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Alles M, Gunasena M, Zia T, D'Mello A, Bhattarai S, Mulhern W, Terry L, Scherger T, Wijeratne S, Singh S, Wijeratne AJ, Kasturiratna D, Tettelin H, Weyand NJ, Liyanage NPM. Unveiling the immune dynamics of Neisseria persistent oral colonization. Infect Immun 2024:e0004824. [PMID: 38814083 DOI: 10.1128/iai.00048-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/27/2024] [Indexed: 05/31/2024] Open
Abstract
Commensal bacteria are crucial in maintaining host physiological homeostasis, immune system development, and protection against pathogens. Despite their significance, the factors influencing persistent bacterial colonization and their impact on the host still need to be fully understood. Animal models have served as valuable tools to investigate these interactions, but most have limitations. The bacterial genus Neisseria, which includes both commensal and pathogenic species, has been studied from a pathogenicity to humans perspective but lacks models that study immune responses in the context of long-term persistence. Neisseria musculi, a recently described natural commensal of mice, offers a unique opportunity to study long-term host-commensal interactions. In this study, for the first time, we have used this model to study the transcriptional, phenotypic, and functional dynamics of immune cell signatures in the mucosal and systemic tissue of mice in response to N. musculi colonization. We found key genes and pathways vital for immune homeostasis in palate tissue, validated by flow cytometry of immune cells from the lung, blood, and spleen. This study offers a novel avenue for advancing our understanding of host-bacteria dynamics and may provide a platform for developing efficacious interventions against mucosal persistence by pathogenic Neisseria.
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Affiliation(s)
- Mario Alles
- Department of Microbial Infection and Immunity, College of Medicine, Ohio State University, Columbus, Ohio, USA
| | - Manuja Gunasena
- Department of Microbial Infection and Immunity, College of Medicine, Ohio State University, Columbus, Ohio, USA
- Department of Veterinary Biosciences, College of Veterinary Medicine, Ohio State University, Columbus, Ohio, USA
- Infectious Diseases Institute, The Ohio State University, Columbus, Ohio, USA
| | - Tauqir Zia
- Department of Biological Sciences, Ohio University, Athens, Ohio, USA
| | - Adonis D'Mello
- Department of Microbiology and Immunology, Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Saroj Bhattarai
- Department of Biological Sciences, Ohio University, Athens, Ohio, USA
| | - Will Mulhern
- Department of Microbial Infection and Immunity, College of Medicine, Ohio State University, Columbus, Ohio, USA
| | - Luke Terry
- Department of Microbial Infection and Immunity, College of Medicine, Ohio State University, Columbus, Ohio, USA
| | - Trenton Scherger
- Department of Microbial Infection and Immunity, College of Medicine, Ohio State University, Columbus, Ohio, USA
| | - Saranga Wijeratne
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sachleen Singh
- Arkansas Biosciences Institute, Arkansas State University, Jonesboro, Arkansas, USA
| | - Asela J Wijeratne
- Arkansas Biosciences Institute, Arkansas State University, Jonesboro, Arkansas, USA
| | - Dhanuja Kasturiratna
- Department of Mathematics and Statistics, Northern Kentucky University, Highland Heights, Kentucky, USA
| | - Hervé Tettelin
- Department of Microbiology and Immunology, Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nathan J Weyand
- Department of Biological Sciences, Ohio University, Athens, Ohio, USA
- The Infectious and Tropical Disease Institute, Ohio University, Athens, Ohio, USA
- Molecular and Cellular Biology Program, Ohio University, Athens, Ohio, USA
| | - Namal P M Liyanage
- Department of Microbial Infection and Immunity, College of Medicine, Ohio State University, Columbus, Ohio, USA
- Department of Veterinary Biosciences, College of Veterinary Medicine, Ohio State University, Columbus, Ohio, USA
- Infectious Diseases Institute, The Ohio State University, Columbus, Ohio, USA
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2
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Melchior K, Gerner RR, Hossain S, Nuccio SP, Moreira CG, Raffatellu M. IL-22-dependent responses and their role during Citrobacter rodentium infection. Infect Immun 2024; 92:e0009924. [PMID: 38557196 PMCID: PMC11075456 DOI: 10.1128/iai.00099-24] [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: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024] Open
Abstract
The mouse pathogen Citrobacter rodentium is utilized as a model organism for studying infections caused by the human pathogens enteropathogenic Escherichia coli (EPEC) and enterohemorrhagic E. coli (EHEC) and to elucidate mechanisms of mucosal immunity. In response to C. rodentium infection, innate lymphoid cells and T cells secrete interleukin (IL)-22, a cytokine that promotes mucosal barrier function. IL-22 plays a pivotal role in enabling mice to survive and recover from C. rodentium infection, although the exact mechanisms involved remain incompletely understood. Here, we investigated whether particular components of the host response downstream of IL-22 contribute to the cytokine's protective effects during C. rodentium infection. In line with previous research, mice lacking the IL-22 gene (Il22-/- mice) were highly susceptible to C. rodentium infection. To elucidate the role of specific antimicrobial proteins modulated by IL-22, we infected the following knockout mice: S100A9-/- (calprotectin), Lcn2-/- (lipocalin-2), Reg3b-/- (Reg3β), Reg3g-/- (Reg3γ), and C3-/- (C3). All knockout mice tested displayed a considerable level of resistance to C. rodentium infection, and none phenocopied the lethality observed in Il22-/- mice. By investigating another arm of the IL-22 response, we observed that C. rodentium-infected Il22-/- mice exhibited an overall decrease in gene expression related to intestinal barrier integrity as well as significantly elevated colonic inflammation, gut permeability, and pathogen levels in the spleen. Taken together, these results indicate that host resistance to lethal C. rodentium infection may depend on multiple antimicrobial responses acting in concert, or that other IL-22-regulated processes, such as tissue repair and maintenance of epithelial integrity, play crucial roles in host defense to attaching and effacing pathogens.
