1
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Ghorbanalipoor S, Matsumoto K, Gross N, Heimberg L, Krause M, Veldkamp W, Magens M, Zanken J, Neuschutz KJ, De Luca DA, Kridin K, Vidarsson G, Chakievska L, Visser R, Kunzel S, Recke A, Gupta Y, Boch K, Vorobyev A, Kalies K, Manz RA, Bieber K, Ludwig RJ. High throughput screening identifies repurposable drugs for modulation of innate and acquired immune responses. J Autoimmun 2024; 148:103302. [PMID: 39163739 DOI: 10.1016/j.jaut.2024.103302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/22/2024]
Abstract
A balanced immune system is essential to maintain adequate host defense and effective self-tolerance. While an immune system that fails to generate appropriate response will permit infections to develop, uncontrolled activation may lead to autoinflammatory or autoimmune diseases. To identify drug candidates capable of modulating immune cell functions, we screened 1200 small molecules from the Prestwick Chemical Library for their property to inhibit innate or adaptive immune responses. Our studies focused specifically on drug interactions with T cells, B cells, and polymorphonuclear leukocytes (PMNs). Candidate drugs that were validated in vitro were examined in preclinical models to determine their immunomodulatory impact in chronic inflammatory diseases, here investigated in chronic inflammatory skin diseases. Using this approach, we identified several candidate drugs that were highly effective in preclinical models of chronic inflammatory disease. For example, we found that administration of pyrvinium pamoate, an FDA-approved over-the-counter anthelmintic drug, suppressed B cell activation in vitro and halted the progression of B cell-dependent experimental pemphigoid by reducing numbers of autoantigen-specific B cell responses. In addition, in studies performed in gene-deleted mouse strains provided additional insight into the mechanisms underlying these effects, for example, the receptor-dependent actions of tamoxifen that inhibit immune-complex-mediated activation of PMNs. Collectively, our methods and findings provide a vast resource that can be used to identify drugs that may be repurposed and used to promote or inhibit cellular immune responses.
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Affiliation(s)
| | - Kazuko Matsumoto
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Natalie Gross
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Linda Heimberg
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Malin Krause
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Wendelien Veldkamp
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Moritz Magens
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Johannes Zanken
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Kerstin J Neuschutz
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - David A De Luca
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany; Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Gestur Vidarsson
- Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Biomolecular Mass Spectrometry and Proteomics, Utrecht Institute for Pharmaceutical Sciences and Bijvoet Center for Biomolecular Research, Utrecht University, Utrecht, the Netherlands
| | - Lenche Chakievska
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Remco Visser
- Sanquin Research and Landsteiner Laboratory, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Biomolecular Mass Spectrometry and Proteomics, Utrecht Institute for Pharmaceutical Sciences and Bijvoet Center for Biomolecular Research, Utrecht University, Utrecht, the Netherlands
| | - Sven Kunzel
- Max Planck Institute for Evolutionary Biology, Plön, Germany
| | - Andreas Recke
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Yask Gupta
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Katharina Boch
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Artem Vorobyev
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany; Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Kathrin Kalies
- Institute for Anatomy, University of Lübeck, Lübeck, Germany
| | - Rudolf A Manz
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany; Department of Dermatology, University of Lübeck, Lübeck, Germany
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2
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Valei Lopes de Oliveira E, Tremeschin de Almeida Vieira F, de Souza Pinhel MA, Gripp AC, Marzocchi-Machado CM, Donadi EA, Roselino AM. Differential FCGR2A and FCGR3A Alleles/Genotypes in Pemphigus Vulgaris and Pemphigus Foliaceus in Southeastern Brazil. J Invest Dermatol 2024; 144:702-705.e1. [PMID: 37806444 DOI: 10.1016/j.jid.2023.09.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Ederson Valei Lopes de Oliveira
- University Hospital, Division of Dermatology, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes Ribeirão Preto, Brazil; Biology Molecular Laboratory, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, Ribeirão Preto, Brazil
| | - Flavia Tremeschin de Almeida Vieira
- Biology Molecular Laboratory, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, Ribeirão Preto, Brazil
| | - Marcela Augusta de Souza Pinhel
- Laboratory of Studies in Nutrigenomic, Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, Ribeirão Preto, Brazil
| | - Alexandre Carlos Gripp
- Dermatologia, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cleni Mara Marzocchi-Machado
- Department of Clinical Analyses, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Avenida dos Bandeirantes, Ribeirão Preto, Brazil
| | - Eduardo Antonio Donadi
- Biology Molecular Laboratory, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, Ribeirão Preto, Brazil; Division of Clinical Immunology, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, Ribeirão Preto, Brazil
| | - Ana Maria Roselino
- University Hospital, Division of Dermatology, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes Ribeirão Preto, Brazil; Biology Molecular Laboratory, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, Ribeirão Preto, Brazil.
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3
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Kløve-Mogensen K, Terp SK, Steffensen R. Comparison of real-time quantitative PCR and two digital PCR platforms to detect copy number variation in FCGR3B. J Immunol Methods 2024; 526:113628. [PMID: 38331313 DOI: 10.1016/j.jim.2024.113628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/10/2024]
Abstract
The importance of structural genetic variants, such as copy number variations (CNVs), in modulating human disease is being increasingly recognized. Several clinical conditions require investigation of human neutrophil antigen (HNA-1), which is encoded by the Fc gamma receptor IIIb gene (FCGR3B), including suspicion of neutropenia, infections, and proactive testing of blood component donors to reduce the potential risk in transfusion. In this study, we compared real-time quantitative polymerase chain reaction (qPCR) with two digital PCR (dPCR) platforms, namely droplet digital PCR and an array-based platform, to determine copy numbers (CNs) in FCGR3B. We initially tested 400 anonymous blood donors with qPCR using a commercially available TaqMan probe assay (Applied Biosystems) on a Quant Studio 12 Flex. CNs was determined for all 400 tested individuals with CNs ranging from zero to four. Zero copies were detected in 0.2% (1/400), one copy was detected in 3.8% (15/400), two copies were detected in 87.8% (351/400), three copies were detected in 8.0% (32/400), and four copies were detected in 0.2% (1/400) of tested individuals. From this cohort, we selected 32 donors with CNs from zero to four for analyses with Digital Real-Time PCR (dPCR) using Lab on an array (LOAA) on an On-Point analyzer from Optolane Technologies Inc. and the Droplet Digital PCR (ddPCR) platform from Bio-Rad Laboratories. We compared the obtained CNs of FCGR3B on the three platforms and found full concordance between the CNs obtained. We therefore conclude that all three platforms can be used for quantification of CNs for FCGR3B, and although dPCR has some advantages over qPCR, it was not necessary for reliably estimating CNs of the FCGR3B gene.
