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Forde AJ, Kolter J, Zwicky P, Baasch S, Lohrmann F, Eckert M, Gres V, Lagies S, Gorka O, Rambold AS, Buescher JM, Kammerer B, Lachmann N, Prinz M, Groß O, Pearce EJ, Becher B, Henneke P. Metabolic rewiring tunes dermal macrophages in staphylococcal skin infection. Sci Immunol 2023; 8:eadg3517. [PMID: 37566679 DOI: 10.1126/sciimmunol.adg3517] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 07/19/2023] [Indexed: 08/13/2023]
Abstract
The skin needs to balance tolerance of colonizing microflora with rapid detection of potential pathogens. Flexible response mechanisms would seem most suitable to accommodate the dynamic challenges of effective antimicrobial defense and restoration of tissue homeostasis. Here, we dissected macrophage-intrinsic mechanisms and microenvironmental cues that tune macrophage signaling in localized skin infection with the colonizing and opportunistic pathogen Staphylococcus aureus. Early in skin infection, the cytokine granulocyte-macrophage colony-stimulating factor (GM-CSF) produced by γδ T cells and hypoxic conditions within the dermal microenvironment diverted macrophages away from a homeostatic M-CSF- and hypoxia-inducible factor 1α (HIF-1α)-dependent program. This allowed macrophages to be metabolically rewired for maximal inflammatory activity, which requires expression of Irg1 and generation of itaconate, but not HIF-1α. This multifactorial macrophage rewiring program was required for both the timely clearance of bacteria and for the provision of local immune memory. These findings indicate that immunometabolic conditioning allows dermal macrophages to cycle between antimicrobial activity and protection against secondary infections.
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Affiliation(s)
- Aaron James Forde
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Faculty of Biology, University of Freiburg, 79104 Freiburg, Germany
| | - Julia Kolter
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Pascale Zwicky
- Institute of Experimental Immunology, University of Zurich, CH-8057 Zurich, Switzerland
| | - Sebastian Baasch
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Florens Lohrmann
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Spemann Graduate School of Biology and Medicine, University of Freiburg, 79104 Freiburg, Germany
- Center for Pediatrics and Adolescent Medicine, University Medical Center, 79106 Freiburg, Germany
| | - Marleen Eckert
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Faculty of Biology, University of Freiburg, 79104 Freiburg, Germany
| | - Vitka Gres
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Faculty of Biology, University of Freiburg, 79104 Freiburg, Germany
| | - Simon Lagies
- Spemann Graduate School of Biology and Medicine, University of Freiburg, 79104 Freiburg, Germany
- 1 Core Competence Metabolomics, Institute of Organic Chemistry, University of Freiburg, 79104 Freiburg, Germany
| | - Oliver Gorka
- Institute of Neuropathology, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Angelika S Rambold
- Department of Developmental Immunology, Max-Planck-Institute of Immunobiology and Epigenetics, Freiburg, Germany
| | - Joerg M Buescher
- Department of Immunometabolism, Max-Planck-Institute of Immunobiology and Epigenetics, Freiburg, Germany
| | - Bernd Kammerer
- Spemann Graduate School of Biology and Medicine, University of Freiburg, 79104 Freiburg, Germany
- 1 Core Competence Metabolomics, Institute of Organic Chemistry, University of Freiburg, 79104 Freiburg, Germany
- Signalling Research Centre's BIOSS and CIBSS, University of Freiburg, 79104 Freiburg, Germany
| | - Nico Lachmann
- Department of Pediatric Pneumology, Allergology and Neonatology and Cluster of Excellence RESIST (EXC 2155), Hannover Medical School, 30625 Hannover, Germany
| | - Marco Prinz
- Institute of Neuropathology, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Signalling Research Centre's BIOSS and CIBSS, University of Freiburg, 79104 Freiburg, Germany
- Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- CIBSS-Center for Integrative Biological Signaling Studies, University of Freiburg, 79104 Freiburg, Germany
| | - Olaf Groß
- Institute of Neuropathology, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Signalling Research Centre's BIOSS and CIBSS, University of Freiburg, 79104 Freiburg, Germany
- Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- CIBSS-Center for Integrative Biological Signaling Studies, University of Freiburg, 79104 Freiburg, Germany
| | - Edward J Pearce
- Department of Immunometabolism, Max-Planck-Institute of Immunobiology and Epigenetics, Freiburg, Germany
| | - Burkhard Becher
- Institute of Experimental Immunology, University of Zurich, CH-8057 Zurich, Switzerland
| | - Philipp Henneke
