Doctoral Thesis Autoantibody and environmental damage to the brain María Teresa Arango Guerrero October, 2016 Autoantibody and environmental damage to the brain María Teresa Arango Guerrero Universidad del Rosario Bogotá, Colombia Professor Yehuda Shoenfeld MD, FRCP, MaACR Professor Miri Blank PhD Doctor Shaye Kivity MD Zabludowicz Center for Autoimmune Diseases Tel Aviv University Sheba Medical Center Tel Hashomer, Israel 1 CONTENT Abstract ............................................................................................................................................... 4 Resumen .............................................................................................................................................. 6 Acknowledgments ............................................................................................................................... 8 Agradecimientos ............................................................................................................................... 11 Abbreviations .................................................................................................................................... 14 1 Introduction .............................................................................................................................. 16 1.1 The immune system and the brain ................................................................................... 16 1.2 Antibodies and the brain ................................................................................................... 17 1.2.1 Auto antibodies and systemic lupus erythematosus ................................................ 19 1.2.2 Autoantibodies and Narcolepsy ................................................................................ 20 1.2.3 Autoantibodies caused by environmental factors in narcolepsy .............................. 22 1.2.4 Adjuvants, autoimmunity and the brain ................................................................... 25 2 Project aims ............................................................................................................................... 30 3 Papers ........................................................................................................................................ 31 3.1 Paper I: .............................................................................................................................. 31 3.2 Paper II: ............................................................................................................................. 31 3.3 Paper III: ............................................................................................................................ 31 3.4 Paper IV: ............................................................................................................................ 32 3.5 Paper V: ............................................................................................................................. 32 4 Brief description of additional activities that were performed regarding narcolepsy ............. 32 4.1 Methodology ..................................................................................................................... 33 4.1.1 PET-CT scan and autoradiography ............................................................................ 33 4.1.2 Active Immunization of peptides .............................................................................. 33 4.1.3 ELISA: ......................................................................................................................... 34 2 4.1.4 Purification of specific antibodies: ............................................................................ 34 4.1.5 Videotaping and scoring of narcoleptic episodes ..................................................... 35 4.2 Results ............................................................................................................................... 35 4.2.1 Radiolabeled total IgG (Japanese collaboration) ...................................................... 35 4.2.2 Peptide immunization ............................................................................................... 35 5 General discussion of the articles ............................................................................................. 37 5.1 Passive transfer of autoantibodies to the brain replicate specific symptoms .................. 37 5.2 SLE and neuropsychiatric manifestations associated to specific antibodies .................... 39 5.3 Narcolepsy as an autoimmune disease trigger by H1N1 vaccination ............................... 41 5.4 Inflammatory mechanisms in narcolepsy ......................................................................... 42 5.5 Importance of autoantibodies in narcolepsy .................................................................... 44 5.6 Aluminum adjuvanted vaccines as risk factors for behavioral changes associated with autoimmune mediated processes ................................................................................................. 46 5.7 Phospholipid supplementation ameliorates depression-like behavior induce by vaccines 49 6 Conclusions and Perspectives ................................................................................................... 50 7 List of other relevant publications ............................................................................................ 53 8 References ................................................................................................................................. 54 9 Figures ....................................................................................................................................... 69 10 Appendices: ........................................................................................................................... 73 10.1 Papers and Copyright permissions: ................................................................................... 73 3 ABSTRACT Behavioral abnormalities and cognitive dysfunction may be present in patients with autoimmune diseases. These symptoms range from mild symptoms to acute life- threatening events. The mechanisms that responsible for these neuropsychiatric manifestations are still largely unknown, however several pathogenic pathways have been identified such as antibody-mediated neurotoxicity, vasculopathy induced by anti- phospholipid antibodies, cytokine-induced neurotoxicity, as well as external factors such as toxics, and medications. In order to further investigate some of these mechanisms we evaluated the effect of autoantibodies in animal models such as 16/6 idiotypic antibody and anti-ribosomal P antibodies in neuropsychiatric systemic lupus erythematosus , total IgG from narcoleptic patients in narcolepsy, and the effect of the human papillomavirus vaccine in naïve mice. Using the passive immunization method through intracerebro-ventricular injection of the antibodies, we demonstrated histological and behavioral changes. Mice immunized with 16/6 idiotypic antibodies developed cognitive impairments while those immunized with anti-ribosomal P antibodies developed depression. The mice that received total IgG from narcoleptic patients developed sleep disturbances and brain histological changes consistent with the disease. Further analyses of the role of the human anti-ribosomal P autoantibody revealed that it can cross-react with the neuronal protein Gap43, thus interfering with cellular processes. 4 Immunization with the human papillomavirus vaccine caused the production of antibodies against brain components. Moreover, the mice immunized with the vaccine or with its adjuvant developed cognitive and behavioral deficiencies, which were ameliorated with dietary phospholipid supplementation. Overall, herein we demonstrate that the behavioral and cognitive abnormalities can be part of the wide spectrum of clinical autoimmune manifestations. In addition, they can be caused by collateral damage due to the immune dysregulation caused by autoimmune conditions as well as by vaccination. We also suggest that different autoantibodies cause different symptoms based on different interactions with brain tissue. 5 RESUMEN Las anormalidades de comportamiento y disfunciones cognitivas pueden presentarse en pacientes con enfermedades autoinmunes. Estos síntomas pueden fluctuar de leves hasta eventos potencialmente mortales. En su gran mayoría los mecanismos responsables de estas manifestaciones neuropsiquiatricas siguen siendo desconocidas, sin embargo se han identificado varias vías patogénicas. Por ejemplo; neurotoxicidad mediada por anticuerpos, vasculopatía inducida por anticuerpos anti-fosfolípidos, neurotoxicidad inducida por citoquinas, así como factores externos que incluyen sustancias tóxicas y medicamentos. Para poder investigar algunos de estos mecanismos, evaluamos el efecto de auto- anticuerpos relacionados con el lupus eritematoso sistémico neuropsiquiátrico en modelos animales (Anticuerpo idiotípico 16/6 y el anticuerpo anti-ribosoma P) y narcolepsia (empleando IgG de pacientes narcolépticos), así como el efecto de la vacuna del virus del papiloma humano en ratones. La inmunización pasiva por inyección intracerebro-ventricular de estos anticuerpos condujo a cambios histológicos, cognitivos y de comportamiento. En particular, los ratones inmunizados con el anticuerpo idiotípico 16/6 desarrollaron déficit cognitivo y los ratones inmunizados con el anticuerpo