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Holmegaard L, Stanne TM, Andreasson U, Zetterberg H, Blennow K, Blomstrand C, Jood K, Jern C. Proinflammatory protein signatures in cryptogenic and large artery atherosclerosis stroke. Acta Neurol Scand 2021; 143:303-312. [PMID: 33107019 PMCID: PMC7898473 DOI: 10.1111/ane.13366] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/03/2020] [Accepted: 10/12/2020] [Indexed: 01/17/2023]
Abstract
Objectives The cause of ischemic stroke remains unknown, cryptogenic, in 25% of young and middle‐aged patients. We hypothesized that if atherosclerosis is prominent in cryptogenic stroke, it would have a similar proinflammatory protein signature as large artery atherosclerosis (LAA) stroke. Materials & Methods Blood was collected in the acute phase and after 3 months from cryptogenic (n = 162) and LAA (n = 73) stroke patients aged 18–69 years and once from age‐matched controls (n = 235). Cryptogenic stroke was divided into Framingham Risk Score (FRS) quartiles to compare low and high risk of atherosclerosis. Plasma concentrations of 25 proteins were analyzed using a Luminex multiplex assay. The discriminating properties were assessed with discriminant analysis and C‐statistics. Results We identified proteins that separated cryptogenic and LAA stroke from controls (area under the curves, AUCs ≥ 0.85). For both subtypes, RANTES, IL‐4, and IFN‐γ contributed the most at both time points. These associations were independent of risk factors of atherosclerosis. We also identified proteins that separated cryptogenic strokes in the lowest quartile of FRS from those in the highest, and from LAA stroke (AUCs ≥ 0.76), and here eotaxin and MCP‐1 contributed the most. Conclusions The protein signature separating cases from controls was different from the signature separating cryptogenic stroke with low risk of atherosclerosis from those with high risk and from LAA stroke. This suggests that increased RANTES, IL‐4, and IFN‐γ in stroke may not be primarily related to atherosclerosis, whereas increased eotaxin and MCP‐1 in cryptogenic stroke may be markers of occult atherosclerosis as the underlying cause.
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Affiliation(s)
- Lukas Holmegaard
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Neurology Sahlgrenska University Hospital Gothenburg Sweden
| | - Tara M. Stanne
- Department of Laboratory Medicine Institute of Biomedicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Clinical Genetics and Genomics Sahlgrenska University Hospital Gothenburg Sweden
| | - Ulf Andreasson
- Department of Psychiatry and Neurochemistry Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital Mölndal Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital Mölndal Sweden
- Department of Neurodegenerative Disease UCL Institute of Neurology, Queen Square London UK
- UK Dementia Research Institute at UCL London UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital Mölndal Sweden
| | - Christian Blomstrand
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Neurology Sahlgrenska University Hospital Gothenburg Sweden
| | - Christina Jern
- Department of Laboratory Medicine Institute of Biomedicine Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Clinical Genetics and Genomics Sahlgrenska University Hospital Gothenburg Sweden
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Cantini G, Pisati F, Pessina S, Finocchiaro G, Pellegatta S. Immunotherapy against the radial glia marker GLAST effectively triggers specific antitumor effectors without autoimmunity. Oncoimmunology 2021; 1:884-893. [PMID: 23162756 PMCID: PMC3489744 DOI: 10.4161/onci.20637] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The glutamate-aspartate transporter GLAST is a radial glia marker that is highly expressed in GL261 stem-like cells (GSCs). To target GLAST, we treated glioma-bearing mice with three subcutaneous injections of four GLAST peptides emulsified with Montanide ISA-51 in association with granulocyte macrophage colony-stimulating factor (GM-CSF) injections. Vaccination with GLAST peptides significantly prolonged survival, effectively enhanced systemic T-cell and NK-cell responses and promoted robust antitumor cytotoxicity. GLAST expression significantly decreased in gliomas from immunized mice, as evaluated by histological analysis and real-time PCR (RT-PCR). Moreover, the immunization protocol led to the upregulation of interferonγ (IFNγ) and tumor necrosis factorα (TNFα) as well as to the downregulation of transforming growth factor (TGF) β1 and β2 in the tumor. Beyond these changes, gliomas from immunized mice exhibited an increased recruitment of NK cells and antigen-specific CD8+ T cells expressing the tumor homing molecule VLA-4, as well as a local chemotactic gradient featuring expression of CXCL10 (which may be responsible for the recruitment of CTLs), CCL3, CCL4 and CCL5 (which are involved in NK-cell migration), and NKG2D ligand on glioma cells. Importantly, although GLAST is expressed in the central nervous system, autoimmune reactions were not observed in immunized mice. Altogether, these results support the contention that GLAST may constitute a glioma antigen against which immune responses can be efficiently induced without major safety concerns.