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Center for Pediatrics and Adolescent Medicine, University Medical Center, 79106 Freiburg, Germany
- CIBSS-Center for Integrative Biological Signaling Studies, University of Freiburg, 79104 Freiburg, Germany
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2
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Prodjinotho UF, Gres V, Henkel F, Lacorcia M, Dandl R, Haslbeck M, Schmidt V, Winkler AS, Sikasunge C, Jakobsson PJ, Henneke P, Esser-von Bieren J, Prazeres da Costa C. Helminthic dehydrogenase drives PGE 2 and IL-10 production in monocytes to potentiate Treg induction. EMBO Rep 2022; 23:e54096. [PMID: 35357743 PMCID: PMC9066053 DOI: 10.15252/embr.202154096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 01/03/2023] Open
Abstract
Immunoregulation of inflammatory, infection‐triggered processes in the brain constitutes a central mechanism to control devastating disease manifestations such as epilepsy. Observational studies implicate the viability of Taenia solium cysts as key factor determining severity of neurocysticercosis (NCC), the most common cause of epilepsy, especially in children, in Sub‐Saharan Africa. Viable, in contrast to decaying, cysts mostly remain clinically silent by yet unknown mechanisms, potentially involving Tregs in controlling inflammation. Here, we show that glutamate dehydrogenase from viable cysts instructs tolerogenic monocytes to release IL‐10 and the lipid mediator PGE2. These act in concert, converting naive CD4+ T cells into CD127−CD25hiFoxP3+CTLA‐4+ Tregs, through the G protein‐coupled receptors EP2 and EP4 and the IL‐10 receptor. Moreover, while viable cyst products strongly upregulate IL‐10 and PGE2 transcription in microglia, intravesicular fluid, released during cyst decay, induces pro‐inflammatory microglia and TGF‐β as potential drivers of epilepsy. Inhibition of PGE2 synthesis and IL‐10 signaling prevents Treg induction by viable cyst products. Harnessing the PGE2‐IL‐10 axis and targeting TGF‐ß signaling may offer an important therapeutic strategy in inflammatory epilepsy and NCC.
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Affiliation(s)
- Ulrich Fabien Prodjinotho
- Institute for Medical Microbiology, Immunology and Hygiene, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany.,Center for Global Health, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Vitka Gres
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Fiona Henkel
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Munich, Germany
| | - Matthew Lacorcia
- Institute for Medical Microbiology, Immunology and Hygiene, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Ramona Dandl
- Department of Chemistry, Technical University Munich (TUM), Garching, Germany
| | - Martin Haslbeck
- Department of Chemistry, Technical University Munich (TUM), Garching, Germany
| | - Veronika Schmidt
- Center for Global Health, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany.,Department of Neurology, University Hospital, Klinikum rechts der Isar, Technical University Munich (TUM), Munich, Germany.,Center for Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Andrea Sylvia Winkler
- Center for Global Health, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany.,Department of Neurology, University Hospital, Klinikum rechts der Isar, Technical University Munich (TUM), Munich, Germany.,Center for Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Chummy Sikasunge
- Department of Paraclinicals, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | - Per-Johan Jakobsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska University Hospital, Stockholm, Sweden
| | - Philipp Henneke
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Freiburg, Germany.,Centre for Integrative Biological Signalling Studies, University of Freiburg, Freiburg, Germany
| | - Julia Esser-von Bieren
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Munich, Germany
| | - Clarissa Prazeres da Costa
- Institute for Medical Microbiology, Immunology and Hygiene, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany.,Center for Global Health, TUM School of Medicine, Technical University of Munich (TUM), Munich, Germany.,German Center for Infection and Research (DZIF), Munich, Germany
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3
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Mahú I, Barateiro A, Rial-Pensado E, Martinéz-Sánchez N, Vaz SH, Cal PMSD, Jenkins B, Rodrigues T, Cordeiro C, Costa MF, Mendes R, Seixas E, Pereira MMA, Kubasova N, Gres V, Morris I, Temporão C, Olivares M, Sanz Y, Koulman A, Corzana F, Sebastião AM, López M, Bernardes GJL, Domingos AI. Brain-Sparing Sympathofacilitators Mitigate Obesity without Adverse Cardiovascular Effects. Cell Metab 2020; 31:1120-1135.e7. [PMID: 32402266 PMCID: PMC7671941 DOI: 10.1016/j.cmet.2020.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 03/03/2020] [Accepted: 04/14/2020] [Indexed: 02/02/2023]
