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Journal of Autoimmunity 52 (2014) 146e153

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Journal of Autoimmunity
journal homepage: www.elsevier.com/locate/jautimm

Review

Genetic basis of myasthenia gravis e A comprehensive review


Nili Avidan a, *, Rozen Le Panse b, Sonia Berrih-Aknin b, Ariel Miller a, c
a

Pharmacogenetics and Translational Genetics Center, Rappaport Faculty of Medicine & Research Institute, Technion-Israel Institute of Technology, Efron 1,
Haifa 31096, Israel
b
INSERM U974, CNRS UMR 7215, UPMC Univ Paris 6, AIM-Institute of Myology, Paris, France
c
Division of Neuroimmunology and Multiple Sclerosis Center, Carmel Medical Center, Haifa, Israel

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 8 July 2013
Accepted 2 December 2013

Myasthenia gravis (MG) is a rare autoimmune disease characterized by the production of autoantibodies
against proteins of the postsynaptic membrane in the neuromuscular junction. The estimated number of
MG patients is steadily increasing, and it had more than doubled in the last 20 years. Monozygotic MG
twin concordance is estimated to be about 35% supporting the central role of environmental factors in
MG etiology. Epigenetics, presume to be the mechanistic link between environmental and genetic risk
factors in disease development, provides support for specic microRNAs associated with MG. Genetic
studies have mainly pointed at specic HLA alleles implicated in MG susceptibility, however recently
both TNFAIP3-interacting protein 1 (TNIP1) and tyrosine phosphatase non-receptor 22 (PTPN22) were
indicated to be associated with MG in a GWAS study. A gender bias was observed for SNPs in the HLAlocus, suggesting female-specic alleles have an increase risk for MG. Moreover, sex hormones play a
pivotal role in the gender bias in autoimmunity in general and in MG in particular. Hence the genetic
basis of gender bias might be highly pertinent to MG and deserves further characterization. Pathwaybased analyses that combine information across multiple genes into a limited number of molecular
networks have been found to be a powerful approach. Both regulatory T-cell (Treg) differentiation and
NF-kB signaling pathway have been shown to have relevance to MG pathophysiology. Hence studies
centered around two pathways might be a fruitful approach to identify additional polymorphisms
associated with myasthenia gravis.
2013 Elsevier Ltd. All rights reserved.

Keywords:
Epigenetic
Genetics
Gender
Myasthenia gravis
NF-kB signaling pathway
TNIP1

1. Autoimmune myasthenia gravis (MG) a rare complex


disorder
Myasthenia gravis (MG) is a relatively rare autoimmune
neuromuscular disorder, clinically characterized by weakness and
fatigability of skeletal and extraocular muscles [1]. MG is a B-cell
driven, T-cell dependent, complement and antibody-mediated
disease, due to autoantibodies directed against molecules at the
neuromuscular junction, including antibodies against the acetylcholine receptor (AChR) (85% of patients), the muscle-specic kinase (MuSK) or the lipoprotein-related protein 4 (LRP4) [2e4]. The
binding of anti-AChR antibodies to their target impairs neuromuscular transmission by complement-mediated destruction of
the postsynaptic membrane [5]. About 80% of AChR-positive patients have thymic abnormalities (follicular hyperplasia or

* Corresponding author. Tel.: 972 4 8295358; fax: 972 4 8295436.


E-mail address: navidan@tx.technion.ac.il (N. Avidan).
0896-8411/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jaut.2013.12.001

thymoma). In early onset AChR MG patient, the thymus is characterized by the presence of anti-AChR autoreactive T cells and
autoantibody-producing B cells [4]. While the cause for AChR
autosensitization in the thymus is unclear, chronic inammation,
characterized by high expression of inammatory cytokines which
may increase AChR expression [6,7], and impaired regulatory Tcell(Treg)function [8,9], have been suggested to be involved in the
pathogenesis. The current hypothesis is that MG is a rare complex
disease with numerous genetic polymorphisms, each having a
small effect, contributing to MG predisposition. Because of it low
prevalence and disease complexity the genetic basis of MG remain
largely unknown.
1.1. Geo-epidemiology and prevalence
Current estimates place the MG prevalence at a high value of
about 3e30 per 100,000 persons depending on the study and
geographic location [10e13]. The estimated number of MG patients
is steadily increasing, and it had more than doubled in the last 20

N. Avidan et al. / Journal of Autoimmunity 52 (2014) 146e153

years in Western countries as well as in Japan and Taiwan [14e16].


