History of oral tolerance and mucosal immunity

Supplementation of Yeast Cell Wall Fraction Tends to Improve Intestinal Health in Adult Dogs Undergoing an Abrupt Diet Transition

When owners decide to change their pet's food, a rapid transition may cause gastrointestinal distress. Yeast products may help with digestive upset during diet transition due to the bioactive compounds they possess, which may lead to improved intestinal morphology and integrity, modified gut microbiota, and modulated immune responses. The objective of this study was to determine the effects of a yeast cell wall fraction supplement on measures of gut integrity and fecal characteristics of adult dogs undergoing an abrupt diet transition. Twelve adult female beagles (mean age: 5.16 ± 0.87 years; mean body weight: 13.37 ± 0.68 kg) were used in a replicated 4 × 4 Latin square design with four 28-day experimental periods. During days 1-14, dogs were fed a dry kibble diet and supplemented with a placebo (cellulose; 125 mg/d) or yeast product (365 mg/d; equivalent to 0.2% of diet). During days 15-28, dogs remained on their placebo or yeast treatments but were rapidly transitioned to a canned diet or high-fiber diet. Fresh fecal samples were collected on days 13, 16, 20, 24, and 27 for measurement of pH, dry matter, calprotectin, immunoglobulin A (IgA), Escherichia coli, and Clostridium perfringens. Blood samples were collected on days 14, 17, and 28 to measure serum lipopolysaccharide-binding protein concentrations. All data were analyzed using the Mixed Models procedure of SAS 9.4. Fecal pH, dry matter, calprotectin, IgA, and E. coli were not affected (P > 0.05) by treatment before diet transition. Dogs supplemented with yeast cell wall fraction tended to have higher (P = 0.06) fecal C. perfringens counts than the controls. After diet transition, most parameters were not altered (P > 0.05) by treatment except that yeast-supplemented dogs tended to have higher (P = 0.06) fecal IgA than controls. Our results suggest that the yeast product may modestly improve intestinal health after an abrupt diet transition in adult dogs by enhancing intestinal immunity.

Oral sex is associated with reduced incidence of recurrent miscarriage

A possible way of immunomodulation of the maternal immune system before pregnancy would be exposure to paternal antigens via seminal fluid to oral mucosa. We hypothesized that women with recurrent miscarriage have had less oral sex compared to women with uneventful pregnancy. In a matched case control study, 97 women with at least three unexplained consecutive miscarriages prior to the 20^th week of gestation with the same partner were included. Cases were younger than 36 years at time of the third miscarriage. The control group included 137 matched women with an uneventful pregnancy. The association between oral sex and recurrent miscarriage was assessed with conditional logistic regression, odds ratios (ORs) were estimated. Missing data were imputed using Imputation by Chained Equations. In the matched analysis, 41 out of 72 women with recurrent miscarriage had have oral sex, whereas 70 out of 96 matched controls answered positive to this question (56.9% vs. 72.9%, OR 0.50 95%CI 0.25-0.97, p = 0.04). After imputation of missing exposure data (51.7%), the association became weaker (OR 0.67, 95%CI 0.36-1.24, p = 0.21). In conclusion, this study suggests a possible protective role of oral sex in the occurrence of recurrent miscarriage in a proportion of the cases. Future studies in women with recurrent miscarriage explained by immune abnormalities should reveal whether oral exposure to seminal plasma indeed modifies the maternal immune system, resulting in more live births.

Murine models for mucosal tolerance in allergy

Immunity is established by a fine balance to discriminate between self and non-self. In addition, mucosal surfaces have the unique ability to establish and maintain a state of tolerance also against non-self constituents such as those represented by the large numbers of commensals populating mucosal surfaces and food-derived or air-borne antigens. Recent years have seen a dramatic expansion in our understanding of the basic mechanisms and the involved cellular and molecular players orchestrating mucosal tolerance. As a direct outgrowth, promising prophylactic and therapeutic models for mucosal tolerance induction against usually innocuous antigens (derived from food and aeroallergen sources) have been developed. A major theme in the past years was the introduction of improved formulations and novel adjuvants into such allergy vaccines. This review article describes basic mechanisms of mucosal tolerance induction and contrasts the peculiarities but also the interdependence of the gut and respiratory tract associated lymphoid tissues in that context. Particular emphasis is put on delineating the current prophylactic and therapeutic strategies to study and improve mucosal tolerance induction in allergy.

Diabetes tolerogenic vaccines targeting antigen-specific inflammation

Tolerance controls the magnitude of inflammation, and balance between beneficial and harmful effects of inflammation is crucial for organ function and survival. Inadequate tolerance leads to various inflammatory diseases. Antigen specific tolerance is ideal for inflammation control as alternative anti-inflammatory interventions are non-specific and consequently increase the risk of infection and tumorigenesis. With inherent antigen specificity, tolerogenic vaccines are potentially ideal for control of inflammation. Although the concept of tolerogenic vaccines is still in its infancy, tolerogenic mucosal vaccines and specific immuno-therapies have long been proven effective in pioneering examples. Now a body of evidence supporting the concept of tolerogenic vaccines has also accumulated. Here we comment on recent successes of the tolerogenic vaccine concept, present new evidence with a type 1 diabetes vaccine as an example and draw conclusions on the advantages and potential for inflammatory disease control at the bedside.

[Prostaglandins and the immune response at the intestinal submucosal level. A potential site for interference with the repeated use of paracetamol and ibuprofen at a young age?]

Immune deviations have been shown to exponentially increase in young children. As a consequence, research investigating possible environmental reasons for this increase is considered a public health priority. An improved understanding of the immunity of the intestinal submucosal lamina propria has demonstrated the importance of prostaglandins (PGE2s) on its local development with general immune consequences further on. PGE2s appear at this intestinal submucosal level from the metabolism of arachidonic acid mediated by type-2 cyclooxygenases (COX2s) situated in the membranes of many immune cells. The potential risk of repeated inhibition of PGE2 synthesis at a young age has been demonstrated in experiments with animals systemically exposed to a non-steroidal anti-inflammatory drug (NSAID). The repeatedly exposed animal cannot develop tolerance to food antigens and exhibits autoimmune deviations. Acetaminophen (paracetamol) and ibuprofen are analgesic and antipyretic medications given to children either alone or in combination, most often without medical prescription. Recently, it has been demonstrated that paracetamol, like ibuprofen, also carries, besides its central action, a non-selective inhibitory action on peripheral COXs. However, this inhibitory action only relates to physiological concentrations of arachidonic acid and explains the difference in their respective anti-inflammatory effects. Since recently published data have repeatedly reported an increase of immune deviations associated with paracetamol exposure at a young age, it appears important to better understand the possible negative impact of excessive and repetitive inhibitions of the physiological synthesis of prostaglandins by COX2s in childhood during which all immune mechanisms are built up at the intestinal submucosal level. Therefore, a well-designed prospective strategy for pharmacovigilance of these COX inhibitors repeatedly given during childhood is urgently needed.

