HLA antigens and susceptibility to myasthenia gravis

HLA-A, -B, -C and -DR antigen frequencies determined in a group of 73 myasthenia gravis (MG) patients were compared with those of a control group of 205 subjects. The strongest positive association with MG was found antigens B8 and DR3 (relative risks 9.56 and 8.84 respectively). Analysis of our data indicates that both antigens, independently from their linkage disequilibrium, are involved in susceptibility to MG. No relationship between HLA antigens on thymic pathology was observed in our material. In male MG patients the association with DR3 was weaker than in female patients. The difference in DR3 frequency between male and female patients was statistically significant; no significant difference was found for antigen B8. It appears that DR3 contributes to development of MG only in females. In male patients aged more than 30 years at the onset of disease, MG was not associated with B8 or DR3. In contrast, in female patients aged more than 30 years at the onset of disease there was a strong association of B8 and DR3 with the disease.     

Myasthenia gravis: studies on HL-A antigens and lymphocyte subpopulations in patients with myasthenia gravis.

Thirth-three patient with a clinical diagnosis of myasthenia gravis were tissue-typed for HL-A antigens. In agreement with earlier reports a significant increase in antigens HL-A1 and HL-A8 were found in this material. Two of the patients were treated with chronic thoracic duct drainage. Proportions of T and B lymphocytes in lymph and peripheral blood were estimated in these patients. In the lymph an initial decrease in the proportion of T cells occurred, which was accompanied by a subsequent increase in the proportion of B cells. Towards the end of the chronic drainage period this effect was reversed. A slightly different picture occurred in blood lymphocytes. Initially, there was an increase in both T and B cells, followed by a decrease in T-cells numbers in one patient, whereas in the second patient the proportion of T cells decreased from the onset of drainage while the proportion of B cells steadily increased. These studies showed that available markers for determination of T ANd B cells were useful for studies of lymphocyte subpopulations in blood and lymph. Lmyphocytes from the thoracic duct were also tested for their reactivity to various mitogens specific for either T or B cells. The B-cell mitogens which were used were dextran sulphate, lipopolysaccharide, purified protein derivative, as well as rabbit anti-human beta2-microglobulin serum. The T-cell mitogens investigated were concanavalin A and phytohaemagglutinin. No significant differences in the responsiveness of thoracic duct lymphocytes compared to normal peripheral blood lymphocytes were found.     

Myasthenia gravis patients with thymus hyperplasia and myasthenia gravis patients with thymoma display different HLA associations

Thirty myasthenia gravis (MG) patients (9 with thymoma, 12 with thymus hyperplasia and 9 with thymic atrophy) and 181 Norwegian healthy controls were serologically typed for HLA-A, -B and -DR antigens and genomically typed for HLA-DQA1 and HLA-DQB1 alleles by probing in vitro amplified DNA with sequence-specific oligonucleotides. In patients with thymus hyperplasia the frequency of the DQB1*0201 allele was increased compared to controls (RR = 3.5, p less than 0.05), whereas among the patients with thymoma this allele was not observed (RR = 0.06, p less than 0.01). The frequencies of HLA-B8, -DR3 and -DQA1*0501, which are in strong linkage disequilibrium with DQB1*0201, were increased in patients with hyperplasia and reduced in patients with thymoma. The data suggest that different HLA genes predispose to two different forms of MG.     

LD antigens associated with HL-A8 and myasthenia gravis.