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Affiliation(s)
- Karine Melchior
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, University of California San Diego, La Jolla, California, USA
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | - Romana R. Gerner
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, University of California San Diego, La Jolla, California, USA
- School of Life Sciences, ZIEL – Institute for Food and Health, Freising-Weihenstephan, Technical University of Munich, Munich, Germany
- Department of Internal Medicine III, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Suzana Hossain
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, University of California San Diego, La Jolla, California, USA
| | - Sean-Paul Nuccio
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, University of California San Diego, La Jolla, California, USA
| | - Cristiano Gallina Moreira
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
- Department of Biological Sciences, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Manuela Raffatellu
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, University of California San Diego, La Jolla, California, USA
- Center for Microbiome Innovation, University of California San Diego, La Jolla, California, USA
- Chiba University-UC San Diego Center for Mucosal Immunology, Allergy, and Vaccines (CU-UCSD cMAV), La Jolla, California, USA
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3
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Bagri P, Anipindi VC, Kaushic C. The Role of IL-17 During Infections in the Female Reproductive Tract. Front Immunol 2022; 13:861444. [PMID: 35493460 PMCID: PMC9046847 DOI: 10.3389/fimmu.2022.861444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/22/2022] [Indexed: 11/15/2022] Open
Abstract
Interleukin-17 (IL-17A) is a cytokine involved in a complex array of both protective and detrimental processes. Although early biological studies focused on the pro-inflammatory function of IL-17 in the context of autoimmune and inflammatory disorders, it has become increasingly evident that the roles of IL-17 are far more nuanced. Recent work has demonstrated that the functions of IL-17 are highly context- and tissue-dependent, and there is a fine balance between the pathogenic and protective functions of IL-17. This is especially evident in mucosal tissues such as the female reproductive tract, where IL-17 has been shown to play an important role in the immune response generated during fungal, bacterial and viral infections associated with protection, but also with inflammation. In this review, we discuss the evolving landscape of IL-17 biology within the context of the vaginal mucosa, focusing on key findings that highlight the importance of this cytokine in genital mucosal immunity.
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Affiliation(s)
- Puja Bagri
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Varun C. Anipindi
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Charu Kaushic
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- *Correspondence: Charu Kaushic,
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Scurtu LG, Jinga V, Simionescu O. Fascinating Molecular and Immune Escape Mechanisms in the Treatment of STIs (Syphilis, Gonorrhea, Chlamydia, and Herpes Simplex). Int J Mol Sci 2022; 23:ijms23073550. [PMID: 35408911 PMCID: PMC8998805 DOI: 10.3390/ijms23073550] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023] Open
Abstract
The incidence of syphilis, gonorrhea, chlamydia, and herpes simplex has increased over the last decade, despite the numerous prevention strategies. Worldwide scientists report a surge in drug-resistant infections, particularly in immunocompromised patients. Antigenic variations in syphilis enable long-term infection, but benzathine penicillin G maintains its efficiency, whereas macrolides should be recommended with caution. Mupirocin and zoliflodacin were recently introduced as therapies against ceftriaxone-resistant gonococcus, which poses a larger global threat. The gastrointestinal and prostatic potential reservoirs of Chlamydia trachomatis may represent the key towards complete eradication. Similar to syphilis, macrolides resistance has to be considered in genital chlamydiosis. Acyclovir-resistant HSV may respond to the novel helicase-primase inhibitors and topical imiquimod, particularly in HIV-positive patients. Novel drugs can overcome these challenges while nanocarriers enhance their potency, particularly in mucosal areas. This review summarizes the most recent and valuable discoveries regarding the immunopathogenic mechanisms of these sexually transmitted infections and discusses the challenges and opportunities of the novel molecules and nanomaterials.
