key: cord-0005841-93wcaeh6
authors: RODRIGUEZ, MOSES
title: Multiple Sclerosis: Basic Concepts and Hypothesis
date: 2012-12-13
journal: Mayo Clin Proc
DOI: 10.1016/s0025-6196(12)65563-3
sha: 587236e2df1d792802bcae5d78d7e9db5766bb4b
doc_id: 5841
cord_uid: 93wcaeh6

Multiple sclerosis, an inflammatory disease of the central nervous system, is characterized by primary destruction of myelin. This review covers recent advances in neuropathology, immunogenetics, neuroimmunology, and neurovirology that have provided insights regarding its pathogenesis. Three hypotheses are discussed: (1) autoimmunity, (2) “bystander” demyelination, and (3) immune destruction of persistently infected oligodendrocytes. A paradigm for induction of primary demyelination is proposed in which immune cells recognize “foreign” antigens on the surface of oligodendrocytes in the context of major histocompatibility complex gene products. The final result of this scheme may be “dying-back gliopathy,” the alteration being noted first in the most distal extension of the oligodendrocyte—that is, the myelin sheaths.

Individual reprints of this article are not available. The entire Symposium on Multiple Sclerosis will be available for purchase as a bound booklet from the Proceedings Circulation Office in July. gliosis by astrocytes and aberrant attempts at remyelination with oligodendrocytes proliferating at the edges of the plaque. 1 In addition, immunoglobulins are deposited within each plaque. 3 Whether the principal effector cells that mediate demyelination are T cells or macrophages is un known. Attempts to type the cells that infiltrate the brain in MS have yielded conflicting results. 4 7 Both CD8 + (cytotoxic/suppressor) T lymphocytes and CD4 + (helper/inducer) T lymphocytes surround the MS plaque. The relative proportions of T-cell subsets are controversial. Some investigators have found an excess of CD8 + cells in the perivascular cuffs at the edge of the lesion. 7 Others have found an excess of CD4 + cells. 4 These discrepancies probably result from examination of the plaques at different stages of their evolution.

Recent experiments have analyzed antigens of the major histocompatibility complex (MHC) in the brains of patients with MS. 8 The MHC is a set of closely linked genes that play a central role in the control of immune responses to self and foreign antigens. This function is of particular importance because CD4 + and CD8 + T cells recognize foreign antigen in the context of class II (HLA-DR, la) or class I (HLA-ABC) MHC gene products, respectively. The class II gene products, found primarily on macrophages and B cells, are important in presentation of antigen to T cells. Class I gene products are on the majority of cells in the body and are important in the generation of the cytotoxic response against viruses. The central nervous system is unique because MHC antigens normally are not present on neurons and glial cells. 8 In MS, however, class I and class II MHC-positive astrocytes are found with high fre quency in active lesions. The class I-reactive glia are primarily associated with T-cell infiltrates, whereas class II-reactive astrocytes are found in many lesions, independently of the composition of inflammatory cells. Thus, class I and II MHC-positive astrocytes might play a role in local antigen presentation to T cells. In addition, the simultaneous presence of high numbers of class I MHC-positive astrocytes and CD8 + cells in acute lesions suggests the possibility that CD8 + cells play a role as cytotoxic T cells during early development of the lesion.

The final consequence-that is, demyelination-in chronic active plaques may be attributable to several immunologic mechanisms, including receptor-medi ated endocytosis by macrophages, cytotoxicity by T cells, or lymphokine release.

One piece of evidence that provides an important clue to the pathogenesis of MS is the association between susceptibility and specific MHC haplotypes. 9 North ern Caucasians with MS have an overrepresentation of the A3, B7, DR2, and Dw2 histocompatibility al leles with relative risks of 2 to 3 for the class I MHC alleles (A3, B7) and 4 to 5 for class II MHC alleles (DR2, Dw2). Because linkage disequilibria exist between these class I alleles and DR2, the possible increased representation of one group of alleles may merely reflect this phenomenon.

The indefinite association between susceptibility and MHC haplotypes suggests that either more than one gene is involved or a strong environmental agent "breaks through" to disease in the absence of the MS susceptibility allele. The frequency of occurrence of A2, B12, DR7, and Dw7 is decreased in patients with MS. 9 The data that pertain to this occurrence are in much better agreement, suggesting that some MHC alleles may protect against MS. Investigators have also reported that some MHC alleles (DR2) are asso ciated with more progressive disease whereas others (DR3) are associated with more benign disease. 10 Studies in various populations (American blacks, Japanese, Arabs, Israeli Jews) have also shown an association with MHC but with different alleles in each case.

