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Immunoglobulin M in the Cerebrospinal Fluid: an Indicator of Recent Immunological Stimulation

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Immunoglobulin M in the Cerebrospinal Fluid: an Indicator of Recent Immunological Stimulation J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.8.949 on 1 August 1989. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry 1989;52:949-953 Immunoglobulin M in the cerebrospinal fluid: an indicator of recent immunological stimulation M K SHARIEF, E J THOMPSON From the Department ofClinical Neurochemistry, Institute ofNeurology, The National Hospitalfor Nervous Diseases, London SUMMARY Using a sensitive new method for detecting oligoclonal immunoglobulin M (IgM) in unconcentrated cerebrospinal fluid (CSF), the intrathecal synthesis of IgM was correlated with that of free light chains in patients with multiple sclerosis, infections of the central nervous system and other neurological conditions. A strong correlation was found between the presence of oligoclonal IgM and that offree light chains in the CSF from patients with multiple sclerosis and infections ofthe central nervous system. No oligoclonal IgM response was observed in patients with non-inflam- matory or non-infectious neurological conditions. This implies that oligoclonal IgM has the same diagnostic significance as free light chains. Electrophoretically restricted immunoglobulins (Ig) Despite the potential importance of CSF oligo- Protected by copyright. commonly occur in the cerebrospinal fluid (CSF) of clonal IgM, the pace of progress in this field has been patients with inflammatory and infectious diseases of hampered by methodological difficulties in detecting the central nervous system (CNS) in the form of the very low amounts of IgM that are usually present oligoclonal bands where each band represents the in CSF. We have applied a new sensitive method'" of product of a single B-lymphocyte clone. detecting qualitative alterations of CSF IgM to study Another immunological parameter is CSF free light the relationship between intrathecally synthesised chains. Cohen and Bannister' established that IgM and free light chains in patients with various lymphocytic cells obtained from the CSF of a patient neurological disorders. The present paper reports with multiple sclerosis do synthesise a relatively high these findings and discusses the potential diagnostic amount of kappa light chains. Since that observation, importance of oligoclonal IgM in neurological CSF examination for light chains has become a useful diseaseg. diagnostic test in inflammatory diseases of the CNS2' as they were regarded as further evidence of intra- thecal synthesis of Igs, especially during intense Patients immunogenic stimulation.5 A total of 399 patients with various CNS diseases were The oligoclonal nature of free light chains is well studied (table 1). They were selected according to the http://jnnp.bmj.com/ established.'9 Hitherto, in almost all reports their provisional diagnosis at the time of their admission to detection in CSF is correlated with that of oligoclonal hospital. Paired CSF and serum specimens were available IgG. But if free light chains are related to an antigenic from all of them. All specimens were examined within a week challenge within the CNS, their correlation with of the lumbar puncture and blind to diagnosis. oligoclonal IgM is more significant. Immunoglobulin After the completion of the study, we retrospectively M is responsible for the primary immune response gathered reliable clinical data on all patients from the and its detection in CSF indicates the presence of admission notes and/or discharge summaries. The largest patient group was that with multiple sclerosis, the majority of committed lymphocyte clones elaborating an immune on September 29, 2021 by guest. or a whom were considered to be either "clinically definite" or response against a recent offending antigen "early probable or latent" cases." Only nine patients were persistent antigenic challenge. "suspected" cases of multiple sclerosis. Patients with CNS infections include 22 with encephalitis, Address for reprint requests: Dr M K Sharief, Department of Clinical six with treated three cases Neurochemistry, The National Hospital for Nervous Diseases, Queen 21 with meningitis, neurosyphilis, London WClN 3BG, UK. of Lyme disease, and five with tropical spastic paraparesis. Square, Inflammatory CNS diseases comprised nine patients with Received 19 September 1988 and in revised form 24 February 1989. neurosarcoid, four CNS lupus, three Behqet's encephalitis, Accepted 3 March 1989 five with acute disseminated encephalomyelitis, three with 949 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.8.949 on 1 August 1989. Downloaded from 950 Sharief, Thompson Table 1 Number ofpatients with positive oligoclonal IgM, Tolosa-Hunt syndrome, and seven with various acute free kappa, andftee lambda light chains in the CSF, listed demyelinating conditions. Degenerative CNS diseases according to their diagnostic categories included Alzheimer disease and other