Lesiones cerebrales captantes de gadolinio en el brote de los pacientes con esclerosis múltiple

Esclerosis múltiple; Brote; Resonancia magnéticaEsclerosi múltiple; Brot; Imatge per ressonància magnèticaMultiple sclerosis; Outbreak; Magnetic resonance imagingObjective To study the clinico-radiological paradox in multiple sclerosis (MS) relapse by analyzing the number and location of gadolinium-enhanced (Gd+) lesions on brain MRI before methylprednisolone (MP) treatment. Methods We analyzed brain MRI from 90 relapsed MS patients in two Phase IV multicenter double-blind randomized clinical trials that showed the noninferiority of different routes and doses of MP administration. A 1.5- or 3-T brain MRI was performed at baseline before MP treatment and within 15 days of symptom onset. The number and location of Gd+ lesions were analyzed. Associations were studied using univariate analysis. Results Sixty-two percent of patients had at least 1 Gd+ brain lesion; the median number was 1 (interquartile range 0–4), and 41% of patients had 2 or more lesions. The most frequent location of Gd+ lesions was subcortical (41.4%). Gd+ brain lesions were found in 71.4% of patients with brainstem-cerebellum symptoms, 57.1% with spinal cord symptoms and 55.5% with optic neuritis (ON). Thirty percent of patients with brain symptoms did not have Gd+ lesions, and only 43.6% of patients had symptomatic Gd+ lesions. The univariate analysis showed a negative correlation between age and the number of Gd+ lesions (p = 0.002). Conclusion Most patients with relapse showed several Gd+ lesions on brain MRI, even when the clinical manifestation was outside of the brain. Our findings illustrate the clinico-radiological paradox in MS relapse and support the value of brain MRI in this scenario.Objetivo Estudiar la paradoja clínico-radiológica en el brote de la esclerosis múltiple (EM) mediante el análisis de lesiones captantes de gadolinio (Gd+) en la RM cerebral antes del tratamiento con metilprednisolona (MP). Métodos Analizamos la RM cerebral basal de 90 pacientes con EM en brote de 2 ensayos clínicos aleatorizados multicéntricos fase IV que demostraron la no inferioridad de diferentes vías y dosis de MP, realizadas antes del tratamiento con MP y en los 15 días siguientes a la aparición de los síntomas. Se analizaron el número y la localización de las lesiones Gd+. Se estudiaron las asociaciones mediante análisis univariado. Resultados El 62% de los pacientes tenía al menos una lesión Gd+ cerebral y el 41% de los pacientes tenía 2 o más lesiones. La localización más frecuente fue la subcortical (41,4%). Se encontraron lesiones Gd+ cerebrales en el 71,4% de los pacientes con síntomas de tronco cerebral o cerebelo, en el 57,1% con síntomas medulares y en el 55,5% con neuritis óptica. El 30% de los pacientes con síntomas cerebrales no tenían lesiones Gd+ y sólo el 4,.6% de los pacientes tenían lesiones Gd+ sintomáticas. El análisis univariante mostró una correlación negativa entre la edad y el número de lesiones Gd+ (p = 0,002). Conclusiones La mayoría de los pacientes en brote mostraron varias lesiones Gd+ en la RM cerebral, incluso cuando la manifestación clínica fue medular u óptica. Nuestros hallazgos ilustran la paradoja clínico-radiológica en el brote de la EM y apoyan el valor de la RM cerebral en este escenario.This work was supported in part by the Ministry of Health of Spain (grant numbers EC07/90278 and EC11/132) and personal grant Rio Hortega CM19/00042 to LMA

MAP7 and MUCL1 are biomarkers of Vitamin D3-induced tolerogenic dendritic cells in multiple sclerosis patients