The risk of MS developing among first-degree rela tives of patients with MS is increased 15-to 20-fold over the risk in the general population. 9 This finding may reflect either genetic factors or shared environ mental agents. Attempts to analyze linkage between disease and HLA haplotypes in siblings affected by MS have substantiated a loose link between MS and MHC but do not permit conclusions about the mode of inheritance. 11 For more distant relatives, concor dance for MS is lower but exceeds chance expectation. In contrast, for non-blood-relatives living together (for example, husband and wife), the concordance for MS is not increased above chance. Studies in twins have shown greater concordance between monozygotic twins than between dizygotic twins. 1215 Many monozygotic pairs, however, are discordant for MS, a strong argument that genetic influence is insufficient for the development of MS. Also, the severity and expression of the disease vary greatly between members of concordant pairs.

Diseases that have been linked to the HLA complex have numerous similar features, including chronic course, inflammatory component, and weak genetic predisposition that does not obey mendelian genetics. One theory is that these disorders may have an autoimmune basis. The development of experimental autoimmune encephalomyelitis (EAE) as an animal model of MS has prompted investigation of the au toimmune basis of human demyelinating diseases. 16 EAE can be induced by injection of central nervous system myelin or its components along with adjuvants. From the EAE model has evolved the concept that the primary target in MS may be myelin and not the oligodendrocyte. 17 In addition, the disease can be transferred to naive animals with cells enriched for T lymphocytes reactive to the basic protein component of myelin. 1719 Therefore, attempts have been made to determine whether an immune response to normal myelin develops in patients with MS. To date, efforts to measure such a response in patients with MS have failed even though these responses can be detected in patients with postinfectious encephalomyelitis. 20 Although certain immunologic abnormalities have been reported in MS, many of the findings are still controversial. 21 CD8 + lymphocytes apparently are decreased in the blood of patients with active MS and in those with a progressive course, 22-26 a situation that leads to a relative increase in the CD4/CD8 ratio. Disease activity is not always associated with these Tcell changes, however. The data on T-cell subsets in the cerebrospinal fluid are more discordant. 26 28 Some investigators have reported a corresponding decrease in CD8 + cells in the cerebrospinal fluid, 28 whereas others have found no change. 26,27 Some investigators have argued that the loss of CD8 + cells from the blood represents a disorder of immunoregulation. 22 Others have suggested that the imbalance is the result of preferential sequestration of CD8 + cells in the central nervous system or lymphoid organs. 25 Recent experiments suggest a decrease in the suppressor/inducer subset (CD4 + , 2H4 + ) in serum of patients with progressive MS. 29 These suppressor/ inducer cells are not found in the cerebrospinal fluid, an indication that the loss of such cells is not due to migration into the central nervous system. Suppres sor T-cell function is also defective during active disease, as measured by concanavalin A-induced Tcell suppression 3031 or by polyclonal IgG stimulation of peripheral blood mononuclear cells by pokeweed mitogen. 32 Natural killer cell activity against tumor or virally infected targets may be decreased in MS, 33 but these results have not been confirmed. 3435

Attempts to identify a single infectious agent as the cause of MS have been unsuccessful thus far. 36 Many infectious agents have been isolated in cultures of specimens from patients with MS, but the majority represent contaminants or noncausal agents. In addition, direct inoculation of brain material into primates, so successful in identifying a transferable agent in Creutzfeldt-Jakob disease, has been nega tive or inconclusive. The more sensitive technique of looking for "footprints" of virus infection in brain tissue by nucleic acid hybridization with radiolabeled DNA probes or RNA probes (riboprobes) complemen tary to viral genomes has suggested that some brains of subjects with MS harbor measles virus. 37 The finding of measles virus genome in several control subjects without MS, however, suggested that viruses may reside in the nervous system without causing disease. 37 Analysis of the cerebrospinal fluid of patients with MS shows increased IgG levels along with oligoclonal Ig bands. 3840 Attempts to identify the antigen to which the IgG is directed have been unsuccessful. 40 In serum samples from patients with MS, titers of anti body to measles virus are increased. 4041 In many patients with MS, however, antibody titers to two or more viruses are increased in the cerebrospinal fluid. In diseases that are known to be caused by a virus (subacute sclerosing panencephalitis [measles] and mumps meningitis), IgG and oligoclonal bands in the cerebrospinal fluid are directed almost exclusively against the infectious agent. 4243 Because this is not the case with MS, some investigators have suggested that, in MS, the IgG in the central nervous system is "nonsense antibody" that represents a dysfunction in immune regulation. The alternative hypothesis is that the humoral immune response is to an unrecog nized infectious agent that is the cause of MS.

