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Liu ZY, Tang F, Yang JZ, Chen X, Wang ZF, Li ZQ. The Role of Beta2-Microglobulin in Central Nervous System Disease. Cell Mol Neurobiol 2024; 44:46. [PMID: 38743119 PMCID: PMC11093819 DOI: 10.1007/s10571-024-01481-6] [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: 01/06/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
Central nervous system (CNS) disorders represent the leading cause of disability and the second leading cause of death worldwide, and impose a substantial economic burden on society. In recent years, emerging evidence has found that beta2 -microglobulin (B2M), a subunit of major histocompatibility complex class I (MHC-I) molecules, plays a crucial role in the development and progression in certain CNS diseases. On the one hand, intracellular B2M was abnormally upregulated in brain tumors and regulated tumor microenvironments and progression. On the other hand, soluble B2M was also elevated and involved in pathological stages in CNS diseases. Targeted B2M therapy has shown promising outcomes in specific CNS diseases. In this review, we provide a comprehensive summary and discussion of recent advances in understanding the pathological processes involving B2M in CNS diseases (e.g., Alzheimer's disease, aging, stroke, HIV-related dementia, glioma, and primary central nervous system lymphoma).
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Affiliation(s)
- Zhen-Yuan Liu
- Brain Glioma Center & Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Feng Tang
- Brain Glioma Center & Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jin-Zhou Yang
- Brain Glioma Center & Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xi Chen
- Brain Glioma Center & Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Ze-Fen Wang
- Department of Physiology, Wuhan University School of Basic Medical Sciences, Wuhan, Hubei, China.
| | - Zhi-Qiang Li
- Brain Glioma Center & Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.
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Pons-Fuster E, Bernal E, Guillamón CF, Gimeno L, Martínez-Sánchez MV, Ruiz-Lorente I, Campillo JA, Ceballos D, Torres A, Tomás C, Muñoz Á, Alcaraz A, Selma P, Ruiz-Nicolas C, Muro M, Minguela A. HLA-C*07 is associated with symptomatic HIV-1-associated neurocognitive disorders (HAND) and immune dysregulation. Infect Dis (Lond) 2024:1-12. [PMID: 38743055 DOI: 10.1080/23744235.2024.2351047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/29/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND HIV-1-associated neurocognitive disorders (HAND) in stable patients undergoing antiretroviral therapy (ART) may result from ongoing immune dysregulation and chronic inflammation. A contributing factor may result from the unstable HLA class I allele, HLA-C*07. OBJECTIVE To assess the genetic profile of killer-cell immunoglobulin-like receptors (KIR), human leukocyte antigens (HLA), and immune activation or senescence markers and their association with HAND in stable HIV-1 patients receiving ART. METHODS An observational cross-sectional study was carried out with 96 patients with asymptomatic or symptomatic HAND. HLA and KIR as well as immune activation/senescence biomarkers in peripheral blood cells were assessed by SSO-Luminex typing and flow cytometry, respectively. RESULTS HLA-C*07 is associated with symptomatic HAND. The frequency of two copies of HLA-C*07 was higher in patients with symptomatic than with asymptomatic HAND (12.0 vs. 2.2%, ρ < 0.001). The percentage of senescent CD8+CD28- T-cells was higher in patients with two copies of HLA-C*07 (ρ < 0.05). In patients with symptomatic HAND, the percentages of non-senescent CD8+CD28+ T cells were inversely proportional to the number of copies of the HLA-C*07 (ρ < 0.05). CONCLUSION Patients with symptomatic HAND showed a higher frequency of the homozygotic unstable HLA-C*07 allotype, which could be associated with neurocognitive complications. Two copies of HLA-C*07 were associated with immune senescent T lymphocyte profiles characterized by the loss of CD28 expression.
