A Proposed Mechanism for Autoimmune Mediated Motor Dysfunctions,and a Hypothesis for Therapeutic Intervention in Tourette ...
Page       2                        Outline1. Streptococcus – Association with Movement Disorders/Obsessive   Compulsive D...
Page          3Streptococcus – Association with Movement Disorder/OCD/Attention Deficit DisorderA movement disorder called...
Page         4The existence of a syndrome designated PANDAS (pediatric autoimmuneneuropsychiatric disorder associated with...
Page         5patients with ARF.(47) The injection of cardiac myosin has been shown in studies to becapable of inducing my...
Page          6culture and ASO and Dnase B antibody tests for group A strep were negative, the authorundertook a further i...
Page        7                   The identities of the proteins are listed in Table 1.TABLE 1 (Proteins Bound by Patient An...
Page       8Table 2 represents the proteins from Table 1 which are brain proteins, and are notubiquitous or do not represe...
Page        9TABLE 3 (Proteins containing KLAKE sequence)Number                        Name                           Acce...
Page        10reactivity with brain cross reacting antibodies observed in Sydenham’s chorea. Therelative tissue expression...
Page        11is found primarily in brain and kidney. The expression of nedasin S-form was also foundto increase in parall...
Page       12                                 Figure 2Activation of NMDA receptors by glutamate leads to an entry of Ca+2 ...
Page        13Interestingly, calmodulin was also found to be one of the proteins bound by the patientantibody column (see ...
Page        14Association of NE-dlg/SAP Proteins and Movement Disorders/OCD/ADHD with Areasof the BrainAs shown in Table 4...
Page         15Disorder                Dysfunction/Atypical Imaging Method (if Reference                        Area of th...
Page         16                                    Figure 4               +/-        CORTEX                    +          ...
Page        17HypothesisGroup A streptococcus infections may induce antibodies, in certain susceptibleindividuals, which c...
Page        18although side effects of the drugs limit their use. Dopamine agonists can also precipitateor exacerbate tics...
Page        19Additional evidence points to hypoglutamatergic conditions producing the symptomsobserved in autism. Mohn et...
Page        20atrophy (DRPLA) is another inherited polyglutamine CAG repeat disease which canproduce a similar clinical pr...
Page        21both passage of antibodies across the blood brain barrier, and intrathecal synthesis of theantibodies. B cel...
Page        22including neurotransmission, and also longer term effects on cell metabolism, structure,and function.(191) T...
Page        23It is proposed that antibodies to the nedasin S-form protein, by some mechanism, create adeficiency in activ...
Page         24(Note 2011 - The result of this project pointed toward a protein (nedasin orguanine deaminase) which blocks...
Page         2510.   Trifiletti RR, Packard AM, "Immune Mechanisms in Pediatric Neuropsychiatric      Disorders; Tourettes...
Page       2624.   Giedd JN, Rapoport JL, Kruesi MJP, et al., "Sydenhams Chorea: Magnetic      Resonance Imaging of the Ba...
Page   2737.   Dale JB, Beachey EH, “Epitopes of Streptococcal M Proteins Shared with Cardiac      Myosin,” J. Exp. Med., ...
Page         2851.   Cunningham MW, Hall, NK, Krisher, KK, et.al., “A study of monoclonal antibodies against      streptoc...
Page      2964.   Fujita A, Kurachi Y, “SAP Family Proteins,” Biochem. Biophys. Res. Comm., vol. 269, p.      1-6, 2000.65...
Page        3078.   Stein DJ, “Neurobiology of the Obsessive-Compulsive Spectrum Disorders,” Biol.      Psychiatry, vol. 4...
Page          3192.    Jadresic D, “Tourette’s Syndrome and the Amygdaloid Complex,” Brit. J. Psychiatry, vol. 162,       ...
Page         32107.   Casey BJ, Castellanos FX, Giedd JN, et al., “Implication of Right Frontostriatal Circuitry in       ...
Page           33123.   Ravenscroft P, Brotchie J, “NMDA Receptors in the Basal Ganglia,” J. Anat., vol. 196 p. 577-      ...
Page     34137.   Anderson GM, Pollak ES, Chatterjee D, et al., “Brain Monoamines and Amino Acids in       Gilles de la To...
Page           35151.   Shattock P, Kennedy A, Rowell F, “Role of Neuropeptides in Autism and Their       Relationships wi...
Page           36166.   Menage P, Thibault G, Barthelemy C, et al., “CD4+CD45RA+ T Lymphocyte Deficiency in       Autistic...
A Proposed Mechanism for Autoimmune Mediated Motor Dysfunctions, and a Hypothesis for Therapeutic Intervention in Tourette...
A Proposed Mechanism for Autoimmune Mediated Motor Dysfunctions, and a Hypothesis for Therapeutic Intervention in Tourette...
Upcoming SlideShare
Loading in …5
×

A Proposed Mechanism for Autoimmune Mediated Motor Dysfunctions, and a Hypothesis for Therapeutic Intervention in Tourette Syndrome, Choreas, Autism, and Attention Deficit Hyperactivity Disorder

983 views

Published on

A research study involving autoantibodies, PANDAS, autism, anti-brain antibodies, proteomics, choreas, thalamocortical pathways, ADHD, streptococcus and a wonderful research subject who makes her parents proud every day.

Published in: Health & Medicine, Education
1 Comment
0 Likes
Statistics
Notes
  • Why did I wait 12 years to put this on the web? A lot of personal and professional reasons. I have noticed the (very welcome) increase in basic research in autism, and I see a few things point toward glutamate receptors and scaffolding proteins. So I thought I would throw this old study out there in the hopes it would stimulate someone's research. Thank you all, whether autism researcher, parent, both, or interested person. My daughter (who is now 23) makes me swell with pride every day I see her go off to her part time job.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Be the first to like this

No Downloads
Views
Total views
983
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
1
Likes
0
Embeds 0
No embeds

No notes for slide

A Proposed Mechanism for Autoimmune Mediated Motor Dysfunctions, and a Hypothesis for Therapeutic Intervention in Tourette Syndrome, Choreas, Autism, and Attention Deficit Hyperactivity Disorder

  1. 1. A Proposed Mechanism for Autoimmune Mediated Motor Dysfunctions,and a Hypothesis for Therapeutic Intervention in Tourette Syndrome,Choreas, Autism, and Attention Deficit Hyperactivity Disorder(Keywords – Autism, Glutamate NMDR receptor, NR2B, Nedasin, Neurexin, Neuroligin,Sydenhams chorea, OCD, tics, PSD-95, thalamocortical pathway)Richard Wicks(Former) PresidentFortron Bio Science Inc.Morrisville, NCSept. 25, 2000Copy ___ of 15dickwicks@nc.rr.com
  2. 2. Page 2 Outline1. Streptococcus – Association with Movement Disorders/Obsessive Compulsive Disorder (OCD)/Attention Deficit Hyperactivity Disorder (ADHD)2. Search for Streptococcal Target Autoantigens3. Current Study on Proposed Target Autoantigen4. Nedasin S-form/Synaptic Associated Proteins (SAPs)5. Association of NE-dlg/SAP102 Proteins with Movement Disorders/OCD/ADHD and Specific Areas of the Brain6. Hypothesis – target autoantigen and NMDA NR2B activity in CSTC motor circuits7. Evidence in support of hypothesis: A. Involvement of glutamate and dopamine in movement and neurobehavioral disorders B. Parkinson’s Disease C. Tourette Syndrome D. Sydenham’s chorea E. Autism F. Attention Deficit Hyperactivity Disorder G. SLE with CNS involvement8. Glutamate NMDA NR2B Enhancement9. Acute Post-Streptococcal Glomerulonephritis10.Nedasin S-form (guanine deaminase activity)11. Summary12. Ongoing and Proposed Studies
  3. 3. Page 3Streptococcus – Association with Movement Disorder/OCD/Attention Deficit DisorderA movement disorder called “St. Vitus’ Dance” was first described in 1686.(1) Nowtermed Sydenham’s chorea (SC), it is characterized by frequent adventitious anduncoordinated movements. SC is a major manifestation of acute rheumatic fever (ARF).ARF is known to be due to an abnormal susceptibility to group A beta hemolyticstreptococcal infections, which induces antibodies to the streptococcus cell wall that crossreact with and damage heart tissue.(2,3) SC occurs in 20-40% of patients with ARF.(4) Itis usually accompanied by obsessions and compulsions, emotional lability, andhyperactivity, along with motor dysfunction. The incidence of SC has fallen dramaticallysince the 1960’s in parallel with the decline in the incidence of ARF. However, over thepast decade, there has been a resurgence in this disorder, primarily in the United States. (5)Substantial clinical overlap occurs between SC (choreic symptoms, obsessive compulsivedisorder or OCD, hyperactivity), Tourette’s syndrome (motor tics, OCD, oppositionalbehavior), autism (motor tics and stereotypical movements, OCD), and attention deficitdisorder or ADHD (hyperactivity, increased incidence of OCD and oppositionalbehavior).(6-13) In SC, the obsessive compulsive symptoms typically begin shortly beforethe onset of chorea.(7) In 1976, Husby demonstrated antibodies in the serum of patientswith SC, which cross reacted with human caudate and subthalamic nuclei in the brain. (14)They further showed a temporal relationship between the presence of these anti-neuronalantibodies and the choreic symptoms. The antibodies also showed specificity for groupA streptococci, since absorbing the serum with group A streptococcal membranesabolished the anti-neuronal activity. This reactivity appeared to be an example of thesame molecular mimicry mechanism associated with antibodies to streptococcus whichcross react with heart tissue in acute rheumatic fever.In 1989, Kiessling noticed an increased incidence of abrupt onset of motor tics inchildren after a local group A strep epidemic.(15) They studied children with motor tics,and also found an increased incidence of antibodies in their serum which reacted withhuman brain tissue. These antibodies reacted primarily with the caudate, putamen, andglobus pallidus in the brain.(16) Numerous studies have now shown a correlation betweengroup A strep infections and antibodies to the basal ganglia area of the brain in Tourette’ssyndrome, SC, OCD, and attention deficit disorder.(8, 17-20) In addition, MRI imagingstudies have documented changes in the size of the basal ganglia in patients which showa temporal relationship to the brain reactive antibody levels and their symptoms.(21-24)Treatment of patients with plasmapheresis, IV gamma globulin, or immunosuppressivedoses of prednisone have shown significant reductions in the OC and motor dysfunctionsymptoms of some patients, further supporting an immunological basis for thesedisorders.(7, 20, 25, 26) An animal model has also provided support for this hypothesis.(27) Inthis study, rats were microinfused into the caudate area with serum from patients withTourette’s syndrome. The rats developed episodic phonic utterances and stereotypicdyskinesias, which persisted for several days post-infusion.