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Affiliation(s)
- Gabriele Cantini
- Unit of Molecular Neuro-Oncology; Neurological Institute C. Besta; Milan, Italy ; Department of Experimental Oncology; European Institute of Oncology; Campus IFOM-IEO; Milan, Italy
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Sun K, Gong C, Peng H, Fang H, Zhou J, Li J, Chen S, Zheng H. High CCL5 expression is associated with osteosarcoma metastasis and poor prognosis of patients with osteosarcoma. Mol Med Rep 2017; 16:6953-6957. [PMID: 28901496 DOI: 10.3892/mmr.2017.7458] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 03/02/2017] [Indexed: 11/06/2022] Open
Abstract
Osteosarcoma is the most common primary malignant tumor of the skeletal system and is characterized by an aggressive clinical course and high metastatic potential. Regulated upon Activation Normal T cell Expressed and Secreted, also termed C‑C motif chemokine ligand 5 (CCL5), is associated with metastasis and poor prognosis in various types of cancer. The aim of the current study was to investigate the association between CCL5 expression and clinicopathological features and prognosis in patients with osteosarcoma. Tissue microarrays and reverse transcription‑quantitative polymerase chain reaction and immunohistochemistry were used to examine the expression of CCL5 in human osteosarcoma tissues. The prognostic value of CCL5 expression was evaluated by the Kaplan‑Meier method and Cox proportional hazards regression model. The rate of high CCL5 expression was significantly higher in metastatic osteosarcomas than in osteosarcomas without metastases. The overall survival rates (P=0.001) and the metastasis‑free survival rates (P<0.001) of the low CCL5 expression group were significantly higher than the CCL5 high expression group. Multivariate Cox regression analysis indicated that CCL5 expression had independent predictive value for the prognosis of patients with osteosarcoma. In conclusion, the data of the current study indicated that CCL5 may serve as a biomarker for prognosis of osteosarcoma, and may be a potential molecular target for osteosarcoma therapy.
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Affiliation(s)
- Kai Sun
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Chen Gong
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, P.R. China
| | - Hao Peng
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Hongsong Fang
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Jianlin Zhou
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Jianping Li
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Sen Chen
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Huifeng Zheng
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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Sutherland AG, Cook A, Miller C, Duncan L, Yuecel R, Heys SD, Hutchison JD, Liversidge J. Older Patients Are Immunocompromised by Cytokine Depletion and Loss of Innate Immune Function After HIP Fracture Surgery. Geriatr Orthop Surg Rehabil 2015; 6:295-302. [PMID: 26623165 PMCID: PMC4647197 DOI: 10.1177/2151458515605564] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE/INTRODUCTION We have examined the immune status of elderly patients who underwent surgery for a hip fracture, an injury associated with poor postoperative outcomes, to identify specific immune defects. METHODS In a cohort observational study, 16 patients undergoing surgery for hip fractures had immune function evaluation prior to surgery, and then at 3 and 7 days postoperatively, using flow cytometry for phenotype and for monocyte and granulocyte phagocytic function and respiratory burst. Serum samples were stored and batch analyzed using a human cytokine 25-plex panel. RESULTS We report significant loss of innate immune function, related specifically to reduced granulocyte numbers by day 7 (P < .0001, flow cytometry; P < .05 white blood cells), and although granulocyte ability to take up opsonized Escherichia coli was increased (P < .05), the ability of those cells to generate a respiratory burst was reduced at days 3 and 7 (P < .05). Monocyte respiratory burst was also significantly reduced (P < .05). Serum cytokine levels indicated very poor T-cell function. CONCLUSION We have demonstrated that the antimicrobial immune response is profoundly reduced after surgery in elderly patients with hip fractures. The effect was sustained up to 7 days postoperatively, identifying these patients as particularly vulnerable to bacterial infections.
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Affiliation(s)
| | - Alistair Cook
- Section of Immunology and Infection, University of Aberdeen, Foresterhill, United Kingdom
| | - Clare Miller
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, United Kingdom
| | - Linda Duncan
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, United Kingdom
| | - Raif Yuecel
- Division of Applied Medicine, School of Medicine and Dentistry, Iain Fraser Cytometry Centre, University of Aberdeen, Foresterhill, United Kingdom
| | - Steven D Heys
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, United Kingdom
| | - James D Hutchison
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, United Kingdom
| | - Janet Liversidge
- Section of Immunology and Infection, University of Aberdeen, Foresterhill, United Kingdom
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Liu B, Hassan Z, Amisten S, King AJ, Bowe JE, Huang GC, Jones PM, Persaud SJ. The novel chemokine receptor, G-protein-coupled receptor 75, is expressed by islets and is coupled to stimulation of insulin secretion and improved glucose homeostasis. Diabetologia 2013; 56:2467-76. [PMID: 23979485 DOI: 10.1007/s00125-013-3022-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 07/19/2013] [Indexed: 01/14/2023]
Abstract
AIMS/HYPOTHESIS Chemokine (C-C motif) ligand 5 (CCL5) acts at C-C chemokine receptors (CCRs) to promote immune cell recruitment to sites of inflammation, but is also an agonist at G-protein-coupled receptor 75 (GPR75), which has very limited homology with CCRs. GPR75 is coupled to Gq to elevate intracellular calcium, so we investigated whether islets express this receptor and whether its activation by CCL5 increases beta cell calcium levels and insulin secretion. METHODS Islet CCL5 receptor mRNA expression was measured by quantitative RT-PCR and GPR75 was detected in islets by western blotting and immunohistochemistry. In some experiments GPR75 was downregulated by transient transfection with small interfering RNA. Real-time changes in intracellular calcium were determined by single-cell microfluorimetry. Dynamic insulin secretion from perifused islets was quantified by radioimmunoassay. Glucose homeostasis in lean and obese mice was determined by measuring glucose and insulin tolerance, and insulin secretion in vivo. RESULTS Mouse and human islets express GPR75 and its ligand CCL5. Exogenous CCL5 reversibly increased intracellular calcium in beta cells via GPR75, this phenomenon being dependent on phospholipase C activation and calcium influx. CCL5 also stimulated insulin secretion from mouse and human islets in vitro, and improved glucose tolerance in lean mice and in a mouse model of hyperglycaemia and insulin resistance (ob/ob). The improvement in glucose tolerance was associated with enhanced insulin secretion in vivo, without changes in insulin sensitivity. CONCLUSIONS/INTERPRETATION Although CCL5 is implicated in the pathogenesis of diabetes through activation of CCRs, it has beneficial effects on beta cells through GPR75 activation.
