Acute disseminated encephalomyelitis pathophysiology: Difference between revisions
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*[[Acute]] [[disseminated]] [[encephalomyelitis]] is described as an [[autoimmune]] disorder, resulting in [[central]] [[nervous]] system [[demyelination]].Enviromental [[stimuli]] activate [[cellular]] and [[humoral]] responses which cross-react with [[myelin]] [[autoantigens]] namely, [[myelin]] basic [[protein]], [[myelin]] [[oligoendrocyte]] [[protein]], [[proteolipid]] [[protein]]. | *[[Acute]] [[disseminated]] [[encephalomyelitis]] is described as an [[autoimmune]] disorder, resulting in [[central]] [[nervous]] system [[demyelination]].Enviromental [[stimuli]] activate [[cellular]] and [[humoral]] responses which cross-react with [[myelin]] [[autoantigens]] namely, [[myelin]] basic [[protein]], [[myelin]] [[oligoendrocyte]] [[protein]], [[proteolipid]] [[protein]]. | ||
* In an alternative mechanism, post-[[vaccination]] and [[post-infective]] circulating [[immune]] [[complexes]] in the [[CNS]] give rise to an [[inflammatory]] reaction, resulting in increased [[vascular]] [[permeability]] and [[congestion]]. This disrupts the [[blood]]- [[brain]] barrier, allowing infiltration by [[antigens]] and [[mononuclear]] [[cells]]. They cause [[perivascular]] [[edema]] and [[hemorrhage]] which culminate in [[demyelination]], [[necrosis]] and [[gliosis]]. Although typically observed in [[white matter]], [[gray matter]] involvement is also seen in [[basal ganglia]], [[thalamus]] and [[cerebral]] [[cortex]]<ref name="pmid15437201">{{cite journal| author=VAN BOGAERT L| title=Post-infectious encephalomyelitis and multiple sclerosis; the significance of perivenous encephalomyelitis. | journal=J Neuropathol Exp Neurol | year= 1950 | volume= 9 | issue= 3 | pages= 219-49 | pmid=15437201 | doi=10.1097/00005072-195007000-00001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15437201 }} </ref>. | * In an alternative mechanism, post-[[vaccination]] and [[post-infective]] circulating [[immune]] [[complexes]] in the [[CNS]] give rise to an [[inflammatory]] reaction, resulting in increased [[vascular]] [[permeability]] and [[congestion]]. This disrupts the [[blood]]- [[brain]] barrier, allowing infiltration by [[antigens]] and [[mononuclear]] [[cells]]. They cause [[perivascular]] [[edema]] and [[hemorrhage]] which culminate in [[demyelination]], [[necrosis]] and [[gliosis]]. Although typically observed in [[white matter]], [[gray matter]] involvement is also seen in [[basal ganglia]], [[thalamus]] and [[cerebral]] [[cortex]]<ref name="pmid15437201">{{cite journal| author=VAN BOGAERT L| title=Post-infectious encephalomyelitis and multiple sclerosis; the significance of perivenous encephalomyelitis. | journal=J Neuropathol Exp Neurol | year= 1950 | volume= 9 | issue= 3 | pages= 219-49 | pmid=15437201 | doi=10.1097/00005072-195007000-00001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15437201 }} </ref>. | ||
*Some of the [[vaccine-associated]] [[cases]] can be attributed to the contamination of the [[vaccine]] with [[CNS]] [[tissue]], reported for the [[Semple]] vaccine for [[rabies]]<ref name="pmid2433582">{{cite journal| author=Hemachudha T, Griffin DE, Giffels JJ, Johnson RT, Moser AB, Phanuphak P| title=Myelin basic protein as an encephalitogen in encephalomyelitis and polyneuritis following rabies vaccination. | journal=N Engl J Med | year= 1987 | volume= 316 | issue= 7 | pages= 369-74 | pmid=2433582 | doi=10.1056/NEJM198702123160703 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2433582 }} </ref> and the [[vaccine]] strains of [[Japanese encephalitis]]<ref name="pmid10210877">{{cite journal| author=Plesner AM, Arlien-Soborg P, Herning M| title=Neurological complications to vaccination against Japanese encephalitis. | journal=Eur J Neurol | year= 1998 | volume= 5 | issue= 5 | pages= 479-485 | pmid=10210877 | doi=10.1046/j.1468-1331.1998.550479.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10210877 }} </ref>. | |||
===Current [[pathogenic]] concepts developed from animal models<ref name="pmid164412">{{cite journal| author=Lipton HL| title=Theiler's virus infection in mice: an unusual biphasic disease process leading to demyelination. | journal=Infect Immun | year= 1975 | volume= 11 | issue= 5 | pages= 1147-55 | pmid=164412 | doi=10.1128/iai.11.5.1147-1155.1975 | pmc=415190 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=164412 }} </ref>=== | |||
====[[Inflammatory]] cascade concept<ref name="pmid16286539">{{cite journal| author=Menge T, Hemmer B, Nessler S, Wiendl H, Neuhaus O, Hartung HP | display-authors=etal| title=Acute disseminated encephalomyelitis: an update. | journal=Arch Neurol | year= 2005 | volume= 62 | issue= 11 | pages= 1673-80 | pmid=16286539 | doi=10.1001/archneur.62.11.1673 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16286539 }} </ref>==== | |||
*[[CNS]] [[tissue]] is damaged by direct [[infection]] by a [[neurotropic]] [[pathogen]], resulting in leakage of [[autoantigens]] through a disrupted [[blood-brain barrier]]. | |||
*The [[auto-antigens]] are processed in systemic [[lymphatic]] organs, leading to [[tolerance]] breakdown and a self-reactive [[encephalitogenic]] [[T-cell]] response. | |||
