Journal of the Peripheral Nervous System 10:94–112 (2005) RICHARD P. BUNGE MEMORIAL LECTURE AND REVIEW The immunobiology of Guillain-Barre¤ syndromes Hugh J. Willison Division of Clinical Neurosciences, Southern General Hospital, Glasgow, Scotland, UK Abstract This presentation highlights aspects of the immunobiology of the GuillainBarré syndromes (GBS), the world’s leading cause of acute autoimmune neuromuscular paralysis. Understanding the key pathophysiological pathways of GBS and developing rational, specific immunotherapies are essential steps towards improving the clinical outcome of this devastating disorder. Much of the research into GBS over the last decade has focused on the forms mediated by anti-ganglioside antibodies, and we have made substantial progress in our understanding in several related areas. Particular highlights include (a) the emerging correlations between anti-ganglioside antibodies and specific clinical phenotypes, notably between anti-GM1/anti-GD1a antibodies and the acute motor axonal variant and anti-GQ1b/anti-GT1a antibodies and the Miller Fisher syndrome; (b) the identification of molecular mimicry between GBS-associated Campylobacter jejuni oligosaccharides and GM1, GD1a, and GT1a gangliosides as a mechanism for anti-ganglioside antibody induction; (c) the development of rodent models of GBS with sensory ataxic or motor phenotypes induced by immunisation with GD1b or GM1 gangliosides, respectively. Our work has particularly studied the motor nerve terminal as a model site of injury, and through combined active and passive immunisation paradigms, we have developed murine neuropathy phenotypes mediated by anti-ganglioside antibodies. This has been achieved through use of glycosyltransferase and complement regulator knock-out mice, both for cloning anti-ganglioside antibodies and inducing disease. Through such studies, we have proven a neuropathogenic role for murine anti-ganglioside antibodies and human GBSassociated antisera and identified several determinants that influence disease expression including (a) the level of immunological tolerance to microbial glycans that mimic selfgangliosides; (b) the ganglioside density in target tissue; (c) the level of complement activation and the neuroprotective effects of endogenous complement regulators; and (d) the role of calcium influx through complement pores in mediating axonal injury. Such studies provide us with clear information on an antibody-mediated pathogenesis model for GBS and should lead to rational therapeutic testing of agents that are potentially suitable for use in humans. Key words: autoantibodies, Campylobacter jejuni, complement regulator, gangliosides, glycosyltransferase, Guillain-Barré syndrome, membrane attack complex, neuromuscular synapse, neuropathy, tolerance Introduction Autoimmune neuropathies are a diverse group of paralytic syndromes characterised by inflammation in the peripheral nervous system (PNS), in turn initiated by a range of quite distinct immunopathological events. Understanding the immunological mechanisms Address correspondence to: Prof. Hugh J. Willison, Division of Clinical Neurosciences, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, Scotland, UK. Tel: þ44-141-2012464; Fax: þ44-141-201-2993; E-mail: [email protected] 2005 Peripheral Nerve Society 94 Blackwell Publishing Willison Journal of the Peripheral Nervous System 10:94–112 (2005) underlying any pathological responses is clearly crucial to selecting the correct strategies for novel therapeutic interventions, and this is particularly germane to the GuillainBarré syndromes (GBS) where the relative involvement of T- and B-cell responses is continually debated. In recent years, great progress has been made in our understanding of this group of disorders. Out of many avenues explored, one of the most promising has been the discovery and analysis of antibody responses to peripheral nerve gangliosides and their microbial mimics, the relationships these have to different clinical phenotypes of GBS, and our increasing insights into their mechanisms of action. Despite this rapidly advancing progress, considerable gaps in our knowledge persist. The focus of this lecture is on gangliosides and their corresponding autoantibodies in GBS. I will first provide a brief background to the field, summarise some of the highlights, identify and analyse areas of remaining weakness, and then present some data to support novel therapeutic approaches that could capitalise on the latest experimental findings. most other pro-inflammatory insults that lead to neuropathy. The commonest form of GBS arises from segmental demyelination of peripheral nerve (acute inflammatory demyelinating polyneuropathy [AIDP]), executed by macrophage-mediated stripping of the myelin sheath (Hafer-Macko et al., 1996b). At least a proportion of this injury appears to be mediated by antibody and complement deposition on Schwann cell and myelin membranes, although the putative antigenic target(s) in AIDP remain elusive, as discussed below. Clinically, this demyelinating process is widespread, affecting most myelinated limb, axial and lower cranial motor and sensory nerves, but curiously sparing myelinating axons innervating extraocular muscles that are so sensitively affected in Miller Fisher syndrome (MFS). Resting intraneural Schwann cells proliferate and migrate into the lesion sites to remyelinate denuded axons, producing a good recovery in most cases. In AIDP, demyelinating pathology may be extensive throughout the length of the nerve, especially in proximal nerve roots and the distal intramuscular nerve segments where the blood– nerve barrier (BNB) is weak (Olsson, 1968). In agreement, clinical electrophysiological studies indicate that sites throughout the nerve can be affected but often point towards proximal (absent or delayed F-wave latencies) or distal (prolonged distal motor latencies) as dominant sites of nerve impairment. It would seem intuitively likely that the rate of recovery from AIDP should be independent of the site of demyelination because there is no evidence that the remyelinating capacity of Schwann cells varies along the length of the nerve. Axons are generally unaffected in AIDP, although may suffer so-called bystander injury, the mechanisms for which remain unclear and deserve further study. In contrast to AIDP, the primary target for immune attack in the GBS variant, acute motor (and sensory) axonal neuropathy (AMAN, AMSAN) is the axolemmal membrane (Feasby et al., 1986; McKhann et al., 1993). Again, this inflammatory process occurs predominantly either in the nerve roots