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In generalized myasthenia gravis (MG) patients without detectable acetylcholine receptor (AChR) antibodies (SNMG), the thymus is often reported as "normally involuted." We analyzed thymic compartments in 67 patients with generalized MG, with AChR antibodies (AChR+, n = 23), with muscle-specific kinase (MuSK) antibodies (MuSK+, n = 14) or with neither (MuSK-, n = 30), and in 11 non-MG controls. Four of 14 MuSK+ thymi had rare small germinal centers, but overall they were not different from age-matched controls. However, approximately 75% MuSK- samples showed lymph node-type infiltrates similar to those in AChR+ patients, but with fewer germinal centers. These variations may explain some apparent differences in responses to thymectomy in SNMG.

Myasthenia gravis (MG) is a prototype Ab-mediated autoimmune disease in which Abs against nicotinic acetylcholine receptors (AChR) induce loss of functional receptors at the neuromuscular junction. Germinal centers present in MG hyperplastic thymus contain activated B cells spontaneously producing anti-human AChR (anti-huAChR) Ab in vitro. To access the anti-huAChR repertoire, phage display Fab libraries of thymic lymphocytes were constructed from two MG patients. Four Fabs highly specific for huAChR were isolated that bind to determinants in or near the main immunogenic region. These anti-huAChR Fabs showed evidence of significant somatic mutations, supporting the idea that the anti-huAChR Ab response in MG patients is driven by Ag. Two Fabs were able to inhibit up to 90% of donor serum anti-huAChR Abs. Competition with serum anti-huAChR Ab was also observed in unrelated MG patients and indicate that anti-huAChR Fabs bind to epitopes on huAChR recognized by the majority of MG patients. In vitro antigenic modulation studies demonstrated that anti-huAChR Fabs were able to induce AChR loss when cross-linked by an anti-Fab Ab but not as monovalent Fab. Moreover, anti-huAChR Fabs were able to protect against AChR loss by antigenic modulation induced by MG serum Abs, suggesting a potential therapeutic role for these recombinant Fabs in patients with a myasthenic crisis.

