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Klaus T, Wilson A, Fichter M, Bros M, Bopp T, Grabbe S. The Role of LFA-1 for the Differentiation and Function of Regulatory T Cells—Lessons Learned from Different Transgenic Mouse Models. Int J Mol Sci 2023; 24:ijms24076331. [PMID: 37047302 PMCID: PMC10094578 DOI: 10.3390/ijms24076331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Regulatory T cells (Treg) are essential for the maintenance of peripheral tolerance. Treg dysfunction results in diverse inflammatory and autoimmune diseases with life-threatening consequences. β2-integrins (CD11a-d/CD18) play important roles in the migration of leukocytes into inflamed tissues and cell signaling. Of all β2-integrins, T cells, including Treg, only express CD11a/CD18, termed lymphocyte function-associated antigen 1 (LFA-1), on their surface. In humans, loss-of-function mutations in the common subunit CD18 result in leukocyte adhesion deficiency type-1 (LAD-1). Clinical symptoms vary depending on the extent of residual β2-integrin function, and patients may experience leukocytosis and recurrent infections. Some patients can develop autoimmune diseases, but the immune processes underlying the paradoxical situation of immune deficiency and autoimmunity have been scarcely investigated. To understand this complex phenotype, different transgenic mouse strains with a constitutive knockout of β2-integrins have been established. However, since a constitutive knockout affects all leukocytes and may limit the validity of studies focusing on their cell type-specific role, we established a Treg-specific CD18-floxed mouse strain. This mini-review aims to delineate the role of LFA-1 for the induction, maintenance, and regulatory function of Treg in vitro and in vivo as deduced from observations using the various β2-integrin-deficient mouse models.
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Parab S, Doshi G. The Experimental Animal Models in Psoriasis Research: A Comprehensive Review. Int Immunopharmacol 2023; 117:109897. [PMID: 36822099 DOI: 10.1016/j.intimp.2023.109897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/31/2023] [Accepted: 02/11/2023] [Indexed: 02/23/2023]
Abstract
Psoriasis is an autoimmune, chronic, inflammatory skin condition mediated by T cells. It differs from other inflammatory conditions by causing significant alterations in epidermal cell proliferation and differentiation that are both complicated and prominent. The lack of an appropriate animal model has significantly hindered studies into the pathogenic mechanisms of psoriasis since animals other than humans typically do not exhibit the complex phenotypic features of human psoriasis. A variety of methods, including spontaneous mutations, drug-induced mutations, genetically engineered animals, xenotransplantation models, and immunological reconstitution approaches, have all been employed to study specific characteristics in the pathogenesis of psoriasis. Although some of these approaches have been used for more than 50 years and far more models have been introduced recently, they have surprisingly not yet undergone detailed validation. Despite their limitations, these models have shown a connection between keratinocyte hyperplasia, vascular hyperplasia, and a cell-mediated immune response in the skin. The xenotransplantation of diseased or unaffected human skin onto immune-compromised recipients has also significantly aided psoriasis research. This technique has been used in a variety of ways to investigate the function of T lymphocytes and other cells, including preclinical therapeutic studies. The design of pertinent in vivo and in vitro psoriasis models is currently of utmost concern and a crucial step toward its cure. This article outlines the general approach in the development of psoriasis-related animal models, aspects of some specific models, along with their strengths and limitations.
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Affiliation(s)
- Siddhi Parab
- SVKM's Dr. Bhanuben Nanavati College of Pharmacy, V.M. Road, Vile Parle (W), Mumbai, India
| | - Gaurav Doshi
- SVKM's Dr. Bhanuben Nanavati College of Pharmacy, V.M. Road, Vile Parle (W), Mumbai, India.
