Westarp: Neopterin. p : -mi(r l'~ '~ ':-~:::-' r ",-: C\-19-9 in ALS
Pteridines VoL 4, 1993, pp. 81-89
Neopterin, ~~-Microglobulin and Carbohydrate Antigen CA-19-9 in Sporadic Adult Amyotrophic Lateral Sclerosis
2 Martin E. Westarpl§, Dietmar Fuchs , Peter Bartmann3, Rikke Hoff-Jorgensen4, Jorgen Clausen5, 5 Henrik Rasmussen , Helmut Wachter, Maria P. Westarpl and Hans-Helmut Korhnuber' lUlm University Department Neurology, RKU, Oberer Eselsberg 45 0-89081 Ulm, Germany 21nstitute for Medical Chemistry and Biochemistry, and Ludwig-Boltzmann Institute for AIDS Research, A-6020 Innsbruck/Austria 3Ulm University Department Pediatrics, Prittwitzstr. 43 , 0-89075 Ulm, Germany 4National Veterinary Laboratory, 27 Biilowsvej, DK-1790 Copenhagen, Denmark 51nstitute for Life Sciences and Chemistry, POB 260, DK-4000 Roskilde, Denmark
(Received February 28, 1993)
Summary
In 38 patients diagnosed as adult sporadic amyotrophic lateral sclerosis (ALS), and negative for relevant anti-ganglioside, anti-borrelia or anti-Boma disease virus antibodies, we determined serum concentrations of neopterin, ~ r microglobulin, immunoglobulin-G isotypes G1-G", carbohydrate antigen CA-19-9, as well as repeated enzyme linked immuno-assay (ELISA) serum antibodies to human spuma retrovirus (HSRV, human foamy virus=HFV) envelope plus gag./capsid antigen, and competition with maedi-visna virus anti bodies in an blocking ELISA Confirmed by specific HFV-gag immunoblots and measured under code, 26% of tested ALS-patients and 4% of 195 other neurological controls reacted ELISA and immunoblot antibody-positive against HFV. In a maedi-visna virus blocking ELISA, 47/50 sera from 28/30 ALS patients competed with anti-visna lentivirus antibodies more than healthy controls (p<0.05). In serum, however, f3 r microglobulin and neopterin concentrations were normal in different stages of motor neuron disease. Maximal individual mean values for serum CA-19-9, anti-visna competition or circulating IgG immune complexes associated with positive serum antibodies against human recombinant foamy retroviral antigen, while macrophage activation measured as serum neopterin did not
Key words: Amyotrophic lateral sclerosis, ~ rmicroglobulin , Carbohydrate antigen CA-19-9, Human endogenous retroviral sequences (HERy), Human spuma retrovirus (HSRy), Immunoglobulin-G isotypes, Neopterin
Introduction characterized foamy retroviruses (7), in patients with Human foamy retrovirus has become a prime can idiopathic ALS. With documented elevated circulat didate pathogen for neurodegenerative central nerv ing immune complexes (8), cerebral lesions in mag ous motor disorders (I), since transgenic expression netic resonance imaging (9), an inverse correlation is brain- and muscle-specific (2, 3), and mice predom between age and duration as in HIV infection (10), inantly develop myatrophy and encephalopathy an elevated lymphoma incidence (11) and a mono (4). Recently (5, 6), we reported on an upregulated phasic progressive clinical course, ALS shares partial humoral immune response against human spuma analogies with other retroviral diseases (12, 13). In retrovirus, a represent<\tive of the still incompletely adult sporadic motomeuron disease, increased inci dences have been reported for anti-retroviral and §Author to whom correspondence should be addressed. anti-ganglioside GM I antibodies; activated macro-
