Neuron

Review

Multiple Sclerosis: Mechanisms and Immunotherapy

Clare Baecher-Allan,1 Belinda J. Kaskow,1 and Howard L. Weiner1,*
1Department of Neurology, Ann Romney Center for Neurologic Diseases, Partners MS Center, Evergrande Center for Immunologic Diseases,

Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
*Correspondence: hweiner@rics.bwh.harvard.edu
https://doi.org/10.1016/j.neuron.2018.01.021

Multiple sclerosis (MS) is an autoimmune disease triggered by environmental factors that act on a genet-
ically susceptible host. It features three clinical stages: a pre-clinical stage detectable only by MRI; a re-
lapsing-remitting (RRMS) stage characterized by episodes of neurologic dysfunction followed by resolu-
tion; and a progressive stage, which usually evolves from the relapsing stage. Advances in our
understanding of the immune mechanisms that contribute to MS have led to more than ten FDA-approved
immunotherapeutic drugs that target effector T cells, regulatory cells, B cells, and cell trafficking into the
nervous system. However, most drugs for relapsing MS are not effective in treating progressive disease.
Progressive MS features a compartmentalized immune response in the central nervous system, involving
microglia cells and astrocytes, as well as immune-independent processes that drive axonal dysfunction.
Major challenges for MS research involve understanding the mechanisms of disease progression, devel-
oping treatment for progressive MS, and determining the degree to which progressive disease can be
prevented by early treatment. Key priorities for MS research include developing biomarkers, personalized
medicine and advanced imaging, and a better understanding of the microbiome. With a better under-
standing of the genetic and epidemiological aspects of this disease, approaches to prevent MS are
now also being considered.

Introduction neurologic dysfunction progressively worsens, affecting, in

Multiple sclerosis (MS) is a chronic inflammatory disease of
the central nervous system (CNS) of presumed autoimmune
etiology. Our understanding of the immune processes that
contribute to MS has led to FDA-approved, disease-modifying
drugs that are effective in relapsing forms of MS. However, few
treatments are effective for progressive forms of the disease.
It is now accepted that MS is a heterogeneous, multifactorial
disease influenced by both genetic and environmental factors
(Dendrou et al., 2015). The clinical picture of MS is also better
defined and continues to evolve in the current treatment era. In
addition, magnetic resonance imaging (MRI) has provided a ba-
sis for understanding different stages of MS and for developing
treatments. Finally, with advances in our understanding of both
immune and neurobiological processes, new treatment ap-
proaches are being developed. The aim of this Review is to
provide a detailed description of the pathogenesis of MS and
the current directions in research and treatment of the disease.
A summary of our current understanding of MS is given in
Table 1.
MS Pathology and Risk Factors
MS broadly comprises three stages: (1) a pre-clinical stage, in
which a combination of genetic and environmental factors
trigger the disease; (2) a relapsing-remitting (RRMS) clinical
stage, which features discrete, self-limited episodes of neuro-
logic dysfunction, such as optic neuritis, sensory disturbances,
or disturbances in motor and cerebellar function (this inflamma-
tory stage may begin sub-clinically and be evident solely by
MRI imaging); and (3) a progressive clinical stage during which
particular, a patient’s gait (Figure 1). In some patients, MS
can be progressive from onset and is termed primary progres-
sive disease. It is not known the degree to which primary pro-
gressive MS (PPMS) represents a unique form of MS or simply
secondary progressive MS (SPMS), in which the relapses were
not apparent clinically. Trials in the past 10 years demonstrate
that the characteristics and behavior of RRMS cohorts in clin-
ical trials have changed and are characterized by lower clinical
disease activity. This might possibly reflect a change in the nat-
ural history of MS (Uitdehaag et al., 2011). In addition, more
recent natural history studies report longer times to disability
milestones, with the median times to requiring a cane to
walk, ranging from 15 to 32 years (Tremlett et al., 2010). With
MRI imaging and our better understanding of disease mecha-
nisms, the clinical classification of MS has evolved to include
the concept of ‘‘active’’ disease, which is associated with
both the relapsing and the progressive forms of the disease.
This classification reflects the inflammatory component of
MS, which can be visualized by MRI using gadolinium
enhancement (Lublin et al., 2014).
The MS Pathological Process
The MS pathological process includes breakdown of the blood-
brain barrier, multifocal inflammation, demyelination, oligoden-
drocyte loss, reactive gliosis, and axonal degeneration (Trapp
and Nave, 2008). Four neuropathological patterns have been
described for MS based on the presence or absence of comple-
ment and immunoglobulins, apoptotic nuclei, and/or preferential
loss of myelin protein (Lucchinetti et al., 2000). This heterogene-
ity in lesion pattern is observed between patients, but not within

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Table 1. Mechanisms of Multiple Sclerosis

Feature Disease Mechanism
Autoimmunity MS is a cell-mediated autoimmune disease directed against CNS myelin antigens that involves both CD4+ and
CD8+ cells. Autoantibodies may play a secondary or enhancing role. Autoreactive T cells against myelin components
exist in normal individuals and, in these individuals, do not cause disease and may even have brain-protecting
properties. MS is induced when pathogenic Th17- and Th1-type and CD8 myelin autoreactive T cells are induced.
Infection Infectious agents play a crucial role in inducing myelin-reactive pathogenic T cells. Potential mechanisms include
cross reactivity with CNS myelin antigens, triggering an already expanded autoreactive immune repertoire or a
self-limited infection of the brain that releases myelin antigens. MS is not caused by a persistent viral infection
of the brain or transmissible agent.
Genetics Both MHC and non-MHC genes are risk factors for development of MS. MHC genes determine immune repertoire
whereas non-MHC genes determine regulatory and tolerance mechanisms in MS, both of which are defective.
Environment Environmental factors can increase the risk for both the development of MS and the disease course and include
lowered vitamin D, lowered UV radiation exposure, cigarette smoking, obesity, and EBV exposure.
B cells B cells play a central role in MS. Like T cells, there are pro- and anti-inflammatory B cell subsets. In relapsing MS,
B cells serve as primary antigen-presenting cells that drive pathogenic T cells. In progressive MS, B cells enhance
the compartmentalized CNS responses through lymphoid follicles and secreted factors.
Microbiome The microbiome regulates T cell function throughout the body and contains both protective and pathogenic
microbial components, which play an important role in MS by establishing immune set points and by secreting
metabolites.
Relapsing MS Relapsing MS is driven by immune cells that migrate into the CNS. Multiple treatments have been shown to
effectively treat relapsing MS (decrease relapses and new MRI lesions) and act on the following common
pathways: decrease number and/or function of effector cells, increase number and/or function of regulatory cells,
and prevent trafficking of cells to the CNS.
Progressive MS Progressive MS mechanisms include those that are immune dependent and immune independent. In
immune-dependent forms, an innate immune response is established in the brain that involves microglia,
macrophages, B cells, and lymphoid follicles. There may also be chronic activation of peripheral T cells and
innate cells. In immune-independent forms, mitochondrial injury, oxidative stress, and ion imbalance occur.
Current therapy does not effectively target these two processes.
Autoantigen The inciting autoantigen in MS is unknown. However, when MS is diagnosed, there would be no single autoantigen
to target as there is spreading of reactivity to other organ-specific antigens as occurs in type 1 diabetes. Thus,
antigen-specific therapy would have to employ bystander suppression or be given as a preventative strategy in at
risk subjects.
Therapy MS is a heterogeneous disease. There will be responders and non-responders to each ‘‘effective’’ therapy.
The earlier in the disease course that treatment is initiated, the more likely it is to be effective. Effective treatment
will require pulse or continuous therapy and, ultimately, combination therapy. The identification of immune and
MRI biomarkers will be the cornerstone of immunotherapy of MS and the achievement of no evidence of disease
activity (NEDA).

patients. Active lesions are common in relapsing MS patients
but become rare during progressive MS (Trapp et al., 1999).
Transected axons in acute MS lesions are abundant and occur
approximately 12 times more frequently than in chronic lesions
(Kornek and Lassmann, 1999). Thus, axonal loss occurs at
disease onset and is a continuous process. The conversion of
RRMS to SPMS is therefore thought to occur when the brain ex-
hausts its capacity to compensate for further axonal loss (Nave
and Trapp, 2008).
Although MS has historically been considered a demyelinating
disease of the CNS and white matter, in recent years, demyelin-
ation of the cortical and deep gray matter have been recognized
and may exceed white matter demyelination (Kutzelnigg et al.,
2005). Cortical atrophy has been associated with disease pro-
gression and with gray matter atrophy, and it is among the
best predictors of neurological disability in MS (Fisniku et al.,
2008). Inflammatory cortical demyelination has also been identi-
fied in early MS (Lucchinetti et al., 2011). Subpial lesions are
abundant in progressive stages of MS, and microglial activation
is more prominent than peripheral immune cell infiltration (Lass-
mann, 2012). It has been suggested that meningeal infiltrates
activate microglia and that brains with increased meningeal infil-
tration have increased B-cell-like follicles (Magliozzi et al., 2010).
Both macrophages and microglia accumulate at sites of
active demyelination and neurodegeneration in MS. Using newly
defined cell surface markers, it has been possible to distinguish
infiltrating macrophages from resident microglia (Butovsky et al.,
2014). These markers have also shown that microglial activation
is more pronounced in the normal-appearing white matter of
MS patients as compared to controls and increases with disease
duration. Furthermore, as measured by the P2RY12 marker,
there is a loss of the homeostatic microglial phenotype in MS,
which reappears in inactive lesions (Zrzavy et al., 2017).
Genetic Components
MS has a genetic component as evidenced by first-degree rel-
atives having a higher risk for MS (2%–5% risk), by a high

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Figure 1. The Stages of Multiple Sclerosis

Multiple sclerosis is thought to begin before clinical symptoms are evident, and it can be discovered incidentally on MRI as a radiologically isolated
syndrome (RIS). It then usually manifests as a clinically isolated syndrome (CIS), which is followed by a relapsing-remitting stage, characterized by discrete
episodes of neurologic dysfunction with remission. The progressive stage involves steadily worsening disability and usually evolves from the relapsing-
remitting stage, although some patients may have progressive disease from onset (primary progressive MS). MRI correlates of disease include gadolinium-
enhancing lesions, which represent the breakdown of the blood-brain barrier and the movement of cells into the CNS, accumulation of T2 burden of
disease, and a decrease in brain volume as measured by atrophy. Many treatments impact on relapsing forms of MS. Few treatment options are available
for progressive MS.

