An optimized immunohistochemistry technique improves NMO-IgG detection: study comparison with cell-based assays

Cell-based assays (CBA) have increased the sensitivity of the neuromyelitis optica (NMO)-IgG/aquaporin-4-antibody detection compared to classical tissue-based indirect assays. We describe the sensitivity of an optimized immunohistochemistry (IHC-o) to detect NMO-IgG/aquaporin-4-antibody in comparison with that of two CBA: an in-house (CBA-ih) and a commercial (CBA-c) assay (Euroimmun, Germany). Coded serum from 103 patients with definite NMO and 122 inflammatory controls were studied by IHC-o, CBA-ih, and CBA-c. IHC-o used the same protocol described to detect antibodies against cell surface antigens. CBA-ih used live cells transfected with the aquaporin-4-M23-isoform. The sensitivity of the IHC-o was 74.8% (95% confidence interval [CI] 65-83) and was similar to that of the CBA-ih 75.7% (95% CI 66-84) and the CBA-c 73.8% (95% CI 64-82). The specificity of the three assays was 100% (95% CI 97-100). Interassay concordance was high, 100 of 103 samples were coincident in all techniques. The optimized immunohistochemistry proves to be as sensitive and specific as the cell-based assays. This assay extends the available tools for NMO-IgG/aquaporin-4-antibody detection

Prognostic indicators and outcomes of hospitalised COVID-19 patients with neurological disease: An individual patient data meta-analysis

BACKGROUND: Neurological COVID-19 disease has been reported widely, but published studies often lack information on neurological outcomes and prognostic risk factors. We aimed to describe the spectrum of neurological disease in hospitalised COVID-19 patients; characterise clinical outcomes; and investigate factors associated with a poor outcome. METHODS: We conducted an individual patient data (IPD) meta-analysis of hospitalised patients with neurological COVID-19 disease, using standard case definitions. We invited authors of studies from the first pandemic wave, plus clinicians in the Global COVID-Neuro Network with unpublished data, to contribute. We analysed features associated with poor outcome (moderate to severe disability or death, 3 to 6 on the modified Rankin Scale) using multivariable models. RESULTS: We included 83 studies (31 unpublished) providing IPD for 1979 patients with COVID-19 and acute new-onset neurological disease. Encephalopathy (978 [49%] patients) and cerebrovascular events (506 [26%]) were the most common diagnoses. Respiratory and systemic symptoms preceded neurological features in 93% of patients; one third developed neurological disease after hospital admission. A poor outcome was more common in patients with cerebrovascular events (76% [95% CI 67-82]), than encephalopathy (54% [42-65]). Intensive care use was high (38% [35-41]) overall, and also greater in the cerebrovascular patients. In the cerebrovascular, but not encephalopathic patients, risk factors for poor outcome included breathlessness on admission and elevated D-dimer. Overall, 30-day mortality was 30% [27-32]. The hazard of death was comparatively lower for patients in the WHO European region. INTERPRETATION: Neurological COVID-19 disease poses a considerable burden in terms of disease outcomes and use of hospital resources from prolonged intensive care and inpatient admission; preliminary data suggest these may differ according to WHO regions and country income levels. The different risk factors for encephalopathy and stroke suggest different disease mechanisms which may be amenable to intervention, especially in those who develop neurological symptoms after hospital admission

Prognostic indicators and outcomes of hospitalised COVID-19 patients with neurological disease: An individual patient data meta-analysis.

