); and 1 each, to GD1b and chondroitin sulfate C. No reactivity was found in 26 patients (35%). More patients with anti–myelin-associated glycoprotein IgM (62%) than with unknown IgM reactivity (31%) had a predominantly sensory neuropathy (p < 0.025). Nerve conduction findings were consistent with a demyelinating neuropathy in 77% of patients reactive to myelin-associated glycoprotein and 24% with unknown reactivity (p < 0.0001) and the mean conduction velocity of peroneal nerve was lower in the former group (22.9 m/sec) than in the latter group (39.6 m/sec) (p < 0.000001). Patients with anti–sulfatide IgM had a sensorimotor neuropathy with morphological evidence of demyelination while anti–neurofilament IgM was not associated with homogeneous findings. Patients with anti–GD1b or anti–chondroitin sulfate C IgM had a predominantly motor impairment. The frequent occurrence of anti–neural IgM antibodies in neuropathy associated with IgM gammopathy, and their frequent, though not constant association with similar neuropathy features, support their possible pathogenetic role in the neuropathy.     

CIDP患者血清和脑脊液中硫脂抗体、P2蛋白抗体的临床意义

目的　通过测定慢性炎性脱髓鞘性多发性神经病 (CIDP)患者血清和脑脊液 (CSF)中抗硫脂抗体及P2蛋白抗体水平 ,探讨其临床意义和可能的致病机制。方法　应用ELISA法检测 2 4例CIDP患者血清和脑脊液中抗硫脂抗体和P2蛋白抗体水平。结果　 (1 )CIDP组血清中高滴度抗硫脂抗体与其它周围神经病 (OPN)组和其它神经系统疾病 (OND)组比较无显著的差异 (P >0 .0 5) ;脑脊液中IgM 抗硫脂抗体与各对照组比较差异有显著性 (P <0 .0 5)。 (2 )CIDP组血清中高滴度抗P2抗体与OPN、OND组比较无显著的差异 (P >0 .0 5) ;脑脊液中抗P2抗体与各对照组比较有显著性差异 (P <0 .0 5 ,P <0 .0 1 )。 (3) 1 3例抗硫脂抗体阳性CIDP患者中 9例 (69.2 % )为感觉轴索性损害 ,1 1例阴性患者中 3例 (2 7.4 % )为感觉轴索性损害 ,差异有显著性 (P <0 .0 5)。 (4) 1 8例抗P2抗体阳性CIDP患者中 ,1 3例 (72 .2 % )为轴索性损害 ,6例抗P2抗体阴性患者中 3例 (50 % )为轴索性损害 ,差异无显著性 (P >0 .0 5)。结论　CIDP患者脑脊液中IgM 抗硫脂抗体可以作为感觉轴索型周围神经病的临床诊断参考指标 ;血清和脑脊液中P2抗体的检测对CIDP诊断参考价值不大 ,可能与疾病的修复有关。     

How useful are anti-neural IgM antibodies in the diagnosis of chronic immune-mediated neuropathies?

Antibodies against several neural antigens have been associated with different chronic immune-mediated neuropathies but their practical clinical relevance remains unclear. To determine the possible diagnostic usefulness of these antibodies we reviewed the clinical correlate of IgM antibodies to the myelin-associated glycoprotein (MAG), sulfatide, the gangliosides GM1, GM2, GD1a and GD1b in 539 consecutive patients examined for neuropathy or related diseases in our Neuropathy Clinics and tested for these antibodies in our laboratory since 1985. 302 patients (56%) had an established diagnosis of definite or possible chronic immune-mediated neuropathy while 237 had a neuropathy of non-immune-mediated origin or of unknown aetiology or a closely related disease. Antibodies to one or more antigen were more frequent (chi(2)=63.32; p<0.00001) in patients with chronic immune-mediated neuropathy (37.7%) than with other neuropathy or related diseases (7.2%) and their presence was associated in 87% of the patients with an immune-mediated neuropathy, incrementing by 31% the probability of having this form. Testing for MAG permitted to identify 24.8% of patients with an immune-mediated neuropathy, GM1 an additional 9.9%, while GM2, GD1b, GD1a and sulfatide altogether an additional 3% of the patients. Concerning clinical correlations, all 75 patients with anti-MAG IgM had neuropathy and IgM monoclonal gammopathy (PN+IgM) with a positive predictive value for this neuropathy of 100%. A similarly high predictive value for neuropathy (91.4%) was observed among 269 patients with IgM monoclonal gammopathy including 103 patients without neuropathy. Anti-sulfatide IgM, though rare, were also significantly and constantly associated with PN+IgM and permitted to identify few patients not bearing anti-MAG IgM. Anti-GM1 IgM were significantly associated with multifocal motor neuropathy (MMN) (29.2%) but where also found in a few patients with other immune or non-immune neuropathies or related diseases with a positive predictive value for MMN of 25.5%. Anti-GM2 IgM were also significantly associated with MMN and increased the sensitivity (36.2%) for MMN obtained with anti-GM1 IgM only, without affecting its specificity and positive predictive value. Anti-GD1a, GD1b, though not significantly more frequent in patients with immune-mediated neuropathy, were associated in 80 to 100% of patients with these neuropathies. In conclusion anti-neural IgM antibodies may help in identifying patients with a chronic immune-mediated neuropathy, even if only anti-MAG and anti-sulfatide IgM appear to be strictly associated with a definite clinical syndrome.     

