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Hetemäki I, Sarkkinen J, Heikkilä N, Drechsel K, Mäyränpää MI, Färkkilä A, Laakso S, Mäkitie O, Arstila TP, Kekäläinen E. Dysregulated germinal center reaction with expanded T follicular helper cells in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy lymph nodes. J Allergy Clin Immunol 2024; 153:1445-1455. [PMID: 38128835 DOI: 10.1016/j.jaci.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/30/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED, also called APS-1) is an inborn error of immunity with clear signs of B-cell autoimmunity such as neutralizing anti-IFN antibodies. In APECED, mutations in the AIRE gene impair thymic negative selection of T cells. The resulting T-cell alterations may then cause dysregulation of B-cell responses. However, no analysis of interactions of T and B cells in the germinal centers (GCs) in patients' secondary lymphatic tissues has been reported. OBJECTIVE This study examined the relationship between B cells and follicular T helper cells (TfH) in peripheral blood and lymph node (LN) GCs in patients with APECED. METHODS Immunophenotyping of peripheral blood B cells and TfH was performed for 24 patients with APECED. Highly multiplexed fluorescent immunohistochemical staining was performed on 7 LN biopsy samples from the patients to study spatial interactions of lymphocytes in the GCs at the single-cell level. RESULTS The patients' peripheral B-cell phenotype revealed skewing toward a mature B-cell phenotype with marked loss of transitional and naive B cells. The frequency of circulating TfH cells was diminished in the patients, while in the LNs the TfH population was expanded. In LNs the overall frequency of Treg cells and interactions of Treg cells with nonfollicular T cells were reduced, suggesting that aberrant Treg cell function might fail to restrain TfH differentiation. CONCLUSIONS GC reactions are disrupted in APECED as a result of defective T-cell control.
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Affiliation(s)
- Iivo Hetemäki
- Translational Immunology Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Joona Sarkkinen
- Translational Immunology Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nelli Heikkilä
- Translational Immunology Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karen Drechsel
- Translational Immunology Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko I Mäyränpää
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anniina Färkkilä
- Research Program in Systems Oncology, FIMM & HiLIFE University of Helsinki, Helsinki, Finland; iCAN Digital Precision Cancer Medicine, Helsinki, Finland; Department of Obstetrics and Gynecology, University Hospital, Helsinki, Finland
| | - Saila Laakso
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
| | - Outi Mäkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland; Department of Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Stockholm, Sweden
| | - T Petteri Arstila
- Translational Immunology Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eliisa Kekäläinen
- Translational Immunology Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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2
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Gruper Y, Wolff ASB, Glanz L, Spoutil F, Marthinussen MC, Osickova A, Herzig Y, Goldfarb Y, Aranaz-Novaliches G, Dobeš J, Kadouri N, Ben-Nun O, Binyamin A, Lavi B, Givony T, Khalaila R, Gome T, Wald T, Mrazkova B, Sochen C, Besnard M, Ben-Dor S, Feldmesser E, Orlova EM, Hegedűs C, Lampé I, Papp T, Felszeghy S, Sedlacek R, Davidovich E, Tal N, Shouval DS, Shamir R, Guillonneau C, Szondy Z, Lundin KEA, Osicka R, Prochazka J, Husebye ES, Abramson J. Autoimmune amelogenesis imperfecta in patients with APS-1 and coeliac disease. Nature 2023; 624:653-662. [PMID: 37993717 DOI: 10.1038/s41586-023-06776-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/29/2021] [Accepted: 10/23/2023] [Indexed: 11/24/2023]
Abstract
Ameloblasts are specialized epithelial cells in the jaw that have an indispensable role in tooth enamel formation-amelogenesis1. Amelogenesis depends on multiple ameloblast-derived proteins that function as a scaffold for hydroxyapatite crystals. The loss of function of ameloblast-derived proteins results in a group of rare congenital disorders called amelogenesis imperfecta2. Defects in enamel formation are also found in patients with autoimmune polyglandular syndrome type-1 (APS-1), caused by AIRE deficiency3,4, and in patients diagnosed with coeliac disease5-7. However, the underlying mechanisms remain unclear. Here we show that the vast majority of patients with APS-1 and coeliac disease develop autoantibodies (mostly of the IgA isotype) against ameloblast-specific proteins, the expression of which is induced by AIRE in the thymus. This in turn results in a breakdown of central tolerance, and subsequent generation of corresponding autoantibodies that interfere with enamel formation. However, in coeliac disease, the generation of such autoantibodies seems to be driven by a breakdown of peripheral tolerance to intestinal antigens that are also expressed in enamel tissue. Both conditions are examples of a previously unidentified type of IgA-dependent autoimmune disorder that we collectively name autoimmune amelogenesis imperfecta.
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Affiliation(s)
- Yael Gruper
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Anette S B Wolff
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Liad Glanz
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Frantisek Spoutil
- Czech Centre for Phenogenomics & Laboratory of Transgenic Models of Diseases, Institute of Molecular Genetics of the Czech Academy of Sciences v.v.i 252 50, Vestec, Czech Republic
| | - Mihaela Cuida Marthinussen
- Department of Clinical Dentistry, Faculty of Medicine, University of Bergen, Bergen, Norway
- Oral Health Centre of Expertise in Western Norway/Vestland, Bergen, Norway
| | - Adriana Osickova
- Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic
| | - Yonatan Herzig
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Yael Goldfarb
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Goretti Aranaz-Novaliches
- Czech Centre for Phenogenomics & Laboratory of Transgenic Models of Diseases, Institute of Molecular Genetics of the Czech Academy of Sciences v.v.i 252 50, Vestec, Czech Republic
| | - Jan Dobeš
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
- Department of Cell Biology, Faculty of Science, Charles University, Prague, Czech Republic
| | - Noam Kadouri
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Osher Ben-Nun
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Amit Binyamin
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Bar Lavi
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Tal Givony
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Razi Khalaila
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Tom Gome
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Tomáš Wald
- Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic
| | - Blanka Mrazkova
- Czech Centre for Phenogenomics & Laboratory of Transgenic Models of Diseases, Institute of Molecular Genetics of the Czech Academy of Sciences v.v.i 252 50, Vestec, Czech Republic
| | - Carmel Sochen
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Marine Besnard
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
| | - Shifra Ben-Dor
- Bioinformatics Unit, Life Sciences Core Facilities, Weizmann Institute of Science, Rehovot, Israel
| | - Ester Feldmesser
- Bioinformatics Unit, Life Sciences Core Facilities, Weizmann Institute of Science, Rehovot, Israel
| | - Elisaveta M Orlova
- Endocrinological Research Center, Institute of Pediatric Endocrinology, Moscow, Russian Federation
| | - Csaba Hegedűs
- Department of Biomaterials and Prosthetic Dentistry, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - István Lampé
- Department of Biomaterials and Prosthetic Dentistry, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Tamás Papp
- Division of Dental Anatomy, Department of Basic Medical Sciences, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Szabolcs Felszeghy
- Division of Dental Anatomy, Department of Basic Medical Sciences, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
- Institute of Dentistry, University of Eastern Finland, Kuopio, Finland
| | - Radislav Sedlacek
- Czech Centre for Phenogenomics & Laboratory of Transgenic Models of Diseases, Institute of Molecular Genetics of the Czech Academy of Sciences v.v.i 252 50, Vestec, Czech Republic
| | - Esti Davidovich
- Department of Pediatric Dentistry, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel
| | - Noa Tal
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror S Shouval
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raanan Shamir
- The Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carole Guillonneau
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
| | - Zsuzsa Szondy
- Division of Dental Biochemistry, Department of Basic Medical Sciences, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Knut E A Lundin
- K.G. Jebsen Coeliac Disease Research Centre, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Radim Osicka
- Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic
| | - Jan Prochazka
- Czech Centre for Phenogenomics & Laboratory of Transgenic Models of Diseases, Institute of Molecular Genetics of the Czech Academy of Sciences v.v.i 252 50, Vestec, Czech Republic
| | - Eystein S Husebye
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Jakub Abramson
- Department of Immunology and Regenerative Biology, Weizmann Institute of Science, Rehovot, Israel.
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Centanni M, Virili C. Pregnancy Outcome in Poly-Autoimmune Disorders: The Case of APECED Syndrome. J Clin Endocrinol Metab 2022; 107:e1754-e1755. [PMID: 34718626 PMCID: PMC8947229 DOI: 10.1210/clinem/dgab783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina 04100, Italy
- Endocrine Unit, AUSL Latina, Latina 04100, Italy
- Correspondence: Marco Centanni, MD, Department of Medico-Surgical Sciences and Biotechnologies, Corso della Repubblica 79, Latina 04100, Italy.
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, ‘‘Sapienza’’ University of Rome, Latina 04100, Italy
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Laakso S, Holopainen E, Betterle C, Saari V, Vogt E, Schmitt MM, Winer KK, Kareva M, Sabbadin C, Husebye ES, Orlova E, Lionakis MS, Mäkitie O. Pregnancy Outcome in Women With APECED (APS-1): A Multicenter Study on 43 Females With 83 Pregnancies. J Clin Endocrinol Metab 2022; 107:e528-e537. [PMID: 34570215 PMCID: PMC8764323 DOI: 10.1210/clinem/dgab705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Indexed: 01/19/2023]
Abstract
CONTEXT Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED; also known as autoimmune polyendocrine syndrome type 1) has a severe, unpredictable course. Autoimmunity and disease components may affect fertility and predispose to maternal and fetal complications, but pregnancy outcomes remain unknown. OBJECTIVE To assess fetal and maternal outcomes and course of clinical APECED manifestations during pregnancy in women with APECED. DESIGN AND SETTING A multicenter registry-based study including 5 national patient cohorts. PATIENTS 321 females with APECED. MAIN OUTCOME MEASURE Number of pregnancies, miscarriages, and deliveries. RESULTS Forty-three patients had altogether 83 pregnancies at median age of 27 years (range, 17-39). Sixty (72%) pregnancies led to a delivery, including 2 stillbirths (2.4%) and 5 (6.0%) preterm livebirths. Miscarriages, induced abortions, and ectopic pregnancies were observed in 14 (17%), 8 (10%), and 1 (1.2%) pregnancies, respectively. Ovum donation resulted in 5 (6.0%) pregnancies. High maternal age, premature ovarian insufficiency, primary adrenal insufficiency, or hypoparathyroidism did not associate with miscarriages. Women with livebirth had, on average, 4 APECED manifestations (range 0-10); 78% had hypoparathyroidism, and 36% had primary adrenal insufficiency. APECED manifestations remained mostly stable during pregnancy, but in 1 case, development of primary adrenal insufficiency led to adrenal crisis and stillbirth. Birth weights were normal in >80% and apart from 1 neonatal death of a preterm baby, no serious perinatal complications occurred. CONCLUSIONS Outcome of pregnancy in women with APECED was generally favorable. However, APECED warrants careful maternal multidisciplinary follow-up from preconceptual care until puerperium.
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Affiliation(s)
- Saila Laakso
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Correspondence: Saila Laakso, MD, PhD, Children’s Hospital, Stenbäckinkatu 9, FI-00290 Helsinki, Finland.
| | - Elina Holopainen
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Corrado Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua,Italy
| | - Viivi Saari
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Elinor Vogt
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Monica M Schmitt
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Karen K Winer
- Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD,USA
| | | | - Chiara Sabbadin
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua,Italy
| | - Eystein S Husebye
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Michail S Lionakis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Outi Mäkitie
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
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5
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Li CW, Osman R, Menconi F, Faustino LC, Kim K, Clarke OB, Hou H, Tomer Y. Cepharanthine Blocks Presentation of Thyroid and Islet Peptides in a Novel Humanized Autoimmune Diabetes and Thyroiditis Mouse Model. Front Immunol 2021; 12:796552. [PMID: 34987519 PMCID: PMC8721038 DOI: 10.3389/fimmu.2021.796552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/03/2021] [Indexed: 11/13/2022] Open
Abstract
Autoimmune polyglandular syndrome type 3 variant (APS3v) refers to an autoimmune condition in which both type 1 diabetes (T1D) and autoimmune thyroiditis (AITD) develop in the same individual. HLA-DR3 confers the strongest susceptibility to APS3v. Previously we reported a unique amino acid signature pocket that predisposes to APS3v. We found that this pocket is flexible and can trigger APS3v by presenting both thyroid (Tg.1571, TPO.758) and islet (GAD.492) peptides to induce autoimmune response. We hypothesized that blocking the specific APS3v-HLA-DR3 pocket from presenting thyroid/islet antigens can block the autoimmune response in APS3v. To test this hypothesis we performed a virtual screen of small molecules blocking APS3v-HLA-DR3, and identified 11 small molecules hits that were predicted to block APS3v-HLA-DR3. Using the baculovirus-produced recombinant APS3v-HLA-DR3 protein we tested the 11 small molecules in an in vitro binding assay. We validated 4 small molecule hits, S9, S5, S53 and S15, that could block the APS3v-HLA-DR3 pocket in vitro. We then developed a novel humanized APS3v mouse model induced by co-immunizing a peptide mix of Tg.1571, TPO.758 and GAD.492. The immunized mice developed strong T-cell and antibody responses to the thyroid/islet peptides, as well as mouse thyroglobulin. In addition, the mice showed significantly lower free T4 levels compared to controls. Using the APS3v mouse model, we showed that one of the 4 small molecules, Cepharanthine (S53), blocked T-cell activation by thyroid/islet peptides ex vivo and in vivo. These findings suggested Cepharanthine may have a therapeutic potential in APS3v patients carrying the specific APS3v-HLA-DR3 pocket.
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MESH Headings
- Animals
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Antigen Presentation
- Autoantigens/immunology
- Benzylisoquinolines/therapeutic use
- Binding Sites/genetics
- Cells, Cultured
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/immunology
- Disease Models, Animal
- Genetic Predisposition to Disease
- Glutamate Decarboxylase/immunology
- HLA-DR3 Antigen/genetics
- HLA-DR3 Antigen/metabolism
- Humans
- Immunity, Humoral
- Immunization
- Iodide Peroxidase/immunology
- Iron-Binding Proteins/immunology
- Islets of Langerhans/immunology
- Lymphocyte Activation
- Mice
- Mice, SCID
- Peptide Fragments/genetics
- Peptide Fragments/immunology
- Polyendocrinopathies, Autoimmune/drug therapy
- Polyendocrinopathies, Autoimmune/immunology
- T-Lymphocytes/immunology
- Thyroglobulin/genetics
- Thyroglobulin/immunology
- Thyroiditis, Autoimmune/drug therapy
- Thyroiditis, Autoimmune/immunology
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Affiliation(s)
- Cheuk Wun Li
- The Fleischer Institute for Diabetes and Metabolism, Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
| | - Roman Osman
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Larissa C. Faustino
- The Fleischer Institute for Diabetes and Metabolism, Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
| | - Kookjoo Kim
- Department of Anesthesiology, Columbia University, New York, NY, United States
- Department of Physiology, Columbia University, New York, NY, United States
| | - Oliver B. Clarke
- Department of Anesthesiology, Columbia University, New York, NY, United States
- Department of Physiology, Columbia University, New York, NY, United States
| | - Hanxi Hou
- The Fleischer Institute for Diabetes and Metabolism, Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
| | - Yaron Tomer
- The Fleischer Institute for Diabetes and Metabolism, Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
- *Correspondence: Yaron Tomer,
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6
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Delmonte OM, Bergerson JRE, Burbelo PD, Durkee-Shock JR, Dobbs K, Bosticardo M, Keller MD, McDermott DH, Rao VK, Dimitrova D, Quiros-Roldan E, Imberti L, Ferrè EMN, Schmitt M, Lafeer C, Pfister J, Shaw D, Draper D, Truong M, Ulrick J, DiMaggio T, Urban A, Holland SM, Lionakis MS, Cohen JI, Ricotta EE, Notarangelo LD, Freeman AF. Antibody responses to the SARS-CoV-2 vaccine in individuals with various inborn errors of immunity. J Allergy Clin Immunol 2021; 148:1192-1197. [PMID: 34492260 PMCID: PMC8418380 DOI: 10.1016/j.jaci.2021.08.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/19/2021] [Accepted: 08/24/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND SARS-CoV-2 vaccination is recommended in patients with inborn errors of immunity (IEIs); however, little is known about immunogenicity and safety in these patients. OBJECTIVE We sought to evaluate the impact of genetic diagnosis, age, and treatment on antibody response to COVID-19 vaccine and related adverse events in a cohort of patients with IEIs. METHODS Plasma was collected from 22 health care worker controls, 81 patients with IEIs, and 2 patients with thymoma; the plasma was collected before immunization, 1 to 6 days before the second dose of mRNA vaccine, and at a median of 30 days after completion of the immunization schedule with either mRNA vaccine or a single dose of Johnson & Johnson's Janssen vaccine. Anti-spike (anti-S) and anti-nucleocapsid antibody titers were measured by using a luciferase immunoprecipitation systems method. Information on T- and B-cell counts and use of immunosuppressive drugs was extracted from medical records, and information on vaccine-associated adverse events was collected after each dose. RESULTS Anti-S antibodies were detected in 27 of 46 patients (58.7%) after 1 dose of mRNA vaccine and in 63 of 74 fully immunized patients (85.1%). A lower rate of seroconversion (7 of 11 [63.6%]) was observed in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. Previous use of rituximab and baseline counts of less than 1000 CD3+ T cells/mL and less than 100 CD19+ B cells/mL were associated with lower anti-S IgG levels. No significant adverse events were reported. CONCLUSION Vaccinating patients with IEIs is safe, but immunogenicity is affected by certain therapies and gene defects. These data may guide the counseling of patients with IEIs regarding prevention of SARS-CoV-2 infection and the need for subsequent boosts.