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Affiliation(s)
- Kirstine Kløve-Mogensen
- Department of Clinical Immunology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Simone Karlsson Terp
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Molecular Diagnostics, Aalborg University Hospital, Aalborg, Denmark.
| | - Rudi Steffensen
- Department of Clinical Immunology, Aalborg University Hospital, Aalborg, Denmark.
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4
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Pigors M, Patzelt S, Reichhelm N, Dworschak J, Khil'chenko S, Emtenani S, Bieber K, Hofrichter M, Kamaguchi M, Goletz S, Köhl G, Köhl J, Komorowski L, Probst C, Vanderheyden K, Balbino B, Ludwig RJ, Verheesen P, Schmidt E. Bullous pemphigoid induced by IgG targeting type XVII collagen non-NC16A/NC15A extracellular domains is driven by Fc gamma receptor- and complement-mediated effector mechanisms and is ameliorated by neonatal Fc receptor blockade. J Pathol 2024; 262:161-174. [PMID: 37929639 DOI: 10.1002/path.6220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/18/2023] [Accepted: 09/21/2023] [Indexed: 11/07/2023]
Abstract
Bullous pemphigoid (BP) is an autoimmune blistering disease characterized by autoantibodies targeting type XVII collagen (Col17) with the noncollagenous 16A (NC16A) ectodomain representing the immunodominant site. The role of additional extracellular targets of Col17 outside NC16A has not been unequivocally demonstrated. In this study, we showed that Col17 ectodomain-reactive patient sera depleted in NC16A IgG induced dermal-epidermal separation in a cryosection model indicating the pathogenic potential of anti-Col17 non-NC16A extracellular IgG. Moreover, injection of IgG targeting the murine Col17 NC14-1 domains (downstream of NC15A, the murine homologue of human NC16A) into C57BL/6J mice resulted in erythematous skin lesions and erosions. Clinical findings were accompanied by IgG/C3 deposits along the basement membrane and subepidermal blistering with inflammatory infiltrates. Disease development was significantly reduced in either Fc-gamma receptor (FcγR)- or complement-5a receptor-1 (C5aR1)-deficient mice. Inhibition of the neonatal FcR (FcRn), an atypical FcγR regulating IgG homeostasis, with the murine Fc fragment IgG2c-ABDEG, a derivative of efgartigimod, reduced anti-NC14-1 IgG levels, resulting in ameliorated skin inflammation compared with isotype-treated controls. These data demonstrate that the pathogenic effects of IgG targeting the Col17 domain outside human NC16A/murine NC15A are partly attributable to antibody-mediated FcγR- and C5aR1 effector mechanisms while pharmacological inhibition of the FcRn represents a promising treatment for BP. The mouse model of BP will be instrumental in further investigating the role of Col17 non-NC16A/NC15A extracellular epitopes and validating new therapies for this disease. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Manuela Pigors
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Sabrina Patzelt
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Niklas Reichhelm
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Jenny Dworschak
- Institute of Experimental Immunology, EUROIMMUN AG, Lübeck, Germany
| | | | - Shirin Emtenani
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Maxi Hofrichter
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Mayumi Kamaguchi
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Gabriele Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lars Komorowski
- Institute of Experimental Immunology, EUROIMMUN AG, Lübeck, Germany
| | - Christian Probst
- Institute of Experimental Immunology, EUROIMMUN AG, Lübeck, Germany
| | | | | | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
| | | | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Department of Dermatology, Allergology and Venerology, University of Lübeck, Lübeck, Germany
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5
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Nomura H, Wada N, Takahashi H, Kase Y, Yamagami J, Egami S, Iriki H, Mukai M, Kamata A, Ito H, Fujii H, Ishikura T, Koseki H, Watanabe T, Yamada T, Ohara O, Koyasu S, Amagai M. IgM to IgG Class Switching Is a Necessary Step for Pemphigus Phenotype Induction in Desmoglein 3-Specific B Cell Receptor Knock-in Mouse. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 208:582-593. [PMID: 34996836 DOI: 10.4049/jimmunol.2100781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/22/2021] [Indexed: 01/03/2023]
Abstract
Pemphigus vulgaris is an autoimmune blistering disease caused by IgG targeting desmoglein 3 (Dsg3), an adhesion molecule of keratinocytes. Anti-Dsg3 IgG production is prevented in healthy individuals, but it is unclear how Dsg3-specific B cells are regulated. To clarify the immunological condition regulating Dsg3-specific B cells, a pathogenic anti-Dsg3 Ig (AK23) knock-in mouse was generated. AK23 knock-in B cells developed normally without undergoing deletion or acquiring an anergic phenotype in vivo. The knock-in B cells showed Ca2+ influx upon IgM cross-linking and differentiated into AK23-IgG+ B cells after LPS and IL-4 stimulation in vitro that induced a pemphigus phenotype after adoptive transfer into Rag2 -/- mice. However, the knock-in mouse itself produced AK23-IgM but little IgG without blisters in vivo. Dsg3 immunization and skin inflammation caused AK23-IgG production and a pemphigus phenotype in vivo. Furthermore, Fcgr2b deficiency or haploinsufficiency spontaneously induced AK23-IgG production and a pemphigus phenotype with poor survival rates in AK23 knock-in mice. To assess Fcgr2b involvement in Ig class-switch efficiency, postswitch transcripts of B cells were quantified and significantly higher in Fcgr2b -/- and Fcgr2b +/- mice than wild-type mice in a gene dose-dependent manner. Finally, RNA sequencing revealed reduced expression of FCGR2B and FcγRIIB-related genes in patient B cells. These results indicated that Dsg3-specific B cells do not spontaneously perform pathogenic class switching in vivo, and pemphigus phenotype induction was prevented under normal conditions. Attenuated FcγRIIB signaling is also one of the drivers for pathogenic class switching and is consistent with immunological features identified from clinical samples. This study unveiled a characteristic immune state silencing autoreactive B cells in mice.
