Acta Neurol Scand 2016: 133: 268–275 DOI: 10.1111/ane.12453
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA NEUROLOGICA SCANDINAVICA
Impact of Helicobacter pylori on multiple sclerosis-related clinically isolated syndrome Deretzi G, Gavalas E, Boziki M, Tsiptsios D, Polyzos SA, Venizelos I, Zavos C, Koutlas E, Tsiptsios I, Katsinelos P, Kountouras J. Impact of Helicobacter pylori on multiple sclerosis-related clinically isolated syndrome. Acta Neurol Scand 2016: 133: 268–275. © 2015 John Wiley & Sons A/SPublished by John Wiley & Sons Ltd.
G. Deretzi1, E. Gavalas2, M. Boziki3, D. Tsiptsios1, S. A. Polyzos2, I. Venizelos2, C. Zavos2, E. Koutlas1, I. Tsiptsios1, P. Katsinelos2, J. Kountouras2
Objectives – There are no data regarding the relationship between Helicobacter pylori infection (Hp-I) and clinically isolated syndrome (CIS) suggestive of multiple sclerosis. The purpose of this pilot study was to investigate the association between active Hp-I, confirmed by histology, and CIS and to evaluate the impact of Hp eradication on the CIS clinical course. Material and Methods – We conducted a study on 48 patients with CIS and 20 matched controls. At baseline, apart from histology, serum anti-Hp-specific IgG titer, inflammatory mediators, and HLA-A, HLA-B, HLA-DR genetic polymorphisms were estimated. Hp-positive patients received standard triple eradication regimen, and all patients were followed up for 2 years. Results – The prevalence of Hp-I was significantly higher in patients with CIS (43/48, 89.6%) than in control (10/20, 50%) (P < 0.001, OR: 8.6, 95% CI: 2.4–30.8). When compared with controls, patients with CIS also showed significantly higher serum anti-Hp IgG titer and HLA-A26, HLA-A30, and HLA-B57 frequencies. Hp-positive patients also showed higher serum concentrations of inflammatory cytokines and homocysteine. At 2-year clinical endpoint, in the subgroup of CIS patients with successful Hp eradication, the number of patients who presented with a second episode was significantly lower accompanied by significant improvement in mean Expanded Disability Status Scale score. Conclusions – Hp-I seems more frequent in a Greek CIS cohort and its eradication might delay CIS progression, suggesting a possible link between Hp-I and CIS.
1 Multiple Sclerosis Unit, Department of Neurology, “Papageorgiou” Hospital, Thessaloniki, Greece; 2 Department of Medicine, Second Medical Clinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece; 32nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
Introduction
Clinically isolated syndrome (CIS) is a first clinical event compatible with multiple sclerosis (MS) (1). Two-thirds of patients with CIS will have further episodes of neurological dysfunction and will develop clinically definite MS (2). Although the early events in MS remain uncertain, active systemic inflammation may determine the initial phase of the disease and infections may contribute to the inflammatory milieu in active MS lesions (3). In this regard, Helicobacter pylori infection (Hp-I) has been implicated in neurodegenerative diseases (4, 5) including cerebrovascular diseases (6), Alzheimer’s disease (AD) (7), mild cognitive impairment (8), Parkinson’s 268
Key words: clinically isolated syndrome; Helicobacter pylori; histological analysis; HLA alleles; multiple sclerosis; proinflammatory cytokines G. Deretzi, Department of Neurology, Multiple Sclerosis Unit, Papageorgiou General Hospital, Ring Road of Nea Efkarpia, 564 29, Thessaloniki, Macedonia, Greece Tel.: +30 2310 693943 Fax: +30 2310 677692 e-mails: [email protected], [email protected] Accepted for publication May 26, 2015
disease (9), seizure disorders (10), and ophthalmic disorder (11). Moreover, there are few contradictory data showing negative (12–16) or positive (17, 18) correlations between Hp-I and MS spectrum; these conflicting findings may be due to ethnic, population-related, and methodological differences (19). Currently, there are no data regarding the relationship between active Hp-I and CIS. The aim of this study was to investigate the association between active Hp-I, confirmed by histology, and CIS suggestive of MS and to evaluate the effect of Hp eradication on the clinical course of CIS. In this context, baseline inflammatory mediators, including interleukins (ILs), tumor necrosis factor (TNF)-a, interferon (IFN)-c, homocysteine (Hcy),