A spontaneously immortalized Schwann cell line to study the molecular aspects of metachromatic leukodystrophy

The arylsulfatase A (ASA)-deficient mouse is a murine model of human metachromatic leukodystrophy (MLD) caused by a genetic defect in the ASA gene. Deficiency of ASA causes accumulation of cerebroside-3-sulfate (sulfatide) in visceral organs and in the central and peripheral nervous system, which subsequently causes demyelination in these areas. To investigate further the cellular pathomechanism of MLD, we established spontaneously immortalized Schwann cell lines from ASA-deficient mice. Cells showed marked sulfatide storage in the late endosomal/lysosomal compartment. This sulfatide accumulation can be further increased by external treatment with sulfatide using a lipid based transfection reagent as a cargo. The accumulated sulfatide was degraded in response to ASA treatment and first examination revealed that alteration on the molecular level found in ASA-deficient mice can also be observed in the presented cell culture model. Hence, these cells could be a suitable model to study MLD at a molecular level.     

Polyneuropathy attributes: a comparison between patients with anti-MAG and anti-sulfatide antibodies

Thirty-two patients with a peripheral neuropathy and paraproteinemia were tested for IgM antibodies against myelin-associated protein (MAG) and sulfatide by means of enzyme-linked immunosorbent assay. Nine patients (28%) had increased anti-sulfatide IgM antibodies and showed a chronic, slowly progressive, distally pronounced, and symmetric polyneuropathy with sensory to sensory-motor impairment, ataxia, hyporeflexia, and axonal involvement in electrophysiological studies. Ten patients (31%) with increased anti-MAG antibodies had a similar, homogeneous polyneuropathy syndrome but presented with demyelinating features. A weak crossreactivity between anti-MAG and anti-sulfatide antibodies was present in only three patients. In conclusion, although the two neuropathy groups clearly differed in their electrophysiological features, their clinical presentation was rather similar. Received: 19 July 1999 / Received in revised form: 23 December 1999 / Accepted: 2 May 2000     

The clinical correlates of high-titer IgG anti-GM1 antibodies

Serum IgG anti-GM1 antibodies have been reported to occur in a variety of disorders, including Guillain-Barré syndrome and chronic polyneuropathies. Of over 5,000 serums tested in our laboratory, high titers of selective IgG anti-GM1 antibodies (>1: 1,000) and without binding to sulfatide were found in 35 patients. Clinical correlation revealed that almost all patients had axonal, motor neuropathies. One subgroup was comprised of individuals with an acute motor neuropathy, described either as an acute axonal Guillain-Barré–like syndrome that was occasionally associated with a prodrome of Campylobacter jejuni enteritis or as Chinese paralysis syndrome. A second group of patients had chronic asymmetric lower motor neuron (LMN) syndromes with no conduction block or other evidence of demyelination. The presence of selective high-titer IgG anti-GM1 antibody reactivity in serum is uncommon but when present is strongly associated with acute axonal motor neuropathies or chronic asymmetric LMN syndromes.     

The gp120 glycoprotein of HIV-1 binds to sulfatide and to the myelin associated glycoprotein.

We investigated the binding of the gp120 glycoprotein of the human immunodeficiency virus (HIV-1) to neural glycolipids and glycoproteins by ELISA. The gp120 protein bound to sulfatide (GalS), a sulfated glycolipid autoantigen implicated in sensory neuritis, and to the myelin associated glycoprotein (MAG), an autoantigen in demyelinating neuropathy. Binding of gp120 to MAG was inhibited by the HNK-1 antibody, which recognizes a sulfated glucuronic acid epitope, suggesting that the interaction involves carbohydrate determinants. Sulfatide and MAG are potential receptors for gp120 in peripheral nerve and may have a role in the neuropathy associated with HIV-1 infection.     

