Background
A possible role of immune system abnormalities in the pathogenesis of some neurologic disorders, including autism, was postulated. Autoimmunity to the central nervous system is the most common of these abnormalities [
1,
2]. Brain-specific auto-antibodies were detected in the sera of many autistic children [
3‐
10]. In addition, autoimmune disorders are increased in families of some children with autism [
11‐
14]. There is a strong association between autism and the major histocompatibility complex for the null allele of C4B in the class III region. This results in low production of C4B protein, leading to repeated infections that play an important role in the development of autoimmunity [
15‐
18]. Some autistic children have an imbalance of T helper (Th)1/Th2 subsets toward Th2, which are responsible for allergic response and production of autoantibodies [
1].
One of the common serological hallmarks of autoimmune disorders is the presence of various autoantibodies in the sera of patients affected by these disorders [
19]. The presence of abnormal levels of autoantibodies to intracellular antigens is a hallmark of several autoimmune diseases [
20].
Evidence accumulated in recent years suggests that the nucleosome, the fundamental unit of chromatin and a normal product of cell apoptosis, plays a key role in some autoimmune diseases as it is a major target autoantigen for autoantibody mediated tissue lesions [
21,
22]. The broad antinucleosome antibody family includes: the nucleosome-specific antibodies (antinucleosome antibodies without anti ds-DNA and antihistone reactivities), the antinucleosome antibodies with anti ds-DNA reactivity, and the antinucleosome antibodies with antihistone reactivity [
23]. Anti ds-DNA antibodies account for a minor part (<30%) of the serum antinucleosome reactivity in lupus patients and nucleosome-specific autoantibodies are in large excess over anti ds-DNA in lupus patients [
24].
Due to the paucity of studies investigating the frequency of systemic auto-antibodies in autism, we are the first to investigate the frequency of antinucleosome-specific antibodies in a group of autistic children.
Discussion
Autoimmunity may have a role in the pathogenesis of autism. Immune system dysfunction may represent novel targets for treatment in autism [
1‐
3]. In our series, autistic children had significantly higher serum levels of antinucleosome-specific antibodies than healthy controls (
P <0.001). According to the highest cut-off value of serum antinucleosome-specific antibodies, increased serum levels of these antibodies were found in 46.7% of autistic children. We could not trace data in literature regarding the frequency of antinucleosome-specific antibodies in children with autism to compare with our results.
Pathological T cell clones that recognize double-stranded DNA and nucleosomes further drive B cell production of anti-DNA and antinucleosome autoantibodies. Deposition of these autoantibodies within the brain and other organ systems contributes to the pathophysiology and clinical manifestations of autoimmune diseases such as SLE [
28]. Complement-fixing IgG autoantibodies including anti-DNA and antinucleosome antibodies may cross the blood-brain barrier and combine with brain tissue antigens to form immune complexes that damage the neurological tissue in autistic patients [
4].
The term ‘nucleosome’ defines a basic unit of chromatin. Each nucleosome consists of 146 base pairs of double stranded DNA, wrapped twice around a histone octamer, a protein core. A histone octamer consists of two molecules each of histones H2A, H2B, H3, and H4. In chromatin, nucleosomes are connected by 15 to 80 base pairs of linker DNA, to which histone H1 is attached. Anti-dsDNA and anti-histone antibodies belong to the nucleosome family as do antinucleosome-specific antibodies, since nucleosomes share several common epitopes with dsDNA and histones. Nucleosome-specific antibodies do not react with the individual components of the nucleosome (that is, DNA and histones) but recognize conformational epitopes resulting from interactions between the DNA and histone [
29]. Nucleosomes are generated
in vivo by the process of apoptosis, which is disturbed in some autoimmune diseases such as SLE. Nucleosomes are the major target autoantigens for autoantibodies mediating tissue lesions, especially glomerulonephritis in SLE [
30,
31]. Previous studies have reported that antinucleosome antibody reactivity is a very sensitive marker of SLE [
32‐
37]. Similarly, it has been reported that 30% of SLE patients with high antinucleosome-specific antibody reactivity have little, if any, anti ds-DNA or antihistone reactivity [
34].
