Anti-Alpha-2-Macroglobulin-Like-1 Autoantibodies Are Detected Frequently and May Be Pathogenic in Paraneoplastic Pemphigus Sanae Numata, Kwesi Teye,

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Anti-Alpha-2-Macroglobulin-Like-1 Autoantibodies Are Detected Frequently and May Be Pathogenic in Paraneoplastic Pemphigus Sanae Numata, Kwesi Teye, Daisuke Tsuruta, Ryosuke Sogame, Norito Ishii, Hiroshi Koga, Yohei Natsuaki, Atsunari Tsuchisaka, Takahiro Hamada, Tadashi Karashima, Takekuni Nakama, Minao Furumura, Chika Ohata, Tamihiro Kawakami, Isabelle Schepens, Luca Borradori, Takashi Hashimoto Journal of Investigative Dermatology Volume 133, Issue 7, Pages 1785-1793 (July 2013) DOI: 10.1038/jid.2013.65 Copyright © 2013 The Society for Investigative Dermatology, Inc Terms and Conditions

Figure 1 Immunofluorescence (IF) for expression of alpha-2-macroglobulin-like-1 (A2ML1) in the human skin and rat bladder. (a) IF of normal human skin sections. (b) IF of rat bladder sections. Anti-A2ML1 mouse polyclonal antibody (A2ML1 pAb), purified normal mouse IgG, paraneoplastic pemphigus (PNP) serum, and normal human serum were used. Bar=100μm. Journal of Investigative Dermatology 2013 133, 1785-1793DOI: (10.1038/jid.2013.65) Copyright © 2013 The Society for Investigative Dermatology, Inc Terms and Conditions

Figure 2 Immunofluorescence (IF) studies of alpha-2-macroglobulin-like-1 (A2ML1) complementary DNA (cDNA)-transfected COS7 cells. (a) IF of COS7 cells expressing c-Myc-tagged A2ML1, triple-stained with a representative paraneoplastic pemphigus (PNP) serum and 4′,6-diamidino-2-phenylindole (DAPI), as well as with either anti-c-Myc pAb or anti-A2ML1 mouse polyclonal antibody (A2ML1 pAb). Bar=20μm. (b) IF of A2ML1-expressing COS7 cells, double-stained with 58 PNP sera and DAPI. The case numbers are the same as the case numbers in immunoprecipitation and immunoblotting (IP–IB) figure and Supplementary Table S1 online. PNP2, PNP4, PNP7, PNP8, and PNP9 showed positive reactivity, while PNP1, PNP3, PNP11, and PNP13 were negative. Positive cells are indicated by arrows. Bar=100μm. Journal of Investigative Dermatology 2013 133, 1785-1793DOI: (10.1038/jid.2013.65) Copyright © 2013 The Society for Investigative Dermatology, Inc Terms and Conditions

Figure 3 Immunoblotting (IB) study of four fractions of COS7 cells, immunoprecipitation and immunoblotting (IP–IB) of alpha-2-macroglobulin-like-1 (A2ML1) complementary DNA (cDNA)–transfected COS7 cells for various sera, and IB of normal human keratinocyte (NHK) extracts under non-reducing and reducing conditions. (a) Blots of four fractions obtained from A2ML1 cDNA–transfected COS7 cells, stained with amido-black (left panel), and processed for IB for anti-c-Myc pAb (right panel). (b) IP buffer extracts of COS7 cells transfected with or without A2ML1 cDNA were stained with amido-black, and processed for IB using both anti-c-Myc pAb and anti-A2ML1 mouse polyclonal antibody (A2ML1 pAb). (c) IP buffer extracts of transfected COS7 cells were immunoprecipitated with the representative paraneoplastic pemphigus (PNP) sera, disease control sera, and normal sera, as well as anti-c-Myc pAb, and immunoblotted with anti-c-Myc pAb. The A2ML1 recombinant protein (RP) was detected by sera of PNP1–PNP10 (lanes 4–13), but not by sera of PNP11–PNP13 (lanes14–16). In lane 26, IP buffer extract of transfected COS7 cell was directly stained by IB with anti-c-Myc pAb. The positions of molecular weight (MW) markers and A2ML1 RP are shown by bars and arrows, respectively, in the left of each panel. (d) The results of IB under non-reducing condition. MWs are not shown, because MW markers cannot be used in this condition. The PNP sera with numbers surrounded by squares, but no control sera, reacted with the protein band corresponding to A2ML1. Some PNP sera also reacted with envoplakin (EPL) and periplakin (PPL). (e) IB under reducing condition. No sera reacted with the 170kDa A2ML1, while some PNP sera reacted with EPL or PPL. Positions of EPL, PPL, and A2ML1 are shown in the left of each panel. BP, bullous pemphigoid; PF, pemphigus foliaceus. Journal of Investigative Dermatology 2013 133, 1785-1793DOI: (10.1038/jid.2013.65) Copyright © 2013 The Society for Investigative Dermatology, Inc Terms and Conditions

