ECTRIMS-Questioning the EBV

Epstein Barr Virus is it, isn’t it. 
You do the experiment and try and disprove the hypothesis.

P1069 – CSF B-cells in relapsing multiple sclerosis are driven towards a similar, antigen-experienced, inflammatory fate

A. Ramesh1,2, R.D. Schubert1,2, R. Dandekar1,2, A. Greenfield1,2, R. Loudermilk1,2, E. Tran1,2, R. Gomez1,2, A.J. Green1,3, R. Bove1,2, X. Jia1,2, J.L. DeRisi4,5, J.M. Gelfand1,2, B.A.C. Cree1,2, S.L. Hauser1,2, M.R. Wilson1,2

Three prominent hypotheses for the role that B-cells play in MS are 

(1) clonally expanded B-cells in the central nervous system (CNS) target unidentified autoantigens resulting in pathogenic antibody secretion and/or antigen presentation to pathogenic T cells, 

(2) CNS B-cells display a pro-inflammatory phenotype or cause tissue injury through secreted factors other than pathogenic autoantibodies, and 

(3) virally-infected B-cells trigger CNS demyelination.

We isolated cerebrospinal fluid (CSF) and peripheral blood B-cells from treatment naïve, relapsing MS patients (n=7 [5 female], age=23-40 years, disease duration=37-252 days) and sorted them into the following B-cell categories: 

double negative, 
unswitched memory, 
switched memory, 

We performed RNA extraction, reverse transcription, and amplification using random hexamer primers to generate a cDNA library for Illumina sequencing. 

We then used custom bioinformatics tools to assess for 
(1) shared clonal connections and/or similar immunoglobulin class restriction between B-cells , 
(2) differential gene expression between peripheral and CNS B-cell subsets, 
(3) presence of intracellular viral transcripts.

We describe a multi-pronged bioinformatics protocol that mines a unified transcriptomic B-cell dataset to answer questions regarding clonal connections, B-cell phenotypes and infectious triggers of MS. Our findings support the hypothesis that B-cells originating in the periphery undergo clonal expansion and sustain a pro-inflammatory shift in the CSF in MS, without detectable viral infection.

Therefore memory B cells enter from the periphery and may expand in the CNS, but there is no virus detected. This perhaps is where contention lies as there have been some that have suggested that Epstein Barr Virus is a problem, But it is not in the CNS, according to this.

But according to others

Serafini B, Scorsi E, Rosicarelli B, Rigau V, Thouvenot E, Aloisi F. Massive intracerebral Epstein-Barr virus reactivation in lethal multiple sclerosis relapse after natalizumab withdrawal. J Neuroimmunol. 2017; 307:14-17.

Rebound of disease activity in multiple sclerosis patients after natalizumab withdrawal is a potentially life-threatening event. To verify whether highly destructive inflammation after natalizumab withdrawal is associated with Epstein-Barr virus (EBV) reactivation in central nervous system infiltrating B-lineage cells and cytotoxic immunity, we analyzed post-mortem brain tissue from a patient who died during a fulminating MS relapse following natalizumab withdrawal. Numerous EBV infected B cells/plasma cells and CD8+ T cells infiltrated all white matter lesions; the highest frequency of EBV lytically infected cells and granzyme B+ CD8+ T cells was observed in actively demyelinating lesions. These results may encourage switching to B-cell depleting therapy after natalizumab discontinuation.

Moreno MA, Or-Geva N, Aftab BT, Khanna R, Croze E, Steinman L, Han MH. Molecular signature of Epstein-Barr virus infection in MS brain lesions.Neurol Neuroimmunol Neuroinflamm. 2018 Jun 7;5(4):e466.  We report the presence of EBV latent membrane protein 1 (LMP-1) in 93% of MS and 78% of control brains, with a greater percentage of MS brains containing CD138+ plasma cells and LMP-1-rich populations. Notably, 78% of chronic MS lesions and 33.3% of non-MS brains contained parenchymal CD138+ plasma cells. EBV early lytic protein, EBV immediate-early lytic gene (BZLF1), was also observed in 46% of MS, primarily in association with chronic lesions and 44% of non-MS brain tissue. Furthermore, 85% of MS brains revealed frequent EBER-positive cells, whereas non-MS brains seldom contained EBER-positive cells. EBV infection was detectable, by immunohistochemistry and by in situ hybridization, in both MS and non-MS brains, although latent virus was more prevalent in MS brains, while lytic virus was restricted to chronic MS lesions..

However it does not make sense if EBV infected B cells were the targets. As  other diseases are associated with EBV infection too. So one week you would have MS and the next week Lupus and then arthritis, so there must be some specificity in the system. However, does it say EBV is not involved. Probably not. 