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Affiliation(s)
- Hisashi Nomura
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Naoko Wada
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan.,Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan
| | - Hayato Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kase
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Jun Yamagami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Shohei Egami
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan.,Laboratory for Skin Homeostasis, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Hisato Iriki
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Miho Mukai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Aki Kamata
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hiromi Ito
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Fujii
- Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan.,Department of Oral Microbiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Tomoyuki Ishikura
- Laboratory for Developmental Genetics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Haruhiko Koseki
- Laboratory for Developmental Genetics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Takashi Watanabe
- Laboratory for Integrative Genomics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Taketo Yamada
- Department of Pathology, Saitama Medical University, Saitama, Japan; and
| | - Osamu Ohara
- Laboratory for Integrative Genomics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Shigeo Koyasu
- Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo, Japan; .,Laboratory for Immune Cell Systems, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Masayuki Amagai
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan; .,Laboratory for Skin Homeostasis, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
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6
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Kneiber D, Kowalski EH, Amber KT. The Immunogenetics of Autoimmune Blistering Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1367:173-212. [DOI: 10.1007/978-3-030-92616-8_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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7
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Clauder AK, Kordowski A, Bartsch YC, Köhl G, Lilienthal GM, Almeida LN, Lindemann T, Petry J, Rau CN, Gramalla-Schmitz A, Dühring L, Elbracht C, Kenno S, Tillmann J, Wuhrer M, Ludwig RJ, Ibrahim SM, Bieber K, Köhl J, Ehlers M, Manz RA. IgG Fc N-Glycosylation Translates MHCII Haplotype into Autoimmune Skin Disease. J Invest Dermatol 2020; 141:285-294. [PMID: 32653301 DOI: 10.1016/j.jid.2020.06.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/19/2020] [Accepted: 06/03/2020] [Indexed: 11/29/2022]
Abstract
The major histocompatibility complex haplotype represents the most prevalent genetic risk factor for the development of autoimmune diseases. However, the mechanisms by which major histocompatibility complex-associated genetic susceptibility translates into autoimmune disease are not fully understood. Epidermolysis bullosa acquisita is an autoimmune skin-blistering disease driven by autoantibodies to type VII collagen. Here, we investigated autoantigen-specific plasma cells, CD4+ T cells, and IgG fraction crystallizable glycosylation in murine epidermolysis bullosa acquisita in congenic mouse strains with the disease-permitting H2s or disease-nonpermitting H2b major histocompatibility complex II haplotypes. Mice with an H2s haplotype showed increased numbers of autoreactive CD4+ T cells and elevated IL-21 and IFN-γ production, associated with a higher frequency of IgG autoantibodies with an agalactosylated, proinflammatory N-glycan moiety. Mechanistically, we show that the altered antibody glycosylation leads to increased ROS release from neutrophils, the main drivers of autoimmune inflammation in this model. These results indicate that major histocompatibility complex II-associated susceptibility to autoimmune diseases acuminates in a proinflammatory IgG fraction crystallizable N-glycosylation pattern and provide a mechanistic link to increased ROS release by neutrophils.
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Affiliation(s)
- Ann-Katrin Clauder
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Anna Kordowski
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany; Institute for Nutritional Medicine, University of Lübeck and University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Yannic C Bartsch
- Laboratories of Immunology and Antibody Glycan Analysis, Institute for Nutritional Medicine, University of Lübeck and University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Gabriele Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Gina-Maria Lilienthal
- Laboratories of Immunology and Antibody Glycan Analysis, Institute for Nutritional Medicine, University of Lübeck and University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Larissa N Almeida
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Timo Lindemann
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Janina Petry
- Laboratories of Immunology and Antibody Glycan Analysis, Institute for Nutritional Medicine, University of Lübeck and University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Christina N Rau
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | | | - Lara Dühring
- Laboratories of Immunology and Antibody Glycan Analysis, Institute for Nutritional Medicine, University of Lübeck and University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Claudia Elbracht
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Samyr Kenno
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Jenny Tillmann
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Manfred Wuhrer
- Center for Proteomics and Metabolomics, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Saleh M Ibrahim
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany; Division of Immunobiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Marc Ehlers
- Laboratories of Immunology and Antibody Glycan Analysis, Institute for Nutritional Medicine, University of Lübeck and University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Rudolf Armin Manz
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany.
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8
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Petzl-Erler ML. Beyond the HLA polymorphism: A complex pattern of genetic susceptibility to pemphigus. Genet Mol Biol 2020; 43:e20190369. [PMID: 32639508 PMCID: PMC7341728 DOI: 10.1590/1678-4685-gmb-2019-0369] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 04/06/2020] [Indexed: 12/16/2022] Open
Abstract
Pemphigus is a group of autoimmune bullous skin diseases that result in
significant morbidity. As for other multifactorial autoimmune disorders,
environmental factors may trigger the disease in genetically susceptible
individuals. The goals of this review are to summarize the state of knowledge
about the genetic variation that may affect the susceptibility and pathogenesis
of pemphigus vulgaris and pemphigus foliaceus – both the endemic and the
sporadic forms –, to compare and discuss the possible meaning of the
associations reported, and to propose recommendations for new research
initiatives. Understanding how genetic variants translate into pathogenic
mechanisms and phenotypes remains a mystery for most of the polymorphisms that
contribute to disease susceptibility. However, genetic studies provide a strong
foundation for further developments in this field by generating testable
hypotheses. Currently, results still have limited influence on disease
prevention and prognosis, drug development, and clinical practice, although the
perspectives for future applications for the benefit of patients are
encouraging. Recommendations for the continued advancement of our understanding
as to the impact of genetic variation on pemphigus include these partially
overlapping goals: (1) Querying the functional effect of genetic variants on the
regulation of gene expression through their impact on the nucleotide sequence of
cis regulatory DNA elements such as promoters and enhancers, the splicing of
RNA, the structure of regulatory RNAs and proteins, binding of these regulatory
molecules to regulatory DNA elements, and alteration of epigenetic marks; (2)
identifying key cell types and cell states that are implicated in pemphigus
pathogenesis and explore their functional genomes; (3) integrating structural
and functional genomics data; (4) performing disease-progression longitudinal
studies to disclose the causal relationships between genetic and epigenetic
variation and intermediate disease phenotypes; (5) understanding the influence
of genetic and epigenetic variation in the response to treatment and the
severity of the disease; (6) exploring gene-gene and genotype-environment
interactions; (7) developing improved pemphigus-prone and non-prone animal
models that are appropriate for research about the mechanisms that link
genotypes to pemphigus. Achieving these goals will demand larger samples of
patients and controls and multisite collaborations.