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Affiliation(s)
- Lucian G. Scurtu
- Department of Dermatology I, Colentina Clinical Hospital, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020125 Bucharest, Romania;
| | - Viorel Jinga
- Department of Urology, Clinical Hospital Prof. Dr. Th. Burghele, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 030167 Bucharest, Romania;
| | - Olga Simionescu
- Department of Dermatology I, Colentina Clinical Hospital, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020125 Bucharest, Romania;
- Correspondence:
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5
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The serogroup B meningococcal outer membrane vesicle-based vaccine 4CMenB induces cross-species protection against Neisseria gonorrhoeae. PLoS Pathog 2020; 16:e1008602. [PMID: 33290434 PMCID: PMC7748408 DOI: 10.1371/journal.ppat.1008602] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 12/18/2020] [Accepted: 10/08/2020] [Indexed: 12/15/2022] Open
Abstract
There is a pressing need for a gonorrhea vaccine due to the high disease burden associated with gonococcal infections globally and the rapid evolution of antibiotic resistance in Neisseria gonorrhoeae (Ng). Current gonorrhea vaccine research is in the stages of antigen discovery and the identification of protective immune responses, and no vaccine has been tested in clinical trials in over 30 years. Recently, however, it was reported in a retrospective case-control study that vaccination of humans with a serogroup B Neisseria meningitidis (Nm) outer membrane vesicle (OMV) vaccine (MeNZB) was associated with reduced rates of gonorrhea. Here we directly tested the hypothesis that Nm OMVs induce cross-protection against gonorrhea in a well-characterized female mouse model of Ng genital tract infection. We found that immunization with the licensed Nm OMV-based vaccine 4CMenB (Bexsero) significantly accelerated clearance and reduced the Ng bacterial burden compared to administration of alum or PBS. Serum IgG and vaginal IgA and IgG that cross-reacted with Ng OMVs were induced by 4CMenB vaccination by either the subcutaneous or intraperitoneal routes. Antibodies from vaccinated mice recognized several Ng surface proteins, including PilQ, BamA, MtrE, NHBA (known to be recognized by humans), PorB, and Opa. Immune sera from both mice and humans recognized Ng PilQ and several proteins of similar apparent molecular weight, but MtrE was only recognized by mouse serum. Pooled sera from 4CMenB-immunized mice showed a 4-fold increase in serum bactericidal50 titers against the challenge strain; in contrast, no significant difference in bactericidal activity was detected when sera from 4CMenB-immunized and unimmunized subjects were compared. Our findings directly support epidemiological evidence that Nm OMVs confer cross-species protection against gonorrhea, and implicate several Ng surface antigens as potentially protective targets. Additionally, this study further defines the usefulness of murine infection model as a relevant experimental system for gonorrhea vaccine development.
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6
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Sabihi M, Böttcher M, Pelczar P, Huber S. Microbiota-Dependent Effects of IL-22. Cells 2020; 9:E2205. [PMID: 33003458 PMCID: PMC7599675 DOI: 10.3390/cells9102205] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 02/07/2023] Open
Abstract
Cytokines are important contributors to immune responses against microbial and environmental threats and are of particular importance at epithelial barriers. These interfaces are continuously exposed to external factors and thus require immune components to both protect the host from pathogen invasion and to regulate overt inflammation. Recently, substantial efforts have been devoted to understanding how cytokines act on certain cells at barrier sites, and why the dysregulation of immune responses may lead to pathogenesis. In particular, the cytokine IL-22 is involved in preserving an intact epithelium, maintaining a balanced microbiota and a functioning defense system against external threats. However, a tight regulation of IL-22 is generally needed, since uncontrolled IL-22 production can lead to the progression of autoimmunity and cancer. Our aim in this review is to summarize novel findings on IL-22 and its interactions with specific microbial stimuli, and subsequently, to understand their contributions to the function of IL-22 and the clinical outcome. We particularly focus on understanding the detrimental effects of dysregulated control of IL-22 in certain disease contexts.
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Affiliation(s)
| | | | | | - Samuel Huber
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; (M.S.); (M.B.); (P.P.)
