Thomas C. Thannickal

Reduced number of hypocretin neurons in human narcolepsy.

Murine and canine narcolepsy can be caused by mutations of the hypocretin (Hcrt) (orexin) precursor or Hcrt receptor genes. In contrast to these animal models, most human narcolepsy is not familial, is discordant in identical twins, and has not been linked to mutations of the Hcrt system. Thus, the cause of human narcolepsy remains unknown. Here we show that human narcoleptics have an 85%-95% reduction in the number of Hcrt neurons. Melanin-concentrating hormone (MCH) neurons, which are intermixed with Hcrt cells in the normal brain, are not reduced in number, indicating that cell loss is relatively specific for Hcrt neurons. The presence of gliosis in the hypocretin cell region is consistent with a degenerative process being the cause of the Hcrt cell loss in narcolepsy.

Narp immunostaining of human hypocretin (orexin) neurons Loss in narcolepsy

Objective: To investigate whether neuronal activity-regulated pentraxin (Narp) colocalizes with hypocretin (Hcrt or orexin) in the normal human brain and to determine if Narp staining is lost in the narcoleptic human brain. Background: Human narcolepsy is characterized by a loss of the peptide hypocretin in the hypothalamus. This loss could result from the degeneration of neurons containing hypocretin or from a more specific loss of the ability of these neurons to synthesize Hcrt. Narp has been found to colocalize with hypocretin in the rat hypothalamus. Methods: We investigated the distribution of Narp in three normal and four narcoleptic human postmortem brains using immunohistochemistry with an antibody to Narp. Colocalization studies of Narp and hypocretin were also performed in two normal brains using immunohistochemistry with an antibody to Narp and an antibody to hypocretin. Results: We found that Narp colocalizes with hypocretin in the lateral hypothalamic area (LHA), the dorsomedial hypothalamus (DMH), the dorsal hypothalamic area (DHA), and the posterior hypothalamic area (PHA) of the normal human. The number of Narp-positive neurons was reduced by 89% in these areas of the narcoleptic hypothalamus. In contrast, Narp staining in the paraventricular (Pa) and supraoptic nuclei (SO) of the human hypothalamus did not differ between normal and narcoleptic brains. Conclusions: This finding supports the hypothesis that narcolepsy results from the specific loss of hypocretin neurons. Loss of hypothalamic Narp may contribute to the symptoms of narcolepsy.

Pattern of hypocretin (orexin) soma and axon loss, and gliosis, in human narcolepsy

Human narcolepsy is correlated with a greatly reduced number of hypocretin (orexin) containing neurons and axons, and an elevated level of hypothalamic gliosis. We now report that the percentage loss of Hcrt cells and percentage elevation of GFAP staining are variable across forebrain and brainstem nuclei, and are maximal in the posterior and tuberomammillary hypothalamic region. Regional gliosis and percent loss of hypocretin axons in narcoleptics are not correlated with regional hypocretin cell soma density in normals or with regional percent soma loss in narcoleptics. Rather they are independently and strongly correlated with the regional density of hypocretin axons and the message density for hypocretin receptor 2, as quantified in the rat. These results are consistent with the hypotheses that the loss of hypocretin function in narcolepsy results from a cytotoxic or immunologically mediated attack focused on hypocretin receptor 2 or an antigen anatomically linked to hypocretin receptor 2, and that this process is intensified in regions of high axonal density.

Greatly increased numbers of histamine cells in human narcolepsy with cataplexy.

To determine whether histamine cells are altered in human narcolepsy with cataplexy and in animal models of this disease.

A Brief History of Hypocretin/Orexin and Narcolepsy

The hypothalamic peptides named the orexins, or hypocretins, were discovered in 1998. In 1999 it was established that genetic narcolepsy could be caused by mutations in the genes synthesizing these peptides or their receptors. In September of 2000 it was found that most human narcolepsy is caused by loss of hypocretin cells, most likely as a result of a degenerative process. This paper reviews these events and their implications for our understanding of brain arousal and motor control systems.

