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Acetylcholine receptor (AChR) antibodies are present in around 85% of patients with myasthenia gravis (MG) as measured by the conventional radioimmunoprecipitation assay. Antibodies that block the fetal form of the AChR are occasionally present in mothers who develop MG after pregnancy, especially in those whose babies are born with arthrogryposis multiplex congenita. The antibodies cross the placenta and block neuromuscular transmission, leading to joint deformities and often stillbirth. In these mothers, antibodies made in the thymus are mainly specific for fetal AChR and show restricted germline origins, suggesting a highly mutated clonal response; subsequent spread to involve adult AChR could explain development of maternal MG in those cases who first present after pregnancy. In the 15% of "seronegative" MG patients without AChR antibodies (SNMG), there are serum factors that increase AChR phosphorylation and reduce AChR function, probably acting via a different membrane receptor. These factors are not IgG and could be IgM or even non-Ig serum proteins. In a proportion of SNMG patients, however, IgG antibodies to the muscle-specific kinase, MuSK, are present. These antibodies are not found in AChR antibody-positive MG and are predominantly IgG4. MuSK antibody positivity appears to be associated with more severe bulbar disease that can be difficult to treat effectively.

Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder in which antibodies to presynaptic calcium channels at the neuromuscular junction lead to muscle weakness. Around 60% of patients with LEMS have an associated small cell lung carcinoma (SCLC), which is known to express voltage-gated calcium channels (VGCCs). Immunoglobulin (IgG) from patients with LEMS causes inhibition of calcium flux in an SCLC cell line.1 This inhibition has been shown to correlate with disease severity.1 Neuronal VGCCs can be classified into P-, Q-, N-, L-, and R-type according to their electrophysiological and pharmacological properties. Around 92% of LEMS patients have antibodies that immunoprecipitate P/Q-type (125I-CTx-MVIIC labeled) VGCCs and around 30% have antibodies to N-type (125I-CTx-GVIA labeled) VGCCs.2 In addition, antibodies from LEMS patients have been shown to abolish the component of neurotransmitter release subserved by both P-type and Q-type VGCCs in sympathetic and parasympathetic neurons of mice injected with LEMS IgG.3 Neuronal VGCCs consist of an 1 subunit with and 2 subunits. Several of the human genes encoding the different types of VGCC have now been cloned and sequenced, including the 1A, 1B, 1D, 1E, 1–4, and 2 subunits. Human embryonic

Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder of neuromuscular transmission in which antibodies are directed against voltage-gated calcium channels (VGCCs). We studied the action of LEMS immunoglobulin G (IgG) on cloned human VGCCs stably transfected into human embryonic kidney cells (HEK293). All LEMS IgGs tested bound to the surface of the P/Q-type VGCC cell line and caused a significant reduction in whole-cell calcium currents in these cells. By contrast, only 2 out of 6 IgGs bound extracellularly to the N-type VGCC cell line, and none of the LEMS IgGs tested was able to reduce whole-cell calcium currents in these cells. We used this apparent specificity of LEMS IgG for the P/Q-type VGCC to investigate the action of these IgGs on model systems where a number of different VGCC populations exist in equilibrium. LEMS IgG caused a significant downregulation in the omega-agatoxin IVA-sensitive P/Q-type VGCCs of cultured rat cerebellar neurons, but this was accompanied by a concomitant rise in the "resistant" R-type VGCCs. By using the passive transfer model of LEMS, similar results were observed at the mouse neuromuscular junction, where a significant reduction in P/Q-type VGCCs was paralleled by an increase in L- and R-type VGCCs. These results demonstrate an unexpected plasticity in the expression of VGCCs in mammalian neurons and may represent a mechanism by which the pathogenic effects of LEMS IgG are reduced.

The role of antibodies to specific neuronal and muscle ion channels in the etiology of neuromuscular transmission disorders is now well accepted. In addition, maternal antibodies can cross the placenta and cause neonatal disease or even alter the development of the infant, raising the possibility that some neurodevelopmental conditions could be caused by maternal antibodies. Voltage-gated ion channels are expressed in the brain as well as at the neuromuscular junction, and in recent years it has become clear that antibodies to some central nervous system (CNS) channels can be associated with CNS disease. This review highlights features of these conditions, preliminary investigations into neurodevelopmental disorders, and areas for further study.

The Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder of neuromuscular transmission that causes fatigable muscle weakness, loss of tendon reflexes, and autonomic dysfunction.1–3 LEMS antibodies bind to and induce a downregulation of voltage-gated channels (VGCCs),4,5 resulting in a reduction in the nerve-evoked, Ca2+-dependent release of acetylcholine from motor nerve terminals. Approximately 60% of patients have an associated small cell lung carcinoma (SCLC),6 a tumor that is thought to be neuroendocrine in origin. This strong association with cancer makes LEMS a member of the group of paraneoplastic disorders. SCLC cells have been shown to express functional VGCCs,7,8 and preincubation in LEMS sera or IgG reduces the K+-stimulated 45Ca2+ flux into these cells.8–10