James Burns

Daclizumab phase II trial in relapsing and remitting multiple sclerosis: MRI and clinical results

Objective: Daclizumab is an interleukin 2 receptor α chain specific humanized monoclonal antibody that has shown promising therapeutic effects in multiple sclerosis (MS). Daclizumab treatment in patients with relapsing and remitting MS was administered to determine effects on MRI and clinical outcomes. Methods: Patients with MS on interferon (IFN) therapy but with continuing relapses and contrast enhancing lesions (CEL) were selected. Patients were evaluated with monthly MRI scans and clinical rating scales starting 3 months prior to treatment and then at 0.5 to 27.5 months during treatment. Daclizumab (1 mg/kg IV) was administered twice in the first month (initiated and administered again in 2 weeks), followed by treatments every 4 weeks. IFN was continued until 5.5 months after daclizumab was initiated. Patients were then placed on daclizumab monotherapy. Patients with recurrent CEL were restarted on IFN with daclizumab therapy at (1.5 mg/kg IV) every 28 days. Results: Nine patients qualified for inclusion and completed the trial. Efficacy measured by both total CEL and new CEL (p < 0.001), relapses, timed ambulation, Expanded Disability Status Scale, and Neurologic Rating Scale (p < 0.05 to p < 0.01) was observed. Conclusion: Daclizumab was effective in reducing contrast enhancing lesions and improving clinical scores in patients with relapsing and remitting multiple sclerosis with active disease not controlled by interferon therapy. These results provide evidence for long-term efficacy and support further clinical development of daclizumab.

A prospective open-label study of glatiramer acetate: Over a decade of continuous use in multiple sclerosis patients

A decade of continuous glatiramer acetate (GA) use by relapsing remitting multiple sclerosis (RRMS) patients was evaluated in this ongoing, prospective study, and the neurological status of ‘Withdrawn’ patients was assessed at a 10-year long-term follow-up (LTFU) visit. Modified intention-to-treat (mITT, n=232) patients received ≥ 1 GA dose since 1991; ‘Ongoing’ patients (n=108) continued in November 2003. Of 124 patients, 50 Withdrawn patients returned for LTFU. Patients were evaluated every six months (EDSS). Mean GA exposure was 6.99, 10.1 and 4.26 years for mITT, Ongoing, and Withdrawn/LTFU patients, respectively. While on GA, mITT relapse rates declined from 1.18/year prestudy to ∼1 relapse/5 years; median time to ≥ 1 EDSS point increase was 8.8 years; mean EDSS change was 0.739±1.66 points; 58% had stable/improved EDSS scores; and 24, 11 and 3% reached EDSS 4, 6 and 8, respectively. For Ongoing patients, EDSS increased 0.509±1.65; 62% were stable/improved; and 24, 8 and 1% reached EDSS 4, 6 and 8, respectively. For Withdrawn patients at 10-year LTFU, EDSS increased 2.249±1.86; 28% were stable/improved; and 68, 50 and 10% reached EDSS 4, 6 and 8, respectively. While on GA nearly all patients (mean disease duration 15 years) remained ambulatory. At LTFU, Withdrawn patients had greater disability than Ongoing patients.

Platelets Contribute to the Pathogenesis of Experimental Autoimmune Encephalomyelitis

Rationale: Multiple sclerosis (MS) and its mouse model, experimental autoimmune encephalomyelitis (EAE), are inflammatory disorders of the central nervous system (CNS). The function of platelets in inflammatory and autoimmune pathologies is thus far poorly defined. Objective: We addressed the role of platelets in mediating CNS inflammation in EAE. Methods and Results: We found that platelets were present in human MS lesions as well as in the CNS of mice subjected to EAE but not in the CNS from control nondiseased mice. Platelet depletion at the effector-inflammatory phase of EAE in mice resulted in significantly ameliorated disease development and progression. EAE suppression on platelet depletion was associated with reduced recruitment of leukocytes to the inflamed CNS, as assessed by intravital microscopy, and with a blunted inflammatory response. The platelet-specific receptor glycoprotein Ib&agr; (GPIb&agr;) promotes both platelet adhesion and inflammatory actions of platelets and targeting of GPIb&agr; attenuated EAE in mice. Moreover, targeting another platelet adhesion receptor, glycoprotein IIb/IIIa (GPIIb/IIIa), also reduced EAE severity in mice. Conclusions: Platelets contribute to the pathogenesis of EAE by promoting CNS inflammation. Targeting platelets may therefore represent an important new therapeutic approach for MS treatment.