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7
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Russell MW, Jerse AE, Gray-Owen SD. Progress Toward a Gonococcal Vaccine: The Way Forward. Front Immunol 2019; 10:2417. [PMID: 31681305 PMCID: PMC6803597 DOI: 10.3389/fimmu.2019.02417] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/27/2019] [Indexed: 12/26/2022] Open
Abstract
The concept of immunizing against gonorrhea has received renewed interest because of the recent emergence of strains of Neisseria gonorrhoeae that are resistant to most currently available antibiotics, an occurrence that threatens to render gonorrhea untreatable. However, despite efforts over many decades, no vaccine has yet been successfully developed for human use, leading to pessimism over whether this goal was actually attainable. Several factors have contributed to this situation, including extensive variation of the expression and specificity of many of the gonococcal surface antigens, and the ability of N. gonorrhoeae to resist destruction by complement and other innate immune defense mechanisms. The natural host restriction of N. gonorrhoeae for humans, coupled with the absence of any definable state of immunity arising from an episode of gonorrhea, have also complicated efforts to study gonococcal pathogenesis and the host's immune responses. However, recent findings have elucidated how the gonococcus exploits and manipulates the host's immune system for its own benefit, utilizing human-specific receptors for attachment to and invasion of tissues, and subverting adaptive immune responses that might otherwise be capable of eliminating it. While no single experimental model is capable of providing all the answers, experiments utilizing human cells and tissues in vitro, various in vivo animal models, including genetically modified strains of mice, and both experimental and observational human clinical studies, have combined to yield important new insight into the immuno-pathogenesis of gonococcal infection. In turn, these have now led to novel approaches for the development of a gonococcal vaccine. Ongoing investigations utilizing all available tools are now poised to make the development of an effective human vaccine against gonorrhea an achievable goal within a foreseeable time-frame.
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Affiliation(s)
- Michael W. Russell
- Department of Microbiology and Immunology, University at Buffalo, Buffalo, NY, United States
| | - Ann E. Jerse
- Department of Microbiology and Immunology, F. Edward Herbert School of Medicine, Uniformed Services University, Bethesda, MD, United States
| | - Scott D. Gray-Owen
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
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8
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Cheng HY, Ning MX, Chen DK, Ma WT. Interactions Between the Gut Microbiota and the Host Innate Immune Response Against Pathogens. Front Immunol 2019; 10:607. [PMID: 30984184 PMCID: PMC6449424 DOI: 10.3389/fimmu.2019.00607] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/07/2019] [Indexed: 12/12/2022] Open
Abstract
The mammalian intestine is colonized by over a trillion microbes that comprise the "gut microbiota," a microbial community which has co-evolved with the host to form a mutually beneficial relationship. Accumulating evidence indicates that the gut microbiota participates in immune system maturation and also plays a central role in host defense against pathogens. Here we review some of the mechanisms employed by the gut microbiota to boost the innate immune response against pathogens present on epithelial mucosal surfaces. Antimicrobial peptide secretion, inflammasome activation and induction of host IL-22, IL-17, and IL-10 production are the most commonly observed strategies employed by the gut microbiota for host anti-pathogen defense. Taken together, the body of evidence suggests that the host gut microbiota can elicit innate immunity against pathogens.
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Affiliation(s)
- Hong-Yu Cheng
- Veterinary Immunology Laboratory, College of Veterinary Medicine, Northwest Agriculture and Forestry University, Yangling, China
| | - Meng-Xia Ning
- Veterinary Immunology Laboratory, College of Veterinary Medicine, Northwest Agriculture and Forestry University, Yangling, China
| | - De-Kun Chen
- Veterinary Immunology Laboratory, College of Veterinary Medicine, Northwest Agriculture and Forestry University, Yangling, China
| | - Wen-Tao Ma
- Veterinary Immunology Laboratory, College of Veterinary Medicine, Northwest Agriculture and Forestry University, Yangling, China
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9
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Rice PA, Shafer WM, Ram S, Jerse AE. Neisseria gonorrhoeae: Drug Resistance, Mouse Models, and Vaccine Development. Annu Rev Microbiol 2018; 71:665-686. [PMID: 28886683 DOI: 10.1146/annurev-micro-090816-093530] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Gonorrhea, an obligate human infection, is on the rise worldwide and gonococcal strains resistant to many antibiotics are emerging. Appropriate antimicrobial treatment and prevention, including effective vaccines, are urgently needed. To guide investigation, an experimental model of genital tract infection has been developed in female mice to study mechanisms by which Neisseria gonorrhoeae evades host-derived antimicrobial factors and to identify protective and immunosuppressive pathways. Refinements of the animal model have also improved its use as a surrogate host of human infection and accelerated the testing of novel therapeutic and prophylactic compounds against gonococcal infection. Reviewed herein are the (a) history of antibiotic usage and resistance against gonorrhea and the consequences of resistance mechanisms that may increase gonococcal fitness and therefore the potential for spread, (b) use of gonococcal infection in the animal model system to study mechanisms of pathogenesis and host defenses, and
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Affiliation(s)
- Peter A Rice
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605-4321; ,
| | - William M Shafer
- Department of Microbiology and Immunology and Emory Antibiotic Resistance Center, Emory University School of Medicine, Atlanta, Georgia 30322.,Laboratories of Bacterial Pathogenesis, Veterans Affairs Medical Center, Decatur, Georgia 30033;
| | - Sanjay Ram
- Division of Infectious Diseases and Immunology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605-4321; ,
| | - Ann E Jerse
- Department of Microbiology and Immunology, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland 20814-4799;
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Vincent LR, Jerse AE. Biological feasibility and importance of a gonorrhea vaccine for global public health. Vaccine 2018; 37:7419-7426. [PMID: 29680200 PMCID: PMC6892272 DOI: 10.1016/j.vaccine.2018.02.081] [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] [Received: 10/20/2017] [Revised: 02/05/2018] [Accepted: 02/19/2018] [Indexed: 02/06/2023]
Abstract
78 million new infections annually; greatest impact on women and neonates in LMIC. Current control measures are inadequate and challenged by antibiotic resistance. Conserved candidate vaccine antigens and adjuvant strategies are being developed. There is a need for human studies to investigate correlates of immunity. A meningococcal outer membrane vesicle vaccine may protect against gonorrhea.
