POINT OF VIEW
`
`Experimental Allergic Encephalomyelitis:
`A Misleading Model of Multiple Sclerosis
`
`Subramaniam Sriram, MD,1 and Israel Steiner, MD2
`
`Despite many years of intensive research, multiple sclerosis (MS) defies understanding and treatment remains subopti-
`mal. The prevailing hypothesis is that MS is immune mediated and that experimental allergic encephalomyelitis (EAE)
`is a suitable model to elucidate pathogenesis and devise therapy. This review examines critically the validity that EAE is
`an adequate and useful animal model of MS and finds credible evidence lacking. EAE represents more a model of acute
`central nervous system inflammation than the counterpart of MS. We propose to reconsider the utilization of EAE,
`especially when this model is used to define therapy. This will also force us to examine MS without the restraints
`imposed by EAE, as to what it is, rather than what it looks like.
`
`Although the cause and pathogenesis of multiple scle-
`rosis (MS) are unknown, current prevailing hypothesis
`favors MS to represent an autoimmune disorder di-
`rected against nervous system antigens. 1–3 The basic
`concept proposes
`that
`exposure
`to environmental
`pathogens activates autoreactive T cells that recognize
`central nervous system (CNS) autoantigens, leading to
`inflammation and demyelination.4 –7 This belief is pro-
`moted by some similarities between MS and the vari-
`ous animal models of experimental allergic encephalitis
`(EAE).8
`Since the initial experiments by Rivers, the stage was
`set for the use of experimental animal models to study
`CNS inflammation and demyelination.9 Over the last
`30 years, the number of EAE-cited publications in En-
`glish has quadrupled; a Medline search identifies a total
`of 678 articles on EAE between the years 1970 and
`1980, 1,860 articles between 1990 and 2000, and ap-
`proximately 1,600 publications since 2001.
`Besides the utilization of EAE to study MS, it has
`also been harnessed for developing therapeutic strate-
`gies for MS.10 –12 Indeed, the majority of the current
`therapies being planned for phase II and III trials in
`MS were first examined in EAE. Thus, EAE has be-
`come a central player in the arena of MS. Is it indeed
`a suitable and relevant research tool for MS? It has im-
`proved our understanding of acute inflammatory de-
`myelinating syndromes, advanced our knowledge of
`the genetic susceptibility to autoimmunity, and helped
`
`From the 1Department of Neurology Vanderbilt Medical Center,
`Nashville, TN; and 2Department of Neurology, Hadassah Univer-
`sity Hospital, Jerusalem, Israel.
`Received Feb 15, 2005, and in revised form Jul 13 and Sep 28.
`Accepted for publication Oct 8, 2005.
`InterScience
`in Wiley
`Published
`online Nov
`28,
`2005,
`(www.interscience.wiley.com). DOI: 10.1002/ana.20743
`
`Ann Neurol 2005;58:939 –945
`
`uncover mechanisms of lymphocyte trafficking and the
`role of blood–brain barrier in CNS inflammation. We
`propose, however, that although EAE is a useful model
`of acute human CNS demyelination such as acute dis-
`seminated encephalomyelitis (ADEM), its contribution
`to the understanding of MS has been limited. We fo-
`cus here on the lack of resemblance of the EAE model
`with MS and examine its shortcomings when attempt-
`ing to extrapolate the findings from the model to the
`human disease.
`
`Experimental Allergic Encephalomyelitis, The
`Prototypic Autoimmune Model
`Myelin basic protein (MBP), proteolipoprotein (PLP),
`myelin oligodendrocyte glycoprotein (MOG), myelin-
`associated glycoprotein (MAG), and S-100 protein are
`the major known CNS antigens that elicit an immune
`response and cause paralytic disease in mice.13,14
`MOG-induced EAE differs from MBP/PLP-induced
`EAE in two major respects. Unlike MBP and PLP-
`induced EAE, demyelination in EAE induced by
`MOG is aggravated with concomitant administration
`of anti–MOG antibodies, suggesting a prominent role
`for a humoral response in the development of the in-
`flammatory pathology.15 Also, in some strains of mice,
`the immune response to MOG is restricted by CD8⫹
`rather than CD4⫹ T cells.16,17 Two additional myelin
`antigens, MAG and CNP-ase are considered to be po-
`tential autoantigens in MS because they can induce en-
`
`Address correspondence to Dr Sriram, Multiple Sclerosis Center,
`1222H Vanderbilt Stallworth Rehabilitation Hospital, 2201 Chil-
`dren’s Way, Nashville, TN 37212.
