# Patent

## Title
Device and methods for the immunological identification of cerebrospinal fluid

## Abstract

The present disclosure relates to detection of the presence or absence of cerebrospinal fluid (CSF) in a sample by the detection of one or more antigens that are enriched in CSF compared to their levels in other bodily fluids. The devices and methods are suitable for the detection of the presence or absence of cerebrospinal fluid in samples of mixed bodily fluids from a wide variety of human populations crossing ethnicity, age, gender, health status and genetic variability.

## Background
CROSS-REFERENCE TO RELATED APPLICATIONS
This application is a continuation of U.S. patent application Ser. No. 13/864,616 filed on Apr. 17, 2013, which is a divisional of U.S. patent application Ser. No. 12/852,761 filed on Aug. 9, 2010, U.S. Pat. No. 8,445,218 issued on May 21, 2013, which is a no provisional of U.S. Provisional Application No. 61/232,033 filed on Aug. 7, 2009, incorporated herein by reference in their entirety.


FIELD OF THE DISCLOSURE
The present disclosure relates to detection of the presence or absence of cerebrospinal fluid (CSF) in a sample by the detection of one or more proteins that are enriched in CSF compared to their levels in other bodily fluids. Described herein are devices and methods for the detection of the presence or absence of cerebrospinal fluid in samples of mixed bodily fluids from a wide variety of human populations crossing ethnicity, age, gender, health status and genetic variability.
BACKGROUND
Cerebrospinal fluid (CSF), or liquor cerebrospinalis, is found in the subarachnoid space as well as in the ventricles surrounding and penetrating the central nervous system (CNS). CSF bathes the brain and spinal cord and provides hydrative, nutritive, metabolic waste removal, and hydrostatic impact buffer to neurons and glia. CSF is produced from arterial blood by the choroid plexuses of the lateral and fourth ventricles by a combined process of diffusion, pinocytosis and active transfer. The fluid also contains constituents produced by neurons and glia. After diffusion through the ventricular system into the subarachnoid space, most of the CSF is reabsorbed by the arachnoid granulations to reenter the blood stream via the dural venous plexus. Approximately 500 ml of liquor is generated every day; with a total volume of 140-150 ml for an adult, the whole CSF is renewed every 6-8 hours. The CSF is bounded by the dura throughout the CNS. More fluid is produced in the rostral CNS and more ultimately drains in the caudal spinal cord to produce a net rostral to caudal fluid flow. CSF is an isotonic mixture mostly of salts, glucose, protein and water. CSF from the lumbar region contains 15 to 45 mg/dl protein (0.3-1% of serum protein concentration) and 50-80 mg/dl glucose (60% of blood glucose). Protein concentration in cisternal and ventricular CSF is lower.
The protein landscape of the CSF can be divided into two groups: Blood derived proteins, which make up the main fraction in the CSF of healthy individuals, and brain derived proteins. Approximately 20% of the proteins in the CSF originate from the brain parenchyma, but only a subset of those are actually brain specific.
Despite the fact that the majority of liquor proteins are also found in the serum, there are multiple sources for proteins unique to the CSF:
Proteins that are released from neurons and glial cells, e.g. tau protein, S-100, and neuron-specific enolase (NSE).
Proteins released from leptomeniges, e.g. β-trace protein and cystatin C.
Proteins differentially modified by glycosylation or phosphorylation during synthesis in the choroid plexus, e.g. transthyretin (TTR), angiotensin II, and Insulin-like growth factor II.
There is substantial overlap in the protein profile between CSF and plasma, a considerable number of proteins are unique to the CSF or are uniquely modified by phosphorylation or glycosylation in the CNS.
Lateral Flow Tests, or also known as Lateral Flow Immunochromatographic Assays or Strip Tests, are designed to rapidly detect the presence or absence of a given analyte in a heterogenous matrix. A variety of Lateral Flow Tests are currently on the market for home testing, point of care testing, or laboratory use, for instance pregnancy tests (e.g., FirstResponse®, ClearBlue®), HIV tests (e.g., OraQuick ADVANCE®, Clearview® Complete), or Chlamydia tests (e.g., Clearview® Chlamydia, inSTIcheckTM Chlamydia).
What is needed is a test suitable for detection of CSF that is comparable to HIV tests like OraQuick ADVANCE® or Clearview® Complete: It is a point of care test; the test is only qualitative; the operator needs minimal training to use the test; the test has an internal control on the strip to verify accurate sampling.
SUMMARY
In one embodiment, a device for detection of the presence or absence of cerebrospinal fluid in a sample comprises
a sample application region,
a sample labeling region comprising a first antibody to a CSF-enriched protein, wherein the first antibody is conjugated to a mobile particle;
a sample detection region comprising a second antibody to the CSF-enriched protein, wherein the second antibody is fixed to the sample detection region,
wherein the presence of a detectable band in the second region indicates the presence of cerebrospinal fluid in the sample.
In another embodiment, a method for detecting the presence or absence of CSF in a sample, comprises
contacting the sample with a binding partner specific for a CSF-enriched protein, and
detecting binding partner-CSF enriched protein complexes if present, wherein the presence of detectable complexes indicates the presence of CSF in the sample.
In the foregoing embodiments, the CSF antigen is Isoform 1 of Neural cell adhesion molecule-like (SEQ ID NO: 1; Accession Number gi:62088238) protein; Chain A, Human Mesotrypsin Complexed With Bovine Pancreatic Trypsin Inhibitor (Bpti) (SEQ ID NO:2; Accession number gi:162330095); CNTN2 Contactin-2 precursor (SEQ ID NO: 3; Accession Number gi|4827022); CNTN1 Isoform 2 of Contactin-1 (SEQ ID NO: 4; Accession Number gi:28373119); cDNA highly similar to SPARC-like protein 1 (unnamed protein product) (SEQ ID NO: 5; Accession Number: gi|194388050); NRCAM protein (Neuronal cell adhesion molecule)[Homo sapiens] possibly slightly longer fragment ( ̃96 kDa) (Accession Number: SEQ ID NO: 6; gi|68534652 and SEQ ID NO: 7; gi|109731501); NCAM2 Neural cell adhesion molecule 2, isoform CRA_a (SEQ ID NO: 8; Accession Number gi|119630409); SERPINA3 serpin peptidase inhibitor, clade A, member 3 precursor/Isoform 1 of Alpha-1-antichymotrypsin/growth-inhibiting protein 25 [Homo sapiens] or slightly longer fragment of alpha-1-antichymotrypsin precursor (SEQ ID NO: 9; Accession Number gi|46981961); AGT Angiotensinogen (SEQ ID NO: 10; Accession Number gi|553181); Angiotensinogen precursor (Serpin A8) (SEQ ID NO: 11; Accession Number gi|4557287); unnamed protein product also called immunoglobulin superfamily, member 4B; in humans, also called cell adhesion molecule 3 (SEQ ID NO: 12; Accession Number gi|187608363); cDNA FLJ59893, dickkopf homolog 3 precursor (SEQ ID NO: 13; Accession Number gi|40548389); SERPINF1 serine (or cysteine) proteinase inhibitor, clade F (alpha-2 antiplasmin, pigment epithelium derived factor, Pedf), member 1 isoform 4 factor (SEQ ID NO: 14; Accession Number gi|15988024); human protein similar to GC Vitamin D-binding protein PREDICTED: vitamin D-binding protein [Pan troglodytes] (SEQ ID NO: 15; Accession Number 181482); CD14 Human monocyte antigen CD14 (CD14) (SEQ ID NO: 16; Accession Number gi|117646212); CADM3 Homo sapiens cell adhesion molecule 3 (CADM3), transcript variant 1 (SEQ ID NO: 17; Accession Number gi|90080503; SEQ ID NO: 18; gi|187608363 (human); Neural cell adhesion molecule variant (SEQ ID NO: 19; Accession Number gi:62088238); unnamed protein similar to CLU cDNA F1157622, highly similar to Clusterin (SEQ ID NO: 20; Accession number gi|189054091); protein highly similar to Clusterin (SEQ ID NO: 21; Accession number gi|193787502); LMAN2 Vesicular integral-membrane protein VIP36 (SEQ ID NO: 22; Accession number gi|157834800); clusterin isoform 1 [Homo sapiens] (SEQ ID NO: 23; Accession number NM_001831.2); superoxide dismutase 3, extracellular precursor (SEQ ID NO: 24; Accession number gi|118582275); fibrin alpha C term fragment (SEQ ID NO: 25; Accession number gi|223057); Chain A, Human Kallikrein 6 (Hk6) Active Form or KLK6 Isoform 1 of Kallikrein-6 (SEQ ID NO: 26; Accession number gi|21465970); APCS Serum amyloid P-component/Chain A or Pentameric Human Serum Amyloid P Component (SEQ ID NO: 27; Accession number gi|576259); FAM3C Protein FAM3C/family with sequence similarity 3, member C precursor [Homo sapiens] note=“predicted osteoblast protein; interleukin-like EMT inducer (SEQ ID NO: 28; Accession number gi|55629272); protein similar to unnamed protein product [Macaca fascicularis] also called immunoglobulin superfamily, member 4B; in humans, also called cell adhesion molecule 3 (SEQ ID NO: 29; Accession number gi|187608363); a CSF-enriched phosphorylated or dephosphorylated form of the foregoing CSF antigens; or a combination of two or more of the foregoing CSF antigens.
In another embodiment, a method for the detection of a reactant in a body fluid, tissue or microorganism comprises contacting the body fluid, tissue or microorganism with two or more antibodies, wherein each antibody specifically reacts with an antigen in the reactant, wherein reaction with each individual antibody does not indicate a positive test for the reactant, and wherein reaction with the two or more antibodies indicates a positive test for the reactant.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 Lateral Flow assay. Analyte is added to the left end of the strip either by a dropper or by direct dipping. The liquid (around 75 μl) is wicked across the strip to the right. The conjugate pad contains soluble IgG attached to a visible particle (i.e., gold or latex microspheres). If the analyte solution contains the analyte, the antibodies conjugate and the complex migrates across the strip. The mixture first encounters the test strip, which contains immobilized antibody against the analyte. The analyte, soluble primary and visible tag, then bind to the test line. If no analyte is present the soluble faction passes over the test line. Whether the analyte is present or not, excess soluble IgG bound to indicator binds to the immobilized anti-globin IgG bound to the control strip.
FIG. 2 shows advantages of a multi antigen approach to CSF detection. The upper figure represents single antigen assay results for various test conditions and the bottom figure shows results of the multi antigen assay. The bars along the X axis represent different assay conditions and the Y axis represents the degree of immunoreactivity seen by the assay. The upper shaded zone indicates a positive colorimetric response on the test line of the lateral flow assay. Assays with immunoreactivity that enters the shaded zone will produce a positive test result. Bar 1: CSF Bars in the upper graph illustrate immunoreactivity of the single antigen being sufficient to produce a positive test result. Alternatively in the multiple antigen graph (lower) a combination of antigens, each producing a partial signal accumulates to produce positive assay result. Bar 2: CSF contaminated with blood produces a similar positive response with a smaller but additive blood immunoreactivity (upper bar with thick border). Bar 3: Unusual CSF/blood sample in which antigen 1 is poorly immunoreactive. In the single antigen assay, the assay produces a false negative, while the multi antigen assay is still above assay threshold as a result of the other five antigen immunoreactivities being intact. Bar 4: CSF/blood with no antigen 1 immunoreactivity. Same results as in Bar 3. Bar 5: No CSF but blood borne cross-reactive antigen. In this case the single antigen assay produces a false positive, but as the immunoreactivity of the single antigen is not sufficient to produce a positive signal in the multi antigen assay the assay reports the correct negative result. Bar 6: No CSF but blood level of antigen 1 pathologically high. Single antigen assay produces false positive reacting to heightened blood levels. Multi antigen assay reacts to pathogentic antigen 1 levels in blood but does not reach threshold for false positive. This assay is shown with 5 antigen/antibody1/antibody2 mixes, however other embodiments could contain between 2 and as many as 10 antigen/antibody1/antibody2 mixes.
FIG. 3: Two dimensional gel electrophoresis of CSF and blood proteins. An example of a single experiment in which 100 μg of Cy-tagged CSF protein (A) and 100 μg of Cy3-tagged blood proteins (B) are separated in two dimensions. A and B are grayscale images of the same gel using different excitation and emission settings. The pH range is 4-8. C) is the RGB merge of the two channels with yellow spots indicating significant overlap. D) is an automated extraction of spots with >5× enrichment in either the CSF or blood. All samples were 2× depleted of major serum/CSF proteins (see Methods).
FIG. 4: Liquid chromatography-mass spectroscopy analysis of some of the CSF-enriched spots seen on the gel in FIG. 3.
FIG. 5: CSF-enriched proteins FUSS and dickkopf homolog 3 precursor (DKK3). A) Immunoblot of FUSS. Affinity purified polyclonal rabbit anti-human antibody produced against a recombinant fragment of FLJ55 produces immunoreactivity at the correct molecular weight in the CSF sample but not in the serum sample. B) Affinity purified polyclonal rabbit anti-human antibody produced against a recombinant fragment of DKK3 also produces immunoreactivity at the correct molecular weight in the CSF sample but not in the serum sample. In both cases excessive serum protein was loaded at levels higher then that of the sera. C) Four separate samples of CSF indicating immunoreactivity for DKK3 with a different affinity purified antibody (left). Five blood samples fail to produce immunoreactivity. Lane 5 blood is high non specific background.
FIG. 6: Phosphorylated forms of angiotensinogen that are highly enriched in the CSF. An RGB merge of the Cy3 blood (green) and Cy5 CSF (red). We have identified several novel and non-overlapping phosphorylated versions (right four red spots) that are not present in the blood. At least three other combinations (left three spots) are present in both CSF and blood.
FIG. 7: CSF specific post translational modifications. Change in the CSF 2D gel protein distribution pattern before (top panel) and after (middle panel) removal of all secondary modifications of the extracted proteins. Red spots in lower panel indicate a reduction in a particular protein signal following removal of the post-translational modification.
FIG. 8: Experimental flow chart for the production of CSF detection test strips.
FIG. 9: CSF proteins that are phosphorylated. A single DIGE gel in which two samples of serum protein depleted CSF was run. A) the Cy3 labeled proteins from the CSF sample which was incubated in alkaline phosphatase for one hour. B) Equivalent sample of serum protein depleted CSF not treated with alkaline phosphatase. C) Computer generated difference (blue boundaries) between spot volume of the two gels (A vs B). All blue spots represent phosphorylated CSF proteins.