or distal nerve terminals (Hafer-Macko et al., 1996a; Ho et al., 1997a; Kuwabara et al., 2003). Immune attack can lead to reversible axonal conduction block due to reversible axonal injury (at best) or complete axonal transaction (at worst). Wallerian degeneration (Wld) will occur distal to the site if axons are transected; otherwise, myelin is unaffected. Depending on the site of transection (proximal or distal), axonal recovery may be poor or good, owing to the distance over which regeneration is effective (Ho et al., 1997a; 1997b). This is important clinically because extensive radicular involvement in AMAN generally leads to a catastrophic, permanent injury. In contrast, very distal axonal injury would also induce a severe acute axonal syndrome, but one in which rapid reinnervation with functional recovery The Clinical Problem GBS is the prototypic acute inflammatory disorder and the foremost cause of post-infectious neuromuscular paralysis worldwide, with a global incidence of approximately 1.5/105 across all age groups (Hughes and Rees, 1997; Hahn, 1998). The lifetime likelihood of any one individual acquiring the disease is thus approximately 1 : 1000. Onset is rapid, and approximately 20% of cases lead to total paralysis, requiring prolonged intensive therapy with mechanical ventilation. The therapeutic window for GBS is short, and the current optimal treatment with whole plasma exchange or intravenous immunoglobulin (Ig) therapy lacks immunological specificity and only halves the severity of the disease (Visser et al., 1999; 2004; Raphael et al., 2001; Hughes et al., 2004a; 2004b). The patients left severely disabled (approximately 12% survivors unable to walk after 1 year) or dead (UK mortality of 5–10%) represent a major social and economic burden (Buzby et al., 1997). Thus, there is an incentive to understand GBS pathogenesis as a prerequisite to developing and instituting effective, contemporary immunotherapies. Clinical and Pathological Patterns of GBS Despite the all-embracing eponym, GBS’s clinical pathophysiology is long recognised as being highly complex (Hartung et al., 1995a; 1995b). GBS is an acute phase illness occurring 10–14 days after trivial infections, comes and goes rapidly (within 4 weeks), and leaves variable residual injury. The acute, monophasic nature of GBS provides crucial clues to the immunopathological background and quite clearly distinguishes GBS from 95 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) mitigate against the major structural proteins of myelin being dominant AIDP antigens. A chronic ataxic neuropathy has also been reported that may be associated with relapsing ophthalmoplegia in some cases; such patients often have anti-ganglioside antibodies, including anti-GQ1b, which are persistently present, usually occurring as IgM paraproteins (Willison et al., 2001). could readily occur (Ho et al., 1997a; Kuwabara et al., 2003). Formes Frustes of GBS Also Exist as Regional Variants The regional variants of GBS only paralyse specific areas of the body, such as the eyes or face, or the afferent sensory and autonomic systems (Ropper, 1994). The most widely studied of these variants is the MFS (Fisher, 1956; Willison and O’Hanlon, 1999). Our understanding of MFS was revolutionised following Chiba and Kusunoki’s discovery of the anti-GQ1b antibody marker (Chiba et al., 1992; 1993). Since the syndrome was first described in 1956 as the discrete clinical triad of ophthalmoplegia, ataxia, and areflexia, anti-GQ1b antibody testing has allowed MFS to evolve nosologically and now encompasses closely related formes frustes, mainly characterised by acute cranial motor neuropathies with ataxia – the anti-GQ1b antibody syndromes (Odaka et al., 2001; Paparounas, 2004). In the Bickerstaff’s encephalitis, MFS-like features occur in conjunction with brain stem involvement, comprising pyramidal tract signs and impaired consciousness, and two thirds of cases are anti-GQ1b antibody positive (Bickerstaff and Cloake, 1951; Odaka et al., 2003). The close relationship between GBS and MFS is considered because it should direct our search towards common underlying immunopathological mechanisms. Thus, some MFS cases merge into confluent GBS with respiratory and limb involvement, and similarly, some GBS cases also evolve to develop an MFS pattern of clinical involvement – in these overlapping cases, antiGQ1b antibodies are generally detected. MFS variants include solitary ophthalmoplegia or ataxia and oropharyngeal weakness without ophthalmoplegia (O’Leary et al., 1996). Viewed in its broadest contemporary sense, MFS could be considered as a PNS/CNS overlap syndrome with extremely variable degrees of involvement of particular central or peripheral anatomical sites in individual cases, with all permutations being highly associated with anti-GQ1b and anti-GT1a antibodies (O’Leary et al., 1996; Odaka et al., 2001). The selective affliction of cranial and in particular extraocular nerves in the anti-GQ1b antibody syndromes is believed to be due to the enrichment of the target antigen(s) in affected sites (Chiba et al., 1997). However, there are clearly additional levels of complexity influencing the clinical phenotype that remain undiscovered. What is notable by its absence is involvement of extraocular motor nerves in AIDP, arguing that the AIDP antigen(s) may analogously be relatively enriched in limb and axial myelin (in comparison with extraocular motor nerve myelin) as opposed to being a generic myelin antigen(s). This might Anti-Nerve Antibodies in GBS: Lessons From Rodent Models Great progress has been made in correlating clinical phenotypes with serological profiling of anti-nerve antibodies, covering a wide spectrum of peripheral nerve antigens. The myelin protein-specific T and B cell-mediated rodent model of GBS (experimental allergic neuritis [EAN]) was described 50 years ago and has yielded many important experimental insights into peripheral nerve inflammation (Spies et al., 1995; Rostami, 1997; Gabriel et al., 1998; Taylor and Pollard, 2003). However, translational studies identifying equivalent immune responses in human neuropathy cases have been more modest (Gabriel et al., 2000; Ritz et al., 2000; Yan et al., 2000; Favereaux et al., 2003; Latov and Renaud, 2004). Whether further research will overcome this remains to be seen. In contrast, the progress in identifying myelin and axonal glycolipids as antigens has been somewhat more forthcoming. Interestly that ganglioside-/glycolipidinduced rabbit EAN was also first described several decades ago (Nagai et al., 1976; Saida et al., 1979), but in