Age-Dependent B Cell Autoimmunity to a
Myelin Surface Antigen in Pediatric Multiple
Sclerosis
This information is current as
of June 14, 2017.
J Immunol 2009; 183:4067-4076; Prepublished online 17
August 2009;
doi: 10.4049/jimmunol.0801888
http://www.jimmunol.org/content/183/6/4067
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The Journal of Immunology is published twice each month by
The American Association of Immunologists, Inc.,
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Copyright © 2009 by The American Association of
Immunologists, Inc. All rights reserved.
Print ISSN: 0022-1767 Online ISSN: 1550-6606.
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Katherine A. McLaughlin, Tanuja Chitnis, Jia Newcombe,
Bettina Franz, Julia Kennedy, Shannon McArdel, Jens
Kuhle, Ludwig Kappos, Kevin Rostasy, Daniela Pohl,
Donald Gagne, Jayne M. Ness, Silvia Tenembaum, Kevin C.
O'Connor, Vissia Viglietta, Susan J. Wong, Norma P.
Tavakoli, Jerome de Seze, Zhannat Idrissova, Samia J.
Khoury, Amit Bar-Or, David A. Hafler, Brenda Banwell and
Kai W. Wucherpfennig
The Journal of Immunology
Age-Dependent B Cell Autoimmunity to a Myelin Surface
Antigen in Pediatric Multiple Sclerosis1
Katherine A. McLaughlin,*† Tanuja Chitnis,‡§¶ Jia Newcombe,储 Bettina Franz,* Julia Kennedy,#
Shannon McArdel,† Jens Kuhle,** Ludwig Kappos,** Kevin Rostasy,†† Daniela Pohl,‡‡
Donald Gagne,§§ Jayne M. Ness,¶¶ Silvia Tenembaum,储储 Kevin C. O’Connor,‡§ Vissia Viglietta,‡§
Susan J. Wong,## Norma P. Tavakoli,## Jerome de Seze,*** Zhannat Idrissova,††† Samia J. Khoury,‡§
Amit Bar-Or,§§ David A. Hafler,‡§ Brenda Banwell,# and Kai W. Wucherpfennig2*†
M
ultiple sclerosis (MS)3, a chronic inflammatory demyelinating disease of the CNS, is the most common
cause of chronic neurological disability in young
adults (1). There has been increasing recognition of pediatric MS
over the past two decades, in part due to the advent of magnetic
*Department of Cancer Immunology and AIDS, Dana-Farber Cancer Institute, †Program in Immunology and ‡Department of Neurology, Harvard Medical School, §Center for Neurologic Diseases, Brigham and Women’s Hospital, Boston, MA 02115,
¶
Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital for
Children, Boston, MA 02114; 储NeuroResource, University College London Institute
of Neurology, London, United Kingdom; #Institute of Neurology, Department of Paediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, Canada;
**Department of Research and Department of Neurology, University Hospital Basel,
Basel, Switzerland; ††Department of Pediatrics and Pediatric Neurology, GeorgAugust-University, Goettingen, Germany; ‡‡Children’s Hospital of Eastern Ontario,
Ottawa, Ontario, Canada; §§Department of Neurology and Neurosurgery, Montreal
Neurological Institute, Montreal, Quebec, Canada; ¶¶Children’s Hospital of Alabama,
Birmingham, AL 35233; 储储Department of Pediatric Neurology, National Pediatric
Hospital “Dr. J.P. Garrahan”, Buenos Aires, Argentina; ##Diagnostic Immunology
Laboratory, Wadsworth Center, New York State Department of Health, Albany, NY
12207; ***Department of Neurology, Strasbourg University, Alsace, France; and
†††
Department of Neurology, Kazak State Medical University, Almaty, Kazakhstan
Received for publication June 11, 2008. Accepted for publication July 10, 2009.
The costs of publication of this article were defrayed in part by the payment of page
charges. This article must therefore be hereby marked advertisement in accordance
with 18 U.S.C. Section 1734 solely to indicate this fact.
1
This work was supported by Grant PO1 AI045757 from the National Institutes of
Health (to K.W.W.), Grant RG 4122-A-6 from the National Multiple Sclerosis Society (to K.W.W.), and Grant A B-O from the Wadsworth Foundation (to B.B.).
2
Address correspondence and reprint requests to Dr. Kai W. Wucherpfennig, DanaFarber Cancer Institute, 44 Binney Street, Room D1410, Boston, MA 02115. E-mail
address: [email protected]
3
Abbreviations used in this paper: MS, multiple sclerosis; ADEM, acute disseminated encephalomyelitis; CIS, clinically isolated syndrome; CSF, cerebrospinal fluid;
MAG, myelin-associated glycoprotein; MFI, mean fluorescence intensity; MOG, myelin oligodendrocyte glycoprotein; NMO, neuromyelitis optica; OMG, oligodendrocyte-myelin glycoprotein; MRI, magnetic resonance imaging; HA, hemagglutinin.
Copyright © 2009 by The American Association of Immunologists, Inc. 0022-1767/09/$2.00
www.jimmunol.org/cgi/doi/10.4049/jimmunol.0801888
resonance imaging (MRI) techniques, which enable sensitive detection of CNS white matter abnormalities (2). It is now estimated
that 2–5% of cases of MS begin before an age of 16 (3–5), but the
true incidence of pediatric MS remains unknown. The average age
of clinical onset in most pediatric MS cohorts is between 8 and 14
years, but the disease occurs even in children 2–5 years of age. In
the majority of pediatric MS patients (⬎90%), the disease course
is relapsing-remitting. Pediatric disease onset is associated with a
younger age at disease progression milestones, such as the requirement for mobility aids, than adult-onset MS (4 –7). The rate of
disease relapses is significantly higher in pediatric-onset MS than
adult-onset disease, even when the initiation of disease-modifying
therapies following a clinically isolated event is taken into account
(8). A short interval (less than 1 year) between the first two demyelinating episodes, incomplete recovery after the first attack as well as a
secondary progressive disease course are unfavorable prognostic factors (9, 10). Cognitive impairment is common in pediatric-onset MS,
and can seriously affect academic performance (11–13).