DETAILED DESCRIPTION
Described herein are proteins that are enriched in CSF compared to other bodily fluids and methods for the detection of the presence or absence of cerebrospinal fluid (CSF) in a sample by the detection of these proteins. Also described herein are devices and methods for the detection of the presence or absence of CSF in samples of mixed bodily fluids from a wide variety of human populations crossing ethnicity, age, gender, health status and genetic variability. The CSF-enriched proteins are detected with a specific protein binding partner such as an antibody, a ligand, a receptor, and the like. Binding partners can be natural or synthetic binding partners.
Binding can be detected either directly, or indirectly, such as with a fluorescent label attached to the binding partner. While several embodiments are included that use antibodies as binding partners, it should be understood that other binding partners can be used in place of antibodies.
In certain embodiments, the level of the CSF-enriched protein is quantitated. Such quantitation is particularly useful in the identification of brain injury. Quantitation can be performed by using a binding partner with a detectable label. “Detectable moiety” or a “label” refers to a composition detectable by spectroscopic, photochemical, biochemical, immunochemical, or chemical means. Useful labels include 32P, 35S, fluorescent dyes, electron-dense reagents, enzymes (e.g., as commonly used in an ELISA), biotin-streptavadin, dioxigenin, haptens and proteins for which antisera or monoclonal antibodies are available. The detectable moiety often generates a measurable signal, such as a radioactive, chromogenic, or fluorescent signal that can be used to quantitate the amount of bound detectable moiety in a sample. The detectable moiety can be incorporated in or attached to a binding partner either covalently, or through ionic, van der Waals or hydrogen bonds. The detectable moiety may be directly or indirectly detectable. Indirect detection can involve the binding of a second directly or indirectly detectable moiety to the detectable moiety.
In some embodiments, CSF detection is performed using a lateral flow assay, employing for example, antibodies specific for the CSF protein of interest. A lateral flow assay can be a single antigen assay or a multiple antigen assay. In one embodiment, a multiple antigen test uses all of the antigens together to provide a single easy to read answer (i.e., a single band on a strip assay). In another embodiment, a multiple antigen test qualifies or quantifies each of several antigens individually to give a more complex profile of the antigens that are present. Such a profile may be useful to determine the severity of a head injury, that is, the head injury is less severe when certain CSF-specific proteins are present and more severe when other CSF-specific proteins are present or levels of each protein provides a degree of injury
Single Antigen Assay:
While lateral flow technology has been successfully used in many clinical assays, the unique and innovative approach described herein extends the technology to i.) bind single or multiple CSF-enriched proteins, thereby increasing sensitivity and specificity of the test, and/or ii.) detect a CSF-specific post-translational modification (e.g., phosphorylation).
As used herein, a CSF-enriched protein or CSF antigen or polypeptide is an antigen or polypeptide that is specific for CSF or substantially enriched in CSF compared to other bodily fluids. Table 1 identifies several proteins known to be concentrated in the CSF. These are not proteins identified in the current application, although they can, in some embodiments, be combined in an assay with one or more proteins identified herein in a multi-antigen assay.










