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Treatment of refractory hemophagocytic lymphohistiocytosis with emapalumab despite severe concurrent infections. Blood Adv 2020; 3:47-50. [PMID: 30617216 DOI: 10.1182/bloodadvances.2018025858] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 12/06/2018] [Indexed: 11/20/2022] Open
Abstract
Key Points
Neutralization of IFN-γ with emapalumab can reverse severe, refractory hemophagocytic lymphohistiocytosis. Neutralizing IFN-γ did not impair control of multiple viral and other infections in a severely ill patient.
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Prencipe G, Bracaglia C, Caiello I, Pascarella A, Francalanci P, Pardeo M, Meneghel A, Martini G, Rossi MN, Insalaco A, Marucci G, Nobili V, Spada M, Zulian F, De Benedetti F. The interferon-gamma pathway is selectively up-regulated in the liver of patients with secondary hemophagocytic lymphohistiocytosis. PLoS One 2019; 14:e0226043. [PMID: 31846457 PMCID: PMC6917341 DOI: 10.1371/journal.pone.0226043] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/19/2019] [Indexed: 12/24/2022] Open
Abstract
Aim of this study was to investigate the activation of the IFNγ pathway in the affected liver and in the blood of patients with secondary hemophagocytic lymphohistiocytosis (sHLH). To this purpose, the mRNA expression levels of IFNG and IFNγ-inducible genes as well as Tyrosine (701)-phosphorylated signal transducer and activator of transcription 1 (STAT1) protein levels were evaluated in the liver and in peripheral blood mononuclear cells (PBMCs) of three patients with sHLH with predominant liver involvement. The mRNA expression levels of IFNG and IFNγ-inducible genes were markedly higher in patient livers compared to control livers and to one disease control liver. Conversely, slight differences in the expression levels of Type I IFN-inducible genes and other classical inflammatory cytokine genes were found. Further supporting the activation of the IFNγ pathway, higher protein levels of phosphorylated and total STAT1 were detected in patient livers compared to control livers. When the expression of the same genes analysed in liver tissues was evaluated in PBMCs collected from 2 out of 3 patients before the liver biopsy, we found that mRNA levels of IFNγ-inducible genes were markedly increased. Accordingly, high circulating levels of IFNγ-inducible CXCL9 were observed in patients. Altogether, these data demonstrate the selective and marked up-regulation of the IFNγ pathway in the liver tissue and blood of patients with active sHLH. Finally, we show that measurement of circulating CXCL9 levels and evaluation of IFNγ-inducible gene expression levels in PBMCs may represent a new valid tool to better identify patients with suspected HLH with predominant liver involvement.
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Affiliation(s)
- Giusi Prencipe
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- * E-mail:
| | - Claudia Bracaglia
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Ivan Caiello
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonia Pascarella
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Manuela Pardeo
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Giorgia Martini
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Marianna N. Rossi
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giulia Marucci
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Valerio Nobili
- Hepatology Gastroenterology and Nutrition Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Zulian
- Department of Woman and Child Health, University of Padua, Padua, Italy
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Burn TN, Weaver L, Rood JE, Chu N, Bodansky A, Kreiger PA, Behrens EM. Genetic Deficiency of Interferon-γ Reveals Interferon-γ-Independent Manifestations of Murine Hemophagocytic Lymphohistiocytosis. Arthritis Rheumatol 2019; 72:335-347. [PMID: 31400073 DOI: 10.1002/art.41076] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/06/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Familial hemophagocytic lymphohistiocytosis (FHLH) is a complex cytokine storm syndrome caused by genetic abnormalities rendering CD8+ T cells and natural killer cells incapable of cytolytic killing. In murine models of FHLH, interferon-γ (IFNγ) produced by CD8+ T cells has been identified as a critical mediator of disease, and an IFNγ-blocking antibody (emapalumab) has recently been approved by the Food and Drug Administration. However, development of hemophagocytic lymphohistiocytosis (HLH)/macrophage activation syndrome (MAS) in patients who are genetically unresponsive to IFNγ questions the absolute necessity of IFNγ in driving disease. This study was undertaken to determine the necessity of IFNγ in driving HLH. METHODS IFNγ-/- Prf1-/- mice were infected with lymphocytic choriomeningitis virus (LCMV), and HLH immunopathologic features, including survival, weight loss, cytopenias, cytokine profiles, and immune cell phenotypes, were assessed. Mixed bone marrow chimeras were created to determine the immune cell-intrinsic role of IFNγ receptor signaling. CD8+ T cell depletion and interleukin-33 (IL-33)/ST2 blockade were performed using monoclonal antibodies. RESULTS LCMV infection of IFNγ-/- Prf1-/- mice resulted in severe HLH-like disease. CD8+ T cells and the IL-33/ST2 axis remained essential mediators of disease; however, IFNγ-independent HLH immunopathology correlated with a 10-15-fold increase in neutrophilia (P < 0.001) and an altered cytokine milieu dominated by IL-6, IL-1β, and granulocyte-macrophage colony-stimulating factor (GM-CSF) (P < 0.05). Furthermore, IFNγ regulated CD8+ T cell expression of GM-CSF and neutrophil survival. CONCLUSION IFNγ is not necessary for the development of fulminant HLH, requiring physicians to consider case-by-case treatment strategies. Use of therapies that target upstream activators of CD8+ T cells, such as IL-33/ST2 signaling, may be more universally applicable treatment options that ameliorate both IFNγ-dependent and -independent manifestations of HLH/MAS.
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Affiliation(s)
- Thomas N Burn
- Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lehn Weaver
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julia E Rood
- Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Niansheng Chu
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aaron Bodansky
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Edward M Behrens
- Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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54
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Jordan MB, Allen CE, Greenberg J, Henry M, Hermiston ML, Kumar A, Hines M, Eckstein O, Ladisch S, Nichols KE, Rodriguez-Galindo C, Wistinghausen B, McClain KL. Challenges in the diagnosis of hemophagocytic lymphohistiocytosis: Recommendations from the North American Consortium for Histiocytosis (NACHO). Pediatr Blood Cancer 2019; 66:e27929. [PMID: 31339233 PMCID: PMC7340087 DOI: 10.1002/pbc.27929] [Citation(s) in RCA: 216] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/10/2019] [Accepted: 06/28/2019] [Indexed: 12/15/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of pathologic immune activation, often associated with genetic defects of lymphocyte cytotoxicity. Though a distinctive constellation of features has been described for HLH, diagnosis remains challenging as patients have diverse presentations associated with a variety of triggers. We propose two concepts to clarify how HLH is diagnosed and treated: within the broader syndrome of HLH, "HLH disease" should be distinguished from "HLH disease mimics" and HLH subtypes should be categorized by specific etiologic associations, not the ambiguous dichotomy of "primary" and "secondary." We provide expert-based advice regarding the diagnosis and initiation of treatment for patients with HLH, rooted in improved understanding of its pathophysiology.
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Affiliation(s)
- Michael B. Jordan
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carl E. Allen
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jay Greenberg
- Division of Hematology, Children’s National Medical Center, Washington, DC
| | - Michael Henry
- Center for Cancer and Blood Disorders, Phoenix Children’s Hospital, University of Arizona College of Medicine, Tucson, Arizona
| | - Michelle L. Hermiston
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, San Francisco, California
| | - Ashish Kumar
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Melissa Hines
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Olive Eckstein
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephan Ladisch
- Center for Cancer and Immunology Research, Children’s National Medical Center and George Washington University School of Medicine, Washington, DC
| | - Kim E. Nichols
- Division of Cancer Predisposition, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Birte Wistinghausen
- Division of Oncology, Center for Cancer and Blood Disorders, Children’s National Health System, Washington, DC
| | - Kenneth L. McClain
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Additional corresponding author, Kenneth L. McClain, 6701 Fannin St. Suite 1510, Houston, TX 77030,
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Abstract
Emapalumab-Izsg (hereafter referred to as emapalumab) [Gamifant®] is a monoclonal antibody directed against interferon gamma that is available as an intravenous infusion. Emapalumab is being developed by Novimmune and Swedish Orphan Biovitrum for the treatment of haemophagocytic lymphohistiocytosis (HLH). In November 2018, emapalumab received its first global approval in the USA, for the treatment of paediatric (newborn and older) and adult patients with primary HLH, who have refractory, recurrent or progressive disease or intolerance to conventional HLH therapy. Emapalumab is under regulatory review in the EU for the treatment of primary HLH. This article summarizes the milestones in the development of emapalumab leading to this first global approval for HLH in the USA.
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MESH Headings
- Adolescent
- Adult
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Neutralizing/administration & dosage
- Antibodies, Neutralizing/adverse effects
- Antibodies, Neutralizing/immunology
- Child
- Child, Preschool
- Drug Approval
- Female
- Humans
- Infant
- Infant, Newborn
- Infusions, Intravenous
- Interferon-gamma/antagonists & inhibitors
- Interferon-gamma/immunology
- Lymphohistiocytosis, Hemophagocytic/drug therapy
- Lymphohistiocytosis, Hemophagocytic/immunology
- Male
- Middle Aged
- Treatment Outcome
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Affiliation(s)
- Zaina T Al-Salama
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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56
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Ahmed A, Merrill SA, Alsawah F, Bockenstedt P, Campagnaro E, Devata S, Gitlin SD, Kaminski M, Cusick A, Phillips T, Sood S, Talpaz M, Quiery A, Boonstra PS, Wilcox RA. Ruxolitinib in adult patients with secondary haemophagocytic lymphohistiocytosis: an open-label, single-centre, pilot trial. LANCET HAEMATOLOGY 2019; 6:e630-e637. [PMID: 31537486 DOI: 10.1016/s2352-3026(19)30156-5] [Citation(s) in RCA: 189] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis is a cytokine-driven inflammatory syndrome that is associated with substantial morbidity and mortality. Overall survival in adult patients with secondary haemophagocytic lymphohistiocytosis remains suboptimal, and novel therapeutic strategies are needed. The phosphorylation-dependent activation of the Janus family kinases JAK1 and JAK2 are hallmarks of the final common pathway in this disease. We therefore aimed to determine the activity and safety of ruxolitinib, a JAK inhibitor, in adults with secondary haemophagocytic lymphohistiocytosis. METHODS We performed an open-label, single-centre, pilot study of ruxolitinib in adults with secondary haemophagocytic lymphohistiocytosis at the University of Michigan Rogel Cancer Center (Ann Arbor, MI, USA). We included patients aged 18 years or more who fulfilled at least five of the eight HLH-2004 criteria for hemophagocytic lymphohistiocytosis. Discontinuation of corticosteroids was not required for enrolment in this study. Patients received oral ruxolitinib (15 mg twice a day) on a continuous 28-day cycle, or until disease progression or unacceptable toxicity. The primary endpoint was overall survival at 2 months from the first dose of ruxolitinib. Secondary endpoints included the assessment of adverse events, response (defined as the assessment of all quantifiable signs and laboratory abnormalities included in the diagnostic criteria for haemophagocytic lymphohistiocytosis), and pharmacodynamic biomarkers. Analyses were done in all treated patients with available data. This study is registered with ClinicalTrials.gov, number NCT02400463, and is still recruiting. FINDINGS As of Feb 7, 2019, five patients had been enrolled. The first patient was enrolled in February, 2016. No deaths were recorded, with a median follow-up of 490 days (IQR 190-1075). 2-month overall survival was 100% (95% CI 57-100). Regarding response, resolution of symptoms (either partial or complete) and disease-associated laboratory abnormalities was observed in all five patients. Cytopenias improved in all patients within the first week of treatment, leading to relatively rapid transfusion independence, discontinuation of corticosteroids, and hospital discharge. A single serious adverse event (ie, grade 4 febrile neutropenia) was reported. One patient discontinued treatment because of grade 2 extremity pain and no treatment-related deaths were observed. Improvements in inflammatory markers (eg, ferritin, soluble IL-2 receptor) and T cells and monocytes activation (ie, decreased STAT1 phosphorylation) were observed following treatment. INTERPRETATION These preliminary data suggest that ruxolitinib is active, well tolerated, and manageable in the outpatient setting in patients with secondary haemophagocytic lymphohistiocytosis. Given the paucity of effective, non-myelosuppressive therapies, these preliminary findings have important therapeutic implications for patients with haemophagocytic lymphohistiocytosis and other cytokine-release syndromes and warrant further investigation. FUNDING National Cancer Institute, the University of Michigan Rogel Cancer Center, and Incyte Corporation.
