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Ilyas M, Stapleton F, Willcox MDP, Henriquez F, Peguda HK, Rayamajhee B, Zahid T, Petsoglou C, Carnt NA. Epidemiology of and Genetic Factors Associated with Acanthamoeba Keratitis. Pathogens 2024; 13:142. [PMID: 38392880 PMCID: PMC10892102 DOI: 10.3390/pathogens13020142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/14/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
Acanthamoeba keratitis (AK) is a severe, rare protozoal infection of the cornea. Acanthamoeba can survive in diverse habitats and at extreme temperatures. AK is mostly seen in contact lens wearers whose lenses have become contaminated or who have a history of water exposure, and in those without contact lens wear who have experienced recent eye trauma involving contaminated soil or water. Infection usually results in severe eye pain, photophobia, inflammation, and corneal epithelial defects. The pathophysiology of this infection is multifactorial, including the production of cytotoxic proteases by Acanthamoeba that degrades the corneal epithelial basement membrane and induces the death of ocular surface cells, resulting in degradation of the collagen-rich corneal stroma. AK can be prevented by avoiding risk factors, which includes avoiding water contact, such as swimming or showering in contact lenses, and wearing protective goggles when working on the land. AK is mostly treated with an antimicrobial therapy of biguanides alone or in combination with diaminidines, although the commercial availability of these medicines is variable. Other than anti-amoeba therapies, targeting host immune pathways in Acanthamoeba disease may lead to the development of vaccines or antibody therapeutics which could transform the management of AK.
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Affiliation(s)
- Muhammad Ilyas
- Primary & Secondary Healthcare Department, Punjab 54000, Pakistan; (M.I.)
| | - Fiona Stapleton
- School of Optometry and Vision Science, University of NSW, Sydney, NSW 2052, Australia (H.K.P.)
| | - Mark D. P. Willcox
- School of Optometry and Vision Science, University of NSW, Sydney, NSW 2052, Australia (H.K.P.)
| | - Fiona Henriquez
- School of Health and Life Sciences, The University of the West of Scotland, Glasgow G72 0LH, UK
| | - Hari Kumar Peguda
- School of Optometry and Vision Science, University of NSW, Sydney, NSW 2052, Australia (H.K.P.)
| | - Binod Rayamajhee
- School of Optometry and Vision Science, University of NSW, Sydney, NSW 2052, Australia (H.K.P.)
| | - Tasbiha Zahid
- Primary & Secondary Healthcare Department, Punjab 54000, Pakistan; (M.I.)
| | | | - Nicole A. Carnt
- School of Optometry and Vision Science, University of NSW, Sydney, NSW 2052, Australia (H.K.P.)
- Centre for Vision Research, Westmead Institute for Medical Research, Sydney, NSW 2145, Australia
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SLAMF7/STAT6 Pathway Inhibits Innate Immune Response in Late-Stage Human Acanthamoeba Keratitis: A Comparative Transcriptome Analysis. Microorganisms 2023; 11:microorganisms11020365. [PMID: 36838330 PMCID: PMC9961001 DOI: 10.3390/microorganisms11020365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023] Open
Abstract
Acanthamoeba keratitis (AK) is a blinding corneal infection caused by the protozoan Acanthamoeba. The long-term course of AK suggests the host immunity could not kill Acanthamoeba rapidly. The immune status is still unclear in the late stage of AK. The comparative transcriptome analysis was made based on the bulk RNA sequencing of cornea tissues from AK patients and donors. Differentially expressed genes and enriched signaling pathways were calculated. CIBERSORT algorithm was used for immune infiltration analysis of cornea tissue between AK and normal controls. A total of 2668 differentially expressed genes, including 1477 upregulated genes and 1191 downregulated genes, were detected. Gene Ontology analysis revealed that the pathways were significantly enriched in leukocyte migration, regulation of T-cell activation, the external side of plasma membrane, collagen-containing extracellular matrix, immune receptor activity, and cytokine binding. The Kyoto Encyclopedia of Genes and Genomes pathway analysis showed that the pathways were significantly enriched in the cytokine-cytokine receptor interaction, hematopoietic cell lineage, and Staphylococcus aureus infection pathway. The immune infiltration profiles varied little between AK and normal controls. Compared with normal tissue, cornea tissue of AK contained a higher proportion of M0 macrophages and CD8 T cells, while resting memory CD4 T cells contributed to a relatively lower portion (p < 0.05). Finally, the expression levels of cell markers and SLAMF7/STAT6 pathway were confirmed by histopathology examinations, RT-qPCR, and Western blot.