The administration of autologous tolerogenic dendritic cells (tolDC) has become a promising alternative for the treatment of autoimmune diseases, such as multiple sclerosis (MS). Specifically, the use of vitamin D3 for the generation of tolDC (vitD3-tolDC) constitutes one of the most widely studied approaches, as it has evidenced significant immune regulatory properties, both in vitro and in vivo. In this article, we generated human vitD3-tolDC from monocytes from healthy donors and MS patients, characterized in both cases by a semi-mature phenotype, secretion of IL-10 and inhibition of allogeneic lymphocyte proliferation. Additionally, we studied their transcriptomic profile and selected a number of differentially expressed genes compared to control mature and immature dendritic cells for their analysis. Among them, qPCR results validated CYP24A1, MAP7 and MUCL1 genes as biomarkers of vitD3-tolDC in both healthy donors and MS patients. Furthermore, we constructed a network of protein interactions based on the literature, which manifested that MAP7 and MUCL1 genes are both closely connected between them and involved in immune-related functions. In conclusion, this study evidences that MAP7 and MUCL1 constitute robust and potentially functional biomarkers of the generation of vitD3-tolDC, opening the window for their use as quality controls in clinical trials for MS

Seroprevalence of SARS-CoV-2 in a Cohort of Patients with Multiple Sclerosis under Disease-Modifying Therapies

Background: Disease-modifying therapies (DMTs) used to treat multiple sclerosis (MS) alter the immune system and therefore increase the risk of infection. There is growing concern about the impact of COVID-19 on patients with MS (pwMS), especially those treated with DMTs. Methods: This is a single-center prospective observational study based on data from the Esclerosis Múltiple y COVID-19 (EMCOVID-19) study. Demographic characteristics, MS history, laboratory data and SARS-CoV-2 serology, and symptoms of COVID-19 in pwMS treated with any DTM were extracted. The relationship among demographics, MS status, DMT, and COVID-19 was evaluated. Results: A total of 259 pwMS were included. The administration of interferon was significantly associated with the presence of SARS-CoV-2 antibodies (26.4% vs. 10.7%, p = 0.006). Although patients taking interferon were significantly older (49.1 vs. 43.5, p = 0.003), the association of interferon with the presence of SARS-CoV-2 antibodies was still significant in the multivariate analysis (OR 2.99 (1.38; 6.36), p = 0.006). Conclusions: According to our data, pwMS present a higher risk of COVID-19 infection compared with results obtained from the general population. There is no evidence of a worse COVID-19 outcome in pwMS. DMTs did not significantly change the frequency of COVID-19, except for interferon; however, these findings must be interpreted with caution given the small sample of pwMS taking each DMT

Toxic and nutritional factors trigger Leber hereditary optic neuropathy due to a mitochondrial tRNA mutation

Leber hereditary optic neuropathy is a mitochondrial disease mainly due to pathologic mutations in mitochondrial genes related to the respiratory complex I of the oxidative phosphorylation system. Genetic, physiological, and environmental factors modulate the penetrance of these mutations. We report two patients suffering from this disease and harboring a m.15950G > A mutation in the mitochondrial DNA-encoded gene for the threonine transfer RNA. We also provide evidences supporting the pathogenicity of this mutation

Assessing Blood-Based Biomarkers to Define a Therapeutic Window for Natalizumab

Natalizumab is a monoclonal antibody that binds CD49d. Although it is one of the most effective treatments for Relapsing-Remitting Multiple Sclerosis (RRMS), a dosing regimen has not been optimized for safety and efficacy in individual patients. We aimed to identify biomarkers to monitor Natalizumab treatment and to establish a personalized dose utilizing an ongoing longitudinal study in 29 RRMS patients under Natalizumab with standard interval dose (SD) of 300 mg/4 wks or extended interval dose (EID) of 300 mg/6 wks. Blood samples were analyzed by flow cytometry to determine CD49d saturation and expression in several T and B lymphocytes subpopulations. Each patient was analyzed at two different timepoints separated by 3 Natalizumab administrations. Natalizumab and sVCAM-1 levels in serum were also analyzed using ELISA. To determine the reproducibility of various markers, two different timepoints were compared and no significant differences were observed for CD49d expression nor for saturation; SD patients had higher saturation levels (~80%) than EID patients (~60%). A positive correlation exists between CD49d saturation and Natalizumab serum levels. CD49d expression and saturation are stable parameters that could be used as biomarkers in the immunomonitoring of Natalizumab treatment. Moreover, Natalizumab and sVCAM-1 serum levels could be used to optimize an individual's dosing schedule