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Affiliation(s)
- Asra Ahmed
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Samuel A Merrill
- Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Fares Alsawah
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Paula Bockenstedt
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Erica Campagnaro
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Sumana Devata
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Scott D Gitlin
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Mark Kaminski
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Alice Cusick
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Tycel Phillips
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Suman Sood
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Moshe Talpaz
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Albert Quiery
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | - Philip S Boonstra
- Department of Biostatistics and the Center for Cancer Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Ryan A Wilcox
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA.
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Comparison of serum biomarkers for the diagnosis of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis. Clin Immunol 2019; 208:108252. [PMID: 31449879 DOI: 10.1016/j.clim.2019.108252] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 12/17/2022]
Abstract
Our study aimed to compare the accuracy of serum biomarkers for the diagnosis of macrophage activation syndrome (MAS) complicating systemic juvenile idiopathic arthritis (s-JIA). Serum cytokine levels (neopterin, IL-18, and CXCL9 and soluble tumor necrosis factor receptor type I (sTNFR-I) and II) were determined by enzyme-linked immunosorbent assay in 78 patients with s-JIA, including 21 with MAS. Receiver operating characteristic curve analysis revealed area under the curve values and cut off values of neopterin, IL-18, CXCL9, sTNFR-II/I ratio and ferritin were 0.9465/19.5 nmol/l, 0.8895/69250 ng/ml, 0.9333/3130 pg/ml, 0.9395/3.796 and 0.8671/2560 ng/ml, respectively. Serum neopterin levels were significantly elevated in patients with MAS and those were correlated positively with disease activity. In conclusion, serum neopterin levels may be used as a promising indicator of disease activity in s-JIA and MAS and for evaluating it. It may also be a useful marker to diagnose the transition to MAS from active-phase s-JIA.
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Abstract
Hyperferritinemia and pronounced hemophagocytosis help distinguish a subset of patients with a particularly inflammatory and deadly systemic inflammatory response syndrome. Two clinically similar disorders typify these hyperferritinemic syndromes: hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS). HLH is canonically associated with a complete disturbance of perforin/granzyme-mediated cytotoxicity, whereas MAS occurs in the context of the related rheumatic diseases systemic juvenile idiopathic arthritis and adult-onset Still's disease, with associated IL-1 family cytokine activation. In practice, however, there are accumulating lines of evidence for innate immune dysregulation in HLH as well as partial impairments of cytotoxicity in MAS, and these mechanisms likely represent only a fraction of the host and environmental factors driving hyperferritinemic inflammation. Herein, we present new findings that highlight the pathogenic differences between HLH and MAS, two conditions that present with life-threatening hyperinflammation, hyperferritinemia and hemophagocytosis.
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Affiliation(s)
- Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Scott W Canna
- RK Mellon Institute for Pediatric Research, Pittsburgh, PA, USA
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59
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Behrens EM, Koretzky GA. Review: Cytokine Storm Syndrome: Looking Toward the Precision Medicine Era. Arthritis Rheumatol 2019; 69:1135-1143. [PMID: 28217930 DOI: 10.1002/art.40071] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 02/09/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Edward M Behrens
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
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60
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Humblet-Baron S, Franckaert D, Dooley J, Ailal F, Bousfiha A, Deswarte C, Oleaga-Quintas C, Casanova JL, Bustamante J, Liston A. IFN-γ and CD25 drive distinct pathologic features during hemophagocytic lymphohistiocytosis. J Allergy Clin Immunol 2019; 143:2215-2226.e7. [PMID: 30578871 PMCID: PMC7117880 DOI: 10.1016/j.jaci.2018.10.068] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 09/17/2018] [Accepted: 10/22/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Inflammatory activation of CD8+ T cells can, when left unchecked, drive severe immunopathology. Hyperstimulation of CD8+ T cells through a broad set of triggering signals can precipitate hemophagocytic lymphohistiocytosis (HLH), a life-threatening systemic inflammatory disorder. OBJECTIVE The mechanism linking CD8+ T-cell hyperactivation to pathology is controversial, with excessive production of IFN-γ and, more recently, excessive consumption of IL-2, which are proposed as competing hypotheses. We formally tested the proximal mechanistic events of each pathway in a mouse model of HLH. METHODS In addition to reporting a complete autosomal recessive IFN-γ receptor 1-deficient patient with multiple aspects of HLH pathology, we used the mouse model of perforin (Prf1)KO mice infected with lymphocytic choriomeningitis virus to genetically eliminate either IFN-γ production or CD25 expression and assess the immunologic, hematologic, and physiologic disease measurement. RESULTS We found a striking dichotomy between the mechanistic basis of the hematologic and inflammatory components of CD8+ T cell-mediated pathology. The hematologic features of HLH were completely dependent on IFN-γ production, with complete correction after loss of IFN-γ production without any role for CD8+ T cell-mediated IL-2 consumption. By contrast, the mechanistic contribution of the immunologic features was reversed, with no role for IFN-γ production but substantial correction after reduction of IL-2 consumption by hyperactivated CD8+ T cells. These results were complemented by the characterization of an IFN-γ receptor 1-deficient patients with HLH-like disease, in whom multiple aspects of HLH pathology were observed in the absence of IFN-γ signaling. CONCLUSION These results synthesize the competing mechanistic models of HLH pathology into a dichotomous pathogenesis driven through discrete pathways. A holistic model provides a new paradigm for understanding HLH and, more broadly, the consequences of CD8+ T-cell hyperactivation, thereby paving the way for clinical intervention based on the features of HLH in individual patients.
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Affiliation(s)
- Stéphanie Humblet-Baron
- VIB Center for Brain & Disease Research, Leuven, Belgium; KU Leuven-University of Leuven, Department of Microbiology and Immunology, Leuven, Belgium
| | - Dean Franckaert
- VIB Center for Brain & Disease Research, Leuven, Belgium; KU Leuven-University of Leuven, Department of Microbiology and Immunology, Leuven, Belgium
| | - James Dooley
- VIB Center for Brain & Disease Research, Leuven, Belgium; KU Leuven-University of Leuven, Department of Microbiology and Immunology, Leuven, Belgium
| | - Fatima Ailal
- Clinical Immunology Unit, Casablanca Children's Hospital, Ibn Rochd Laboratoire LICIA d'Immunologie Clinique, Inflammation et Allergie, Medical School, Hassan II University, Casablanca, Morocco
| | - Aziz Bousfiha
- Clinical Immunology Unit, Casablanca Children's Hospital, Ibn Rochd Laboratoire LICIA d'Immunologie Clinique, Inflammation et Allergie, Medical School, Hassan II University, Casablanca, Morocco
| | - Caroline Deswarte
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Imagine Institute, Necker Hospital for Sick Children, Paris, France; Paris Descartes University, Paris, France
| | - Carmen Oleaga-Quintas
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Imagine Institute, Necker Hospital for Sick Children, Paris, France; Paris Descartes University, Paris, France
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Imagine Institute, Necker Hospital for Sick Children, Paris, France; Paris Descartes University, Paris, France; St Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY; Howard Hughes Medical Institute, New York, NY; Pediatric Hematology-Immunology Unit, Assistance Publique-Hôpitaux de Paris AP-HP, Necker Hospital for Sick Children, Paris, France
| | - Jacinta Bustamante
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Imagine Institute, Necker Hospital for Sick Children, Paris, France; Paris Descartes University, Paris, France; St Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY; Center for the Study of Primary Immunodeficiencies, Assistance Publique-Hôpitaux de Paris AP-HP, Necker Hospital for Sick Children, Paris, France
| | - Adrian Liston
- VIB Center for Brain & Disease Research, Leuven, Belgium; KU Leuven-University of Leuven, Department of Microbiology and Immunology, Leuven, Belgium.
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Mechanisms of action of ruxolitinib in murine models of hemophagocytic lymphohistiocytosis. Blood 2019; 134:147-159. [PMID: 31015190 DOI: 10.1182/blood.2019000761] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/17/2019] [Indexed: 12/30/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an often-fatal disorder characterized by the overactivation of T cells and macrophages that excessively produce proinflammatory cytokines, including interferon-γ (IFN-γ). Previously, we reported that the JAK inhibitor ruxolitinib dampens T-cell activation and lessens inflammation in a model of HLH in which perforin-deficient (Prf1 -/-) mice are infected with lymphocytic choriomeningitis virus (LCMV). Ruxolitinib inhibits signaling downstream of IFN-γ, as well as several other JAK-dependent cytokines. As a consequence, it remained unclear whether ruxolitinib was exerting its beneficial effects in HLH by inhibiting IFN-γ signaling or by targeting signaling initiated by other proinflammatory cytokines. To address this question, we compared the effects of ruxolitinib with those obtained using an IFN-γ-neutralizing antibody (αIFN-γ) in 2 murine HLH models. In both models, ruxolitinib and αIFN-γ reduced inflammation-associated anemia, indicating that ruxolitinib operates in an IFN-γ-dependent manner to reverse this HLH manifestation. In contrast, the number and activation status of T cells and neutrophils, as well as their infiltration into tissues, were significantly reduced following treatment with ruxolitinib, but they remained unchanged or were increased following treatment with αIFN-γ. Notably, despite discontinuation of ruxolitinib, LCMV-infected Prf1 -/- mice exhibited enhanced survival compared with mice in which αIFN-γ was discontinued. This protective effect could be mimicked by transient treatment with αIFN-γ and a neutrophil-depleting antibody. Thus, ruxolitinib operates through IFN-γ-dependent and -independent mechanisms to dampen HLH by targeting the deleterious effects of T cells and neutrophils, with the latter representing an unappreciated and understudied cell type that contributes to HLH pathogenesis.