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Affiliation(s)
- Eduardo Pons-Fuster
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Enrique Bernal
- Infectious Disease Unit, University Hospital Reina Sofía and Murcia University and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Concepción F Guillamón
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Lourdes Gimeno
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - María V Martínez-Sánchez
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Inmaculada Ruiz-Lorente
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - José A Campillo
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Diana Ceballos
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Ana Torres
- Infectious Disease Unit, University Hospital Reina Sofía and Murcia University and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Cristina Tomás
- Infectious Disease Unit, University Hospital Reina Sofía and Murcia University and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Ángeles Muñoz
- Infectious Disease Unit, University Hospital Reina Sofía and Murcia University and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Antonia Alcaraz
- Infectious Disease Unit, University Hospital Reina Sofía and Murcia University and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Pedro Selma
- Infectious Disease Unit, University Hospital Reina Sofía and Murcia University and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Carlos Ruiz-Nicolas
- Infectious Disease Unit, University Hospital Reina Sofía and Murcia University and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Manuel Muro
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
| | - Alfredo Minguela
- Immunologyservice, Clinic University Hospital Virgen de la Arrixaca and Biomedical Research Institute of Murcia Pascual Parrilla (IMIB), Murcia, Spain
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De Almeida SM, Rotta I, Tang B, Umlauf A, Vaida F, Cherner M, Franklin D, Letendre S, Ellis RJ. Higher Cerebrospinal Fluid Soluble Urokinase-type Plasminogen Activator Receptor, But Not Interferon γ-inducible Protein 10, Correlate With Higher Working Memory Deficits. J Acquir Immune Defic Syndr 2022; 90:106-114. [PMID: 35090158 PMCID: PMC8986587 DOI: 10.1097/qai.0000000000002924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND We hypothesized that the induction of monocyte activation biomarkers, especially soluble urokinase-type plasminogen activator receptor (suPAR) and interferon γ-inducible protein 10 (IP-10), is lower in HIV-1C than HIV-1B, owing to a defective Tat cysteine dimotif (C30S). METHODS A total of 68 paired cerebrospinal fluid (CSF) and blood samples from people with HIV (PWH), free of CNS opportunistic infections, from a Southern Brazil outpatient HIV clinic were evaluated such as HIV-1B subtype (n = 27), HIV-1C (n = 26), other (n = 15), and 19 HIV-negative controls. The levels of suPAR, IP-10, neopterin, and β2 microglobulin (β2m) in the CSF and serum were quantified using different immunoassays. RESULTS Overall, in PWH, increases in CSF suPAR, CSF/serum suPAR, and CSF/serum β2m correlated with worse working memory deficits (r = 0.303, 0.353, and 0.289, respectively, all P < 0.05). The medians of IP-10, suPAR, neopterin, and β2m in CSF and serum and the CSF/serum ratio and suPAR index were comparable between the HIV-1B and HIV-1C subtypes. CSF IP-10 and neopterin and serum IP-10 and suPAR levels were higher in PWH than the HIV-negative controls (P = 0.015, P = 0.001, P < 0.0001, and P < 0.001, respectively). The serum β2m level was higher in HIV-associated dementia than neuropsychologically normal or asymptomatic (P = 0.024). DISCUSSION We observed that higher levels of CSF suPAR and the suPAR quotient correlated with worse working memory deficit. Elevated levels of monocyte activation were similar in both HIV-1 B and C subtypes, providing no evidence of reduced neuropathogenicity of HIV-1 subtype C Tat compared with subtype B.
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Affiliation(s)
- Sergio M De Almeida
- Neuroinfection Unity and Virology Laboratory, Universidade Federal Do Paraná, Curitiba, Paraná, Brazil
| | - Indianara Rotta
- Neuroinfection Unity and Virology Laboratory, Universidade Federal Do Paraná, Curitiba, Paraná, Brazil
| | - Bin Tang
- Department of Psychiatry, University of California, San Diego, CA
| | - Anya Umlauf
- Department of Psychiatry, University of California, San Diego, CA
| | - Florin Vaida
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California, San Diego, CA
| | - Mariana Cherner
- Department of Psychiatry, University of California, San Diego, CA
- HIV Neurobehavioral Research Center, University of California, San Diego, CA
| | - Donald Franklin
- HIV Neurobehavioral Research Center, University of California, San Diego, CA
| | - Scott Letendre
- HIV Neurobehavioral Research Center, University of California, San Diego, CA
- Division of Infectious Diseases, Department of Medicine, University of California, San Diego, CA; and
| | - Ronald J Ellis
- HIV Neurobehavioral Research Center, University of California, San Diego, CA
- Department of Neurosciences, University of California, San Diego, CA
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de Almeida SM, Beltrame MP, Tang B, Rotta I, Schluga Y, Justus JLP, da Rocha MT, Abramson I, Vaida F, Schrier R, Ellis RJ. Main lymphocyte subpopulations in cerebrospinal fluid and peripheral blood in HIV-1 subtypes C and B. J Neurovirol 2022; 28:291-304. [PMID: 35190973 DOI: 10.1007/s13365-022-01054-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/10/2022] [Accepted: 01/21/2022] [Indexed: 11/28/2022]
Abstract
HIV-1 subtype C (HIV-1C) shows reduced Tat protein chemoattractant activity compared with HIV-1B. The impact of HIV-1C Tat on the chemotaxis of the main lymphocyte subpopulations in the cerebrospinal fluid (CSF) and the peripheral blood (PB) is unclear. We hypothesized that there would be a lower frequency of specific lymphocyte subpopulations CD3+ or CD19+ in CSF in HIV-1C than in HIV-1B. The objectives were to detect the differences in the proportions of main lymphocyte subpopulations in CSF and PB, between people with HIV (PWH) and HIV-1-uninfected volunteers (PWoH) and in HIV-1B and HIV-1C. Lymphocyte immunophenotyping was studied in CSF and paired PB samples of PWH (n = 22) and PWoH (n = 14). Lymphocytes were analyzed within the CD45+ gated region. The proportions of CSF CD3+CD4+, CD3+CD8+, and CD3-CD19+ lymphocytes in CSF were comparable in HIV-1B and C. There was an increase in the proportion of CD3+CD8+ cells and a decrease in CD3+CD4+ T cells (ps = 0.016) in the CSF samples of the PWH compared with the PWoH group. In the PWH group, both CD3+CD4+ and CD3+CD8+ lymphocytes were significantly higher in the CSF than in the PB (p = 0.047 and 0.005). The proportion of CD3+CD4+ was lower and that of CD3+CD8+ was higher in the CSF samples of the aviremic group than that of HIV-negative control (p = 0.0008 and < 0.0001, respectively). HIV-1C Tat substitution (C30S) did not interfere with the CNS migration of the main lymphocyte subpopulations. This is the first study to evaluate these lymphocytes in CSF and PB of HIV-1C compared with HIV-1B.
