Research Article| Volume 378, 578088, May 15, 2023

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Alemtuzumab treatment exemplifies discordant immune effects of blood and cerebrospinal fluid in multiple sclerosis


      • Immune responses in the central nervous system (CNS) are highly compartmentalized.
      • pDCs were maintained in CSF but depleted from blood by alemtuzumab.
      • Genes associated with migration were elevated only in the CSF after alemtuzumab.
      • The CSF and blood compartments are thus partially uncoupled.


      Background and objectives

      Immune responses in the central nervous system (CNS) are highly compartmentalized and cerebrospinal fluid (CSF) in particular often reflects CNS pathology better than peripheral blood. While CSF leukocytes are known to be distinct from blood, the immediate effects of peripheral leukocyte depletion on CSF leukocytes have not been studied in humans.


      We here analyzed CSF and blood from two relapsing-remitting multiple sclerosis (RRMS) patients early after peripheral leukocyte depletion with the anti-CD52 antibody alemtuzumab compared to untreated RRMS and control patients using single cell RNA-sequencing.


      As expected for alemtuzumab, most leukocyte lineages including T cells were synchronously depleted from CSF and blood, while - surprisingly - pDCs were maintained in CSF but depleted from blood by alemtuzumab. Transcriptionally, genes associated with migration were elevated only in the CSF after alemtuzumab. Predicted cellular interactions indicated a central role of pDCs and enhanced migration signaling in the CSF after alemtuzumab.


      The CSF and blood compartments are thus partially uncoupled, emphasizing that the CNS is only partially accessible even for treatments profoundly affecting the blood.