`E-mail: subramaniam.sriram@ vanderbilt.edu
`
`© 2005 American Neurological Association
`Published by Wiley-Liss, Inc., through Wiley Subscription Services
`
`939
`
`Coalition Exhibit 1049
`Coalition v. Biogen
`IPR2015-01993
`
`Page 1 of 7
`
`

`

`cephalitis in animals. Studies of the presence of im-
`mune response to MAG in MS patients are limited.18
`Although the immune response to CNP-ase in MS pa-
`tients is as yet undetermined, cross-reactivity in re-
`sponse to heat shock proteins and CNP-ase has sug-
`gested a mechanism for induction of an autoimmune
`response.19 S-100 is an astrocytic protein and immuni-
`zation of rodents produces an encephalitic picture with
`only minimal demyelination.20
`EAE is characteristically an acute monophasic illness
`(as compared with the chronic relapsing course of MS)
`making it more pertinent to ADEM. However, even
`the development of chronic relapsing models of EAE
`(CR-EAE) in rodents has not improved the relevance
`of EAE in view of the continued differences between
`the CR-EAE and MS.21–23
`
`The Nature of the Inflammatory Response in
`Experimental Allergic Encephalomyelitis and
`Multiple Sclerosis
`The ability of CD4⫹ MBP-reactive T cells to induce
`paralytic signs in mice established the immunological
`basis of EAE. Immunohistochemical studies examining
`the phenotype of the inflammatory cells have shown
`the presence of T cells in both EAE and MS le-
`sions.24 –27 However, CD4⫹ T cells dominate the
`perivascular regions of the inflammatory focus in EAE
`induced by MBP and PLP. On the other hand, the
`pathology of the demyelinating lesions in MS span a
`spectrum between those that show prominent inflam-
`mation and demyelination to others that represent an
`oligodendrogliopathy with minimal
`inflammation of
`demyelinated regions.28 In inflammatory MS lesions,
`the predominant cells are macrophages and CD8⫹ T
`cells. CD4⫹ T cells while present are infrequent.29 –31
`Isolation of T cells from MS brains by micromanipu-
`lation, followed by targeted amplification of T-cell re-
`ceptor (TCR) genes showed a restricted expansion of
`CD8 clones. Although CD4 clones were also isolated
`from MS brains, they did not show a restricted TCR
`expression pattern, suggesting they were not represen-
`tative of a clonally expanded population.32,33 In an-
`other study, overrepresentation of CD8⫹ T cells was
`seen in spinal fluid of MS patients. These T cells, some
`of the memory phenotype, were stable over several
`months. In certain patients, the expansion of CD8 T
`cells involved a restricted TCR V gene expression pat-
`tern indicative of a clonal expansion.34,35 In the brain
`parenchyma of MS patients, these CD8⫹ T cells are
`present in close apposition to the myelin membranes,
`signifying that they may indeed play a role in tissue
`damage.36 To further confound the issue, CD8-
`restricted T-cell reactivity to MOG is sufficient to in-
`duce EAE in mice, whereas there is little evidence of
`CD8⫹ T cells reactive to MOG peptides in MS.37,38
`These findings question the relevance of the CD4⫹ au-
`
`940 Annals of Neurology Vol 58 No 6 December 2005
`
`toreactive T-cell repertoire in the periphery of EAE le-
`sions to MS pathogenesis39 (Table 1).
`
`Is Multiple Sclerosis a Th1-Mediated Disease as
`Is Experimental Allergic Encephalomyelitis?
`The separation of T-cell clones into two mutually ex-
`clusive cytokine secretion patterns, Th1 and Th2,
`evolved into dividing presumable inflammatory diseases
`as being either Th1 (characterized by secretion of in-
`terleukin [IL]–2, and ␥-interferon) or Th2 (character-
`ized by secretion of IL-4, IL-5, and IL-13) mediated.40
`Because Th1 cells are sufficient for adoptive transfer of
`EAE, and ␥-interferon is seen in MS lesions, it was
`proposed that Th1 cells may be directly involved in
`both MS and EAE. However, this is not true in all
`EAE models and in every biological context: (1) MBP-
`reactive Th2 cell clones that secrete IL-4 and low levels
`of ␥-interferon also cause EAE41; (2) ␥-interferon–de-
`ficient mice developed EAE with greater severity after
`immunization with either MBP or MOG peptides42;
`(3) treatment of mice with ␥-interferon caused attenu-
`ation of disease and treatment of mice with anti–␥-
`interferon antibodies induced worsening of EAE.43
`A clinical study that reported worsening of the dis-
`ease in patients receiving ␥-interferon has supported
`the view that MS, like EAE, is a Th1-mediated auto-
`immune disease. However, a careful reading of the re-
`port raises several questions. Side effects such as fever,
`myalgias, and arthralgias were noted in virtually all five
`patients in the group of patients receiving high-dose
`␥-interferon which subsided with discontinuation of
`the drug.44,45 All of the exacerbations involved the
`worsening of old symptoms, and at the completion of
`the study there was no residual defect in any of the
`seven patients with relapses. Whether corticosteroids
`were given to the patients with relapses is unclear, and
`the study was done at a time when magnetic resonance
`imaging (MRI) scans were not readily available. Thus,
`the transient neurological symptomatology induced by
`␥-interferon could merely represent clinical decompen-
`sation due to fever or the action of other cytokines
`(“pseudorelapses”) and not necessarily the evolution of
`a new inflammatory process. In other studies, induc-
`tion of ␥-interferon has been observed after treatment
`of MS patients with intravenous immune globulin
`without any increase in the incidence of relapses. Also
`administration of poly-ICLC in secondary progressive
`MS, a known ␥-interferon inducer, has not shown any
`adverse effect in MS patients.46,47 Hence, assigning a
`central role for Th1 cytokines in MS, which therefore
`would serve as a major argument for the relevance of
`EAE to MS, seems unfounded.