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Affiliation(s)
- Sergio M de Almeida
- Laboratório de Virologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Miriam Perlingeiro Beltrame
- Laboratório de Citometria de Fluxo, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Bin Tang
- HNRC- HIV Neurobehavioral Research Center, UCSD, San Diego, CA, USA
| | - Indianara Rotta
- Laboratório de Virologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Yara Schluga
- Laboratório de Citometria de Fluxo, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Julie Lilian P Justus
- Laboratório de Citometria de Fluxo, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Maria Tadeu da Rocha
- Laboratório de Citometria de Fluxo, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Ian Abramson
- HNRC- HIV Neurobehavioral Research Center, UCSD, San Diego, CA, USA
| | - Florin Vaida
- HNRC- HIV Neurobehavioral Research Center, UCSD, San Diego, CA, USA
| | - Rachel Schrier
- HNRC- HIV Neurobehavioral Research Center, UCSD, San Diego, CA, USA
| | - Ronald J Ellis
- HNRC- HIV Neurobehavioral Research Center, UCSD, San Diego, CA, USA
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Hilt ZT, Pariser DN, Ture SK, Mohan A, Quijada P, Asante AA, Cameron SJ, Sterling JA, Merkel AR, Johanson AL, Jenkins JL, Small EM, McGrath KE, Palis J, Elliott MR, Morrell CN. Platelet-derived β2M regulates monocyte inflammatory responses. JCI Insight 2019; 4:122943. [PMID: 30702442 PMCID: PMC6483513 DOI: 10.1172/jci.insight.122943] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/25/2019] [Indexed: 12/13/2022] Open
Abstract
β-2 Microglobulin (β2M) is a molecular chaperone for the major histocompatibility class I (MHC I) complex, hemochromatosis factor protein (HFE), and the neonatal Fc receptor (FcRn), but β2M may also have less understood chaperone-independent functions. Elevated plasma β2M has a direct role in neurocognitive decline and is a risk factor for adverse cardiovascular events. β2M mRNA is present in platelets at very high levels, and β2M is part of the activated platelet releasate. In addition to their more well-studied thrombotic functions, platelets are important immune regulatory cells that release inflammatory molecules and contribute to leukocyte trafficking, activation, and differentiation. We have now found that platelet-derived β2M is a mediator of monocyte proinflammatory differentiation through noncanonical TGFβ receptor signaling. Circulating monocytes from mice lacking β2M only in platelets (Plt-β2M-/-) had a more proreparative monocyte phenotype, in part dependent on increased platelet-derived TGFβ signaling in the absence of β2M. Using a mouse myocardial infarction (MI) model, Plt-β2M-/- mice had limited post-MI proinflammatory monocyte responses and, instead, demonstrated early proreparative monocyte differentiation, profibrotic myofibroblast responses, and a rapid decline in heart function compared with WT mice. These data demonstrate a potentially novel chaperone-independent, monocyte phenotype-regulatory function for platelet β2M and that platelet-derived 2M and TGFβ have opposing roles in monocyte differentiation that may be important in tissue injury responses.