Toxoplasma gondii oral infection induces intestinal inflammation and retinochoroiditis in mice genetically selected for immune oral tolerance resistance

Toxoplasmosis is a worldwide disease with most of the infections originating through the oral route and generates various pathological manifestations, ranging from meningoencephalitis to retinochoroiditis and inflammatory bowel disease. Animal models for these pathologies are scarce and have limitations. We evaluated the outcome of Toxoplasma gondii oral infection with 50 or 100 cysts of the ME-49 strain in two lines of mice with extreme phenotypes of susceptibility (TS) or resistance (TR) to immune oral tolerance. Therefore, the aim of this study was to evaluate the behaviour of TS and TR mice, orally infected by T. gondii, and determine its value as a model for inflammatory diseases study. Mortality during the acute stage of the infection for TR was 50% for both dosages, while 10 and 40% of the TS died after infection with these respective dosages. In the chronic stage, the remaining TS succumbed while TR survived for 90 days. The TS displayed higher parasite load with lower intestinal inflammation and cellular proliferation, notwithstanding myocarditis, pneumonitis and meningoencephalitis. TR presented massive necrosis of villi and crypt, comparable to inflammatory bowel disease, with infiltration of lymphoid cells in the lamina propria of the intestines. Also, TR mice infected with 100 cysts presented intense cellular infiltrate within the photoreceptor layer of the eyes, changes in disposition and morphology of the retina cell layers and retinochoroiditis. During the infection, high levels of IL-6 were detected in the serum of TS mice and TR mice presented high amounts of IFN-γ and TNF-α. Both mice lineages developed different disease outcomes, but it is emphasized that TR and TS mice presented acute and chronic stages of the infection, demonstrating that the two lineages offer an attractive model for studying toxoplasmosis.

Toxic effects of maternal zearalenone exposure on intestinal oxidative stress, barrier function, immunological and morphological changes in rats

The present study was conducted to investigate the effects of maternal zearalenone (ZEN) exposure on the intestine of pregnant Sprague-Dawley (SD) rats and its offspring. Ninety-six pregnant SD rats were randomly divided into four groups and were fed with diets containing ZEN at concentrations of 0.3 mg/kg, 48.5 mg/kg, 97.6 mg/kg or 146.0 mg/kg from gestation days (GD) 1 to 7. All rats were fed with mycotoxin-free diet until their offspring were weaned at three weeks of age. The small intestinal fragments from pregnant rats at GD8, weaned dams and pups were collected and studied for toxic effects of ZEN on antioxidant status, immune response, expression of junction proteins, and morphology. The results showed that ZEN induced oxidative stress, affected the villous structure and reduced the expression of junction proteins claudin-4, occludin and connexin43 (Cx43) in a dose-dependent manner in pregnant rats. Different effects on the expression of cytokines were also observed both in mRNA and protein levels in these pregnant groups. Ingestion of high levels of ZEN caused irreversible damage in weaned dams, such as oxidative stress, decreased villi hight and low expression of junction proteins and cytokines. Decreased expression of jejunal interleukin-8 (IL-8) and increased expression of gastrointestinal glutathione peroxidase (GPx2) mRNA were detected in weaned offspring, indicating long-term damage caused by maternal ZEN. We also found that the Nrf2 expression both in mRNA and protein levels were up-regulated in the ZEN-treated groups of pregnant dams and the high-dose of ZEN group of weaned dams. The data indicate that modulation of Nrf2-mediated pathway is one of mechanism via which ZEN affects gut wall antioxidant and inflammatory responses.

Gut immune response in the presence of hepatitis C virus infection

Hepatitis C virus (HCV) is an important etiologic agent of hepatitis and a major cause of chronic liver infection that often leads to cirrhosis, fibrosis and hepatocellular carcinoma. Although, HCV is a hepatotropic virus, there is strong evidence that HCV could replicate extra-hepatic in the gastrointestinal tissue which could serve as a reservoir for HCV. The outcome of HCV infection depends mainly on the host innate and adaptive immune responses. Innate immunity against HCV includes mainly nuclear factor cells and activation of IFN-related genes. There is an immunologic link between the gut and the liver through a population of T-cells that are capable of homing to both the liver and gut via the portal circulation. However, little is known on the role of Gut immune response in HCV. In this review we discussed the immune regulation of Gut immune cells and its association with HCV pathogenesis, various outcomes of anti-HCV therapy, viral persistence and degree of liver inflammation. Additionally, we investigated the relationship between Gut immune responses to HCV and IL28B genotypes, which were identified as a strong predictor for HCV pathogenesis and treatment outcome after acute infection.

On the origin of immunopathology

Stranded between medicine and experimental biology, immunology is buried in its own problems and remains distant from important areas of current biology, such as evolutionary theory, developmental biology and cognitive sciences. Immunology has treated the living system merely as the place or dimension in which immune activity takes place, inserted on a misleading axis (progressive responsiveness versus no response; memory versus tolerance) which neglects the analysis of a robustly stable dynamics which is always present and is neither tolerance nor immunity-a problem currently approached as one of "regulatory" activity. However, a regulatory response also demands regulation, leading to an endless recursion and the adoption of a stimulus-response framework inevitably drives us away from the physiological processes in which lymphocytes are involved. Herein, we propose that immunological physiology, like everything else in the body is dynamic and conservative. Immunopathology, including inherited immunodeficiencies, severe forms of infectious diseases, allergy and autoimmune diseases, are interferences with this stability which frequently include oligoclonal expansions of T lymphocytes. We suggest that this decrease in clonal diversity results from a loss of the stabilizing connectivity among lymphocytes and are not simply markers of immunopathology, but are rather expressions of basic pathogenic mechanisms. The so-called autoimmune diseases are examples of this disequilibrium. In the last decade the characterization of an enormous and diversified commensal microbiota has posed a new and pressing problem: how to explain the harmonic conviviality with trillions of foreign macromolecules. In addition, robustly stable relations towards macromolecular diet can be established by simple ingestion, a state presently labeled as "oral tolerance", a problem that has been buffered for decades as anti-inflammatory protection of the gut. A major change in terminology is necessary to describe this new panorama. We focus on two important gaps in immunological discussions: (a) the organism, seen simultaneously as the medium with which the immune system is constantly in touch and as the entity that mediates the contact with external materials; and (b) the observer, the immunologist, who operates as a human being in human languaging with other human beings, and characterizes immunological specificity. We acknowledge that we are proposing radical departures from current dogma and that we should justify them. Most of what we propose stem form a way of seeing called Biology of Cognition and Language, that derives from ideas of the neurobiologist/philosopher Humberto Maturana, also known as "autopoiesis theory".