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Affiliation(s)
- Ottavia M Delmonte
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Jenna R E Bergerson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Peter D Burbelo
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md
| | - Jessica R Durkee-Shock
- Center for Cancer and Immunology Research and Division of Allergy and Immunology, Children's National Hospital, Washington, DC
| | - Kerry Dobbs
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Marita Bosticardo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Michael D Keller
- Center for Cancer and Immunology Research and Division of Allergy and Immunology, Children's National Hospital, Washington, DC
| | - David H McDermott
- Laboratory of Molecular Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - V Koneti Rao
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Dimana Dimitrova
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Eugenia Quiros-Roldan
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili di Brescia, Brescia, Italy; CREA Laboratory, Diagnostic Laboratory, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Luisa Imberti
- CREA Laboratory, Diagnostic Laboratory, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Elise M N Ferrè
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Monica Schmitt
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Christine Lafeer
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Justina Pfister
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Dawn Shaw
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Deborah Draper
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Meng Truong
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Jean Ulrick
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Tom DiMaggio
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Amanda Urban
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Michail S Lionakis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Jeffrey I Cohen
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Emily E Ricotta
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
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7
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Oikonomou V, Break TJ, Gaffen SL, Moutsopoulos NM, Lionakis MS. Infections in the monogenic autoimmune syndrome APECED. Curr Opin Immunol 2021; 72:286-297. [PMID: 34418591 PMCID: PMC8578378 DOI: 10.1016/j.coi.2021.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/13/2022]
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is caused by mutations in the Autoimmune Regulator (AIRE) gene, which impair the thymic negative selection of self-reactive T-cells and underlie the development of autoimmunity that targets multiple endocrine and non-endocrine tissues. Beyond autoimmunity, APECED features heightened susceptibility to certain specific infections, which is mediated by anti-cytokine autoantibodies and/or T-cell driven autoimmune tissue injury. These include the 'signature' APECED infection chronic mucocutaneous candidiasis (CMC), but also life-threatening coronavirus disease 2019 (COVID-19) pneumonia, bronchiectasis-associated bacterial pneumonia, and sepsis by encapsulated bacteria. Here we discuss the expanding understanding of the immunological mechanisms that contribute to infection susceptibility in this prototypic syndrome of impaired central tolerance, which provide the foundation for devising improved diagnostic and therapeutic strategies for affected patients.
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Affiliation(s)
- Vasileios Oikonomou
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology (LCIM), National Institute of Allergy & Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Timothy J Break
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology (LCIM), National Institute of Allergy & Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Sarah L Gaffen
- University of Pittsburgh, Division of Rheumatology and Clinical Immunology, Pittsburgh PA, USA
| | - Niki M Moutsopoulos
- Oral Immunity and Inflammation Section, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, MD, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology & Microbiology (LCIM), National Institute of Allergy & Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD, USA.
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8
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Petersen AØ, Jokinen M, Plichta DR, Liebisch G, Gronwald W, Dettmer K, Oefner PJ, Vlamakis H, Chung DC, Ranki A, Xavier RJ. Cytokine-specific autoantibodies shape the gut microbiome in autoimmune polyendocrine syndrome type 1. J Allergy Clin Immunol 2021; 148:876-888. [PMID: 33819509 PMCID: PMC8429070 DOI: 10.1016/j.jaci.2021.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/23/2021] [Accepted: 03/24/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Gastrointestinal dysfunction is a frequent and disabling manifestation of autoimmune polyendocrine syndrome type 1 (APS-1), a rare monogenic multiorgan autoimmune disease caused by the loss of central AIRE-controlled immune tolerance. OBJECTIVES This study aimed to understand the role of the gut microbiome in APS-1 symptoms and potentially alleviate common gastrointestinal symptoms by probiotic intervention. METHODS This study characterized the fecal microbiomes of 28 patients with APS-1 and searched for associations with gastrointestinal symptoms, circulating anti-cytokine autoantibodies, and tryptophan-related metabolites. Additionally, daily doses of the probiotic Lactobacillus rhamnosus GG were administered for 3 months. RESULTS Of 581 metagenomic operational taxonomic units (mOTUs) characterized in total, 14 were significantly associated with patients with APS-1 compared with healthy controls, with 6 mOTUs depleted and 8 enriched in patients with APS-1. Four overabundant mOTUs were significantly associated with severity of constipation. Phylogenetically conserved microbial associations with autoantibodies against cytokines were observed. After the 3-month intervention with the probiotic L rhamnosus GG, a subset of gastrointestinal symptoms were alleviated. L rhamnosus GG abundance was increased postintervention and corresponded with decreased abundances of Alistipes onderdonkii and Collinsella aerofaciens, 2 species positively associated with severity of diarrhea in patients with APS-1. CONCLUSIONS The APS-1 microbiome correlates with several APS-1 symptoms, some of which are alleviated after a 3-month L rhamnosus GG intervention. Autoantibodies against cytokines appear to shape the gut microbiome by positively correlating with a taxonomically consistent group of bacteria.
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Affiliation(s)
- Anders Ø Petersen
- Broad Institute of MIT and Harvard, Cambridge, Mass; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, Mass; Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Martta Jokinen
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Damian R Plichta
- Broad Institute of MIT and Harvard, Cambridge, Mass; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, Mass
| | - Gerhard Liebisch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Wolfram Gronwald
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Katja Dettmer
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Peter J Oefner
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Hera Vlamakis
- Broad Institute of MIT and Harvard, Cambridge, Mass; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, Mass
| | - Daniel C Chung
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Annamari Ranki
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Ramnik J Xavier
- Broad Institute of MIT and Harvard, Cambridge, Mass; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, Mass; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass; Center for Computational and Integrative Biology and Department of Molecular Biology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass.
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9
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Ferré EMN, Schmitt MM, Ochoa S, Rosen LB, Shaw ER, Burbelo PD, Stoddard JL, Rampertaap S, DiMaggio T, Bergerson JRE, Rosenzweig SD, Notarangelo LD, Holland SM, Lionakis MS. SARS-CoV-2 Spike Protein-Directed Monoclonal Antibodies May Ameliorate COVID-19 Complications in APECED Patients. Front Immunol 2021; 12:720205. [PMID: 34504497 PMCID: PMC8421855 DOI: 10.3389/fimmu.2021.720205] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/03/2021] [Indexed: 12/15/2022] Open
Abstract
Patients with the monogenic immune dysregulatory syndrome autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), which is caused by loss-of-function mutations in the autoimmune regulator (AIRE) gene, uniformly carry neutralizing autoantibodies directed against type-I interferons (IFNs) and many develop autoimmune pneumonitis, both of which place them at high risk for life-threatening COVID-19 pneumonia. Bamlanivimab and etesevimab are monoclonal antibodies (mAbs) that target the SARS-CoV-2 spike protein and block entry of SARS-CoV-2 in host cells. The use of bamlanivimab and etesevimab early during infection was associated with reduced COVID-19-associated hospitalization and death in patients at high risk for progressing to severe disease, which led the US Food and Drug Administration to issue an emergency use authorization for their administration in non-hypoxemic, non-hospitalized high-risk patients. However, the safety and efficacy of these mAbs has not been evaluated in APECED patients. We enrolled two siblings with APECED on an IRB-approved protocol (NCT01386437) and admitted them prophylactically at the NIH Clinical Center for evaluation of mild-to-moderate COVID-19. We assessed the safety and clinical effects of early treatment with bamlanivimab and etesevimab. The administration of bamlanivimab and etesevimab was well tolerated and was associated with amelioration of COVID-19 symptoms and prevention of invasive ventilatory support, admission to the intensive care, and death in both patients without affecting the production of antibodies to the nucleocapsid protein of SARS-CoV-2. If given early in the course of COVID-19 infection, bamlanivimab and etesevimab may be beneficial in APECED and other high-risk patients with neutralizing autoantibodies directed against type-I IFNs.
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Affiliation(s)
- Elise M. N. Ferré
- Fungal Pathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD, United States
| | - Monica M. Schmitt
- Fungal Pathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD, United States
| | - Sebastian Ochoa
- Fungal Pathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD, United States
| | - Lindsey B. Rosen
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD, United States
| | - Elana R. Shaw
- Human Immunological Diseases Section, LCIM, NIAID, NIH, Bethesda, MD, United States
| | - Peter D. Burbelo
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, United States
| | - Jennifer L. Stoddard
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, MD, United States
| | - Shakuntala Rampertaap
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, MD, United States
| | - Tom DiMaggio
- Fungal Pathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD, United States
| | | | - Sergio D. Rosenzweig
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, NIH, Bethesda, MD, United States
| | - Luigi D. Notarangelo
- Immune Deficiency Genetics Section, LCIM, NIAID, NIH, Bethesda, MD, United States
| | - Steven M. Holland
- Immunopathogenesis Section, LCIM, NIAID, NIH, Bethesda, MD, United States
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10
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van Wanrooij RLJ, Neefjes-Borst EA, Bontkes HJ, Schreurs MWJ, Langerak AW, Mulder CJJ, Bouma G. Adult-Onset Autoimmune Enteropathy in an European Tertiary Referral Center. Clin Transl Gastroenterol 2021; 12:e00387. [PMID: 34333499 PMCID: PMC8323799 DOI: 10.14309/ctg.0000000000000387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/28/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Adult-onset autoimmune enteropathy (AIE) is a rare cause of severe chronic diarrhea because of small intestinal villous atrophy. We report on patients with adult-onset AIE in an European referral center. METHODS Retrospective study including patients diagnosed with AIE in the Amsterdam UMC, location VUmc, between January 2003 and December 2019. Clinical, serological, and histological features and response to treatment were reported. The specificity of antienterocyte antibodies (AEA) was evaluated by examining the prevalence of AEA in (i) controls (n = 30) and in patients with (ii) AIE (n = 13), (iii) celiac disease (CD, n = 52), (iv) refractory celiac disease type 2 (n = 18), and (v) enteropathy-associated T-cell lymphoma (EATL, n = 10). RESULTS Thirteen AIE patients were included, 8 women (62%), median age of 52 years (range 23-73), and 6 (46%) with an autoimmune disease. AEA were observed in 11 cases (85%), but were also found in CD (7.7%), refractory celiac disease type 2 (16.7%), and EATL (20%). Ten patients (77%) were human leukocyte antigen DQ2.5 heterozygous. Total parenteral nutrition was required in 8 cases (62%). Steroids induced clinical remission in 8 cases (62%). Step-up therapy with rituximab, cyclosporine, infliximab, and cladribine in steroid-refractory patients was only moderately effective. Four patients died (31%), but 4 (31%) others are in long-term drug-free remission after receiving immunosuppressive treatment, including 1 patient who underwent autologous stem cell transplantation. DISCUSSION Adult-onset AIE is a rare but severe enteropathy that occurs in patients susceptible for autoimmune disease. Four patients (31%) died secondary to therapy-refractory malabsorption, while immunosuppressive therapy leads to a long-lasting drug-free remission in one-third of patients.
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Affiliation(s)
- Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, the Netherlands
| | | | - Hetty J Bontkes
- Laboratory Medical Immunology, Department of Clinical Chemistry, Amsterdam UMC, AGEM Research Institute, AI & I Institute, Amsterdam, the Netherlands
| | - Marco W J Schreurs
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Anton W Langerak
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, the Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, the Netherlands
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11
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Hetemäki I, Jian C, Laakso S, Mäkitie O, Pajari AM, de Vos WM, Arstila TP, Salonen A. Fecal Bacteria Implicated in Biofilm Production Are Enriched and Associate to Gastrointestinal Symptoms in Patients With APECED - A Pilot Study. Front Immunol 2021; 12:668219. [PMID: 34367134 PMCID: PMC8339580 DOI: 10.3389/fimmu.2021.668219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/08/2021] [Indexed: 11/24/2022] Open
Abstract
Backgrounds and Aims APECED is a rare autoimmune disease caused by mutations in the Autoimmune Regulator gene. A significant proportion of patients also have gastrointestinal symptoms, including malabsorption, chronic diarrhea, and obstipation. The pathological background of the gastrointestinal symptoms remains incompletely understood and involves multiple factors, with autoimmunity being the most common underlying cause. Patients with APECED have increased immune responses against gut commensals. Our objective was to evaluate whether the intestinal microbiota composition, predicted functions or fungal abundance differ between Finnish patients with APECED and healthy controls, and whether these associate to the patients' clinical phenotype and gastrointestinal symptoms. Methods DNA was isolated from fecal samples from 15 patients with APECED (median age 46.4 years) together with 15 samples from body mass index matched healthy controls. DNA samples were subjected to analysis of the gut microbiota using 16S rRNA gene amplicon sequencing, imputed metagenomics using the PICRUSt2 algorithm, and quantitative PCR for fungi. Extensive correlations of the microbiota with patient characteristics were determined. Results Analysis of gut microbiota indicated that both alpha- and beta-diversity were altered in patients with APECED compared to healthy controls. The fraction of Faecalibacterium was reduced in patients with APECED while that of Atopobium spp. and several gram-negative genera previously implicated in biofilm formation, e.g. Veillonella, Prevotella, Megasphaera and Heamophilus, were increased in parallel to lipopolysaccharide (LPS) synthesis in imputed metagenomics. The differences in gut microbiota were linked to patient characteristics, especially the presence of anti-Saccharomyces cerevisiae antibodies (ASCA) and severity of gastrointestinal symptoms. Conclusions Gut microbiota of patients with APECED is altered and enriched with predominantly gram-negative bacterial taxa that may promote biofilm formation and lead to increased exposure to LPS in the patients. The most pronounced alterations in the microbiota were associated with more severe gastrointestinal symptoms.
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Affiliation(s)
- Iivo Hetemäki
- Translational Immunology Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ching Jian
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Saila Laakso
- Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Clinical and Molecular Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Outi Mäkitie
- Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Clinical and Molecular Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Anne-Maria Pajari
- Department of Food and Nutrition, University of Helsinki, Helsinki, Finland
| | - Willem M. de Vos
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Laboratory of Microbiology, Wageningen University, Wageningen, Netherlands
| | - T. Petteri Arstila
- Translational Immunology Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne Salonen
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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12
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Meisel C, Akbil B, Meyer T, Lankes E, Corman VM, Staudacher O, Unterwalder N, Kölsch U, Drosten C, Mall MA, Kallinich T, Schnabel D, Goffinet C, von Bernuth H. Mild COVID-19 despite autoantibodies against type I IFNs in autoimmune polyendocrine syndrome type 1. J Clin Invest 2021; 131:150867. [PMID: 34061776 PMCID: PMC8279584 DOI: 10.1172/jci150867] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/25/2021] [Indexed: 12/25/2022] Open
Abstract
Autoantibodies against IFN-α and IFN-ω (type I IFNs) were recently reported as causative for severe COVID-19 in the general population. Autoantibodies against IFN-α and IFN-ω are present in almost all patients with autoimmune polyendocrine syndrome type 1 (APS-1) caused by biallelic deleterious or heterozygous dominant mutations in AIRE. We therefore hypothesized that autoantibodies against type I IFNs also predispose patients with APS-1 to severe COVID-19. We prospectively studied 6 patients with APS-1 between April 1, 2020 and April 1, 2021. Biobanked pre-COVID-19 sera of APS-1 subjects were tested for neutralizing autoantibodies against IFN-α and IFN-ω. The ability of the patients' sera to block recombinant human IFN-α and IFN-ω was assessed by assays quantifying phosphorylation of signal transducer and activator of transcription 1 (STAT1) as well as infection-based IFN-neutralization assays. We describe 4 patients with APS-1 and preexisting high titers of neutralizing autoantibodies against IFN-α and IFN-ω who contracted SARS-CoV-2, yet developed only mild symptoms of COVID-19. None of the patients developed dyspnea, oxygen requirement, or high temperature. All infected patients with APS-1 were females and younger than 26 years of age. Clinical penetrance of neutralizing autoantibodies against type I IFNs for severe COVID-19 is not complete.
