ACTIVATION OF T-CELLS- MAJOR KEY TO

MULTIPLE SCLEROSIS
1. INTRODUCTION:

1.1 Multiple Sclerosis:

Multiple Sclerosis(MS) is an autoimmune demyelinating disorder characterized by distinct

episodes of neurologic deficits, separated in time, attributed to white matter lesions that are

separated in space.1 It is one of the most well known disorders related to demyelination occurring

as frequently as approximately 1/1000 persons in the United States and European countries.1 It is

rarely seen in childhood and above the fifth decade, but otherwise its occurrence is widely

distributed. Symptoms begin with vertigo, fatigue, optic neuritis and weakness in the extremities.

Symptomatic progression occurs with ataxia, paraparesis, limb spasms, and cognitive disarray.2

Gender bias is twice for women to men. The disease causes preferential damage to myelin tissue

relative to the axons. Symptoms arise due to the myelin loss and hence its effect on electrical

transmission through axons. The course of the disease is confounded by the fact that myelin-

regeneration is very limited and huge secondary insult is caused to the axons as a result. In most

of the subjects, the clinical course of the disease is seen to evolve round the spiral of relapse and

remission of episodes of neurologic deficits separated by varying time gaps of weeks, months to

years. This is generally followed by gradual or partial improvement in neurologic functions. The

recurrence of this episodic relapse tends to decrease during the course of the disease, but steady

neurologic deterioration is seen in patients.

1.2 Epidemiology & Etiology:

MS is mostly observed in the cold and temperate regions. It is less common in the southern parts

of US, while its prevalence is double near the Lake region.3 In western EU, the rate corresponds

directly to higher latitudes. There have been evidences to show that in certain areas the disease

the prevalence has been sinuous with wars or invasions which led some scientists to believe that

some infective agents brought the disease. It is also seen that migration has a risk for spreading
 the disease, especially under the age of fifteen, to the new environment. The risk of the disease is

practically absent in the color-skinned people of the African Continent and the people of the

Indian Subcontinent, China and Japan. Even the American colored skin and Hispanic population

shows half the risk than the non-colored part. 4

Data collected purely suggest that environment and genetic predisposition are the main cause

behind the onset of the disease.

Genetic Factor

The risk for a first line relative of a patient having MS is 7 times more than a normal subject. In a

demographic study conducted by Elber et al, 27 monozygotic and 47 dizygotic twins were

identified, 25.9% of the former type and 2.3% in the later variety were showing up for MS,

proving the point that MS has a probable genetic link.5 However, multiple cases of family studies

failed to prove the inheritance pattern. It is thought to be in association with HLA alleles. Major

Histocompatibility Complex (its role will be later discussed) is situated on the short arm of

chromosome 6, codes for 3 classes of products which are a part of immune response. Among

them class I & II are related to MS. These are thought to be very important components specially

in coordinating the cross talks between the various components of the immune system in

differentiating between self and non-self forms. They act in concert with the Class Differentiation

proteins which form the basis of the T cell functioning. Class II has two subunits α & β, both

intrinsic proteins, heavy and light respectively. The HLA alleles have a component called the

D2R which is found to be integrally associated with the disease. The HLA d is subdivided into 3

regions, one of those being the DQR2,6 which is commonly distributed in 97% of MS patients

and is significantly scarce in normal population. It is further proposed that the other haplotypes

present may act as protectors. A2, B17 are found in normal population and not in MS. It is

important to mention here that HLA products may act as good markers of MS but not directly

take part in conferring susceptibility.6

1.3 Classification
 Throughout the history of the disease various classifications have been in order. They hold

importance because it helps to determine the essence in prognosis and also takes part in therapy.

In 1996 the presently viable and most widely accepted classification was provided by United

States National Multiple Sclerosis Society:

A. The relapsing-remitting subtype is characterized by relapse in the disease state after periods

of remission ranging upto months and often years which is unpredictable and moresoever, no

new signs are visible during this period. Problems suffered during attacks may either resolve

or leave consequences. This describes the initial course of 85–90% of individuals with

MS. When deficits always resolve between attacks, this is sometimes referred to

as benign MS.

B. Secondary progressive MS describes those which begin with initial relapsing-remitting MS.

This is followed by rapid and gradual decline of neurological states, periods of intermission

being unpredictable. Relapses and remissions may be alternating each other.

C. The primary progressive subtype describes a small amount of the population having MS.

Here there is no remission and rapid deterioration continues right after the first attack. This

happens much later on in age course.