Detection of intestinal intraepithelial lymphocytes, goblet cells and secretory IgA in the intestinal mucosa during Newcastle disease virus infection

Newcastle disease, which is caused by Newcastle disease virus (NDV), is a highly contagious viral disease of poultry and other bird species. The mucosa is the first line of defence to invading pathogens, including NDV, and it has been confirmed that the mucosa can contribute to host protection. This study was conducted to evaluate the intestinal mucosal immunology in NDV infection. Forty specific-pathogen-free chickens were divided into two groups, 20 birds in each group. Group 1 was inoculated with NDV by the intravenous route. Group 2 was used as the control group and was given sterile phosphate-buffered saline by the same route. At 24, 48, 72, and 96 h post infection (h.p.i.), five chickens from each treatment were killed. Samples of the duodenum, jejunum, and ileum were collected to quantify intestinal intraepithelial lymphocytes (IEL), goblet cells and secretory IgA (sIgA) by cytochemistry and immunohistochemistry analysis. The results indicated that IEL were increased from 24 to 72 h.p.i. in the infected tissues, and were significantly higher than in the control group at 48 h.p.i. (P < 0.01). In contrast to IEL, goblet cell numbers were reduced dramatically from 24 to 96 h.p.i. in the infected birds (P < 0.01) Furthermore, the content of sIgA was significantly higher at 48 and 72 h.p.i. in the infected tissues (P < 0.01). sIgA positivity was observed in the epithelial lining of the intestinal mucosa. These data suggest that IEL, goblet cells, and sIgA were involved in the intestinal mucosal immunity against NDV infection.

Intestinal microbiology in early life: specific prebiotics can have similar functionalities as human-milk oligosaccharides

Human milk is generally accepted as the best nutrition for newborns and has been shown to support the optimal growth and development of infants. On the basis of scientific insights from human-milk research, a specific mixture of nondigestible oligosaccharides has been developed, with the aim to improve the intestinal microbiota in early life. The mixture has been extensively studied and has been shown to be safe and to have potential health benefits that are similar to those of human milk. The specific mixture of short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides has been found to affect the development of early microbiota and to increase the Bifidobacterium amounts as observed in human-milk-fed infants. The resulting gut ecophysiology is characterized by high concentrations of lactate, a slightly acidic pH, and specific short-chain fatty acid profiles, which are high in acetate and low in butyrate and propionate. Here, we have summarized the main findings of dietary interventions with these specific oligosaccharides on the gut microbiota in early life. The gut ecophysiology in early life may have consequences for the metabolic, immunologic, and even neurologic development of the child because reports increasingly substantiate the important function of gut microbes in human health. This review highlights major findings in the field of early gut colonization and the potential impact of early nutrition in healthy growth and development.

Prolonged ingestion of ovalbumin diet by Ova sensitized mice suppresses mBSA-induced arthritis

Concomitant chronic diseases are a common finding in clinics and may consist in a major issue in therapeutics. Here, we investigated whether prolonged ingestion of ovalbumin (Ova) by sensitized mice would reduce the severity of an associated concurrent immunomediated condition such as antigen-induced arthritis (AIA). AIA was induced by administration of methylated bovine albumin (mBSA) into the knee joints of previously immunized mice, and evaluated by articular leukocyte trafficking and levels of cytokines (TNF-α, IL-1β) and chemokine (CXCL-1) in the periarticular tissue. Continuous Ova feeding by Ova sensitized mice decreased serum levels of anti-Ova IgE, and led to a significant suppression of leukocyte adhesion and infiltration into synovial tissue and cavity. Also, a marked cytokine reduction was observed, suggesting that prolonged ingestion of ovalbumin by sensitized mice suppresses specific IgE production with concomitant reduction in peripheral T cells, which may impact in the pathogenesis of AIA, a non-related condition.

Gate-keeper function of the intestinal epithelium

There is currently a major focus on the role of the gut barrier function in balancing mucosal immune responses. Increased epithelial permeability for exogenous antigens is a crucial primary or secondary event in the pathogenesis of several disorders affecting body surfaces and beyond. The epithelial gate-keeper function is determined by the individual's age (e.g. preterm vs. term infant), diet, genetics, mucus composition, interactions between mast cells, nerves and neuropeptides, concurrent infection, the commensal microbiota and the epithelium-shielding effect of secretory IgA (SIgA) antibodies provided by breast milk or produced in the individual's gut. The integrity of the epithelial barrier furthermore depends on homeostatic regulatory mechanisms, including mucosal induction of regulatory T cells, where commensal microbiota-host interactions apparently play decisive roles. Thus, both extrinsic and intrinsic factors have been identified that may have an impact on the dynamics of the epithelial cell-cell junctions in the gut and thereby increase or reduce paracellular permeability. Experiments have shown that SIgA normally cooperates with innate defence factors to protect the epithelium and reinforce its barrier function. In the absence of SIgA commensal gut bacteria overstimulate innate epithelial immunity at the expense of expression of genes that regulate fat and carbohydrate metabolism, resulting in an epithelial gene signature that correlates with the development of lipid malabsorption. This shows that the intestinal epithelial barrier is a cross-road between defence and nutrition, and that SIgA is essential to keep the balance between these two functions.