dementias, Parkinson- ism, and motor neuron disease. Oligo- Free light chains Diagnostic clonal Methods categories IgM Kappa Lambda The method of glutaraldehyde enhanced immunofixation" Normal control n=20 0 0 0 was utilised to detect oligoclonal IgM in unconcentrated Multiple sclerosis*: (a) Definite or early n= 143 83 34 78 CSF. In brief, CSF and homologous serum proteins were probable/latent separated by agarose electrophoresis, transferred to (b) Suspected n=9 4 1 1 nitrocellulose membrane which was activated by 1% Active neurosyphilis* n= 12 12 5 7 for IgM by a F(ab')2 CNS infectionst n= 57 36 5 13 glutaraldehyde then immunofixed Acute infective n= 12 5 0 1 fragment of anti-IgM antiserum. The method of replicate polyneuritis immunoblotting technique'2 was used to detect free light Inflammatory CNS n=31 17 2 2 chains in the CSF. diseases Degenerative CNS n=23 0 1 1 diseases Results Neuropathies n= 33 0 0 0 CNStumours n= 13 2 0 1 Cerebrovascular n= 10 0 1 0 Of the 399 patients examined, 159 (40%) were positive diseases for CSF oligoclonal IgM, 104 (26%) had bands offree Spinal cord & root n=36 0 0 0 compression lambda light chains and 49 (12%) had free kappa bands in the CSF (table 1). The number of free kappa Total n= 399 159 49 104 light chains detected in the CSF varied from one to six Pathological values differ significantly from control p <0-001. individual separate bands while free lambda chains tPathological values differ significantly from control p < 0001. ranged from one to nine bands. A more detailed Protected by copyright. >5- >5 5- 00 O 5- 4- cn 4- ._S co =4 u C xro .2_ 3- -m 3- a a) a a s000s a Q Q 2- En 2- http://jnnp.bmj.com/ 0 0 8 0 Rs.IO**st z z0 1- 're- W 1- WV 0- jj j 'I 0' on September 29, 2021 by guest. OC IgM present OC IgM absent OC IgM present OC IgM absent n=83 n=60 n=83 n=60 Fig 1 Plot ofthe number offree kappa and lambda light chains (ordinates) versus intrathecal synthesis of IgM (abscissas) in patients with multiple sclerosis (n = 152). The number ofpatients with more than 2free light chains correlates significantly well with the presence ofoligoclonal IgM (p < 0-0001 forfree kappa, p < 0001forfree lambda). Filled circles represent patients with clinically definite or early probable or latent multiple sclerosis (n = 143), open circles represent patients with suspected multiple sclerosis (n = 9). J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.52.8.949 on 1 August 1989. Downloaded from Immunoglobulin M in the cerebrospinalfluid. an indicator ofrecent immunological stimulation 951 >5- >5- £0 AA- )4 C .C -C ~~~~~~~~~~~~~~~~~~-C .I3- A -T 3- cL 2- *- 2 -*o& 0 0~~~~~~~~~~~~~ zZCU~ ~ n= n=1n48n2 0 *RO *UO£0 0- memo OA0 UOO&0 A*O& LOWA060AA0OO& s.oOAA00000L00 OC 1gM present OC 1gM absent OC 1gM present OC 1gM absent n=48 n=21 n=48 n=21 Protected by copyright. Fig 2 Plot ofnumbers offree kappa andfree lambda light chains (ordinates) versus intrathecal synthesis of IgM (abscissas) in patients with various CNS infections. Filled squares represent patients with encephalitis (n = 22), open squares represent patients with meningitis (n = 21), filled triangles represent patients with active neurosyphilis (n = 12), while open triangles represent patients adequately treatedfor syphilis. Filled circles represent patients with other CNS infections. Taking the entire group, the number ofpatients with more than 2free light chains correlates significantly well with the presence ofoligoclonal IgM in the CSF (p < 0-005forfree kappa, p < 0.01 forfree lambda). correlation between oligoclonal IgM and various light chains in the CSF. In numerical terms, no patient neurological diseases is reported elsewhere.'3 from this group had more than two free light chains. Ofthe 143 patients with definite or early probable or Conversely, patients who were positive for oligoclonal latent multiple sclerosis, 83 (58%) had CSF oligo- IgM did show greater amounts of CSF free light clonal IgM. Of those 83 patients, 30 (36%) also had chains: they usually had more than two free light free kappa light chains (fig 1), while only three patients chains (up to 6 kappa and/or 9 lambda). This (5%) ofthe 60 patients who had no oligoclonal IgM in difference in the number of the free light chains http://jnnp.bmj.com/ the CSF had free kappa light chains. This difference between the two groups ofmultiple sclerosis patients is was very significant (p < 0 0001). The same difference significant (p < 0 005). was applicable to the frequency of occurrence of free The distribution of free light chains in CNS infec- lambda light chains: of the 83 patients who were tions held the same relationship to CSF oligoclonal positive for CSF oligoclonal IgM, 56 (67%) had free IgM bands as that seen in multiple sclerosis patients lambda light chains (fig 1), but only 19 (32%) ofthe 60 (fig 2). Of the 48 patients positive for oligoclonal IgM, patients who were negative for oligoclonal IgM 10 (21%) had CSF free kappa light chains, while no showed free lambda chains. The difference was also patient negative for oligoclonal IgM had free kappa on September 29, 2021 by guest.
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