Folate receptor autoantibodies and autism... replicated

I should warn you that this is another of my long posts, so make yourself a cup of tea/coffee/other, get comfy and read on...

"Overall, 76% of the affected children, 75% of the unaffected siblings, 69% of fathers and 59% of mothers were positive for either blocking or binding Ab, whereas the prevalence of this Ab in the normal controls was 29%."

'Normal controls' is not a term that I would use in the context of autism research, but the findings reported by Edward Quadros and colleagues [1] are a cause for some excitement as the topic of folate receptor alpha (FRα) autoantibodies (Abs) and autism receives some welcome interest and importantly, scientific replication (see here).

Just in case you're new to the concept of folate receptor autoantibodies, it all starts with folate (folic acid). Folates are a pretty important range of nutrient for lots of different reasons, not least the role they play in various brain functions. There are however, a variety of conditions where folate and its various metabolites are 'atypical', one of which is called cerebral folate deficiency (CFD). CFD is characterised by low levels of 5-methyltetrahydrofolate (5-MTHF) in cerebrospinal fluid (CSF) despite fairly typical levels of circulating folates in blood. One of the ways that 5-MTHF gets to the brain is via something called the folate receptor protein alpha. It is this pathway that appears to be 'aberrant' in cases of CFD, and hence use of a compound called folinic acid (leucovorin) (also called 5-formyltetrahydrofolic acid), another 'type' of folate', is used as a result of it utilising an alternative system for getting to the brain (the reduced folate carrier, RFC).

Still here? Good. The hows-and-whys of the folate receptor protein alpha being 'dysfunctional' in relation to CFD has focused on particular autoantibodies (where the immune system starts to mount a response against 'self' tissues) called folate receptor autoantibodies. There are two types of autoantibody: blocking and binding antibodies [2]. These autoantibodies block the transport of folate metabolites to places like the CFS and brain. Finally, there are ways and means that these autoantibodies can be detected in serum samples and, outside of CFD, autism has been a focus for such analyses [3] alongside other, potentially related, diagnoses (see here).

Clear as mud right?

So: "families of 82 children with ASD [autism spectrum disorder], 53 unaffected siblings, 65 fathers, and 70 mothers, along with 52 unrelated... controls" were tested for folate receptor alpha (FRα) autoantibodies in the current Quadros study. I should also mention that Quadros is a name that comes up quite a bit with folate receptor alpha (FRα) autoantibodies in mind. As per the opening line of this post, those autoantibodies were detected in a fairly high frequency in families where autism has been diagnosed. The authors note that the presence of such antibodies "may have a familial origin but the risk of developing ASD is likely influenced by other mitigating factors since some siblings who had the antibodies were not affected." True, absolutely true bearing in mind other work on things like the broader autism phenotype for example (see here).

But there's another strand to this work worthwhile talking about... milk. Milk and autism has been something of real interest to my autism research career down the years (see here) and continues to be. Use of a milk-free - casein-free - diet has filled quite a few peer-reviewed science column inches in relation to both behaviour (see here for example) and physiology (see here) for some on the autism spectrum. In relation to those folate receptor alpha (FRα) autoantibodies, consumption of milk seems to have some rather interesting effects on their presence [4]. The suggestion is that there may be some kind of 'cross-reactivity' going on given the 'homology' between human folate receptor alpha (FRα) and bovine (from cows) folate receptor alpha (FRα). This biological mix-up means that "repeated exposure to milk FR in the digestive tract is the likely mechanism for autoantibody generation" [5]. I'm left wondering a few things: (a) did Quadros and colleagues ask about milk consumption and/or was it recorded? and (b) regarding the 'heritability' issue, could this be part of a wider 'autoantibody heritability' issue among families where autism is present? Y'know, based on the idea that autoantibodies and autoimmunity seems to be a recurring theme for at least some people diagnosed with autism (see here) and in their families (see here)?

And finally, a few research direction suggestions to perhaps take this area forward: (a) wide-scale screening for those for those folate receptor autoantibodies when autism is diagnosed to see if the pretty high 'positives' numbers continue, (b) the requirement for a large (LARGE) study looking at both supplementation with folinic acid and use of a milk-free diet to ascertain exactly what symptoms/traits can potentially be impacted, and finally (c) the inclusion of other parameters when looking at the familial element to folate receptor autoantibodies, such as everyone's favourite 'leaky gut' (also reported in other family members [6]) as a 'vehicle' for possible antibody production. Speculative, yes. Testable, also yes.

Oh, and perhaps a little more inquiry into the thyroid connection (see here) too (with links to yet another autoimmune condition mentioned with autism in mind)...

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[1] Quadros EV. et al. Folate receptor autoantibodies are prevalent in children diagnosed with autism spectrum disorder, their normal siblings and parents. Autism Res. 2018 Feb 2.

[2] Frye RE. et al. Blocking and Binding Folate Receptor Alpha Autoantibodies Identify Novel Autism Spectrum Disorder Subgroups. Frontiers in Neuroscience. 2016;10:80.

[3] Ramaekers V. et al. Clinical recognition and aspects of the cerebral folate deficiency syndromes. Clin Chem Lab Med. 2013 Mar 1;51(3):497-511.

[4] Berrocal-Zaragoza MI. et al. High milk consumers have an increased risk of folate receptor blocking autoantibody production but this does not affect folate status in Spanish men and women. J Nutr. 2009 May;139(5):1037-41.

