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Rubinstein A, Kudryavtsev I, Malkova A, Mammedova J, Isakov D, Isakova-Sivak I, Kudlay D, Starshinova A. Sarcoidosis-related autoimmune inflammation in COVID-19 convalescent patients. Front Med (Lausanne) 2023; 10:1271198. [PMID: 38179278 PMCID: PMC10765615 DOI: 10.3389/fmed.2023.1271198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024] Open
Abstract
Currently, there are a large number of reports about the development of autoimmune conditions after COVID-19. Also, there have been cases of sarcoid-like granulomas in convalescents as a part of the post-COVID-19 syndrome. Since one of the etiological theories of sarcoidosis considers it to be an autoimmune disease, we decided to study changes in the adaptive humoral immune response in sarcoidosis and SARS-CoV-2 infection and to find out whether COVID-19 can provoke the development of sarcoidosis. This review discusses histological changes in lymphoid organs in sarcoidosis and COVID-19, changes in B cell subpopulations, T-follicular helper cells (Tfh), and T-follicular regulatory cells (Tfr), and analyzes various autoantibodies detected in these pathologies. Based on the data studied, we concluded that SARS-CoV-2 infection may cause the development of autoimmune pathologies, in particular contributing to the onset of sarcoidosis in convalescents.
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Affiliation(s)
- Artem Rubinstein
- Almazov National Medical Research Centre, Saint Petersburg, Russia
- Institution of Experimental Medicine, Saint Petersburg, Russia
| | - Igor Kudryavtsev
- Almazov National Medical Research Centre, Saint Petersburg, Russia
- Institution of Experimental Medicine, Saint Petersburg, Russia
- Far Eastern Federal University, Vladivostok, Russia
| | - Annа Malkova
- Ariel University Faculty of Natural Sciences, Ariel, Israel
| | | | - Dmitry Isakov
- First Saint Petersburg State I. Pavlov Medical University, Saint Petersburg, Russia
| | | | - Dmitry Kudlay
- Institute of Pharmacy, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- NRC Institute of Immunology, Moscow, Russia
- Department of Pharmacognosy and Industrial Pharmacy, Faculty of Fundamental Medicine, Moscow, Russia
| | - Anna Starshinova
- Almazov National Medical Research Centre, Saint Petersburg, Russia
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d'Alessandro M, Bergantini L, Gangi S, Cameli P, Armati M, Fanetti M, Mezzasalma F, Baglioni S, Bargagli E. Imbalance of Lymphocyte Subsets and CD45RA-Expressing Cells in Intrathoracic Lymph Nodes, Alveolar Compartment and Bloodstream of Pulmonary Sarcoidosis Patients. Int J Mol Sci 2023; 24:10344. [PMID: 37373490 DOI: 10.3390/ijms241210344] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/12/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
Sarcoidosis is a systemic granulomatous disease mainly affecting the lungs and hilomediastinal lymph nodes. It is characterized by non-caseating epithelioid cell granulomas in lymph nodes and lungs. Our study aimed to evaluate and compare T, B and NK cell subsets in the alveolar compartment, lymph nodes and the bloodstream simultaneously in the same patients to elucidate the immune responses associated with the development and progression of sarcoidosis. A secondary aim was to evaluate the distribution of CD45RA-expressing cells in the different anatomical compartments. Patients suspected to have sarcoidosis and who underwent bronchoscopy with bronchoalveolar lavage (BAL), lung-draining lymph node (LLN) biopsy by EBUS-TBNA and peripheral blood (PB) sampling were included in the study. They were monitored at the Regional Referral Centre of Siena University Hospital and the Respiratory Diseases Unit of Perugia Hospital. Multicolour flow cytometry analysis through FASCLyric was performed to assess T, B and NK cell subsets. Thirty-two patients (median age (IQR) 57 (52-58) years) were consecutively and prospectively enrolled. Machine learning analysis created a model which selected CD56dim16bright, CD8, Tfc, Th17, Th12, Tfh17, Tfh2, TcemRA, ThemRA, T naïve, Tc naïve, Breg, CD1d+CD5+, Th-reg, Tfh, Th1 and CD4 cells with an accuracy of 0.9500 (kappa 0.8750). Comparative analysis found 18 cell populations that differed significantly between the three anatomical compartments. The bloodstream was enriched in ThemRA (p = 0.0416), Tfh2 (p = 0.0189), Tfh17 (p = 0.0257), Th2 (p = 0.0212), Th17 (p = 0.0177), Th-naïve (p = 0.0368), CD56dimCD16bright (p < 0.0001), CD8 (p = 0.0319), TcemRA (p < 0.0001) and Tfc cells (p = 0.0004) compared with the alveolar compartment, while Th-reg were lower in PB than BAL (p = 0.0329). The alveolar compartment was enriched in Breg (p = 0.0249) and CD1d+CD5+ (p = 0.0013) with respect to LLN samples and PB. Conversely, Tfh (p = 0.0470), Th1 (p = 0.0322), CD4 (p = 0.0486) and Tc-naïve (p = 0.0009) were more abundant in LLN than in BAL and PB. It has been speculated that changes in the relative contents of PB cells could be related to changes in production and to the selective redistribution of PB cells to granulomatous foci. This study further supports the fact that sarcoidosis is multisystemic in nature. However, the low level of immune cells in peripheral blood of patients with sarcoidosis is concerning. A re-expression of CD45RA on CD4+ and CD8+ cells could result in a reduction in peripheral immune activity. Thus, changes in the spectrum of the bloodstream may reflect both pathogenic and compensatory processes.
