The B cell tide has turned

Now the geneticists are getting involved with suggesting B cells are important in MS.

Was our paper on B cells in MS so ace and compelling?:-)

or are they on the anti-CD20 gravy train?

CD40 is a costimulatory protein found on antigen presenting cells and is required for their activation. 

The binding of CD154 (CD40L) on TH cells to CD40 activates antigen presenting cells and induces a variety of downstream effects.

The B cell can present antigens to helper T cells. If an activated T cell recognizes the peptide presented by the B cell, the CD40L on the T cell binds to the B cell's CD40 receptor, causing B cell activation. The T cell also produces IL-2, which directly influences B cells. As a result of this net stimulation, the B cell can undergo division, antibody isotype switching, and differentiation to plasma cells. The end-result is a B cell that is able to mass-produce specific antibodies against an antigenic target. 

Early evidence for these effects were that in CD40 or CD154 deficient mice, there is little class switching or germinal centre formation, and immune responses are severely inhibited.

CD40 is also expressed on B cell precursors in the bone marrow, and there is some evidence that CD40-CD154 interactions may play a role in the control of B cell (haematopoiesis) development.

This drove people to target CD40-CD40L to block B cell activity in autoimmunity. 

In Phase II clinical trials regarding multiple sclerosis and Crohn's disease, thromboembolisms occurred in at least three patients. A causal connection could not be proven, but since the same adverse effects were seen in trials with a similar antibody (hu5C8), the trials were halted.

CD86 and B7-2) is a protein expressed on antigen-presenting cells that provides costimulatory signals necessary for T cell activation and survival. It is the ligand for two different proteins on the T cell surface: CD28 (for autoregulation and intercellular association) and CTLA-4 (for attenuation of regulation and cellular disassociation). CD86 works in tandem with CD80 to prime T cells and is present on B cells

They found that carrying the risk allele rs4810485*T lowered the cell-surface expression of CD40 in all tested B cell subtypes. There was an increased proportion of alternative splice-forms leading to decoy receptors (P = 4.00 × 10-7) which would not signal. This CD40 allele was associated with decreased levels of interleukin-10.  This suggests that B cells might have an important antigen presentation and immunoregulatory role in the pathogenesis of multiple sclerosis

The risk allele rs9282641*G increased the expression of CD86..abit with this effect primarily seen in the naïve B cell subset. However I must say this failed the smack you in the eye test.

The authors suggest that "B cells might have an important antigen presentation and immunoregulatory role in the pathogenesis of multiple sclerosis". 

Indeed they may but it has to be said that dendritic cells, which are professional antigen presenting cells, express masses more CD40 and CD86 and so this could be where the true susceptibility association occurs. 

Also one wonders whether this reduced CD40 means that it is easier for the latent membrane protein 1 produced by EBV to mimic CD40 signalling to cause pathogenic B cells to be CD40L and T cell independent, meaning that it would be easier to activate the B cell .

Many of the 200  or so identified susceptibility MS genes are immune-associated and many are thought to be involved in T cell biology such as the IL-2 receptor and the IL-7 receptor. 

However, these are both expressed by B cell lineage cells, so more evidence for the  B club;-).

Is there someone you want to hear from?

You will have noticed over the last 5 months that we have been trying to get more guest bloggers engaged with our blog. We would love to increase the volume of guest posts to increase the diversity of opinions and topics on all things MS. Variety is the spice of life and a lot of what we have to say is repetition. 

We don't want to bore you! You need to hear from other experts in the field. If you know someone engaged in MS who has something to say please ask them to contact us (bartsmsblog@gmail.com) about doing a guest post.

This is a call to potential guest bloggers. If you have done a piece of research and you want to communicate it people with MS, and other MS stakeholders, please contact us (bartsmsblog@gmail.com).

Your intentions should be altruistic and in keeping with our blogging philosophy. We do not want to monetize the blog, therefore, no advertising or links to commercial sites. Please remember the views presented in each post have to be yours and have nothing to do with Barts-MS and our organisations (Queen Mary Universty London & Barts Health NHS Trust). We are also are not a platform for pseudo, or fake, science, nor fake news or alternative facts. We will, therefore, have final editorial control over what we accept and publish on the blog.

To post you have to provide a lay summary of the work with a link to the publication. In addition, we need a short biography, a disclosure statement and a picture. It is important that the readers know who you are. We also expect all guest bloggers to come back to the blog frequently to answer any questions from our readers. 

Thank You! 

A stressed life

Do you suffer from post-traumatic stress disorder? Did you know MS is a potential cause?