`
`Page 2 of 7
`
`

`

`Table 1. Immunopathology and Response to Therapy in EAE and MS
`
`EAE
`
`MS
`
`Pathology
`Location of demyelination
`
`Predominantly, perivenous sleeves of myelin
`loss in spinal cord and brain
`
`Dependent on the autoantigen used for in-
`duction: inflammation dominates in lum-
`bar regions in MBP and PLP EAE and
`brainstem in MOG EAE
`Phenotype of cellular infiltrate CD4⫹ T cells (MBP and PLP EAE) acti-
`vated macrophages and few CD8⫹ T cells
`TH1 bias in MBP and PLP EAE; TH2 bias
`worsens MOG EAE
`Antibodies to myelin antigens present in CSF Antibodies to myelin antigens are infre-
`quent in CSF and do not constitute the
`antigen specificity of oligoclonal bands
`
`Location of lesions
`
`Cytokine predominance
`
`CSF immunology
`
`Effect of immunotherapies
`␥ interferon
`
`␤ interferon
`
`Anti–TNF antibody
`Anti–VLA-4 antibody
`
`Depends on route of administration and can
`either worsen on ameliorate EAE
`Variable; can worsen EAE if given after im-
`munization
`Reverses EAE
`Reverses EAE
`
`Anti–CD4 antibodies
`
`Cures EAE
`
`Demyelination not restricted to perivenous
`regions of white matter; extensive demy-
`elination of cerebral cortex in the ab-
`sence of inflammation is common
`Periventricular areas, cortical mantle,
`brainstem, optic nerves, and upper cer-
`vical cord; lesions are uncommon in
`thoracic and lumbar regions
`Activated macrophages and CD8⫹ T cells
`of a restricted clonotype
`Variable; no clear cytokine preponderance
`
`Worsening of inflammatory lesions un-
`proven
`Decreases relapse rate: effect on progres-
`sion modest
`Worsens MS
`Decreases relapses; effect on progression
`not known
`No evidence of clinical efficacy on relapses
`or progression
`
`EAE ⫽ experimental allergic encephalomyelitis; MS ⫽ multiple sclerosis; MBP ⫽ myelin basic protein; PLP ⫽ proteolipoprotein; MOG ⫽
`myelin oligodendrocyte glycoprotein; CSF ⫽ cerebrospinal fluid.
`
`Fundamental Differences in the Pathology
`between Multiple Sclerosis and Experimental
`Allergic Encephalomyelitis
`In a manner analogous to that seen in EAE, the in-
`flammatory response in MS is thought to be mediated
`by the trafficking to the CNS of autoreactive T cells
`(see Table 1). Such a mechanism, sometimes referred
`to as the “outside to inside hypothesis,” was recently
`challenged by work by Barnett and Prineas48 and sup-
`ported by other studies.24,48 –50 They noted the occur-
`rence of oligodendrocyte death as the very early and
`perhaps
`the initial event
`in the pathology of
`the
`plaque, even before development of
`inflammation.
`These observations are by no means novel.51 Evidence
`of early noninflammatory changes in the CNS has also
`been suggested by imaging studies but not confirmed
`histologically.52–57 However, normal-appearing white
`matter on MRI may still contain microscopic evidence
`of inflammation. This and other observations may in-
`terpret the inflammation in MS as one of the follow-
`ing: (1) an epi-phenomenon that follows areas where
`the loss of myelin is large, such as in the vicinity of
`large fiber tracts or (2) an attempt to fight a damaging
`process
`that
`initiates oligodendrocyte death. Under
`such a scenario, MS (unlike EAE) is not a disease that
`is mediated by the entry of T cells from the periphery
`but is caused by direct death and destruction of ner-
`
`vous system structures including, to a large extent, the
`destruction of myelin. Although the neurological con-
`sequences of inflammation, induced by the destruction
`of the oligodendrocyte-myelin unit cannot be ignored
`and may contribute to morbidity, this concept will
`foretell that long-term reduction in the inflammatory
`response (with the use of either antiinflammatory or
`immunosuppressive therapies) is unlikely to alter the
`natural course of the disease.