contrast to myelin protein-induced EAN, was then virtually neglected for approximately 20 years, and has now been revived with compelling data that reinforce many recent clinical findings. Thus, a series of recent rabbit immunisation studies have led to the generation of models of anti-GD1b antibody-associated ataxic neuropathy and anti-GM1 antibody-associated motor axonal neuropathy that mimic many of the clinical and pathological features of the human syndromes (Kusunoki et al., 1996; Yuki et al., 2001; 2004). These studies have provided some of the most compelling evidence that anti-ganglioside antibodies and their effector pathways can induce clinically relevant phenotypes. In this respect, ganglioside-induced EAN has come full circle. The return of researchers, principally in Japan, to these early rabbit studies was driven in large part by the clinical identification of antiganglioside antibodies in GBS cases, starting in 1988 (Ilyas et al., 1988) and escalating in scope ever since. A wealth of clinical serological associations have now been described and the topic reviewed regularly (Yuki, 2001; Willison and Yuki, 2002). In summary, in human disease, anti-GM1, anti-GD1a, anti-GM1b, and anti-GalNAcGD1a antibodies are highly associated with AMAN (Ogawara et al., 2000) and anti-GQ1b, anti-GT1a, anti-GD3, and 96 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) sulfatides that also have microbial glycan mimics (Yuki, 2001; Willison and Yuki, 2002). anti-GD1b with MFS and chronic ataxic neuropathy (Chiba et al., 1993; Willison et al., 2001). Anti-GM1 IgG/ IgM antibodies are also associated with AIDP and chronic demyelinating clinical phenotypes, the latter with or without concomitant axonopathy, as seen in multifocal motor neuropathy (Pestronk and Choksi, 1997). However, considerable debate still remains as to the relative extent of demyelinating and axonal pathology that can be associated with anti-GM1 antibody syndromes. An exciting new finding has suggested that gangliosides assembled in complexes (in this case GM1 and GD1a) (Kaida et al., 2004) might provide higher avidity targets for GBS-associated autoantibodies than single ganglioside species. Although it has long been known that accessory lipids play an important role in enhancing or attenuating ganglioside–antibody interactions, this provocative finding greatly raises the complexity of examining sera for the new autoantibody specificities, including the elusive AIDP antigen(s). Immunological Tolerance Exists to Self-Ganglioside Structures One of the curiosities of GBS is that such a small proportion of infections or vaccinations triggers the illness. Thus, 99% of humans infected with ganglioside-mimicking strains of C. jejuni neither develop antiLOS/ganglioside antibodies nor GBS (Nachamkin, 2001). The immunological factors that regulate this unresponsiveness to challenge with microbial mimics of self-glycan structures are poorly understood, but it seems likely that B-cell tolerance is an important component. Anti-LOS/ganglioside antibodies exist within the natural antibody repertoire, acting as innate defence against bacteria. Being carbohydrates, gangliosides elicit T cell-independent (TI) humoral responses (Martin et al., 2001; Zubler, 2001) and cannot be presented by major histocompatibility complex molecules (Ishioka et al., 1993) (except via CD1 presentation [Brigl and Brenner, 2004; Watts, 2004] ). Anti-ganglioside antibodies exist as low-affinity IgM isotypes in normal subjects (Willison et al., 1993; Mizutamari et al., 1994; Casali and Schettino, 1996). To prevent autoimmune reactions, their level and affinity are controlled by tolerance (Cornall et al., 1995; Fagarasan and Honjo, 2000). In GBS, the appearance of high titre anti-ganglioside antibodies is a clear failure of tolerance. B-cell tolerance to TI ganglioside antigens is poorly understood and remains a major research goal in the GBS field. Aspects are analogous to organ transplantation paradigms involving Gal(a1–3)Gal antigens as studied in a1–3galactosyltransferase knockout (KO) mice (Kawahara et al., 2003; Galili, 2004) and in the ABO blood group system (Fan et al., 2004; Fehr and Sykes, 2004). We and others anticipated that the expression of gangliosides in tissues outside the nervous system that can be sensed by newly developing and pre-existing B cells (bone marrow and spleen, respectively) would be an important regulator of tolerance, as suggested for anti-Gal(a1–3)Gal (Yang et al., 1998). Thus, we showed that mice lacking complex gangliosides in any tissue (i.e., the GalNAcT KO mice that only express GM3 and GD3, see Fig. 1) develop exaggerated humoral responses to gangliosides compared with wild-type (WT) controls when challenged with C. jejuni LOS (Bowes et al., 2002) or gangliosides (Lunn et al., 2000). An example of the differential antibody responses to GD1a ganglioside and GD1a-bearing C. jejuni LOS in GalNAcT WT and KO mice that clearly illustrates this principle is shown in Figure 2. Gangliosides and Structural Mimics on Microbial Glycans One highly fruitful area has been the discovery of a range of ganglioside and glycolipid mimics on microbial glycans (Yuki et al., 1993; Yuki, 2001). There are approximately 50 structurally distinct gangliosides synthesised through step-wise addition of monosaccharides by Golgi glycosyltransferases in complex developmental, spatial, and cell-specific patterns (Kolter et al., 2002). Gangliosides are enriched in neural tissues and primarily localised to raft domains of the extracellular leaflet of plasma membranes, especially at synapses, where they are available for antiganglioside antibody binding (Ledeen, 1978; Ledeen and Yu, 1982; Ledeen et al., 1998; Ogawa-Goto and Abe, 1998). A simplified scheme of the major ganglioside structures is shown in Figure 1. The carbohydrate moieties of gangliosides are structural mimics of microbial glycans, including the lipo-oligosaccharides (LOS) of Campylobacter jejuni (Aspinall et al., 1994; Yuki et al., 1997; Sheikh et al., 1998; Prendergast and Moran, 2000; Moran et al., 2002) and Haemophilus influenzae (Mori et al., 1999; Ju et al., 2004). Evidence from human and animal studies indicates a key role for this molecular mimicry in GBS pathogenesis (Goodyear et al., 1999; Bowes et al., 2002; Yuki et al., 2004). In this model, well documented for GM1, GD1a, and GQ1b, the acute phase anti-LOS/ganglioside complementfixing IgG antibodies that arise eradicate infections but also bind to peripheral nerve gangliosides where they induce autoimmune injury. Potential pathogenic role(s) exist for other known and unknown