[Progress in allergy/immunology in 2009]

Progresses in allergy in 2009 were particularly noticeable in the field of diagnosis with an increased use of recombinant food allergens; tolerance induction protocols, in particular for egg and milk allergy show promising results for the future; and interesting new possibilities for treatment of mastocytosis with anti-IgE antibodies are reported. Clinical immunology has witnessed advances along two main axes. The first aiming at defining new efficacious therapeutic strategies less toxic compared to those currently in use to control SLE and ANCA-related vasculitis. The second highlights a novel response index appears to be a major advancement toward our understanding of SLE.

[Mastocytosis--diagnostic criteria and treatment]

Mastocytosis is a heterogeneous group of rare diseases characterized by the proliferation and accumulation of mast cells in one or more organs such as the skin, bone marrow, liver, spleen, and lymph nodes. According to the WHO classification, mastocytosis is divided into seven subvariants. The symptoms are associated with mediator release and impaired organ function due to infiltration by neoplastic mast cells. There is a higher risk of anaphylactic shock; therefore education of the patients is very important. Patients may be asymptomatic. Symptomatic treatment is used in cutaneous mastocytosis and in indolent systemic mastocytosis. More aggressive subvariants of mastocytosis are treated with chemotherapy, targeted therapy, and bone marrow transplantation.

Therapeutic Apheresis of Immune Diseases in Nephrology Department

OBJECTIVE

The clinical efficacy of therapeutic apheresis is still controversial. We undertook a retrospective review of apheresis treatment to ascertain its safety and efficacy.

METHODS

We reviewed 31 patients (13 male, 18 female). Plasmapheresis was performed on 7 patients with hematologic disorders, 5 patients with neurologic disorders, 6 patients with systemic diseases, and 3 patients with Lyell syndrome. Immunoadsorption onto protein A sepharose was evaluated as rescue therapy in 7 patients. Low-density lipoprotein (LDL) apheresis was performed on 3 patients.

RESULTS

There were five mortalities due to serious complications of their primary disease. Most complications were mild such as hypotension and hypocalcemia. Two patients who received LDL apheresis had severe anaphylactic reactions. Apheresis was effective in the remaining 24 patients.

CONCLUSIONS

The therapeutic apheresis consists of a continuously improving therapeutic method for diseases with high mortality and morbidity, especially in cases with poor outcome by using current medications.

Immunoinformatics: current trends and future directions

Immunoinformatics has recently emerged as a critical field for accelerating immunology research. Although still an evolving process, computational models now play instrumental roles, not only in directing the selection of key experiments, but also in the formulation of new testable hypotheses through detailed analysis of complex immunologic data that could not be achieved using traditional approaches alone. Immunomics, which combines traditional immunology with computer science, mathematics, chemistry, biochemistry, genomics and proteomics for the large-scale analysis of immune system function, offers new opportunities for future bench-to-bedside research. In this article, we review the latest trends and future directions of the field.

Stem cell through present and future

Stem cell transplantation (SCT) has the potential to transform the lives of children with a wide variety of genetic diseases, ranging from inherent defects of hemopoietic cell production or function through to metabolic diseases mostly affecting solid organs. For these children life expectancy or quality of life would otherwise be very poor. It ranks as one of the most remarkable therapeutic advances of the past 40 years. Despite rapid technological improvements, however, there are still many short term risks and potential long term toxicities. Consequently, the rapid emergence of alternative therapies (including new drugs, enzyme and gene therapies), necessitate constant re-evaluation of the risk/benefit ratio for each disease and hence the appropriateness of SCT. This review describes the major aspects of the transplant process, indications for transplantation, outcome statistics, and areas where alternative therapies are becoming available. SCT remains a highly experimental therapy. Due to the relatively short history of the discipline no data exists on truly long term follow up. This is important as some organs benefit relatively poorly or problems may emerge which were never apparent as part of the untreated disease. The speed of technological change makes randomised trials on these diseases, which are individually quite rare, almost impossible to perform.