Figure 4 Influence of the presence of anti-alpha-2-macroglobulin-like-1 (A2ML1) antibodies on age at onset of paraneoplastic pemphigus (PNP) and the appearance of various mucosal lesions. Statistically significant differences were seen in age at disease onset and ocular mucosal lesion, but not in oral, nasal, or genital mucosal lesions. *P=0.05 (after Bonferroni adjustment). Journal of Investigative Dermatology 2013 133, 1785-1793DOI: (10.1038/jid.2013.65) Copyright © 2013 The Society for Investigative Dermatology, Inc Terms and Conditions

Figure 5 Anti-alpha-2-macroglobulin-like-1 (A2ML1) polyclonal Ab (pAb) caused cell–cell dissociation and plasmin activation in cultured normal human keratinocytes (NHKs). (a) A2ML1 expression in cultured NHKs. Immunoblotting (IB) using anti-A2ML1 mouse polyclonal antibody (A2ML1 pAb) was performed for either 100 × concentrated culture media or cell extracts of NHKs cultured in low calcium (at day 1) and in high calcium (at days 1–5). The position of A2ML1 recombinant protein (RP) is shown by an arrow in the left. (b) Anti-A2ML1 pAb bound to A2ML1 in NHK culture medium. IB using anti-A2ML1 pAb was performed for either 100 × concentrated culture media of NHKs. Lane 4 was for culture medium without treatments of antibody and protein G, lane 5 for culture medium incubated with anti-A2ML1 pAb and precipitated with protein G, and lane 6 for culture medium incubated with negative control mouse IgG and precipitated with protein G. Although the reactivity was weak, A2ML1 disappeared in culture medium incubated with anti-A2ML1 pAb after precipitation with protein G agarose (lane 5). The position of A2ML1 RP is shown by arrows in both sides. Extracts of COS7 cells with or without transfection of A2ML1 complementary DNA (cDNA) were used as positive and negative controls, respectively, in both panels (a) and (b). The positions of molecular weight (MW) markers and a nonspecific band are indicated by bars and asterisks (*), respectively, in the left of both panels (a) and (b). (c) Anti-A2ML1 pAb decreased cell–cell adhesion of NHKs. Upper panel shows culture dishes after the process of dissociation assay, and lower panel shows numbers of fragments by histograms, in which each bar corresponds to the dish in the upper panel. NHKs were cultured with anti-A2ML1 pAb, anti-periplakin (PPL) mAb, or normal mouse IgG at a concentration of 1μgml−1, or without antibody (Ab(-)), for one day after calcium shift. After treatment with dispase II, detached cell sheets were pipetted and fragments were counted. (d) Anti-A2ML1 pAb increased plasmin activity. Casein zymography was performed using culture media of NHKs cultured with anti-A2ML1 pAb, anti-PPL mAb, or normal mouse IgG at a concentration of 1μgml−1, or without antibody (Ab(-)), for one day after calcium shift. The arrows in the left indicate the position of the 91kDa plasmin and the 23kDa trypsin. Journal of Investigative Dermatology 2013 133, 1785-1793DOI: (10.1038/jid.2013.65) Copyright © 2013 The Society for Investigative Dermatology, Inc Terms and Conditions