Coexistence of narcolepsy and Alzheimer's disease

A recent publication suggested that hypocretin (Hcrt, orexin) may mediate the neuropathological process leading to Alzheimers disease (AD) and that antagonism of hypocretin receptors decreases this process. Narcoleptics have an approximately 90% loss of Hcrt neurons and commensurate reductions in the levels of Hcrt in their cerebrospinal fluid beginning at disease onset, usually before the age of 30. If Hcrt mediates the disease process, narcoleptics should be protected against AD. We examined the postmortem neuropathology and clinical records of 12 sequentially encountered cases of human narcolepsy. We found that AD was present in 4 of these narcoleptics, a prevalence that is similar to that of the general population.

Opiates increase the number of hypocretin-producing cells in human and mouse brain and reverse cataplexy in a mouse model of narcolepsy

Heroin addiction is accompanied by an increase in detected hypocretin (orexin) neurons, and in narcoleptic mice deficient in these neurons, morphine can reverse cataplexy. Opiate addiction and narcolepsy: Opposite sides of the same coin? The neurological mechanisms that maintain opiate addiction and prevent long-term withdrawal are not well understood. In a new study, Thannickal et al. found that human heroin addicts have, on average, 54% more hypocretin-producing neurons than do neurologically normal control individuals. They show that a similar increase in hypocretin-producing neurons could be induced in mice through long-term morphine administration. This long-lasting increase in hypocretin neurons may be responsible for maintaining addiction. Narcolepsy is caused by a loss of hypocretin-producing neurons. Morphine administration restored the population of hypocretin neurons in hypocretin cell–depleted mice back to normal numbers and decreased cataplexy in narcoleptic animals. Induction of specific long-term changes in neuropeptide production, outlasting the half-life of the administered drugs, may be useful in treating diseases characterized by loss of neurons producing these neuropeptides. The changes in brain function that perpetuate opiate addiction are unclear. In our studies of human narcolepsy, a disease caused by loss of immunohistochemically detected hypocretin (orexin) neurons, we encountered a control brain (from an apparently neurologically normal individual) with 50% more hypocretin neurons than other control human brains that we had studied. We discovered that this individual was a heroin addict. Studying five postmortem brains from heroin addicts, we report that the brain tissue had, on average, 54% more immunohistochemically detected neurons producing hypocretin than did control brains from neurologically normal subjects. Similar increases in hypocretin-producing cells could be induced in wild-type mice by long-term (but not short-term) administration of morphine. The increased number of detected hypocretin neurons was not due to neurogenesis and outlasted morphine administration by several weeks. The number of neurons containing melanin-concentrating hormone, which are in the same hypothalamic region as hypocretin-producing cells, did not change in response to morphine administration. Morphine administration restored the population of detected hypocretin cells to normal numbers in transgenic mice in which these neurons had been partially depleted. Morphine administration also decreased cataplexy in mice made narcoleptic by the depletion of hypocretin neurons. These findings suggest that opiate agonists may have a role in the treatment of narcolepsy, a disorder caused by hypocretin neuron loss, and that increased numbers of hypocretin-producing cells may play a role in maintaining opiate addiction.

Hypocretin/Orexin Pathology in Human Narcolepsy with and Without Cataplexy

Hypocretin (Hcrt, also called orexin) neurons have been implicated in the pathology underlying narcolepsy. The number of Hcrt cells in normal humans ranges from 51,000–83,000. Human narcolepsy is correlated with a greatly reduced number of Hcrt containing neurons and axons, and an elevated level of hypothalamic gliosis. Narcolepsy with cataplexy is characterized by a loss of approximately 90 % of Hcrt neurons. However, more than a quarter of narcoleptics do not have cataplexy and have normal levels of Hcrt in their cerebrospinal fluid. Narcolepsy without cataplexy has an overall a loss of 33 % of Hcrt cells compared to normal, with maximal cell loss in the posterior hypothalamus. A better understanding of the pattern of damage to Hcrt containing somas and axons and of the gliosis occurring in narcolepsy should clarify the nature of the pathological process responsible for this disorder.