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62
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Tsuboi I, Harada T, Hirabayashi Y, Aizawa S. Senescence-accelerated mice (SAMP1/TA-1) treated repeatedly with lipopolysaccharide develop a condition that resembles hemophagocytic lymphohistiocytosis. Haematologica 2019; 104:1995-2005. [PMID: 30819910 PMCID: PMC6886438 DOI: 10.3324/haematol.2018.209551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/25/2019] [Indexed: 11/21/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening systemic hyperinflammatory disorder with primary and secondary forms. Primary hemophagocytic lymphohistiocytosis is associated with inherited defects in various genes that affect the immunological cytolytic pathway. Secondary hemophagocytic lymphohistiocytosis is not inherited, but complicates various medical conditions including infections, autoinflammatory/autoimmune diseases, and malignancies. When senescence-accelerated mice (SAMP1/TA-1) with latent deterioration of immunological function and senescence-resistant control mice (SAMR1) were treated repeatedly with lipopolysaccharide, SAMP1/TA-1 mice displayed the clinicopathological features of hemophagocytic lymphohistiocytosis such as hepatosplenomegaly, pancytopenia, hypofibrinogenemia, hyperferritinemia, and hemophagocytosis. SAMR1 mice showed no features of hemophagocytic lymphohistiocytosis. Lipopolysaccharide induced upregulation of proinflammatory cytokines such as interleukin-1β, interleukin-6, tumor necrosis factor-α, and interferon-γ, and interferon-γ-inducible chemokines such as c-x-c motif chemokine ligands 9 and 10 in the liver and spleen in both SAMP1/TA-1 and SAMR1 mice. However, upregulation of proinflammatory cytokines and interferon-γ-inducible chemokines in the liver persisted for longer in SAMP1/TA-1 mice than in SAMR1 mice. In addition, the magnitude of upregulation of interferon-γ in the liver and spleen after lipopolysaccharide treatment was greater in SAMP1/TA-1 mice than in SAMR1 mice. Furthermore, lipopolysaccharide treatment led to a prolonged increase in the proportion of peritoneal M1 macrophages and simultaneously to a decrease in the proportion of M2 macrophages in SAMP1/TA-1 mice compared with SAMR1 mice. Lipopolysaccharide appeared to induce a hyperinflammatory reaction and prolonged inflammation in SAMP1/TA-1 mice, resulting in features of secondary hemophagocytic lymphohistiocytosis. Thus, SAMP1/TA-1 mice represent a useful mouse model to investigate the pathogenesis of bacterial infection-associated secondary hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Isao Tsuboi
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, Tokyo .,Cellular and Molecular Toxicology Division, National Center for Biological Safety and Research, National Institute of Health Science, Kawasaki, Japan
| | - Tomonori Harada
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, Tokyo
| | - Yoko Hirabayashi
- Cellular and Molecular Toxicology Division, National Center for Biological Safety and Research, National Institute of Health Science, Kawasaki, Japan
| | - Shin Aizawa
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, Tokyo
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63
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Diagnosis, Treatment, and Management of Hemophagocytic Lymphohistiocytosis in the Critical Care Unit. CRITICAL CARE OF THE PEDIATRIC IMMUNOCOMPROMISED HEMATOLOGY/ONCOLOGY PATIENT 2019. [PMCID: PMC7123852 DOI: 10.1007/978-3-030-01322-6_9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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64
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Lehmberg K, Moshous D, Booth C. Haematopoietic Stem Cell Transplantation for Primary Haemophagocytic Lymphohistiocytosis. Front Pediatr 2019; 7:435. [PMID: 31709205 PMCID: PMC6823612 DOI: 10.3389/fped.2019.00435] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/07/2019] [Indexed: 12/24/2022] Open
Abstract
Haematopoietic stem cell transplantation currently remains the only curative treatment of primary forms of haemophagocytic lymphohistiocytosis (HLH). Rapid diagnosis, efficient primary treatment of hyperinflammation, and conditioning regimens tailored to this demanding condition have substantially improved prognosis in the past 40 years. However, refractory hyperinflammation, central nervous system (CNS) involvement, unavailability of matched donors, susceptibility to conditioning-related toxicities, and a high frequency of mixed chimaerism remain a challenge in a substantial proportion of patients. Gene therapeutic approaches for several genetic defects of primary HLH are being developed at pre-clinical and translational levels.
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Affiliation(s)
- Kai Lehmberg
- Division of Paediatric Stem Cell Transplantation and Immunology, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
| | - Despina Moshous
- Department of Immunohematology, Necker-Enfants Malades Hospital, APHP, and Imagine Institute, Inserm U 1163, Descartes University, Paris Sorbonne Cité, Paris, France
| | - Claire Booth
- Department of Paediatric Immunology, Great Ormond Street Hospital, London, United Kingdom.,Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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65
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Prader S, Felber M, Volkmer B, Trück J, Schwieger-Briel A, Theiler M, Weibel L, Hambleton S, Seipel K, Vavassori S, Pachlopnik Schmid J. Life-Threatening Primary Varicella Zoster Virus Infection With Hemophagocytic Lymphohistiocytosis-Like Disease in GATA2 Haploinsufficiency Accompanied by Expansion of Double Negative T-Lymphocytes. Front Immunol 2018; 9:2766. [PMID: 30564229 PMCID: PMC6289061 DOI: 10.3389/fimmu.2018.02766] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/12/2018] [Indexed: 12/16/2022] Open
Abstract
Two unrelated patients with GATA2-haploinsufficiency developed a hemophagocytic lymphohistiocytosis (HLH)-like disease during a varicella zoster virus (VZV) infection. High copy numbers of VZV were detected in the blood, and the patients were successfully treated with acyclovir and intravenous immunoglobulins. After treatment with corticosteroids for the HLH, both patients made a full recovery. Although the mechanisms leading to this disease constellation have yet to be characterized, we hypothesize that impairment of the immunoregulatory role of NK cells in GATA2-haploinsufficiency may have accentuated the patients' susceptibility to HLH. Expansion of a double negative T-lymphocytic population identified with CyTOF could be a further factor contributing to HLH in these patients. This is the first report of VZV-triggered HLH-like disease in a primary immunodeficiency and the third report of HLH in GATA2-haploinsufficiency. Since HLH was part of the presentation in one of our patients, GATA2-haploinsufficiency represents a potential differential diagnosis in patients presenting with the clinical features of HLH-especially in cases of persisting cytopenia after recovery from HLH.
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Affiliation(s)
- Seraina Prader
- Division of Immunology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Matthias Felber
- Division of Immunology, University Children's Hospital Zurich, Zurich, Switzerland
- Division of Stem Cell Transplantation University Children's Hospital Zurich, Zurich, Switzerland
| | - Benjamin Volkmer
- Division of Immunology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Johannes Trück
- Division of Immunology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Agnes Schwieger-Briel
- Department of Pediatric Dermatology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Theiler
- Department of Pediatric Dermatology, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Lisa Weibel
- Department of Pediatric Dermatology, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Sophie Hambleton
- Institute of Cellular Medicine, International Centre for Life, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Katja Seipel
- Department for Biomedical Research, University of Bern, Bern, Switzerland
| | - Stefano Vavassori
- Division of Immunology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jana Pachlopnik Schmid
- Division of Immunology, University Children's Hospital Zurich, Zurich, Switzerland
- Pediatric Immunology, University of Zurich, Zurich, Switzerland
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66
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Gansner JM, Berliner N. The rheumatology/hematology interface: CAPS and MAS diagnosis and management. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:313-317. [PMID: 30504326 PMCID: PMC6245968 DOI: 10.1182/asheducation-2018.1.313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Catastrophic antiphospholipid antibody syndrome (CAPS) and macrophage activation syndrome (MAS) are both life-threatening hematologic disorders that infrequently afflict patients with rheumatologic disease. CAPS is characterized by fulminant multiorgan damage related to small vessel thrombosis in the setting of persistent antiphospholipid antibodies. It can occur in patients with rheumatologic diseases such as systemic lupus erythematosus but can also affect patients who do not have rheumatologic disease. By contrast, the term MAS is applied when patients with rheumatologic disease develop hemophagocytic lymphohistiocytosis (HLH); therefore, patients with MAS have an underlying rheumatologic disease by definition. Similar to CAPS, HLH/MAS can have a fulminant presentation, but the pathogenesis and manifestations are different. In both CAPS and MAS, management generally includes but is not limited to immunosuppression with steroids. Fatalities are relatively common and morbidity is often significant. Early recognition of these disorders and initiation of timely treatment are important. More effective therapies for both syndromes are urgently needed.
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Affiliation(s)
- John M Gansner
- Department of Medicine, Division of Hematology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Nancy Berliner
- Department of Medicine, Division of Hematology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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67
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Lemiale V, Valade S, Calvet L, Mariotte E. Management of Hemophagocytic Lympho-Histiocytosis in Critically Ill Patients. J Intensive Care Med 2018; 35:118-127. [PMID: 30384814 DOI: 10.1177/0885066618810403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hemophagocytic syndrome remains a rare but life-threatening complication and is associated with intensive care unit (ICU) admission. The pathophysiology is based on a defect of cytotoxicity in T cells that results in a state of hyperinflammation in the presence of a trigger. As a consequence, patients may develop multiorgan failure. The diagnosis of hemophagocytic syndrome (HS) remains difficult and relies on persistant high-grade fevers in the absence of infection and on constellation of laboratory parameters. However, prompt diagnosis and treatment (supportive care and specific treatment) are associated with improved outcome. Interaction with other specialists (hematologist, internist) may improve the diagnosis and treatment strategy. This article describes diagnostic tools, organ failures associated with HS, main etiologies, and management.
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Affiliation(s)
| | | | - Laure Calvet
- Medical ICU, AP_HP Saint Louis hospital, Paris, France
| | - Eric Mariotte
- Medical ICU, AP_HP Saint Louis hospital, Paris, France
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68
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Ruscitti P, Giacomelli R. Pathogenesis of adult onset still’s disease: current understanding and new insights. Expert Rev Clin Immunol 2018; 14:965-976. [DOI: 10.1080/1744666x.2018.1533403] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Piero Ruscitti
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Roberto Giacomelli
- Division of Rheumatology, Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
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69
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Crow YJ, Lebon P, Casanova JL, Gresser I. A Brief Historical Perspective on the Pathological Consequences of Excessive Type I Interferon Exposure In vivo. J Clin Immunol 2018; 38:694-698. [PMID: 30187308 DOI: 10.1007/s10875-018-0543-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/20/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Yanick J Crow
- Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
- INSERM UMR 1163, Laboratory of Neurogenetics and Neuroinflammation, Institute Imagine, Paris, France.
| | - Pierre Lebon
- Hopital Cochin-St Vincent de Paul, Faculté de médecine Paris Descartes, Paris, France
| | - Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, The Rockefeller University, New York, NY, USA
- Howard Hughes Medical Institute, New York, NY, USA
- Laboratory of Human Genetics of Infectious Diseases, INSERM UMR 1163, Necker Hospital for Sick Children, Paris, France
- Paris Descartes University, Imagine Institute, Paris, France
- Pediatric Hematology and Immunology Unit, Necker Hospital for Sick Children, Paris, France
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70
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Ghosh S, Carmo M, Calero-Garcia M, Ricciardelli I, Bustamante Ogando JC, Blundell MP, Schambach A, Ashton-Rickardt PG, Booth C, Ehl S, Lehmberg K, Thrasher AJ, Gaspar HB. T-cell gene therapy for perforin deficiency corrects cytotoxicity defects and prevents hemophagocytic lymphohistiocytosis manifestations. J Allergy Clin Immunol 2018; 142:904-913.e3. [PMID: 29355678 PMCID: PMC6127027 DOI: 10.1016/j.jaci.2017.11.050] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 11/13/2017] [Accepted: 11/23/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Mutations in the perforin 1 (PRF1) gene account for up to 58% of familial hemophagocytic lymphohistiocytosis syndromes. The resulting defects in effector cell cytotoxicity lead to hypercytokinemia and hyperactivation with inflammation in various organs. OBJECTIVE We sought to determine whether autologous gene-corrected T cells can restore cytotoxic function, reduce disease activity, and prevent hemophagocytic lymphohistiocytosis (HLH) symptoms in in vivo models. METHODS We developed a gammaretroviral vector to transduce murine CD8 T cells in the Prf-/- mouse model. To verify functional correction of Prf-/- CD8 T cells in vivo, we used a lymphocytic choriomeningitis virus (LCMV) epitope-transfected murine lung carcinoma cell tumor model. Furthermore, we challenged gene-corrected and uncorrected mice with LCMV. One patient sample was transduced with a PRF1-encoding lentiviral vector to study restoration of cytotoxicity in human cells. RESULTS We demonstrated efficient engraftment and functional reconstitution of cytotoxicity after intravenous administration of gene-corrected Prf-/- CD8 T cells into Prf-/- mice. In the tumor model infusion of Prf-/- gene-corrected CD8 T cells eliminated the tumor as efficiently as transplantation of wild-type CD8 T cells. Similarly, mice reconstituted with gene-corrected Prf-/- CD8 T cells displayed complete protection from the HLH phenotype after infection with LCMV. Patients' cells showed correction of cytotoxicity in human CD8 T cells after transduction. CONCLUSION These data demonstrate the potential application of T-cell gene therapy in reconstituting cytotoxic function and protection against HLH in the setting of perforin deficiency.