Unlike adult-onset MS, which is more common in females and
populations with European ancestry, pediatric MS occurs in many
ethnic groups and does not have a strong gender bias before puberty (14, 15). An analysis of MS patients cared for in Toronto
showed that parents were of non-European descent for a substantially larger percentage of pediatric MS patients (41.9% of mothers
and 48.8% of fathers) than for adult-onset MS patients (8.1% of
mothers and 7.1% of fathers), and represented ethnic groups from
Asia, the Caribbean, and the Middle East (15). Similar to these
findings, a recent study in the northeastern United States revealed
that only 86.2% of patients with pediatric-onset MS identified
themselves as Caucasian, compared with 93.1% of patients with
adult-onset MS ( p ⫽ 0.014) (3). Specifically, the proportions of
African-American and Hispanic- or Latin-American patients were
higher in the pediatric-onset group.
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Multiple sclerosis (MS) typically manifests in early to mid adulthood, but there is increasing recognition of pediatric-onset MS, aided
by improvements in imaging techniques. The immunological mechanisms of disease are largely unexplored in pediatric-onset MS, in
part because studies have historically focused on adult-onset disease. We investigated autoantibodies to myelin surface Ags in a large
cohort of pediatric MS cases by flow cytometric labeling of transfectants that expressed different myelin proteins. Although Abs to native
myelin oligodendrocyte glycoprotein (MOG) were uncommon among adult-onset patients, a subset of pediatric patients had serum Abs
that brightly labeled the MOG transfectant. Abs to two other myelin surface Ags were largely absent. Affinity purification of MOG Abs
as well as competition of binding with soluble MOG documented their binding specificity. Such affinity purified Abs labeled myelin and
glial cells in human CNS white matter as well as myelinated axons in gray matter. The prevalence of such autoantibodies was highest
among patients with a very early onset of MS: 38.7% of patients less than 10 years of age at disease onset had MOG Abs, compared
with 14.7% of patients in the 10- to 18-year age group. B cell autoimmunity to this myelin surface Ag is therefore most common in
patients with a very early onset of MS. The Journal of Immunology, 2009, 183: 4067– 4076.
4068
MOG in a subset of patients with ADEM (13/69 patients, 18.8%)
(31). Interestingly, one of 19 pediatric MS sera gave a strong signal in this radioimmunoassay, whereas only one of 109 adult-onset
MS sera was positive. This pediatric MS serum sample also labeled a MOG-GFP transfectant, indicating that autoantibodies in
this patient indeed bound native MOG. We therefore decided to
examine a larger cohort of pediatric and adult-onset MS patients to
define the relationship between the presence of such autoantibodies and age at disease onset.
Materials and Methods
Clinical samples
Pediatric and adult samples were collected by international neurological
centers that care for adults or children with MS and other demyelinating
diseases. Pediatric MS was defined using the McDonald Criteria (32, 33).
None of the cases defined as pediatric MS met the criteria for multiphasic
or recurrent ADEM (19). The majority of pediatric-onset MS and pediatric
control serum samples were obtained from centers participating in the
Wadsworth International Pediatric MS Consortium, which did not make
MRI scans available for centralized review. Adult-onset MS was defined
using the Poser or McDonald criteria (32–34). Most adult-onset MS (including relapsing-remitting, secondary progressive, and primary progressive MS), CIS, and control serum and CSF samples were collected at the
Partners Multiple Sclerosis Center at Brigham and Women’s Hospital
(Boston, MA). Serum samples from patients with NMO were from the
Hôpital Civil (Strasbourg, France), and viral encephalitis samples were
provided by the New York State Department of Health. Each site collected
samples using a protocol approved by their Institutional Review Board, and
informed consent was obtained from all subjects. Samples were stored at
⫺80°C in aliquots.
Selection of MOG-GFP clones
The cloning of human MOG into the pEGFP-N1 vector (Clontech) and
transfection of Jurkat cells was previously described (31). Transfected cells
were grown in DMEM (Invitrogen) supplemented with 10% FBS (Atlanta
Biologicals), 100 IU/ml penicillin, 100 ␮g/ml streptomycin, 35 mM
HEPES, and 2 mM L-glutamine (Mediatech) with 1 mg/ml G418 (Invitrogen) to maintain selection. MOG-GFP and GFP clones were generated by
sorting single GFPhigh cells on a FACSAria (BD Biosciences). After expansion, MOG clones were stained with an Ab to MOG (clone 8-18C5),
and MOG-GFP and GFP clones with a matching level of GFP brightness
were selected.
Flow cytometry
Cells were harvested, washed in PBS containing 1% BSA (Fisher) (PBS/
BSA), and resuspended at a density of 1 ⫻ 106/ml. A total of 50,000 cells
(50 ␮l) were incubated with serum at a 1/50 dilution (or other, as indicated)
in V-bottom plates (Corning) for 1 h at 4°C. For CSF stains, 25,000 cells
at a density of 2 ⫻ 106/ml were incubated with 50 ␮l of CSF. Cells were
washed twice with 200 ␮l of PBS/BSA, and incubated with biotinylated
secondary Abs to human IgG (pan-IgG clone HP-6017 (Sigma-Aldrich), or
subclass-specific IgG1 clone HP6069, IgG2 clone HP6002, IgG3 clone
HP6047, and IgG4 clone HP6023 (Calbiochem)) at a 1/1000 dilution for 30
min at 4°C. Cells were washed twice and incubated with streptavidin-PE
(Invitrogen) at a 1/1000 dilution for 20 min, washed once with PBS alone
and fixed with 1% formaldehyde in PBS at 4°C before analysis. A total of
10,000 events per well were recorded on an LSRII instrument equipped
with a high-throughput sampler (BD Biosciences). Data analysis was performed in FlowJo (Tree Star) and Excel (Microsoft). Nonparametric statistical tests were performed in SISA Tables (Quantitative Skills).
Affinity purification of Abs to MOG for FACS analysis
The Ig domain of MOG and the membrane proximal Ig domain of CD80
were linked to a BirA biotinylation site and cloned into the pET22b vector
(Promega). Proteins were expressed in Escherichia coli, refolded from inclusion bodies, purified by HPLC, and biotinylated using the BirA enzyme
using published protocols (35, 36). A total of 100 ␮g of biotinylated MOG
or CD80 was incubated with 50 ␮l of settled streptavidin-agarose beads
(Sigma-Aldrich) in 200 ␮l of PBS/BSA overnight at 4°C on an orbital
rotator, and washed to remove unbound Ag. The 10 ␮l of settled beads
were incubated with 5 ␮l of serum and 200 ␮l of PBS/BSA for 5 h at 4°C.