D. Progressive relapsing MS describes those persons who from the very beginning, have a

rapid neurologic snub. They may also have concurrent attacks.7

1.1 Morphology of MS:

MS is nothing but a neurodegenerative disoreder of the white matter. Much of the surface of

the hemispheres is covered by gray matter and macroscopic diagnosis of the peripheral

aspects of gyri is confusing. But on the contrary, the pathologic condition may be found in

the surface areas of the brain stem such as the basis pontis and the length of the spinal cord.
 Fig. 1 Graph Representing Various Kinds Of MS

Here the myelin tracts can often be seen on the surface. Lesions appear as large numbered,

distinctly marked, concave shaped at the centre, translucent gray colored and undulating rough

surfaced plaques. Plaques can be observed all along the white matter of the neural axis.

Sometimes extensions into gray matter may be seen. This is because they have white matter

running in between them, the recognition however being somewhat precarious. When fresh they

have more solid consistency than the surrounding white matter also called the sclerosis.. Diameter

of lesions may vary, the ones with smaller foci may only be visible with microscopy ranging to

ones which are confluent enough to cover larger parts of centrum semiovale. Plaques are present

by the lateral ventricles and follow the path of paraventricular vein. These are also found to be

present in the optic nerve, chiasma, brain stem, asneding and descending fiber tracts, cerebellum

and spinal cord.1

 The lesions have very precise borders. Plaques are of 3 types: active, inactive and shadow

plaques. In the first kind there proof of progressive myelin breakdown with plenty of

macrophages containing lipid rich, PAS positive debris. Inflammatory lymphocytes and

monocytes are present as perivascular cuffs. These are mostly found on the outer edge of the

lesion. Smaller ones are often found on the edge of veinlets. Inside a plque there is relative

preservation of axons and depletion of oligodendrocytes. In course of the disease they undergo

reactive changes. As lesions quiescent out inflamaory cell infiltration and macrophage invasion

diminishes. But in case of the inactive plaque, little or no myelin is found along with decrease in

oligodendrocytes nuclei. Instead it is seen that astrocytic proliferation and gliosis predominates.

Axons in older gliotic plaques are mostly devoid of myelin and show decrease in population.

In some plaques also called the shadowy plaques, the adjutant region of the normal to diseased

white matter is diffuse. Here exceptionally thinned out myelin sheaths can seen. This can be

attributed to partial loss or even remylination by surviving oligodendrocytes. Recently MRI

studies have ushered the fact that plaques may be silent in any stage of disease and even when

MS is clinically active. Sub-classification of active plaques have recently been made, ones are

sharply demarcated and placed at the centre of vessels.8 They may have(I) or may not have(II)

immunoglobulin and complement deposition, the others are not well marked or centrally

situated(III & IV). In the later two oligodendrocyte apoptosis is marked either in a varied or

concentrated fashion. Autopsy studies indicate that only two types of patterns are present in an

affected individual referring to the fact that they may be related by common mechanisms rather

than symbollising the stage of the disease.9

2. IMMUNOLLOGY BEHIND MS

2.1 Autoimmune Components of MS

MS is by and large a neurodegenerative disorder, but autoimmune responses are the causative

agent behind the neurodegenration. The likelihood of the start of an AI response is largely
 dependent on environmental and genetic factors.1, 8 In this case the cellular immune response is

misdirected towards the myelin tissue causing enormous damage to the insulating materials.

sImmune response has a great deal to do with the majority of the inflammatory components

present in and around the plaques. The link to the MHC and the D2R long haplotype has also

been a spot of affirmative speculation. The inflammatory reactions that occur help direct the

immune reaction towards the myelin tissue and the inflammatory components released. This

causes the basis of the misdirected response of the immune system towards the tissue. The

immune response is lead by the Th 1 and Th2 cells, whereas the CD 4+ system plays a vital role

alongwith. These autoimmune attacks cause secretion of interleukins locally causing recruitment

of macrophages. The macrophages are the components who cause the eating of the myelin

tissues.

2.2 T Cells, MHC And Class Differentiation Proteins

Before we understand the bedrock cause of the autoimmune reaction that underlies MS, it is

better to put some insight into the individual players. T cells are a major component of the

autoimmune response in MS. What are they?