  4. 4. Page 4The existence of a syndrome designated PANDAS (pediatric autoimmuneneuropsychiatric disorder associated with streptococcal infections) is still somewhatcontroversial. It is not clear whether some of these cases define a narrow subset, or areindicative of a more generalized etiology for these varied disorders. Indeed, one recentstudy suggests that previous reports on the association of streptococcal/brain antibodiesand chronic tic disorders and OCD were confounded by the presence of comorbidADHD.(28) This study found a significant correlation between streptococcal antibodiesand ADHD, but not to OCD or chronic tic disorders. In subjects with ADHD or OCD, orboth disorders, higher antibody titers predicted changes in the size of the basal ganglia.Further studies may clarify the relationship between the streptococcal infection and thevarious clinical syndromes.An additional factor linking streptococcal infections and neuropsychiatric disorders is theprevalence of the D8/17 marker. In an attempt to discern why the majority of patientswho develop strep throat do not go on to develop ARF, Zabriskie and colleaguesdeveloped a panel of mouse monoclonal antibodies to surface antigens on lymphocytes ofpatients with rheumatic fever. A monoclonal antibody reacting with a B cell surfaceantigen termed D8/17 was found to discriminate between patients developing rheumaticfever and chorea, and those who did not.(29) The patients with ARF typically have theD8/17 marker on 30-40% of their lymphocytes, while patients with strep infectionswithout ARF have less than 10% reactivity. Family studies have shown the vulnerabilityto ARF, and the presence of the D8/17 marker are inherited in a recessive manner.(30)Expanding on this study, Swedo et.al., studied children with streptococcal inducedPANDAS, and found 85% of the children were D8/17 positive.(31) Two other studieshave shown an increased expression of D8/17 in Tourette’s syndrome (TS), and OCDpatients without a clear streptococcal infection trigger.(32,33) A more recent study lookedat D8/17 expression in autism and found 78% of the patients positive for the marker, withthe degree of D8/17 antigen positivity correlating with the severity of compulsivebehaviors.(34)Search for Streptococcal Target AutoantigensConsiderable efforts have been made to explore the mechanism of the cardiac damagefound in ARF, with most of the emphasis on the streptococcal M proteins which are themain virulence factors for group A strep infections.(35) These M proteins have beenfound to be similar immunochemically and structurally to a number of human hostautoantigens including myosin,(36-40) tropomyosin,(41) and vimentin.(42) The M5 serotypeof S. pyogenes has most often been associated with rheumatic fever outbreaks.(43) T-cellclones have been isolated from the affected heart valves of rheumatic fever patients.These clones have been shown to react with both heart tissue and streptococcal M5protein, suggesting that these M proteins are crucial to the pathogenesis of ARF.(44) Oneregion of the streptococcal M5 protein has been reported to be a so-called“superantigenic” site.(45) It represents amino acid residues 157 to 197 in the publishedM5 gene sequence.(46) This superantigenic site contains a 5 amino acid sequence(QKSKQ), which has previously been reported to react with anti-myosin antibodies in
  5. 5. Page 5patients with ARF.(47) The injection of cardiac myosin has been shown in studies to becapable of inducing myocarditis in animals.(48,49) A molecular analysis of T cell epitopesof the M5 protein which react with cardiac myosin has been localized to key regions withmyosin like repeats within the M5 molecule.(50) Numerous other studies have implicatedcardiac myosin as the target autoantigen in rheumatic fever.(51-55)In 1993, Bronze and Dale published a study which examined the epitopes onstreptococcal M proteins which cross reacted with the antibodies to the brain tissue whichwere observed in SC patients.(17) They demonstrated that purified M proteins from type5, 6, and 19 streptococci induced antibodies in rabbits which cross reacted strongly withthe basal ganglia area of human brain. Using western blot analysis, they showed thatthese antibodies reacted with multiple proteins in the brain extracts. With the use ofsynthetic peptides, they localized the epitope specificity of the antibodies bydemonstrating inhibition of the binding in the western blot analysis. The epitope alanine-lysine-glutamate (AKE) was found to represent the common conserved sequence foundin the M5, M6, and M19 proteins which inhibited the binding of the brain reactiveantibodies. The M5 and M6 streptococcal proteins contained either a KLAKE or KIAKEepitope. This KLAKE epitope (M5 residues 179-183) is contained within the 41 aminoacid region which is presumed to be a superantigenic site for type 5 streptococci. It isalso contiguous with the QKSKQ epitope which was reported to react with anti-myosinpatients in ARF. Serum from a patient with SC also demonstrated strong reactivity to thebrain which was inhibited by a synthetic peptide corresponding to M5 residues 164-197.Superantigenic site (aa 157-197) KEQENKETIGTLKKILDETVKDKLAKEQKSKQNIGALKQELM5 protein (aa 164-197) TIGTLKKILDETVKDKLAKEQKSKQNIGALKQELM6 protein TVKDKIAKEQESTM19 protein IIDDLDAKENMyosin heavy chain DQNCKLAKEKKLLPrevious studies showed that antibodies to M5 residues 164-197 cross reacted withpurified sarcolemmal membranes in human heart, as well as type 5, 6, and 19streptococci.(56) Since the KLAKE epitope was contained within residues 164-197 of theM5 protein, they examined these antibodies (which were affinity purified fromsarcolemmal membrane preparations) for brain cross reactivity, and found that they didindeed produce a binding pattern to brain proteins similar to the M5 protein antiserum.This indicated that the same epitopes might be responsible for the damage to heart tissuein ARF patients and the antibody binding to basal ganglia in SC patients.Current Study on Proposed Target AutoantigenA study by the author in 1994 demonstrated an antibody in the serum of a patient withautism (his daughter) which reacted with a 47 kd protein in human brain by Western blotanalysis. No attempt was made to identify the protein due to technological limitations atthat time. Recently, this patient demonstrated an abrupt onset of motor tics, coincidentwith an epidemic of strep A infection in her classroom and school. Although a throat
  6. 6. Page 6culture and ASO and Dnase B antibody tests for group A strep were negative, the authorundertook a further investigation due to the extremely sudden onset of tics, and theprevious literature suggesting an association of motor tics with strep infection.Serum was collected from this patient approximately two weeks after the sudden onset ofmotor tics, and a total immunoglobulin fraction isolated and bound to a solid phaseagarose gel. A human brain soluble extract was prepared and incubated with the solidphase antibody from the patient’s serum. After extensive washing of the column, theantibody bound proteins were eluted from the column and a concentrated sample of theeluted proteins run on 2 dimensional (2D) SDS-PAGE electrophoresis. Proteins werevisualized with Coomasie blue staining, and 2D gel spots were identified by thetraditional proteomic method of in-gel trypsin digestion, followed by MALDI-TOFanalysis of the digested peptides and peptide mass fingerprinting and database searching.Figure 1 shows the pattern of the 2D gel electrophoresis of the antibody bound proteins.(The proteins at approximately 55 kD and 24 kD represent IgG which was stripped fromthe affinity column by the elution buffers). Figure 1 3.5 pI 10
  7. 7. Page 7 The identities of the proteins are listed in Table 1.TABLE 1 (Proteins Bound by Patient Antibody Column)Gel Spot Name AccessionNumber #1 Alpha-fodrin (alpha II spectrin) – N terminal fragment AAA517022 Human Non-erythroid alpha-spectrin (brain) CAB537103 Heat shock 71 kD protein P111424 Inter-alpha trypsin inhibitor, heavy chain Q146245 Gamma enolase P091046 Nedasin S-form (identical to guanine deaminase and AAF13301 KIAA1258)7 Heat shock 71kD protein P111428 Glutamine synthetase P151049 IgG gamma chain (leakage from the antibody column) P0185710 Fructose-biphosphate aldolase C P0997211 Calmodulin-3 (phosphorylase kinase, delta) NP_00517512 Ferritin heavy chain P0279413 Ferritin light chain P0279214 Ferritin light chain “15 Flavin reductase P3004316 Flavin reductase “17 14kD beta galactoside-binding lectin (galectin) X1525618 Hemoglobin beta chain P0202319 Hemoglobin beta chain “20 Hemoglobin alpha chain P0192221 Complement C1S component P0987122 No ID23 78 kD Glucose regulated protein (IgG binding protein) P1102124 No ID25 Glial fibrillary acidic protein NP_00204626 Vacuolar ATPase isoform VA68 (from hypothalamus) AAF1487027 No ID28 Alpha 1-syntrophin U4057129 IgG kappa chain (leakage from the antibody column) BAA3356030A 14-3-3 protein zeta/delta (protein kinase C inhibitor P29312 protein)30B 14-3-3 protein gamma BAA8518431 No ID32 Profilin II P3508033 No ID34 Neuropolypeptide h3 AAB3287635 Ferritin heavy chain P02794
  8. 8. Page 8Table 2 represents the proteins from Table 1 which are brain proteins, and are notubiquitous or do not represent apparent artifacts from the immunoaffinitychromatography. Table 2 – Brain Proteins Bound by Patient Antibody ColumnGel Spot Number Name Accession Number2 Human Non-erythroid CAB53710 alpha spectrin (brain)3 Heat shock 71 kD protein P111425 Gamma enolase P091046 Nedasin –S form (guanine AAF13301 deaminase)8 Glutamine synthetase P1510410 Fructose biphosphate P09972 aldolase C11 Calmodulin-3 NP_005175 (phosphorylase kinase, delta)15 Flavin reductase P3004317 14 kD beta galactoside X15256 binding lectin (galectin)25 Glial fibrillary acidic NP_002046 protein26 Vacuolar ATPase isoform AAF14870 VA68 (from hypothalamus)28 Alpha 1-syntrophin U4057130 A/B 14-3-3 proteins (protein P29312/BAA85184 kinase C inhibitor proteins)32 Profilin II P3508034 Neuropolypeptide h3 AAB32876Since the sequenced genes in the public protein databases are rapidly being expanded, itwas thought that analysis of proteins containing the conserved epitopes previously foundto exist in strep group A proteins and brain tissue might be fruitful. Since the 5 aminoacid sequence of “KLAKE” was the predominant epitope common to the superantigenicsite of the M5 streptococcal protein, the brain cross-reactive antibodies found in SCpatients, and the myosin heavy chain molecule which was the protein most oftenassociated with cardiac damage in ARF, this sequence was used for database mining. Asearch of the NR database at NCBI revealed a total of 8,934 entries which contained thekeywords “human” and “brain”. A modified BLAST search of the NR database at NCBIrevealed only the following 24 proteins which contained this KLAKE sequence (0.27%of the estimated human brain proteins present in the database).