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Affiliation(s)
- Christian Meisel
- Department of Immunology, Labor Berlin GmbH, Berlin, Germany
- Institute of Medical Immunology, Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bengisu Akbil
- Institute of Virology, and German Centre for Infection Research (DZIF), associated partner, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité — Universitätsmedizin Berlin, Germany
| | - Tim Meyer
- Department of Immunology, Labor Berlin GmbH, Berlin, Germany
| | - Erwin Lankes
- Berlin Institute of Health, Center for Chronically Sick Children, Pediatric Endocrinology, Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Victor M. Corman
- Institute of Virology, and German Centre for Infection Research (DZIF), associated partner, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité — Universitätsmedizin Berlin, Germany
| | - Olga Staudacher
- Department of Immunology, Labor Berlin GmbH, Berlin, Germany
- Berlin Institute of Health at Charité — Universitätsmedizin Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | | | - Uwe Kölsch
- Department of Immunology, Labor Berlin GmbH, Berlin, Germany
| | - Christian Drosten
- Institute of Virology, and German Centre for Infection Research (DZIF), associated partner, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité — Universitätsmedizin Berlin, Germany
| | - Marcus A. Mall
- Berlin Institute of Health at Charité — Universitätsmedizin Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- German Center for Lung Research (DZL), associated partner, Berlin, Germany
| | - Tilmann Kallinich
- Berlin Institute of Health at Charité — Universitätsmedizin Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), an Institute of the Leibniz association, Germany
| | - Dirk Schnabel
- Berlin Institute of Health, Center for Chronically Sick Children, Pediatric Endocrinology, Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christine Goffinet
- Institute of Virology, and German Centre for Infection Research (DZIF), associated partner, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité — Universitätsmedizin Berlin, Germany
| | - Horst von Bernuth
- Department of Immunology, Labor Berlin GmbH, Berlin, Germany
- Berlin Institute of Health at Charité — Universitätsmedizin Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité — Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
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13
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Bastard P, Orlova E, Sozaeva L, Lévy R, James A, Schmitt MM, Ochoa S, Kareva M, Rodina Y, Gervais A, Le Voyer T, Rosain J, Philippot Q, Neehus AL, Shaw E, Migaud M, Bizien L, Ekwall O, Berg S, Beccuti G, Ghizzoni L, Thiriez G, Pavot A, Goujard C, Frémond ML, Carter E, Rothenbuhler A, Linglart A, Mignot B, Comte A, Cheikh N, Hermine O, Breivik L, Husebye ES, Humbert S, Rohrlich P, Coaquette A, Vuoto F, Faure K, Mahlaoui N, Kotnik P, Battelino T, Trebušak Podkrajšek K, Kisand K, Ferré EM, DiMaggio T, Rosen LB, Burbelo PD, McIntyre M, Kann NY, Shcherbina A, Pavlova M, Kolodkina A, Holland SM, Zhang SY, Crow YJ, Notarangelo LD, Su HC, Abel L, Anderson MS, Jouanguy E, Neven B, Puel A, Casanova JL, Lionakis MS. Preexisting autoantibodies to type I IFNs underlie critical COVID-19 pneumonia in patients with APS-1. J Exp Med 2021; 218:e20210554. [PMID: 33890986 PMCID: PMC8077172 DOI: 10.1084/jem.20210554] [Citation(s) in RCA: 160] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 12/15/2022] Open
Abstract
Patients with biallelic loss-of-function variants of AIRE suffer from autoimmune polyendocrine syndrome type-1 (APS-1) and produce a broad range of autoantibodies (auto-Abs), including circulating auto-Abs neutralizing most type I interferons (IFNs). These auto-Abs were recently reported to account for at least 10% of cases of life-threatening COVID-19 pneumonia in the general population. We report 22 APS-1 patients from 21 kindreds in seven countries, aged between 8 and 48 yr and infected with SARS-CoV-2 since February 2020. The 21 patients tested had auto-Abs neutralizing IFN-α subtypes and/or IFN-ω; one had anti-IFN-β and another anti-IFN-ε, but none had anti-IFN-κ. Strikingly, 19 patients (86%) were hospitalized for COVID-19 pneumonia, including 15 (68%) admitted to an intensive care unit, 11 (50%) who required mechanical ventilation, and four (18%) who died. Ambulatory disease in three patients (14%) was possibly accounted for by prior or early specific interventions. Preexisting auto-Abs neutralizing type I IFNs in APS-1 patients confer a very high risk of life-threatening COVID-19 pneumonia at any age.
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Affiliation(s)
- Paul Bastard
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | | | | | - Romain Lévy
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
- Pediatric Immunology, Hematology and Rheumatology Unit, Necker Hospital for Sick Children, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alyssa James
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Monica M. Schmitt
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Sebastian Ochoa
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | | | - Yulia Rodina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Adrian Gervais
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
| | - Tom Le Voyer
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
| | - Jérémie Rosain
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
| | - Quentin Philippot
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
| | - Anna-Lena Neehus
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
| | - Elana Shaw
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mélanie Migaud
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
| | - Lucy Bizien
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
| | - Olov Ekwall
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden
- Department of Rheumatology and Inflammation Research, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Stefan Berg
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | | | - Lucia Ghizzoni
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gérard Thiriez
- Intensive Care Unit, Besançon Hospital, Besançon, France
| | - Arthur Pavot
- Intensive Care Unit, Kremlin-Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Cécile Goujard
- Internal Medicine Department, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Paris Saclay University, Institut National de la Santé et de la Recherche Médicale U1018, Le Kremlin-Bicêtre, France
| | - Marie-Louise Frémond
- Pediatric Immunology, Hematology and Rheumatology Unit, Necker Hospital for Sick Children, Assistance Publique Hôpitaux de Paris, Paris, France
- Laboratory of Neurogenetics and Neuroinflammation, Université de Paris, Imagine Institute, Paris, France
| | - Edwin Carter
- Centre for Genomic and Experimental Medicine, Medical Research Council Institute of Genetics and Molecular Medicine, Edinburgh, UK
| | - Anya Rothenbuhler
- Pediatric Endocrinology Department, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Agnès Linglart
- Pediatric Endocrinology Department, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Brigite Mignot
- Pediatric Medicine Unit, University Hospital of Besançon, Besançon, France
| | - Aurélie Comte
- Pediatric Medicine Unit, University Hospital of Besançon, Besançon, France
| | - Nathalie Cheikh
- Pediatric Hematology Unit, University Hospital of Besançon, Besançon, France
| | - Olivier Hermine
- University of Paris, Imagine Institute, Paris, France
- Hematology department, University of Paris, Necker Hospital for Sick Children, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Lars Breivik
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Eystein S. Husebye
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
| | | | - Pierre Rohrlich
- Pediatric Hematology and Oncology unit, Centre Hospitalier Universitaire de Nice, Nice, France
| | | | - Fanny Vuoto
- Infectious Disease Unit, Lille Hospital, Lille, France
| | - Karine Faure
- Infectious Disease Unit, Lille Hospital, Lille, France
| | - Nizar Mahlaoui
- Pediatric Immunology, Hematology and Rheumatology Unit, Necker Hospital for Sick Children, Assistance Publique Hôpitaux de Paris, Paris, France
- Centre de Référence Déficits Immunitaires Héréditaires, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Primož Kotnik
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia
| | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia
| | - Katarina Trebušak Podkrajšek
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- University Medical Centre Ljubljana, University Children's Hospital, Ljubljana, Slovenia
| | - Kai Kisand
- Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Elise M.N. Ferré
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Thomas DiMaggio
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Lindsey B. Rosen
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Peter D. Burbelo
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | | | - Nelli Y. Kann
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Maria Pavlova
- Department of Endocrinology N°1, Sechenov University, Moscow, Russia
| | | | - Steven M. Holland
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Shen-Ying Zhang
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Yanick J. Crow
- Laboratory of Neurogenetics and Neuroinflammation, Université de Paris, Imagine Institute, Paris, France
- Centre for Genomic and Experimental Medicine, Medical Research Council Institute of Genetics and Molecular Medicine, Edinburgh, UK
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Helen C. Su
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Laurent Abel
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Mark S. Anderson
- Diabetes Center, University of California, San Francisco, San Francisco, CA
| | - Emmanuelle Jouanguy
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Bénédicte Neven
- University of Paris, Imagine Institute, Paris, France
- Pediatric Immunology, Hematology and Rheumatology Unit, Necker Hospital for Sick Children, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Anne Puel
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Necker Hospital for Sick Children, Paris, France
- University of Paris, Imagine Institute, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
- Howard Hughes Medical Institute, New York, NY
| | - Michail S. Lionakis
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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14
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Lemarquis A, Campbell T, Aranda-Guillén M, Hennings V, Brodin P, Kämpe O, Blennow K, Zetterberg H, Wennerås C, Eriksson K, Landegren N, Bryceson Y, Berg S, Ekwall O. Severe COVID-19 in an APS1 patient with interferon autoantibodies treated with plasmapheresis. J Allergy Clin Immunol 2021; 148:96-98. [PMID: 33892926 PMCID: PMC8051851 DOI: 10.1016/j.jaci.2021.03.034] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Andri Lemarquis
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Rheumatology and Inflammation Research, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Tessa Campbell
- Centre for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institute, Stockholm, Sweden; Division of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Maribel Aranda-Guillén
- Centre for Molecular Medicine, Department of Medicine (Solna), Karolinska Institute, Stockholm, Sweden
| | - Viktoria Hennings
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Rheumatology and Inflammation Research, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Petter Brodin
- Science for Life Laboratory, Department of Women's and Children's Health, Karolinska Institute, Solna, Sweden
| | - Olle Kämpe
- Centre for Molecular Medicine, Department of Medicine (Solna), Karolinska Institute, Stockholm, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, United Kingdom; UK Dementia Research Institute at UCL, London, United Kingdom
| | - Christine Wennerås
- Department of Infectious Diseases, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Eriksson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nils Landegren
- Centre for Molecular Medicine, Department of Medicine (Solna), Karolinska Institute, Stockholm, Sweden; Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Yenan Bryceson
- Centre for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institute, Stockholm, Sweden; Division of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden; Broegelmann Research Laboratory, Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Stefan Berg
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Pediatrics, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olov Ekwall
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Rheumatology and Inflammation Research, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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15
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Halabi I, Barohom MN, Peleg S, Trougouboff P, Elias-Assad G, Agbaria R, Tenenbaum-Rakover Y. Case Report: Severe Hypocalcemic Episodes Due to Autoimmune Enteropathy. Front Endocrinol (Lausanne) 2021; 12:645279. [PMID: 34194389 PMCID: PMC8237854 DOI: 10.3389/fendo.2021.645279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/19/2021] [Indexed: 12/23/2022] Open
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare monogenic disorder, associated with endocrine deficiencies and non-endocrine involvement. Gastrointestinal (GI) manifestations appear in approximately 25% of patients and are the presenting symptom in about 10% of them. Limited awareness among pediatricians of autoimmune enteropathy (AIE) caused by destruction of the gut endocrine cells in APECED patients delays diagnosis and appropriate therapy. We describe an 18-year-old female presenting at the age of 6.10 years with hypoparathyroidism, oral candidiasis and vitiligo. The clinical diagnosis of APECED was confirmed by sequencing the autoimmune regulator-encoding (AIRE) gene. Several characteristics of the disease-Hashimoto's thyroiditis, Addison's disease, diabetes mellitus type 1 and primary ovarian insufficiency-developed over the years. She had recurrent episodes of severe intractable hypocalcemia. Extensive GI investigations for possible malabsorption, including laboratory analyses, imaging and endoscopy with biopsies were unremarkable. Revision of the biopsies and chromogranin A (CgA) immunostaining demonstrated complete loss of enteroendocrine cells in the duodenum and small intestine, confirming the diagnosis of AIE. Management of hypocalcemia was challenging. Only intravenous calcitriol maintained calcium in the normal range. Between hypocalcemic episodes, the proband maintained normal calcium levels, suggesting a fluctuating disease course. Repeated intestinal biopsy revealed positive intestinal CgA immunostaining. The attribution of severe hypocalcemic episodes to AIE emphasizes the need for increased awareness of this unique presentation of APECED. The fluctuating disease course and repeated intestinal biopsy showing positive CgA immunostaining support a reversible effect of GI involvement. CgA immunostaining is indicated in patients with APECED for whom all other investigations have failed to reveal an explanation for the malabsorption.
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Affiliation(s)
- Inbal Halabi
- Pediatric Endocrine Institute, Ha’Emek Medical Center, Afula, Israel
- Pediatric Health Center, Clalit Health Services, Naharia, Israel
| | - Marie Noufi Barohom
- Pediatric Endocrine Institute, Ha’Emek Medical Center, Afula, Israel
- Pediatric Health Center, Clalit Health Services, Naharia, Israel
- Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Sarit Peleg
- Pediatric Health Center, Clalit Health Services, Hadera, Israel
| | - Phillippe Trougouboff
- Tissue Diagnosis and Cancer Research Department, Ha’Emek Medical Center, Afula, Israel
| | - Ghadir Elias-Assad
- Pediatric Endocrine Institute, Ha’Emek Medical Center, Afula, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Rhania Agbaria
- Pediatric Gastroenterology Unit, Ha’Emek Medical Center, Afula, Israel
| | - Yardena Tenenbaum-Rakover
- Pediatric Endocrine Institute, Ha’Emek Medical Center, Afula, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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16
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Zhu F, Willette-Brown J, Zhang J, Ferre EMN, Sun Z, Wu X, Lionakis MS, Hu Y. NLRP3 Inhibition Ameliorates Severe Cutaneous Autoimmune Manifestations in a Mouse Model of Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy-Like Disease. J Invest Dermatol 2021; 141:1404-1415. [PMID: 33188780 PMCID: PMC8110612 DOI: 10.1016/j.jid.2020.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/25/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
Abstract
Patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy show diverse endocrine and nonendocrine manifestations initiated by self-reactive T cells because of AIRE mutation-induced defective central tolerance. A large number of American patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy suffer from early-onset cutaneous inflammatory lesions accompanied by an infiltration of T cells and myeloid cells. The role of myeloid cells in this setting remains to be fully investigated. In this study, we characterize the autoinflammatory phenotypes in the skin of both autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy-like kinase-dead Ikkα knockin mice and patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. We found a marked infiltration of autoreactive CD4 T cells, macrophages, and neutrophils; elevated uric acid; and increased NLRP3, a major inflammasome component. Depleting autoreactive CD4 T cells or ablating Ccl2/Cxcr2 genes significantly attenuated the inflammasome activity, inflammation, and skin phenotypes in kinase-dead Ikkα knockin mice. Importantly, treatment with an NLRP3 inhibitor reduced skin phenotypes and decreased infiltration of CD4 T cells, macrophages, and neutrophils. These results suggest that increased myeloid cell infiltration contributes to autoreactive CD4 T cell-mediated skin autoinflammation. Thus, our findings reveal that the combined infiltration of macrophages and neutrophils is required for autoreactive CD4 T cell-mediated skin disease pathogenesis and that the NLRP3-dependent inflammasome is a potential therapeutic target for the cutaneous manifestations of autoimmune diseases.
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Affiliation(s)
- Feng Zhu
- Laboratory of Cancer Immunometabolism, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, Maryland, USA
| | - Jami Willette-Brown
- Laboratory of Cancer Immunometabolism, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, Maryland, USA
| | - Jian Zhang
- Laboratory of Cancer Immunometabolism, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, Maryland, USA; Department of Ophthalmology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China; Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China; National Clinical Research Center for Eye Diseases, Shanghai, China; Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, China
| | - Elise M N Ferre
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Zhonghe Sun
- Cancer Research Technology Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Xiaolin Wu
- Cancer Research Technology Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Yinling Hu
- Laboratory of Cancer Immunometabolism, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, Maryland, USA.
