Cytokine storm in aged people with CoV-2: possible role of vitamins as therapy or preventive strategy

BACKGROUND

In December 2019, a novel human-infecting coronavirus, SARS-CoV-2, had emerged. The WHO has classified the epidemic as a "public health emergency of international concern". A dramatic situation has unfolded with thousands of deaths, occurring mainly in the aged and very ill people. Epidemiological studies suggest that immune system function is impaired in elderly individuals and these subjects often present a deficiency in fat-soluble and hydrosoluble vitamins.

METHODS

We searched for reviews describing the characteristics of autoimmune diseases and the available therapeutic protocols for their treatment. We set them as a paradigm with the purpose to uncover common pathogenetic mechanisms between these pathological conditions and SARS-CoV-2 infection. Furthermore, we searched for studies describing the possible efficacy of vitamins A, D, E, and C in improving the immune system function.

RESULTS

SARS-CoV-2 infection induces strong immune system dysfunction characterized by the development of an intense proinflammatory response in the host, and the development of a life-threatening condition defined as cytokine release syndrome (CRS). This leads to acute respiratory syndrome (ARDS), mainly in aged people. High mortality and lethality rates have been observed in elderly subjects with CoV-2-related infection.

CONCLUSIONS

Vitamins may shift the proinflammatory Th17-mediated immune response arising in autoimmune diseases towards a T-cell regulatory phenotype. This review discusses the possible activity of vitamins A, D, E, and C in restoring normal antiviral immune system function and the potential therapeutic role of these micronutrients as part of a therapeutic strategy against SARS-CoV-2 infection.

Nuclear Receptors, Ligands and the Mammalian B Cell

Questions concerning the influences of nuclear receptors and their ligands on mammalian B cells are vast in number. Here, we briefly review the effects of nuclear receptor ligands, including estrogen and vitamins, on immunoglobulin production and protection from infectious diseases. We describe nuclear receptor interactions with the B cell genome and the potential mechanisms of gene regulation. Attention to the nuclear receptor/ligand regulation of B cell function may help optimize B cell responses, improve pathogen clearance, and prevent damaging responses toward inert- and self-antigens.

Infant cortisol stress-response is associated with thymic function and vaccine response

Stress can impair T cell-mediated immunity. To determine if infants with high stress responses had deficits in T-cell mediated immunity, we examined the association of pain-induced cortisol responsiveness with thymic function and vaccine responses in infants. This study was performed among 306 (male = 153 and female = 153) participants of a randomized, controlled trial examining the effect of neonatal vitamin A supplementation on immune function in Bangladesh (NCT01583972). Salivary cortisol was measured before and 20 min after a needle stick (vaccination) at 6 weeks of age. The thymic index (TI) was determined by ultrasonography at 1, 6, 10 and 15 weeks. T-cell receptor excision circle and blood T-cell concentrations were measured at 6 and 15 weeks. Responses to Bacillus Calmette-Guérin (BCG), tetanus toxoid, hepatitis B virus and oral poliovirus vaccination were assayed at 6 and 15 weeks. Cortisol responsiveness was negatively associated with TI at all ages (p < .01) in boys only, was negatively associated with naïve helper T-cell concentrations in both sexes at both 6 (p = .0035) and 15 weeks (p = .0083), and was negatively associated with the delayed-type hypersensitivity (DTH) skin test response to BCG vaccination at 15 weeks (p = .034) in both sexes. Infants with a higher cortisol response to pain have differences in the T-cell compartment and a lower DTH response to vaccination. Sex differences in the immune system were seen as early as 6 weeks of age in these healthy infants.

Modulation of Intestinal Immune and Barrier Functions by Vitamin A: Implications for Current Understanding of Malnutrition and Enteric Infections in Children

The micronutrient vitamin A refers to a group of compounds with pleiotropic effects on human health. These molecules can modulate biological functions, including development, vision, and regulation of the intestinal barrier. The consequences of vitamin A deficiency and supplementation in children from developing countries have been explored for several years. These children live in an environment that is highly contaminated by enteropathogens, which can, in turn, influence vitamin A status. Vitamin A has been described to modulate gene expression, differentiation and function of diverse immune cells; however, the underlying mechanisms are not fully elucidated. This review aims to summarize the most updated advances on elucidating the vitamin A effects targeting intestinal immune and barrier functions, which may help in further understanding the burdens of malnutrition and enteric infections in children. Specifically, by covering both clinical and in vivo/in vitro data, we describe the effects of vitamin A related to gut immune tolerance/homeostasis, intestinal barrier integrity, and responses to enteropathogens in the context of the environmental enteric dysfunction. Some of the gaps in the literature that require further research are also highlighted.