  9. 9. Page 9TABLE 3 (Proteins containing KLAKE sequence)Number Name Accession #1 Human dynamin 2 P505702 Diaphanous 2 isoform 12C NP_0092933 SWI/SNF related, actin NP_003060 dependent chromatin regulator4 Unnamed protein product BAA917785 Serine protease 16 NP_0058566 Homeobox protein ZHX1 NP_0091537 Non-muscle myosin heavy BAA01989 chain8 NADH dehydrogenase 1 NP_004535 alpha complex9 Glycerol kinase CAB5485910 Moesin (membrane NP_002435 organizing extension spike protein11 Cell cycle progression 3 NP_004213 protein12 Proteasome 26S subunit NP_00280713 KIAA1258 protein BAA86572 (Nedasin S-form)14 KIAA1360 protein BAA9259815 Guanine deaminase NP_004284 (Nedasin S-form)16 Retinoblastoma binding NP_005047 protein 217 RAB-26 protein BAA8470718 KIAA0820 protein BAA7484319 Nuclear matrix protein p84 NP_00512220 Unnamed protein product BAA9133121 dna-J like HIRA interacting NP_005871 protein22 KIAA0882 protein BAA7490523 Mitochondrial import Q15388 receptor subunit24 RAS-like protein NP_036381Surprisingly, proteins 13 and 15 from TABLE 3 are homologous to the gene for nedasinS-form, which is one of the proteins identified in Table 2 which bound to antibodies fromthe patient’s serum (Gel Spot #6). Therefore, of only 15 identified brain proteins boundby the patient’s antibodies, one contained the KLAKE epitope common to streptococcalM5 protein, cardiac myosin, and a region of the M5 protein which demonstrates
  10. 10. Page 10reactivity with brain cross reacting antibodies observed in Sydenham’s chorea. Therelative tissue expression of the KIAA1258 (Nedasin S-form) gene as measured byReverse Transcriptase PCR ELISA is shown in Table 4 (from www.kazusa.or.jp/huge) TABLE 4 (Expression of KIAA1258/Nedasin S-form gene) Tissue Relative expressionHeart 1Brain 1000Lung 1Liver 300Smooth muscle 5Kidney 1000Pancreas 3Spleen 1Testes 5Ovary 30Amygdala 1000Corpus callosum 80Cerebellum 1Caudate nucleus 300Hippocampus 1000Substantia nigra 5Subthalamic nuclei 40Thalamus 30Spinal cord 30Fetal brain 1000As seen in Table 4, the KIAA1258/nedasin S-form gene is highly expressed in thecaudate nucleus, hippocampus, and amygdala, three areas with previously showncorrelation to OCD, motor function, learning and memory.Nedasin S-form/Synaptic Associated Proteins (SAPs)Nedasin S-form is a recently described 51 kD protein which has significant homology toa superfamily of proteins with deaminase activity.(57) Another group also recently founda gene with guanine deaminase activity which had an identical predicted amino acidsequence to nedasin S-form.(58) Guanine deaminase catalyzes the deamination ofguanine, producing xanthine and ammonium. Recent work has suggested that somedeaminase (aminohydrolase) proteins no longer function as enzymes, but use the folds forother types of biological functions. For example, the C. elegans protein UNC-33 whichbelongs to this protein family has been shown to be required for the appropriate directionof axonal extension of neurons, and mutations in this gene cause severely uncoordinatedmovements and abnormalities in neuronal axons.(59) The nedasin gene was shown tohave four alternative splicing isoforms at the C-terminus, and one of these forms (S-form)
  11. 11. Page 11is found primarily in brain and kidney. The expression of nedasin S-form was also foundto increase in parallel with the progress of synaptogenesis in cultured neurons.(57)Nedasin S-form (but not the other splicing variants) was also found to be co-localizedwith NE-dlg/SAP102 protein in neuronal cells. NE (neuroendocrine)-dlg is a member ofan increasingly important family of proteins called MAGUKS (Membrane AssociatedGuanylate Kinase homologs). Originally identified as a tumor suppressor gene (discs-large or dlg) in Drosophila, this family of proteins has been shown to act as essentialscaffolding proteins to organize the structural and functional elements of cell junctions.In neurons, these dlg proteins are known as synaptic associated proteins (SAPs), and theyplay an essential role in clustering and anchoring proteins in the post synaptic membraneduring synaptogenesis.(60) They are also apparently critical for proper signal transmissionand synaptic plasticity in the brain.(61)NE-dlg is the human homologue of the rat SAP102 protein. (62,63) The SAP proteins havea number of distinct domains that bind to other proteins including 3 PDZ domains, a srchomology 3 (SH3) region, and a non-enzymatically active guanylate kinase sequence.(64)The SH3 region apparently acts to bind to cytoskeletal proteins, allowing for anchoring ofthe complexes in the membrane. The PDZ domains have been found in many proteins,and in the case of MAGUKs, they have been shown to mediate binding to the C-terminaltails of transmembrane proteins including receptors, channels, and cell adhesionmolecules. A number of studies have shown that the rat SAP102 protein is involved inbinding to the C-terminal end of glutamate NMDA type receptors in the post synapticdensity (PSD) of the brain.(63-67) Various other proteins that are involved withintracellular signaling which are stimulated by glutamate receptor activation includingnitric oxide synthase (NOS) and synaptic Ras-GTPase activating protein (SynGAP) alsointeract with the SAP family of proteins.(64,68-70) It is thought that SAPs may not only beinvolved in ordering and maintenance of receptor integrity, but may also facilitateefficient signaling in neurons by keeping enzymes in close proximity.(64) In addition, theSAP family of proteins interact with subunits from several voltage-dependent K+ (Kv)channels in neurons, where they are proposed to regulate cell membraneexcitability.(64,71,72) There is also evidence that they interact with inwardly-rectifying K+channels in neurons.(64)The NE-dlg/SAP102 protein has been shown to bind to the NR2B type of NMDAreceptors in rat hippocampal neurons, and calmodulin has been shown to be bound also tothe NE-dlg/SAP102 and NMDA receptor complexes.(65,73) One proposed modelspeculates that calcium entry for the NMDA receptor can modulate the interaction of NE-dlg/SAP102 and the NMDA receptors, and the redistribution of these molecules may becritical in synapse assembly.(65) (see Figure 2 on next page)The NE-dlg/SAP102 gene has been mapped to the DYT3 (dystonia-parkinsonismsyndrome) region of Xq13.1.(61) It is currently a candidate gene for this neurologicaldisease, which is characterized by involuntary postural and motor disturbances. Thesesymptoms appear to be characterized by improper impulse transmission in the basalganglia region of the brain.(74)
  12. 12. Page 12 Figure 2Activation of NMDA receptors by glutamate leads to an entry of Ca+2 ions through thechannel. Binding of Ca+2 to calmodulin allows calmodulin to interact with NR1, NE-dlg/SAP102, and PSD-95. The binding of Ca+2/calmodulin to NR induces detachment ofNMDA receptors from the actin cytoskeleton and their redistribution. The binding ofCa+2/calmodulin to NE-dlg/SAP102 and PSD-95 results in heteromeric complexformation of these MAGUK proteins and leads to clustering of the NMDA receptorsduring synaptic activity. (from reference 65, figure 9)
  13. 13. Page 13Interestingly, calmodulin was also found to be one of the proteins bound by the patientantibody column (see Table 1 and 2). Although NMDA receptors are normally foundonly in post-synaptic membrane, the NE-dlg/SAP102 protein was also found in one studyto be located in the cytoplasm of neurons where it was not complexed with NMDANR2B receptors.(65) The general mechanism proposed for the SAP family of proteins isone where they assemble receptors and channels in the membrane, and fix them atspecialized domains through their interactions with cell adhesion molecules.Brain alpha spectrin (fodrin) was also one of the 15 identified brain proteins bound by thepatient antibody coumn (Table 2). This protein is a major component of the post-synaptic density (PSD), and has been shown to interact with NMDA receptors.(76) It hasbeen shown to interact selectively with NR1A, NR2A, and NR2B subunits of NMDAreceptors.(76) The spectrin functions to link membrane proteins such as receptors and ionchannels to the actin cytoskeleton, thus anchoring them in place. Three of the 15identified brain proteins from Table 2 are therefore presumed to be found complexed inthe brain, where they are believed to be critical for synaptic activity.In the original study by Kuwahara, nedasin S-form was found to interfere with theassociation between NE-dlg/SAP102 and NMDA receptor 2B in vitro, suggesting that theinteractions of nedasin S-form may play a role in the clustering of NMDA receptors insynapses during neuronal development. Due to the assocation of the SAP proteins withproteins such as NOS and SynGAP, nedasin S-form may also be involved in intracellularsignaling in neurons. In addition, NE-dlg/SAP102 may bind to neuroligin (neural celladhesion molecule or NCAM), which is critical for detailing synaptic connections in thecentral nervous system.(67,75)Figure 3 summarizes some of the known and postulated interactions of the NE-dlg/SAP102 protein.Nedasin S-form(blocking action) Figure 3NE-dlg/SAP102 NMDA NR2B receptors Nitric Oxide Synthase (NOS) SynGAP Voltage Gated K+ channels Inwardly Rectifying K+ channels Calmodulin Neural Cell Adhesion Molecule (NCAM) ErbB-4 (Tyrosine Kinase receptor)
  14. 14. Page 14Association of NE-dlg/SAP Proteins and Movement Disorders/OCD/ADHD with Areasof the BrainAs shown in Table 4, the nedasin S-form gene is most highly expressed in the amygdala,hippocampus, and caudate nucleus in the brain. The glutamate NMDA NR2B gene inhumans has been shown to have a very similar distribution, with the highest levels foundin the fronto-parietal-temporal cortex and hippocampus, and lower levels in the basalganglia and amygdala.(77) The gene distributions of both proteins therefore agree with theproposed association of the nedasin S-form gene and NR2B glutamate receptors.Other studies lend support to the involvement of these same areas of the brain withmovement disorders, obsessive compulsive disorder (OCD), and attentional difficulties.The following table summarizes studies which have been done, and the areas of the brainwhich have been most frequently found to be atypical or dysfunctional. Table 5Disorder Dysfunction/Atypical Imaging method (if Reference Area of the Brain used)Tourette’s Basal ganglia (BG) 78syndrome(TS)/OCDHuntington’s BG 79Disease (HD)Systemic lupus BG MRI 80erythematosus(SLE)with choreaADHD Caudate MRI 81ADHD Prefrontal cortex/BG MRI 82ADHD Prefrontal cortex/BG MRI 83ADHD Putamen Functional MRI 84ADHD Prefrontal cortex/BG 85ADHD Prefrontal MRI 86 cortex/CaudateTS BG 87TS Prefrontal cortex/BG 88SLE with chorea BG MRI 89TS/OCD BG MRI 90Movement Disorder BG 91TS Amygdala 92OCD BG 93OCD Caudate 94TS BG MRI 95TS BG MRI 96OCD/tics BG MRI 22TS/OCD/HD Prefrontal lobes/BG 97
  15. 15. Page 15Disorder Dysfunction/Atypical Imaging Method (if Reference Area of the Brain used)Sydenham’s chorea BG MRI 7(SC)TS BG MRI 11SC BG MRI 28SC BG MRI 98SC BG MRI 99SC BG MRI 100TS/OCD/ADHD Prefrontal lobe/BG 101OCD Frontal MRI 102 lobe/amygdalaADHD Frontal lobe PET 103ADHD Striatum SPECT 104ADHD Prefrontal lobe SPECT 105ADHD Right Caudate Functional MRI 106ADHD Prefrontal MRI 107 lobe/CaudateADHD Caudate MRI 108ADHD Globus pallidus MRI 109The common thread between the various disorders listed in Table 5 is the involvement ofareas constituting the prefrontal-striatal-thalamo-cortical pathway. These feedbackcircuits were first postulated by Alexander et.al. in 1986. They described prefrontalafferents to basal ganglia relay stations, which would then synapse on thalamic nuclei,which in turn would feedback to the cortical areas.(110) This circuit would providefeedback to other cortical regions, and it is currently believed to serve as the substrate formany of the executive functions in the brain.(111) A simplified schematic of this circuit isshown in Figure 4.Signals traveling from the caudate directly to the internal globus pallidus result inamplification of the thalamic excitatory fibers by disinhibition, which then feedback tothe cortex. This represents the so-called direct pathway. The indirect pathway representssignals traveling from the caudate to the external globus pallidus, then to the subthalamicnucleus and internal globus pallidus, and finally reaching the thalamus and then back tothe cortex. Neuronal traffic over the indirect pathway results in inhibition of the system,and has been described as the brain’s braking mechanism.(112) A deficient inhibitoryactivity of the indirect pathway, or excessive stimulation of the direct pathway has beenpostulated as a mechanism explaining the pathology of ADHD, Tourette’s syndrome, andOCD.(89,113-115) Indeed, one study has suggested that most hyperkinetic and hypokineticmovement disorders are caused by a dysfunctional basal ganglia-thalamo-cortical loop.(91)The indirect pathway appears to dominate behavior in humans for unknown reasons.(116)
  16. 16. Page 16 Figure 4 +/- CORTEX + Glu/GABA Glu + GluVentralTegmentalArea CAUDATE - GlobusSubstantia Pallidus-nigra Dopamine GABA external + Glu - GABA - GABA Globus + + Pallidus – Sub- internal Glu Thalamic Glu Nuclei Nuclei - GABA THALAMUS
  17. 17. Page 17HypothesisGroup A streptococcus infections may induce antibodies, in certain susceptibleindividuals, which cross react with a protein called nedasin S-form in the brain. It ispostulated that these antibodies precipitate chorea and/or obsessive compulsivebehavioral symptoms by interfering with glutamatergic NMDA NR2B activity in thecortico-striatal-thalamocortical (CSTC) motor circuits. Dysfunction of nedasin S-formand NR2B receptors in the CSTC circuits may be involved in the pathogenesis ofdisorders such as Tourette syndrome, Sydenham’s chorea, obsessive-compulsivedisorder, autism, and attention deficit hyperactivity disorder (ADHD). Autoantibodies tonedasin S-form may also interfere with NE-dlg/SAP102 interactions with other proteinsas outlined in Figure 3, and they may represent possible drug targets.Evidence in Support of Hypothesis A. Involvement of glutamate and dopamine in movement and neurobehavioral disorders.Considerable evidence supports the concept of a reciprocal interaction of glutamateNMDA receptor activity and dopaminergic activity in the CSTC motor circuits.(118-120) Inone model of chorea, underactivity of the indirect pathway of the CSTC circuits due todysfunction of the striatum or subthalamic nuclei results in reduced excitatory (NMDA)output to the internal globus pallidus, with resultant disinhibition of the thalamus andexcessive motor activity.(121,122) B. Parkinson’s Disease (PD)Although perhaps a simplistic comparison, the reduced motor activity observed in PD canbe viewed as a reverse chorea disorder. In PD, the loss of dopaminergic neuronsprojecting from the substantia nigra to the striatum results in overactivity of the indirectpathway, and excessive inhibition of the thalamocortical path, leading to muscle rigidityand hypokinesia.(123-125) Cognitive declines are also part of the clinical picture in PD.Parkinsonian brains are characterized by excessive glutamatergic activity in theprojection from the subthalamic nuclei to the internal globus pallidus. (124,126,127) Indeed,recent animal studies have shown improvements in PD models with agents that blockNMDA NR2B receptors in the brain.(125,128,129) Recent clinical studies in humans havealso shown improvements in PD symptoms with NR2B antagonists.(130-132) C. Tourette Syndrome (TS)Tourette syndrome is a lifelong disorder which is characterized by motor and phonic ticsand obsessive compulsive behaviors. It is thought that the cortical excitations are causedby dopamine excess leading to a reduced inhibition in the indirect CSTC motorpathway.(87,133,134) Abnormal dopamine uptake sites have been demonstrated in thecaudate and putamen in post mortem studies of TS patients.(135) Dopaminergicantagonists such as haloperidol are effective in suppressing the tics in many cases,
