IgG-specific cell-based assay detects potentially pathogenic MuSK-Abs in seronegative MG

<jats:sec><jats:title>Objective:</jats:title><jats:p>To increase the detection of MuSK-Abs using a CBA and test their pathogenicity.</jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p>Sera from 69 MuSK-RIA–positive patients with myasthenia gravis (MG) (Definite MuSK-MG), 169 patients negative for MuSK-RIA and AChR-RIA (seronegative MG, SNMG), 35 healthy individuals (healthy controls, HCs), and 16 NMDA receptor-Ab–positive (NMDAR-Ab) disease controls were tested for binding to MuSK on a CBA using different secondary antibodies.</jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p>Initially, in addition to 18% of SNMG sera, 11% of HC and 19% of NMDAR-Ab sera showed positive binding to MuSK-transfected cells; this low specificity was due to anti-IgG(H+L) detection of IgM bound nonspecifically to MuSK. Using an IgG Fc gamma-specific secondary antibody, MuSK-Abs were detected by CBA in 68/69 (99%) of Definite MuSK-MG, 0/35 HCs, 0/16 NMDAR-Ab, and 14/169 (8%) of SNMG sera, providing increased sensitivity with high specificity. The RIA-negative, CBA-positive MuSK-IgG sera, but not IgM-MuSK–binding sera, reduced agrin-induced AChR clustering in C2C12 myotubes, qualitatively similar to RIA-positive MuSK-Abs.</jats:p></jats:sec><jats:sec><jats:title>Conclusions:</jats:title><jats:p>An IgG-specific MuSK-CBA can reliably detect IgG MuSK-Abs and increase sensitivity. In the MuSK-CBA, IgG specificity is essential. The positive sera demonstrated pathogenic potential in the in vitro AChR-clustering assay, although less effective than Definite MuSK-MG sera, and the patients had less severe clinical disease. Use of IgG-specific secondary antibodies may improve the results of other antibody tests.</jats:p></jats:sec><jats:sec><jats:title>Classification of evidence:</jats:title><jats:p>This study provides Class III evidence that an IgG-specific MuSK-CBA identifies patients with MG.</jats:p></jats:sec>