Combined Clinical, Viral And Immunological Studies In Neuromuscular Diseases

进行了临床、实验室和治疗研究，以确定各种神经肌肉疾病的病因(自身免疫、神经毒性、遗传学)，并设计或应用有效的治疗方法。2007财年的研究涉及以下患者：a)炎症性肌病，重点是包涵体肌炎(IBM)；b)遗传性空泡性肌病，重点是由于GNE突变引起的遗传性IBM和结蛋白相关肌病；c)脱髓鞘多神经病；d)僵人综合征(SPS)。 在炎症性肌病中，T细胞受体的特异性和肌内T细胞的原位克隆性增殖被纵向检测。研究表明，IBM的T细胞是由特定的抗原驱动的。为了寻找可能的抗原(S)，已经从肌内T细胞浸润物中建立了T细胞克隆；目前利用组合肽库探索驱动T细胞反应并作为自身抗原的候选免疫优势肽。研究发现，在IBM中，趋化因子和共刺激分子如ICOS、ICOS-L和PDI上调，肌纤维可能起到抗原提呈细胞的作用。由于细胞因子与类阿尔茨海默病的β-APP淀粉样沉积具有共同的抗原决定因素，因此我们探索了这些分子之间的相互关系。细胞因子、趋化因子和淀粉样变性分子之间存在线性关系，不仅在体内患者的肌肉中，而且在体外的人肌管中也是如此。在临床层面，一项考察IBM自然历史的纵向研究已经完成。为了抑制T细胞的肌细胞毒作用，一项治疗性和研究性的临床试验已经开始使用CamPath，一种人源化的单抗，可以诱导成熟T细胞的持续耗尽，从而产生耐受性T细胞反应。这项研究已经完成，正在进行分析。 在与抗MAG和糖脂的IgM自身抗体相关的脱髓鞘神经病中，使用人源化的抗B细胞克隆的单抗利妥昔单抗进行了一项新的对照治疗研究。研究现已完成，数据正在分析中。初步分析表明，利妥昔单抗在某些亚群中对该病有效，并通过增强免疫调节T细胞发挥作用。 为了在僵人综合征(SPS)患者中寻找负责任的自身抗原，从脑脊液中建立了T细胞克隆，并针对组合肽文库进行了测试。利用患者血清中的蛋白质组学，抗原肽GABARAP(GABA受体相关蛋白)被发现减少。此外，在多达65%的SPS患者中检测到了抗GABARAP抗体。这些抗体可能破坏GABAA受体的稳定性，并在导致患者大脑中GABA能通路功能障碍和GABA水平下降中发挥作用，如MRS所示。使用去除B细胞的单抗利妥昔单抗进行的一项新的双盲临床试验已经完成，所有23名患者都已入选。数据正在进行分析。恐惧症是SPS患者的常见特征，人们正在使用一系列神经认知测量来探索恐惧症的起源。研究发现，恐惧症是残疾的次要原因，而不是原发病。 在遗传性IBM患者中，由于Gne基因突变，我们观察到肌肉蛋白糖基化的缺陷和α-肌营养不良蛋白聚糖的减少。在4名患者中完成了一项使用静脉注射免疫球蛋白以增加肌肉糖基化的初步临床试验。结果很有希望，目前正在进行分析。由于结蛋白基因的致病突变，遗传性肌病患者的表型/基因相关已经完成。已经得出结论，结蛋白肌病是一种影响中间丝的独特疾病，突变类型可能决定临床上心肌病的严重程度或存在。

Clinical, laboratory and therapeutic studies were conducted to determine etiology (autoimmunity, neurotoxicity, genetics) of various neuromuscular diseases and design, or apply, effective therapies. Studies in FY07 involved patients with: a) inflammatory myopathies with emphasis on inclusion body myositis (IBM); b) inherited vacuolar myopathies with emphasis on hereditary IBM due to GNE mutations and desmin-related myopathies; c) demyelinating polyneuropathies; and d) the stiff-person syndrome(SPS). In inflammatory myopathies, the specificity of the T cell Receptors and the in situ clonal expansion of the endomysial T cells are examined longitudinally. The studies have shown that in IBM the T cells are driven by specific antigens. To search for putative antigen(s), T cell clones have been established from the endomysial T cell infiltrates; candidate immunodominant peptides that drive the T cell responses and serve as autoantigens are currently explored using combinatorial peptide libraries. It has been found that in IBM chemokines and costimulatory molecules such as ICOS, ICOS-L and PDI are upregulated and the muscle fiber may function as Antigen Presenting cell. Because cytokines share common antigenic determinants with the Alzheimer-like beta-APP amyloid deposits, an interrelationship between these molecules was explored. A linear relationship was found between cytokines, chemokines and amyloid-related degenerating molecules not only in vivo in the patient's muscles but also in vitro in human myotubes. At the clinical level, a longitudinal study examining the natural history of IBM has been completed. To suppress the myocytotoxic effect of T cells, a therapeutic and investigational clinical trial has begun using CAMPATH, a humanized monoclonal antibody that induces a sustained depletion of mature T cells allowing for toleragenic T cell responses. The study has been completed and is being analysed. In demyelinating neuropathies associated with IgM autoantibodies to MAG and glycolipids,a new controlled therapeutic study was performed using Rituximab, a humanized monoclonal antibody against B cell clones. The study is now completed and the data are being analysed. Preliminary analysis demonstrates that Rituximab is effective in the disease in some subgroups and exerts its action by enhancing immunoregulatory T cells. In an effort to find responsible autoantigens in patients with Stiff Person Syndrome (SPS), T cell clones were established from the CSF and being tested against combinatorial peptide libraries. Using proteomics in the patients' serum, the antigenic peptide GABARAP (GABA-Receptor Associated Protein), was found to be reduced. Further, anti-GABARAP antibodies were detected in up to 65% of SPS patients. These antibodies may destabilize the GABAA receptors and play a role in inducing the dysfunction of GABAergic pathways and the reduced level of GABA in the patients' brains as demonstrated with MRS spectroscopy. A new double-blind clinical trial using the B cell-depleting monoclonal antibody Rituximab has been completed and all 23 patients have been enrolled. The data is undergoing analysis. The origin of phobias, a common feature in SPS patients, was being explored using a series of neurocognitive measurements. It was found that the phobias are secondary to disability and not due to the primary disease. In patients with hereditary IBM due to mutations in the GNE gene we observed a defect in glycosylation of muscle proteins and reduction of alpha-dystroglycan. A pilot clinical trial using intravenous immunoglobulin in an effort to increase muscle glycosylation was completed in 4 patients. The results are promising and are currently analyzed. A phenotype/genotype correlation has been completed in patients with hereditary myopathies due to pathogenic mutations in the desmin gene. It has been concluded that desmin myopathy is a distinct disease affecting intermediate filaments and the type of mutations may dictate clinical severity or presence of cardiomyopathy.