H. pylori and clinically isolated syndrome cyanocobalamin (B12), and folate (Fol) were estimated, and HLA-A, HLA-B, HLA-DR genetic polymorphisms were analyzed. Material and methods Study population
This was a two-phase study. Phase 1 was crosssectional designed to evaluate the prevalence of Hp-I in patients with CIS. Forty-eight patients with documented CIS (1), selected randomly, and 20 age- and gender-matched non-CIS controls, who were undergoing upper and lower gastrointestinal (GI) endoscopy for the investigation of mild iron-deficiency anemia (IDA), but in whom endoscopy was without obvious macroscopic abnormalities, were included in this phase of the study. The main exclusion criteria were as follows: (i) evidence of a second clinical demyelinating episode before endoscopic procedure and (ii) the presence of diagnostic criteria of other demyelinating diseases (1, 2). Additional exclusion criteria were described previously (20). All patients were diagnosed and followed up at the MS Unit of Neurology Department of ‘Papa-
Recruitment Hp (–) CIS (n = 5)
georgiou’ General Hospital of Thessaloniki. All patients and controls underwent diagnostic upper GI endoscopy after providing informed consent. Hp detection method has been described previously (20). Specifically, the pathologist (I.V.) who assessed all gastric mucosa biopsy specimens was unaware of Hp serology and clinical diagnosis. In the second phase of the study, we performed a 2-year, open label interventional study to evaluate the effect of Hp eradication treatment on the natural history of CIS. The type of Hp eradication regimen received by Hp-positive CIS patients and the success rate were described previously (20). Therefore, the follow-up study population was classified into three CIS groups: consisting of the patients who were Hp negative at baseline (Group A); those in whom Hp treatment was successful (Group B); and those in whom eradication of Hp had failed (Group C) (Fig. 1). Six Hp-positive CIS patients refused to present to follow-up visits and were excluded from the study (Fig. 1). Two neurologists (G.D. and E.K.) assessed Expanded Disability Status Scale (EDSS), the time of the second attack, and number of patients with relapses, over a 2-year follow-up (6, 12, and 24 post-initial attack months). Magnetic
Recruitment
Outcome
Hp (–) CIS (n = 5)
Group A (n = 5)
CIS patients (n = 48)
Hp (+) CIS patients (n = 43)
6 CIS patients excluded
Hp (+) CIS (n = 37)
Successful eradication Hp (–) (n = 28)
Group B (n = 28)
Unsuccessful eradication Hp (+) (n = 9)
Group C (n = 9)
Underwent eradication (n = 37)
Controls (n = 20)
Figure 1. Flow chart of the study. Group A, Helicobacter pylori (Hp)-negative clinical isolated syndrome (CIS) patients at baseline (n = 5); Group B, patients with CIS in whom Hp treatment was successful (n = 28); Group C, patients with CIS in whom eradication of Hp had failed (n = 9).
269
Deretzi et al. resonance imaging (MRI) was performed at baseline and at 12 post-initial attack months. MRI parameters were defined as number of lesions on brain and cervical MRI. All neurological parameters were assessed blindly to the Hp status of the patients. Serological markers
Apart from Hp serology estimated in all participants (patients and controls) at baseline and described previously (20), in all patients with CIS, serum cytokine concentrations (IL-1b, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, TNF-a, and IFN-c) were measured by enzyme-linked immunosorbent assay (ELISA), using commercially available kits (BioSourceTM, Nivelles, Belgium). Serum Hcy, B12, and Fol concentrations were also measured by a competitive immunoassay, using direct chemiluminescence (Siemens Healthcare Diagnostics, Deerfield. Νormal ranges: Hcy, 3.7–13.9 lmol/l; B12, 211–911 pg/ml; Fol
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA NEUROLOGICA SCANDINAVICA
Impact of Helicobacter pylori on multiple sclerosis-related clinically isolated syndrome Deretzi G, Gavalas E, Boziki M, Tsiptsios D, Polyzos SA, Venizelos I, Zavos C, Koutlas E, Tsiptsios I, Katsinelos P, Kountouras J. Impact of Helicobacter pylori on multiple sclerosis-related clinically isolated syndrome. Acta Neurol Scand 2016: 133: 268–275. © 2015 John Wiley & Sons A/SPublished by John Wiley & Sons Ltd.
