David Hunt

A Highly Enriched Niche of Precursor Cells with Neuronal and Glial Potential Within the Hair Follicle Dermal Papilla of Adult Skin

Skin‐derived precursor cells (SKPs) are multipotent neural crest‐related stem cells that grow as self‐renewing spheres and are capable of generating neurons and myelinating glial cells. SKPs are of clinical interest because they are accessible and potentially autologous. However, although spheres can be readily isolated from embryonic and neonatal skin, SKP frequency falls away sharply in adulthood, and primary sphere generation from adult human skin is more problematic. In addition, the culture‐initiating cell population is undefined and heterogeneous, limiting experimental studies addressing important aspects of these cells such as the behavior of endogenous precursors in vivo and the molecular mechanisms of neural generation. Using a combined fate‐mapping and microdissection approach, we identified and characterized a highly enriched niche of neural crest‐derived sphere‐forming cells within the dermal papilla of the hair follicle of adult skin. We demonstrated that the dermal papilla of the rodent vibrissal follicle is 1,000‐fold enriched for sphere‐forming neural crest‐derived cells compared with whole facial skin. These “papillaspheres” share a phenotypic and developmental profile similar to that of SKPs, can be readily expanded in vitro, and are able to generate both neuronal and glial cells in response to appropriate cues. We demonstrate that papillaspheres can be efficiently generated and expanded from adult human facial skin by microdissection of a single hair follicle. This strategy of targeting a highly enriched niche of sphere‐forming cells provides a novel and efficient method for generating neuronal and glial cells from an accessible adult somatic source that is both defined and minimally invasive.

Multipotent skin-derived precursors: from biology to clinical translation

Skin-derived precursor cells (SKPs) are a novel population of neural crest-related precursor cells that can be isolated from embryonic and adult skin. SKPs are capable of generating neuronal, glial and mesodermal progeny. Fate mapping and microdissection experiments have demonstrated a neural crest origin of SKPs within defined niches in adult skin. The finding that SKP derivatives such as Schwann cells and neuronal cells have in vitro and in vivo function raises the possibility of SKPs being both an experimental and therapeutic resource for disease modelling and regenerative medicine. This review focuses on the increased understanding of the developmental and anatomical origins of SKPs and the biotechnological potential of these cells.

Natalizumab-associated progressive multifocal leucoencephalopathy: a practical approach to risk profiling and monitoring

Natalizumab reduces relapse frequency, delays onset of disease progression and improves disease outcomes in relapsing–remitting multiple sclerosis (MS) and is a cost-effective treatment for rapidly evolving severe relapsing–remitting MS. However, it is associated with the development of progressive multifocal leucoencephalopathy (PML), a serious opportunistic brain infection caused by a neurotropic strain of the JC virus (JCV). Until May 2011, 83 300 patients had received natalizumab for MS. One hundred and twenty-four patients had developed PML, of whom 23 (19%) died. In order to maximise the benefit–risk ratio of natalizumab for MS patients it is important to develop a strategy for risk profiling and monitoring for PML. Central to this is an understanding of the biology of the JCV and the emerging clinical picture of natalizumab-associated PML. This paper reviews the evidence for managing the risk of PML in natalizumab-treated patients and the authors propose an algorithm for risk profiling and risk management. Key features of this algorithm include risk stratification based on emerging risk factors, heightened clinical vigilance for the clinical features of natalizumab-associated PML and considerations for temporary and permanent cessation of natalizumab dosing.

Detection of interferon alpha protein reveals differential levels and cellular sources in disease

Type I interferons (IFNs) are essential mediators of antiviral responses. These cytokines have been implicated in the pathogenesis of autoimmunity, most notably systemic lupus erythematosus (SLE), diabetes mellitus, and dermatomyositis, as well as monogenic type I interferonopathies. Despite a fundamental role in health and disease, the direct quantification of type I IFNs has been challenging. Using single-molecule array (Simoa) digital ELISA technology, we recorded attomolar concentrations of IFN&agr; in healthy donors, viral infection, and complex and monogenic interferonopathies. IFN&agr; protein correlated well with functional activity and IFN-stimulated gene expression. High circulating IFN&agr; levels were associated with increased clinical severity in SLE patients, and a study of the cellular source of IFN&agr; protein indicated disease-specific mechanisms. Measurement of IFN&agr; attomolar concentrations by digital ELISA will enhance our understanding of IFN biology and potentially improve the diagnosis and stratification of pathologies associated with IFN dysregulation.

