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Rajamanickam A, Pavan Kumar N, Pandiaraj AN, Selvaraj N, Munisankar S, Renji RM, Venkataramani V, Murhekar M, Thangaraj JWV, Muthusamy SK, Chethrapilly Purushothaman GK, Bhatnagar T, Ponnaiah M, Ramasamy S, Velusamy S, Babu S. Characterization of memory T cell subsets and common γ-chain cytokines in convalescent COVID-19 individuals. J Leukoc Biol 2022; 112:201-212. [PMID: 35258122 PMCID: PMC9088480 DOI: 10.1002/jlb.5cova0721-392rr] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/30/2021] [Accepted: 01/21/2022] [Indexed: 01/08/2023] Open
Abstract
T cells are thought to be an important correlates of protection against SARS‐CoV2 infection. However, the composition of T cell subsets in convalescent individuals of SARS‐CoV2 infection has not been well studied. The authors determined the lymphocyte absolute counts, the frequency of memory T cell subsets, and the plasma levels of common γ−chain in 7 groups of COVID‐19 individuals, based on days since RT‐PCR confirmation of SARS‐CoV‐2 infection. The data show that both absolute counts and frequencies of lymphocytes as well as, the frequencies of CD4+ central and effector memory cells increased, and the frequencies of CD4+ naïve T cells, transitional memory, stem cell memory T cells, and regulatory cells decreased from Days 15–30 to Days 61–90 and plateaued thereafter. In addition, the frequencies of CD8+ central memory, effector, and terminal effector memory T cells increased, and the frequencies of CD8+ naïve cells, transitional memory, and stem cell memory T cells decreased from Days 15–30 to Days 61–90 and plateaued thereafter. The plasma levels of IL‐2, IL‐7, IL‐15, and IL‐21—common γc cytokines started decreasing from Days 15–30 till Days 151–180. Severe COVID‐19 patients exhibit decreased levels of lymphocyte counts and frequencies, higher frequencies of naïve cells, regulatory T cells, lower frequencies of central memory, effector memory, and stem cell memory, and elevated plasma levels of IL‐2, IL‐7, IL‐15, and IL‐21. Finally, there was a significant correlation between memory T cell subsets and common γc cytokines. Thus, the study provides evidence of alterations in lymphocyte counts, memory T cell subset frequencies, and common γ−chain cytokines in convalescent COVID‐19 individuals.
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Affiliation(s)
- Anuradha Rajamanickam
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | | | - Arul Nancy Pandiaraj
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - Nandhini Selvaraj
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - Saravanan Munisankar
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - Rachel Mariam Renji
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - Vijayalakshmi Venkataramani
- ICMR-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - Manoj Murhekar
- National Institute of Epidemiology (ICMR), Near Ambattur, Ayapakkam, Chennai, India
| | | | | | | | - Tarun Bhatnagar
- National Institute of Epidemiology (ICMR), Near Ambattur, Ayapakkam, Chennai, India
| | - Manickam Ponnaiah
- National Institute of Epidemiology (ICMR), Near Ambattur, Ayapakkam, Chennai, India
| | | | | | - Subash Babu
- ICMR-NIRT-International Center for Excellence in Research, Chennai, India
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Loucif H, Dagenais-Lussier X, Avizonis D, Choinière L, Beji C, Cassin L, Routy JP, Fritz JH, Olagnier D, van Grevenynghe J. Autophagy-dependent glutaminolysis drives superior IL21 production in HIV-1-specific CD4 T cells. Autophagy 2021; 18:1256-1273. [PMID: 34612140 DOI: 10.1080/15548627.2021.1972403] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The maintenance of a strong IL21 production in memory CD4 T cells, especially in HIV-1-specific cells, represents a major correlate of natural immune protection against the virus. However, the molecular mechanisms underlying IL21 production during HIV-1 infection, which is only elevated among the naturally protected elite controllers (EC), are still unknown. We recently found out that lipophagy is a critical immune mediator that control an antiviral metabolic state following CD8A T cell receptor engagement, playing an important role in the natural control of HIV-1 infection. This led us to investigate whether the beneficial role of a strong macroautophagy/autophagy, could also be used to ensure effective IL21 production as well. Herein, we confirm that after both polyclonal and HIV-1-specific activation, memory CD4 T cells (Mem) from EC display enhanced activity of the autophagy-mediated proteolysis compared to ART. Our results indicate that the enhanced autophagy activity in EC was controlled by the energy-sensing PRKAA1 (protein kinase AMP-activated catalytic subunit alpha 1). We further confirmed the critical role of the autophagy-mediated proteolysis in the strong IL21 production in EC by using BECN1 gene silencing as well as protease, PRKAA1, and lysosomal inhibitors. Finally, we established that high autophagy-mediated proteolysis in EC fuels their cellular rates of mitochondrial respiration due to glutaminolysis. Our data confirm the critical role of autophagy in dictating the metabolic input, which is required not only to ensure protective cytotoxic CD8A T cell responses, but also to provide strong IL21 production among antiviral CD4 T cells.Abbreviations: AKG: alpha-ketoglutarate; ART: patients under antiretroviral therapy; ATG7: autophagy related 7; BaF: bafilomycin A1; BECN1: beclin 1; Chloro.: chloroquine; EC: elite controllers; EIF4EBP1: eukaryotic translation initiation factor 4E binding protein 1; FOXO3: forkhead box O3; GLS: glutaminase; GLUD1: glutamate dehydrogenase 1; HIVneg: HIV-1-uninfected control donors; IFNG/IFN-γ: interferon gamma; IL21: interleukin 21; MTOR: mechanistic target of rapamycin kinase; PBMC: peripheral blood mononuclear cells; PRKAA1: protein kinase AMP-activated catalytic subunit alpha 1; SQSTM1: sequestosome 1; TCA: tricarboxylic acid cycle; ULK1: unc-51 like autophagy activating kinase.