The finding that the SD antigen HL-A8 is associated with myasthenia gravis has raised the question as to whether or not there is also an association between some specific LD antigen and myasthenia gravis and/or HL-A8. MLC technique was used to study LD antigens in 33 myasthenic patients. The cells of a myasthenic patient who was homozygous for both HL-A and LD products were used in MLC tests as stimulators with HL-A8 bearing cells from 24 myasthenics, their 17 relatives and 16 controls and to non-HL-A8 cells from nine myasthenics and 16 controls. At least three different LD genes were found to be associated with HL-A8. One of them, called LDm' was present in 17 (63 %) of the 27 HL-A8-bearing haplotypes of myasthenics, and in nine (47 %) of the 19 HL-A8-bearing haplotypes of controls. In our study LDm was not found in the 84 haplotypes devoid of HL-A8. LDm is strongly associated with HL-A8 and through this also with myasthenia. Calculated from phenotype frequencies for HL-A8 and its association to LDm' the LDm frequencies are 9 % in the control population, 30 % in myasthenics and 48 % in young females with onset of myasthenia below 35 years. LDm had no indendent correlation with any of the clinical parameters of myasthenia gravis, even though is was found more often in HL-A8+ females with the onset of myasthenia before 35 years than in the whole myasthenic group. LDm appears to be similar to LD8a antigen.     

HLA class II and class I polymorphism in Venezuelan patients with myasthenia gravis

Oligotyping performed among ethnically mixed Venezuelan patients with myasthenia gravis (MG) and controls has revealed positive associations of HLA class I A*31, B*08, B*39, B*40, C*15, C*17, and class II DRB1*09 and negative associations of DQB1*06 and DQA1*02 with the disease. Sequential removal of human leukocyte antigen B (HLA-B) alleles when relative predispositional effects (RPEs) were looked for demonstrated that B*08 is the allele group with the largest contribution in the overall MG patients followed by B*39 and B*40. Several specificities (A*31, B*08, C*17, DRB1*03, DQA1*05, and DQB1*02) indicated increased frequencies among patients with thymic hyperplasia versus patients without hyperplasia or controls. Tests to identify alleles with the strongest association to MG in our patients detected DRB1*13 and B*38 as possible predisposing secondarily associated alleles in patients with hyperplasia. The associations observed disappear after Bonferoni correction of probability values and have been described in patients of Caucasian and/or Oriental ethnic background. Thus, our results reflect the heterogeneity of our population and of the patients tested and suggest a limited influence of several HLA genes in this heterogeneous disease or that these might be only markers of nearby non-HLA genes responsible for the susceptibility or resistance effect.     

Therapeutic options in autoimmune myasthenia gravis

Autoimmune myasthenia gravis (MG) is associated with circulating antibodies to AChR, modification of the synaptic cleft, and destruction of the postsynaptic neuromuscular membrane. The hallmark is fluctuating muscular weakness and fatigability of muscles on sustained repeated activity. Various drugs and invasive procedures have been used in the treatment of MG including acetylcholinesterase inhibitors, corticosteroids, azathioprine, cyclosporine, cyclophosphamide, mycophenolate mofetil, tacrolimus, etanercept, intravenous immunoglobulin, plasma exchange and thymectomy. We review the role of each of these drugs and invasive procedures in MG. Although current treatment is highly successful and mortality is almost nil, further trials are required to identify the most suitable treatments for different subgroups of MG patients. In addition, safer and more potent drugs are required as most current drugs have major side effects due to immunosuppression. Therefore, the goal of novel therapies should be increased specificity of the immune-directed agents.     

HLA class I and class II polymorphisms in Saudi patients with myasthenia gravis

Myasthenia gravis (MG) is a rare autoimmune disease of the neuromuscular junction. MG has been shown to be associated with many HLA antigens in different populations. Here we have analysed the frequency of HLA‐A, B, DR and DQ in a group of Saudi MG patients and compared their results to a group of healthy controls. MG in Saudi patients is found to be associated with HLA‐A*23, B*08, B*18, DRB1*16 and DRB1*13. The strongest association was with HLA‐B*08, which was associated with young age at onset and female gender. Our results are in line with other published results from around the world and warrant fine mapping of the area using microsatellite to map the disease gene.     

Immunological similarities between an experimental autoimmune myasthenia gravis model and human myasthenia gravis

The induction of experimental autoimmune myasthenia gravis (EAMG) in rabbits after immunization with an acetylcholine (ACh) conjugate was found to possess immunological similarities with human myasthenia gravis. Anti-ACh antibodies, present in human sera, recognized the antigenic determinant, glutarylcholine, used to raise anti-ACh antibodies in rabbits. Identification of anti-anti-ACh antibodies in MG patients enabled us to test for recognition of the anti-ACh antibodies present in rabbit sera. The reverse, the recognition of rabbit auto-anti-anti-ACh antibodies by human anti-ACh antibodies was also tested and found to be specific.     