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Affiliation(s)
- Sujal Ghosh
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine-University, Dusseldorf, Germany
| | - Marlene Carmo
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Miguel Calero-Garcia
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ida Ricciardelli
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Juan Carlos Bustamante Ogando
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Michael P Blundell
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Axel Schambach
- Institute of Experimental Hematology, Hannover Medical School, Hannover, Germany
| | - Philip G Ashton-Rickardt
- Section of Immunobiology, Division of Inflammation and Immunology, Department of Medicine, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Claire Booth
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Stephan Ehl
- Center for Chronic Immunodeficiency, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Kai Lehmberg
- Department of Paediatric Haematology and Oncology, Division of Paediatric Stem Cell Transplantation and Immunology, University Medical Centre Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | - Adrian J Thrasher
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - H Bobby Gaspar
- Infection, Immunity, Inflammation, Molecular and Cellular Immunology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.
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71
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Clayton KL, Collins DR, Lengieza J, Ghebremichael M, Dotiwala F, Lieberman J, Walker BD. Resistance of HIV-infected macrophages to CD8 + T lymphocyte-mediated killing drives activation of the immune system. Nat Immunol 2018; 19:475-486. [PMID: 29670239 PMCID: PMC6025741 DOI: 10.1038/s41590-018-0085-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/13/2018] [Indexed: 12/19/2022]
Abstract
CD4+ T lymphocytes are the principal target of human immunodeficiency virus (HIV), but infected macrophages also contribute to viral pathogenesis. The killing of infected cells by CD8+ cytotoxic T lymphocytes (CTLs) leads to control of viral replication. Here we found that the killing of macrophages by CTLs was impaired relative to the killing of CD4+ T cells by CTLs, and this resulted in inefficient suppression of HIV. The killing of macrophages depended on caspase-3 and granzyme B, whereas the rapid killing of CD4+ T cells was caspase independent and did not require granzyme B. Moreover, the impaired killing of macrophages was associated with prolonged effector cell-target cell contact time and higher expression of interferon-γ by CTLs, which induced macrophage production of pro-inflammatory chemokines that recruited monocytes and T cells. Similar results were obtained when macrophages presented other viral antigens, suggestive of a general mechanism for macrophage persistence as antigen-presenting cells that enhance inflammation and adaptive immunity. Inefficient killing of macrophages by CTLs might contribute to chronic inflammation, a hallmark of chronic disease caused by HIV.
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Affiliation(s)
| | - David R Collins
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA.,Howard Hughes Medical Institute, Chevy Chase, MD, USA
| | - Josh Lengieza
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | | | - Farokh Dotiwala
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Judy Lieberman
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Bruce D Walker
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA. .,Howard Hughes Medical Institute, Chevy Chase, MD, USA. .,Institute of Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA.
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72
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Ragab G, Atkinson TP, Stoll ML. Macrophage Activation Syndrome. THE MICROBIOME IN RHEUMATIC DISEASES AND INFECTION 2018. [PMCID: PMC7123081 DOI: 10.1007/978-3-319-79026-8_14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH), or termed macrophage activation syndrome (MAS) when associated with rheumatic disorders, is a frequently fatal complication of infections, rheumatic disorders, and hematopoietic malignancies. Clinically, HLH/MAS is a life-threatening condition that is usually diagnosed among febrile hospitalized patients (children and adults) who commonly present with unremitting fever and a shock-like multiorgan dysfunction scenario. Laboratory studies reveal pancytopenia, elevated liver enzymes, elevated markers of inflammation (ESR, CRP), hyperferritinemia, and features of coagulopathy. In about 60% of cases, excess hemophagocytosis (macrophages/histiocytes engulfing other hematopoietic cell types) is noted on biopsy specimens from the bone marrow, liver, lymph nodes, and other organs. HLH/MAS has been hypothesized to occur when a threshold level of inflammation has been achieved, and genetic and environmental risk factors are believed to contribute to the hyperinflammatory state. A broad variety of infections, from viruses to fungi to bacteria, have been identified as triggers of HLH/MAS, either in isolation or in addition to an underlying inflammatory disease state. Certain infections, particularly by members of the herpesvirus family, are the most notorious triggers of HLH/MAS. Treatment for infection-triggered MAS requires therapy for both the underlying infection and dampening of the hyperactive immune response.
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Affiliation(s)
- Gaafar Ragab
- Faculty of Medicine, Cairo University, Cairo, Egypt
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73
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Taylor MD, Burn TN, Wherry EJ, Behrens EM. CD8 T Cell Memory Increases Immunopathology in the Perforin-Deficient Model of Hemophagocytic Lymphohistiocytosis Secondary to TNF-α. Immunohorizons 2018; 2:67-73. [PMID: 29795796 DOI: 10.4049/immunohorizons.1800003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Familial hemophagocytic lymphohistiocytosis 2 (FHL2) is a cytokine storm syndrome characterized by immune hyperactivation with viral infection due to a CD8 T cell cytotoxic killing defect secondary to a perforin deficiency. As most studies of FHL2 mice have used pathogen naïve animals, the effects of immune memory on FHL2 are understudied. We utilized an immunization model of the perforin-deficient mouse to study the effects of immune memory on FHL2. Prior CD8 T cell specific antigen exposure leads to enhanced HLH disease with increased morbidity and decreased time to mortality. Enhanced disease is associated with altered cytokine production and T cell proliferation. Response to IFNγ blockade is reduced and TNFα gains a pathogenic role, while blockade of the IL-33 receptor ST2 remains effective. These results suggest that pre-existing immune memory may worsen outcome and alter treatment response for FHL2 patients who may not be naïve to their immune triggers.
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Affiliation(s)
- Matthew D Taylor
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Thomas N Burn
- Division of Rheumatology, Childen's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - E John Wherry
- Department of Microbiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Division of Rheumatology, Childen's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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74
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Interleukin-18 diagnostically distinguishes and pathogenically promotes human and murine macrophage activation syndrome. Blood 2018; 131:1442-1455. [PMID: 29326099 DOI: 10.1182/blood-2017-12-820852] [Citation(s) in RCA: 257] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 01/06/2018] [Indexed: 12/21/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening hyperferritinemic systemic inflammatory disorders. Although profound cytotoxic impairment causes familial HLH (fHLH), the mechanisms driving non-fHLH and MAS are largely unknown. MAS occurs in patients with suspected rheumatic disease, but the mechanistic basis for its distinction is unclear. Recently, a syndrome of recurrent MAS with infantile enterocolitis caused by NLRC4 inflammasome hyperactivity highlighted the potential importance of interleukin-18 (IL-18). We tested this association in hyperferritinemic and autoinflammatory patients and found a dramatic correlation of MAS risk with chronic (sometimes lifelong) elevation of mature IL-18, particularly with IL-18 unbound by IL-18 binding protein, or free IL-18. In a mouse engineered to carry a disease-causing germ line NLRC4T337S mutation, we observed inflammasome-dependent, chronic IL-18 elevation. Surprisingly, this NLRC4T337S-induced systemic IL-18 elevation derived entirely from intestinal epithelia. NLRC4T337S intestines were histologically normal but showed increased epithelial turnover and upregulation of interferon-γ-induced genes. Assessing cellular and tissue expression, classical inflammasome components such as Il1b, Nlrp3, and Mefv predominated in neutrophils, whereas Nlrc4 and Il18 were distinctly epithelial. Demonstrating the importance of free IL-18, Il18 transgenic mice exhibited free IL-18 elevation and more severe experimental MAS. NLRC4T337S mice, whose free IL-18 levels were normal, did not. Thus, we describe a unique connection between MAS risk and chronic IL-18, identify epithelial inflammasome hyperactivity as a potential source, and demonstrate the pathogenicity of free IL-18. These data suggest an IL-18-driven pathway, complementary to the cytotoxic impairment of fHLH, with potential as a distinguishing biomarker and therapeutic target in MAS.
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75
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Unopposed IL-18 signaling leads to severe TLR9-induced macrophage activation syndrome in mice. Blood 2018; 131:1430-1441. [PMID: 29295842 DOI: 10.1182/blood-2017-06-789552] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 12/20/2017] [Indexed: 11/20/2022] Open
Abstract
The term macrophage activation syndrome (MAS) defines a severe, potentially fatal disorder characterized by overwhelming inflammation and multiorgan involvement. Interleukin-18 (IL-18) is a proinflammatory cytokine belonging to the IL-1 family, the activity of which is regulated by its endogenous inhibitor IL-18 binding protein (IL-18BP). Elevated IL-18 levels have been reported in patients with MAS. Herein, we show that on repeated toll-like receptor 9 (TLR9) stimulation with unmethylated cytosine guanine dinucleotide containing single-stranded DNA (CpG), IL-18BP-/- mice display severe MAS manifestations, including increased weight loss, splenomegaly, anemia, thrombocytopenia, hyperferritinemia, and bone marrow hemophagocytosis as compared with wild-type mice. Serum-free IL-18 was detected in CpG-treated IL-18BP-/- mice only. Levels of interferon-γ (IFN-γ) and of IFN-γ signature genes, such as the chemokine Cxcl9 or the transcription factor CIIta, were significantly increased in IL-18BP-/- mice. Blocking IL-18 receptor signaling attenuated the severity of MAS and IFN-γ responses in IL-18BP-/- mice. Blocking IFN-γ had comparable effects to IL-18 inhibition on most MAS manifestations. Our data indicate that endogenous IL-18BP exerts a protective role in CpG-induced MAS and that IL-18, which acts upstream of IFN-γ, is involved in the severity of MAS.
