HTLV-1 was the first defined human pathogenic retrovirus. Seroepidemiologic and molecular genetic data firmly establish an association between HTLV-1 infection and a chronic, slowly progressive neurologic condition previously termed tropical spastic paraparesis (TSP) that often emanated from clusters in tropical areas, including the Caribbean Basin, India, and Africa. A similar condition described in Japan is referred to as HTLV-1-associated myelopathy (HAM). It is now recognized that HAM and TSP (HAM/TSP) are identical clinical conditions. The clinical course in HAM/TSP is predominantly that of a slowly progressive spastic paraparesis associated with bladder and bowel dysfunction. Importantly, this disease shares many clinical similarities with the primary progressive form of multiple sclerosis (MS). Indeed, many HAM/TSP patients have been diagnosed as MS up until the time that HTLV-I has been dected in sera or cerebrospinal fluid (CSF). The histopathological changes in HAM/TSP, again similar to MS, include a considerable mononuclear cell inflammation with lymphocytic perivascular cuffing, capillary proliferation, demyelination, and a reactive astrocytosis. Demyelination and axonal damage affects the spinal cord most severely, predominantly in the lateral columns. However, the entire neuroaxis may be involved including optic nerves, cerebrum, cerebellum, brainstem and peripheral nerves. Regulation of HTLV-1 production is mediated by non-structural gene products, particularly through the transcriptional activator known as HTLV-1 Tax. This transactivating protein induces the expression of host cellular genes, especially those that play crucial roles in cell proliferation and differentiation, such as interleukin-2 and its receptor. This in turn likely contributes to a state of ongoing lymphocyte activation seen in this disease. HTLV-1 has minimal direct cytopathic effect and the observed tissue destruction in HAM/TSP is thought to be a consequence of immune mediated pathological events. In addition, clinically manifest disease attributable to HTLV-1 such as HAM/TSP is seen in only a small percentage of infected individuals. This suggests the contribution of several susceptibility factors including genetic and immunological makeup of infected individuals in addition to viral characteristics. Antibodies to HTLV-1 can be detected in sera and CSF of infected patients by using enzyme linked immunosorbent assays (ELISA). Radioimmunoprecipitation assay (RIPA) or Western Blotting techniques are used to confirm positive HTLV-1 results. The World Health Organization accepts for diagnosis a positive HTLV-1 ELISA followed by a Western Blot with antibody banding with p19 or p24 encoded protein in combination with banding for rgp21 or rgp46env protein. Individuals with a positive HTLV-I ELISA but a Western Blot that only partially fulfills the above criteria are considered to be sero-indeterminate. Whether this incomplete banding pattern in sero-indeterminate individuals is due to defective retrovirus or due to low virus load has been a subject of our investigation. We are investigating novel techniques for the detection of antibodies to different HTLV-I proteins in patients infected with HTLV-I and seroindeterminates. We have demonstrated HTLV-I specific antibody banding patterns that can differentiate between HTLV-I infected individuals with and without neurological disease. A major emphasis within the Viral Immunology Section is to examine clinical, virological and immunological parameters in individuals with HAM/TSP, asymptomatic sero-positive individuals, family members at risk for acquiring HTLV-1, and individuals with HTLV-1 indeterminate serology. Specific focus is on the effect of viral load, presumed route of infection and genetic makeup on immunological function. Whole blood, lymphocytes, and plasma/serum obtained from individuals with HAM/TSP, asymptomatic sero-positive individuals, sero-indeterminate individuals, as well as, healthy controls. We will assess virological and immunological parameters using these samples. In HTLV-1 seropositive individuals these studies will be extended to cerebrospinal fluid. Basic laboratory investigations have demonstrated the importance of the cytokine IL-15 in the life and death of lymphocytes and for its role in autoimmune disorders such as HAM/TSP. IL-15 is pivotally involved in the survival of CD8+ memory T-cells including self-directed cells and we have shown that in HAM/TSP, IL-15 is essential for the survival of HLA class I restricted virus antigen-specific effector and memory CD8+ T-cells. These CD8+ antigen-specific CTL are thought to play a major role in the immunopathogenesis of HAM/TSP since they have been localized in brain and spinal cord sections of patients. As IL-15 is a pro-inflammatory cytokine that stimulates the production of TNFα, IL-1β and other inflammatory cytokines, the release of IL-15 induced by HTLV-I tax in patients with HAM/TSP may underlie the pathogenesis of this autoimmune disease. Collaborative research by the Viral Immunology Section, NINDS and the Metabolism Branch, NCI have initiated a phase I clinical trial for the treatment of HAM/TSP using Hu MiK-beta-1 that blocks the action of IL-15. We have assessed the effects of intravenously administered Hu-MiK-beta-1 on the cellular immune response in patients with HAM/TSP, with particular focus on virus-specific memory CD8+ T cells. Secondary outcomes to be measured are clinical responses, including toxicity, and the effect on CD4+CD25+ T regulatory cells. As IL-15 over expression has been demonstrated in patients in a wide variety of autoimmune disorders including, rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis and psoriasis, the successful application of Hu MiK-beta-1 in HAM/TSP has significant and broad therapeutic implications. There is evidence that active HTLV-1 replication, through the retroviral life cycle with new virus integration, is occurring in vivo and contributes to the total HTLV-1 proviral load (PVL) in infected subjects. Recently it was shown that Raltegravir could inhibit cell-free and cell-to-cell transmission of HTLV-1 in vitro. Given the substantial clinical experience with its use in HIV-1 infection and particularly its excellent safety profile, we have initiated a phase I/II clinical trial to determine the effects of Raltegravir in vivo on HTLV-1 PVL and immune activation markers in patients with HAM/TSP. The primary outcome measure is HTLV-1 proviral load, which will be measured by quantitative PCR. Secondary outcome measures include safety and tolerability of Raltegravir, which will be assessed by clinical exam and standardized neurological disability scales as well as clinical laboratory studies. In addition, viral and immunologic outcome measures investigating the impact of Raltegravir on HTLV-1 biology and its effects on immune function will be measured including HTLV-1 proviral load in different lymphocyte populations, the number of long terminal repeat (LTR) circles and HTLV-1 mRNA expression levels in freshly isolated PBMC, assays of spontaneous lymphoproliferation and T-cell phenotype analysis.
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