The supernatant was saved, and the beads were washed four times with 1
ml of PBS/BSA, followed by elution in 200 ␮l of 0.1 M glycine (pH 2.5).
Eluted proteins were separated from the beads by spin filtration (Spin-X 0.2
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Early during the disease course, there can be substantial difficulties distinguishing between pediatric MS and acute disseminated encephalomyelitis (ADEM) (16). ADEM is characterized
by an acute onset of widespread CNS inflammation and demyelination and is more common in children than adults (16 –18).
For a diagnosis of ADEM, new criteria established by the International Pediatric MS Study Group require a polysymptomatic clinical presentation that includes encephalopathy, which is
defined as either a behavioral change (such as confusion, excessive irritability) or alteration in consciousness (lethargy,
coma) (19). ADEM typically follows a monophasic course with
partial or complete recovery. However, recurrent ADEM (defined as a new event of ADEM with a recurrence of the initial
symptoms 3 mo or more after the initial event) and multiphasic
ADEM (two or more distinct ADEM episodes, each meeting
clinical criteria for ADEM but involving new areas of the CNS,
separated by at least 3 mo) occur rarely (20). Because the prognosis and treatment regimens for MS and ADEM differ substantially, it is essential to understand the biological similarities
and differences between these conditions.
The largest reported study of pediatric demyelinating diseases
illustrates this issue (21). In this study, 296 patients were followed
after an initial demyelinating episode; 168 patients (57%) experienced two or more episodes of demyelination and were given a
diagnosis of MS. Although MS was more commonly preceded by
a clinically isolated syndrome (CIS), 20% of the patients with a
final diagnosis of MS were considered to have ADEM at clinical
onset. Given these diagnostic difficulties, biomarkers that reflect
differences in disease pathogenesis would be valuable. For example, Abs to aquaporin-4, a water channel enriched on astrocytic
foot processes at the blood-brain barrier, are commonly found in
neuromyelitis optica (NMO), an inflammatory demyelinating disease that affects the optic nerves and the spinal cord (22). Hightiter Abs are associated with increased disease activity (23), and
the presence of aquaporin Abs has recently been incorporated into
the diagnostic criteria for NMO (24).
Little is currently known about disease mechanisms in pediatric
MS, in particular with respect to similarities and differences to
adult-onset MS. Recent clinical trials with rituximab in adult MS
patients have shown that B cell depletion results in a pronounced
reduction in new demyelinating lesions (25), proving that B cells
play a central role in the disease. Oligoclonal IgG Abs are present
in the cerebrospinal fluid (CSF) of the majority of adult-onset MS
patients, and CSF analysis of 136 patients with a disease onset
before age 16 identified oligoclonal IgG in 92% of cases (26), but
the specificity of these Abs remains unknown.
Pathogenic autoantibodies need to be able to bind to structures on the surface of the myelin or oligodendrocytes, but the
abundant myelin Ags myelin basic protein and proteolipid protein are inaccessible to Abs in the intact myelin sheath. Myelin
oligodendrocyte glycoprotein (MOG), a CNS-specific myelin
and oligodendrocyte surface protein, is one of the relevant candidate Ags, and a mAb (8-18C5) against MOG induces severe
demyelination in mice or rats with mild experimental autoimmune encephalomyelitis (27, 28). Although Abs able to bind to
the native conformation of the protein cause demyelination,
Abs to MOG peptides that do not bind the folded protein are not
pathogenic (29, 30). It is therefore critical to differentiate between Abs to folded MOG and denatured or linear epitopes, a
task for which traditional assays such as Western blot and
ELISA analyses are poorly suited.
We recently reported a radioimmunoassay with a tetrameric
form of MOG for the detection of MOG autoantibodies in patients
with inflammatory demyelinating CNS diseases and found Abs to
MOG AUTOANTIBODIES IN PEDIATRIC MS
The Journal of Immunology
4069
micron; Corning) and the pH was neutralized by addition of 2 M Tris base.
The 60 ␮l of unbound or eluted proteins were incubated with 50,000 cells
in a volume of 125 ␮l with or without 25 ␮g of nonbiotinylated recombinant MOG as a competitor, and bound Abs were detected by FACS as
described above.
Immunocytochemistry on human CNS tissue sections
Cloning and transfection of hemagglutinin (HA)-tagged Ags
The pCI-neo vector (Promega) was modified to create a vector suitable for
expression of N-terminal tagged type I transmembrane proteins with a
fluorescent reporter under control of an internal ribosome entry site (IRES).
Oligonucleotides were used to link the H2-Kb signal peptide and HA
epitope tag (YPYDVPDYASL) to a unique multiple cloning site containing XcmI, Bsu36I, EspI, and XbaI recognition sequences, which was inserted at the NheI-XbaI restriction sites of pCI-neo. IRES and ZsGreen
sequences were amplified from the pHAGE-CMV-fullEF1␣-IRES-ZsGreen vector, as created by J.-S. Lee provided by the Dana-Farber/Harvard
Cancer Center DNA Resource Core (Boston, MA) and inserted at a NotI
site downstream of the pCI-neo multiple cloning site.
Human myelin-associated glycoprotein (MAG) and oligodendrocytemyelin glycoprotein (OMG) cDNA were obtained from GeneService (www.
geneservice.co.uk) and used to clone the extracellular, transmembrane, and
cytoplasmic domains of each Ag by PCR using Phusion polymerase (New
England Biolabs). These sequences, minus the endogenous signal peptide,
were cloned into the modified vector with XcmI and XbaI enzymes (New
England Biolabs). Jurkat cells were transfected by electroporation, and
stable transfectants selected with 2 mg/ml G418. Cells expressing ZsGreen
were sorted and stained with a biotinylated Ab to the HA tag (clone 3F10;
Roche) and streptavidin-PE (Invitrogen). Single PEhigh, ZsGreenhigh cells
were sorted as described, and the clones with highest HA expression were
used for autoantibody detection.
Results
Detection of high-titer autoantibodies to native MOG in
pediatric MS patients
Our previous FACS experiments used a MOG-GFP construct in
which GFP was fused to the cytoplasmic domain of full length
human MOG so that the brightness of GFP fluorescence reported
on the level of MOG expression. A stably transfected Jurkat cell
line had been generated, containing cells with different levels of
MOG-GFP expression. FACS analysis of serum samples from
ADEM patients showed a diagonal staining pattern for IgG binding vs GFP fluorescence (31), indicating that the labeling intensity
closely correlated with the density of the Ag at the cell surface.