*Such activated [[T-cells]] perpetuate a vicious cycle of further [[CNS]] damage and [[inflammation]]. | |||
====[[Molecular mimicry]] concept<ref name="pmid16286539">{{cite journal| author=Menge T, Hemmer B, Nessler S, Wiendl H, Neuhaus O, Hartung HP | display-authors=etal| title=Acute disseminated encephalomyelitis: an update. | journal=Arch Neurol | year= 2005 | volume= 62 | issue= 11 | pages= 1673-80 | pmid=16286539 | doi=10.1001/archneur.62.11.1673 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16286539 }} </ref>==== | |||
*It is attributed to a structural or partial [[amino acid]] sequence [[homology]] between the foreign [[pathogen]] and the [[myelin]] [[proteins]] of the host. | |||
*[Antigen-presenting]] [[B cells]] or [[dendritic cells]] process the [[antigen]] at the site of [[inoculation]], leading to [[T-cell]] stimulation, which may [[cross-activate]] production of [[antigen-specific]] [[B cells]]. | |||
*Both [[T-cells]] and [[B-cells]] are capable to entering the [[CNS]] and encounters the indigenous [[myelin]] [[proteins]] during routine [[CNS]] [[surveillance]]. | |||
*They may become reactivated by local [[antigen-presenting cells]] such as the [[microglia]], inciting an [[inflammatory]] response against the presumed [[foreign]] [[antigen]]. | |||
*Thus, the initial [[physiologic]] response culminates in detrimental [[autoimmunity]]. | |||
==References== | ==References== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sujaya Chattopadhyay, M.D.[2]
Overview
The exact mechanism of acute disseminated encephalomyelitis is not determined. However, it is usually preceded by an environmental trigger, e.g. an infection or vaccination and affects individuals with a genetic predisposition.
Pathophysiology[1]
- Acute disseminated encephalomyelitis is described as an autoimmune disorder, resulting in central nervous system demyelination.Enviromental stimuli activate cellular and humoral responses which cross-react with myelin autoantigens namely, myelin basic protein, myelin oligoendrocyte protein, proteolipid protein.
- In an alternative mechanism, post-vaccination and post-infective circulating immune complexes in the CNS give rise to an inflammatory reaction, resulting in increased vascular permeability and congestion. This disrupts the blood- brain barrier, allowing infiltration by antigens and mononuclear cells. They cause perivascular edema and hemorrhage which culminate in demyelination, necrosis and gliosis. Although typically observed in white matter, gray matter involvement is also seen in basal ganglia, thalamus and cerebral cortex[2].
- Some of the vaccine-associated cases can be attributed to the contamination of the vaccine with CNS tissue, reported for the Semple vaccine for rabies[3] and the vaccine strains of Japanese encephalitis[4].
Current pathogenic concepts developed from animal models[5]
Inflammatory cascade concept[6]
- CNS tissue is damaged by direct infection by a neurotropic pathogen, resulting in leakage of autoantigens through a disrupted blood-brain barrier.
- The auto-antigens are processed in systemic lymphatic organs, leading to tolerance breakdown and a self-reactive encephalitogenic T-cell response.
- Such activated T-cells perpetuate a vicious cycle of further CNS damage and inflammation.
Molecular mimicry concept[6]
- It is attributed to a structural or partial amino acid sequence homology between the foreign pathogen and the myelin proteins of the host.
- [Antigen-presenting]] B cells or dendritic cells process the antigen at the site of inoculation, leading to T-cell stimulation, which may cross-activate production of antigen-specific B cells.
- Both T-cells and B-cells are capable to entering the CNS and encounters the indigenous myelin proteins during routine CNS surveillance.
- They may become reactivated by local antigen-presenting cells such as the microglia, inciting an inflammatory response against the presumed foreign antigen.
- Thus, the initial physiologic response culminates in detrimental autoimmunity.
References
- ↑ Torisu H, Okada K (2019). "Vaccination-associated acute disseminated encephalomyelitis". Vaccine. 37 (8): 1126–1129. doi:10.1016/j.vaccine.2019.01.021. PMID 30683508.
- ↑ VAN BOGAERT L (1950). "Post-infectious encephalomyelitis and multiple sclerosis; the significance of perivenous encephalomyelitis". J Neuropathol Exp Neurol. 9 (3): 219–49. doi:10.1097/00005072-195007000-00001. PMID 15437201.
- ↑ Hemachudha T, Griffin DE, Giffels JJ, Johnson RT, Moser AB, Phanuphak P (1987). "Myelin basic protein as an encephalitogen in encephalomyelitis and polyneuritis following rabies vaccination". N Engl J Med. 316 (7): 369–74. doi:10.1056/NEJM198702123160703. PMID 2433582.
- ↑ Plesner AM, Arlien-Soborg P, Herning M (1998). "Neurological complications to vaccination against Japanese encephalitis". Eur J Neurol. 5 (5): 479–485. doi:10.1046/j.1468-1331.1998.550479.x. PMID 10210877.
- ↑ Lipton HL (1975). "Theiler's virus infection in mice: an unusual biphasic disease process leading to demyelination". Infect Immun. 11 (5): 1147–55. doi:10.1128/iai.11.5.1147-1155.1975. PMC 415190. PMID 164412.
- ↑ 6.0 6.1 Menge T, Hemmer B, Nessler S, Wiendl H, Neuhaus O, Hartung HP; et al. (2005). "Acute disseminated encephalomyelitis: an update". Arch Neurol. 62 (11): 1673–80. doi:10.1001/archneur.62.11.1673. PMID 16286539.