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Grümme L, Dombret S, Knösel T, Skapenko A, Schulze-Koops H. Colitis induced by IL-17A-inhibitors. Clin J Gastroenterol 2024; 17:263-270. [PMID: 38060157 PMCID: PMC10960887 DOI: 10.1007/s12328-023-01893-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/01/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Interleukin (IL)-17A is essential for intestinal mucosal integrity, contributing to the prevention of detrimental immunity such as infectious colitis and inflammatory bowel disease (IBD). Indeed, neutralization of IL-17A has been abandoned as a therapeutic principle in IBD because of increased disease activity. However, it is controversial whether IL-17A inhibitors increase the risk of developing colitis in patients who do not have underlying IBD. Here, we present two cases of different forms of colitis that occurred during treatment with two IL-17A inhibitors, secukinumab and ixekizumab. CASE PRESENTATIONS We report the case of a 35-year-old female with SAPHO (synovitis-acne-pustulosis-hyperostosis-osteitis) syndrome who was admitted due to severe colitis with bloody diarrhea, fever, abdominal pain and weight loss after receiving secukinumab for 3 months as well as the case of a 41-year-old male with psoriatic arthritis who presented himself to the outpatient clinic with bloody stools, abdominal pain and nausea 5 months after changing his therapy from secukinumab to ixekizumab. In both patients, treatment with IL-17A-inhibitors was stopped and tumor necrosis factor inhibitors were started. Both patients recovered, are clinically stable and show no more signs of active colitis. CONCLUSION The role of IL-17A inhibitors in the pathogenesis of infectious colitis and new-onset IBD is not fully understood and requires further research. Patients receiving IL-17A-inhibitor therapy should be carefully screened and notified of the possible side effects.
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Affiliation(s)
- Lea Grümme
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU Clinic Munich, Pettenkoferstraße 8a, 80336, Munich, Germany
| | - Sophia Dombret
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU Clinic Munich, Pettenkoferstraße 8a, 80336, Munich, Germany
| | - Thomas Knösel
- Institute of Pathology, LMU Clinic Munich, Munich, Germany
| | - Alla Skapenko
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU Clinic Munich, Pettenkoferstraße 8a, 80336, Munich, Germany
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU Clinic Munich, Pettenkoferstraße 8a, 80336, Munich, Germany.
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Saito K, Yoza K, Takeda S, Shimoyama Y, Takeuchi K. Drug-induced entero-colitis due to interleukin-17 inhibitor use; capsule endoscopic findings and pathological characteristics: A case report. World J Gastroenterol 2023; 29:4912-4919. [PMID: 37701132 PMCID: PMC10494761 DOI: 10.3748/wjg.v29.i32.4912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Interleukin-17 (IL-17) inhibitors are known to cause exacerbation or new onset of inflammatory bowel disease upon administration. However, few reports have described characteristic endoscopic and histopathologic findings, and no small intestinal lesions have been reported so far. CASE SUMMARY A woman in her 60s with psoriasis was administered ixekizumab (IXE), an anti-IL-17A antibody, for the treatment of psoriasis. Twenty months after commencing treatment, the patient visited our hospital because of persistent diarrhea. Blood tests performed at the time of the visit revealed severe inflammation, and colonoscopy revealed multiple round ulcers throughout the colon. A tissue biopsy of the ulcer revealed infiltration of inflammatory cells and granuloma-like findings in the submucosal layer. Capsule endoscopy revealed multiple jejunal erosions. After the withdrawal of IXE, the symptoms gradually improved, and ulcer reduction and scarring of the colon were endoscopically confirmed. CONCLUSION To the best of our knowledge, 17 reports have documented IL-17 inhibitor-induced entero-colitis with endoscopic images, endoscopic findings, and pathological characteristics, including the present case. Nine of these cases showed diffuse loss of vascular pattern, coarse mucosa/ulcer formation in the left colon, and endoscopic findings similar to those of ulcerative colitis. In the remaining eight cases, discontinuous erosions and ulcerations from the terminal ileum to the rectum were seen, with endoscopic findings similar to those of Crohn's disease. In this case, the findings were confirmed by capsule endoscopy, which has not been previously reported.