J Nerv Ment Dis. 2018 Feb;206(2):149-151. doi: 10.1097/NMD.0000000000000780.

Prevalence of Posttraumatic Stress Disorder in Patients With Multiple Sclerosis.

Carletto S, Borghi M, Scavelli F, Francone D, Perucchini ML, Cavallo M, Pagnini F, Bertolotto A, Oliva F, Ostacoli L.

Abstract


Chronic and life-threatening illnesses, such as multiple sclerosis (MS), have been identified as significant stressors potentially triggering posttraumatic stress disorder (PTSD). The study aims to investigate the prevalence of PTSD according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) criteria in a large sample of patients with MS. A total of 988 patients with MS were screened with the Impact of Event Scale-Revised, and then assessed with the PTSD module of the Structured Clinical Interview for DSM-IV and with the Clinician-Administered PTSD Scale to confirm PTSD diagnosis. Posttraumatic symptoms were reported by 25.5% of the sample. A confirmed diagnosis of PTSD was found in 5.7% of patients, but prevalence could reach 8.5%, including also dropout patients. Further studies are needed to evaluate if adjustment disorder could better encompass the frequently encountered subthreshold posttraumatic stress symptoms and how clinicians can deal with these symptoms with appropriate interventions.

In her book "Bossy Pants", Tina Fey (comedian) coined a new word "Blorft meaning 'Completely overwhelmed but proceeding as if everything is fine and reacting to the stress with the torpor of a possum'. I have been blorft every day for the past seven years", she says.

Blorft sadly in the current climate is firmly situated in our working lives, but the concern is that it may eventually lead to an even scarier entity, that of PTSD (post traumatic stress disorder). Lucky for us PTSD is rare (prevalence is 6.8% in the general population), well publicized and now accepted by the medical profession as a real condition.

The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) classifies PTSD as a clinical condition developed after exposure to a traumatic event. First described initially in relation to war, the definition has diversified to include chronic illnesses as a stressor that can trigger it. In those affected by chronic illnesses it is rarely screened for and therefore a largely an unknown entity.

According to the authors of this paper, a couple of things are already known about PTSD:

• has a long-lasting impact on relational, social and working functioning
• may be difficult to identify a single traumatic stressor
• may persist over time and worsen with disease progression
• criterion for reexperiencing the threatening event is linked to the reoccurence of the symptoms (e.g. fear of relapsing episodes, fear of disease progression).

For many, the diagnosis of MS alone can be considered a significant traumatic event. Previous studies have reported as much as 55% PwMS said MS was at least traumatic on an internet survey, although the PTSD criteria was not specifically tested (Counsell A, Hadjistavropoulos HD, Kehler MD, Asmundson GJG (2013) Posttraumatic stress disorder symptoms in individuals with multiple sclerosis. Psychol Trauma Theory Res Pract Policy. 5:448–452).

Here, they investigated the prevalence of PTSD in 988 PwMS according to the DSM-IV criteria. They found a significantly lower prevalence than previously reported at 5.2% and therefore in line with the general population; although 25% presented with an IES-R (Impact of Event Scale - Revised) above threshold, suggesting the possibility of PTSD. The latter probably, have sub-threshold PTSD, but like PTSD may have the same implications in terms of impact of mental and physical functioning (Grubaugh AL, Magruder KM, Waldrop AE, Elhai JD, Knapp RG, Frueh BC (2005) Subthreshold PTSD in primary care: Prevalence, psychiatric disorders, healthcare use, and functional status. J NervMent Dis. 193:658–664).

The current DSM-V criteria now states that medical disease per se cannot be considered as a stressor event that qualifies for PTSD, and now classifies this as an adjustment disorder for those who do not display the full house of PTSD symptoms. Adjustment disorder is not surprisingly more prevalent than PTSD, but may respond to the same treatment strategies that are used in PTSD. The two are likely to be on the same continuum.

Disease activation after alemtuzumab. Was it the B cells? or the fingolimod?

Rebound disease activity in people taking alemtuzumab.

Whats it the B cell surge or

Because they had taken fingolimid


Activation of disease during therapy with alemtuzumab in 3 patients with multiple sclerosis.

Wehrum T, Beume LA, Stich O, Mader I, Mäurer M, Czaplinski A, Weiller C, Rauer S.

Neurology. 2018 Jan 19. pii: 10.1212/WNL.0000000000004950. doi: 10.1212/WNL.0000000000004950. [Epub ahead of print]

OBJECTIVE:To report 3 patients with multiple sclerosis showing severe activation of disease during immunotherapy with alemtuzumab.

METHODS:

Retrospective case series.