TABLE 1






MW
CSF concen- 
CSF/


Protein
(kDa)
tration
serum ratio



















β-trace protein 
25
16.6 
mg/l
34:1


Cystatin C
  13.3
3.1 
mg/l
 5:1


Tau-protein
55-74
0.2 
μg/l
10:1


S-100 B
21
1.5 
μg/l
18:1


NSE
78
8 
mg/l
 1:1


Transthyretin
55
17 
mg/l
 1:18


Albumin
67
245 
mg/l
  1:205


IgG
150 
25 
mg/l
  1:440









Described herein are proteins that are present in sufficient quantities and enriched significantly in CSF compared to their levels in other bodily fluids, to act as a marker of CSF. The proteins found in pooled samples of CSF were compared to the proteins in blood, nasal fluid, saliva, sweat, tears and ear effluents (referred to as ‘other bodily fluids’). CSF from a range of ages (1-70 years) and from both males and females was examined. Prior to comparative 2D gel electrophoresis, all fluids were treated to remove dominant serum proteins that are present in most bodily fluids (i.e., albumin, IgG, etc.). The remaining proteins from CSF and another bodily fluid were differentially tagged with Cy3 and Cy5 and run on two-dimensional PAGE. Using this approach, a novel set of proteins which are highly concentrated in the CSF over other bodily fluids were identified. CSF-enriched secondary modified proteins (i.e., phosphorylated) have also been identified. Dephosphorylation of CSF extracts confirmed that the CSF unique spots represent differential migration in the isoelectric dimension based on phosphorylation.
In one embodiment, the proteins that are enriched in CSF are used to detect CSF in an assay, such as a lateral flow assay. A lateral flow system consists of overlapping membranes containing the dried components needed for the test performance (FIG. 1). These membranes are assembled to small strips which can be placed into a plastic housing for better handling. The patient's material is loaded to the Sample Pad. In the case of whole blood/capillary blood samples a separation of blood cells and plasma takes place. The liquid fraction of the patient's sample diffuses through the Conjugate Pad containing labeled antibodies, which are specifically directed against the analyte of interest. The antibodies (conjugate) are re-dissolved and the analyte is specifically bound by the gold (or latex) conjugate. The analyte-gold-conjugate complex further diffuses through the Analytical Membrane. On this membrane two lines are arranged one after the other: (i) the Test Line containing a second set analyte-specific antibodies responsible for immobilizing the analyte-gold conjugate complexes and (ii) the Control Line fixing non-bound gold antibodies indicating that the conjugate has overflown the Test Line. If the analyte of interest is available above the detection limit the Test Line and the Control Line are clearly visible; if the analyte is below the detection limit only the Control Line appears during test time. The last component of the rapid test is the Wicking (or Sink) Pad which simply collects the fluid miming through the test system and preventing backflow of the fluid through the test system.
Lateral Flow Immunochromatographic Assays are designed either as sandwich assays or as competitive assays. Sandwich assays makes use of two different antibodies raised against the same analyte, one to color the analyte and one to concentrate the analyte at the test line. The test line will show as a colored band in positive samples. Competitive assays provide already colored analyte on the test strip and a set of antibodies against the analyte at the test line. The sample flows with the provided colored analyte towards the test line and competes for antibody binding. The test line will show as a colored band in negative samples.
CSF Assay Design Specifications:
The assay described herein can be used to accurately identify traces of CSF when it is mixed with a variety of non-CSF bodily fluids. These ‘other fluids’ are, for example, nasal and ear effluents, saliva, tears, sweat, urine and blood. The assay is intended to minimize false positive or false negative results regardless of the physiologic, metabolic or pathologic state, gender, age or ethnicity of the subject.
In one embodiment, the limit of detection is >5% CSF in a pure fluid or mixture of any of the above fluids. It may be possible to achieve a higher sensitivity but it will be essential to maintain the specificity in addition to the increased sensitivity. Thus, in some embodiments, a limit of detection of >1% CSF is achieved.
Multi Antigen CSF ‘Tissue’ Assay:
In one embodiment, the assay is one that will allow the detection of the presence of CSF via simultaneous detection of multiple CSF-enriched proteins. That is, the test includes two or more markers for CSF to provide improved reliability of CSF detection. Rather than testing for a single ‘biomarker’, the multiple marker assay will be robust and provide the correct answer under a variety of potential and unknown circumstances with high selectivity and sensitivity. For example, a single antigen assay may produce a false positive if the antibody recognizes an antigen in a fluid other than CSF (i.e. blood). If the assay tests for a antigen which is ‘enriched’ in CSF but not ‘exclusive’ to CSF, an aberrantly high blood level could produce a false positive. This may be problematic because it is not feasible to test the strip under all possible physiologic, pathologic, ethnic, sex, dietary, age-related, etc. conditions to look for false results. Further, the level of particular CSF antigen may be reduced below detection level, or a particular CSF antigen may have a rare genotypic difference, thus reducing reactivity in certain human populations thereby producing a false negative. These are all potential difficulties that arise from basing a test on a single CSF-enriched antigen (see FIG. 2). The novel ‘Multi antigen’ assay for detecting CSF in mixed body fluid samples should provide substantial improvement over single-antigen tests. In certain embodiments, the multi-antigen test includes at least one antibody specific for each of 2, 3, 4, 5, 6, 7, 8, 9 or 10 antigens that are enriched in CSF compared to their levels in other bodily fluids. In other embodiments, at least two antibodies specific for each antigen are employed.
As described herein, a large number of CSF-enriched protein spots have been extracted and analyzed by LC-MS. The rationale for this approach is illustrated in FIG. 2. Several CSF-enriched antigens have been identified and at least two different antibodies have been produced to each antigen. Mixtures of each of the two sets of IgG are added to the mobile and immobilized portions of the test strip (see FIG. 2), respectively. The multi antigen assay works by applying a concentration of antibodies for a particular antigen that are below the threshold for detection when all antibody molecules are bound. A mixture of several antibodies each a subthreshold levels are utilized in the assay. When CSF is added, all antibodies bind and accumulate producing a positive signal. The optimal embodiment would use at least 5-6 different antigens with a detection threshold of 4 so loss of a single antigen will not cause a false negative. In one embodiment, the device or test comprises 4 to 10 different antibodies that each specifically binds a different CSF antigens, wherein a positive test does not require binding to all antibodies. Accumulation of IgG/antigen on the test strip is linear and subthreshold levels for individual detection of each antibody are used then only the addition of other positive antibodies will produce a positive reaction. A positive response requiring accumulation of at least 4 IgG/antigens the assay will be more robust in the face of fluctuations in the levels of any one antigen. The assay will also be more robust in the face of aberrant increases in single antigen immunoreactivity in contaminating bodily fluids. Artifactual immunoreactivity of 1-3 of the antigens will not produce a positive test, therefore the test will be more robust and produce fewer false positives.
Identification of CSF-Enriched Proteins:
CSF samples from 1-40 individuals are pooled and 200 μl of the pooled samples are analyzed. Samples of sera from 1-40 individuals are pooled and 1 ml of pooled sera are analyzed. Major proteins shared by the blood and CSF (i.e. albumin, immunoglobins, etc.) were removed from both samples by repeated affinity chromatography.
In vitro label 50 μg of the control protein extract and 50 μg of the experimental protein extract with GE Healthcare Cy-3 and Cy-5 N-hydroxysuccinimidyl ester dyes. These dyes have been matched with respect to charge and mass—with the single positive charge of the dye replacing the charge lost by the modified lysine or N-terminus of the protein. Cy-3 and Cy-5 labeled proteins co-migrate—with the dye label adding approximately 450 Da to the proteins in each sample.