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Klaus T, Wilson AS, Vicari E, Hadaschik E, Klein M, Helbich SSC, Kamenjarin N, Hodapp K, Schunke J, Haist M, Butsch F, Probst HC, Enk AH, Mahnke K, Waisman A, Bednarczyk M, Bros M, Bopp T, Grabbe S. Impaired Treg-DC interactions contribute to autoimmunity in leukocyte adhesion deficiency type 1. JCI Insight 2022; 7:162580. [PMID: 36346673 PMCID: PMC9869970 DOI: 10.1172/jci.insight.162580] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Leukocyte adhesion deficiency type 1 (LAD-1) is a rare disease resulting from mutations in the gene encoding for the common β-chain of the β2-integrin family (CD18). The most prominent clinical symptoms are profound leukocytosis and high susceptibility to infections. Patients with LAD-1 are prone to develop autoimmune diseases, but the molecular and cellular mechanisms that result in coexisting immunodeficiency and autoimmunity are still unresolved. CD4+FOXP3+ Treg are known for their essential role in preventing autoimmunity. To understand the role of Treg in LAD-1 development and manifestation of autoimmunity, we generated mice specifically lacking CD18 on Treg (CD18Foxp3), resulting in defective LFA-1 expression. Here, we demonstrate a crucial role of LFA-1 on Treg to maintain immune homeostasis by modifying T cell-DC interactions and CD4+ T cell activation. Treg-specific CD18 deletion did not impair Treg migration into extralymphatic organs, but it resulted in shorter interactions of Treg with DC. In vivo, CD18Foxp3 mice developed spontaneous hyperplasia in lymphatic organs and diffuse inflammation of the skin and in multiple internal organs. Thus, LFA-1 on Treg is required for the maintenance of immune homeostasis.
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Affiliation(s)
- Tanja Klaus
- Department of Dermatology,,Research Center for Immunotherapy, and
| | - Alicia S. Wilson
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Elisabeth Vicari
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Eva Hadaschik
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany.,Department of Dermatology, University Hospital Essen, Essen, Germany
| | - Matthias Klein
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | | | - Nadine Kamenjarin
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Katrin Hodapp
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Jenny Schunke
- Department of Dermatology,,Research Center for Immunotherapy, and
| | - Maximilian Haist
- Department of Dermatology,,Research Center for Immunotherapy, and
| | | | - Hans Christian Probst
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Alexander H. Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Karsten Mahnke
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Ari Waisman
- Research Center for Immunotherapy, and,Institute for Molecular Medicine, University of Mainz Medical Center, Mainz, Germany
| | | | - Matthias Bros
- Department of Dermatology,,Research Center for Immunotherapy, and
| | - Tobias Bopp
- Research Center for Immunotherapy, and,Institute of Immunology, University of Mainz Medical Center, Mainz, Germany
| | - Stephan Grabbe
- Department of Dermatology,,Research Center for Immunotherapy, and
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Mitroulis I, Alexaki VI, Kourtzelis I, Ziogas A, Hajishengallis G, Chavakis T. Leukocyte integrins: role in leukocyte recruitment and as therapeutic targets in inflammatory disease. Pharmacol Ther 2014; 147:123-135. [PMID: 25448040 DOI: 10.1016/j.pharmthera.2014.11.008] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 11/06/2014] [Indexed: 02/06/2023]
Abstract
Infection or sterile inflammation triggers site-specific attraction of leukocytes. Leukocyte recruitment is a process comprising several steps orchestrated by adhesion molecules, chemokines, cytokines and endogenous regulatory molecules. Distinct adhesive interactions between endothelial cells and leukocytes and signaling mechanisms contribute to the temporal and spatial fine-tuning of the leukocyte adhesion cascade. Central players in the leukocyte adhesion cascade include the leukocyte adhesion receptors of the β2-integrin family, such as the αLβ2 and αMβ2 integrins, or of the β1-integrin family, such as the α4β1-integrin. Given the central involvement of leukocyte recruitment in different inflammatory and autoimmune diseases, the leukocyte adhesion cascade in general, and leukocyte integrins in particular, represent key therapeutic targets. In this context, the present review focuses on the role of leukocyte integrins in the leukocyte adhesion cascade. Experimental evidence that has implicated leukocyte integrins as targets in animal models of inflammatory disorders, such as experimental autoimmune encephalomyelitis, psoriasis, inflammatory bone loss and inflammatory bowel disease as well as preclinical and clinical therapeutic applications of antibodies that target leukocyte integrins in various inflammatory disorders are presented. Finally, we review recent findings on endogenous inhibitors that modify leukocyte integrin function, which could emerge as promising therapeutic targets.