Pteridines / VoL 4 / No.2 82 Westarp: Neopterin. J3 2-microglobulin and CA-19-9 in ALS phages have been found infiltrating the spinal cord gammopathy, relevant anti-glycolipid antibodies to in ALS (14). While in ALS T-Iymphocyte subpopu GM-l, GD-lb, GA-l, 3'-LMI and sulfatide, separate lations were normal (11 , 13, 14), ~rmicroglobulin ly tested anti-GMI IgM antibody titers, or IgG and neopterin as markers of a cellular immune re ELISA antibodies to Boma disease virus (21). A sponse have not been documented; in autoimmune maedi-visna lentivirus competition ELISA was done disorders neopterin levels correlate with extent and in 50 sera available unfrozen from 30 ALS patients activity of the disease (15). Neopterin and ~ 2 -micro aged 19-78 years and tested for HFV' antibodies globulin are regularly increased in human immuno within three weeks. Blocking of specific polyclonal deficiency virus type-l (HlV-1) infection, elevated in anti-visna antibodies was expressed as reduction in a proportion of human T-Iymphotropic retrovirus binding after pre-incubating visna antigen with pa (HTLV-l)-positive neurological patients (16), yet un tient sera, and standardizing blocking ELISA end changed in Parkinson's disease (17). D-erythro-neo point optical densities as described (22, 23) to values pterin is produced by stimulated macrophages, and established for healthy Danish adults. Results in % correlates well with in-vitro replicative capacity of reduction were compared with 28 age and sex mat HlV-l isolates (18); ~rmicrogJobu1in constitutes the ched patient controls (not tested for HFV) as well light chain of major histocompatibility complex as 15 "other neurologic diseases" tested HFV-sero (MHC) class I antigens HLA-A, -B and -C, identical negative. Circulating IgG immune complexes (CIC) with thymotaxin, and present in high densities on were quantitated by standard Raji cell assay (healthy lymphocytes. In this paper, we examine anti-retrovi references<2.4 mg/L, patient normal reference limit ral antibodies, neopterin, ~ 2-microglobulin, carbohy 14 mg/L); sera had been frozen immediately. drate antigen CA-19-9 and serum immunoglobulin isotypes in ALS. Anti-HFV seronegativity correlates with low IgG3 plasma concentrations, while anti Results HFV seropositivity associates with increased binding of ALS sera to maedi-visna antigen or elevated lev Foamy retrovirus els of circulating asialo-gangJioside CA-19-9, respec tively. Antibody seropositivity for human foamy retrovi ral (HFV, human spuma retrovirus) antibodies was a significant finding in idiopathic ALS (p<0.01). Patients and Methods Examined consecutively and under code, 18/38 ALS patients reacted HFV-env and/or HFV-gag ELISA Human foamy virus (HFV)=spuma retroviral antibody positive compared with 33/195 neurological (HSRV) antibodies were determined in 38 ALS pa controls and 7/52 orthopedic patients (Fig. 1). In tients, 396 non-ALS patients and a total of 600 cod contrast to only 8/ 195 (4%) of "other neurological ed sera as described in (1, 19) using identical recom controls", 26% of ALS patients could be confirmed binant HFV envPX envelope and gagCA capsid an seropositive for anti-HFV-gag antibodies by immuno tigens (20); 195 Ulm neurological in-patients without blot. Over the last 24 months, 18/38 ALS patients acute cranial nerve affection, myelopathy or Parkin (45%) and 34/ 195 other neurological controls (18%) son's syndromes served as controls ("other neurolo had reacted either ELISA or immunoblot HFV anti gical diseases"). Diagnostic criteria for 38 patients body positive. Seropositivity was independent of du with definite idiopathic ALS (aged 19-78 years, mean ration of disease, age, circulating immune complexes, age of 58.4 years) were signs of lower motor neuron total