Background

Genome-wide association studies (GWAS) identified 233 SNPs (Single Nucleotide Polymorphisms) increasing multiple sclerosis (MS) susceptibility, with a main involvement of immune peripheral cells and microglia. One of these variants, rs7923837, described as eQTL in healthy individuals, is located near the HHEX (Hematopoietically Expressed Homeobox) gene, which encodes a key transcription factor in lymphopoiesis and contributes to metabolism-related traits and diseases.

Objectives

We aimed at understanding the impact of rs7923837 polymorphism located in the 3'UTR (Untranslated Region) of the HHEX gene on MS risk

Methods

The study included 154 MS patients and 117 healthy controls. The SNP rs7923837 was genotyped by TaqMan technology. Levels of expression of the HHEX gene were ascertained by real time PCR and normalized to the GUS housekeeping gene. HHEX nuclear translocation was analyzed by confocal microscopy. Extracellular acidification (ECAR) and oxygen consumption rate (OCR) were measured in peripheral blood mononuclear cells (PBMCs) with and without phytohemagglutinin (PHA) stimulation, in a Seahorse XFp Extracellular Flux Analyzer (Agilent). Mitochondrial mass was measured by FACS in PBMCs with mitotracker florescence probe.

Results

Lower levels of expression of the HHEX gene were detected in MS patients compared to controls (p=0.037). As previously described in whole blood of healthy controls, the risk polymorphism acts as eQTL in PBMCs of MS patients. The AA genotype not only showed reduced levels of mRNA expression in MS patients, but also an increased nuclear localization, in contrast to the lower nuclear localization found in controls with this genotype. In addition, PHA stimulation in PBMCs of AA-homozygotes significantly increased mitochondrial mass in controls compared with MS patients (p=0.009). The influence of genotypes in rs7923837 on the values of ECAR and OCR, indicative of glycolysis and oxidative phosphorylation respectively, were analyzed. Significant differences in ECAR were evidenced by comparison of either homozygous genotype between MS patients and controls. In basal conditions, a consistent trend to higher OCR was observed for MS patients compared with healthy controls. After PHA stimulation, AA-homozygous individuals presented increased mitochondrial maximal respiration and spare respiratory capacity, and AA-homozygous patients showed higher no mitochondrial oxygen consumption.

Conclusions

In MS patients, the homozygous AA genotype of rs7923837 in HHEX determines low levels of mRNA expression and increased nuclear location, presumably altering its function as a transcription factor. Moreover, MS patients display higher values than healthy controls in some parameters of mitochondrial respiration. Those differences are increased in minor allele homozygotes for rs7923837, and reflect a differential coupling between minor and major homozygous genotypes in MS patients.

Background

The SARS-Cov2 produced a world-wide health-pandemia situation where people must stay home. People with multiple sclerosis (MS) were considered one of high-risk infection population groups due to their immunological status. This situation may increase the risk of emotional unbalance and produced a high uncertainty for MS patients.

Objectives

To describe medical, demographical and emotional characteristics of a sample from our own MS Unit in a tertiary Hospital in Madrid during lockdown.

Methods

In one month we consecutively interviewed 138 MS patients, collecting information about their demographic characteristics (age, gender, years of education, house-company), their MS (physical disability, treatment, years with MS), the SARS-Cov2 (if they had it, someone living with him, the type of lockdown, protection method used outdoors) and their emotional status (previously to SARS-Cov2, compare to before, about their quality of live (QoL), coping strategies, depression and anxiety). We applied standardized questionnaires for QoL, disability related to health condition and emotion.

Results

The majority of participants were woman (69,9%) middle age (42,8) and high education (71% university), with a low disability (EDSS mode=1) after 10,3 years with MS and under treatment (97%). Smokers as frequent comorbidity (23,9%), they lived with company at home (87%) and they followed lockdown completely (61,6%), using mainly face-mask and gel as outdoors protection. Emotional situation during lockdown was described as “worse than before” in 46,4% but some patients reported feeling better (15,2%). Self-reported health was rated as 67,1 over 100 with a high EQ-5D index (M=0,73) and they were not depressed (M=4,8; SD=3,7) neither anxious (M=6,7; SD= 4,3). Infected-MS patients (only 8 cases) showed significantly higher depression (p=0,039) and lower rating in health (p=0,012) in EQ-5D than non-infected patients, using equivalent coping-strategies and rating similar physical independence.

Conclusions

Despite the immunological special status of MS patients, we found that the prevalence of SARS-Cov2 was really low, as stated in the literature. Our patients were quite responsible with lockdown rules and almost half of them confessed that lockdown affected their emotional status to the worse even though they were not infected. Interestingly, those who reported a positive lockdown indicated that not commuting, slowing down and teleworking improved their QoL significantly.

