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Hu Z, Cinque P, Dravid A, Hagberg L, Yilmaz A, Zetterberg H, Fuchs D, Gostner J, Blennow K, Spudich SS, Kincer L, Zhou S, Joseph S, Swanstrom R, Price RW, Gisslén M. Changes in Cerebrospinal Fluid Proteins across the Spectrum of Untreated and Treated Chronic HIV-1 Infection. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.03.592451. [PMID: 38746436 PMCID: PMC11092784 DOI: 10.1101/2024.05.03.592451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Using the Olink Explore 1536 platform, we measured 1,463 unique proteins in 303 cerebrospinal fluid (CSF) specimens from four clinical centers that included uninfected controls and 12 groups of people living with HIV-1 infection representing the spectrum of progressive untreated and treated chronic infection. We present three initial analyses of these measurements: an overview of the CSF protein features of the sample; correlations of the CSF proteins with CSF HIV-1 RNA and neurofilament light chain protein (NfL) concentrations; and comparison of the CSF proteins in HIV-associated dementia ( HAD ) and neurosymptomatic CSF escape ( NSE ). These reveal a complex but coherent picture of CSF protein changes that includes highest concentrations of many proteins during CNS injury in the HAD and NSE groups and variable protein changes across the course of neuroasymptomatic systemic HIV-1 progression, including two common patterns, designated as lymphoid and myeloid patterns, related to the principal involvement of their underlying inflammatory cell lineages. Antiretroviral therapy reduced CSF protein perturbations, though not always to control levels. The dataset of these CSF protein measurements, along with background clinical information, is posted online. Extended studies of this unique dataset will provide more detailed characterization of the dynamic impact of HIV-1 infection on the CSF proteome across the spectrum of HIV-1 infection, and further the mechanistic understanding of HIV-1-related CNS pathobiology.
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Singh H, Koury J, Maung R, Roberts AJ, Kaul M. Interferon-β deficiency alters brain response to chronic HIV-1 envelope protein exposure in a transgenic model of NeuroHIV. Brain Behav Immun 2024; 118:1-21. [PMID: 38360376 PMCID: PMC11173373 DOI: 10.1016/j.bbi.2024.02.014] [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: 07/11/2023] [Revised: 01/26/2024] [Accepted: 02/08/2024] [Indexed: 02/17/2024] Open
Abstract
Human immunodeficiency virus-1 (HIV-1) infects the central nervous system (CNS) and causes HIV-associated neurocognitive disorders (HAND) in about half of the population living with the virus despite combination anti-retroviral therapy (cART). HIV-1 activates the innate immune system, including the production of type 1 interferons (IFNs) α and β. Transgenic mice expressing HIV-1 envelope glycoprotein gp120 (HIVgp120tg) in the CNS develop memory impairment and share key neuropathological features and differential CNS gene expression with HIV patients, including the induction of IFN-stimulated genes (ISG). Here we show that knocking out IFNβ (IFNβKO) in HIVgp120tg and non-tg control mice impairs recognition and spatial memory, but does not affect anxiety-like behavior, locomotion, or vision. The neuropathology of HIVgp120tg mice is only moderately affected by the KO of IFNβ but in a sex-dependent fashion. Notably, in cerebral cortex of IFNβKO animals presynaptic terminals are reduced in males while neuronal dendrites are reduced in females. The IFNβKO results in the hippocampal CA1 region of both male and female HIVgp120tg mice in an ameliorated loss of neuronal presynaptic terminals but no protection of neuronal dendrites. Only female IFNβ-deficient HIVgp120tg mice display diminished microglial activation in cortex and hippocampus and increased astrocytosis in hippocampus compared to their IFNβ-expressing counterparts. RNA expression for some immune genes and ISGs is also affected in a sex-dependent way. The IFNβKO abrogates or diminishes the induction of MX1, DDX58, IRF7 and IRF9 in HIVgp120tg brains of both sexes. Expression analysis of neurotransmission related genes reveals an influence of IFNβ on multiple components with more pronounced changes in IFNβKO females. In contrast, the effects of IFNβKO on MAPK activities are independent of sex with pronounced reduction of active ERK1/2 but also of active p38 in the HIVgp120tg brain. In summary, our findings show that the absence of IFNβ impairs memory dependent behavior and modulates neuropathology in HIVgp120tg brains, indicating that its absence may facilitate development of HAND. Moreover, our data suggests that endogenous IFNβ plays a vital role in maintaining neuronal homeostasis and memory function.