G. Deretzi1, E. Gavalas2, M. Boziki3, D. Tsiptsios1, S. A. Polyzos2, I. Venizelos2, C. Zavos2, E. Koutlas1, I. Tsiptsios1, P. Katsinelos2, J. Kountouras2
Objectives – There are no data regarding the relationship between Helicobacter pylori infection (Hp-I) and clinically isolated syndrome (CIS) suggestive of multiple sclerosis. The purpose of this pilot study was to investigate the association between active Hp-I, confirmed by histology, and CIS and to evaluate the impact of Hp eradication on the CIS clinical course. Material and Methods – We conducted a study on 48 patients with CIS and 20 matched controls. At baseline, apart from histology, serum anti-Hp-specific IgG titer, inflammatory mediators, and HLA-A, HLA-B, HLA-DR genetic polymorphisms were estimated. Hp-positive patients received standard triple eradication regimen, and all patients were followed up for 2 years. Results – The prevalence of Hp-I was significantly higher in patients with CIS (43/48, 89.6%) than in control (10/20, 50%) (P < 0.001, OR: 8.6, 95% CI: 2.4–30.8). When compared with controls, patients with CIS also showed significantly higher serum anti-Hp IgG titer and HLA-A26, HLA-A30, and HLA-B57 frequencies. Hp-positive patients also showed higher serum concentrations of inflammatory cytokines and homocysteine. At 2-year clinical endpoint, in the subgroup of CIS patients with successful Hp eradication, the number of patients who presented with a second episode was significantly lower accompanied by significant improvement in mean Expanded Disability Status Scale score. Conclusions – Hp-I seems more frequent in a Greek CIS cohort and its eradication might delay CIS progression, suggesting a possible link between Hp-I and CIS.
1 Multiple Sclerosis Unit, Department of Neurology, “Papageorgiou” Hospital, Thessaloniki, Greece; 2 Department of Medicine, Second Medical Clinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece; 32nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
Introduction
Clinically isolated syndrome (CIS) is a first clinical event compatible with multiple sclerosis (MS) (1). Two-thirds of patients with CIS will have further episodes of neurological dysfunction and will develop clinically definite MS (2). Although the early events in MS remain uncertain, active systemic inflammation may determine the initial phase of the disease and infections may contribute to the inflammatory milieu in active MS lesions (3). In this regard, Helicobacter pylori infection (Hp-I) has been implicated in neurodegenerative diseases (4, 5) including cerebrovascular diseases (6), Alzheimer’s disease (AD) (7), mild cognitive impairment (8), Parkinson’s 268
Key words: clinically isolated syndrome; Helicobacter pylori; histological analysis; HLA alleles; multiple sclerosis; proinflammatory cytokines G. Deretzi, Department of Neurology, Multiple Sclerosis Unit, Papageorgiou General Hospital, Ring Road of Nea Efkarpia, 564 29, Thessaloniki, Macedonia, Greece Tel.: +30 2310 693943 Fax: +30 2310 677692 e-mails: [email protected], [email protected] Accepted for publication May 26, 2015
disease (9), seizure disorders (10), and ophthalmic disorder (11). Moreover, there are few contradictory data showing negative (12–16) or positive (17, 18) correlations between Hp-I and MS spectrum; these conflicting findings may be due to ethnic, population-related, and methodological differences (19). Currently, there are no data regarding the relationship between active Hp-I and CIS. The aim of this study was to investigate the association between active Hp-I, confirmed by histology, and CIS suggestive of MS and to evaluate the effect of Hp eradication on the clinical course of CIS. In this context, baseline inflammatory mediators, including interleukins (ILs), tumor necrosis factor (TNF)-a, interferon (IFN)-c, homocysteine (Hcy),