disease concordance rate in monozygotic (MZ) twins (25%),
and by a difference in disease prevalence among different
ancestral groups (Hollenbach and Oksenberg, 2015; Sawcer
et al., 2014). MS is rare in black Africans although it occurs in Af-
rican Americans (Hollenbach and Oksenberg, 2015). Genetics
contributes to geographic variations in MS but cannot explain
differences in risk among people of common ancestry, who
migrate to areas of high or low MS prevalence (as discussed
below). There is no evidence of Mendelian inheritance. The
HLA-DRB1*15:01 allele in the class II major histocompatibility
complex (MHC) (odds ratio [OR] 3) is the earliest, and most
dominant, risk factor identified in MS (Sawcer et al., 2005). Sub-
sequent genome-wide association studies (GWASs) have found
that the interleukin-2 receptor alpha gene (IL2RA) and inter-
leukin-7 receptor alpha gene (IL7R) are also inheritable risk fac-
tors (Hafler et al., 2007). These studies have identified a total of
110 polymorphisms in 103 discreet loci outside the MHC that
are associated with susceptibility (Sawcer et al., 2014). The
class I variants HLA-A*02 (OR 0.6) and HLA B*44 are associ-
ated with protection from disease (Sawcer et al., 2014). The
presence of DRB1*15:01 and absence of HLA-A*02 has a com-
bined OR 5. Patients with DRB1*15:01 develop more lesions
(T2 foci) on MRI and a decrease in brain volume (Okuda et al.,
2009), whereas those with B*44 have reduced T2 lesion load
and preserved brain volume (Healy et al., 2010). Virtually all
MS-associated genes regulate either innate or adaptive immu-
nity. It is likely that HLA variants are related to disease speci-
ficity, whereas non-HLA variants influence broad aspects of im-
mune activation and tolerance. Although some of the genetic
associations linked to MS are found in other autoimmune dis-
eases, few are shared with other neurodegenerative diseases,
such as Alzheimer’s and Parkinson’s diseases. Finally, although
the clinical features of the disease may have a genetic compo-
nent in some families with MS (Hensiek et al., 2007) and
although the increased disease severity observed in African
Americans may have a genetic component, disease severity
and disease type do not appear to have a strong genetic
component. Even in the case of affected MZ twins, one twin
can have mild relapsing disease while the other has disabling
progressive disease. It thus appears that the primary genetic ef-
fect in MS relates to disease susceptibility rather than to dis-
ease course or severity.

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Environmental Factors
It is now recognized that environmental and lifestyle factors
interact with genetics to influence both MS susceptibility and
the course of the disease. Importantly, some environmental fac-
tors are modifiable. The earliest clues to environmental influ-
ences came from studies into the effect of latitude and migration.
It has long been recognized that there is a latitudinal gradient in
MS; it is more prevalent the further one is from the equator (Simp-
son et al., 2011). Furthermore, migration studies have shown
that migrants who move from a high-risk to a low-risk country
before adolescence have a decreased disease rate, whereas
those that move from a low-risk to a high-risk country acquire
a higher risk (Gale and Martyn, 1995; Ahlgren et al., 2012). This
strongly suggests that exposure to an environmental factor in
the first two decades of life can influence disease risk. Further-
more, the incidence of MS appears to be increasing in women
in certain areas of the world that were previously areas of low
MS prevalence.
Vitamin D and ultraviolet (UV) radiation are two environmental
factors known to be associated with MS susceptibility that might
also help to explain the latitude effect. Increased vitamin D levels,
especially before the age of 20, are associated with a reduced
risk of MS in later life (Munger et al., 2006). UV radiation also pro-
tects against MS, probably both through its effects on vitamin D
and through independent effects on the immune system (Lucas
et al., 2015). Vitamin D has broad effects on the immune sys-
tem, including the suppression of both B cell and T cell prolifer-
ation, skewing T cells away from inflammatory responses and
toward regulatory T cell (Treg) responses, and promoting tolero-
genic monocyte and dendritic cell phenotypes (Aranow, 2011).
Vitamin D is not only linked to MS, but also to other autoimmune
diseases, including rheumatoid arthritis (RA), type 1 diabetes
(T1D), and systemic lupus erythematous (SLE). It is now common
practice to provide vitamin D supplementation to all MS patients
(Stein et al., 2011). Of note, there is also evidence that people
with lower levels of vitamin D have increased infections (Kalluri
et al., 2017).
Cigarette smoking is another well-recognized environmental
factor that is linked to both MS risk and disease activity (Wing-
erchuk, 2012). Smoking appears to mediate its effect by driving
T-helper 17 (Th17)-type responses in the lung. Oral tobacco
doesn’t have this effect (Hedström et al., 2011). As with other
risk factors, smoking appears to influence susceptibility to
MS in conjunction with genetic factors and with other environ-
mental factors. As the environment is being more systemati-
cally investigated, other factors are being identified that in-
crease disease risk, including adolescent obesity, exposure
to organic solvents, and night shift work. By contrast, oral to-
bacco use, cytomegalovirus virus infection, alcohol, and coffee
consumption are associated with decreased risk (Olsson et al.,
2017). All of these factors most likely impact on the immune
system.
Although it has long been suspected that an infectious agent is
at the heart of MS, no MS infectious agent has been identified.
Indeed, the first drug approved for treatment of MS, beta inter-
feron, was tested based on the hypothesis that MS was due to
a viral infection. Nonetheless, there is a link between Epstein-
Barr virus (EBV) infection and MS as there is an increased risk
of MS in individuals who have infectious mononucleosis or
elevated antibody titers against EBV nuclear antigen 1
(EBNA1). There is also a higher prevalence of EBV infection in in-
dividuals with MS relative to controls (Plavina et al., 2014). As
with other environmental factors, only EBV infection during
adolescence or later increases the risk of MS. It is not clear
how EBV infection could contribute to MS. It could have a spe-
cific effect, through a mechanism such as molecular mimicry,
or general immune effects on B cells or on other immune regula-
tory elements, or it could be a secondary phenomenon. Of note,
EBV infection is also reported to be a risk factor for SLE (Harley
and James, 2006).
No specific diet is associated with an increased risk of MS.
The role of dietary factors appears to be complex and related
to the influence of multiple dietary components on immune
regulation, including vitamins A and D, salt, omega-3-unsatu-
rated fatty acid, and polyphenol. Recent reports have sug-
gested that salt modulates the differentiation of human and
mouse Th17 cells (Wu et al., 2013). A more aggressive course
of experimental autoimmune encephalomyelitis (EAE), which
serves as the animal model for MS, was observed in mice
fed a high-sodium diet (Wu et al., 2013). In addition, in a small,
2-year observational study of 122 patients with MS, a higher
sodium intake was associated with increased MS disease ac-
tivity, as assessed clinically and radiologically (Farez et al.,
2015). However, a 5-year longitudinal study (of 465 MS pa-
tients) found no association between salt intake and either
the rate of CIS conversion to MS or the severity of disease (Fitz-
gerald et al., 2017), and it was not associated with a reduced
time to relapse in pediatric MS (Nourbakhsh et al., 2016).
With regard to whether pregnancy affects the risk for MS, it
has been found that giving birth, or having a terminated preg-
nancy, protects women from developing MS over the next 5
years (Hedström et al., 2014).
The Role of the Microbiome
The human microbiome encompasses trillions of organisms that
inhabit the gut and that shape the gut-associated lymphoid tis-
sue. It is now known that the gut microbiome contributes to
health and disease, influencing infection, atherosclerosis, can-
cer, autoimmunity, and inflammatory and metabolic disease
(Lynch and Pedersen, 2016). Recent studies have shown that
the gut microbiome participates in immunoregulatory pathways
that can both contribute to, and protect individuals from, dis-
ease. In a spontaneous, relapsing EAE model, animals raised un-
der germ-free conditions were resistant to disease, while those
exposed to commensal bacteria developed EAE (Berer et al.,
2011). It has also been shown that segmented filamentous bac-
teria in the gut can induce Th17 cells (Ivanov et al., 2009) and that
pro-inflammatory T cell responses to gut microbiota promote
EAE (Lee et al., 2011). Conversely, Tregs can be induced in the
gut by commensal gut bacteria (Round and Mazmanian, 2010),
and in the EAE model, polysaccharide A from the human
commensal Bacteroides fragilis protects against EAE (Ochoa-
Repáraz et al., 2010). Thus, the gut microbiome has both
disease-inducing and disease-protecting influences on CNS
autoimmunity. Moreover, it has been recently shown that trypto-
phan-derived aryl hydrocarbon receptor (AHR) ligands produced
by intestinal commensals can reach the CNS to modulate
Neuron 97, February 21, 2018 745

astrocyte function and suppress inflammation and neurodegen-
eration (Rothhammer et al., 2016). Thus, the gut microbiome
participates in immunoregulatory pathways to modulate CNS
autoimmunity.
Studies have also investigated the gut microbiome of MS
patients. We have found the bacterial species Methanobrevi-
bacter and Akkermansia to be increased and the bacteria Bu-
tyricimonas to be decreased in patients with MS relative to
control subjects (Jangi et al., 2016). Patients on disease-modi-
fying treatment also show increased abundances of Prevotella
and Sutterella and decreased levels of Sarcina compared to
untreated MS patients. Immune profiling of peripheral blood
from these subjects demonstrated an association between
gene expression in T cells and monocytes with bacterial spe-
cies in the gut. Other MS studies have found that perturba-
tions in the gut microbiota were associated with parallel pre-
dicted enrichment of metabolic pathways associated with
neurodegeneration in recent-onset pediatric MS (Tremlett
et al., 2016), exhibited dysbiosis with depletion of major buty-
rate producers belonging to Clostridial clusters XIVa and IV
clusters (Miyake et al., 2015), as well as changes in gut micro-
biota that are associated with glatiramer acetate and vitamin D
supplementation (Cantarel et al., 2015), and a distinct microbi-
al community profile that is consistent with gut microbial dys-
biosis (Chen et al., 2016). Recently, it was also shown that a
high frequency of intestinal Th17 cells correlates with microbi-
al alterations and disease activity in MS (Cosorich et al., 2017),
that gut bacteria from MS individuals modulate human T cells
and worsen EAE when transplanted to germ-free mice (Baran-
zini et al., 2017), that gut microbiota from unaffected twins
promoted EAE and was associated with less IL-10 production
in recipient mice (Berer et al., 2017), and that the human gut-
derived commensal Prevotella suppresses EAE in an HLA
class II transgenic mouse model (Mangalam et al., 2017).
Although these reports do not establish causation, they sug-
gest that the microbiome plays an important role in MS and
provide new avenues for the investigation of the microbiome
and MS.
How could the microbiome be related to MS? One possibility
is that molecular mimicry exists between a gut organism and
structures in the CNS. This has been observed for Staphylo-
coccus and Syndenham’s chorea. Also in neuromyelitis optica,
the immunodominant epitope of aquaporin-4 cross reacts with
a homologous sequence found in the adenosine triphosphate-
binding cassette transporter of Clostridium perfringens (Cree
et al., 2016). Thus, it is possible that the gut holds the key to
the long-sought after infectious agent of MS. Another possibility
is that gut dysbiosis associated with diet and the environment
could affect immune regulation, promoting a less tolerant state
to CNS autoantigens. The hygiene hypothesis suggests that a
lack of early childhood exposure to infectious agents, symbiotic
microorganisms (such as the gut microbiota or probiotics), and
parasites increases an individual’s susceptibility to allergic and
autoimmune diseases by suppressing the natural development
of the immune system and causing defects in the establishment
of immune tolerance. A third possibility is that current immuno-
modulatory therapy might partly act through the gut. The
modulation of the gut microbiome through probiotics, tolero-
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genic microorganisms, or fecal replacement therapy could serve
as a physiological, non-toxic form of therapy and might also aid
disease prevention.
The Adaptive Immune System in MS
The success of clinical trials in MS that target immune mole-
cules or specific cell types both reinforces the idea that the im-
mune system plays a central role in MS and provides strong ev-
idence for the involvement of particular immune pathways in
the pathogenesis of the disease. These data have suggested
that B cells and different effector T cell populations of the adap-
tive immune system, together with natural killer (NK) and micro-
glial cells of the innate immune system, play unique roles in
contributing to the disease. In addition, not only have the in-
flammatory lesions within the CNS white matter been reported
to contain CD4 and CD8 T cells, but also the meninges in pro-
gressive MS to contain ectopic germinal centers that include B
cells and other immune populations. Studies into how these
effector or regulatory cell types function in healthy donors, as
compared to in patients with MS, shed light on how their func-
tional dysregulation might contribute to disease. As such, we
discuss below our current understanding of the role that
distinct populations of effector T cells, regulatory cells, and B
cells might play in MS.
Effector T Cells in MS
MS is believed to be caused by the activation of peripheral au-
toreactive effector CD4 T cells that migrate into the CNS and
initiate the disease process (Figure 2). This has been referred
to as the ‘‘outside-in hypothesis’’ of MS as opposed to the ‘‘in-
side-out hypothesis, in which MS begins with an initial event in
the CNS (Malpass, 2012). Once in the CNS, autoreactive
effector CD4 T cells are locally reactivated by antigen-present-
ing cells (APCs) and recruit additional T cells and macrophages
to establish the inflammatory lesion. MS lesions contain CD8
T cells, which are mostly found at the edges of lesions, and
CD4 T cells, which are found deep in the lesions (Traugott
et al., 1983; Hauser et al., 1986). These cells cause myelin
loss, oligodendrocyte destruction, and axonal damage, leading
to neurologic dysfunction. In parallel, immune-modulatory net-
works are triggered to limit inflammation and to initiate repair,
which results in at least partial remyelination and is associated
with clinical remission. Nonetheless, without treatment, further
attacks that ultimately lead to the progressive form of the dis-
ease occur. Our current understanding of how effector CD4
and CD8 T cells promote the disease process is dis-
cussed below.
Effector CD4 T Cells
CD4 T cells are found deep within CNS lesions and in the cere-
brospinal fluid (CSF) of patients with MS (Traugott et al., 1983).
Evidence that myelin-reactive T cells participate in the inflamma-
tory demyelination in MS includes a trial in which MS patients
were treated with an altered peptide ligand of myelin basic pro-
tein (MBP) (Martin et al., 2000). Although this treatment shifted
the MBP response from pathogenic to tolerogenic in mouse
models, in humans, treatment resulted in disease exacerbation,
as evidenced by an increase in contrast-enhancing lesions
and up to a 2,000-fold expansion of circulating MBP-specific
CD4 T cells. The strongest genetic risk factor for development
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Figure 2. Effector T Cells in Multiple Sclerosis