Abstract
Anti-obesity drugs in the amphetamine (AMPH) class act in the brain to reduce appetite and increase locomotion. They are also characterized by adverse cardiovascular effects with origin that, despite absence of any in vivo evidence, is attributed to a direct sympathomimetic action in the heart. Here, we show that the cardiac side effects of AMPH originate from the brain and can be circumvented by PEGylation (PEGyAMPH) to exclude its central action. PEGyAMPH does not enter the brain and facilitates SNS activity via theβ2-adrenoceptor, protecting mice against obesity by increasing lipolysis and thermogenesis, coupled to higher heat dissipation, which acts as an energy sink to increase energy expenditure without altering food intake or locomotor activity. Thus, we provide proof-of-principle for a novel class of exclusively peripheral anti-obesity sympathofacilitators that are devoid of any cardiovascular and brain-related side effects.
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Affiliation(s)
- Inês Mahú
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal
| | - Andreia Barateiro
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal; Neuron Glia Biology in Health and Disease, Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon 1649-028, Portugal
| | - Eva Rial-Pensado
- NeurObesity Group, Department of Physiology, CIMUS, University of Santiago de Compostela, Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña 15782, Spain
| | - Noelia Martinéz-Sánchez
- Department of Physiology, Anatomy and Genetics, University of Oxford, Parks Road, Oxford OX1 3PT, UK
| | - Sandra H Vaz
- Instituto de Medicina Molecular, João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Av. Prof., Egas Moniz, Lisbon 1649-028, Portugal; Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal
| | - Pedro M S D Cal
- Instituto de Medicina Molecular, João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Av. Prof., Egas Moniz, Lisbon 1649-028, Portugal
| | - Benjamin Jenkins
- NIHR BRC Core Metabolomics and Lipidomics Laboratory, Wellcome Trust, MRL Institute of Metabolic Science, University of Cambridge, Pathology building Level 4, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Tiago Rodrigues
- Instituto de Medicina Molecular, João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Av. Prof., Egas Moniz, Lisbon 1649-028, Portugal
| | - Carlos Cordeiro
- Laboratório de FT-ICR e Espectrometria de Massa Estrutural, Faculdade de Ciências da Universidade de Lisboa, Lisbon 1749-016, Portugal
| | - Miguel F Costa
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal; Department of Bioengineering, Instituto Superior Técnico, Universidade de Lisboa, Lisbon 1049-001, Portugal
| | - Raquel Mendes
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal
| | - Elsa Seixas
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal
| | - Mafalda M A Pereira
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal
| | - Nadiya Kubasova
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal
| | - Vitka Gres
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal
| | - Imogen Morris
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal
| | - Carolina Temporão
- Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal
| | - Marta Olivares
- Microbial Ecology, Nutrition & Health Research Unit, Institute of Agrochemistry and Food Technology, National Research Council, Valencia (IATA-CSIC), Catedratico Agustin Escardino 7, 46980, Paterna, Valencia, Spain
| | - Yolanda Sanz
- Microbial Ecology, Nutrition & Health Research Unit, Institute of Agrochemistry and Food Technology, National Research Council, Valencia (IATA-CSIC), Catedratico Agustin Escardino 7, 46980, Paterna, Valencia, Spain
| | - Albert Koulman
- NIHR BRC Core Metabolomics and Lipidomics Laboratory, Wellcome Trust, MRL Institute of Metabolic Science, University of Cambridge, Pathology building Level 4, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Francisco Corzana
- Departamento de Química, Universidad de La Rioja, Centro de Investigación en Síntesis Química, 26006 Logroño, Spain
| | - Ana M Sebastião
- Instituto de Medicina Molecular, João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Av. Prof., Egas Moniz, Lisbon 1649-028, Portugal; Instituto de Farmacologia e Neurociências, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal
| | - Miguel López
- NeurObesity Group, Department of Physiology, CIMUS, University of Santiago de Compostela, Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña 15782, Spain
| | - Gonçalo J L Bernardes
- Instituto de Medicina Molecular, João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Av. Prof., Egas Moniz, Lisbon 1649-028, Portugal; Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge CB2 1EW, UK.