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Affiliation(s)
| | | | | | - Amy Mohan
- Aab Cardiovascular Research Institute
| | | | - Akua A. Asante
- Center for Pediatric Biomedical Research, Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York, USA
| | | | - Julie A. Sterling
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Cancer Biology, Medicine, Division of Clinical Pharmacology, Bone Biology Center, and Biomedical Engineering, and
- Department of Cancer Biology, Vanderbilt University, Nashville, Tennessee, USA
| | - Alyssa R. Merkel
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Cancer Biology, Medicine, Division of Clinical Pharmacology, Bone Biology Center, and Biomedical Engineering, and
- Department of Cancer Biology, Vanderbilt University, Nashville, Tennessee, USA
| | | | | | | | - Kathleen E. McGrath
- Center for Pediatric Biomedical Research, Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York, USA
| | - James Palis
- Center for Pediatric Biomedical Research, Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York, USA
| | - Michael R. Elliott
- Department of Microbiology and Immunology, University of Rochester School of Medicine, Rochester, New York, USA
| | - Craig N. Morrell
- Aab Cardiovascular Research Institute
- Department of Microbiology and Immunology, University of Rochester School of Medicine, Rochester, New York, USA
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Zipeto D, Serena M, Mutascio S, Parolini F, Diani E, Guizzardi E, Muraro V, Lattuada E, Rizzardo S, Malena M, Lanzafame M, Malerba G, Romanelli MG, Tamburin S, Gibellini D. HIV-1-Associated Neurocognitive Disorders: Is HLA-C Binding Stability to β 2-Microglobulin a Missing Piece of the Pathogenetic Puzzle? Front Neurol 2018; 9:791. [PMID: 30298049 PMCID: PMC6160745 DOI: 10.3389/fneur.2018.00791] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/03/2018] [Indexed: 01/09/2023] Open
Abstract
AIDS dementia complex (ADC) and HIV-associated neurocognitive disorders (HAND) are complications of HIV-1 infection. Viral infections are risk factors for the development of neurodegenerative disorders. Aging is associated with low-grade inflammation in the brain, i.e., the inflammaging. The molecular mechanisms linking immunosenescence, inflammaging and the pathogenesis of neurodegenerative disorders, such as Alzheimer's disease (AD) and Parkinson's disease, are largely unknown. ADC and HAND share some pathological features with AD and may offer some hints on the relationship between viral infections, neuroinflammation, and neurodegeneration. β2-microglobulin (β2m) is an important pro-aging factor that interferes with neurogenesis and worsens cognitive functions. Several studies published in the 80-90s reported high levels of β2m in the cerebrospinal fluid of patients with ADC. High levels of β2m have also been detected in AD. Inflammatory diseases in elderly people are associated with polymorphisms of the MHC-I locus encoding HLA molecules that, by associating with β2m, contribute to cellular immunity. We recently reported that HLA-C, no longer associated with β2m, is incorporated into HIV-1 virions, determining an increase in viral infectivity. We also documented the presence of HLA-C variants more or less stably linked to β2m. These observations led us to hypothesize that some variants of HLA-C, in the presence of viral infections, could determine a greater release and accumulation of β2m, which in turn, may be involved in triggering and/or sustaining neuroinflammation. ADC is the most severe form of HAND. To explore the role of HLA-C in ADC pathogenesis, we analyzed the frequency of HLA-C variants with unstable binding to β2m in a group of patients with ADC. We found a higher frequency of unstable HLA-C alleles in ADC patients, and none of them was harboring stable HLA-C alleles in homozygosis. Our data suggest that the role of HLA-C variants in ADC/HAND pathogenesis deserves further studies. If confirmed in a larger number of samples, this finding may have practical implication for a personalized medicine approach and for developing new therapies to prevent HAND. The exploration of HLA-C variants as risk factors for AD and other neurodegenerative disorders may be a promising field of study.
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Affiliation(s)
- Donato Zipeto
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Michela Serena
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Simona Mutascio
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Francesca Parolini
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Erica Diani
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | | | | | | | - Marina Malena
- U.O.S. Infectious Diseases, AULSS 9 Scaligera, Verona, Italy
| | | | - Giovanni Malerba
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maria Grazia Romanelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Davide Gibellini
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Abstract
Human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) remain a common end-organ manifestation of viral infection. Subclinical and mild symptoms lead to neurocognitive and behavioral abnormalities. These are associated, in part, with viral penetrance and persistence in the central nervous system. Infections of peripheral blood monocytes, macrophages, and microglia are the primary drivers of neuroinflammation and neuronal impairments. While current antiretroviral therapy (ART) has reduced the incidence of HIV-associated dementia, milder forms of HAND continue. Depression, comorbid conditions such as infectious liver disease, drugs of abuse, antiretroviral drugs themselves, age-related neurodegenerative diseases, gastrointestinal maladies, and concurrent social and economic issues can make accurate diagnosis of HAND challenging. Increased life expectancy as a result of ART clearly creates this variety of comorbid conditions that often blur the link between the virus and disease. With the discovery of novel biomarkers, neuropsychologic testing, and imaging techniques to better diagnose HAND, the emergence of brain-penetrant ART, adjunctive therapies, longer life expectancy, and better understanding of disease pathogenesis, disease elimination is perhaps a realistic possibility. This review focuses on HIV-associated disease pathobiology with an eye towards changing trends in the face of widespread availability of ART.