Cerebral Small Vessel Disease Burden Is Increased in Systemic Lupus Erythematosus

Background and Purpose— Systemic lupus erythematosus (SLE) increases stroke risk, but the mechanism is uncertain. This study aimed to determine the association between SLE and features on neuroimaging of cerebral small vessel disease (SVD), a risk factor for stroke. Methods— Consecutive patients attending a clinic for SLE were recruited. All patients underwent brain magnetic resonance imaging; had blood samples taken for markers of inflammation, endothelial dysfunction, cholesterol, and autoantibodies; and underwent cognitive and psychiatric testing. The data were compared with sex- and age-matched healthy controls and patients with minor stroke. Features of SVD were measured, a total SVD score calculated, and associations sought with vascular risk factors, cognition, SLE activity, and disease duration. Results— Fifty-one SLE patients (age: 48.8 years; SD: 14.3 years) had a greater total SVD score compared with healthy controls (1 versus 0; P<0.0001) and stroke patients (1 versus 0; P=0.02). There were higher perivascular spaces and deep white matter hyperintensity scores and more superficial brain atrophy in SLE patients versus healthy controls. Despite fewer vascular risk factors than similarly aged stroke patients, SLE patients had similar or more of some SVD features. The total SVD score was not associated with SLE activity, cognition, disease duration, or any blood measure. Conclusions— In this data set, SLE patients had a high burden of SVD features on magnetic resonance imaging, particularly perivascular spaces. A larger longitudinal study is warranted to determine the causes of SVD features in SLE and clinical implications.

Hematopoietic origin of Langerhans cell histiocytosis and Erdheim Chester disease in adults

Langerhans cell histiocytosis (LCH) and Erdheim-Chester disease (ECD) are rare histiocytic disorders induced by somatic mutation of MAPK pathway genes. BRAFV600E mutation is the most common mutation in both conditions and also occurs in the hematopoietic neoplasm hairy cell leukemia (HCL). It is not known if adult LCH or ECD arises from hematopoietic stem cells (HSCs), nor which potential blood borne precursors lead to the formation of histiocytic lesions. In this study, BRAFV600E allele-specific polymerase chain reaction was used to map the neoplastic clone in 20 adults with LCH, ECD, and HCL. BRAFV600E was tracked to classical monocytes, nonclassical monocytes, and CD1c+ myeloid dendritic cells (DCs) in the blood, and mutations were observed in HSCs and myeloid progenitors in the bone marrow of 4 patients. The pattern of involvement of peripheral blood myeloid cells was indistinguishable between LCH and ECD, although the histiocytic disorders were distinct to HCL. As reported in children, detection of BRAFV600E in peripheral blood of adults was a marker of active multisystem LCH. The healthy counterparts of myeloid cells affected by BRAF mutation had a range of differentiation potentials depending on exogenous signals. CD1c+ DCs acquired high langerin and CD1a with granulocyte-macrophage colony-stimulating factor and transforming growth factor β alone, whereas CD14+ classical monocytes required additional notch ligation. Both classical and nonclassical monocytes, but not CD1c+ DCs, made foamy macrophages easily in vitro with macrophage colony-stimulating factor and human serum. These studies are consistent with a hematopoietic origin and >1 immediate cellular precursor in both LCH and ECD.

Origins of Gliogenic Stem Cell Populations Within Adult Skin and Bone Marrow

The generation of Schwann cells from precursors within adult skin and bone marrow is of significant clinical interest because of the opportunities for disease modelling and strategies for remyelination. Recent evidence has suggested that glial cells can be generated from (i) mesenchymal stem cells (MSCs) within adult bone marrow and (ii) skin-derived precursor cells (SKPs) within adult skin. However, there is a need to clarify the developmental mechanism whereby such multipotent adult stem cell populations generate glia. We used Wnt1-Cre/Rosa26R(LacZ) and Wnt1-Cre/Rosa26R(YFP) neural crest reporter mice to test the hypothesis that (i) MSCs and (ii) SKPs represent adult gliogenic precursor cells of neural crest origin. We demonstrate that, although labeled cells can be identified within long bone preparation, such cells are rarely found in marrow plugs. Moreover, we did not find evidence of a neural crest origin of bone marrow-derived MSCs and were not able to provide a developmental rationale for the derivation of glial cells from MSCs using this approach. In contrast, we provide robust evidence for the neural crest origin of SKPs derived from adult skin. These precursor cells reliably generate cells with a Schwann cell phenotype, expressing appropriate transcription factors and Schwann cell markers. We demonstrate multiple anatomical origins of gliogenic SKPs within adult skin. We conclude that SKPs, rather than bone marrow-derived MSCs, represent a more defined and developmentally rational source for the study and generation of Schwann cells from readily accessible adult tissues.