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Affiliation(s)
- Maria Luiza Petzl-Erler
- Laboratório de Genética Molecular Humana, Departamento de Genética, Universidade Federal do Paraná, Curitiba, PR, Brazil
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9
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Zhang J, Wang G. Genetic predisposition to bullous pemphigoid. J Dermatol Sci 2020; 100:86-91. [PMID: 33129650 DOI: 10.1016/j.jdermsci.2020.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 11/26/2022]
Abstract
Bullous pemphigoid (BP) is a common autoimmune blistering skin disease that mainly affects elderly patients. Although BP risk is strongly influenced by age, genetic factors are also important determinants of this disease. Many genomic regions, especially in the HLA-II region, have been found to influence BP susceptibility through targeted sequencing studies. However, the relationship between non-HLA regions and BP susceptibility remains poorly understood and the identification of functional variants and key genes within these association regions remains a major challenge. In this review, we summarize the genetic predisposition to BP through an overview of the research history in this field.
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Affiliation(s)
- Jieyu Zhang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Gang Wang
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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10
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Gornowicz-Porowska J, Kowalczyk MJ, Seraszek-Jaros A, Bowszyc-Dmochowska M, Kaczmarek E, Żaba R, Dmochowski M. A Comparative Analysis of CD32A and CD16A Polymorphisms in Relation to Autoimmune Responses in Pemphigus Diseases and Subepithelial Autoimmune Blistering Disorders. Genes (Basel) 2020; 11:genes11040371. [PMID: 32235430 PMCID: PMC7231204 DOI: 10.3390/genes11040371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/24/2020] [Accepted: 03/28/2020] [Indexed: 12/27/2022] Open
Abstract
Autoimmune blistering dermatoses (ABDs) are characterized by autoantibodies to keratinocyte surface antigens and molecules within the dermal–epidermal junction causing disruption of skin integrity. The affinity of Fc receptors (FcRs) causing an autoimmune response in ABDs may vary based on single-nucleotide polymorphisms (SNPs) in FcRs determining the course of disease. This study aimed to explore the effects of CD16A and CD32A SNPs on the autoimmune response in several ABDs. In total, 61 ABDs patients were investigated. ELISA tests, direct immunofluorescence (DIF), TaqMan SNP Genotyping Assays, and statistical analyses were performed. The CA genotype (composed of allele C and A) of rs396991 in CD16A had a higher affinity for tissue-bound IgG1 in pemphigus and for C3 in subepithelial ABDs, showing statistical significance. The greatest relative risk (odds ratio) was reported for AA (rs396991 of CD16A) and CC (rs1801274 of CD32A) homozygotes. There were no statistically significant differences between certain genotypes and specific circulating autoantibodies (anti-DSG1, anti-DSG3 IgG in pemphigus; anti-BP180, anti-BP230 IgG) in subepithelial ABDs. Our findings indicated that rs396991 in CD16A may be of greater importance in ABDs development. Moreover, FcR polymorphisms appeared to have a greater impact on tissue-bound antibodies detected using DIF than circulating serum antibodies in ABDs.
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Affiliation(s)
- Justyna Gornowicz-Porowska
- Department of Medicinal and Cosmetic Natural Products, Poznan University of Medical Sciences, Mazowiecka 33 Street, 60-623 Poznań, Poland
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Przybyszewskiego 49 Street, 60-355 Poznań, Poland;
- Correspondence: (J.G.-P.); (M.J.K.); Tel.: +48-61-848-04-75 (J.G.-P.)
| | - Michał J. Kowalczyk
- Department of Dermatology and Venereology, Poznan University of Medical Sciences, Przybyszewskiego 49 Street, 60-355 Poznań, Poland;
- Correspondence: (J.G.-P.); (M.J.K.); Tel.: +48-61-848-04-75 (J.G.-P.)
| | - Agnieszka Seraszek-Jaros
- Department of Bioinformatics and Computational Biology, Poznan University of Medical Sciences, Rokietnicka 4 Street, 60-806 Poznań, Poland; (A.S.-J.); (E.K.)
| | - Monika Bowszyc-Dmochowska
- Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznan University of Medical Sciences, Przybyszewskiego 49 Steet, 60-355 Poznań, Poland;
| | - Elżbieta Kaczmarek
- Department of Bioinformatics and Computational Biology, Poznan University of Medical Sciences, Rokietnicka 4 Street, 60-806 Poznań, Poland; (A.S.-J.); (E.K.)
| | - Ryszard Żaba
- Department of Dermatology and Venereology, Poznan University of Medical Sciences, Przybyszewskiego 49 Street, 60-355 Poznań, Poland;
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Przybyszewskiego 49 Street, 60-355 Poznań, Poland;
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11
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Kovacs B, Tillmann J, Freund LC, Nimmerjahn F, Sadik CD, Bieber K, Ludwig RJ, Karsten CM, Köhl J. Fcγ Receptor IIB Controls Skin Inflammation in an Active Model of Epidermolysis Bullosa Acquisita. Front Immunol 2020; 10:3012. [PMID: 31993051 PMCID: PMC6971089 DOI: 10.3389/fimmu.2019.03012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 12/09/2019] [Indexed: 12/21/2022] Open
Abstract
Epidermolysis bullosa acquisita (EBA) is an autoimmune skin blistering disease characterized by IgG autoantibodies (aAb) against type VII collagen (COL7). The mechanisms controlling the formation of such aAbs and their effector functions in the skin tissue are incompletely understood. Here, we assessed whether the inhibitory IgG Fc receptor, FcγRIIB, controls the development of autoimmune skin blistering disease in an active model of EBA. For this purpose, we immunized congenic EBA-susceptible B6.SJL-H2s (B6.s) and B6.s-Fcgr2b−/− mice with the immunodominant vWFA2 region of COL7. B6.s-Fcgr2b−/− mice developed a strong clinical phenotype with 15 ± 3.3% of affected body surface area at week 4. In contrast, the body surface area in B6.s mice was affected to a maximum of 5% at week 6 with almost no disease signs at week 4. Surprisingly, we already found strong but similar COL7-specific serum IgG1 and IgG2b aAb production at week 2. Further, aAb and C3b deposition in the skin of B6.s and B6.s-Fcgr2b−/− mice increased between weeks 2 and 6 after vWFA2 immunization. Importantly, neutrophil skin infiltration and activation was much stronger in B6s-Fcgr2b−/− than in B6.s mice and already present at week 2. Also, the early aAb response in B6.s-Fcgr2b−/− mice was more diverse than in wt B6.s mice. Reactive oxygen species (ROS) release from infiltrating neutrophils play a crucial role as mediator of skin inflammation in EBA. In line, sera from B6.s and B6.s-Fcgr2b−/− mice induced strong ROS release from bone marrow-neutrophils in vitro. In contrast to the antibody-transfer-induced EBA model, individual targeting of FcγRIII or FcγRIV decreased ROS release to 50%. Combined FcγR blocking abrogated ROS release from BM neutrophils. Also, ROS release induced by COL7-specific serum IgG aAbs was significantly higher using BM neutrophils from B6.s-Fcgr2b−/− than from B6.s mice. Together, our findings identified FcγRIIB as a suppressor of skin inflammation in the active EBA model through inhibition of early epitope spreading, protection from strong early neutrophil infiltration to and activation of neutrophils in the skin and suppression of FcγRIII activation by IgG1 aAbs which drive strong ROS release from neutrophils leading to tissue destruction at the dermal-epidermal junction.