Repeated oral administration of lipopolysaccharide from Escherichia coli 0111:B4 modulated humoral immune responses in periparturient dairy cows

The objective of this study was to evaluate the effects of repeated oral exposure to LPS on humoral immune responses of periparturient dairy cows. Sixteen Holstein cows were assigned to two treatment groups 2 wk before the expected day of parturition. Cows were administered orally, twice weekly at wk -2, -1 and +1 around parturition, with the following treatments: 3 ml saline; or 3 ml of saline containing LPS from Escherichia coli 0111:B4. The amount of LPS administered during wk -2, -1, and +1 was 0.01, 0.05, or 0.1 µg/kg body weight, respectively. Multiple blood samples were collected by jugular vein and various immune and clinical variables were measured. Results indicated that, on one hand, concentrations of plasma IgG anti-LPS Abs decreased (P < 0.01) and those of IgM anti-LPS Abs increased (P < 0.01) in cows treated with oral LPS. On the other hand, there were no overall differences (P > 0.05) in the concentrations of serum amyloid A, LPS-binding protein, haptoglobin, cortisol, IgA anti-LPS Abs in the plasma, feed intake, body temperature and rumen contractions rate between the control and treatment groups. To our knowledge, this study is the first to show that repeated oral administration with LPS from E. coli 0111:B4 has the potential to stimulate humoral immune responses in periparturient dairy cows.

The early settlers: intestinal microbiology in early life

The human intestinal microbiota forms an integral part of normal human physiology, and disturbances of the normal gut microbiology have been implicated in many health and disease issues. Because newborns are essentially sterile, their microbiota must establish and develop from the very first days of life. The first colonizers play an important role in the development of the ecosystem and may impact the long-term composition and activity of the microbiota. These first settlers obviously develop and proliferate dependent on host characteristics and diet, but other factors can also significantly contribute to this vital biological process. Considering the importance of the microbiota for the human immune, metabolic, and neurological systems, it is important to understand the dynamics and driving determinants of this development. This review gives a global overview of our current understanding of the different factors impacting the intestinal microbiology in early life.

Prolonged antigen ingestion by sensitized mice ameliorates airway inflammation

Food allergy frequently precedes or coexists with respiratory allergy, and although restriction of contacts with the allergen is the elected clinical procedure, oral immunotherapy (OIT) has proven to be surprisingly efficient in clinical trials. We investigated whether prolonged restriction and voluntary exposure of previously sensitized (immunized) mice to ovalbumin (OVA) in the drinking water would alter subsequent responses to bronchial (aerosol) challenge with OVA. We found a significant suppression of bronchial inflammation, with marked reduction of eosinophils. IL-4, CCL-2, and CCL-11 are not associated with elevation in IL-10 production or Foxp3 expression, with only minor digestive symptoms.

[Implementation of the intestinal micro flora in the early stage and adequate immunity later on]

The pre and postnatal development of human immunity are remarkably continuous. The feto-placental unit builds up to promote a climate of immune tolerance specifically driven in this way by the maternal immunity. The process of birth triggers the development of the infant's postnatal immunity, in first place through the bacterial colonisation of a sterile intestinal mucosa. The progressive immune response stabilisation at the sub-mucosa level during the first year of life will arise from the interface between the host and its microflora. It will take place progressively and will occur thanks to a variety of successive and complementary very complex immune mechanisms, under the influence of a rich and diversified intestinal microbiotia. Solid scientific arguments allow hypothesising that immune deviances later in life could be the consequence of an inadequate bacterial pressure on the intestinal mucosa at the early stage. A variety of epigenetic modifications taking place in this early stage could account for the deviant programming of later immunity. Each health care provider should acknowledge that some therapeutic and nutritional interventions during the first year of life may interfere with this complex immune development, giving rise to a risk of increasing immune deviancies later on.

Anti-inflammatory glucocorticoid drugs: reflections after 60 years

This review considers the problem of the serious concomitant side effects of powerful anti-inflammatory drugs modelled upon the principal human glucocorticoid hormone, cortisol. The very nature of the original bio-assays to validate their cortisol-like hormonal and anti-inflammatory activities ensured that pleiotropic toxins were selected for clinical studies. Other complicating factors have been (1) considerable reliance on bio-assays conducted in laboratory animals that primarily secrete corticosterone, not cortisol, as their principal anti-inflammatory adrenal hormone; (2) some differences in the binding of xenobiotic cortisol analogues (vis á vis cortisol) to transport proteins, detoxifying enzymes and even some intra-cellular receptors; (3) the "rogue" properties of these hormonal xenobiotics, acting independently of--but still able to suppress--hormonal mechanisms regulating endogenous cortisol; and (4) problems of intrinsic/acquired "steroid resistance", diminishing their clinical efficacy, but not necessarily all their toxicities. The rather gloomy conclusion is that devising new drugs to reproduce the effect of multi-potent hormones may be a recipe for disaster, in contexts other than simply remedying an endocrine deficiency. Promising new developments include "designed" combination therapies that allow some reduction in total steroid doses (and hopefully their side effects); sharpening strategies to limit the actual duration of steroid administration; and resurgent interest in searching for more selective analogues (both steroidal and non-steroid) with less harmful side effects. Some oversights and neglected areas of research are also considered. Overall, it now seems timely to engage in some drastic rethinking about (retaining?) these "licensed toxins" as fundamental therapies for chronic inflammation.

Homeostatic impact of indigenous microbiota and secretory immunity

In the process of evolution, the mucosal immune system has generated two layers of anti-inflammatory defence: (1) immune exclusion performed by secretory IgA (and secretory IgM) antibodies to modulate or inhibit surface colonisation of microorganisms and dampen penetration of potentially dangerous antigens; and (2) suppressive mechanisms to avoid local and peripheral hypersensitivity to innocuous antigens, particularly food proteins and components of commensal bacteria. When induced via the gut, the latter phenomenon is called 'oral tolerance', which mainly depends on the development of regulatory T (Treg) cells in mesenteric lymph nodes to which mucosal dendritic cells (DCs) carry exogenous antigens and become conditioned for induction of Treg cells. Mucosally induced tolerance appears to be a rather robust adaptive immune function in view of the fact that large amounts of food proteins pass through the gut, while overt and persistent food allergy is not so common. DCs are 'decision makers' in the immune system when they perform their antigen-presenting function, thus linking innate and adaptive immunity by sensing the exogenous mucosal impact (e.g. conserved microbial molecular patterns). A balanced indigenous microbiota is required to drive the normal development of both mucosa-associated lymphoid tissue, the epithelial barrier with its secretory IgA (and IgM) system, and mucosally induced tolerance mechanisms including the generation of Treg cells. Notably, polymeric Ig receptor (pIgR/SC) knock-out mice that lack secretory IgA and IgM antibodies show reduced epithelial barrier function and increased uptake of antigens from food and commensal bacteria. They therefore have a hyper-reactive immune system and show predisposition for systemic anaphylaxis after sensitisation; but this development is counteracted by enhanced oral tolerance induction as a homeostatic back-up mechanism.