cerebro-spinal fluid protein, course or variant involvement (fasciculations, progressive muscular of motor neuron disease. Of 35 patients who recalled wasting and weakness in the absence of progressive the onset of first signs or symptoms by month, 9 sensory deficits and multi focal conduction block), HFV-positive and 9 HFV-negative patients reported involvement of upper motor neuron at some stage a clinical onset in their upper extremities, 7 HFV of the disease, and possible development of bulbar positive and 5 HFV-negative patients in their legs symptoms and signs. No patient was suffering from or feet, and 1 HFV-positive and 4 HFV-negative pa recurrent or concomitant infectious diseases. includ tients a (pseudo-) bulbar onset of the disease. Mean ing hepatitis, borreliosis or acute herpes infection, age at first clinical symptoms was 59.7 years for pri all 24 consenting patients examined were negative mary bulbar disease, 56.7 years for start in the upper for antibodies to human immune deficiency virus. extremities, and 53.6 years for begin in the legs (see All patients had areactive treponema pallidum hem Table 1). Two seropositive idiopathic ALS patients agglutination tests, were negative for monoclonal had been treated for sporadic -essential tremor"
Pteridines / Vol. 4 / No. 2 Westarp: Neopterin, ~rmicroglobulin and CA-J9-9 in ALS 83
Human foamy retrovirus antibodies o
~ .------. -- - ELISA, 86/ 41 8 positive (10%) IMMUNOBLOT, 30 positive (8%)
LO ~--- - .--'---- o 20 40 60 eo Yf:eAR OF 81R1 H 1920 1940 1960 1980 '!90() %EIA env and / or gag+ %immunoblot HSRV gag+ o ALL ALS S E: RA (n z 60)
_ Figure 2. Competition by ALS sera with polyc1onal maedi-vis 41 '\. ALS" 15't.O,tho 3'\Ortho na virus antibodies (blocking ELISA): n - 32 D n - 52 D n_35
41 '='> CMP Reduction in optical density (ELISA) by pre-incubation with n - 27 ALS sera (in %, standardized to healthy controls = 0%) as pa 26" Parkinson ~ 17%ONP ~ 4%ONO n = 38 ~ n - 195 ~ "",74 rameter for competition of ALS sera with specific polyclonal anti-visna antibodies. 47/50 sera of 28/30 ALS patients reduce .) Chi- square p Figure I. Significantly elevated anti HFV-env and/or HFV-gag %) was 89.0%± 1.9 (SE) for ALS sera and 93.1%± 1.0 ELISA and anti HSRV-gag immunoblot antibodies in ALS: (SE) for age and sex matched Ulm control patients Summary of ELISA and immunoblot screening for human (PWilcoxon<0.05). Expanding the immuno-assay to 50 foamy virus antibodies in diagnostic subgroups larger than sera from 30 ALS patients (age 34-78 years), and 30 patients; ALS = amyotrophic lateral sclerosis, Park. = Parki standardizing to previously established values of nson's syndromes, MedPer= hospital personnel, OND = other normal Danish adults, 12 HFV-positive ALS pa neurological diseases as defined (cf. methods), Ortho=ortho tients demonstrated a reduction of anti-visna antibody pedic patients Ulm 1990-1992. SurgPat= South-West German binding by - 14% (± 1.3% SE), HFV-negative pa- ' surgical patients repol1ed earlier (I) and tested in the same tients by -9.2% (p<0.05), and 15 HFV-negative "acute laboratory 1989-1991. other neurologic controls" by mean - 5.7% (p Pteridines / Vol. 4 / No.2 84 Westarp: Neopterin, ~rmicroglobulin and CA-19-9 in ALS Table 1. 