Background

The emergence of a new coronavirus (COVID-19) and the subsequent pandemic present a unique challenge to neurologists managing patients with multiple sclerosis (MS). Preliminary reports do not support an increased risk of severe outcome associated with disease modifying therapies (DMTs) but real-world evidence is lacking.

Objectives

To describe our experience in 14 patients with MS who have been affected by SARS-CoV-2 (with a clinical, RT-PCR, or serological diagnosis) and who were being treated with cladribine in Spain.

Methods

We conducted a consecutive clinical series study including cases occurred in Spain since January 31, 2020 when the first COVID-19 patient was detected in Spain until the end of June 2020.

Results

Patients were mostly female (64%), with an average age of 40.1 (± 12.0) years and a disease duration of 9.7 (± 8.9) years. Median EDSS was 1 (IQR 0–2.5), and the average time on treatment with cladribine was 7.7 (±5.77) months. Two patients had grade 1 lymphopenia, five patients had grade 2 lymphopenia, one patient had grade 3 lymphopenia and six patients were in normal range. Only 1 patient required hospitalization. None required ICU care, or intubation. 93% of the patients improved without any specific treatment. 2 patients (14%) were asymptomatic, 11 (79%) were mild and 1 (7%) was moderate. All recovered without sequelae. 7 of the patients (50%) had a serology test done that showed presence of anti-viral antibodies of IgG and IgM type in all cases.

In our series the patients had a favorable evolution, and all recovered. Factors that could have influenced those results could be the age of the patients, the lack of other risk factors and the mechanism of action of cladribine. It is known that the limited activity of cladribine on cells of the innate immune system and its relatively minor impact on CD8 T cells and plasma cells may have implications for maintained protection from bacterial and viral infections. Importantly, cladribine CD4+ T cell and B cells depletion is partial and transient. The short-term dosing regimen of oral cladribine, potentially reduces depleting effects on the innate immune system.

Conclusions

From this limited number of patients our observations suggest that cladribine treatment does not appear to worsen COVID-19 disease prognosis. MS is a debilitating disease and discontinuing effective treatments might have adverse consequences, benefit/risk assessment is crucial in the current context. Our patients treated with cladribine had an adequate resolution of COVID-19 and mounted an immune response, however more studies are necessary to confirm and extend our preliminary findings.

Background

It´s stated that as we get older, cognitive processes change. Healthy control (HC) and people with multiple sclerosis (MS) share a decrement in speed of processing with age. Nevertheless, demyelinating and neurodegenerative characteristics of MS may implicate neuropsychological differences when analyzing aging.

Objectives

To study the differences in cognitive processes between MS patients and HC when considering two age groups: yound adults and older ones.

Methods

We had two groups: MS from 45 to 55 years old (MS1) and from 56 to 70 (MS2) and a HC group (HC1 and HC2) paired in age and years of education (YoE). We applied a neuropsychological comprehensive battery including Symbol Digit Modality Test (SDMT), PASAT 3”, Spanish California Verbal Learning Test (TAVEC), Spatial Recall Test (SPART), Brief Visual Memory Test (BVMT-R), Five Digit Test (5DT), WAIS-Digits and Corsi and verbal fluency (letter, category and exclusion). Mild (MCI) and moderated (ModCI) cognitive impairment was based on Z scores for the following cognitive domains: speed of processing (SP), attention, working memory, verbal and visual memory and executive functions.

Results

We assessed 137 MS patients, 62,7% women with a mean age of 52.7, secondary education (M=14.3) with a mean Expanded Disability Status Scale (EDSS) of 3.3 (Mode=6), relapsing-remitting MS (82,5%) after a mean of 14,3 years having MS. We also evaluated 34 matching HC. MS patients were MCI (43.1%) followed by no impairment (33.6%) and they were equivalent in age, YoE or EDSS. When comparing groups, HC1 scored higher than HC2 in SDMT (p<0.001), SPART-recall (p=0.21) and they retrieved more words in TAVEC when cued were offered short-term (p=0.024), long-term (p=0.034) and free long-term recall (p=0.043). When MS group was analyzed, MS1 performed better than MS2 in SDMT (P=0.004), total learning in TAVEC (p=0.026 list A and p=0.004 list B), hits and dyads in PASAT (p=0.004 and P=0.01), digits-forward (p=0.035) and exclusion fluency (p=0.014). When comparing the same age group, MS1 scored lower in SMDT, SPART learning and recall compared to HC1. In older group, MS2 showed less hits and dyads in PASAT with higher interference errors and less fluency in exclusion trial compared to HC2.

