The association between lymphopenia and autoimmunity is recognized, but the underlying mechanisms are poorly understood and have not been studied systematically in humans. People with multiple sclerosis treated with the lymphocyte-depleting monoclonal antibody alemtuzumab offer a unique opportunity to study this phenomenon; one in three people develops clinical autoimmunity, and one in three people develops asymptomatic autoantibodies after treatment. Here, we show that T-cell recovery after alemtuzumab is driven by homeostatic proliferation, leading to the generation of chronically activated (CD28) capable of producing proinflammatory cytokines. Individuals who develop autoimmunity after treatment are no more lymphopenic than their nonautoimmune counterparts, but they show reduced thymopoiesis and generate a more restricted T-cell repertoire. Taken together, these findings demonstrate that homeostatic proliferation drives lymphopeniaassociated autoimmunity in humans.T lymphocytes | reconstitution | immunotherapy T he anti-CD (cluster of differentiation molecule) 52 monoclonal antibody alemtuzumab has proven efficacy in relapsing remitting multiple sclerosis (RRMS) (1-3). Each cycle of alemtuzumab leads to profound panlymphopenia, but relatively infrequent dosing allows reconstitution to occur: B cells recovery rapidly, whereas CD4 and CD8 cells take 35 and 20 mo, respectively, to reach normal values (4). For 5 y after alemtuzumab and maximally, at 2 y, secondary autoimmune conditions may develop: 30% of individuals experience thyroid autoimmunity, and 1% of individuals have idiopathic thrombocytopenic purpura (ITP); there are rare cases of autoimmune hemolytic anemia, autoimmune neutropenia, and Goodpasture syndrome (1-3). One-third of patients develop asymptomatic autoantibodies.An association between lymphopenia and autoimmunity is recognized; in humans, T lymphopenia is a feature of systemic lupus erythematosus, rheumatoid arthritis, and Crohn and Sjogren syndromes (5), and animal models of autoimmunity often involve the induction of lymphopenia. The mechanism driving autoimmunity in these situations is unclear. In some cases it has been attributed to loss of regulatory cells; however, although treatment of lymphopenic hosts with CD4 +
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