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Affiliation(s)
- Keita Saito
- Department of Gastroenterology, Tsujinaka Hospital Kashiwano-Ha, Kashiwa 277-0871, Japan
| | - Kiichiro Yoza
- Department of Gastroenterology, Tsujinaka Hospital Kashiwano-Ha, Kashiwa 277-0871, Japan
| | - Shinichiro Takeda
- Department of Gastroenterology, Tsujinaka Hospital Kashiwano-Ha, Kashiwa 277-0871, Japan
| | - Yoshihiro Shimoyama
- Department of Gastroenterology, Tsujinaka Hospital Kashiwano-Ha, Kashiwa 277-0871, Japan
| | - Ken Takeuchi
- Department of Gastroenterology, Tsujinaka Hospital Kashiwano-Ha, Kashiwa 277-0871, Japan
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Brabec T, Vobořil M, Schierová D, Valter E, Šplíchalová I, Dobeš J, Březina J, Dobešová M, Aidarova A, Jakubec M, Manning J, Blumberg R, Waisman A, Kolář M, Kubovčiak J, Šrůtková D, Hudcovic T, Schwarzer M, Froňková E, Pinkasová T, Jabandžiev P, Filipp D. IL-17-driven induction of Paneth cell antimicrobial functions protects the host from microbiota dysbiosis and inflammation in the ileum. Mucosal Immunol 2023; 16:373-385. [PMID: 36739089 DOI: 10.1016/j.mucimm.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/11/2023] [Indexed: 02/05/2023]
Abstract
Interleukin (IL)-17 protects epithelial barriers by inducing the secretion of antimicrobial peptides. However, the effect of IL-17 on Paneth cells (PCs), the major producers of antimicrobial peptides in the small intestine, is unclear. Here, we show that the targeted ablation of the IL-17 receptor (IL-17R) in PCs disrupts their antimicrobial functions and decreases the frequency of ileal PCs. These changes become more pronounced after colonization with IL-17 inducing segmented filamentous bacteria. Mice with PCs that lack IL-17R show an increased inflammatory transcriptional profile in the ileum along with the severity of experimentally induced ileitis. These changes are associated with a decrease in the diversity of gut microbiota that induces a severe ileum pathology upon transfer to genetically susceptible mice, which can be prevented by the systemic administration of IL-17a/f in microbiota recipients. In an exploratory analysis of a small cohort of pediatric patients with Crohn's disease, we have found that a portion of these patients exhibits a low number of lysozyme-expressing ileal PCs and a high ileitis severity score, resembling the phenotype of mice with IL-17R-deficient PCs. Our study identifies IL-17R-dependent signaling in PCs as an important mechanism that maintains ileal homeostasis through the prevention of dysbiosis.
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Affiliation(s)
- Tomáš Brabec
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic; Department of Cell Biology, Faculty of Science, Charles University, Prague, Czech Republic
| | - Matouš Vobořil
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Dagmar Schierová
- Laboratory of Anaerobic Microbiology, Institute of Animal Physiology and Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Evgeny Valter
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Iva Šplíchalová
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Jan Dobeš
- Department of Cell Biology, Faculty of Science, Charles University, Prague, Czech Republic
| | - Jiří Březina
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Martina Dobešová
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Aigerim Aidarova
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Martin Jakubec
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Jasper Manning
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Richard Blumberg
- Brigham and Women's Hospital, Gastroenterology Division, Boston, USA
| | - Ari Waisman
- Institute for Molecular Medicine, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Michal Kolář
- Laboratory of Genomics and Bioinformatics, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Jan Kubovčiak
- Laboratory of Genomics and Bioinformatics, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Dagmar Šrůtková
- Laboratory of Gnotobiology, Institute of Microbiology of the Czech Academy of Sciences, Novy Hradek, Czech Republic
| | - Tomáš Hudcovic
- Laboratory of Gnotobiology, Institute of Microbiology of the Czech Academy of Sciences, Novy Hradek, Czech Republic
| | - Martin Schwarzer
- Laboratory of Gnotobiology, Institute of Microbiology of the Czech Academy of Sciences, Novy Hradek, Czech Republic
| | - Eva Froňková
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tereza Pinkasová
- Department of Pediatric, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Jabandžiev
- Department of Pediatric, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Dominik Filipp
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic.
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Khouri A, Moreno C, Niland B. New-Onset Crohn's Disease following Initiation of Secukinumab: A Case Report and Review of the Role of IL-17 in the Pathogenesis of Crohn's Disease. Case Rep Gastrointest Med 2023; 2023:1769290. [PMID: 37260537 PMCID: PMC10228216 DOI: 10.1155/2023/1769290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 06/02/2023] Open
Abstract
Patients with autoimmune conditions show a high expression of proinflammatory cytokines including interleukin (IL)-17. While IL-17 inhibitors have demonstrated efficacy in managing autoimmune disorders, rare instances of de novo or exacerbated inflammatory bowel disease (IBD) have been reported. The factors that affect the onset and severity remain unclear. Here, we present a case of a 38-year-old female who developed manifestations of Crohn's disease within 1 month of initiating secukinumab treatment for psoriatic arthritis, in addition to a review of the role of IL-17 in the pathophysiology of Crohn's disease.