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Harilall SL, Choonara YE, Tomar LK, Tyagi C, Kumar P, du Toit LC, Modi G, Naidoo D, Iyuke SE, Danckwerts MP, Pillay V. Development and in vivo evaluation of an implantable nano-enabled multipolymeric scaffold for the management of AIDS dementia complex (ADC). Int J Pharm 2015; 496:863-77. [PMID: 26456249 DOI: 10.1016/j.ijpharm.2015.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/04/2015] [Indexed: 10/22/2022]
Abstract
This study reports the use of biocompatible and biodegradable polymers for the formulation and design of an implantable multipolymeric drug delivery device (MDDD) for the management of AIDS dementia complex (ADC), a debilitating condition affecting the cognitive, motor and behavioral systems in HIV+ individuals. A 3-factor Box-Behnken statistical design was employed for the optimization of nanoparticle and multipolymeric scaffold formulations. Fifteen formulations were generated using the Box-Behnken template, which were assessed for physicochemical and physicomechanical characterization. The optimised nanoparticle formulation yielded nanoparticles measuring 68.04nm in size and zeta potential (ZP) of -13.4mV was calculated for the colloidal system. In an attempt to further retard drug release and to formulate a device for implantation in the frontal lobe of the brain, nanoparticles were dispersed within a multipolymeric matrix. Matrix erosion was calculated at 28% for multipolymeric scaffold and a matrix resilience of 4.451% was observed 30 days post exposure to PBS, indicating slow degradation of the MDDD. In vivo studies showed 12.793ng/mL and 35.225ng/mL AZT level in plasma and CSF. In view of the physicomechanical properties, in vitro and in vivo drug release kinetics of MDDD makes it a potential candidate for the management of the ADC.
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Affiliation(s)
- Sheri-Lee Harilall
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Yahya E Choonara
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Lomas Kumar Tomar
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Charu Tyagi
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Pradeep Kumar
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Lisa C du Toit
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Girish Modi
- Department of Neurology, Division of Neurosciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Dinesh Naidoo
- Department of Neurosurgery, Division of Neurosciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Sunny E Iyuke
- School of Chemical and Metallurgical Engineering, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael P Danckwerts
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa
| | - Viness Pillay
- Wits Advanced Drug Delivery Platform Research Unit, Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa.
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Cassol E, Misra V, Morgello S, Gabuzda D. Applications and limitations of inflammatory biomarkers for studies on neurocognitive impairment in HIV infection. J Neuroimmune Pharmacol 2013; 8:1087-97. [PMID: 24259252 PMCID: PMC3889222 DOI: 10.1007/s11481-013-9512-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 10/23/2013] [Indexed: 12/31/2022]
Abstract
Despite reduced prevalence of severe forms of HIV-associated neurocognitive disorders (HAND) on current antiretroviral therapy (ART) regimens, milder forms of neurocognitive impairment (NCI) remain prevalent in HIV-infected populations. These mild forms of HAND consist of subtypes, probably reflecting distinct, though possibly overlapping, pathophysiological mechanisms. Factors associated with HAND in HIV patients with prolonged viral suppression on ART include older age, low nadir CD4, active HCV co-infection, and cardiovascular risk factors, but underlying mechanisms and their relationship to innate immune activation, chronic inflammation, and other features of systemic disease are poorly understood. In this article, we discuss applications and limitations of plasma inflammatory biomarkers for studies on HAND in HIV patients on ART and describe an analysis pipeline to reduce common sources of noise and increase likelihood of identifying relevant inflammatory biomarkers. Clinical covariates and comorbidities that influence inflammatory biomarkers, such as aging, obesity, metabolic abnormalities, HCV co-infection, and substance abuse, are also reviewed. As an example for using this analytic pipeline, we present an exploratory study of 22 plasma inflammatory biomarkers (IFN-α 2b and -γ, 16 cytokines/chemokines, sIL-2R, sCD14, HA, and YKL-40) in a cohort of HIV-infected individuals with advanced disease, frequent HCV co-infection, and viral suppression on ART. The identification of inflammatory biomarkers associated with HAND in HIV+ patients on ART may be useful to distinguish between HAND subtypes with distinct pathophysiology, and is important for achieving a systems-level understanding of the biology of these disorders, developing effective therapies, and evaluating therapeutic outcomes.
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Affiliation(s)
- Edana Cassol
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA USA
| | - Vikas Misra
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA USA
| | | | - Dana Gabuzda
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA USA
- Dana Farber Cancer Institute, 450 Brookline Avenue CLS 1010, Boston, MA 02215 USA
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Dahiya S, Irish BP, Nonnemacher MR, Wigdahl B. Genetic variation and HIV-associated neurologic disease. Adv Virus Res 2013; 87:183-240. [PMID: 23809924 DOI: 10.1016/b978-0-12-407698-3.00006-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
HIV-associated neurologic disease continues to be a significant complication in the era of highly active antiretroviral therapy. A substantial subset of the HIV-infected population shows impaired neuropsychological performance as a result of HIV-mediated neuroinflammation and eventual central nervous system (CNS) injury. CNS compartmentalization of HIV, coupled with the evolution of genetically isolated populations in the CNS, is responsible for poor prognosis in patients with AIDS, warranting further investigation and possible additions to the current therapeutic strategy. This chapter reviews key advances in the field of neuropathogenesis and studies that have highlighted how molecular diversity within the HIV genome may impact HIV-associated neurologic disease. We also discuss the possible functional implications of genetic variation within the viral promoter and possibly other regions of the viral genome, especially in the cells of monocyte-macrophage lineage, which are arguably key cellular players in HIV-associated CNS disease.