Peripherally activated T cells cross the blood-brain barrier (BBB) into the central nervous system (CNS), where they are re-activated and secrete cytokines to exert
their effector functions. T helper (Th)-1 cells produce their lineage-defining cytokine, IFNg, as well as TNFa, while Th17 cells secrete their defining cytokine IL-17,
as well as IL-21 and IL-22, and can also express IFNg, which contributes to their pathogenicity. CD8+ effector T cells (Teffs) can also be a source of IL-17 and
IFNg. This cytokine secretion leads to the activation of CNS-resident immune cells (such as microglia, astrocytes, and macrophages), as well as to the production
of cytokines, increased antigen-presenting cell (APC) function, and the enhanced production of reactive oxygen species (ROS) and reactive nitrogen species
(RNS). CD8 T cells can also release cytolytic granules causing axonal dissection. Effector T cells can be regulated in the periphery or in the CNS by FoxP3+
regulatory T cells (Tregs) and by Tr1 cells, CD8 Tregs, natural killer cells (NK cells), and regulatory B (Breg) cells.

of MS is the MHC class II locus DR2 (DRB*1501/DQ6). This
class II allele itself regulates the activation of CD4 T cells. This
is because proteins encoded by each MHC allele contain charge
and structural features that restrict the type of peptide that
can be bound and presented to activate T cell receptor (TCR)
molecules on mature peripheral T cells (Hemmer et al., 2000).
MHC class II proteins can also affect thymic selection to shape
the TCR repertoire and the self-tolerance of thymic emigrant
T cells (Klein et al., 2014). Mice that express both MS-associated
HLA-DR and MS-patient-derived TCRs develop spontaneous
EAE (Madsen et al., 1999). Some have argued that these obser-
vations contradict a trial in which MS patients underwent CD4
T cell depletion to no clinical benefit (van Oosten et al., 1997).
However, it is important to note that anti-CD4 therapy would
also have depleted Treg and Tr1 CD4+ regulatory populations
that were unknown at the time but are now known to limit the
activity of autoimmune T cells. Furthermore, depleting CD4
T cells may not ameliorate disease as it would not affect CD8
T cells, which make up the majority of CNS-resident T cells in
patients and may play a crucial role in the disease once it is
initiated by CD4 T cells.
Interferon gamma (IFNg)- and interleukin-17 (IL-17)-
secreting CD4 T cells are believed to be the pathogenic initia-
tors of MS. In the late 1980s, CD4 T cells were first separated
into the functionally distinct IFNg-producing Th1 cells, which
clear extracellular pathogens, and the IL-4-producing Th2
cells, which mediate allergic responses (Tada et al., 1978).
Subsequent studies then identified CD4+ Th17 cells, which
play a central role in autoimmunity (Bettelli et al., 2006). Prior
to the identification of IL-17 cells, whose secretion is stabilized
by IL-23, IFNg-producing Th1 cells induced by IL-12 were
believed to be critical mediators of EAE because EAE did
not occur in the absence of the IL-12 p40 subunit. However,
this interpretation was altered upon finding that p40 is also a
component of IL-23 and that genetic deletion of IFNg actually
enhanced the severity of EAE (Becher et al., 2002). Yet, the
role of IL-23 in potentiating MS is less well supported. This
is because a trial of the drug ustekinumab, which blocks the
common p40 subunit in IL-12/IL-23, failed to show a clinical
effect in multiple sclerosis (Segal et al., 2008). Thus, although
IL-17 is believed to a central mediator of autoimmunity in EAE,
with IFNg possibly being protective in mice (Berghmans et al.,