Conclusions

Cognitive ageing for MS patients is different: as HC, they get slower when processing information but they also perform worse in verbal and visual learning tasks together with executive functioning, whereas for HC the cognitive deficit is more memory-specific related. When younger, MS were equal to HC but slower. When older, MS displayed dysexecutive aspects instead of mainly amnesic ones. The added cognitive features of the older MS group support the idea of an added subcortical damage, responsible of a frontal-like neuropsychological profile.

Background

There is controversial data on the differential activity of the default mode network (DMN) in patients with Multiple Sclerosis (MS), and how it is linked to cognitive status. For some authors, there could be an initial hypercompensation, followed by a late exhaustion of the DMN. More research is needed to clarify how those changes may be related to cognition and the different phenotypes of MS.

Objectives

To evaluate the functional connectivity of DMN of MS patients with different phenotypes (relapsing-remitting (RR), clinically isolated syndrome (CIS) and primary progressive (PP) compared to healthy controls (HC).

Methods

Sixty-two participants (16 HC, 16 RR, 15 CIS and 14 PP) were evaluated with a neuropsychological battery to establish their cognitive profile. A functional magnetic resonance (fMRI) with a seed-to-voxel approach was performed to study the DMN, as defined by the Human Connectome Project. We selected four regions of interest: Posterior cingulated cortex (PCC); Medial prefrontal cortex (MPFC); Lateral parietal cortex Left (L-LPC) and Lateral parietal cortex Right (R-LPC). Correlation of their functional connectivity was analyzed considering different groups according to the MS phenotype.

Results

MS patients and HC were equivalent in age, years of education and gender. A 35,5% of MS patients were cognitively preserved, whereas 24(64,5%) had cognitive impairment: 12 were mild(MCI) and 12 moderate(ModCI). RR patients were significantly younger (M=37,9 old; SD=7,3) compared to CIS (M=40,8; SD=9,9) and PP (M= 49,4; SD=7,8). CIS patients had a shorter duration of MS (M=4,3 years; SD=3,9; p=0,013) compared to RR (age M=9,5; SD=5,6) and PP (M=9,9; SD=6,9). Groups were not homogeneous in terms of physical disability, being PP the most disabled (Mode=6) vs RR (Mode=2) or CIS (Mode=0). Regarding global DMN connectivity, no differences were found between HC and MS patients. However, when focusing on phenotypes, we found that CIS had a trend to a higher connectivity than HC and that connectivity steadily decreased though RR to PP, so that PP activity was significantly lower than that of CIS (p=0,019). No differences were found based on cognitive impairment. Antero-posterior connectivity was significantly higher for CIS than RR (p=0,017) and PP (p=0,018); and in cognitively preserved vs ModCI (p=0,03).

Conclusions

Our data supports the dynamic theory for functional connectivity that suggests an initial overcompensation followed by a gradual decline, which is elicited by studying MS phenotypes. Within the DMN, anterior-posterior connectivity was related to a worse cognitive performance.

Background

Pregnancy is a special period within the clinical course of multiple sclerosis (MS), characterized by a reduction in the relapse rate and slower disease progression. On the contrary, during puerperium, relapse rate increases again. Viruses have been related to the etiopathogenesis of the disease, especially with disease activity.

Objectives

To analyse the serum antibody titters against Epstein-Barr virus (EBV) (EBNA-1 and VCA) and human herpesvirus 6 A/B (HHV-6A/B), as well as the expression of the envelope protein of the MS-associated retrovirus (MSRV ENV) in pregnant MS patients during pregnancy and postpartum. To study their possible relationship with the disease activity during pregnancy and postpartum, as well as their potential role in predicting the risk of relapses.

Methods

Serum samples were collected from 71 pregnant women, 50 with MS and 21 healthy controls, at every trimester of pregnancy and in the postpartum. Antibody titters against the above mentioned viruses were analysed by ELISA commercial kits, following manufacturer instructions; gene expression of MSRV ENV was analysed by qRT-PCR.

Results

IgM titres against HHV-6A/B were higher in MS patients than in healthy controls in the three trimesters of pregnancy and in the postpartum period (U-Mann Whitney): p =0.00001 for the first trimester; p=0.021 for the second trimester; p = 0.000005 for the third trimester; p =0.001, for the postpartum period). Furthermore, IgM titres against HHV-6A/B in the first trimester were higher in patients with relapses (U Mann Whitney, p = 0.052). Regarding the expression of MSRV ENV, the percentage of positivity during the first trimester was significantly higher in MS patients with relapses during pregnancy compared to those who did not (Fisher, p = 0.038).