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Affiliation(s)
- Satinder Dahiya
- Department of Microbiology and Immunology, Center for Molecular Virology and Translational Neuroscience, Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Bryan P Irish
- Department of Microbiology and Immunology, Center for Molecular Virology and Translational Neuroscience, Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael R Nonnemacher
- Department of Microbiology and Immunology, Center for Molecular Virology and Translational Neuroscience, Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Brian Wigdahl
- Department of Microbiology and Immunology, Center for Molecular Virology and Translational Neuroscience, Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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11
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Monocyte activation markers in cerebrospinal fluid associated with impaired neurocognitive testing in advanced HIV infection. J Acquir Immune Defic Syndr 2012; 60:234-43. [PMID: 22569268 DOI: 10.1097/qai.0b013e318256f3bc] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Activated monocytes/macrophages play a role in severe forms of HIV-associated neurocognitive disorders (HAND), but little is known about the mechanisms driving milder forms that are prevalent despite combination antiretroviral therapy (cART). To examine relationships of monocyte activation markers to HAND of varying severity, we compared plasma and cerebrospinal fluid (CSF) biomarker levels with neurocognitive test scores in HIV+ subjects. METHODS Plasma and CSF soluble CD14 (sCD14), CCL2, and interleukin (IL) 6 were measured by enzyme-linked immunosorbent assay in 67 HIV+ subjects with nadir CD4 <300, and CSF inflammatory biomarkers were measured by multiplex assay in 14 subjects on suppressive cART. RESULTS Eighty-two percent were on cART, with 31% having undetectable plasma viral load (VL). CSF sCD14 was increased in subjects with impaired neurocognitive testing (P = 0.02), correlated inversely with global T scores in subjects with detectable but not undetectable plasma VL (P = 0.02), and yielded higher area under the receiver operating characteristic curve values for predicting impaired T scores (0.659) than plasma or CSF VL and current or nadir CD4 counts in single-marker and multivariate models. CSF sCD14, IL-6, IL-8, CCL2, CCL3, CXCL10, and interferon (IFN) gamma were increased in subjects on suppressive cART regardless of cognitive status and predicted patient class in unsupervised analyses, with IL-8, CCL2, and IFNγ explaining most of the variance. CONCLUSIONS CSF sCD14 is associated with impaired neurocognitive testing in patients with HIV on nonsuppressive cART, suggesting potential utility as a biomarker to monitor HAND progression. CSF sCD14, IL-6, IL-8, CCL2, CCL3, CXCL10, and IFNγ remain elevated in patients on suppressive cART regardless of cognitive status, implying ongoing intrathecal inflammation even in the absence of clinical manifestations.
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12
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Abstract
PURPOSE OF REVIEW The present review discusses current concepts of HIV-associated neurocognitive disorders (HAND) in the era of antiretroviral therapy (ART). As the HIV epidemic enters its fourth decade (the second decade of ART), research must address evolving factors in HAND pathogenesis. These include persistent systemic and central nervous system (CNS) inflammation, aging in the HIV-infected brain, HIV subtype (clade) distribution, concomitant use of drugs of abuse, and potential neurotoxicity of ART drugs. RECENT FINDINGS Although the severest form of HAND, HIV-associated dementia (HAD), is now rare due to ART, the persistence of milder, functionally important HAND forms persist in up to half of HIV-infected individuals. HAND prevalence may be higher in areas of Africa where different HIV subtypes predominate, and ART regimens that are more effective in suppressing CNS HIV replication can improve neurological outcomes. HAND are correlated with persistent systemic and CNS inflammation, and enhanced neuronal injury due to stimulant abuse (cocaine and methamphetamine), aging, and possibly ART drugs themselves. SUMMARY Prevention and treatment of HAND requires strategies aimed at suppressing CNS HIV replication and effects of systemic and CNS inflammation in aging and substance-abusing HIV populations. Use of improved CNS-penetrating ART must be accompanied by evaluation of potential ART neurotoxicity.