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Affiliation(s)
- Hamza Loucif
- Institut National de la Recherche Scientifique (INRS)-Centre Armand-Frappier Santé Biotechnologie, Laval, Quebec, Canada
| | - Xavier Dagenais-Lussier
- Institut National de la Recherche Scientifique (INRS)-Centre Armand-Frappier Santé Biotechnologie, Laval, Quebec, Canada
| | - Daina Avizonis
- Metabolomics Innovation Resource, Rosalind and Morris Goodman Cancer Center, McGill University, Montreal, QC, Canada
| | - Luc Choinière
- Metabolomics Innovation Resource, Rosalind and Morris Goodman Cancer Center, McGill University, Montreal, QC, Canada
| | - Cherifa Beji
- Institut National de la Recherche Scientifique (INRS)-Centre Armand-Frappier Santé Biotechnologie, Laval, Quebec, Canada
| | - Léna Cassin
- Department of Biomedicine, Research Center for Innate Immunology, Aarhus University, Aarhus, Denmark
| | - Jean-Pierre Routy
- Chronic Viral Illness Service and Division of Hematology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jörg H Fritz
- Department of Microbiology and Immunology, McGill University, Montreal, Quebec, Canada
| | - David Olagnier
- Department of Biomedicine, Research Center for Innate Immunology, Aarhus University, Aarhus, Denmark
| | - Julien van Grevenynghe
- Institut National de la Recherche Scientifique (INRS)-Centre Armand-Frappier Santé Biotechnologie, Laval, Quebec, Canada
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Kathamuthu GR, Moideen K, Sridhar R, Baskaran D, Babu S. Altered plasma levels of βC and γC chain cytokines and post-treatment modulation in tuberculous lymphadenitis. Cytokine 2020; 138:155405. [PMID: 33341600 DOI: 10.1016/j.cyto.2020.155405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Alterations in β common (βC) and γ common (γC) chain cytokines have been described in pulmonary tuberculosis. However, their role in tuberculous lymphadenitis (TBL) disease has not been assessed. METHODS Thus, in the present study, we have examined the systemic levels of βC and γC chain cytokines in TBL, latent tuberculosis (LTB) and healthy control (HC) individuals. We have examined the discriminatory potential of both family of cytokines using ROC analysis. Finally, we measured the pre and post-treatment responses of these cytokines after anti-tuberculosis treatment. RESULTS TBL individuals exhibit significantly increased (IL-3) and diminished systemic levels of (IL-5, GM-CSF) βC cytokines compared to LTB and HC individuals. TBL individuals also exhibit significantly diminished (IL-2, IL-7) and elevated (IL-4, IL-9) levels of γC cytokines compared to LTB and/or HC. ROC analysis shows a clear discriminatory capacity of both βC (IL-5) and γC (IL-2) chain cytokines to distinguish TBL from LTB and HCs. The systemic levels of βC chain cytokines were not significantly altered, but in contrast γC (IL-2 and IL-7) cytokines were significantly modulated after treatment. Finally, no significant correlation was observed for βC and γC chain cytokines with their respective lymphocyte count of TBL individuals. CONCLUSIONS Hence, we conclude that altered plasma levels of βC and γC cytokines are the characteristics of immune alteration in TBL disease and certain cytokines were modulated after treatment.
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Affiliation(s)
- Gokul Raj Kathamuthu
- National Institutes of Health-NIRT-International Center for Excellence in Research, Chennai, India; National Institute for Research in Tuberculosis (NIRT), Chennai, India.
| | - Kadar Moideen
- National Institutes of Health-NIRT-International Center for Excellence in Research, Chennai, India
| | | | - Dhanaraj Baskaran
- National Institute for Research in Tuberculosis (NIRT), Chennai, India
| | - Subash Babu
- National Institutes of Health-NIRT-International Center for Excellence in Research, Chennai, India; Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Valencia JC, Egbukichi N, Erwin-Cohen RA. Autoimmunity and Cancer, the Paradox Comorbidities Challenging Therapy in the Context of Preexisting Autoimmunity. J Interferon Cytokine Res 2018; 39:72-84. [PMID: 30562133 DOI: 10.1089/jir.2018.0060] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Today, improvements in diagnostic and therapeutic options allow patients with autoimmune diseases (ADs) to live longer and have more active lives compared with patients receiving conventional anti-inflammatory therapy just two decades ago. Current therapies for ADs aim to inhibit immune cell activation and effector immune pathways, including those activated by cytokines and cytokine receptors. Understandably, such goals become more complicated in patients with long-term established ADs who develop parallel chronic or comorbid conditions, including life-threatening diseases, such as cancer. Compared with the general population, patients with ADs have an increased risk of developing hematological, lymphoproliferative disorders, and solid tumors. However, the aim of current cancer therapies is to activate the immune system to create autoimmune-like conditions and eliminate tumors. As such, their comorbid presentation creates a paradox on how malignancies must be addressed therapeutically in the context of autoimmunity. Because the physiopathology of malignancies is less understood in the context of autoimmunity than it is in the general population, we undertook this review to highlight the peculiarities and mechanisms governing immune cells in established ADs. Moreover, we examined the role of the autoimmune cytokine milieu in the development of immune-related adverse events during the implementation of conventional or immune-based therapy.