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Affiliation(s)
- Bo Liu
- Diabetes Research Group, Division of Diabetes & Nutritional Sciences, School of Medicine, 2.9N Hodgkin Building, King's College London, Guy's Campus, London, SE1 1UL, UK
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Nahas R, Fakhoury HM, Chmaisse HN, Makki RF. Study of the association between -403G/A and -28C/G RANTES gene polymorphisms and asthma in Lebanon. Ann Thorac Med 2012; 7:16-20. [PMID: 22347345 PMCID: PMC3277035 DOI: 10.4103/1817-1737.91558] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Accepted: 08/08/2011] [Indexed: 11/08/2022] Open
Abstract
CONTEXT: Asthma is a complex inflammatory condition often associated with bronchial hyper reactivity and atopy. Genetic and environmental factors are implicated in the etiopathogenesis of asthma. Regulated upon Activation Normal T- cell Expressed and Secreted (RANTES) is a CC chemokine responsible for the recruitment of inflammatory cells, suggesting a possible role for this chemokine in asthma. Both -403A and -28G alleles of the RANTES promoter region were found to be associated with asthma/atopy in some but not all studies. AIM: The purpose of this study was to investigate the genetic influence of -403A and -28G alleles of the RANTES promoter region on the development of asthma in Lebanon. SETTINGS AND DESIGN: This case control study was conducted at Makassed Hospital, Beirut on 40 asthmatic patients and 38 healthy controls. METHODS: RANTES gene polymorphisms -403G/A and -28C/G alleles were genotyped using PCR-RFLP. RESULTS: No significant differences in allele or genotype frequencies for the RANTES gene polymorphisms between asthmatic patients and controls were found. The difference of the -403 GA genotype frequency between patients and controls was not statisti-cally significant; (OR=0.8, 95% CI=0.2-2.3, P=0.8). Similarly, the difference of the A-allele frequencies between patients and con-trols was not significant (OR=0.824, CI=0.3–2.2, P=0.7). CONCLUSIONS: Our data show that RANTES gene promoter polymorphisms are not associated with asthma susceptibility in the Lebanese population.
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Affiliation(s)
- Rana Nahas
- Department of Pharmacology, Faculty of Pharmacy, Beirut Arab University, Riyadh, Saudi Arabia
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Liou JT, Yuan HB, Mao CC, Lai YS, Day YJ. Absence of C-C motif chemokine ligand 5 in mice leads to decreased local macrophage recruitment and behavioral hypersensitivity in a murine neuropathic pain model. Pain 2012; 153:1283-1291. [PMID: 22494919 DOI: 10.1016/j.pain.2012.03.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 02/23/2012] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
Accumulated evidence suggests that the C-C motif chemokine ligand 5 (CCL5) modulates migration of inflammatory cells in several pathological conditions. This study tested the hypothesis that lack of CCL5 would modulate the recruitment of inflammatory cells to painful, inflamed sites and could attenuate pain in a murine chronic neuropathic pain model. Nociceptive sensitization, immune cell infiltration, multiple cytokine expression, and opioid peptide expression in damaged nerves were studied in wild-type (CCL5 +/+) and CCL5-deficient (CCL5 -/-) mice after partial sciatic nerve ligation (PSNL). Results indicated that CCL5 -/- mice had less behavioral hypersensitivity after PSNL. Macrophage infiltration and proinflammatory cytokines (tumor necrosis factor-α, interleukin [IL]-1β, IL-6, and interferon-γ) in damaged nerves following PSNL were significantly decreased in CCL5 -/- mice. Conversely, several antiinflammatory cytokine (IL-4 and IL-10) proteins were significantly increased in CCL5 -/- animals and the expression of enkephalin, β-endorphin, and dynorphin mRNA was significantly lower than in wild-type control mice. These results represent the first evidence that CCL5 is capable of regulating the pathway that controls hyperalgesia at the level of the peripheral injured site in a murine chronic neuropathic pain model. We demonstrated that lack of CCL5 modulated cell infiltration and the proinflammatory milieu within the injured nerve. Attenuated behavioral hypersensitivity in CCL5 -/- mice observed in the current study could be a result of decreased macrophage infiltration, mobilization, and functional ability at injured sites. Collectively, the present study results suggest that CCL5 receptor antagonists may ultimately provide a novel class of analgesics for therapeutic intervention in chronic neuropathic pain.
