J Neurol (2008) 255 [Suppl 6]:2–6 DOI 10.

1007/s00415-008-6001-2

Thomas Korn

Pathophysiology of multiple sclerosis

T. Korn (౧) Technische Universität München Klinikum rechts der Isar Dept. of Neurology Ismaninger Str. 22 81675 München, Germany Tel.: +49-89/4140-5617 Fax: +49-89/4140-4675 E-Mail: korn@lrz.tum.de and Harvard Medical School Center for Neurologic Diseases 77 Avenue Louis Pasteur Boston, MA 02115, USA

■ Abstract Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS). Both genetic and environmental causes for MS have been suggested. Recent genome-wide association studies revealed new susceptibility alleles for MS besides the HLA complex that are all related with immune functions. Whereas there is little evidence to support a purely environmental trigger for the disease in the sense of an infectious agent, the autoimmune hypothesis of MS is well

established. Myelin antigen-specific CD4+ T cells become activated in the peripheral immune compartment, cross the blood-brain barrier and trigger the disease. Here, current concepts of the commitment of T cells to pro-inflammatory effector T helper cell lineages including Th17 cells that appear to be important inducers of organ-specific autoimmunity will be discussed. ■ Key words multiple sclerosis · autoimmune inflammation · risk alleles · T helper cell subsets

Genetic studies
The risk of developing MS is increased if a first-degree relative suffers from the disease. Whereas the lifetime incidence of MS is 0.1 % in the normal population, siblings of MS patients carry a lifetime risk of 3 % or – if they are twins – even up to 25 % will develop the disease [28]. Although these rates change depending on gender and age, epidemiologic data strongly suggest the existence of a genetic disposition [28]. Recently huge efforts have been undertaken to identify potential risk alleles that predispose for MS. Whereas linkage studies revealed specific HLA alleles as MS risk genes [5, 29], this approach is usually not powered to identify risk alleles which contribute to the risk of developing MS with an odds ratio of less than two [27]. In order to overcome this problem, association studies that measure the frequency of an MS patient to inherit a certain (pre-defined) allele from heterozygous parents have been performed. This technique requires the availability of genetic material from parents and offspring (so-called trios) to detect risk al-

leles based on single nucleotide polymorphisms (SNPs) on a genome-wide level. Using this genome-wide association study approach, several alleles including polymorphic variants of the IL2Rα, the IL7R, and the CD58 genes were newly identified as risk alleles for MS [10]. The expression of the related gene products on leukocytes suggests a role of these molecules in the immune-mediated pathologic cascade of MS. Further studies will have to correlate the genetic variants with altered protein expression or function and provide mechanistic support for the significance of these gene polymorphisms.

Infectious agents and MS
Every once in a while, MS has been hypothesized to be an infectious disease. Potential pathogens blamed to cause MS have been among others Chlamydia pneumoniae [32], human herpes virus-6 (HHV-6) [31], and Epstein-Barr virus (EBV) [30]. Evidence for these hypotheses was based on the isolation of genetic material or

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proteins of microbial agents from MS lesions. Additionally, T cell or antibody responses against various microbial agents have been measured in MS patients. In a recent report, EBV genes and EBV proteins associated with both latent infection and re-activation of the virus have been identified in post-mortem brain specimens of MS patients [30]. However, this has not yet been reproduced by other groups. The significance of these findings is unclear at present. Unless unequivocal evidence can be provided by illustrating that the postulates of Koch have been met, a pathogenic role of a specific infectious agent in MS cannot be established.

Autoimmune hypothesis of MS
The hypothesis that MS is an autoimmune disorder is supported by several lines of evidence. First, myelin antigen-specific T cells can be isolated from peripheral blood lymphocytes of human individuals [24]. Thus, either aberrantly high precursor frequencies of autoreactive T cells due to failure of central (thymic) tolerance mechanisms or aberrant activation or skewing of autoreactive T cells in the peripheral immune compartment due to failure of peripheral tolerance mechanisms can potentially lead to T cell-triggered autoimmune tissue inflammation. It is unclear how T cells with autoreactive T cell receptors (TcRs) are activated in the peripheral immune compartment when their cognate autoantigen is sequestered in the CNS and thus is not presented to T cells in the periphery. However, since TcRs are degenerate, there is the possibility of cross reactivity and the concept of molecular mimicry implies that autoreactive T cells might become activated in the peripheral immune compartment by cross-reacting with antigens such as particular microbial agents. Second, excellent evidence supporting that MS is an autoimmune disease comes from studies with altered peptide ligands (APL) in humans. APL were designed as partial agonists or antagonists to the TcR of autoreactive T cells. The initial idea was to either abrogate the activation of autoreactive T cells or to induce antigen-specific T cells with regulatory rather than inflammatory properties. Unfortunately, when tested in a clinical phase II trial, an APL to MBP83-99 led to exacerbation of MS and clinical relapses in a subgroup of patients. In prospective immunological studies it was shown that relapses were preceded by expansion and activation of MBP-specific and presumably encephalitogenic CD4+ T cells in the peripheral immune compartment [2]. These data strongly suggest that MS is triggered by autoreactive CD4+ T cells activated in the peripheral immune compartment. Third, experimental autoimmune encephalomyelitis (EAE) is an animal model that recapitulates key histopathological features of MS and is widely used to simu-