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Affiliation(s)
- Balint Kovacs
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany.,Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Jenny Tillmann
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Lisa-Christin Freund
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Falk Nimmerjahn
- Department of Biology, Chair of Genetics, University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - Katja Bieber
- Lübeck Institute for Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Lübeck Institute for Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Christian M Karsten
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany.,Division of Immunobiology, Cincinnati Children's Hospital and College of Medicine, University of Cincinnati, Cincinnati, OH, United States
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12
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Nagelkerke SQ, Schmidt DE, de Haas M, Kuijpers TW. Genetic Variation in Low-To-Medium-Affinity Fcγ Receptors: Functional Consequences, Disease Associations, and Opportunities for Personalized Medicine. Front Immunol 2019; 10:2237. [PMID: 31632391 PMCID: PMC6786274 DOI: 10.3389/fimmu.2019.02237] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/04/2019] [Indexed: 12/23/2022] Open
Abstract
Fc-gamma receptors (FcγR) are the cellular receptors for Immunoglobulin G (IgG). Upon binding of complexed IgG, FcγRs can trigger various cellular immune effector functions, thereby linking the adaptive and innate immune systems. In humans, six classic FcγRs are known: one high-affinity receptor (FcγRI) and five low-to-medium-affinity FcγRs (FcγRIIA, -B and -C, FcγRIIIA and -B). In this review we describe the five genes encoding the low-to-medium -affinity FcγRs (FCGR2A, FCGR2B, FCGR2C, FCGR3A, and FCGR3B), including well-characterized functionally relevant single nucleotide polymorphisms (SNPs), haplotypes as well as copy number variants (CNVs), which occur in distinct copy number regions across the locus. The evolution of the locus is also discussed. Importantly, we recommend a consistent nomenclature of genetic variants in the FCGR2/3 locus. Next, we focus on the relevance of genetic variation in the FCGR2/3 locus in auto-immune and auto-inflammatory diseases, highlighting pathophysiological insights that are informed by genetic association studies. Finally, we illustrate how specific FcγR variants relate to variation in treatment responses and prognosis amongst autoimmune diseases, cancer and transplant immunology, suggesting novel opportunities for personalized medicine.
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Affiliation(s)
- Sietse Q Nagelkerke
- Sanquin Research and Landsteiner Laboratory, Department of Blood Cell Research, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - David E Schmidt
- Sanquin Research and Landsteiner Laboratory, Department of Experimental Immunology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Masja de Haas
- Sanquin Diagnostic Services, Department of Immunohematology Diagnostics, Amsterdam, Netherlands.,Sanquin Research, Center for Clinical Transfusion Research, Leiden, Netherlands.,Jon J. van Rood Center for Clinical Transfusion Science, Leiden University Medical Center, Leiden, Netherlands.,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Taco W Kuijpers
- Sanquin Research and Landsteiner Laboratory, Department of Blood Cell Research, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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13
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Nagelkerke SQ, Tacke CE, Breunis WB, Tanck MWT, Geissler J, Png E, Hoang LT, van der Heijden J, Naim ANM, Yeung RSM, Levin ML, Wright VJ, Burgner DP, Ponsonby AL, Ellis JA, Cimaz R, Shimizu C, Burns JC, Fijnvandraat K, van der Schoot CE, van den Berg TK, de Boer M, Davila S, Hibberd ML, Kuijpers TW. Extensive Ethnic Variation and Linkage Disequilibrium at the FCGR2/3 Locus: Different Genetic Associations Revealed in Kawasaki Disease. Front Immunol 2019; 10:185. [PMID: 30949161 PMCID: PMC6437109 DOI: 10.3389/fimmu.2019.00185] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/21/2019] [Indexed: 12/23/2022] Open
Abstract
The human Fc-gamma receptors (FcγRs) link adaptive and innate immunity by binding immunoglobulin G (IgG). All human low-affinity FcγRs are encoded by the FCGR2/3 locus containing functional single nucleotide polymorphisms (SNPs) and gene copy number variants. This locus is notoriously difficult to genotype and high-throughput methods commonly used focus on only a few SNPs. We performed multiplex ligation-dependent probe amplification for all relevant genetic variations at the FCGR2/3 locus in >4,000 individuals to define linkage disequilibrium (LD) and allele frequencies in different populations. Strong LD and extensive ethnic variation in allele frequencies was found across the locus. LD was strongest for the FCGR2C-ORF haplotype (rs759550223+rs76277413), which leads to expression of FcγRIIc. In Europeans, the FCGR2C-ORF haplotype showed strong LD with, among others, rs201218628 (FCGR2A-Q27W, r2 = 0.63). LD between these two variants was weaker (r2 = 0.17) in Africans, whereas the FCGR2C-ORF haplotype was nearly absent in Asians (minor allele frequency <0.005%). The FCGR2C-ORF haplotype and rs1801274 (FCGR2A-H131R) were in weak LD (r2 = 0.08) in Europeans. We evaluated the importance of ethnic variation and LD in Kawasaki Disease (KD), an acute vasculitis in children with increased incidence in Asians. An association of rs1801274 with KD was previously shown in ethnically diverse genome-wide association studies. Now, we show in 1,028 European KD patients that the FCGR2C-ORF haplotype, although nearly absent in Asians, was more strongly associated with susceptibility to KD than rs1801274 in Europeans. Our data illustrate the importance of interpreting findings of association studies concerning the FCGR2/3 locus with knowledge of LD and ethnic variation.