Conclusions

High IgM titters against HHV-6A/B and the expression of MSRV ENV during the first trimester of pregnancy could act as predictors of relapse risk during pregnancy / postpartum. Although further studies are needed to validate these results, this study support the relation between viruses and relapses in pregnant MS patients.

Background

Viruses have been involved in multiple sclerosis (MS) in last years. However, almost all of the studies published so far have focused on patients with relapsing-remitting MS (RRMS), with no data about viruses in patients with progressive primary MS (PPMS). Due to the differences that exist between these two forms of MS it would be interesting to know if there is also differences regarding viruses previously related to the etiopathogenesis of the disease.

Objectives

The aim of this study was to analyze the prevalence and titters of different viral antibodies: IgG against EBNA-1 and VCA of Epstein-Barr virus (EBV), IgG and IgM against Human herpesvirus 6 (HHV-6) and cytomegalovirus (CMV), in PPMS patients and to compare those results with other cohort of RRMS patients.

Methods

A total of 166 MS patients were recruited: 71 with PPMS and 95 with RRMS (mean age: 48 and 43.6 years, respectively; gender: 47.9% and 61% female, respectively). We analyzed the presence and titters of the antibodies above mentioned with ELISA commercial kits, following manufacturer instructions.

Results

1. Herpesvirus prevalences: we only found a statistical significant difference for IgG antibodies against EBNA-1 of EBV (84.5% of PPMS patients were positive vs. 97.8% of RRMS patients; p=0.002). When we analyzed these prevalences by age groups (<45 and >45 years), we only found statistical significant differences between PPMS and RRMS patients under 45 years: 84.6% of PPMS patients were positive for IgG against EBNA-1 vs. 100% of RRMS patients (p=0.015), and 26.9% of PPMS patients were positive for IgM against HHV-6 vs. 7.7% of RRMS patients (p=0.021). 2. Herpesvirus titters: we found that IgG titters against CMV were higher among PPMS patients than in RRMS patients (31.3 AU vs. 16.01 AU, p=0.0001); IgG titters against HHV-6 were also higher in PPMS patients (29.3 AU vs. 20.5, p=0.004); IgG titters against EBNA-1 of EBV were lower in PPMS patients than in RRMS patients (16.4 AU vs. 22.8 AU, p<0.0001).

Conclusions

We have found statistical significant differences between different herpesvirus prevalences and titters between PPMS and RRMS patients that should be deeper studied to evaluate their possible contribution to the existing differences between these two forms of MS.

Background

Objective: Pregnancy reduces the annualized relapse rate (ARR) in multiple sclerosis (MS). However it is temporarily increased at puerperium. The exact mechanism underlying this clinical observation remains unknown.

Objectives

We aimed to explore the changes of the short-chain fatty acids (SCFAs) profiles in MS patients and healthy women (HCW) during pregnancy, and to assess any potential biomarker predicting the appearance of relapses during pregnancy and postpartum.

Methods

Methods: We included 53 pregnant MS patients and 21 HCW followed at Hospital Universitario Gregorio Marañón between 2007 and 2018. Patients were evaluated at every trimester of pregnancy and in the puerperium. Serum SCFAs were measured by liquid chromatography-mass spectrometry

Results

Results: Seventeen patients (32%) experienced relapses during pregnancy or puerperium (ACT group) and 37(68%) did not (NO-ACT group). We did not found differences in clinical characteristics or treatment status between the two groups. We observed differences in the SCFAs profile between ACT:NO-ACT groups during pregnancy and puerperium. Acetate levels were higher during the pregnancy-puerperium period in MS patients, regardless of clinical activity, compared to HCW (p: 0.0001). Interestingly, levels of propionate and butyrate below 1,985 μM (1,283 - 3.55) and 0.515 μM (0.01-2.943) respectively during the first trimester were associated with relapses during the pregnancy-puerperium period (p: 0.0001). The ACT group had a lower ratio of propionate/acetate and butyrate/acetate during pregnancy compared to NO-ACT group (<0.0001). The ROC curve showed that a propionate/acetate ratio of 0.36 (AUC 0.96, sensitivity 94%, specificity 92%;) has an OR=165 [CI: 10.2-239.4], p <0.0001) to predict relapses during pregnancy-puerperium.