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Affiliation(s)
- Miriana d'Alessandro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Laura Bergantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Sara Gangi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Martina Armati
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Matteo Fanetti
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Fabrizio Mezzasalma
- Diagnostic and Interventional Bronchoscopy Unit, Cardio-Thoracic and Vascular Department, University Hospital of Siena (Azienda Ospedaliera Universitaria Senese, AOUS), 53100 Siena, Italy
| | | | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
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d'Alessandro M, Bergantini L, Gangi S, Conticini E, Cavallaro D, Cameli P, Mezzasalma F, Cantarini L, Frediani B, Bargagli E. Immunological Pathways in Sarcoidosis and Autoimmune Rheumatic Disorders-Similarities and Differences in an Italian Prospective Real-Life Preliminary Study. Biomedicines 2023; 11:1532. [PMID: 37371628 DOI: 10.3390/biomedicines11061532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The pathogenesis of sarcoidosis involves T cells and B lymphocytes that produce autoantibodies. We compared the expression of different T and B cell subsets in sarcoidosis and three B-mediated rheumatic diseases that can affect the lungs in an attempt to identify similarities and differences that distinguish these diseases. METHODS The study included patients referred to Siena University Hospital's respiratory disease and rheumatology units. Patients were enrolled prospectively and consecutively. Healthy volunteers were also included. Multicolor flow cytometry was performed on phenotype T and B cell subsets. Multivariate analysis was carried out to reduce the dimensionality of the data. RESULTS Fifteen patients had a diagnosis of sarcoidosis, fourteen idiopathic inflammatory myopathies (IIM), five granulomatosis with polyangiitis (GPA), ten microscopic polyangiitis (MPA), and seven were controls. Thirty-five T and B cell subsets were phenotyped, 15 of which were significantly different in sarcoidosis, B-mediated rheumatic disorders, and controls. Principal components analysis distinguished the four groups of patients with a total explained variance of 54.7%. A decision tree was constructed to determine which clustering variables would be most useful for distinguishing sarcoidosis, IIM, MPA, and GPA. The model showed regulatory T helper cells (Th-reg) > 5.70% in 91% of sarcoidosis patients as well as Th-reg ≤ 5.70 and Th17 > 43.27 in 100% of MPA. It also showed Th-reg ≤ 5.70, Th17 ≤ 43.27 and Tfh-reg ≥ 7.81 in 100% of GPA patients, and Th-reg ≤ 5.70, Th17 ≤ 43.27 and Tfh-reg ≤ 7.81 in 100% of IIM patients. CONCLUSION The immune cell profile sheds light on similarities and differences between sarcoidosis and B-mediated rheumatic diseases. Sarcoidosis and autoimmune diseases show similar patterns of cellular immune dysregulation, suggesting a common pathogenic pathway that may provide an opportunity for further understanding autoimmunity and exploring biological therapies to treat sarcoidosis.