Am J Pathol. 2007 Sep;171(3):893-905. Epub 2007 Aug 3. Myasthenia gravis thymus: complement vulnerability of epithelial and myoid cells, complement attack on them, and correlations with autoantibody status. Leite MI, Jones M, Ströbel P, Marx A, Gold R, Niks E, Verschuuren JJ, Berrih-Aknin S, Scaravilli F, Canelhas A, Morgan BP, Vincent A, Willcox N. Department of Clinical Neurology, University of Oxford, Oxford, United Kingdom. Abstract In early-onset myasthenia gravis, the thymus contains lymph node-type infiltrates with frequent acetylcholine receptor (AChR)-specific germinal centers. Our recent evidence/two-step hypothesis implicates hyperplastic medullary thymic epithelial cells (expressing isolated AChR subunits) in provoking infiltration and thymic myoid cells (with intact AChR) in germinal center formation. To test this, we screened for complement attack in a wide range of typical generalized myasthenia patients. Regardless of the exact serology, thymi with sizeable infiltrates unexpectedly showed patchy up-regulation of both C5a receptor and terminal complement regulator CD59 on hyperplastic epithelial cells. These latter also showed deposits of activated C3b complement component, which appeared even heavier on infiltrating B cells, macrophages, and especially follicular dendritic cells. Myoid cells appeared particularly vulnerable to complement; few expressed the early complement regulators CD55, CD46, or CR1, and none were detectably CD59(+). Indeed, when exposed to infiltrates, and especially to germinal centers, myoid cells frequently labeled for C1q, C3b (25 to 48%), or even the terminal C9, with some showing obvious damage. This early/persistent complement attack on both epithelial and myoid cells strongly supports our hypothesis, especially implicating exposed myoid cells in germinal center formation/autoantibody diversification. Remarkably, the similar changes place many apparent AChR-seronegative patients in the same spectrum as the AChR-seropositive patients. PMID: 17675582 [PubMed - indexed for MEDLINE]PMCID: PMC1959483Free PMC Article Images from this publication.See all images (6) Free text Figure 1 Distribution of complement receptors C3aR, C5aR, and CR1 (receptor for C3b and C4b) (all in red) in epithelial areas and/or infiltrates in thymi from non-MG controls (A and B), AChRAb+ (C–E), or SNMG (F) MG patients. A and B: In control thymi, occasional mTECs are weakly C5aR+, as in some areas in MG thymi, bu... Myasthenia Gravis Thymus Am J Pathol. 2007 September;171(3):893-905.Figure 2 Distribution of complement regulators CD46, CD55, and CD59 (all in red) in epithelial areas and infiltrates in control (A and D) and MG thymi (B, C, and E–I). Cytokeratin (CK, green). A: In controls, CD46 (A) and CD55 (not shown) expression is minimal; in MG, both are much stronger in the MEBs than in the nMe... Myasthenia Gravis Thymus Am J Pathol. 2007 September;171(3):893-905.Figure 3 Labeling for C1q and C3b complement fragments (both in red) in epithelial areas and infiltrates in MG and control thymi. Cytokeratin (CK, green). A and B: In MG, there is extensive patchy labeling for C1q in mTECs and other cells in MEBs and in infiltrates and GC in AChRAb+ (A) or SNMG (B) samples. C: In co... Myasthenia Gravis Thymus Am J Pathol. 2007 September;171(3):893-905.Figure 4 Rarity of complement regulators on myoid cells. In both control (not shown) and MG thymi (A), myoid cells (MC) are uniformly CD59− (red), even when exposed to infiltrates, but ∼5% of the latter express detectable CD55 (red) (B, inset). (Donors both female: A, 20 years of age; B, 16 years of age). Desmin (De, ... Myasthenia Gravis Thymus Am J Pathol. 2007 September;171(3):893-905.Figure 5 Labeling for C1q, C3b, or C9 (all in red) on exposed myoid cells (MC) in MG thymi. Desmin (De, green). A and B: Some exposed myoid cells label for C1q in AChRAb+ (A) or SNMG (B) MG samples, in which many of them label for C3b (C and D; enlarged in insets) and some for C9 in AChRAb+ (E) or SNMG (F) samples. Note aggr... Myasthenia Gravis Thymus Am J Pathol. 2007 September;171(3):893-905.Figure 6 Percentages of myoid cells exposed to the infiltrates in non-MG controls and MG patient subgroups. Their rarity in the control and MuSKAb+ samples reflects the paucity of infiltrates. There were significantly fewer myoid cells/mm2 in the AChRAb+ group than in the controls (see mini-table below; *P < 0.0... Myasthenia Gravis Thymus Am J Pathol. 2007 September;171(3):893-905.

Most patients with Myasthenia Gravis (MG) present a thymic hyperplasia characterized by the presence of lymphoid follicles. The acetylcholine receptor autoantigen, as well as autoantigen specific activated T and B cells found in the thymus, strongly suggest that auto-sensitization could take place in this organ. Since IL-6 is involved in T and B cell growth and differentiation, we thought that abnormal IL-6 expression by thymic epithelial cells (TEC) could be related to thymic hyperplasia in MG. In this paper, IL-6 protein and gene expression by cultured TEC from patients with MG were examined. TEC from patients presented a dramatic IL-6 hyperproduction phenotype as compared to controls when stimulated by exogenous signals such as LPS and cytokines (IL-1 beta, TNF-alpha) alone or in combination. Moreover, we observed a similar effect with a physiological signal such as the syngeneic lympho-epithelial cell contact. Autologous thymocytes stimulated normal and MG TEC IL-6 production in a time- and dose- dependent way, and with a higher magnitude in MG TEC compared to controls. In all stimulation conditions, induction of IL-6 production required protein synthesis and was associated with increased IL-6 mRNA level expression as assessed by computer-aided quantification after in situ mRNA hybridization. In addition, recombinant IL-6 induced in vitro growth of TEC, demonstrating that IL-6 is a possible autocrine growth factor for these cells. This deregulated IL-6 production as well as the ability of TEC to use it as a growth factor may be of pathophysiological relevance in MG. It provides an explanation for morphological changes of the thymus and may have a key role in initiation, exacerbation and ongoing of the autoimmune response in MG. Therefore this study extends our current understanding of the molecular pathophysiology of MG.