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76
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Gene transfer into hematopoietic stem cells reduces HLH manifestations in a murine model of Munc13-4 deficiency. Blood Adv 2017; 1:2781-2789. [PMID: 29296930 DOI: 10.1182/bloodadvances.2017012088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/19/2017] [Indexed: 12/21/2022] Open
Abstract
Patients with mutations in the UNC13D gene (coding for Munc13-4 protein) suffer from familial hemophagocytic lymphohistiocytosis type 3 (FHL3), a life-threatening immune and hyperinflammatory disorder. The only curative treatment is allogeneic hematopoietic stem cell (HSC) transplantation, although the posttreatment survival rate is not satisfactory. Here, we demonstrate the curative potential of UNC13D gene correction of HSCs in a murine model of FHL3. We generated a self-inactivating lentiviral vector, used it to complement HSCs from Unc13d-deficient (Jinx) mice, and transplanted the cells back into the irradiated Jinx recipients. This procedure led to complete reconstitution of the immune system (ie, to wild-type levels). The recipients were then challenged with lymphocytic choriomeningitis virus to induce hemophagocytic lymphohistiocytosis (HLH)-like manifestations. All the clinical and biological signs of HLH were significantly reduced in mice having undergone HSC UNC13D gene correction than in nontreated animals. This beneficial effect was evidenced by the correction of blood cytopenia, body weight gain, normalization of the body temperature, decreased serum interferon-γ level, recovery of liver damage, and decreased viral load. These improvements can be explained by the restoration of the CD8+ T lymphocytes' cytotoxic function (as demonstrated here in an in vitro degranulation assay). Overall, our results demonstrate the efficacy of HSC gene therapy in an FHL-like setting of immune dysregulation.
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Brisse E, Imbrechts M, Mitera T, Vandenhaute J, Wouters CH, Snoeck R, Andrei G, Matthys P. Lytic viral replication and immunopathology in a cytomegalovirus-induced mouse model of secondary hemophagocytic lymphohistiocytosis. Virol J 2017; 14:240. [PMID: 29258535 PMCID: PMC5738214 DOI: 10.1186/s12985-017-0908-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/08/2017] [Indexed: 12/28/2022] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rare immunological disorder caused by unbridled activation of T cells and macrophages, culminating in a life-threatening cytokine storm. A genetic and acquired subtype are distinguished, termed primary and secondary HLH, respectively. Clinical manifestations of both forms are frequently preceded by a viral infection, predominantly with herpesviruses. The exact role of the viral infection in the development of the hemophagocytic syndrome remains to be further elucidated. Methods We utilized a recently developed murine model of cytomegalovirus-associated secondary HLH and dissected the respective contributions of lytic viral replication and immunopathology in its pathogenesis. Results HLH-like disease only developed in cytomegalovirus-susceptible mouse strains unable to clear the virus, but the severity of symptoms was not correlated to the infectious viral titer. Lytic viral replication and sustained viremia played an essential part in the pathogenesis since abortive viral infection was insufficient to induce a full-blown HLH-like syndrome. Nonetheless, a limited set of symptoms, in particular anemia, thrombocytopenia and elevated levels of soluble CD25, appeared less dependent of the viral replication but rather mediated by the host’s immune response, as corroborated by immunosuppressive treatment of infected mice with dexamethasone. Conclusion Both virus-mediated pathology and immunopathology cooperate in the pathogenesis of full-blown virus-associated secondary HLH and are closely entangled. A certain level of viremia appears necessary to elicit the characteristic HLH-like symptoms in the model.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Maya Imbrechts
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Tania Mitera
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Jessica Vandenhaute
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Carine H Wouters
- Laboratory of Pediatric Immunology, Department of Microbiology and Immunology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.
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Confirmed efficacy of etoposide and dexamethasone in HLH treatment: long-term results of the cooperative HLH-2004 study. Blood 2017; 130:2728-2738. [PMID: 28935695 DOI: 10.1182/blood-2017-06-788349] [Citation(s) in RCA: 370] [Impact Index Per Article: 52.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 09/05/2017] [Indexed: 12/13/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome comprising familial/genetic HLH (FHL) and secondary HLH. In the HLH-94 study, with an estimated 5-year probability of survival (pSu) of 54% (95% confidence interval, 48%-60%), systemic therapy included etoposide, dexamethasone, and, from week 9, cyclosporine A (CSA). Hematopoietic stem cell transplantation (HSCT) was indicated in patients with familial/genetic, relapsing, or severe/persistent disease. In HLH-2004, CSA was instead administered upfront, aiming to reduce pre-HSCT mortality and morbidity. From 2004 to 2011, 369 children aged <18 years fulfilled HLH-2004 inclusion criteria (5 of 8 diagnostic criteria, affected siblings, and/or molecular diagnosis in FHL-causative genes). At median follow-up of 5.2 years, 230 of 369 patients (62%) were alive (5-year pSu, 61%; 56%-67%). Five-year pSu in children with (n = 168) and without (n = 201) family history/genetically verified FHL was 59% (52%-67%) and 64% (57%-71%), respectively (familial occurrence [n = 47], 58% [45%-75%]). Comparing with historical data (HLH-94), using HLH-94 inclusion criteria, pre-HSCT mortality was nonsignificantly reduced from 27% to 19% (P = .064 adjusted for age and sex). Time from start of therapy to HSCT was shorter compared with HLH-94 (P =020 adjusted for age and sex) and reported neurological alterations at HSCT were 22% in HLH-94 and 17% in HLH-2004 (using HLH-94 inclusion criteria). Five-year pSu post-HSCT overall was 66% (verified FHL, 70% [63%-78%]). Additional analyses provided specific suggestions on potential pre-HSCT treatment improvements. HLH-2004 confirms that a majority of patients may be rescued by the etoposide/dexamethasone combination but intensification with CSA upfront, adding corticosteroids to intrathecal therapy, and reduced time to HSCT did not improve outcome significantly.
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79
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Brisse E, Wouters CH, Andrei G, Matthys P. How Viruses Contribute to the Pathogenesis of Hemophagocytic Lymphohistiocytosis. Front Immunol 2017; 8:1102. [PMID: 28936212 PMCID: PMC5594061 DOI: 10.3389/fimmu.2017.01102] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/22/2017] [Indexed: 11/23/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening, hyperinflammatory syndrome, characterized by the uncontrolled activation of macrophages and T cells, eliciting key symptoms such as persistent fever, hepatosplenomegaly, pancytopenia, hemophagocytosis, hyperferritinemia, and coagulopathy. Viral infections are frequently implicated in the onset of active HLH episodes, both in primary, genetic HLH as in the secondary, acquired form. Infections with herpesviruses such as Epstein-Barr virus and cytomegalovirus are the most common. In autoimmune diseases, a link between viral infections and autoreactive immune responses has been recognized for a considerable time. However, the mechanisms by which viruses contribute to HLH pathogenesis remain to be clarified. In this viewpoint, different factors that may come into play are discussed. Viruses, particularly larger DNA viruses such as herpesviruses, are potent modulators of the immune response. By evading immune recognition, interfering with cytokine balances and inhibiting apoptotic pathways, viruses may increase the host's susceptibility to HLH development. In particular cases, a direct connection between the viral infection and inhibition of natural killer cell or T cell cytotoxicity was reported, indicating that viruses may create immunological deficiencies reminiscent of primary HLH.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Carine H. Wouters
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
- University Hospital Gasthuisberg, Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute, KU Leuven, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
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Ruscitti P, Cipriani P, Di Benedetto P, Liakouli V, Carubbi F, Berardicurti O, Ciccia F, Guggino G, Triolo G, Giacomelli R. Advances in immunopathogenesis of macrophage activation syndrome during rheumatic inflammatory diseases: toward new therapeutic targets? Expert Rev Clin Immunol 2017; 13:1041-1047. [PMID: 28837367 DOI: 10.1080/1744666x.2017.1372194] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Macrophage activation syndrome (MAS) is a severe, hyperinflammatory life-threatening syndrome, generally complicating different rheumatic diseases. Despite the severity of the disease, little is known about the pathogenic mechanisms and, thus, possible targeted therapies in the management of these patients. Areas covered: In this review, we aimed to update the current pathogenic knowledge of MAS, during rheumatic diseases, focusing mainly on immunologic abnormalities and on new possible therapeutic strategies. Expert commentary: The difficult pathogenic scenario of MAS, in which genetic defects, predisposing diseases, and triggers are mixed together with the high mortality rate, make it difficult to manage these patients. Although most efforts have been focused on investigating the disease in children, in recent years, several studies are trying to elucidate the possible pathogenic mechanism in adult MAS patients. In this context, genetic and immunological studies might lead to advances in the knowledge of pathogenic mechanisms and possible new therapeutic targets. In the future, the results of ongoing clinical trials are awaited in order to improve the management and, thus, the survival of these patients.
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Affiliation(s)
- Piero Ruscitti
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | - Paola Cipriani
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | | | - Vasiliky Liakouli
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | - Francesco Carubbi
- a Division of Rheumatology , University of L'Aquila , L'Aquila , Italy
| | | | - Francesco Ciccia
- b Division of Rheumatology , University of Palermo , Palermo , Italy
| | - Giuliana Guggino
- b Division of Rheumatology , University of Palermo , Palermo , Italy
| | - Giovanni Triolo
- b Division of Rheumatology , University of Palermo , Palermo , Italy
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Neutralization of IFN-γ reverts clinical and laboratory features in a mouse model of macrophage activation syndrome. J Allergy Clin Immunol 2017; 141:1439-1449. [PMID: 28807602 DOI: 10.1016/j.jaci.2017.07.021] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The pathogenesis of macrophage activation syndrome (MAS) is not clearly understood: a large body of evidence supports the involvement of mechanisms similar to those implicated in the setting of primary hemophagocytic lymphohistiocytosis. OBJECTIVE We sought to investigate the pathogenic role of IFN-γ and the therapeutic efficacy of IFN-γ neutralization in an animal model of MAS. METHODS We used an MAS model established in mice transgenic for human IL-6 (IL-6TG mice) challenged with LPS (MAS mice). Levels of IFN-γ and IFN-γ-inducible chemokines were evaluated by using real-time PCR in the liver and spleen and by means of ELISA in plasma. IFN-γ neutralization was achieved by using the anti-IFN-γ antibody XMG1.2 in vivo. RESULTS Mice with MAS showed a significant upregulation of the IFN-γ pathway, as demonstrated by increased mRNA levels of Ifng and higher levels of phospho-signal transducer and activator of transcription 1 in the liver and spleen and increased expression of the IFN-γ-inducible chemokines Cxcl9 and Cxcl10 in the liver and spleen, as well as in plasma. A marked increase in Il12a and Il12b expression was also found in livers and spleens of mice with MAS. In addition, mice with MAS had a significant increase in numbers of liver CD68+ macrophages. Mice with MAS treated with an anti-IFN-γ antibody showed a significant improvement in survival and body weight recovery associated with a significant amelioration of ferritin, fibrinogen, and alanine aminotransferase levels. In mice with MAS, treatment with the anti-IFN-γ antibody significantly decreased circulating levels of CXCL9, CXCL10, and downstream proinflammatory cytokines. The decrease in CXCL9 and CXCL10 levels paralleled the decrease in serum levels of proinflammatory cytokines and ferritin. CONCLUSION These results provide evidence for a pathogenic role of IFN-γ in the setting of MAS.