Neuroimmunomodulation by nutrition in stress situations

Stress has long been suspected to play a role in the etiology of many diseases and may be detrimental to health. Nowadays, the communication between the neuroendocrine and the immune systems is well established and there is enough evidence that the magnitude of stress-associated immune dysregulation is large enough to have health implications. In stress conditions, modulation of the immune system by the central nervous system (CNS) is mediated by a complex network of signals, showing a relationship between stress and resistance to infection. On the other hand, an adequate balanced diet plays a crucial role in the management of stress, and nutrition seems to be a critical determinant in the interactions among CNS and the immune system under stress conditions. Thus, interactions among nutrition, CNS and the immune system could be a key to understand implications in physiological stress situations. The present article will briefly review nutrition approaches on stress-related immune response and CNS communication.

Is exchange transfusion a possible treatment for neonatal hemochromatosis?

Neonatal hemochromatosis is a rare congenital disorder of the liver associated to a poor prognosis. Liver transplantation is often required, since no effective medical treatment has been found. Despite mounting evidence of an alloimmune etiology of this condition, exchange transfusion has never been proposed as a specific treatment for neonatal hemochromatosis. Here we describe two siblings affected by neonatal hemochromatosis. The first, a female, died at 18 days of severe coagulopathy and acute renal failure, diagnosed as affected by neonatal hemochromatosis only when the second sibling was suspected as being affected by the same disease. The second child showed a rapidly worsening coagulopathy which was treated with two exchange transfusions, followed by rapid clinical and laboratory improvement, before reaching a definite diagnosis of neonatal hemochromatosis. He is healthy at present after a follow-up of 12 months. Although exchange transfusion has never been considered as treatment for neonatal hemochromatosis, this case suggests that it could be a feasible treatment option for children affected by this disease, as for other alloimmune conditions.

Taking dendritic cells into medicine

Dendritic cells (DCs) orchestrate a repertoire of immune responses that bring about resistance to infection and silencing or tolerance to self. In the settings of infection and cancer, microbes and tumours can exploit DCs to evade immunity, but DCs also can generate resistance, a capacity that is readily enhanced with DC-targeted vaccines. During allergy, autoimmunity and transplant rejection, DCs instigate unwanted responses that cause disease, but, again, DCs can be harnessed to silence these conditions with novel therapies. Here we present some medical implications of DC biology that account for illness and provide opportunities for prevention and therapy.

Pathobiology of transforming growth factor beta in cancer, fibrosis and immunologic disease, and therapeutic considerations

Transforming growth factor beta (TGF-beta) is a highly pleiotropic cytokine that plays an important role in wound healing, angiogenesis, immunoregulation and cancer. The cells of the immune system produce the TGF-beta1 isoform, which exerts powerful anti-inflammatory functions, and is a master regulator of the immune response. However, this is context dependent, because TGF-beta can contribute to the differentiation of both regulatory (suppressive) T cells (Tr cells) and inflammatory Th17 cells. While TGF-beta might be underproduced in some autoimmune diseases, it is overproduced in many pathological conditions. This includes pulmonary fibrosis, glomerulosclerosis, renal interstitial fibrosis, cirrhosis, Crohn's disease, cardiomyopathy, scleroderma and chronic graft-vs-host disease. In neoplastic disease, TGF-beta suppresses the progression of early lesions, but later this effect is lost and cancer cells produce TGF-beta, which then promotes metastasis. This cytokine also contributes to the formation of the tumor stroma, angiogenesis and immunosuppression. In view of this, several approaches are being studied to inhibit TGF-beta activity, including neutralizing antibodies, soluble receptors, receptor kinase antagonist drugs, antisense reagents and a number of less specific drugs such as angiotensin II antagonists and tranilast. It might be assumed that TGF-beta blockade would result in severe inflammatory disease, but this has not been the case, presumably because the neutralization is only partial. In contrast, the systemic administration of TGF-beta for therapeutic purposes is limited by toxicity and safety concerns, but local administration appears feasible, especially to promote wound healing. Immunotherapy or vaccination stimulating TGF-beta production and/or Tr differentiation might be applied to the treatment of autoimmune diseases. The benefits of new therapies targeting TGF-beta are under intense investigation.