Fatigue and cognitive function in systemic lupus erythematosus: associations with white matter microstructural damage. A diffusion tensor MRI study and meta-analysis

Objective The objective of this study was to investigate fatigue and cognitive impairments in systemic lupus erythematous (SLE) in relation to diffuse white matter microstructural brain damage. Methods Diffusion tensor MRI, used to generate biomarkers of brain white matter microstructural integrity, was obtained in patients with SLE and age-matched controls. Fatigue and cognitive function were assessed and related to SLE activity, clinical data and plasma biomarkers of inflammation and endothelial dysfunction. Results Fifty-one patients with SLE (mean age 48.8u2009±u200914.3 years) were included. Mean diffusivity (MD) was significantly higher in all white matter fibre tracts in SLE patients versus age-matched healthy controls (pu2009<u20090.0001). Fatigue in SLE was higher than a normal reference range (pu2009<u20090.0001) and associated with lower MD (ßu2009=u2009−0.61, pu2009=u20090.02), depression (ßu2009=u20090.17, pu2009=u20090.001), anxiety (ßu2009=u20090.13, pu2009=u20090.006) and higher body mass index (ßu2009=u20090.10, pu2009=u20090.004) in adjusted analyses. Poorer cognitive function was associated with longer SLE disease duration (pu2009=u20090.003) and higher MD (pu2009=u20090.03) and, in adjusted analysis, higher levels of IL-6 (ßu2009=u2009−0.15, pu2009=u20090.02) but not with MD. Meta-analysis (10 studies, nu2009=u2009261, including the present study) confirmed that patients with SLE have higher MD than controls. Conclusion Patients with SLE have more microstructural brain white matter damage for age than the general population, but this does not explain increased fatigue or lower cognition in SLE. The association between raised IL-6 and worse current cognitive function in SLE should be explored in larger datasets.

Targeted treatment of brainstem neurohistiocytosis guided by urinary cell-free DNA

Objective: To identify a treatment-responsive BRAFV600E mutation in brainstem neurohistiocytosis, where no lesional tissue was readily obtainable, using a cell-free DNA approach. Methods: Cell-free DNA was extracted from urine and allele-specific PCR for the BRAFV600E mutation was performed. Response to conventional treatment (corticosteroids and interferon) and targeted treatment with a BRAF inhibitor was assessed by clinical evaluation, gadolinium-enhanced MRI brain scan, and serial testing of urinary cell-free DNA for mutant alleles. Results: BRAFV600E mutation could be readily identified in urinary cell-free DNA at an allele frequency of 4.2%. Treatment of Erdheim-Chester disease with corticosteroids and interferon was ineffective and associated with disease progression. Treatment with BRAF inhibitors was associated with clinical improvement and near-complete radiologic remission. Following 6 months of BRAF inhibitor therapy, no enhancing lesions could be detected in the brain and mutant alleles were cleared from the urine. Conclusions: Analysis of urinary cell-free DNA using allele-specific PCR for BRAFV600E mutations allows rapid noninvasive identification of a highly treatment-responsive pathway, leading to clinical and radiologic remission of disease. Our case demonstrates that this assay may have a particular role in challenging neurohistiocytosis cases, where attempts at obtaining lesional tissue have failed or are not feasible. Classification of evidence: This study provides Class IV evidence. This is a single observation study without controls.

Neuroinflammation: Synapses pruned in lupus

Lupus is an autoimmune disease that can cause brain dysfunction. Studies in mouse models of lupus find that interferon proteins can cause the brains immune cells to trim the synaptic connections between neurons. See Letter p.539 Systemic lupus erythematosus (SLE) is an incurable autoimmune disease that also causes some neuropsychiatric symptoms in roughly three-quarters of patients with SLE. However, the mechanisms underlying these neurological symptoms are unknown. Michael Carroll and colleagues provide evidence that, in some SLE mouse models, microglia-derived type-1 interferon promotes the elimination of central nervous system synapses correlating with neurological symptoms and behavioural phenotypes. Microglial-mediated synaptic loss may be a potential cause of cognitive decline in central nervous system lupus and this study may point to new therapeutic options for this disease.