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82
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Systemic juvenile idiopathic arthritis: New insights into pathogenesis and cytokine directed therapies. Best Pract Res Clin Rheumatol 2017; 31:505-516. [DOI: 10.1016/j.berh.2018.02.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 12/13/2022]
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84
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Proliferation through activation: hemophagocytic lymphohistiocytosis in hematologic malignancy. Blood Adv 2017; 1:779-791. [PMID: 29296722 DOI: 10.1182/bloodadvances.2017005561] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/11/2017] [Indexed: 12/16/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of cytokine-driven immune activation. Cardinal features include fever, hemophagocytosis, hepatosplenomegaly, lymphocytic infiltration, and hypercytokinemia that result in multisystem organ dysfunction and failure. Familial HLH is genetically driven, whereas secondary HLH (SHL) is caused by drugs, autoimmune disease, infection, or cancer. SHL is associated with worse outcomes, with a median overall survival typically of less than 1 year. This reflects difficulty in both diagnostic accuracy and in establishing reliable treatments, especially in cases of malignancy-induced SHL, which have significantly worse outcomes. Malignancy-induced HLH is seen almost exclusively with hematologic malignancies, constituting 97% of cases in the literature over the past 2 years. In these situations, the native immune response driven by CD8 T cells produces an overabundance of T helper 1 cytokines, notably interferon-γ, tumor necrosis factor-α, and interleukin-6, which establish a positive feedback loop of inflammation, enhancing replication of hematologic malignancies while leaving the host immune system in disarray. In this paper, we present 2 case studies of secondary HLH driven by HM, followed by a review of the literature discussing the cytokines driving HLH, diagnostic criteria, and current treatments used or undergoing investigation.
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85
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Pharmacological targeting of plasmin prevents lethality in a murine model of macrophage activation syndrome. Blood 2017; 130:59-72. [PMID: 28325863 DOI: 10.1182/blood-2016-09-738096] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/10/2017] [Indexed: 12/12/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a life-threatening disorder characterized by a cytokine storm and multiorgan dysfunction due to excessive immune activation. Although abnormalities of coagulation and fibrinolysis are major components of MAS, the role of the fibrinolytic system and its key player, plasmin, in the development of MAS remains to be solved. We established a murine model of fulminant MAS by repeated injections of Toll-like receptor-9 (TLR-9) agonist and d-galactosamine (DG) in immunocompetent mice. We found plasmin was excessively activated during the progression of fulminant MAS in mice. Genetic and pharmacological inhibition of plasmin counteracted MAS-associated lethality and other related symptoms. We show that plasmin regulates the influx of inflammatory cells and the production of inflammatory cytokines/chemokines. Collectively, our findings identify plasmin as a decisive checkpoint in the inflammatory response during MAS and a potential novel therapeutic target for MAS.
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86
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Weaver LK, Behrens EM. Weathering the storm: Improving therapeutic interventions for cytokine storm syndromes by targeting disease pathogenesis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:33-48. [PMID: 28944163 DOI: 10.1007/s40674-017-0059-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cytokine storm syndromes require rapid diagnosis and treatment to limit the morbidity and mortality caused by the hyperinflammatory state that characterizes these devastating conditions. Herein, we discuss the current knowledge that guides our therapeutic decision-making and personalization of treatment for patients with cytokine storm syndromes. Firstly, ICU-level supportive care is often required to stabilize patients with fulminant disease while additional diagnostic evaluations proceed to determine the underlying cause of cytokine storm. Pharmacologic interventions should be focused on removing the inciting trigger of inflammation and initiation of an individualized immunosuppressive regimen when immune activation is central to the underlying disease pathophysiology. Monitoring for a clinical response is required to ensure that changes in the therapeutic regimen can be made as clinically warranted. Escalation of immunosuppression may be required if patients respond poorly to the initial therapeutic interventions, while a slow wean of immunosuppression in patients who improve can limit medication-related toxicities. In certain scenarios, a decision must be made whether an individual patient requires hematopoietic cell transplantation to prevent recurrence of disease. Despite these interventions, significant morbidity and mortality remains for cytokine storm patients. Therefore, we use this review to propose a clinical schema to guide current and future attempts to design rational therapeutic interventions for patients suffering from these devastating conditions, which we believe speeds the diagnosis of disease, limits medication-related toxicities, and improves clinical outcomes by targeting the heterogeneous and dynamic mechanisms driving disease in each individual patient.
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Affiliation(s)
- Lehn K Weaver
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Edward M Behrens
- Division of Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Buatois V, Chatel L, Cons L, Lory S, Richard F, Guilhot F, Johnson Z, Bracaglia C, De Benedetti F, de Min C, Kosco-Vilbois MH, Ferlin WG. Use of a mouse model to identify a blood biomarker for IFNγ activity in pediatric secondary hemophagocytic lymphohistiocytosis. Transl Res 2017; 180:37-52.e2. [PMID: 27559680 PMCID: PMC7185816 DOI: 10.1016/j.trsl.2016.07.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 07/27/2016] [Accepted: 07/27/2016] [Indexed: 02/01/2023]
Abstract
Life-threatening cytokine release syndromes include primary (p) and secondary (s) forms of hemophagocytic lymphohistiocytosis (HLH). Below detection in healthy individuals, interferon γ (IFNγ) levels are elevated to measurable concentrations in these afflictions suggesting a central role for this cytokine in the development and maintenance of HLH. Mimicking an infection-driven model of sHLH in mice, we observed that the tissue-derived levels of IFNγ are actually 500- to 2000-fold higher than those measured in the blood. To identify a blood biomarker, we postulated that the IFNγ gene products, CXCL9 and CXCL10 would correlate with disease parameters in the mouse model. To translate this into a disease relevant biomarker, we investigated whether CXCL9 and CXCL10 levels correlated with disease activity in pediatric sHLH patients. Our data demonstrate that disease control in mice correlates with neutralization of IFNγ activity in tissues and that the 2 chemokines serve as serum biomarkers to reflect disease status. Importantly, CXCL9 and CXCL10 levels in pediatric sHLH were shown to correlate with key disease parameters and severity in these patients. Thus, the translatability of the IFNγ-biomarker correlates from mouse to human, advocating the use of serum CXCL9 or CXCL10 as a means to monitor total IFNγ activity in patients with sHLH.
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Key Words
- hlh, hemophagocytic lymphohistiocytosis
- phlh, primary hemophagocytic lymphohistiocytosis
- shlh, secondary hemophagocytic lymphohistiocytosis
- ifnγ, interferon γ
- tlrs, toll-like receptors
- tnfα, tumor necrosis factor α
- mifnγ, mouse ifnγ
- alt, alanine transaminase
- ldh, lactate dehydrogenase
- mrna, messenger rna
- qpcr, quantitative pcr
- il-6, interleukin 6
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Affiliation(s)
| | | | - Laura Cons
- Novimmune S.A., Plan-les-Ouates, Switzerland
| | | | | | | | - Zoë Johnson
- Novimmune S.A., Plan-les-Ouates, Switzerland
| | - Claudia Bracaglia
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Fabrizio De Benedetti
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Ospedale Pediatrico Bambino Gesù, Rome, Italy
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88
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Wang YR, Qiu YN, Bai Y, Wang XF. A retrospective analysis of 56 children with hemophagocytic lymphohistiocytosis. J Blood Med 2016; 7:227-231. [PMID: 27785117 PMCID: PMC5067061 DOI: 10.2147/jbm.s92438] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Aim The aim of this study was to investigate the etiological factors, clinical features, and prognostic factors in children with hemophagocytic lymphohistiocytosis (HLH). Methods Fifty-six children with HLH in Wuhan Union Hospital, People’s Republic of China, were retrospectively analyzed in recent years. We reviewed the medical records of 56 HLH children hospitalized from 2000 to 2013 to identify the possible prognostic factors. Results In more than half of the cases (64.29%), the etiological factor was found to be infection. Clinical characteristics such as prolonged fever (100.00%), hepatosplenomegaly (95.24%), and pancytopenia (100.00%) were observed. Characteristic laboratory values presented with increased ferritin (64.29%), triglycerides (78.57%), transaminases (80.95%), bilirubin (67.54%), lactate dehydrogenase (95.23%), and decreased fibrinogen (61.90%), natrium (40.48%), and potassium (30.94%). Bone marrow aspiration showed hemophagocytosis in 48 cases (85.71%). Forty-two patients were treated according to HLH-2004 protocol. Out of the 42 patients, 19 cases acquired remission and 13 cases died. Ten cases lost follow-up. High lactate dehydrogenase (>2,000 U/L), high bilirubin (>2 mg/mL), and younger age (<2 years) at the time of diagnosis were adverse prognostic factors. Conclusion HLH is a life-threatening syndrome caused by complicated etiology. The level of lactate dehydrogenase and bilirubin accompanied with younger age were adverse factors.
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Affiliation(s)
- Yan-Rong Wang
- Department of Pediatrics, The Affiliated Shenzhen Third Hospital, Guangdong Medical College, Shenzhen
| | - Yi-Ning Qiu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yan Bai
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xian-Feng Wang
- Department of Pediatrics, The Affiliated Shenzhen Third Hospital, Guangdong Medical College, Shenzhen
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Wunderlich M, Stockman C, Devarajan M, Ravishankar N, Sexton C, Kumar AR, Mizukawa B, Mulloy JC. A xenograft model of macrophage activation syndrome amenable to anti-CD33 and anti-IL-6R treatment. JCI Insight 2016; 1:e88181. [PMID: 27699249 DOI: 10.1172/jci.insight.88181] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Transgenic expression of key myelosupportive human cytokines in immune-deficient mice corrects for the lack of cross-species activities of stem cell factor (SCF), IL-3, and GM-CSF. When engrafted with human umbilical cord blood (UCB), these triple-transgenic mice produce BM and spleen grafts with much higher myeloid composition, relative to nontransgenic controls. Shortly after engraftment with UCB, these mice develop a severe, fatal macrophage activation syndrome (MAS) characterized by a progressive drop in rbc numbers, increased reticulocyte counts, decreased rbc half-life, progressive cytopenias, and evidence of chronic inflammation, including elevated human IL-6. The BM becomes strikingly hypocellular, and spleens are significantly enlarged with evidence of extramedullary hematopoiesis and activated macrophages engaged in hemophagocytosis. This manifestation of MAS does not respond to lymphocyte-suppressive therapies such as steroids, i.v. immunoglobulin, or antibody-mediated ablation of human B and T cells, demonstrating a lymphocyte-independent mechanism of action. In contrast, elimination of human myeloid cells using gemtuzumab ozogamicin (anti-CD33) completely reversed the disease. Additionally, the IL-6R antibody tocilizumab delayed progression and prolonged lifespan. This new model of MAS provides an opportunity for investigation of the mechanisms driving this disease and for the testing of directed therapies in a humanized mouse.