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17
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Sakaguchi H, Mizuochi T, Haruta M, Takase R, Yoshida S, Yamashita Y, Nishikomori R. AIRE Gene Mutation Presenting at Age 2 Years With Autoimmune Retinopathy and Steroid-Responsive Acute Liver Failure: A Case Report and Literature Review. Front Immunol 2021; 12:687280. [PMID: 34122451 PMCID: PMC8194255 DOI: 10.3389/fimmu.2021.687280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/13/2021] [Indexed: 12/11/2022] Open
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare monogenic autosomal recessive disorder caused by mutation in the autoimmune regulator (AIRE) gene. Patients usually are diagnosed at ages between 5 and 15 years when they show 3 or more manifestations, most typically mucocutaneous candidiasis, Addison's disease, and hypoparathyroidism. APECED-associated hepatitis (APAH) develops in only 10% to 40% of patients, with severity varying from subclinical chronic active hepatitis to potentially fatal acute liver failure (ALF). Ocular abnormalities are fairly common, most often keratopathy but sometimes retinopathy. Here we report a 2-year-old Japanese girl with an AIRE gene mutation who developed APAH with ALF, preceded by autoimmune retinopathy associated with anti-recoverin antibody before major symptoms suggested a diagnosis of APECED. Intravenous pulse methylprednisolone therapy followed by a corticosteroid combined with azathioprine treatment resolved ALF and achieved control of APAH. To our knowledge, our patient is the youngest reported to have ALF resulting from an AIRE gene mutation. Pulse methylprednisolone induction therapy followed by treatment with corticosteroid plus azathioprine may well be effective in other children with APAH and AIRE gene mutations.
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MESH Headings
- Administration, Intravenous
- Adrenal Cortex Hormones/administration & dosage
- Autoantibodies/blood
- Autoimmune Diseases/diagnosis
- Autoimmune Diseases/drug therapy
- Autoimmune Diseases/genetics
- Autoimmune Diseases/immunology
- Azathioprine/administration & dosage
- Child, Preschool
- Drug Therapy, Combination
- Female
- Genetic Predisposition to Disease
- Humans
- Immunosuppressive Agents/administration & dosage
- Liver Failure, Acute/diagnosis
- Liver Failure, Acute/drug therapy
- Liver Failure, Acute/genetics
- Liver Failure, Acute/immunology
- Methylprednisolone/administration & dosage
- Mutation
- Phenotype
- Polyendocrinopathies, Autoimmune/diagnosis
- Polyendocrinopathies, Autoimmune/drug therapy
- Polyendocrinopathies, Autoimmune/genetics
- Polyendocrinopathies, Autoimmune/immunology
- Pulse Therapy, Drug
- Recoverin/immunology
- Retinal Diseases/diagnosis
- Retinal Diseases/drug therapy
- Retinal Diseases/genetics
- Retinal Diseases/immunology
- Transcription Factors/genetics
- Treatment Outcome
- AIRE Protein
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Affiliation(s)
- Hirotaka Sakaguchi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Tatsuki Mizuochi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Masatoshi Haruta
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Ryuta Takase
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Shigeo Yoshida
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Yushiro Yamashita
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Ryuta Nishikomori
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
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18
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Savvateeva EN, Yukina MY, Nuralieva NF, Filippova MA, Gryadunov DA, Troshina EA. Multiplex Autoantibody Detection in Patients with Autoimmune Polyglandular Syndromes. Int J Mol Sci 2021; 22:5502. [PMID: 34071130 PMCID: PMC8197071 DOI: 10.3390/ijms22115502] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 12/15/2022] Open
Abstract
The diagnosis of autoimmune polyglandular syndrome (APS) types 1/2 is difficult due to their rarity and nonspecific clinical manifestations. APS-1 development can be identified with assays for autoantibodies against cytokines, and APS-2 development with organ-specific antibodies. In this study, a microarray-based multiplex assay was proposed for simultaneous detection of both organ-specific (anti-21-OH, anti-GAD-65, anti-IA2, anti-ICA, anti-TG, and anti-TPO) and APS-1-specific (anti-IFN-ω, anti-IFN-α-2a, and anti-IL-22) autoantibodies. Herein, 206 serum samples from adult patients with APS-1, APS-2, isolated autoimmune endocrine pathologies or non-autoimmune endocrine pathologies and from healthy donors were analyzed. The prevalence of autoantibodies differed among the groups of healthy donors and patients with non-, mono- and multi-endocrine diseases. APS-1 patients were characterized by the presence of at least two specific autoantibodies (specificity 99.5%, sensitivity 100%). Furthermore, in 16 of the 18 patients, the APS-1 assay revealed triple positivity for autoantibodies against IFN-ω, IFN-α-2a and IL-22 (specificity 100%, sensitivity 88.9%). No anti-cytokine autoantibodies were found in the group of patients with non-APS-1 polyendocrine autoimmunity. The accuracy of the microarray-based assay compared to ELISA for organ-specific autoantibodies was 88.8-97.6%. This multiplex assay can be part of the strategy for diagnosing and predicting the development of APS.
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Affiliation(s)
- Elena N. Savvateeva
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (M.A.F.); (D.A.G.)
| | - Marina Yu. Yukina
- Endocrinology Research Centre, Ministry of Health of Russia, 117036 Moscow, Russia; (M.Y.Y.); (N.F.N.); (E.A.T.)
| | - Nurana F. Nuralieva
- Endocrinology Research Centre, Ministry of Health of Russia, 117036 Moscow, Russia; (M.Y.Y.); (N.F.N.); (E.A.T.)
| | - Marina A. Filippova
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (M.A.F.); (D.A.G.)
| | - Dmitry A. Gryadunov
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (M.A.F.); (D.A.G.)
| | - Ekaterina A. Troshina
- Endocrinology Research Centre, Ministry of Health of Russia, 117036 Moscow, Russia; (M.Y.Y.); (N.F.N.); (E.A.T.)
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19
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Szeliga A, Calik-Ksepka A, Maciejewska-Jeske M, Grymowicz M, Smolarczyk K, Kostrzak A, Smolarczyk R, Rudnicka E, Meczekalski B. Autoimmune Diseases in Patients with Premature Ovarian Insufficiency-Our Current State of Knowledge. Int J Mol Sci 2021; 22:ijms22052594. [PMID: 33807517 PMCID: PMC7961833 DOI: 10.3390/ijms22052594] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/21/2021] [Accepted: 03/02/2021] [Indexed: 12/20/2022] Open
Abstract
Premature ovarian insufficiency (POI), previously known as premature ovarian failure or premature menopause, is defined as loss of ovarian function before the age of 40 years. The risk of POI before the age of 40 is 1%. Clinical symptoms develop as a result of estrogen deficiency and may include amenorrhea, oligomenorrhea, vasomotor instability (hot flushes, night sweats), sleep disturbances, vulvovaginal atrophy, altered urinary frequency, dyspareunia, low libido, and lack of energy. Most causes of POI remain undefined, however, it is estimated that anywhere from 4-30% of cases are autoimmune in origin. As the ovaries are a common target for autoimmune attacks, an autoimmune etiology of POI should always be considered, especially in the presence of anti-oocyte antibodies (AOAs), autoimmune diseases, or lymphocytic oophoritis in biopsy. POI can occur in isolation, but is often associated with other autoimmune conditions. Concordant thyroid disorders such as hypothyroidism, Hashimoto thyroiditis, and Grave's disease are most commonly seen. Adrenal autoimmune disorders are the second most common disorders associated with POI. Among women with diabetes mellitus, POI develops in roughly 2.5%. Additionally, autoimmune-related POI can also present as part of autoimmune polyglandular syndrome (APS), a condition in which autoimmune activity causes specific endocrine organ damage. In its most common presentation (type-3), APS is associated with Hashomoto's type thyroid antibodies and has a prevalence of 10-40%. 21OH-Antibodies in Addison's disease (AD) can develop in association to APS-2.
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Affiliation(s)
- Anna Szeliga
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (A.S.); (M.M.-J.); (A.K.)
| | - Anna Calik-Ksepka
- Department of Gynaecological Endocrinology, Medical University of Warsaw, 00-315 Warsaw, Poland; (A.C.-K.); (M.G.); (R.S.)
| | - Marzena Maciejewska-Jeske
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (A.S.); (M.M.-J.); (A.K.)
| | - Monika Grymowicz
- Department of Gynaecological Endocrinology, Medical University of Warsaw, 00-315 Warsaw, Poland; (A.C.-K.); (M.G.); (R.S.)
| | - Katarzyna Smolarczyk
- Department of Dermatology and Venereology, Medical University of Warsaw, 00-315 Warsaw, Poland;
| | - Anna Kostrzak
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (A.S.); (M.M.-J.); (A.K.)
| | - Roman Smolarczyk
- Department of Gynaecological Endocrinology, Medical University of Warsaw, 00-315 Warsaw, Poland; (A.C.-K.); (M.G.); (R.S.)
| | - Ewa Rudnicka
- Department of Gynaecological Endocrinology, Medical University of Warsaw, 00-315 Warsaw, Poland; (A.C.-K.); (M.G.); (R.S.)
- Correspondence: (E.R.); (B.M.); Tel.: +48-22-59-66-470 (E.R.); +48-61-65-99-366 (B.M.); Fax: +48-61-65-99-454 (B.M.)
| | - Blazej Meczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, 60-535 Poznan, Poland; (A.S.); (M.M.-J.); (A.K.)
- Correspondence: (E.R.); (B.M.); Tel.: +48-22-59-66-470 (E.R.); +48-61-65-99-366 (B.M.); Fax: +48-61-65-99-454 (B.M.)
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20
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Abstract
Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) is a rare life-threatening autoimmune disease that attacks multiple organs and has its onset in childhood. It is an inherited condition caused by a variety of mutations in the autoimmune regulator (AIRE) gene that encodes a protein whose function has been uncovered by the generation and study of Aire-KO mice. These provided invaluable insights into the link between AIRE expression in medullary thymic epithelial cells (mTECs), and the broad spectrum of self-antigens that these cells express and present to the developing thymocytes. However, these murine models poorly recapitulate all phenotypic aspects of human APECED. Unlike Aire-KO mice, the recently generated Aire-KO rat model presents visual features, organ lymphocytic infiltrations and production of autoantibodies that resemble those observed in APECED patients, making the rat model a main research asset. In addition, ex vivo models of AIRE-dependent self-antigen expression in primary mTECs have been successfully set up. Thymus organoids based on pluripotent stem cell-derived TECs from APECED patients are also emerging, and constitute a promising tool to engineer AIRE-corrected mTECs and restore the generation of regulatory T cells. Eventually, these new models will undoubtedly lead to main advances in the identification and assessment of specific and efficient new therapeutic strategies aiming to restore immunological tolerance in APECED patients.
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Affiliation(s)
- Marine Besnard
- Université de Nantes, Inserm, CNRS, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France
| | - Francine Padonou
- Université de Nantes, Inserm, CNRS, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France
| | - Nathan Provin
- Université de Nantes, Inserm, CNRS, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France
| | - Matthieu Giraud
- Université de Nantes, Inserm, CNRS, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France
| | - Carole Guillonneau
- Université de Nantes, Inserm, CNRS, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, F-44000 Nantes, France
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21
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Abstract
Autoimmune-polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), a monogenic disorder caused by biallelic mutations in the AIRE gene, has historically been defined by the development of chronic mucocutaneous candidiasis together with autoimmune endocrinopathies, primarily hypoparathyroidism and adrenal insufficiency. Recent work has drawn attention to the development of life-threatening non-endocrine manifestations such as autoimmune pneumonitis, which has previously been poorly recognized and under-reported. In this review, we present the clinical, radiographic, autoantibody, and pulmonary function abnormalities associated with APECED pneumonitis, we highlight the cellular and molecular basis of the autoimmune attack in the AIRE-deficient lung, and we provide a diagnostic and a therapeutic roadmap for patients with APECED pneumonitis. Beyond APECED, we discuss the relevance and potential broader applicability of these findings to other interstitial lung diseases seen in secondary AIRE deficiency states such as thymoma and RAG deficiency or in common polygenic autoimmune disorders such as idiopathic Sjögren's syndrome.
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Affiliation(s)
| | - Michail S. Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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22
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Break TJ, Oikonomou V, Dutzan N, Desai JV, Swidergall M, Freiwald T, Chauss D, Harrison OJ, Alejo J, Williams DW, Pittaluga S, Lee CCR, Bouladoux N, Swamydas M, Hoffman KW, Greenwell-Wild T, Bruno VM, Rosen LB, Lwin W, Renteria A, Pontejo SM, Shannon JP, Myles IA, Olbrich P, Ferré EMN, Schmitt M, Martin D, Barber DL, Solis NV, Notarangelo LD, Serreze DV, Matsumoto M, Hickman HD, Murphy PM, Anderson MS, Lim JK, Holland SM, Filler SG, Afzali B, Belkaid Y, Moutsopoulos NM, Lionakis MS. Aberrant type 1 immunity drives susceptibility to mucosal fungal infections. Science 2021; 371:eaay5731. [PMID: 33446526 PMCID: PMC8326743 DOI: 10.1126/science.aay5731] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/05/2020] [Accepted: 11/13/2020] [Indexed: 12/13/2022]
Abstract
Human monogenic disorders have revealed the critical contribution of type 17 responses in mucosal fungal surveillance. We unexpectedly found that in certain settings, enhanced type 1 immunity rather than defective type 17 responses can promote mucosal fungal infection susceptibility. Notably, in mice and humans with AIRE deficiency, an autoimmune disease characterized by selective susceptibility to mucosal but not systemic fungal infection, mucosal type 17 responses are intact while type 1 responses are exacerbated. These responses promote aberrant interferon-γ (IFN-γ)- and signal transducer and activator of transcription 1 (STAT1)-dependent epithelial barrier defects as well as mucosal fungal infection susceptibility. Concordantly, genetic and pharmacologic inhibition of IFN-γ or Janus kinase (JAK)-STAT signaling ameliorates mucosal fungal disease. Thus, we identify aberrant T cell-dependent, type 1 mucosal inflammation as a critical tissue-specific pathogenic mechanism that promotes mucosal fungal infection susceptibility in mice and humans.
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Affiliation(s)
- Timothy J Break
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Vasileios Oikonomou
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Nicolas Dutzan
- Oral Immunity and Inflammation Section, National Institute of Dental and Craniofacial Research (NIDCR), Bethesda, MD, USA
| | - Jigar V Desai
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Marc Swidergall
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tilo Freiwald
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, USA
| | - Daniel Chauss
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, USA
| | - Oliver J Harrison
- Metaorganism Immunity Section, Laboratory of Immune System Biology, NIAID, Bethesda, MD, USA
| | - Julie Alejo
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute (NCI), Bethesda, MD, USA
| | - Drake W Williams
- Oral Immunity and Inflammation Section, National Institute of Dental and Craniofacial Research (NIDCR), Bethesda, MD, USA
| | - Stefania Pittaluga
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute (NCI), Bethesda, MD, USA
| | - Chyi-Chia R Lee
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute (NCI), Bethesda, MD, USA
| | - Nicolas Bouladoux
- Metaorganism Immunity Section, Laboratory of Immune System Biology, NIAID, Bethesda, MD, USA
| | - Muthulekha Swamydas
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Kevin W Hoffman
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Teresa Greenwell-Wild
- Oral Immunity and Inflammation Section, National Institute of Dental and Craniofacial Research (NIDCR), Bethesda, MD, USA
| | - Vincent M Bruno
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Wint Lwin
- Diabetes Center, University of California, San Francisco, CA, USA
| | - Andy Renteria
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Sergio M Pontejo
- Molecular Signaling Section, Laboratory of Molecular Immunology, NIAID, Bethesda, MD, USA
| | - John P Shannon
- Viral Immunity and Pathogenesis Unit, LCIM, NIAID, Bethesda, MD, USA
| | - Ian A Myles
- Epithelial Therapeutics Unit, LCIM, NIAID, Bethesda, MD, USA
| | - Peter Olbrich
- Immunopathogenesis Section, LCIM, NIAID, Bethesda, MD, USA
| | - Elise M N Ferré
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Monica Schmitt
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA
| | - Daniel Martin
- Genomics and Computational Biology Core, NIDCR, Bethesda, MD, USA
| | - Daniel L Barber
- T Lymphocyte Biology Section, Laboratory of Parasitic Diseases, NIAID, Bethesda, MD, USA
| | - Norma V Solis
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | | | - Mitsuru Matsumoto
- Division of Molecular Immunology, Institute for Enzyme Research, Tokushima University, Tokushima, Japan
| | - Heather D Hickman
- Viral Immunity and Pathogenesis Unit, LCIM, NIAID, Bethesda, MD, USA
| | - Philip M Murphy
- Molecular Signaling Section, Laboratory of Molecular Immunology, NIAID, Bethesda, MD, USA
| | - Mark S Anderson
- Diabetes Center, University of California, San Francisco, CA, USA
| | - Jean K Lim
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Scott G Filler
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Behdad Afzali
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, USA
| | - Yasmine Belkaid
- Metaorganism Immunity Section, Laboratory of Immune System Biology, NIAID, Bethesda, MD, USA
| | - Niki M Moutsopoulos
- Oral Immunity and Inflammation Section, National Institute of Dental and Craniofacial Research (NIDCR), Bethesda, MD, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD, USA.