There is a growing public health interest in controlling sexually transmitted infections (STIs) through vaccination due to increasing recognition of the global disease burden of STIs and the role of STIs in women’s reproductive health, adverse pregnancy outcomes, and the health and well-being of neonates. Neisseria gonorrhoeae has historically challenged vaccine development through the expression of phase and antigenically variable surface molecules and its capacity to cause repeated infections without inducing protective immunity. An estimated 78 million new N. gonorrhoeae infections occur annually and the greatest disease burden is carried by low- and middle-income countries (LMIC). Current control measures are clearly inadequate and threatened by the rapid emergence of antibiotic resistance. The gonococcus now holds the status of “super-bug” as there is currently no single reliable monotherapy for empirical treatment of gonorrhea. The problem of antibiotic resistance has elevated treatment costs and necessitated the establishment of large surveillance programs to track the spread of resistant strains. Here we review the need for a gonorrhea vaccine with respect to global disease burden and related socioeconomic and treatment costs, with an emphasis on the impact of gonorrhea on women and newborns. We also highlight the challenge of estimating the impact of a gonorrhea vaccine due to the need for more data on the burden of gonococcal pelvic inflammatory disease and related sequelae and of gonorrhea-associated adverse pregnancy outcomes and the problem of empirical diagnosis and treatment of STIs in LMIC. There is also a lack of clinical and basic science research in the area of gonococcal/chlamydia coinfection, which occurs in a high percentage of individuals with gonorrhea and should be considered when testing the efficacy of gonorrhea vaccines. Finally, we review recent research that suggests a gonorrhea vaccine is feasible and discuss challenges and research gaps in gonorrhea vaccine development.
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Affiliation(s)
- Leah R Vincent
- National Institute of Allergy and Infectious Diseases, 5601 Fishers Lane, Rockville, MD 20852, United States.
| | - Ann E Jerse
- Department of Microbiology and Immunology F. Edward Herbert School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20854, United States.
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11
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Abstract
The host-adapted human pathogen Neisseria gonorrhoeae is the causative agent of gonorrhoea. Consistent with its proposed evolution from an ancestral commensal bacterium, N. gonorrhoeae has retained features that are common in commensals, but it has also developed unique features that are crucial to its pathogenesis. The continued worldwide incidence of gonorrhoeal infection, coupled with the rising resistance to antimicrobials and the difficulties in controlling the disease in developing countries, highlights the need to better understand the molecular basis of N. gonorrhoeae infection. This knowledge will facilitate disease prevention, surveillance and control, improve diagnostics and may help to facilitate the development of effective vaccines or new therapeutics. In this Review, we discuss sex-related symptomatic gonorrhoeal disease and provide an overview of the bacterial factors that are important for the different stages of pathogenesis, including transmission, colonization and immune evasion, and we discuss the problem of antibiotic resistance.
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Affiliation(s)
- Sarah Jane Quillin
- Department of Microbiology-Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
| | - H Steven Seifert
- Department of Microbiology-Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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12
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Cerny KL, Ribeiro RAC, Li Q, Matthews JC, Bridges PJ. Effect of lipopolysaccharide on the expression of inflammatory mRNAs and microRNAs in the mouse oviduct. Reprod Fertil Dev 2017; 30:600-608. [PMID: 28945983 DOI: 10.1071/rd17241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 08/25/2017] [Indexed: 11/23/2022] Open
Abstract
Infection with Gram-negative bacteria is a major cause of aberrant inflammation in the oviduct; consequences can include tubal-based infertility and/or ectopic pregnancy. Understanding the inflammatory response is necessary for the development of novel treatment options that counter inflammation-induced infertility. The aim of the present study was to determine the effect of intraperitoneal (i.p.) administration of Escherichia coli-derived lipopolysaccharide (LPS) on the acute expression of inflammatory mRNAs and microRNAs (miRNAs) in the oviduct. On the day of oestrus, 6- to 8-week-old CD1 mice were injected i.p. with 0, 2 or 10µg LPS in 100μL phosphate-buffered saline. Mice were killed 24h later and the oviducts collected for gene expression analyses. The effect of treatment on the expression of mRNAs and miRNAs was evaluated by one-way analysis of variance (ANOVA), with treatment means of differentially expressed (P<0.05) transcripts separated using Scheffé's test. LPS treatment affected 49 of 179 targeted inflammatory mRNAs and 51 of 578 miRNAs (P<0.05). The identity of differentially expressed miRNAs predicted as regulators of chemokine and interleukin ligand mRNAs was then extracted using the microRNA.org database. The results of the present study indicate that systemic treatment with LPS induces a robust inflammatory response in the oviducts of mice, and identify key mRNAs and putative miRNAs modulating this effect.