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Affiliation(s)
- Sietse Q Nagelkerke
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Carline E Tacke
- Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Willemijn B Breunis
- Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Judy Geissler
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Eileen Png
- Infectious Diseases, Genome Institute of Singapore, Singapore, Singapore
| | - Long T Hoang
- Infectious Diseases, Genome Institute of Singapore, Singapore, Singapore
| | - Joris van der Heijden
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ahmad N M Naim
- Infectious Diseases, Genome Institute of Singapore, Singapore, Singapore
| | - Rae S M Yeung
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Michael L Levin
- Department of Pediatrics, Imperial College London, London, United Kingdom
| | - Victoria J Wright
- Department of Pediatrics, Imperial College London, London, United Kingdom
| | - David P Burgner
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Anne-Louise Ponsonby
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Justine A Ellis
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.,Faculty of Health, Centre for Social and Early Emotional Development, Deakin University, Burwood, VIC, Australia
| | - Rolando Cimaz
- Rheumatology Unit, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Chisato Shimizu
- Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, CA, United States
| | - Jane C Burns
- Department of Pediatrics, University of California San Diego School of Medicine, La Jolla, CA, United States
| | - Karin Fijnvandraat
- Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Plasma Proteins, Sanquin Research, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - C Ellen van der Schoot
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Timo K van den Berg
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Molecular Cell Biology and Immunology, Amsterdam Infection and Immunity Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Martin de Boer
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sonia Davila
- Human Genetics, Genome Institute of Singapore, Singapore, Singapore
| | - Martin L Hibberd
- Infectious Diseases, Genome Institute of Singapore, Singapore, Singapore.,Department of Pathogen Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Taco W Kuijpers
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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14
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Powell RLR, Fox A, Itri V, Zolla-Pazner S. Primary Human Neutrophils Exhibit a Unique HIV-Directed Antibody-Dependent Phagocytosis Profile. J Innate Immun 2018; 11:181-190. [PMID: 30557875 DOI: 10.1159/000494371] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/29/2018] [Indexed: 12/11/2022] Open
Abstract
The only clinical HIV vaccine trial to demonstrate efficacy, RV144, correlated protection with the antibodies (Abs) mediating function via the "constant" immunoglobulin region, the crystallizable fragment (Fc). These data have supported a focus on the induction of Abs by vaccines that trigger antiviral activities by relevant leukocytes via Fc receptors (FcRs). Neutrophils are phagocytes that comprise > 50% of leukocytes and display unique FcRs. We sought to compare the Ab-dependent cellular phagocytosis (ADCP) activity of human neutrophils to the commonly assayed THP-1 cell line. HIV-specific Abs were employed to elicit ADCP of beads coated with HIV envelope protein. Overall, trends were noted among neutrophil donors and the ADCP profile was different from that of THP-1 cells. mAb ELISA titers correlated with ADCP by THP-1 cells but not neutrophils. Monoclonal (m)Abs were also tested with primary monocytes. Donor-to-donor variation was high, and hindered the analysis of this dataset, but it was, in itself, an important finding. This study illustrates the concept that the assessment of FcR-mediated Ab activity with a frequently used cell line such as THP-1 is not necessarily indicative of relevant Ab functionality in vivo, and this calls for in-depth study of the properties of the HIV antibodies best-suited to eliciting antiviral activities by primary cells.
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Affiliation(s)
- Rebecca L R Powell
- Department of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA,
| | - Alisa Fox
- Department of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vincenza Itri
- Department of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Susan Zolla-Pazner
- Department of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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15
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Chakievska L, Holtsche MM, Künstner A, Goletz S, Petersen BS, Thaci D, Ibrahim SM, Ludwig RJ, Franke A, Sadik CD, Zillikens D, Hölscher C, Busch H, Schmidt E. IL-17A is functionally relevant and a potential therapeutic target in bullous pemphigoid. J Autoimmun 2018; 96:104-112. [PMID: 30219389 DOI: 10.1016/j.jaut.2018.09.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 01/19/2023]
Abstract
IL-17A has been identified as key regulatory molecule in several autoimmune and chronic inflammatory diseases followed by the successful use of anti-IL-17 therapy, e.g. in ankylosing spondylitis and psoriasis. Bullous pemphigoid (BP) is the most frequent autoimmune blistering disease with a high need for more specific, effective and safe treatment options. The aim of this study was to clarify the pathophysiological importance of IL-17A in BP. We found elevated numbers of IL-17A+ CD4+ lymphocytes in the peripheral blood of BP patients and identified CD3+ cells as major source of IL-17A in early BP skin lesions. IL17A and related genes were upregulated in BP skin and exome sequencing of 51 BP patients revealed mutations in twelve IL-17-related genes in 18 patients. We have subsequently found several lines of evidence suggesting a significant role of IL-17A in the BP pathogenesis: (i) IL-17A activated human neutrophils in vitro, (ii) inhibition of dermal-epidermal separation in cryosections of human skin incubated with anti-BP180 IgG and subsequently with anti-IL-17A IgG-treated leukocytes, (iii) close correlation of serum IL-17A levels and diseases activity in a mouse model of BP, (iv) IL17A-deficient mice were protected against autoantibody-induced BP, and (v) pharmacological inhibition of lL-17A reduced the induction of BP in mice. Our data give evidence for a pivotal role of IL-17A in the pathophysiology of BP and advocate IL-17A inhibition as potential novel treatment for this disease.
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Affiliation(s)
- Lenche Chakievska
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Maike M Holtsche
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Axel Künstner
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Stephanie Goletz
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | | | - Diamant Thaci
- Institute for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Saleh M Ibrahim
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, University of Kiel, Kiel, Germany
| | | | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Christoph Hölscher
- Division of Infection Immunology, Research Center Borstel, Borstel, Germany
| | - Hauke Busch
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute for Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany; Department of Dermatology, University of Lübeck, Lübeck, Germany.