This increase is probably due to improved diagnostic accuracy, the
improved efcacy of treatment and care, but also by the increasing
longevity of the population. MG shows a bimodal distribution with
two incidence peaks: Early-onset MG (EOMG) in the third decade
(strong female predominance) and late-onset MG (LOMG) in the
elderly (slight male predominance). The elderly-onset MG is the
major source of the overall increase and showed a 2.3-fold rise in
the last 20 years both in Western and in Asian countries [17,18]. The
reason for the increase is unclear and might be due to a better
awareness of neurologists to discriminate MG symptoms from
classical fatigue due to aging. However, the immunological background and the genetic basis are distinct from that in younger
patients. In contrast in China, the overall prevalence is similar to the
above reports, but with a younger age of onset and a ratio of 1:1
between male and female [19]. This geographic difference in
prevalence might reect difference in the methodology between
different studies or might be due to genetic and environmental
factors inuencing disease frequency.
1.2. Familial autoimmune MG is very rare
Familial autoimmune MG is mostly reported as rare case reports
[20e22]. A unique case of a Hungarian family was reported where
nine members from two generations develop MG [23,24]. Recently,
a sequence variant in the ecto-NADH oxidase 1 gene (ENOX1) was
strongly linked to EOMG in an Italian-American kinder with four
affected siblings [25]. The variant sequence was not found in 764
controls, in sporadic MG, or in other patients with familial autoimmune MG. The ENOX1 variant decreased ENOX1 levels in a
lymphoblastoid cell line in a dose-dependent manner, with a
reduction of mRNA levels of up to 80% compared with normal
variants. How ENOX1 could predispose to MG is unknown, but
immunological function studies could help elucidate its role in MG
pathogenesis. Although MG is rarely inherited within a family
occurrence of another autoimmune and immune-mediated diseases (AID) among myasthenic patients kins is relatively common
[26]. The most common concomitant AIDs being Rheumatoid
Arthritis (RA) and thyroid disorders [27,28]. This suggests that
common genetic and environmental factors might predispose to
autoimmune disorders and MG being one of them.

147

2. Genetic susceptibility
2.1. Specic HLA alleles implicated in MG susceptibility
Like most autoimmune diseases, genetic studies have mainly
pointed at specic HLA alleles implicated in MG susceptibility. The
association of HLA A1-B8-DR3-DQ2 haplotype, also known as AH8.1
[29], with EOMG in the Caucasian population has been reproduced
by numerous groups [30e33]. Remarkably, AH8.1 haplotype has
been associated with other autoimmune diseases, such as celiac and
systemic lupus erythematosus (SLE), supporting the hypothesis of
shared genetic risk factors for several autoimmune diseases [34,35].
Other MHC variants have been described in Asiatic MG patients [36],
LOMG [37] and anti-MuSK patients [38]. Childhood-onset of
ocular MG in Southern Han Chinese is suggested to be a particular
subgroup with distinct genetic background since 90.1% of patients
were reported to be positively associated with DQ9 haplotype [36].
In contrast, in a northern Han Chinese population HLA-DRB1(*)09
allele was signicantly more prevalent among patients with MG
than among healthy controls [39]. DRB1*15:01, DQB1*05:02 and
DRB1*16 have been associated with increased risk for LOMG in
Norwegian and Italian cohorts [37,40]. Patients with MuSK-MG, a
rare and relatively newly described clinical entity, appear to be
associated with DQ5 alleles in populations with diverse ancestries
both from Southern and Northern Europe [38,41].
Tumor necrosis factor-alpha (TNF-a) is a potent proinammatory cytokine located within the HLA locus that is
tightly linked to AH8.1 haplotype. A functional SNP, rs1800629,
at 308 nucleotides upstream from the transcription initiation site
has been shown to affect TNF-a expression, with the 308A allelic
form having a two-fold greater level of transcription than the 308G
form [42]. The 308A allelic form was linked with elevated serum
levels of TNF-a and with a more severe disease outcome in several
diseases [43e46]. The A allele of this functional SNP has been
linked to higher expression level and higher serum level of TNF-a in
MG by several independent groups [47e49]. In a recently complete
EOMG association study rs1800629 was found to be the most
signicantly associated SNP, increasing the odd ratio (OD) to 2 in
males and to over 4 in females (submitted manuscript). All these
results suggest a physiological role of TNF-a polymorphism in MG
predisposition that needs to be further evaluated.