Food allergy: separating the science from the mythology

Numerous genes are involved in innate and adaptive immunity and these have been modified over millions of years. During this evolution, the mucosal immune system has developed two anti-inflammatory strategies: immune exclusion by the use of secretory antibodies to control epithelial colonization of microorganisms and to inhibit the penetration of potentially harmful agents; and immunosuppression to counteract local and peripheral hypersensitivity against innocuous antigens, such as food proteins. The latter strategy is called oral tolerance when induced via the gut. Homeostatic mechanisms also dampen immune responses to commensal bacteria. The mucosal epithelial barrier and immunoregulatory network are poorly developed in newborns. The perinatal period is, therefore, critical with regard to the induction of food allergy. The development of immune homeostasis depends on windows of opportunity during which innate and adaptive immunity are coordinated by antigen-presenting cells. The function of these cells is not only orchestrated by microbial products but also by dietary constituents, including vitamin A and lipids, such as polyunsaturated omega-3 fatty acids. These factors may in various ways exert beneficial effects on the immunophenotype of the infant. The same is true for breast milk, which provides immune-inducing factors and secretory immunoglobulin A, which reinforces the gut epithelial barrier. It is not easy to dissect the immunoregulatory network and identify variables that lead to food allergy. This Review discusses efforts to this end and outlines the scientific basis for future food allergy prevention.

The high affinity IgE receptor Fc epsilonRI is expressed by human intestinal epithelial cells

BACKGROUND

IgE antibodies play a paramount role in the pathogenesis of various intestinal disorders. To gain insights in IgE-mediated pathophysiology of the gut, we investigated the expression of the high affinity IgE receptor Fc epsilonRI in human intestinal epithelium.

METHODOLOGY/PRINCIPAL FINDINGS

Fc epsilonRI alpha-chain, as detected by immunohistochemistry, was positive in epithelial cells for eight of eleven (8/11) specimens from colon cancer patients and 5/11 patients with inflammation of the enteric mucosa. The Fc epsilonRIalpha positive epithelial cells co-expressed Fc epsilonRIgamma, whereas with one exception, none of the samples was positive for the beta-chain in the epithelial layer. The functionality of Fc epsilonRI was confirmed in situ by human IgE binding. In experiments with human intestinal tumor cell lines, subconfluent Caco-2/TC7 and HCT-8 cells were found to express the alpha- and gamma-chains of Fc epsilonRI and to bind IgE, whereas confluent cells were negative for gamma-chains.

CONCLUSIONS/SIGNIFICANCE

Our data provide the first evidence that the components of a functional Fc epsilonRI are in vitro expressed by the human intestinal epithelial cells depending on differentiation and, more importantly, in situ in epithelia of patients with colon cancer or gastrointestinal inflammations. Thus, a contribution of Fc epsilonRI either to immunosurveillance or pathophysiology of the intestinal epithelium is suggested.

Mucosal immunity: induction, dissemination, and effector functions

Prevention of infections by vaccination remains a compelling goal to improve public health. Most infections involve the mucosae, but the development of vaccines against many of these pathogens has yet to be successful. Mucosal vaccines would make immunization procedures easier, be better suited for mass administration, and most efficiently induce immune exclusion - a term coined for non-inflammatory antibody shielding of internal body surfaces - mediated principally by secretory immunoglobulin A (SIgA). The exported antibodies are polymeric, mainly IgA dimers (pIgA) - produced by local plasma cells stimulated by antigens that target the mucosae. SIgA was early shown to be complexed with an epithelial glycoprotein - the secretory component (SC). In 1974, a common SC-dependent transport of pIgA and pentameric IgM was proposed. From the basolateral surface, pIg-SC complexes are taken up by endocytosis and finally extruded into the lumen. Membrane SC is now referred to as polymeric Ig receptor (pIgR). In 1980, it was shown to be synthesized as a larger transmembrane protein - first cloned from rabbit and then from human. Mice deficient for pIgR showed that this is the only receptor responsible for epithelial transport of IgA and IgM. In the gut, induction of B cells occurs in gut-associated lymphoid tissue, particularly the Peyer's patches, but also in mesenteric lymph nodes. Plasma cell differentiation is accomplished in the lamina propria to which the memory/effector cells home. The airways also receive such cells from nasopharynx-associated lymphoid tissue - but by different homing receptors. Such compartmentalization is a challenge for development of mucosal vaccines.

The role of protein digestibility and antacids on food allergy outcomes

Digestion assays with simulated gastric fluid have been introduced for characterization of food proteins to imitate the effect of stomach proteolysis on dietary compounds in vitro. By using these tests, dietary proteins can be categorized as digestion-resistant class 1 (true allergens triggering direct oral sensitization) or as labile class 2 allergens (nonsensitizing elicitors). Thus the results of these digestion assays mirror situations of intact gastric proteolysis. Alterations in the gastric milieu are frequently experienced during a lifetime either physiologically in the very young and the elderly or as a result of gastrointestinal pathologies. Additionally, acid-suppression medications are frequently used for treatment of dyspeptic disorders. By increasing the gastric pH, they interfere substantially with the digestive function of the stomach, leading to persistence of labile food protein during gastric transit. Indeed, both murine and human studies reveal that antiulcer medication increases the risk of food allergy induction. Gastric digestion substantially decreases the potential of food proteins to bind IgE, which increases the threshold dose of allergens required to elicit symptoms in patients with food allergy. Thus antiulcer agents impeding gastric protein digestion have a major effect on the sensitization and effector phase of food allergy.

Sustained delayed-type hypersensitivity reaction after in vivo priming but successful induction of unresponsiveness after adoptive transfer of CD4+ effector T cells

Potential reasons for weak effects of oral tolerance in the primed immune system are still under discussion. In the present study, impacts of oral antigen uptake were studied in adoptive transfer models using T cell receptor transgenic CD4(+) T cells allowing analysis of antigen-specific donor cells on single cell level. After in vivo priming and subsequent feeding, an antigen-specific delayed-type hypersensitivity reaction was sustained. Concomitantly, donor cells preferentially found in the draining lymph nodes remained at equal numbers. In contrast, adoptively transferred Th1 cells that migrated preferentially into spleen and liver became fewer upon feeding accompanied by a suppressed delayed-type hypersensitivity reaction. Thus, antigen-experienced cells did not seem to become generally resistant to tolerogenic stimuli. Our data suggest that besides a permanent inflammatory stimulus provided by the persisting antigen, diverse tissue distribution of in vivo-induced compared to adoptively transferred effector cells might interfere with oral tolerance in the experienced immune system.