Two approaches to distinguish whether antibody is "nonsense" or "sense" have been used: analysis of banding patterns of IgG eluted from different MS plaques in the same patient 44 and study of idiotypes (combining sites of antibody molecules) of the oli goclonal IgG in cerebrospinal fluid from multiple patients. 4546 The first approach showed that each MS plaque may have unique IgG banding patterns. The second approach showed that anti-idiotypic antisera raised against cerebrospinal fluid IgG fail to crossreact with cerebrospinal fluid from other patients with MS. These results are consistent with the possibility that the antibody is, indeed, a "nonsense antibody."

An important impetus to continuation of the search for a viral cause for MS has come from study of several naturally occurring model diseases in animals in which viruses cause demyehnation. 47 These diseases include canine distemper virus (paramyxovirus) in dogs, 48 visna virus (nononcogenic retrovirus) in sheep, 49 JHM virus (coronavirus) in mice 50 and rats, 51 Semliki Forest virus (togavirus) in mice, 52 and Theiler's virus (picornavirus) in mice. 53 The mechanisms of the demyehnation in these viral models are beginning to be understood. For example, in JHM virus infection in mice the demyehnation seems to be the result of direct cytopathic injury of oligodendrocytes, the myelin-producing cells. 50 In contrast, in rats the demyehnation by JHM may be a consequence of autoimmune mechanisms by which sensitized T cells recognize myelin antigens. 51 In visna virus, macrophages that are persistently infected are actively in volved in the demyelinating process. 53 With infection by Theiler's virus, viral antigens have been detected on the inner and outer glial loops of oligodendrocytes such that an immune response seems to be directed against viral or "novel" antigens on the surface of these glial cells. 5456 These experiments emphasize that viruses from different "families" may induce primary demyelination, probably by unique mecha nisms. 44 The recent discovery, in Japan 67 and in the Carib bean, 58 that chronic progressive myelopathy may be the result of persistent infection with human T-lymphotropic virus type I (HTLV-I) has stimulated specu lation that viruses may be implicated in MS. Koprowski and associates 59 reported that serum and spinal fluid samples from patients with MS in Sweden and in Key West, Florida, contained antibodies reactive with viral protein (p24) of HTLV-I. Others have failed to detect any antibody to HTLV-I, II, or III in pa tients with MS. 6061 In Japan, however, investigators 62 found that 11 of 46 patients with MS reacted to purified HTLV-I proteins by Western blot analysis. The discrepancies in the results may be due to differ ences in sensitivity of various methods. Recently, Reddy and associates 63 amplified and molecularly cloned HTLV-I sequences from DNA of lymphocytes from patients with MS. Confirmation of these results by other investigators will be necessary before a firm statement can be made about its role in pathogenesis.

Several hypotheses have been proposed to explain the clinical and experimental features of this demyelinating disorder, three of which will be discussed. They are relevant to the possibility of an immunemediated demyelination triggered by viral infection.

Autoimmunity.-The most widely considered hypothesis is that MS is the result of an immune reaction directed against self myelin antigens. 64 T cells are thought to enter the central nervous system through endothelial cells and to react with normal white matter. The myelin antigens may be presented to helper T cells (CD4 + ) by endothelial cells 65 or astrocytes, 66 which are known to carry class II MHC antigens in MS lesions. As a result of T-cell activa tion, lymphokines and macrophages could mediate myelin destruction. 3 This hypothesis is supported by elegant experi ments, using EAE, that demonstrated that T-cell clones (CD4 + ) sensitized to myelin proteins can medi ate demyelination in the central nervous system. 1819 In addition, the linkage of the disease with class II MHC gene products (DR2) is further evidence that this mechanism may be important. A series of crucial experiments by Hafler and associates 20 on T-cell clones isolated from the cerebrospinal fluid of patients with MS, however, failed to identify a single clone that was reactive for myelin antigens despite the ongoing demyelination. In contrast, myelin-reactive clones were demonstrated in patients with postinfectious encephalomyelitis.