T cells are a part of the subtype of adaptive immunity called the cellular immunity, mostly

responsible for the protection of intercellular microbes. These are generated from precursor naïve

cells in the thymus. The genetic programming of T cells enable them to recognize antigens

associated with cells with T-cell Receptor(TCR). These are further antigen specific and recognize

the pattern of major histocompatibility complex molecules on the cells themselves associated

with the antigens. The TCR contains multiple polypeptide chains. Three of them form the CD

complex. Their main function is to transfer signals from the antigen to the T cell. The CD

complex is a polymorphic set which is assigned specific function. They are many in number

which inckude CD3, 4, 3+, 8, 25, 35, 72 and so on and so forth. More than half of the CD3+ cells

are found to express the CD4 and 8 cells. They serve the function of co-receptor in receiving
 signal from the T-cells. They are glycoprotein in structure. The antigen presenting cells, as

mentioned earlier, express the MHC class on it, and the CD molecules bind to them during

antigen-presentation. This CD and MHC together form the bedrock of functioning of the Th1 and

2 cells. Thus it is apparent that antigen recognition is dependent on the CD proteins to bind with

the MHC and hence the functioning of the T cells. The CD 4 are associated with MHC I and the

CD 8 rae associated with the MHC II subset. The T cells require two signals in order to become

active, one from the Cd 4 and 8 in association with the MHC and the other sent by the interaction

of CD 28 with stimulatory B7-1 or CD 80 molecules. The Cd 8 cells act for the cytotoxicity and

natural killer cells. While the CD 4 cells act as an overall regulator. The T helper cells, Th1 is

associated with the secretion of inreleukin2 and interferon gama, whereas the Th2 subset is

responsible for synthesis of inflammatory components IL 4, 5 and 13. Thus they along with CDs

act to synthesize ILs and IGEs and render their cytotoxic power.

It is pertinent here to mention that a fine balance exists among all of these components, any

disturbance leads to conditions of autoimmune response. The balance is maintained by natural

capacities of immune tolerances, both central and peripheral. Anergy, suppression and clonal

detection are responsible for fine tuning, their detailed role is beyond the scope of the present

discussion. Gene succeptibilites, viral infections and inflammatory processes along with

abnormal expression of proteins are responsible factors destabilizing the balance.

2.3 Targeting The Myelin Tissue

When the lesions are formed, an inflammatory process quickly attacks them. They are infested by

the inflammatory components. The macrophages along with T lymphocytes are abundantly

present in or around the plaques. The myelin sheath has a protein called the MLP which often

mimics viral antigens or other antigen presenting cells. This cause the massive recruitment of

inflammatory processes to circumvent the entire region and T cells response to the entire change

in micro-environment. This in turn starts recruiting the macrophages and oligoclonal antibodies

like IgG. Interleukin secretion starts locally and a massive onslaught is experienced by the region
 in terms of immune attack, inflammatory response, antigen antibody response and scavenger

system activation, causing an outright insult to the myelin tissue. Activated T cells are found to

infiltrate as far as the centre of the lesions in old and chronic cases. The immune response is

mounted from the peripheral system when the auto-suppression mechanism fails to act properly.

Moreover, it is seen that migration of Nk cells and T cells takes place from peripheral parts to the

CNS. Whether the disease starts from peripheral regions or the CNS is a matter of further study,

as there is immense records suggesting that serum levels of T cells and IgG increase before

subsequent attacks.6 But it is uncertain what is the cuastive mechanism that underlies this sudden

increase in immune components and their trafficking towards the CNS, especially the Myelin

tissues. It is proposed that the pressor-supressor action of the CD 8 cells are somewhat disturbed.

IFN gama may play a role here by mounting cell mediated immune response. This is further

supported by the fact that IFN gama has been widely found in the glial and inflammatory plaques.

Studies have shown that IFN and T cells in vivo can also cause severe myelin degradation.

1. INFLAMATORY AND VIRAL CAUSE FOR AI REACTION

1.1 Inflamatory Process in MS

The formation of plaques as discussed earlier is promulgated by AI response. But it has been

studied to details that inflammatory processes both in and out of the CNS are the starting factor

for the AI response to be mounted on the target tissue. Many inflammatory components inside the

plaques and presence of macrophages targeted towards the myelin tissue and oligodendrocytes

points to the fact that inflammatory processes participate in the plaque formation. Both the

peripheral T cells of the immune system and the insider inflammatory components act in concert

in precipitating MS attacks. Though the starting point of the inflammatory process is not yet

certain but hypotheses have been propounded opining that a small injury caused in the tissue or

walls in surrounding vasculature attracts inflammatory agents and starts the process of cytokine