`The former view that MS is exclusively a white
`matter disease was challenged and proved wrong by
`histological and imaging studies. Indeed, axonal dam-
`age and neuronal
`loss are common features of MS
`and may be a direct consequence of inflammation or
`because loss of trophic factors necessary to maintain
`the integrity of the neural-axonal unit. Histological
`and MRI studies have shown significant cortical and
`axonal damage in MS that is not seen in EAE.58 – 60
`Whatever the mechanism, demyelination in the cor-
`tical gray matter mantle extends from the pial surface
`to the gray white junction and spreads laterally over
`several contiguous gyrii.58 – 60 Most importantly, these
`areas of myelin loss lack an inflammatory response.
`Similarly, large regions of the spinal cord around the
`central canal showed loss of myelin with decrease of
`neuronal structures.
`
`Sriram and Steiner: Rethinking EAE and MS
`
`941
`
`Page 3 of 7
`
`

`

`Pitfalls in Extension of Immunotherapies from
`Experimental Allergic Encephalomyelitis to
`Multiple Sclerosis
`The most disappointing aspect of EAE as a potential
`model for MS is its almost total inability to point to-
`ward a meaningful therapy or therapeutic approach for
`MS (Table 2). The spectrum of agents and approaches
`that showed promising results in EAE is immense and
`range from turmeric (used in Asian cooking) and
`Padma-28 (exotic natural drug found in health food
`stores) to modern genetic manipulation of the immune
`system with cytokines and antigen. Nevertheless, when
`applied to the human “counterpart,” most, but not all,
`these therapies proved disappointing.61,62 Glati-
`of
`ramer acetate represents the only drug currently in use
`whose application in a clinical setting was first proved
`useful in EAE.63 Glatiramer acetate is modestly effec-
`tive in reducing relapses but has not prevented the pro-
`gression of MS.64
`The reasons for this failure are not only, as shown
`here, that MS and EAE differ quite substantially, but
`also that even from the larger, more comprehensive
`picture, most of the evidence suggests that the EAE
`models do not reflect the pathology of a progressive
`disorder as MS. Moreover, the various EAE models are
`dissimilar in their pathology and immunology to such
`an extent that it is unclear why one EAE model will be
`better served than another.
`
`In clinical studies aimed at inducing antigen-specific
`tolerance to a potential encephalitogenic autoantigen
`such as MBP, either worsening of disease was noted or
`there was no change in the clinical course.65,66 Induc-
`tion of oral tolerance in trials aimed to prove this point
`were also a disappointment.67 Likewise, there was no
`beneficial effect of anti-CD4 antibody therapy on the
`progression of MS despite profound decrease of CD4⫹
`T cells in peripheral blood.68,69 Equally, examination
`of the therapeutic approach of switching from a Th1 to
`a Th2 profile in MS patients might prove a dangerous
`experiment, because pathological studies of brains of
`patients with MS show a Th2 response (presence of
`antibodies and complement) in the most destructive of
`lesions and glatiramer acetate induced a Th2 profile
`only after prolonged in vitro cultures of
`lympho-
`cytes.31,70,71 All this puts into question the hope that
`an immunosuppressive and/or antiinflammatory drug
`are likely to have a significant impact on MS.72 The
`reports of worsening of MS after bone marrow trans-
`plantation may become disheartening proof.73,74
`
`Conclusions
`He who would distinguish the true from the false, must
`have an adequate idea of what is true and false.—Baruch
`Spinoza 1632–1677
`The arguments we have presented should lead to
`several conclusions: EAE is a disorder that differs im-
`
`Table 2. Agents Successful in Treating EAE
`
`Antibodies to T-cell surface antigens
`Antibodies directed to antigen-presenting cells
`Antibodies to NK cells
`Antibodies to adhesion molecules
`Antibodies to cytokines
`Antibodies to chemokines
`Antiinflammatory cytokines
`Antagonists of signaling molecules
`
`Activation of nuclear receptors
`Hormones
`Antibiotics
`Antimetabolites and immunosuppressants