This finding suggested that the sensitivity of the assay could be
improved by single cell cloning of the cells that expressed the
highest level of MOG-GFP. We therefore sorted single cells
based on GFP fluorescence from MOG-GFP or control GFP
FIGURE 1. Identification of autoantibodies to native MOG in pediatric
MS patients. A, Brightness of fluorescent labeling with different positive
pediatric MS sera. FACS data representing Ab binding to the MOG-GFP
transfectant (open histograms) and the control GFP transfectant (shaded
histograms) are shown for sera from six pediatric MS patients. Sera were
incubated at a dilution of 1/50 with cells, and bound Abs were detected
using biotinylated anti-human IgG and streptavidin-PE. For each sample,
the ratio of the MFI for the MOG-GFP and the control transfectant is
shown (top left corner). The six depicted examples represent the entire
range of fluorescent intensities for positive sera, with binding ratios of
⬃5–200 for the MOG vs the control transfectant. B, Ab titers measured by
FACS analysis. Sera were incubated with MOG-GFP cells at the indicated
dilutions. Abs to MOG were detectable in all positive sera at a dilution of
1/400 and many at a dilution of 1/800.
transfectants and selected MOG-GFP (used as MOG throughout
study) and GFP control clones with similar GFP expression
levels for our experiments.
To enable sensitive detection of autoantibodies, a three-step
staining procedure was used in which 50,000 MOG-GFP or control
GFP cells were incubated with serum at a 1/50 dilution and bound
Abs were detected using biotinylated anti-human IgG and streptavidin-PE. Specific autoantibody binding was expressed as the ratio
of the PE mean fluorescence intensity (MFI) of the MOG vs the
GFP clone (binding ratio), and ratios greater than 5 were considered to be positive. This threshold is three SDs above the mean
binding ratio of all nonautoimmune and non-neurological controls
(rounded off from the actual value of 5.03). Samples with binding
ratios greater than 3 were analyzed for a total of two to five measurements per sample, depending on the volume of serum available. Sera with average binding ratios greater than 5 were reproducibly positive (see supplemental Fig. 1).4
Fig. 1A shows that labeling of the MOG clone by a number of
pediatric MS sera was very bright (binding ratios greater than 50)
and illustrates the range of staining intensities for positive pediatric
4
The online version of this article contains supplemental material.
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Abs used for immunocytochemistry were purified from sera by protein G
immunoprecipitation, eluted with 0.1 M glycine (pH 2.5), dialyzed into
PBS, and biotinylated using sulfo-NHS-biotin (Pierce) at a 50-fold molar
ratio of biotin to IgG. MOG and BSA were conjugated to cyanogen bromide-activated Sepharose beads (Amersham) per the manufacturer’s instructions and blocked in PBS plus 5% BSA overnight. The 200 ␮g of total
biotinylated IgG was affinity purified on MOG and BSA beads in PBS plus
2% BSA overnight, and unbound Abs were retained before the first wash.
Bound Abs were eluted using 0.1 M glycine (pH 2.5) plus 1% BSA as a
carrier protein. Bound and unbound Abs were concentrated to ⬃200 ␮l
using Microcon concentrators (Millipore).
Tissue sections from the CNS of six adult tissue donors without CNS
disease were from the NeuroResource tissue bank, UCL Institute of
Neurology, London, U.K. Serial cryostat sections (10 ␮m) were captured onto polylysine-coated slides, acetone-fixed and incubated with
blocking sera. Sections were incubated for 2 h with 20 ␮g of total
biotinylated IgG or Abs corresponding to 100 ␮g total IgG further
purified on MOG or BSA beads. Immunoperoxidase staining was performed with a Vectastain avidin-biotin peroxidase kit (Vector Laboratories) using diaminobenzidine and nickel (II) chloride to give black
staining (37). Staining patterns observed with patient IgG were compared with adjacent sections labeled with the myelin-specific anti-MOG
mAb 8-18C5 and the oligodendrocyte-specific mAb 14E (38). Primary
Abs were omitted for immunocytochemistry controls.
4070
MOG AUTOANTIBODIES IN PEDIATRIC MS
Table I. Demographics of all pediatric- or adult-onset MS patient groupsa
Pediatric MS
Pediatric neurological control
Pediatric non-neurological control
Juvenile diabetes
Adult-onset MS
Adult control
Clinically isolated syndrome
Neuromyelitis optica
Viral encephalitis
Age at Sample (y)
MS Subtype
N
Percentage
Female
(%)
Median
Range
RRMS
SPMS
PPMS
Marburg
131
34
37
28
254
86
30
13
29
63.3
55.9
67.6
71.4
67.9
56.5
80.0
84.6
n/a
14.6
13.7
12.3
10.7
42
40
37.9
41
n/a
5.0–19.4
2.1–18.5
2.0–16.0
5.7–17.6
18–76.9
22–64
22.9–54.3
24–55
n/a
93
3
0
1
171
49
34
0
a
Sera from pediatric- or adult-onset MS donors as well as control donors from an international group of clinics were tested for Abs to MOG. Types
of MS include relapsing-remitting (RRMS), secondary progressive (SPMS), and primary progressive (PPMS).
Data not available (n/a).
tometric assay are that it enables higher throughput and avoids the
use of radioactivity.
MOG Abs define a subset of pediatric MS patients
Sera from patients with pediatric- or adult-onset MS as well as
control donors from an international group of clinics (Table I)
were tested for Abs to MOG at a 1/50 dilution. Abs to MOG were
detected in 28 of 131 pediatric-onset MS samples (21.3%) but
rarely found in controls (Fig. 2A). In particular, all samples from
patients with juvenile diabetes (n ⫽ 28) as well as patients with
FIGURE 2. Autoantibodies to native MOG are more prevalent in pediatric-onset than in adult-onset MS patients, and infrequent in other inflammatory
demyelinating CNS diseases. A, Sera from pediatric (left) or adult individuals (right) were assayed for Abs to MOG at a dilution of 1/50. The MOG to
control binding ratio for each sample was calculated as described, and ratios greater than 5 were considered positive. Abs to MOG were significantly more
common in pediatric- than adult-onset MS patients (p ⫽ 4.48 ⫻ 10⫺7) or control subjects and labeled the transfectant more brightly. B, Analysis of MOG
Abs in patient populations from MS centers in different countries. Although anti-MOG was detectable in pediatric MS samples from all countries studied,
the frequency of MOG Abs in adults varied considerably between centers.