Table 1
Non-HLA genes associated with MG.
Locus symbol, gene product

Variant or marker

Mechanism

References

Cathepsin L2 (CTSL2)
Cellular tyrosine phosphatase 22 (PTPN22)
Cytotoxic T cell late antigen 4 (CTLA4)
Galectin-1 (LGALS1)

Association between rs4361859 with EO MG


Coding (Arg620Trp)
Two SNPs in the promoter region
Association with regulatory region
(rs4820293, rs4820294)
SNP in the intron region IVS9459
(A/G, rs2280883)
Association with regulatory region
(rs743777, rs228941)
Noncoding SNP (874A/T)
Coding I75V
50 anking sequence of the human IL-10 gene
(rs45552637 (A/C),
rs1800872 (T/C), and rs1800896 (A/G))
Upstream polymorphism (478A/G)

Unknown
Trp allele impairs binding to Csk kinase
Abnormal alternative splicing
Unknown

[104]
[60,61,65,105]
[70,71]
[106]

Unknown

[73]

Unknown

[106]

Putative NF-kB binding site


Reduced responsiveness to interleukin-4
Correlated with IL-10 protein production in vitro

[107]
[108]
[109,110]

Alters binding of IRF8

[79,81]

Intronic microsatellite

Unknown

[78]

Rs1800629(-308G<A)
rs2233290(Pro151Ala)

Higher secretion of TNF-alpha


Ubiquitin-dependent dysregulation of
NF-kappaB signaling

[45,47,48]
[54]

Fork head/winged-helix transcription


factor 3 (FOXP3)
Interleukin receptor 2b (IL2Rb)
Interferon-g (IFNG)
Interleukin-4 receptor a (IL4R)
Interleukin-10 (IL10)

Muscle nicotinic acetylcholine receptor


a-subunit (CHRNA1)
Muscle nicotinic acetylcholine receptor
d-subunits (CHRND)
Tumor necrosis factor alpha (TNF)
TNFAIP3-interacting protein 1 (TNIP1)

148

N. Avidan et al. / Journal of Autoimmunity 52 (2014) 146e153

The four million base-pair HLA super locus contains a large


number of genes related to immune system function in humans.
However, the identication of the true predisposing gene(s) has
been handicapped by the strong linkage disequilibrium across the
region. A recent study renes the association signals for RA susceptibility in the HLA region to ve amino-acid positions encoded
in three HLA genes, all within peptide-binding grooves [50,51]. A
similar approach could be applied to identify functional variants in
MG with the rs1800629(-308 G > A) in the promoter of TNF-a gene
most likely being one of these functional variants.
2.2. Genome-wide association studies (GWAS) of EOMG
In the past ve years, important biologic discoveries have come
from genome-wide association studies (GWAS) aimed at unbiased
detection of variants at loci predisposing to complex traits [52,53].
GWAS of MG is quite a challenge because of its low prevalence and
the modest effect sizes anticipated. Recently, a GWAS with more than
600 patients from northern Europe has found that TNFAIP3interacting protein 1 (TNIP1) is associated with EOMG and conrms
the known association with HLA-B08 and protein tyrosine phosphatase non-receptor 22 (PTPN22) [54]. Imputation and conditional
analysis suggest an association with a putative functional amino acid
change in the TNIP1, rs2233290, a variant encoding a non-conservative Pro151Ala change. TNIP1 has been reported as a risk allele in
other autoimmune diseases, such as lupus and Sjogrens syndrome
[55,56] and has been implicated in chronic inammatory diseases
such as psoriasis and rheumatoid arthritis [57]. In vivo and in vitro
models strongly suggest that TNIP1 plays a crucial role in regulating
several cellular pathways involved in inammation and immunerelated disorders. TNIP1, also known as ABIN-1, is thought to be
involved in ubiquitin-dependent dysregulation of NF-kB signaling
[58,59] and co-repression of nuclear receptors such as retinoic acid
receptors and peroxisome proliferator-activated receptors [57].