`
`Gene therapies
`Inhibitors of enzymes
`Peptides/proteins
`Food supplements
`Small organic molecules
`
`Miscellaneous
`
`CD3,CD4,T-cellreceptor,CD2,IL-2R,IL-2R,CD24,CD40LCD28
`MHC class II antigens, CD40, B7-1 and B7-2, Fc receptor blockade
`Anti–NK cell antibody, ␣-Gal ceramide
`VLA-4, ICAM-1, LFA-1
`IL-2, IL-6, IL-12, IL-15, TNF-␣, IL-1, IL-23
`Anti–MIP-1—␣ Rantes
`IL-4, IL-10, TGF-␤, IFN-␤, IFN-␣, ?␥-IFN
`Tyrphostins (inhibitors of JAK-Stat activation), lysofyline, inhibitors of
`MAP kinase pathway, inhibitors of NF-␬B activation, Inhibitors of
`iNOS activation, amsamycin, cholera toxin, AMPA antagonists, gluta-
`mate receptor antagonists, IL-1 receptor antagonists
`PPAR-␥ retinoic acid
`Estrogen, progesterone, vitamin D, DHEA, leptin antagonists
`Minocycline, rapamycin
`FK-506, cyclosporin, dyspergualin, corticosteroids, azathioprine, cyclo-
`phosphamide, mycophenolate, bone marrow transplantation
`Targeted delivery of IL-4, IL-10
`HOMG coreductase inhibitors (statins), COX-2 inhibitors
`Oral myelin proteins, glatiramer acetate, myelin peptides (iv)
`Essential fatty acid, omega 3 fatty acid, curcumin, padma-28, fish oil
`Linomide, silica, sodium phenyl acetate, copper chelators (N-
`acetylcysteine aminde), laquinamod, piperazylbutroxide, uric acid, der-
`matan sulphate, amionoguanidine, cuprizone, roliprim, H-2 receptor
`antagonists, indoleamine 2-3 deoxygenase, FTY-270, pentoxyfyline
`Incomplete Fruend’s adjuvant, BCG vaccination, Helminthic infections
`
`AMPA ⫽ alpha-amino hydroxy methyl propionic acid; BCG ⫽ Bacille Calmette Guerin; DHEA ⫽ dehydro epi androsterone; EAE ⫽
`experimental allergic encephalomyelitis; HMG ⫽ hydroxymethyl glutaryl coreductase; IFN ⫽ interferon; IL ⫽ interleukin; iNOS ⫽ inducible
`nitric oxide synthase; MAP ⫽ microtubule-associated protein; MHC ⫽ major histocompatibity complex; MIP ⫽ macrophage inflammatory
`protein; TGF-␤ ⫽transforming growth factor-␤.
`
`942 Annals of Neurology Vol 58 No 6 December 2005
`
`Page 4 of 7
`
`

`

`munologically and pathologically between species, ac-
`cording, in part, to the type of antigen used to induce
`it and the species in which the model is tested. None
`of the EAE models represent MS and they therefore are
`imprecise methods to elucidate either the pathogenesis
`or to develop therapeutic strategies in MS. In addition,
`EAE is not a valuable vehicle to examine therapies: the
`inability to apply the therapeutic successes of our find-
`ings from the EAE model to the human condition is
`one of the arguments against the autoimmune hypoth-
`esis for the pathogenesis of MS.
`We propose a much more careful use of EAE, espe-
`cially when this model is utilized to define therapy.
`There are more than 100 compounds of proven effi-
`cacy in EAE, and we believe that it is pointless to add
`any more to this list (see Table 2). It may also be im-
`portant not to extrapolate successful therapies from
`other dysimmune conditions in the hope that MS may
`represent a variation on the theme of a common dis-
`ease mechanism.
`We therefore are forced to examine MS without the
`restraints of EAE, as to what it is, rather than what it
`looks like. It would be interesting to ask the question
`of how one could approach the disease if animal mod-
`els were unavailable, and the only recourse would be to
`examine the clues offered by our patients and from rel-
`evant genetic, imaging, and epidemiological studies in
`humans. We believe that the current available patho-
`logic as well as radiological data would argue favorably
`in examining issues outside of the “autoimmune hy-
`pothesis” as central elements in the disease process.
`
`We are grateful to Drs Nisipiano, Steiner-Birmanns, and Wirguin
`for careful reading of the manuscript and useful suggestions and to
`the families of J. Falker, P. Griffin, W. Weaver, T. West, and S.
`Smith for their support of the MS Center.
`
`References
`1. Hemmer B, Archelos JJ, Hartung HP. New concepts in the
`immunopathogenesis of multiple sclerosis. Nat Rev Neurosci
`2002;3:291–301.
`2. Noseworthy JH, Lucchinetti C, Rodriguez M, Weinshenker
`BG. Multiple sclerosis. New Engl J Med 2000;343:938 –946.