Either technology is not sensityive enough to detect the virus or there is a problem of wishful thinking. However, I am not going to get trapped in this argument as it still fails to exclude EBV having an important role in MS, as EBV-free memory cells may be descended from memory cells that contained episomal EBVLaurence M, Benito-León J. Epstein-Barr virus and multiple sclerosis: updating Pender’s hypothesis. 2017:8-14.

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    • "don't understand the idea of using allogeneic cellsthey will probably get rejected."

      Not if they're HLA matched..Problem is seems like they don't as
      of yet have a full spectrum available,,but I guess in time.

      Reason you have to use allogeneic is because in general MS
      T cells are exhausted and only have .1% reactivity to EBV.

      So to take 1 million MS patient T cells and gather and expand
      them so the T cells are 20-50% reactive to EBV is immpossible.
      Using a healthy allogeneic T cell allows for more EBV
      reactive product. However the phase 1 autologous trial
      allowed them to learn how to boost exhausted T cells and
      so they decided to go for a phase 2 autologous trial ATA 190
      since it is ready to go and won't take additional time and
      it will provide additional info. to FDA and any possible
      future pharma partners.

      CEO talks allogeneic ATA 188 and autologous ATA 190 trials


    • This is data from the phase 1 ATA 190 progressive MS trial.
      Scroll down 3/4 to see data.

      Only 10 patients but kind of proves EBV theory as those with the
      most reactive EBV T cells showed the most improvement.
      Patient 1 and 2 were the patients and when have a 60 y/o PPMS/SPMS ever gone down in EDSS..In 2000 years of history I
      suspect never.

      Doctors love to blame nonresponders on age..when it's
      the therapy's fault..which is why it's great the 2 responders
      in the trial are 60 y/o.

    • Hla matched . They will have to match six class I alleles A B C one from Mum and dad

      T cells can sometimes express class ii so another six molecules then there are the minor alloantigens.

      So i doubt a.match will be complete. If there is not a perfect match the anti ebv. Could react against host mhc mhc cause graft verses host disease.

  • Hhmmm….something to look into
    ATA188, also known as autologous Epstein-Barr virus-specific T-cell therapy, developed by Atara Biotherapeutics, is an immunomodulatory molecule that uses a technology in which T-cells are “taught” to recognize the specific antigens of Epstein-Barr virus (EBV) that are involved in multiple sclerosis. In people with multiple sclerosis, ATA188 recognizes and eliminates cells infected by the Epstein-Barr virus in the brain and spinal cord that may trigger autoimmune response and multiple sclerosis disease development.

  • Conflict results

    In favour of the black swan

    "We demonstrate that CD8+ CD57+ T
    cells are a population of effector cytotoxic cells with strong
    ability to kill EBV-infected cells. A potential role for EBV in
    MS is supported by strong epidemiological evidence45–47
    but the presence of EBV infection in MS tissue remains
    controversial.9,15,48 A characterization of the cytotoxic
    CD8+ T-cell response against EBV, its regulation and its
    relationship to MS disease activity may contribute to a better
    understanding of the immunopathological processes in
    MS and help to develop new therapeutic approaches.

    Our results show that PD-1 expression by CD8+ CD57+ T cells
    is associated with a reduction of degranulation, cytokine
    release and cytotoxicity towards EBV-infected targets. This
    is confirmed by the inverse correlation between functional
    cytotoxic capacity and PD-1 expression. We also confirm
    that blockade of PD-1 restores CD8+ CD57+ T effector
    function, specifically allowing more efficient degranulation,
    cytokine release and cytotoxicity. Detection of a higher frequency
    of PD-1 expressing CD8+ CD57+ cells in the blood
    of patients with RR-MS during clinical remission, and concomitantly
    suppressed degranulation, suggests a regulatory
    role of the molecule on cytotoxic function.
    the back of this, our finding of a substantial proportion
    of CD57+ cells expressing PD-1 in the meningeal infiltrates
    of post-mortem MS cases suggests the involvement
    of these cells and molecule in the inflammatory immune
    response. It is plausible to suggest that the inability of
    CD8+ CD57+ T cells to clear EBV infection in the CNS
    enables the persistence of chronic inflammation that
    underlies the observed more rapid progression of MS.
    However, we cannot rule out that the CD8+ CD57+ T
    cells’ involvement in the disease process, documented by
    their detection in MS brain tissue, could be secondary to
    other inflammatory events occurring in the MS process
    and that the cells may play a disease-countering role,
    potentially through immune regulatory mechanisms, as
    we suggested in one previous report