in a Han Chinese population [73]. Pending validation of an additional


cohort, the biological relevance FOXP3 to MG is clear, since FOXP3
polymorphisms might inuence both the number and function of
CD4CD25 Tregs that is signicantly decreased in MG [74].
In addition to the loci shared by several AID, specic loci have
been associated with MG. the neuromuscular AChR complex consists of an alpha (CHNRA1), a beta (CHRNB1), a delta (CHRND) and
either a gamma subunit (CHRNG) in fetal muscle or an epsilon
subunit (CHRNE) in adults [75]. No association was found between
CHRNB1 or CHRNE and EOMG [76,77]. However polymorphisms in
CHNRA1 and CHRND have been shown to confer increased risk of
MG and are probably minor susceptibility genes for developing MG
[78e80]. Resequencing of the genomic region encompassing the
upstream regulatory and coding regions of CHRNA1 identied a
unique SNP, rs16862847, located in the CHRNA1 promoter region
that might disrupt a transcription binding motif. This SNP was
found to be more twice more frequent in MG cases versus control in
two different cohorts from France and UK [81].

3. Environmental and epigenetic implication


3.1. Twin studies in myasthenia
Comparison of disease concordance between monozygotic (MZ,
identical), and dizygotic (DZ, fraternal) twins has been used to estimate the contribution of genetics factors to disease risk [82]. Over
Table 2
Published Articles on MG monozygotic twins.
Year

1966

2.3. Non-HLA genes associated with MG


1971

The non-HLA genes associated with MG are summarized in


Table 1. One of the best example of a non-HLA common susceptibility allele for autoimmunity is the association of PTPN22 with a
number of autoimmune diseases including MG [60e62]. PTPN22,
also name lymphoid-specic phosphatase (Lyp), is an intracellular
PTP and physically bound to c-src tyrosine kinase (Csk), and these
two proteins mediate T-cell activation [62]. Recent ndings have
revealed that the change of amino acid at position 620 from an
arginine (R) to a tryptophan (W) in PTPN22 disrupts the interaction
between PTPN22 and Csk. In vitro experiments have shown that the
T-allele of PTPN22 binds less efciently to Csk than the C-allele
does, suggesting that T-cells expressing the T-allele may be hyperresponsive, and consequently, individuals carrying this allele may
be prone to autoimmunity [63,64]. Indeed, The W620 variant was
signicantly overrepresented in MG patients [65], and a higher titer
of anti-AChR antibodies in W620 carriers were found [60].
Cytotoxic T lymphocyteeassociated antigen 4 (CTLA4) has also
been associated with several autoimmune diseases such as type 1
diabetes, celiac disease [66], RA [67], and Graves disease [68]. An
association between SNPs in the promoter region of CTLA4 and MG
has been found by several independent groups [69e71]. It has been
proposed that these SNPs might cause aberrant splicing of CTLA4
and/or cellular abnormalities of MG T-cells that contribute to disease pathogenicity.
Treg cell specic transcription factor, Fork head/winged-helix
transcription factor (FOXP3), has been shown to regulate both the
development and the function of Tregs [72]. Recently the frequency
of the FOXP3 IVS9459 G allele was associated with lower risk of MG

Title

1960 Myasthenia gravis in one monozygotic


twin
1966 Myasthenia gravis in identical twins

1971
1978

1984

1984
1986
1989

1989
1991

1994

1997
2004

2008

2011

Reference
Alter & Talbert, 1960 [111]