Uptake of systemically administered human anticerebellar antibody by rat Purkinje cells following blood-brain barrier disruption

Paraneoplastic cerebellar degeneration accompanying gynecological or breast malignancies is frequently associated with an autoantibody response, termed “type I” or “anti-Yo” directed against cytoplasmic antigens of cerebellar Purkinje cells. The role of this antibody response in the pathogenesis of paraneoplastic cerebellar degeneration is unknown; however, it is also not known whether anti-Purkinje cell antibodies from the systemic circulation bind to target Purkinje cell antigens under the conditions of brain inflammation and blood-brain barrier disruption, which are frequently present at the onset of cerebellar symptoms. Inbred Lewis rats received intraperitoneal injections of type I or normal IgG in the setting of blood-brain barrier disruption induced by adoptive transfer of experimental allergic encephalomyelitis (EAE) and were killed after 24, 48, and 96h. Brains of these animals were studied histologically for evidence of EAE and immunohistochemically for binding of human or endogenous rat IgG to target neurons. Rat IgG was detected around vessels and in Purkinje cells of all animals studied. Human IgG was detected around vessels of all animals. In animals examined 96 h after receiving type I human IgG, human IgG was identified within processes of Purkinje cells and within occasional Purkinje cell bodies. Uptake of type I IgG by other cell types was not observed, and neuronal uptake of IgG was not seen in brains of animals receiving normal human IgG. Our data demonstrate that circulating type I IgG is internalized by cerebellar Purkinje cells in the setting of blood-brain barrier disruption and suggest a mechanism by which an antibody response directed against cytoplasmic antigens of Purkinje cells may reach target antigens at the onset of paraneoplastic cerebellar degeneration.

Failure of copolymer I to inhibit the human T‐cell response to myelin basic protein

In clinical trials, copolymer I (Cop 1) appears to reduce the number of exacerbations in early relapsing-remitting multiple sclerosis. The mechanism of this effect is uncertain, but Cop 1 also reduces the severity of experimental allergic encephalomyelitis and inhibits the response of murine myelin basic protein (MBP)-specific T cells. We tested MBP-specific T-cell lines and clones from four subjects to determine whether Cop 1 also limits the human response to MBP. We found no inhibition by Cop 1 of the human T-cell response to MBP.

Assessment of antigenic determinants for the human T cell response against myelin basic protein using overlapping synthetic peptides

Immunization of experimental animals with myelin basic protein (MBP) or with specific MBP encephalitogenic determinants induces an autoimmune central nervous system (CNS) disease, experimental allergic encephalomyelitis, often studied as a model for human demyelinating disorders. This study examines the antigenic determinants of MBP recognized by human T cells using overlapping, synthetic peptides and T cell lines and clones isolated from four HLA-typed, neurologically normal subjects. T cell lines and clones isolated from individual subjects recognized at least one and as many as five distinct T cell determinants. In some instances the peptides recognized included determinants previously shown to induce experimental allergic encephalomyelitis (EAE) in experimental animals. In this group of four subjects, some determinants of MBP, including residues 5-25, 35-47, 65-75, and 81-100, were recognized by T cells derived from more than one individual suggesting that these regions may be particularly immunogenic for humans.