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Saari V, Holopainen E, Mäkitie O, Laakso S. Pubertal development and premature ovarian insufficiency in patients with APECED. Eur J Endocrinol 2020; 183:513-520. [PMID: 33107435 DOI: 10.1530/eje-20-0516] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/13/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the natural course of pubertal development, growth during puberty, and development of POI in females with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), also called autoimmune polyendocrine syndrome type I. DESIGN Longitudinal follow-up study. METHODS A national cohort of females with APECED aged ≥12 years were followed during 1965-2018. Attainment of adult height was defined when patients' height increased less than 1 cm per year. Diagnosis of POI was based on delayed puberty or POI symptoms with amenorrhea, and/or FSH ≥40 IU/L. RESULTS Altogether 40 women with APECED were followed up to the average age of 37.3 (range: 14.6-61.9) years; 16 females (40%) were ≥ 40 years. Pubertal development started spontaneously in 34 patients and 29 had spontaneous menarche. POI developed in 28 patients (70%) at the median age of 16.0 years (range: 11.3-36.5), and in 20 of them (71%) before attaining adult height. In 11 cases puberty was induced or completed by hormonal therapy. Patients with POI were significantly shorter at menarche, but adult heights did not differ from non-POI females. Patients with POI had more often primary adrenocortical insufficiency (93% vs 58%, P = 0.017) and ovarian antibodies (81% vs 30%, P=0.003) compared to those with normal ovarian function (n = 12). CONCLUSIONS POI developed in the majority of patients with APECED, often before or shortly after menarche. Timely commencement of hormonal replacement therapy is important to ensure optimal pubertal development and growth. The possibility of fertility preservation before development of POI in APECED patients should be further studied.
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Affiliation(s)
- Viivi Saari
- Children's Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Elina Holopainen
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Outi Mäkitie
- Children's Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Saila Laakso
- Children's Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
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24
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Manso J, Censi S, Iacobone M, Galuppini F, Pennelli G, Betterle C, Mian C. First proof of association between autoimmune polyglandular syndrome and multiple endocrine neoplasia in humans. Endocr J 2020; 67:929-934. [PMID: 32475862 DOI: 10.1507/endocrj.ej20-0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Autoimmune Addison's disease (AAD) is a rare condition occurring either in isolation or associated with other autoimmune diseases as part of an autoimmune polyglandular syndrome (APS) type 1, 2 or 4. Multiple endocrine neoplasia (MEN) type 1, 2 or 4 is a hereditary autosomal dominant cancer syndrome. Medullary thyroid carcinoma and pheochromocytoma are neoplasms common to MEN-2a and MEN-2b. We describe a unique, complex case of a man resulted affected by both APS-2 and MEN-2a. The patient developed Hashimoto's thyroiditis, diabetes mellitus type 1 and AAD, despite testing negative for adrenal cortex autoantibodies (ACA) and steroid 21-hydroxylase autoantibodies (21-OHAb). Moreover, he had also a family history for MEN-2a and he first developed medullay thyroid cancer, then bilateral pheochromocytoma on the adrenal substrate of an AAD. On adrenal histology we found complete bilateral cortical atrophy in the presence of a lymphocytic infiltration and fibrosis, confirming an ACA and 21-OHAb-negative AAD. This datum is the first documented in a living individual and confirms that the absence of autoantibodies is not incompatible with an autoimmune disease and confirms that AAD is a cell-mediated autoimmune disease limited to the adrenal cortex and sparing medullary. In the light of a literature review concerning the association between APS and MEN, this is the first proven case to be reported in humans. Finally, our findings suggest that adrenal medullary tumor can develop even on an adrenal gland with cortical atrophy due to autoimmune adrenalitis.
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Affiliation(s)
- Jacopo Manso
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Simona Censi
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Maurizio Iacobone
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), Endocrine Surgery Unit, Padua University Hospital, Padua, Italy
| | - Francesca Galuppini
- Department of Medicine (DIMED), Surgical Pathology and Cytopathology Unit, Padua University, Padua, Italy
| | - Gianmaria Pennelli
- Department of Medicine (DIMED), Surgical Pathology and Cytopathology Unit, Padua University, Padua, Italy
| | - Corrado Betterle
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Caterina Mian
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
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Pham-Dobor G, Hanák L, Hegyi P, Márta K, Párniczky A, Gergics M, Sarlós P, Erőss B, Mezősi E. Prevalence of other autoimmune diseases in polyglandular autoimmune syndromes type II and III. J Endocrinol Invest 2020; 43:1-9. [PMID: 32227311 PMCID: PMC7431444 DOI: 10.1007/s40618-020-01229-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/17/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Polyglandular autoimmune syndromes (PAS) are complex, heterogeneous disorders in which various autoimmune diseases can occur, affecting both endocrine and non-endocrine organs. In this meta-analysis, the prevalence of associated autoimmune disorders was investigated in PAS II and III. METHODS A comprehensive search in MEDLINE and Embase databases identified 479 studies with the keywords of PAS II and PAS III. 18 records containing a total of 1312 patients fulfilled our inclusion criteria (original studies reporting at least 10 cases and containing the combination of other autoimmune disorders) and were selected for further analysis. A meta-analysis of prevalence was performed using the random-effects model with the calculation of 95% confidence intervals (CI). Results of each meta-analysis were displayed graphically using forest plots. RESULTS Distinction between PAS II and PAS III was made in 842 cases, of which 177 and 665 were PAS II and III (21.1 vs 78.9%), respectively. The prevalence of Hashimoto's thyroiditis was significantly higher than that of Graves's disease (39% [95% CI 17-65%] vs. 4% [95% CI 0-10%], respectively; p = 0.001). In PAS II, Addison's disease (AD) coexisted with AITDs, T1DM or the combination of these conditions in 65, 18 and 10% of cases, respectively. In addition, one other endocrine and five non-endocrine organ-specific autoimmune disorders were reported. In PAS III, two other autoimmune endocrinopathies, six non-endocrine organ-specific, and four systemic autoimmune disorders were found in combination with AITDs. CONCLUSIONS AITDs, T1DM and AD are the most common combinations in PAS, thus screening for these conditions seems to be reasonable.
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Affiliation(s)
- G Pham-Dobor
- First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság, Pecs, 7624, Hungary
- Szentágothai Research Centre, University of Pécs, Pecs, Hungary
| | - L Hanák
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - P Hegyi
- First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság, Pecs, 7624, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - K Márta
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - A Párniczky
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
- Heim Pál National Institute of Pediatrics, Budapest, Hungary
| | - M Gergics
- First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság, Pecs, 7624, Hungary
- Szentágothai Research Centre, University of Pécs, Pecs, Hungary
| | - P Sarlós
- First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság, Pecs, 7624, Hungary
| | - B Erőss
- First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság, Pecs, 7624, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pecs, Hungary
| | - E Mezősi
- First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság, Pecs, 7624, Hungary.
- Szentágothai Research Centre, University of Pécs, Pecs, Hungary.
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Inoue H, Yamada K, Fujii A, Tomonari T, Mizuno K, Mita K, Higuchi O, Akao M, Matsukawa N. A Patient with Fulminant Myasthenia Gravis Is Seropositive for Both AChR and LRP4 Antibodies, Complicated by Autoimmune Polyglandular Syndrome Type 3. Intern Med 2020; 59:2177-2181. [PMID: 32461531 PMCID: PMC7516320 DOI: 10.2169/internalmedicine.4708-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
This article describes the first reported case of myasthenia gravis (MG) seropositive for both acetylcholine receptor antibody and low-density lipoprotein receptor-related protein 4 antibody, complicated by autoimmune polyglandular syndrome (APS) type 3. The patient exhibited myasthenic weakness restricted to the ocular muscles and ptosis. Severe clinical deterioration ensued with predominant bulbar symptoms. MG rapidly worsened, the patient was intubated, and agranulocytosis due to thiamazole was also present, so it was necessary to perform thyroidectomy with tracheostomy and thymectomy in two phases. Both the double-seropositive MG and the APS were involved in the patient's rapid deterioration.
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Affiliation(s)
- Hiroyasu Inoue
- Department of Neurology, Nagoya City East Medical Center, Japan
- Department of Neurology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Kentaro Yamada
- Department of Neurology, Nagoya City East Medical Center, Japan
| | - Asami Fujii
- Department of Diabetes & Endocrinology, Nagoya City East Medical Center, Japan
| | - Tatsuya Tomonari
- Department of Nephrology, Nagoya City East Medical Center, Japan
| | - Kotaro Mizuno
- Department of Surgery, Nagoya City East Medical Center, Japan
| | - Keiko Mita
- Department of Surgery, Nagoya City East Medical Center, Japan
| | - Osamu Higuchi
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Japan
| | - Masaya Akao
- Department of Diabetes & Endocrinology, Nagoya City East Medical Center, Japan
| | - Noriyuki Matsukawa
- Department of Neurology, Nagoya City University Graduate School of Medical Sciences, Japan
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Ebert A, König J, Frommer L, Schuppan D, Kahaly GJ. Chromogranin Serves as Novel Biomarker of Endocrine and Gastric Autoimmunity. J Clin Endocrinol Metab 2020; 105:5841628. [PMID: 32436949 DOI: 10.1210/clinem/dgaa288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT The glycoprotein chromogranin A (CgA) is expressed by endocrine and neuroendocrine cells. High levels of serum CgA serve as markers of neuroendocrine tumors (NET), but its role in autoimmunity has not been assessed. OBJECTIVE To investigate CgA utility as a marker of endocrine autoimmunity. METHODS CgA serum levels were evaluated in 807 consecutive unselected participants (cross-sectional study) with the time-resolved amplified cryptate emission technology. RESULTS Serum CgA concentrations were increased in 66%, 39%, 38%, and 24% of patients with NET, type 1 diabetes (T1D), autoimmune gastritis (AG) and autoimmune polyendocrinopathy (AP), respectively. Compared with healthy participant controls (C), the odds of positive CgA measurement were up to 28 times higher in the disease groups. In detail, the odds ratios (ORs) for positive CgA levels were 27.98, 15.22, 7.32 (all P < 0.0001) and 3.89 (P = 0.0073) in patients with NET, T1D, AG, and AP, respectively. In AG, CgA and serum gastrin correlated positively (r = 0.55; P < 0.0001). The area under the receiver operating characteristic curve to predict AG was higher for parietal cell antibody (PCA) positivity than for CgA (0.84 vs 0.67; P < 0.0001). However, in combination with PCA and intrinsic factor autoantibodies, CgA independently improved prediction of AG (OR 6.5; P = 0.031). An impact of age on CgA positivity and on CgA value was detected (P < 0.0001) while current smoking significantly increased CgA serum levels by 25% (P = 0.0080). CONCLUSION CgA qualifies as a novel biomarker for T1D, AP, and AG.
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Affiliation(s)
- Antonia Ebert
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Lara Frommer
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Detlef Schuppan
- Institute for Translational Immunology and Research Center for Immunotherapy (FZI), Johannes Gutenberg University Medical Center, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
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Benitez AA, Khalil-Agüero S, Nandakumar A, Gupta NT, Zhang W, Atwal GS, Murphy AJ, Sleeman MA, Haxhinasto S. Absence of central tolerance in Aire-deficient mice synergizes with immune-checkpoint inhibition to enhance antitumor responses. Commun Biol 2020; 3:355. [PMID: 32641748 PMCID: PMC7343867 DOI: 10.1038/s42003-020-1083-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 06/19/2020] [Indexed: 02/06/2023] Open
Abstract
The endogenous anti-tumor responses are limited in part by the absence of tumor-reactive T cells, an inevitable consequence of thymic central tolerance mechanisms ensuring prevention of autoimmunity. Here we show that tumor rejection induced by immune checkpoint blockade is significantly enhanced in Aire-deficient mice, the epitome of central tolerance breakdown. The observed synergy in tumor rejection extended to different tumor models, was accompanied by increased numbers of activated T cells expressing high levels of Gzma, Gzmb, Perforin, Cxcr3, and increased intratumoural levels of Cxcl9 and Cxcl10 compared to wild-type mice. Consistent with Aire's central role in T cell repertoire selection, single cell TCR sequencing unveiled expansion of several clones with high tumor reactivity. The data suggest that breakdown in central tolerance synergizes with immune checkpoint blockade in enhancing anti-tumor immunity and may serve as a model to unmask novel anti-tumor therapies including anti-tumor TCRs, normally purged during central tolerance.
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Affiliation(s)
- Asiel A Benitez
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA
| | - Sara Khalil-Agüero
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA
| | - Anjali Nandakumar
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA
| | - Namita T Gupta
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA
| | - Wen Zhang
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA
| | - Gurinder S Atwal
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA
| | - Andrew J Murphy
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA
| | - Matthew A Sleeman
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA
| | - Sokol Haxhinasto
- Regeneron Pharmaceuticals, Inc. 777 Old Saw Mill River Road, Tarrytown, NY, 10591, USA.
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29
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Frommer L, Flesch BK, König J, Kahaly GJ. Amino Acid Polymorphisms in Hla Class II Differentiate Between Thyroid and Polyglandular Autoimmunity. J Clin Endocrinol Metab 2020; 105:5610951. [PMID: 31675055 DOI: 10.1210/clinem/dgz164] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/28/2019] [Indexed: 12/17/2022]
Abstract
CONTEXT The structure of the human leucocyte antigen (HLA) peptide-binding clefts strongly contributes to monoglandular and polyglandular autoimmunity (AP). OBJECTIVE To investigate the impact of amino acid polymorphisms on the peptide-binding interactions within HLA class II and its association with AP. DESIGN Immunogenetic study. SETTING Tertiary referral center for autoimmune endocrine diseases. SUBJECTS 587 subjects with AP, autoimmune thyroid disease (AITD), type 1 diabetes (T1D), and healthy unrelated controls were typed for HLA class II. METHODS Amino acids within the peptide binding cleft that are encoded by HLA class II exon 2 were listed for all codon positions in all subjects. Overall comparisons between disease and control groups with respect to allele distribution at a given locus were performed by assembling rare alleles applying an exact Freeman Halton contingency table test with Monte-Carlo P values based on 150 000 samples. RESULTS The Monte Carlo exact Fisher test demonstrated marked differences in all 3 loci, DQA1, DQB1, and DRB1 (P < .0001) between AP and both AITD and controls, as well as between AP type II (Addison's disease as a major endocrine component) and AP type III (T1D + AITD). Differences were also noted between AP and T1D pertaining to the DRB1 allele (P < .041). Seven amino acid positions, DRB1-13, DRB1-26, DRB1-71, DRB1-74, DQA1-47, DQA1-56, and DQB1-57, significantly contributed to AP. Five positions in DQA1 (11, 47, 50, 56, and 69) completely correlated (P < .0001). CONCLUSION Amino acid polymorphisms within HLA class II exon 2 mediate the AP risk and differentiate between thyroid and polyglandular autoimmunity.