Osborne & Simcock,


1966 [112]
A case of myasthenia gravis in identical Motoki et al., 1966 [113]
twin brothers
The familial occurrence of myasthenia
Herrmann, 1971 [114]
gravis
Myasthenia gravis occurring in twins
Namba et al., 1971b [84]
Michalski et al., 1978 [115]
Monozygotic twins with Klinefelters
snydrome discordant for systemic lupus
erythematosus and symptomatic
myasthenia gravis
Allen et al., 1984 [116]
Myasthenia gravis in monozygotic
twins. Clinical follow-up nine years
after thymectomy
Thymectomy for myasthenia in twin
Vasilev et al., 1984 [117]
sisters
Myasthenia gravis in identical twins
Murphy & Murphy,
1986 [118]
B cell and autoantibody repertoire in a Lefvert et al., 1989 [119]
pair of monzygotic twins discordant for
myasthenia gravis
Familial myasthenia gravis: a case
Dias-Tosta et al., 1989 [120]
report in identical twins
Grinlinton et al., 1991 [121]
A pair of monozygotic twins who are
concordant for myasthenia gravis but
became discordant for systemic lupus
erythematosus post-thymectomy
Theile and Kessler, 1994 [122]
Effect of heredity and environment in
immune diseases. Presentation of twin
data
Twin studies of myasthenia
Agafonov et al., 1997 [85]
Kakoulidou et al., 2004 [123]
The autoimmune T and B cell
repertoires in monozygotic twins
discordant for myasthenia gravis
Monozygous twins with neuromuscular Punga et al., 2009 [124]
transmission defects at opposite sides
of the motor endplate
Discordant thymectomy in identical
Riggs et al., 2011 [125]
twins concordant for myasthenia gravis

N. Avidan et al. / Journal of Autoimmunity 52 (2014) 146e153

the last 50 years, MZ-MG twins have been reported in over 15


different publications summarized in Table 2, however because of
the small number of cases reported, the lack of adequate follow-up,
and unsatisfactory zygosity determination concordance rate estimated from these case reports should be view as a rough estimate.
Ramanujam et al. estimated MG concordance to be between 30 and
40% in monozygotic twins, compare to 4e5% in dizygotic twins
based on extensive literature search [83]. A recent survey set up by
the European network FIGHT-MG to identify and recruit MZ MG
twins throughout Europe and USA identied 14 MZ pairs (3 males
and 11 females aged between 11 and 85 years) for which 5 are
concordant and 9 discordant MG twins (unpublished data). The
concordance rate found in this survey is in the same range as
Multiple Sclerosis (MS) and similar to Ramanujam et al. publication
[82,83]. On one hand, this result emphasis the large contribution of
genetics to disease predisposition, on the other hand, the high
percentage of diseaseediscordant pairs in monozygotic twins
demonstrates the central role of environmental factors in the etiology of MG [84,85]. Indeed, despite the identical genetic material,
the share uterus environmental, and the common household
experience during the rst two decades of twin life, about two third
of MZ-MG twins are discordant.
3.2. MG and epigenetics
Epigenetics pertains to heritable alterations in gene expression
that do not involve modication of the underlying genomic DNA
sequence. Epigenetic patterning is modied by environmental exposures and may be a mechanistic link between environmental and
genetic risk factors in pathogenesis of diseases. Historically, the
study of epigenetic mechanisms has focused on DNA methylation
and histone modications, but the concept of epigenetics has been
more recently extended to include microRNAs as well. MicroRNAs
are small noncoding RNAs that inhibit sequence-specic translation and tag mRNA for degradation. Epigenetic modulation of
gene expression by specic microRNAs has been associated with a
variety of autoimmune diseases [86]. MicroRNAs appear to be new
key mediators in the immunoregulatory processes and excessive
activation of inammatory pathways [87]. In particular miR-155,
miR-146a, and miR-326 appear to be associated with several
autoimmune diseases and linked to T-cell response, immuneregulation, and inammation [88,89]. The aberrant expression of
several microRNA, including miR-320a and let-7c, were found in
lymphocytes from MG patients in comparison to controls [90,91].
Low-expression of miR-320a was correlated with over-expression
of pro-inammatory cytokines in MG patients presumably via the
NFkB pathway [90]. Inverse correlation between endogenous let-7c
and IL-10 expression was found in MG patients and it was shown
that IL-10 is negatively regulated by let-7c via a specic target site
within IL-10 30 UTR [91]. In an animal model for MG it was shown
that down-regulation of miR-145 promotes pathogenic Th17 cell
response [92]. The detection of myasthenia gravis-specic microRNAs and the study of their functions could provide valuable information about MG pathogenesis and open new therapeutic
avenues.
4. Gender bias
4.1. The role of sex hormones in the MG gender bias
There are clear biological and physiological differences between
men and women, including differences in disease prevalence. For
instance, autoimmune diseases are known to be much more
prevalent in women while Coronary Artery Diseases are much more
prevalent in men. The immune, endocrine and nervous systems

