ProfG has hope

ProgG is giving a rallying call, let’s hope he is correct and that people buy into the idea. However it is clear that this is no quick fix and to think that you get it right first time, is also a concern, because if you get it wrong is there the chance for another go. For example Epstein Barr Virus (EBV) RNA vaccines have been made and they are only designed to prevent infection, but are unlikely to get rid of the hidden virus. But if you don’t start you can’t fail.. However you have a biomarker toknow if the strategy works and that is blocking glandular fever. Will it then be associated with reduced autoimmunity….I would argue that it is more thanjust MS…bt I guessit depends on how you look at what EBV is doing. Here is an abridged copy of the content.

ONSET OF MULTIPLE SCLEROSIS IS PREVENTABLE – TIME TO ACT NOW! Hawkes CH, Giovannoni G, Lechner-Scott J, Levy M, Yeh A. Mult Scler Relat Disord. 2022 ;62:103875. doi: 10.1016/j.msard.2022.103875.

It is generally acknowledged that relapses in multiple sclerosis (MS) are significantly reduced by the latest selection of immunotherapies, especially those that target CD20. The progressive forms remain a challenge and preventing the onset of MS has not been achieved.

There is abundant evidence that exposure to Epstein Barr virus (EBV) is universal in those with MS . Raised serum antibody titres against EBV nuclear antigens (EBNAs) and the presence of EBV in MS demyelinated lesions are reported in most pathological studies. In fact, someone who is EBV-antibody negative, probably does not have the disease. A past history of infectious mononucleosis (glandular fever) and the main MS risk gene increases the risk of MS by ∼10 fold

It was shown that there was a 32-fold increased risk of MS in those who had prior exposure to EBV within the previous 7.5 years (on average). This figure represents the highest known MS risk for any proposed MS aetiological factor. This evidence, combined with the fact that CD20 monoclonal antibodies that target B-cells, a primary site for latent EBV infection, are highly effective, makes the case for EBV infection as necessary, if not sufficient, to cause MS. Even assuming that EBV is merely in the causal pathway, cutting the chain, by for example, a vaccine, should prevent MS.

So what next? Public health measures to discourage the exchange of saliva and other body fluids directed at susceptible groups, namely adolescents, seem obvious but likely impractical. Could targeting EBV with antiviral agents be a solution? Antivirals could be tested in people with MS and importantly, offered to those with infectious mononucleosis, which occurs typically during adolescence or early adulthood. Antiviral agents, however, would need to target both lytic (exploding cells to release content including new virus particles) and latent (hidden from the immune system inside cells ) EBV infection. At present, there is no licensed antiviral agent for treating EBV, although rituximab (anti-CD20) is widely used and effective for EBV-associated lymphoproliferative diseases. The aim of an antiviral agent would be to ‘sterilize’ the body of EBV, but this may not be possible, or if it were, it might only be short-lived. Better still would be a large-scale prophylactic vaccine programme, which could be given early in life to prevent primary EBV infection.

Hitherto, progress in the domain of EBV vaccine development has been slow and fraught with technical issues but advances have now been made, in part stimulated by the need to develop vaccines against SARS Cov-2. There are a number of potential approaches

This would just be the start…..What would be the best time to vaccinate given that 70% of those aged 1-5 years are seropositive for EBV? Is there a case for adding an EBV vaccine to the usual 6-in-1 / rotavirus / meningitis B vaccines offered to UK infants aged 8 weeks? Should we offer an EBV vaccine only to EBV negative individuals? Should a vaccine be offered to those with MS to enhance their passive immunity?

Another concern with most vaccines is that they do not necessarily guarantee life-long immunity. Thus, primary EBV infection may be postponed into middle age resulting in severe glandular fever and subsequent late presenting MS. Thus a booster vaccine would be needed to counter such risk.

A vaccine for EBV-seronegative adolescents is a major unmet health need. We now have technology that has the potential to eliminate MS once and for all. If we assume 5 years for vaccine trials followed by the administration in the first instance to all children ag ed say, 12-18 years, then EBV infection and subsequent adult-onset MS should be abolished.In other words, adolescent-onset glandular fever should gradually fall to zero from 2028 onwards followed by a marked reduction in subsequent MS over the ensuing decade. Whoever achieves this first will rightly receive the highest medical accolade of the 21^st century.

Disclaimer these are the view of the author

Post-alemtuzumab Graves’ disease remitting after switch to ocrelizumab.Popescu V, Beirinckx A, Decallonne B.Acta Neurol Belg. 2022 . doi: 10.1007/s13760-022-01962-9

Alemtuzumab is used for active cases of multiple sclerosis (MS), typically administered in two yearly courses. The most frequent long-term side-effect is secondary autoimmune thyroid disease in 35–40% of people where this manifests as Graves’ disease (over active thyroid gland) in about 70% of people, characterised by antibodies against the thyrotropin receptor, requiring antithyroid drugs or therapies such as radio-iodine or removal of the thyroid gland. Anti-CD20 monoclonal antibody, is also used for the treatment of active MS…. A case of an MS patient who developed clinically and biochemically overt alemtuzumab-induced Graves’ disease, remitting 6 months after treatment with ocrelizumab and methylprednisolone pulse-therapy. This case highlights the possibility of treating both autoimmune diseases with methylprednisolone pulse-therapy and ocrelizumab.

We have heard of the Texan “Whack a Mole” approach where by you bash B cells with CD20 depleting antibodies as the B cells recover to stop anti-body related autoimmunity occuring as a side effect. The problem with that approach is that you could be whacking forever and you whack the worms and the ground feeding bird and other innocent creatures and you then kill the moles that aren’t ruining your lawn. It is evident that the cells that come back after depletionare not the same as before, so you needlessly beat the ground forever. We have made the suggestion that you dont have to treat with ant-CD20 forever to treat MS,and I would argue that this view has yet to be disproved as is supported more and more. After alemtuzumab you can get antibodiy-mediated side-effects. Although anti-CD20 do not target the antibody producing cells there are plenty of examples whereby rituximab (anti-CD20) is used successfully in antibody-mediated disease, so is it surprising that benefit can be had using anti-CD20 after alemtuzumab to control MS and the drug-induced side-effects. The question is why would ant-CD20 work when anti-CD52 (alemtuzumab) did not?. Maybe it is the CD52-negative cells that develop after alemtzumab that are invisible to alemtzumab but not ocrelizumab or maybe alemtuzumab wasstill working and rather than 1 lesion prompting the switch would have been 20 lesions had it not been teated.

This observation should be simple to repeat and you may have youronw personalexperience.

COI: None relevant