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2006; Furlan et al., 2001), the increased production of either
IFNg or IL-17 is associated with human MS (Lock et al.,
2002). A pathogenic role for IFNg in MS is supported by a trial
in 1987 in which the administration of IFNg to MS patients
exacerbated their disease (Panitch et al., 1987a). A role for
IL-17 is supported by a double blind trial in which the admin-
istration of an anti-IL-17 compound to MS patients reduced
lesion formation, as assessed by MRI (Havrdová et al.,
2016). Thus, both IL-17 and IFNg appear to play a role in the
human disease, which is consistent with adoptive transfer
EAE experiments that have shown that both Th1 and Th17
cells can independently induce CNS autoimmunity with
distinct patterns of EAE histology (Luger et al., 2008; Lee
and Goverman, 2013).
IL-17-producing CD4 T cells can be pathogenic or non-path-
ogenic (Gaublomme et al., 2015). In contrast to non-encephali-
togenic Th17 cells, murine pathogenic Th17 cells express IL-21,
which regulates B cell activation and plasma cell generation;
IL-22, which augments inflammation via STAT3 activation;
and pro-inflammatory TNFa. They also exhibit decreased
expression of the anti-inflammatory cytokine IL-10. Importantly,
encephalitogenic IL-17-secreting T cells are also believed to
co-produce IFNg and IL-17, which may function early in disease
to activate resident microglia (Murphy et al., 2010). Pure popu-
lations of Th1/17 cells display gene signatures that show
marked similarity to mouse pathogenic Th17 cells as opposed
to nonpathogenic Th17 cells (Lee et al., 2012b). In MS-pa-
tient-derived Th1/17 cells, our group found IL-10 expression
to be reduced and CXCR3 expression to be elevated, while
Th17 cells expressed higher levels of IL-10 in stable versus
active patients (Hu et al., 2017). Similarly, libraries generated
from patient- and healthy donor-derived CCR6+ myelin reactive
T cells demonstrated that patient cells expressed more IFNg,
IL-17, and GM-CSF and less IL-10 than did the cells of healthy
donors (Cao et al., 2015). While these data strongly implicate
IFNg and IL-17 as being pathological in MS, it is important
to note that IL-17 can also be secreted by non-T cells, such
as NK cells and astrocytes (Cua and Tato, 2010; Tzartos
et al., 2008).
How IFNg and IL-17 initiate or augment disease is not
completely understood. IFNg increases the expression of HLA
class I and class II molecules (Keskinen et al., 1997) and en-
hances the antigen-presenting capabilities of macrophages,
astrocytes, and microglia (Kato and Suzumura, 2003; Mouzaki
et al., 2015). It is less clear how IL-17 mediates autoimmunity,
as responses to IL-17 are pleiotropic and the receptors for
IL-17 are ubiquitously expressed, with IL-17-induced re-
sponses differing depending upon cell type (Zhang et al.,
2013; Gu et al., 2013). However, in addition to inducing the
release of a host of pro-inflammatory cytokines, it is believed
that IL-17 plays a crucial role in the breakdown of the blood-
brain barrier by inducing reactive oxygen species within endo-
thelial cells (Huppert et al., 2010).
Effector CD8 T Cells
Although much research has focused on the encephalitogenic
role of CD4 T cells in MS, it appears that CD8 T cells also play
a significant role in human MS. In MS, in contrast to EAE, CD8
T cells make up the majority of T cells in the CNS perivascular
748 Neuron 97, February 21, 2018
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infiltrate and at the edge of CNS lesions (Traugott et al., 1983).
We found that perivascular cuffs at the edge of active demy-
elinating plaques in progressive MS contain up to 50 times
more CD8+ than CD4+ T cells (Hauser et al., 1986), while the
CD4+:CD8+ ratio in the CSF ranges from 3:1 to 6:1 and in
the peripheral blood is 2:1 in MS patients (Friese and Fugger,
2005). CD8 T cells are also often present in disease progres-
sion-associated cortical plaques (Losy, 2013). A portion of
CD8 T cells isolated from the CNS of patients with MS exhibit
evidence of oligoclonal expansion, indicating that these oligo-
clonal cells have been amplified via antigen-specific re-
sponses (Jacobsen et al., 2002). These oligoclonally
expanded CD8 T cells were shown to exist not only in the
CNS, but also in the CSF and blood in a small number of
tested MS patients. Strikingly, it was also shown that some
of these expanded CD8 T cells persisted in the blood and
CSF for several years.
CD8 T cells recognize peptides of endogenous intracellular
proteins presented in the context of MHC class I molecules
and kill cells via a cell-contact-mediated process involving
the activities of granzyme A (GzmA) and granzyme B (GzmB)
(Barry and Bleackley, 2002). While MHC class I is ubiquitously
and constitutively expressed on all cells, oligodendrocytes,
astrocytes, and neurons in patients with disease activity
exhibit enhanced MHC class I and class II expression (Gobin
et al., 2001). The identity of pathogenic class I-restricted anti-
gens remains elusive; however, antigen-presenting microglial
cells have the capacity to cross present exogenous antigens
on their MHC class I molecules, potentially leading to the
high frequency of myelin-reactive CD8 T cells that has been
reported in patients with MS (Zang et al., 2004). These
myelin-reactive CD8 T cells secrete IFNg and kill cells that ex-
press endogenously produced myelin. The cytotoxic function
of effector CD8 T cells might play a central role in axonal dam-
age, as their intracellular lytic granules are directionally posi-
tioned toward nearby axons in immunohistochemical analysis
of postmortem CNS tissue slices. Axonal injury has been
correlated with the presence of lesional CD8 T cells in close
apposition to neurons (Melzer et al., 2009), and enhanced
levels of GzmA and GzmB have been found in the CSF of pa-
tients with active disease flares as compared to those in
remission (Malmeström et al., 2008). Pathogenic CD8 T cells
might also contribute to pathology by secreting IFNg and
IL-17 (Huber et al., 2013). These IFNg-, IL-17-, and GzmB-pro-
ducing effector CD8 T cells also potentially undergo enhanced
endothelial transmigration in a blood-brain barrier model with
human cells and in mouse models (Larochelle et al., 2015;
Duan et al., 2013). Thus, CD8 T cells may not only cause oligo-
dendrocyte death and neuronal damage, but they may also
potentiate IFNg- and IL-17-mediated pathology once inside
the CNS.
Distinct populations of CD8 T cells may play unique roles in
MS. A novel subset of CD8 T cells that are defined by the sur-
face expression of CD161 is reportedly elevated in the circula-
tion of patients with MS and contains all IL-17-producing CD8
T cells (Annibali et al., 2011). Within this population reside the
potentially functionally distinct, mucosal-associated-invariant
CD8 T cells (MAIT cells) that exhibit restricted TCR usage,
Neuron
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expressing TCR Va2 (Billerbeck et al., 2010). In contrast, reports
have suggested that populations of regulatory CD8 T cells
might also play a role in suppressing the immune response
and disease activity. These regulatory CD8 T cell subsets
have been identified via a unique expression of molecules,
including CD122 (IL-2Rb chain) (Lu et al., 2016), CD28 (Vudda-
malay and van Meerwijk, 2017), CD103 (Uss et al., 2006), or
HLA-G (Lozano et al., 2009), and have been proposed to func-
tion via distinct mechanisms. In summary, it appears that
different subsets of CD8 T cells play a pathogenic or beneficial
role in MS.
Regulatory Cells in MS
Subsets of T cells that modulate immune activation and control
the development of autoimmunity have been identified (Sakagu-
chi et al., 2001). At least two subsets of CD4+ regulatory T cells
have been identified and studied in the context of MS. Tregs are
a subset of regulatory T cells that express the transcription factor
Forkhead box protein 3 (FoxP3), as well as a myriad of inhibitory
immune checkpoint surface molecules that contribute to their
capacity to suppress T cell proliferation in vitro via a cell-con-
tact-mediated mechanism (Lu and Rudensky, 2009). A second
type of CD4+ regulatory T cell is the Tr1 regulatory CD4+ T cell
that inhibits cell proliferation primarily via the secretion of IL-10
(Gregori et al., 2012). Each of these Tregs exhibit unique charac-
teristics during autoimmune neuro-inflammation, and both are
believed to be important in MS. NK cells also have regulatory
properties and suppress immune responses via their capacity
to kill activated, and potentially pathogenic, CD4 T cells. Daclizu-
mab has been shown to enhance CD56hi NK regulatory activity
and to be effective in relapsing forms of MS (Bielekova et al.,
2006). CD8 regulatory T cells may also exist and are dis-
cussed above.
CD4 FoxP3+ Tregs
FoxP3+ Tregs, which make up less than 4% of circulating CD4
T cells, are referred to as ‘‘professional’’ suppressor cells as
they exert a dominant inhibition of the activation of other cell
types via a process that requires cell contact (Baecher-Allan
et al., 2001; Schmidt et al., 2012). In contrast to the non-self-
reactivity of effector T cell TCRs, the TCR repertoire of Tregs is
selected to recognize self-antigens (Pacholczyk and Kern,
2008; Lee et al., 2012a). Accordingly, Tregs are activated by
self-antigens. FoxP3 is absolutely required for their suppressive
activity as the loss of a functional, X-linked FoxP3 gene in male
children born with immunodysregulation polyendocrinopathy
enteropathy X-linked (IPEX) syndrome results in a lethal multi-
organ autoimmunity (d’Hennezel et al., 2009). The direct role
that Tregs play in blocking autoimmunity has been demonstrated
in mouse strains generated with either mutations or deletions
of FoxP3 (Sakaguchi et al., 1985). Treg function has been shown
to directly affect the ability to induce EAE in the mouse, as the
co-transfer of Tregs with pathogenic CD4+CD25– cells prevents
EAE (Read et al., 2000). MBP-reactive, disease-ameliorating
Tregs have been identified in the mouse (Stephens et al.,
2009), while in humans the existence of MBP-reactive natural
Tregs is unclear since suppressive, FoxP3-expressing human
MBP-reactive clones are suggested to have arisen from non-
Treg populations (Hong et al., 2009). Several studies have
demonstrated that inflammation can adversely affect Treg
suppression (Schadenberg et al., 2011), as high numbers of
non-suppressing Tregs have been found to co-exist with pro-
inflammatory T cells in autoimmune target tissues at peak dis-
ease in both EAE in the CNS and in RA in the synovium (O’Connor
et al., 2007; Cao et al., 2003).
Tregs from MS patients have a reduced suppressive capacity
as measured by the co-culture of MS-derived Tregs and
effector T cells (Teffs) (Viglietta et al., 2004; Haas et al., 2005;
Costantino et al., 2008). Most studies, however, have not found
a difference in the frequency of Tregs in the blood, suggesting
a qualitative versus a quantitative abnormality. Although
increased Treg function has been proposed as a therapy for
MS, such approaches do not address whether the Treg defect
observed in MS is related to the resistance of effector cells to
Treg suppression or to an inherent defect in the Tregs them-
selves. Recent studies of Tregs and Teffs isolated from patients
with a number of autoimmune diseases, including MS, have
demonstrated that patient-derived Teff are, in fact, resistant
to Treg-mediated suppression (Schneider et al., 2013; Bhela
et al., 2015). Thus, published studies suggest that in MS there
exists both a defect in Tregs and a resistance to Treg suppres-
sion by Teff cells.
Inflammatory molecules expressed in autoimmune diseases
can negatively affect Treg suppression. The pro-inflammatory
cytokine IL-6, which exacerbates EAE, can alter CD4 T cell dif-
ferentiation and promote the generation of Th17 cells at the
expense of Tregs (Kimura and Kishimoto, 2010; Becher and
Segal, 2011). IL-6 can also directly inhibit Treg suppression
in co-culture experiments via its ability to augment the secre-
tion of GzmB, which contributes to Teff cell resistance to Treg
suppression (Bhela et al., 2015). Thus, while clinical trials to
target IL-6 in MS have been proposed, therapeutically block-
ing IL-6R (for example, with the compound tocilizumab) has
been found to induce MS-like lesions in RA patients (Coma-
bella, 2016). Similarly to IL-6, the pro-inflammatory cytokine
TNFa inhibits Treg suppression, but unlike IL-6, TNFa
concomitantly induces Tregs to undergo proliferation (Valencia
et al., 2006). Surprisingly, anti-TNFa therapy worsened MS
and unmasked MS in arthritis patients being treated with
anti-TNFa (Kaltsonoudis et al., 2014) even though blocking
TNFa reduces disease in patients with psoriasis and RA (van
Oosten et al., 1996).
CD4+ Tr1 Regulatory Cells
Tr1-type regulatory T cells were first described in the mouse
model of colitis and were shown to produce IL-10 (Groux
et al., 1997). They were subsequently identified in patients
with severe combined immunodeficiency (SCID), who ex-
hibited chimerism having undergone HLA-mismatched he-
matopoietic stem cell transplantation (Gregori et al., 2012).
These Tr1 cells secreted high amounts of IL-10 and killed
myeloid APCs via a GzmB-mediated mechanism. The
absence of specific surface antigens or transcription factors
unique to Tr1 cells means that they are primarily identified
operationally as CD4 T cells that exhibit an IL-10high IL-2low
IFNg+ cytokine secretion profile. However, it has recently
been proposed that Tr1 cells co-express CD49b and LAG3
(Gagliani et al., 2013). Cellular therapy with human Tr1-type
cells enriched by the in vitro co-culture of CD4 T cells with
Neuron 97, February 21, 2018 749