149

communicate with each other through a myriad of molecules


including cytokines, hormones and neurotransmitters [93]. Sex
hormones play a pivotal role in the gender bias with a commonly
accepted view that androgens are protective. A number of studies
implicate estrogen as a primary mediator of MG disease [94]. Estrogen is known to modify both innate and adaptive immunity and
can promote production of antibodies by B lymphocytes as well as
inuence Treg function [95]. At elevated concentrations, estrogen
can enhance humoral immunity by inducing helper T cell responses
[95]. In addition, numerous HLA-region genes, including HLA-DRA
and TNF, contain estrogen response elements [96]. It has been
suggested that polymorphisms in these response elements might
inuence transcription in a gender specic manner.
The gut microbes can modulate, tune and tame the host immune response and disturbance in this population can incite
imbalance in immune system, leading to molecular mimicry and
therefore autoimmunity [97]. In an animal model for type 1 diabetes (T1D) hormone-dependent differences in microbiota
composition were found, and these differences conferred protection against T1D in males [98]. This result suggests that a core set of
microbial properties, functions, or genes, working in concert with
sex-hormones might inuence autoimmune disease predisposition. Hence, identication of the pathways and molecules from
both host and microbes that mediate susceptibility and to translate
this knowledge into the designing of new therapeutics might be a
new direction for autoimmune disease treatments.
4.2. Sex-specic genetic architecture modulate disease
susceptibility
Recent studies suggest that sex-specic genetic architecture
inuences human disease phenotypic traits and interplays between
genes, gender, and environmental factors to modulate disease
susceptibility. A systematically analysis for sex differences in genee
disease associations of seven common diseases identied several
SNPs that are signicantly associated with disease in only one sex
[99]. Gender-specic SNP associations have been also shown in a
meta-analysis for the regulation of hypothalamicepituitaryethyroid axis hormones [100]. In MG, in both a GWAS and in a genetic
association study of 35 candidate genes, a gender bias association
was observed for SNPs in the HLA locus [54]. This increased female
risk may reect hormonal effects, a female bias in environmental
exposure, or gender-related epigenetic changes playing a role in
disease risk. The results from these different studies suggest that
sexually dimorphic SNP-disease associations are relevant to understand the molecular mechanisms of autoimmune diseases and
the genetic basis of complex diseases in general and might be
highly pertinent to myasthenia.
5. The added value of network and pathway analyses
It has previously been observed that different genes harboring
causal mutations for the same Mendelian disease often physically
interact. The concept has been extended to complex diseases were
multiple loci contribute to disease predisposition. Pathway-based
analyses that combine information across multiple genes into a
limited number of molecular networks have been found to be a
powerful approach. This approach allows to gain further insights
into the biology of associated genes, to prioritize candidates for
subsequent genetic studies of complex traits, and to discover new
drug targets. GWAS associated genes were found to be more likely
to interact physically and to be enriched in specic pathways in
several autoimmune diseases [101e103]. Moreover, these networks
have been shown to have predictive power and to highlight relevant disease associated loci even before shown in extended GWAS

150

N. Avidan et al. / Journal of Autoimmunity 52 (2014) 146e153

analysis [101]. TNIP1, that has been shown to promote proteasomedependent polyubiquitination degradation as well as VAV1, CD86,
and BAFF that were recently shown to be associated with EOMG
(submitted manuscript) are all part of NF-kB signaling pathway as
depicted in Fig. 1. Otherwise it was previously shown that Treg cells
from the thymus of MG patients are profoundly defective in their
suppressive activity [74]. Hence genes involved in these two
pathways, Treg differentiation and NF-kB signaling, are anticipated
to be associated with myasthenia predisposition. A candidate gene
association study centered on these two pathways might be a more
rewarding approach to identify additional polymorphisms associated with MG, a rare complex disease.