RESULTS:

Patient 1, a 21-year-old woman, developed severe cognitive impairment, sight deterioration, severe gait ataxia, urinary retention, and extensive progression of cerebral lesion load, including new lesions that exhibited gadolinium ring enhancement and dominance of CD19/20-positive B lymphocytes, 6 months after induction of alemtuzumab. 

Patient 2, a 28-year-old man, developed left-sided hemihypesthesia and ∼60 new cerebral and spinal lesions including lesions with gadolinium ring enhancement 6 months after induction of alemtuzumab. 

Patient 3, a 37-year-old woman, developed ataxia and numbness of the left thigh, 16 new gadolinium-positive supratentorial lesions, and partly ring-enhancing and dominance of CD19/20-positive B lymphocytes 6 months after induction of alemtuzumab.

CONCLUSION:

This is a case series reporting severe activation of disease during immunotherapy with alemtuzumab. All patients showed onset of symptoms 6 months after induction of alemtuzumab, strikingly similar MRI lesion morphology, and unexpected high total B cell count, which may suggest a B-cell-mediated activation of disease. 

This study reports on the development of highly active disease after alemtuzumab treatment and they suggest that it may be due to B cells, hence I have decided to report it as it keeps up the B cell momentum. 

But importantly was the reactivation really due to B cells. previously it has been reported that repopulation of CD19 B cells was not associated with relapse activity in alemtuzumab studies. We also reported that this was the case with cladribine too. But are we looking at the right B cells. In these studies the B cells had repopulated to over 250% of their starting value after 6 months and so this is high compared to what you might expect. We have said previously that alemtuzumab may not clear the bone marrow well and so immature and then mature B cells rapidly repopulate the blood. However, what happened to the memory B cell subset. Did they repopulate. studies to properly interrogate the repopulating B cell subsets 

However importantly all three of these individuals were switched from fingolimod. So is the real interest from these three individuals. In a study from a group in Wales 25% of those switching to alemtuzumab  after fingolimod. So it is important to think how you switch from one treatment to another. In this case people were switched from alemtuzumab to rituximab. It will be interesting to know if these people will develop secondary autoimmunity due to alemtuzumab. It would help us know if it is the B cell hyperproliferation in the absence of T cell regulation that is the key...Time will tell. 

Do you want to learn about MS and live in the Middle and Far East?

It is clear that the incidence and prevalence of MS are increasing globally. We are in the throes of an MS pandemic. The one region that is documenting and seeing this change in MS epidemiology is the Middle East and North Africa. 

In response to the unmet need, Barts-MS have been invited by the Alfaisal University and Global Academy for Health Sciences (GAHS) to run an MS teaching course in Dubai on the 30^th & 31^st March 2018. You may be interested in attending.

Multiple Sclerosis Teaching Program Dubai from Gavin Giovannoni

ProfG    

Astrocyte as bad guys. A piece in the jigsaw

Whilst hunting through some papers MD2 came across the following paper. I don't remember seeing it and don't remember posting on it, so a year late, I thought I would give it an airing especially since the senior author recently passed away.

However we are looking for Jigsaw pieces to help understand progressive MS and this, which looks at astrocyte activity, may be one of them

Liddelow SA, Guttenplan KA, Clarke LE, Bennett FC, Bohlen CJ, Schirmer L, Bennett ML, Münch AE, Chung WS, Peterson TC, Wilton DK, Frouin A, Napier BA, Panicker N, Kumar M, Buckwalter MS, Rowitch DH, Dawson VL, Dawson TM, Stevens B, Barres BA.Neurotoxic reactive astrocytes are induced by activated microglia. Nature. 2017;541(7638):481-487. doi: 10.1038/nature21029.

Astrocytes are probably the most overlooked glial cell in MS

They are important and support many functions:

• Structural: They are involved in the physical structuring of the brain. Astrocytes get their name because they are "star-shaped". They are the most abundant glial cells in the brain that are closely associated with neuronal synapses. They regulate the transmission of electrical impulses within the brain.
• Glycogen fuel reserve buffer: Astrocytes contain glycogen and are capable of glycogenesis. Thus, astrocytes can fuel neurons with glucose during periods of high rate of glucose consumption and glucose shortage. 
• Metabolic support: They provide neurons with nutrients such as lactate.
• Blood–brain barrier: The astrocyte end-feet encircling endothelial cells were thought to aid in the maintenance of the blood–brain barrier.
• Transmitter uptake and release: Astrocytes express plasma membrane transporters such as glutamate transporters for several neurotransmitters, including glutamate, ATP, and GABA. 
• Regulation of ion concentration in the extracellular space: Astrocytes express potassium channels at a high density. When neurons are active, they release potassium, increasing the local extracellular concentration. Because astrocytes are highly permeable to potassium, they rapidly clear the excess accumulation in the extracellular space.^[
• Modulation of synaptic transmission and memory formation: 
• Vasomodulation: Astrocytes may serve as intermediaries in neuronal regulation of blood flow.
• Promotion of the myelinating activity of oligodendrocytes: Electrical activity in neurons causes them to release ATP, which serves as an important stimulus for myelin to form. However, the ATP does not act directly on oligodendrocytes. Instead, it causes astrocytes to secrete cytokine leukemia inhibitory factor (LIF), a regulatory protein that promotes the myelinating activity of oligodendrocytes. 
• Nervous system repair: Upon injury to nerve cells within the central nervous system, astrocytes fill up the space to form a glial scar, and may contribute to neural repair. Although, the glial scar has traditionally been described as an impermeable barrier to regeneration.

Neuroinflammation and ischeamia induced two different types of reactive astrocytes, termed “A1” and “A2,” respectively. This terminology parallels the “M1” and “M2” macrophage nomenclature, which has also been applied to microglia in the CNS. 

In this study they talk about astrocytes, as being bad (A1) and good (A2) guys. 

A1 (Toxic) astrocytes, which are induced by injury, neuroinflammation, and neurodegenerative disease, produce proinflammatory molecules. 

A2 (Trophic) astrocytes secrete molecules that provide neurotrophic support and modulate inflammatory responses. This astrocyte phenotype is present following ischemia and has been shown to promote neuronal survival and tissue repair.

They showed that three proteins called interleukin-1 alpha. This is an immunoregulatory molecule that can help production of tumour necrosis factor alpha, which is another one of the proteins that has immunoregulatory function and  complement component 1, Subcomponent q, which is part of the antibody killing pathway and a molecule involved in cell aging drive the production of A1 astrocytes.

So can block them?

There Interleukin_1_receptor_antagonist, which mops up IL-1 but you would need loads of it to get into the brain and being a protein this isn't going to happen very much. Same problem is for the neutralizing antibodies available and as IL-1 has some many function, block this pathway every where long term-isn't going to be good news. As for C1q, well we have the humble aspirin.

There are lots of anti-TNFs that are available, but they can stimulate memory B cells and they can and sometimes do make MS worse. 

However this study indicates that you want the anti-TNF need to get into the brain, so antibodies are not the sensible way to go this. However there are anti-TNF chemicals such as thalidomide and less tetragenic (creates deformities in unborn babies) variants. Their are phosphodiesterase 4 inhibitors (PDE4) like rolipram which has made MS worse and ibudilast which has completed a trial in SPMS recently. We showed many years ago that you needed to inhibit the TNF in the brain

Baker D, Butler D, Scallon BJ, O'Neill JK, Turk JL, Feldmann M. Control of established experimental allergic encephalomyelitis by inhibition of tumor necrosis factor (TNF) activity within the central nervous system using monoclonal antibodies and TNF receptor-immunoglobulin fusion proteins. Eur J Immunol. 1994; 24:2040-8.

These molecules all come from hot microglia, which in this study was mimicked by an infection

Once the A1s had become the bad guys you didn't need to keep giving them the three cytokines to keep them bad. Once formed they were mean bad-ass cells for good. 

However they could be salvaged and it was found that it was partially possible to make the cells more astrocyte like again.

This was done by treating A1 astrocytes with the anti-inflammatory molecules transforming growth factor beta , a cytokine with immunoregulatory activity and Fibroblast growth factor cytokine that makes fibroblasts grow in part turns them back into a normal astrocyte.

So great let's stick TGFbeta into MS and that's sorted? 

However, some neuross did this in MS with active cytokine and not the natural cytokine and disaster struct. 

The trial was stopped because TGFbeta did not just do what they wanted but it bound to TGFbeta receptor where ever it was and activated the cells it bound to. 

This just happened to be fibroblasts (which are involved in tissue modeling), they grew like mad and cause fibrosis of the kidney. 

In nature, TGF-beta is not produced as an active molecule. The active site is covered by a latent protein cap/shell that has to be cleaved to make an active molecule. This means it can travel round the body and is not active thing unless there is the right environment, such as inflammation, to cleave the latent protein.

Likewise if we start injecting Fibroblast growth factor,I now think you can what would happen.....yep probably more fibrosis in the kidneys and liver and the lungs which are going to filter the proteins.