38 patients with idiopathic ALS: sec clin anti anti CSP serum6 IgG7 survivalR CA-" age" start2 HFVJ visna4 prot IgG-3 CIC months 19-9 128 4L 43 >44 1.1 3.6 o DO 9[ + -17% 337 .29 >75 62 f3l 10h + -21% 270 >54 1.4 4.3 o f49 3bu -14% .22 + 18 1.6 5.1 o f53 lOs - 4% 336 .25 + >70 1.3 5.1 "8 [55 3a - 5% .38 >70 2.0 o f55 3bu -(0) - 7% 276 ++ 33 [55 lOA +++ - 8% 404* +++ 64 1.1 6.7 21 f60 7H ++ -13.5%* 531 + 42 1.4 6.3 o f60 12H - 4% + 70 1.8 6.9 o [64 IlH - 12% 500 .16 + 50 1.6 7.0 o [67 9f 536 .53 >50 1.7 8.1 f73 Ibu +++ -19% 443 .44* +++ 39 1.9 8.2 15 f77 lA _ (C) - 4% + 12 2.2 8.5 o ml8 3L ++ + -1l.5%* 248 .37 + ++ >74 1.4 5.4 o m33 -L .20* >100 1.4 4.4 6 m35 9h 505 .21 * + >24 1.2 5.1 o m37 -L (+) 9%* .13 ++ >192 1.8 5.3 o m39 6% >228 m39 11 6% 10 m43 8bu -10% 467 .50 + 25 1.7 6.1 5 m46 3s ++ + -11% .31 >24 1.4 5.9 o m50 8a + +4.5%* 480 .34 + >50 1.5 7.8 m54 Is -17.5%* 300 .27 +++ 37 1.2 5.5 12 m54 7A +++ - 8% 20 m55 lOA + - 9.5%* .42 ++ + >89 m56 61 + -12.5%* .37 ++ 90 1.3 3.7 80 m58 7AL +** .48* 12 1.9 6.9 7 m60 3h + ++ -18.5%* 602* .98 +++ 45 2.3 8.2 o m60 121 484 .15 ++ 15 1.7 7.2 o m61 4a - 7% >80 m63 7f - 5%* 500 .28 + 74 1.6 5.0 16 m65 IL + -18.5%* 595 .43 + 34 1.5 4.8 9 m66 12a ++ - 16% 658 .36 + 15 1.5 6.6 m67 5L + IE) 381 18 >12 2.8 o m69 2bu _ IN) - 17.5%* .13 ++ 23 1.7 5.9 o m69 21 -15.5%* 803 .24 31 1.5 6.1 o m70 3L + 9% 662 >33 2.6 10.1 149 18/ 38 30/31 20/27 23/32 27/28 ELISA reduce <.4 giL CICs de neopt. pos. binding IgGJ tectable <8.8 nM I) sex and age in years at onset of the disease. [0= cerebral lesions in magnetic resonance imaging plus autochthonous oligoclonal IgG banding in cerebro-spinal fluid; N = acute neurologic disease within two years before symptoms of ALS. i.e. torticollis (f. aged 28 years) and temporal seizures (m. aged 69 years); C= i.m. injections of homogenized calf spinal cord and cortex by non-medical practitioner prior to first sypmtoms of ALS (f. aged 77 years); E= multilocular echinococcosis diagnos ed four years before ALS (m. aged 67 years)]; 2) site of first clinical deficits (f= foot, f= feel. I- leg. L=legs, a=arm. A=arms, h=hand, H=hands, s= shoulder, S=shoulders. bu= bulbar or pseudobulbar); 3) + + + =HFV-env plus HFV-gag antibodies at more than one measurement, + + = more than one env and/or gag antibody-positive measurement, + = confirmed env or gag antibodies at one measurement: bold=anti-HFV-gag capsid antigen immunoblot positive; 4) reduction of secondary anti-visna antibody binding compared with healthy controls (=: 100%): 5) cerebro-spinal fluid total protein in mg/L; 6) immuno globulin JgG, isotype serum concentration in gIL: 7) maximal circulating immune complexes + + + = CIC> 50 mglL, + + = 50 mg/L~CJC> 14 mglL, + = 14 mg/L~CIC>2.5 mg/L; 8) months between first signs or symptoms and death (or last contact i[ still alive); 9) ~rmicroglobulin serum concentration in mg/L: 10) neopterin serum concentration in nmol/L: II) serum CA- 19-9 in V/ml (RIA): *) mean of two independent measurements. Pteridines / Vol. 4 / No.2 Westarp: Neopterin, 132-microglobulin and CA-I9- ~ . - ~_L~ 85 3.0 ,------o SERA (HFV . ) HFV antibodies (mean age 55.9 years, range 19-75 ~ 2.5 E " S ERA (HFV - ) years) had a higher mean IgG3 concentration (47 2 .0 . mg/dl± 11 SE, PWiJcoxon <0.05) than 15 sera from anti .=...... -: ;. HFV negative patients (24 mg/dl± 2 SE; mean age l ... ~ = .. =~.. ~a. c :> 1.05f .. 