BackgroundNeurological COVID-19 disease has been reported widely, but published studies often lack information on neurological outcomes and prognostic risk factors. We aimed to describe the spectrum of neurological disease in hospitalised COVID-19 patients; characterise clinical outcomes; and investigate factors associated with a poor outcome.MethodsWe conducted an individual patient data (IPD) meta-analysis of hospitalised patients with neurological COVID-19 disease, using standard case definitions. We invited authors of studies from the first pandemic wave, plus clinicians in the Global COVID-Neuro Network with unpublished data, to contribute. We analysed features associated with poor outcome (moderate to severe disability or death, 3 to 6 on the modified Rankin Scale) using multivariable models.ResultsWe included 83 studies (31 unpublished) providing IPD for 1979 patients with COVID-19 and acute new-onset neurological disease. Encephalopathy (978 [49%] patients) and cerebrovascular events (506 [26%]) were the most common diagnoses. Respiratory and systemic symptoms preceded neurological features in 93% of patients; one third developed neurological disease after hospital admission. A poor outcome was more common in patients with cerebrovascular events (76% [95% CI 67-82]), than encephalopathy (54% [42-65]). Intensive care use was high (38% [35-41]) overall, and also greater in the cerebrovascular patients. In the cerebrovascular, but not encephalopathic patients, risk factors for poor outcome included breathlessness on admission and elevated D-dimer. Overall, 30-day mortality was 30% [27-32]. The hazard of death was comparatively lower for patients in the WHO European region.InterpretationNeurological COVID-19 disease poses a considerable burden in terms of disease outcomes and use of hospital resources from prolonged intensive care and inpatient admission; preliminary data suggest these may differ according to WHO regions and country income levels. The different risk factors for encephalopathy and stroke suggest different disease mechanisms which may be amenable to intervention, especially in those who develop neurological symptoms after hospital admission

Etude des processus auto-immuns dans la narcolepsie avec cataplexie

La narcolepsie avec cataplexie est un trouble du sommeil rare et handicapant. Cette affection est induite par la destruction spécifique des neurones produisant l'orexine et localisés dans l'hypothalamus latéral. Cette pathologie est associée à des facteurs génétiques, environnementaux et biologiques, qui pointent vers une origine auto-immune. Par ailleurs, en 2009, la campagne de vaccination contre le virus grippal H1N1, utilisant le vaccin Pandemrix(r), a aboutit à une augmentation drastique du nombre de cas de narcolepsie en Europe. Les modèles animaux actuels de narcolepsie ne permettent pas l'étude de l'étiologie de cette affection. Notre objectif était donc de générer un modèle murin, permettant l'étude de la physiopathologie de la narcolepsie, ainsi que des mécanismes auto-immuns qui peuvent mener à la perte des neurones à orexine. Dans un premier temps, nous avons développé une souche de souris (Orex-HA), exprimant l'hémagglutinine (HA) du virus influenza, au sein des neurones à orexine. Ensuite, nous avons injecté des lymphocytes CD4 Th1, ainsi que des lymphocytes T CD8 cytotoxiques spécifiques de HA chez ces animaux et des souris non transgéniques, afin d'analyser leur capacité à créer de l'inflammation, au sein de l'hypothalamus. De façon intéressante, nous avons remarqué que, si les deux populations migrent au sein de la zone des neurones à orexine, seuls les lymphocytes T cytotoxiques sont capables d'induire une perte des neurones à orexine uniquement chez les souris Orex-HA. Cette destruction d'environs 70% des neurones aboutit à des signes électrophysiologiques et comportementaux proches des ceux observés dans la narcolepsie humaine. Dans un deuxième temps, pour tester l'impact de la vaccination, nous avons transféré des lymphocytes T CD4 et/ou CD8, naïfs spécifiques de HA, chez les souris Orex-HA et non transgéniques, avant de les immuniser avec le vaccin Pandemrix(r). La vaccination par Pandemrix(r) induit alors la différentiation des lymphocytes T CD4 et CD8 en sous-types inflammatoires chez les souris sauvages ou Orex-HA. Par contre, seul le transfert de lymphocytes T CD4 ou de la combinaison de lymphocytes T CD4 et CD8, aboutit à un infiltrat hypothalamique chez les animaux transgéniques. De manière intéressante, les lymphocytes T CD8 représentent la majorité des lymphocytes T, infiltrant le système nerveux central. Ces résultats indiquent que les lymphocytes T, sont à même d'induire une destruction des neurones à orexine de façon antigène dépendante. De façon cohérente, si l'on considère l'association de la narcolepsie avec un variant du locus HLA de classe II, les lymphocytes T CD4 semblent jouer un rôle clé dans l'initiation de la pathologie. Cependant dans notre modèle, les lymphocytes T CD8 sont les effecteurs finaux d'une destruction au sein de l'hypothalamus. Ces résultats encouragent à poursuivre l'investigation des processus auto-immuns à l'œuvre dans la narcolepsie, afin de proposer des immunothérapies aux patients.Narcolepsy with cataplexy is a rare and severe sleep disorder caused by the selective destruction of hypothalamic neurons secreting orexin. This disease has been associated with genetic, environmental and biological factors pointing to an autoimmune origin. Furthermore, in 2009, the pandemic H1N1 influenza vaccination campaign using Pandemrix(r)(GlaxoSmith Kline Vaccine) led to a marked increase of narcoleptic cases in Europe. Current animals models of narcolepsy do not allow studying the etiology of this disorder. Our goal was to develop a mouse model in order to study pathophysiology of narcolepsy including the immune mechanisms in response to vaccination leading to orexin neuron loss. We have generated mice (called Orex-HA) expressing influenza virus hemagglutinin (HA) in the orexin neuron. First, we have injected either CD4 Th1 cells or CD8 cytotoxic T lymphocytes in Orex-HA mice and controls, in order to analyze their ability to create hypothalamic inflammation. Interestingly, whereas both subsets were able to create local inflammation within the hypothalamus, only cytotoxic T lymphocytes were able to induce orexin neuron loss. This destruction, of about 70% of orexin neurons in Orex-HA, led to development of both electrophysiological and behavioral manifestations reminiscent of human narcolepsy. To test the impact of vaccination on development of narcolepsy, we transferred naive HA-specific CD4 and/or CD8 T cells into Orex-HA recipients before immunizing with Pandemrix(r). The vaccination with Pandemrix(r) induced pro-inflammatory differentiation of both CD4 and CD8 T cells in Wild Type (WT) and Orex-HA animals. However, only the transfer of CD4 or combination of CD4 and CD8 T cells led to hypothalamic inflammation in transgenic animals. Interestingly, CD8 T cells were the main population of T lymphocytes infiltrating the brain. Collectively, these findings demonstrate that T cells can mediate the destruction of orexin neurons. Consistent with the outstanding genetic association of narcolepsy with a specific class II HLA variant, CD4 T cells are likely to play a major role in enhancing the pathogenic autoimmune response in periphery. However, CD8 T cells appeared as the final effector of neuronal destruction in the central nervous system. These results incite to continue to study in depth the autoimmune origin of this disorder in order to propose immunoactive treatment to narcoleptic patients