glycolipids enriched in Schwann cell, myelin, and axonal membranes, such as galactocerebroside, LM1, and 97 Willison A Ugcg–/– GlcCer Journal of the Peripheral Nervous System 10:94–112 (2005) Cer A simplified scheme of the ganglioside biosynthetic pathway Cer LacCer Cer Cer GA2 Cer GA1 Cer GM1b Cer GD1c 0 series GM3 Cer Cer GM2 Cer GM1a Cer GD1a Cer GT1a a series Cer Cer GD2 Cer GD1b Cer GT1b Cer GQ1b b series GD3s–/– GD3 GalNAcT–/– Candidate oligosaccharide fragments for inhibition/immunoadsorption studies B GD1a GM1 GQ1b Examples of Campylobacter jejuni LOS stuctures C HS:19(GM1+, GD1a+) and HS:4 Key Lipid A Galactose Lipid A GalNAc HS:19(GM1+, GT1a+) HS:10 Lipid A Lipid A Glucose NeuNAc Lipid A Cer Ceramide Figure 1. A schematic representation of the key structures and enzymes in ganglioside biosynthesis, relevant glycan fragments, and core structures identified in Campylobacter jejuni lipo-oligosaccharides. Note that GalNAc transferase (GalNAcT) and GD3 synthase (GD3s) deficiency result in the loss of all complex and b-series gangliosides, respectively. Isolating and Characterising Murine Monoclonal Anti-Ganglioside Antibodies immunisation protocols using ganglioside–protein conjugates and LOS/ganglioside liposome-encapsulated proteins to provide the necessary T cell-dependent (TD) environment required to produce the magnitude of immune responses seen in Figure 2. Using these methods, we and others have generated long-lived IgG memory responses to gangliosides and to LOS in glycosyltransferase KO mice. Using such an approach, we have cloned approximately 50 IgG/IgM monoclonal antibodies specific for discrete ganglioside epitopes for use in a wide range of pathogenesis and therapeutic studies (Boffey et al., 2004; Willison et al., 2004). An offshoot of these experiments aimed at bypassing tolerance to microbial glycans has been the creation of high-affinity IgG responses to gangliosides that are suitable for cloning top quality anti-ganglioside antibodies – a long-awaited goal for these poorly immunogenic structures. In addition to overcoming any tolerogenic factors, to circumvent any TI restriction on affinity maturation and class switching (including that which might occur in glycosyltransferase KO mice), we have developed hapten-carrier 98 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) resonance) indicate that affinity maturation for most AG monoclonal antibodies is modest, even amongst class-switched monoclonal antibodies isolated from glycosyltransferase KO mice (Townson, unpublished data). Collectively, these murine data indicate that diverse antibody specificities encoded by restricted sets of VH/VL genes reside within the natural antibody repertoire and can be expanded by bacterial LOS once released from tolerance. This is not necessarily associated with affinity maturation; nevertheless, such antibodies can readily injure the PNS, as described below. The observations we have made with murine antibodies has shifted our predictions about the likely shape of the human anti-ganglioside antibody repertoire in GBS, which is not well understood because few have been cloned to date apart from long-lived IgM antibodies (Paterson et al., 1995). It is known that the antibody response in GBS has class-switched from IgM to the TD complement-fixing IgG1 and IgG3 isotypes (Willison and Veitch, 1994). This would usually co-occur with affinity maturation of a range of clones within the B-cell repertoire. However, we now suspect that the repertoire may be considerably more clonally restricted and unmutated in GBS than previously thought and are currently investigating this area. In support of the relatively low affinity for GBS-associated antibodies are our findings that (a) human IgG anti-GQ1b antibodies can be readily displaced from antigen by polyclonal human IgG (IVIg therapy) (Jacobs et al., 2003) and (b) they slowly elute off immuno-affinity columns in the presence of physiological strength buffers (Willison et al., 2004). This has important implications for several therapeutic strategies aimed at inhibition of antibody–glycan interactions or selective ablation of ganglioside-specific B-cell pools, as outlined in Figure 3. GalNAcT+/+ 1.2 1.4 HS:4 GD1a GD1a GM1 Blank Optical density 0.6 0.7 0 0 Pre 1st 2nd 3rd Pre 1st 2nd 3rd GalNAcT–/– 1.2 1.4 HS:4 GD1a * 0.6 0.7 0 Pre 1st 2nd 3rd 0 Pre 1st 2nd 3rd Immunisation number Figure 2. Anti-ganglioside IgG antibody responses in GalNAc transferase (GalNAcT)þ/þ and GalNAcT–/– mice following intraperitoneal immunisation with HS:4 lipo-oligosaccharides (bearing a GD1a epitope, left-hand panels) or GD1a/ ovalbumin liposomes (right-hand panels). Mice were immunised at 2-weekly intervals and bled 4 days after each immunisation. Elevated anti-GD1a antibody titres are evident in GalNAcT–/– mice (deficient in GD1a) by the second or third immunisation, compared with non-responding GalNAcTþ/þ mice (*p < 0.005). Modified from Bowes et al. (2002). These antibodies have been powerful tools in enhancing our understanding of pathogenic pathways that model the human disorders. One area of particular interest is in understanding structure–specificity relationships amongst antibodies and their binding partner glycans. Thus, Ig variable (V) region sequencing, affinity, and glycan-binding studies on the above IgG/IgM mouse monoclonal antibodies have allowed us to investigate whether (a) specificity is dictated by particular V-gene usage and (b) class switching from IgM to IgG is associated with affinity maturation. Interestly that the minor alteration in specificity from terminal disialosyl residues (on GQ1b, GT1a, and GD3) to internal disialosyl residues (on GD1b and GT1b) is mutually exclusively associated with a change from murine VH7183.3b to VH10.2b gene segment usage (Boffey et al., 2004; Boffey, unpublished data). V-gene mutation rates and affinity measurements (using Biacore surface plasmon The Sites and Mechanisms by Which AntiGanglioside Antibodies Paralyse the PNS Anti-ganglioside antibodies could potentially bind any ganglioside-containing membranes, provided that they can gain access and binding is not subject to steric inhibition locally in the membrane. One site for antibody action we discovered and have worked on extensively is the ganglioside-rich, pre-synaptic component of the neuromuscular junction (NMJ), lying outside the BNB where its membranes are readily accessible to circulating antibodies. Other important proximal axonal and glial sites of injury exist, especially exposed axolemma at nodes of Ranvier and paranodal myelin, as has been well demonstrated in a wide range of human