[5] Ramaekers VT. et al. A milk-free diet downregulates folate receptor autoimmunity in cerebral folate deficiency syndrome. Developmental medicine and child neurology. 2008;50(5):346-352.

[6] de Magistris L. et al. Alterations of the intestinal barrier in patients with autism spectrum disorders and in their first-degree relatives. J Pediatr Gastroenterol Nutr. 2010 Oct;51(4):418-24.

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"Autoimmune epilepsy is an underrecognized condition..."

"Among adult patients with epilepsy of unknown etiology, a significant minority had detectable serum Abs [autoantibodies] suggesting an autoimmune etiology."

So said the findings reported by Divyanshu Dubey and colleagues [1] continuing a research theme previously discussed on this blog (see here) on how epilepsy / seizure-type disorder(s) for some might have more to do with immune function than many people might think.

OK, a brief bit of background: epilepsy is a blanket term covering a wide variety of different presentations that affect the brain and specifically, 'the electrics' of the brain. Seizures are the most common symptom. Treatment typically comes in the form of anti-epileptic medicines (although other options are being considered for some). It's been known for a while that outside of the 'brain' focus of epilepsy, other biological systems might also play a role in the development/maintenance of the condition(s); specifically the immune system and quite often in cases where traditional anti-epileptic medicines don't seem to be able to control seizures effectively. The details are still a little sketchy but studies like the one from Dubey et al are trying to put some scientific flesh on to the bones of what facets of the immune system are potentially involved, specifically under 'autoimmune' conditions where the body fails to recognise 'self' as self and mounts an immune response against the body's own tissue(s).

Dubey and colleagues looked at a group of participants "presenting to neurology services with new-onset epilepsy or established epilepsy of unknown etiology" and tested donated serum samples "for Abs reported to be associated with autoimmune epilepsy (NMDAR-Ab, VGKCc-Ab, leucine-rich glioma-inactivated protein 1 [LGI1] Ab, GAD65-Ab, γ-aminobutyric acid type B receptor [GABAB] Ab, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic receptor [AMPAR] Ab, antineuronal nuclear antibody type 1 [ANNA-1 or anti-Hu] Ab, Purkinje cell cytoplasmic antibody type 2 [PCA-2] Ab, amphiphysin Ab, collapsin-response mediator protein 5 [CRMP-5] Ab, and thyroperoxidase [TPO] Ab)." Quite a lot of those autoantibodies probably sound like gibberish to the lay reader but some of them have been discussed in other contexts on this blog (see here and see here for examples).

Results: some (15) of the 127 participants initially enrolled in the study were "subsequently excluded after identification of an alternative diagnosis." This in itself is interesting, as diagnoses such as "hypoxic or anoxic injury following cardiac arrest" and "ischemic stroke" are mentioned, illustrating how several different roads can lead to epilepsy and/or the presentation of seizures.

Then: "Serum Abs suggesting a potential autoimmune etiology were detected in 39 (34.8%) cases." Over a third of the cohort showed serological evidence of autoantibodies and some presented with more than one type of autoantibody as being present. Breaking down those serologically positive participants, we are told that: "19 patients (48.7%) had new-onset epilepsy and 20 patients (51.3%) had established epilepsy." The authors did also subsequently limit their findings to those cases excluding TPO-Ab and low-titer GAD65-Ab (autoantibodies where a specific role to epilepsy is unclear or not specific) but even then reported that: "23 patients (20.5%) with unexplained epilepsy had positive serologic findings strongly suggestive of an autoimmune cause of epilepsy." There is also a final part to the Dubey paper which also merits mention: "Among the 23 patients who were seropositive, 15 (65.2%) received some sort of immunotherapy. Better seizure outcome was associated with use of immunomodulatory therapy... especially with use of intravenous methylprednisolone... or plasmapheresis."

Alongside other (independent) studies in this area, the peer-reviewed evidence does seem to growing to suggest that within the wide (and heterogeneous) 'spectrum' that is epilepsy, at least some of that epilepsy might have an important immune component to it. To quote again from Dubey: "The data presented here suggest that autoimmune encephalitis may explain at least 20% of adult-onset epilepsies of unknown etiology." Aside from the importance of screening for said autoantibodies when certain cases of epilepsy appear at clinic, there are a few other potentially important points that could be raised about such data. Autism is area that I would be interested to see some further investigations carried out on with the Dubey findings in mind. Epilepsy is an important comorbidity 'over-represented' when it comes to autism (see here) and given the suggestions down the years that immune function (specifically autoimmunity) might be a facet of 'some' autism (see here for example) it's not beyond the realms of possibility that comorbid epilepsy might be a further facet of any autoimmune processes. Birds of an autoimmune feather tend to stick together and all that (see here). Add in the findings specifically talking about 'anti-NMDA-receptor encephalitis "mimicking an autistic regression"' (see here) and how methlyprednisolone might not be an uncommon medicine for some types of (autoimmune-related autistic presentation) and the hypotheses to be tested are laid out in front of you. By saying that, I don't want to take anything away from the more typical forms of epilepsy that can present (either alone or alongside autism) but rather point to the expanding knowledge base suggesting that immune functions may extend much further than just protecting the host from infection et al...

To close, slightly related to some of the content included in this post, the trailer for the film Brain on Fire (from the book of the same name) is out and looking like required viewing.

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[1] Dubey D. et al. Neurological Autoantibody Prevalence in Epilepsy of Unknown Etiology. JAMA Neurol. 2017 Feb 6.