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Affiliation(s)
- Julio C Valencia
- Cancer and Inflammation Program, National Cancer Institute at Frederick, Frederick, Maryland
| | - Nkolika Egbukichi
- Cancer and Inflammation Program, National Cancer Institute at Frederick, Frederick, Maryland
| | - Rebecca A Erwin-Cohen
- Cancer and Inflammation Program, National Cancer Institute at Frederick, Frederick, Maryland
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Altered levels of memory T cell subsets and common γc cytokines in Strongyloides stercoralis infection and partial reversal following anthelmintic treatment. PLoS Negl Trop Dis 2018; 12:e0006481. [PMID: 29795573 PMCID: PMC5991401 DOI: 10.1371/journal.pntd.0006481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 06/06/2018] [Accepted: 04/28/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND CD4+ and CD8+ T cells are central players in immunity to helminth infections. However, the role of T cell subsets in human helminth infections is not well understood. In addition, the common γc cytokines, IL-2, IL-4, IL-7, IL-9 and IL-15 play an important role in the maintenance of these CD4+ and CD8+ T cell subsets. METHODS To examine the major T cell subsets and their association with the common γc cytokines, the absolute numbers of CD4+ and CD8+ naïve, central memory, effector memory and effector cells and the plasma levels of IL-2, IL-4, IL-7, IL-9 and IL-15 were measured in Strongyloides stercoralis (Ss) infected (INF, n = 60), helminth-uninfected (UN, n = 58) and in post treatment INF individuals. RESULTS Ss infection is characterized by significantly increased absolute numbers of naïve and decreased absolute numbers of central and effector memory CD4+ T cells in comparison to UN individuals. No significant difference in the numbers of CD8+ T cell subsets was observed between the groups. The numbers of naïve cells and central memory CD4+ T cells were significantly reversed after anthelmintic treatment. Circulating levels of IL-2, IL-7 and IL-15 were significantly diminished, whereas the levels of IL-4 and IL-9 were significantly increased in INF compared to UN individuals. Following anthelminthic treatment, IL-2, IL-7 and IL-15 levels were significantly increased, while IL-4 and IL-9 levels were significantly decreased. Our data also showed a significant positive correlation between the levels of IL-7 and the numbers of central and effector memory CD4+ T cells. CONCLUSION Ss infection is characterized by alterations in the absolute numbers of CD4+ T cell subsets and altered levels of common γc cytokines IL-2, IL-4, IL-7, IL-9 and IL-15; alterations which are partially reversed after anthelmintic treatment.
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Diminished plasma levels of common γ-chain cytokines in pulmonary tuberculosis and reversal following treatment. PLoS One 2017; 12:e0176495. [PMID: 28448542 PMCID: PMC5407607 DOI: 10.1371/journal.pone.0176495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 04/11/2017] [Indexed: 12/14/2022] Open
Abstract
Background The immune response to tuberculosis (TB) is T cell dependent. T cells are the major facilitators of protection and effector functions with CD4+ T cells being the most important players, followed by CD8+ T cells. The common γ-chain cytokines IL-2, IL-7, IL-15, and IL-21 play a vital role in peripheral T cell growth and survival. However, the role of common γ-chain cytokines in pulmonary TB (PTB) is poorly understood. Aim and methods To examine the association of circulating common γ-chain cytokines with TB disease or infection, we examined the systemic levels of IL-2, IL-7, IL-15, and IL-21 in individuals with PTB, latent TB (LTB) or no TB infection (NTB). We also examined the levels of these cytokines in PTB individuals before and after anti-tuberculosis treatment. Results Circulating levels of IL-2, IL-7 and IL-21 were significantly diminished in PTB compared to LTB or NTB individuals. Moreover, TB antigen stimulated whole blood also exhibited diminished levels of common γ-chain cytokines in PTB compared to LTB or NTB individuals. The plasma levels of common γ-chain cytokines exhibited no significant association with the severity or extent of TB disease or with bacterial burdens. However, upon standard anti-TB treatment, both the systemic as well as the TB antigen stimulated levels of IL-2, IL-7 and IL-21 were significantly increased in PTB individuals. Conclusion Therefore our data demonstrate that diminished levels of common γ-chain cytokines are a common characteristic of PTB and potentially highlight the importance of boosting these responses to improve treatment outcomes.