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Affiliation(s)
- Miriana d'Alessandro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Laura Bergantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Sara Gangi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Dalila Cavallaro
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Paolo Cameli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Fabrizio Mezzasalma
- Diagnostic and Interventional Bronchoscopy Unit, Cardio-Thoracic and Vascular Department, Azienda Ospedaliera Universitaria Senese (AOUS), University Hospital of Siena, 53100 Siena, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery & Neurosciences, University of Siena, 53100 Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences & Neurosciences, University of Siena, 53100 Siena, Italy
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Danila E, Aleksonienė R, Besusparis J, Gruslys V, Jurgauskienė L, Laurinavičienė A, Laurinavičius A, Mainelis A, Zablockis R, Zeleckienė I, Žurauskas E, Malickaitė R. Lymphocyte Subsets and Pulmonary Nodules to Predict the Progression of Sarcoidosis. Biomedicines 2023; 11:biomedicines11051437. [PMID: 37239108 DOI: 10.3390/biomedicines11051437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
The search for biological markers, which allow a relatively accurate assessment of the individual course of pulmonary sarcoidosis at the time of diagnosis, remains one of the research priorities in this field of pulmonary medicine. The aim of our study was to investigate possible prognostic factors for pulmonary sarcoidosis with a special focus on cellular immune inflammation markers. A 2-year follow-up of the study population after the initial prospective and simultaneous analysis of lymphocyte activation markers expression in the blood, as well as bronchoalveolar lavage fluid (BALF) and lung biopsy tissue of patients with newly diagnosed pulmonary sarcoidosis, was performed. We found that some blood and BAL fluid immunological markers and lung computed tomography (CT) patterns have been associated with a different course of sarcoidosis. We revealed five markers that had a significant negative association with the course of sarcoidosis (worsening pulmonary function tests and/or the chest CT changes)-blood CD4+CD31+ and CD4+CD44+ T lymphocytes, BALF CD8+CD31+ and CD8+CD103+ T lymphocytes and a number of lung nodules on chest CT at the time of the diagnosis. Cut-off values, sensitivity, specificity and odds ratio for predictors of sarcoidosis progression were calculated. These markers may be reasonable predictors of sarcoidosis progression.
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Affiliation(s)
- Edvardas Danila
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Regina Aleksonienė
- Center of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Justinas Besusparis
- National Center of Pathology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
| | - Vygantas Gruslys
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Laimutė Jurgauskienė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Laboratory Medicine, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Aida Laurinavičienė
- National Center of Pathology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
| | - Arvydas Laurinavičius
- National Center of Pathology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
| | - Antanas Mainelis
- Faculty of Mathematics and Informatics, Vilnius University, 03225 Vilnius, Lithuania
| | - Rolandas Zablockis
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Pulmonology and Allergology, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Ingrida Zeleckienė
- Center of Radiology and Nuclear Medicine, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
| | - Edvardas Žurauskas
- National Center of Pathology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
| | - Radvilė Malickaitė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Center of Laboratory Medicine, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania
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Kudryavtsev I, Zinchenko Y, Starshinova A, Serebriakova M, Malkova A, Akisheva T, Kudlay D, Glushkova A, Yablonskiy P, Shoenfeld Y. Circulating Regulatory T Cell Subsets in Patients with Sarcoidosis. Diagnostics (Basel) 2023; 13:diagnostics13081378. [PMID: 37189479 DOI: 10.3390/diagnostics13081378] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023] Open
Abstract
Over recent years, many researchers have supported the autoimmune theory of sarcoidosis. The presence of uncontrolled inflammatory response on local and system levels in patients with sarcoidosis did not define that the immunoregulatory mechanisms could be affected. The aim of this study was to evaluate the distribution and the disturbance circulating Treg cell subsets in the peripheral blood in patients with sarcoidosis. MATERIALS AND METHODS A prospective comparative study was performed in 2016-2018 (34 patients with sarcoidosis (men (67.6%), women (32.3%)) were examined). Healthy subjects-the control group (n = 40). The diagnosis of pulmonary sarcoidosis was performed according to the standard criteria. We used two ten-color combinations of antibodies for Treg immunophenotyping. The first one contained CD39-FITC, CD127-PE, CCR4-PE/Dazzle™ 594, CD25-PC5.5, CD161-PC7, CD4-APC, CD8-APC-AF700, CD3-APC/Cy7, HLA-DR-PacBlue, and CD45 RA-BV 510™, while the second consisted of CXCR3-Alexa Fluor 488, CD25-РЕ, CXCR5-РЕ/Dazzle™ 594, CCR4-PerСP/Сy5.5, CCR6-РЕ/Cy7, CD4-АPC, CD8 АPC-AF700, CD3-АPC/Cy7, CCR7-BV 421, and CD45 RA-BV 510. The flow cytometry data were analyzed by using Kaluza software v2.3. A statistical analysis was performed with Statistica 7.0 and GraphPad Prism 8 software packages. RESULTS OF THE STUDY Primarily, we found that patients with sarcoidosis had decreased absolute numbers of Treg cells in circulation. We noted that the level of CCR7-expressing Tregs decreased in patients with sarcoidosis vs. the control group (65.55% (60.08; 70.60) vs. 76.93% (69.59; 79.86) with p < 0.001). We noticed that the relative numbers of CD45RA-CCR7+ Tregs decreased in patients with sarcoidosis (27.11% vs. 35.43%, p < 0.001), while the frequency of CD45 RA-CCR7- and CD45RA+ CCR7- Tregs increased compared to the control group (33.3% vs. 22.73% and 0.76% vs. 0.51% with p < 0.001 and p = 0.028, respectively). CXCR3-expressing Treg cell subsets-Th1-like CCR60078CXCR3+ Tregs and Th17.1-like CCR6+ CXCR3+ Tregs-significantly increased in patients with sarcoidosis vs. the control group (14.4% vs. 10.5% with p < 0.01 and 27.9% vs. 22.8% with p < 0.01, respectively). Furthermore, the levels of peripheral blood EM Th17-like Tregs significantly decreased in the sarcoidosis group vs. the control group (36.38% vs. 46.70% with p < 0.001). Finally, we found that CXCR5 expression was increased in CM Tregs cell subsets in patients with sarcoidosis. CONCLUSIONS Our data indicated a decrease in circulating Tregs absolute numbers and several alterations in Treg cell subsets. Moreover, our results highlight the presence of increased levels of CM CXCR5+ follicular Tregs in the periphery that could be linked with the imbalance of follicular Th cell subsets and alterations in B cell, based on the immune response. The balance between the two functionally distinct Treg cell populations-Th1-like and Th17-like Tregs-could be used in sarcoidosis diagnosis and the determination of prognosis and disease outcomes. Furthermore, we want to declare that analysis of Treg numbers of phenotypes could fully characterize their functional activity in peripherally inflamed tissues.