A1 astrocytes lose many typical astrocytic functions. They showed that A1 astrocytes no longer promote neuronal survival, outgrowth, and synapse formation, or phagocytize synapses or debris. 

Importantly they suggest that A1 astrocytes secrete a compound that is toxic to neural cells.  What is it/are they?

Well a recent paper suggests something

Li S, Uno Y, Rudolph U, Cobb J, Liu J, Anderson T, Levy D, Balu DT, Coyle JT. Astrocytes in primary cultures express serine racemase, synthesize d-serine and acquire A1reactive astrocyte features. Biochem Pharmacol. 2018. pii: S0006-2952(17)30735-9.

d-Serine is a co-agonist at forebrain N-methyl-d-aspartate receptors (NMDAR) and is synthesized by serine racemase (SR). A1 reactive astrocytes express SR and release d-serine under pathologic conditions, which may contribute to their neurotoxic effects by activating extra-synaptic NMDA receptors.

So we have the hot micorglia. One way to get these as shown here was via toll-like receptor 4 and infection signals. But we can bring in other ideas in how B cells and B cell products could be key drivers in creating the hot microglia.

So the axis of evil could be

B cells------Hot Microglial-------Astrocytes-----Nerve damage

Plus abit more
B cells------Nerve damage
B cells------Hot Micrroglia-------Nerve damage
T cells------Hot Microglia--------Nerve damage
Infection---Hot Microglia--------Nerve damage

There are many targets in these pathways the central issue is to find those that do not cause too many side-effect

Trial in Remyelination is safe in humans

You want to hear about remyelination trials and here is one. The idea that there are naturally occurring antibodies that promote remyelination was suggested by the group of Moses Rodriguez at the Mayo clinic many, many years ago. 

They then generated an oligodendrocyte/myelin-specific recombinant human monoclonal IgM, rHIgM22. Apparently the antibody is well-endowed with strong anti-apoptotic and pro-proliferative effects on oligodendrocytes.

So this study says it is safe in humans

However, I must admit that I find the whole approach very weird. 

We know that to promote remyelination that the treatment has to enter the brain and bind the oligodendrocytes.

In the Lingo-1 studies they injected massive amounts of antibody such as up to 100mg/kg, which was was about 99.9% excluded from the target. But that tiny percent apparently did something. 

In this current study they used 50 to 100th less antibody and amazing 99.997%  was excluded although this increased to about 99.95 at 1mg/kg and 99.5 at 2mg/kg so again most of what injected went no where useful.

Surely the starting point needs to develop agents that get into the brain.  Maybe I'm just being thick again.

However, I guess other people think differently

Eisen A, Greenberg BM, Bowen JD, Arnold DL, Caggiano AO. A double-blind, placebo-controlled, single ascending-dose study of remyelinating antibody rHIgM22 in people with multiple sclerosis. Mult Scler J Exp Transl Clin. 2017 Nov 21;3(4):2055217317743097.

OBJECTIVE:The objective of this paper is to assess, in individuals with clinically stable multiple sclerosis (MS), the safety, tolerability, pharmacokinetics (PK) and exploratory pharmacodynamics of the monoclonal recombinant human antibody IgM22 (rHIgM22).
METHODS:Seventy-two adults with stable MS were enrolled in a double-blind, randomized, placebo-controlled, single ascending-dose, Phase 1 trial examining rHIgM22 from 0.025 to 2.0 mg/kg. Assessments included MRI, MR spectroscopy, plasma PK, and changes in clinical status, laboratory values and adverse events for three months. The final cohort had additional clinical, ophthalmologic, CSF collection and exploratory biomarker evaluations. Participants were monitored for six months.
RESULTS: rHIgM22 was well tolerated with no clinically significant safety signals. Non-compartmental PK modeling demonstrated linear dose-proportionality both of Cmax and AUC0-Last. The steady-state apparent volume of distribution of approximately 58 ml/kg suggested primarily vascular compartmentalization. CSF:plasma rHIgM22 concentration increased from 0.003% on Day 2 for both 1.0 and 2.0 mg/kg to 0.056% and 0.586% for 1.0 and 2.0 mg/kg, respectively, on Day 29. No statistically significant treatment-related changes were observed in exploratory pharmacodynamic outcome measures included for the 21 participants of the extension cohort.
CONCLUSIONS: Single doses of rHIgM22 were well tolerated and exhibited linear PK, and antibody was detected in the CSF.

Is the problem of MS due to EBV in the B cells?

What genes are active in MS? 

In this study they looked at lesions and surrounding white matter and found a load of CD8 T cells, a lot of CD20 B cells and a few CD4 T cells and plasma cells (antibody making cells).