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Bortell N, Morsey B, Basova L, Fox HS, Marcondes MCG. Phenotypic changes in the brain of SIV-infected macaques exposed to methamphetamine parallel macrophage activation patterns induced by the common gamma-chain cytokine system. Front Microbiol 2015; 6:900. [PMID: 26441851 PMCID: PMC4568411 DOI: 10.3389/fmicb.2015.00900] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 08/17/2015] [Indexed: 12/12/2022] Open
Abstract
One factor in the development of neuroAIDS is the increase in the migration of pro-inflammatory CD8 T cells across the blood–brain barrier. Typically these cells are involved with keeping the viral load down. However, the persistence of above average numbers of CD8 T cells in the brain, not necessarily specific to viral peptides, is facilitated by the upregulation of IL15 from astrocytes, in the absence of IL2, in the brain environment. Both IL15 and IL2 are common gamma chain (γc) cytokines. Here, using the non-human primate model of neuroAIDS, we have demonstrated that exposure to methamphetamine, a powerful illicit drug that has been associated with HIV exposure and neuroAIDS severity, can cause an increase in molecules of the γc system. Among these molecules, IL15, which is upregulated in astrocytes by methamphetamine, and that induces the proliferation of T cells, may also be involved in driving an inflammatory phenotype in innate immune cells of the brain. Therefore, methamphetamine and IL15 may be critical in the development and aggravation of central nervous system immune-mediated inflammatory pathology in HIV-infected drug abusers.
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Affiliation(s)
- Nikki Bortell
- Department of Molecular and Cellular Neurosciences, The Scripps Research Institute La Jolla, CA, USA
| | - Brenda Morsey
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center Omaha, NE, USA
| | - Liana Basova
- Department of Molecular and Cellular Neurosciences, The Scripps Research Institute La Jolla, CA, USA
| | - Howard S Fox
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center Omaha, NE, USA
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Parra M, Herrera D, Jácome MF, Mesa MC, Rodríguez LS, Guzmán C, Angel J, Franco MA. Circulating rotavirus-specific T cells have a poor functional profile. Virology 2014; 468-470:340-350. [PMID: 25238642 DOI: 10.1016/j.virol.2014.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 05/12/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
Abstract
Frequencies of circulating T cells producing IFN-γ, TNF-α, and IL-2, and percentages of T cells proliferating after stimulation with rotavirus (RV), tetanus toxoid, and influenza were evaluated in PBMC derived from healthy adults and children. In addition, the potential anergic state of RV-specific T cells was analyzed by stimulation of PBMC with RV antigen in the presence of three anergy inhibitors (rIL-2, rIL-12, or DGKα-i). The quality and magnitude of RV-T cell responses were significantly lower than those of tetanus toxoid and influenza antigens. RV-CD4 T cell response was enriched in monofunctional IFN-γ(+) cells, while influenza-CD4 and tetanus toxoid-CD4 T cell responses were enriched in multifunctional T cells. Moreover, rIL-2--unlike rIL-12 or DGKα-i--increased the frequencies of RV-CD4 TNF-α(+), CD4 IFN-γ(+), and CD8 IFN-γ(+) cells. Thus, circulating RV-T cells seem to have a relatively poor functional profile that may be partially reversed in vitro by the addition of rIL-2.
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Affiliation(s)
- Miguel Parra
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
| | - Daniel Herrera
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
| | - María Fernanda Jácome
- Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Martha C Mesa
- Departamento de Microbiología, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Luz-Stella Rodríguez
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
| | - Carolina Guzmán
- Departamento de Pediatría, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Juana Angel
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
| | - Manuel A Franco
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Pontificia Universidad Javeriana, Carrera 7 # 40-62, Bogotá, Colombia
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Spranger S, Gajewski T. Rational combinations of immunotherapeutics that target discrete pathways. J Immunother Cancer 2013; 1:16. [PMID: 24829752 PMCID: PMC4019905 DOI: 10.1186/2051-1426-1-16] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 09/12/2013] [Indexed: 12/25/2022] Open
Abstract
An effective anti-tumor immune response requires the coordinated action of the innate and adaptive phases of the immune system. Critical processes include the activation of dendritic cells to present antigens, produce cytokines including type I interferons, and express multiple costimulatory ligands; induction of a productive T cell response within lymph nodes; migration of activated T cells to the tumor microenvironment in response to chemokines and homing receptor expression; and having effector T cells gain access to antigen-expressing tumor cells and maintain sufficient functionality to destroy them. However, tumors can become adept at escaping the immune response, developing multiple mechanisms to disrupt key processes. In general, tumors can be assigned into two different, major groups depending on whether the tumor there is an 'inflamed' or 'non-inflamed' tumor microenvironment. Improvements in our understanding of the interactions between the immune system and cancer have resulted in the development of various strategies to improve the immune-mediated control of tumors in both sub-groups. Categories of major immunotherapeutic intervention include methods to increase the frequency of tumor antigen-specific effector T cells in the circulation, strategies to block or uncouple a range of immune suppressive mechanisms within the tumor microenvironment, and tactics to induce de novo immune inflammation within the tumor microenvironment. The latter may be particularly important for eliciting immune recognition of non-inflamed tumor phenotypes. The premise put forth in this review is that synergistic therapeutic effects in vivo may be derived from combination therapies taken from distinct "bins" based on these mechanisms of action. Early data in both preclinical and some clinical studies provide support for this model. We also suggest that optimal application of these combinations may be aided by appropriate patient selection based on predictive biomarkers.