"Bystander" Hypothesis.-One important hy pothesis being considered is that in MS the myelin is an "innocent bystander" that is destroyed as a conse quence of an immune response occurring within the nervous system. 47 This hypothesis may help explain why different viruses can induce demyelination in the nervous system of rodents and why different "etiologic" agents have been isolated from MS-involved brains. The scenario would be that viruses or other infectious agents frequently invade the central ner vous system. During the defense against this infec tion, T lymphocytes and macrophages are recruited to the lesion. Subsequently, in the process of clearance of virus by T cells, myelin is destroyed nonspecifically by lymphokines or neutral proteases released by acti vated macrophages.

Experiments by Wisniewski and Bloom 67 support this hypothesis by demonstrating that animals previ ously sensitized to purified protein derivative (PPD) of tuberculin will undergo demyelination if challenged by this antigen in the nervous system. In addition, myelin basic protein can be degraded by neutral proteases in vitro. 68 The concept of bystander demye lination, however, is not supported by the observation that demyelination is a rare consequence of an im mune response to viral or fungal encephalitides. If bystander demyelination were more prominent, then demyelination would occur each time the immune system interacts with viruses that infect the central nervous system (that is, measles, mumps, and her pes). It may be argued, however, that genetic factors control whether specific lymphokines that could in duce demyelination are released.

Immune Destruction of Persistently Infected Oligodendrocytes.-On the basis of the paradigm of demyelination in mice induced by Theiler's virus, Rodriguez and colleagues 56 proposed that the demye lination in MS may be the result of immune-mediated destruction of virus-infected oligodendrocytes. This hypothesis would incorporate epidemiologic data (exogenous agent) and a contribution of immunogenetics to pathogenesis. Immunogenetic data in MS implicate that specific genes within the MHC protect against the development of MS. Genes may play a role in host resistance against the exogenous agent that is acquired early in life.

In resistant hosts, viral antigens would be recog nized in the context of class I or class II MHC gene products, and viral replication would be limited as a consequence of a protective immune response. Virus would be cleared from the central nervous system without long-term sequelae.

In susceptible hosts, absence of specific MHC gene products may result in failure of clearance of the virus; thus, the virus persists in glial cells. During the course of infection, the virus could infect oligodendrocytes in a manner such that novel antigens are present on the surface of these cells (Fig. 1) . These novel antigens may be virus antigens or "up-regu lated" normal host antigens that are seen as foreign in the context of specific MHC alleles. The virus itself may be capable of inducing demyelination by interfer ing with the function of the myelin-producing cell. The current evidence suggests, however, that im mune cells must also play a role in demyelination because immunosuppression seems to have a favor able effect on the course of MS. The presence of a novel antigen on an oligodendrocyte or on myelin could result in immunoglobulin-directed killing (in jury by complement, antibody-dependent cell-medi ated cytotoxicity, or activation of macrophages).

The final result would be injury to the myelinproducing cell or to the myelin sheath. This result may occur as a dying-back gliopathy, 6970 the altera tion being noted first in the most distal extension of the oligodendrocytes (that is, the glial loops and myelin sheaths) and interfering with the differential function of the oligodendrocyte (that is, the mainte nance of myelin).

The evidence suggests that an exogenous agent (that is, a virus) may be important in triggering demyelin ation in MS. If multiple exogenous agents are able to induce this pathologic process, however, then identi fying the offending agent may prove to be difficult. If common pathogens can produce demyelination, then distinguishing these etiologic agents from the viruses that "normally" reside in the central nervous system may be impossible. Alternatively, attempts to inter fere specifically with various arms of the immune response by use of monoclonal antibody therapy may be beneficial without the requirement of knowing the causative agent. The scheme proposed in Figure 1 may provide the basis for designing specific immunotherapy to interfere with demyelination. Fig. 1 . Hypothesis by which immune cells injure persistently infected oligodendrocytes and produce primary demyelination. During the course of viral infections of the central nervous system, specific viruses in "susceptible" patients may not be cleared by the immune system. Viruses may then persist in oligodendrocytes (myelin-producing cells) and injure these cells either by direct effects or by becoming targets of immune-mediated destruction. Oligodendrocytes infected by virus may express viral antigen (V), processed viral antigen (P), or novel antigens (AD on their surfaces. Immunoglobulins secreted by B cells may be directed at viral or novel antigens and thus result in injury to oligodendrocytes by complement, antibody-dependent cell-mediated cytotoxicity, or receptor-mediated phagocytosis by macrophages. Processed viral antigens (peptides) may be expressed on surface of oligodendro cytes and be presented to CD4* cells in context of class II major histocompatibility complex (MHC) antigens (la antigens). These CD4* cells (class II-restricted cytotoxic T cells or "helper" T cells) could directly injure oligodendrocytes or help B cells. Novel virusinduced antigens may be expressed on surface of oligodendrocytes and be seen in context of class I MHC antigens by CD8* cells (cytotoxic T cells). These CD8* cells may injure oligodendrocytes in an effort to clear viral infection or by interacting with normal host proteins. The final consequence of these mechanisms would be injury to the oligodendrocyte. The initial pathologic process could be in the inner and outer glial loops of myelin-producing cells such that destruction of myelin would occur before visible struc tural damage to the oligodendrocyte ("dying-back gliopathy"). This process would result in primary demyelination. Therapeutic strategies to deplete B cells, CD4 + cells, or CD8* cells and to "downregulate" expression of class I or class II MHC gene products may prove beneficial.

