Comprehensive multimodal analysis of patients with neuroimmunological diseases

中枢神经系统(CNS)的神经免疫学疾病有多种不同的诊断方法，其中大多数被认为是罕见的疾病。除了多发性硬化症(MS)、急性脱髓鞘脑脊髓炎(ADEM)、横贯性脊髓炎(TM)和中枢神经系统狼疮外，文献中报道的队列病例很少超过10-20例，收集这些数字需要数年时间。此外，除了多发性硬化症外，几乎所有的报告都集中在临床表现上，而这些患者的鞘内或全身免疫反应的数据非常缺乏。因此，人们对这些疾病的病理生理学知之甚少，有效的治疗方法也非常罕见。 新出现的数据表明，免疫反应不仅受到病原体的影响，还受到炎症过程发展的组织的影响。从这个角度来看，中枢神经系统组织是独一无二的。优雅的动物数据表明，如果将异体移植物移植到中枢神经系统组织中，绕过其抗原的系统递呈，外国移植物可以无限期存活，而当移植到其他器官时，它们很容易被排斥。事实上，T细胞与神经元的相互作用可以塑造T细胞效应器的表型，从致病到更具调节性。毫无疑问，这些复杂的免疫调节机制是一种保证，即对宿主的功能和生存至关重要的中枢神经系统组织将受到保护，免受免疫系统的无意损害。因此，临床表现为CNS自身免疫的免疫系统的明显失败可能源于支配CNS-免疫系统相互作用的自然免疫调节机制的崩溃。 本项目研究NIB患者的鞘内和全身免疫反应，用于神经免疫性中枢神经系统疾病的诊断工作。本研究的目的是明确中枢神经系统免疫介导性疾病中残疾发生的病理生理机制，并将其与人类免疫系统对中枢神经系统损伤的生理反应(通常是有益的)区分开来。我们已经建立了自然病史方案(09-N-0032)，根据该方案，所有疑似中枢神经系统免疫介导性疾病的未经治疗的患者在NIB接受详细的评估，包括收集疾病活动和残疾的临床和临床旁定量指标、来自脑脊液(CSF)的标准和新型定量神经成像标志物以及来自脑脊液(CSF)、血清和免疫细胞的免疫和分子生物标志物。此外，患者可能会接受皮肤活检，收集成纤维细胞，将其转化为诱导的多能干细胞(IPS)，以便开发自体神经细胞来源，以研究人类的生理神经免疫相互作用，这到目前为止还不可能。 所有患者都被编码，临床旁、神经成像和分子生物标记物的分析以无偏见(即盲法)的方式进行，以确定哪些生物标记物与特定的神经免疫性疾病或表型相关。 到目前为止，我们取得的成果摘要如下： 1.我们已经建立了从有限的脑脊液(CSF)样本中扩增CD4+和CD8+T细胞的方法，目前我们正在测试这些细胞的抗原特异性。 2.建立了从有限的脑脊液标本中扩增和永生化B细胞的方法学。我们对我们的数据进行了非盲化，并总结了过去两年EBV-CSF B细胞转化的疗效：我们观察到，与炎症性和非炎症性神经系统疾病对照组相比，MS患者EBV诱导的CSF B细胞永生化效率显著提高(5倍)。此外，我们应用流式细胞术对100多个永生化的脑脊液B细胞株进行了表面和细胞内细胞因子联合染色，以盲法研究了来自MS患者和对照组的EBV永生化B细胞的表型。我们观察到多发性硬化症患者和对照组脑脊液B细胞的表型有显著差异。描述我们发现的论文目前正在审查中。 3.我们分析了脑脊液抗体(Ab)对人髓鞘的反应性，发现MS患者鞘内产生的抗体不识别来自MS患者或对照组的人髓鞘中天然构象中的蛋白质和脂类。 4.我们正在开发和应用无偏见的新方法，旨在确定MS患者鞘内产生抗体的靶点(S) 5.我们正在开发和验证鞘内氧化应激和中枢神经系统组织破坏的多个生物标志物。 这项研究的长期目标是获得知识，使我们能够从治疗上抑制免疫介导的中枢神经系统疾病的致病机制和增强修复机制，从而将中枢神经系统组织损伤的程度降至最低，促进康复。此外，我们预计这些研究将导致生物标记物(成像、免疫学和分子)的发展，反映同时存在的免疫介导和神经退行性病变的病理生理机制，以及那些能够区分不同诊断实体的生物标记物。这将导致合理开发和更快地筛选特定过程的治疗方法，并将能够识别具有普遍疾病机制的患者，这是个性化医学方法的要求。最终，了解疾病过程的机制将影响整个中枢神经系统免疫介导性疾病的管理。

Neuroimmunological diseases of the central nervous system (CNS) represent a broad spectrum of very diverse diagnoses, most of which are considered rare disorders. With the exception of multiple sclerosis (MS), acute demyelinating encephalomyelitis (ADEM), transverse myelitis (TM) and CNS lupus, reported cohorts in the literature rarely exceed 10-20 patients, and it takes years to collect these numbers. Additionally, with the exception of MS, virtually all reports focus on clinical findings and there is a great paucity of data characterizing intrathecal or systemic immune responses in these patients. As a result, the pathophysiology of these diseases is poorly understood and effective therapies are very rare. Emerging data indicate that the immune response is shaped not only by pathogens, but also by the tissue where the inflammatory process develops. From this standpoint, CNS tissue is unique. Elegant animal data indicate that foreign grafts survive indefinitely if transplanted into CNS tissue, bypassing systemic presentation of its antigens, whereas they are readily rejected when transplanted into other organs. Indeed, interactions of T cells with neurons can shape T cell effector phenotype, from pathogenic to more regulatory. There is little doubt that these complex immunoregulatory mechanisms emerged as an assurance that CNS tissue, which is vital for the function and survival of the host, will be protected from inadvertent damage by the immune system. Therefore, the apparent failure of the immune system that presents clinically as CNS autoimmunity may originate as a breakdown of natural immunoregulatory mechanisms that govern CNS-immune system interactions. This project studies intrathecal and systemic immune responses in patients referred to NIB for diagnostic work-ups of neuroimmunological CNS disorders. The goal of this study is to define the pathophysiological mechanisms underlying the development of disability in immune-mediated disorders of the CNS and