Circulating follicular helper T cells exhibit reduced ICOS expression and impaired function in narcolepsy type 1 patients

International audienceDespite genetic and epidemiological evidence strongly supporting an autoimmune basis for narcolepsy type 1, the mechanisms involved have remained largely unknown. Here, we aimed to investigate whether the frequency and function of circulating follicular helper and follicular regulatory T cells are altered in narcolepsy type 1. Peripheral blood mononuclear cells were collected from 32 patients with narcolepsy type 1, including 11 who developed disease after Pandemrix® vaccination, and 32 age-, sex-, and HLA-DQB1*06:02-matched healthy individuals. The frequency and phenotype of the different circulating B cell and follicular T cell subsets were examined by flow cytometry. The function of follicular helper T cells was evaluated by assessing the differentiation of naïve and memory B cells in a co-culture assay. We revealed a notable increase in the frequency of circulating B cells and CD4+CXCR5+ follicular T cells in narcolepsy patients compared to age-, sex- and HLA-matched healthy controls. However, the inducible T-cell costimulator molecule, ICOS, was selectively down-regulated on follicular T cells from patients. Reduced frequency of activated ICOS+ and PD1high blood follicular T cells was also observed in the narcolepsy group. Importantly, follicular T cells isolated from patients with narcolepsy type 1 had a reduced capacity to drive the proliferation/survival and differentiation of memory B cells. Our results provide novel insights into the potential involvement of T cell-dependent B cell responses in the pathogenesis of narcolepsy type 1 in which down-regulation of ICOS expression on follicular helper T cells correlates with their reduced function. We hypothesize that these changes contribute to regulation of the deleterious autoimmune process after disease onset

An optimized immunohistochemistry technique improves NMO-IgG detection: study comparison with cell-based assays

Cell-based assays (CBA) have increased the sensitivity of the neuromyelitis optica (NMO)-IgG/aquaporin-4-antibody detection compared to classical tissue-based indirect assays. We describe the sensitivity of an optimized immunohistochemistry (IHC-o) to detect NMO-IgG/aquaporin-4-antibody in comparison with that of two CBA: an in-house (CBA-ih) and a commercial (CBA-c) assay (Euroimmun, Germany). Coded serum from 103 patients with definite NMO and 122 inflammatory controls were studied by IHC-o, CBA-ih, and CBA-c. IHC-o used the same protocol described to detect antibodies against cell surface antigens. CBA-ih used live cells transfected with the aquaporin-4-M23-isoform. The sensitivity of the IHC-o was 74.8% (95% confidence interval [CI] 65-83) and was similar to that of the CBA-ih 75.7% (95% CI 66-84) and the CBA-c 73.8% (95% CI 64-82). The specificity of the three assays was 100% (95% CI 97-100). Interassay concordance was high, 100 of 103 samples were coincident in all techniques. The optimized immunohistochemistry proves to be as sensitive and specific as the cell-based assays. This assay extends the available tools for NMO-IgG/aquaporin-4-antibody detection