Control, experimental, and internal standard samples were mixed together (i.e., 150 μg total protein) and then an equal volume of 2× Sample Buffer added.
The volume was brought up to 450 ul with Rehydration Buffer ImmobilineTM (IPG) Drystrips (GE Healthcare) 24 cm were rehydrated for 10-24 hours, and isoelectric focusing carried out. We used a number of different pH ranges including: 3-7, 4-7, 3.5-4.5, 4.0-5.0, 4.5-5.5, 5.0-6.0, 5.5-6.7, and 6-9. SDS polyacrylamide gel electrophoresis (second) dimension was carried out on a 10 inch wide by 7.5 inch tall by 1.0 mm thick gel with one side coated with Gelbond®. We used a 12.5% polyacrylamide gel which will optimally separate 12-100 kD proteins.
Immediately after SDS PAGE, the gel (which is still held between two glass plates) was scanned at all 3 wavelengths simultaneously on the GE Healthcare TyphoonTM 9410 Imager. After scanning, 16 bit TIFF files of each color channel were exported for image analysis using the differential in-gel analysis module of the GE Healthcare DeCyder software package. After spot detection (which includes automatic background correction, spot volume normalization and volume ratio calculation), a user defined “dust filter” was applied to each gel. This has the effect of automatically removing non-protein spot features from the gel and is followed by recalculation of experimental parameters.
The front glass plate was removed and the gel was then fixed and stained with Sypro Ruby, which is the fluorescent stain that was used as a guide to excise spots of interest from the gel. The reason for using Spyro Ruby, which stains all protein in the gel, is that the Cy-dye labeling is carried out such that the extent of incorporation will be <5% in terms of mole Cy-dye/mole protein. Since the Cy-dye has a MW of about 580 Da, low MW proteins (e.g., 10 Kd) labeled with Cy-dyes will not exactly co-migrate in the SDS PAGE dimension with their non-labeled counterparts.
GE Healthcare DeCyderTM software was used to quantify the gel image and to identify a “pick list” of differentially expressed protein spots to be excised and subjected to MS-based protein identification. The DeCyderTM software can analyze any two Cy-dyed gel images, either on the same gel or on different gels, match the spots between the two images, and then identify differentially expressed protein spots. The DeCyderTM software automatically outputs a listing of statistically significant differences in protein expression including t-test values, using the Cy-2 internal standard. Differentially expressed spots were identified using a number of criteria including area, volume, 3D peak slope, 3D peak height, and/or statistical variation. Protein spots that show different degrees of intensity between the two samples were highlighted by the software and confirmed manually. The DeCyderTM software was also used to analyze Sypro Ruby images, match the spots found with Sypro staining to those identified with the Cy-dye stains, and then choose a ‘pick list’ from the Sypro stained gel image.
The protein spot pick list was transferred to the EttanTM Spot Picker instrument (GE Healthcare) which automatically excised the selected protein spots from the gel and transferred them into a 96-well microtiter plate.
The excised protein spots were then subjected to automated in-gel tryptic digestion on the EttanTM TA Digester.
An aliquot of each digest was spotted (along with matrix) onto a MALDI-MS target.
High mass accuracy, automated MALDI-MS/MS spectra were acquired on each target (using an Applied Biosystems 4800 Tof/Tof instrument) and the resulting peptide masses were subjected to database searching using Mascot algorithms.
The remaining aliquots of digests of protein spots that are not identified by this approach were subjected to nanospray or LC/MS/MS analysis (Micromass Q-Tof) with the resulting MS/MS spectra then being subjected to Sequest database searches to identify proteins present in the sample.
CSF-Enriched Protein Phosphorylation Sites as Antigens for a CSF Test Strip:
During the course of Fluorescence Difference Gel Electrophoresis (DIGE) experiments to identify CSF-enriched proteins, spots distributed in the pH dimension that were highly CSF-enriched (i.e. not present in blood samples) were identified, however upon protein identification by LC-MS, it was established that many of these proteins were in fact present in the blood but had a different patterns in the pH dimension of the gel (FIG. 6). Regularly spaced spots of the same molecular weight often represent differentially phosphorylated versions of the same protein. The differential and regular migration in the pH dimension is indicative of the large but quantal nature of the negative charge on the PO3− groups. Upon phosphopeptide mapping of these spot arrays, it was determined that this was in fact the case. Several of these proteins (including angiotensinogen, (FIG. 6) had highly CSF-enriched phosphorylations. In some cases these phosphorylation sites were serine/threonine phosphorylations, and in other cases they were tyrosine phosphorylations. In all, proteins were selected with multiple CSF-enriched sites per protein (i.e. angiotensinogen). As it is possible to produce antibodies that recognize a single epitope only when phosphorylated, phosphorylation sites will be included as antigens in the assays described herein. These phosphorylated epitopes are attractive as candidates as they are very prevalent and the presence of two CSF-enriched phosphorylation sites on a single protein opens the door to making pairs of antibodies to different sites that can be used differentially on the mobile and immobile regions of the strip to require dual phosphorylation for a positive response. We have run DIGE gels comparing CSF proteins that have been dephosphorylated with alkaline phosphatase (FIG. 9). This has identified proteins listed herein as differentially phosphorylated in the CSF.
Identification of antigens is performed using 2 dimensional DIGE gel electrophoresis followed by trypsin digestion and LC-MS. The dominant proteins in both blood and CSF are removed by affinity columns prior to electrophoresis. These proteins are ubiquitously present in bodily fluids (i.e. albumin, immunoglobins etc.). We run all samples doubly across columns to remove 14 dominate serum proteins. We run the extracted proteins from 1-2 mls of whole blood on gels along with proteins from 200 μl of CSF. This enriched the blood proteins to ensure we are identifying proteins that are enriched in the CSF. Proteins from the CSF are labeled using either Cy3 or Cy5 fluorophores. In contrast blood proteins are labeled with either Cy5 or Cy3, respectively. The samples are then mixed and loaded on a 2 dimensional PAGE gel. Numerous different gels are run focusing on different regions of the molecular mass dimension (Y-dimension) and pH dimension (X-dimension). Following running of the gel, the intensity of the differentially visualized fluorescently labeled proteins are quantified and compared by an automated computer program. Those spots that are enriched by at least 5× in the CSF are robotically collected, trypsin digested and analyzed by LC-MS. Peptide molecular weights are compared to published databases. Enriched proteins are selected as candidates and standard molecular biologic methodology are employed for the production of Histidine-tagged recombinant proteins in bacteria or alternatively peptides corresponding to specific regions of the proteins are produced synthetically. Monoclonal and polyclonal antibodies are produced by a commercial house using provided antigens. Affinity purification is performed by standard column techniques utilizing cyanogen bromide-activated columns and recombinant proteins used for immunization. CSF-specific antigens are identified by trypsin and chymotrypsin digestion followed by LC-MS and phosphopeptide determination.
Validation of CSF-enriched antibodies is conducted by separating discrete volumes of whole bodily fluid proteins on SDS-PAGE, transferring to nitrocellulose membranes, immunoblotting first with primary antibodies against the antigens and then HRP-labeled secondary antibodies followed by ECL quantification. Antigens that have a >5× immunoreactivity in CSF over levels larger volumes of whole blood, nasal and ear effluents, tear, saliva or sweat are pursued. Samples of bodily fluids from 20 to 30 different individuals of each are tested for each antigen. Fluid samples are purchased from commercial laboratories that assure purity or directly collected. Bodily fluids are tested from individuals ranging in age from infants to elderly (75 years), male and female, as well as several common pathological conditions (i.e. advanced stage diabetes, coronary artery disease, asthma, etc.).