IL-10-generated dendritic cells (DC-10) is being tested
in allogeneic hematopoietic stem cell transplantation and, if
successful, could be applied to MS.
Although not as extensively studied as FoxP3+ Tregs, Tr1 cells
from patients with MS have also been found to be dysfunctional.
By stimulating CD4 T cells through CD46, which strongly induces
IL-10, it was found that MS CD4 T cells express less IL-10 than
those from healthy individuals. (Astier et al., 2006). Numerous
studies have demonstrated the importance of IL-10 in amelio-
rating murine EAE (Mayo et al., 2016) and the effects of adminis-
tering Tr1-like cells induced by dexamethasone and vitamin D3
(Kleinewietfeld and Hafler, 2014). In MS, the capacity of CD4
T cells to secrete IL-10 is associated with decreased disease ac-
tivity as the expression of IL-10 and CD46 is enhanced in patients
who respond to IFNb therapy compared to cells from patients
who did not respond (Chiarini et al., 2012). Non-pathogenic
Th17 cells have also been reported to secrete increasing
amounts of Il-10 (Lee et al., 2012b).
Regulatory Natural Killer Cells
NK cells are innate immune cells involved in early host defense
against infection and tumor transformation. NK cells secrete
both pro-inflammatory (IFNg, TNFa) and anti-inflammatory
(IL-4, IL-10) cytokines and have been suggested to play dual
roles in disease (Schleinitz et al., 2010). It is unclear whether
the specific types of NK cells, two of which are commonly
defined as CD56dimCD16hi or CD56bright, play unique roles in
autoimmunity (Caruana et al., 2017; Laroni et al., 2016). Although
the CD56dimCD16hi cells that represent 90% of NK cells in
peripheral blood are immediately cytotoxic, they are found in
much lower frequency in tissue. In contrast, the CD56bright cells,
which primarily secrete cytokines and acquire cytotoxic activity
over time, predominate in tissues.
Most lines of evidence suggest that NK cells play an immuno-
regulatory role in MS even though NK cells have been found
in the demyelinating lesions of MS patients (Traugott, 1985).
CD56bright NK cells are increased by immunomodulatory and
immunosuppressant therapies, increases in NK frequency
correlate with treatment response (Bielekova et al., 2006),
reduced NK frequency has been associated with relapse (Mor-
andi et al., 2008), and in vitro NK functional activity increases
at times of remission (Infante-Duarte et al., 2005). Daclizumab,
an FDA-approved drug that reduces MS relapses, is a human-
ized antibody against the IL-2 receptor that expands CD56bright
NK cells (Bielekova et al., 2006). A similar increase in CD56bright
NK cell frequency has also been described in MS patients
treated with IFNb (Saraste et al., 2007).
CD56bright NK cells from untreated MS patients have reduced
ability to inhibit the proliferation of autologous activated T cells,
which might relate both to the dysfunction of CD56bright NK cells
and to the finding that MS CD4 T cells might be less sensitive
to NK cell regulation (Laroni et al., 2016). This apparent ‘‘NK
resistance’’ by patient-derived T cells was suggested to involve
enhanced T cell expression of the NK-inhibitory ligand HLA-E or
reduced expression of CD155 on patient-derived T cells (Gross
et al., 2016). Daclizumab treatment increases expression of
CD155 on CD4 T cells and enhances in vitro suppression of
autologous activated T cells by NK cells (Gross et al., 2016).
Mouse studies of NK cells in CNS autoimmunity have given
750 Neuron 97, February 21, 2018
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mixed results, which might be due to the marked differences
between human and mouse NK cells (Shi and Van Kaer, 2006).
B Cell Populations in MS
Although MS is considered to be a T-cell-mediated disease, the
dramatic effects produced by anti-CD20 therapy (rituximab and
ocrelizumab) in MS demonstrate a central role for B cells in its
pathogenesis (Greenfield and Hauser, 2017). One of the classic
findings in MS is the presence of oligoclonal bands (OCBs) in
the CSF, which is observed in 95% of patients and which arise
from clonally expanded Ig-secreting cells (Heidelberger et al.,
1942; Schirmer et al., 2014). Although the specificity of most
OCBs remains unclear, CSF OCB antibodies from four MS pa-
tients exhibited specificity for a number of ubiquitous intracellular
proteins that are released as debris during tissue destruction
(Bra€ndle et al., 2016). Although CSF antibodies that bind myelin
lipids have been associated with aggressive MS (Villar et al.,
2005), similar anti-lipid antibodies exist in SLE and Grave’s dis-
eases (Endo et al., 1984). Nonetheless, a number of autoantibody
targets have been identified in MS, including MOG in pediatric
and NMOSD phenotypes, KIR4.1, and MBP (discussed below
in Biomarkers).
Clonally expanded B cells are found in the brain paren-
chyma, meninges, and CSF of MS patients (Lovato et al.,
2011) and are present in the CNS at greater frequency earlier
in the disease (Henderson et al., 2009). Increased B cell fre-
quency in the CSF correlates with a rapider disease progres-
sion (Cepok et al., 2001). Beyond their potential ability to pro-
duce autoantibodies, B cells in the CNS could act in MS by
secreting chemokines/cytokines and by presenting antigen
to T cells (Figure 3). Strengthening the hypothesis that B cell
antigen presentation might be central to disease pathology,
the capacity to induce disease in the EAE mouse model was
shown to require B cell expression of MHC class II (Molnarfi
et al., 2013). B cells can cross the blood-brain barrier and
become long-term CNS residents in lymph-node-like follicles
found in the meninges, which are often adjacent to cortical le-
sions (Selter et al., 2013; Cross et al., 2006; Serafini et al.,
2004). These cellular aggregates, often referred to as ectopic
lymphoid follicles, were identified within the meninges in
two-thirds of SPMS brain specimens. The existence of these
follicle-like structures suggests that B cells undergo intra-
thecal expansion and differentiation to plasmablasts and
plasma cells in the CNS itself (Magliozzi et al., 2007; Serafini
et al., 2004).
A central challenge in MS is to understand why depleting
B cells with anti-CD20 has such a dramatic effect in abolishing
MS relapses and a modest effect on progression in primary
progressive MS (Castillo-Trivino et al., 2013). CD20 is ex-
pressed on most B cells and is found on maturing B cells
just before the cell becomes a terminally differentiated plasma
cell (Leandro, 2013). Anti-CD20 therapy in MS patients results
in an 88% reduction in gadolinium-enhancing lesions (Nai-
smith et al., 2010; Bourdette and Yadav, 2008) within 2 months
in association with the immediate loss of B cells from the cir-
culation and from the CSF by 20 weeks. Anti-CD20 also re-
duces the number of T cells in the blood and CSF by 20%
and 50%, respectively (Naismith et al., 2010), and reduces
the capacity of the remaining T cells to secrete IL-17 and
Neuron

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Figure 3. The Pathogenic Role of B Cells in Multiple Sclerosis

B cells present antigens in the context of MHC class II molecules to activate CD4 T cells, contributing to an inflammatory environment. Regulatory B (Breg) cells
can inhibit effector T (Teff) cells via IL-10, IL-35, TGF-b, or PD-L1 and can be dysfunctional in MS. B cells can produce autoantibodies in the periphery and CNS.
B cells can cross the blood-brain barrier and form follicle-like ectopic germinal centers in the CNS, which becomes compartmentalized and functions
independently of the periphery. B cells present in these follicles can undergo expansion and differentiation into antibody-secreting plasma cells within the CNS
itself. B cells also secrete the pro-inflammatory cytokines TNFa, IL-6, and GM-CSF, which promote CNS inflammation.

IFNg (Baker et al., 2017). Plasma cells that produce OCBs do
not express CD20. Thus, the rapid effect on disease relapses
is not accompanied by changes in antibody levels or OCBs. In
contrast, treatment with natalizumab does lead to a reduction
in OCBs over time (Mancuso et al., 2014). Of note, another B-
cell-targeting drug, atacicept, which blocks memory B cells
and plasmablasts from using the TACI growth factor, exacer-
bated MS, suggesting that it negatively affects a disease-
ameliorating B cell subset (Bible, 2014). Thus, it appears that
the rapid onset of the beneficial effect of anti-CD20 relates
to deleting a pro-inflammatory B cell subset that drives
T cell activation via antigen presentation or cytokine secretion.
The longer-term benefit of such treatment might arise from re-
establishing the activity of inhibitory regulatory B cell popula-
tions (Barun and Bar-Or, 2012).
Functionally Distinct B Cell Populations in MS
The striking disease-ameliorating effect of anti-CD20 has
focused interest on understanding the immune-regulating prop-
erties of human B cell populations. B cell lymphopoiesis begins
in the bone marrow when B cell precursors undergo antigen-
independent differentiation into transitional B cells that migrate
from the marrow into the blood. These transitional B cells (CD38hi
CD24hiIgD+CD27 CD10+/ ) are then subject to antigen-driven
maturation and represent the stage at which negative selection
against autoreactive B cells is believed to occur (Palanichamy
et al., 2009). Transitional B cells are expanded in human immu-
nodeficiencies (Cuss et al., 2006). After an early transitional
state, B cells undergo maturation from the mature naive to the
pre-germinal center non-switched memory, switched memory
plasmablast, and, ultimately, to the antibody-secreting plasma
cell. The B cell becomes more proliferative and exhibits
enhanced survival as it matures (Palanichamy et al., 2009).
CD19, which modulates the signaling threshold for B cell activa-
tion, is expressed on all circulating B cell lineage cells from the
earliest B lineage cells coming from the bone marrow through
to the plasmablast. CD20 is a surface protein whose function
in unknown and is expressed at the pre-B cell stage through to
the development of mature naive and memory B cells but is
lost when the cell develops into a plasma cell. As a result,
CD20 depletion targets all the mature naive and memory mature
B cell populations but leaves the immature and plasma cell com-
partments untouched. Thus, although memory B cells, short-
lived plasmablasts, and long-lived plasma cells are increased
in the CNS in MS (Michel et al., 2015) and correlate with MRI le-
sions (Kuenz et al., 2008), anti-CD20 therapy may only deplete
the memory B cell population.