H. pylori and clinically isolated syndrome cyanocobalamin (B12), and folate (Fol) were estimated, and HLA-A, HLA-B, HLA-DR genetic polymorphisms were analyzed. Material and methods Study population
This was a two-phase study. Phase 1 was crosssectional designed to evaluate the prevalence of Hp-I in patients with CIS. Forty-eight patients with documented CIS (1), selected randomly, and 20 age- and gender-matched non-CIS controls, who were undergoing upper and lower gastrointestinal (GI) endoscopy for the investigation of mild iron-deficiency anemia (IDA), but in whom endoscopy was without obvious macroscopic abnormalities, were included in this phase of the study. The main exclusion criteria were as follows: (i) evidence of a second clinical demyelinating episode before endoscopic procedure and (ii) the presence of diagnostic criteria of other demyelinating diseases (1, 2). Additional exclusion criteria were described previously (20). All patients were diagnosed and followed up at the MS Unit of Neurology Department of ‘Papa-
Recruitment Hp (–) CIS (n = 5)
georgiou’ General Hospital of Thessaloniki. All patients and controls underwent diagnostic upper GI endoscopy after providing informed consent. Hp detection method has been described previously (20). Specifically, the pathologist (I.V.) who assessed all gastric mucosa biopsy specimens was unaware of Hp serology and clinical diagnosis. In the second phase of the study, we performed a 2-year, open label interventional study to evaluate the effect of Hp eradication treatment on the natural history of CIS. The type of Hp eradication regimen received by Hp-positive CIS patients and the success rate were described previously (20). Therefore, the follow-up study population was classified into three CIS groups: consisting of the patients who were Hp negative at baseline (Group A); those in whom Hp treatment was successful (Group B); and those in whom eradication of Hp had failed (Group C) (Fig. 1). Six Hp-positive CIS patients refused to present to follow-up visits and were excluded from the study (Fig. 1). Two neurologists (G.D. and E.K.) assessed Expanded Disability Status Scale (EDSS), the time of the second attack, and number of patients with relapses, over a 2-year follow-up (6, 12, and 24 post-initial attack months). Magnetic
Recruitment
Outcome
Hp (–) CIS (n = 5)
Group A (n = 5)
CIS patients (n = 48)
Hp (+) CIS patients (n = 43)
6 CIS patients excluded
Hp (+) CIS (n = 37)
Successful eradication Hp (–) (n = 28)
Group B (n = 28)
Unsuccessful eradication Hp (+) (n = 9)
Group C (n = 9)
Underwent eradication (n = 37)
Controls (n = 20)
Figure 1. Flow chart of the study. Group A, Helicobacter pylori (Hp)-negative clinical isolated syndrome (CIS) patients at baseline (n = 5); Group B, patients with CIS in whom Hp treatment was successful (n = 28); Group C, patients with CIS in whom eradication of Hp had failed (n = 9).
269
Deretzi et al. resonance imaging (MRI) was performed at baseline and at 12 post-initial attack months. MRI parameters were defined as number of lesions on brain and cervical MRI. All neurological parameters were assessed blindly to the Hp status of the patients. Serological markers
Apart from Hp serology estimated in all participants (patients and controls) at baseline and described previously (20), in all patients with CIS, serum cytokine concentrations (IL-1b, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, TNF-a, and IFN-c) were measured by enzyme-linked immunosorbent assay (ELISA), using commercially available kits (BioSourceTM, Nivelles, Belgium). Serum Hcy, B12, and Fol concentrations were also measured by a competitive immunoassay, using direct chemiluminescence (Siemens Healthcare Diagnostics, Deerfield. Νormal ranges: Hcy, 3.7–13.9 lmol/l; B12, 211–911 pg/ml; Fol