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MS sera. All positive sera labeled the MOG transfectant at a 1/400
dilution and several sera even at a 1/800 dilution (Fig. 1B). Comparison of the MOG-GFP and control GFP clones for each sample
was important because the sera differed in the level of nonspecific
binding to the Jurkat cells (Fig. 1A). The MOG clone gave a higher
fluorescence signal than the MOG line and binding ratios that were
typically 5- to 10-fold higher than with the lines (see supplemental
Fig. 2).4 Because of their superior properties, these GFP and MOG
clones were used in all subsequent analyses. Compared with the
tetramer radioimmunoassay, the major advantages of this flow cy-
The Journal of Immunology
MOG Abs are most prevalent in patients with a very early
disease onset
A number of possible factors may be responsible for the presence
of MOG Abs in a subset of pediatric MS patients. No significant
association between anti-MOG and gender or ethnicity was found
(see supplemental Table I).4 However, the presence of Abs significantly correlated with a younger age at disease onset ( p ⫽ 0.009):
38.7% of individuals with a first clinical event before age 10 had
MOG Abs, compared with 14.7% of patients with a disease onset
FIGURE 3. MOG Abs are most prevalent in MS patients with a very
early disease onset. A, Abs to MOG are most common in MS patients with
a disease onset before 10 years of age. Pediatric-onset MS patients were
ranked by age at the first clinical event. Although the majority of samples
were from older patients (⬎10 years), the frequency of Abs to MOG was
significantly higher (p ⫽ 0.009) in individuals under 10 years of age at the
first clinical event. B, Analysis of MOG Abs in pediatric- and adult-onset
MS patients based on age at disease onset. Abs to MOG were most common in the youngest pediatric-onset MS cases, whereas a correlation with
age at diagnosis was not apparent among the infrequent adult-onset cases
with MOG Abs. C, Relationship between the presence of MOG Abs and
the time interval since diagnosis of MS. Abs were found in pediatric-onset
MS patients with recent disease onset and established disease.
between 10 to 18 years (Fig. 3A). As stated above, the frequency
of MS patients with MOG Abs was even lower in the adult-onset
population (4.3%). In adult-onset MS, 3 of the 6 MOG-positive
patients for whom data were available had their first clinical event
at an age of over 40 years (Fig. 3B), and there was no correlation
between the presence of these Abs and age at first clinical event
( p ⫽ 0.1835). Abs to MOG were found in pediatric MS patients
with recent disease onset (⬍1 year) and also those with a longer
disease course (⬎5 years) (Fig. 3C), indicating that MOG can
be a target in early stages of MS, and that the Abs may persist,
at least for some time. Most patients were either untreated or
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non-neurological diseases (n ⫽ 37) were negative. Among patients
with other neurological diseases (n ⫽ 34), one (with a developmental delay) was clearly positive, whereas the other was marginally positive.
By comparison, MOG Abs were only detected in a small subset
of adult-onset MS patients (11/254 sera, 4.3%) and the brightness
of labeling with these serum samples was substantially lower than
with the positive pediatric MS samples. The difference in antiMOG frequency between all adult- and pediatric-onset MS cases
was statistically significant ( p ⫽ 4.48 ⫻ 10⫺7). All anti-MOGpositive pediatric MS sera were from individuals with relapsingremitting MS, the most common MS subtype in our pediatric
group (Table I). Abs to MOG were found in all major clinical
subtypes of adult-onset MS, including 6/171 relapsing-remitting,
3/49 primary progressive, and 2/34 secondary progressive patients.
Abs to MOG were not detected in adults with NMO or viral encephalitis, and were rarely found at low levels in adults with a CIS
(Fig. 2A). We have also initiated a prospective analysis of MOG
Abs in pediatric demyelinating diseases to examine persistence of
such Abs. As part of this ongoing study, we obtained serial serum
samples from 39 children with demyelinating events, 5 of whom
were positive for Abs to MOG. Serial samples were available in
four of the five cases, and serum anti-MOG was detectable at each
follow-up interval. Three patients had two samples each, taken at
the first clinic visit and 4, 6, or 13 mo later. One patient had Abs
to MOG in each of n ⫽ 3 serial samples, the last taken 33 mo after
the initial visit and more than 4 years after the first clinical event
of ADEM.
Matched serum and CSF samples were available from 13 pediatric patients; difficulties in obtaining CSF prevented analysis of
more pediatric MS samples. Abs to MOG were detectable in the
CSF of one pediatric-onset MS patient (binding ratio of 8.63 for
CSF, ratio of 23.7 for paired serum) who had a first clinical event
at 13.3 years of age. In two other pediatric MS cases with paired
samples, MOG-specific Abs were detectable in the serum (binding ratios of 20.4 for CSF and 5.8 for paired serum) but not in
paired CSF. It is important to consider that the IgG concentration is ⬃1000-fold higher in the serum compared with the CSF
and that detection in the serum may therefore be more sensitive.
Also, it is possible that Abs in CSF are present as immune
complexes and therefore not able to bind MOG in our assay or
that a fraction of MOG Abs are absorbed by their target Ag on
oligodendrocytes/myelin.
The pediatric MS samples came from medical centers for MS in
six different countries, and MOG-positive cases were identified for
each center (Fig. 2B), with some differences in the frequency of
positive cases. Among adult-onset MS patients, the frequency of
Abs to MOG differed between centers (0 – 8.3% of positive sera).
Although 12 of 43 pediatric MS samples from Canada contained
anti-MOG, none of the 53 Canadian adult MS samples were MOGpositive (Fig. 2B). Because all these samples were analyzed by one
individual using the same assay, differences in the frequency of
MOG-positive adult-onset MS cases reported by different groups
may reflect differences in the studied patient populations.
4071
4072
MOG AUTOANTIBODIES IN PEDIATRIC MS
had received IFNs at the time of sample collection (see supplemental Table II),4 and the usage of specific immunomodulatory
drugs was not significantly different in the MOG-positive and
-negative groups ( p ⫽ 0.636904).
Based on our previous findings of MOG Abs in ADEM and the
fact that this disease is most common in children, we investigated
the relationship between Abs to MOG and clinical presentation at
the first demyelinating event. A significant association was found
between anti-MOG and a first clinical event diagnosed as ADEM
( p ⫽ 0.0049): 30.8% of MOG-positive MS patients had an initial
diagnosis of ADEM, compared with 8% of MOG-negative cases.