studies described above and in animal studies (Kusunoki et al., 1996; Yuki et al., 2001; Sheikh et al., 2004). One reason why our studies initially focused on the NMJ was because of the longheld appreciation of 99 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) A Mechanistic Pathway for NerveTerminal Axonal Injury Culminating in Synaptic Necrosis Immunoadsorption columns We first demonstrated using in vitro mouse hemidiaphragm preparations that anti-GQ1b antibodies associated with MFS bind the motor nerve terminal where they locally activate complement (Roberts et al., 1994; Plomp et al., 1999; Halstead et al., 2004). A schematic diagram of the pathological processes occurring in this model that summarises an extensive series of experiments is shown in Figure 4. Following antibody binding with local complement fixation, an uncontrolled influx of calcium into the nerve terminal through membrane attack complex (MAC) complement pores then provokes spontaneous exocytosis, accompanied by calpainmediated structural degradation of the terminal axonal cytoskeleton and calcium-mediated mitochondrial injury, with resultant paralysis (O’Hanlon et al., 2001; 2003). MAC formation is essential because C6-deficient conditions abolish the effect (Halstead et al., 2004). Features of this lesion are similar to those induced by the poreforming toxin, a-latrotoxin (O’Hanlon et al., 2002). We have used the term ‘synaptic necrosis’ to describe these events in distinction from other forms of synapse elimination including synaptosis (Gillingwater and Ribchester, 2003). To illustrate this process, Figure 5 shows synaptic necrosis occurring at nerve terminals in Thy1-CFP/YFP transgenic mice that express fluorescent protein in the cytosolic compartment of the whole motor axon including the nerve terminal (collaboration, R. Ribchester) and Figure 6 shows the electrophysiological events occurring concomitantly with this structural disintegration (collaboration, J. Plomp). There is evidence that anti-GM1, anti-GD1a, and anti-GalNAcGD1a antibodies may also act in part at the NMJ (Roberts et al., 1995; Taguchi et al., 2004a; Goodfellow et al., 2005), as described below and seen in Figures 6 and 7. The extent to which anti-ganglioside antibodymediated nerve terminal degeneration extends proximally up the axon remains uncertain and may be influenced by the ganglioside specificity of the antiganglioside antibodies and the integrity of the BNB and local regulators of complement activation. The pathophysiological pathways underlying synaptic and axonal degeneration may be distinct, as suggested by studies in the slow Wld (Wlds) mutant mouse (Mack et al., 2001; Gillingwater and Ribchester, 2003). When applying anti-GQ1b antibodies to this MFS model, the nerve terminal of Wlds mice is not protected from MAC-mediated injury, undergoing degeneration to the same extent as seen in WT mice (Willison et al., unpublished data), however, any influence of Wlds in protecting the more proximal axon from injury is unknown. GM1 GM1-sepharose column From patient To patient Axon GD1a Soluble oligosaccharide fragments as inhibitors C1 GQ1b C2 C4 Complement components and regulators C3 DAF C3 convertase Crry Axon/synapse necrosis C5 convertase CR1 C5 C5b C6,7,8,9 MAC Ca2+ – CD59 MAC Figure 3. A schematic diagram of potential therapeutic targets and strategies based on inhibition or removal of antiganglioside antibodies, inhibition of steps in complement activation, or enhancement of complement regulation. the clinical resemblance between MFS and botulism (Marvaud et al., 2002). Botulinum toxins bind the nerve terminal in part by using gangliosides as ectoacceptors (Montecucco et al., 1988; Kitamura et al., 1999; Bullens et al., 2002), prior to their cytosolic uptake and proteolytic action on proteins of the release machinery (Schiavo et al., 2000). It thus seemed logical that anti-ganglioside antibodies might also act at the NMJ to induce paralysis, albeit through a different mechanism. Emerging clinical electrophysiological evidence suggests that nerve terminal dysfunction occurs in both MFS and GBS (Uncini and Lugaresi, 1999; Wirguin et al., 2002; Kuwabara et al., 2003; Spaans et al., 2003; Lo et al., 2004). However, it is also important to recognise the immunohistological observations of Chiba and colleagues that have clearly demonstrated anti-GQ1b antibodies binding to extra-ocular nerve nodes of Ranvier and it may well be that multiple neural sites for antibody attack exist that may differ both between syndromes and individuals (Chiba et al., 1993). 100 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) C1q Ca2+ Complement classical pathway activation Ab α-Latrotoxin VGCC Ca2+ Lipid Raft VGCC MAC Ca2+ Ca2+ Synaptic vesicle Calcium-mediated mitochondrial dysfunction + NF Calpain-mediated cytoskeleton disintegration Figure 4. A schematic diagram of the events occurring at nerve terminals in experimental nerve-muscle preparations exposed to anti-ganglioside antibodies in the presence of complement. Exocytosis is normally initiated by highly regulated calcium entry through voltage-gated calcium channels that activate the adjacent SNARE complex and initiate synaptic vesicle fusion with the pre-synaptic membrane. When membrane attack complex (MAC) pores are deposited in the pre-synaptic membrane, unregulated calcium entry triggers massive, uncontrolled exocytosis and calcium-/calpain-mediated intra-terminal injury, including cytoskeletal degradation and mitochondrial death. The pore-forming toxin, a-latrotoxin, is believed to act in part through a similar mechanism, allowing unregulated calcium influx with electrophysiological and morphological sequelae similar to those resulting from MAC pores. Anti-Disialylated Ganglioside Antibodies Target the Perisynaptic Schwann Cell to which perisynaptic Schwann cell (pSC) injury might contribute to distal motor axonal degeneration. Similarly to the axonal element of the nerve terminal, the pSC lies outside the BNB where it is fully exposed An interesting neuropathogenic mechanism that has not been explored in human disease is the extent A B Figure 5. Neuromuscular junctions in triangularis sternae muscle preparations from B6.Cg-Tg(Thy1-CFP) green fluorescent mice were exposed in vitro to anti-GQ1b monoclonal antibody and the nuclear marker, ethidium dimer (EthD-1). Images were collected before (A) and 7 min after (B) the addition of human serum as a source of complement. (A) Normally appearing green fluorescence is visible in axon terminals overlying the post-synaptic membrane (stained for bungarotoxin, blue) and EthD-1 is excluded (and therefore not seen in this image) from perisynaptic Schwann cell (pSC) nuclei, as normal. (B) Green fluorescence has disappeared through leakage from the axon terminal undergoing acute synaptic necrosis. Concomitantly, EthD-1, which is normally excluded from the intracellular compartment, has been taken up into pSC nuclei (that now appear red) because of pSC plasma membrane injury. 