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Dubey D, Alqallaf A, Hays R, Freeman M, Chen K, Ding K, Agostini M, & Vernino S (2017). Neurological Autoantibody Prevalence in Epilepsy of Unknown Etiology. JAMA neurology PMID: 28166327

Expanding MAR autism

MAR autism - maternal autoantibody-related autism - is a term that has graced this blog before (see here). Describing a state where autoantibodies directed against foetal brain proteins have been detected in some mothers who have children diagnosed with an autism spectrum disorder (ASD), the suggestion is that such evidence further substantiates a role for various maternal immune functions and processes when it comes to offspring risk of at least some types of autism.

Although interesting, the research road travelled by MAR autism has not been a smooth one (see here). Indeed one of the outstanding questions has been whether the detection of such autoantibodies is more or less likely when various other conditions affecting the mother might be present (see here) and perhaps synergistically elevating the risk of offspring autism. The paper by Paula Krakowiak and colleagues [1] further explored this question and concluded that: "mothers whose children had severe ASD and who experienced diabetes were more likely to have anti-fetal brain autoantibodies 2–5 years later."

Some media about the Krakowiak study can be seen here. Based on participants - "227 mothers of 2–5 year old children with confirmed ASD" - all enrolled in CHARGE (be in CHARGE!) researchers set about looking at whether "ASD-specific maternal autoantibodies identified postnatally were associated with metabolic conditions (MCs) during gestation." Said metabolic conditions (MCs) included "diabetes, hypertensive disorders, and prepregnancy obesity or overweight, ascertained from medical records or structured telephone interviews." Indeed Paula Krakowiak has some research history with MCs in mind (see here) that has subsequently been replicated in other cohorts (see here).

Results: well, aside from a quarter of mothers presenting with those autoantibodies (based on the analysis of archived blood samples) authors reported that: "Ab+ [anti-fetal brain autoantibodies positive] prevalence was higher among mothers with diabetes, hypertensive disorders, or overweight compared to healthy mothers, but differences were not statistically significant." What this means is that overall there was a trend towards elevated risk of Ab+ in  those mothers with various metabolic conditions but this might have just been a chance finding. Unfortunately some of the media reports on this specific point are found wanting...

When it came however to looking at those mothers who had children who "exhibited severe ASD" they suggested that those diagnosed with type-2 diabetes or gestational diabetes "were 2.7-fold more likely to be Ab+." Further: "Gestational diabetes specifically was associated with a 3.2-fold increased Ab+ prevalence."

As per some of the media interest in these results there are a few [cautious] 'take-away messages' from the findings. The idea for example, that the presence of certain metabolic conditions "may alter the maternal immune tolerance to the fetus during pregnancy" is an important one in the context of words like 'inflammation' being potentially involved (see here for another example of this). I would however like to see a little more science done on the specific biology of how obesity might bring about autoantibodies with autism specifically in mind based on other findings [2].

That preferential screening of the offspring of those mothers diagnosed with a metabolic condition either before or during pregnancy might be offered is another message bearing in mind how stretched screening and diagnostic services seem to be in many parts of the world. The idea also that where and when 'severe ASD' is reported, further research investigations might focus in further on this topic and how findings might manifest in the children with ASD themselves is also deserving of attention.

Oh, and then there is the further evidence afforded to the term 'the autisms' by the Krakowiak results...

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[1] Krakowiak P. et al. Autism-specific maternal anti-fetal brain autoantibodies are associated with metabolic conditions. Autism Research. 2016. June 17.

[2] Arai S. et al. Obesity-associated autoantibody production requires AIM to retain the immunoglobulin M immune complex on follicular dendritic cells. Cell Rep. 2013 Apr 25;3(4):1187-98.

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Krakowiak P, Walker CK, Tancredi D, Hertz-Picciotto I, & Van de Water J (2016). Autism-specific maternal anti-fetal brain autoantibodies are associated with metabolic conditions. Autism research : official journal of the International Society for Autism Research PMID: 27312731

Autoantibodies not implicated in cases of autism?

Contrary results are a common feature of the autism peer-reviewed research landscape. No sooner does one group publish the next 'big thing' when it comes to the singular term 'autism' than seemingly opposite results follow suit.

So it is with the paper under discussion today by Simran Kalra and colleagues [1] (open-access) who concluded that: "The idea that autoantibodies represent an underlying cause or are biomarkers for autism pathophysiology is not supported by this report."

Autoantibodies by the way, are part of the process whereby the body's immune system fails to recognise self as 'self' and mounts a response against the body's own tissue. It's a topic that has been discussed quite extensively with the autism spectrum in mind (see here for example) as part of a wider scientific debate about a role for immune function in at least some autism (see here).

The Kalra paper is open-access but a few details might be useful:

• "Serological analysis was performed on typically developing children (n = 55), developmentally delayed children without autism (n = 24) and children diagnosed with autism (n = 104)." I believe this cohort of children were part of a larger study titled: 'Clinical and Immunological Investigations of Subtypes of Autism'.
• Based on an interesting analytical method - Luciferase Immunoprecipitation Systems (LIPS) - used as an alternative to the more traditional ELISA methods, researchers initially set about looking for the presence of "autoantibodies against GAD65." GAD65 by the way, is part and parcel of the mechanism for synthesising GABA (see a previous post on this topic). They then extended the study focus to look for antibodies "against several other autoimmune-associated autoantigens, candidate neurological autoantigens, and viral proteins."
• Results: well, when comparing study samples against samples from three people with diagnosed type 1 diabetes where GAD65 autoantibodies were to be expected to be present (and indeed were): "testing of serum from the typically developed children..., developmentally delayed children... and children with ASD... demonstrated no seropositive autoantibodies to GAD65." 
• Likewise when comparing autism samples with samples from "three positive control samples from subjects with systemic lupus erythematosus" for Ro52 - one of the anti-Ro antibodies found in cases of SLE - there was again nothing of note to see. Collectively the authors conclude that: "These findings rule out the possibility that GAD65 and Ro52 autoantibodies are biomarkers in ASD [autism spectrum disorder]."
• Among the other results reported is an interesting remark when it comes to a retrovirus called XMRV. For those in chronic fatigue syndrome / myalgic encephalomyelitis circles, XMRV will probably be remembered for all the wrong reasons (see here) albeit with not all questions completely answered (see here). Kalra et al found nothing in terms of seropositivity when it came to autism and XMRV (and another target, mouse mammary tumor virus (MMTV)). They do however caution that "additional studies are needed to determine if other infectious agents, or the body's response to such infections agents, might play a role" in some autism.

These results are interesting. As per my opening comment on contrary results being part and parcel of autism research, the lack of GAD65 antibodies detailed is in direct contrast to previous findings such as those produced by Rout and colleagues [2] for example. Whilst there may be various reasons for the difference in findings including a role for the analytical method used, I was drawn to one comment made by Rout et al suggesting that there may be a subgroup of children with autism and/or ADHD (attention-deficit hyperactivity disorder) where further characterisation may be needed. That also reduced levels of GAD65 mRNA levels have been reported [3] in relation to autism (with appropriate caveats regarding tissue used for study) does not mean that GAD65 is off the research menu just yet.

The lack of XMRV antibody findings reported by Kalra et al in relation to their autism group is not necessarily new news. Previous studies such as the one from Satterfield and colleagues [4] basically said as much.

There are of course quite a few other types of autoantibodies and/or antibodies to infective agents that perhaps require more study using the technique utilised by Kalra and colleagues with autism in mind. The various contributions in this research area from the Saudi-Egyptian research tag-team that crop up on this blog every now and again (see here and see here) might be a next port of call. Anti-brain antibodies detailed by other teams might also receive the same treatment (see here). Who knows, researchers might also consider putting a little more flesh on the bones of all that folate receptor autoantibody research that is crying out for independent replication (see here) or even antimitochondrial antibodies (see here). Quite a few areas to consider.

As for the infection side of things and realising the important contribution that at least one of the authors on the Kalra paper has made to another area of research (Swedo and PANDAS/PANS) I can think of quite a few research studies to be done. My growing interest in enterovirus and autism (see here) or even enterovirus and ADHD (see here) is again requiring some further investigation. Perhaps a little more 'out there' are the ways and means that the methods detailed by Kalra might also be transferable to more ancient retroviruses such as the HERVs that have been discussed before on this blog (see here) with autism and various other conditions in mind (see here).

Music: John Newman - Come And Get It.

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[1] Kalra S. et al. No evidence of antibodies against GAD65 and other specific antigens in children with autism. BBA Clinical. 2015. August 8.

[2] Rout UK. et al. Presence of GAD65 autoantibodies in the serum of children with autism or ADHD. Eur Child Adolesc Psychiatry. 2012 Mar;21(3):141-7.

[3] Yip J. et al. Decreased GAD65 mRNA levels in select subpopulations of neurons in the cerebellar dentate nuclei in autism: an in situ hybridization study. Autism Res. 2009 Feb;2(1):50-9.

[4] Satterfield BC. et al. PCR and serology find no association between xenotropic murine leukemia virus-related virus (XMRV) and autism. Mol Autism. 2010 Oct 14;1(1):14.

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Kalra, S., Burbelo, P., Bayat, A., Ching, K., Thurm, A., Iadarola, M., & Swedo, S. (2015). No evidence of antibodies against GAD65 and other specific antigens in children with autism BBA Clinical DOI: 10.1016/j.bbacli.2015.08.001

Autoimmune disease or anti-nuclear antibodies and non-coeliac wheat sensitivity

"Higher proportions of patients with NCWS [wheat sensitivity among people without celiac disease] or celiac disease develop autoimmune disorders, are ANA [anti-nuclear antibodies] positive, and showed DQ2/DQ8 haplotypes compared to patients with IBS [irritable bowel syndrome]."

Those were the conclusions reached in the paper by Antonio Carroccio and colleagues [1] who sought to evaluate: "the prevalence of autoimmune diseases among patients with NCWS, and investigated whether they carry anti-nuclear antibodies (ANA)." Continuing a theme that the classic autoimmune condition known as coeliac (celiac) disease (CD) may be only one part of a 'issues with gluten' spectrum, researchers reviewed the files of over 100 participants diagnosed with NCWS (or even NCGS) "to identify those with autoimmune diseases" and compare rates with those diagnosed with CD and/or IBS. Further, serum samples were analysed prospectively for 42 participants diagnosed with NCWS and "ANA levels were measured by immunofluorescence analysis" again, compared with CD / IBS control data. ANA by the way, are antibodies against 'self' tissue and in particular, antibodies against the contents of the cell nucleus.

Results. The rates of autoimmune disease in cases of NCWS were comparable with those reported in CD, hovering around the 20-30% frequency mark in each case. The frequency rates for autoimmune disease in the IBS group were quite a bit lower; between 2-4%.