Conclusions

Conclusions: SCFA levels during pregnancy may be associated with clinical activity in MS, and that their measurement could be useful in predicting the occurrence of relapses during this pregnancy-puerperium period

Background

It has been previously reported that the ratio of an individual`s second and fourth digit lengths (2D:4D ratio) reflects influence of prenatal androgen levels. A higher ratio is associated with a lower in-utero balance of androgens to estrogen. This exposure has been related to the risk of developing MS.

Objectives

To determine whether 2D:4D ratio differs in patients with Multiple Sclerosis (MS), healthy volunteers, and patients suffering other autoimmune diseases (o-AD) and if the ratio correlates with MS severity.

Methods

We obtained two measures of the second and fourth fingers of the right hand of MS patients, healthy volunteers and o-AD patients. 2D:4D ratio was calculated using calipers. We retrospectively reviewed demographic and clinical data. Multiple Sclerosis Severity Score (MSSS) was used as a MS severity outcome measure. Non-parametric tests were used.

Results

In total, we included 120 people. Sixty with MS, median age was 44 years, and 41 (68.3%) were female. Fifty three patients (88.3%) suffered from Relapsing Remitting MS and 7 patients primary or secondary progressive forms of MS. There were sixty people as controls, median age 46 years, and 36 were female (60%). Thirty three patients (55%) had o-AD, mainly ankylosing spondylitis (n=18). Groups were homogeneous for age and sex.

We did not find statistically significant differences between 2D:4D ratio between people with MS and without MS [median: 1 (IQR, 0.055) vs 1 (IQR, 0.043); p>0.05]; and between MS patients and o-AD group [median: 1 (IQR, 0.055) vs 1 (IQR, 0.052); p>0.05]. Severity of MS was not associated with 2D:4D ratio (p=0.358). 2D:4D ratio in men with MS was lower than in men without MS (median: 0.97 (IQR, 0.05) vs 1 (IQR, 0.07); p=0.049].

Conclusions

In our study, 2D:4D ratio was not associated with a higher risk of MS or a greater disease severity (MSSS). Our results suggest that 2D:4D ratio measure does not reflect prenatal androgen influence accurately, or that in-utero exposure to androgens might have a lesser impact on the risk of MS.

Background

There is controversial data on the differential activity of the default mode network (DMN) in patients with Multiple Sclerosis (MS), and how it is linked to cognitive status. For some authors, there could be an initial hypercompensation, followed by a late exhaustion of the DMN. More research is needed to clarify how those changes may be related to cognition and the different phenotypes of MS.

Objectives

To evaluate the functional connectivity of DMN of MS patients with different phenotypes (relapsing-remitting (RR), clinically isolated syndrome (CIS) and primary progressive (PP) compared to healthy controls (HC).

Methods

Sixty-two participants (16 HC, 16 RR, 15 CIS and 14 PP) were evaluated with a neuropsychological battery to establish their cognitive profile. A functional magnetic resonance (fMRI) with a seed-to-voxel approach was performed to study the DMN, as defined by the Human Connectome Project. We selected four regions of interest: Posterior cingulated cortex (PCC); Medial prefrontal cortex (MPFC); Lateral parietal cortex Left (L-LPC) and Lateral parietal cortex Right (R-LPC). Correlation of their functional connectivity was analyzed considering different groups according to the MS phenotype.

Results

MS patients and HC were equivalent in age, years of education and gender. A 35,5% of MS patients were cognitively preserved, whereas 24(64,5%) had cognitive impairment: 12 were mild(MCI) and 12 moderate(ModCI). RR patients were significantly younger (M=37,9 old; SD=7,3) compared to CIS (M=40,8; SD=9,9) and PP (M= 49,4; SD=7,8). CIS patients had a shorter duration of MS (M=4,3 years; SD=3,9; p=0,013) compared to RR (age M=9,5; SD=5,6) and PP (M=9,9; SD=6,9). Groups were not homogeneous in terms of physical disability, being PP the most disabled (Mode=6) vs RR (Mode=2) or CIS (Mode=0). Regarding global DMN connectivity, no differences were found between HC and MS patients. However, when focusing on phenotypes, we found that CIS had a trend to a higher connectivity than HC and that connectivity steadily decreased though RR to PP, so that PP activity was significantly lower than that of CIS (p=0,019). No differences were found based on cognitive impairment. Antero-posterior connectivity was significantly higher for CIS than RR (p=0,017) and PP (p=0,018); and in cognitively preserved vs ModCI (p=0,03).

Conclusions

Our data supports the dynamic theory for functional connectivity that suggests an initial overcompensation followed by a gradual decline, which is elicited by studying MS phenotypes. Within the DMN, anterior-posterior connectivity was related to a worse cognitive performance.