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        • Alteber Z.
        • Sharbi-Yunger A.
        • Pevsner-Fischer M.
        • et al.
        The anti-inflammatory IFITM genes ameliorate colitis and partially protect from tumorigenesis by changing immunity and microbiota.
        Immunol. Cell Biol. 2018; 96: 284-297
        • Alves de Lima K.
        • Rustenhoven J.
        • Kipnis J.
        Meningeal immunity and its function in maintenance of the central nervous system in health and disease.
        Annu. Rev. Immunol. 2020; 38: 597-620
        • Arneth B.
        Contributions of T cells in multiple sclerosis: what do we currently know?.
        J. Neurol. 2021; 268: 4587-4593
        • Carp R.I.
        • Davidson A.L.
        • Merz P.A.
        A method for obtaining cerebrospinal fluid from mice.
        Res. Vet. Sci. 1971; 12: 499
        • Cohen J.A.
        • Coles A.J.
        • Arnold D.L.
        • et al.
        Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised controlled phase 3 trial.
        Lancet. 2012; 380: 1819-1828
        • Coles A.J.
        • Twyman C.L.
        • Arnold D.L.
        • et al.
        Alemtuzumab for patients with relapsing multiple sclerosis after disease-modifying therapy: a randomised controlled phase 3 trial.
        Lancet. 2012; 380: 1829-1839
        • Coles A.J.
        • Jones J.L.
        • Vermersch P.
        • et al.
        Autoimmunity and long-term safety and efficacy of alemtuzumab for multiple sclerosis: benefit/risk following review of trial and post-marketing data.
        Mult Scler Houndmills Basingstoke Engl. 2022; 28: 842-846
        • Cooles F.A.H.
        • Anderson A.E.
        • Drayton T.
        • et al.
        Immune reconstitution 20 years after treatment with alemtuzumab in a rheumatoid arthritis cohort: implications for lymphocyte depleting therapies.
        Arthritis Res Ther. 2016; 18: 302
        • Ellwardt E.
        • Vogelaar C.F.
        • Maldet C.
        • Schmaul S.
        • Bittner S.
        • Luchtman D.
        Targeting CD52 does not affect murine neuron and microglia function.
        Eur. J. Pharmacol. 2020; 871172923
        • Esaulova E.
        • Cantoni C.
        • Shchukina I.
        • et al.
        Single-cell RNA-seq analysis of human CSF microglia and myeloid cells in neuroinflammation.
        Neurol - Neuroimmunol Neuroinflammation. 2020; 7e732
        • Fleming J.O.
        • Ting J.Y.P.
        • Stohlman S.A.
        • Weiner L.P.
        Improvements in obtaining and characterizing mouse cerebrospinal fluid☆application to mouse hepatitis virus-induced encephalomyelitis.
        J. Neuroimmunol. 1983; 4: 129-140
        • Frederiks J.A.M.
        • Koehler P.J.
        The first lumbar puncture*.
        J. Hist. Neurosci. 1997; 6: 147-153
        • Friedman D.I.
        • Liu G.T.
        • Digre K.B.
        Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children.
        Neurology. 2013; 81: 1159-1165
        • Gross C.C.
        • Ahmetspahic D.
        • Ruck T.
        • et al.
        Alemtuzumab treatment alters circulating innate immune cells in multiple sclerosis.
        Neurol - Neuroimmunol Neuroinflammation. 2016; 3e289
        • Han S.
        • Lin Y.C.
        • Wu T.
        • et al.
        Comprehensive Immunophenotyping of cerebrospinal fluid cells in patients with Neuroimmunological diseases.
        J. Immunol. 2014; 192: 2551-2563
        • Heming M.
        • Li X.
        • Räuber S.
        • et al.
        Neurological manifestations of COVID-19 feature T cell exhaustion and dedifferentiated monocytes in cerebrospinal fluid.
        Immunity. 2021; 54: 164-175.e6
        • Heming M.
        • Börsch A.L.
        • Wiendl H.
        • Meyer Zu Hörste G.
        High-dimensional investigation of the cerebrospinal fluid to explore and monitor CNS immune responses.
        Genome Med. 2022; 14(1):94
        • Hu Y.
        • Turner M.J.
        • Shields J.
        • et al.
        Investigation of the mechanism of action of alemtuzumab in a human CD52 transgenic mouse model.
        Immunology. 2009; 128: 260-270
        • Jelcic I.
        • Al Nimer F.
        • Wang J.
        • et al.
        Memory B cells activate brain-homing, autoreactive CD4+ T cells in multiple sclerosis.
        Cell. 2018; 175: 85-100.e23
        • Jin Z.
        • Fan W.
        • Jensen M.A.
        • et al.
        Single-cell gene expression patterns in lupus monocytes independently indicate disease activity, interferon and therapy.
        Lupus Sci Med. 2017; 4e000202
        • Jones D.E.
        • Goldman M.D.
        Alemtuzumab for the treatment of relapsing-remitting multiple sclerosis: a review of its clinical pharmacology, efficacy and safety.
        Expert. Rev. Clin. Immunol. 2014; 10: 1281-1291
        • Jordão M.J.C.
        • Sankowski R.
        • Brendecke S.M.
        • et al.
        Single-cell profiling identifies myeloid cell subsets with distinct fates during neuroinflammation.
        Science. 2019; 363: eaat7554
        • Kivisäkk P.
        • Mahad D.J.
        • Callahan M.K.
        • et al.
        Expression of CCR7 in multiple sclerosis: implications for CNS immunity: CCR7 and CNS immunity.
        Ann. Neurol. 2004; 55: 627-638
        • Korsunsky I.
        • Millard N.
        • Fan J.
        • et al.
        Fast, sensitive and accurate integration of single-cell data with harmony.
        Nat. Methods. 2019; 16: 1289-1296
        • Kunkl M.
        • Frascolla S.
        • Amormino C.
        • Volpe E.
        • Tuosto L.
        T helper cells: the modulators of inflammation in multiple sclerosis.
        Cells. 2020; 9: 482
        • Ostkamp P.
        • Deffner M.
        • Schulte-Mecklenbeck A.
        • et al.
        A single-cell analysis framework allows for characterization of CSF leukocytes and their tissue of origin in multiple sclerosis.
        Sci. Transl. Med. 2022; 14: eadc9778
        • Patil V.S.
        • Madrigal A.
        • Schmiedel B.J.
        • et al.
        Precursors of human CD4 + cytotoxic T lymphocytes identified by single-cell transcriptome analysis.
        Sci Immunol. 2018; 3: eaan8664
        • Ransohoff R.M.
        • Engelhardt B.
        The anatomical and cellular basis of immune surveillance in the central nervous system.
        Nat Rev Immunol. 2012; 12: 623-635
        • Ruck T.
        • Bittner S.
        • Wiendl H.
        • Meuth S.
        Alemtuzumab in multiple sclerosis: mechanism of action and beyond.
        Int. J. Mol. Sci. 2015; 16: 16414-16439
        • Ruck T.
        • Barman S.
        • Schulte-Mecklenbeck A.
        • et al.
        Alemtuzumab-induced immune phenotype and repertoire changes: implications for secondary autoimmunity.
        Brain. 2022; 145: 1711-1725
        • Schafflick D.
        • Xu C.A.
        • Hartlehnert M.
        • et al.
        Integrated single cell analysis of blood and cerebrospinal fluid leukocytes in multiple sclerosis.
        Nat. Commun. 2020; 11: 247
        • Skinnider M.A.
        • Squair J.W.
        • Kathe C.
        • et al.
        Cell type prioritization in single-cell data.
        Nat. Biotechnol. 2021; 39: 30-34
        • Stuart T.
        • Butler A.
        • Hoffman P.
        • et al.
        Comprehensive integration of single-cell data.
        Cell. 2019; 177: 1888-1902.e21
        • Thompson A.J.
        • Baranzini S.E.
        • Geurts J.
        • Hemmer B.
        • Ciccarelli O.
        Multiple sclerosis.
        Lancet Lond Engl. 2018; 391: 1622-1636
        • Tuohy O.
        • Costelloe L.
        • Hill-Cawthorne G.
        • et al.
        Alemtuzumab treatment of multiple sclerosis: long-term safety and efficacy.
        J. Neurol. Neurosurg. Psychiatry. 2015; 86: 208-215
        • van Langelaar J.
        • Rijvers L.
        • Smolders J.
        • van Luijn M.M.
        B and T cells driving multiple sclerosis: identity, mechanisms and potential triggers.
        Front Immunol. 2020; 11: 760
        • Wolf M.J.
        • Seleznik G.M.
        • Zeller N.
        • Heikenwalder M.
        The unexpected role of lymphotoxin β receptor signaling in carcinogenesis: from lymphoid tissue formation to liver and prostate cancer development.
        Oncogene. 2010; 29: 5006-5018