Testing positive for ANA was however a slightly different ballgame as per the findings that those with NCWS were quite a bit more likely to show ANA than either CD or IBS participants. Depending on which arm of the study was used (retrospective vs. prospective) researchers reported that: "serum samples tested positive for ANA in 46% of subjects with NCWS..., 24% of subjects with celiac disease..., and 2% of subjects IBS... ; in the prospective study, serum samples were positive for ANA in 28% of subjects with NCWS, 7.5% of subjects with celiac disease..., and 6% of subjects with IBS." They also noted a relationship between ANA positivity and the presence of DQ2/DQ8 haplotypes (part of the so-called genetics of CD).

These are interesting results. Not only because of the overlap between autoimmune diseases and CD and NCWS (birds of an autoimmune feather flocking together and all that) but also that a higher burden of anti-nuclear antibody positivity might accompany NCWS in even greater frequency than CD. That Hashimoto's thyroiditis was the most common autoimmune condition identified is also an interesting prospect and ripe for further study in light of some research history in this area [2].

Wearing my autism research hat, I might also forward the idea that the Carroccio data intersects with quite a few potentially important papers published with [some] autism in mind. So, NCGS as a feature of some autism... well, there have been some hints of this in the peer-reviewed research literature as per the 'not quite coeliac disease' paper (see here) and other commentaries (see here). What I will also say is that although there are some gaps in the research in this area including how one clinically defines NCGS, we can perhaps assume that autism is not protective against developing something like NCGS. ANA and autism... I can direct you to the paper by Mostafa and colleagues [3] covered in a previous post (see here) and how: "anti-ds-DNA antibodies and ANA were found in the sera of a subgroup of autistic children." It strikes me that further study of NCGS, autoimmune comorbidty and anti-nuclear antibodies in cases of autism is a way to resolve any correlation or not.

Music: Oasis - Champagne Supernova.

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[1] Carroccio A. et al. High Proportions of People with Non-Celiac Wheat Sensitivity Have Autoimmune Disease or Anti-nuclear Antibodies. Gastroenterology. 2015 May 27. pii: S0016-5085(15)00767-2.

[2] Hakanen M. et al. Clinical and subclinical autoimmune thyroid disease in adult celiac disease. Dig Dis Sci. 2001 Dec;46(12):2631-5.

[3] Mostafa GA. et al. Systemic auto-antibodies in children with autism. J Neuroimmunology. 2014; 272: 94-98.

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Carroccio A, D'Alcamo A, Cavataio F, Soresi M, Seidita A, Sciumè C, Geraci G, Iacono G, & Mansueto P (2015). High Proportions of People with Non-Celiac Wheat Sensitivity Have Autoimmune Disease or Anti-nuclear Antibodies. Gastroenterology PMID: 26026392

Antimitochondrial antibodies and autism?

"The current study demonstrated significantly high levels of AMA-M2 [antimitochondrial antibodies subtype 2] in autistic subjects when compared with healthy controls. Further large-scale studies are required to dissect any pathogenic role of these antibodies in the development of autism."

Accepting that 'healthy controls' is not the terminology that I personally would use to describe 'not-autism' control participants and to 'dissect' findings perhaps conjures up some rather gruesome images probably not intended by researchers, I was rather intrigued by the results reported by Muhammad Iqbal and colleagues [1] including one Laila Al-Ayadhi on the authorship list.

Mitochondria - not to be confused with those 'knowledge of the Force' giving organisms, the midichlorians - are an organelle of some research note when it comes to autism research these days as per quite a few previous entries on this blog (see here and see here for example). The paper by Suzanne Goh et al [2] (see here for my take) talking about a 'neurobiological subtype of autism' characterised by mitochondrial dysfunction kinda says it all when it comes to where further investigations might want to head bearing in mind the 'plurality' of autism - the autisms (see here).

The Iqbal study looked for the presence of antimitochondrial antibodies in autism (n=62) vs control (n=14) samples thus continuing another potentially important theme to 'some' autism: immune system involvement and specifically, the concept of autoimmunity (where the body fails to recognise 'self' tissue as self and mounts an immune response as it would when meeting 'foreign'). Indeed, autoimmunity is something that Dr/Prof. Al-Ayadhi and her various co-authors seemingly have some interest in with autism in mind (see here).

Based on the use of "indirect solid phase enzyme immunoassay" researchers reported that: "Significantly elevated levels of AMA-M2 were observed in the sera of autistic children... compared with healthy controls." AMA-M2, I think, refers to antibodies specifically directed towards pyruvate dehydrogenase complex which opens up some potential involvement for the branched-chain α-ketoacid dehydrogenase complex in cases. More usually [partially] diagnostic for primary biliary cirrhosis (PBC), a long-term autoimmune liver disease, the findings of elevated levels of AMA-M2 in children with autism are a potential worry perhaps requiring further healthcare screening and monitoring. Doubly so in light of other findings [3] reporting "anti-ds-DNA antibodies and ANA [anti-nuclear antibodies]... found in the sera of a subgroup of autistic children."

The ever-increasing volume of peer-reviewed research hinting at immune system 'issues' coincidental to at least some cases of autism [4] really can't be ignored for much longer. As with many such biological correlates linked to a diagnosis of autism, the idea that receipt of said diagnosis should be a starting point for further characterisation of genetic / epigenetic / biological processes potentially pertinent to the presentation of behavioural symptoms continues to gather momentum. This may be particularly important when it comes not just autism or autistic traits but also the presentation other comorbidity in years to come...

Music: Walk the Moon - Shut Up and Dance (all very '80s).