The pleiotropic role of vitamin A in regulating mucosal immunity

The effect of vitamin A on mucosal immunity has never been subjected to extensive studies until recently. We started to work in this area in the early 1970s when we observed that children with protein-calorie malnutrition (PCM) often had defective mucosal immunity, judging from the incidence of respiratory tract infections and diarrhea. We reported that these children had depressed secretory IgA (sIgA) levels in their nasal wash fluids. The IgA level in specimens collected from those superimposed with some degrees of vitamin A deficiency state appeared to be more severely affected. In order to better understand the underlying mechanism associated with this condition, we started to study more detail the deficiency state using experimental vitamin A-deficient rats. From a series of experiments using this animal model, we proposed that vitamin A was needed for transport and/or secretion of sIgA across the mucosa. This conclusion was based on the observation that the secretory component of sIgA synthesized by the epithelial cells of these vitamin A deficient animals was adversely affected as compared to the control animals. From that time onward, much progress has been made by several other groups showing that other mechanisms could also influence the integrity and immune function of the mucosa. For instance, recent studies demonstrated that retinoic acid which is a biologically active form of vitamin A has an essential role in mucosal homeostasis, controlling tolerance and immunity in these non-lymphoid tissues. Such a conclusion was made possible by the availability of sophisticated new molecular biology and genetic engineering techniques together with advances in the field of immunoregulation, e.g., the discovery of dendritic cells (DCs) and T helper cell subsets in 1980s, and the role of Toll-like receptors (TLRs) together with other innate immune regulators in controlling adaptive immune response in the early 1990s. These advances provided considerable new insights into the pleiotropic roles of vitamin A including educating mucosal DCs, differentiation of lymphocyte lineages and imprinting them with mucosal-homing properties as well as in regulating tolerance and immunity. The identification of a novel lymphocyte subpopulation, innate lymphoid cells (ILCs), at the beginning of this century has provided us with an additional insight into a new role of vitamin A in regulating homeostasis at the mucosal surface through influencing ILCs. Another new player that regulates intestinal homeostasis and mucosal immune response is microbiota whose composition is known to vary with vitamin A status. So it appears now that the role of vitamin A on mucosal immunity is far beyond regulating the adaptive Th1-Th2 cell response, but is highly pleiotropic and more complicating, e.g., polarizing the phenotype of mucosal DCs and macrophages, directing gut-homing migration of T and B cells, inducing differentiation of effector T cells and Treg subpopulation, balancing mucosal ILCs subpopulation and influencing the composition of microbiota. In this review, I will attempt to bring together these important advances to provide a comprehensive and contemporary perspective on the role of vitamin A in regulating mucosal immunity.

Retinoid and TGF-β families: crosstalk in development, neoplasia, immunity, and tissue repair

Transforming growth factor-β (TGF-β) isoforms are profibrotic cytokines, par excellence, and have complex multifunctional effects on many systems, depending on the biologic setting. Retinoids are vitamin A derivatives that also have diverse effects in development, physiology, and disease. The interactions between these classes of molecules are, not surprisingly, highly complex and are dependent on the tissue, cellular, and molecular settings.

From the diet to the nucleus: vitamin A and TGF-beta join efforts at the mucosal interface of the intestine

The vitamin A metabolites, including retinoic acid (RA), form ligands for retinoic acid-related nuclear receptors and together they play pleiotropic roles in various biological processes. Recently, we described that RA also functions as a key modulator of transforming growth factor-beta (TGF-beta)-driven immune deviation, capable of suppressing the differentiation of interleukin-17 secreting T helper cells (T(H)17) and conversely promoting the generation of Foxp3(+) T regulatory (Treg) cells. This review will focus on the role of RA in the reciprocal TGF-beta-driven differentiation of T(H)17 and Treg and on the importance of such regulatory mechanism to control a functional immune system, in particular at the mucosal interface of the intestine.