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Affiliation(s)
- Katheryn L Cerny
- Department of Animal and Food Sciences, University of Kentucky, Lexington, KY 40546, USA
| | - Rosanne A C Ribeiro
- Department of Animal and Food Sciences, University of Kentucky, Lexington, KY 40546, USA
| | - Qing Li
- Department of Animal and Food Sciences, University of Kentucky, Lexington, KY 40546, USA
| | - James C Matthews
- Department of Animal and Food Sciences, University of Kentucky, Lexington, KY 40546, USA
| | - Phillip J Bridges
- Department of Animal and Food Sciences, University of Kentucky, Lexington, KY 40546, USA
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13
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Li P, Xu Z, Sun X, Yin Y, Fan Y, Zhao J, Mao X, Huang J, Yang F, Zhu L. Transcript profiling of the immunological interactions between Actinobacillus pleuropneumoniae serotype 7 and the host by dual RNA-seq. BMC Microbiol 2017; 17:193. [PMID: 28899359 PMCID: PMC5596872 DOI: 10.1186/s12866-017-1105-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/05/2017] [Indexed: 02/08/2023] Open
Abstract
Background The complexity of the pathogenic mechanism underlying the host immune response to Actinobacillus pleuropneumonia (App) makes the use of preventive measures difficult, and a more global view of the host-pathogen interactions and new insights into this process are urgently needed to reveal the pathogenic and immune mechanisms underlying App infection. Here, we infected specific pathogen-free Mus musculus with App serotype 7 by intranasal inoculation to construct an acute hemorrhagic pneumonia infection model and isolated the infected lungs for analysis of the interactions by dual RNA-seq. Results Four cDNA libraries were constructed, and 2428 differentially expressed genes (DEGs) of the host and 333 DEGs of App were detected. The host DEGs were mainly enriched in inflammatory signaling pathways, such as the TLR, NLR, RLR, BCR and TCR signaling pathways, resulting in large-scale cytokine up-regulation and thereby yielding a cytokine cascade for anti-infection and lung damage. The majority of the up-regulated cytokines are involved in the IL-23/IL-17 cytokine-regulated network, which is crucial for host defense against bacterial infection. The DEGs of App were mainly related to the transport and metabolism of energy and materials. Most of these genes are metabolic genes involved in anaerobic metabolism and important for challenging the host and adapting to the anaerobic stress conditions observed in acute hemorrhagic pneumonia. Some of these genes, such as adhE, dmsA, and aspA, might be potential virulence genes. In addition, the up-regulation of genes associated with peptidoglycan and urease synthesis and the restriction of major virulence genes might be immune evasion strategies of App. The regulation of metabolic genes and major virulence genes indicate that the dominant antigens might differ during the infection process and that vaccines based on these antigens might allow establishment of a precise and targeted immune response during the early phase of infection. Conclusion Through an analysis of transcriptional data by dual RNA-seq, our study presents a novel global view of the interactions of App with its host and provides a basis for further study. Electronic supplementary material The online version of this article (10.1186/s12866-017-1105-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ping Li
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China.,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China
| | - Zhiwen Xu
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China.,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China
| | - Xiangang Sun
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China
| | - Yue Yin
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China.,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China
| | - Yi Fan
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China.,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China
| | - Jun Zhao
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China.,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China
| | - Xiyu Mao
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China.,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China
| | - Jianbo Huang
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China.,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China
| | - Fan Yang
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China.,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China
| | - Ling Zhu
- College of Veterinary Medicine, Sichuan Agricultural University, Huimin Road 211, Weenjiang District, Chengdu, Sichuan, China. .,Key Laboratory of Animal Diseases and Human Health of Sichuan Province, Chengdu, Sichuan, China.
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14
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TIR Domain-Containing Adapter-Inducing Beta Interferon (TRIF) Mediates Immunological Memory against Bacterial Pathogens. Infect Immun 2015; 83:4404-15. [PMID: 26351279 DOI: 10.1128/iai.00674-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/26/2015] [Indexed: 01/08/2023] Open
Abstract
Induction of adaptive immunity leads to the establishment of immunological memory; however, how innate immunity regulates memory T cell function remains obscure. Here we show a previously undefined mechanism in which innate and adaptive immunity are linked by TIR domain-containing adapter-inducing beta interferon (TRIF) during establishment and reactivation of memory T cells against Gram-negative enteropathogens. Absence of TRIF in macrophages (Mϕs) but not dendritic cells led to a predominant generation of CD4(+) central memory T cells that express IL-17 during enteric bacterial infection in mice. TRIF-dependent type I interferon (IFN) signaling in T cells was essential to Th1 lineage differentiation and reactivation of memory T cells. TRIF activated memory T cells to facilitate local neutrophil influx and enhance bacterial elimination. These results highlight the importance of TRIF as a mediator of the innate and adaptive immune interactions in achieving the protective properties of memory immunity against Gram-negative bacteria and suggest TRIF as a potential therapeutic target.