  18. 18. Page 18although side effects of the drugs limit their use. Dopamine agonists can also precipitateor exacerbate tics.(9,136) As previously mentioned, TS patients have demonstratedautoantibodies to the basal ganglia area, and injection of these antibodies into miceprecipitated typical TS symptoms. If these antibodies had the effect of reducingglutamatergic function in the basal ganglia and amygdala, this could lead to thedopaminergic sensitivity observed in this disorder. In another post mortem study,decreased glutamate concentrations were found in the globus pallidus and substantianigra pars reticulata of TS patients.(137) In a transgenic mouse model of comorbid TS andOCD, MK-801 (a non-competitive NMDA antagonist) exacerbated the TS symptoms.(138)Again, a reciprocal action between glutamatergic and dopaminergic activity is apparent. D. Sydenham’s chorea (SC)In SC, where antibodies to the basal ganglia are also observed, there appears to be alifelong hypersensitivity to dopaminergic drugs,(139) and an increased severity of the OCDsymptoms with relapse.(140) Although the disease is considered to be self limiting, thereappear to be psychiatric problems such as difficulty in social adjustment that persist longafter the chorea has resolved.(141-143) Clinically, there is substantial overlap in symptomsbetween TS, SC, and OCD.(7,8) Palumbo et.al. have coined the term developmental basalganglia syndrome (DBGS) to refer to patients with dysfunctional basal ganglia whopresent with tics and OCD.(144) Dopaminergic antagonists are also helpful in suppressingchorea in SC patients.(122) It is interesting that speech impairment also occurs inapproximately 40% of SC cases.(122) Also, one report described an unidentified 45 kDprotein in brain which reacted with serum from SC patients.(145) E. AutismAutism is also a lifelong disorder, and includes symptoms of impaired social interactionsand speech, obsessive compulsive symptoms, sensory dysfunctions, and stereotypicalmovements. Carlsson has proposed that autism may represent a hypoglutamatergicdisorder.(146) Some evidence for this includes the observation that autistic-like symptomscan be produced in neurotypical individuals by glutamate antagonists like phencyclidine(PCP) or ketamine. Serotonin 5-HT2A agonists such as LSD and psilocybin also mimicmany of the perceptual disturbances of autism when given to neurologically normalindividuals. The NMDA receptor antagonism has been shown to lead to enhanced 5-HT2A receptor transmission, and 5-HT2A stimulation leads to a weaker glutamatergictransmission. PET brain studies in healthy volunteers show that ketamine and psilocybinboth produce hypermetabolism in the frontal cortex.(147) Direct treatment with glutamateagonists is hazardous due to the possibility of neurotoxicity and seizures. Animalexperiments by this group have shown that a 5-HT2A receptor antagonist (M100907) iseffective in reducing hyperactivity in mouse psychosis models produced either byNMDA receptor antagonism or dopamine agonists.(148) They suggest that 5-HT2Areceptor antagonists could be useful in hypoglutamatergic disorders such as autism andschizophrenia.
  19. 19. Page 19Additional evidence points to hypoglutamatergic conditions producing the symptomsobserved in autism. Mohn et.al. have produced mice which display only 5% of thenormal levels of the essential NR1 glutamate NMDA subunit.(149) These mice did notsleep with their litter mates, engaged in less social interactions with other mice, and hadreduced sexual activity. Surprisingly, all of these symptoms could be ameliorated withclozapine (a dopamine antagonist). This again supports the reciprocity of glutamate anddopamine interactions in behavior. Clozapine has demonstrated some promising resultsin autism, although since it also has some 5-HT2A receptor blocking properties, it isdifficult to pinpoint the mechanism.(150) Other evidence points to excess dopaminergicactivity in autism. In animals, autistic behaviors can be induced with dopamineagonists,(151) and dopamine antagonists such as haloperidol have shown some benefits inpatients.(152-154)It has long been noted (mostly anecdotally) that autistic patients show improvementduring episodes of fever. In fact, the author’s daughter suddenly spoke using multiplewords for the first time during a bout of influenza when she had a fever. A publishedreference to this observation has been made.(155) A possible mechanism for this could bean enhancement in glutamatergic activity. It has been shown that hyperthermia elevatesthe glutamate content in the brain.(156,157) Hypothermia has been shown to reduce theNMDA receptor mediated excitotoxicity of neurons after ischemic episodes in the brain,and has even been used therapeutically to limit the extent of ischemic damage after astroke.(158,159)That autism could be due to an abnormal immune system fits with a large body of data.Studies have reported deficient complement C4B genes,(160,161) altered cytokines,(162) T-cell changes,(163-166) and other immune system defects.(167,168) An overactive immunesystem could lead to a greater tendency toward autoimmune reaction to brain tissue.Autoantibodies to the nedasin S-form could cause alterations in any of the proteins whichthe NE-dlg/SAP102 protein has been shown to bind, including neural cell adhesionmolecule (NCAM). One report has described that autistics showed only 50% of thenormal serum levels of NCAM.(169) NCAM appears to regulate the detachment ofsynaptic connections critical in the brain. It is also possible that maternal antibodies togroup A strep, cross reacting with nedasin S-form, could interfere in utero with thedevelopment of the post synaptic density of key areas of the brain, causing autism. F. Huntington’s disease (HD)Huntington’s disease is an inherited neurodegenerative disease characterized by choreaand progressive cognitive decline. It is one of a number of diseases caused by expandedCAG polyglutamine repeats in the causative gene. Husby et.al. first described thatantibodies to caudate and subthalamic nuclei were observed in 50% of HD patients.(170)These antibodies could possibly be produced as a response to the glutamatergicneurotoxicity in these areas. HD is frequently found comorbid with obsessivecompulsive disorder(171) and TS.(94) The basal ganglia and frontal lobes have been foundto be dysfunctional in this disorder.(78,79,94,172) Lower levels of NMDA NR2B expressionin the neostriatum of HD patients have been reported.(173) Dentatorubro-pallidoluysian
  20. 20. Page 20atrophy (DRPLA) is another inherited polyglutamine CAG repeat disease which canproduce a similar clinical presentation to HD.(79) G. Attention Deficit Hyperactivity Disorder (ADHD)As previously mentioned, a recent report demonstrated an association between group Astreptococcal infections and ADHD.(28) Higher strep antibody titers predicted MRIdocumented changes in the size of the basal ganglia in these patients. Numerous imagingstudies have shown changes in the structures involved in the CSTC circuits of the brain.Dopaminergic overactivity has been documented in ADHD,(111) and abnormalities in theD4 dopamine receptor subtype reported.(174) D4 dopamine receptors are abundant in theglobus pallidus, and in GABAergic interneurons in prefrontal cortex.(175)Castellanos has reported a proposed model for ADHD which describes a mechanism forthe efficacy of stimulants such as methylphenidate in ADHD.(111) In this model,dopamine neurons in the VTA diffusely innervate the frontal cortex forming themesocortical dopamine system, which has few inhibitory autoreceptors. These terminalsregulate cortical inputs. In this circuit, stimulants are hypothesized to increase postsynaptic dopaminergic effects, and integrate inputs from other cortical regions, improvingexecutive function. Due to the lack of autoreceptors, tolerance in this system is notproduced. However, symptoms of hyperactivity in ADHD are hypothesized to beassociated with overactivity in dopamine circuits which go from the substantia nigra tothe striatum. This circuit is tightly regulated by autoreceptors and feedback from thecortex, and slow diffusion of stimulants are hypothesized to produce net reduction indopaminergic transmission, with the resulting disinhibition of the thalamocorticalpathway and increased motor activity. Since the indirect pathway of the CSTC circuithas been described as the brain’s braking mechanism, a familiarity with ADHD patientswill lead immediately to the conclusion that you are dealing with a person who “cannotput on the brakes.” H. Systemic Lupus Erythematosus (SLE) with CNS involvementSLE is an autoimmune disease which is characterized by autoantibody formation andmultiple clinical manifestations, including nephritis. Central nervous systeminvolvement occurs in 35-75% of patients.(176) Up to 4% of SLE patients experiencechorea.(177,178) MRI imaging studies have shown transient alterations in the basal gangliaof the brain of patients with chorea.(80,89) The transient nature of the imagingabnormalities has led to speculation about the role of brain autoantibodies to the basalganglia as a factor in the chorea. Numerous studies have shown autoantibodies to brainproteins in patients with SLE and CNS involvement. One study showed that 95% ofpatients with SLE/CNS had antibodies to a 50kD protein in synaptic membranes.(179) Theantibodies were also detected in the CSF of these patients. The protein target of theseantibodies was not identified. In a mouse model of SLE with neurobehavioraldisturbances (MRL/lpr mouse), the behavioral disturbances are associated withautoantibodies.(180) The source of these antibodies is not clear, but there was evidence for
  21. 21. Page 21both passage of antibodies across the blood brain barrier, and intrathecal synthesis of theantibodies. B cells were found in the brains of MRL/lpr mice, suggesting that some ofthe antibodies were produced in the CNS.(181)The concept of the brain as an immunologically privileged organ has been modified inrecent times.(182-184) Antibodies from serum could enter the brain through areas whichlack a blood brain barrier such as the pineal gland. Alternatively, a number of studieshave shown that peripherally activated B cells can migrate into the CNS, thendifferentiate into plasma cells under the influence of cytokines, and begin secretingantibodies.(183,185,186) Autoantibodies to brain proteins have been shown to be importantin other neurological disorders such as Rasmussen’s encephalitis(182) (glutamate receptorGluR3), Stiff man syndrome(184) (glutamic acid decarboxylase), and myastheniagravis(187) (acetylcholine receptors).Glutamate NR2B EnhancementAn interesting study was recently reported by Tang et.al.(188) In contrast to the study ofMohn(149) which showed that mice with reduced expression of glutamate NR1 subunitsshowed autistic or schizophrenic behaviors, Tang and his group engineered transgenicmice which overexpressed the NR2B receptor subunit in cortex, striatum, amygdala, andhippocampus. These mice showed enhanced activation of NMDA receptors, facilitatingsynaptic potentiation. The mice also showed superior learning and memory on a widevariety of behavioral tasks, demonstrating that NR2B is essential in synaptic plasticityand memory formation.Acute Post-Streptococcal Glomerulonephritis (APSGN)Most cases of acute glomerulonephritis today are associated with group A streptococcalinfections, and occur mostly in children.(189) The nephritogenicity appears to be related tothe specific M serotype of S. pyogenes. The pathogenesis of APSGN is unknown, but itis thought to be related to an immunological phenomenon involving immunecomplexes.(53,190) Although a number of studies have demonstrated antibodies againstkidney protein targets, a consensus target has not been found. Streptokinase, which isinvolved in the spread of streptococci through tissue, has been the focus of a number ofstudies, although it is thought that additional factors are required for development of thedisease.(53,190) As seen in Table 4, the expression of nedasin S-form is very high inkidney. It is tempting to speculate that antibodies with the same specificity could beinvolved in APSGN, as well as producing heart damage through reaction with myosin,and chorea/tics by binding nedasin S-form in the brain.Nedasin S-form - Guanine Deaminase activityAnother possible mechanism for antibodies to nedasin S-form to interfere in brain motorfunction and behavior is by a direct inhibitory effect on the guanine deaminase activity ofthe protein. Purine nucleotides, nucleosides, and free bases are known to play criticalroles in brain cells. They have been shown to mediate a diverse array of functions
  22. 22. Page 22including neurotransmission, and also longer term effects on cell metabolism, structure,and function.(191) They can interact at the level of signal-transduction pathways withneurotransmitters like glutamate. A delicate balance exists between adenine and guaninenucleotides and free bases in the brain. Interference with the degradative pathway ofguanine could lead to a disturbance in the balance between the nucleotides.Some evidence exists for altered purine metabolism in a number of CNS disorders. Acritical enzyme for maintenance of nucleoside concentrations in the brain ishypoxanthine-guanine phosphoribosyl transferase (HGPRT). This enzyme convertsguanine or hypoxanthine back into the nucleoside forms, representing the so-called“salvage” pathway needed to maintain nucleoside concentrations. A genetic deficiencyin this enzyme produces Lesch-Nyhan syndrome, which is characterized by severe motordisabilities, cognitive deficits, and disturbances of behavioral control.(192) It is thought tobe attributable to dysfunction in the basal ganglia. Transgenic mice lacking the HGPRTgene show abnormalities in uptake of guanine and hypoxanthine into cells, increasedrates of purine synthesis, and alterations in nucleotide concentrations.(193)There is a considerable amount of biochemical data supporting a link between the purinesand the dopaminergic system.(194) Adenosine A2A receptors are highly localized in thebasal ganglia, and have a reciprocal relationship with dopaminergic activity.(194) This hasled to the hypothesis that adenosine receptors may play a role in Huntington’s chorea andParkinson’s disease (PD), via interference with the indirect pathway of the cortico-striatal-thalamocortical circuit.(194) In fact, adenosine A2A antagonists are beinginvestigated as potential treatments for PD.(195)Autism has long been known to be associated with dysfunctions in purine metabolism ina subset of patients.(196-199) Indeed, the term “purine autism” has been used for this groupof patients. Approximately 20-30% of autistic patients have increased uric acidexcretion, resulting from the degradative breakdown of purines. In a recent study,accelerated rates of purine synthesis were observed, and the ratio of adenine to guaninenucleotides was found to be lower in this subset of patients.(200) This altered purinemetabolism could also lead to effects on the dopaminergic systems of the basal ganglia.SUMMARYSerum was collected from a patient who demonstrated an abrupt onset of motor tics,coincident with exposure to group A streptococcus. Antibodies from this serum werefound to bind to a protein (nedasin S-form) from human brain which interacts with theSAP family of proteins involved in regulation of glutamate NMDA activity in the brain.The pattern of expression of the nedasin gene matches areas of the brain known to beinvolved in motor disturbances and obsessive compulsive symptoms. Nedasin S-formcontains an amino acid epitope (KLAKE) common to myosin heavy chain, streptococcalM5 protein, and a region from the M5 protein which has shown cross reactivity withantibodies to human basal ganglia.