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Affiliation(s)
- Ioannis Mitroulis
- Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Vasileia I Alexaki
- Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Ioannis Kourtzelis
- Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Athanassios Ziogas
- Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - George Hajishengallis
- Department of Microbiology, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Triantafyllos Chavakis
- Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
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Vasconcelos DDM, Beitler B, Martinez GA, Pereira J, Amigo Filho JU, Klautau GB, Lian YC, Della Negra M, Duarte AJDS. CD18 deficiency evolving to megakaryocytic (M7) acute myeloid leukemia: case report. Blood Cells Mol Dis 2014; 53:180-4. [PMID: 25106692 DOI: 10.1016/j.bcmd.2014.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 07/08/2014] [Accepted: 07/08/2014] [Indexed: 12/14/2022]
Abstract
Leukocyte adhesion deficiency type 1 (LAD 1 - CD18 deficiency) is a rare disease characterized by disturbance of phagocyte function associated with less severe cellular and humoral dysfunction. The main features are bacterial and fungal infections predominantly in the skin and mucosal surfaces, impaired wound healing and delayed umbilical cord separation. The infections are indolent, necrotic and recurrent. In contrast to the striking difficulties in defense against bacterial and fungal microorganisms, LAD 1 patients do not exhibit susceptibility to viral infections and neoplasias. The severity of clinical manifestations is directly related to the degree of CD18 deficiency. Here, a 20 year-old female presenting a partial CD18 deficiency that developed a megakaryocytic (M7) acute myeloid leukemia is described for the first time. The clinical features of the patient included relapsing oral thrush due to Candida, cutaneous infections and upper and lower respiratory tract infections, followed by a locally severe necrotic genital herpetic lesion. The patient's clinical features improved for a period of approximately two years, followed by severe bacterial infections. At that time, the investigation showed a megakaryocytic acute myeloid leukemia, treated with MEC without clinical improvement. The highly aggressive evolution of the leukemia in this patient suggests that adhesion molecules could be involved in the protection against the spread of neoplastic cells.
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Affiliation(s)
- Dewton de Moraes Vasconcelos
- Medical Investigation Laboratory Unit 56 (LIM/56), Faculdade de Medicina da Universidade de São Paulo, Brazil; Primary Immunodeficiency Outpatient Unit (ADEE-3003), Faculdade de Medicina da Universidade de São Paulo, Brazil.
| | - Beatriz Beitler
- Hematology Division, Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Gracia A Martinez
- Hematology Division, Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Juliana Pereira
- Hematology Division, Faculdade de Medicina da Universidade de São Paulo, Brazil
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Coriolano MC, de Melo CML, Silva FDO, Schirato GV, Porto CS, dos Santos PJP, Correia MTDS, Porto ALF, Carneiro-Leão AMDA, Coelho LCBB. Parkia pendula seed lectin: potential use to treat cutaneous wounds in healthy and immunocompromised mice. Appl Biochem Biotechnol 2014; 172:2682-93. [PMID: 24425299 DOI: 10.1007/s12010-013-0692-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 12/25/2013] [Indexed: 12/26/2022]
Abstract
Parkia pendula seed lectin was used to treat cutaneous wounds of normal and immunocompromised mice, inducing cicatrization. Methotrexate (0.8 mg/kg/week) was used as immunosuppressive drug. Wounds were produced in the dorsal region (1 cm(2)) of female albino Swiss mice (Mus musculus), health and immunocompromised. Wounds were daily topically treated with 100 μL of the following solutions: (1) control (NaCl 0.15 M), (2) control Im (0.15 M NaCl), (3) P. pendula seed lectin (100 μg/mL), and (4) P. pendula seed lectin Im (100 μg/mL). Clinical evaluation was performed during 12 days. Biopsies for histopathology analysis and microbiological examinations were carried out in the second, seventh, and 12th days. The presence of edema and hyperemia was observed in all groups during inflammatory period. The first crust was detected from the second day, only in the groups treated with P. pendula seed lectin. Microbiological analysis of wounds from day 0 to day 2 did not show bacterium at P. pendula seed lectin group; however, Staphylococcus sp. was detected every day in the other groups. The lectin markedly induced a total wound closing at P. pendula seed lectin and P. pendula seed lectin Im groups on 11th day of evolution. The present study suggests that P. pendula seed lectin is a biomaterial potential to show pharmacological effect in the repair process of cutaneous wounds.