SIN-1降低重症肌无力大鼠的自身免疫反应

用一氧化氮 (NO)供体 3 吗啉 斯德酮亚胺 (SIN 1)干预乙酰胆碱受体 (AChR)致敏的实验性自身免疫性重症肌无力 (EAMG)大鼠模型。并进行临床评分、体重测量、免疫学指标及细胞凋亡检测。结果显示在大鼠致敏后 0～ 7天和 16～ 2 5天给药后 ,SIN 1组大鼠临床症状明显减轻伴发病延迟 ,血清IgG含量始终明显低于对照组 ;致敏后第10天 ,SIN 1组大鼠脾单个核细胞AChR反应性IFN γ分泌性细胞数 (6 38± 1 0 6 )比对照组 (8 2 5± 1 6 7)明显减少(P <0 0 5 ) ,外周血AChR反应性凋亡细胞含量 (8 5 9± 1 35 )与对照组 (5 0 5± 0 6 3)相比明显增多 (P <0 0 1)。实验证明SIN 1可以促使AChR反应性MNC凋亡增加 ,下调自身免疫反应 ,在EAMG的发病和疾病进展中起保护作用。     

CD45 isoform expression in autoimmune myasthenia gravis

In myasthenia gravis (MG), humoral and cellular immune mechanisms are involved in the autoimmune pathogenesis. In this study, we investigated the role of the CD45 molecule in MG, having recently reported an association in multiple sclerosis. CD45, a protein-tyrosine phophatase receptor type C (PTPRC), is essential for both thymic selection and peripheral activation of T and B cells. Our aims were to determine (a) the prevalence of a functional mutation in the CD45 gene (exon 4 77C --> G; prevalence analysis), and (b) the distribution of memory (CD45RO+) and naive (CD45RA+) T cells in the peripheral blood (subset analysis). T cells from 78 patients with generalised MG were stained with monoclonal antibodies against CD45RO, CD45RA, CD4 and CD8 and quantified by four-colour flow cytometry. The control panel for the prevalence analysis (a) consisted of 303 healthy individuals. (b) From those, 67 age- and sex-matched probands were randomly selected as controls for the subset analysis. Patients were stratified according to their MG onset age, thymic pathology and immunosuppressive treatment. Statistical analysis was performed by Fisher's exact test, asymptotic chi2 test, the two-sided Mann-Whitney test and Spearman's correlation coefficient. As a result, the 77C --> G mutation in exon 4 of the CD45 gene was found in 1 of 78 patients versus none of the 303 controls. Thus, no association was detected with this single nucleotide polymorphism in MG patients overall. Surprisingly, however, ratios of CD45RO+ to CD45RA+ T cells were lower among CD8+ T cells from patients with late-onset MG (P = 0.023). Thymoma patients also showed a similar trend among CD4+ and CD8+ T-cells, as expected. These differences were not related to immunosuppressive drug treatment or thymectomy (in the 67 informative patients). Since there is no other evidence for increased thymopoiesis in late-onset MG, we propose an altered subset balance in the circulation.     