secretion and proliferation. Cytokines such as IL beta and 6 along with TNF alpha has been

actively found in plaques in molecular level. CSF studies of MS patients show the presence of
 secondary inflammatory agents such as Csf, chemokines and lipids and eicosanoids in circulation

and in the plaques themselves. This secretion of cytokines and presence of leukocytes in and

around the gray and white matter sets the stage for an immune response mounted by the cellular

system, where the tolerance and self recognition threshold, by now, seems to be overdrawn. To

add to this school of thoughts is the fact that myelin specific immune components are available in

the blood of normal subjects. It is found that inflammatory response helps in coupling of the

naïve and memory CD cells. Their increase in concentration in response to TNF, IL and IFN is

correlated with increase in Ca ion concentration by either IP3 or IFN activity. 10 The CNS part of

the inflammatory process helps in damaging the myelin tissue. These released debris attract or

recruit microglial cells, starts eating the tissue and help expressing the MHC. Thus the peripheral

triggering of the autoimmune component via T cells due to peripheral increase in inflammatory

components and the concomitant release of inflammatory components inside the CNS cause a

dual triggering attack on the myelin tissue. The Th1 cells cause further damage to the myelin

tissue due to the presence of myelin components and alreadt present myelin antigen in the natural

immune repertoire. The process would have been controlled in a normal person by apoptosis if

there would not be present the constant challenge of anti-myelin components. There is also an

inward flow into the CNS of the peripherally circulating T cells attracted by the T cell activation

and pairing with the MHC. So the activation and inactivation of the T cells and CD subset in

response to the inflammatory process is the key to MS plaque formation which ultimately leads to

myelin eating by targeting antigens.

3.2Viral Element

Many has proposed for a viral back ground for the MS origin. As stated earlier, a school of

scientists opined that even in some countries, which were previously unknown of MS, the disease

came thorugh some viral vector during wars. There has been a long drawn relation between the

Measles virus and MS which in recent times has been speculated to a great extent, as there is no

link between the two to confirm the link. Antibody studies have shown that there is not enough
 amount missle antibody in the CSF of MS patients. 6 A link however exists between the myelin

basic protein and the nucleocapsid structure of the viral body. Various states of the

neurodegenerative disorders have been linked with viral genomes and reisdues. It is thought that

there is link between the inflammatory process and the virus. But this an area of further debate to

show any definite relation between the two.

2. INTERVENTION

2.1 Therapies Available And The Most Used One

There have been a set of therapy available for MS, most of the used ones being ameliorative and

not addressing the cause of myelin regeneration. They give a symptomatic relief and except for

the potential application of stem cells no other therapies hold promise for regeneration of lost

myelin tissue. The tissue itself has very limited regenerative capacity and most of the

interventions are immune-modulatory. Here we look at the immuno-modulatory therapies

available. How they act on the T cell and the CD subset is a matter of great interest to all of us, as

it holds key to better understanding of the autoimmune part and can help us target better drugs in

future. As mentioned above the Hematopoietic Stem Cell Transplantation (HSCT) following

aggressive high dose immune-suppressive therapy is the area which is being looked upon with

great interest. High Dose Cyclophosphamide (HDC) “Rebooting” and Fingolimod treatment are

some other means of treatment11. Detail of these are beyond the scope of this article as we

concentrate on the monoclonal antibodies and the zumabs as the immune-modulatory approach

dealing with AI attack.

Monoclonal antibodies are really good targeted form of therapeutics. They act by specific surface

molecule detection mechanisms. The character and position of the molecule targeted defines its

function and fate. They can either bind to or block or cause change in signal transduction with the

targeted molecule. The effect on the molecule depends on killing of the molecule or the targeted

cell by activating classical pathway by complement dependent cytotoxicity. The cells may also

die by antibody dependent cellular cytotoxicity which may terminate the immune onslaught
towards the myelin tissue. And last but not the least is the mechanism of phagocytosis which

helps in clearing the debris and inflammatory leftovers. Anti T12, anti CD3, OKT3, anti TNF2

and anti CD152 are some of the many mAbs used in MS. Alemtuzumab, the anti-CD52 AB is

another potent therapeutic intervention.12 It binds with CD52 which is expressed on Th2 cells and

is human IgG1k. they have been used in MS when the severity of new plaque formation has been

reduced to a great extent. Results are yielded in 3 to 9 months. They probably act by the CDC and

antigen dependent mechanisms. It has a strong effect on the inflammatory process involved in

MS. Various experiments have proved that it is very efficacious in early MS cases and decreases

a lot of progression in regard to debilitating symptoms. They probably cause a rapid decrease in

the CD52 cells and make the Th2 cells more susceptible to apoptosis. Steep decrease in CD

concentration in the peripheral blood takes place after systematic treatment with the drug.