`3. Wekerke H. Immunology of MS. In: McAlpine’s multiple scle-
`rosis. 3rd ed. New York: Churchill Livingstone, 1998:
`379 – 407.
`4. Zamvil S, Steinman LS. EAE and autoimmunity. Annu Rev
`Immunol 1990;8:579 – 621.
`5. Bright JJ, Sriram S. Immunotherapy of inflammatory demyeli-
`nating diseases of the central nervous system. Immunol Res
`2001;23:245–252.
`6. Owens T, Sriram S. The immunology of multiple sclerosis and
`its animal model, experimental allergic encephalomyelitis. Neu-
`rol Clin 1995;13:51–73.
`7. Sospedra M, Martin R. Immunology of multiple sclerosis.
`Annu Rev Immunol 2005;23:683–747.
`8. Raine CS. The Dale McFarlin memorial lecture. The immu-
`nology of the MS lesion. Ann Neurol 1994;36:S61–S72.
`
`9. Rivers TM, Schwentker FF. Encephalomyelitis accompanied by
`myelin destruction experimentally produced in monkeys. J Exp
`Med 1935;61:689 –701.
`10. Steinman L. Assessment of animal models for MS and demy-
`elinating disease in the design of rational therapy. Neuron
`1999;24:511–514.
`11. Martin R, McFarland H. Experimental immunotherapies for
`multiple sclerosis. Semin Immunopathol 1996;18:1–24.
`12. Jyothi MD, Flavell RA, Geiger TL. Targeting autoantigen-
`specific T cells and suppression of autoimmune encephalomy-
`elitis with receptor-modified T lymphocytes. Nat Biotechnol
`2002;20:1215–1220.
`13. Kies MW, Alvord EC. Allergic encephalitis. New York: C.C.
`Thomas, 1959:293–299.
`14. Pettinelli CB, McFarlin DE. Adoptive transfer of experimental
`allergic encephalomyelitis in SJL/J mice after in vitro activation
`of lymph node cells by myelin basic protein: requirement for
`Lyt 1⫹ 2- T lymphocytes. J Immunol 1981;127:1420 –1423.
`15. Genain CP, Abel K, Belmar N, et al. Late complications of
`immune deviation therapy in a nonhuman primate. Science
`1996;274:2054 –2057.
`16. Huseby ES, Liggitt D, Brabb T, et al. A pathogenic role for
`myelin-specific CD8(⫹) T cells in a model for multiple sclero-
`sis. J Exp Med 2001;194:669 – 676.
`17. Sun D, Whitaker JN, Huang Z, et al. Myelin antigen-specific
`CD8⫹ T cells are encephalitogenic and produce severe disease
`in C57BL/6 mice. J Immunol 2001;166:7579 –7587.
`18. Schmidt S. Candidate autoantigens in MS. Mult Scler 1999;5:
`145–160.
`19. Rosener M, Muraro PA, Riethmuller A, et al. 2⬘,3⬘-cyclic nu-
`cleotide 3⬘-phosphodiesterase: a novel candidate autoantigen in
`demyelinating diseases. J Neuroimmunol 1997;75:28 –34.
`20. Kojima K, Berger T, Lassmann H, et al. Experimental autoim-
`mune panencephalitis and uveoretinitis transferred to the Lewis
`rat by T lymphocytes specific for the S100 beta molecule, a
`calcium binding protein of astroglia. J Exp Med 1994;180:
`817– 829.
`21. Gold R, Hartung HP, Toyka KV. Animal models for autoim-
`mune demyelinating disorders of the nervous system. Mol Med
`2000;6:88 –91.
`22. Rose LM, Richards TL, Petersen R, et al. Remitting-relapsing
`EAE in nonhuman primates: a valid model of multiple sclerosis.
`Clin Immunol Immunopathol 1991;59:1–15.
`23. Lublin FD, Maurer PH, Berry RG, Tippett D. Delayed relaps-
`ing experimental allergic encephalomyelitis in mice. J Immunol
`1981;126:819 – 824.
`24. Prineas JW. The neuropathology of acute MS lesion. Hand-
`book of clinical neurology 1985;3:213–257.
`25. Raine CS. Multiple sclerosis: immunopathological mechanisms
`in the progression and resolution of inflammatory demyelina-
`tion. Res Publ Assoc Res Nerv Ment Dis 1990;68:37–54.
`26. Traugott U, Reinherz EL, Raine CS. Multiple sclerosis. Distri-
`bution of T cells, T cell subsets and Ia-positive macrophages in
`lesions of different ages. J Neuroimmunol 1983;4:201–221.