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16
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Recke A, Konitzer S, Lemcke S, Freitag M, Sommer NM, Abdelhady M, Amoli MM, Benoit S, El-Chennawy F, Eldarouti M, Eming R, Gläser R, Günther C, Hadaschik E, Homey B, Lieb W, Peitsch WK, Pföhler C, Robati RM, Saeedi M, Sárdy M, Sticherling M, Uzun S, Worm M, Zillikens D, Ibrahim S, Vidarsson G, Schmidt E. The p.Arg435His Variation of IgG3 With High Affinity to FcRn Is Associated With Susceptibility for Pemphigus Vulgaris-Analysis of Four Different Ethnic Cohorts. Front Immunol 2018; 9:1788. [PMID: 30116249 PMCID: PMC6082936 DOI: 10.3389/fimmu.2018.01788] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/19/2018] [Indexed: 01/15/2023] Open
Abstract
IgG3 is the IgG subclass with the strongest effector functions among all four IgG subclasses and the highest degree of allelic variability among all constant immunoglobulin genes. Due to its genetic position, IgG3 is often the first isotype an antibody switches to before IgG1 or IgG4. Compared with the other IgG subclasses, it has a reduced half-life which is probably connected to a decreased affinity to the neonatal Fc receptor (FcRn). However, a few allelic variants harbor an amino acid replacement of His435 to Arg that reverts the half-life of the resulting IgG3 to the same level as the other IgG subclasses. Because of its functional impact, we hypothesized that the p.Arg435His variation could be associated with susceptibility to autoantibody-mediated diseases like pemphigus vulgaris (PV) and bullous pemphigoid (BP). Using a set of samples from German, Turkish, Egyptian, and Iranian patients and controls, we were able to demonstrate a genetic association of the p.Arg435His variation with PV risk, but not with BP risk. Our results suggest a hitherto unknown role for the function of IgG3 in the pathogenesis of PV.
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Affiliation(s)
- Andreas Recke
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany.,Department of Dermatology, Allergology and Venereology, University of Lübeck, Lübeck, Germany
| | - Sarah Konitzer
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Susanne Lemcke
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Miriam Freitag
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Nele Maxi Sommer
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Mohammad Abdelhady
- Department of Dermatology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Mahsa M Amoli
- Metabolic Disorders Research Center, Endocrinology and Metabolism Molecular - Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sandrine Benoit
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Farha El-Chennawy
- Department of Clinical Pathology, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohammad Eldarouti
- Department of Dermatology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Rüdiger Eming
- Department of Dermatology and Allergology, Phillips-Universität Marburg, Marburg, Germany
| | - Regine Gläser
- Department of Dermatology, Venereology and Allergology, Christian Albrecht University, Kiel, Germany
| | - Claudia Günther
- Department of Dermatology, University Hospital of Dresden, Dresden, Germany
| | - Eva Hadaschik
- Department of Dermatology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - Bernhard Homey
- Department of Dermatology, Heinrich Heine University, Düsseldorf, Germany
| | - Wolfgang Lieb
- Institute of Epidemiology, Christian-Albrechts-University, Kiel, Germany.,Popgen Biobank, Christian-Albrechts-University, Kiel, Germany
| | - Wiebke K Peitsch
- Department of Dermatology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany.,Department of Dermatology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Claudia Pföhler
- Department of Dermatology, Saarland University Medical School, Homburg/Saar, Germany
| | - Reza M Robati
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marjan Saeedi
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Miklós Sárdy
- Department of Dermatology, Ludwig Maximilian University Munich, Munich, Germany
| | - Michael Sticherling
- Department of Dermatology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Soner Uzun
- Department of Dermatology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Margitta Worm
- Department of Dermatology, Venerology and Allergology, Allergy Center Charité, Charité-Medical University Berlin, Berlin, Germany
| | - Detlef Zillikens
- Department of Dermatology, Allergology and Venereology, University of Lübeck, Lübeck, Germany
| | - Saleh Ibrahim
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Gestur Vidarsson
- Department of Experimental Hematology, Sanquin Research Institute, Amsterdam, Netherlands
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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17
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Recke A, Regensburger AK, Weigold F, Müller A, Heidecke H, Marschner G, Hammers CM, Ludwig RJ, Riemekasten G. Autoantibodies in Serum of Systemic Scleroderma Patients: Peptide-Based Epitope Mapping Indicates Increased Binding to Cytoplasmic Domains of CXCR3. Front Immunol 2018; 9:428. [PMID: 29623076 PMCID: PMC5874968 DOI: 10.3389/fimmu.2018.00428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/16/2018] [Indexed: 12/30/2022] Open
Abstract
Systemic sclerosis (SSc) is a severe chronic autoimmune disease with high morbidity and mortality. Sera of patients with SSc contain a large variety of autoantibody (aab) reactivities. Among these are functionally active aab that bind to G protein-coupled receptors (GPCR) such as C-X-C motif chemokine receptor 3 (CXCR3) and 4 (CXCR4). Aab binding to the N-terminal portion of these two GPCRs have been shown to be associated with slower disease progression in SSc, especially deterioration of lung function. Aabs binding to GPCRs exhibit functional activities by stimulating or inhibiting GPCR signaling. The specific functional activity of aabs crucially depends on the epitopes they bind to. To identify the location of important epitopes on CXCR3 recognized by aabs from SSc patients, we applied an array of 36 overlapping 18-20mer peptides covering the entire CXCR3 sequence, comparing epitope specificity of SSc patient sera (N = 32, with positive reactivity with CXCR3) to healthy controls (N = 30). Binding of SSc patient and control sera to these peptides was determined by ELISA. Using a Bayesian model approach, we found increased binding of SSc patient sera to peptides corresponding to intracellular epitopes within CXCR3, while the binding signal to extracellular portions of CXCR3 was found to be reduced. Experimentally determined epitopes showed a good correspondence to those predicted by the ABCpred tool. To verify these results and to translate them into a novel diagnostic ELISA, we combined the peptides that represent SSc-associated epitopes into a single ELISA and evaluated its potential to discriminate SSc patients (N = 31) from normal healthy controls (N = 47). This ELISA had a sensitivity of 0.61 and a specificity of 0.85. Our data reveals that SSc sera preferentially bind intracellular epitopes of CXCR3, while an extracellular epitope in the N-terminal domain that appears to be target of aabs in healthy individuals is not bound by SSc sera. Based upon our results, we could devise a novel ELISA concept that may be helpful for monitoring of SSc patients.