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Affiliation(s)
- Jiin-Tarng Liou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou, Taiwan, ROC Transgenic & Molecular Immunogenetics Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan, ROC Graduate Institutes of Clinical Medical Sciences, Chang Gung University, Linkou, Taiwan, ROC Department of Anesthesiology, Taipei-Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC Department of Medicine, Chang Gung University, Linkou, Taiwan, ROC
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Abstract
IMPORTANCE OF THE FIELD To date cancer immunotherapy has only achieved limited clinical efficacy, thus more efficient immunotherapeutic approaches need to be explored. The CC chemokine CCL5 plays a role in chemoattraction and activation of immune cells implying its potential clinical application as an adjuvant for boosting anti-tumor immunity, although an effect on carcinogenesis and tumor cell invasiveness is also reported to be associated with CCL5. AREAS COVERED IN THIS REVIEW Recent progress in exploiting CCL5 as an adjuvant for cancer prevention and treatment, and updated understanding on how CCL5 is involved in tumor invasiveness and carcinogenesis. WHAT THE READER WILL GAIN CCL5 represents a natural adjuvant for enhancing anti-tumor immune responses. However, animal experiments and clinical reports suggest that CCL5 plays a role in carcinogenesis and invasiveness of tumor cells. Therefore, a CCL5-based cancer therapeutic approach needs to avoid the CCL5-associated potential detrimental effects. TAKE HOME MESSAGE CCL5 has a pre-eminent role in chemotaxis and activation of a wide spectrum of immune cells. CCL5 functions as an adjuvant to boost anti-tumor immunity by diverse protocols such as co-immunization of recombinant CCL5 protein with tumor-associated antigen, vaccination with CCL-5-expressing tumor cells, or viral vector delivery of CCL5 cDNA into growing tumor. CCL5 may also promote tumor cell survival, proliferation and invasion by different mechanisms.
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Affiliation(s)
- Natalia Lapteva
- Department Molecular Microbiology & Immunology, 1450 Biggy Street, NRT 7506, Los Angeles, CA 90033, USA
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Jayasinghe MM, Golden JM, Nair P, O'Donnell CM, Werner MT, Kurt RA. Tumor-derived CCL5 does not contribute to breast cancer progression. Breast Cancer Res Treat 2007; 111:511-21. [PMID: 17978871 DOI: 10.1007/s10549-007-9802-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Accepted: 10/18/2007] [Indexed: 11/30/2023]
Abstract
Besides functioning as a chemotactic factor, CCL5 has been associated with progression of disease in women with breast cancer, immune modulation and metastasis. Here we asked whether CCL5 produced by tumor cells contributed to growth or metastasis of breast cancer. For this purpose, we used two murine mammary carcinomas, the 4T1 tumor which is metastatic and constitutively expresses CCL5, and the 168 tumor which is not metastatic and does not constitutively express CCL5. RNA interference was used to inhibit CCL5 expression from the 4T1 tumor, and a CCL5 transgene was used to express CCL5 by the 168 tumor. Six different clones of 4T1 that exhibited stable reduction in CCL5 expression, and three different clones of 168 that exhibited stable CCL5 expression were compared to the parental tumors and vector transfected controls. Significantly, in both models, tumor-derived CCL5 expression did not correlate with MHC expression, growth rate, or metastatic ability of the tumors. These results show that tumor-derived CCL5 expression alone does not make a significant contribution to breast cancer progression.
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Castellani ML, Shanmugham LN, Petrarca C, Simeonidou I, Frydas S, De Colli M, Vecchiet J, Falasca K, Tetè S, Salini V, Conti P. Expression and secretion of RANTES (CCL5) in granulomatous calcified tissue before and after lipopolysaccharide treatment in vivo. Calcif Tissue Int 2007; 80:60-7. [PMID: 17164972 DOI: 10.1007/s00223-006-0115-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Accepted: 07/23/2006] [Indexed: 01/12/2023]
Abstract
RANTES (regulated on activation, normal T cell-expressed and secreted) is a CC chemokine appearing to be involved in the recruitment of leukocytes at inflammation sites. RANTES is produced by CD8(+) T cells, epithelial cells, fibroblasts, and platelets. It acts in vitro in leukocyte activation and human immunodeficiency virus suppression, but its role in vivo is still uncertain. In our study, we established the involvement of RANTES in an in vivo model of chronic inflammation induced by potassium permanganate, leading to calcified granulomas. In our rat model, RANTES expression (mRNA and protein) was significantly upregulated in granulomatous tissue; RANTES expression was further increased upon i.p. injection of lipopolysaccharide (LPS), while it was kept at basal levels by dexamethasone (Dex) given 18 hours before sacrifice. LPS and Dex increased and decreased, respectively, the recruitment of mononuclear cells in granulomatous tissue compared with control granulomas from phosphate-buffered saline (PBS)-treated animals. In granuloma tissue, levels of RANTES were higher in LPS-treated rats and lower in the Dex group compared to controls. RANTES was also found in the conditioned medium of granuloma tissue from treated (LPS or Dex) and untreated (PBS) rats. When LPS was added in vitro for 18 hours, RANTES was further increased, except in the Dex group (P > 0.05). On serum analysis, RANTES levels were higher in the LPS group and lower in the Dex group compared to controls. This study shows for the first time that RANTES is produced in vivo in chronic, experimental inflammatory states, an effect increased by LPS and inhibited by Dex.