101 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) A WT Before et al., 1998; Auld and Robitaille, 2003; Love et al., 2003; Reddy et al., 2003; Halstead et al., 2004; Liu et al., 2004). The selective ablation of pSCs at mammalian NMJs has not been previously achieved and their role in human disease not considered. We have recently been able to segregate injury to these two compartments. Interestingly, pSC ablation induced no acute electrophysiological or morphological changes to the underlying nerve terminal, suggesting that at mammalian NMJs, acute pSC injury or ablation has no major deleterious influence on synapse function. However, it is expected that the absence of pSCs may well have a deleterious effect on the longer-term integrity of the underlying synapse, and this area deserves further attention. Information on ganglioside distribution in different membranes and cell types at the human NMJ is sparse, although this is known to be a ganglioside- and glycan-rich area (Martin, 2003). One might expect to see variations in ganglioside distribution that correlate with clinically affected sites (e.g., cranial nerves, polysialylated gangliosides; limb nerves, ‘a series’ gangliosides) (Ogawa-Goto et al., 1992; Chiba et al., 1997; Ogawa-Goto and Abe, 1998; Gong et al., 2002), and this is an area that deserves further study. GD3s–/– 1 mv 100 ms After anti-GD1a mAb Complement addition EPP amplitude (mV) B t=0 t=5 t = 10 40 30 t = 11 20 10 0 5 10 Time (min) 0 15 t = 12 10 mV t = 13 20 ms Figure 6. Microelectrode recordings from GD3s–/– and wildtype (WT) mouse ex vivo hemidiaphragm preparations exposed to anti-GD1a antibodies raised in GalNAcT–/– mice immunised with Campylobacter jejuni lipo-oligosaccharides. (A) Acute exposure of nerve terminals to anti-GD1a antibody causes a massive increase in miniature endplate potential (MEPP) frequency at the GD3s–/– neuromuscular junction (NMJs), with no effect at WT NMJs. The anti-GD1a antibody effect is entirely dependent on the presence of a source of complement. (B) An example of neurotransmission failure at GD3s–/– NMJ induced by anti-GD1a antibody plus complement. The phrenic nerve of a GD3s–/– diaphragm nerve-muscle preparation was stimulated once every 30 s over a 13-min monitoring period, in the presence of m-conotoxin-GIIIB to prevent muscle action potentials. Endplate potentials (EPPs) were recorded at an NMJ where MEPP frequency was very high (>100/s, visible at the baseline of traces). EPPs were normalised to 75 mV and superimposed. The EPP decreased with time after complement addition and became blocked. This did not occur at WT or GalNAcT–/– nerve terminals and did not occur without the anti-GD1a monoclonal antibody (experiments conducted by J. Plomp, modified from Goodfellow et al., 2005). The Role of Complement Regulators and Therapeutic Inhibitors in Attenuating Nerve Injury An important body of evidence has proven that antiganglioside antibodies exert their paralytic effects directly (Buchwald et al., 1998; 2001; Ortiz et al., 2001; Taguchi et al., 2004a; 2004b). Nevertheless, tissuebound antibody of the appropriate class should automatically fix complement that would therefore exacerbate injury over and above any direct actions of antibody (Koski et al., 1987). It is for this reason that many of our recent studies have focused on complement-dependent injury and begun to investigate complement inhibitors and regulators as therapeutic targets, as outlined in Figure 3. Complement activation is regulated by an equally complex inhibitory process, mediated by human and mouse decay-accelerating factor (DAF), CD59, complement receptor 1 (CR1), and mouse CR1-related gene y (Crry) (Morgan and Harris, 2003; Turnberg and Botto, 2003; Mizuno and Morgan, 2004). CD59 inhibits the formation of MAC and DAF accelerates the decay of C3/C5 convertases (Lukacik et al., 2004; Mizuno and Morgan, 2004; Harris et al., 2005). Thus, we recently discovered that CD59-deficient mice are excessively vulnerable to anti-ganglioside antibody-dependent complement-mediated injury (Halstead et al., 2004). An example of this effect is shown in Figure 9. These findings agree with data from experimental myasthenia to the extracellular fluid environment. Using antiganglioside antibodies with different specificities for GQ1b, GT1a, and GD3, and for GM1 and GD1a, we have shown that anti-ganglioside antibodies can (a) destroy the nerve terminal (i.e., synaptic necrosis), (b) kill the pSC that envelops the pre-synaptic region, or (c) destroy both nerve terminal and pSC (Halstead et al., 2004; Halstead et al., 2005). Model schemes of this injury are shown in Figure 7, and an electron micrograph of selective pSC damage induced by an antidisialosyl antibody is shown in Figure 8. pSCs support the underlying motor nerve terminal, both in the steady state and during development and regeneration (Kong 102 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) A B Normal NMJ Injured NT; reactive pSC Perisynaptic Schwann cell Nerve terminal Muscle surface C Key D Injured NT and pSC Injured pSC; normal NT Vesicles Antibody MAC pores Mitochondria Neurofilaments Figure 7. (A) Schematic representation of the normal neuromuscular junction (NMJ) and (B–D) different patterns of NMJ injury occurring on exposure to complement-fixing anti-ganglioside antibodies. At NMJs in which the nerve terminal (NT) alone is injured (e.g., by anti-GD1a antibodies), the terminal axon disintegrates and the perisynaptic Schwann cell (pSC) becomes reactive, extending processes that interdigitate between the axonal fragments and envelope the remaining terminal with wraps of Schwann cell membranes. If the pSC is concomitantly injured by complement deposits along with the NT (e.g., by anti-disialosyl antibodies), the pSC reactive response does not take place, and the pSC undergoes rapid necrotic disintegration. Antibodies that induce acute pSC death alone appear to spare the nerve terminal in the short term, both morphologically and functionally. immunised mice both ex vivo and in vivo, as shown in Figure 10 (Halstead et al., unpublished data). The therapeutic window for APT070 intervention in passive and active immunisation models of GBS remains unknown, but clearly, it