Diagnostic and clinical classification of autoimmune myasthenia gravis

Myasthenia gravis is characterized by muscle weakness and abnormal fatigability. It is an autoimmune disease caused by the presence of antibodies against components of the muscle membrane localized at the neuromuscular junction. In most cases, the autoantibodies are against the acetylcholine receptor (AChR). Recently, other targets have been described such as the MuSK protein (muscle-specific kinase) or the LRP4 (lipoprotein related protein 4). Myasthenia gravis can be classified according to the profile of the autoantibodies, the location of the affected muscles (ocular versus generalized), the age of onset of symptoms and thymic abnormalities.The disease generally begins with ocular symptoms (ptosis and/or diplopia) and extends to other muscles in 80% of cases. Other features that characterize MG include the following: variability, effort induced worsening, successive periods of exacerbation during the course of the disease, severity dependent on respiratory and swallowing impairment (if rapid worsening occurs, a myasthenic crisis is suspected), and an association with thymoma in 20% of patients and with other autoimmune diseases such as hyperthyroidism and Hashimoto's disease. The diagnosis is based on the clinical features, the benefit of the cholinesterase inhibitors, the detection of specific autoantibodies (anti-AChR, anti-MuSK or anti-LRP4), and significant decrement evidenced by electrophysiological tests.In this review, we briefly describe the history and epidemiology of the disease and the diagnostic and clinical classification. The neonatal form of myasthenia is explained, and finally we discuss the main difficulties of diagnosis.     

Studies in myasthenia gravis: Heat stability and species specificity of active muscle antigens

Both myosin and actomyosin, active antigens related to antibody induction in myasthenia gravis, show different stabilities. With time or increasing heat treatment, myosin rapidly loses antigenic activity. While actomyosin showed lower initial antigenic activity, both with time and various heat treatments it showed greater stability and final activity. Utilization of actomyosin from several animal sources showed antigenic sites were species related. Human, monkey and rabbit actomyosin were good sources of antigen for studies with human myasthenic sera.     

The effect of thalidomide on experimental autoimmune myasthenia gravis

Thalidomide is reported to have immunosuppressive and anti-inflammatory effects which have led to its use in the treatment of a number of immune-mediated disorders including leprosy, prurigo, discoid lupus, and Behcet's disease. In addition, thalidomide has recently been used to prevent immunological rejection phenomena following skin and bone-marrow grafts. The immune responses in these conditions are thought to be cell-mediated. However, little is known about the effectiveness of thalidomide in suppressing antibody-mediated immune responses. In the present study, we have examined the effect of thalidomide in a model antibody-mediated autoimmune disorder--experimental autoimmune myasthenia gravis (EAMG). To induce EAMG, Lewis rats were immunized with acetylcholine receptor (AChR) purified from the electric organ of Torpedo californicus. Groups of rats were treated daily, either with thalidomide in excess of doses reported to prevent graft-versus-host (GVH) disease in bone-marrow-transplanted rats, or with control treatments. Our results show that thalidomide failed to inhibit AChR antibody production despite good absorption and high blood levels of the drug. This suggests that thalidomide is not likely to be generally useful in the treatment of antibody-mediated autoimmune conditions. However the selective effect of thalidomide in suppressing certain presumably cellular immune responses, while sparing antibody production, is inherently interesting, and merits further study.     

Prevention and therapy with electrolectin of experimental autoimmune myasthenia gravis in rabbits

Electrolectin (EL), an endogenous β-D -galactoside-binding lectin from Electrophorus electricus, was found to have a prophylactic and therapeutic action on the experimental autoimmune myasthenia gravis (EAMG) in rabbits. EAMG is an autoimmune disease induced by immunization with the purified acetylcholine receptor protein (AChR) and is considered to be a good model for the human disease myasthenia gravis. Simultaneous immunization with AChR and EL completely prevented the onset of myasthenic symptoms. This preventive effect was accompanied by a decrease in the recognition of AChR by anti-AChR antibodies. The administration of EL to myasthenic rabbits led, in most cases, to a complete recovery which was not accompanied by any significant change in the level of circulating anti-AChR antibodies. No evidence for an action of EL at the muscular level could be obtained. EL, however, was found to bind to rabbit lymphocytes and to stimulate their mitosis. These results suggest that EL produces its effects on EAMG by acting at the level of the immune system. It is proposed that EL may play a role in the immunological regulation of the response to self-antigen, which could be one of the biological functions of this animal lectin.     

Antibodies to polyadenylic acid in patients with myasthenia gravis.