| | - Ana I Domingos
- Department of Physiology, Anatomy and Genetics, University of Oxford, Parks Road, Oxford OX1 3PT, UK; Obesity Laboratory, Instituto Gulbenkian de Ciência, Oeiras 2780-156, Portugal; Howard Hughes Medical Institute, IGC, Oeiras, Portugal.
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4
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Feuerstein R, Gres V, Elias Perdigó N, Baasch S, Freudenhammer M, Elling R, Henneke P. Macrophages Are a Potent Source of Streptococcus-Induced IFN-β. J Immunol 2019; 203:3416-3426. [PMID: 31732532 DOI: 10.4049/jimmunol.1900542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 10/14/2019] [Indexed: 11/19/2022]
Abstract
IFN-β essentially modulates the host response against mucocutaneous colonizers and potential pathogens, such as group B Streptococcus (GBS). It has been reported that the dominant signaling cascade driving IFN-β in macrophages (MΦ) in streptococcal infection is the cGAS-STING pathway, whereas conventional dendritic cells (DC) exploit endosomal recognition by intracellular TLRs. In this study, we revisited this issue by precisely monitoring the phenotypic dynamics in mixed mouse MΦ/DC cultures with GM-CSF, which requires snapshot definition of cellular identities. We identified four mononuclear phagocyte populations, of which two were transcriptionally and morphologically distinct MΦ-DC-like subsets, and two were transitional types. Notably, GBS induced a TLR7-dependent IFN-β signal only in MΦ-like but not in DC-like cells. IFN-β induction did not require live bacteria (i.e., the formation of cytolytic toxins), which are essential for IFN-β induction via cGAS-STING. In contrast to IFN-β, GBS induced TNF-α independently of TLR7. Subsequent to the interaction with streptococci, MΦ changed their immunophenotype and gained some typical DC markers and DC-like morphology. In summary, we identify IFN-β formation as part of the antistreptococcal repertoire of GM-CSF differentiated MΦ in vitro and in vivo and delineate their plasticity.
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Affiliation(s)
- Reinhild Feuerstein
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; and
| | - Vitka Gres
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; and
| | - Núria Elias Perdigó
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; and
| | - Sebastian Baasch
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; and
| | - Mirjam Freudenhammer
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; and.,Center for Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Roland Elling
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; and.,Center for Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Philipp Henneke
- Institute for Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; and .,Center for Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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5
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Gres V, Kolter J, Erny D, Henneke P. The role of CNS macrophages in streptococcal meningoencephalitis. J Leukoc Biol 2019; 106:209-218. [PMID: 30762892 DOI: 10.1002/jlb.4mr1118-419r] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 12/18/2022] Open
Abstract
In the healthy brain, microglia and other CNS macrophages are the most abundant immune cell type. Thus, they form the natural immune cell interface with streptococci, which are the leading cause of bacterial meningitis and encephalitis in infants and young children. In homeostasis, the blood-brain barrier allows for very limited access of immune cells circulating in the periphery. During bacterial meningoencephalitis, however, origin and fate of CNS macrophages are massively altered. This review summarizes the emerging knowledge on the sequence of reciprocal events between streptococci and CNS macrophages leading to host resistance, acute inflammation, changes in resident innate immune cells of the brain, and long-term neuronal damage.
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Affiliation(s)
- Vitka Gres
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Julia Kolter
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Daniel Erny
- Institute of Neuropathology, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp Henneke
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Pediatrics and Adolescent Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
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