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Meeker RB, Poulton W, Markovic-Plese S, Hall C, Robertson K. Protein changes in CSF of HIV-infected patients: evidence for loss of neuroprotection. J Neurovirol 2011; 17:258-73. [PMID: 21556959 DOI: 10.1007/s13365-011-0034-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/25/2011] [Accepted: 04/04/2011] [Indexed: 12/21/2022]
Abstract
To begin to unravel the complexity of HIV-associated changes in the brain, broader, multifaceted analyses of cerebrospinal fluid (CSF) are needed that examine a wide range of proteins reflecting different functions. To provide the first broad profiles of protein changes in the CSF of HIV-infected patients, we used antibody arrays to measure 120 cytokines, chemokines, growth factors, and other proteins. CSF from HIV-infected patients with a range of cognitive deficits was compared to CSF from uninfected, cognitively normal patients to begin to identify protein changes associated with HIV infection and neurological disease progression. Uninfected patients showed relatively consistent patterns of protein expression. Highly expressed proteins in CSF included monocyte chemotactic protein-1, tissue inhibitors of metalloproteases, granulocyte colony-stimulating factor, adiponectin, soluble tumor necrosis factor receptor-1, urokinase-type plasminogen activator receptor, and insulin-like growth factor binding protein-2. Inflammatory and anti-inflammatory cytokines were expressed at low levels. HIV-infected patients showed increases in inflammatory proteins (interferon-gamma, tumor necrosis factor-alpha), anti-inflammatory proteins (IL-13), and chemokines but these correlated poorly with neurological status. The strongest correlation with increasing severity of neurological disease was a decline in growth factors, particularly, brain-derived neurotrophic factor and NT-3. These studies illustrate that HIV infection is associated with parallel changes in both inflammatory and neuroprotective proteins in the CSF. The inverse relationship between growth factors and neurological disease severity suggests that a loss of growth factor neuroprotection may contribute to the development of neural damage and may provide useful markers of disease progression.
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Affiliation(s)
- Rick B Meeker
- Department of Neurology, University of North Carolina, CB #7025, 6113 Neuroscience Research Bldg, 115 Mason Farm Road, Chapel Hill, NC 27599, USA.
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Abstract
With the introduction of combination antiretroviral therapy AIDS dementia complex or HIV-associated dementia, as it was termed later, largely disappeared in clinical practice. However, in the past few years, patients, long-term infected and treated, including those with systemically well controlled infection, started to complain about milder memory problems and slowness, difficulties in concentration, planning, and multitasking. Neuropsychological studies have confirmed that cognitive impairment occurs in a substantial (15-50%) proportion of patients. Among HIV-1-infected patients cognitive impairment was and is one of the most feared complications of HIV-1 infection. In addition, neurocognitive impairment may affect adherence to treatment and ultimately result in increased morbidity for systemic disease. So what may be going on in the CNS after so many years of apparently controlled HIV-1 infection is an urgent and important challenge in the field of HIV medicine. In this review we summarize the key currently available data. We describe the clinical neurological and neuropsychological findings, the preferred diagnostic approach with new imaging techniques and cerebrospinal fluid analysis. We try to integrate data on pathogenesis and finally discuss possible therapeutic interventions.
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Burdo TH, Ellis RJ, Fox HS. Osteopontin is increased in HIV-associated dementia. J Infect Dis 2008; 198:715-22. [PMID: 18616394 DOI: 10.1086/590504] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Since the introduction of highly active antiretroviral therapy, survival rates for human immunodeficiency virus (HIV) infection have markedly improved, but less of an effect has been found for HIV-associated neurocognitive disorders. On the basis of our previous findings, we hypothesized that increased production of osteopontin might contribute to the persistence of central nervous system (CNS) dysfunctions. We found increased levels of osteopontin in the brains of humans with HIV encephalitis and monkeys with simian immunodeficiency virus (SIV) encephalitis. In cerebrospinal fluid, osteopontin levels were found to be elevated in HIV-infected individuals, regardless of their neuropsychological status. However, plasma osteopontin levels were significantly increased in individuals with HIV-associated dementia. In addition, a longitudinal study of monkeys revealed that plasma levels of osteopontin increased before the development of SIV-induced neurological and clinical abnormalities. Thus, plasma levels of osteopontin are significantly correlated with HIV-induced CNS dysfunction in the current era of efficacious antiviral treatment, and this finding suggests that the development of interventions to modulate osteopontin production or signaling might be beneficial in the prevention or treatment of HIV-induced CNS disorders.
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Affiliation(s)
- Tricia H Burdo
- Molecular and Integrative Neurosciences Department, The Scripps Research Institute, La Jolla, California, USA
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16
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Abstract
In this review we critically assess biomarkers of the direct effects of HIV related brain disease. This area is becoming increasingly complex because of the presence of confounds and varying degrees of activity of HIV brain disease. Sensitive and specific biomarkers are urgently needed although existing biomarkers do have some utility. The review will focus on the practical implications of the more established biomarkers. We discuss blood, cerebrospinal fluid and neurophysiological biomarkers but not neuroimaging techniques as they are beyond the scope of this review.