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15
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16
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Pham TAN, Clare S, Goulding D, Arasteh JM, Stares MD, Browne HP, Keane JA, Page AJ, Kumasaka N, Kane L, Mottram L, Harcourt K, Hale C, Arends MJ, Gaffney DJ, Dougan G, Lawley TD. Epithelial IL-22RA1-mediated fucosylation promotes intestinal colonization resistance to an opportunistic pathogen. Cell Host Microbe 2014; 16:504-16. [PMID: 25263220 PMCID: PMC4190086 DOI: 10.1016/j.chom.2014.08.017] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/12/2014] [Accepted: 08/18/2014] [Indexed: 12/17/2022]
Abstract
Our intestinal microbiota harbors a diverse microbial community, often containing opportunistic bacteria with virulence potential. However, mutualistic host-microbial interactions prevent disease by opportunistic pathogens through poorly understood mechanisms. We show that the epithelial interleukin-22 receptor IL-22RA1 protects against lethal Citrobacter rodentium infection and chemical-induced colitis by promoting colonization resistance against an intestinal opportunistic bacterium, Enterococcus faecalis. Susceptibility of Il22ra1(-/-) mice to C. rodentium was associated with preferential expansion and epithelial translocation of pathogenic E. faecalis during severe microbial dysbiosis and was ameloriated with antibiotics active against E. faecalis. RNA sequencing analyses of primary colonic organoids showed that IL-22RA1 signaling promotes intestinal fucosylation via induction of the fucosyltransferase Fut2. Additionally, administration of fucosylated oligosaccharides to C. rodentium-challenged Il22ra1(-/-) mice attenuated infection and promoted E. faecalis colonization resistance by restoring the diversity of anaerobic commensal symbionts. These results support a model whereby IL-22RA1 enhances host-microbiota mutualism to limit detrimental overcolonization by opportunistic pathogens.
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Affiliation(s)
- Tu Anh N Pham
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Simon Clare
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - David Goulding
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Julia M Arasteh
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Mark D Stares
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Hilary P Browne
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Jacqueline A Keane
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Andrew J Page
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Natsuhiko Kumasaka
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Leanne Kane
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Lynda Mottram
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Katherine Harcourt
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Christine Hale
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Mark J Arends
- Department of Pathology, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Daniel J Gaffney
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Gordon Dougan
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK
| | - Trevor D Lawley
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, CB10 1SA, UK.
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17
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Behnsen J, Jellbauer S, Wong CP, Edwards RA, George MD, Ouyang W, Raffatellu M. The cytokine IL-22 promotes pathogen colonization by suppressing related commensal bacteria. Immunity 2014; 40:262-73. [PMID: 24508234 PMCID: PMC3964146 DOI: 10.1016/j.immuni.2014.01.003] [Citation(s) in RCA: 219] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 11/27/2013] [Indexed: 12/16/2022]
Abstract
Interleukin-22 (IL-22) is highly induced in response to infections with a variety of pathogens, and its main functions are considered to be tissue repair and host defense at mucosal surfaces. Here we showed that IL-22 has a unique role during infection in that its expression suppressed the intestinal microbiota and enhanced the colonization of a pathogen. IL-22 induced the expression of antimicrobial proteins, including lipocalin-2 and calprotectin, which sequester essential metal ions from microbes. Because Salmonella enterica ser. Typhimurium can overcome metal ion starvation mediated by lipocalin-2 and calprotectin via alternative pathways, IL-22 boosted its colonization of the inflamed intestine by suppressing commensal Enterobacteriaceae, which are susceptible to the antimicrobial proteins. Thus, IL-22 tipped the balance between pathogenic and commensal bacteria in favor of a pathogen. Taken together, IL-22 induction can be exploited by pathogens to suppress the growth of their closest competitors, thereby enhancing pathogen colonization of mucosal surfaces.