Sera from 100 patients with myasthenia gravis and 45 patients with non-myasthenia gravis neuromuscular diseases were studied for antibodies to poly rA, poly rA-rU, native and denatured DNA. All patients with myasthenia gravis had significant anti-acetylcholine receptor antibodies with a mean titre of 1.2 X 10(-7)M. Forty-eight per cent of the myasthenia gravis patients had anti-poly rA antibody levels which were greater than 3 standard deviations from the mean of 65 control patients by Millipore filter radioimmunoassay. The antibody was specific for poly rA and present in a much higher frequency than antibodies to the other nucleic acids tested. Sucrose-gradient ultracentrifugation demonstrated that the antibody was limited to the IgM class alone. Mechanisms relating these findings to a more generalized immunological dysfunction are discussed.     

Acetylcholine receptor and thymus in experimental autoimmune myasthenia gravis and experimental myositis.

This study was attempted to obtain information about biological properties of junctional acetylcholine receptor (AChR) and extrajunctional AChR, and about nerve influences on muscles AChRs under the pathological conditions of experimental myasthenia and myositis. Experimental autoimmune myasthenia gravis (EAMG) was induced in Wistar rats by immunizations with AChR purified from the electric organ of Narke Japonica without using Freund's complete adjuvant experimental myositis by immunization with rat muscle extract depleted of AChR. Thirty-five days after the initial immunization, unilateral dissection of the ischiadic nerve was performed in all immunized rats. Contents of AChR in both hind limb muscles were measured by double immunoprecipitation assay method 15 days after the experimental denervation. In the control animals the amount of AChR extractable from innervated muscles was 2.7 +/- 0.5 (mean +/- s.d.) pmole/g muscle and increased about 10-fold 15 days after the denervation (30 +/- 7.9). In rats with EAMG, AChR contents was reduced in both denervated (1.1 +/- 1.0) and innervated muscles (1.3 +/- 0.9). In experimental myositis, the increase of muscle AChR was impaired in denervated muscles (2.4 +/- 0.6), but AChR contents was not reduced in innervated muscles (2.7 +/- 0.9). These results suggest that nerves may influence AChR metabolism, keeping numbers of AChR constant even in inflammatory condition. In addition, germinal centre formation in thymic medulla was detected in EAMG rats.     

Antiacetylcholine receptor and antinuclear antibodies in myasthenia gravis. Correlation with HLA, sex and Gm

Sera from 27 subjects with myasthenia gravis (MG) were examined by immunoassay for antibodies to double-stranded DNA (ds-DNA), RNA-nucleoprotein complexes (ENA) and acetylcholine receptor (ACHR). The prevalence of the genetic markers of sex, HLA and Gm were analyzed in relation to various parameters of these autoantibodies. The highest levels of ds-DNA antibodies were associated with HLA B8 as compared to other HLA antigens (p less than 0.05), females as compared with males (p less than 0.05), and females with HLA B8 (p less than 0.05) when both sex and HLA were analyzed concurrently. An association between low titers and HLA B7 (p less than 0.05), with a significant difference between the B8 females and B7 males (p less than 0.05) was also noted. By contrast, no Gm association was noted for antinuclear antibody parameters, but was observed in females between high ACHR antibody titers and the homozygous phenotype (3; 5, 13) (p less than 0.05). This study of MG implicated HLA and sex factors in the production of a broad spectrum of antinuclear antibodies, while the contrasting Gm association noted with ACHR antibody titers was indicative of distinctive immunogenetic influences over autoantibody production in MG.     

Complicating autoimmune diseases in myasthenia gravis: a review

Abstract

Myasthenia gravis (MG) is a rare autoimmune disease of skeletal muscle endplates. MG subgroup is relevant for comorbidity, but usually not accounted for. MG patients have an increased risk for complicating autoimmune diseases, most commonly autoimmune thyroid disease, systemic lupus erythematosus and rheumatoid arthritis. In this review, we present concomitant autoimmune disorders associated with the different MG subgroups, and show how this influences treatment and prognosis. Concomitant MG should always be considered in patients with an autoimmune disorder and developing new neuromuscular weakness, fatigue or respiratory failure. When a second autoimmune disorder is suspected, MG should be included as a differential diagnosis.