Gluten tolerance in adult patients with celiac disease 20 years after diagnosis?

BACKGROUND AND OBJECTIVE

Celiac disease (CD) is believed to be a permanent intolerance to gluten. A number of patients, however, discontinue the gluten-free diet (GFD) without developing symptoms or signs. The aim of our study was to investigate whether CD patients are capable of developing tolerance to gluten.

METHODS

All 77 adult patients from our hospital known to have biopsy-proven CD for more than 10 years were invited to participate. We investigated symptoms, gluten consumption, antibodies for CD and other autoimmunity, human leukocyte antigen (HLA)-typing, bone mineral density, and performed small bowel biopsies. Tolerance was defined as no immunological or histological signs of CD while consuming gluten.

RESULTS

Sixty-six patients accepted participation, but after review of the diagnostic biopsies 53 were found to have true CD. Twenty-three percent of patients had a gluten-containing diet, 15% admitted gluten transgression and 62% followed the GFD. Patients on a GFD had significantly more osteoporosis. Normal small bowel mucosa was found in four of eight on gluten-containing diet and in four of four with gluten transgression. Two patients were considered to have developed tolerance to gluten. One of them was HLA-DQ2/DQ8 negative.

CONCLUSION

Development of tolerance to gluten seems possible in some patients with CD. Further follow-up will show whether this tolerance is permanent or only a long-term return to latency. This feature may be associated with genetic characteristics, especially with HLA genotypes that differ from DQ2 or DQ8. More insight into the mechanisms of the development of gluten tolerance may help to distinguish those CD patients that might not require life-long GFD.

Susceptibility to nasal and oral tolerance induction to the major birch pollen allergen Bet v 1 is not dependent on the presence of the microflora

The indigenous microflora plays an integrative role in the maintenance of immunological homeostasis. Several studies reported that immunological tolerance is dependent on microbial colonization of the gut. In the present study, we investigated whether the absence of the microflora influences the sensitization process to an allergen as well as the ability to develop mucosal tolerance in a mouse model of birch pollen allergy. Germ-free or conventional BALB/c mice were intranasally or intragastrically pre-treated with the major birch pollen allergen Bet v 1 prior to sensitization with this allergen. Both germ-free and conventional mice displayed comparable Th2 biased immune responses after allergic sensitization. Oral as well as intranasal tolerization led to suppression of allergen-specific serum antibodies (IgG1, IgE, IgA) as well as cytokine production by splenocytes (IL-5, IFN-gamma) in both germ-free and conventional animals. Peyer's patches of germ-free animals were approximately 20 times smaller than in conventional animals, but the relative distribution of lymphocyte subpopulations was equal. We conclude that the absence of the microflora does not influence the ability to mount Th2 responses nor to establish tolerance towards the aeroallergen Bet v 1. Our findings may challenge the view that the commensal microflora is a key factor for breakdown of physiological tolerance and allergy development.

Proportion of peripheral blood and decidual CD4(+) CD25(bright) regulatory T cells in pre-eclampsia

CD4(+) CD25(bright) regulatory T (T(reg)) cells have been identified as a principle regulator of tolerance during pregnancy. In the setting of pre-eclampsia, however, little is known about the dynamics of these cells. In the current study, we determined CD4(+) CD25(bright) T(reg) cells in the peripheral blood using flow cytometry and forkhead box P3 (FoxP3(+)) cells at the placental bed using immunohistochemical staining. Peripheral blood mononuclear cells (PBMC) of 38 pre-eclamptic cases (17 cases Japanese, 21 cases Polish), 40 normal late pregnancy subjects (20 subjects Japanese, 20 subjects Polish), and 21 non-pregnant healthy controls (10 subjects Japanese, 11 subjects Polish) were included. We found the percentage of CD25(bright) cells within the CD4(+) T cell population in PBMC was reduced significantly in both Japanese and Polish pre-eclamptic cases than in normal pregnancy subjects (P < 0.001) and non-pregnant healthy controls (P < 0.001). Also, the percentage of FoxP3(+) cells within CD3(+) T cells in the placental bed biopsy samples of pre-eclamptic cases were decreased compared to those in normal pregnancy subjects. These findings suggest that a decreased number of T(reg) cells was present in pre-eclampsia, and these changes might break the maternal tolerance to the fetus.

Should a new tuberculosis vaccine be administered intranasally?

Most of the world's population is vaccinated with the only available vaccine against tuberculosis (TB), the Bacillus Calmette-Guérin (BCG) vaccine that was developed almost a century ago. Despite the wide coverage of the BCG vaccine, there are great variations in protective efficacy among different study populations. BCG vaccination protects against childhood forms of TB, but this immunity wanes with age, resulting in none, or insufficient, protection against adult pulmonary TB (PTB). PTB is the major disease manifestation of TB in adults and it causes death at the most productive age, further adding to poverty in already impoverished countries. Therefore, new more effective vaccines and novel immunisation strategies are urgently needed. The most common route of TB is by inhalation of tubercle bacilli leading to the establishment of a primary infection in the lung. Immunising through the nasal mucosal surface should therefore have advantage over other routes, as such vaccine administration elicits protective immune responses also in the lung, i.e. at the site of primary infection. Several new TB-vaccine candidates have been evaluated for their protective efficacy in animal models using the mucosal route of immunisation. In formulating such vaccines, the adjuvants and delivery systems are crucially important.

Systematic review: adipose tissue, obesity and gastrointestinal diseases

BACKGROUND

Obesity is increasingly being recognized as a risk factor for a number of benign and malignant gastrointestinal conditions. However, literature on the underlying pathophysiological mechanisms is sparse and ambiguous. Insulin resistance is the most widely accepted link between obesity and disease, particularly colorectal cancer. The recognition that intra-abdominal fat is immunologically active sheds new light not only on the pathogenesis of obesity-related gastrointestinal conditions, but also on inflammatory conditions such as Crohn's disease.

AIM

To describe the biology of adipose tissue, its impact on the immune system and explores the possible underlying mechanisms linking obesity to gastrointestinal diseases. It also looks at the role of mesenteric fat in determining severity and course of Crohn's disease.

METHODS

Relevant English-language literature and abstracts cited on MEDLINE database were reviewed.