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Affiliation(s)
- M L Castellani
- Department of Medicine and Aging, Medical School, University of Chieti-Pescara, 66100 Chieti, Italy
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Trakatelli C, Frydas S, Hatzistilianou M, Papadopoulos E, Simeonidou I, Founta A, Paludi D, Petrarca C, Castellani ML, Papaioannou N, Salini V, Conti P, Kempuraj D, Vecchiet J. Chemokines as markers for parasite-induced inflammation and tumors. Int J Biol Markers 2006; 20:197-203. [PMID: 16398400 DOI: 10.1177/172460080502000401] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chemokines are a group of small secreted proteins (8-10 kDa) produced and released by a wide variety of cell types. They were originally described as mediators of leukocyte recruitment, which is essential in acute and chronic inflammation. They also play a critical role in many pathophysiological processes such as allergic responses, infections and autoimmune diseases, tumor growth and hematopoietic development. This review introduces the three supergene families of chemokines (CXC, CC and C) with emphasis on their important role in different states in humans and in animal models with parasitic diseases. The concentration of transcription and translation of the cytokines and chemokines in the parasitic diseases may be an important marker for evaluation of the inflammatory state.
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Affiliation(s)
- C Trakatelli
- Department of Internal Medicine, Georgios Gennimatas Hospital, Thessaloniki
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Castellani ML, Kempuraj D, Frydas S, Theoharides TC, Simeonidou I, Conti P, Vecchiet J. Inhibitory effect of quercetin on tryptase and MCP-1 chemokine release, and histidine decarboxylase mRNA transcription by human mast cell-1 cell line. Neuroimmunomodulation 2006; 13:179-86. [PMID: 17191019 DOI: 10.1159/000098131] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Accepted: 10/27/2006] [Indexed: 12/31/2022] Open
Abstract
Mast cells are important in reactions of allergic disease and are also involved in a variety of neuroinflammatory diseases. Mast cells can be immunologically activated by IgE through their Fc receptors, as well as by neuropeptides and cytokines to secrete mediators. Here we used a human mast cell-1 (HMC-1) cell line cultured and treated with a physiological activator, anti-IgE, and a nonphysiological activator, calcium ionophore A23187, for tryptase and MCP-1 generation and transcription of histidine decarboxylase. We used quercetin, a potent antioxidant, cytoprotective and anti-inflammatory compound capable of inhibiting histamine and some cytokines released from several cell types, as an inhibitor of immunological and nonimmunological stimulus for mast cells. In this study quercetin inhibits, in a dose-response manner, tryptase and MCP-1. Moreover, using RT-PCR quercetin inhibited the transcription of histidine decarboxylase, the rate-limiting enzyme responsible for the generation of histamine from histidine, and MCP-1. Our data suggest that quercetin is an important and good candidate for reducing the release of pro-inflammatory mast cell mediators activated by physiological and nonphysiological stimulators.
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Marsella R, Nicklin CF, Saglio S, Lopez J. Investigation on the effects of topical therapy with 0.1% tacrolimus ointment (ProtopicR) on intradermal skin test reactivity in atopic dogs. Vet Dermatol 2004; 15:218-24. [PMID: 15305928 DOI: 10.1111/j.1365-3164.2004.00387.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Tacrolimus ointment (TAC) is an effective treatment for atopic dermatitis in humans and dogs. The purposes of the present study were to evaluate the effect of 4 weeks of TAC on intradermal skin testing (IST), and in case of suppression, to investigate if reactivity returned to baseline by 2 or 4 weeks post treatment. Intradermal skin test was performed using saline, histamine, lipopolysaccharide (LPS, 0.4 mg mL(-1)), house dust (25 PNU mL(-1)) and house dust mite (1 : 40 000 w/v) at weeks 0, 4, 6 and 8 on nine dogs enrolled in a blinded, crossover, clinical trial, using 0.1% TAC or placebo once daily for 4 weeks. Reactions were evaluated at 15 min, and at 4 and 6 h. Ointment was applied after the 15-min evaluation on weeks 0 and 4. Data were analysed using the statistical software SAS System for Windows. At week 4, TAC did not affect 15-min IST, but some reactions in the TAC group were suppressed at 6 h compared to baseline. In the TAC group, 4-h IST reactivity was reduced 2 weeks after discontinuation but returned to baseline by 4 weeks. In conclusion, TAC has no effect on immediate reactions but decreased some late-phase reactions. Therefore, no withdrawal is recommended to evaluate only immediate reactions, but a 4-week withdrawal may be necessary for evaluation of late-phase reactions.
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Affiliation(s)
- R Marsella
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32610-0126, USA.
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Conti P, Kempuraj D, Kandere K, Di Gioacchino M, Barbacane RC, Castellani ML, Felaco M, Boucher W, Letourneau R, Theoharides TC. IL-10, an inflammatory/inhibitory cytokine, but not always. Immunol Lett 2003; 86:123-9. [PMID: 12644313 DOI: 10.1016/s0165-2478(03)00002-6] [Citation(s) in RCA: 173] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
IL-10 has been previously called cytokine synthesis inhibiting factor, produced mostly by Th2 cells, macrophages and CD8+ cell clones. IL-10 is capable of inhibiting the synthesis of several cytokines from different cells, antigen or mitogen activated. IL-10 exerts its inhibition at the mRNA transcriptional and translational level. In addition, IL-10 is a co-stimulatory cytokine on activated T cells. For example, IL-10 inhibits NK cell activity, the production of Th1 cytokines, cytokines generated by peripheral blood mononuclear cells, and macrophage activity. On the other hand, IL-10 exerts immunostimulatory effects on B cells, cytotoxic T cell development and thymocytes. In mast cells derived from CD4+/CD133+ cells, IL-10 inhibits IL-6 and TNFalpha, and prostaglandin E(1) and E(2) induced by IL-6. Here, we report for the first time that IL-10 fails to inhibit tryptase and IL-6 from human mast cell-1 (HMC-1) and human umbilical cord blood-derived mast cells.