is a possible intervention in human neuropathies in which complement deposits are implicated. gravis (Lin et al., 2002; Kaminski et al., 2004) and experimental allergic encephalomyelitis (Mead et al., 2004). It is very clear that complement activation with MAC formation drives neural membrane injury in anti-GQ1btreated mouse tissue (Halstead et al., 2004). It is also well established that MAC is present in human GBS biopsy material (Lu et al., 2000; Putzu et al., 2000; Wanschitz et al., 2003). It would thus appear likely that blocking MAC formation locally should prevent MACdependent tissue injury, even if anti-ganglioside antibody is deposited in the membrane. One therapy we have used to investigate this is the complement inhibitor, APT070 (collaboration, R. Smith, Inflazyme). APT070 contains the C3/C5 convertase-inhibiting region of CR1 and a membrane-localising peptide that allows it to inhibit complement accumulation (Linton et al., 2000; Smith and Smith, 2001; Pratt et al., 2003). Using APT070, we can completely abrogate MAC formation and acute tissue injury by pre-treatment of anti-ganglioside antibody- The Influence of Ganglioside Density on Nerve Vulnerability to Anti-Ganglioside Antibody Attack One of the most interesting enigmas surrounding GBS is the regional pattern of clinical involvement and the way that this links in with anti-ganglioside antibody specificities. Clearly, this regional involvement can potentially be accounted for at many different levels. The most striking example of this is MFS, in which anti-GQ1b and anti-GT1a antibodies appear to target the oculomotor and bulbar nerves because GQ1b and 103 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) pSC pSC MN MN NT NT Figure 8. Mouse monoclonal anti-disialosyl antibodies segregate into groups according to whether they injure the nerve terminal, the perisynaptic Schwann cell (pSC), or both, following passive exposure of mouse neuromuscular junctions to antibody in the presence of complement. In this low-magnification electron micrograph, an antibody that kills the pSC and spares the axon is shown. A motor axon is wrapped by the last myelinating Schwann cell just proximally to the nerve terminals (NTs) that form synaptic contact with a muscle fibre. The NTs have a normal morphology, with electron-dense mitochondria and tightly packed synaptic vesicles. Two pSCs sitting on either side of the terminal axon appear severely damaged with swollen and electron lucent cytoplasm, damaged organelles, nuclear membrane blebbing, and perinuclear bodies (arrowheads), all indicative of necrotic cell death. Two myonuclei (MN) beneath the post-synaptic membrane projecting into this plane of section are of normal appearance. By immunofluorescence, these pSCs would be laden with anti-disialosyl antibody and complement products. Scale bar ¼ 5 mm (Halstead et al., unpublished data). GalNAcT–/– and anti-GD1a antibody into GD3s–/– mice) that this enhancement of ganglioside levels confers sensitivity to development of disease compared with the relatively insensitive WT mice that express ‘normal’ levels of ganglioside (Bullens et al., 2002; Goodfellow et al., 2005). This is particularly well illustrated in the GD3s–/– mouse exposed to anti-GD1a antibody, as shown pictorially in Figure 11. What is now required is an extensive regional evaluation of the human PNS to map ganglioside density in key sites, including axonal, glial, and nerve terminal membranes, most easily conducted by quantitative immunofluorescence in order to preserve gross anatomical information that is largely lost when using preparative biochemical techniques. GT1a are enriched in those sites. By corollary, because AMAN or AIDP occurring in the absence of anti-GQ1b antibody spares the oculomotor nerves, the relevant antigens should be missing or at a low enough density to escape targeting by antibody. In considering this, the term density is solely intended here to refer to the total amount of membrane ganglioside, independent of any effect of raft compartmentalisation that might concentrate antigen in discrete regions (Herreros et al., 2001; McKerracher, 2002; Guan, 2004). In this area, GalNAcT–/– and GD3s–/– mice have told us a lot about the extent to which ganglioside density in neural membranes influences the degree of antiganglioside antibody-mediated neural injury. Firstly, it is necessary to recall that glycosyltransferase KO mice develop precursor substrate build-up above the enzyme block and direct excess gangliosides down other available routes in the biosynthetic pathway (Sandhoff and Kolter, 2003). Thus, GalNAcT–/– mice contain only GM3 and GD3, but in excess amounts, whereas GD3s–/– mice lack all ‘b series’ gangliosides and overexpress the ‘a series’ products, GM1 and GD1a (Kawai et al., 2001; Okada et al., 2002). We have discovered in two models (passive immunisation of anti-GD3 antibody into Treatment of GBS by Removal or Neutralisation of Anti-Ganglioside Antibodies As stated earlier, GBS is unlikely to ever be preventable; thus, optimising acute therapy is paramount. We have considered a number of therapeutic interventions that would be suitable for use at clinical presentation in what we believe to be antibody-mediated forms 104 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) A MAC CD59+/+, anti-GQ1b antibody BTx Signal (% BTx area) 80 CD59+/+, PBS CD59–/–, anti-GQ1b antibody 60 CD59–/–, PBS 40 20 0 IgM B C NF BTx MAC NF BTx Figure 9. Complement regulator intact (CD59þ/þ) and deficient (CD59–/–) mice were passively immunised for 20 h with anti-GQ1b immunoglobulin (Ig)M monoclonal antibody plus human serum as a heterologous source of complement. Diaphragm neuromuscular junctions (NMJs) were analysed for deposits of anti-GQ1b IgM and membrane attack complex (MAC) and for neurofilament (NF) degradation as an index of neuronal injury. Whereas IgM deposits were equal, MAC deposits were increased nearly twofold in CD59–/– mice compared with CD59þ/þ wild-type mice (p < 0.001). NF signals over the NMJ were greatly reduced in CD59–/– compared with CD59þ/þ mice, in relation to their phosphate-buffered saline (PBS)-treated controls (p < 0.001). (A) Deposits of MAC over bungarotoxin (BTx)-labelled NMJs in CD59–/– mice. (B) Normally appearing synaptic and pre-synaptic NF as a measure of axonal integrity in a CD59–/– mouse exposed to PBS, compared with the CD59–/– mouse passively immunised with anti-GQ1b antibody plus complement, in which the nerve terminal NF signal is lost (C). Scale bar ¼ 20 mm. Modified from Halstead et al. (2004). (Andersen et al., 2004; Willison et al., 2004). Some of these