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Affiliation(s)
- Stefani Spranger
- Biological Sciences Division, Pathology, The University of Chicago, 929 E. 57th Street, GCIS W-423, Chicago, IL 60637, USA
| | - Thomas Gajewski
- Department of Pathology and Department of Medicine, Section of Hematology/Oncology, The University of Chicago, 5841 S. Maryland Ave., MC2115, Chicago, IL 60637, USA
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Porebski G, Pecaric-Petkovic T, Groux-Keller M, Bosak M, Kawabata TT, Pichler WJ. In vitrodrug causality assessment in Stevens-Johnson syndrome - alternatives for lymphocyte transformation test. Clin Exp Allergy 2013; 43:1027-37. [DOI: 10.1111/cea.12145] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 12/17/2022]
Affiliation(s)
| | | | | | - M. Bosak
- Department of Neurology; Jagiellonian University Medical College; Krakow; Poland
| | - T. T. Kawabata
- Drug Safety Research and Development; Pfizer; Groton; CT; USA
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Mujib S, Jones RB, Lo C, Aidarus N, Clayton K, Sakhdari A, Benko E, Kovacs C, Ostrowski MA. Antigen-independent induction of Tim-3 expression on human T cells by the common γ-chain cytokines IL-2, IL-7, IL-15, and IL-21 is associated with proliferation and is dependent on the phosphoinositide 3-kinase pathway. THE JOURNAL OF IMMUNOLOGY 2012; 188:3745-56. [PMID: 22422881 DOI: 10.4049/jimmunol.1102609] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
T cell Ig mucin domain-containing molecule 3 (Tim-3) is a glycoprotein found on the surface of a subset of CD8(+) and Th1 CD4(+) T cells. Elevated expression of Tim-3 on virus-specific T cells during chronic viral infections, such as HIV-1, hepatitis B virus, and hepatitis C virus, positively correlates with viral load. Tim-3(+) cytotoxic T cells are dysfunctional and are unable to secrete effector cytokines, such as IFN-γ and TNF-α. In this study, we examined potential inducers of Tim-3 on primary human T cells. Direct HIV-1 infection of CD4(+) T cells, or LPS, found to be elevated in HIV-1 infection, did not induce Tim-3 on T cells. Tim-3 was induced by the common γ-chain (γc) cytokines IL-2, IL-7, IL-15, and IL-21 but not IL-4, in an Ag-independent manner and was upregulated on primary T cells in response to TCR/CD28 costimulation, as well as γc cytokine stimulation with successive divisions. γc cytokine-induced Tim-3 was found on naive, effector, and memory subsets of T cells. Tim-3(+) primary T cells were more prone to apoptosis, particularly upon treatment with galectin-9, a Tim-3 ligand, after cytokine withdrawal. The upregulation of Tim-3 could be blocked by the addition of a PI3K inhibitor, LY 294002. Thus, Tim-3 can be induced via TCR/CD28 costimulation and/or γc cytokines, likely through the PI3K pathway.
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Affiliation(s)
- Shariq Mujib
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario M5S 1A8, Canada
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From murine to human nude/SCID: the thymus, T-cell development and the missing link. Clin Dev Immunol 2012; 2012:467101. [PMID: 22474479 PMCID: PMC3303720 DOI: 10.1155/2012/467101] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/09/2011] [Indexed: 11/17/2022]
Abstract
Primary immunodeficiencies (PIDs) are disorders of the immune system, which lead to increased susceptibility to infections. T-cell defects, which may affect T-cell development/function, are approximately 11% of reported PIDs. The pathogenic mechanisms are related to molecular alterations not only of genes selectively expressed in hematopoietic cells but also of the stromal component of the thymus that represents the primary lymphoid organ for T-cell differentiation. With this regard, the prototype of athymic disorders due to abnormal stroma is the Nude/SCID syndrome, first described in mice in 1966. In man, the DiGeorge Syndrome (DGS) has long been considered the human prototype of a severe T-cell differentiation defect. More recently, the human equivalent of the murine Nude/SCID has been described, contributing to unravel important issues of the T-cell ontogeny in humans. Both mice and human diseases are due to alterations of the FOXN1, a developmentally regulated transcription factor selectively expressed in skin and thymic epithelia.
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Haney D, Quigley MF, Asher TE, Ambrozak DR, Gostick E, Price DA, Douek DC, Betts MR. Isolation of viable antigen-specific CD8+ T cells based on membrane-bound tumor necrosis factor (TNF)-α expression. J Immunol Methods 2011; 369:33-41. [PMID: 21501617 PMCID: PMC3116017 DOI: 10.1016/j.jim.2011.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 03/30/2011] [Accepted: 04/01/2011] [Indexed: 11/16/2022]
Abstract
Current technology to isolate viable cytokine-producing antigen-specific primary human T cells is limited to bi-specific antibody capture systems, which suffer from limited sensitivity and high background. Here, we describe a novel procedure for isolating antigen-specific human T cells based on their ability to produce tumor necrosis factor (TNF)-α. Unlike many cytokines, TNF-α is initially produced in a biologically active membrane-bound form that is subsequently cleaved by TNF-α converting enzyme (TACE) to release the soluble form of TNF-α. By preventing this cleavage event, we show that TNF-α can be 'trapped' on the surface of the T cells from which it originates and directly labeled for viable isolation of these antigen-specific T cells. Together with other existing sorting procedures to isolate activated T cells, this new technique should permit the direct isolation of multi-functional T lymphocytes for further protein and gene expression analyses, as well as a detailed functional assessment of the potential role that TNF-α producing T cells play in the adaptive immune system.