  23. 23. Page 23It is proposed that antibodies to the nedasin S-form protein, by some mechanism, create adeficiency in activity of the NMDA NR2B receptors of the cortico-striatal-thalamo-cortical pathway, leading to the observed motor dysfunction. It is further proposed thatdeficient NR2B activity in the brain could represent a pathogenic mechanism in Tourettesyndrome, autism, and attention deficit hyperactivity disorder. Therapies aimed atcorrecting this deficient glutamatergic activity may have therapeutic value in all of theseclinical conditions. Finally, it is speculated that an additional or alternative pathogenicmechanism could be direct interference by the autoantibodies with the guanine deaminaseenzymatic activity of nedasin S-form, leading to disruption of the balance betweenpurines, and resulting dysfunction in the basal ganglia.Ongoing and Proposed StudiesAntibodies have been produced in rabbits to three synthetic peptides corresponding toimmunogenic regions of the nedasin S-form protein. Immunaffinity columns are beingprepared in order to isolate the nedasin S-form protein from human brain extracts.(Note 2011 – these antibodies did not succeed in pulling theprotein out of a brain extract. Indeed, they did not reactwith the native protein, probably due to conformationalissues, an unfortunately common problem I had found).An ELISA technique will be developed to test for the incidence of autoantibodies to thisprotein in movement disorders, autism, and ADHD. NE-dlg/SAP102 protein will also beisolated (or obtained from another source) to study the in vitro interactions of theseproteins with NMDA NR2B receptors.(Note 2011 – I did develop an ELISA comparing results ofreactivity of my daughters serum with normal sera using the3 synthetic nedasin peptides as antigen. No difference inreactivity was seen - possibly due to the conformationaldifferences with the native protein again).An appropriate animal model will be developed which can be used to confirm thehypothesis that the autoantibodies to nedasin S-form can precipitate motor dysfunctionsand/or obsessive compulsive symptoms. The possibility of generating mice with reduced(not complete knockout) NMDA NR2B gene expression in the brain will be explored,since knockout mice without NR2B subunits apparently do not survive. In vitro studieswill also be performed to investigate the possibility of an altered balance between purinesin an appropriate model system.(This work was not attempted – May, 2011)
  24. 24. Page 24(Note 2011 - The result of this project pointed toward a protein (nedasin orguanine deaminase) which blocks the action of some other proteins involved in synapticconnections and scaffolding.After this report was written, futher studies were done to examine the reactivity ofantibodies to streptococcal M5 protein with various tissues. Polyclonal antibodies wereprepared in rabbits to the streptococcal M5 protein and immunohistochemical studiesperformed using various human tissues. Unfortunately, the antibodies showed broadreactivity to most peripheral tissues as well as to brain tissue. Due to this lack ofspecificity, the research was discontinued.However, recent research has found an association between neuroligin and neurexindefects and autism. The fact that these are also NMDA glutamate receptor proteins maybe of interest in this regard. Bibliography1. Sydenham (1624-1689): In the Encyclopedia Britannica, vol. XXVI, Ed. 12, New York, 1911, p. 277.2. Behar SM, Porcelli SA, "Mechanisms of Autoimmune Disease Induction. The Role of the Immune Response to Microbial Pathogens.,". Arthritis and Rheumatism, vol. 38, p. 458-476, 1995.3. Zabriskie JB, Hsu KC, Seegal BC, "Heart-Reactive Antibody Associated with Rheumatic Fever: Characterization and Diagnostic Significance," Clin. Exp. Immunol., vol. 7, p. 147-159, 1970.4. Kushner HI, Kiessling LS, "The Controversy Over the Classification of Gilles de la Tourettes Syndrome, 1800-1995," Perspect. Biol. Med., vol. 39, p. 409-435, 1996.5. Kaplan EL, "Recent Epidemiology of Group A Streptococcal Infections in North America and Abroad: An Overview," Pediatrics, vol. 97, p. 945-948, 1996.6. Baron-Cohen S, Scahill VL, Izaguirre J, et al., "The Prevalence of Gilles de la Tourette Syndrome in Children and Adolescents with Autism: A Large Scale Study," Psychol. Med., vol. 29, p. 1151-1159, 1999.7. Garvey MA, Swedo SE, "Sydenhams Chorea; Clinical and Therapeutic Update, " Streptococci and the Host, ed. Horaud et al., p. 115-120, Plenum Press, NY, 1997.8. Swedo SE, Leonard HL, Schapiro MB, et al., "Sydenhams Chorea: Physical and Psychological Symptoms of St. Vitus Dance," Pediatrics, vol. 91, p. 706-713, 1993.9. Comings DE, Comings BG, "Clinical and Genetic Relationships Between Autism- Pervasive Development Disorder and Tourette Syndrome: A Study of 19 Cases," Amer. J. Med. Genetics, vol. 39, p. 180-191, 1991.
  25. 25. Page 2510. Trifiletti RR, Packard AM, "Immune Mechanisms in Pediatric Neuropsychiatric Disorders; Tourettes Syndrome, OCD, and PANDAS," Child Adol. Psych. Clinics NA, vol. 8, p. 767-775, 1999.11. Saunders-Pullman R, Braun I, Bressman S, "Pediatric Movement Disorders," Child Adol. Psych. Clinics NA, vol. 8, p. 747-765, 1999.12. Comings DE, "Tourettes Syndrome: A Behavioral Spectrum Disorder." Adv. Neurology, vol. 65, p. 293-303, 1995.13. Comings DE, "The Role of Genetic Factors in Conduct Disorder Based on Studies of Tourette Syndrome and Attention-Deficit Hyperactivity Disorder Probands and Their Relatives." J. Dev. Behav. Pediatrics, vol. 16, p. 142-157, 1995.14. Husby G, van de Rijn I, Zabriskie JB, et al., "Antibodies Reacting with Cytoplasm of Subthalamic and Caudate Nuclei Neurons in Chorea and Acute Rheumatic Fever," J. Exp. Med., vol. 144, p. 1094-1110, 1976.15. Kiessling LS, "Tic Disorders Associated with Evidence of Invasive Group A Betahemolytic Streptococcal Disease," Devel. Med. Child Neurol. (Suppl No. 59), vol. 31, p. 48, 1989.16. Kiessling LS, Marcotte AC, Culpepper L, "Antineuronal Antibodies: Tics and Obsessive-Compulsive Symptoms," J. Dev. Behav. Pediatrics, vol. 15, p. 421-425, 1994.17. Bronze MS, Dale JB, "Epitopes of Streptococcal M Proteins that Evoke Antibodies that Cross-React with Human Brain.," J. Immunology, vol. 151, p. 2820- 2828, 1993.18. Singer HS, Giuliano JD, Hansen BH, et al., "Antibodies Against Human Putamen in Children With Tourette Syndrome," Neurology, vol. 50, p. 1618-1624, 1998.19. Muller N, Riedel M, Straube A, et al., "Increased Anti-Streptococcal Antibodies in Patients with Tourettes Syndrome.," Psychiatry Res., vol. 94, p. 43-49, 2000.20. Swedo SE, "Sydenhams Chorea; A Model for Childhood Autoimmune Neuropsy- chiatric Disorders," JAMA, vol. 272, p. 1788-1791, 1994.21. Giedd JN, Rapoport JL, Leonard HL, et al., "Case Study: Acute Basal Ganglia Enlargement and Obsessive-Compulsive Symptoms in an Adolescent Boy," J. Am. Acad. Child Adolesc. Psychiatry, vol. 35, p. 913-915, 1996.22. Giedd JN, Rapoport JL, Garvey MA, et al., "MRI Assessment of Children With Obsessive-Compulsive Disorder or Tics Associated With Streptococcal Infection," Am. J. Psychiatry, vol. 157, p. 281-283, 2000.23. Garvey MA, Giedd J, Swedo SE, "PANDAS: The Search for Environmental Triggers of Pediatric Neuropsychiatric Disorders. Lessons from Rheumatic Fever," J. Child Neurology, vol. 13, p. 413-423, 1998.