To identify phosphorylation state specific antigens, two-dimensional gels are produced as described above however three labeled protein fractions are produced (Cy2, Cy3 and Cy5): CSF, whole blood and CSF proteins in which all protein phosphorylations have been removed by alkaline phosphatase in an additional step prior to labeling. A comparison is then made between the dephosphorylated and normal CSF channels for alterations. Spots that disappear following dephosphorylation and are not present in the blood protein fluorescence channel are collected and sequenced. Absolute identification of the site of phosphorylation is determined by phospho peptide and phospho amino acid analysis, in vitro phosphorylation of recombinant proteins and protein fragments and immunoreactivity with phosphostate specific antibodies.
Once antibodies have been selected for use in the test strips, the relative affinity of each of the antibodies will be determined by running dilution curves using pure samples of recombinant antigens. This will guide the mixing of antibodies for inclusion on test strips.
In one embodiment, included herein are devices and methods for rapid, bedside or triage site testing of bodily fluids, surgical sites or wounds for the presence of cerebrospinal fluid. In another embodiment a test is proposed that allows detection of CSF enriched proteins in samples of blood, plasma or sera as an indication of central nervous system (CNS) injury, breach or damage. Tests can include a single or multiples of the antigens described herein as markers of damage to the CNS. Described herein are newly-identified CSF-specific or enriched antigens that can be used individually or in combination to detect CSF in a broad spectrum of individuals from pediatric to geriatric, and despite the presence of diseases, personal habits, or individual genetic variability that might alter the composition of bodily fluids.
In one embodiment, included herein are devices for the detection of cerebrospinal fluid in samples such as those suspected of containing cerebrospinal fluid, wherein the devices include one or more antibodies specific for one or more CSF antigens as described above. The CSF antigens can be employed in combinations to enhance the signal to noise ratio and to overcome individual variability in the expression of the antigens described above in different bodily fluids. In some embodiments, the detection of multiple antigens provides superior sensitivity and selectivity over detection of a single CSF-enriched antigen.
In one embodiment, described herein are devices for the detection of cerebrospinal fluid in samples such as those suspected of containing cerebrospinal fluid, wherein the devices include one or more antibodies specific for one or more CSF antigens in a state of post-translational modification that is specific to the cerebrospinal fluid and distinguishable from the same antigen in other bodily fluids by virtue of the post-translational modification.
In some embodiments, described herein are devices for the detection of cerebrospinal fluid in samples such as those suspected of containing cerebrospinal fluid, wherein the devices include one or more antibodies specific for one or more CSF antigens in a state of phosphorylation that is specific to the cerebrospinal fluid and distinguishable from the same antigen in other bodily fluids by virtue of the phosphorylation.
Samples for testing using the devices disclosed herein can be taken from different sites in the human body, such as at a site of surgery (i.e. head, neck, ear, throat, nasal or spinal surgeries) where the potential for CSF leakage is possible; at a site of epidural injection or spinal tap; or at a site of wounds in areas where a breach of the meninges is possible (i.e. head, neck, spinal cord, nasal compartment, nose, ears, throat, skull, etc.), or where the injured party demonstrates signs of possible meningeal breach or serious injury to the central nervous system; or at a site of epidural injection, spinal injection or spinal tap. The antigens identified herein are particularly good markers for brain injury. Additional samples include saliva and urine samples.
The unique approach of performing 2D-DIGE studies to compare the components of human CSF and serum has yielded a number of antigens that are specific to, or highly enriched in CSF. Antibodies specific for these antigens are markers of the presence of CSF in bodily fluids, or at wound, surgical or injections sites where its presence would be atypical and potentially threaten the health or life of a patient or trauma victim.
In some embodiments, the above-described CSF antigens have post-translational modifications such as phoshorylation, glycosylation, sumoylation, ubiquitination, lipidation, nitrosylation, acetylation, neddylation, where those post-translational modification are specific to the CSF form of the antigen may be used by the lateral flow assay, western blots, ELISA or immunoprecipitation.
In some embodiments, multiple antigens may be used and may include combinations of antibodies that detect simple antigens (i.e., unmodified antigens) with antibodies that detect post-translationally modified antigens such as described above and in any of the various assays, lateral flow, Western blot, ELISA, or immunoprecipitation.
In one embodiment, antibodies are used to determine if a sample contains polypeptides associated with the presence of CSF indicating the presence or absence of CSF. Antibody binding is detected by, for example, radioimmunoassay, ELISA (enzyme-linked immunosorbant assay), “sandwich” immunoassays, immunoradiometric assays, surface plasmon resonance, immunocytochemistry, immunohistochemistry, gel diffusion precipitation reactions, immunodiffusion assays, in situ immunoassays (e.g., using colloidal gold, enzyme or radioisotope labels, for example), Western blots, precipitation reactions, agglutination assays (e.g., gel agglutination assays, hemagglutination assays, etc.), complement fixation assays, immunofluorescence assays, protein A assays, and immunoelectrophoresis assays, and the like. Detection of antibody binding can be achieved using enzymatic, colorimetric, fluorescent, bioluminescent, luminescent, colored latex beads, colloidal gold and/or silver methods.
In one embodiment, antibody binding is detected by detecting a label on the primary antibody. In another embodiment, the primary antibody is detected by detecting binding of a secondary antibody or reagent to the primary antibody. In a further embodiment, the secondary antibody is labeled. Many methods are known in the art for detecting binding in an immunoassay.
In some embodiments, an automated detection assay is utilized. Methods for the automation of immunoassays include those described in U.S. Pat. Nos. 5,885,530, 4,981,785, 6,159,750, and 5,358,691, each of which is herein incorporated by reference. In some embodiments, the analysis and presentation of results is also automated. For example, in some embodiments, software that generates a score correlating to the presence of specific polypeptides and likelihood of CSF in a sample based on the result of the immunoassay is utilized.
In other embodiments, the immunoassay is as described in U.S. Pat. Nos. 5,599,677 and 5,672,480, each of which is herein incorporated by reference.
Provided herein are isolated antibodies or antibody fragments (e.g., Fab fragments, Fab2 fragments, and the like). Antibodies can be generated to allow for the detection of polypeptides associated with the presence of CSF. The antibodies are prepared using various polypeptides, synthetic peptides and/or recombinant proteins associated with the presence of CSF and fragments thereof. In one embodiment, the immunogens are polypeptides, synthetic peptides and/or recombinant proteins associated with the presence of CSF to generate antibodies that recognize the polypeptides associated with the presence of CSF. In one embodiment, the antibody is reactive with a native or “folded” protein. In another embodiment, an antibody is reactive with denatured protein (including detergent solubilized). Such antibodies include, but are not limited to polyclonal, monoclonal, chimeric, single chain, Fab fragments, Fab expression libraries, or recombinant (e.g., chimeric, humanized, etc.) antibodies, as long as it can recognize the protein. Antibodies can be produced by using a protein or peptide as the antigen according to a conventional antibody or antiserum preparation process.