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Affiliation(s)
- Anas Khouri
- Department of Internal Medicine, University of South Alabama, Mobile, AL, USA
| | - Cesar Moreno
- Department of Internal Medicine, University of South Alabama, Mobile, AL, USA
| | - Benjamin Niland
- Department of Internal Medicine, University of South Alabama, Mobile, AL, USA
- Division of Gastroenterology, University of South Alabama, Mobile, AL, USA
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Deng Z, Wang S, Wu C, Wang C. IL-17 inhibitor-associated inflammatory bowel disease: A study based on literature and database analysis. Front Pharmacol 2023; 14:1124628. [PMID: 37033665 PMCID: PMC10076642 DOI: 10.3389/fphar.2023.1124628] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Objective: Few real-world studies have shown clear association between interleukin (IL)-17 inhibitors and inflammatory bowel disease (IBD) onset. This study investigated the reporting prevalence and evaluated the clinical features and management of IL-17 inhibitor-related IBD events. Methods: We used the US FDA Adverse Event Reporting System database and retrieved data, from 2015 to 2022, on IL-17 inhibitors to identify gastrointestinal inflammatory events and conduct disproportionality analyses by estimating the reporting odds ratios (RORs) and corresponding 95% confidence intervals (CIs). Furthermore, case reports and case series, from 2015 to 30 November 2022, on IBD induced by IL-17 inhibitors were collected for retrospective analysis. Results: A total of 388 cases of primary suspected IL-17 inhibitor-associated gastrointestinal events were reported (268 IBD and 120 colitis), including 348 cases involving secukinumab (SEC), 36 cases involving ixekizumab (IXE), and 4 cases involving brodalumab (BRO). Statistically significant reporting rates of total IBD events were observed for SEC and IXE (ROR = 2.13, 95% CI [1.96-2.30] and ROR = 2.79, 95% CI [2.39-3.27], respectively), whereas BRO did not trigger a safety signal. Twenty-nine studies, which included 34 cases, showed evidence of IBD, following SEC (79.4%) and IXE (20.6%) treatment. The median age was 42 years; typical initial symptoms included diarrhea (90.9%), abdominal pain (57.6%), bloody diarrhea (51.5%), and fever (36.4%). The median time to onset of IBD symptoms was 2.9 months. Some cases were accompanied by elevated white blood cell (WBC) count (87.5%), erythrocyte sedimentation rate (ESR; 85.7%), C-reactive protein (CRP; 100%), and fecal calprotectin (FC; 100%). Cessation of IL-17 inhibitors plus treatment with corticosteroids and TNF antagonists, as either monotherapy or in combination, could lead to complete clinical remission. The median time to remission after IL-17 inhibitor discontinuation was 4 weeks. Conclusion: IL-17 inhibitor treatment is associated with exacerbation and new onset of IBD and colitis. Obtaining a detailed patient history before initiation of treatment and monitoring gastrointestinal symptoms and intestinal inflammatory biomarkers during IL-17 inhibitor treatment is important for safe use of these drugs.
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Esme P, Akoglu G, Dalkıran CD, Caliskan E. Certolizumab Pegol in the Treatment of Severe Hidradenitis Suppurativa After Adalimumab Failure: A Real-Life Experience. Dermatol Ther 2022; 35:e15782. [PMID: 35996992 DOI: 10.1111/dth.15782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/23/2022] [Accepted: 08/18/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There exists an unmet need to treat hidradenitis suppurativa (HS) despite several approved therapeutic agents for its treatment. We sought to investigate the role of certolizumab pegol in severe, recalcitrant HS patients unresponsive to adalimumab. PATIENTS AND METHODS This retrospective cohort includes HS patients over 18 years of age who had a history of unresponsiveness to adalimumab and whose treatments were switched to certolizumab pegol with dosing similar to psoriasis (400 mg every two weeks). For subjects who achieved a hidradenitis suppurativa clinical response (HiSCR) following 12 and 24 weeks of treatment, dermatological life quality index (DLQI), abscess, inflammatory nodule count (AN count), and International Hidradenitis Suppurativa Severity Score System (IHS4) were evaluated as outcome measures. RESULTS Eleven severe, recalcitrant HS patients with Hurley stage III HS were enrolled for this study. All patients were male and had a history of prior adalimumab exposure. Only three (27.2%) patients also had a history of using biologic agents other than adalimumab for HS. Six of 11 patients (54.5%) achieved HiSCR at week 12. However, two among these six responders lost response at week 24 despite continued therapy (HiSCR at week 24: 33.3%). The decrease in DLQI (p: 0.017 and 0.021) and IHS4 (p: 0.008 and 0.007) scores of the patients at weeks 12 and 24 showed a significant difference compared to the baseline. CONCLUSION Certolizumab pegol is a promising treatment option for severe, recalcitrant HS patients who are unresponsive to adalimumab. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Pelin Esme