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Affiliation(s)
| | | | | | | | | | - Ashish R Kumar
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | | | - James C Mulloy
- Division of Experimental Hematology and Cancer Biology and
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Pascutti MF, Erkelens MN, Nolte MA. Impact of Viral Infections on Hematopoiesis: From Beneficial to Detrimental Effects on Bone Marrow Output. Front Immunol 2016; 7:364. [PMID: 27695457 PMCID: PMC5025449 DOI: 10.3389/fimmu.2016.00364] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/02/2016] [Indexed: 01/17/2023] Open
Abstract
The ability of the bone marrow (BM) to generate copious amounts of blood cells required on a daily basis depends on a highly orchestrated process of proliferation and differentiation of hematopoietic stem and progenitor cells (HSPCs). This process can be rapidly adapted under stress conditions, such as infections, to meet the specific cellular needs of the immune response and the ensuing physiological changes. This requires a tight regulation in order to prevent either hematopoietic failure or transformation. Although adaptation to bacterial infections or systemic inflammation has been studied and reviewed in depth, specific alterations of hematopoiesis to viral infections have received less attention so far. Viruses constantly pose a significant health risk and demand an adequate, balanced response from our immune system, which also affects the BM. In fact, both the virus itself and the ensuing immune response can have a tremendous impact on the hematopoietic process. On one hand, this can be beneficial: it helps to boost the cellular response of the body to resolve the viral infection. But on the other hand, when the virus and the resulting antiviral response persist, the inflammatory feedback to the hematopoietic system will become chronic, which can be detrimental for a balanced BM output. Chronic viral infections frequently have clinical manifestations at the level of blood cell formation, and we summarize which viruses can lead to BM pathologies, like aplastic anemia, pancytopenia, hemophagocytic lymphohistiocytosis, lymphoproliferative disorders, and malignancies. Regarding the underlying mechanisms, we address specific effects of acute and chronic viral infections on blood cell production. As such, we distinguish four different levels in which this can occur: (1) direct viral infection of HSPCs, (2) viral recognition by HSPCs, (3) indirect effects on HSPCs by inflammatory mediators, and (4) the role of the BM microenvironment on hematopoiesis upon virus infection. In conclusion, this review provides a comprehensive overview on how viral infections can affect the formation of new blood cells, aiming to advance our understanding of the underlying cellular and molecular mechanisms to improve the treatment of BM failure in patients.
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Affiliation(s)
- Maria Fernanda Pascutti
- Landsteiner Laboratory, Department of Hematopoiesis, Sanquin, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Martje N. Erkelens
- Landsteiner Laboratory, Department of Hematopoiesis, Sanquin, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Martijn A. Nolte
- Landsteiner Laboratory, Department of Hematopoiesis, Sanquin, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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Therapeutic effect of JAK1/2 blockade on the manifestations of hemophagocytic lymphohistiocytosis in mice. Blood 2016; 128:60-71. [DOI: 10.1182/blood-2016-02-700013] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/10/2016] [Indexed: 12/14/2022] Open
Abstract
Key Points
Treatment with clinical dose of JAK1/2 inhibitor (ruxolitinib) countered manifestations of HLH in 2 cytotoxicity-impaired murine models. JAK1/2 inhibitor therapy in mice is effective on survival, cytopenia, inflammatory syndrome, central nervous system involvement, and liver tissue repair.
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92
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Bracaglia C, de Graaf K, Pires Marafon D, Guilhot F, Ferlin W, Prencipe G, Caiello I, Davì S, Schulert G, Ravelli A, Grom AA, de Min C, De Benedetti F. Elevated circulating levels of interferon-γ and interferon-γ-induced chemokines characterise patients with macrophage activation syndrome complicating systemic juvenile idiopathic arthritis. Ann Rheum Dis 2016; 76:166-172. [PMID: 27296321 DOI: 10.1136/annrheumdis-2015-209020] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 05/12/2016] [Accepted: 05/17/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Interferon-γ (IFNγ) is the pivotal mediator in murine models of primary haemophagocytic lymphohistiocytosis (pHLH). Given the similarities between primary and secondary HLH (sec-HLH), including macrophage activation syndrome (MAS), we investigate the involvement of the IFNγ pathway in MAS by evaluating levels of IFNγ and of the induced chemokines, and their relation with laboratory parameters of MAS in systemic juvenile idiopathic arthritis (sJIA) patients with MAS and in a murine MAS model. METHODS The Luminex multiplexing assay was used to assess serum levels of interleukin (IL)-1β, IL-6, IFNγ and of the IFNγ-induced chemokines CXCL9, CXCL10 and CXCL11 in patients with sec-HLH (n=11) and in patients with sJIA (n=54), of whom 20 had active MAS at sampling. Expression of IFNγ-induced chemokines was assessed in IL-6 transgenic mice in which MAS is induced by TLR4 stimulation with lipopolysaccharide. RESULTS Levels of IFNγ and of IFNγ-induced chemokines were markedly elevated during active MAS and sec-HLH and were significantly higher in patients with MAS compared with active sJIA without MAS. Levels in patients with active sJIA without MAS were comparable to those of patients with clinically inactive sJIA. During MAS, ferritin and alanine transferase levels and neutrophil and platelet counts were significantly correlated with serum levels of IFNγ and CXCL9. In murine MAS, serum levels of ferritin were significantly correlated with mRNA levels of Cxcl9 in liver and spleen. CONCLUSIONS The high levels of IFNγ and of IFNγ-induced chemokines and their correlation with the severity of laboratory abnormalities of MAS suggest a pivotal role of IFNγ in MAS.
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Affiliation(s)
- Claudia Bracaglia
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | | | | | | | - Giusi Prencipe
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Ivan Caiello
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Sergio Davì
- University of Genoa, Istituto Giannina Gaslini, Genoa, Italy
| | - Grant Schulert
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Angelo Ravelli
- University of Genoa, Istituto Giannina Gaslini, Genoa, Italy
| | - Alexei A Grom
- Division of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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93
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Brisse E, Wouters CH, Matthys P. Advances in the pathogenesis of primary and secondary haemophagocytic lymphohistiocytosis: differences and similarities. Br J Haematol 2016; 174:203-17. [PMID: 27264204 DOI: 10.1111/bjh.14147] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) comprises a heterogeneous spectrum of hyperinflammatory conditions that are inherited (primary HLH) or acquired in a context of infections, malignancies or autoimmune/autoinflammatory disorders (secondary HLH). Genetic defects in the cytotoxic machinery of natural killer and CD8(+) T cells underlie primary HLH, with residual cytotoxicity determining disease severity. Improved sequencing techniques have expanded the range of causal mutations and have redefined many cases of secondary HLH as primary HLH and vice versa, blurring the distinction between both subtypes. These insights allow HLH to be conceptualized as a threshold disease, in which interplay between various genetic and environmental factors causes progressive inflammation into a critical point, beyond which uncontrolled activation of immune cells and excessive cytokine production give rise to the cardinal symptoms of HLH. Various pathogenic pathways may thus converge to a common end stage of fulminant HLH.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Carine H Wouters
- Laboratory of Paediatric Immunology, KU Leuven, University Hospital Gasthuisberg, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
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94
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Abstract
Macrophage activation syndrome (MAS) refers to acute overwhelming inflammation caused by a 'cytokine storm'. Although increasingly recognized as a life-threatening complication of various rheumatic diseases, clinically, MAS is strikingly similar to primary and secondary forms of haemophagocytic lymphohistiocytosis (HLH). Not surprisingly, many rheumatologists prefer the term secondary HLH rather than MAS to describe this condition, and efforts to change the nomenclature are in progress. The pathophysiology of MAS remains elusive, but observations in animal models, as well as data on the effects of new anticytokine therapies on rates and clinical presentations of MAS in patients with systemic juvenile idiopathic arthritis (sJIA), provide clues to the understanding of this perplexing clinical phenomenon. In this Review, we explore the latest available evidence and discuss potential diagnostic challenges in the era of increasing use of biologic therapies.
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Affiliation(s)
- Alexei A Grom
- Division of Rheumatology, ML 4010, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - AnnaCarin Horne
- Department of Women's and Children's Health, Karolinska University Hospital, Karolinska vägen, 171 76 Solna, Stockholm, Sweden
| | - Fabrizio De Benedetti
- Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio, 4, Rome, Italy
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95
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Put K, Brisse E, Avau A, Imbrechts M, Mitera T, Janssens R, Proost P, Fallarino F, Wouters CH, Matthys P. IDO1 Deficiency Does Not Affect Disease in Mouse Models of Systemic Juvenile Idiopathic Arthritis and Secondary Hemophagocytic Lymphohistiocytosis. PLoS One 2016; 11:e0150075. [PMID: 26914138 PMCID: PMC4767214 DOI: 10.1371/journal.pone.0150075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 02/04/2016] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Indoleamine 2,3-dioxygenase-1 (IDO1) is an immune-modulatory enzyme that catalyzes the degradation of tryptophan (Trp) to kynurenine (Kyn) and is strongly induced by interferon (IFN)-γ. We previously reported highly increased levels of IFN-γ and corresponding IDO activity in patients with hemophagocytic lymphohistiocytosis (HLH), a hyper-inflammatory syndrome. On the other hand, IFN-γ and IDO were low in patients with systemic juvenile idiopathic arthritis (sJIA), an autoinflammatory syndrome. As HLH can occur as a complication of sJIA, the opposing levels of both IFN-γ and IDO are remarkable. In animal models for sJIA and HLH, the role of IFN-γ differs from being protective to pathogenic. In this study, we aimed to unravel the role of IDO1 in the pathogenesis of sJIA and HLH. METHODS Wild-type and IDO1-knockout (IDO1-KO) mice were used in 3 models of sJIA or HLH: complete Freund's adjuvant (CFA)-injected mice developed an sJIA-like syndrome and secondary HLH (sHLH) was evoked by either repeated injection of unmethylated CpG oligonucleotide or by primary infection with mouse cytomegalovirus (MCMV). An anti-CD3-induced cytokine release syndrome was used as a non-sJIA/HLH control model. RESULTS No differences were found in clinical, laboratory and hematological features of sJIA/HLH between wild-type and IDO1-KO mice. As IDO modulates the immune response via induction of regulatory T cells and inhibition of T cell proliferation, we investigated both features in a T cell-triggered cytokine release syndrome. Again, no differences were observed in serum cytokine levels, percentages of regulatory T cells, nor of proliferating or apoptotic thymocytes and lymph node cells. CONCLUSIONS Our data demonstrate that IDO1 deficiency does not affect inflammation in sJIA, sHLH and a T cell-triggered cytokine release model. We hypothesize that other tryptophan-catabolizing enzymes like IDO2 and tryptophan 2,3-dioxygenase (TDO) might compensate for the lack of IDO1.