RESULTS

Our recent finding of an association between obesity and subclinical bowel inflammation suggests that, apart from promoting generalized immune activation, fat also evokes local immune responses. We propose that the proinflammatory milieu promoted by obesity could underlie many of these associations and that the mechanism implicating insulin resistance may merely represent an epiphenomenon. In Crohn's disease, on the other hand, intra-abdominal fat may provide a protective mechanism.

CONCLUSION

The potential of adipose tissue as a therapeutic target is vast and needs exploration.

The changing immunological paradigm in coeliac disease

When coeliac disease is referred to as an inflammatory disorder, this may detract from its true nature. Activation of innate and adaptive immunity takes place in the mucosal lesion, but the tissue reaction is not that of classical inflammation. In fact, coeliac disease contrasts strikingly with typical inflammatory bowel disorders such as ulcerative colitis and Crohn's disease. The coeliac lesion apparently reflects, in the main, immune-driven remodelling of mucosal architecture with only a minor inflammatory component - initially most likely resulting from innate signals. Complement split products might be one of several potential initial hits that lead to activation of lamina propria and epithelial cells with release of mediators such as interleukin-15. This cytokine appears to stimulate potentially pathogenic intraepithelial lymphocytes. In genetically susceptible individuals, such early innate events could turn into persistent pathogenic signalling with subsequent adaptive cellular and humoral immunopathology resulting in a chronic lesion. Nevertheless, mucosal homeostasis is surprisingly well preserved as signified by the remarkable dominance of plasma cells that produce dimeric immunoglobulin A as a basis for enhanced secretory immunity. This shows that the microvascular endothelium in the lesion largely maintains its 'gatekeeper' function for mucosal immune cells - in striking contrast to the 'promiscuous' situation in inflammatory bowel disease. Altogether, a two-signal model is emerging for the pathogenesis of coeliac disease - signal 1 generated by innate immunity and signal 2 by adaptive immunity. Hence, there is currently an increased focus on immune activation in the epithelial compartment rather than on changes in the microvasculature as a basis for classical inflammation.

Ultrastructural anatomy of CALT follicles in the rabbit reveals characteristics of M-cells, germinal centres and high endothelial venules

Conjunctiva-associated lymphoid tissue (CALT) is a part of the eye-associated lymphoid tissue (EALT) at the ocular surface. Its lymphoid follicles are usually characterized by using light microscopy, but its ultrastructure remains largely unknown. In this study, flat whole-mount conjunctival tissues (n = 42) from 21 young adult rabbits were investigated native in reflected light, and further stained and cleared (n = 6), in paraffin histology sections (n = 6), scanning electron microscopy (SEM, n = 4) and transmission electron microscopy (TEM, n = 4). Secondary lymphoid follicles accumulated into a dense group nasally towards the lacrimal punctum of the lower lid. High endothelial venules (HEV) with typical ultrastructure occurred in the parafollicular zone. The bright germinal centre (GC) contained lymphoblasts, follicular dendritic cells, apoptotic cells and tingible body macrophages. The follicle-associated epithelium (FAE) was devoid of goblet cells and contained groups of lymphoid cells. TEM showed these cells to be located in cytoplasmic pockets of superficial electron-lucent cells with a thin cytoplasmic luminal lining that contained a fine filament meshwork and numerous endocytotic vesicles. These M-cells were sitting between and on top of the ordinary dense epithelial cells that were located basally and formed pillar-like structures. In stereoscopic SEM, the surface cells were very large, had a polygonal outline and covered cavernous spaces. The rabbit has a CALT with typical follicular morphology, including HEV for regulated lymphocyte migration and epithelial cells with ultrastructural characteristics of M-cells that allow antigen transport as indicated by the GC-reaction. The arrangement of these M-cells on top of and between epithelial pillar cells may reflect a special structural requirement of the multilayered CALT FAE.

Epicutaneously induced TGF-β-dependent tolerance inhibits experimental autoimmune encephalomyelitis

Multiple sclerosis (MS) is a devastating autoimmune disorder of the central nervous system (CNS) with limited treatment modalities. To evaluate the efficacy of epicutaneous (e.c.) tolerance induction in the prevention of CNS autoimmunity, we utilized an animal model of multiple sclerosis: experimental autoimmune encephalomyelitis (EAE). We show that application of myelin basic protein (MBP) to the skin prior to the induction of EAE by immunization with MBP protected mice from developing disease. In addition, e.c. application of MBP at the first clinical signs of EAE, also resulted in suppression of disease. This therapeutic effect was transferable to naïve recipients with lymph node cells from MBP-treated mice. These regulatory cells were found to be antigen non-specific, as suppression of EAE also occurred when the foreign antigens OVA or TNP were e.c. applied. The mechanistic basis for the tolerance was found to be the production of TGF-beta by the antigen induced toleragenic regulatory T cells. These data demonstrate that e.c.-induced regulatory T cells are potent inhibitors of antigen-specific T cell responses, and suggest that e.c. tolerization may have potential effectiveness in the treatment of autoimmune disorders.

Induction of systemic and mucosal cross-clade neutralizing antibodies in BALB/c mice immunized with human immunodeficiency virus type 1 clade A virus-like particles administered by different routes of inoculation

We have recently developed a candidate human immunodeficiency virus type 1 (HIV-1) vaccine model, based on virus-like particles (VLPs) expressing gp120 from a Ugandan HIV-1 isolate of clade A (HIV-VLP(A)s), which shows the induction of neutralizing antibodies as well as cytotoxic T lymphocytes (CTL) in BALB/c mice by intraperitoneal (i.p.) administration. In the present study, immunization experiments based on a multiple-dose regimen have been performed with BALB/c mice to compare different routes of administration. i.p. and intranasal (i.n.), but not oral, administration induce systemic as well as mucosal (vaginal and intestinal) immunoglobulin G (IgG) and IgA responses. These immune sera exhibit >50% ex vivo neutralizing activity against both autologous and heterologous primary isolates. Furthermore, the administration of HIV-VLP(A)s by the i.n. immunization route induces a specific CTL activity, although at lower efficiency than the i.p. route. The HIV-VLP(A)s represent an efficient strategy to stimulate both arms of immunity; furthermore, the induction of specific humoral immunity at mucosal sites, which nowadays represent the main port of entry for HIV-1 infection, is of great interest. All these properties, and the possible cross-clade in vivo protection, could make these HIV-VLP(A)s a good candidate for a mono- and multicomponent worldwide preventive vaccine approach not restricted to high-priority regions, such as sub-Saharan countries.