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MESH Headings
- Amino Acids/genetics
- Biomarkers/analysis
- Case-Control Studies
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/immunology
- Diagnosis, Differential
- Female
- Follow-Up Studies
- Genetic Predisposition to Disease
- Histocompatibility Antigens Class II/genetics
- Humans
- Male
- Polyendocrinopathies, Autoimmune/diagnosis
- Polyendocrinopathies, Autoimmune/genetics
- Polyendocrinopathies, Autoimmune/immunology
- Polymorphism, Genetic
- Prognosis
- Thyroiditis, Autoimmune/diagnosis
- Thyroiditis, Autoimmune/genetics
- Thyroiditis, Autoimmune/immunology
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Affiliation(s)
- Lara Frommer
- Molecular Thyroid Research Laboratory, Department of medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Brigitte K Flesch
- German Red Cross Blood Service West, Laboratory of Immunogenetics/HLA, Bad Kreuznach and Hagen, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, JGU Medical Center, Mainz, Germany
| | - George J Kahaly
- Molecular Thyroid Research Laboratory, Department of medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
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Vazquez SE, Ferré EMN, Scheel DW, Sunshine S, Miao B, Mandel-Brehm C, Quandt Z, Chan AY, Cheng M, German M, Lionakis M, DeRisi JL, Anderson MS. Identification of novel, clinically correlated autoantigens in the monogenic autoimmune syndrome APS1 by proteome-wide PhIP-Seq. eLife 2020; 9:e55053. [PMID: 32410729 PMCID: PMC7228772 DOI: 10.7554/elife.55053] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/08/2020] [Indexed: 12/15/2022] Open
Abstract
The identification of autoantigens remains a critical challenge for understanding and treating autoimmune diseases. Autoimmune polyendocrine syndrome type 1 (APS1), a rare monogenic form of autoimmunity, presents as widespread autoimmunity with T and B cell responses to multiple organs. Importantly, autoantibody discovery in APS1 can illuminate fundamental disease pathogenesis, and many of the antigens found in APS1 extend to more common autoimmune diseases. Here, we performed proteome-wide programmable phage-display (PhIP-Seq) on sera from a cohort of people with APS1 and discovered multiple common antibody targets. These novel APS1 autoantigens exhibit tissue-restricted expression, including expression in enteroendocrine cells, pineal gland, and dental enamel. Using detailed clinical phenotyping, we find novel associations between autoantibodies and organ-restricted autoimmunity, including a link between anti-KHDC3L autoantibodies and premature ovarian insufficiency, and between anti-RFX6 autoantibodies and diarrheal-type intestinal dysfunction. Our study highlights the utility of PhIP-Seq for extensively interrogating antigenic repertoires in human autoimmunity and the importance of antigen discovery for improved understanding of disease mechanisms.
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Affiliation(s)
- Sara E Vazquez
- Medical Scientist Training Program, University of California, San FranciscoSan FranciscoUnited States
- Tetrad Graduate Program, University of California, San FranciscoSan FranciscoUnited States
- Diabetes Center, University of California, San FranciscoSan FranciscoUnited States
- Department of Biochemistry and Biophysics, University of California, San FranciscoSan FranciscoUnited States
| | - Elise MN Ferré
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of HealthBethesdaUnited States
| | - David W Scheel
- Diabetes Center, University of California, San FranciscoSan FranciscoUnited States
| | - Sara Sunshine
- Department of Biochemistry and Biophysics, University of California, San FranciscoSan FranciscoUnited States
- Biomedical Sciences Graduate Program, University of California, San FranciscoSan FranciscoUnited States
| | - Brenda Miao
- Diabetes Center, University of California, San FranciscoSan FranciscoUnited States
| | - Caleigh Mandel-Brehm
- Department of Biochemistry and Biophysics, University of California, San FranciscoSan FranciscoUnited States
| | - Zoe Quandt
- Department of Medicine, University of California, San FranciscoSan FranciscoUnited States
| | - Alice Y Chan
- Department of Pediatrics, University of California, San FranciscoSan FranciscoUnited States
| | - Mickie Cheng
- Diabetes Center, University of California, San FranciscoSan FranciscoUnited States
| | - Michael German
- Diabetes Center, University of California, San FranciscoSan FranciscoUnited States
- Department of Medicine, University of California, San FranciscoSan FranciscoUnited States
- Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San FranciscoSan FranciscoUnited States
| | - Michail Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy & Infectious Diseases, National Institutes of HealthBethesdaUnited States
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California, San FranciscoSan FranciscoUnited States
- Chan Zuckerberg BiohubSan FranciscoUnited States
| | - Mark S Anderson
- Diabetes Center, University of California, San FranciscoSan FranciscoUnited States
- Department of Medicine, University of California, San FranciscoSan FranciscoUnited States
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31
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Kaleviste E, Rühlemann M, Kärner J, Haljasmägi L, Tserel L, Org E, Trebušak Podkrajšek K, Battelino T, Bang C, Franke A, Peterson P, Kisand K. IL-22 Paucity in APECED Is Associated With Mucosal and Microbial Alterations in Oral Cavity. Front Immunol 2020; 11:838. [PMID: 32477345 PMCID: PMC7232598 DOI: 10.3389/fimmu.2020.00838] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/14/2020] [Indexed: 12/19/2022] Open
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is caused by recessive mutations in the AIRE gene. The hallmark of the disease is the production of highly neutralizing autoantibodies against type I interferons and IL-22. Considering the importance of IL-22 in maintaining mucosal barrier integrity and shaping its microbial community, we sought to study potential changes in the oral cavity in this model of human IL-22 paucity. We found that besides known Th22 cell deficiency, APECED patients have significantly fewer circulating MAIT cells with potential IL-22 secreting capacity. Saliva samples from APECED patients revealed local inflammation, the presence of autoantibodies against IFN-α and IL-22, and alterations in the oral microbiota. Moreover, gene expression data of buccal biopsy samples suggested impaired antimicrobial response and cell proliferation, both of which are processes regulated by IL-22. Our data complement the knowledge gained from mouse models and support the concept of IL-22 being a critical homeostatic cytokine in human mucosal sites.
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Affiliation(s)
- Epp Kaleviste
- Department of Biomedicine, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Malte Rühlemann
- Institute of Clinical Molecular Biology, University of Kiel, Kiel, Germany
| | - Jaanika Kärner
- Department of Biomedicine, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Liis Haljasmägi
- Department of Biomedicine, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Liina Tserel
- Department of Biomedicine, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Elin Org
- Estonian Genome Centre, University of Tartu, Tartu, Estonia
| | | | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Corinna Bang
- Institute of Clinical Molecular Biology, University of Kiel, Kiel, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, University of Kiel, Kiel, Germany
| | - Pärt Peterson
- Department of Biomedicine, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Kai Kisand
- Department of Biomedicine, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
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32
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Huoh YS, Wu B, Park S, Yang D, Bansal K, Greenwald E, Wong WP, Mathis D, Hur S. Dual functions of Aire CARD multimerization in the transcriptional regulation of T cell tolerance. Nat Commun 2020; 11:1625. [PMID: 32242017 PMCID: PMC7118133 DOI: 10.1038/s41467-020-15448-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 03/12/2020] [Indexed: 11/20/2022] Open
Abstract
Aggregate-like biomolecular assemblies are emerging as new conformational states with functionality. Aire, a transcription factor essential for central T cell tolerance, forms large aggregate-like assemblies visualized as nuclear foci. Here we demonstrate that Aire utilizes its caspase activation recruitment domain (CARD) to form filamentous homo-multimers in vitro, and this assembly mediates foci formation and transcriptional activity. However, CARD-mediated multimerization also makes Aire susceptible to interaction with promyelocytic leukemia protein (PML) bodies, sites of many nuclear processes including protein quality control of nuclear aggregates. Several loss-of-function Aire mutants, including those causing autoimmune polyendocrine syndrome type-1, form foci with increased PML body association. Directing Aire to PML bodies impairs the transcriptional activity of Aire, while dispersing PML bodies with a viral antagonist restores this activity. Our study thus reveals a new regulatory role of PML bodies in Aire function, and highlights the interplay between nuclear aggregate-like assemblies and PML-mediated protein quality control.
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Affiliation(s)
- Yu-San Huoh
- Department of Biological Chemistry and Molecular Pharmacology Blavatnik Institute at Harvard Medical School, Boston, MA, 02115, USA
- Program in Cellular and Molecular Medicine Boston Children's Hospital, Boston, MA, 02115, USA
| | - Bin Wu
- Department of Biological Chemistry and Molecular Pharmacology Blavatnik Institute at Harvard Medical School, Boston, MA, 02115, USA
- Program in Cellular and Molecular Medicine Boston Children's Hospital, Boston, MA, 02115, USA
- NTU Institute of Structural Biology, School of Biological Sciences, Nanyang Technological University, Singapore, 637551, Singapore
| | - Sehoon Park
- Program in Cellular and Molecular Medicine Boston Children's Hospital, Boston, MA, 02115, USA
| | - Darren Yang
- Department of Biological Chemistry and Molecular Pharmacology Blavatnik Institute at Harvard Medical School, Boston, MA, 02115, USA
- Program in Cellular and Molecular Medicine Boston Children's Hospital, Boston, MA, 02115, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, 02115, USA
| | - Kushagra Bansal
- Department of Immunology Blavatnik Institute at Harvard Medical School, Boston, MA, 02115, USA
- Molecular Biology & Genetics Unit, Jawaharlal Nehru Centre for Advanced Scientific Research, Bangalore, 560 064, India
| | - Emily Greenwald
- Program in Cellular and Molecular Medicine Boston Children's Hospital, Boston, MA, 02115, USA
| | - Wesley P Wong
- Department of Biological Chemistry and Molecular Pharmacology Blavatnik Institute at Harvard Medical School, Boston, MA, 02115, USA
- Program in Cellular and Molecular Medicine Boston Children's Hospital, Boston, MA, 02115, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, 02115, USA
| | - Diane Mathis
- Department of Immunology Blavatnik Institute at Harvard Medical School, Boston, MA, 02115, USA
| | - Sun Hur
- Department of Biological Chemistry and Molecular Pharmacology Blavatnik Institute at Harvard Medical School, Boston, MA, 02115, USA.
- Program in Cellular and Molecular Medicine Boston Children's Hospital, Boston, MA, 02115, USA.
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Lahner E, Conti L, Cicone F, Capriello S, Cazzato M, Centanni M, Annibale B, Virili C. Thyro-entero-gastric autoimmunity: Pathophysiology and implications for patient management. Best Pract Res Clin Endocrinol Metab 2020; 34:101373. [PMID: 31864909 DOI: 10.1016/j.beem.2019.101373] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The association between autoimmune atrophic gastritis and thyroid disorders has been observed since the early 1960s and the expression "thyrogastric syndrome" was coined to indicate the presence of thyroid autoantibodies or autoimmune thyroid disease in patients with pernicious anemia, a late clinical stage of autoimmune atrophic gastritis. More recently, it was confirmed that autoimmune thyroid disorders, in particular Hashimoto's thyroiditis, may be frequently associated with other organ-specific, immune-mediated disorders, such as autoimmune atrophic gastritis or celiac disease. The association of Hashimoto's thyroiditis with autoimmune atrophic gastritis or celiac disease in adult patients is currently considered part of the polyglandular autoimmune syndromes which include several autoimmune disorders associated with an autoaggressive impairment of endocrine glands. From a clinical point of view, the thyro-entero-gastric autoimmunity may lead to potentially serious consequences like anemia, micronutrients deficiencies, and drugs malabsorption, as well as to an increased risk for malignancies. These alterations may frequently present in an underhand manner, with consequent diagnostic and treatment delays. Many aspects of the association between thyroid, gastric and intestinal autoimmune diseases still await clarification. The present review focuses on the embryological, genetic and pathophysiological aspects of thyro-entero-gastric autoimmunity. In particular, the current diagnostic criteria of autoimmune thyroid disease, autoimmune atrophic gastritis, and celiac disease are reviewed, along with the evidences for their association in poly-autoimmunity syndromes. The benefits of proactive screening of autoimmune thyroid disorders in patients with autoimmune gastritis or enteropathy and viceversa are also discussed.
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Affiliation(s)
- Edith Lahner
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Laura Conti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Francesco Cicone
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Silvia Capriello
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
| | - Maria Cazzato
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Marco Centanni
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sant'Andrea Hospital, School of Medicine, Sapienza University of Rome, Via Grottarossa 1035, 00189, Rome, Italy
| | - Camilla Virili
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale Policlinico 155, 00161, Rome, Italy
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Flesch BK, König J, Frommer L, Hansen MP, Kahaly GJ. Sex Alters the MHC Class I HLA-A Association With Polyglandular Autoimmunity. J Clin Endocrinol Metab 2019; 104:1680-1686. [PMID: 30520966 DOI: 10.1210/jc.2018-01974] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/30/2018] [Indexed: 12/27/2022]
Abstract
CONTEXT The major histocompatibility complex (MHC) strongly contributes to the development of polyglandular autoimmunity (PGA). OBJECTIVE To evaluate the impact of sex on human leukocyte antigen (HLA) association with PGA for the first time. DESIGN Cross-sectional immunogenetic study. SETTING Academic tertiary referral Orphan Disease Center for PGA (ORPHA 282196) and immunogenetics laboratory. SUBJECTS Patients (158) with coexistent type 1 diabetes and autoimmune thyroid disease (adult type 3 PGA, ORPHA 227982) and 479 unrelated healthy controls. INTERVENTIONS All 637 white subjects were typed for HLA-A, -B, -DRB1, -DQA1, and -DQB1 alleles at a two-field level. MAIN OUTCOME MEASURES Modification of the gene-disease association by sex. RESULTS MHC class I HLA-A association was sex related to both the total white adult type 3 PGA collective (n = 158, P = 0.0065), as well as in PGA patients with autoimmune Hashimoto thyroiditis (n = 91, P = 0.010). Compared with HLA-A*02:01, A*11:01 was over-represented in male patients, yet under-represented in women (OR 1.49, 95% CI 0.55 to 3.88 vs 0.42, 0.12 to 1.17). A*24:02 was under-represented in male but not in female patients (OR 0.37, 95% CI 0.11 to 1.04 vs 1.19, 0.65 to 2.15). With the exclusion of the five most frequent alleles (A*01:01, A*02:01, A*03:01, A*11:01, and A*24:02), the sum of all other identified alleles was under-represented in male patients (OR 0.37, 0.18 to 0.72, P = 0.0046). The strong MHC HLA-B association with PGA (P < 0.0001) was not sex related (P = 0.55). Furthermore, no interaction with sex was observed for the MHC class II HLA-DRB1, -DQA1, and -DQB1 alleles. CONCLUSION MHC class I HLA-A association with type 3 PGA is significantly affected by sex.
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Affiliation(s)
- Brigitte K Flesch
- Laboratory of Immunogenetics/HLA, German Red Cross Blood Service West, Bad Kreuznach and Hagen, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Lara Frommer
- Molecular Thyroid Research Laboratory, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Martin P Hansen
- Molecular Thyroid Research Laboratory, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - George J Kahaly
- Molecular Thyroid Research Laboratory, Johannes Gutenberg University Medical Center, Mainz, Germany
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35
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Sng J, Ayoglu B, Chen JW, Schickel JN, Ferre EMN, Glauzy S, Romberg N, Hoenig M, Cunningham-Rundles C, Utz PJ, Lionakis MS, Meffre E. AIRE expression controls the peripheral selection of autoreactive B cells. Sci Immunol 2019; 4:eaav6778. [PMID: 30979797 PMCID: PMC7257641 DOI: 10.1126/sciimmunol.aav6778] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/04/2019] [Indexed: 12/13/2022]
Abstract
Autoimmune regulator (AIRE) mutations result in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) syndrome characterized by defective central T cell tolerance and the production of many autoantibodies targeting tissue-specific antigens and cytokines. By studying CD3- and AIRE-deficient patients, we found that lack of either T cells or AIRE function resulted in the peripheral accumulation of autoreactive mature naïve B cells. Proteomic arrays and Biacore affinity measurements revealed that unmutated antibodies expressed by these autoreactive naïve B cells recognized soluble molecules and cytokines including insulin, IL-17A, and IL-17F, which are AIRE-dependent thymic peripheral tissue antigens targeted by autoimmune responses in APECED. AIRE-deficient patients also displayed decreased frequencies of regulatory T cells (Tregs) that lacked common TCRβ clones found instead in their conventional T cell compartment, thereby suggesting holes in the Treg TCR repertoire of these patients. Hence, AIRE-mediated T cell/Treg selection normally prevents the expansion of autoreactive naïve B cells recognizing peripheral self-antigens.