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Affiliation(s)
- Pio Conti
- Immunology Division, University of Chieti, School of Medicine, Chieti, Italy.
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15
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Conti P, Frydas S, Reale M, Barbacane RC, Di Gioacchino M, Felaco M, Trakatellis A. Inhibition of MCP-1 and MIP-2 transcription and translation by mimosine in muscle tissue infected with the parasite Trichinella spiralis. Mol Cell Biochem 2002; 229:129-37. [PMID: 11936838 DOI: 10.1023/a:1017989014906] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Mimosine is a non-toxic plant aminoacid which is an effective inhibitor of DNA replication by acting at the S-phase. In this study we infected mice with T. spiralis, a nematode parasite, and studied the inflammatory response through the determination of MIP-2, a C-X-C chemokine and MCP-1, a C-C chemokine in the inflamed area around the parasitic cyst. The animals were infected and their diaphragms were tested for inflammatory response. MCP-1 and MIP-2 was tested after 1, 10, 20, 30, and 40 days post inoculation, before and after mimosine treatment. The inflammatory index was calculated by counting the white blood cells around the nematode cysts, while expression of MIP-2 and MCP-1 was calculated by ELISA method and transcription by Northern blot and RT-PCR. Here we found that mimosine strongly inhibited the inflammatory index in the diaphragmatic tissue at 10, 20, 30 and 40 days post-treatment. In these experiments, mimosine had no effect on the number of cysts produced. In addition, we found that MCP-1 transcription and translation was completely inhibited by mimosine, while MIP-2 transcription and translation was partially inhibited at 30 and 40 days; yet it was totally inhibited after 10 and 20 days in encysted diaphragm tissue infected by T. spiralis. Our studies suggest that mimosine has an inhibitory effect through the inhibition of cytoplasmatic serine hydroxymethyltransferase altering the cell cycle of white blood cells. This study suggests for the first time the premise that mimosine acts as an anti-inflammatory compound.
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Affiliation(s)
- Pio Conti
- Department of Oncology and Neurosciences, University of Chieti, Italy.
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16
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Reale M, Barbacane RC, DiGioacchino M, Felaco M, Croce A, Ferro FM, Lotti TM, Conti P. Differential expression and secretion of RANTES and MCP-1 in activated peripheral blood mononuclear cell cultures of atopic subjects. Immunol Lett 2001; 76:7-14. [PMID: 11222907 DOI: 10.1016/s0165-2478(00)00320-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
RANTES and MCP-1 represent a link between the activation of monocytes, lymphocytes, basophils, mast cells and eosinophils in inflammatory disorders, such as the late phase allergic reaction. These C-C chemokines also play a role in regulating Th cell cytokine production and leukocyte trafficking. In this study, we determined the expression and secretion of RANTES and MCP-1 from PHA-activated PBMC of healthy and atopic subjects with no symptoms. Levels of RANTES from PHA-activated PBMC of atopic patients were higher, at 18 and 24 h incubations (42+/-5.5 and 48+/-4), compared to controls (20+/-4 and 35+/-4), respectively; while MCP-1 was not (12+/-3 and 17+/-3) compared to controls (10.5+/-3 and 15+/-2), respectively. This effect was also revealed on RANTES mRNA expression, as determined by reverse transcriptase polymerase chain reaction (RT-PCR) analysis. In addition, PHA-activated PBMC of atopic subjects produce more IL-4 (five times more) than healthy subjects, while IFN-gamma did not vary. RANTES, compared to MCP-1, may have more influence on signal transduction pathways, either in physiologic or inflammatory states and may induce profound effects on the regulation of cell activity. The differential production of RANTES and MCP-1 may lead to diverse regulation of the function and development of cells involved in the allergic response. These studies emphasize the importance of chemokine selectivity during inflammation.