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Affiliation(s)
- Hina Singh
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, 900 University Ave, Riverside, CA, 92521, USA; Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA.
| | - Jeffrey Koury
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, 900 University Ave, Riverside, CA, 92521, USA.
| | - Ricky Maung
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, 900 University Ave, Riverside, CA, 92521, USA; Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA.
| | - Amanda J Roberts
- Animal Models Core, The Scripps Research Institute, 10550 North Torrey Pines Road, MB6, La Jolla, CA 92037, USA.
| | - Marcus Kaul
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, 900 University Ave, Riverside, CA, 92521, USA; Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA.
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Ellis RJ, Marquine MJ, Kaul M, Fields JA, Schlachetzki JCM. Mechanisms underlying HIV-associated cognitive impairment and emerging therapies for its management. Nat Rev Neurol 2023; 19:668-687. [PMID: 37816937 PMCID: PMC11052664 DOI: 10.1038/s41582-023-00879-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/12/2023]
Abstract
People living with HIV are affected by the chronic consequences of neurocognitive impairment (NCI) despite antiretroviral therapies that suppress viral replication, improve health and extend life. Furthermore, viral suppression does not eliminate the virus, and remaining infected cells may continue to produce viral proteins that trigger neurodegeneration. Comorbidities such as diabetes mellitus are likely to contribute substantially to CNS injury in people living with HIV, and some components of antiretroviral therapy exert undesirable side effects on the nervous system. No treatment for HIV-associated NCI has been approved by the European Medicines Agency or the US Food and Drug Administration. Historically, roadblocks to developing effective treatments have included a limited understanding of the pathophysiology of HIV-associated NCI and heterogeneity in its clinical manifestations. This heterogeneity might reflect multiple underlying causes that differ among individuals, rather than a single unifying neuropathogenesis. Despite these complexities, accelerating discoveries in HIV neuropathogenesis are yielding potentially druggable targets, including excessive immune activation, metabolic alterations culminating in mitochondrial dysfunction, dysregulation of metal ion homeostasis and lysosomal function, and microbiome alterations. In addition to drug treatments, we also highlight the importance of non-pharmacological interventions. By revisiting mechanisms implicated in NCI and potential interventions addressing these mechanisms, we hope to supply reasons for optimism in people living with HIV affected by NCI and their care providers.
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Affiliation(s)
- Ronald J Ellis
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA.
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.
| | - María J Marquine
- Department of Medicine, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Marcus Kaul
- School of Medicine, Division of Biomedical Sciences, University of California Riverside, Riverside, CA, USA
| | - Jerel Adam Fields
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Johannes C M Schlachetzki
- Department of Cellular and Molecular Medicine, University of California San Diego, La Jolla, CA, USA
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Kataras TJ, Jang TJ, Koury J, Singh H, Fok D, Kaul M. ACCT is a fast and accessible automatic cell counting tool using machine learning for 2D image segmentation. Sci Rep 2023; 13:8213. [PMID: 37217558 PMCID: PMC10202925 DOI: 10.1038/s41598-023-34943-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 05/10/2023] [Indexed: 05/24/2023] Open
Abstract
Counting cells is a cornerstone of tracking disease progression in neuroscience. A common approach for this process is having trained researchers individually select and count cells within an image, which is not only difficult to standardize but also very time-consuming. While tools exist to automatically count cells in images, the accuracy and accessibility of such tools can be improved. Thus, we introduce a novel tool ACCT: Automatic Cell Counting with Trainable Weka Segmentation which allows for flexible automatic cell counting via object segmentation after user-driven training. ACCT is demonstrated with a comparative analysis of publicly available images of neurons and an in-house dataset of immunofluorescence-stained microglia cells. For comparison, both datasets were manually counted to demonstrate the applicability of ACCT as an accessible means to automatically quantify cells in a precise manner without the need for computing clusters or advanced data preparation.
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Affiliation(s)
- Theodore J Kataras
- Graduate Program of Genetics, Genomics and Bioinformatics, University of California, Riverside, Riverside, CA, 92521, USA
- School of Medicine, Division of Biomedical Sciences, University of California, Riverside, Riverside, CA, 92521, USA
| | - Tyler J Jang
- Graduate Program of Genetics, Genomics and Bioinformatics, University of California, Riverside, Riverside, CA, 92521, USA
- School of Medicine, Division of Biomedical Sciences, University of California, Riverside, Riverside, CA, 92521, USA
| | - Jeffrey Koury
- School of Medicine, Division of Biomedical Sciences, University of California, Riverside, Riverside, CA, 92521, USA
| | - Hina Singh
- School of Medicine, Division of Biomedical Sciences, University of California, Riverside, Riverside, CA, 92521, USA
| | - Dominic Fok
- School of Medicine, Division of Biomedical Sciences, University of California, Riverside, Riverside, CA, 92521, USA
| | - Marcus Kaul
- Graduate Program of Genetics, Genomics and Bioinformatics, University of California, Riverside, Riverside, CA, 92521, USA.