structures are shown in Figure 1. By using such approaches, we have established that all mouse antiGQ1b monoclonal antibodies and >50% human MFS sera bind NeuNAc (a2–8)NeuNAc(a2–3)Gal- (disialylgalactose, DSG), the terminal trisaccharide of GQ1b, GT1a, and GD3. Anti-GM1 monoclonal antibodies either require Gal(b1–3)GalNAc or whole GM1 pentasaccharide (100 nM GM1 for >90% inhibition). By using DSG- or GM1-sepharose immunoabsorption columns, we can readily deplete anti-GQ1b and anti-GM1 antibody from MFS and GBS sera. In a collaborative study with K. Nillson (Glycorex, Lund), who manufactures glycan immunoadsorption columns in human use for ABO-mismatched transplantation (Tyden et al., 2003; Rydberg et al., 2005), and with E. Samain (Grenoble), who is able to synthesise gram quantities of GM1 pentasaccharide from glycosyltransferase-transfected Escherichia coli (Antoine et al., 2003), we are now taking this proposal towards clinical of GBS, as outlined in Figure 3. Treatment could be aimed at antibody neutralisation or removal or at suppression of antibody effector function (e.g., inhibition of complement activation) and key downstream inflammatory pathways (e.g., chemotaxis and cellular extravasation). In consideration of the former, antiganglioside antibodies could be (a) removed from the circulation by immunoadsorption plasmaphoresis, (b) neutralised with soluble oligosaccharides/glycans, peptide mimics, or anti-idiotypic IVIg, or (c) deleted through selective plasma cell/B-cell ablation (e.g., by using ricin– antigen complexes) (Tanemura et al., 2002). In an approach aimed at antibody neutralisation or removal, we have identified the minimum epitope requirements for murine monoclonal antibody and human anti-GQ1b, anti-GM1, and anti-GD1a antibody binding and have chemically or enzymatically synthesised these epitopes and related candidate analogues in collaborations (D. Bundle, Edmonton; A. Bernardi and S. Sonnino, Milan; N. Bovin and O. Galanina, Moscow) 105 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) A B BTx s100 MAC NF/BTx C D Figure 10. Neuromuscular junctions (NMJs) in triangularis sternae muscle preparations from C57/Bl6 mice exposed in vitro to antiGQ1b monoclonal antibody plus human serum as a source of complement, in the absence (A, B) or presence (C, D) of the complement inhibitor APT070. Post-synaptic membranes are stained with bungarotoxin (BTx). In the absence of APT070 (A, B), membrane attack complex (MAC) (A, green) is formed that disrupts the nerve terminal and overlying perisynaptic Schwann cell (pSC) membrane integrity, resulting in loss of neurofilament (NF) (B, green) and S100 (A, blue) staining, respectively. In the presence of APT070, no MAC is formed and NMJ architecture is preserved with normal NF architecture (D, green) and intact S100-positive pSCs (C, blue) overlying the nerve terminal. Scale bar ¼ 20 mm (Halstead et al., unpublished data). use. Substitution of blood group glyco-antigens for ganglio-series glycans is relatively straightforward, and prototype columns are currently being constructed. We are also testing the inhibitory activity of soluble oligosaccharides in ex vivo physiological preparations and in mouse models in vivo. However, the pharmacokinetics and glycan metabolism aspects of such an approach in humans are likely to present greater complexities than extra-corporeal immunoadsorption, and we thus favour the former therapeutic strategy. very long way in a short space of time and opened up a wealth of potential therapeutic avenues. Whether the identification of further ganglioside and glycolipid antigens will lead to new areas for enquiry remains to be seen. Progress is most especially needed in the search for the elusive AIDP antigen(s), and this is the most pressing research goal in the GBS field. If further advances in identifying novel glycan antigens are not fruitful, the tables may turn back to the myelin proteins or other Schwann cell antigens in the quest for major disease targets, either as T- or B-cell antigens, and many preliminary studies suggest that such searches may be fruitful (Pestronk et al., 1998; Gabriel et al., 2000). Conclusion Our advances in understanding the immunopathological pathways underlying GBS have come a 106 Willison Journal of the Peripheral Nervous System 10:94–112 (2005) especially confounded by the fact that large trials are complex and time consuming to organise and execute; this reinforces the need to make rational choices for novel immunotherapy testing, informed by basic studies that reasonably reflect the pathogenesis of the human disease. Such an approach is essential to prevent the GBS field from following false trails or floundering in the therapeutic doldrums well into the 21st century, especially as other autoimmune diseases make significant headway by the use of contemporary treatments. A Acknowledgements B C The research work described here was supported by grants from the Wellcome Trust, National Institutes of Health, Guillain-Barré Syndrome Support Group UK, and Guillain-Barré Syndrome Foundation International. The dedicated effort of all the graduate students and scientific staff in my laboratory over the last decade who conducted this work is gratefully recognised. Amongst many external collaborators, particular mention is due to my long-standing collaborator, Dr. Jaap Plomp, Leiden University, whose electrophysiological expertise has constantly stimulated and advanced our work. D References Andersen SM, Ling CC, Zhang P, Townson K, Willison HJ, Bundle DR (2004). 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Reconstructed confocal images (three-colour composite image, A) show the localisation of post-synaptic AChRs (Texas red-BTx staining, red, B), anti-GD1a antibody (green, C), and neurofilament (NF) in the terminal axon arborisations (anti-NF antibody, blue, D). Anti-GD1a antibody is localised directly over the endplate gutters, ensheathing the terminal axon. Wild-type mice show faint anti-GD1a antibody staining in the same distribution, and no staining is seen in the GD1adeficient GalNAcT–/– mice. Scale bar ¼ 10 mm. Modified from Goodfellow et al. (2005). An important consequence of identifying antibodies as the main pathogenic mediators of GBS (or not) is that such knowledge should direct therapeutic approaches towards blockade of antibody-mediated effector pathways, such as complement inhibition or B-cell suppression. Because an ever-growing array of ‘pathway-specific’ immunotherapies becomes increasingly available for human use, this issue has a true urgency. 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