Neuron 97, February 21, 2018 751


Dysfunctional Pro-inflammatory B Cells in MS
B cells are heterogeneous in their production of pro-inflamma-
tory (IL-6, TNFa, LTa, and GM-CSF) and anti-inflammatory
(IL-10 and IL-35) cytokines. Both STAT5 and STAT6 can induce
B cell GM-CSF production. B cells from MS patients secrete
more GM-CSF and less IL-10 than do the B cells of healthy sub-
jects, and B-cell-derived GM-CSF enhances myeloid secretion
of the T-cell-activating cytokines IL-12 and IL-6, which play
a role in directing Th1 and Th17 development (Li et al., 2015).
Strikingly, in MS patients treated with anti-CD20, reconstituting
B cells were found to produce reduced amounts of GM-CSF
and increased amounts of IL-10. As B cell production of GM-
CSF and IL-10 is mutually exclusive, it is unclear whether the
same B cell is differentially regulated to secrete either pro- or
anti-inflammatory cytokines or whether these cytokines are pro-
duced by distinct subsets within the mature B cell population.
Regardless, anti-CD20 treatment results in a long-lasting benefit
that appears to correlate with the absence of memory B cells and
with reduced B cell secretion of pro-inflammatory cytokines
(Hauser et al., 2013).
Changes in mature B cell number and activity correlate with
disease activity and treatment response. Unlike B cells in pa-
tients with RA or T1D, the deletion of autoreactive B cells at
the development stage of the transitional B cell is not aberrant
in MS. Yet, despite an apparently normal response to checkpoint
deletion, mature naive B cells exhibit abnormal activation and
proliferation in MS (Kinnunen et al., 2013). Furthermore, memory
B cells from patients with MS show enhanced expression of
CD80 and CD86 (Bar-Or et al., 2001). The unsuccessful trial of
atacicept, designed to block BAFF growth factor activation
of mature B cells, actually enhanced memory B cell activation
and exacerbated CNS inflammation (Sergott et al., 2015b).
This exacerbation appeared to involve the unexpected induction
of an IL-15-mediated increase in memory B cell activity by ataci-
cept (Ma et al., 2014). Enhanced B cell activation might also have
been responsible for the development of MS following anti-TNFa
therapy in patients with RA or Crohn’s disease as treatment re-
sulted in increased numbers of memory B cells (Roll et al.,
2012; Souto-Carneiro et al., 2009). Also, IL-21, which is pro-
duced by pathogenic Th17 cells, might enhance the proliferation
and survival of memory B cells (Gharibi et al., 2016). Thus, in MS,
memory B cells exhibit enhanced pro-inflammatory properties
and have the capacity to drive T cell activation.
In addition to affecting mature B cells, anti-CD20 treatments
might affect other immune system populations. Unique CD20-
transitional B cell subsets are expanded relative to other popula-
tions after anti-CD20 therapy and may be involved in restoring
immune homeostasis (Palanichamy et al., 2009). An ignored
area related to anti-CD20 efficacy in MS is a small compartment
of T cells that express CD20. These CD20+ T cells are highly pro-
apoptotic, contain both CD4 and CD8 subpopulations, and
show increased production of IL-17, IFNg, and TNFa (Schuh
et al., 2016). The depletion of these CD20+ T cells by anti-
CD20 therapy would be beneficial were they to play a pathogenic
role in MS (Palanichamy et al., 2014).
Regulatory Anti-inflammatory B Cells in MS
Subsets of B cells that suppress immune responses are referred
to as regulatory B cells or Bregs. Bregs are primarily identified
752 Neuron 97, February 21, 2018
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Review
by their production of IL-10; to date, no specific surface markers
or transcription factors have been identified that define a Breg
(Mauri and Menon, 2015). Bregs have also been reported to
suppress via IL-35, TGFb, PD-L1, and GzmB (Ray and Dittel,
2017; Molnarfi et al., 2017; Yang et al., 2013). Thus, they may
be a heterogeneous population at different stages of differentia-
tion. Mechanisms of Breg suppression include IL-10-mediated
inhibition of dendritic cell priming, the induction of Tr1, and
induced Tregs (iTregs) via IL-10, TGFb, or PD-L1 and the killing
of T cells via GzmB cytotoxicity. In contrast to naive B cells,
B10-type Bregs reside in the memory CD19+CD24hiCD27+
B cell population and are identified by their ability to produce
high amounts of IL-10 in response to TLR4/9 stimulation (Iwata
et al., 2011). Breg activity is also present in immature transitional
CD27 CD19+CD24hiCD38hi B cells and CD27+CD24 CD38hi
plasmablasts, which can utilize IL-10 and PD-L1 to induce CD4
T cells to become Tr1 or iTregs, which are the suppressive
FoxP3+ cells that are generated in the periphery after thymic se-
lection (Blair et al., 2010; Flores-Borja et al., 2013; Siewe et al.,
2014). In contrast, the Breg cells that express CD19+CD38+
CD1d+IgM+CD147+, which are induced by IL-21, produce both
IL-10 and GzmB and suppress by killing (Lindner et al., 2013).
Using a functional definition to identify Bregs makes it difficult
to determine whether disease-associated differences in Breg
activity are due to defective Breg function or to Breg paucity.
Furthermore, being restrained by a functional definition makes
it difficult to determine whether Breg subsets have a fixed or a
transient suppressive function.
Changes in Breg frequency and activity have been reported
in disease. Bregs from MS patients who had a concurrent
Helminth infection exhibited increased IL-10 production and
a greater capacity to suppress T cells in vitro (Correale
et al., 2008). The frequency of IL-10-secreting B cells are
decreased in patients with RA (Flores-Borja et al., 2013)
and Grave’s disease (Zha et al., 2012), while Bregs in patients
with SLE exhibit an impaired secretion of IL-10 in response to
CD40 activation (Blair et al., 2010). However, it is not clear
whether the frequency of IL-10-secreting Bregs is altered in
MS (Michel et al., 2014a; Habib et al., 2015). The reset of
Breg function could be one way in which anti-CD20 therapy
in SLE patients restored the expression of CD1d on
CD19+CD24hiCD38hi Bregs, along with restoring other im-
mune populations (such as invariant NK T cell activity)
(Bosma et al., 2012). In MS, one way to explain the rapid ef-
fect of CD20 therapy is that it quickly depletes the pro-in-
flammatory cytokine-producing memory B cells that are
increased in MS (von Bu €dingen et al., 2015). In this regard,
the long-term benefit of Alemtuzumab (an anti-CD52) therapy
for MS patients might be due to the long-term reversal of
naive versus memory B cell ratios (Baker et al., 2017).
Thus, the long-term benefit of anti-CD20 in MS may be
related to both a reduction in pro-inflammatory memory B
cells and the restoration of Bregs.
As more has been learned about both MS and the complex
immune networks that drive autoimmunity, pivotal roles for the
innate immune system, and for B cells, endothelial function,
and different T cells subpopulations, have been identified, estab-
lishing them as key contributors to MS immune dysregulation.
Neuron
Review
Progressive MS
The pathologic features associated with progressive MS
include brain atrophy, which is related to axonal loss, cortical
demyelination, microglia activation, and failure of remyelination.
The physical decline and disability experienced by MS patients
are generally related to this form of the illness. Progressive MS
can develop from the relapsing form of MS or can be progres-
sive from the outset (primary progressive). From MRI imaging
studies, it is clear that, in most instances, primary progressive
MS is simply the secondary progressive form, in which the re-
lapsing stage involved sub-clinical relapses. However, in some
instances, the disease begins as primary progressive MS, rep-
resenting a unique subtype of the disease, although the pro-
cesses that drive both primary and secondary progressive
MS are likely to be the same. In general terms, relapsing dis-
ease involves the movement of immune cells from the periph-
ery into the CNS, whereas progressive disease involves the
development of a compartmentalized pathological process in
the brain. This is evident by the decrease in gadolinium
enhancement on MRI of the brain of progressive MS patients,
indicating a reduced breakdown of the blood-brain barrier
and less movement of cells into the brain. Importantly, few
drugs that are effective in relapsing forms of MS are effective
in progressive disease as most of these drugs target the adap-
tive peripheral immune system as opposed to a compartmen-
talized CNS immune response. Unlike relapsing MS, which is
primarily immune system driven, progressive MS involves
both immune-dependent and -independent mechanisms,
although the immune-independent mechanisms are triggered
by the immune system (Figure 4).
Immune-Dependent and -Independent Mechanisms of
Progression
Whereas the peripheral adaptive immune system (T cells)
drives relapsing MS, the innate immune system (microglia
and astrocytes) with B cells is the primary driver of progressive
MS. B lymphocytes are prominent, particularly in the context
Figure 4. Mechanisms in Progressive
Multiple Sclerosis
CNS resident immune cells, including microglia
and astrocytes, as well as B cells potentially from
ectopic germinal centers, can drive the disease
processes in progressive MS that contribute
to neurodegeneration. The immune-dependent
components of disease might activate various
disease processes that then become self-main-
taining and immune-independent deleterious
mechanisms in the neuron. Mitochondrial injury
occurs as a result of mitochondrial DNA
(mtDNA) mutation and reduced respiratory chain
activity, leading to energy deficiency, owing to
the enhanced production of ROS/RNS. Iron is
released from regions of active demyelination
and contributes to oxidative stress, while gluta-
mate excitotoxicity causes a massive influx of
calcium into neurons, resulting in ionic imbalance.
These immune-dependent and -independent
mechanisms all lead to axonal atrophy and neu-
rodegeneration. ROS, reactive oxygen species;
RNS, reactive nitrogen species; Fe3+, iron; Ca2+,
calcium.
of meningeal inflammation and in the formation of ectopic
germinal centers and follicle-like structures, which are en-
riched in B cells, plasma cells, and follicular dendritic cells
(Serafini et al., 2004). Meningeal inflammation appears to be
an important cause of cortical demyelination, which might be
induced by soluble factors that diffuse from the meninges. Mi-
croglia are resident innate immune cells of the brain and have
a unique molecular signature (Butovsky et al., 2014). They are
activated in MS and can secrete pro-inflammatory cytokines,
reactive oxygen intermediates, proteinase, and complement
proteins. PET imaging demonstrates diffuse microglial inflam-
mation in progressive MS, including in normal-appearing white
matter (Rissanen et al., 2014). Visualization of leptomeningeal
enhancements at T7 may also be useful (Zurawski et al.,
2017). Microglia also have neuroprotective phenotypes, such
as upregulating indoleamine 2,3-dioxygenase, which modu-
lates tryptophan metabolism and promotes an anti-inflamma-
tory microenvironment (Kwidzinski et al., 2005). However, mi-
croglia lose their normal homeostatic phenotype in MS (Zrzavy
et al., 2017). Astrocytes are involved in multiple aspects of
CNS function, including synapse maintenance, neurotransmis-
sion, phagocytosis, and blood-brain barrier formation. A
neurotoxic subpopulation of astrocytes (termed A1 astrocytes)
has been described (Liddelow et al., 2017), and the primary
driver of A1 astrocytes are microglia. Astrocytes promote
MS by producing neurotoxic molecules, such as NO and
TNFa, and by recruiting neurotoxic inflammatory monocytes
to the CNS. Of note, in the acute EAE model of MS, the dele-
tion of astrocytes worsens disease whereas astrocyte deletion
in the progressive EAE model improves disease (Mayo et al.,
2014). Changes in the innate immune system have also been
identified in the peripheral blood of patients with progressive
MS, who exhibit enhanced IFNg production by non-T cells
(Balashov et al., 1997) as well as increased numbers of
blood-derived myeloid dendritic cells that express CD80 and
secrete IL-12 and TNFa (Karni et al., 2006). Once CNS
Neuron 97, February 21, 2018 753
754 Neuron 97, February 21, 2018

Table 2. Treatment for Multiple Sclerosisa

1. FDA-approved therapies
Drug (Date of Approval) Target Mechanism of Action Efficacy Adverse Events References
Commercial Name
IFNb (1993) (IFNb-1b Binds to type I IFN Inhibits T cell division, matrix Reduction in annualized Post-injection flu-like Bermel et al., 2013;
Betaseron, Extavia) receptor on human metallo-proteinase, BBB relapse rate in RRMS. Delays symptoms, liver toxicity, and Schubert et al., 2015;
(IFNb-1a Avonex, cells migration, and conversion to clinically depression. Neutralizing Abs Goodkin, 1996; Kappos
Rebif, Plegridy) proinflammatory cytokines. definite MS in CIS. associated with reduced et al., 2016
Induces Tregs, suppressive efficacy
transitional CD19+CD24++
CD38++ B cells
Glatiramer Acetate Random polymers of Competes with peptide Reduction in annualized Post-injection idiosyncratic Arnon and Aharoni, 2004;
(1997) Copaxone, glutamic acid, lysine, binding to MHC, increases relapse rate in RRMS. reactions, lymphadenopathy Racke et al., 2010; Simpson
Glatopa alanine, and tyrosine IL- 10, IL-4, TGFb, and CD8 et al., 2002; Tennakoon et al.,
to bind to MHC Tregs, induces type II 2006; Weber et al., 2007
monocytes that cause a Th1
to Th2 shift
Mitoxantrone (2000) Interferes with DNA Causes nucleotide Reduction in annualized Bone marrow suppression, Martinelli Boneschi et al.,
Novantrone repair crosslinking and DNA strand relapse rate and disease cardiomyopathy, leukemia 2013; Vollmer et al., 2010
breaks. Inhibits lymphocyte progression in clinically
and monocyte migration, B worsening RRMS
cell function, and secretion of and SPMS.
TNFa, IL-2 and IFNg
Natalizumab (2004) CD49d, the a4 Blocks B and T cell migration Reduction in annualized Reactivation of the JC virus Polman et al., 2006;
Tysabri subunit of VLA4 into the CNS. Blocks VLA4 relapse rate in RRMS. in the CNS may occur in Sellebjerg et al., 2016
integrin (humanized binding to VCAM-1 and some patients (PML),
mAb) fibronectin infusion reactions
Fingolimod (2010) S1PR (Sphinosine-1- Sequesters lymphocytes in Reduction in annualized Bradycardia, infection, Willis and Cohen, 2013
Gilenya phosphate receptor) lymph nodes by inhibiting relapse rate in RRMS. macular edema,
lymphocyte egress. Inhibits lymphopenia rare PML cases
the migration of dendritic
cells to secondary lymphoid
organs
Teriflunomide (2012) Inhibits dihydroorotate Inhibits pyrimidine synthesis. Reduction in annualized Hair thinning, liver toxicity, O’Connor et al., 2011;
Aubagio dehydrogenase Inhibits secretion of relapse rate in RRMS. teratogenesis Tallantyre et al., 2008
proinflammatory cytokines