Various procedures are used for the production of polyclonal antibodies directed against polypeptides associated with the presence of CSF. For the production of an antibody, various host animals are immunized by injection with the polypeptides, synthetic peptides and/or recombinant proteins associated with the presence of CSF or a fragment thereof including but not limited to rabbits, mice, rats, sheep, goats, chicken, donkey, etc. In a specific embodiment, the peptide is conjugated to an immunogenic carrier (e.g., diphtheria toxoid, bovine serum albumin (BSA), or keyhole limpet hemocyanin (KLH)). Various adjuvants may be used to increase the immunological response, depending on the host species, including but not limited to Freund's (complete and incomplete), mineral gels (e.g., aluminum hydroxide), surface active substances (e.g., lysolecithin, pluronic polyols, polyanions, peptides, oil emulsions, keyhole limpet hemocyanins, dinitrophenol, and potentially useful human adjuvants such as BCG (Bacille Calmette-Guerin) and Corynebacterium parvum).
For preparation of monoclonal antibodies directed toward polypeptides, synthetic peptides and recombinant proteins associated with the presence of CSF, it is contemplated that a technique that provides for the production of antibody molecules by continuous cell lines in culture will find use herein. These include, but are not limited to, the hybridoma technique originally developed by Kohler and Milstein, as well as the trioma technique, the human B-cell hybridoma technique, and the EBV-hybridoma technique to produce human monoclonal antibodies.
In additional embodiments, monoclonal antibodies are produced in germ-free animals. Furthermore, it is contemplated that human antibodies will be generated by human hybridomas or by transforming human B cells with EBV virus in vitro.
In addition, it is contemplated that techniques described for the production of single chain antibodies will find use in producing single chain antibodies. An additional embodiment utilizes the techniques described for the construction of Fab expression libraries to allow rapid and easy identification of monoclonal Fab fragments with the desired specificity.
In other embodiments, contemplated are recombinant antibodies or fragments thereof to polypeptides associated with the presence of CSF. Recombinant antibodies include, but are not limited to, humanized and chimeric antibodies. Methods for generating recombinant antibodies are known in the art.
It is contemplated that a technique suitable for producing antibody fragments will find use in generating antibody fragments that contain the idiotype (antigen binding region) of the antibody molecule. For example, such fragments include but are not limited to: F(ab′)2 fragment that can be produced by pepsin digestion of the antibody molecule; Fab′ fragments that can be generated by reducing the disulfide bridges of the F(ab′)2 fragment, and Fab fragments that can be generated by treating the antibody molecule with papain and a reducing agent.
In one embodiment, antibody binding is detected by detecting a label on the primary antibody. In another embodiment, the primary antibody is detected by detecting binding of a secondary antibody or reagent to the primary antibody. In a further embodiment, the secondary antibody is labeled. The immunogenic peptide may be provided free of the carrier molecule used in any immunization protocol. For example, if the peptide was conjugated to KLH, it may be conjugated to BSA, or used directly, in a screening assay.
The foregoing antibodies can be used in methods known in the art relating to the localization and structure of polypeptides associated with the presence of CSF (e.g., for Western blotting), measuring levels thereof in appropriate biological samples, etc. The antibodies can be used to detect polypeptides associated with the presence of CSF in a biological sample from an individual. The biological sample is a biological fluid, such as, but not limited to, tissue, blood, serum, plasma, urine, nasal and ear effluents, saliva, sweat, tears and the like. In one embodiment, the sample is from an individual suspected of having a brain injury, such as mild traumatic head injury received during participation in sporting events, auto accidents, military activity and motorcycle accidents. The test would be most useful when the injury is mild to moderate in severity. More severe head injury including penetrating injuries generally already receive the necessary level of medical attention. Diagnosis of traumatic brain injuries generally requires a short neurological exam (the GCS). The precise designations of mild and moderate are sometimes hard to objectively identify without a recent baseline, pre injury test. Other injuries or treatments (sedative, anesthetics, etc.) can interfere with the test. The current set of antigens can represent “biomarkers” which could be used to “fingerprint” the existence and severity of a head injury. A rapid test that is qualitative or quantitative of the existence of a subset of these antigens in blood or other bodily fluids (sweat, urine, saliva, etc.) can be used as a measure of the severity of an injury in combination with a GCS or any such neurological exam. Often the severity of a mild to moderate head injury is not known and to what degree the person should continue to engage in critical activities (i.e. continuing to participate in a sporting event, continue to work or drive a vehicle, remain in the combat arena, continue to assume a command position in combat, operate heavy machinery, etc.). A more objective test of blood borne or secreted proteins normally found enriched only in the CSF would represent a diagnostic test of injury.
The biological samples can then be tested directly for the presence of polypeptides associated with the presence of CSF using an appropriate strategy (e.g., ELISA or radioimmunoassay) and format (e.g., microwells, dipstick (e.g., as described in International Patent Publication WO 93/03367), etc. Alternatively, proteins in the sample can be size separated (e.g., by polyacrylamide gel electrophoresis (PAGE), in the presence or not of sodium dodecyl sulfate (SDS) Triton, Noniodet (or other ionic or non-ionic detergents), and the presence of a CSF antigen detected by immunoblotting (Western blotting). Immunoblotting techniques are generally more effective with antibodies generated against a peptide corresponding to an epitope of a protein, and hence, are particularly suited to the present disclosure.
The correlation step mentioned above may be implemented qualitatively or quantitatively, for example in a fluorophoric or colorimetric assay.
Kits and Devices:
Also provided are kits and devices for determining whether a sample contains polypeptides associated with the presence of CSF. The diagnostic kits and devices are produced in a variety of ways. In some embodiments, the kits and devices contain at least one reagent for specifically detecting a polypeptide associated with the presence of CSF. In specific embodiments, the kits and devices contain multiple reagents for detecting polypeptides associated with the presence of CSF. In other embodiments, the reagents are antibodies that preferentially bind polypeptides associated with the presence of CSF. The test can produce a single result indicating the presence of CSF from a number (2-10) of tests for multiple antigens or each test can produce a different evident result that can be interpreted to indicate the presence or absence of CSF.
In some embodiments, the kit or device contains instructions for determining whether the sample contains polypeptides associated with the presence of CSF. In specific embodiments, the instructions specify that presence or absence of CSF is determined by detecting the presence or absence of polypeptides associated with the presence of CSF in a sample from the subject.
In some embodiments, the kits and devices include ancillary reagents such as buffering agents, protein stabilizing reagents, and signal producing systems (e.g., fluorescence generating systems such as FRET systems). The test kit or device is packaged in a suitable manner, typically with the elements in a single container or various containers as necessary, along with a sheet of instructions for carrying out the test. In some embodiments, the kits or devices also include a positive control sample. In further embodiments, the kit or device contains comparative reference material to interpret the presence or absence of polypeptides associated with the presence of CSF according to intensity, color spectrum, or other physical attribute of an indicator.