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Affiliation(s)
- M Reale
- Department of Oncology and Neurosciences, Immunology Division, School of Medicine, University of Chieti, Via dei Vestini, 66013, Chieti, Italy
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17
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Heinemann A, Hartnell A, Stubbs VE, Murakami K, Soler D, LaRosa G, Askenase PW, Williams TJ, Sabroe I. Basophil responses to chemokines are regulated by both sequential and cooperative receptor signaling. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2000; 165:7224-33. [PMID: 11120855 DOI: 10.4049/jimmunol.165.12.7224] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To investigate human basophil responses to chemokines, we have developed a sensitive assay that uses flow cytometry to measure leukocyte shape change as a marker of cell responsiveness. PBMC were isolated from the blood of volunteers. Basophils were identified as a single population of cells that stained positive for IL-3Ralpha (CDw123) and negative for HLA-DR, and their increase in forward scatter (as a result of cell shape change) in response to chemokines was measured. Shape change responses of basophils to chemokines were highly reproducible, with a rank order of potency: monocyte chemoattractant protein (MCP) 4 (peak at <1 nM) >/= eotaxin-2 = eotaxin-3 >/= eotaxin > MCP-1 = MCP-3 > macrophage-inflammatory protein-1alpha > RANTES = MCP-2 = IL-8. The CCR4-selective ligand macrophage-derived chemokine did not elicit a response at concentrations up to 10 nM. Blocking mAbs to CCR2 and CCR3 demonstrated that responses to higher concentrations (>10 nM) of MCP-1 were mediated by CCR3 rather than CCR2, whereas MCP-4 exhibited a biphasic response consistent with sequential activation of CCR3 at lower concentrations and CCR2 at 10 nM MCP-4 and above. In contrast, responses to MCP-3 were blocked only in the presence of both mAbs, but not after pretreatment with either anti-CCR2 or anti-CCR3 mAb alone. These patterns of receptor usage were different from those seen for eosinophils and monocytes. We suggest that cooperation between CCRs might be a mechanism for preferential recruitment of basophils, as occurs in tissue hypersensitivity responses in vivo.
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Affiliation(s)
- A Heinemann
- Leukocyte Biology Section, Biomedical Sciences Division, Imperial College School of Medicine, South Kensington, London, United Kingdom
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18
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Waller A, Nayee P, Czaplewski LG. Identification and characterization of a rat macrophage inflammatory protein-1alpha receptor. JOURNAL OF HEMATOTHERAPY & STEM CELL RESEARCH 2000; 9:703-9. [PMID: 11091494 DOI: 10.1089/15258160050196740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A macrophage inflammatory protein-1alpha (MIP-1alpha) receptor has been cloned from rat (Rattus norvegicus) genomic DNA by PCR using oligonucleotides based on the mouse CCR1 DNA sequence and expressed in HEK293 cells to enable its characterization. The receptor was cloned three times in independent experiments to generate a consensus sequence. The rat ccrl receptor amino acid sequence is 92% identical to mouse and 80% identical to human CCR1. A consensus clone was transfected into HEK293 cells using the expression vector pIRES, and stable receptor expressing cell lines were isolated. In competitive receptor binding assays using iodinated human MIP-1alpha, rat ccrl binds hMIP-1alpha, hMIP-1beta, and hMCP-3, but not hRANTES or human interleukin-8 (hIL-8). We have been unable to demonstrate calcium mobilization by rat ccrl in HEK293 cells using human chemokines as ligands. Therefore, we have adopted lowercase nomenclature for the receptor until signaling is observed. This receptor and cell line may be of use in the preclinical development of CCR1 antagonists.
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Affiliation(s)
- A Waller
- British Biotech Pharmaceuticals, Ltd, Oxford, UK
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19
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Iarlori C, Reale M, Lugaresi A, De Luca G, Bonanni L, Di Iorio A, Feliciani C, Conti P, Gambi D. RANTES production and expression is reduced in relapsing-remitting multiple sclerosis patients treated with interferon-beta-1b. J Neuroimmunol 2000; 107:100-7. [PMID: 10808056 DOI: 10.1016/s0165-5728(00)00261-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RANTES (regulated upon activation, normal T-cell expressed and secreted), a CC chemokine, appears to play a role in the pathogenesis of relapsing-remitting multiple sclerosis (RR-MS), enhancing the inflammatory response within the nervous system. We have demonstrated that RANTES production is increased in RR-MS compared to controls. Interferon-beta-1b (IFN-beta-1b) treatment reduces RANTES production in sera and peripheral blood adherent mononuclear cell (PBAM) supernatants both in relapse and remission. IFN-beta-1b also reduces RANTES expression in PBAM. Our results suggest that RANTES modulation might represent one of the mechanisms of action of IFN-beta-1b in RR-MS.
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Affiliation(s)
- C Iarlori
- Department of Oncology and Neuroscience, Neuroimmunology Unit, University 'Gabriele d'Annunzio', Via dei Vestini, 66013, Chieti, Italy
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20
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Frydas S, Papaioanou N, Vlemmas I, Theodoridis I, Anogiannakis G, Vacalis D, Trakatellis A, Barbacane RC, Reale M, Conti P. Vitamin B6-deficient diet plus 4-deoxypyridoxine (4-DPD) reduces the inflammatory response induced by T. spiralis in diaphragm, masseter and heart muscle tissue of mice. Mol Cell Biochem 1999; 197:79-85. [PMID: 10485327 DOI: 10.1023/a:1006958310081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Animals fed diets deficient in vitamin B6 develop microcytic anemia, alterations of growth, and other pathologies. 4-deoxypirydoxine is a potent antagonist of vitamin B6 coenzyme which depresses IL-1, TNF and IL-6 and has anti-inflammatory properties. The aim of this study was to show the anti-inflammatory effects of 4-DPD on chronic inflammation caused by the nematode parasite T. spiralis, specifically on the recruitment and the activation of inflammatory cells. Two groups of mice, 6 weeks of age, were used: one was maintained on a vitamin B6-deficient synthetic pellet diet for 15 days before injection of the nematode, and administered an intraperitoneal injection (i.p.) of 4-DPD (250 microg/mouse) for 15 days (the first, 5 days before infection), and the second group was maintained on a normal diet for the total duration of the experiment. These two groups were then injected with 150 larvae (L1-T7 spiralis) per os. Chronic inflammation was caused by infection of treated or untreated mice with T7 spiralis parasite. After 14 days post-infection all mice developed a chronic inflammatory response. Mice fed with a B6-deficient diet showed a significant decrease in the number of cysts found in the diaphragm when compared to mice treated with normal diet. In addition, in all mice treated with vitamin B6-deficient diet plus 4-DPD the average body weight was significantly lower, compared to the mice on normal diet in all weeks examined. Moreover, in sections of the diaphragm, masseter and myocardium muscles, the infiltration of inflammatory cells, such as macrophages, lymphocytes, and eosinophils were more intense in untreated mice compared to those fed a vitamin B6-deficient diet. These results show that BALB/c mice infected with T. spiralis and fed a vitamin B6-deficient diet plus the vitamin B6 antagonist, 4-DPD, prolong the time of invasion of the larvae in the muscle cells, influence the recruitment of inflammatory cells and the intensity of the inflammatory reaction compared to infected untreated mice (control).