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Affiliation(s)
- Danielle Haney
- Department of Microbiology, University of Pennsylvania, Philadelphia, PA 19104, USA
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14
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Andreola G, Chittenden M, Shaffer J, Cosimi A, Kawai T, Cotter P, LoCascio S, Morokata T, Dey B, Tolkoff-Rubin N, Preffer F, Bonnefoix T, Kattleman K, Spitzer T, Sachs D, Sykes M. Mechanisms of donor-specific tolerance in recipients of haploidentical combined bone marrow/kidney transplantation. Am J Transplant 2011; 11:1236-47. [PMID: 21645255 PMCID: PMC3140222 DOI: 10.1111/j.1600-6143.2011.03566.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We recently reported long-term organ allograft survival without ongoing immunosuppression in four of five patients receiving combined kidney and bone marrow transplantation from haploidentical donors following nonmyeloablative conditioning. In vitro assays up to 18 months revealed donor-specific unresponsiveness. We now demonstrate that T cell recovery is gradual and is characterized by memory-type cell predominance and an increased proportion of CD4⁺ CD25⁺ CD127⁻ FOXP3⁺ Treg during the lymphopenic period. Complete donor-specific unresponsiveness in proliferative and cytotoxic assays, and in limiting dilution analyses of IL-2-producing and cytotoxic cells, developed and persisted for the 3-year follow-up in all patients, and extended to donor renal tubular epithelial cells. Assays in two of four patients were consistent with a role for a suppressive tolerance mechanism at 6 months to 1 year, but later (≥ 18 months) studies on all four patients provided no evidence for a suppressive mechanism. Our studies demonstrate, for the first time, long-term, systemic donor-specific unresponsiveness in patients with HLA-mismatched allograft tolerance. While regulatory cells may play an early role, long-term tolerance appears to be maintained by a deletion or anergy mechanism.
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Affiliation(s)
- G. Andreola
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - M. Chittenden
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - J. Shaffer
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - A.B. Cosimi
- Transplant Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - T. Kawai
- Transplant Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - P. Cotter
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - S.A. LoCascio
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - T. Morokata
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - B.R. Dey
- Bone Marrow Transplant Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - N.T. Tolkoff-Rubin
- Transplant Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - F. Preffer
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - T. Bonnefoix
- INSERM, U823, Oncogenic Pathways in the Haematological Malignancies, Institut Albert Bonniot, Grenoble Cedex 9, France, and Pôle de Recherche et Pôle de Biologie, Cellular and Molecular Haematology Unit, Plateforme Hospitalière de Génétique Moléculaire des Tumeurs, Centre Hospitalier Universitaire de Grenoble, Cedex 9, France
| | - K. Kattleman
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - T.R. Spitzer
- Bone Marrow Transplant Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - D.H. Sachs
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - M. Sykes
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA, Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA
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15
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Tabi Z, Spary LK, Coleman S, Clayton A, Mason MD, Staffurth J. Resistance of CD45RA- T cells to apoptosis and functional impairment, and activation of tumor-antigen specific T cells during radiation therapy of prostate cancer. THE JOURNAL OF IMMUNOLOGY 2010; 185:1330-9. [PMID: 20548027 DOI: 10.4049/jimmunol.1000488] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The effect of radiation therapy (RT) to the pelvis on circulating T cells was studied in prostate cancer (PCa) patients to provide a baseline for a more informed design of combination radioimmunotherapy. Peripheral blood samples taken from 12 PCa patients with locally advanced tumor before, during, and after hypofractionated RT were analyzed for T cell phenotype and function. There was significantly more loss of naive and early memory compared with more differentiated T cells during RT. The proportions of annexin-V(+) and Fas-expressing T cells were elevated in patients during RT and in PBMC irradiated in vitro (< or = 5.0 Gy), with preferential increases in CD45RA(+) T cells. The baseline level of apoptosis of CD45RA(-) T cells increased > 2-fold in the presence of an IkappaB-kinase inhibitor, indicating a protective effect via this pathway. T cell proliferation was impaired during RT with IL-2-dependent recovery post-RT. Recall T cell responses to common viral Ags, measured by IFN-gamma production, were little affected by RT. In vitro irradiation of healthy donor PBMCs resulted in a significantly increased frequency of responding T cells, due at least partly to the preferential elimination of CD45RA(+) T cells. Most importantly, antitumor CD4(+) and CD8(+) T cell responses were detectable after, but not before or during RT. The results indicate that generating tumor-specific T cell responses before RT and boosting their activity post-RT are ways likely to amplify the frequency and function of antitumor T cells, with implications for scheduling immunotherapy in PCa.
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Affiliation(s)
- Zsuzsanna Tabi
- Department of Pharmacology, Radiology and Oncology, School of Medicine, Cardiff University, Cancer Research Wales Research Laboratories, Velindre Cancer Centre, Whitchurch, Cardiff, CF14 2TL, UK.