The need for a rapid, reproducible, sensitive and simple diagnostic test, which can be used in the health care for diagnosing CSF, is of major importance. Such a test has the obvious advantage over the existing laboratory tests, i.e., immunofixation electrophoresis, enzyme-linked immunosorbant assay (ELISA) and immunoblotting, in that it can be performed immediately beside the patient giving a result in a few minutes of time instead of several days when the sample is sent for analysis to a laboratory. A lateral flow immunochromatographic test may be utilized for making a diagnostic kit for the detection of CSF in biological fluids.
In one embodiment, a device includes a solid phase comprising a first region comprising a mobile indicator suitable for binding a CSF antigen, and a second region comprising a fixed indicator suitable for binding the CSF antigen.
In one embodiment, a lateral flow device comprises a test strip optionally with a plastic test cassette. Antibodies are attached to three different zones on the membrane; a sample zone (S) containing a first monoclonal antibody to a polypeptide associated with the presence of CSF; a test zone (T) that contains a second monoclonal or polyclonal antibody to polypeptides associated with the presence of CSF immobilized to the membrane; and a control zone (C), which contains a control antibody, for example, an immobilized rabbit anti-mouse antibody. The first monoclonal antibody in the sample (S) zone may be conjugated to a mobile particle, for example, a colored latex particle or a gold particle. Alternatively, the first monoclonal antibody is conjugated to a chromophoric indicator, such as a fluorescent molecule or tag (Green Fluorescent Protein (GFP) or FP orthologs mutants and other naturally occurring GFP-like fluorescent and chromo proteins, fluorescein (and orthologs), rhodamine (and orthologs), Cy3, Cy5, Cy2, Cy7, Cy8, Alexa® dyes, Texas Red, and the like).
An exemplary device is implemented utilizing an immunochromatographic test based on the use of two monoclonal antibodies. Sample is added to the S-zone, and if the polypeptide associated with the presence of CSF is present, it binds to the first monoclonal antibody to form a polypeptide-conjugate-complex. This complex migrates chromatographically on the membrane, and when it reaches the immobilized antibody in the T-zone, agglutination takes place and a blue colored band is formed.
Briefly and in one embodiment, the first monoclonal antibody is conjugated to a mobile particle, for example, gold or latex beads. These beads have the intrinsic color of either being red (for gold) or can come in different colors if using latex beads. When the sample is applied on the “S-zone”, the marker, a polypeptides associated with the presence of CSF if present in the sample, binds to the first monoclonal antibody that is conjugated to the beads and then because of the lateral flow absorbent pad on which the beads are placed, the complex (beads+antibody+polypeptide if present in the sample) migrates laterally. Once the complex reaches the “T-zone” where the second antibody is immobilized on the strip, the marker that is now migrating with the complex binds to the second immobilized antibody. As the second antibody is stationary/fixed/immobilized, the whole complex gets trapped and as the complex now contains colored beads, the immobilized T-zone line lights up according to the beads that are used (red for gold or different colors {like blue} if latex beads are used). The excess complex sample migrates to the end of the strip and at the “C-zone” the first antibody conjugated to the beads is trapped by immobilized/fixed/stationary rabbit-anti mouse antibody and gives a colored line indicating that the test is complete). Thus, a colored band indicates a positive result. No band in the T-zone is significant for a negative result. The immobilized polyclonal antibody in the C-zone will bind the latex conjugate with both positive and negative samples. This blue band assures a correct test performance.
In practice, the kits and devices are utilized in a variety of clinical settings to determine the presence of CSF in a sample.
The invention is illustrated by the following non-limiting examples.
EXAMPLES
CSF-specific antigens newly identified herein include Isoform 1 of Neural cell adhesion molecule-like (Accession Number gi|62088238) protein; Chain A, Human Mesotrypsin Complexed With Bovine Pancreatic Trypsin Inhibitor (Bpti) (Accession number gi|162330095); CNTN2 Contactin-2 (Accession Number gi|4827022); CNTN1 Isoform 2 of Contactin-1 (Accession Number gi:28373119); cDNA highly similar to SPARC-like protein 1 (Accession Number: gi|194388050); NRCAM protein (Neuronal cell adhesion molecule)[Homo sapiens] possibly slightly longer fragment ( ̃96 kDa) (Accession Number: gi|68534652 and gi|109731501); NCAM2 Neural cell adhesion molecule 2 (Accession Number gi|119630409); SERPINA3 serpin peptidase inhibitor, clade A, member 3 precursor/Isoform 1 of Alpha-1-antichymotrypsin/growth-inhibiting protein 25 [Homo sapiens] or slightly longer fragment of alpha-1-antichymotrypsin precursor (Accession Number gi|46981961); AGT Angiotensinogen (Accession Number gi|553181); Angiotensinogen precursor (Serpin A8) (Accession Number gi|4557287); unnamed protein product also called immunoglobulin superfamily, member 4B; in humans, also called cell adhesion molecule 3; possible fragment (Accession Number gi|187608363); cDNA FLJ59893, dickkopf homolog 3 precursor (Accession Number gi|40548389); SERPINF1 serine (or cysteine) proteinase inhibitor, clade F (alpha-2 antiplasmin, pigment epithelium derived factor), member 1 isoform 4 [Pan troglodytes] factor (Accession Number gi|15988024); GC Vitamin D-binding protein PREDICTED: vitamin D-binding protein [Pan troglodytes] (Accession Number 181482); CD14 Human monocyte antigen CD14 (CD14) (Accession Number gi|117646212); CADM3 Homo sapiens cell adhesion molecule 3 (CADM3), transcript variant 1 (Accession Number gi|90080503; gi|187608363 (human); Neural cell adhesion molecule variant (Accession Number gi62088238); CLU cDNA FLJ57622, highly similar to Clusterin (Accession number gi|189054091); protein highly similar to Clusterin (Accession number gi|193787502); LMAN2 Vesicular integral-membrane protein VIP36 (Accession number gi|157834800); superoxide dismutase 3, extracellular precursor (Accession number gi|118582275); fibrin alpha C term fragment (Accession number gi|223057); KLK6 Isoform 1 of Kallikrein-6 (Accession number gi|21465970); APCS Serum amyloid P-component/Chain A, The Structure Of Pentameric Human Serum Amyloid P Component (Accession number gi|576259); FAM3C Protein FAM3C/family with sequence similarity 3, member C precursor [Homo sapiens] note=“predicted osteoblast protein; interleukin-like EMT inducer (Accession number gi|55629272); Chain A, Human Kallikrein 6 (Hk6) Active Form With Benzamidine Inhibitor (Accession number gi|21465970); unnamed protein product [Macaca fascicularis] also called immunoglobulin superfamily, member 4B; in humans, also called cell adhesion molecule 3; possible fragment (Accession number gi|187608363); a CSF-enriched phosphorylated or dephosphorylated form of the foregoing CSF antigens; or a combination of two or more of the foregoing CSF antigens.
The terms “a” and “an” herein do not denote a limitation of quantity, but rather denote the presence of at least one of the referenced item.
All ranges disclosed herein are inclusive and combinable. While the invention has been described with reference to a preferred embodiment, it will be understood by those skilled in the art that various changes may be made and equivalents may be substituted for elements thereof without departing from the scope of the invention. In addition, many modifications may be made to adapt a particular situation or material to the teachings of the invention without departing from essential scope thereof. Therefore, it is intended that the invention not be limited to the particular embodiment disclosed as the best mode contemplated for carrying out this invention, but that the invention will include all embodiments falling within the scope of the appended claims.
All cited patents, patent applications, and other references are incorporated herein by reference in their entirety.

## Claims

1. A lateral flow immunoassay device for detection of the presence or absence of cerebrospinal fluid (CSF) in a sample, comprising
a sample application region,
a sample labeling region comprising a first antibody to a CSF-enriched protein of SEQ ID NO: 13, wherein the first antibody is conjugated to a mobile particle,
a sample detection region comprising a second antibody to the CSF-enriched protein of SEQ ID NO: 13, wherein the second antibody is fixed to the sample detection region, and
wherein, when said sample contains cerebrospinal fluid, said device displays a detectable band in the sample detection region.