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Wei Z, Cao K, Wang L, Baudouin C, Labbé A, Liang Q. Corneal Changes in Acanthamoeba Keratitis at Various Levels of Severity: An In Vivo Confocal Microscopic Study. Transl Vis Sci Technol 2021; 10:10. [PMID: 34110388 PMCID: PMC8196423 DOI: 10.1167/tvst.10.7.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To investigate the relationship between Acanthamoeba cysts and inflammatory cells in Acanthamoeba keratitis (AK) by in vivo confocal microscopy (IVCM). Methods A case-control study included 30 patients with AK and 20 normal controls. The severity of the AK was divided into mild, moderate, and severe. The central cornea and four standard quadrants of the peripheral cornea were imaged by IVCM. The cyst infiltration and dendritic cell (DC) density and maturity (size, length, field, and number of dendrites) were quantified. The relationship between clinical severity, cyst density, and DC alterations was characterized by Spearman correlation analysis. Results The maximum cyst density in the mild, moderate, and severe groups was 31.3 cysts/mm2 (17.2-32.8), 62.5 cysts/mm2 (59.3-103.1), and 162.5 cysts/mm2 (65.6-215.6), respectively. Compared to normal participants, a significant increase in the mean corneal DC density was detected in patients with AK (290.2 ± 97.0 vs. 25.3 ± 8.3 cells/mm2; P < 0.001). Patients with AK presented an increase in median DC size (178.3 vs. 63.6 µm2/cell, P < 0.001), median DC field (518.1 vs. 256.6 µm2/cell, P = 0.008), and median DC dendrite length (42.3 vs. 14.7 µm/cell, P < 0.001). Increased AK severity was correlated with an increase in cyst density, DC size, and dendrite length (all P < 0.05). An increase in cyst density was significantly correlated with an increase in DC density (β = 0.484, P = 0.026) and DC size (β = 0.557, P = 0.009). Conclusions Cyst density and depth of infiltration as well as maturity of the surrounding DC increased significantly with the severity of AK. Translational Relevance Quantitative analysis of cyst density and DC maturity may provide a new method of evaluating the severity of AK.
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Affiliation(s)
- Zhenyu Wei
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Kai Cao
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Leying Wang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Christophe Baudouin
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China.,Quinze-Vingts National Ophthalmology Hospital, IHU FOReSIGHT, Paris and Versailles Saint-Quentin-en-Yvelines University, Versailles, France.,Institut de la Vision, IHU FOReSIGHT, Sorbonne Université, INSERM, CNRS, Paris, France
| | - Antoine Labbé
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China.,Quinze-Vingts National Ophthalmology Hospital, IHU FOReSIGHT, Paris and Versailles Saint-Quentin-en-Yvelines University, Versailles, France.,Institut de la Vision, IHU FOReSIGHT, Sorbonne Université, INSERM, CNRS, Paris, France
| | - Qingfeng Liang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
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Sun Y, Li W, Wang M, Xing Q, Sun X. Clinical diagnosis and treatment of rare painless keratitis caused by three pathogens: clinical practice and experiential discussion. J Int Med Res 2020; 48:300060519895671. [PMID: 31937173 PMCID: PMC7142360 DOI: 10.1177/0300060519895671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There have been numerous reports regarding the occurrence of keratitis in
patients with soft contact lenses, but few reports in patients with rigid gas
permeable contact lenses. To the best of our knowledge, the occurrence of
infection associated with three species of pathogens has never been reported.
Here, we describe a patient who exhibited refractory painless keratitis caused
by three pathogens (Staphylococcus epidermidis,
Acanthamoeba, and herpes simplex virus) and summarize
similar reports published at multiple centers worldwide, with the aim of
providing guidance for clinicians who might encounter mixed-type corneal
infections. We describe the results of many ophthalmologic and laboratory
investigations, which guided our treatment selection. We achieved good treatment
efficacy, such that the patient exhibited a corrected visual acuity of 20/20 in
the affected eye after a series of treatments, including curettage of ulcer
lesions. Corneal infections caused by multiple pathogens are challenging in
clinical practice. This summary of our experience in patient diagnosis and
treatment can help clinicians to achieve a favorable prognosis in treatment of
future patients.