Anti-sulfatide antibodies in neurological disease: binding to rat dorsal root ganglia neurons.

Increased titers of anti-sulfatide antibodies were detected by ELISA in 5 of 200 patients and control subjects. All 5 patients had sensory impairment; 4 had neuropathy, and one had multiple sclerosis. Of the patients with neuropathy, 2 had a clinical syndrome of small fiber sensory neuropathy with normal electrophysiological or nerve biopsy studies, 1 had a sensorimotor axonal neuropathy associated with IgM monoclonal gammopathy, and 1 had sensorimotor neuropathy with multifocal motor conduction block and anti-GM1 antibodies. The anti-sulfatide antibodies bound to the surface of unfixed rat dorsal root ganglia neurons and human neuroblastoma cells, and to fixed sections of central and peripheral myelin. No binding was detected following intraneural injection into rat sciatic nerves. Pre-absorption with sulfatide but not with galactocerebroside eliminated the tissue binding activity. These findings indicate that increased titers of anti-sulfatide antibodies are found in patients with sensory impairment but are not restricted to a particular neurological syndrome or type of neuropathy. The significance of anti-sulfatide antibodies is uncertain although sulfatide on dorsal root ganglia neurons may be a target antigen.     

Expression of the myelin and oligodendrocyte progenitor marker sulfatide in neurons and astrocytes of adult rat brain

Sulfatide is a myelin component of the central (CNS) and peripheral nervous system (PNS) and is used extensively to identify oligodendrocyte progenitor cells. We have explored sulfatide expression in CNS gray matter (cerebellum, cerebral cortex, and hippocampus) and the PNS in adult rats using an anti-sulfatide antibody (Sulph I) and confocal microscopy. Biochemical analyses revealed two Sulph I antigens, sulfatide and seminolipid; sulfatide was present at about five times higher concentration, and the affinity of Sulph I for sulfatide was 2.5 times higher than that for seminolipid. Thus sulfatide was considered the dominant antigen. We found Sulph I immunostaining, in addition to that in myelinated areas in subpopulations of astrocytes and neurons. Astrocyte Sulph I staining was localized to the cell bodies and in some cases also to the processes. In the cerebellum, some Sulph I-positive astrocytes corresponded to Golgi epithelial cell bodies. We also found Sulph I staining in neuronal cell bodies, which in some neurons was clearly localized to the cytoplasm and in others to the nuclear membrane. Sulph I immunostaining in the PNS was located in the myelin sheath and paranodal end segments. These results demonstrate the expression of sulfatide in cell types other than oligodendrocytes and Schwann cells, showing that sulfatide is not a selective marker for adult oligodendrocyte progenitor cells. Moreover, these findings show that sulfatide is localized also to intracellular compartments and indicate that other roles of sulfatide in astrocytes and neurons, compared to myelin, might be considered.     

硫脂致敏的实验性变态反应性神经炎病理和电生理特点

目的探讨硫脂诱导的实验性变态反应性神经炎病理和电生理特点。方法以硫脂免疫豚鼠，观察其周围神经电生理、病理及免疫细胞化学的变化。结果被致敏动物坐骨神经、脊神经根发生脱髓鞘改变，神经鞘膜ＩｇＧ荧光沉积明显，有的同时伴有髓鞘再生，病损区ＣＤ１１ｂ＋细胞显著增加而ＣＤ５＋细胞增加不明显，坐骨神经传导阻滞及传导速度减慢。结论硫脂致敏的实验性变态反应性神经炎与慢性格林－巴利综合征更相似。     

Immunopathogenetic Role Of The M-Protein In Neuropathy Associated With IgA Monoclonal Gammopathy

Neuropathy has been reported in some patients with IgA monoclonal gammopathy of undetermined significance (MGUS) but the clinical and pathogenetic relevance of this association remains unclear. This is because the clinical and electrophysiological features of the neuropathy in reported patients were quite heterogeneous and only occasionally endoneurial deposits or anti-neural reactivity of IgA M-proteins were found. In order to clarify the possible role of IgA M-proteins in the neuropathy we studied their reactivity with nerve antigens in 12 patients with neuropathy associated with IgA MGUS and in 15 patients with IgA MGUS without clinical or electrophysiological evidence of neuropathy. Patients' sera were tested for IgA reactivity with the glycolipids GM1, GM2, GD1a, GD1b, GQ1b and sulfatides by ELISA and with central (CNS) and peripheral nervous system (PNS) myelin and whole nerve homogenates by Western Blot. No IgA reactivity with any of the gangliosides tested or sulfatide was detected by ELISA in patients with neuropathy and IgA MGUS. By Western blot only one neuropathy patient had an intense IgA reactivity with several protein bands of the molecular weight (MW) of 80 to 200 kD, including high MW neurofilaments. A similar though less intense IgA reactivity with the same bands was detected in one patient without neuropathy. No other reactivity with neural proteins was detected in patients' sera more frequently or more intensely than in controls. The clinical features of the neuropathy in the four patients whose clinical reports were available showed an usually mild, predominantly motor (2) or sensory (1) or mixed (1) impairment, while electrophysiological studies showed a predominant axonal (2), demyelinating (1) or mixed (1) neuropathy. In the only patient in whom sural nerve biopsy was performed no endoneurial deposits of IgA were found. The heterogeneity of the clinical and electrophysiological findings in these patients together with the lack of a consistent pattern of IgA reactivity with neural antigens in the 12 patients examined fail to support, at least in these patients, a possible immunopathogenetic role of the IgA M-proteins in the neuropathy.     