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MESH Headings
- Animals
- Apoptosis/immunology
- Arthritis, Experimental/genetics
- Arthritis, Experimental/immunology
- Arthritis, Juvenile/genetics
- Arthritis, Juvenile/pathology
- Cell Proliferation
- Cytokines/blood
- Cytomegalovirus/immunology
- Cytomegalovirus Infections/immunology
- Cytomegalovirus Infections/pathology
- Freund's Adjuvant/immunology
- Indoleamine-Pyrrole 2,3,-Dioxygenase/genetics
- Indoleamine-Pyrrole 2,3,-Dioxygenase/metabolism
- Inflammation/immunology
- Interferon-gamma/genetics
- Interferon-gamma/immunology
- Interferon-gamma/metabolism
- Lymphohistiocytosis, Hemophagocytic/genetics
- Lymphohistiocytosis, Hemophagocytic/pathology
- Macrophage Activation Syndrome/genetics
- Macrophage Activation Syndrome/pathology
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Mice, Knockout
- T-Lymphocytes/immunology
- Tryptophan Oxygenase/metabolism
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Affiliation(s)
- Karen Put
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Ellen Brisse
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Anneleen Avau
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Maya Imbrechts
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Tania Mitera
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Rik Janssens
- Laboratory of Molecular Immunology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Paul Proost
- Laboratory of Molecular Immunology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Francesca Fallarino
- Department of Experimental Medicine and Biochemical Sciences, University of Perugia, Perugia, Italy
| | - Carine H. Wouters
- Laboratory of Pediatric Immunology, University Hospitals Leuven, KU Leuven – University of Leuven, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega-Institute for Medical Research, Department of Immunology and Microbiology, KU Leuven – University of Leuven, Leuven, Belgium
- * E-mail:
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96
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Brisse E, Imbrechts M, Put K, Avau A, Mitera T, Berghmans N, Rutgeerts O, Waer M, Ninivaggi M, Kelchtermans H, Boon L, Snoeck R, Wouters CH, Andrei G, Matthys P. Mouse Cytomegalovirus Infection in BALB/c Mice Resembles Virus-Associated Secondary Hemophagocytic Lymphohistiocytosis and Shows a Pathogenesis Distinct from Primary Hemophagocytic Lymphohistiocytosis. THE JOURNAL OF IMMUNOLOGY 2016; 196:3124-34. [PMID: 26903481 DOI: 10.4049/jimmunol.1501035] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 01/22/2016] [Indexed: 01/04/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immunological disorder that is characterized by systemic inflammation, widespread organ damage, and hypercytokinemia. Primary HLH is caused by mutations in granule-mediated cytotoxicity, whereas secondary HLH occurs, without a known genetic background, in a context of infections, malignancies, or autoimmune and autoinflammatory disorders. Clinical manifestations of both HLH subtypes are often precipitated by a viral infection, predominantly with Herpesviridae. Exploiting this knowledge, we established an animal model of virus-associated secondary HLH by infecting immunocompetent wild-type mice with the β-herpesvirus murine CMV. C57BL/6 mice developed a mild inflammatory phenotype, whereas BALB/c mice displayed the clinicopathologic features of HLH, as set forth in the Histiocyte Society diagnostic guidelines: fever, cytopenia, hemophagocytosis, hyperferritinemia, and elevated serum levels of soluble CD25. BALB/c mice also developed lymphadenopathy, liver dysfunction, and decreased NK cell numbers. Lymphoid and myeloid cells were in a hyperactivated state. Nonetheless, depletion of CD8(+) T cells could not inhibit or cure the HLH-like syndrome, highlighting a first dissimilarity from mouse models of primary HLH. Immune cell hyperactivation in BALB/c mice was accompanied by a cytokine storm. Notably, plasma levels of IFN-γ, a key pathogenic cytokine in models of primary HLH, were the highest. Nevertheless, murine CMV-infected IFN-γ-deficient mice still developed the aforementioned HLH-like symptoms. In fact, IFN-γ-deficient mice displayed a more complete spectrum of HLH, including splenomegaly, coagulopathy, and decreased NK cell cytotoxicity, indicating a regulatory role for IFN-γ in the pathogenesis of virus-associated secondary HLH as opposed to its central pathogenic role in primary HLH.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Maya Imbrechts
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Karen Put
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Anneleen Avau
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Tania Mitera
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Nele Berghmans
- Laboratory of Molecular Immunology, Rega Institute, University of Leuven, 3000 Leuven, Belgium
| | - Omer Rutgeerts
- Laboratory of Experimental Transplantation, University of Leuven, 3000 Leuven, Belgium
| | - Mark Waer
- Laboratory of Experimental Transplantation, University of Leuven, 3000 Leuven, Belgium
| | - Marisa Ninivaggi
- Synapse BV, Cardiovascular Research Institute Maastricht School for Cardiovascular Diseases, Maastricht University, 6229 Maastricht, the Netherlands
| | - Hilde Kelchtermans
- Synapse BV, Cardiovascular Research Institute Maastricht School for Cardiovascular Diseases, Maastricht University, 6229 Maastricht, the Netherlands
| | - Louis Boon
- Epirus Biopharmaceuticals Netherlands, 3584 Utrecht, the Netherlands
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Rega Institute, University of Leuven, 3000 Leuven, Belgium; and
| | - Carine H Wouters
- Laboratory of Pediatric Immunology, University Hospital Gasthuisberg, University of Leuven, 3000 Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute, University of Leuven, 3000 Leuven, Belgium; and
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, University of Leuven, 3000 Leuven, Belgium;
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97
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Polygenic mutations in the cytotoxicity pathway increase susceptibility to develop HLH immunopathology in mice. Blood 2016; 127:2113-21. [PMID: 26864340 DOI: 10.1182/blood-2015-12-688960] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/06/2016] [Indexed: 02/06/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory disease. Inherited forms of HLH are caused by biallelic mutations in several effectors of granule-dependent lymphocyte-mediated cytotoxicity. A small proportion of patients with a so-called "secondary" form of HLH, which develops in the aftermath of infection, autoimmunity, or cancer, carry a monoallelic mutation in one or more HLH-associated genes. Although this observation suggests that HLH may have a polygenic mode of inheritance, the latter is very difficult to prove in humans. In order to determine whether the accumulation of partial genetic defects in lymphocyte-mediated cytotoxicity can contribute to the development of HLH, we generated mice that were doubly or triply heterozygous for mutations in HLH-associated genes, those coding for perforin, Rab27a, and syntaxin-11. We found that the accumulation of monoallelic mutations did indeed increase the risk of developing HLH immunopathology after lymphocytic choriomeningitis virus infection. In mechanistic terms, the accumulation of heterozygous mutations in the two degranulation genes Rab27a and syntaxin-11, impaired the dynamics and secretion of cytotoxic granules at the immune synapse of T lymphocytes. In addition, the accumulation of heterozygous mutations within the three genes impaired natural killer lymphocyte cytotoxicity in vivo. The genetic defects can be ranked in terms of the severity of the resulting HLH manifestations. Our results form the basis of a polygenic model of the occurrence of secondary HLH.
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98
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Janus kinase inhibition lessens inflammation and ameliorates disease in murine models of hemophagocytic lymphohistiocytosis. Blood 2016; 127:1666-75. [PMID: 26825707 DOI: 10.1182/blood-2015-12-684399] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 01/13/2016] [Indexed: 02/06/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) comprises an emerging spectrum of inherited and noninherited disorders of the immune system characterized by the excessive production of cytokines, including interferon-γ and interleukins 2, 6, and 10 (IL-2, IL-6, and IL-10). The Janus kinases (JAKs) transduce signals initiated following engagement of specific receptors that bind a broad array of cytokines, including those overproduced in HLH. Based on the central role for cytokines in the pathogenesis of HLH, we sought to examine whether the inhibition of JAK function might lessen inflammation in murine models of the disease. Toward this end, we examined the effects of JAK inhibition using a model of primary (inherited) HLH in which perforin-deficient (Prf1(-∕-)) mice are infected with lymphocytic choriomeningitis virus (LCMV) and secondary (noninherited) HLH in which C57BL/6 mice receive repeated injections of CpG DNA. In both models, treatment with the JAK1/2 inhibitor ruxolitinib significantly lessened the clinical and laboratory manifestations of HLH, including weight loss, organomegaly, anemia, thrombocytopenia, hypercytokinemia, and tissue inflammation. Importantly, ruxolitinib treatment also significantly improved the survival of LCMV-infectedPrf1(-∕-)mice. Mechanistic studies revealed that in vivo exposure to ruxolitinib inhibited signal transducer and activation of transcription 1-dependent gene expression, limited CD8(+)T-cell expansion, and greatly reduced proinflammatory cytokine production, without effecting degranulation and cytotoxic function. Collectively, these findings highlight the JAKs as novel, druggable targets for mitigating the cytokine-driven hyperinflammation that occurs in HLH. These observations also support the incorporation of JAK inhibitors such as ruxolitinib into future clinical trials for patients with these life-threatening disorders.
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99
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Avau A, Matthys P. Therapeutic Potential of Interferon-γ and Its Antagonists in Autoinflammation: Lessons from Murine Models of Systemic Juvenile Idiopathic Arthritis and Macrophage Activation Syndrome. Pharmaceuticals (Basel) 2015; 8:793-815. [PMID: 26610523 PMCID: PMC4695810 DOI: 10.3390/ph8040793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/09/2015] [Accepted: 11/18/2015] [Indexed: 01/05/2023] Open
Abstract
Interferon-γ (IFN-γ) affects immune responses in a complex fashion. Its immunostimulatory actions, such as macrophage activation and induction of T helper 1-type responsiveness, are widely acknowledged, however, as documented by a large body of literature, IFN-γ has also the potential to temper inflammatory processes via other pathways. In autoimmune and autoinflammatory disorders, IFN-γ can either play a disease-enforcing role or act as protective agent, depending on the nature of the disease. In animal models of any particular autoimmune disease, certain changes in the induction procedure can reverse the net outcome of introduction or ablation of IFN-γ. Here, we review the role of endogenous IFN-γ in inflammatory disorders and related murine models, with a focus on systemic juvenile idiopathic arthritis (sJIA) and macrophage activation syndrome (MAS). In particular, we discuss our recent findings in a mouse model of sJIA, in which endogenous IFN-γ acts as a regulatory agent, and compare with results from mouse models of MAS. Also, we elaborate on the complexity in the activity of IFN-γ and the resulting difficulty of predicting its value or that of its antagonists as treatment option.
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Affiliation(s)
- Anneleen Avau
- Laboratory of Immunobiology, Department of Microbiology and Immunology, Rega Institute, KU Leuven - University of Leuven, Leuven B-3000, Belgium.
| | - Patrick Matthys
- Laboratory of Immunobiology, Department of Microbiology and Immunology, Rega Institute, KU Leuven - University of Leuven, Leuven B-3000, Belgium.
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100
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Bacterial Stimulation of Toll-Like Receptor 4 Drives Macrophages To Hemophagocytose. Infect Immun 2015; 84:47-55. [PMID: 26459510 DOI: 10.1128/iai.01149-15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/07/2015] [Indexed: 01/25/2023] Open
Abstract
During acute infection with bacteria, viruses or parasites, a fraction of macrophages engulf large numbers of red and white blood cells, a process called hemophagocytosis. Hemophagocytes persist into the chronic stage of infection and have an anti-inflammatory phenotype. Salmonella enterica serovar Typhimurium infection of immunocompetent mice results in acute followed by chronic infection, with the accumulation of hemophagocytes. The mechanism(s) that triggers a macrophage to become hemophagocytic is unknown, but it has been reported that the proinflammatory cytokine gamma interferon (IFN-γ) is responsible. We show that primary macrophages become hemophagocytic in the absence or presence of IFN-γ upon infection with Gram-negative bacterial pathogens or prolonged exposure to heat-killed Salmonella enterica, the Gram-positive bacterium Bacillus subtilis, or Mycobacterium marinum. Moreover, conserved microbe-associated molecular patterns are sufficient to stimulate macrophages to hemophagocytose. Purified bacterial lipopolysaccharide (LPS) induced hemophagocytosis in resting and IFN-γ-pretreated macrophages, whereas lipoteichoic acid and synthetic unmethylated deoxycytidine-deoxyguanosine dinucleotides, which mimic bacterial DNA, induced hemophagocytosis only in IFN-γ-pretreated macrophages. Chemical inhibition or genetic deletion of Toll-like receptor 4, a pattern recognition receptor responsive to LPS, prevented both Salmonella- and LPS-stimulated hemophagocytosis. Inhibition of NF-κB also prevented hemophagocytosis. These results indicate that recognition of microbial products by Toll-like receptors stimulates hemophagocytosis, a novel outcome of prolonged Toll-like receptor signaling, suggesting hemophagocytosis is a highly conserved innate immune response.
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