Also, 50% of pediatric MS cases with an initial ADEM-like first
event had MOG Abs (see supplemental Table I).4
Functional properties of MOG Abs from pediatric MS patients
Abs to MOG may cause demyelination and oligodendrocyte death
by either complement activation or Fc receptor-dependent mechanisms. IgG subtypes differ in the ability to fix complement and
induce Ab-dependent cellular cytotoxicity, and we therefore subclassified MOG-specific IgG Abs by FACS using a panel of secondary Abs specific for defined IgG subtypes (IgG1-IgG4). The
majority of sera contained only MOG-specific IgG1 (7 of 12 sera),
one sample had both MOG-specific IgG1 and IgG3 and another
was dominated by IgG2 (Fig. 4). The lower sensitivity of the subclass-specific secondary Abs compared with the pan-IgG Ab prevented identification of the dominant IgG subtype in three samples.
Human IgG1 is efficient in fixing complement and inducing Abdependent cell-mediated cytotoxicity.
The murine 8-18C5 mAb to MOG is well known to bind oligodendrocytes in culture and induce demyelination in vivo. We
tested whether Abs from pediatric MS patients could compete with
8-18C5 for binding to MOG-GFP cells. Because the secondary Ab
used to detect bound IgG recognizes human but not mouse proteins, this assay was not confounded by detection of 8-18C5 on the
cells. Addition of 8-18C5 decreased the binding of patient serum
Abs to MOG-GFP cells in a dose-dependent manner for all samples tested (Fig. 5A). This result shows that the Abs from pediatric
MS patients bind to surfaces on MOG that significantly overlap
with the 8-18C5 epitope.
FIGURE 5. Abs in pediatric MS sera are specific for MOG. A, A mAb
to MOG competes with serum Abs for Ag binding. Sera and indicated
amounts of the MOG-specific Ab 8-18C5 were incubated together with
MOG-GFP cells for 1 h. A human-specific secondary Ab was used to
detect bound IgG. Addition of increasing amounts of 8-18C5 decreased the
amount of serum Ab bound to cells. B, Affinity-purified Abs specifically
bind to MOG transfectants. Biotinylated recombinant MOG (rMOG, extracellular domain) or an Ig superfamily control protein (membrane-proximal Ig domain of CD80) were captured onto streptavidin beads for affinity
isolation of MOG-specific Abs from 5 ␮l of serum. Unbound and eluted
Abs were used to stain MOG and control transfectants. Binding ratios
obtained with purified Abs from four sera are summarized in the table. Abs
purified on MOG beads bound MOG on the cell surface, and addition of 25
␮g of soluble recombinant MOG inhibited binding of eluted MOG-specific
Abs for all four sera tested.
To further verify the specificity of these Abs, we affinity purified
polyclonal Abs from sera using a MOG protein preparation representing the extracellular domain that had been refolded from E.
coli inclusion bodies. The protein carried a C-terminal BirA tag for
site-specific biotinylation, enabling capture onto streptavidin
beads. The MOG extracellular domain contains a single Ig domain
and we used a protein of similar size (membrane proximal Ig domain of CD80) as a control. Biotinylated MOG or CD80 were
bound to streptavidin-coated agarose beads and incubated with pediatric MS sera. Both bound and unbound Abs were used to stain
MOG and GFP clones. Abs capable of staining the MOG clone did
not bind to control beads, but were isolated from all four sera using
MOG beads (Fig. 5B). Addition of soluble recombinant MOG protein as a competitor to the staining reaction substantially reduced
the level of specific binding to the MOG clone. The recombinant
MOG protein used for affinity purification and competition of Ab
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FIGURE 4. The majority of pediatric MS patients have MOG IgG1
Abs, an IgG subtype that can fix complement and bind to Fc receptors. IgG
subclass-specific secondary Abs were used to detect the binding of serum
Abs to the MOG transfectant. In the example shown, only MOG-specific
IgG1 Abs were detected. IgG1 was the most common subtype among these
pediatric MS patients, found in 8 of 12 tested sera. IgG2 and IgG3 were
rarely found, and IgG4 was not detected in any sample.
The Journal of Immunology
binding was not glycosylated, indicating that at least a subset of
MOG-specific Abs in pediatric MS sera do not require the Nlinked glycan for binding. These experiments firmly establish that
the Abs detected with our flow cytometric assay are indeed specific
for MOG.
MOG-specific Abs label human white matter and myelinated
axons
We next sought to determine whether MOG-specific Abs from
pediatric MS patients can bind MOG in the CNS and therefore
performed immunocytochemistry on acetone-fixed human brain
sections containing both white and gray matter using biotinylated
Abs detected with avidin-peroxidase. As a positive control, myelin
was stained with the anti-MOG mAb 8-18C5 (Fig. 6A) (and see
supplemental Fig. 3A)4 and Abs directed against myelin basic protein and Wolfgram protein (data not shown). Glial cells with the
FIGURE 7. Abs to other myelin surface proteins in pediatric MS sera.
A, Generation of transfectants that express other myelin proteins on the cell
surface. Jurkat cells were transfected with vectors that drove expression of
ZsGreen as well as MOG, MAG, or OMG. Transfectants were cloned by
single cell sorting and surface expression was verified using an Ab to the
HA tag attached to the N terminus of each protein. B, Examples of labeling
of these transfectants with MOG-GFP-positive pediatric MS sera. Samples
were incubated at a 1/50 dilution with Jurkat cells transfected with HAtagged Ags, and bound IgG was detected with biotinylated anti-human IgG
and streptavidin-PE. C, Pediatric MS sera with MOG Abs do not show
broad anti-myelin reactivity. Ab binding for 13 serum samples is shown as
the MFI of PE. Although Abs to MAG and OMG were detectable at low
levels in a few sera, the labeling of MOG transfectants was considerably
brighter in all cases. Abs to OMG and MAG were not detected in MOGnegative pediatric MS sera or pediatric controls (data not shown).
morphology of oligodendrocytes were immunostained on adjacent
sections with the oligodendrocyte-specific Abs 14E (Fig. 6A) (and
see supplemental Fig. 3A),4 CNPase, and carbonic anhydrase (data
not shown).