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Affiliation(s)
- Marília Cavalcanti Coriolano
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Pernambuco, Recife, Pernambuco, 50670-420, Brazil
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Abstract
PURPOSE OF REVIEW The leukocyte adhesion deficiency (LAD) syndromes are rare genetically determined conditions with challenging clinical features. These immunodeficiencies also provide insights that are broadly relevant to the biology of leukocytes, platelets, intercellular interactions, and intracellular signaling. Recent discoveries merit their review in the context of existing knowledge. RECENT FINDINGS New activities of β(2) integrins, which are deficient or absent in LAD-I, and new β(2) integrin-dependent functions of neutrophils and other leukocytes have recently been identified. Genetic defects and mechanisms accounting for impaired fucosylation of selectin ligands and defective selectin binding and signaling in LAD-II are now apparent. LAD-III, which presents with bleeding similar to that in Glanzmann thrombasthenia and platelet dysfunction in addition to impaired leukocyte adhesion, is now known to be due to absence of KINDLIN-3, a cytoplasmic protein that acts cooperatively with TALIN-1 in activating β(1), β(2), and β(3) integrins. Understanding of the leukocyte adhesion cascade and interactions of leukocytes with inflamed endothelium, which are impaired in each of the LAD syndromes, continues to be refined. SUMMARY Although LAD syndromes are rare maladies, their investigation is generating new knowledge directly applicable to the diagnosis and care of patients and to fundamental paradigms in immunobiology and hemostasis.
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Healing activity induced by Cramoll 1,4 lectin in healthy and immunocompromised mice. Int J Pharm 2011; 408:113-9. [DOI: 10.1016/j.ijpharm.2011.02.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 02/07/2011] [Accepted: 02/08/2011] [Indexed: 12/30/2022]
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Wagner EF, Schonthaler HB, Guinea-Viniegra J, Tschachler E. Psoriasis: what we have learned from mouse models. Nat Rev Rheumatol 2010; 6:704-14. [PMID: 20877306 DOI: 10.1038/nrrheum.2010.157] [Citation(s) in RCA: 147] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Psoriasis is a common inflammatory skin disease of unknown etiology, for which there is no cure. This heterogeneous, cutaneous, inflammatory disorder is clinically characterized by prominent epidermal hyperplasia and a distinct inflammatory infiltrate. Crosstalk between immunocytes and keratinocytes, which results in the production of cytokines, chemokines and growth factors, is thought to mediate the disease. Given that psoriasis is only observed in humans, numerous genetic approaches to model the disease in mice have been undertaken. In this Review, we describe and critically assess the mouse models and transplantation experiments that have contributed to the discovery of novel disease-relevant pathways in psoriasis. Research performed using improved mouse models, combined with studies employing human cells, xenografts and patient material, will be key to our understanding of why such distinctive patterns of inflammation develop in patients with psoriasis. Indeed, a combination of genetic and immunological investigations will be necessary to develop both improved drugs for the treatment of psoriasis and novel curative strategies.
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Affiliation(s)
- Erwin F Wagner
- Fundación Banco Bilbao Vizcaya Argentaria (F-BBVA)-CNIO Cancer Cell Biology Program, Centro Nacional de Investigaciones Oncológicas, Melchor Fernández Almargo 3, 29029 Madrid, Spain.