6. Concluding remarks
Understanding the molecular mechanisms involved in the
pathophysiology of autoimmune diseases is essential for the
introduction of effective, target-directed therapies. EOMG is one of
the most characterized autoimmune diseases with the pathogenic
autoantigen, AChR, identied more than four decades ago. Nevertheless, the genetic basis and the functional defects of the disease
remain largely unknown. The increased number of MG patients in
the last two decades makes the need for better prevention and
treatment even more essential. The detection of MG-specic
microRNAs and the study of their functions could provide

Fig. 1. TCR/CD28-mediated activation of the canonical NF-kB pathway in a PI3-K-dependent manner. The T-cell signalosome convey activation signals to the IL-2 gene promoter,
that bind multiple transcription factors, such as c-Jun, NF-KappaB, and NFAT. Cooperative interaction between these factors is required for efcient IL-2 gene expression. TCR/CD3
engagement induces activation of Src (Fyn and Lck), Syk, ZAP70 and Tec-family PTKs, leading to stimulation and membrane recruitment of PLC-Gamma1, PI3-K and Vav-1. Vav-1
induces the activation of the canonical p50/p65(RelA) NF-kB through a pathway involving Rac-1 and MEKK1. Vav-1 may also activate the alternative p52/p65(RelA) NF-kB pathway,
by recruiting and activating IKKa. TCR/CD28 costimulation with its CD80/CD86 ligands activates a transcriptional element that is a combinatorial binding site for NF-kB and
Activator Protein-1, SEK1 and IKKs. This activation signal proceeds through the synergistic activation of JNK by SEK1 and Ca2/Calcineurin signals. PI3-K e Phosphatidylinositiol-3Kinase, NF-kB eNuclear Factor-KappaB, NFAT e Nuclear Factor Of Activated T-Cells, PTKs e Protein Trosine Kinases, PLC-Gamma1 e Phospholipase-C-Gamma1, SEK1 e Activator
Protein-1, (SAPK/ERK Kinase-1), IKKs e I-KappaB Kinases. This image is a modication of QIAGENs original, copyrighted image by Dr. Nili Avidan. The original image may be found
at http://www.qiagen.com/products/genes%20and%20pathways/pathway%20details?pwid240; http://www.qiagen.com/products/genes%20and%20pathways/pathway%20details?
pwid235; http://www.qiagen.com/products/genes%20and%20pathways/pathway%20details?pwid361.

N. Avidan et al. / Journal of Autoimmunity 52 (2014) 146e153

valuable information about MG pathogenesis and open new therapeutic avenues. In addition, comprehension of the interplays between genes, gender, and environmental factors that might
modulate disease development is highly pertinent to myasthenia.
Few important biological discoveries have been made in the last
ve years through GWASs, but only well powered GWASs using
thousands of patients samples produce reproducible association
[52,53]. Candidate gene approach requires a few hundred samples
to highlight modest genotype-risk effects with the caveat that it
requires some knowledge of disease pathophysiology, knowledge
that may be biased. Pathway-based gene selection, that combines
biological information into a limited number of molecular networks might be the optimal solution. Hence, candidate genes association study centered on these two pathways, Treg development
and regulation, and NF-kB signaling, might be a fruitful approach to
identify additional polymorphisms associated with myasthenia.
Acknowledgments
This work was supported by 7th Framework Program of the
European Union FIGHT-MG (grant no. 242210), the Association
Franaise contre les Myopathies (AFM) and the Sacta-Rashi
Foundation (N.A).
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