TGFβ prevents IgE-mediated allergic disease by restraining T follicular helper 2 differentiation

Allergic diseases are common, affecting more than 20% of the population. Genetic variants in the TGFβ pathway are strongly associated with atopy. To interrogate the mechanisms underlying this association, we examined patients and mice with Loeys-Dietz syndrome (LDS) who harbor missense mutations in the kinase domain of TGFΒR1/2. We demonstrate that LDS mutations lead to reduced TGFβ signaling and elevated total and allergen-specific IgE, despite the presence of wild-type T regulatory cells in a chimera model. Germinal center activity was enhanced in LDS and characterized by a selective increase in type 2 follicular helper T cells (TFH2). Expression of Pik3cg was increased in LDS TFH cells and associated with reduced levels of the transcriptional repressor SnoN. PI3Kγ/mTOR signaling in LDS naïve CD4+ T cells was elevated after T cell receptor cross-linking, and pharmacologic inhibition of PI3Kγ or mTOR prevented exaggerated TFH2 and antigen-specific IgE responses after oral antigen exposure in an adoptive transfer model. Naïve CD4+ T cells from nonsyndromic allergic individuals also displayed decreased TGFβ signaling, suggesting that our mechanistic discoveries may be broadly relevant to allergic patients in general. Thus, TGFβ plays a conserved, T cell-intrinsic, and nonredundant role in restraining TFH2 development via the PI3Kγ/mTOR pathway and thereby protects against allergic disease.

Dysregulated TGF-β Signaling Leads to Cell-Intrinsic Changes in T cell Development that Promote Allergic Inflammation

Variants in genes in the Transforming Growth Factor Beta (TGFβ) signaling pathway are associated with allergic diseases suggesting that this cytokine may be a central player in the allergic diathesis. The role of TGFβ in preserving T cell mediated self-tolerance is well appreciated but how disruption in this pathway promotes allergic inflammation is unclear. We previously demonstrated that patients with Loeys-Dietz Syndrome (LDS), an autosomal dominant disorder caused by mutations in TGFBR1 and TGFBR2, are highly predisposed to allergic disease. LDS patients and mice harboring a knock in allele (Tgfbr1mut) of an LDS mutation known to cause severe disease in humans exhibit higher levels of total and food specific IgE. These serologic changes were associated with higher frequencies of T follicular helper (Tfh) cells and lower T follicular regulatory (Tfr) cells. Using a mixed bone marrow and fetal liver chimera model, we showed that these alterations in T cell development are cell intrinsic. Chimera models also demonstrated that the TGFβ mutation drives higher IgE production despite the presence of wildtype Tregs. Furthermore OVA specific Tgfbr1mutOTII cells were more likely to accumulate in the peyers patch and differentiate into Tfh cells in response to orally ingested OVA. These findings correlated with increased AKT/pS6 signaling downstream of TCR in Tgfbr1mut T cells, and mTOR inhibition decreased Tgfbr1mut OTII Tfh cells in response to fed ova. Additionally, RNA sequence analysis of murine Tgfbr1mut Tfh cells revealed enhanced PI3K/AKT pathway activity. These findings suggest that TGFβ signaling plays an important role in T cell development and function via the PI3K/AKT pathway that when disrupted promotes allergic inflammation.

C-spine injury associated with gunshot wounds to the head: retrospective study and literature review

OBJECTIVE

To determine the incidence of C-spine injury (CSI) associated with gunshot wounds (GSWs) to the head.

METHODS

A retrospective chart review including patients with GSWs to the head and excluding those with penetrating facial/neck trauma was performed. Cervical clearance was by clinical/radiologic criteria in survivors, and autopsy in nonsurvivors. A MEDLINE literature search was performed and relevant articles reviewed.

RESULTS

One hundred seventy-four charts were available for review; 90 had C-spine radiographs (complete series [49], lateral [33], and computed tomographic scan [8]). Of 84 with no radiographs, 29 were clinically cleared, and 55 died (32 cleared at autopsy). Twenty-three died without evaluation. None of the remaining 151 (87%) had CSI. Literature search yielded only three relevant articles. Combining the data from these articles yielded 534 patients, and CSI was excluded in 507 (95%).

CONCLUSION

C-spine immobilization and diagnostic radiography are probably not necessary in patients with isolated GSWs to the head and may complicate and delay emergency airway management.