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Affiliation(s)
- Joel Sng
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Burcu Ayoglu
- School of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, CA 94305, USA
| | - Jeff W Chen
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Jean-Nicolas Schickel
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Elise M N Ferre
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD USA
| | - Salomé Glauzy
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Neil Romberg
- Division of Immunology and Allergy, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Manfred Hoenig
- Department of Pediatrics, University Medical Centre Ulm, Ulm, Germany
| | - Charlotte Cunningham-Rundles
- Division of Allergy and Immunology, Department of Medicine, Icahn School of Medicine, Mount Sinai, New York, NY 10029, USA
| | - Paul J Utz
- School of Medicine, Division of Immunology and Rheumatology, Stanford University, Stanford, CA 94305, USA
- Institute for Immunity, Transplantation, and Infection (ITI), Stanford University, Stanford, CA 94305, USA
| | - Michail S Lionakis
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD USA
| | - Eric Meffre
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06511, USA.
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Ahmed Z, Imdad A, Connelly JA, Acra S. Autoimmune Enteropathy: An Updated Review with Special Focus on Stem Cell Transplant Therapy. Dig Dis Sci 2019; 64:643-654. [PMID: 30415406 PMCID: PMC8260026 DOI: 10.1007/s10620-018-5364-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/01/2018] [Indexed: 12/12/2022]
Abstract
Autoimmune enteropathy (AIE) is a complex disease affecting both children and adults. Although associated with significant morbidity and mortality, the pathophysiology of the disease and its treatment have not been well characterized. This study aims to review the medical literature available on this rare but clinically significant ailment, to help establish a better understanding of its pathophysiology and enumerate the available diagnostic and treatment modalities. A literature search was conducted on PubMed using key terms related to autoimmune enteropathy and intractable diarrhea, with no restrictions on the date of publication or language. We found a total of 98 reports of AIE published in the form of case reports and case series. The evidence reviewed suggests that AIE is a multifaceted disorder that requires a high index of suspicion in the appropriate clinical setting to be able to make an early diagnosis. Current evidence supports the use of supportive care to correct nutritional and metabolic deficiencies, and immunosuppressives and immunomodulators as directed therapies. Hematopoietic stem cell transplant is an aggressive, but successful curative modality for patients with AIE as part of immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome. Cumulative clinical experience with management of AIE has allowed improved outcomes in transplanted and non-transplanted AIE patients even though morbidity and mortality with are still high in patients with this condition. More research is needed to further define the role of new therapies for AIE, and a central registry with participation of multiple institutions might help share and standardize care of patients with this rare but serious condition.
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Affiliation(s)
- Zunirah Ahmed
- School of Medicine, University of Alabama, Montgomery Campus, 2055 E South Blvd Ste 202, Montgomery, AL, 36116, USA
| | - Aamer Imdad
- Division of Pediatric Gastroenterology, SUNY Upstate Medical University, 725 Irving Street, Suite 501, Syracuse, NY, 13210, USA
| | - James A Connelly
- Division of Pediatric Hematology-Oncology, Vanderbilt University Medical Center, 2100 Children's Way, Nashville, TN, 37212, USA
| | - Sari Acra
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 2100 Children's Way, Nashville, TN, 37212, USA.
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37
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Van Gool F, Nguyen MLT, Mumbach MR, Satpathy AT, Rosenthal WL, Giacometti S, Le DT, Liu W, Brusko TM, Anderson MS, Rudensky AY, Marson A, Chang HY, Bluestone JA. A Mutation in the Transcription Factor Foxp3 Drives T Helper 2 Effector Function in Regulatory T Cells. Immunity 2019; 50:362-377.e6. [PMID: 30709738 PMCID: PMC6476426 DOI: 10.1016/j.immuni.2018.12.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 10/25/2018] [Accepted: 12/14/2018] [Indexed: 12/30/2022]
Abstract
Regulatory T (Treg) cells maintain immune tolerance through the master transcription factor forkhead box P3 (FOXP3), which is crucial for Treg cell function and homeostasis. We identified an IPEX (immune dysregulation polyendocrinopathy enteropathy X-linked) syndrome patient with a FOXP3 mutation in the domain swap interface of the protein. Recapitulation of this Foxp3 variant in mice led to the development of an autoimmune syndrome consistent with an unrestrained T helper type 2 (Th2) immune response. Genomic analysis of Treg cells by RNA-sequencing, Foxp3 chromatin immunoprecipitation followed by high-throughput DNA sequencing (ChIP-sequencing), and H3K27ac-HiChIP revealed a specific de-repression of the Th2 transcriptional program leading to the generation of Th2-like Treg cells that were unable to suppress extrinsic Th2 cells. Th2-like Treg cells showed increased intra-chromosomal interactions in the Th2 locus, leading to type 2 cytokine production. These findings identify a direct role for Foxp3 in suppressing Th2-like Treg cells and implicate additional pathways that could be targeted to restrain Th2 trans-differentiated Treg cells.
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MESH Headings
- Animals
- Cell Differentiation/genetics
- Cell Differentiation/immunology
- Child
- Cytokines/genetics
- Cytokines/immunology
- Cytokines/metabolism
- Forkhead Transcription Factors/genetics
- Forkhead Transcription Factors/immunology
- Forkhead Transcription Factors/metabolism
- Gene Expression Regulation
- Genetic Diseases, X-Linked/genetics
- Genetic Diseases, X-Linked/immunology
- Genetic Diseases, X-Linked/metabolism
- Humans
- Male
- Mice, Inbred C57BL
- Mice, Knockout
- Mutation
- Polyendocrinopathies, Autoimmune/genetics
- Polyendocrinopathies, Autoimmune/immunology
- Polyendocrinopathies, Autoimmune/metabolism
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/metabolism
- Th2 Cells/immunology
- Th2 Cells/metabolism
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Affiliation(s)
- Frédéric Van Gool
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA; Sean N. Parker Autoimmune Research Laboratory, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Michelle L T Nguyen
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Maxwell R Mumbach
- Center for Personal Dynamic Regulomes, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ansuman T Satpathy
- Center for Personal Dynamic Regulomes, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Wendy L Rosenthal
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA; Sean N. Parker Autoimmune Research Laboratory, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Simone Giacometti
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Duy T Le
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA; Sean N. Parker Autoimmune Research Laboratory, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Weihong Liu
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA; Sean N. Parker Autoimmune Research Laboratory, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Todd M Brusko
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mark S Anderson
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Alexander Y Rudensky
- Howard Hughes Medical Institute, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Alexander Marson
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA; Department of Microbiology and Immunology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Howard Y Chang
- Center for Personal Dynamic Regulomes, Stanford University School of Medicine, Stanford, CA 94305, USA; Howard Hughes Medical Institute, Stanford University, Stanford, CA 94305, USA
| | - Jeffrey A Bluestone
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143, USA; Sean N. Parker Autoimmune Research Laboratory, University of California, San Francisco, San Francisco, CA 94143, USA.
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38
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Meloni A, Corda G, Saba L, Ferri GL, Mariotti S, Cocco C. Reduction of Total Brain and Cerebellum Volumes Associated With Neuronal Autoantibodies in Patients With APECED. J Clin Endocrinol Metab 2019; 104:150-162. [PMID: 30339230 DOI: 10.1210/jc.2018-01313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/15/2018] [Indexed: 01/16/2023]
Abstract
CONTEXT In autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), autoantibodies (AutoAbs) labeling brain neurons were reported; conversely, brain MRI alterations associated with these AutoAbs were never reported. OBJECTIVES To describe brain alterations in APECED and to correlate them with AutoAbs against glutamic acid decarboxylase (GAD), tyrosine hydroxylase (TH), and 5-tryptophan hydroxylase (5-HT) neurons. DESIGN AND PARTICIPANTS Fourteen Sardinian patients with APECED and age-matched control subjects were recruited for MRI analysis and blood sampling to detect AutoAbs to GAD, TH, and 5-HT neurons by using rat brain sections. The majority of patients (n = 12) were investigated for AutoAbs a decade earlier, and 7 of 12 were positive for AutoAbs to GAD and TH neurons. MAIN OUTCOMES Patients with APECED had smaller cerebellum and gray matter volumes, with a ventricular enlargement and a total cerebrospinal fluid (CSF) increase, compared with controls (P < 0.01). In 11 of 14 patients, brain abnormalities were associated with AutoAbs to GAD or TH neurons (titer 1:100 to 15,000) that had persisted for 10 years in 7 of 11 patients. AutoAbs to 5-HT neurons were revealed in all patients with AutoAbs to TH neurons. A decrease in whole brain and cerebellum volumes (P = 0.028) was associated with AutoAbs to GAD neurons, and a CSF increase was associated with AutoAbs to GAD and TH/5-HT neurons (P < 0.05). HLA alleles did not appear to be involved in neuronal autoimmunity. CONCLUSIONS Brain alterations and neuronal AutoAbs were observed in 78.6% of Sardinian patients with APECED, suggesting a brain autoimmune reaction. Prolonged clinical follow-up must be conducted for the possible appearance of clinical neurologic consequences.
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Affiliation(s)
- Antonella Meloni
- Clinica Pediatrica II, Ospedale Pediatrico Microcitemico Antonio Cao, Clinical and Molecular Medicine, University of Cagliari, Cagliari (CA), Italy
- Sardinian APECED Association, Baunei (OG), Italy
| | - Giulia Corda
- NEF Laboratory, Department of Biomedical Sciences, University of Cagliari, Monserrato (CA), Italy
| | - Luca Saba
- Department of Radiology, AOU, University of Cagliari, Monserrato (CA), Italy
| | - Gian-Luca Ferri
- NEF Laboratory, Department of Biomedical Sciences, University of Cagliari, Monserrato (CA), Italy
| | - Stefano Mariotti
- Endocrinology Department of Medical Sciences and Public Health, University of Cagliari, Monserrato (CA), Italy
| | - Cristina Cocco
- NEF Laboratory, Department of Biomedical Sciences, University of Cagliari, Monserrato (CA), Italy
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Habibullah M, Porter JA, Kluger N, Ranki A, Krohn KJE, Brandi ML, Brown EM, Weetman AP, Kemp EH. Calcium-Sensing Receptor Autoantibodies in Patients with Autoimmune Polyendocrine Syndrome Type 1: Epitopes, Specificity, Functional Affinity, IgG Subclass, and Effects on Receptor Activity. J Immunol 2018; 201:3175-3183. [PMID: 30381479 DOI: 10.4049/jimmunol.1701527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 09/27/2018] [Indexed: 11/19/2022]
Abstract
A major manifestation of autoimmune polyendocrine syndrome type 1 (APS1) is hypoparathyroidism, which is suggested to result from aberrant immune responses against the parathyroid glands. The calcium-sensing receptor (CaSR), which plays a pivotal role in maintaining calcium homeostasis by sensing blood calcium levels and regulating release of parathyroid hormone (PTH), is an autoantibody target in APS1. In this study, the aim was to characterize the binding sites, specificity, functional affinity, IgG subclass, and functional effects of CaSR autoantibodies using phage-display technology, ELISA, and bioassays. The results indicated that CaSR autoantibody binding sites were at aa 41-69, 114-126, 171-195, and 260-340 in the extracellular domain of the receptor. Autoantibodies against CaSR epitopes 41-69, 171-195, and 260-340 were exclusively of the IgG1 subclass. Autoantibody responses against CaSR epitope 114-126 were predominantly of the IgG1 with a minority of the IgG3 subclass. Only autoantibodies recognizing CaSR epitopes 114-126 and 171-195 affected receptor activity; inositol-phosphate accumulation was increased significantly in HEK293-CaSR cells, and PTH secretion from PTH-C1 cells was reduced significantly when either were incubated with purified Ab and Ca2+ compared with Ca2+ alone. In conclusion, although the majority of APS1 patients do not have CaSR-stimulating autoantibodies, the hypoparathyroid state in a small minority of patients is the result of functional suppression of the parathyroid glands.
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Affiliation(s)
- Mahmoud Habibullah
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2RX, United Kingdom
| | - Julie A Porter
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2RX, United Kingdom
| | - Nicolas Kluger
- Department of Dermatology, Allergology and Venereology, Institute of Clinical Medicine, University of Helsinki and Helsinki University Central Hospital, 00250 Helsinki, Finland
| | - Annamari Ranki
- Department of Dermatology, Allergology and Venereology, Institute of Clinical Medicine, University of Helsinki and Helsinki University Central Hospital, 00250 Helsinki, Finland
| | - Kai J E Krohn
- Clinical Research Institute HUCH Ltd., 00250 Helsinki, Finland
| | - Maria L Brandi
- Department of Surgery and Translational Medicine, University of Florence, 50139 Florence, Italy; and
| | - Edward M Brown
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Boston, MA 02115
| | - Anthony P Weetman
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2RX, United Kingdom
| | - E Helen Kemp
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2RX, United Kingdom;
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40
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Weiler FG, Peterson P, Costa-Carvalho BT, de Barros Dorna M, Correia-Deur JE, Sader SL, Espíndola-Antunes D, Guerra-Junior G, Dias-da-Silva MR, Lazaretti-Castro M. The heterogeneity of autoimmune polyendocrine syndrome type 1: Clinical features, new mutations and cytokine autoantibodies in a Brazilian cohort from tertiary care centers. Clin Immunol 2018; 197:231-238. [PMID: 30287219 DOI: 10.1016/j.clim.2018.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/16/2018] [Accepted: 09/26/2018] [Indexed: 12/31/2022]
Abstract
Autoimmune polyendocrine syndrome type 1 (APS1) is characterized by multiorgan autoimmunity. We aim at characterizing a multi-center Brazilian cohort of APS1 patients by clinical evaluation, searching mutation in the AIRE gene, measuring serum autoantibodies, and investigating correlations between findings. We recruited patients based on the clinical criteria and tested them for AIRE mutations, antibodies against interferon type I and interleukins 17A, 17F and 22. We identified 12 unrelated families (13 patients) with typical signs of APS1 in the proband, and the screening of relatives recognized an asymptomatic child. Candidiasis was present in all cases, and 19 other manifestations were observed. All patients carried one of 10 different mutations in AIRE, being 3 new ones, and were positive for anti-interferon type I serum antibody. Anti-interleukin-17A levels inversely correlated with the number of manifestations in each patient. This negative correlation may suggest a protective effect of anti-interleukin-17A with a potential therapeutic application.
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Affiliation(s)
- Fernanda Guimarães Weiler
- Division of Endocrinology, Department of Medicine, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Pärt Peterson
- Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | | | - Mayra de Barros Dorna
- Allergy and immunology unit, Department of Pediatrics, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | | | - Soraya Lopes Sader
- Department of Pediatrics, Ribeirao Preto Medical School, Universidade de Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | | | - Gil Guerra-Junior
- Department of Pediatrics, Universidade Estadual de Campinas, Campinas, Sao Paulo, Brazil
| | - Magnus Régios Dias-da-Silva
- Division of Endocrinology, Department of Medicine, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil.
| | - Marise Lazaretti-Castro
- Division of Endocrinology, Department of Medicine, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
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41
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Humbert L, Cornu M, Proust-Lemoine E, Bayry J, Wemeau JL, Vantyghem MC, Sendid B. Chronic Mucocutaneous Candidiasis in Autoimmune Polyendocrine Syndrome Type 1. Front Immunol 2018; 9:2570. [PMID: 30510552 PMCID: PMC6254185 DOI: 10.3389/fimmu.2018.02570] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/18/2018] [Indexed: 11/13/2022] Open
Abstract
Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) is an autosomal recessive disease caused by mutations in the autoimmune regulator (AIRE) gene, characterized by the clinical triad of chronic mucocutaneous candidiasis (CMC), hypoparathyroidism, and adrenal insufficiency. CMC can be complicated by systemic candidiasis or oral squamous cell carcinoma (SCC), and may lead to death. The role of chronic Candida infection in the etiopathogenesis of oral SCC is unclear. Long-term use of fluconazole has led to the emergence of Candida albicans strains with decreased susceptibility to azoles. CMC is associated with an impaired Th17 cell response; however, it remains unclear whether decreased serum IL-17 and IL-22 levels are related to a defect in cytokine production or to neutralizing autoantibodies resulting from mutations in the AIRE gene.