to distinguish these from physiological (and often beneficial) responses of the human immune system to CNS injury. We have established natural history protocol (09-N-0032) under which all untreated patients with suspected immune-mediated disorders of the CNS undergo detailed evaluation at NIB, consisting of the collection of clinical and paraclinical quantitative measures of disease activity and disability, standard and novel quantitative neuroimaging markers and immunological and molecular biomarkers originating from cerebrospinal fluid (CSF), serum and immune cells collected both from peripheral blood and CSF. Additionally, patients may undergo skin biopsy for collection of fibroblasts for their transformation into induced pluripotent stem (iPS) cells in order to develop autologous source of neural cells to study physiological neural-immune interactions in humans, which has not been possible thus far. All patients are coded and analysis of paraclinical, neuroimaging and molecular biomarkers are performed in an unbiased (i.e. blinded) fashion in order to define which biomarkers are associated with specific neuroimmunological disease or phenotype. Our results obtained so far are summarized below: 1. We have developed the methodology for expansion of CD4+ and CD8+ T cells from the limited sample of cerebrospinal fluid (CSF) and we are currently testing the antigen-specificity of these cells. 2. We have developed methodology for expansion and immortalization of B cells from the limited sample of CSF. We have unblinded our data and summarized the efficacy of EBV CSF B cell transformation for the past 2 years: we observed significantly higher (5 fold increased) efficacy of CSF B cell immortalization by EBV in MS patients, as compared to both inflammatory and non-inflammatory neurological diseases controls. Additionally, we studied phenotype of EBV-immortalized B cells derived from MS patients versus controls in blinded fashion, by combination of surface and intracellular cytokine staining by flow cytometry applied to over 100 immortalized CSF B cell lines. We observed significant differences in the phenotype of CSF B cells derived from MS versus control cohorts. The paper describing our findings is currently in review. 3. We analyzed CSF antibody (Ab) reactivity to human myelin and found that intrathecally-produced antibodies of MS patients do not recognize proteins and lipids in their native conformation that are present in human myelin derived from MS patients or control diseased subjects. 4. We are developing and applying unbiased novel methodologies that aim to determine the target(s) of the intrathecal Ab production in MS patients 5. We are developing and validating multiple biomarkers of intrathecal oxidative stress and CNS tissue destruction. The long-term objective of the study is to acquire knowledge that would allow us to therapeutically inhibit the pathogenic mechanisms and enhance repair mechanisms in immune-mediated CNS diseases, thereby minimizing the extent of CNS tissue damage and promoting recovery. Additionally, we expect that these studies will lead to the development of biomarkers (imaging, immunological and molecular) reflecting concurrent immune-mediated and neurodegenerative pathophysiological mechanisms and those that would able to distinguish among different diagnostic entities. This will lead to rational development and faster screening of process-specific therapies, and will permit the identification of patients with prevailing disease mechanisms, which is a requirement for an individualized approach to medicine. Ultimately, understanding the mechanisms of disease processes will impact the management of immune-mediated diseases of the CNS as a whole.