`27. Traugott U, Reinherz EL, Raine CS. Multiple sclerosis: distri-
`bution of T cell subsets within active chronic lesions. Science
`1983;219:308 –310.
`28. Lucchinetti C, Bruck W, Parisi J, et al. Heterogeneity of mul-
`tiple sclerosis lesions: implications for the pathogenesis of de-
`myelination. Ann Neurol 2000;47:707–717.
`29. Booss J, Esiri MM, Tourtellotte WW, Mason DY. Immunohis-
`tological analysis of T lymphocyte subsets in the central nervous
`system in chronic progressive multiple sclerosis. J Neurol Sci
`1983;62:219 –232.
`
`Sriram and Steiner: Rethinking EAE and MS
`
`943
`
`Page 5 of 7
`
`

`

`30. Hauser SL, Bhan AK, Gilles F, et al. Immunohistochemical
`analysis of the cellular infiltrate in multiple sclerosis lesions.
`Ann Neurol 1986;19:578 –587.
`31. Lassmann H, Ransohoff RM. The CD4-Th1 model for multi-
`ple sclerosis: a crucial re-appraisal. Trends Immunol 2004;25:
`132–137.
`32. Skulina C, Schmidt S, Dornmair K, et al. Multiple sclerosis:
`brain-infiltrating CD8⫹ T cells persist as clonal expansions in
`the cerebrospinal fluid and blood. Proc Natl Acad Sci USA
`2004;101:2428 –2433.
`33. Babbe H, Roers A, Waisman A, et al. Clonal expansions of
`CD8(⫹) T cells dominate the T cell infiltrate in active multiple
`sclerosis lesions as shown by micromanipulation and single cell
`polymerase chain reaction. J Exp Med 2000;192:393– 404.
`34. Cepok S, Jacobsen M, Schock S, et al. Patterns of cerebrospinal
`fluid pathology correlate with disease progression in multiple
`sclerosis. Brain 2001;124:2169 –2176.
`35. Jacobsen M, Cepok S, Quak E, et al. Oligoclonal expansion of
`memory CD8⫹ T cells in cerebrospinal fluid from multiple
`sclerosis patients. Brain 2002;125:538 –550.
`36. Neumann H, Medana IM, Bauer J, Lassmann H. Cytotoxic T
`lymphocytes in autoimmune and degenerative CNS diseases.
`Trends Neurosci 2002;25:313–319.
`37. Van der Aa A, Hellings N, Bernard CC, et al. Functional prop-
`erties of myelin oligodendrocyte glycoprotein-reactive T cells in
`multiple sclerosis patients and controls. J Neuroimmunol 2003;
`137:164 –176.
`38. Koehler NK, Genain CP, Giesser B, Hauser SL. The human T
`cell response to myelin oligodendrocyte glycoprotein: a multiple
`sclerosis family-based study. J Immunol 2002;168:5920 –5927.
`39. Ota K, Matsui M, Milford EL, et al. T cell recognition of an
`immunodominant myelin basic protein epitope in multiple
`sclerosis 1990;346:183–185.
`40. Abbas AK, Murphy KM, Sher A. Functional diversity of helper
`T lymphocytes. Nature 1996;383:787–793.
`41. Lafaille JJ, Nagashima K, Katsuki M, Tonegawa S. High inci-
`dence of spontaneous autoimmune encephalomyelitis in immu-
`nodeficient anti-myelin basic protein T cell receptor transgenic
`mice. Cell 1994;78:399 – 408.
`42. Ferber IA, Brocke S, Taylor-Edwards C, et al. Mice with a dis-
`rupted IFN-gamma gene are susceptible to the induction of ex-
`perimental autoimmune encephalomyelitis (EAE). J Immunol
`1996;156:5–7.
`43. Owens T, Wekerle H, Antel J. Genetic models of CNS inflam-
`mation. Nat Med 2001;7:161–166.
`44. Panitch HS, Hirsch RL, Haley AS, Johnson KP. Exacerbations
`of multiple sclerosis in patients treated with gamma interferon.
`Lancet 1987;1:893– 895.
`45. Panitch HS, Hirsch RL, Schindler J, Johnson KP. Treatment of
`multiple sclerosis with gamma interferon: exacerbations associ-
`ated with activation of the immune system. Neurology 1987;
`37:1097–1102.
`46. Bever CT Jr, Panitch HS, Levy HB, et al. Gamma-interferon
`induction in patients with chronic progressive MS. Neurology
`1991;41:1124 –1127.
`47. Ling ZD, Yeoh E, Webb BT, et al. Intravenous immunoglob-
`ulin induces interferon-gamma and interleukin-6 in vivo. J Clin
`Immunol 1993;13:302–309.