The B cells contained EBV 


In this study they take brain tissue and then cut it into very thin slices (eg. a 100th of a mm) and then you look to see if you can find a lesion. You use a laser to cut out the cells from the section (laser capture) and then you remove the nucleus to see what proteins the cells were making. 

There were CD4 T cells in all the lesions, CD8 T cells in all of the lesions and CD19 B cells in all the lesions. Not many CD4 T cells and only 1-3% lesions contained IL-17/IL-22 (Th17 cytokines). If if there is more IL-17 in the blood (see beleow) how come there 

So are these few cells causing autoimmunity as the EAEers would have us believe There were 70% of lesions with gamma interferon, which could be Th1 derived or could come from CD8.

There was about 70-95% of lesions with clear B cell growth and differentiation factors like IL-6, IL-10 (yes it is a B cell factor and IL-10 does not have to be a regulatory cytokine), BAFF, lymphotoxin etc etc.

There are CXCR3 and CXCL12 chemokines in most lesions ,which recruit B cells 

However the paper is open access and they do vastly different association for these products 

One or more EBV genes were detected in immune infiltrates from 9 of 11 MS cases and in 41.3% of the samples. 

EBV genes were detected more frequently in meningeal than in WM perivascular infiltrates (55.6 vs 28% of the samples) and genes expressed during viral latency were detected more frequently (i.e. present in memory cells) than genes associated with the viral lytic which is where the virus kills the cell and releases the cells contents which is live virus). 

LMP1 and LMP2A are viral genes, deliver surrogate B cell survival and differentiation signals (CD40 and B cell receptor, LMP1 was detected more commonly than LMP2 suggest that the B cells may be more T cell-independent .

The authors suggests that "EBV could be the main antigenic trigger of an immunopathological, CD8+ T cell-mediated response that damages the brain/spinal cord in MS. This model is consistent with the notion that CD8+ T cells are the main drivers of bystander tissue damage in EBV-associated immunopathologic diseases"

So are CD8 cells in the brain to destroy EBV infected B cells? 

The authors suggest that "the use of drugs that, by directly targeting the virus and its cellular reservoir, could be more effective in normalizing an altered EBV-host interaction in MS. For example, B cell-depleting therapies could lower EBV load and hence the burden of EBV-induced immunopathology in MS more efficiently than other drugs". 

Is this what we are doing?

Veroni C, Serafini B, Rosicarelli B, Fagnani C, Aloisi F. Transcriptional profile and Epstein-Barr virus infection status of laser-cut immune infiltrates from the brain of patients with progressive multiple sclerosis. J Neuroinflammation. 2018;15:18.

BACKGROUND:It is debated whether multiple sclerosis (MS) might result from an immunopathological response toward an active Epstein-Barr virus (EBV) infection brought into the central nervous system (CNS) by immigrating B cells. Based on this model, a relationship should exist between the local immune milieu and EBV infection status in the MS brain. To test this hypothesis, we analyzed expression of viral and cellular genes in brain-infiltrating immune cells.

METHODS:Twenty-three postmortem snap-frozen brain tissue blocks from 11 patients with progressive MS were selected based on good RNA quality and prominent immune cell infiltration. White matter perivascular and intrameningeal immune infiltrates, including B cell follicle-like structures, were isolated from brain sections using laser capture microdissection. Enhanced PCR-based methods were used to investigate expression of 75 immune-related genes and 6 EBV genes associated with latent and lytic infection. Data were analyzed using univariate and multivariate statistical methods.

RESULTS: Genes related to T cell activation, cytotoxic cell-mediated (or type 1) immunity, B cell growth and differentiation, pathogen recognition, myeloid cell function, type I interferon pathway activation, and leukocyte recruitment were found expressed at different levels in most or all MS brain immune infiltrates. EBV genes were detected in brain samples from 9 of 11 MS patients with expression patterns suggestive of in situ activation of latent infection and, less frequently, entry into the lytic cycle. Comparison of data obtained in meningeal and white matter infiltrates revealed higher expression of genes related to interferonγ production, B cell differentiation, cell proliferation, lipid antigen presentation, and T cell and myeloid cell recruitment, as well as more widespread EBV infection in the meningeal samples. Multivariate analysis grouped genes expressed in meningeal and white matter immune infiltrates into artificial factors that were characterized primarily by genes involved in type 1 immunity effector mechanisms and type I interferon pathway activation.

CONCLUSION: These results confirm profound in situ EBV deregulation and suggest orchestration of local antiviral function in the MS brain, lending support to a model of MS pathogenesis that involves EBV as possible antigenic stimulus of the persistent immune response in the central nervous system.