- School of Medicine, Division of Biomedical Sciences, University of California, Riverside, Riverside, CA, 92521, USA.
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Byrnes SJ, Busman-Sahay K, Angelovich TA, Younger S, Taylor-Brill S, Nekorchuk M, Bondoc S, Dannay R, Terry M, Cochrane CR, Jenkins TA, Roche M, Deleage C, Bosinger SE, Paiardini M, Brew BJ, Estes JD, Churchill MJ. Chronic immune activation and gut barrier dysfunction is associated with neuroinflammation in ART-suppressed SIV+ rhesus macaques. PLoS Pathog 2023; 19:e1011290. [PMID: 36989320 PMCID: PMC10085024 DOI: 10.1371/journal.ppat.1011290] [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: 08/11/2022] [Revised: 04/10/2023] [Accepted: 03/10/2023] [Indexed: 03/30/2023] Open
Abstract
HIV-associated neurocognitive disorders (HAND) affect ~40% of virally suppressed people with HIV (PWH), however, the precise viral dependent and independent changes to the brain are unclear. Here we characterized the CNS reservoir and immune environment of SIV-infected (SIV+) rhesus macaques during acute (n = 4), chronic (n = 12) or ART-suppressed SIV infection (n = 11). Multiplex immunofluorescence for markers of SIV infection (vRNA/vDNA) and immune activation was performed on frontal cortex and matched colon tissue. SIV+ animals contained detectable viral DNA+ cells that were not reduced in the frontal cortex or the gut by ART, supporting the presence of a stable viral reservoir in these compartments. SIV+ animals had impaired blood brain barrier (BBB) integrity and heightened levels of astrocytes or myeloid cells expressing antiviral, anti-inflammatory or oxidative stress markers which were not abrogated by ART. Neuroinflammation and BBB dysfunction correlated with measures of viremia and immune activation in the gut. Furthermore, SIV-uninfected animals with experimentally induced gut damage and colitis showed a similar immune activation profile in the frontal cortex to those of SIV-infected animals, supporting the role of chronic gut damage as an independent source of neuroinflammation. Together, these findings implicate gut-associated immune activation/damage as a significant contributor to neuroinflammation in ART-suppressed HIV/SIV infection which may drive HAND pathogenesis.
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Affiliation(s)
- Sarah J. Byrnes
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
| | - Kathleen Busman-Sahay
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, Oregon, United States of America
- Division of Pathobiology and Immunology, Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Thomas A. Angelovich
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
- Life Science, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia
| | - Skyler Younger
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Sol Taylor-Brill
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Michael Nekorchuk
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Stephen Bondoc
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Rachel Dannay
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Margaret Terry
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, Oregon, United States of America
| | | | - Trisha A. Jenkins
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
| | - Michael Roche
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia
| | - Claire Deleage
- AIDS and Cancer Virus Program, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Steven E. Bosinger
- Division of Microbiology and Immunology, Emory National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Mirko Paiardini
- Division of Microbiology and Immunology, Emory National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Bruce J. Brew
- Peter Duncan Neurosciences Unit, Departments of Neurology and Immunology St Vincent’s Hospital, University of New South Wales and University of Notre Dame, Sydney, New South Wales, Australia
| | - Jacob D. Estes
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Portland, Oregon, United States of America
- Division of Pathobiology and Immunology, Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Melissa J. Churchill
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
- Life Science, Burnet Institute, Melbourne, Australia
- Departments of Microbiology and Medicine, Monash University, Clayton, Australia
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Yuan NY, Maung R, Xu Z, Han X, Kaul M. Arachidonic Acid Cascade and Eicosanoid Production Are Elevated While LTC4 Synthase Modulates the Lipidomics Profile in the Brain of the HIVgp120-Transgenic Mouse Model of NeuroHIV. Cells 2022; 11:2123. [PMID: 35805207 PMCID: PMC9265961 DOI: 10.3390/cells11132123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Combination antiretroviral therapy (cART) has transformed HIV infection from a terminal disease to a manageable chronic health condition, extending patients' life expectancy to that of the general population. However, the incidence of HIV-associated neurocognitive disorders (HANDs) has persisted despite virological suppression. Patients with HIV display persistent signs of immune activation and inflammation despite cART. The arachidonic acid (AA) cascade is an important immune response system responsible for both pro- and anti-inflammatory processes. METHODS Lipidomics, mRNA and Western blotting analysis provide valuable insights into the molecular mechanisms surrounding arachidonic acid metabolism and the resulting inflammation caused by perturbations thereof. RESULTS Here, we report the presence of inflammatory eicosanoids in the brains of a transgenic mouse model of NeuroHIV that expresses soluble HIV-1 envelope glycoprotein in glial cells (HIVgp120tg mice). Additionally, we report that the effect of LTC4S knockout in HIVgp120tg mice resulted in the sexually dimorphic transcription of COX- and 5-LOX-related genes. Furthermore, the absence of LTC4S suppressed ERK1/2 and p38 MAPK signaling activity in female mice only. The mass spectrometry-based lipidomic profiling of these mice reveals beneficial alterations to lipids in the brain. CONCLUSION Targeting the AA cascade may hold potential in the treatment of neuroinflammation observed in NeuroHIV and HANDs.
