Development of New Autoimmunity Against T Cell Antigens Derived From Retinal Proteins After Allogeneic Hematopoietic Cell Transplantation.

Graft versus host disease (GvHD) is mainly mediated by T cells recognizing major (MHC) and minor (miHAG) histocompatibility antigens (human leukocyte antigens and MHC-restricted epitopes, respectively). The clinical appearance of a GvHD affecting the central nervous system (CNS) and the retina as part of the CNS is rare and evidence is limited to single case reports. Some publications describe the development of new autoimmunity after hematopoietic cell transplantation (HCT) manifested as hemolytic anemia (AIHA), immune thrombocytopenia (ITP) or myasthenia gravis. Of note, new autoinflammatory diseases affecting the retina have not been reported. In this study we investigated the GvHD of the retina and examined the development of new autoimmune T cell responses against epitopes derived from proteins exclusively expressed in the retina.

We analyzed T cells from 8 women and 12 men with a median age of 55 years (range 29 – 69 years) that had underwent HCT. Underlying diseases were acute lymphoblastic leukemia (n = 1), acute myeloid leukemia, (n = 6), chronic myeloid leukemia (n = 1), myelodysplastic syndrome (n = 3), myeloproliferative syndromes (primary myelofibrosis, n = 2; essential thrombocytemia with secondary myelofibrosis, n = 2; polycythemia vera with secondary myelofibrosis, n = 1), B-cell non-Hodgkin lymphoma (gray zone lymphoma, n = 1; follicular lymphoma, n = 1; peripheral T cell lymphoma, n = 1) and Hodgkin's lymphoma (n = 1). Potential T cell epitopes from four unique highly polymorphic retinal proteins (membrane-bound retinal guanylate cyclase 1 protein (retGC), the guanylate cyclase activating proteins 1 and 2 (GCAP1 and GCAP2) and the retinoid binding protein 3 (RBP3)) were identified using 2 approaches. First, genomic DNA derived from both donor and recipient coding for these proteins was sequenced by Sanger sequencing in search of single nucleotide polymorphisms (SNP). Second, alternate peptide expression based on known SNP was predicted using internet based databases (EpiToolKit). The predicted epitopes were synthesized and used in T cell assays. Peripheral blood mononuclear cells (PBMCs) from patients after hematopoietic regeneration (neutrophils > 500/μl) were stimulated with SNP peptide pairs (peptides pairs differing in one amino acid) and analyzed by IFNg-ELISPOT and flow cytometry.

In 5 out of 20 patients (25%), strong T cell responses against peptides derived from retGC as well as from GCAP1 and GCAP2 were observed which were not detectable before HCT and not reflected by a difference in the DNA sequence between donor and recipient. Two patients of the cohort presented with visual loss which was due to cone dystrophy (n = 1) and retrobulbar optic neuritis (n = 1). In the patient with cone dystrophy, we observed circulating antigen specific T cells against peptides derived from retGC. The patient with retrobulbar optic neuritis did not have antigen specific T cell responses. In 2 clinically silent patients, we found IFNg producing CD4⁺ T cells that recognized a predicted GCAP1-derived self-peptide. One patient also had a strong T cell response against a GCAP2-derived self-peptide. The T cells specifically recognized the peptide represented in the autologous DNA sequence; no reactivity was seen after stimulation with the SNP peptide. Furthermore, the T cell reactions persisted over time and were still detectable one year after HCT. In another patient, T cell responses against the pair of GCAP2 peptides were detected. Here, the reactivity against one peptide could not be discriminated due to limited availability of patient T cells. One further patient displayed T cell responses against GCAP and retGC peptides, which were directed against both self- and SNP peptides. As controls we stimulated T cells from 5 HLA-matched healthy individuals with all respective peptides and observed no T cell reaction.

25% of the patients revealed strong T cell responses against retinal autoantigens after HCT. T cell responses detected late after HCT as observed in 3 patients might indicate a chronic antigen exposure. Clinical manifestations were cone dystrophy (here, antigen-specific T cells against cone protein-derived peptides could be detected) and retrobulbar optic neuritis. To our knowledge, this is the first report on antigen-specificity of neoautoinflammatory cells after allogeneic HCT.

No relevant conflicts of interest to declare.