    In addition, CD8+ CD57+ T cells
    express CX3CR1, the receptor for fractalkine that has
    been detected in the CSF of patients with early MS and
    in inflamed MS brain lesions.53,54 Interestingly, in our
    study we show that CD8+ CD57+ T cells express high
    levels of PD-1 with an exhaustion-like phenotype in
    patients with MS in the stable phase of the disease, displaying
    a weak response upon TCR activation with low
    release of cytokines and granzyme B. Additionally,
    CD8+ CD57+ T cells from patients with MS in the active
    phase of the disease display a low expression of PD-1,
    and high release of IFN-c and granzyme B, consistent
    with a profile of terminally differentiated effector/cytotoxic
    virus-specific CD8+ T cells. Our results suggest that
    the inability of cytotoxic T cells to control EBV replication
    during inactive MS could set the stage for viral reactivation
    in the CNS and for disease progression

  • All this evidence supports a
    less efficient immune control of EBV infection in patients
    with MS. An impaired immune response to the virus is
    evident when the infection becomes chronic.27 In this
    case, the virus persists and effector CD8+ T cells become
    unresponsive and anergic. In contrast to chronic infection,
    in acute viral infection, the immune system is highly
    functional and enables clearance of the virus through
    cytotoxicity against infected cells and secretion of antiviral
    factors (e.g. interferon).61 Although those studies support
    the hypothesis that altered immune reactivity to EBV
    may favour the reactivation of the virus in intrathecal B
    cells, which could represent one mechanism causing brain
    pathology in MS, several studies using similar technologies
    were unable to detect EBV in the brain tissue and
    CSF.14,15,48,62 The discrepant results have been the matter
    of discussion and it has been suggested that methodological
    differences, including in the preparation and preservation
    of the brain tissue, may have affected the sensitivity
    and specificity of EBV detection.63

    In patients with
    MS during remission, the high expression of PD-1 in
    CD8+ CD57+ T cells suggests a dysfunctional, reduced
    cytotoxic response. It is plausible to speculate that PD-1-
    related suppression of cytotoxicity allows MS-associated
    viruses such as EBV to persist in the CNS and favours
    persistent inflammation with tissue damage and consequent
    relapses. Newly activated CD8+ CD57+ T cells
    might be induced to clear virus-infected targets in active
    MS but the repeated antigenic stimulation and inflammatory
    cytokines contribute to up-regulation of PD-1 with a
    decrease of effector function

    Programmed death 1 is highly expressed on CD8(+) CD57(+) T cells in patients with stable multiple sclerosis and inhibits their cytotoxic response to Epstein-Barr virus

  • Here's a idea. Instead of speculating on the causes of MS for the last 20 years why not design experiment to prove or disapprove the theory? Let me help you with some ideas.

    Extract T cell from ms patients with EBV infections that are EBV reactive. Grow them in lab. Inject them back to ms patient. See Ms is cured. Of yeah but will need millions in funding from pharma so will never get of the ground. As you cannot extrapolate 1 patient result. OK try for 10 patients, etc.
    This will never happen as Ms is money making machine lining the pokers of all involved. Shamefull.

    • "Instead of speculating on the causes of MS for the last 20 years.."

      Agreed..every MS paper in last 10 years mentions EBV..but then
      does absolutely no research on it. Problem is there's no vaccine
      or drug against it so you can only use bio-pharma agents against it. The below treatment was done in 1995 for EBV lymphomas and most likely could have helped all the PPMS patients who had no therapy..
      for the last 2 decades.

      "But while the treatment helped to cure their leukaemia, it left the children at high risk of developing EBV-related lymphoma.

      To bridge the gap, Rooney and her team rescued the T cells removed from the donor marrow and separated out the ones that could specifically attack EBV. They then grew these ‘EBV killer T cells’ in the lab until they had sufficient numbers to inject into the children following their transplant.

      The results were remarkable."

  • How about instead of speculating on the cause for another 100 years and suppressing the immune system with a new drug every 5 years, we start treating MS like any other infectious disease? We just don't know what pathogens are involved.

    Maybe we don't find the cause of MS, because there isn't one. There are multiple possible causes, which is why there are so many leads. Maybe all those different studies finding viral, bacterial, fungal or parasitic abnormalities are right, just not exclusively.

    Start trials combining different antivirals, antibiotics and antifungals. It's relatively cheap and of low-risk.

    • However trials are not cheap…if you go early you cant go placebo (un ethical) so you need to buy the drugs for the control arm.

    • Here's totally radical idea. Why not recruit patients on treatment via NHS so no cost for drugs. But there's still another expense I over looked? And cost billions in withdrawal of. Pharma sponsored research.

  • My sentiments exactly. Hold of pharma is so strong no academic researcher will stick his neck out. Days of maverick scientist like Barry Marshall are truly dead. God help those inflicted with in curable disease. No cure is ever likely as. Treatment is more profitable.

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