Intracellular sulfatide expression in a subpopulation of astrocytes in primary cultures

A highly specific antibody against sulfatide, a myelin-associated glycolipid, has been investigated using indirect double immunocytochemistry in rat primary astroglial cultures from cerebral cortex. Sulfatide was expressed in a selected subpopulation of astrocytes (2–3%) and was found to be exclusively located intracellularly. The sulfatide-positive cells appeared in two different morphologies: flat and stellate. Immunolabeling of the astroglial cultures showed that sulfatide always co-existed with GFAP or S-100, and in some cells with GD3 (flat 90% and stellate 50%) or A2B5 (1%) antibody. The sulfatide-positive cells did not bind the O1 antibody, which is used as a marker for oligodendrocytes. Glial cultures from other regions and mixed cultures, with both neurons and glial cells, were examined and showed similar results. Biochemical analysis by TLC-ELISA verified the presence of sulfatide in the astroglial culture and showed decreasing amounts of sulfatide with days in vitro; 0.05 nmol/mg protein at day 10 and 0.01 nmol/mg protein at day 17. This analysis also showed that neither sulpholactosylceramide nor seminolipid was present, each of which also has affinity for the sulfatide antibody. This selective and intracellular expression encourages further identification of the astrocytes expressing sulfatide and the biological role of sulfatide in these cells. J. Neurosci. Res. 52:559–568, 1998. © 1998 Wiley-Liss, Inc.     

A variant form of metachromatic leukodystrophy without arylsulfatase deficiency

The clinical, pathological, and biochemical findings in a young woman with a new variant of metachromatic leukodystropy (MLD) are reported. The patient showed slow early development and deteriorated further during her first two decades. Nerve conductions were slow, and a sural nerve biopsy showed features of a sulfatide lipidosis. Urinary sulfatide excretion was comparable to that of patients with classic MLD, yet in vitro activity of arylsulfatase A and B and cerebroside sulfatase activity were normal. Skin fibroblasts cultured in medium supplemented with ³H-labeled sulfatide showed accumulation of labeled sulfatide in large amounts, implying a defect in sulfatide hydrolysis in vivo in spite of intact enzyme activity in vitro.     

Gallbladder cancer with ascites in a child with metachromatic leukodystrophy

IntroductionMetachromatic leukodystrophy (MLD) refers to leukodystrophy caused by the accumulation of sulfatide from arylsulfatase A (ARSA) gene mutations. Sulfatide also accumulates in various organs, including the peripheral nerves, kidney, and gallbladder.Proliferative changes in the gallbladder have been reported in several patients, while gallbladder cancer is reported in only two adult MLD cases. We report what is likely the first pediatric case of MLD with gallbladder cancer.Case reportThe patient was a 5-year-old girl diagnosed with MLD using head magnetic resonance imaging and detecting a homozygous mutation of c.302G>A (p.Gly101Asp) in ARSA. Abdominal bloating was observed at the age of 4 years; CT revealed a giant tumor in the gallbladder and massive ascites. Cholecystectomy was performed and pathological examination revealed adenocarcinoma. Measurement of serum sulfatide revealed increased levels compared to the average healthy range.DiscussionRapidly increased ascites and large polyps which are reported as risk factors for cancer were characteristic in our MLD case. When such lesions are detected, they should be removed immediately because of the possibility of cancer, even in a pediatric patient.     