CD8 T cell-mediated killing of orexinergic neurons induces a narcolepsy-like phenotype in mice

International audienceNarcolepsy with cataplexy is a rare and severe sleep disorder caused by the destruction of orexinergic neurons in the lateral hypothalamus. The genetic and environmental factors associated with narcolepsy, together with serologic data, collectively point to an autoimmune origin. The current animal models of narcolepsy, based on either disruption of the orexinergic neurotransmission or neurons, do not allow study of the potential autoimmune etiology. Here, we sought to generate a mouse model that allows deciphering of the immune mechanisms leading to orexin(+) neuron loss and narcolepsy development. We generated mice expressing the hemagglutinin (HA) as a "neo-self-antigen" specifically in hypothalamic orexin(+) neurons (called Orex-HA), which were transferred with effector neo-self-antigen-specific T cells to assess whether an autoimmune process could be at play in narcolepsy. Given the tight association of narcolepsy with the human leukocyte antigen (HLA) HLA-DQB1*06:02 allele, we first tested the pathogenic contribution of CD4 Th1 cells. Although these T cells readily infiltrated the hypothalamus and triggered local inflammation, they did not elicit the loss of orexin(+) neurons or clinical manifestations of narcolepsy. In contrast, the transfer of cytotoxic CD8 T cells (CTLs) led to both T-cell infiltration and specific destruction of orexin(+) neurons. This phenotype was further aggravated upon repeated injections of CTLs. In situ, CTLs interacted directly with MHC class I-expressing orexin(+) neurons, resulting in cytolytic granule polarization toward neurons. Finally, drastic neuronal loss caused manifestations mimicking human narcolepsy, such as cataplexy and sleep attacks. This work demonstrates the potential role of CTLs as final effectors of the immunopathological process in narcolepsy

Influenza vaccination induces autoimmunity against orexinergic neurons in a mouse model for narcolepsy

International audienceAbstract Narcolepsy with cataplexy or narcolepsy type 1 is a disabling chronic sleep disorder resulting from the destruction of orexinergic neurons in the hypothalamus. The tight association of narcolepsy with HLA-DQB1*06:02 strongly suggest an autoimmune origin to this disease. Furthermore, converging epidemiological studies have identified an increased incidence for narcolepsy in Europe following Pandemrix® vaccination against the 2009–2010 pandemic ‘influenza’ virus strain. The potential immunological link between the Pandemrix® vaccination and narcolepsy remains, however, unknown. Deciphering these mechanisms may reveal pathways potentially at play in most cases of narcolepsy. Here, we developed a mouse model allowing to track and study the T-cell response against ‘influenza’ virus haemagglutinin, which was selectively expressed in the orexinergic neurons as a new self-antigen. Pandemrix® vaccination in this mouse model resulted in hypothalamic inflammation and selective destruction of orexin-producing neurons. Further investigations on the relative contribution of T-cell subsets in this process revealed that haemagglutinin-specific CD4 T cells were necessary for the development of hypothalamic inflammation, but insufficient for killing orexinergic neurons. Conversely, haemagglutinin-specific CD8 T cells could not initiate inflammation but were the effectors of the destruction of orexinergic neurons. Additional studies revealed pathways potentially involved in the disease process. Notably, the interferon-γ pathway was proven essential, as interferon-γ-deficient CD8 T cells were unable to elicit the loss of orexinergic neurons. Our work demonstrates that an immunopathological process mimicking narcolepsy can be elicited by immune cross-reactivity between a vaccine antigen and a neuronal self-antigen. This process relies on a synergy between autoreactive CD4 and CD8 T cells for disease development. This work furthers our understanding of the mechanisms and pathways potentially involved in the development of a neurological side effect due to a vaccine and, likely, to narcolepsy in general