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Affiliation(s)
- S Frydas
- Immunology Division, University of Chieti School of Medicine, Italy
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21
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Conti P, Reale M, Barbacane RC, Letourneau R, Theoharides TC. Intramuscular injection of hrRANTES causes mast cell recruitment and increased transcription of histidine decarboxylase in mice: lack of effects in genetically mast cell-deficient W/WV mice. FASEB J 1998; 12:1693-700. [PMID: 9837859 DOI: 10.1096/fasebj.12.15.1693] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
RANTES (regulated upon activation, normal T cell expressed and presumably secreted) and other chemoattractant proteins are members of the intercrine or chemokine family of proinflammatory basic polypeptides. RANTES is a prototype of the C-C chemokine subfamily that acts as a selective chemoattractant for human monocytes and CD4-positive lymphocytes and increases the adherence of monocytes to endothelial cells. However, the role of RANTES in white cells is still unclear. We report here that hrRANTES at 20 ng/50 microl in mice causes mast cell recruitment 4 h after intramuscular injection, an effect inhibited by anti-RANTES, as evidenced by 0.1% Toluidine blue, a specific dye for coloring mast cells. Injections of PBS (50 microl) vehicle (negative control) did not produce any appreciable inflammatory response, whereas injection of lipopolysaccharide 20 ng/50 microl (positive control) generated a marked inflammatory state. When RANTES was injected intramuscularly in genetically mast cell-deficient W/Wv mice, the inflammatory effect was not present. The RANTES injection sites were then excised and studied under an optical and electron microscope. A Northern blot analysis was performed using a probe that was prepared to detect mRNA encoding the histidine decarboxylase (HDC) gene on excised muscle tissue. We found that hrRANTES provoked generation of HDC mRNA from muscle tissue after 4 h. These effects were inhibited by an anti-RANTES antibody and were absent in genetically mast cell-deficient mice. The increasing number of mast cells in the RANTES injection sites led to an augmentation of histamine content compared to controls (PBS). The injection of hrRANTES 20 ng/20 microl into the sole of a rat paw confirmed the inflammatory and the mast cell recruitment potential of this chemokine. In these studies, hrRANTES injections in muscle tissue provided direct in vivo evidence that RANTES has a significant effect on mast cell recruitment and HDC mRNA generation.
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Affiliation(s)
- P Conti
- Immunology Division, University of Chieti School of Medicine, Chieti, Italy.
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22
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Conti P, Reale M, Barbacane RC, Felaco M, Grilli A, Theoharides TC. Mast cell recruitment after subcutaneous injection of RANTES in the sole of the rat paw. Br J Haematol 1998; 103:798-803. [PMID: 9858235 DOI: 10.1046/j.1365-2141.1998.01060.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The effect of hrRANTES was studied after the injection in the sole of the rat paw, an area particularly rich in mast cells. Subcutaneous injections of RANTES 50 ng/10 microl produced an erythematous reaction which was inhibited by anti-RANTES antibody 50 microg/rat injected in the tail vein 30 min before hrRANTES 50 ng/10 microl was injected. In another set of experiments the animals were injected subcutaneously in the sole of the paw with PBS 10 microl (control), LPS (100 ng/10 microl) hrRANTES 50 ng/10 microl or anti-RANTES 50 microl/rat injected in the tail vein 30 min before hrRANTES 50 ng/10 microl was injected. The biopsies were analysed after 4 h and counted in an optic field. hrRANTES produced a strong recruitment of mast cells selectively coloured with 0.1% toluidine blue and inhibited by anti-RANTES antibody. In addition to the optical and electron microscope study, in some of the excised tissue Northern blot analysis for histidine decarboxylase (HDC) mRNA was performed to estimate the amount of histamine generation in the tissue of the injection sites. We found that subcutaneous injections of hrRANTES 50 ng/10 microl in the sole of the rat paw produced an accumulation of a great number of mast cells compared to PBS 10 microl (negative control) or LPS 100 ng/10 microl (positive control) after 4 h. The hrRANTES effect was inhibited by anti-RANTES antibody injected in the tail vein 30 min before hrRANTES exposure. Moreover, hrRANTES increased HDC mRNA and histamine generation.
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Affiliation(s)
- P Conti
- Immunology Division, University of Chieti School of Medicine, Italy
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