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Oreshkova T, Wang H, Seier AM, Sindrilaru A, Varga G, Grabbe S, Scharffetter-Kochanek K, Peters T. Beta(2) integrin deficiency yields unconventional double-negative T cells distinct from mature classical natural killer T cells in mice. Immunology 2009; 128:271-86. [PMID: 19740384 DOI: 10.1111/j.1365-2567.2009.03116.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Expressed on leucocytes, beta(2) integrins (CD11/CD18) are specifically involved in leucocyte function. Using a CD18-deficient (CD18(-/-)) mouse model, we here report on their physiological role in lymphocyte differentiation and trafficking. CD18(-/-) mice present with a defect in the distribution of lymphocytes with highly reduced numbers of naïve B and T lymphocytes in inguinal and axillary lymph nodes. In contrast, cervical lymph nodes were fourfold enlarged harbouring unconventional T-cell receptor-alphabeta (TCR-alphabeta) and TCR-gammadelta CD3(+) CD4(-) CD8(-) (double-negative; DN) T cells that expanded in situ. Using adoptive transfer experiments, we found that these cells did not home to peripheral lymph nodes of CD18(wt) recipients but, like antigen-experienced T or natural killer (NK) T cells, recirculated through non-lymphoid organs. Lacking regulatory functions in vitro, CD18(-/-) TCR-alphabeta DN T cells did not suppress the proliferation of polyclonally activated CD4(+) or CD8(+) (single-positive; SP) T cells. Most interestingly, CD18(-/-) TCR-alphabeta DN T cells showed intermediate TCR expression levels, an absent activation through allogeneic major histocompatibility complex and a strong proliferative dependence on interleukin-2, hence, closely resembling NKT cells. However, our data oppose former reports, clearly showing that, because of an absent reactivity with CD1d-alphaGalCer dimers, these cells are not mature classical NKT cells. Our data indicate that CD18(-/-) TCR-alphabeta DN T cells, like NKT and TCR-gammadelta T cells, share characteristics of both adaptive and innate immune cells, and may accumulate as a compensatory mechanism to the functional defect of adaptive immunity in CD18(-/-) mice.
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Affiliation(s)
- Tsvetelina Oreshkova
- Department of Dermatology and Allergic Diseases, Ulm University, D-89081 Ulm, Germany
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Reactive oxygen intermediate-induced pathomechanisms contribute to immunosenescence, chronic inflammation and autoimmunity. Mech Ageing Dev 2009; 130:564-87. [PMID: 19632262 DOI: 10.1016/j.mad.2009.07.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 06/07/2009] [Accepted: 07/15/2009] [Indexed: 02/07/2023]
Abstract
Deregulation of reactive oxygen intermediates (ROI) resulting in either too high or too low concentrations are commonly recognized to be at least in part responsible for many changes associated with aging. This article reviews ROI-dependent mechanisms critically contributing to the decline of immune function during physiologic - or premature - aging. While ROI serve important effector functions in cellular metabolism, signalling and host defence, their fine-tuned generation declines over time, and ROI-mediated damage to several cellular components and/or signalling deviations become increasingly prevalent. Although distinct ROI-associated pathomechanisms contribute to immunosenescence of the innate and adaptive immune system, mutual amplification of dysfunctions may often result in hyporesponsiveness and immunodeficiency, or in chronic inflammation with hyperresponsiveness/deregulation, or both. In this context, we point out how imbalanced ROI contribute ambiguously to driving immunosenescence, chronic inflammation and autoimmunity. Although ROI may offer a distinct potential for therapeutic targeting along with the charming opportunity to rescue from deleterious processes of aging and chronic inflammatory diseases, such modifications, owing to the complexity of metabolic interactions, may carry a marked risk of unforeseen side effects.
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Abstract
Tissue-specific silencing of genes may be used for genetic engineering in mice and has possible therapeutic applications in humans. Current strategies in mice rely on Cre/loxP technology requiring the generation of multiple transgenic lines and breeding strategies. Here, we describe the selective silencing of CD18, a leukocyte-specific integrin in neutrophils using a micro RNA (miRNA) strategy that requires the generation of one transgenic line. CD18-specific miRNA hairpin driven by the myeloid specific human MRP8 promoter resulted in the generation of transgenic lines with 75% to 95% reduction in CD18 protein levels in neutrophils and monocytes. Minimal decreases in T cells and a partial diminution in macrophages were observed. Neutrophil CD18 silencing resulted in neutrophilia, splenomegaly, and significant defects in neutrophil trafficking with the degree of alterations correlating with the extent of CD18 silencing. Thus, our data demonstrate the utility of using miRNA approaches to silence genes in neutrophils, which are terminally differentiated cells with a short half-life that largely precludes their genetic manipulation in vitro. Furthermore, the mouse models provide a valuable tool to examine the contribution of CD18 on neutrophils to leukocyte adhesion deficiency type I (LAD-I), a complex inherited disorder in which reduced or absent CD18 expression in multiple leukocyte subsets leads to impaired innate and adaptive immune responses.
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