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Affiliation(s)
- Andreas Recke
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Lübeck Institute of Dermatological Research, University of Lübeck, Lübeck, Germany
| | | | - Florian Weigold
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - Antje Müller
- Department of Rheumatology, University of Lübeck, Lübeck, Germany
| | | | | | | | - Ralf J Ludwig
- Lübeck Institute of Dermatological Research, University of Lübeck, Lübeck, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology, University of Lübeck, Lübeck, Germany.,Priority Area Asthma & Allergy, Research Center Borstel, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
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18
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Karsten CM, Beckmann T, Holtsche MM, Tillmann J, Tofern S, Schulze FS, Heppe EN, Ludwig RJ, Zillikens D, König IR, Köhl J, Schmidt E. Tissue Destruction in Bullous Pemphigoid Can Be Complement Independent and May Be Mitigated by C5aR2. Front Immunol 2018; 9:488. [PMID: 29599777 PMCID: PMC5862877 DOI: 10.3389/fimmu.2018.00488] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/23/2018] [Indexed: 12/12/2022] Open
Abstract
Bullous pemphigoid (BP), the most frequent autoimmune bullous disorder, is a paradigmatic autoantibody-mediated disease associated with autoantibodies against BP180 (type XVII collagen, Col17). Several animal models have been developed that reflect important clinical and immunological features of human BP. Complement activation has been described as a prerequisite for blister formation, however, the recent finding that skin lesions can be induced by anti-Col17 F(ab')2 fragments indicates complement-independent mechanisms to contribute to blister formation in BP. Here, C5-/- mice injected with anti-Col17 IgG showed a reduction of skin lesions by about 50% associated with significantly less skin-infiltrating neutrophils compared to wild-type mice. Reduction of skin lesions and neutrophil infiltration was seen independently of the employed anti-Col17 IgG dose. Further, C5ar1-/- mice were protected from disease development, whereas the extent of skin lesions was increased in C5ar2-/- animals. Pharmacological inhibition of C5a receptor 1 (C5aR1) by PMX53 led to reduced disease activity when applied in a prophylactic setting. In contrast, PMX-53 treatment had no effect when first skin lesions had already developed. While C5aR1 was critically involved in neutrophil migration in vitro, its role for Col17-anti-Col17 IgG immune complex-mediated release of reactive oxygen species from neutrophils was less pronounced. Our data demonstrate that complement-dependent and -independent mechanisms coexist in anti-Col17-autoantibody-mediated tissue destruction. C5aR1 and C5aR2 seem to play opposing roles in this process with C5aR1 exerting its primary effect in recruiting inflammatory cells to the skin during the early phase of the disease. Further studies are required to fully understand the role of C5aR2 in autoantibody-mediated skin inflammation.
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MESH Headings
- Animals
- Autoantibodies/genetics
- Autoantibodies/immunology
- Autoantigens/genetics
- Autoantigens/immunology
- Complement C5/genetics
- Complement C5/immunology
- Mice
- Mice, Inbred BALB C
- Mice, Knockout
- Neutrophil Infiltration
- Neutrophils/immunology
- Neutrophils/pathology
- Non-Fibrillar Collagens/genetics
- Non-Fibrillar Collagens/immunology
- Pemphigoid, Bullous/chemically induced
- Pemphigoid, Bullous/genetics
- Pemphigoid, Bullous/immunology
- Pemphigoid, Bullous/pathology
- Peptides, Cyclic/pharmacology
- Reactive Oxygen Species/immunology
- Receptor, Anaphylatoxin C5a/antagonists & inhibitors
- Receptor, Anaphylatoxin C5a/genetics
- Receptor, Anaphylatoxin C5a/immunology
- Skin/immunology
- Skin/pathology
- Collagen Type XVII
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Affiliation(s)
| | - Tina Beckmann
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | | | - Jenny Tillmann
- Institute of Systemic Inflammation, University of Lübeck, Lübeck, Germany
| | - Sabrina Tofern
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Franziska S. Schulze
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Eva Nina Heppe
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Ralf J. Ludwig
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Inke R. König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Jörg Köhl
- Institute of Systemic Inflammation, University of Lübeck, Lübeck, Germany
- Division of Immunobiology, Cincinnati Children’s Hospital and College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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19
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Sadik CD, Bischof J, van Beek N, Dieterich A, Benoit S, Sárdy M, Worm M, Meller S, Gläser R, Zillikens D, Homey B, Setterfield J, Minassian D, Schmidt E, Dart J, Ibrahim SM. Genomewide association study identifies GALC
as susceptibility gene for mucous membrane pemphigoid. Exp Dermatol 2017; 26:1214-1220. [DOI: 10.1111/exd.13464] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Christian D. Sadik
- Department of Dermatology, Allergy, and Venereology; University of Lübeck; Lübeck Germany
| | - Julia Bischof
- Lübeck Institute of Experimental Dermatology; University of Lübeck; Lübeck Germany
| | - Nina van Beek
- Department of Dermatology, Allergy, and Venereology; University of Lübeck; Lübeck Germany
| | - Anabelle Dieterich
- Department of Dermatology, Allergy, and Venereology; University of Lübeck; Lübeck Germany
| | - Sandrine Benoit
- Department of Dermatology, Venereology and Allergology; University Hospital Würzburg; Würzburg Germany
| | - Miklós Sárdy
- Department of Dermatology and Allergy; Ludwig Maximilian University; Munich Germany
| | - Margitta Worm
- Department of Dermatology, Allergy, and Venereology; Charité; Berlin Germany
| | - Stephan Meller
- Department of Dermatology; Heinrich Heine University; Düsseldorf Germany
| | - Regine Gläser
- Department of Dermatology, Venereology, and Allergy; Christian Albrechts University zu Kiel; Kiel Germany
| | - Detlef Zillikens
- Department of Dermatology, Allergy, and Venereology; University of Lübeck; Lübeck Germany
| | - Bernhard Homey
- Department of Dermatology; Heinrich Heine University; Düsseldorf Germany
| | - Jane Setterfield
- Guy's and St Thomas's NHS Foundation Trust and King's College London; London UK
| | | | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology; University of Lübeck; Lübeck Germany
| | - John Dart
- Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology; London UK
| | - Saleh M. Ibrahim
- Lübeck Institute of Experimental Dermatology; University of Lübeck; Lübeck Germany
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20
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Affiliation(s)
- Frank Antonicelli
- Laboratory of Dermatology, UFR of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Department of Biological Sciences, Immunology, UFR Odontology, University of Reims Champagne-Ardenne, Reims, France
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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21
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Koga H, Recke A, Vidarsson G, Pas HH, Jonkman MF, Hashimoto T, Kasprick A, Ghorbanalipoor S, Tenor H, Zillikens D, Ludwig RJ. PDE4 Inhibition as Potential Treatment of Epidermolysis Bullosa Acquisita. J Invest Dermatol 2016; 136:2211-2220. [DOI: 10.1016/j.jid.2016.06.619] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 06/05/2016] [Accepted: 06/13/2016] [Indexed: 12/20/2022]
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22
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