INTRODUCTION: Alemtuzumab is highly effective in the treatment of patients with relapsing multiple sclerosis (PwRMS) and selectively targets the CD52 antigen, with a consequent profound lymphopenia, particularly of CD4+ T lymphocytes. However, the immunological basis of its long-term efficacy has not been clearly elucidated. METHODS: We followed up 29 alemtuzumab-treated RMS patients over a period of 72 months and studied the immunological reconstitution of their CD4+ T cell subsets by means of phenotypic and functional analysis and through mRNA-related molecule expression, comparing them to healthy subject (HS) values (rate 2:1). RESULTS: In patients receiving only two-course alemtuzumab, the percentage of CD4+ lymphocytes decreased and returned to basal levels only at month 48. Immune reconstitution of the CD4+ subsets was characterized by a significant increase (p < 0.001) in Treg cell percentage at month 24, when compared to baseline, and was accompanied by restoration of the Treg suppressor function that increased within a range from 2- to 6.5-fold compared to baseline and that persisted through to the end of the follow-up. Furthermore, a significant decrease in self-reactive myelin basic protein-specific Th17 (p < 0.0001) and Th1 (p < 0.05) cells reaching HS values was observed starting from month 12. There was a change in mRNA of cytokines, chemokines, and transcriptional factors related to Th17, Th1, and Treg cell subset changes, consequently suggesting a shift toward immunoregulation and a reduction of T cell recruitment to the central nervous system. CONCLUSIONS: These data provide further insight into the mechanism that could contribute to the long-term 6-year persistence of the clinical effect of alemtuzumab on RMS disease activity.

Department of Clinical and Biological Sciences University of Torino Torino Italy

Department of Medical Science and Public Health University of Cagliari and Multiple Sclerosis Center Cagliari Italy

Department of Molecular Biotechnology and Health Sciences University of Torino Torino Italy

Department of Neurology and Center of Clinical Neuroscience 1st Faculty of Medicine Charles University and General University Hospital Prague Czechia

Department of Neurology Clinical Hospital Sveti Duh Zagreb and Medical Faculty University J J Strossmayer Osijek Prague Croatia

Laboratory of Microbiology and Virology Amedeo di Savoia Hospital Torino Italy

Multiple Sclerosis Centre Gallarate Hospital ASST Valle Olona Gallarate Italy

Referral Center for Autonomic Nervous System University Hospital Center Zagreb Zagreb Croatia

School of Medicine University of Zagreb Zagreb Croatia

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