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[1] Iqbal M. et al. Prevalence of antimitochondrial antibodies in autism spectrum subjects. Future Neurology. 2015; 10: 203-209.

[2] Goh S. et al. Mitochondrial dysfunction as a neurobiological subtype of autism spectrum disorder: evidence from brain imaging. JAMA Psychiatry. 2014 Jun;71(6):665-71.

[3] Mostafa GA. et al. Systemic auto-antibodies in children with autism. J Neuroimmunol. 2014 Jul 15;272(1-2):94-8.

[4] Mead J. & Ashwood P. Evidence supporting an altered immune response in ASD. Immunol Lett. 2015 Jan;163(1):49-55.

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Iqbal, M., Bashir, S., & Al-Ayadhi, L. (2015). Prevalence of antimitochondrial antibodies in autism spectrum subjects Future Neurology, 10 (3), 203-209 DOI: 10.2217/fnl.15.11

Maternal thyroid autoantibody and offspring autism risk

I have, on this blog, previously mentioned the paper by Alan Brown and colleagues [1] suggesting that: "The prevalence of maternal TPO-Ab+ [thyroid peroxidase antibody] was significantly increased in pregnancies giving rise to autism cases (6.15%) compared to controls (3.54%)." It was during some discussion on the suggested diagnosis of Down syndrome disintegrative disorder (see here) and the idea that some signs and symptoms of regressive autism (?) might overlap with TPO antibodies in some cases of Down syndrome.

You've got a playdate with destiny!

I've had a few weeks to further reflect on the Brown paper and decided that their suggestion of: "the first biomarker-based evidence that a class of known maternal autoimmune disorders is related to autism in offspring" is worthy of a post all of its own.

A quick recap first: thyroid peroxidase antibodies translates as the body mounting an immune response against thyroid peroxidase, an important enzyme in the production of the thyroid hormones. As per another mention of TPO based on research suggestive of a tentative link between anti-TPO antibodies and [some] depressive disorder (see here), the more usual clinical occasion regarding detection of such antibodies is in relation to something like Hashimoto's thyroiditis, an autoimmune condition.

Brown and colleagues drew upon collected data from the Finnish Prenatal Study of Autism (FiPS-A) [2], an initiative which had at its disposal "archived maternal serum specimens from virtually the entire pregnant population of Finland beginning in 1983". Alongside quite a bit of other registry based information on things like an ICD-10 diagnosis of autism in offspring, Brown et al set to work analysing those archived serum specimens for some "967 matched case-control pairs" (autism cases matched 1:1 with sex and date of birth linked asymptomatic controls) for the presence of thyroid peroxidase antibody (TPO-Ab).

As per the previous sentence, serum samples from mums who went on to have a child with autism were significantly more likely to present with TPO-Ab; indeed: "The odds of autism were increased by nearly 80% among offspring of mothers who were TPO-Ab+ during pregnancy" compared with those antibody negative. Perhaps just as important, authors also reported that: "Measures of maternal thyroid hormones did not differ between groups" suggesting that the actual antibodies might be the more important factor over and above a thyroid hormone link (see here for discussion on other work in this area).

For those who follow this blog, the idea that [some] autism and [some] autoimmunity / autoimmune conditions might show [some] linkage is not a new one. If one delves deeper into the peer-reviewed research arena one finds other hints that other maternal antibodies might also show a connection to offspring autism risk as per the idea of MAR autism (see here), that is, maternal autoantibody-related autism. Granted, the research road has not run entirely smoothly when it comes to any possible connection (see here) and there are still questions to be answered, not least when it comes to the effects of comorbidity common to autism and how they may likewise have an autoimmune connection too (see here for example). The Brown results however cannot be readily brushed under the scientific carpet given their origin and pretty powerful participant numbers used in the current study alongside some prior research 'form in the inflammatory area (see here). I for one, am keenly awaiting further investigations perhaps including a study or two on offspring autism risk among mothers with autoimmune thyroiditis [3]...?

To close: California Über Alles. Let moshing commence...

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[1] Brown AS. et al. Maternal thyroid autoantibody and elevated risk of autism in a national birth cohort. Prog Neuropsychopharmacol Biol Psychiatry. 2015 Mar 3;57:86-92.

[2] Lampi KM. et al. Finnish Prenatal Study of Autism and Autism Spectrum Disorders (FIPS-A): overview and design. J Autism Dev Disord. 2011 Aug;41(8):1090-6.

[3] Molloy CA. et al. Familial autoimmune thyroid disease as a risk factor for regression in children with Autism Spectrum Disorder: a CPEA Study. J Autism Dev Disord. 2006 Apr;36(3):317-24.

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Brown, A., Surcel, H., Hinkka-Yli-Salomäki, S., Cheslack-Postava, K., Bao, Y., & Sourander, A. (2015). Maternal thyroid autoantibody and elevated risk of autism in a national birth cohort Progress in Neuro-Psychopharmacology and Biological Psychiatry, 57, 86-92 DOI: 10.1016/j.pnpbp.2014.10.010

Folate receptor autoantibodies and (some) schizophrenia

I am the league's director, Silas Ramsbottom.