52.4 years, range 30-71). Immunoglobulins IgA, IgM and IgGI - 4 did not differ between men and women '" 0 5 1l with ALS. Mean values (n=58) were IgA=2.6 gIL, ~ _ _ L______~ _ _ ~ 8 10 12 IgM = 1.2 gIL, IgG = 10.9 gIL, and IgG1 = 54% IgG, Neoc:er'n nmol/L IgG2 =36% IgG, IgG3 =3.7% IgG, IgG4 =6.3% IgG. 30,------, o SERA (HFV-) Most frequent alterations were low total IgG3 and 25 E low total IgG1• Immunoglobulin reference limits ':.: 2 .0 were rarely exceeded, and this never concerned total ~ o IgA, IgM, IgG, and IgG1 or IgG4• Immunoglobulin g 15 o U isotypes did not correlate with 132-microglogulin, :> 10 N neopterin, CA-19-9 circulating immune complexes ~ 0.5 D or serum creatine kinase. o 6 8 10 12 Neopterin nmol/L Carbohydrate antigen CA-19-9 Figure 3. Serum t'h-microglobulin and neopterin in 55 ALS sera: We compared CA-19-9 concentrations in 60 ALS In 55 sera from 28 ALS-patients (14 HFY-seropositive, 14 sera from 15 HFV-seropositive and 20 HFV-serone HSRV-seronegative), concentrations of the two macrophage gative patients, and in 10 other neurological sera activation markers 13r microglobulin and neopterin correlated from 7 HFV-seropositive patients. HFV-seronegative positively (r=0.7, p<0.05). More CSF measurements are need motorneuron patients showed a CA-19-9 distribution ed. similar to 1539 healthy controls, and HFV-seroposi tive motorneuron sera (n=26) rather approximated ce (S8.7 nmollL), measuring 9.2, 9.3, and 9.5 the results from 308 patients with non-malignant gas nmollL for neopterin, and 2.6, 2.2 and 0.6 mg/L tro-intestinal disorders (Fig. 4, 26). In both HFV for I3rmicroglobulin. Vsing age-adjusted reference li seropositive ALS and HFV -seropositive other neuro mits for I3rmicroglobulin (S2.5 mgIL at age <60 logical patients, CA-19-9 concentrations tended to years, and <3.2 mgIL at age >60 years), all ALS wards higher carbohydrate levels. Three ALS pa patients tested within normal ranges (Fig. 3). ALS tients exceeded the upper reference limit of 37 V lml, patients with simultaneously high anti-HFV-env and two neurological control patients with Parkinsonian -gag antibody titers did not differ in neopterin levels syndromes reproducibly demonstrated CA-19-9 levels (Fig. 3b). CSF concentrations of both I3rmicroglobu between 23 and 34 V lml. Individual mean concen lin and neopterin never exceeded corresponding se trations of six ALS patients exceeded the reference rum levels. Including seven moribund and severely range for healthy individuals (14 V lml), only one affected patients, we could not demonstrate a defi of whom had never demonstrated anti-HFV anti nite elevation of I3rmicroglobulin and neopterin in bodies in serum. In three of the HFV- seropositive ALS ALS; both serum concentrations correlated well (r= patients with elevated CA-19-9, no significant gastro 0.7, p Pteridines / Vol. 4 / No.2 86 Westarp: Neopterin, f3 r microglobulin and CA-19-9 in ALS 100 AN T I- VISN A ANTI BODY COMPETITIO N (In %) 25 « _ healthy n o 1539 ~ ALS.HFV- n-34 :-5 80 1 - ~ 20 [ "0* II (f) 60 ~ ~ 15 1 \I " 0 40 w (') ;;, ~ 20 0 a: w lL ;0,_0 __ __ ---'----_ -\ 0 ~ <10 1- o 50 100 15 0 100 « M EAN SERUM C!\- 19 - 9 CONCENTRATION IN U/ml ffi Cf) 80 O n' 11 A L S (H F V - ) 0 W f- (J) 60 Figure 5. High CA-19-9 and visna antibody competition in ~ HFY-seropositive ALS patients: , 0 w 40 Asialo-ganglioside CA-19-9 in serum. and competition with (') ;;, visna antibodies by ALS sera is maximal in HFV-seropositive z w 20 0 patients (8/8 sera CA-19-9> 17.5 U/ml or reduction of visna II W lL antibody binding> 17.5% have tested HFV-seropositive). though 0 <10 <25 <37 <5 0 >50 carbohydrate antigen and maedi-visna retroviral competition SERUM CA -19-9 CONCEN TRATI ONS (U/mL ) are not correlated (n=23). D GI-pall9nts n-308 ~ ALS.HFV · n 0 26 E.illl OND.HFV· n olO Figure 4. CA-19-9 in HFY-seropositive patients resembles be nign gastro-intestinal disease: Distribution of carbohydrate antigen 19-9 (asialo-ganglioside) in serum of 34 HFY-antibody negative ALS, 26 HFY-antibody Table 2. Higher serum Ca-19-9 in patients seroreactive to posotive ALS, and 10 anti-HFY