  26. 26. Page 2624. Giedd JN, Rapoport JL, Kruesi MJP, et al., "Sydenhams Chorea: Magnetic Resonance Imaging of the Basal Ganglia.," Neurology, vol. 45, p. 2199-2202, 1995.25. Swedo SE, Leonard HL, Kiessling LS, "Speculations on Antineuronal Antibody-Mediated Neuropsychiatric Disorders of Childhood," Pediatrics, vol. 93, p. 323-326, 1994.26. Allen AJ, Leonard HL, Swedo SE, "Case Study: A New Infection-Triggered, Autoimmune Subtype of Pediatric OCD and Tourettes Syndrome," J. Am. Acad. Child Adolesc. Psychiatry, vol. 34, p. 307-311, 1995.27. Hallett JJ, Harling-Berg CJ, Agrawal JR, et al., "Tic-like Phonation and Dyskinesia in Rats after Intracaudate Microinfusion of Sera from Children with Tourette Syndrome," Antibody Mediated Mechanisms of Autoimmune Disease, Abstract 2064, p. A1357.28. Peterson BS, Leckman JF, Tucker D, et al., "Preliminary Findings of Antistreptococcal Antibody Titers and Basal Ganglia Volumes in Tic, Obsessive- compulsive, and Attention-Deficit/Hyperactivity Disorders," Arch. Gen. Psychiatry, vol. 57, p. 364-372, 2000.29. Patarroyo ME, Winchester RJ, Vejerano A,et al., "Association of a B-cell Alloantigen with Susceptibility to Rheumatic Fever," Nature, vol. 278, p. 173, 1979.30. Gibofsky A, Khanna A, Suh E, et al., "The Genetics of Rheumatic Fever: Relationship to Streptococcal Infection and Autoimmune Disease," J. Rheumatol. (Suppl), vol. 30, p. 1, 1991.31. Swedo SE, Leonard HL, Mittleman BB, et al., "Identification of Children with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections by a Marker Associated With Rheumatic Fever," Am. J. Psychiatry, vol. 154, p. 110- 112, 1997.32. Murphy TK, Goodman WK, Fudge MW, et al., "B Lymphocyte Antigen D8/17: A Peripheral Marker for Childhood-Onset Obsessive-Compulsive Disorder and Tourettes Syndrome?," Am. J. Psychiatry, vol. 154, p. 402-407, 1997.33. Chapman F, Visvanathan K, Carreno-Manjarrez R, et al., "A Flow Cytometric Assay for D8/17 B Cell Marker in Patients with Tourettes Syndrome and Obsessive Compulsive Disorder.", J. Immunol. Methods, vol. 219, p. 181-186, 1998.34. Hollander E, DelGiudice-Asch G, Simon L, et al., "B Lymphocyte Antigen D8/17 and Repetitive Behaviors in Autism," Am. J. Psychiatry, vol. 156, p. 317-320, 1999.35. Fischetti VA, “Streptococcal M-protein: Molecular Design and Biological Behavior,” Clin. Microbiol. Rev., vol. 2, p. 285-314, 1989.36. Krisher KK, Cunningham MW, “Myosin: A Link Between Streptococci and Heart,” Science, vol. 227, p. 413-415, 1985.
  27. 27. Page 2737. Dale JB, Beachey EH, “Epitopes of Streptococcal M Proteins Shared with Cardiac Myosin,” J. Exp. Med., vol. 162, p. 583, 1985.38. Cunningham MW, Antone SM, Gulizia JM, et al., “Cytotoxic and Viral Neutralizing Antibodies Crossreact with Streptococcal M Protein, Enteroviruses, and Human Cardiac Myosin,” Proc. Natl. Acad. Sci., vol. 89, p. 1320-1324, 1992.39. Dell A, Antone SM, Gauntt CJ, et al., “Autoimmune Determinants of Rheumatic Carditis: Localization of Epitopes in Human Cardiac Myosin,” Eur. Heart J., vol. 12, p. 158-162, 1991.40. Krisher K, Cunningham MW, “Myosin: A Link Between Streptococci and Heart,” Science, vol. 227, p. 413-415, 1985.41. Fenderson PG, Fischetti VA, Cunningham MW, “Tropomyosin Shares Immunologic Epitopes with Group A Streptococcal M Proteins,” J. Immunology, vol. 142, p. 2475- 2481, 1989.42. Kraus W, Seyer JM, Beachey EH, “Vimentin-Cross-Reactive Epitope of Type 12 Streptococcal M Proteins,” Infect. Immun., vol. 57, p. 2457-2461, 1989.43. Bisno A, “Nonsuppurative Poststreptococcal Sequelae: Rheumatic Fever and Glomerulonephritis,” p. 1528-1539 in Principles and Practices of Infectious Diseases, ed. by Mandell GL, Bennett JE; Churchill Livingstone, New York, NY, 1990.44. Guilherme L, Cunha-Neto E, Coelho V, et al., “Human Heart-Filtrating T Cell Clones from Rheumatic Heart Disease Patients Recognize Both Streptococcal and Cardiac Proteins,” Circulation, vol. 92, p. 415-420, 1995.45. Wang B, Schlievert PM, Gaber AO, et al., “Localization of an Immunologically Functional Region of the Streptococcal Superantigen Pepsin-Extracted Fragment of Type 5 M Protein,” J. Immunology, vol. 151, p. 1419-1429, 1993.46. Manjula BN, Acharya AS, Mische SM, et al., “The Complete Amino Acid Sequence of a Biologically Active 197-Residue Fragment of M Protein Isolated from Type 5 Group A Streptococci,” J. Biol. Chem., vol. 259, p. 3686-3693, 1984.47. Cunningham MW, McCormack JM, Fenderson PG, et al., “Human and Murine Antibodies Cross- Reactive with Streptococcal M Protein and Myosin Recognize the Sequence GLN-LYS-SER- LYS-GLN in M Protein,” J. Immunology, vol. 143, p. 2677-2683, 1989.48. Smith SC, Allen PM, “Myosin-Induced Acute Myocarditis is a T Cell Mediated Disease,” J. Immunology, vol. 147, p. 2141-2147, 1991.49. Wegmann KW, Zhao W, Griffin AC, et al., “Identification of Myocarditogenic Peptides Derived from Cardiac Myosin Capable of Inducing Experimental Allergic Myocarditis in the Lewis Rat,” J. Immunology, vol. 153, p. 892-900, 1994.50. Cunningham MW, Antone SM, Smart M, et al., “Molecular Analysis of Human Cardiac Myosin-Cross-Reactive B- and T-Cell Epitopes of the Group A Streptococcal M5 Protein,” Infect. Immun., vol. 65, p. 3913-3923, 1997.
  28. 28. Page 2851. Cunningham MW, Hall, NK, Krisher, KK, et.al., “A study of monoclonal antibodies against streptococci and myosin”, J. Immunology, vol. 136, p. 293-298, 1985.52. Dale JB, Beachey EH, “Sequence of Myosin-Crossreactive Epitopes of Streptococcal M Protein,” J. Exp. Med., vol. 164, p. 1785-1790, 1986.53. Cunningham, MW, “Pathogenesis of Group A Streptococcal Infections,” Clin. Microbiology Rev., vol. 13, p. 470-511, 2000.54. Dale JB, Beachey EH, “Protective Antigenic Determinant of Streptococcal Protein Shared with Sarcolemmal Membrane Protein of Human Heart,” J. Exp. Med., vol. 156 p. 1165-1176, 1982.55. Cunningham MW, McCormack JM, Talaber LR, et al., “Human Monoclonal Antibodies Reactive with Antigens of the Group A Streptococcus and Human Heart,” J. Immunology, vol. 141, p. 2760-2766, 1988.56. Sargent SJ, Beachey EH, Corbett CE, et al., “Sequence of Protective Epitopes of Streptococcal M Proteins Shared with Cardiac Sarcolemmal Membranes,” J. Immunology, vol. 139, p. 1285, 1987.57. Kuwahara H, Araki N, Keishi M, et al.,“A Novel NE-dlg/SAP102-associated Protein, p51-nedasin, Related to the Amidohydrolase Superfamily, Interferes with the Association between NE-dlg/SAP102 and N-Methyl-D-aspartate Receptor,” J. Biol. Chem., vol. 274, p. 32204-32214, 1999.58. Yuan G, Bin JC, McKay DJ, et al., “Cloning and Characterization of Human Guanine Deaminase. Purification and Partial Amino Acid Sequence of the Mouse Protein.,” J. Biol. Chem, vol. 274, p. 8175-8180, 1999.59. Hedgecock EM, Culotti JG, Thomson JN, et al., “Axonal Guidance Mutants of Caenor-habditis Elegans Identified by Filling Sensory Neurons with Fluorescein Dyes,” Dev. Biol., vol. 111, p. 158-170, 1985.60. Sheng M, “PDZs and Receptor/Channel Clustering: Rounding up the Latest Suspects,” Neuron, vol. 17, p. 575-578, 1996.61. Stathakis DG, Lee D, Bryant PJ, “DLG3, the Gene Encoding Human Neuroendocrine Dlg (NE-Dlg), is Located within the 1.8-Mb Dystonia-Parkinsonism Region at Xq13.1,” Genomics, vol. 49, p. 310-313, 1998.62. Hanada N, Makino K, Koga H, et al., “NE-dlg, A Mammalian Homolog of Drosophila DLG Tumor Suppressor, Induces Growth Suppression and Impairment of Cell Adhesion: Possible Involvement of Down-Regulation of -Catenin by Ne-dlg Expression,” Int. J. Cancer, vol. 86, p. 480-488, 2000.63. Muller BM, Kistner U, Kindler S, et al., “SAP102, a Novel Postsynaptic Protein That Interacts with NMDA Receptor Complexes in Vivo,” Neuron, vol. 17, p. 255-265, 1996.
  29. 29. Page 2964. Fujita A, Kurachi Y, “SAP Family Proteins,” Biochem. Biophys. Res. Comm., vol. 269, p. 1-6, 2000.65. Masuko N, Makino K, Kuwahara H, et al., “Interaction of NE-dlg/SAP102, a Neuronal and Endocrine Tissue-specific Membrane-associated Guanylate Kinase Protein, with Calmodulin and PSD-95/SAP90; A Possible Regulatory Role in Molecular Clustering At Synaptic Sites,” J. Biol. Chem, vol. 274, p. 5782-5790, 1999.66. Lau L, Mammen A, Ehlers MD, et al., “Interaction of the N-Methyl-D-Aspartate Receptor Complex with a Novel Synapse-Associated Protein, SAP102,” J. Biol. Chem., vol. 271, p. 21622-21628, 1996.67. Fanning A, Bryant P, “PDZ Proteins and their Binding Partners,” http://mamba.biouci.edu/-pjbryant/lab/PDZ_binders.html, 1999.68. Brenman JE, Chao DS, Gee SH, et al., “Interaction of Nitric Oxide Synthase with the Postsynaptic Density Protein PSD-95 and Alpha1-Syntrophin Mediated by PDZ Domains,” Cell, vol. 84, p. 757-767, 1996.69. Chen HJ, Rojas-Soto M, Oguni A, et al., “A Synaptic Ras-GTPase Activating Protein (p135 SynGAP) Inhibited by CaM Kinase II,” Neuron, vol. 20, p. 895-904, 1998.70. Kim JH, Liao D, Lau LF, et al., “SynGAP: a Synaptic RasGAP that Associates with the PSD-95/SAP90 Protein Family,” Neuron, vol. 20, p. 683-691, 1998.71. Sheng M, “Excitatory Synapses. Glutamate Receptors Put in their Place,” Nature, vol. 386, p. 221-223, 1997.72. Kim E, Niethammer M, Rothschild A, et al., “Clustering of ShakerType- K+ Channels by Interaction with a Family of Membrane-Associated Guanylate Kinases,” Nature, vol. 378, p. 85-88, 1995.73. Ehlers MD, Zhang S, Bernhardt JP, et al., “Inactivation of NMDA Receptors by Direct Interaction of Calmodulin with the NR1 Subunit,” Cell, vol. 84, p. 745-755, 1996.74. Lee LV, Kupke KG, Caballar-Gonzaga F, et al., “The Phenotype of the X-linked Dysto- nia-Parkinsonism Syndrome. An Assessment of 42 Cases in the Philippines,” Medicine, vol. 70, p. 179-187, 1991.75. Edelman GM, “Cell Adhesion Molecules in the Regulation of Animal Form and Tissue Pattern,” Ann. Rev. Cell Biol., vol. 2, p. 81-116, 1986.76. Wechsler A, Teichberg VI, “Brain Spectrin Binding to the NMDA Receptor is Regulated by Phosphorylation, Calcium and Calmodulin,” EMBO J, vol. 17, p. 3931- 3939, 1998.77. Schito AM, Pizzuti A, Di Maria E, et al., “mRNA Distribution in Adult Human Brain of GRIN2B, a N-methyl-D-aspartate (NMDA) Receptor Subunit,” Neuroscience Letters, vol. 239, p. 49-53, 1997.