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Affiliation(s)
- Linda Humbert
- Department of Endocrinology and Metabolism, CHU Lille, Lille, France
| | - Marjorie Cornu
- Department Parasitology-Mycology, CHU, Lille, France
- Inserm, U995-LIRIC, Fungal Associated Invasive & Inflammatory Diseases, Lille, France
| | | | - Jagadeesh Bayry
- Inserm, Center de Recherche des Cordeliers, Sorbonne Université, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jean-Louis Wemeau
- Department of Endocrinology and Metabolism, CHU Lille, Lille, France
| | - Marie-Christine Vantyghem
- Department of Endocrinology and Metabolism, CHU Lille, Lille, France
- UMR 1190, Translational Research in Diabetes Inserm, Lille, France
- European Genomic Institute for Diabetes, Univ Lille, Lille, France
| | - Boualem Sendid
- Department Parasitology-Mycology, CHU, Lille, France
- Inserm, U995-LIRIC, Fungal Associated Invasive & Inflammatory Diseases, Lille, France
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42
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Zhao B, Chang L, Fu H, Sun G, Yang W. The Role of Autoimmune Regulator (AIRE) in Peripheral Tolerance. J Immunol Res 2018; 2018:3930750. [PMID: 30255105 PMCID: PMC6142728 DOI: 10.1155/2018/3930750] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 07/02/2018] [Accepted: 08/11/2018] [Indexed: 02/07/2023] Open
Abstract
Autoimmune regulator (AIRE), whose gene mutation is considered to be a causative factor of autoimmune polyglandular syndrome type 1 (APS1), is an important transcriptional regulator. Studies on the role of AIRE in the central immune system have demonstrated that AIRE can eliminate autoreactive T cells by regulating the expression of a series of tissue specific antigens promiscuously in medullary thymic epithelial cells (mTECs) and induce regulatory T cell (Treg) production to maintain central immune tolerance. However, the related research of AIRE in peripheral tolerance is few. In order to understand the current research progress on AIRE in peripheral tolerance, this review mainly focuses on the expression and distribution of AIRE in peripheral tissues and organs, and the role of AIRE in peripheral immune tolerance such as regulating Toll-like receptor (TLR) expression and the maturation status of antigen presenting cells (APCs), inducing T cell tolerance and differentiation. This review will show us that AIRE also plays an indispensable role in the periphery.
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Affiliation(s)
- Bingjie Zhao
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
| | - Lu Chang
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
| | - Haiying Fu
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
| | - Guangyu Sun
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
| | - Wei Yang
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
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43
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Frunza-Stefan S, Whitlatch HB, Rao GG, Malek R. Unusual case of anti-N-methyl-D-aspartic acid-receptor (NMDA-R) encephalitis and autoimmune polyglandular syndrome (APS). BMJ Case Rep 2018; 2018:bcr-2018-224821. [PMID: 29724875 PMCID: PMC5935153 DOI: 10.1136/bcr-2018-224821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 01/06/2023] Open
Abstract
Anti-N-methyl-D-aspartic acid-receptor (NMDA-R) encephalitis is a novel disease discovered within the past 10 years. It is an autoimmune disease (AD) that has been associated with other ADs, such as Graves' disease. However, association with autoimmune polyglandular syndromes (APS) has not been previously described. A 58-year-old woman presented with altered mental status and an 8-month history of weight loss, apathy and somnolence. Laboratory evaluation confirmed Graves' disease with thyrotoxicosis and type 1 diabetes mellitus. Despite treatment, she continued to have a fluctuating mental status. Further diagnostic evaluation included an abdominal MRI that showed a cystic lobular left adnexal mass. Serum anti-NMDA-R antibodies were positive, raising concern for NMDA-R encephalitis. Bilateral salpingo-oophorectomy was performed, with pathology consistent with cystadenofibroma. She had a favourable recovery with marked clinical improvement. Anti-NMDA-R antibodies were negative 2 months following surgery. The concomitant occurrence of APS and anti-NMDA-R encephalitis suggests a shared mechanism of autoimmune pathophysiology.
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Affiliation(s)
- Simona Frunza-Stefan
- Department of Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Hilary B Whitlatch
- Department of Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Gautam G Rao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Rana Malek
- Department of Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
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Abstract
Primary antibody deficiency syndromes are a rare group of disorders present at any age, with complex polygenic disorders. We report the forth case of polyglandular autoimmune syndrome (PAS) type IIIc worldwide with complex clinical features and no family history of endocrine disorders or primary immunodeficiencies. Our patient, a 44-year-old Caucasian female was diagnosed with PAS type IIIc due to the presence of autoimmune thyroiditis, autoimmune alopecia diffusa and primary ovarian insufficiency, associated with lymphoproliferative disease and primary antibody failure. Treatment included lifelong intravenous immunoglobulin, supplements and antibiotics. The clinical complexity and rare occurrence made it challenging to determine diagnosis and provide better treatment for the patient. The current case provides an insight of the challenges to determine primary antibody failure signs in the presence of PAS which will further help to determine diagnosis and therapeutic treatment for PAS patients.
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Affiliation(s)
- Adina Elena Stanciu
- a Department of Carcinogenesis and Molecular Biology , Institute of Oncology Bucharest , Bucharest , Romania
| | - Florentina Sava
- b First Department of Obstetrics and Gynecology , Semmelweis University , Budapest , Hungary
| | - Gergely Toldi
- b First Department of Obstetrics and Gynecology , Semmelweis University , Budapest , Hungary
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45
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MESH Headings
- Diabetes Mellitus, Type 1/congenital
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/immunology
- Diabetes Mellitus, Type 1/therapy
- Diarrhea/genetics
- Diarrhea/immunology
- Diarrhea/therapy
- Genetic Diseases, X-Linked/genetics
- Genetic Diseases, X-Linked/immunology
- Genetic Diseases, X-Linked/therapy
- Humans
- Immune System Diseases/congenital
- Immune System Diseases/genetics
- Immune System Diseases/immunology
- Immune System Diseases/therapy
- Polyendocrinopathies, Autoimmune/genetics
- Polyendocrinopathies, Autoimmune/immunology
- Polyendocrinopathies, Autoimmune/therapy
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Affiliation(s)
- Eystein S Husebye
- From the Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen (E.S.H., O.K.), and the Department of Medicine, Haukeland University Hospital (E.S.H.), Bergen, Norway; the Department of Medicine (Solna), Karolinska Institutet, Stockholm (E.S.H., O.K.); and the Diabetes Center and the Department of Medicine, University of California, San Francisco, San Francisco (M.S.A.)
| | - Mark S Anderson
- From the Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen (E.S.H., O.K.), and the Department of Medicine, Haukeland University Hospital (E.S.H.), Bergen, Norway; the Department of Medicine (Solna), Karolinska Institutet, Stockholm (E.S.H., O.K.); and the Diabetes Center and the Department of Medicine, University of California, San Francisco, San Francisco (M.S.A.)
| | - Olle Kämpe
- From the Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen (E.S.H., O.K.), and the Department of Medicine, Haukeland University Hospital (E.S.H.), Bergen, Norway; the Department of Medicine (Solna), Karolinska Institutet, Stockholm (E.S.H., O.K.); and the Diabetes Center and the Department of Medicine, University of California, San Francisco, San Francisco (M.S.A.)
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46
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de Albuquerque JAT, Banerjee PP, Castoldi A, Ma R, Zurro NB, Ynoue LH, Arslanian C, Barbosa-Carvalho MUW, Correia-Deur JEDM, Weiler FG, Dias-da-Silva MR, Lazaretti-Castro M, Pedroza LA, Câmara NOS, Mace E, Orange JS, Condino-Neto A. The Role of AIRE in the Immunity Against Candida Albicans in a Model of Human Macrophages. Front Immunol 2018; 9:567. [PMID: 29666621 PMCID: PMC5875531 DOI: 10.3389/fimmu.2018.00567] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 03/06/2018] [Indexed: 01/08/2023] Open
Abstract
Autoimmune-polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a primary immunodeficiency caused by mutations in the autoimmune regulator gene (AIRE). Patients with AIRE mutations are susceptible to Candida albicans infection and present with autoimmune disorders. We previously demonstrated that cytoplasmic AIRE regulates the Syk-dependent Dectin-1 pathway. In this study, we further evaluated direct contact with fungal elements, synapse formation, and the response of macrophage-like THP-1 cells to C. albicans hyphae to determine the role of AIRE upon Dectin receptors function and signaling. We examined the fungal synapse (FS) formation in wild-type and AIRE-knockdown THP-1 cells differentiated to macrophages, as well as monocyte-derived macrophages from APECED patients. We evaluated Dectin-2 receptor signaling, phagocytosis, and cytokine secretion upon hyphal stimulation. AIRE co-localized with Dectin-2 and Syk at the FS upon hyphal stimulation of macrophage-like THP-1 cells. AIRE-knockdown macrophage-like THP-1 cells exhibited less Dectin-1 and Dectin-2 receptors accumulation, decreased signaling pathway activity at the FS, lower C. albicans phagocytosis, and less lysosome formation. Furthermore, IL-1β, IL-6, or TNF-α secretion by AIRE-knockdown macrophage-like THP-1 cells and AIRE-deficient patient macrophages was decreased compared to control cells. Our results suggest that AIRE modulates the FS formation and hyphal recognition and help to orchestrate an effective immune response against C. albicans.
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Affiliation(s)
| | - Pinaki Prosad Banerjee
- Center for Human Immunobiology, Texas Children’s Hospital, Houston, TX, United States
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Angela Castoldi
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Royce Ma
- Center for Human Immunobiology, Texas Children’s Hospital, Houston, TX, United States
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Nuria Bengala Zurro
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Leandro Hideki Ynoue
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Christina Arslanian
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | | | - Luis Alberto Pedroza
- Colegio de Ciencias de la Salud, Escuela de Medicina, Hospital de los Valles, Universidad San Francisco de Quito, Quito, Ecuador
| | | | - Emily Mace
- Center for Human Immunobiology, Texas Children’s Hospital, Houston, TX, United States
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Jordan Scott Orange
- Center for Human Immunobiology, Texas Children’s Hospital, Houston, TX, United States
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Antonio Condino-Neto
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
- Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
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Bichele R, Kärner J, Truusalu K, Smidt I, Mändar R, Conti HR, Gaffen SL, Peterson P, Laan M, Kisand K. IL-22 neutralizing autoantibodies impair fungal clearance in murine oropharyngeal candidiasis model. Eur J Immunol 2018; 48:464-470. [PMID: 29150834 PMCID: PMC5844855 DOI: 10.1002/eji.201747209] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/31/2017] [Accepted: 11/14/2017] [Indexed: 12/30/2022]
Abstract
Protection against mucocutaneous candidiasis depends on the T helper (Th)17 pathway, as gene defects affecting its integrity result in inability to clear Candida albicans infection on body surfaces. Moreover, autoantibodies neutralizing Th17 cytokines have been related to chronic candidiasis in a rare inherited disorder called autoimmune polyendocriopathy candidiasis ectodermal dystrophy (APECED) caused by mutations in autoimmune regulator (AIRE) gene. However, the direct pathogenicity of these autoantibodies has not yet been addressed. Here we show that the level of anti-IL17A autoantibodies that develop in aged Aire-deficient mice is not sufficient for conferring susceptibility to oropharyngeal candidiasis. However, patient-derived monoclonal antibodies that cross-react with murine IL-22 increase the fungal burden on C. albicans infected mucosa. Nevertheless, the lack of macroscopically evident infectious pathology on the oral mucosa of infected mice suggests that additional susceptibility factors are needed to precipitate a clinical disease.
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MESH Headings
- Animals
- Antibodies, Neutralizing/immunology
- Autoantibodies/immunology
- Candida albicans/immunology
- Candidiasis, Chronic Mucocutaneous/immunology
- Candidiasis, Chronic Mucocutaneous/microbiology
- Candidiasis, Oral/immunology
- Candidiasis, Oral/microbiology
- Colony Count, Microbial
- Cross Reactions
- Disease Models, Animal
- Disease Susceptibility
- Female
- Humans
- Interleukin-17/immunology
- Interleukins/immunology
- Male
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Mice, Knockout
- Polyendocrinopathies, Autoimmune/immunology
- Th17 Cells/immunology
- Transcription Factors/deficiency
- Transcription Factors/genetics
- Transcription Factors/immunology
- AIRE Protein
- Interleukin-22
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Affiliation(s)
- Rudolf Bichele
- Department of Molecular Pathology, Institute of Biomedical and Translational Medicine, University of Tartu, Estonia
| | - Jaanika Kärner
- Department of Molecular Pathology, Institute of Biomedical and Translational Medicine, University of Tartu, Estonia
| | - Kai Truusalu
- Department of Microbiology, Institute of Biomedical and Translational Medicine, University of Tartu, Estonia
| | - Imbi Smidt
- Department of Microbiology, Institute of Biomedical and Translational Medicine, University of Tartu, Estonia
| | - Reet Mändar
- Department of Microbiology, Institute of Biomedical and Translational Medicine, University of Tartu, Estonia
| | - Heather R. Conti
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania
- University of Toledo, Toledo, Ohio
| | - Sarah L. Gaffen
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pärt Peterson
- Department of Molecular Pathology, Institute of Biomedical and Translational Medicine, University of Tartu, Estonia
| | - Martti Laan
- Department of Molecular Pathology, Institute of Biomedical and Translational Medicine, University of Tartu, Estonia
| | - Kai Kisand
- Department of Molecular Pathology, Institute of Biomedical and Translational Medicine, University of Tartu, Estonia
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48
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Dobeš J, Edenhofer F, Vobořil M, Brabec T, Dobešová M, Čepková A, Klein L, Rajewsky K, Filipp D. A novel conditional Aire allele enables cell-specific ablation of the immune tolerance regulator Aire. Eur J Immunol 2018; 48:546-548. [PMID: 29193031 DOI: 10.1002/eji.201747267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 11/05/2017] [Accepted: 11/23/2017] [Indexed: 11/12/2022]
Abstract
Medullary thymic epithelial cell (mTEC)-restricted expression of autoimmune regulator (Aire) is essential for establishment of immune tolerance. Recently, Aire was also shown to be expressed in cells of hematopietic and reproductive lineages. Thus, the generation of Airefl/fl mouse strain enables the investigation of the cell-specific function of Aire.
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Affiliation(s)
- Jan Dobeš
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Frank Edenhofer
- Institute of Genetics, University of Cologne, Cologne, Germany
| | - Matouš Vobořil
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
- Department of Cell biology, Faculty of Science, Charles University in Prague, Prague, Czech Republic
| | - Tomáš Brabec
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Martina Dobešová
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Adéla Čepková
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
| | - Ludger Klein
- Laboratory of Thymusfuction, Institute for Immunology, Ludwig-Maxmilians-Universität München, Munich, Germany
| | - Klaus Rajewsky
- Institute of Genetics, University of Cologne, Cologne, Germany
| | - Dominik Filipp
- Laboratory of Immunobiology, Institute of Molecular Genetics of the Czech Academy of Sciences, Prague, Czech Republic
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49
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Bottazzo GF, Florin-Christensen A, Doniach D. Pillars Article: Islet-cell Antibodies in Diabetes Mellitus with Autoimmune Polyendocrine Deficiencies. Lancet. 1974. 304: 1279-1283. J Immunol 2018; 199:3014-3018. [PMID: 29061712 DOI: 10.4049/jimmunol.1701303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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50
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Abstract
About two decades ago, cloning of the autoimmune regulator (AIRE) gene materialized one of the most important actors on the scene of self-tolerance. Thymic transcription of genes encoding tissue-specific antigens (ts-ags) is activated by AIRE protein and embodies the essence of thymic self-representation. Pathogenic AIRE variants cause the autoimmune polyglandular syndrome type 1, which is a rare and complex disease that is gaining attention in research on autoimmunity. The animal models of disease, although not identically reproducing the human picture, supply fundamental information on mechanisms and extent of AIRE action: thanks to its multidomain structure, AIRE localizes to chromatin enclosing the target genes, binds to histones, and offers an anchorage to multimolecular complexes involved in initiation and post-initiation events of gene transcription. In addition, AIRE enhances mRNA diversity by favoring alternative mRNA splicing. Once synthesized, ts-ags are presented to, and cause deletion of the self-reactive thymocyte clones. However, AIRE function is not restricted to the activation of gene transcription. AIRE would control presentation and transfer of self-antigens for thymic cellular interplay: such mechanism is aimed at increasing the likelihood of engagement of the thymocytes that carry the corresponding T-cell receptors. Another fundamental role of AIRE in promoting self-tolerance is related to the development of thymocyte anergy, as thymic self-representation shapes at the same time the repertoire of regulatory T cells. Finally, AIRE seems to replicate its action in the secondary lymphoid organs, albeit the cell lineage detaining such property has not been fully characterized. Delineation of AIRE functions adds interesting data to the knowledge of the mechanisms of self-tolerance and introduces exciting perspectives of therapeutic interventions against the related diseases.
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Affiliation(s)
- Roberto Perniola
- Department of Pediatrics, Neonatal Intensive Care, Vito Fazzi Regional Hospital, Lecce, Italy
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