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16
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Zawodniak A, Lochmatter P, Yerly D, Kawabata T, Lerch M, Yawalkar N, Pichler WJ. In vitro detection of cytotoxic T and NK cells in peripheral blood of patients with various drug-induced skin diseases. Allergy 2010; 65:376-84. [PMID: 19793058 DOI: 10.1111/j.1398-9995.2009.02180.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cytotoxic cells are involved in most forms of drug-induced skin diseases. Till now, no in vitro test addressed this aspect of drug-allergic responses. Our report evaluates whether drug-induced cytotoxic cells can be detected in peripheral blood of nonacute patients with different forms of drug hypersensitivity, and also whether in vitro detection of these cells could be helpful in drug-allergy diagnosis. METHODS GranzymeB enzyme-linked immunosorbent spot-forming (ELISPOT) and cell surface expression of the degranulation marker CD107a were evaluated on peripheral blood mononuclear cells from 12 drug-allergic patients in remission state and 16 drug-exposed healthy controls. RESULTS In 10/12 allergic patients culprit but not irrelevant drug elicited granzymeB release after 48-72 h stimulation. It was clearly positive in patients with high proliferative response to the drug, measured in lymphocyte transformation tests. In patients, who showed moderate or low proliferation and low drug-response in granzymeB ELISPOT, overnight preincubation with interleukin (IL)-7/IL-15 enhanced drug-specific granzymeB release and allowed to clearly identify the offending agent. CD107a staining was positive on CD4+/CD3+, CD8+/CD3+ T cells as well as CD56+/CD3- natural killer cells. None of the drug-exposed healthy donors reacted to the tested drugs and allergic patients reacted only to the offending, but not to tolerated drugs. CONCLUSION GranzymeB ELISPOT is a highly specific in vitro method to detect drug-reacting cytotoxic cells in peripheral blood of drug-allergic patients even several years after disease manifestation. Together with IL-7/IL-15 preincubation, it may be helpful in indentifying the offending drug even in some patients with weak proliferative drug-response.
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Affiliation(s)
- A Zawodniak
- Division of Allergology, Clinic for Rheumatology and Clinical Immunology/Allergology Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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17
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Kinter AL, Godbout EJ, McNally JP, Sereti I, Roby GA, O'Shea MA, Fauci AS. The common gamma-chain cytokines IL-2, IL-7, IL-15, and IL-21 induce the expression of programmed death-1 and its ligands. THE JOURNAL OF IMMUNOLOGY 2008; 181:6738-46. [PMID: 18981091 DOI: 10.4049/jimmunol.181.10.6738] [Citation(s) in RCA: 398] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The programmed death (PD)-1 molecule and its ligands (PD-L1 and PD-L2), negative regulatory members of the B7 family, play an important role in peripheral tolerance. Previous studies have demonstrated that PD-1 is up-regulated on T cells following TCR-mediated activation; however, little is known regarding PD-1 and Ag-independent, cytokine-induced T cell activation. The common gamma-chain (gamma c) cytokines IL-2, IL-7, IL-15, and IL-21, which play an important role in peripheral T cell expansion and survival, were found to up-regulate PD-1 and, with the exception of IL-21, PD-L1 on purified T cells in vitro. This effect was most prominent on memory T cells. Furthermore, these cytokines induced, indirectly, the expression of PD-L1 and PD-L2 on monocytes/macrophages in PBMC. The in vivo correlate of these observations was confirmed on PBMC isolated from HIV-infected individuals receiving IL-2 immunotherapy. Exposure of gamma c cytokine pretreated T cells to PD-1 ligand-IgG had no effect on STAT5 activation, T cell proliferation, or survival driven by gamma c cytokines. However, PD-1 ligand-IgG dramatically inhibited anti-CD3/CD28-driven proliferation and Lck activation. Furthermore, following restimulation with anti-CD3/CD28, cytokine secretion by both gamma c cytokine and anti-CD3/CD28 pretreated T cells was suppressed. These data suggest that gamma c cytokine-induced PD-1 does not interfere with cytokine-driven peripheral T cell expansion/survival, but may act to suppress certain effector functions of cytokine-stimulated cells upon TCR engagement, thereby minimizing immune-mediated damage to the host.