The mechanisms that lead to the induction of antinucleosome specific autoantibodies in some autoimmune diseases remain obscure. In view of the prominence of nucleosomes which circulate at high levels in some autoimmune diseases such as SLE [
38], it has been speculated that highly accelerated rates of apoptosis [
39], and/or abnormal sites or abnormal processing of apoptotic cells could lead to autoantibody production [
40]. Also, nucleosomes may elicit the production of interleukin-6 and stimulation of lymphoproliferation and IgG synthesis by splenic B cells. This could result in a polyclonal activation that triggers both a specific (nucleosome-driven) and nonspecific antibody production [
38]. Alteration of the selected parameters confirm the role of apoptosis and neuroinflammation mechanisms in the etiology of autism [
41]. The apoptotic marker soluble fatty acid synthase antigen was reported to be high in Saudi children with severe autism, and can be considered an indicator of disease severity [
42]. Disturbances in brain glutathione homeostasis may contribute to oxidative stress, immune dysfunction and apoptosis, particularly in the cerebellum and temporal lobe, and may lead to neurodevelopmental abnormalities in autism [
43]. Thus, accelerated rates of apoptosis in autism, like in SLE, may be the possible reason behind the increased frequency of antinucleosome-specific autoantibodies in some autistic children as shown in this study. Additional investigation designed to expand on these data is warranted.
Other possible reasons behind the initiation of autoimmunity and the production of autoantibodies in some autistic children may be attributed to the exposure to some environmental cross-reacting antigens, which initiate autoimmune reactions in genetically susceptible individuals [
4]. These environmental antigens include food allergies to certain peptides as casein of milk and gluten of wheat [
44,
45], heavy metals exposure [
46,
47] and
Hevea brasiliensis proteins in natural rubber latex [
48]. In addition, infectious agents (for example, virus-induced autoimmunity) may play a causal in autism [
1,
49].
Studies investigating the frequency of systemic antibodies in autism are very few. Seropositivity of antinuclear antibodies was reported in only 20% of 80 Egyptian children with autism, and this percentage was significantly higher than healthy children (2.5%) [
7]. Brain specific autoantibodies were reported in sera of a large proportion of children with autism [
4‐
10]. This may be attributable to the imbalance of T helper (Th)1/Th2 subsets toward Th2, which are responsible for the production of antibodies and allergic response, in some children with autism [
1]. In 2008, Mostafa and associates [
6] reported seropositivity for antimyelin-associated glycoprotein antibodies in 62.5% of a group of 32 Egyptian autistic children between 3 and 8 years of age.
The explanation of the lower percentage of systemic antibodies (such as antinuclear antibodies and antinucleosome-specific antibodies) than the percentage of brain-specific autoantibodies reported by other studies [
4‐
10] may be explained by the fact that autoimmunity in autism is organ-specific (that is, to brain) and not multisystemic. Diseases with multisystem autoimmunity (for example, SLE) have an increased frequency of systemic antibodies (such as antinuclear antibodies and antinucleosome-specific antibodies) and in these diseases, measurement of systemic antibodies is a reliable screening test [
14]. Thus, testing for brain-specific autoantibodies seems to be more reliable than an antinucleosome-specific antibodies test in screening for autoimmunity in autism.
To further understand if autoimmunity could play a role in autism, we studied the frequency of autoimmune diseases in families of patients with autism in comparison to healthy children. The frequency of autoimmune disease among families of the former group (40%) was significantly higher than that of the latter group (8.3%). Previous research had also found an increased frequency of autoimmunity in families of children with autism compared to those of healthy and autoimmune control subjects [
11‐
15]. In one study [
11], a family history of autoimmune diseases was reported in 46% of children with autism. They also reported that as the number of family members with autoimmune disorders increased from one to three, the risk of autism was greater with an odds ratio that increased from 1.9 to 5.5, respectively. Thus, this may be an outstanding feature among patients with autism that points to their autoimmune background, with the target in this case being the developing brain.
In our series, the finding of the increased frequency of autoimmune diseases in the mothers of children with autism (25%) was also in agreement with that of Comi
et al. [
11] who reported an autoimmune disease in 16% of the mothers of their studied patients with autism. The high rate of autoimmune diseases in the mothers of the children with autism could also suggest that an autoimmune process exists in the mothers that targets the developing fetus
in utero. Although this would be more consistent with the female preponderance in autoimmune disorders, it does not explain the high male-to-female ratio observed in autism [
12].
The current study revealed a more significant increase of the frequency of serum antinucleosome-specific antibodies in autistic children with a family history of autoimmunity (83.3%) than patients without such a history (22.2%),
P <0.001. This implies that in some families, immune dysfunction, perhaps induced by certain environmental triggers, could express itself in the form of autism in one of its offspring. Immune-related genes in the major histocompatibility complex (MHC) may play a central role in the development of autoimmunity in autism. These genes have been associated with some autoimmune diseases such as systemic lupus erythematous and diabetes mellitus. A previous study reported that mothers and their sons had a significantly higher frequency of HLA-DR4 than normal control subjects [
50].
To date, a definitive relationship between autism and autoimmunity has not been fully established. On the basis of the preliminary results reported in this study, however, there seems to be a suggestion of evidence in support of autoimmune contributions to the pathophysiology of autism in some cases. Additional investigation designed to expand on these data is warranted.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
Both authors designed, performed and wrote the research. In addition, both authors read and approved the final manuscript.