Total IgG was isolated from anti-MOG positive and negative
sera, biotinylated and then further purified using beads with
immobilized MOG or BSA as a control protein. In samples from
two MOG-positive pediatric MS cases (W52 and W24), Abs
affinity purified on MOG beads but not control BSA beads labeled CNS white matter, whereas no staining was observed with
affinity purified Abs from control donor D14 (Fig. 6B). Abs
from patient W52, and more weakly with W24, also labeled cell
bodies in the white matter similar in morphology to cells identified with the oligodendrocyte-specific Ab 14E and other
oligodendrocyte-specific Abs.
Myelinated axon bundles in the subpial cortical gray matter
were stained with the anti-MOG mAb 8-18C5 and serum IgG from
a previously studied ADEM patient (R4) with high-titer MOG Abs
(31) (Fig. 6C). Similar small bundles of myelinated axons and glial
satellite cells in the gray matter were stained with Abs affinity
purified on MOG beads from pediatric MS patient W52, but no
staining was seen with Abs eluted from BSA beads (Fig. 6C).
These glial cells were also 14E-immunopositive.
We also performed staining with total biotinylated serum IgG
not purified on MOG or BSA beads (see supplemental Fig. 3).4
IgG from ADEM patient R4 stained white matter in a myelin-like
pattern (see supplemental Fig. 3B).4 IgG from pediatric MS patient
W52 labeled myelin and glial cells, whereas IgG from pediatric
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FIGURE 6. Abs to MOG stain myelin in human brain. A, MOG protein
and oligodendrocytes in the white matter were detected with mAbs 8-18C5
and 14E, respectively. Scale bar represents 25 microns. B, Immunocytochemistry with affinity-purified Abs from pediatric MS patients. Biotinylated total serum IgG was purified on MOG or BSA-coated beads, and
affinity purified Ab corresponding to 100 ␮g of total IgG was used per
stain. MOG-specific Abs from pediatric MS patients W52 and W24 labeled
white matter in a myelin and oligodendrocyte-like pattern. No staining was
seen with Abs isolated on BSA control beads or Abs from a control donor
(D14). Scale bar represents 25 microns. C, MOG-specific Abs label myelinated axons and satellite glia in the subpial gray matter. Regions of gray
matter in the same tissue sections as shown above were assessed for Ab
binding. Small bundles of myelinated axons were labeled by the MOG
mAb 8-18C5 and total IgG from a MOG-positive ADEM patient (R4), and
satellite glia cell bodies were identified with Ab 14E (data not shown).
Pediatric MS serum Abs (patient W52) purified on MOG but not BSA
beads also bound myelinated axons. Scale bar represents 50 microns.
4073
4074
MS patient W24 primarily labeled cells with a glial morphology
(see supplemental Fig. 3B).4 Only weak cell body staining was
observed with IgG from a control donor (D14) and MOG-negative
pediatric MS and juvenile diabetes samples (data not shown).
Overall, labeling with MOG affinity purified Abs was stronger because the specific Abs were more concentrated. Also, affinity purification reduced nonspecific staining. The finding that affinity
purified MOG-specific Abs label CNS myelin, myelinated axons,
and glial cells with oligodendrocyte morphology demonstrates that
these serum Abs recognize their CNS target Ag.
Evaluation of other myelin surface Ags
Discussion
These results show that circulating high-titer Abs to MOG are
present in a substantial subset of pediatric-onset MS patients, in
particular children with a very early disease onset. Stringent criteria establish their Ag specificity: the Abs label MOG but not
control transfectants, they can be affinity purified with recombinant
MOG but not a structurally related control protein, and addition of
soluble MOG inhibits Ab binding. Abs to MOG from pediatriconset MS patients also bound myelin in normal human white matter and myelinated axons in subpial gray matter. The majority of
MOG-specific Abs have the IgG1 subtype that can fix complement
and bind to Fc receptors, indicating that they have the potential to
damage myelin or oligodendrocytes if they gain access to the CNS.
Such Abs were rarely detected in pediatric controls or patients with
adult-onset demyelinating conditions, including MS. In the pediatric patient population, their presence strongly correlated with age
at disease onset and an initial ADEM-like presentation, but not
with gender or ethnicity. Future prospective studies will examine
the relationship between such an Ab response and clinical disease
course, MRI features, response to treatment, and prognosis.
The pronounced therapeutic response to B cell depletion with
rituximab shows that B cells play a central role in the pathogenesis
of adult-onset MS. It is likely that B cells contribute to disease
progression not only as a source of autoantibodies, but also by
presenting myelin-derived Ags to autoreactive T cells and driving
inflammation through production of cytokines and chemokines.
Ag-specific B cells are highly effective as APCs (39, 40), and their
elimination could substantially decrease T cell priming and activation. The relative importance of these different mechanisms to
the pathogenesis of MS remains unresolved. Also, the specificities
of the involved B cells and their Ab products remain largely
unknown.
Previous studies of autoantibodies in adult-onset MS yielded
conflicting results. Although some found Abs to MOG in patients
with MS or CIS (41, 42), others reported no difference in the frequency of anti-MOG between MS and other neurological diseases
(43– 45) or healthy controls (46). This controversy surrounding the
presence of MOG Abs in MS patients is likely attributable to differences in detection methods. Our flow cytometric approach
therefore emphasized detection of Abs to native, properly folded
MOG protein.
Three other groups also generated MOG-expressing cells to examine the presence of autoantibodies in adult-onset MS patients.
Haase et al. (47) generated a stable MOG transfectant in LTK3⫺
cells and found that only one of 17 serum samples from adult MS
patients labeled this transfectant, even though all patients as well
as healthy control subjects had Abs that detected linear MOG peptides in an ELISA. Lavile et al. compared serum Ab staining of a
MOG transfected Chinese hamster ovary cell line to nontransfected Chinese hamster ovary cells and concluded that IgG Abs
specific for native MOG were most frequently found in the serum
of patients with CIS and relapsing-remitting MS (48). However,
the binding ratios of the MOG and control cells were less than two
for all positive samples, even though high serum concentrations
were used for staining (1/10 dilution, compared with the 1/50 dilution used in this study). We defined binding ratios over 5 as
positive, and obtained binding ratios as high as 200.2 in pediatric
MS samples.