Review
and T cell activation
(Continued on next page)

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 Review
Neuron
Table 2. Continued
Dimethyl fumarate Nrf2 pathway Activates the Nrf2 Reduction in annualized GI side effects, flushing, Kappos et al., 2008
(2013) Tecfidera transcriptional pathway relapse rate in RRMS. lymphopenia, and rare PML
Alemtuzumab (2014) CD52 on T and B cells Depletes B and T cells via Reduction in annualized Autoimmune diseases Coles et al., 2008; Havrdová
Lemtrada (humanized mAb) ADCC and complement relapse rate in RRMS. including thyroid, immune et al., 2015
thrombocytopenia purpura,
and glomerulonephritis
Daclizumab (2016) CD25, anti-IL2R Prevents IL-2 signaling Reduction in annualized Liver toxicity, skin reactions Giovannoni et al., 2014;
Zinbryta (humanized mAb) through the high affinity relapse rate in RRMS. Gross et al., 2016; Kappos
IL-2R. Augments CD56+ NK et al., 2015
cell activity
Ocrelizumab (2017) CD20+ B cells Depletes CD20+ B cells. Decreased annualized Infusion reactions, risk of Hauser et al., 2017;
Ocrevus (humanized mAb) Reduces pathogenic B cell relapse rate in RRMS. breast cancer, low risk Montalban et al., 2017;
antigen presentation Reduced disease of PML Sørensen and
progression in PPMS. Blinkenberg, 2016
Cladribine (2017) Adenosine deaminase Depletes immune cells by Reduction in annualized Infection, lymphopenia Giovannoni et al., 2010;
(EMA/Canadian inducing lymphocyte relapse rate in RRMS. Leist et al., 2014
approval) apoptosis. Sustained
reduction in CD4 and CD8 T
cells and transient reduction
in B cells
2. Off-label immune therapy
Drug Target Mechanism of Action Efficacy Adverse Events References
Bone Marrow Immune reconstitution Global immune suppression Suppresses relapses and Transplant-related morbidity Burt et al., 2015; Fassas
Transplantation may slow disease and secondary malignancy et al., 1997; Daikeler
progression. et al., 2012
Cyclophosphamide Alkylating metabolite Immune suppression and Suppresses relapses and Alopecia, myelosuppression, Comabella et al., 1998;
immune deviation may slow disease cancer, sterility Stankiewicz et al., 2013
progression.
Azathioprine; General immune Inhibits T and B cell activity, Suppresses relapses in GI and hepatic toxicity; GI Vollmer et al., 2010; Gray
Methotrexate; suppressants proliferation, and BBB uncontrolled trials. toxicity, myelosuppression, et al., 2004; Michel
Neuron 97, February 21, 2018 755

Mycophenolate migration. Inhibits de novo GI toxicity, pneumonitis; et al., 2014b

mofetil purine synthesis; leukopenia, anemia,
dihydrofolic acid reductase; headaches and diarrhea
and inosine monophosphate
dehydrogenase
(Continued on next page)
756 Neuron 97, February 21, 2018

Table 2. Continued
Intravenous steroids Anti-inflammatory Dampens inflammatory Accelerates relapse recovery Sleep problems, mood Sloka and Stefanelli, 2005;
cytokine cascade, inhibits (3–5 day course). disturbance, weight gain Sellebjerg et al., 1998
the activation of T cells, limits
lymphocyte extravasation
into CNS induces apoptosis
of activated immune cells
Intravenous Immune modulation Idiotypic regulation of B May be useful in RRMS and Hypercoagulability, renal Katz et al., 2006; Sørensen et
Immunoglobulin cells, reduces serum pregnancy. failure al., 2002
autoantibody and
inflammatory cytokines
Rituximab Rituxan CD20+ B cells Depletes CD20+ B cells. Reduces relapse rate Infusion reactions Castillo-Trivino et al., 2013;
(Chimeric Ab) Reduces pathogenic B cell in RRMS. Hauser et al., 2008
antigen presentation
Plasmapheresis Removal of serum Immune modulation Accelerates relapse recovery Hypotension and Weiner et al., 1989;
factors and limits disability accrual. hypocoagulability Weinshenker, 2001
3. Clinical trials
Drug Target Mechanism of Action Efficacy Adverse Events References
Siponimod; Ozanimod S1PR (Sphinosine-1- Sequesters lymphocytes in Reduction of annualized Bradycardia, lymphopenia Kappos et al., 2016, 2017;
phosphate receptor) Lymph nodes by inhibiting relapse rate in RRMS. Selmaj et al., 2013; Cohen
egress. May have direct Reduces risk of disability et al., 2016
antiinflammatory effects progression in SPMS.
in CNS
Laquinimod Derivative of linomide Induces Tregs and secretion Reduction of annualized Liver toxicity Comi et al., 2012; Polman
(quinoline- of TGFb and Th2 cytokines. relapse rate in RRMS. et al., 2005
3-carboxamide) Neuro-protective effect:
increased serum BDNF, and
reduced excitatory currents
High-dose biotin Vitamin B7 An essential co-factor for Stabilization of disease Infrequent diarrhea, renders Sedel et al., 2015; Tourbah
fatty acid synthesis and progression and biotinylated assays et al., 2016
energy production improvement of disability in inaccurate
30% of patients.
Secukinumab Anti-IL-17A Blocks the activity of IL-17 Reduction of new Infection Havrdová et al.; 2016
gadolinium-enhancing T1
lesions.
4. Treatments that worsened MS
Drug (Date of Trial) Target Mechanism of Action Comments References

Review
IFNg (1987) IFNg receptor Increased monocyte MHC Induced disease exacerbation Panitch et al., 1987b
class II expression in 7/15 patients.
(Continued on next page)

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 Review
Neuron
Table 2. Continued
TNFa (1996) TNFa blockade Reduction of TNFa activity Increased MRI and disease activity in an open label study. A Arnason et al., 1999; van
Lenercept/Infliximab (sTNFR-Ig) multi-center trial of Lenercept was halted due to increased Oosten et al., 1996
relapses and severity of exacerbations.
Atacicept (2014) BLyS/April receptor Depletes mature B cells and Exacerbated disease activity in RRMS (beneficial in RA Kappos et al., 2014; Sergott
blockade plasma cells and SLE). et al., 2015a
Tocilizumab (2016) IL-6R (humanized Blocks IL6R In RA patients, blocking IL-6R induced MS-like lesions. Beauchemin and
mAb) Carruthers, 2016;
Comabella, 2016
5. Antigen-specific therapies for MS
Drug (Date of Trial) Target Mechanism of Action Comments References
Oral Myelin (1993) Ag-specific cells Mucosal induction of No side effects. No detectable benefit. Weiner et al., 1993
regulatory cells, tolerization
of antigen-specific cells
APL for MBP (2000) Antigen peptide of Block T cell responses by Worsened disease by MRI in some patients; increased MBP Bielekova et al., 2000
MBP with modifications acting as TCR antagonist or reactive T cells in circulation.
made to TCR contact by inducing regulatory T cell
sites populations
BHT-3009 (2008) DNA vaccine Immune tolerance to myelin Reduction of gadolinium enhancement in double blind trial. Garren et al., 2008
encoding myelin basic basic protein
protein
Transdermal Myelin MOG, MBP, and PLP Immune tolerance to myelin Reduction in antigen-specific T cell responses. Walczak et al., 2013
Peptides (2013) peptides antigens
ETIMS antigen Autologous PBMCs Induction of antigen-specific No new lesions in low-disease patients, new lesions in highly Lutterotti et al., 2013
specific therapy coupled to peptides tolerance. Decreased active patients.
(2013) antigen-specific T cell
responses
ATX-MS-1467 (2018) Antigen-specific Cocktail of four myelin First trial (6 patients): no adverse events, unchanged EDSS Streeter et al., 2015;
pathogenic T cells antigen peptides to score. Second trial (43 patients): effect on gadolinium Chataway et al., 2018
induce tolerance, given enhancement measured at 16 weeks.
intradermally
Neuron 97, February 21, 2018 757