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Terapia personalizada con células dendríticas tolerogénicas en pacientes con esclerosis múltiple. Ensayo clínico fase i (TOLERVIT-MS)

L’esclerosi múltiple (EM) és la malaltia inflamatòria més freqüent del sistema nerviós central (SNC). Tot i que sabem que es tracta d’una malaltia immunomediada, avui dia molts dels mecanismes implicats en la seva patogènia continuen sent desconeguts. És precisament això el que dificulta trobar la curació de la malaltia. En les darreres 2 dècades s’han comercialitzat uns 10 fàrmacs immunosupressors o immunomoduladors amb diferents mecanismes d’acció que ens permeten controlar l’activitat inflamatòria, però malgrat això molts pacients experimenten progressió de la malaltia. D’altra banda, aquests fàrmacs tenen riscos potencialment greus que els pacients han d’assumir. En aquest context emergeixen les teràpies cel·lulars com a tractaments que ens permeten abordar la malaltia des del seu origen, intentant reparar la disfunció del sistema immune sense afectar la immunitat protectora. Fa més d’una dècada que el nostre equip investiga en el desenvolupament d’una teràpia basada en cèl·lules dendrítiques tolerogèniques (CDtol) per a pacients amb EM. Els estudis realitzats in vitro i in vivo al model animal van apuntar que la teràpia podia ser beneficiosa per al control de la malaltia. Per això es va posar en marxa un assaig clínic fase I en pacients amb EM per avaluar la seguretat de la teràpia cel·lular amb CDtol tractades amb vitamina D3 (CDtol-VitD3) i carregades amb pèptids de mielina administrada directament als ganglis limfàtics cervicals. Els resultats derivats d’aquest assaig clínic, descrits en aquesta tesi doctoral, confirmen que l’administració intraganglionar de la nostra teràpia cel·lular amb CDtol-VitD3 és segura i ben tolerada. El benefici terapèutic serà determinat en futurs assaigs de fase II.La esclerosis múltiple (EM) es la enfermedad inflamatoria más frecuente del sistema nervioso central (SNC). Aunque sabemos que se trata de una enfermedad inmunomediada, a día de hoy muchos de los mecanismos implicados en su patogenia siguen siendo desconocidos. Es precisamente esto lo que dificulta encontrar la curación de la enfermedad. En las últimas 2 décadas se han comercializado unos 10 fármacos inmunosupresores o inmunomoduladores con diferentes mecanismos de acción que nos permiten controlar la actividad inflamatoria, pero a pesar de ello, muchos pacientes experimentan progresión de la enfermedad. Por otra parte, estos fármacos tienen riesgos potencialmente graves que los pacientes deben asumir. En este contexto emergen las terapias celulares como tratamientos que nos permiten abordar la enfermedad desde su origen, intentado reparar la disfunción del sistema inmune sin afectar la inmunidad protectora. Nuestro equipo lleva más de una década investigando en el desarrollo de una terapia basada en células dendríticas tolerogénicas (CDtol) para pacientes con EM. Los estudios realizados in vitro e in vivo en el modelo animal apuntaron que la terapia podía ser beneficiosa para el control de la enfermedad. Por ello se puso en marcha un ensayo clínico fase I en pacientes con EM para evaluar la seguridad de la terapia celular con CDtol tratadas con vitamina D3 (CDtol-VitD3) y cargadas con péptidos de mielina administrada directamente en los ganglios linfáticos cervicales. Los resultados derivados de este ensayo clínico, descritos en la presente tesis doctoral, confirman que la administración intraganglionar de nuestra terapia celular con CDtol-VitD3 es segura y bien tolerada. El beneficio terapéutico será determinado en futuros ensayos de fase II.Multiple sclerosis (MS) is the most common inflammatory disease of the central nervous system (CNS). Although we know that it is an immune-mediated disease, today many of the mechanisms involved in its pathogenesis remain unknown. It is precisely this, which makes it difficult to find a cure for the disease. In the last 2 decades, some 10 immunosuppressive or immunomodulatory drugs have been marketed with different mechanisms of action that allow us to control inflammatory activity but, despite this, many patients experience progression of the disease. On the other hand, these drugs have potentially serious risks which patients must assume. In this context, cell therapies emerge as treatments that allow us to address the disease from its origin, trying to repair the dysfunction of the immune system, without affecting protective immunity. Our team has spent more than a decade researching the development of a tolerogenic dendritic cell (tolDC)-based therapy for MS patients. The studies carried out in vitro and in vivo in the animal model, pointed out that the therapy could be beneficial for the control of the disease. For this reason, a phase I clinical trial was launched to assess the safety of cell therapy with tolDC treated with vitamin D3 (tolDC-vitD3) and loaded with myelin peptides for patients with MS administrated directly in the cervical lymph nodes. The results derived from this clinical trial, described in this doctoral thesis, confirm that the intranodal administration of our cell therapy with tolDC-vitD3 is safe and well tolerated. The therapeutic benefit will be determined in future phase II trials.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin

Terapia personalizada con células dendríticas tolerogénicas en pacientes con esclerosis múltiple. Ensayo clínico fase i (TOLERVIT-MS)

L'esclerosi múltiple (EM) és la malaltia inflamatòria més freqüent del sistema nerviós central (SNC). Tot i que sabem que es tracta d'una malaltia immunomediada, avui dia molts dels mecanismes implicats en la seva patogènia continuen sent desconeguts. És precisament això el que dificulta trobar la curació de la malaltia. En les darreres 2 dècades s'han comercialitzat uns 10 fàrmacs immunosupressors o immunomoduladors amb diferents mecanismes d'acció que ens permeten controlar l'activitat inflamatòria, però malgrat això molts pacients experimenten progressió de la malaltia. D'altra banda, aquests fàrmacs tenen riscos potencialment greus que els pacients han d'assumir. En aquest context emergeixen les teràpies cel·lulars com a tractaments que ens permeten abordar la malaltia des del seu origen, intentant reparar la disfunció del sistema immune sense afectar la immunitat protectora. Fa més d'una dècada que el nostre equip investiga en el desenvolupament d'una teràpia basada en cèl·lules dendrítiques tolerogèniques (CDtol) per a pacients amb EM. Els estudis realitzats in vitro i in vivo al model animal van apuntar que la teràpia podia ser beneficiosa per al control de la malaltia. Per això es va posar en marxa un assaig clínic fase I en pacients amb EM per avaluar la seguretat de la teràpia cel·lular amb CDtol tractades amb vitamina D3 (CDtol-VitD3) i carregades amb pèptids de mielina administrada directament als ganglis limfàtics cervicals. Els resultats derivats d'aquest assaig clínic, descrits en aquesta tesi doctoral, confirmen que l'administració intraganglionar de la nostra teràpia cel·lular amb CDtol-VitD3 és segura i ben tolerada. El benefici terapèutic serà determinat en futurs assaigs de fase II.La esclerosis múltiple (EM) es la enfermedad inflamatoria más frecuente del sistema nervioso central (SNC). Aunque sabemos que se trata de una enfermedad inmunomediada, a día de hoy muchos de los mecanismos implicados en su patogenia siguen siendo desconocidos. Es precisamente esto lo que dificulta encontrar la curación de la enfermedad. En las últimas 2 décadas se han comercializado unos 10 fármacos inmunosupresores o inmunomoduladores con diferentes mecanismos de acción que nos permiten controlar la actividad inflamatoria, pero a pesar de ello, muchos pacientes experimentan progresión de la enfermedad. Por otra parte, estos fármacos tienen riesgos potencialmente graves que los pacientes deben asumir. En este contexto emergen las terapias celulares como tratamientos que nos permiten abordar la enfermedad desde su origen, intentado reparar la disfunción del sistema inmune sin afectar la inmunidad protectora. Nuestro equipo lleva más de una década investigando en el desarrollo de una terapia basada en células dendríticas tolerogénicas (CDtol) para pacientes con EM. Los estudios realizados in vitro e in vivo en el modelo animal apuntaron que la terapia podía ser beneficiosa para el control de la enfermedad. Por ello se puso en marcha un ensayo clínico fase I en pacientes con EM para evaluar la seguridad de la terapia celular con CDtol tratadas con vitamina D3 (CDtol-VitD3) y cargadas con péptidos de mielina administrada directamente en los ganglios linfáticos cervicales. Los resultados derivados de este ensayo clínico, descritos en la presente tesis doctoral, confirman que la administración intraganglionar de nuestra terapia