Human T lymphocytes reactive with whole myelin recognize predominantly myelin basic protein

Human T-cell lines and clones reactive with whole human myelin were isolated from three normal subjects by in vitro sensitization techniques. The CD4+ T-cell lines were maintained in long-term culture by periodic antigen restimulation with myelin and use of interleukin-2. Although myelin basic protein (MBP) represents only about 10% of the dry weight of myelin and the myelin-reactive T-cell populations were never exposed to purified MBP, each of the three cell lines responded to in vitro stimulation with both MBP and whole myelin. Seventeen of 18 T-cell clones derived from the myelin-reactive cell lines also responded to MBP. One myelin-reactive T-cell clone did not recognize MBP or the major myelin lipids but responded to delipidated myelin proteins suggesting that this clone recognized another myelin protein antigen. These results indicate that MBP is the predominant antigen in whole myelin recognized by human T cells under the culture conditions described. However, there is at least one additional protein antigen in myelin that is also immunogenic.

Sporadic Fatal Insomnia Masquerading as a Paraneoplastic Cerebellar Syndrome

BACKGROUND Sporadic fatal insomnia is a rare prion disease that has recently been recognized. OBJECTIVE To report a unique case of sporadic fatal insomnia in a woman with progressive cerebellar deterioration who was originally thought to have a paraneoplastic cerebellar syndrome. DESIGN Case report describing a patient with autopsy-proven sporadic fatal insomnia. PATIENT A 56-year-old woman with progressive cerebellar ataxia who was found to have a retroperitoneal non-Hodgkin lymphoma. RESULTS Autopsy demonstrated marked degenerative changes in the thalamus, cerebellum, and inferior olivary nucleus. A mild spongiform change was present in the thalamus and cortical gray matter. Western blot analysis confirmed the presence of abnormal, protease-resistant prion protein (PrP(Sc)), characteristic of sporadic fatal insomnia. CONCLUSIONS Clinicians should be aware of this rare prion disease and should strongly consider the importance of autopsy toward the investigation of unusual neurological diseases.

γ δ T cells participate in the immune response against activated, myelin basic protein-specific, human T cells

Abstract γδ T cells are over-represented in some multiple sclerosis (MS) parenchymal lesions and in the cerebrospinal fluid (CSF) of individuals with early MS. In this investigation we studied the T cell-T cell interactions between human, myelin basic protein-reactive T cells and peripheral blood mononuclear cells (PBMC) isolated from MS and control subjects. We detected brisk proliferation by PBMC in response to activated, but not resting, MBP-specific T cells. The magnitude of proliferation approached that induced by superantigens and was distinctly greater than the response to standard recall antigens. Examination of the responding T cells revealed predominant expansion of T cells using γδ rather than αβ T cell receptors. This finding suggests that the accumulation of γδ T cells noted in some MS parenchymal lesions may represent recruitment by activation markers expressed by other T cells in these lesions. The response to activated but not resting MBP-specific T cells may parallel observations that protective T cell vaccination in experimental encephalomyelitis is more effective using activated rather than resting, myelin-specific T cells.

Autoantigen-induced self lysis of human myelin basic protein-specific T lymphocytes

Cytotoxic T cells reactive with myelin basic protein (MBP) may be isolated from most human subjects. Since activated T cells express major histocompatibility complex (MHC) class II antigens, we assessed whether MBP-specific, CD4+ T cells could present MBP or synthetic MBP peptides to themselves and whether this provoked self lysis. We examined two MBP-specific cell lines and eight T cell clones recognizing four different MBP epitopes. All T cell populations presented MBP as well as synthetic peptides to themselves eliciting self lysis of the T cell clones. CD4+ T cell populations recognizing another central nervous system (CNS) protein, proteolipid protein (PLP), or the recall antigen, Candida, did not exhibit this antigen-induced, autocytolytic activity. However, activated, PLP-reactive T cells were susceptible to lysis by cytotoxic MBP-specific T cells in the presence of MBP. These results suggest that antigen-induced self lysis of activated human T cells might limit an autoimmune response within a target organ independent of other immunoregulatory mechanisms.