Upon reading the paper published by Ramaekers and colleagues [1] talking about the use of folinic acid in cases of schizophrenia as a function of the presence of "Auto-antibodies against folate receptor alpha (FRα)", I raised a little smile. Not only because the authors suggested that there may be quite a lot more to see in this area on top of some already interesting discussions about the folate cycle and schizophrenia, but also because of the 'overlap' with some autism findings which have been previously discussed on this blog (see here). Indeed, if readers would like quite a nice summary of this area of investigation - folate receptor autoantibodies - I'm minded to direct them to the paper by Richard Frye and colleagues [2] (open-access) which initially presented the idea of cerebral folate receptor autoantibodies occurring in autism to the world and was the source material for that previous blog post.

Quoting from the Ramaekers study text: "Fifteen of 18 patients (83.3%) had positive serum FR auto-antibodies compared to only 1 in 30 controls". This was a study of those described as having "schizophrenia unresponsive to conventional treatment" and alongside the presence of those autoantibodies, researchers also assessed what some of the metabolic knock-on effects might have been in terms of analysis of spinal fluid levels of "MTHF [5,10-Methylenetetrahydrofolate] and the metabolites of pterins, dopamine and serotonin". It appears that FR autoantibodies may indeed affect levels of said compounds alongside "intermediates linked to metabolic processes affecting homocysteine levels... [and] synthesis of tetrahydrobiopterin". Homocysteine and tetrahydrobiopterin (BH4) in schizophrenia y'say?

"Administration of folinic acid (0.3-1mg/kg/day) to 7 participating patients during at least six months resulted in clinical improvement." Without wishing to provide any medical or clinical advice on the utility of folinic acid for schizophrenia or anything else, these are interesting findings. This is not the first time that folinic acid has been discussed in the research literature with schizophrenia in mind as per the case report by Wang and colleagues [3]. In that single case, authors described the presence of the MTHFR mutation - "665C>T homozygous mutations in the MTHFR gene" - as the reason for secondary cerebral folate deficiency. Other authors have discussed more pertinent cases [4]. Obviously one would like to see more formal clinical trials on the use of folinic acid as potentially being appropriate for at least some of the [plural] schizophrenias. The important thing to take from the Ramaekers and other studies is that a panel of tests might be able to spot who might be best responders to this kind of intervention...

Music to close, and Peter Griffin sings the opening tune to Indiana Jones and The Last Crusade? Why not.

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[1] Ramaekers VT. et al. Folinic acid treatment for schizophrenia associated with folate receptor autoantibodies. Mol Genet Metab. 2014 Oct 12. pii: S1096-7192(14)00311-4.

[2] Frye RE. et al. Cerebral folate receptor autoantibodies in autism spectrum disorder. Molecular Psychiatry 2013;18(3):369-381. doi:10.1038/mp.2011.175.

[3] Wang Q. et al. Methylenetetrahydrofolate reductase deficiency-induced schizophrenia in a school-age boy. Zhongguo Dang Dai Er Ke Za Zhi. 2014 Jan;16(1):62-6.

[4] Ho A. et al. Cerebral folate deficiency presenting as adolescent catatonic schizophrenia: a case report. J Child Neurol. 2010 Jul;25(7):898-900.

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Ramaekers VT, Thöny B, Sequeira JM, Ansseau M, Philippe P, Boemer F, Bours V, & Quadros EV (2014). Folinic acid treatment for schizophrenia associated with folate receptor autoantibodies. Molecular genetics and metabolism PMID: 25456743

Chronic fatigue syndrome by ASIA?

Unicorns, I love them. Unicorns, I love them. 

ASIA, in the context of this post, does not refer to the continent but rather the suggestion of an: ‘autoimmune (auto-inflammatory) syndrome induced by adjuvants’ and some potentially contentious findings reported by Nancy Agmon-Levin and colleagues [1].

Describing a small cohort of participants diagnosed with chronic fatigue syndrome (CFS) and/or fibromyalgia (FM), the authors put forward the idea that "some cases CFS and FM can be temporally related to immunization, as part of ASIA syndrome", more specifically following hepatitis B vaccination (HBVv). They report on a latency period (the interval between exposure and clinical appearance of symptoms) ranging "from days to a year" with a mean temporal period of around 38 days. They also report specific manifestations of symptoms (neurological, fatigue, muscoskeletal and gastrointestinal) and importantly that: "Autoantibodies were detected in 71 % of patients tested". Autoantibodies by the way, refers to antibodies against self tissue as per what has been noted in various autoimmune conditions/diseases. The authors conclude: "ASIA criteria were fulfilled in all patients eluding the plausible link between ASIA and CFS/FM."

OK. There are a few words of caution that one needs to exercise with this kind of work before anyone gets too enthusiastic. This was an information-gathering study, so authors were specifically describing their cohort of participants "following HBVv immunization". There were no control groups, so one also needs to be aware of that.

A quick trawl of the other research literature on the topic of ASIA reveals however that this is not the first time that this concept has cropped up in the peer-reviewed science sector. Shoenfeld &Agmon-Levin [2] (the same authors on the current paper) first advanced the concept of ASIA or [Yehuda] Shoenfeld's syndrome a few years back. Based on the examination of four conditions: "siliconosis, the Gulf war syndrome (GWS), the macrophagic myofasciitis syndrome (MMF) and post-vaccination phenomena" they concluded that some commonalities were present and ASIA was born. An editorial accompanying their paper [3] kinda said it all: "It is an intriguing issue and one that is likely to be provocative and lead to further biologic and molecular investigations". I might also direct you to other discussions titled: What is ASIA?