late autoimmune inflammation and demyelination in the CNS [9]. In “classic” EAE, disease is induced by immunization of susceptible rodent strains with a myelin autoantigen emulsified in complete Freund’s adjuvant. Within a week after immunization autoreactive myelin antigen-specific CD4+ T cells are activated and expand within the peripheral lymphoid tissue [37]. Ten days after immunization, activated T cells begin to cross the blood-brain barrier in massive amounts; in contrast, unactivated T cells are not able to cross the blood-brain barrier [7]. In the perivascular space of the CNS vasculature, myelin antigen-specific CD4+ T cells become reactivated in a MHC class II restricted manner [14]. This leads to further activation of T cells and production of effector cytokines and chemokines in the CNS. Subsequently, immune cells like granulocytes and macrophages are attracted into the CNS parenchyma mediating tissue inflammation and demyelination [4]. Secretion of toxic species, such as, nitric oxide (NO) and tumor necrosis factor(TNF), and degradation of myelin are consequences of this cascade [25, 38]. As in MS, the inflammatory episode in EAE wanes spontaneously and the animals recover suggesting that T cell-mediated inflammation in the CNS is regulated even in the absence of a therapeutic intervention. Depending on the strain of mice and the autoantigen used to immunize, relapses can occur. EAE has been an invaluable tool to investigate the T cell-dependent pathogenesis of autoimmune inflammation in the CNS and firmly established the pathogenic role of activated autoreactive CD4+ effector T helper cells in orchestrating autoimmune demyelinating inflammation in the CNS. Moreover, three of four approved treatments for MS, i. e., glatiramer acetate [16, 35, 36], mitoxantrone [26], and natalizumab [42], were first validated in EAE.

CD4+ T cell driven organ-specific autoimmunity and Th17 cells
Apart from recapitulating clinical and histopathological properties of MS, EAE has been used to investigate the differentiation of CD4+ effector T helper cells in vivo and to define essential effector functions of autoreactive T cells. Upon activation of their TcR in the presence of costimulatory molecules, naïve T cells differentiate into various subsets of effector T cells with distinct effector functions. Whereas Th1 cells secrete large amounts of IFN-γ, Th2 cells do not produce IFN-γ, but secrete IL-4. Th1 cells are essential in host defense against intracellular pathogens, whereas Th2 cells mediate humoral immunity and are important in clearing extracellular pathogens [23]. This Th1/Th2 paradigm has been firmly established since differentiation factors and master transcription factors for Th1 and Th2 cells have been de-

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IL-12
IFN -γ

STAT4 T-bet

Th1 (IFN-γ): Host defense (IC pathogens) Autoimmunity

Naïve T cell

IL-4
TG F -β + IL-6

STAT6 GATA3 c-maf

Th2 (IL-4, IL-5, IL-13, IL-25): Host defense (parasites) Allergy, asthma

/IL-

21
STAT3 RORγt

IL-23

Th17 (IL-17, IL-17F, IL-21, IL-22): Host defense (EC pathogens) Inflammation, autoimmunity