However, without wanting to upset the authors too much, they are the group that have proposed that B cell follicles ares associating with, and implicated in, the cause of progression. However as in their own words

"several groups have reported absence or paucity of EBV in postmortem MS brain samples"....whilst....

"we have repeatedly shown not only presence of EBVinfected B-lineage cells but also EBV latency disruption and reactivation in the MS brain"

"RNA/protein nor deregulated EBV infection was detected in brain tissues from patients with other infectious and non-infectious neuroinflammatory diseases"..."ruling out the possibility that an active EBV infection in the CNS is the general consequence of immune cell invasion and local activation."

Therefore not all people agree on this and so requires replication by other groups who do not have a vested interest in this story.

What do others find?

Trenova AG, Slavov GS, Draganova-Filipova MN, Mateva NG, Manova MG, Miteva LD, Stanilova SA. Circulating levels of interleukin-17A, tumor necrosis factor-alpha, interleukin-18, interleukin-10, and cognitive performance of patients with relapsing-remitting multiple sclerosis. Neurol Res. 2018 Jan 3:1-7. doi: 10.1080/01616412.2017.1420522. [Epub ahead of print]

Multiple sclerosis (MS) is associated with cytokine imbalance and high rate (40-70%) of cognitive impairment. The objective of this study is to investigate the relationship between serum concentrations of tumor necrosis factor (TNF)-alpha, interleukin (IL)-17A, IL-18, IL-10, and cognitive performance in patients with relapsing-remitting MS (RRMS). 
Methods The study comprised 159 patients with RRMS (mean age 40.08 ± 8.48 years) in remission phase and 86 age-, gender-, and education-matched healthy controls. Paced Auditory Serial Addition Test (PASAT), Symbol Digit Modalities test (SDMT), and Isaacs test were used for assessment of working memory, attention, visuo-perceptual abilities, information processing speed, and executive functions. Serum cytokine concentrations were measured by enzyme-linked immunosorbent assay (ELISA). 

Results Patients had significantly increased serum concentrations of TNF-alpha and IL-17A and decreased levels of IL-10 compared to the controls (p < 0.05). Negative correlation was found between serum TNF-alpha and SDMT score in patients with disease evolution longer than 10 years (rxy = -0.258 p = 0.033); PASAT and SDMT scores were in negative correlation with concentration of IL-17A (rxy = -0.229 p = 0.004; rxy = -0.166 p = 0.041). Cognitive impairment was established in 46.5% (n = 74) of the patients. Cognitively impaired patients had significantly higher serum IL-17A than cognitively preserved individuals (p = 0.007). Multiple linear regression analysis revealed IL-17A as a significant predictor of cognitive performance in RRMS patients. 

Conclusion The results from this study suggest that pro-inflammatory cytokines IL-17A and TNF-alpha simultaneously with decreased IL-10 are involved in cognitive deterioration in RRMS.

When I was rreally interested in cytokines, we looked for cytokines like TNF in the blood and didn't find any. Now it could be sensitivity of the assay.Alternatively it mean what was produced was used, so that if excess is found, it suggests more is produced than needed. 

However it had been reported that TNF levels in blood in MS, correlated with disease activity and the the results appeared to good. Indeed when the person writing the paper was asked to repeat the analysis with coded and blinded samples, so they wouldn't know what was what...They ran a mile never to be heard off again. 

So you can guess what I thought of the data. This report may suggest the neuro was correct. They find what you expect if you follow dogma...an increase in pro-inflammatory cytokines and a decrease in regulatory cytokines. 

Education: How does a nerve fire?

We have talked about how does a nerve work a number of times but watching a video is much easier.

This video was spotted by one out our readers and I think that it explains how a nerve impulse travels pretty nicely.



It is well worth the ten minutes to watch it.

In MS the signs and symptoms are often caused by the nerves being too excited or under-inhibited, so that the nerve impulses occur in a way that is not adequately controlled.

MS removes the myelin that affects how quickly these impulses fire and removal of the myelin on one nerve within a network, can affect the co-ordination of the system, leading to signs.

Too much nerve excitation, can in some cases also drive the nerves to excite themselves to death, because it uses up all the nerves' energy. So blocking some of the excitatory channels or augmenting the inhibitor symptoms can be beneficial to control symptoms and may be useful in advanced MS.

If we look at some treatments that deal with MS symptoms, now hopefully you can see how and why they work.

Please add your suggestions for these education posts in the comments.

Tragic news: have you had your flu jab?