In another study, Zhou et al. (49) transduced a human glioblastoma cell line with a lentivirus encoding MOG and stained these
cells at a serum dilution of 1/36. The MOG-specific Ab response
was calculated by subtracting median fluorescence intensity values
obtained with MOG and control transfectants. The authors reported that 32% of adult-onset MS patients and 4% of control
subjects had detectable Abs, but the difference in MFI between the
MOG and control cells was rather small (⬍50) for most sera. By
comparison, we observed differences in MFI of 516 to 22,102 for
the six representative examples shown in Fig. 1A. We prefer to
express the data as a binding ratio between the MOG and control
transfectants rather than as a difference in MFI because the level of
background differs greatly between sera. For example, a sample
with a high background and a small MOG-specific increase in
binding can have a large change in MFI (for example, MFI values
of 600 and 500 for MOG and GFP transfectants, respectively),
even though the binding ratio is small (1.2 in this example). Although both analysis methods permit the identification of samples
with high levels of MOG-specific Abs, using MFI differences can
result in the classification of samples with a high background as
positive.
In this study, we have analyzed the largest collection of adultonset MS sera to date (n ⫽ 254), and the results show differences
in the frequency of MOG-positive cases between samples from
MS centers in Canada (0/53, 0%), the US (5/129, 3.9%), and Switzerland (6/72, 8.3%). These apparent differences may be caused by
the overall low frequency of Abs to MOG in adult-onset MS, but
differences in patient selection or genetic and environmental factors cannot be excluded. Sample handling may also be a contributing factor, but appears unlikely because we observed that MOG
Abs remain detectable after multiple freeze-thaw cycles.
Our findings support the conclusion that Abs to MOG are rather
uncommon among adult-onset MS patients, whereas the anti-MOG
reactivity identified in a subset of pediatric MS cases is among the
strongest autoantibody responses observed so far in MS. Using
multimeric forms of folded and glycosylated MOG protein, we
previously detected similar Abs to MOG in a subset of ADEM
patients (31). In the current study of pediatric MS, the presence of
MOG Abs strongly correlated with an initial ADEM-like onset,
although all children subsequently experienced two or more nonADEM demyelinating events as required for a diagnosis of MS
(19). The 50% of pediatric MS patients with an initial diagnosis of
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To determine whether patients with Abs to MOG also have circulating Abs to other myelin surface proteins, we created a set of
Jurkat transfectants expressing MAG, OMG, or MOG. The proteins carried an N-terminal HA epitope tag to verify expression on
the cell surface and clones expressing high levels of the HA
epitope tag on the surface and a fluorescent reporter (ZsGreen) in
the cytosol (Fig. 7A) were sorted and used to detect specific Abs in
pediatric MS sera by FACS. Examples of five anti-MOG-positive
sera are shown in Fig. 7B. Abs to MAG and OMG were not found
in most sera, but when detected only weakly stained the respective
transfectant (Fig. 7C). Sera from 25 anti-MOG-negative pediatric
MS patients and 25 pediatric controls did not contain Abs to OMG
or MAG (data not shown). MOG is therefore a more frequent
target for autoantibodies in pediatric MS than MAG or OMG.
MOG AUTOANTIBODIES IN PEDIATRIC MS
The Journal of Immunology
Acknowledgments
We acknowledge the contributions of the site investigators who contributed
to the collection of the clinical samples. Members of the Wadsworth Pediatric Multiple Sclerosis project include: Silvia Tenembaum (Hospital de
Pediatria, Buenos Aires, Argentina), Anita Belman (SUNY, Stony Brook,
NY), Alexei Boiko and Olga Bykova (Russian State Medical University,
Moscow, Russia), Jayne Ness (Children’s Hospital of Alabama, Birmingham, AL), Jean Mah and Cristina Stoian (University of Calgary, Calgary,
Ontario, Canada), Marcelo Kremenchutzky (London Health Sciences, London, Ontario, Canada), Mary Rensel (Cleveland Clinic Foundation, Cleveland, OH), Jin Hahn (Stanford University, Stanford, CA), Bianca Weinstock-Guttman and Ann Yeh (SUNY, Buffalo, NY), Kevin Farrell
(University British Columbia, Vancouver, BC, Canada), Mark Freedman
(University of Ottawa, Ottawa, Ontario, Canada), Emmanuelle Waubant,
University of California, San Francisco, CA), Martino Ruggieri (University
of Catania, Catania, Italy), Matti Iivanainen (University of Helsinki, Helsinki, Finland), Virender Bhan (Dalhousie University, Halifax, Nova Scotia, Canada), and Marie-Emmanuelle Dilenge (Montreal Children’s Hospital, Montreal, Quebec, Canada).
Disclosures
The authors have no financial conflict of interest.
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ADEM had Abs to MOG, whereas 92% of MOG negative pediatric MS patients did not have an ADEM-like initial event. Prospective studies are required to further define the relationship between MOG Abs and ADEM as well as pediatric MS.
Why have we only detected Abs to MOG, but not MAG or
OMG, which are also myelin surface Ags with large extracellular
domains? Chronic inflammation can result in immune responses to
multiple self-Ags, a phenomenon referred to as epitope spreading
(50). However, significant immune responses are not mounted to
every Ag in the target structure. MOG is a highly encephalitogenic
protein in immunization-based animal models of MS and is the
only known myelin component to induce pathogenic Ab and T cell
responses (51, 52). MOG also has substantial sequence similarity
with the milk protein butyrophilin, and Ab as well as T cell crossreactivity between these Ags has been demonstrated (53, 54).
Why does the prevalence of these autoantibodies change with
age at disease onset in pediatric populations? Several general and
possibly interrelated factors may be involved: genetic susceptibility, the kinetics and magnitude of the autoimmune response, environmental factors, and the biology of myelination during childhood. In type I diabetes, children with particular combinations of
MHC class II genes are more likely to become diabetic at a young
age and thus appear to carry a higher genetic risk (55). Similarly,
children who develop MS at a young age may carry combinations
of genes that raise susceptibility to MS to a higher level than in
individuals who develop MS later in life. The frequency and functionality of MOG-specific T cells could also affect production of
MOG Abs. The importance of T cell–B cell collaboration was
highlighted by recent studies which showed that genetically engineered mice with a high frequency of both MOG-specific T cells
and B cells spontaneously develop severe CNS inflammation,
whereas mice with only a high frequency of MOG-specific B cells
remain healthy (56 –58).
This study shows that MOG Abs identify a subset of pediatric
MS patients with a very early disease onset. In contrast, MOG Abs
are less common in patients with adult-onset disease. Future studies will address the pathogenetic significance of the emergence of
such autoantibodies in pediatric demyelinating diseases.
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MOG AUTOANTIBODIES IN PEDIATRIC MS