Immunotherapy of idiopathic inflammatory neuropathies

Evaluation of peripheral neuropathy is a common reason for referral to a neurologist. Recent advances in immunology have identified an inflammatory component in many neuropathies and have led to treatment trials using agents that attenuate this response. This article reviews the clinical presentation and treatment of the most common subacute inflammatory neuropathies, Guillain-Barré syndrome (GBS) and Fisher syndrome, and describes the lack of response to corticosteroids and the efficacy of treatment with plasma exchange and intravenous immunoglobulin (IVIG). Chronic inflammatory demyelinating polyneuropathy, although sharing some clinical, electrodiagnostic, and pathologic similarities to GBS, improves after treatment with plasma exchange and IVIG and numerous immunomodulatory agents. Controlled trials in multifocal motor neuropathy have shown benefit after treatment with IVIG and cyclophosphamide. Also discussed is the treatment of less common inflammatory neuropathies whose pathophysiology involves monoclonal proteins or antibodies directed against myelin-associated glycoprotein or sulfatide. Little treatment data exist to direct the clinician to proper management of rare inflammatory neuropathies resulting from osteosclerotic myeloma; POEMS syndrome; vasculitis; Sj?gren's syndrome; and neoplasia (paraneoplastic neuropathy).     

Adult forms of metachromatic leukodystrophy: clinical and biochemical approach.

The clinical and biochemical characteristics of metachromatic leukodystrophy (MLD), true adult forms and late juvenile forms which are still living at adulthood, are reviewed as they both are observed in adult Neurology and Psychiatry departments. Mental deterioration is often the first symptom, evolving progressively; and dementia finally occurs. The latency before the appearance of neurological objective symptoms may be long and extend for several years. In many cases, the behavioral abnormalities are the first symptoms. Some of these forms have been diagnosed as schizophrenia. Very seldom, neurological symptoms, especially ataxia, occur without cognitive or psychiatric disturbances. Most of these cases have pyramidal and cerebellar symptoms, at diverse degrees. Seizures can also occur which is some cases can be early symptoms associated to mental deterioration. The association of central and peripheral neurological symptoms is very characteristic of MLD. The peripheral neuropathy is not generally clinically evidenced, but is rarely missing electrophysiologically. Arylsulfatase A determination should be performed for diagnosis as a first step, and confirmed by the accumulation of sulfatide, either by quantitative determinations in urine or by the sulfatide loading test. It is as yet not clear why certain forms have a rather rapid evolution in 5 years, and others have a very protracted course during decades.     

AUTOIMMUNE RESPONSES TO GLYCOLIPIDS IN PARANEOPLASTIC NEUROPATHY: REPORT OF TWO CASES

Glycolipids (GL) have been implicated as potential antigens in autoimmune neuropathies, but their role in paraneoplastic neuropathy has been poorly investigated. We describe two patients affected by lung neoplasia and subacute sensori-motor axonal neuropathy with high titres of IgG auto-antibodies against GM1, GD1b, GQ1b, GD1a, GD2, GM2, GM3, GD3, asialo-GM1 and sulfatide. The first patient showed prevalent sensory axonal neuropathy, ophthalmoplegia and dysphagia. Small cell lung carcinoma was bioptically discovered and treated with chemotherapy and irradiation, which yielded clinical stabilization and decline of anti-GL IgG titre in a two years follow-up. The second patient complained of subacute, progressive distal hypostenia. Neurologic examination showed areflexic, hypotonic tetraparesis with marked wasting, fasciculations, mimicking lower motor neuron disease. In addition to anti-GL IgG, we detected expansion of peripheral γ/δ T lymphocytes (3% of total T cells, n.v. <0.5%), a T cell subset known to recognize lipid antigens. Lung adenocarcinoma was discovered and surgically removed. After two months, neuropathy stabilized and both anti-GL IgG and γ/δ T lymphocytes markedly declined. Immunohistochemistry on this patients' tumor showed expression of GM1, GD1a, GD2, GM2, GM3, GD3 on neoplastic cells, which were infiltrated by IgG and CD8 and γ/δ T lymphocytes. The association of neoplasia, peripheral neuropathy and autoimmune responses to GL observed in our patients proposes a previously underestimated role for GL as putative antigens in paraneoplastic neuropathy. GL should be considered as candidate antigens in paraneoplastic neuropathy and anti-GL IgG should be evaluated in patients with subacute sensory and/or motor neuropathy.     

The AB-variant of metachromatic leukodystrophy (Postulated activator protein deficiency)

Summary The histopathological findings in a sural nerve biopsy of a new distinct variant of metachromatic leukodystrophy (MLD) are compared to those of classical MLD. The clinical and histological features are typical of a sulfatide lipidosis, yet in vitro activities of arylsulfatases A and B and cerebroside sulfatase are normal. Intact skin fibroblasts, when cultured in a medium supplemented with labelled sulfatide, show impaired in vivo sulfatide hydrolysis. A deficiency of the requisite activator protein is postulated.