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Affiliation(s)
- Yiming Sun
- The Medical College of Qingdao University, Qingdao, China
| | - Wenjing Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - MiMi Wang
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Quansheng Xing
- The Affiliated Women and Children's Hospital of Qingdao University, Qingdao, China
| | - Xuguang Sun
- Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Anwar A, Siddiqui R, Hameed A, Shah MR, Khan NA. Synthetic Dihydropyridines as Novel Antiacanthamoebic Agents. Med Chem 2019; 16:841-847. [PMID: 31544702 DOI: 10.2174/1573406415666190722113412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Acanthamoeba is an opportunistic pathogen widely spread in the environment. Acanthamoeba causes excruciating keratitis which can lead to blindness. The lack of effective drugs and its ability to form highly resistant cyst are one of the foremost limitations against successful prognosis. Current treatment involves mixture of drugs at high doses but still recurrence of infection can occur due to ineffectiveness of drugs against the cyst form. Pyridine and its natural and synthetic derivatives are potential chemotherapeutic agents due to their diverse biological activities. OBJECTIVE To study the antiamoebic effects of four novel synthetic dihydropyridine (DHP) compounds against Acanthamoeba castellanii belonging to the T4 genotype. Furthermore, to evaluate their activity against amoeba-mediated host cells cytopathogenicity as well as their cytotoxicity against human cells. METHODS Dihydropyridines were synthesized by cyclic dimerization of alkylidene malononitrile derivatives. Four analogues of functionally diverse DHPs were tested against Acanthamoeba castellanii by using amoebicidal, encystation and excystation assays. Moreover, Lactate dehydrogenase assays were carried out to study cytopathogenicity and cytotoxicity against human cells. RESULTS These compounds showed significant amoebicidal and cysticidal effects at 50 μM concentration, whereas, two of the DHP derivatives also significantly reduced Acanthamoebamediated host cell cytotoxicity. Moreover, these DHPs were found to have low cytotoxicity against human cells suggesting a good safety profile. CONCLUSION The results suggest that DHPs have potential against Acanthamoeba especially against the more resistant cyst stage and can be assessed further for drug development.
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Affiliation(s)
- Ayaz Anwar
- Department of Biological Sciences, School of Science and Technology, Sunway University, Petaling Jaya 47500, Selangor, Malaysia
| | - Ruqaiyyah Siddiqui
- Department of Biology, Chemistry and Environmental Sciences, American University of Sharjah, Sharjah 26666, Malaysia
| | - Abdul Hameed
- Department of Chemistry, Forman Christian College, Lahore 54600, Punjab, Pakistan
| | - Muhammad R Shah
- HEJ Research Institute of Chemistry, International Center for Chemical and Biological Sciences, University of Karachi, Karachi 75270, Pakistan
| | - Naveed A Khan
- Department of Biology, Chemistry and Environmental Sciences, American University of Sharjah, Sharjah 26666, Malaysia
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Kot K, Kosik-Bogacka D, Łanocha-Arendarczyk N, Wojtkowiak-Giera A, Kolasa-Wołosiuk A. Expression of Toll-Like Receptors (TLR2 and TLR4) in the Eyes of Mice with Disseminated Acanthamoebiasis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1401894. [PMID: 31309100 PMCID: PMC6594330 DOI: 10.1155/2019/1401894] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/28/2019] [Indexed: 12/20/2022]
Abstract
Toll-like receptors (TLRs) play a key role in the innate immune response to numerous pathogens, including Acanthamoeba spp. The aim of this study was to determine the expression of TLR2 and TLR4 in the eyes of mice following intranasal infection with Acanthamoeba spp. in relation to the host's immunological status. Amoebae used in this study were isolated from the bronchial aspirate of a patient with acute myeloid leukemia (AML) and atypical symptoms of pneumonia. We found statistically significant differences in the expression of TLR2 and TLR4 in the eye of immunocompetent mice at 8, 16, and 24 days after Acanthamoeba spp. infection (dpi) compared to control group. Immunosuppressed mice showed significant differences in the expression of TLR2 at 16 and 24 dpi compared to uninfected animals. Our results indicate that TLR2 and TLR4 are upregulated in the eyes of mice in response to Acanthamoeba spp. We suggest that it is possible for trophozoites to migrate through the optic nerve from the brain to the eyes. The course of disseminated acanthamoebiasis may be influenced by the host's immunological status, and the observed changes in expression of TLR2 and TLR4 in the host's organs may indicate the role of these receptors in the pathomechanism of acanthamoebiasis.