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Affiliation(s)
- Igor Kudryavtsev
- Department of Immunology, Institution of Experimental Medicine, 197376 St. Petersburg, Russia
| | - Yulia Zinchenko
- Phthisiopulmonology Department, St. Petersburg Research Institute of Phthisiopulmonology, 194064 St. Petersburg, Russia
| | - Anna Starshinova
- Almazov National Medical Research Centre, 197341 St. Petersburg, Russia
| | - Maria Serebriakova
- Department of Immunology, Institution of Experimental Medicine, 197376 St. Petersburg, Russia
| | - Anna Malkova
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, 199034 St. Petersburg, Russia
| | - Tatiana Akisheva
- Department of Immunology, Institution of Experimental Medicine, 197376 St. Petersburg, Russia
| | - Dmitriy Kudlay
- Department of Pharmacology, Sechenov First Moscow State Medical University, 119992 Moscow, Russia
- Institute of Immunology, 115552 Moscow, Russia
| | - Anzhela Glushkova
- Bekhterev National Research Medical Center for Psychiatry and Neurology, 19201 St. Petersburg, Russia
| | - Piotr Yablonskiy
- Phthisiopulmonology Department, St. Petersburg Research Institute of Phthisiopulmonology, 194064 St. Petersburg, Russia
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, 199034 St. Petersburg, Russia
| | - Yehuda Shoenfeld
- Laboratory of the Mosaic of Autoimmunity, St. Petersburg State University, 199034 St. Petersburg, Russia
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer 5265601, Israel
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Bergantini L, d’Alessandro M, Del Zotto G, Marcenaro E, Bargagli E. Characterization of natural killer and T cells in bronchoalveolar lavage and peripheral blood of sarcoidosis patients. Front Immunol 2023; 13:1080556. [PMID: 36685602 PMCID: PMC9846229 DOI: 10.3389/fimmu.2022.1080556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/25/2022] [Indexed: 01/06/2023] Open
Abstract
The characterization of frequency and phenotypes of natural killer (NK) cells and T cells in BAL and peripheral blood of patients with sarcoidosis was evaluated, to discriminate the differential status of these cells in these two compartments. The analysis revealed that CD56brightCD16neg resulted higher in BAL than PB of sarcoidosis and healthy subjects, while CD56dimCD16+ showed a different proportion between BAL and PB of both Sarcoidosis patients and HC. Moreover, in comparison with autologous PB, BAL was characterized by a higher expression of activated NK cell markers NKp44, CD69 and CD25. Significantly increased levels of PD-1+ NK cells in the BAL of patients were detected. Regarding the maturation of CD4 and CD8, an increase of Effector Memory T cells (TEM) was reported in BAL compared to PB. A better characterization of NK and T cells may lead to an improvement of the pathogenetic mechanisms in sarcoidosis.
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Affiliation(s)
- Laura Bergantini
- Respiratory Diseases Unit, Department of Medical Science, Surgery and Neurosciences, University of Siena, Siena, Italy,*Correspondence: Laura Bergantini,
| | - Miriana d’Alessandro
- Respiratory Diseases Unit, Department of Medical Science, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Genny Del Zotto
- Department of Research and Diagnostics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Emanuela Marcenaro
- Dipartimento di Medicina Sperimentale (DIMES), Università degli Studi di Genova, Genova, Italy,IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Elena Bargagli
- Respiratory Diseases Unit, Department of Medical Science, Surgery and Neurosciences, University of Siena, Siena, Italy
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