The artwork for Twin study of multiple sclerosis: an epidemiologic inquiry. 

The neuropathology of multiple sclerosis

Macrophages, lymphocytes, and plasma cells in the perivascular compartment in chronic multiple sclerosis

Multiple sclerosis: capping of surface immunoglobulin G on macrophages engaged in myelin breakdown

The use and abuse of the cerebrospinal fluid IgG profile in the adult: a practical evaluation

Occurrence of oligoclonal bands in multiple sclerosis and other CNS diseases

Viral and bacterial antibody responses in multiple sclerosis

Measles antibodies in multiple sclerosis

Oligoclonal IgG antibody response in the central nervous system to different measles virus anti gens in subacute sclerosing panencephalitis

Viral antibodies in oli goclonal and polyclonal IgG synthesized within the central nervous system over the course of mumps meningitis

Isoelectric focusing of IgG eluted from multiple sclerosis and subacute sclerosing panencephalitis brains

Analysis of a predominant immunoglobulin population in the cerebrospinal fluid of a multiple sclerosis patient by means of an anti-idiotypic hybridoma antibody

Longitudinal analysis of three intrathecally produced immunoglobulin subpopulations in an MS patient

Experimental models of virus-induced demyelination of the central nervous system

Experimental canine distemper virus-induced demyelination

Pathogenesis of lentivirus infections

Mechanism of demye lination in JHM virus encephalomyelitis: electron micro scopic studies

Adoptive transfer of EAE-like lesions from rats with coronavirus-induced de my elinating encephalomyelitis

Virusassociated demyelination: a model using avirulent Semliki Forest virus infection of mice

Theiler's virus infection in mice: an unusual biphasic disease process leading to demyelination

Theiler's murine encephalomyelitis: a model of demyelination and persis tence of virus

Persistent infec tion of oligodendrocytes in Theiler's virus-induced encepha lomyelitis

Immune-mediated injury of virus-infected oligodendrocytes: a model of mul tiple sclerosis

Chronic progressive myelopathy associated with elevated antibodies to human T-lymphotropic virus type I and adult T-cell leukemialike cells

Endemic tropical spastic paraparesis associated with human T-lymphotropic virus type I: a clinical and seroepidemiological study of 25 cases

Multiple sclerosis and human T-cell lymphotropic retroviruses

Lack of evidence for involvement of known human retroviruses in multiple sclerosis (letter to the editor)

Analysis of human T-lymphotropic virus sequences in multiple sclerosis tissue (letter to the editor)

Sera from patients with multiple sclerosis react with human T cell lymphotropic virus-I gag proteins but not env proteins-Western blotting analysis

Amplification and molecular cloning of HTLV-I sequences from DNA of multiple sclerosis patients

Relevance of experimental allergic en cephalomyelitis to multiple sclerosis

Presen tation of myelin basic protein by murine cerebral vascular endothelial cells

Immunoregulatory molecules and IL 2 receptors identified in multiple sclerosis brain

Primary demyelination as a nonspecific consequence of a cell-mediated immune reac tion

Degradation of basic protein in myelin by neutral proteases secreted by stimulated macrophages: a possible mechanism of inflam matory demyelination

Evidence for a "dying-back" gliopathy in demyelinating disease

Virus-induced demyelination in mice: "dying back" of oligodendrocytes