celular con CDtol-VitD3 es segura y bien tolerada. El beneficio terapéutico será determinado en futuros ensayos de fase II.Multiple sclerosis (MS) is the most common inflammatory disease of the central nervous system (CNS). Although we know that it is an immune-mediated disease, today many of the mechanisms involved in its pathogenesis remain unknown. It is precisely this, which makes it difficult to find a cure for the disease. In the last 2 decades, some 10 immunosuppressive or immunomodulatory drugs have been marketed with different mechanisms of action that allow us to control inflammatory activity but, despite this, many patients experience progression of the disease. On the other hand, these drugs have potentially serious risks which patients must assume. In this context, cell therapies emerge as treatments that allow us to address the disease from its origin, trying to repair the dysfunction of the immune system, without affecting protective immunity. Our team has spent more than a decade researching the development of a tolerogenic dendritic cell (tolDC)-based therapy for MS patients. The studies carried out in vitro and in vivo in the animal model, pointed out that the therapy could be beneficial for the control of the disease. For this reason, a phase I clinical trial was launched to assess the safety of cell therapy with tolDC treated with vitamin D3 (tolDC-vitD3) and loaded with myelin peptides for patients with MS administrated directly in the cervical lymph nodes. The results derived from this clinical trial, described in this doctoral thesis, confirm that the intranodal administration of our cell therapy with tolDC-vitD3 is safe and well tolerated. The therapeutic benefit will be determined in future phase II trials

Epstein-Barr Virus and Multiple Sclerosis: A Convoluted Interaction and the Opportunity to Unravel Predictive Biomarkers

Since the early 1980s, Epstein-Barr virus (EBV) infection has been described as one of the main risk factors for developing multiple sclerosis (MS), and recently, new epidemiological evidence has reinforced this premise. EBV seroconversion precedes almost 99% of the new cases of MS and likely predates the first clinical symptoms. The molecular mechanisms of this association are complex and may involve different immunological routes, perhaps all running in parallel (i.e., molecular mimicry, the bystander damage theory, abnormal cytokine networks, and coinfection of EBV with retroviruses, among others). However, despite the large amount of evidence available on these topics, the ultimate role of EBV in the pathogenesis of MS is not fully understood. For instance, it is unclear why after EBV infection some individuals develop MS while others evolve to lymphoproliferative disorders or systemic autoimmune diseases. In this regard, recent studies suggest that the virus may exert epigenetic control over MS susceptibility genes by means of specific virulence factors. Such genetic manipulation has been described in virally-infected memory B cells from patients with MS and are thought to be the main source of autoreactive immune responses. Yet, the role of EBV infection in the natural history of MS and in the initiation of neurodegeneration is even less clear. In this narrative review, we will discuss the available evidence on these topics and the possibility of harnessing such immunological alterations to uncover predictive biomarkers for the onset of MS and perhaps facilitate prognostication of the clinical course