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Affiliation(s)
- Karolina Kot
- Department of Biology and Medical Parasitology, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
| | - Danuta Kosik-Bogacka
- Independent of Pharmaceutical Botany, Department of Biology and Medical Parasitology, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
| | - Natalia Łanocha-Arendarczyk
- Department of Biology and Medical Parasitology, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
| | - Agnieszka Wojtkowiak-Giera
- Department of Biology and Medical Parasitology, Poznan University of Medical Sciences, Fredry 10, 61-701 Poznan, Poland
| | - Agnieszka Kolasa-Wołosiuk
- Department of Histology and Embryology, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
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Cano A, Mattana A, Henriquez FL, Alexander J, Roberts CW. Acanthamoebaproteases contribute to macrophage activation through PAR1, but not PAR2. Parasite Immunol 2019; 41:e12612. [DOI: 10.1111/pim.12612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/07/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Antonella Cano
- Strathclyde Institute of Pharmacy & Biomedical SciencesUniversity of Strathclyde Glasgow UK
| | - Antonella Mattana
- Department of Biomedical SciencesDivision of Experimental and Clinical MicrobiologyUniversity of Sassari Sassari Italy
| | - Fiona L. Henriquez
- Infection and MicrobiologyInstitute of Biomedical and Environmental HealthSchool of Science & SportUniversity of the West of Scotland Paisley UK
| | - James Alexander
- Strathclyde Institute of Pharmacy & Biomedical SciencesUniversity of Strathclyde Glasgow UK
| | - Craig W. Roberts
- Strathclyde Institute of Pharmacy & Biomedical SciencesUniversity of Strathclyde Glasgow UK
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Acanthamoeba Activates Macrophages Predominantly through Toll-Like Receptor 4- and MyD88-Dependent Mechanisms To Induce Interleukin-12 (IL-12) and IL-6. Infect Immun 2017; 85:IAI.01054-16. [PMID: 28348053 DOI: 10.1128/iai.01054-16] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/09/2017] [Indexed: 12/14/2022] Open
Abstract
Acanthamoeba castellanii is a ubiquitous free-living amoeba with a worldwide distribution that can occasionally infect humans, causing particularly severe infections in immunocompromised individuals. Dissecting the immunology of Acanthamoeba infections has been considered problematic due to the very low incidence of disease, despite the high exposure rates. While macrophages are acknowledged as playing a significant role in Acanthamoeba infections, little is known about how this facultative parasite influences macrophage activity. Therefore, in this study we investigated the effects of Acanthamoeba on the activation of resting macrophages. Consequently, murine bone marrow-derived macrophages were cocultured with trophozoites of either the laboratory Neff strain or a clinical isolate of A. castellaniiIn vitro real-time imaging demonstrated that trophozoites of both strains often established evanescent contact with macrophages. Both Acanthamoeba strains induced a proinflammatory macrophage phenotype characterized by the significant production of interleukin-12 (IL-12) and IL-6. However, macrophages cocultured with the clinical isolate of Acanthamoeba produced significantly less IL-12 and IL-6 than the Neff strain. The utilization of macrophages derived from MyD88-, TRIF-, Toll-like receptor 2 (TLR2)-, TLR4-, and TLR2/4-deficient mice indicated that Acanthamoeba-induced proinflammatory cytokine production was through MyD88-dependent, TRIF-independent, TLR4-induced events. This study shows for the first time the involvement of TLRs expressed on macrophages in the recognition of and response to Acanthamoeba trophozoites.