Foxp3

T-reg (TGF-β, IL-10): Tolerance, immunosuppression

Fig. 1 Upon stimulation of their TcR in the presence of costimulatory signals, naïve T cells in the peripheral immune compartment develop into different subsets of effector T helper cells. This differentiation process is directed by a specific cytokine milieu as indicated leading to the expression of transcription factors specific for the respective lineages. For example, STAT-4 and T-bet are the transcription factors that direct commitment to the Th1 cell lineage. The target genes of the master transcription factors both ensure responsiveness of T cells to specific maturation and growth factors such as IL-12 for Th1 cells and IL-23 for Th17 cells and also stabilize the functional phenotype of the T helper subsets. The effector functions of T helper cells are defined by the hallmark cytokines that they produce. For example IFN-γ is the key effector cytokine of Th1 cells which is essential for their function in host defense against intracellular (IC) pathogens such as Listeria monocytogenes. In contrast, IL-4 is the hallmark cytokine of Th2 cells and is important to orchestrate humoral immune responses to clear extracellular (EC) pathogens. Th17 cells have recently been defined as a subset of their own (see text). Their presumed effector functions are indicated. Interestingly, whereas TGF-β alone leads to the induction of the transcription factor Foxp3 and thus the development of regulatory T cells (Treg) in the peripheral immune compartment, the combination of TGF-β plus IL-6 or IL-21 induces inflammatory Th17 cells suggesting a reciprocal developmental pathway between these newly defined T cell subsets. Defining the switch factors between the T-reg and Th17 developmental pathways in vivo might provide us with exciting new molecular targets for therapeutic interventions in our effort to modulate immune responses in autoimmunity, chronic inflammation and cancer

not be categorized according to the Th1/Th2 paradigm, these effector T helper cells were subsequently termed Th17 cells (Fig. 1). Since naïve T cells do not express the IL-23 receptor, IL-23 was refuted as an initial differentiation factor of Th17 cells. Rather the combination of TGF-β plus IL-6 or IL-21 were identified as differentiation factors of Th17 cells in mouse and man [1, 17, 21, 34, 39]. However, IL-23 is still required as growth and maturation factor of pathogenic Th17 cells in vitro and in vivo [22]. Since the discovery of their differentiation factors (TGF-β plus IL-6) and the transcription factors STAT-3 and ROR-γt required for the development of Th17 cells [13, 40, 41], this subset of effector T helper cells has been firmly established as independent lineage. Th17 cells have effector functions that are distinct from those of Th1 or Th2 cells and it is believed that specific pathogens such as perhaps Klebsiella spp. or fungi that may not be well covered by Th1 or Th2 responses are particularly prone to induce Th17 responses for host defense. However, due to their exquisite capacity to infiltrate tissues and cause severe tissue inflammation, Th17 cells are associated with a series of autoimmune or chronic inflammatory disorders such as MS [15, 19, 33], rheumatoid arthritis [11], psoriasis [20], and inflammatory bowel disease [8]. It is unlikely that Th17 cells exert their highly inflammatory potential solely by secreting IL-17, but other cytokines or effector molecules produced by these cells will contribute to their unique effector phenotype. Thus, further efforts will be required to investigate the effector functions of Th17 cells in vivo and to define molecular targets, such as IL-23 or its receptor, that might be suitable for specific therapeutic interventions.

fined (Fig. 1). Dysregulated Th1 responses have largely been regarded as responsible for organ-specific autoimmunity including MS since IFN-γ has been detected in active MS lesions and in EAE at the peak of disease, whereas the levels of IFN-γ declined during recovery [12]. However, this concept was seriously challenged, when it was discovered that mice genetically deficient in IFN-γ were not only unprotected from EAE, but also developed more severe disease [6]. On the other hand, IL-23 deficient mice are completely protected from EAE [3]. IL-23 is a member of the IL-12 family of heterodimeric cytokines and shares the p40 subunit with IL-12, but has a unique p19 subunit. Whereas IL-12 is an essential differentiation factor for Th1 cells, the function of IL-23 was unknown. IL-23 KO mice, which are completely resistant to EAE, were found to be devoid of a particular subset of CD4+ T cells that produced IL-17 [18]. Thus, IL-23 was hypothesized to be important for the differentiation of a subset of IL-17 producing T helper cells. Since IL-17 can-

F TG -β

Concluding remarks
At present MS has to be considered an autoimmune disease which is triggered by autoreactive CD4+ T helper cells. Although many aspects of the pathogenesis of MS including the role of antibodies in demyelination are still incompletely understood, the role of effector T helper cells in the initiation of autoimmune tissue inflammation is fairly well established. The discovery of Th17 cells has resolved many inconsistencies in the concept of T cell triggered organ-specific autoimmunity. But many questions are still unanswered, such as what are the exact effector functions of Th17 cells in vivo, how – if at all – do Th17 cells have to cooperate with IFN-γ producing Th1 cells in order to induce tissue inflammation in the CNS, and which mechanisms control and restrain Th17 mediated autoimmune reactions. It is certainly too much to announce another paradigm shift in MS pathogenesis, but we are currently witnessing important conceptual changes in T cell biology, including

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important questions such as lineage commitment of T cells and T cell plasticity. The answers to these questions will improve our understanding of the pathogenesis of chronic inflammatory disorders.

■ Conflict of interest The author declares no conflict of interest. ■ Acknowledgment T. Korn is supported by the Deutsche Forschungsgemeinschaft.

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