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Affiliation(s)
- Bruce James Brew
- Departments of Neurology and HIV Medicine, St Vincent's Hospital, Sydney, Australia
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Cinque P, Brew BJ, Gisslen M, Hagberg L, Price RW. Cerebrospinal fluid markers in central nervous system HIV infection and AIDS dementia complex. HANDBOOK OF CLINICAL NEUROLOGY 2007; 85:261-300. [PMID: 18808988 DOI: 10.1016/s0072-9752(07)85017-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Paola Cinque
- Clinic of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
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Chang L, Ernst T, St Hillaire C, Conant K. Antiretroviral Treatment Alters Relationship between Mcp-1 and Neurometabolites in HIV Patients. Antivir Ther 2004; 9:431-40. [PMID: 15259906 DOI: 10.1177/135965350400900302] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective The relationships between neurometabolites and macrophage chemoattractant protein (MCP-1) in serum and cerebrospinal fluid (CSF) were evaluated in HIV patients before and after antiretroviral treatment. Design: Prior studies found higher CSF MCP-1 levels in patients with HIV-associated dementia compared to those in neuroasymptomatic. We hypothesized that CSF MCP-1 levels would correlate inversely to neuronal metabolites [including N-acetyl compounds, gluta-mate+glutamine, as assessed by principal component analyses (PCA)] and positively to glial metabolites (including myo-inositol and choline compounds). Methods Thirty-nine antiretroviral-naive HIV patients were evaluated prospectively with proton magnetic resonance spectroscopy (1H MRS), and serum and CSF MCP-1 measurements prior to highly active antiretroviral therapy (HAART); 31 of these patients completed follow-up studies after 3 months of HAART but only 24 had follow-up CSF studies. Results After HAART, brain metabolites and clinical signs showed no change despite improvements in systemic (CD4 counts, plasma viral load, MCP-1) and CSF (viral load and MCP-1) variables. CSF, but not serum, MCP-1 levels correlated inversely with the neuronal component (from PCA) prior to treatment ( r=-0.59, P=0.0008). Conversely, after 3 months of HAART, the glial component (from PCA) correlated positively with CSF MCP-1 levels ( r=0.70, P=0.0002; ANCOVA interaction for treatment status, P=0.003). Conclusions These findings suggest that higher CSF MCP-1 levels are associated with neuronal dysfunction in untreated patients. After 3 months of HAART, the decreased systemic factors (viral burden, systemically derived MCP-1) no longer associate with neuronal dysfunction, but subjects with the strongest glial response in the brain continue to produce the highest levels of MCP-1.
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Affiliation(s)
- Linda Chang
- Department of Medicine, John A. Burns School of Medicine, University of Hawai, Honolulu, HI, USA.
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Stark M, Danielsson O, Griffiths WJ, Jörnvall H, Johansson J. Peptide repertoire of human cerebrospinal fluid: novel proteolytic fragments of neuroendocrine proteins. JOURNAL OF CHROMATOGRAPHY. B, BIOMEDICAL SCIENCES AND APPLICATIONS 2001; 754:357-67. [PMID: 11339279 DOI: 10.1016/s0378-4347(00)00628-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Polypeptides in human cerebrospinal fluid (CSF), isolated by phase separation in chloroform-methanol-water and reversed-phase HPLC, were characterised by sequence analysis and mass spectrometry. This identified the presence of peptide fragments of testican, neuroendocrine specific protein VGF, neuroendocrine protein 7B2, chromogranin B/secretogranin I, chromogranin A, osteopontin, IGF-II E-peptide and proenkephalin. The majority of these fragments were generated by proteolysis at dibasic sites, suggesting that they are derived by activities related to prohormone convertase(s). Several of the fragments have previously not been detected, and their functions in CSF or elsewhere are unknown. A characteristic feature of all these fragments is a very high content of acidic residues, in particular glutamic acid. In addition to the fragments of neuroendocrine proteins, endothelin-binding receptor-like protein 2, ribonuclease 1, IGF-binding protein 6, albumin, alpha1-acid glycoprotein 1, prostaglandin-H2 D-isomerase, apolipoprotein A1, transthyretin, beta2-microglobulin, ubiquitin, fibrinopeptide A, and C4A anaphylatoxin were found.
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Affiliation(s)
- M Stark
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
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Abstract
HIV-1 infects the central nervous system (CNS) and it has been feared that the CNS may be a sanctuary site where HIV-1 could hide and continue to replicate despite otherwise effective antiretroviral treatment. Neurological HIV-1 related symptoms, cerebrospinal fluid (CSF) viral load, intrathecal immunoactivation and CSF drug concentration measurements are considered in this review of antiretroviral treatment effects on CNS HIV-1 infection. We conclude that antiretroviral combination treatment regimens improve neurocognitive symptoms in HIV-1 infection and substantially lower CSF viral load. The threat of an increasing number of patients with neurological symptoms and continued HIV-1 replication in the brain despite otherwise effective antiretroviral therapy has not yet proved to be a problem. It is, however, important to keep this potential risk in mind, and more longitudinal prospective studies addressing the issue of antiretroviral treatment effects on CNS HIV-1 infection are needed.
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Affiliation(s)
- M Gisslén
- Department of Infectious Diseases, Sahlgrenska University Hospital, Göteborg, Sweden.
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