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Affiliation(s)
- Audrey L Kinter
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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18
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Higher homologous and lower cross-reactive Gag-specific T-cell responses in human immunodeficiency virus type 2 (HIV-2) than in HIV-1 infection. J Virol 2008; 82:8619-28. [PMID: 18562522 DOI: 10.1128/jvi.00027-08] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Human immunodeficiency virus type 2 (HIV-2) infection results in slower CD4(+) T-cell decline, lower plasma viral load levels, and hence slower progression of the disease than does HIV-1 infection. Although the reasons for this are not clear, it is possible that HIV-2 replication is more effectively controlled by host responses. We used aligned pools of overlapping HIV-1 and HIV-2 Gag peptides in an enhanced gamma interferon enzyme-linked immunospot assay to compare the levels of homologous and cross-reactive Gag-specific T-cell responses between HIV-1- and HIV-2-infected patients. HIV-2-infected patients showed broader and stronger homologous Gag-specific T-cell responses than HIV-1-infected patients. In contrast, the cross-reactive T-cell responses in HIV-2-infected patients were both narrower and weaker than those in HIV-1-infected patients, in line with overall weaker correlations between homologous and heterologous T-cell responses among HIV-2-infected patients than among HIV-1-infected patients. Cross-reactive responses in HIV-2-infected patients tended to correlate directly with HIV-1/HIV-2 Gag sequence similarities; this was not found in HIV-1-infected patients. The CD4(+) T-cell counts of HIV-2-infected patients correlated directly with homologous responses and inversely with cross-reactive responses; this was not found in HIV-1-infected patients. Our data support a model whereby high-level HIV-2-specific T-cell responses control the replication of HIV-2, thus limiting viral diversification and priming of HIV-1 cross-reactive T-cell responses over time. However, we cannot exclude the possibility that HIV-2 replication is controlled by other host factors and that HIV-2-specific T-cell responses are better maintained in the context of slow viral divergence and a less damaged immune system. Understanding the nature of immune control of HIV-2 infection could be crucial for HIV vaccine design.
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19
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Davis ID, Skak K, Smyth MJ, Kristjansen PEG, Miller DM, Sivakumar PV. Interleukin-21 signaling: functions in cancer and autoimmunity. Clin Cancer Res 2008; 13:6926-32. [PMID: 18056166 DOI: 10.1158/1078-0432.ccr-07-1238] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Interleukin-21 (IL-21) is a cytokine with structural and sequence homology to IL-2 and IL-15, yet possesses several biological properties distinct from these cytokines. IL-21 is produced mainly by activated CD4(+) T cells and natural killer T cells and mediates its activity by binding to the IL-21 receptor (IL-21R), consisting of an IL-21-specific alpha chain (IL-21Ralpha; JAK/STAT) that heterodimerizes with the common gamma chain (CD132). Intracellular signaling occurs through the Janus-activated kinase/signal transducer and activator of transcription pathways. Physiologic expression of IL-21R is restricted to lymphoid tissues and peripheral blood mononuclear cells; however, other tissues such as epithelium, synovium, or transformed cells can acquire expression of both components of IL-21R heterodimer. IL-21 has complex activities on a wide variety of cell types, leading to enhancement of adaptive T-cell immunity, antibody production, activation of natural killer cell subtypes, and opposition to suppressive effects mediated by regulatory T cells. Functionally, these activities promote immune responses and point to a physiologic role of IL-21 in autoimmunity and immune enhancement. Therapeutic manipulation of IL-21 activity may allow improved immunotherapy for cancer as well as insights into autoimmune disease. Recently conducted phase 1 trials in metastatic melanoma and renal cell carcinoma have shown that recombinant IL-21 has a favorable safety profile and support its continued investigation as a potential anticancer drug.
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Affiliation(s)
- Ian D Davis
- Ludwig-Austin Joint Medical Oncology Unit, Austin Health, Melbourne, Australia.
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20
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Fonseca SG, Reis MM, Coelho V, Nogueira LG, Monteiro SM, Mairena EC, Bacal F, Bocchi E, Guilherme L, Zheng XX, Liew FY, Higuchi ML, Kalil J, Cunha-Neto E. Locally produced survival cytokines IL-15 and IL-7 may be associated to the predominance of CD8+ T cells at heart lesions of human chronic Chagas disease cardiomyopathy. Scand J Immunol 2007; 66:362-71. [PMID: 17635814 DOI: 10.1111/j.1365-3083.2007.01987.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Human chronic Chagas disease cardiomyopathy (CCC) is an inflammatory-dilated cardiomyopathy occurring years after infection by the protozoan Trypanosoma cruzi. The heart inflammatory infiltrate in CCC shows a 2:1 predominance of CD8(+) in relation to CD4(+) T cells, with a typical Th1-type cytokine profile. However, in vitro expansion of infiltrating T cells from heart biopsy-derived fragments with interleukin-2 (IL-2) and phytohaemagglutinin leads to the outgrowth of CD4(+) over CD8(+) T cells. We hypothesized that survival cytokines, such as IL-2, IL-7 and IL-15 might be differentially involved in the growth and maintenance of heart-infiltrating and peripheral CD8(+) T cells from CCC patients. We found that IL-7 and IL-15 were superior to IL-2 in the expansion and viability of CD8(+) T cells from both PBMC and heart-infiltrating T-cell lines from CCC patients, and the combination of the three cytokines showed synergic effects. Heart-infiltrating CD8(+) T cells showed higher expression of both IL-15R alpha and gamma(c) chain than CD4(+) T cells, which may explain the improvement of CD8(+) T-cell growth in the presence of IL-2 + IL-7 + IL-15. Immunohistochemical identification of IL-15 and the higher mRNA expression of IL-15R alpha, IL-7 and gamma(c) chain in CCC heart tissues compared with control individuals indicate in situ production of survival cytokines and their receptors in CCC hearts. Together, our results suggest that local production of IL-7 and IL-15 may be associated with the maintenance and predominance of CD8(+) T cells, the cells effecting tissue damage in CCC hearts.
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Affiliation(s)
- S G Fonseca
- Laboratory of Immunology, Heart Institute of the Sao Paulo University Medical School, Sao Paulo, Brazil
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