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Dermatology and Venereology, Ankara, Turkey
| | - Gulsen Akoglu
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Dermatology and Venereology, Ankara, Turkey
| | - Cansu Dogan Dalkıran
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Dermatology and Venereology, Ankara, Turkey
| | - Ercan Caliskan
- University of Health Sciences, Gulhane Training and Research Hospital, Department of Dermatology and Venereology, Ankara, Turkey
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Lin X, Gaudino SJ, Jang KK, Bahadur T, Singh A, Banerjee A, Beaupre M, Chu T, Wong HT, Kim CK, Kempen C, Axelrad J, Huang H, Khalid S, Shah V, Eskiocak O, Parks OB, Berisha A, McAleer JP, Good M, Hoshino M, Blumberg R, Bialkowska AB, Gaffen SL, Kolls JK, Yang VW, Beyaz S, Cadwell K, Kumar P. IL-17RA-signaling in Lgr5 + intestinal stem cells induces expression of transcription factor ATOH1 to promote secretory cell lineage commitment. Immunity 2022; 55:237-253.e8. [PMID: 35081371 PMCID: PMC8895883 DOI: 10.1016/j.immuni.2021.12.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 07/06/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
The Th17 cell-lineage-defining cytokine IL-17A contributes to host defense and inflammatory disease by coordinating multicellular immune responses. The IL-17 receptor (IL-17RA) is expressed by diverse intestinal cell types, and therapies targeting IL-17A induce adverse intestinal events, suggesting additional tissue-specific functions. Here, we used multiple conditional deletion models to identify a role for IL-17A in secretory epithelial cell differentiation in the gut. Paneth, tuft, goblet, and enteroendocrine cell numbers were dependent on IL-17A-mediated induction of the transcription factor ATOH1 in Lgr5+ intestinal epithelial stem cells. Although dispensable at steady state, IL-17RA signaling in ATOH1+ cells was required to regenerate secretory cells following injury. Finally, IL-17A stimulation of human-derived intestinal organoids that were locked into a cystic immature state induced ATOH1 expression and rescued secretory cell differentiation. Our data suggest that the cross talk between immune cells and stem cells regulates secretory cell lineage commitment and the integrity of the mucosa.
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Affiliation(s)
- Xun Lin
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Stephen J Gaudino
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Kyung Ku Jang
- Kimmel Center for Biology and Medicine at the Skirball Institute, New York University Grossman School of Medicine, New York, NY, USA
| | - Tej Bahadur
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Ankita Singh
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Anirban Banerjee
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Michael Beaupre
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Timothy Chu
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Hoi Tong Wong
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Chang-Kyung Kim
- Department of Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Cody Kempen
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Huakang Huang
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Saba Khalid
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Vyom Shah
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Onur Eskiocak
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Olivia B Parks
- University of Pittsburgh School of Medicine, Medical Scientist Training Program, Pittsburgh, PA 15213, USA
| | - Artan Berisha
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA
| | - Jeremy P McAleer
- Department of Pharmaceutical Science, Marshall University School of Pharmacy, Huntington, WV 25701, USA
| | - Misty Good
- Washington University School of Medicine, Department of Pediatrics, Division of Newborn Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA
| | - Miko Hoshino
- Department of Biochemistry and Cellular Biology, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Tokyo 187-8502, Japan
| | - Richard Blumberg
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Agnieszka B Bialkowska
- Department of Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Sarah L Gaffen
- Division of Rheumatology and Clinical Immunology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Jay K Kolls
- Center for Translational Research in Infection and Inflammation, Tulane School of Medicine, New Orleans, LA 70112, USA
| | - Vincent W Yang
- Department of Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Semir Beyaz
- Cold Spring Harbor Laboratory, Cold Spring Harbor, NY 11724, USA
| | - Ken Cadwell
- Kimmel Center for Biology and Medicine at the Skirball Institute, New York University Grossman School of Medicine, New York, NY, USA; Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; Department of Microbiology, New York University Grossman School of Medicine, New York, NY 10016, USA.
| | - Pawan Kumar
- Department of Microbiology and Immunology, Stony Brook University, Stony Brook, NY, USA.
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