I have just heard the tragic news that one of my patients, who was admitted to intensive care over the weekend with pneumonia as a complication of influenza,  sadly passed away last night. I called the patient's partner to express my sympathy and was surprised to hear that she had not had this season's flu jab. This is a problem. 

We are in the throes of a major, and more virulent, flu epidemic than usual. People with MS are at high risk and are therefore eligible for the dwindling stocks of this season's flu vaccine. There has been a national appeal for all high-risk patients to get vaccinated. 

If you live in the UK and have not yet had the vaccination please contact your GP for an appointment to have the vaccine. In some parts of the country, you can get vaccinated by your pharmacist. For more information please read the NHS webpage on the vaccine. 

ProfG    

The interpretation of results can depend on the way you look at things.

Look at this picture. What do you see?

Do you see an old woment (you see a nose) or a young women (you see a jaw)?

Now Look at this. What do you see?

Don't know what this is?.

An educational comment for pwMS and researchers

It is interleukin 10.

It maybe doesn't mean much to you, but it may help you understand papers a bit better and questions whether you should accept dogma without thought.


Say this to a T cell immunologist and they see an immunoregulatory cytokine.

"Interleukin 10 (IL-10), also known as human cytokine synthesis inhibitory factor (CSIF), is an anti-inflammatorycytokine"

In humans, IL-10 is primarily produced by monocytes and, to a lesser extent, lymphocytes, namely type 2 T helper cells (T_H2), mast cells, CD4⁺CD25⁺Foxp3⁺ regulatory T cells, and in a certain subset of activated T cells and B cells. 

IL-10 is a cytokine with multiple, pleiotropic, effects in immunoregulation and inflammation. It downregulates the expression of Th1 cytokines, MHC class II antigens, and co-stimulatory molecules on macrophages.

Now show this to a B cell immunologist and they see something different 

IL-10 is a cytokine that enhances B cell survival, proliferation, and antibody production and could be produced to help make antibody producing cells

How about Interleukin 4.

T cell immunologist says "IL-4 decreases the production of Th1 cells, macrophages, IFN-gamma, and dendritic cell IL-12."

or a  B cell immunologist says "IL-4 stimulates activated B-cell proliferation, and the differentiation of B cells into plasma cells. It is a key regulator in humoral  immunity. IL-4 induces B-cell class switching and up-regulates MHC class II production to potentially act as an antigen presenting cell.

How about interleukin 6?

It is viewed as being pro-inflammatory?, 

However, It can be anti-Inflammatory but it can also supports the growth of B cells .

So lets looks in MS and see what has been have found

Guerrier T, Labalette M, Launay D, Lee-Chang C, Outteryck O, Lefèvre G, Vermersch P, Dubucquoi S, Zéphir H.Proinflammatory B-cell profile in the early phases of MS predicts an active disease. Neurol Neuroimmunol Neuroinflamm. 2017; 5(2):e431. 

OBJECTIVE:To assess whether any alteration of B-cell subset distribution and/or the cytokine production capacities of B cells could be associated with any stage of MS and could be predictive of MS evolution.
METHODS:We prospectively enrolled radiologically isolated syndrome (RIS), clinically isolated syndrome (CIS), naive patients with relapsing remitting MS (RRMS) of any disease modifying drug, and healthy controls (HCs). Peripheral blood B-cell subset distributions and the interleukin (IL)-6/IL-10-producing B-cell ratio were assessed by flow cytometry to evaluate their proinflammatory and anti-inflammatory functional properties.
RESULTS:Twelve RIS, 46 CIS, 31 RRMS patients, and 36 HCs were enrolled. We observed that a high IL-6/IL-10-producing B-cell ratio in patients with RIS/CIS was associated with the evolution of the disease in the short term (6 months). This imbalance in cytokine production was mainly explained by an alteration of the production of IL-10 by B cells, especially for the transitional B-cell subset. In addition, a significant increase in IgD-/CD27- memory B cells was detected in patients with CIS and RRMS compared with Hs (p = 0.01). Apart from this increase in exhausted B cells, no other variation in B-cell subsets was observed.
CONCLUSIONS:The association between a high IL-6(pro-inflammatory)/IL-10(anti-inflammatory) -producing B-cell ratio and the evolution of patients with RIS/CIS suggest a skew of B cells toward pro-inflammatory properties that might be implicated in the early phases of MS disease.

So as you can see the B cell production of IL-6 is viewed as pro-inflammatory and IL-10 is antiinflammatory, but are these simply B cell producing agents? 

I don't have the answer which is which, but use this to illustrate that many things you get told you may have different explanations