  30. 30. Page 3078. Stein DJ, “Neurobiology of the Obsessive-Compulsive Spectrum Disorders,” Biol. Psychiatry, vol. 47, p. 296-304, 2000.79. Quinn N, Schrag A, “Huntington’s Disease and Other Choreas,” J. Neurology, vol. 245, p. 709- 716, 1998.80. al Jishi F, al Kawi MZ, el Ramahi K, et al., “Hemichorea in Systemic Lupus Erythe- matosus: Significance of MRI Findings,” Lupus, vol. 4, p. 321-323, 1995.81. Mataro M, Garcia-Sanchez C, Junque C, et al., “Magnetic Resonance Imaging Measurement of the Caudate Nucleus in Adolescents with Attention-Deficit Hyperactivity Disorder and its Relationship with Neuropsychological and Behavioral Measures,” Arch. Neurol., vol. 54, p. 963-968, 1997.82. Hendren RL, De Backer I, Pandina GJ, “Review of Neuroimaging Studies of Child and Adolescent Psychiatric Disorders from the Past 10 Years,” J. Am. Acad. Child Adolesc. Psychiatry, vol. 39, p. 815-828, 2000.83. Swanson J, Castellanos FX, Murias M, et al., “Cognitive Neuroscience of Attention Deficit Hyperactivity Disorder and Hyperkinetic Disorder,” Curr. Opin. Neurobiol., Vol. 8, p. 263-271, 1998.84. Teicher MH, Anderson CM, Polcari A, et al., “Functional Deficits in Basal Ganglia of Children with Attention-Deficit/Hyperactivity Disorder Shown with Functional Magnetic Resonance Imaging Relaxometry,” Nat. Med., vol. 6, p. 470-473, 2000.85. Williams D, Stott CM, Goodyer IM, et al., “Specific Language Impairment with or Without Hyperactivity: Neuropsychological Evidence for Frontostriatal Dysfunction,” Dev. Med. Child Neurol., vol. 42, p. 368-375, 2000.86. Filipek PA, Semrud-Clikeman M, Steingard RJ, et al., “Volumetric MRI Analysis Comparing Subjects Having Attention-Deficit Hyperactivity Disorder with Normal Controls,” Neurology, vol. 48, p. 589-601, 1997.87. Leckman JF, Knorr AM, Rasmusson AM, et al., “Basal Ganglia Research and Tourette’s Syndrome,” TINS, vol. 14, p. 94, 1991.88. Leckman JF, Pauls DL, Peterson BS, et al., “Pathogenesis of Tourette Syndrome. Clues from the Clinical Phenotype and Natural History,” Adv. Neurol., vol. 58, p. 15-24, 1992.89. Kashihara K, Nakashima S, Kohira I, et al., “Hyperintense Basal Ganglia on T1- Weighted MR Images in a Patient with Central Nervous System Lupus and Chorea,” Am. J. Neuroradiol., vol. 19, p. 284-286, 1998.90. Saint-Cyr JA, Taylor AE, Nicholson K, “Behavior and the Basal Ganglia,” Adv. Neurology, vol. 65, 9. 1-28, 1995.91. Muller-Vahl KR, Kolbe H, Schneider U, et al., “Cannabis in Movement Disorders,” Forsch Komplementarmed, vol. 6, Suppl 3, p. 23-27, 1999.
  31. 31. Page 3192. Jadresic D, “Tourette’s Syndrome and the Amygdaloid Complex,” Brit. J. Psychiatry, vol. 162, p. 851-852, 1993.93. Roy BF, Benkelfat C, Hill, JL, et al., “Serum Antibody for Somatostatin-14 and Prodynorphin 109-240 in Patients with Obsessive-Compulsive Disorder, Schizophrenia, Alzheimer’s Disease, Multiple Sclerosis, and Advanced HIV Infection,” Biol. Psychiatry, vol. 35, p. 335-344, 1994.94. Jankovic J, Ashizawa T, “Tourettism Associated with Huntington’s Disease,” Movement Disorders, vol. 10, p. 103-105, 1995.95. Peterson B, Riddle MA, Cohen DJ, et al., “Reduced Basal Ganglia Volumes in Tourette’s Syndrome Using Three-Dimensional Reconstruction Techniques from Magnetic Resonance Images,” Neurology, vol. 43, p. 941-949, 1993.96. Singer HS, Reiss AL, Brown JE et al., “Volumetric MRI Changes in Basal Ganglia of Children with Tourette’s Syndrome,” Neurology, vol. 43, p. 950-956, 1993.97. Cummings JL, Cunningham K, “Obsessive-Compulsive Disorder in Huntington’s Disease,” Biol. Psychiatry, vol. 31, p. 263-270, 1992.98. Kienzle GD, Breger RK, Chun RW, et al., Sydenham Chorea: MR Manifestations in Two Cases,” Am. J. Neuroradiol., vol. 12, p. 73-76, 1991.99. Traiil A, Pike M, Byrne J, “Sydenham’s Chorea: A Case Showing Striatal Abnormalities on CT and MRI,” Dev. Med. Child Neurol., vol. 37, p. 270-273, 1995.100. Giedd NJ, Rapoport JL, Kruesi MJP, et al., “Sydenham’s Chorea: Magnetic Resonance Imaging of the Basal Ganglia,” Neurology, vol. 45, p. 2199-2202, 1995.101. Sheppard DM, Bradshaw JL, Purcell R, et al., “Tourette’s and Comorbid Syndromes: Obsessive Compulsive and Attention Deficit Hyperactivity Disorder. A Common Etiology?”, Clin. Psychol. Rev., vol. 19, p. 531-552, 1999.102. Szeszko PR, Robinson D, Alvir JMJ, et al., “Orbital Frontal and Amygdala Volume Reductions in Obsessive-Compulsive Disorder,” Arch. Gen. Psychiatry, vol. 56, p. 913-919, 1999.103. Zametkin AJ, Nordahl TE, Gross M, et al., “Cerebral Glucose Metabolism in Adults with Hyperactivity of Childhood Onset,” N. Engl. J. Med., vol. 323, p. 1361-1366, 1990.104. Lou HC, Henriksen L, Bruhn P, “Focal Cerebral Dysfunction in Developmental Learning Disabilities,” Lancet, vol. 335, p. 8-11, 1990.105. Amen DG, Paldi JH, Thisted RA, “Brain SPECT Imaging,” J. Am. Acad. Child Adolesc. Psychiatry, vol. 32, p. 1080-1081, 1993.106. Teicher MH, Polcari A, Anderson CM, et al., “Methylphenidate Effects on Hyperactivity and fMRI in Children with ADHD,” Am. Acad. Child Adolesc. Psychiatry, 12 (Abstract), 1996.
  32. 32. Page 32107. Casey BJ, Castellanos FX, Giedd JN, et al., “Implication of Right Frontostriatal Circuitry in Response Inhibition and Attention-Deficit/Hyperactivity Disorder,” J. Am. Acad. Child Adolesc. Psychiatry, vol. 36, p. 374-383, 1997.108. Hynd GW, Hern KL, Novey ES, et al., “Attention Deficit Hyperactivity Disorder and Asymmetry of the Caudate Nucleus,” J. Child Neurol., vol. 8, p. 339-347, 1993.109. Aylward EH, Reiss AL, Reader MJ, et al., “Basal Ganglia Volumes in Children with Attention-Deficit Hyperactivity Disorder,” J. Child Neurol., vol. 11, p. 112-115, 1996.110. Alexander GE, DeLong MR, Strick PL, “Parallel Organization of Functionally Segregated Circuits Linking Basal Ganglia and Cortex,” Ann. Rev. Neurosci., vol. 9, p. 357-381, 1986.111. Castellanos FX, “Toward a Pathophysiology of Attention-Deficit/Hyperactivity Disorder,” Clin. Pediatrics, vol. 36, p. 381-393, 1997.112. Wichmann T, DeLong MR, “Pathophysiology of Parkinsonian Motor Abnormalities,” Adv. Neurology, vol. 60, p. 53-61, 1993.113. Hallett M, “Physiology of Basal Ganglia Disorders: An Overview,” Can. J. Neurol. Sci., vol. 20, p. 177-183, 1993.114. Modell JG, Mountz JM, Curtis GC, et al., “Neurophysiologic Dysfunction in Basal Ganglia/Limbic Striatal and Thalamocortical Circuits as a Pathogenetic Mechanism Of Obsessive-Compulsive Disorder,” J. Neuropsychiatry, vol. 1, p. 27-36, 1989.115. Baxter LR, “Brain Imaging as a Tool in Establishing a Theory of Brain Pathology in Obsessive Compulsive Disorder,” J. Clin. Psychiatry, vol. 51 (Suppl 2), p. 22-25, 1990.116. Schmidt WJ, Kretschmer BD, “Behavioral Pharmacology of Glutamate Receptors in the Basal Ganglia,” Neurosci. Biobehav. Rev., vol. 21, no. 4, p. 381-392, 1997.117. Wechsler A, Teichberg VI, “Brain Spectrin Binding to the NMDA Receptor is Regulated by Phosphorylation, Calcium and Calmodulin,” EMBO J, vol. 17, p. 3931-3939, 1998.118. Schmidt WJ, Bubser M, Hauber W, “Behavioral Pharmacology of Glutamate in the Basal Ganglia,” J. Neural Transm., vol. 38 (Suppl), p. 65-89, 1992.119. Dourmap N, Costentin J, “Involvement of Glutamate Receptors in the Striatal Enkephalin- Induced Dopamine Release,” Eur. J. Pharm., vol. 253, p. R9-R11, 1994.120. Greenamyre JT, O’Brien CF, “N-Methyl-D-Aspartate Antagonists in the Treatment of Parkinsons Disease,” Arch Neurol., vol. 48, p. 977-81, 1991.121. Storey E, Beal MF, “Neurochemical Substrates of Rigidity and Chorea in Huntington’s Disease,” Brain, vol. 116, p. 1201-1222, 1993.122. Janavs JL, Aminoff MJ, “Dystonia and Chorea in Acquired Systemic Disorders,” J. Neurol. Neurosurg. Psychiatry, vol. 65, p. 436-445, 1998.