Role of regulatory T cells and FOXP3 in human diseases

Immune regulation and tolerance are specific functions of the immune system, meaning at prevention or limitation of effector immune responses against inner and external insults. Regulatory T (Treg) cells are crucial players in this immune balance network. Research over the last 10 years has significantly contributed to characterizing Treg cell features, their mechanisms of function, and their role in human pathologies. The discovery of FOXP3 as an essential transcription factor not only for differentiation and function of naturally occurring Treg cells but also for regulation of intracellular molecules related to effector T-cell responses has provided new insights into the pathogenesis of immune-mediated diseases. Interestingly, there is increasing evidence that the individual signature of genes relevant for immune regulation definitely influences the final outcome of an immune response.

Applying Embryo-Derived Immune Tolerance to the Treatment of Immune Disorders

Pregnancy is a unique immune state in which both mother and embryo/fetus tolerate and interact with one another through term, without interfering with the mother's native immunity. When the embryo is viable, it initiates maternal immune tolerance (IT)--ut not immune suppression. The balance is complex: some immune disorders are ameliorated during pregnancy, despite the presence of an "inflammatory" environment. We have identified a pregnancy viability biomarker--preimplantation factor (PIF)--secreted only by viable embryos, which helps to initiate this maternal tolerance and uterine receptivity. Using anti-PIF antibodies, we have detected PIF in the fetus and placenta. Beyond enhancing uterine receptivity locally, PIF has also been detected in maternal circulation, and may promote peripheral tolerance. In the fetus, PIF may help avoid a "graft-versus-host"-type reaction PIF exhibits unique potent immune-modulatory effects and its synthetic analogue has been shown to exert significant protection in diverse immune scenarios. Nontoxic, low-dose, short-term PIF administration has led to long-term effects in preclinical models of multiple sclerosis (MS), juvenile diabetes mellitus (JDM), and graft-versus-host disease (GVHD), in a manner enabling its translation into a clinical setting. Further investigation of this compound is warranted.

Granulocyte transfusions in neutropaenic children: a systematic review of the literature

BACKGROUND

Granulocyte transfusions (GTX) have been used for decades in paediatric neutropaenic patients, but uncertainty remains regarding their effectiveness. We reviewed all the paediatric data available on GTX, to gain a insight in to the indications for use, favourable effects and side effects in patients and donors.

METHODS

A comprehensive search was done in MEDLINE, EMBASE, LILACS and CENTRAL (1966 until 2006). All studies including children (1-18 years) who received GTX were included.

RESULTS

A total of 66 observational studies were included:Seven using prophylactic and 59 therapeutic GTX. Of the therapeutic studies 55 reported a proven sepsis caused by Gram-negative bacteria (34%) or fungal disease (48%) as the indication for GTX. Concerning effectiveness 70% survival was reported, but no controlled studies were identified. Side effects were mentioned in 27 studies including mild respiratory symptoms, allergic reactions and infection related complications (CMV). Side effects in the donor were mainly flu-like illness.

DISCUSSION

In this first review covering 30 years of experience on the use of GTX in children, we found no randomised evidence showing a positive benefit risk ratio. The available case reports and cohort studies alert us as to the potential benefits and harms of the use of GTX in neutropaenic children and provides the basis for a well designed trial in children.

11th annual Inflammatory and Immune Diseases Drug Discovery and Development Summit 12-13 March 2007, San Francisco, USA

The Strategic Research Institute (SRi) hosted the 11th International Inflammation and Immune Diseases Drug Discovery and Development World Summit in San Francisco during 12-13 March 2007. The summit comprised keynote sessions and two parallel tracks and focussed on targeting mechanisms for drug discovery and development, which modulate the immune response and which have anti-inflammatory activity in a number of human diseases. Indications included psoriasis, hepatitis C, allergic dermatitis, systemic lupus erythematosus, rheumatoid arthritis and osteoarthritis, multiple sclnerosis, cardiovascular disease and asthma. Data were presented supporting all stages of drug discovery from target identification and validation through to lead identification and optimisation to both early- and late-stage clinical development.

Altered macrophage differentiation and immune dysfunction in tumor development

Tumors require a constant influx of myelomonocytic cells to support the angiogenesis and stroma remodeling needed for their growth. This is mediated by tumor-derived factors, which cause sustained myelopoiesis and the accumulation and functional differentiation of myelomonocytic cells, most of which are macrophages, at the tumor site. An important side effect of the accumulation and functional differentiation of these cells is that they can induce lymphocyte dysfunction. A complete understanding of the complex interplay between neoplastic and myelomonocytic cells might offer novel targets for therapeutic intervention aimed at depriving tumor cells of important growth support and enhancing the antitumor immune response.