Bacterial translocation in the normal human appendix parallels the development of the local immune system

Experimental modes and pathological conditions may result in bacterial translocation (BT), that is, the passage of indigenous bacteria colonizing the intestine through the intestinal mucosa to mesenteric lymph nodes. Yet no data are available on BT in the normal human gut. We determined the occurrence of BT and its extent in histologically normal, incidentally removed human vermiform appendices (VA) from individuals of different ages and correlated the findings with the development with age of associated lymphatic tissue. BT appears to pertain to normal antigen-sampling processes of the GALT in the VA. It also parallels the development of the GALT and its maintenance during adulthood. In the first two weeks after birth, when bacterial colonization of the gut evolves and when the VA lacks the protection of secretory IgA, BT was not detected. Thereafter, BT occurs along with development of the local GALT, which is fully built up after the first year. A physiological uptake of, or invasion by, bacteria may be instrumental (1) for tolerance induction against the indigenous flora and (2) for the stimulation and normal development of the GALT.

The role of transforming growth factor-{beta} in a model of oral tolerance to the diet antigen dextrin

In a model of immunodeficiency provoked by protein deficiency, cytosol fractions from gut IELS isolated from immunodeficient rats presenting oral tolerance to dextrin showed increased expression of TGF-beta to reduce the effect of higher levels of inflammatory cytokines.

Rabbit tonsil-associated M-cells express cytokeratin 20 and take up particulate antigen

M-cells are believed to play a pivotal role in initiation of the immune response. These cells, located in the epithelia that overlie mucosal lymphoid follicles, are responsible for the active uptake of particulate antigens and for their translocation to the underlying lymphoid tissue. The identification of reliable markers for M-cells is therefore extremely important for the study of the initial steps that lead to the immune response. For this purpose, we studied cytokeratin 20 (CK20) expression in the epithelium of rabbit palatine tonsils by immunofluorescence, confocal microscopy, and Western blotting. CK20+ cells were observed in all rabbit palatine tonsils examined. By Western blotting, one CK20-immunoreactive band was identified at 46 kD on samples of proteins from the intermediate filament-enriched cytoskeletal fraction of tonsil epithelium. Double labeling of CK20+ cells with cell-specific markers confirmed that such cells were actually M-cells. Moreover, CK20+ M-cells displayed a mature phenotype (they formed pockets harboring lymphoid cells) and were functionally competent because they could take up particulate antigens from the pharyngeal lumen. We conclude that CK20 is an M-cell marker for rabbit palatine tonsils. Moreover, we can hypothesize the use of M-cells as a possible site for antigen delivery of particle-based vaccines.

Mucosal vaccine made from live, recombinant Lactococcus lactis protects mice against pharyngeal infection with Streptococcus pyogenes

A novel vaccine (LL-CRR) made from live, nonpathogenic Lactococcus lactis that expresses the conserved C-repeat region (CRR) of M protein from Streptococcus pyogenes serotype 6 was tested in mice. Nasally vaccinated mice produced CRR-specific salivary immunoglobulin A (IgA) and serum IgG. Subcutaneously vaccinated mice produced CRR-specific serum IgG but not salivary IgA. A combined regimen produced responses similar to the salivary IgA of nasally vaccinated mice and serum IgG of subcutaneously vaccinated mice. Mice vaccinated nasally or with the combined regimen were significantly protected against pharyngeal infection following a nasal challenge with S. pyogenes M serotype 14. Mice vaccinated subcutaneously were not protected against pharyngeal infection. Mice in all three LL-CRR vaccination groups were significantly protected against the lethal effects of S. pyogenes. Only 1 of 77 challenged mice that were vaccinated with LL-CRR died, whereas 60 of 118 challenged mice that were vaccinated with a control strain or phosphate-buffered saline died. In conclusion, mucosal vaccination with LL-CRR produced CRR-specific salivary IgA and serum IgG, prevented pharyngeal infection with S. pyogenes, and promoted survival.

CCR5 Regulates High Dose Oral Tolerance by Modulating CC Chemokine Ligand 2 Levels in the GALT

Oral tolerance is an immunomodulatory mechanism used by gut tissues to induce systemic tolerance to ingested proteins. In models of disease, such as experimental autoimmune encephalomyelitis, oral tolerance has been used to protect against paralysis induced by immunization with myelin proteins. Previous work in our laboratory has shown a role for the chemokine, CCL2, and its receptor in the induction of high dose oral tolerance. In the present study, we report that two CCR5 ligands, CCL4 and CCL5, are expressed in gut tissues after Ag feeding. CCR5(-/-) mice were unable to be tolerized by feeding a high dose of Ag and were not protected from developing experimental autoimmune encephalomyelitis. Moreover, CCR5(-/-) mice did not display cytokine deviation as normally seen after high dose oral Ag. Using a selective CCR5 antagonist, methionine-RANTES, CCL2 expression was inhibited, resulting in enhanced IL-12 production and the inability for mice treated with methionine-RANTES to become orally tolerized. This current study suggests that CCR5 ligands may function to modulate CCL2 levels in the gut after Ag feeding, promoting a cellular environment that favors tolerance rather than immunity.

[Dry eye disease as a complex dysregulation of the functional anatomy of the ocular surface. New concepts for understanding dry eye disease]

INTRODUCTION

Dry eye disease is a disorder of the tear film that results in epithelial damage and in a disruption of the normal homeostasis at the ocular surface. It is widespread and causes symptoms ranging from discomfort to blindness.

METHODS

A review of the existing literature was used to compare different past and recent concepts for the understanding of dry eye disease with a focus on aspects of the integrating functional anatomy of the ocular surface.

RESULTS

The understanding of the pathogenesis of dry eye disease has proceeded from the mere recognition of a lack of tears to a consideration of their quality and to the concept of wetting of the ocular surface. However, several other aspects as epithelial differentiation, innervation, hormonal status or immune protection contribute to the intact functional anatomy of the ocular surface. Recently it has been recognized that immunologically regulated mechanisms of inflammation represent a primary or secondary pathogenetic factor for dry eye disease. This is conceivably regulated by the cells of the physiological mucosal immune defence system, the eye-associated lymphoid tissue (EALT). Androgens represent an important trophic factor for the ocular surface and their deficiency predisposes to inflammation.

CONCLUSION

Dry eye disease represents a complex dysregulation of the functional anatomy of the ocular surface that can start from different alterations (e.g. insufficient secretion, defects in wetting or innervation). Immune-based inflammation is able to interconnect and negatively reinforce these different pathomechanisms, resulting in a vicious circle.