  33. 33. Page 33123. Ravenscroft P, Brotchie J, “NMDA Receptors in the Basal Ganglia,” J. Anat., vol. 196 p. 577- 585, 2000.124. O’Connor WT, “Functional Neuroanatomy of the Basal Ganglia as Studied by Dual- Probe Microdialysis,” Nucl. Med. Biol., vol. 25, p. 743-746, 1998.125. Nash JE, Hill MP, Brotchie JM, “Antiparkinsonian Actions of Blockade of NR2B- Containing NMDA Receptors in the Reserpine-Treated Rat,” Exp. Neurol., vol. 155, p. 42-48, 1999.126. Brotchie JM, Crossman AR, “D-[3H]Aspartate and [14C]GABA Uptake in the Basal Ganglia of Rats Following Lesions in the Subthalamic Region Suggest a Role for Excitatory Amino Acid but not GABA-Mediated Transmission in Subthalamic Nucleus Efferents,” Exp. Neurol., vol. 113, p. 171-181, 1991.127. Schmidt WJ, “Dopamine-Glutamate Interactions in the Basal Ganglia,” Amino Acids, vol. 14, p. 5-10, 1998.128. Steece-Collier K, Chambers LK, Jaw-Tsai SS, et al., “Antiparkinsonian Actions of CP- 101,606, an Antagonist of NR2B Subunit-Containing N-methyl-D-aspartate Receptors,” Exp. Neurol., vol. 163, p. 239-243, 2000.129. Chase TN, Oh JD, “Striatal Mechanisms and Pathogenesis of Parkinsonian Signs and Motor Complications,” Ann. Neurol., vol. 47 (4 Suppl 1), p. S122-129, 2000.130. Verhagen ML, Del Dotto P, Blanchet PJ, et al., “Blockade of Glutamatergic Transmis- sion as Treatment for Dyskinesias and Motor Fluctuations in Parkinson’s Disease,” Amino Acids, vol. 14, p. 75-82, 1998.131. Verhagen ML, Del Dotto P, Blanchet PJ et al., “Amantadine as Treatment for Dyskinesias and Motor Fluctuations in Parkinson’s Disease,” Neurology, vol. 50, p. 1323-1326, 1998.132. Mitchell IJ, Hughes N, Carroll CB, et al., “Reversal of Parkinsonian Symptoms by Intrastriatal and Systemic Manipulation of Excitatory Amino Acid and Dopamine Transmission in the Bilateral 6-OHDA Lesioned Marmoset,” Behav. Pharm., vol. 6, p. 492-507, 1995.133. DeLong MR, “Primate Models of Movement Disorders of Basal Ganglia Origin,” Trends Neurosci., vol. 13, p. 281-285, 1990.134. Leckman JF, Hardin MT, Riddle MA, et al., “Clonidine Treatment of Gilles de la Tourette’s Syndrome,” Arch. Gen. Psychiatry, vol. 48, p. 324-328, 1991.135. Singer HS, In-Hei Hahn BA, Moran TH, “Abnormal Dopamine Uptake Sites in Postmortem Striatum from Patients with Tourette’s Syndrome,” Ann. Neurol., vol. 30, p. 558-562, 1991.136. Goodman WK, McDougle CJ, Price LH, et al., “Beyond the Serotonin Hypothesis: A Role for Dopamine in Some Forms of Obsessive Compulsive Disorder?,” J. Clin. Psychiatry, vol. 51, p. S36-43, 1990.
  34. 34. Page 34137. Anderson GM, Pollak ES, Chatterjee D, et al., “Brain Monoamines and Amino Acids in Gilles de la Tourette’s Syndrome: A Preliminary Study of Subcortical Regions,” Arch. Gen. Psychiatry, vol. 49, p. 584-586, 1992.138. McGrath MJ, Campbell KM, Parks CR, et al., “Glutamatergic Drugs Exacerbate Symptomatic Behavior in a Transgenic Model of Comorbid Tourette’s Syndrome and Obsessive-Compulsive Disorder,” Brain Res., vol. 877, p. 23-30, 2000.139. Nausieda PA, Bieliauskas LA, Bacon LD, et al., “Chronic Dopaminergic Sensitivity After Sydenham’s Chorea,” Neurology, vol. 33, p. 750-754, 1983.140. Asbahr FR, Ramos RT, Negrao AB, et al., “Case Series: Increased Vulnerability to Obsessive- Compulsive Symptoms with Repeated Episodes of Sydenham Chorea”, J. Amer. Acad. Child Psychiatry, vol. 38, p. 1522-1525, 1999.141. Krause S, “Personality Changes After Chorea Minor,” Schweiz Arch. Neurol. Neuro- chir Psychiatr, vol. 34, p. 94-108, 1934.142. Krause S, “Choreic Personality and Neurosis,” J. Ment. Sci., vol. 92, p. 75-77, 1946.143. Breutsch W, “Late Cerebral Sequelae of Rheumatic Fever,” Arch. Itern. Med., vol. 73, p. 472- 482, 1944.144. Palumbo D, Maugham A, Kurlan R, “Hypothesis III: Tourette Syndrome is Only One of Several Causes of a Developmental Basal Ganglia Syndrome,” Arch. Gen. Psychiatry, vol. 54, p. 475- 483, 1997.145. Frucht J, Zabriskie J, Trifiletti R, “Immunoblot Characterization of Antineuronal Antibody Targets in Sydenham’s Chorea,” Ann. Neurol., vol. 42, p. 533, 1997.146. Carlsson ML, “Hypothesis: Is Infantile Autism a Hypoglutamatergic Disorder? Relevance of Glutamate-Serotonin Interactions for Pharmacotherapy,” J. Neural. Transm., vol. 105, p. 525-535, 1998.147. Vollenweider FX, Leenders KL, Scharfetter C, et al., “Positron Emission Tomography and Fluorodeoxyglucose Studies of Metabolic Hyperfrontality and Psychopathology in the Psilocybin Model of Psychosis,” Neuropsychopharm., vol. 16, p. 357-372, 1997.148. Carlsson ML, Martin P, Nilsson M, et al., “The 5-HT2A Receptor Antagonist M100907 is More Effective in Counteracting NMDA Antagonist- Than Dopamine Agonist-Induced Hyperactivity in Mice,” J. Neural. Transm., vol. 106, p. 123-129, 1999.149. Mohn AR, Gainetdinov RR, Caron MG, et al., “Mice with Reduced NMDA Receptor Expression Display Behaviors Related to Schizophrenia,” Cell, vol. 98, p. 427-436, 1999.150. Zuddas A, Ledda MG, Fratta A, et al., “Clinical Effects of Clozapine on Autistic Disorder,” Am. J. Psychiatry, vol. 153, p. 738, 1996.
  35. 35. Page 35151. Shattock P, Kennedy A, Rowell F, “Role of Neuropeptides in Autism and Their Relationships with Classical Neurotransmitters,” Brain Dysfunct., vol. 3, p. 328-345, 1990.152. Deutsch SI, Campbell M, “Relative Affinities for Different Classes of Neurotransmitter Receptors Predict Neuroleptic Efficacy in Infantile Autism: a Hypothesis,” Neuropsychobiology, vol. 15, p. 160-164, 1986.153. Barthelemy C, Bruneau N, Jouve J, et al., “Urinary Dopamine Metabolites as Indicators of the Responsiveness to Fenfluramine Treatment in Children with Autistic Behavior,” J. Autism Dev. Disorders, vol. 19, p. 241-254, 1989.154. Sloman L, “Use of Medication in Pervasive Developmental Disorders,” Psychiatr. Clin. North Am., vol. 14, p. 165-182, 1991.155. Cotterill RMJ, “Fever in Autistics,” Nature, vol. 313, p. 426, 1985.156. Engelsen B, “Neurotransmitter Glutamate: Its Clinical Importance,” Acta Neurol. Scand., vol. 74, p. 337-355, 1986.157. Adachi H, Fujisawa H, Maekawa T, et al., “Changes in the Extracellular Glutamate Concentrations in the Rat Cortex Following Localized by Hyperthermia,” Int. J. Hyperthermia, vol. 11, p. 587-599, 1995.158. Zornow MH, “Inhibition of Glutamate Release: A Possible Mechanism of Hypothermic Neuroprotection,” J. Neurosurg. Anesthesiol., vol. 7, p. 148-151, 1995.159. Kataoka K, Yanase H, “Mild Hypothermia-A Revived Countermeasure Against Ischemic Neuronal Damages,” Neurosci. Res., vol. 32, p. 103-117, 1998.160. Warren RP, Burger RA, Odell JD, et al., “Decreased Plasma Concentrations of the C4B Complement Protein in Autism,” Arch. Pediatr. Adolesc. Med., vol. 148, p. 180-183, 1994.161. Warren RP, Singh VK, Cole P, et al., “Increased Frequency of the Null Allele at the Complement C4b Locus in Autism,” Clin. Exp. Immunol., vol. 83, p. 438-440, 1991.162. Singh VK, Warren RP, Odell JD, et al., “Changes of Soluble Interleukin-2, Interleukin-2 Receptor, T8 Antigen, and Interleukin-1 in the Serum of Autistic Children,” Clin. Immunol. Immunopath., vol. 61, p. 448-455, 1991.163. Marchetti B, Scifo R, Batticane N, et al., “Immunological Significance of Opioid Peptide Dysfunction in Infantile Autism,” Brain Dysfunction, vol. 3, p. 346-354, 1990.164. Yonk LJ, Warren RP, Burger RA, et al., “CD4+ Helper T Cell Depression in Autism,” Immunol. Lett, vol. 25, p. 341-345, 1990.165. Warren RP, Foster A, Margaretten NC, “Reduced Natural Killer Cell Activity in Autism,” J. Amer. Acad. Child Adol. Psychol., vol. 26, p. 333-335, 1987.
  36. 36. Page 36166. Menage P, Thibault G, Barthelemy C, et al., “CD4+CD45RA+ T Lymphocyte Deficiency in Autistic Children: Effect of a Pyridoxine-Magnesium Treatment,” Brain Dysfunct., vol. 5, p. 326-333, 1992.167. Warren RP, Yonk LJ, Burger RA, et al., “Deficiency of Suppressor-Inducer (CD4+CD45RA+) T Cells in Autism,” Immunol. Invest., vol. 19, p. 245-251, 1990.168. Singh VK, Warren RP, Odell JD, et al., “Antibodies to Myelin Basic Protein in Children with Autistic Behavior,” Brain Behav. Immun., vol. 7, p. 97-103, 1993.169. Plioplys AV, Hemmens SE, Regan CM, “Expression of a Neural Cell Adhesion Molecule Serum Fragment is Depressed in Autism,” J. Neuropsychiatry Clin. Neurosci., vol. 2, p. 413-417, 1990.170. Husby G, Li L, Davis LE, et al., “Antibodies to Human Caudate Nucleus Neurons in Huntington’s Chorea,” J. Clin. Invest., vol. 59, p. 922-932, 1977.171. Cummings JL, Cunningham K, “Obsessive-Compulsive Disorder in Huntington’s Disease,” Biol. Psychiatry, vol. 31, p. 263-270, 1992.172. Maia AS, Barbosa ER, Menezes PR, et al., “Relationship Between Obsessive-Compulsive Disorders and Diseases Affecting Primarily the Basal Ganglia,” Rev. Hosp. Clin. Fac. Med. Sao Paulo, vol. 54, p. 213-221, 1999.173. Arzberger T, Krampfl K, Leimgruber S, et al., “Changes of NMDA Receptor Subunit (NR1, NR2B) and Glutamate Transporter (GLT1) mRNA Expression in Huntington’s Disease – an In Situ Hybridization Study,” J. Neuropathol. Exp. Neurol., vol. 56, p. 440-454, 1997.174. LaHoste GJ, Swanson JM, Wigal SB, et al., “Dopamine D4 Receptor Gene Polymorphism is Associated with Attention Deficit Hyperactivity Disorder,” Mol. Psychiatry, vol. 1, p. 121-124, 1996.175. Mrzljak L, Bergson C, Pappy M, et al., “Localization of Dopamine D4 Receptors in GABAergic Neurons of the Primate Brain,” Nature, vol. 38, p. 245-248, 1996.176. Johnson RT, Richardson EP, “The Neurological Manifestation of Systemic Lupus Erythematosus,” Medicine, vol. 47, p. 337, 1968.177. Moore PM, Lasak RP, “Systemic Lupus Erythematosus: Immunopathogenesis of Neurologic Dysfunction,” Springer Semin. Immunopathol., vol. 17, p. 43-60, 1995.178. Cervera R, Asherson RA, Font J, et al., “Chorea in the Antiphospholipid Syndrome: Clinical Radiologic, and Immunologic Characteristics of 50 Patients from Our Own Clinics and the Literature,” Medicine, vol. 76, p. 203-212, 1997.179. Hanson VG, Horowitz M, Rosenbluth D, et al., “Systemic Lupus Erythematosus Patients with Central Nervous System Involvement Show Autoantibodies to a 50-kD Neuronal Membrane Protein,” J Exp Med., vol. 176, p. 565-73, 1992.180. Sakie B, Szechtman H, Denburg S, et al., “Brain-reactive Antibodies and Behavior of Autoimmune MRL-lpr Mice,” Physiol. Behav., vol. 54, p. 1025-1029, 1993.

×