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Affiliation(s)
- Judith Behnsen
- Department of Microbiology, University of California, Irvine, Irvine, CA 92697, USA; Institute for Immunology, University of California, Irvine, Irvine, CA 92697, USA
| | - Stefan Jellbauer
- Department of Microbiology, University of California, Irvine, Irvine, CA 92697, USA; Institute for Immunology, University of California, Irvine, Irvine, CA 92697, USA
| | - Christina P Wong
- Department of Microbiology, University of California, Irvine, Irvine, CA 92697, USA; Institute for Immunology, University of California, Irvine, Irvine, CA 92697, USA
| | - Robert A Edwards
- Institute for Immunology, University of California, Irvine, Irvine, CA 92697, USA; Department of Pathology and Laboratory Medicine, University of California, Irvine, Irvine, CA 92697, USA
| | - Michael D George
- Department of Medical Microbiology and Immunology, School of Medicine, University of California, Davis, CA 95616, USA
| | - Wenjun Ouyang
- Department of Immunology, Genentech, South San Francisco, CA 94080, USA
| | - Manuela Raffatellu
- Department of Microbiology, University of California, Irvine, Irvine, CA 92697, USA; Institute for Immunology, University of California, Irvine, Irvine, CA 92697, USA.
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18
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Liu Y, Liu W, Russell MW. Suppression of host adaptive immune responses by Neisseria gonorrhoeae: role of interleukin 10 and type 1 regulatory T cells. Mucosal Immunol 2014; 7:165-76. [PMID: 23757303 PMCID: PMC3812424 DOI: 10.1038/mi.2013.36] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 04/23/2013] [Indexed: 02/04/2023]
Abstract
Infection with Neisseria gonorrhoeae triggers an intense inflammatory response characterized by an influx of neutrophils in the genital tract, yet natural gonococcal infection does not induce a state of protective immunity. Our previous studies in a mouse model of N. gonorrhoeae infection demonstrated that transforming growth factor-β (TGF-β) is involved in the suppression of adaptive immunity by this organism, but complete inhibition of TGF-β activity only partially reverses N. gonorrhoeae-mediated suppression of T helper type 1 (Th1) and Th2 responses. In this study, we show that N. gonorrhoeae strongly induced the production of interleukin (IL)-10 and type 1 regulatory T (Tr1) cells. Blockade of IL-10 and Tr1 cell activity enhanced both Th1/Th2-dependent adaptive immune responses and Th17-governed innate responses to N. gonorrhoeae. Treatment of mice with anti-IL-10 antibody during gonococcal challenge led to faster clearance of infection and induced protection against secondary infection, with the generation of circulating and vaginal anti-gonococcal antibodies. Our results suggest that inhibition of IL-10 and Tr1 cells affords a new approach to the treatment of gonorrhea and facilitates the development of specific protective immunity.
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Affiliation(s)
- Yingru Liu
- Department of Microbiology and Immunology, Witebsky Center for Microbial Pathogenesis and Immunology, University at Buffalo, Buffalo, NY 14214, USA
| | - Wensheng Liu
- Digestive Diseases and Nutrition Center, Department of Pediatrics, University at Buffalo, Buffalo, NY 14214, USA
| | - Michael W. Russell
- Department of Microbiology and Immunology, Witebsky Center for Microbial Pathogenesis and Immunology, University at Buffalo, Buffalo, NY 14214, USA
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19
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Frazer LC, Scurlock AM, Zurenski MA, Riley MM, Mintus M, Pociask DA, Sullivan JE, Andrews CW, Darville T. IL-23 induces IL-22 and IL-17 production in response to Chlamydia muridarum genital tract infection, but the absence of these cytokines does not influence disease pathogenesis. Am J Reprod Immunol 2013; 70:472-84. [PMID: 24238108 PMCID: PMC3852156 DOI: 10.1111/aji.12171] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 10/03/2013] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Chlamydia trachomatis infections are a significant cause of reproductive tract pathology. Protective and pathological immune mediators must be differentiated to design a safe and effective vaccine. METHODS Wild-type mice and mice deficient in IL-22 and IL-23 were infected intravaginally with Chlamydia muridarum, and their course of infection and oviduct pathology were compared. Local genital tract and draining lymph node immune responses were also examined in IL-23-deficient mice. RESULTS IL-22- and IL-23-deficient mice exhibited normal susceptibility to infection and oviduct pathology. IL-23 was required for the development of a Chlamydia-specific Th17 response in the lymph nodes and for production of IL-22 and IL-17 in the genital tract. However, influx of Th1 and innate immune cells was not compromised in the absence of IL-23. CONCLUSION IL-22 and IL-23 play either redundant or minimal roles in the pathogenesis of Chlamydia infection in the mouse model. Induction of Th17-associated cytokines by a Chlamydia vaccine should be avoided as these responses are not central to resolution of infection and have pathologic potential.
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Affiliation(s)
- Lauren C. Frazer
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15201
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
| | - Amy M. Scurlock
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital Research Institute, Little Rock, Arkansas 72202
| | - Matthew A. Zurenski
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
| | - Melissa M. Riley
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
| | - Margaret Mintus
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
| | - Derek A. Pociask
- Richard King Mellon Foundation Institute for Pediatric Research, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
| | - Jeanne E. Sullivan
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
| | | | - Toni Darville
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15201
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
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