Since then, a number of articles have appeared discussing ASIA / Shoenfeld's syndrome. Bassi and colleagues [4] reported findings involving a mouse model of lupus - "a lupus-prone murine model" - injected with complete Freund's adjuvant (CFA) (an immunostimulant). They reported that: "the injection of CFA in NZB/NZWF1 mice accelerated autoimmune manifestations resembling 'ASIA' syndrome in humans." A more thorough review of the animal model findings can be found in the article by Cruz-Tapias and colleagues [5].

The types of adjuvant noted as being potentially connected to ASIA have also been discussed, as per the article by Vera-Lastra and colleagues [6]. Squalene, aluminum hydroxide and silicone are mentioned. Squalene with regards to Gulf-War syndrome was something which particularly stuck out to me given my previous interest in this collection of symptoms present for some post Operation Desert Storm (see here). Although the source of some speculation, papers such as the one from Pamela Asa and colleagues [7] noting that squalene antibodies were linked to the "majority of symptomatic GWS patients" is an interesting finding. For balance, I will also refer you to the paper by Lippi and colleagues [8] standing up for squalene.

The paper from Perricone and colleagues [9] (open-access) brings us back to the involvement of ASIA in the 'mosaic of autoimmunity' and how genetics and environment might merge. The discussions move into various areas including that of anti-phospholipid syndrome (Hughes syndrome) as well as other well-known autoimmune areas (e.g. coeliac disease). Connective tissues disorders also discussed in the Perricone paper also bring in one reason why hepatitis B vaccine was also considered in the starting paper in question, as per the report by Perricone and Shoenfeld [10] and their discussions on hepatitis B vaccine and 'undifferentiated connective tissue disease' as being: "Another brick in the wall of the.. ASIA". Further research has added to such sentiments [11].

As things stand with the body of research detailing ASIA, I don't think that this is a concept we can readily discard as being potentially real and relevant to at least some clinical presentation potentially including CFS/FM. I know to talk adverse effects from vaccination, or their adjuvants, can stir up some heated discussions in some quarters (see here) but even in contentious areas covering something like autism or autistic presentation, science might still have a role to play [12]. I say this reiterating the important value of vaccination as per this CDC infographic.

This is also the second time that I've talked about vaccination and autoimmunity as potentially being linked on this blog as per another contentious paper in another contentious area (see here). It strikes me that there is quite a bit more to do in looking at any possible connection, particularly when one considers that ASIA has been similarly discussed (albeit in case studies) with other biologics in mind [13].

Music: The Ragtime Gals and a certain celebrity..

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[1] Agmon-Levin N. et al. Chronic fatigue syndrome and fibromyalgia following immunization with the hepatitis B vaccine: another angle of the 'autoimmune (auto-inflammatory) syndrome induced by adjuvants' (ASIA). Immunol Res. 2014 Nov 27.

[2] Shoenfeld Y. & Agmon-Levin N. 'ASIA' - autoimmune/inflammatory syndrome induced by adjuvants. J Autoimmun. 2011 Feb;36(1):4-8.

[3] Meroni PL. Autoimmune or auto-inflammatory syndrome induced by adjuvants (ASIA): old truths and a new syndrome? J Autoimmun. 2011 Feb;36(1):1-3.

[4] Bassi N. et al. Induction of the 'ASIA' syndrome in NZB/NZWF1 mice after injection of complete Freund's adjuvant (CFA). Lupus. 2012 Feb;21(2):203-9.

[5] Cruz-Tapias P. et al. Autoimmune (auto-inflammatory) syndrome induced by adjuvants (ASIA)--animal models as a proof of concept. Curr Med Chem. 2013;20(32):4030-6.

[6] Vera-Lastra O. et al. Autoimmune/inflammatory syndrome induced by adjuvants (Shoenfeld's syndrome): clinical and immunological spectrum. Expert Rev Clin Immunol. 2013 Apr;9(4):361-73.

[7] Asa PB. et al. Antibodies to squalene in Gulf War syndrome. Exp Mol Pathol. 2000 Feb;68(1):55-64.

[8] Lippi G. et al. Vaccination, squalene and anti-squalene antibodies: facts or fiction? Eur J Intern Med. 2010 Apr;21(2):70-3.

[9] Perricone C. et al. Novel pebbles in the mosaic of autoimmunity. BMC Med. 2013 Apr 4;11:101.

[10] Perricone C. & Shoenfeld Y. Hepatitis B Vaccination and Undifferentiated Connective Tissue Disease: Another Brick in the Wall of the Autoimmune/Inflammatory Syndrome Induced by Adjuvants (ASIA). JCR: Journal of Clinical Rheumatology. 2013; 19: 231-233.

[11] Zafrir Y. et al. Autoimmunity following hepatitis B vaccine as part of the spectrum of 'Autoimmune (Auto-inflammatory) Syndrome induced by Adjuvants' (ASIA): analysis of 93 cases. Lupus. 2012 Feb;21(2):146-52.

[12] Singh VK. Phenotypic expression of autoimmune autistic disorder (AAD): a major subset of autism. Ann Clin Psychiatry. 2009 Jul-Sep;21(3):148-61.

[13] Barros SM. & Carvalho JF. Shoenfeld's syndrome after pandemic influenza A/H1N1 vaccination. Acta Reumatol Port. 2011 Jan-Mar;36(1):65-8.

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Agmon-Levin N, Zafrir Y, Kivity S, Balofsky A, Amital H, & Shoenfeld Y (2014). Chronic fatigue syndrome and fibromyalgia following immunization with the hepatitis B vaccine: another angle of the 'autoimmune (auto-inflammatory) syndrome induced by adjuvants' (ASIA). Immunologic research PMID: 25427994