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Affiliation(s)
- Nina Y. Yuan
- Division of Biomedical Sciences, School of Medicine, University of California Riverside, 900 University Ave, Riverside, CA 92521, USA; (N.Y.Y.); (R.M.)
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, 10901 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Ricky Maung
- Division of Biomedical Sciences, School of Medicine, University of California Riverside, 900 University Ave, Riverside, CA 92521, USA; (N.Y.Y.); (R.M.)
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, 10901 North Torrey Pines Road, La Jolla, CA 92037, USA
| | - Ziying Xu
- Barshop Institute for Longevity and Aging Studies, University of Texas Health San Antonio, San Antonio, TX 78229, USA; (Z.X.); (X.H.)
| | - Xianlin Han
- Barshop Institute for Longevity and Aging Studies, University of Texas Health San Antonio, San Antonio, TX 78229, USA; (Z.X.); (X.H.)
- Department of Medicine-Diabetes, University of Texas Health San Antonio, San Antonio, TX 78229, USA
| | - Marcus Kaul
- Division of Biomedical Sciences, School of Medicine, University of California Riverside, 900 University Ave, Riverside, CA 92521, USA; (N.Y.Y.); (R.M.)
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, 10901 North Torrey Pines Road, La Jolla, CA 92037, USA
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Ojeda-Juárez D, Kaul M. Transcriptomic and Genetic Profiling of HIV-Associated Neurocognitive Disorders. Front Mol Biosci 2021; 8:721954. [PMID: 34778371 PMCID: PMC8586712 DOI: 10.3389/fmolb.2021.721954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/24/2021] [Indexed: 12/20/2022] Open
Abstract
Early in the HIV pandemic, it became evident that people living with HIV (PLWH) develop a wide range of neurological and neurocognitive complications. Even after the introduction of combination antiretroviral therapy (cART), which dramatically improved survival of PLWH, the overall number of people living with some form of HIV-associated neurocognitive disorders (HAND) seemed to remain unchanged, although the incidence of dementia declined and questions about the incidence and diagnosis of the mildest form of HAND arose. To better understand this complex disease, several transcriptomic analyses have been conducted in autopsy samples, as well as in non-human primates and small animal rodent models. However, genetic studies in the HIV field have mostly focused on the genetic makeup of the immune system. Much less is known about the genetic underpinnings of HAND. Here, we provide a summary of reported transcriptomic and epigenetic changes in HAND, as well as some of the potential genetic underpinnings that have been linked to HAND, and discuss future directions with hurdles to overcome and angles that remain to be explored.
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Affiliation(s)
- Daniel Ojeda-Juárez
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, CA, United States
| | - Marcus Kaul
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, CA, United States
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Mazewski C, Perez RE, Fish EN, Platanias LC. Type I Interferon (IFN)-Regulated Activation of Canonical and Non-Canonical Signaling Pathways. Front Immunol 2020; 11:606456. [PMID: 33329603 PMCID: PMC7719805 DOI: 10.3389/fimmu.2020.606456] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
For several decades there has been accumulating evidence implicating type I interferons (IFNs) as key elements of the immune response. Therapeutic approaches incorporating different recombinant type I IFN proteins have been successfully employed to treat a diverse group of diseases with significant and positive outcomes. The biological activities of type I IFNs are consequences of signaling events occurring in the cytoplasm and nucleus of cells. Biochemical events involving JAK/STAT proteins that control transcriptional activation of IFN-stimulated genes (ISGs) were the first to be identified and are referred to as "canonical" signaling. Subsequent identification of JAK/STAT-independent signaling pathways, critical for ISG transcription and/or mRNA translation, are denoted as "non-canonical" or "non-classical" pathways. In this review, we summarize these signaling cascades and discuss recent developments in the field, specifically as they relate to the biological and clinical implications of engagement of both canonical and non-canonical pathways.
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Affiliation(s)
- Candice Mazewski
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
- Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ricardo E. Perez
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
- Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Eleanor N. Fish
- Toronto General Hospital Research Institute, University Health Network and Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Leonidas C. Platanias
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
- Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Department of Medicine, Jesse Brown Veterans Affairs Medical Center, Chicago, IL, United States
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