antibody positive other neuro HFV: logical patients, compared to published controls (26) serum CA-19-9 ~17.5 U/ml >17.5 U/ml HSRV-capsid (gag) and/or envelope (env) antigens HFV-seropositive* 8 4 Fisher's exact which are located on different sites of the proviral test p<0.05 DNA Seropositivity was not confined to motor neu HFV-seronegative II o ron disease, yet significantly more frequent than in *at least one reproducible anti-HFV-env/gag serum anti 195 control patients. Standardized to healthy indivi body duals, ALS sera competed with secondary visna-an **healthy reference <14 U/ml. use as intestinal tumor marker tibodies binding on maedi-visna-viral antigen (p< >37 U/ml Table 3. Characteristics of patients with permanently detectable serum CA-19-9 (mean concentrations> 14 U /ml): Patient CA-19-9 anti l HFY disease duration IgG, visna4 132M Ineopt.s m71 149 env+. gag- ALS2 36 months nma -9% nma m63 79.5 env+. gag- ALS 90 months .37 -12.5% 1.3/3.7 f35 62.1 env+ . gag- ALS' 70 months .29 -17% nma m69 26.5 env+. gag + Parkins'> 12 months .65 -14.7% 7.0/ 19.4 f79 28.5 env+, gag+ Parkins.3 12 years .51 nma nma m33 19.6 env+/gag+ SMA' susp. 12 months .31 -13% 1.3/4.8 m68 16.3 env-. gag- ALS 74 months .28 -5% 1.6/5.3 f75 15.5 env+. gag+ ALS 39 months .44 -19% 1.9/8.8 ALS=amyotrophic lateral sclerosis. SMA=progressive spinal muscular atrophy. nma=no valid measurement available. I) anti human foamy retrovirus (HFY) antibody reactivity against recombinant envelope andlor capsid (gag) antigen (bold=very high titers/confirmed by immunoblot). 2) isulin-dependent diabetes mellitus for >five years. 3) no gastro-intestinal pathology confirm ed. 4) competition with specific anti-visna retroviral antibodies (% reduction in hinding to visna-maedi lentiviral antigen compared to healthy controls). 5) f3rmicroglubulin (mg/L) and neopterin (nmol'L) serum lewis (underlined=elevated) Pteridines I Vol. 4 I No.2 Westarp: Neoplerin. P:-r.1kTcr:Jv(,L.ilr. ;,nJ \..· .-\-i~-~ in ALS 87 0.05); this reactivity correlated with anti-foamy retro viduals up to now; there is, however, foamy-retrovi virus seropositivity (p<0.05). In 25/28 ALS patients, rus immunoreactive antigenemia in ALS patients we neither found any increase of neopterin as (unpublished). A regional, low-active retroviral ex known from pulmonary or gastro-intestinal malig pression. potentially expanding without completion nancies, nor decreased serum concentrations as seen of viral particles (42), would be compatible with both In anxiety or schizophrenia (27). Neopterin and ~2- antiretroviral seroreactivities and a lack of evidence microglobulin are markers of a cellular immune for generalized lymphoproliferation. In known retro .:2tivation, regularly elevated in HIV, and increased viral central nervous system diseases with immune .:\ parts of human T-Iymphotropic retrovirus stimulation, increased concentrations are reported HTLV -1 )-positive neurologic patients (16). Despite for interleukin-6 (43), soluble tumor necrosis factor relatively progressed states of disease, including bul receptor (44) or quinolinic acid (45). Though their bar, hemiparetic, tetra paretic and moribund patients, production depends on macrophage stimulation and neopterin and ~:-mi.: r0 :;l o bulin were not elevated endogenous interferon-gamma production not observ in serum and :,in,;LLr ~ .1 mrles of cerebro-spinal ed in ALS, studies clarifYing this issue are needed. fluid; in neurobo rrelio'is. CSF neopterin increases In motor neuron disease in general, and ALS in in the absence ot serum alterations. While activated