Daclizumab is another human IgG1 which is found to at on the alpha chain of the IL 2 binding

domain. CD25 is rapidly up regulated in the activated T cells and in turn cause increased

receiving of IL2 signals. This scene of action on the IL2 is important in action of the Th2 cells,

which, it is believed, is blocked when the CD25 is checked to interact with the MHC and hence

has been proved to act as a very useful pathway to stop aggravation of MS plaques. Treatment

with this particular drug led to rapid change in plque morphology including decrease in volume

and roughness of plaques. The number of contrasting plaques has also decreased and the drug has

shown better results in comparison with IFNs. In studies it has been found that daclizumab acts

on the immature dendritic cells and also check the production of cytokines and T cell priming in

the lymph nodes. There has been found a significant increase in the Nk cells and depletion of

CD4+ and CD8+ cells in patients treated with the drug. The drug natalizumab is also a humanized

IgG4k derived mAb. It does not act by CDC but rather inhibits the ligand binding in the T cells

and the CD subset. Its mechanism of action has not yet been confirmed but evidence points

towards the fact that they inhibit interaction of cell adhesion molecules with the subunits of

antibodies which is otherwise important to cross the BBB. The drug is presently in phase-II

clinical trial but the only hurdle with it is that it has shown increased rates of relapses in some MS
 patients. These drugs significantly decrease the concentration of the Cd4 and Cd8 cells along with

lymphocytes and inflammatory components in the peripheral blood stream and the CSF. Another

drug rituximab is also an IgG1k of human origin which is used as add on therapy. It has a strong

anti-inflammatory action.

2.2 Drawbacks

All of these therapies mentioned above have some or the other plethora of side effects, adverse

drug reactions, elimination problems or farfetched effects which limits their use in chronic

therapeutics. Nonhuman source derived materials have the potent threat of immunogenicity. That

is why research have been dedicated towards chimerical and primate sources plus attenuation of

certain characters. Drugs like aletuzumab has the typical cytokine release syndrome associated

with it, fever, blood pressure abnormality and malaise being common. Above all it builds up

resistance after repeated use and also has shown some chances of immune reactions in

individuals. No long-term data is yet available to prove its safe and efficacious use in chronic

cases. Daclizumab has relatively lower side effects but resistance and mis-targetting remains a

problem. Its action through NK cells has profound effect on all kinds of CD subsets and causes

myelosuppression. Natalizumab has got serious infections associated with it, such as pneumonia

and urosepsis. Rituximab too has serious implications such as respiratory distress, myocardial

infarction, anaphylactic shocks, hyperkalemia, hypocalcaemia, tumor lysis syndrome and acute

renal failure. So it has been seen that the most important and common side effects in all the drugs

presently available for treatment of MS are immune reactions which are unwanted and resistance

alongwith the potent side effects like bone-marrow suppression and organ failures.

4.3 Discussion And Conclusion

Thus it has been seen in the above discussion that the drug targets presently available are not

leak-proof. The mechanism of precipitation of plaques lies in the fact that the CD and the Th2

cells are targeted towards the myelin tissue either aroused by the inflammatory response or

mounted by cytokine release. Possible and viable mechanisms of targeting MS is off-course

controlling the Cd and Th2 cell release and their targeting towards the myelin tissue. Therapies

help in controlling this self directed immune response by causing immunomodulation. The other

side of the therapeutics involves aggressive anti-inflammatory intervension. Future studies should

be aimed at better targeting of the immunomodulatory agents towards specific sites. The question

that is unresolved till date is what is the certain mechanism that causes his inflammatory process

to start and cause the homing of the T cells. It is also not fully understood how the plaques are

related to the myelin eating process and what are the specific mode of action of the

immnuomodulatory agents in controlling the plaque advancement and immune onslaught. A

deeper understanding of this mode of action or rather more close knowhow of the interaction at

molecular level related to CD and T cells activation perhaps hold the key to better drug targeting.

The drugs could be bound with specific surface coating of antibodies or glycol[roteins which can

differentiate between the diseased state and the normal functioning of the immune system so that

only selective immunomodulation takes place. Genetic trends and subject specificity are other

areas where a database would rather help in rationalizing therapy.

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