a
see MScenter.partners.org for updates to table

damage has occurred, MS progression is predominantly
driven by immune-independent mechanisms, which also partly
explains why immunomodulatory therapy has generally been
unsuccessful in treating progressive MS. These immune-inde-
pendent mechanisms include mitochondrial injury, iron accu-
mulation leading to oxidative stress, ion channel dysfunction,
glutamate excitotoxicity, excess intra-axonal calcium, tissue
hypoxia, and defects in axonal transport (Mahad et al., 2015;
Correale et al., 2017).
Treatment of Progressive MS
Most trials of disease-modifying therapy for progressive MS
have not succeeded, and we refer readers to recent reviews
for more information on these trials (Comi, 2013; Correale
et al., 2017). The reason for the failure of these trials has
become clearer as the different pathophysiologic mechanisms
of progressive versus relapsing disease have been defined.
The partial success of immunomodulatory therapy for progres-
sive MS has generally been due to the treatment of cohorts
who were in the early stages of progressive disease and still
had a component of inflammation (Hohol et al., 1999). It is
noteworthy that anti-CD20 treatment with ocrelizumab did
succeed in a phase III clinical trial of patients with primary pro-
gressive MS that were diagnosed with primary progressive
multiple sclerosis and had disease for either less than 15 years
with an Expanded Disability Status Scale (EDSS) score of
more than 5.0 or less than 10 years with an EDSS score of
up to 5.0 while excluding patients with relapsing-remitting,
secondary progressive, or progressive relapsing disease
(Montalban et al., 2017). As a result, ocrelizumab has been
approved to treat primary progressive MS by the FDA. Siponi-
mod, a selective S1P inhibitor, has also reported positive re-
sults in a phase III trial of progressive MS even though another
S1P inhibitor (fingolimod) did not succeed (Smith and Cohen,
2016) The mechanism(s) by which these treatments ameliorate
progressive MS is not well understood but may relate to direct
or indirect effects on the innate immune response in the CNS.
A trial of intrathecal anti-CD20 has been proposed to better
target B cells in the CNS.
Studies in animal models of progressive MS have identified
unique pathways by which the CNS innate immune system
may be targeted. Sphingosine 1-phosphate receptor modula-
tion suppresses pathogenic astrocyte activation and progres-
sive CNS inflammation (Rothhammer et al., 2017) as does
modulation of astrocyte activity by dietary tryptophan (Roth-
hammer et al., 2016). Laquinomid, which affects brain atrophy
and progression in MS but didn’t affect relapses, might act by
inducing an effect on astrocytes. Nasally delivered anti-CD3 in-
duces IL-10-secreting Tregs that migrate to the brain,
decrease both microglial and astrocyte activation, and slow
disease progression (Mayo et al., 2016). A carbon-based
fullerene linked to an NMDA receptor with anti-excitotoxic
properties slows disease progression and prevents axonal
damage in a progressive animal model (Basso et al., 2008). A
unique approach that has shown promise in a double-blind
study of severe progressive MS is high-dose biotin (Tourbah
et al., 2016), which might reduce axonal hypoxia through
enhanced energy production and also promote axonal remye-
lination. High-dose statins (simvastatin) were also tested in a
758 Neuron 97, February 21, 2018
Neuron
Review
phase II placebo-controlled trial showing a reduction in the
annualized whole-brain atrophy rate (Chataway et al., 2014).
Other approaches include re-myelination strategies (Franklin,
2017; Stangel et al., 2017), inhibition of ion channels, and tar-
geting mitochondria (Correale et al., 2017). To that end, Lipoic
acid, an antioxidant, reduced annualized changes in brain vol-
ume in SPMS patients (Spain et al., 2017), while Clemastine
fumerate, a remyelination drug, showed efficacy in RRMS sub-
jects (Green et al., 2017). The effective treatment of progres-
sive forms of MS will depend on the early treatment of inflam-
mation to prevent compartmentalized inflammation developing
in the CNS, treatment that targets innate immune processes in
the brain, and non-immune approaches that target neurode-
generation and axonal dysfunction. Progress in meeting this
challenge relies on the development of biomarkers and of
new imaging approaches that can, for example, image gray
matter and microglial activation. MRI imaging has been crucial
in the development of the many treatments now available for
relapsing forms of MS.
Treatment for Relapsing MS
The remarkable advances made in the treatment of MS are
shown in Table 2, with more than ten drugs approved by the
FDA for treating this disease. All of these drugs target the im-
mune system and impact the immune networks shown in Fig-
ures 2 and 3, and virtually all of them impact the inflammatory
relapsing stage of the disease. Treatment for progressive
forms of MS constitute a major unmet need. Broadly consid-
ered, these immunomodulatory drugs have the following
modes of action: decrease disease-inducing Th1/Th17 cells,
induce Treg cells, affect the trafficking of cells to the nervous
system, and affect B cells. The availability of so many treat-
ments for relapsing forms of MS raises two important consid-
erations in deciding how to use them in patients: what is the
relative efficacy of one drug versus another, and what are
the side effects associated with treatment? Although head-
to-head comparative studies are not available for all drugs,
among FDA-approved drugs, alemtuzumab, natalizumab,
and ocrelizumab appear to have the strongest anti-inflamma-
tory effects as measured by reducing relapses and affecting
inflammation (as assessed by MRI, using gadolinium enhance-
ment) (Tramacere et al., 2015). Among oral medications, fingo-
limod appears to have stronger anti-inflammatory effects than
either teriflunomide or dimethylfumarate. Injectable medica-
tions, such as interferons and glatiramer acetate, appear to
be comparable, with higher doses of interferon providing a
better treatment outcome than lower doses. All FDA-approved
drugs have an effect on brain atrophy as measured by MRI,
although it is difficult to compare drugs given the different
technologies used to quantify brain atrophy. Clinicians gener-
ally base treatment decisions for an individual patient on the
patient’s relapse history and the number of inflammatory
events and new T2 lesions on MRI. In the future, measures
of atrophy linked to progression might also become a basis
for treatment decisions.
There are various side effects associated with MS immuno-
therapy (see Table 2), and these side effects can often determine
which drug is used to treat MS once the risks and benefits
Neuron
Review
are considered. One of the most concerning side effects is pro-
gressive multifocal leukoencephalopathy (PML), which is partic-
ularly associated with treatment with natalizumab. Risk factors
for developing natalizumab-associated PML include prior immu-
nosuppressive therapy, the presence of antibodies to John
Cunningham virus (JCV), and treatment for more than 2 years.
The incidence of PML is 13 per 1,000 MS patients treated with
all three risk factors. Cases of PML have also been reported
following treatment with fingolimod and dimethylfumarate. An
important conceptual point to consider is whether early treat-
ment with drugs that have the strongest anti-inflammatory prop-
erties is the best approach to preventing later disability. There is
no consensus on the best sequence of treatment or on the
optimal combination therapy. Because it is considered unethical
not to treat relapsing MS, the testing of new drugs against a pla-
cebo is problematical.
There have also been immunomodulatory treatments that
have made MS worse (Table 2). Some of these effects, such
as the increased number of attacks following IFNg, which is
known to increase class II expression and to stimulate the
innate immune system, were not unexpected given our current
knowledge. Less easy to explain is the worsening of MS
following treatment with anti-TNFa and atacicept. Anti-TNFa
is an effective therapy for RA, and yet some RA patients
treated with anti-TNFa develop MS. Worsening of MS with
the anti-B cell drug Ataticept illustrates the complex role of
B cells in MS.
If MS is an antigen-specific, cell-mediated autoimmune dis-
ease, the most specific and least toxic therapy for MS would
be an antigen-specific approach, which has been attempted in
MS with limited success. One of the difficulties of this approach
is the development of reactivity to multiple CNS antigens as the
disease progresses and the lack of a clear inciting antigen for
which there is common reactivity in MS, such as reactivity to
AQP4 in neuromyelitis optica.
Biomarkers
Biomarkers are beginning to play an increasingly important role
in MS with a better understanding of its disease mechanisms
and with advances in technology. The most commonly used
biomarker is MRI imaging, which is primarily used as a
biomarker of disease activity. MRI serves as a measure of the
inflammatory component of MS as evidenced by gadolinium-
enhancing lesions and the appearance of new T2 lesions. Given
that there are multiple drugs for the treatment of the relapsing
and inflammatory components of MS, MRI imaging is routinely
used to help adjust therapy to minimize the appearance of new
lesions. There are no analogous MRI markers for progressive
MS, although physicians may choose to treat this form of MS
with more aggressive forms of therapy depending on the de-
gree of MRI disease activity, including brain atrophy and spinal
cord involvement. Another clinically useful biomarker is the
measurement of JC virus antibody titers, the presence of which
increases the risk of PML. JV virus titers are measured in all pa-
tients being treated with natalizumab and treatment with this
drug is generally limited if a patient’s titers are high. The pres-
ence of elevated IgG in the CSF has classically been used as a
diagnostic biomarker but has now largely been replaced
by MRI.
Despite the advances in treatment options and an emerging
recognition of disease heterogeneity, to date, no single biochem-
ical or immune marker is able to accurately reflect disease path-
ogenesis, segregate the different disease phenotypes, serve as a
monitor of disease activity, or predict the future course of dis-
ease. It is beyond the scope of this article to provide a detailed
discussion of the plethora of biomarkers under study; instead,
we refer readers to recent comprehensive reviews on this topic
(El Ayoubi and Khoury, 2017; Comabella and Montalban, 2014).
One particular biomarker of note, serum neurofilament levels (a
biomarker of neuroaxonal damage), appears to be associated
with the progression of brain atrophy and disability in early MS
(Kuhle et al., 2017), although elevated serum neurofilament levels
are not specific to MS. Serum antigen-array patterns (Quintana
et al., 2008) and microRNAs (Gandhi et al., 2013) can also distin-
guish different subtypes of MS, and cellular transcription signa-
tures can identify patients with different levels of disease activity
(Ottoboni et al., 2012). Nevertheless, studies of biomarkers suffer
from a lack of independent validation. For example, reports that
anti-myelin antibodies predict conversion from CIS to RRMS
(Berger et al., 2003) and that the potassium channel KIR4.1 is
an immune target in MS (Srivastava et al., 2012) could not be
replicated. Thus, the implementation of biomarkers for MS
requires vigorous clinical and multicenter validation.
No Evidence of Disease Activity
The emergence of ‘‘no evidence of disease activity’’ (NEDA) as a
concept has its roots in rheumatology, in which disease-free
status is the goal for clinical trials and for patient care. In MS,
the NEDA composite measure consists of the following fea-
tures: (1) no new or enlarging T2-weighted lesions, (2) no new
gadolinium-enhancing lesions, (3) no relapses, and (4) no
confirmed worsening of EDSS scores (Bevan and Cree, 2014).
Clinical trials have begun to report NEDA as a secondary
outcome measure. The percentage of patients achieving
NEDA is usually measured in the first 2 years and varies among
studies from 28% to 42%. These numbers may be very different
in a real-world setting compared with those obtained in clinical
trials. We recently explored the percentage of patients
achieving NEDA status in a real-world setting (Rotstein et al.,
2015), and although 46.0% of patients in this study demon-
strated NEDA after 1 year of observation during therapy, only
7.9% of patients maintained durable NEDA after 7 years. This
demonstrates that NEDA is difficult to sustain in a real-world
cohort of MS patients.
Conclusion
Enormous progress has been made in our understanding of MS.
This understanding has led to treatments for MS, especially in the
relapsing and inflammatory stages. Major advances in MS are
linked to the identification of abnormal immune responses in
the disease and how to measure and modify them. It is now clear
that MS is primarily an autoimmune disease and not a persistent
infection even though an infectious agent may trigger the disease
or be associated with the disease. All genetic studies point to the
immune system as being the primary cause of MS pathology, with
a complex interaction occurring between genes and environ-
ment. MRI imaging provides an important opportunity to monitor
the disease. There have been surprises along the way, including
Neuron 97, February 21, 2018 759

the lack of a beneficial effect from anti-TNFa therapy and the dra-
matic effect of anti-CD20 therapy. Precision medicine has
evolved as a major theme in medicine and is becoming a major
goal in MS (Zhao et al., 2017). The current key unanswered ques-
tion in MS is how to treat and better understand the progressive
form of this disease. This will require new approaches to target
compartmentalized processes in the CNS.
Finally, if MS is triggered by the environment in susceptible
individuals, it might be possible to prevent MS. Some believe
vaccination against EBV or treating children at high risk for
development of MS with vitamin D could be effective initial ap-
proaches. Prevention would be the ultimate cure for MS and
would depend on a treatment that modulates the immune sys-
tem in childhood or adolescence. Such a vaccine could initially
be given to higher-risk individuals, such as children whose par-
ents have MS and where there is a strong family history. Modu-
lation of the gut microbiome appears as an attractive approach
as it may have no negative effects. In addition, our understanding
of MS could change with new discoveries. The most impactful
would be the identification of an infectious agent truly linked
to the disease. Over the last century, MS has moved from an un-
known, untreatable disease to one with many treatment options
and many unexplored roads ahead.
ACKNOWLEDGMENTS
Supported by grants from the National Multiple Sclerosis Society to H.L.W.
(RR 205-A-13, RG-1507-05029. NMSS ICT 0010) and to C.B.-A. (RG-1506-
04836), by NIH grants to H.L.W. (R01 NS087226, UH3TR000890), by the Ever-
grande Center for Immunologic Diseases, and by the Nancy Davis Foundation.
We thank Dr. Tanuja Chitnis, Dr. Vijay Kuchroo, and Dr. Rohit Bakshi for their
discussions on the manuscript.
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