Complementary and alternative medicine and coping in neuroimmunological diseases

The utilisation of complementary and alternative medicine (CAM) is widespread in neuroimmunological diseases like multiple sclerosis (MS) but has been disregarded in research until lately. After describing the problems of definition in CAM, different categories will be described. Various confounding factors on CAM utilisation exist, though hardly investigated. Besides sociodemographic variables like education, income, gender and age, illness-related factors like severity of disease are discussed. Furthermore, the important role of coping and CAM utilisation has not been investigated in neuroimmunological diseases, yet. Results derived from our investigations on CAM utilisation in MS indicate that users of CAM apply coping strategies, such as "rumination", "search for information" and "search for meaning in religion", more frequently than non-users and that current CAM utilisation is related to depression. Further research is needed in this field, as well as in other neuroimmunological diseases.

Immune circuitry in the peripheral nervous system

PURPOSE OF REVIEW

The aim of this review is to describe the local immune circuitry in the peripheral nervous system and its dialogue with systemic immunity under pathological conditions. Specifically, interactions of the immune system with cellular and extracellular components within peripheral nerve and immune functions of tissue-resident endoneurial macrophages and Schwann cells will be discussed.

RECENT FINDINGS

New insights into the elements involved in the pathogenesis of immune-mediated disorders of the peripheral nervous system provide a better understanding of the complex interplay of these cellular and molecular components in the immunology of the peripheral nervous system.

SUMMARY

The application of innovative and cutting-edge technologies to the study of immunoinflammatory disorders of the peripheral nervous system provides a better understanding of underlying principles of the organization of the immune network present in the peripheral nerve and its dialogue with the systemic immune system. This may foster the development of specific and highly effective therapies for immune-mediated disorders of the peripheral nerve.

Epratuzumab in the therapy of oncological and immunological diseases

B cells play an important role in the pathogenesis of certain lymphomas and leukemias, as well as many autoimmune diseases. Antagonistic B-cell antibodies are thus gaining an increasing role in the management of these diseases. The first antibody target in this regard was CD20, with the development and introduction of rituximab in the management of B-cell malignancies, as well as rheumatoid arthritis. A second candidate target is CD22. The first antagonistic antibody to this B-cell marker, epratuzumab, appears to function, in contrast to CD20 antibodies, more by modulation of B cells rather than by their high depletion in circulation. Originally developed for the treatment of non-Hodgkin's lymphoma, epratuzumab has now been found to be effective, with a very good safety profile, in two prototype autoimmune diseases: systemic lupus erythematosus and primary Sjögren's syndrome. Recent studies have demonstrated the activity and safety of epratuzumab in non-Hodgkin's lymphoma patients who have relapsed or are refractive to conventional therapy, including rituximab, and has also shown good activity in follicular and diffuse large B-cell lymphoma in combination with rituximab. As such, this new investigative antibody may have a significant market potential owing to the multitude of diseases and patients who may benefit from a CD22, B-cell antibody immunotherapy that is complementary to the known effects and role of CD20 antibodies, but can usually be administered within 1 h and depletes approximately 50% of circulating B cells.

Helminths as governors of immune-mediated inflammation

Immune-mediated diseases (e.g. inflammatory bowel disease, asthma, multiple sclerosis and autoimmune diabetes) are increasing in prevalence and emerge as populations adopt meticulously hygienic lifestyles. This change in lifestyles precludes exposure to helminths (parasitic worms). Loss of natural helminth exposure removes a previously universal Th2 and regulatory immune biasing imparted by these organisms. Helminths protect animals from developing immune-mediated diseases (colitis, reactive airway disease, encephalitis and diabetes). Clinical trials show that exposure to helminths can reduce disease activity in patients with ulcerative colitis or Crohn's disease. This paper summarises work by multiple groups demonstrating that colonization with helminths alters immune reactivity and protects against disease from dysregulated inflammation.