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Acanthamoeba castellanii Genotype T4 Stimulates the Production of Interleukin-10 as Well as Proinflammatory Cytokines in THP-1 Cells, Human Peripheral Blood Mononuclear Cells, and Human Monocyte-Derived Macrophages. Infect Immun 2016; 84:2953-62. [PMID: 27481240 PMCID: PMC5038060 DOI: 10.1128/iai.00345-16] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/24/2016] [Indexed: 12/11/2022] Open
Abstract
Free-living amoebae of the genus Acanthamoeba can cause severe and chronic infections in humans, mainly localized in immune privileged sites, such as the brain and the eye. Monocytes/macrophages are thought to be involved in Acanthamoeba infections, but little is known about how these facultative parasites influence their functions. The aim of this work was to investigate the effects of Acanthamoeba on human monocytes/macrophages during the early phase of infection. Here, THP-1 cells, primary human monocytes isolated from peripheral blood, and human monocyte-derived macrophages were either coincubated with trophozoites of a clinical isolate of Acanthamoeba (genotype T4) or stimulated with amoeba-derived cell-free conditioned medium. Production of proinflammatory cytokines (tumor necrosis factor alpha [TNF-α], interleukin-6 [IL-6], and IL-12), anti-inflammatory cytokine (IL-10), and chemokine (IL-8) was evaluated at specific hours poststimulation (ranging from 1.5 h to 23 h). We showed that both Acanthamoeba trophozoites and soluble amoebic products induce an early anti-inflammatory monocyte-macrophage phenotype, characterized by significant production of IL-10; furthermore, challenge with either trophozoites or their soluble metabolites stimulate both proinflammatory cytokines and chemokine production, suggesting that this protozoan infection results from the early induction of coexisting, opposed immune responses. Results reported in this paper confirm that the production of proinflammatory cytokines and chemokines by monocytes and macrophages can play a role in the development of the inflammatory response during Acanthamoeba infections. Furthermore, we demonstrate for the first time that Acanthamoeba stimulates IL-10 production in human innate immune cells, which might both promote the immune evasion of Acanthamoeba and limit the induced inflammatory response.
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Suryawanshi A, Cao Z, Sampson JF, Panjwani N. IL-17A-mediated protection against Acanthamoeba keratitis. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2015; 194:650-63. [PMID: 25505284 PMCID: PMC4282964 DOI: 10.4049/jimmunol.1302707] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acanthamoeba keratitis (AK) is a very painful and vision-impairing infection of the cornea that is difficult to treat. Although past studies have indicated a critical role of neutrophils and macrophages in AK, the relative contribution of the proinflammatory cytokine, IL-17A, that is essential for migration, activation, and function of these cells into the cornea is poorly defined. Moreover, the role of the adaptive immune response, particularly the contribution of CD4(+) T cell subsets, Th17 and regulatory T cells , in AK is yet to be understood. In this report, using a mouse corneal intrastromal injection-induced AK model, we show that Acanthamoeba infection induces a strong CD4(+) T effector and regulatory T cell response in the cornea and local draining lymph nodes. We also demonstrate that corneal Acanthamoeba infection induces IL-17A expression and that IL-17A is critical for host protection against severe AK pathology. Accordingly, IL-17A neutralization in Acanthamoeba-infected wild-type mice or Acanthamoeba infection of mice lacking IL-17A resulted in a significantly increased corneal AK pathology, increased migration of inflammatory cells at the site of inflammation, and a significant increase in the effector CD4(+) T cell response in draining lymph nodes. Thus, in sharp contrast with other corneal infections such as herpes and Pseudomonas aeruginosa keratitis where IL-17A exacerbates corneal pathology and inflammation, the findings presented in this article suggest that IL-17A production after Acanthamoeba infection plays an important role in host protection against invading parasites.
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Affiliation(s)
- Amol Suryawanshi
- New England Eye Center, Boston, MA 02111; Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111; and
| | - Zhiyi Cao
- New England Eye Center, Boston, MA 02111; Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111; and
| | - James F Sampson
- New England Eye Center, Boston, MA 02111; Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111; and
| | - Noorjahan Panjwani
- New England Eye Center, Boston, MA 02111; Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111; and Department of Biochemistry, Tufts University School of Medicine, Boston, MA 02111
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