particular, the immune system seems to be altered macrophages haw been found infiltrating spinal in rather peculiar ways (30), and younger patients cord in ALS (14). basically normal ~Tmicroglobulin or patients with multi focal conduction block, anti and neopterin levels in amyotrophic lateral sclerosis ganglioside antibodies and immunoglobulin abnor argue against a persisting, generalized macrophage malities may live longer than respective control pa response in the disease. tients (31). Whether retroviral serology, carbohydrate The monoclonal antibody detecting carbohydrate antigen, or immunoglobulin-G isotyping help iden antigep. CA-19-9 recognizes a ganglioside containing tify diagnostic or prognostic subgroups remains to glycosylated lacto-N-fucopentose-II (28). Both in be elucidated. HFV-seropositive ALS and HFV-antibody positive Accompanied by diverse changes in the humoral other neurological patients all negative for anti-GM\ immune response (46), the observed anti-retroviral ganglioside antibodies, CA-l9-9 concentrations seem seroreactivity could be due to a) an exogenous agent ed to be distributed similar to patients with non-ma partially homologous to HFV and maedi-visna virus lignant gastro-intestinal disorders (26). Maximal anti altering the host immune system (47), b) human HFV seroreactivity cosegregates with both anti-visna endogenous retrovirus-like sequences (HERY) that competition and elevated CA-19-9 serum ganglioside may comprise 0.1-0.6% of the human genome (48) (Fig. 4). A cross-reactivity of unidentified macromo and mimick an anti-human foamy retroviral im lecules may contribute to anti-ganglioside reactivities mune response, or c) a complex interaction of exo in neurologic patients (29). genous and/or endogenous retroviral sequences (49) Anti HSRV-seronegativity (not anti-visna blocking with host genes or gene products. HFV indeed trans activity) segreated with low IgG3 serum concentra activates other retroviral agents (50). In experimental tions. IgG3 represents a predominant isotype in clear retroviral motor neuron disease, mice suffer a non ing intracerebral alphavirus encephalitic infection immunogenic retroviral injury to anterior hom neu (32), and low IgG3 concentrations are found in disim rons (12), and in natural rodent motor neuron dis mune disorders and chronic fatigue syndrome (33). ease, the translation products of endogenous murine If HFV-seroreactivity does not characterize a disease leukemia retrovirus serve as surrogate receptor for variant, low circulating IgG3 in HFV-seronegative another viral agent, lactate dehydrogenase-elevating ALS could result from specific or non-specific anti virus (51). If transgenic mice defective for ciliary body sequestration. In ALS, clinical progression pat neuronotrophic factor (52) similar to mice expressing terns (34), a "remarkably regional disease" (35), ele human foamy virus genes (4) die with progressive vated circulating immune complexes (36, 8, 10, 37), . muscular atrophy, -though CNTF mRNA is preserv non-inflammatory dermal alterations (10, 37, 38, 39), ed in ALS spinal cord-, a retroviral interference an inverse correlation between age and duration with cellular signaling may be responsible (53). (10), and elevated lymphoma incidence (40, 11) par tially remind of other retroviral diseases (41, 13). Ne vertheless, we have neither observed any epidemio Acknowledgements logic peculiarity of anti-retroviral seroreactive ALS patients, nor detected foamy viral genomic informa We thank Rolf M. 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