`48. Barnett MH, Prineas JW. Relapsing and remitting multiple
`sclerosis: pathology of the newly forming lesion. Ann Neurol
`2004;55:458 – 468.
`49. Lumsden CE. The immunogenesis of the MS plaque. Brain Res
`1971;28:365–371.
`
`944 Annals of Neurology Vol 58 No 6 December 2005
`
`50. Trapp BD. Pathogenesis of multiple sclerosis: the eyes only see
`what the mind is prepared to comprehend. Ann Neurol 2004;
`55:455– 457.
`In:
`sclerosis.
`51. Lumsden CE. Neuropathology of multiple
`Koetsler JC, ed. Handbook of clinical neurology. Vol 3. New
`York: Elsevier Science Publishing, 1972:217–309.
`52. Matthews PM, Arnold DL. Magnetic resonance imaging of
`multiple sclerosis: new insights linking pathology to clinical
`evolution. Curr Opin Neurol 2001;14:279 –287.
`53. Wolinsky JS, Narayana PA. Magnetic resonance spectroscopy in
`multiple sclerosis: window into the diseased brain. Curr Opin
`Neurol 2002;15:247–251.
`54. De Stefano N, Guidi L, Stromillo ML, et al. Imaging neuronal
`and axonal degeneration in multiple sclerosis. Neurol Sci 2003;
`24(suppl 5):S283–S286.
`55. Zivadinov R, Bakshi R. Role of MRI in multiple sclerosis I:
`inflammation and lesions. Front Biosci 2004;9:665– 683.
`56. Ranjeva JP, Pelletier J, Confort-Gouny S, et al. MRI/MRS of
`corpus callosum in patients with clinically isolated syndrome
`suggestive of multiple sclerosis. Mult Scler 2003;9:554 –565.
`57. Fernando KT, McLean MA, Chard DT, et al. Elevated white
`matter myo-inositol in clinically isolated syndromes suggestive
`of multiple sclerosis. Brain 2004;127:1361–1369.
`58. Bjartmar C, Wujek JR, Trapp BD. Axonal loss in the pathology
`of MS: consequences for understanding the progressive phase of
`the disease. J Neurol Sci 2003;206:165–171.
`59. Bjartmar C, Trapp BD. Axonal degeneration and progressive
`neurologic disability in multiple sclerosis. Neurotox Res 2003;
`5:157–164.
`60. Bo L, Vedeler CA, Nyland H, et al. Intracortical multiple scle-
`rosis lesions are not associated with increased lymphocyte infil-
`tration. Mult Scler 2003;9:323–331.
`61. Badmaev V, Kozlowski PB, Schuller-Levis GB, Wisniewski
`HM. The therapeutic effect of an herbal formula Badmaev 28
`(padma 28) on experimental allergic encephalomyelitis (EAE)
`in SJL/J mice. Phytother Res 1999;13:218 –221.
`62. Natarajan C, Bright JJ. Curcumin inhibits experimental allergic
`encephalomyelitis by blocking IL-12 signaling through Janus
`kinase-STAT pathway in T lymphocytes. J Immunol 2002;168:
`6506 – 6513.
`63. Lisak RP, Zweiman B, Blanchard N, Rorke LB. Effect of treat-
`ment with Copolymer 1 (Cop-1) on the in vivo and in vitro
`manifestations
`of
`experimental
`allergic
`encephalomyelitis
`(EAE). J Neurol Sci 1983;62:281–293.
`64. Munari L, Lovati R, Boiko A. Therapy with glatiramer acetate
`for multiple sclerosis. Cochrane Database Syst Rev 2004:
`CD004678.
`65. Bielekova B, Goodwin B, Richert N, et al. Encephalitogenic
`potential of the myelin basic protein peptide (amino acids 83-
`99) in multiple sclerosis: results of a phase II clinical trial with
`an altered peptide ligand. Nat Med 2000;6:1167–1175.
`66. Kappos L, Comi G, Panitch H, et al. Induction of a non-
`encephalitogenic type 2 T helper-cell autoimmune response in
`multiple sclerosis after administration of an altered peptide li-
`gand in a placebo-controlled, randomized phase II trial. The
`Altered Peptide Ligand in Relapsing MS Study Group. Nat
`Med 2000;6:1176 –1182.
`67. Quinn S. Human trials: scientists, investors, and patients in the
`quest for a cure. Perseus Publishing, Cambridge, MA: 2002.
`68. van Oosten BW, Lai M, Hodgkinson S, et al. Treatment of
`multiple sclerosis with the monoclonal anti-CD4 antibody cM-
`T412:
`results of
`a
`randomized, double-blind, placebo-
`controlled, MR-m