Men with low vitamin A stores respond adequately to primary yellow fever and secondary tetanus toxoid vaccination

Current recommendations for vitamin A intake and liver stores (0.07 micromol/g) are based on maintaining normal vision. Higher levels may be required for maintaining normal immune function. The objective of this study was to assess the relationship between total body vitamin A stores in adult men and measures of adaptive immune function. We conducted an 8-wk residential study among 36 healthy Bangladeshi men with low vitamin A stores. Subjects received a standard diet and were randomized in a double-blind fashion to receive vitamin A (240 mg) or placebo during wk 2 and 3. Subjects received Yellow Fever Virus (YFV) and tetanus toxoid (TT) vaccines during wk 5. Vitamin A stores were estimated by isotopic dilution during wk 8. Vaccine-specific lymphocyte proliferation, cytokine production, and serum antibody responses were evaluated before and after vaccination. Vitamin A supplementation increased YFV- and TT-specific lymphocyte proliferation and YFV-specific interleukin (IL)-5, IL-10, and tumor necrosis factor-alpha production but inhibited development of a TT-specific IL-10 response. Both groups developed protective antibody responses to both vaccines. Some responses correlated positively with vitamin A stores. These findings indicate that the currently recommended vitamin A intake is sufficient to sustain a protective response to YFV and TT vaccination. However, YFV-specific lymphocyte proliferation, some cytokine responses, and neutralizing antibody were positively associated with liver vitamin A stores > 0.084 micromol/g. Such increases may enhance vaccine protection but raise the question of whether immune-mediated chronic diseases may by exacerbated by high-level dietary vitamin A.

Supplementation with vitamins C, E, beta-carotene and selenium has no effect on anti-oxidant status and immune responses in allergic adults: a randomized controlled trial

BACKGROUND

Anti-oxidants are of growing interest in early treatment and prevention of allergic diseases in early life, but the effects on allergen-specific immune responses need to be documented further before intervention studies in infants are undertaken. The aim of this study in adults was to determine the effects of dietary anti-oxidants on allergen-specific immune responses in sensitized individuals.

METHODS

In a randomized controlled trial, 54 allergic adults received an anti-oxidant supplement (n=36) comprising beta-carotene (9 mg/day), vitamin C (1500 mg/day), vitamin E (130 mg/day), zinc (45 mg/day), selenium (76 microg/day) and garlic (150 mg/day) or a placebo (n=18) for 4 weeks. Anti-oxidant capacity (AC), serum levels of vitamin C, vitamin E, beta-carotene and selenium, peripheral blood responses, exhaled nitric oxide (eNO), as a marker of airway inflammation, and plasma F(2) isoprostanes, as a measure of oxidative stress, were measured before and after supplementation.

RESULTS

Anti-oxidant supplementation resulted in significant increases in serum levels of vitamin C, vitamin E, beta-carotene and selenium levels, compared with the placebo group (P<0.001). There was no change in serum AC, plasma F(2)-isoprostanes, eNO or immune responses following supplementation with anti-oxidants compared with placebo.

CONCLUSION

Supplementation with anti-oxidants resulted in significantly increased levels of vitamin C, vitamin E, beta-carotene and selenium but no change in immune responses, serum AC or plasma F(2)-isoprostanes.

Regulation of CD8+ T lymphocyte effector function and macrophage inflammatory cytokine production by retinoic acid receptor gamma

Vitamin A and its derivatives regulate a broad array of immune functions. The effects of these retinoids are mediated through members of retinoic acid receptors (RARs) and retinoid X receptors. However, the role of individual retinoid receptors in the pleiotropic effects of retinoids remains unclear. To dissect the role of these receptors in the immune system, we analyzed immune cell development and function in mice conditionally lacking RARgamma, the third member of the RAR family. We show that RARgamma is dispensable for T and B lymphocyte development, the humoral immune response to a T-dependent Ag and in vitro Th cell differentiation. However, RARgamma-deficient mice had a defective primary and memory CD8(+) T cell response to Listeria monocytogenes infection. Unexpectedly, RARgamma-deficient macrophages exhibited impaired inflammatory cytokine production upon TLR stimulation. These results suggest that under physiological condition, RARgamma is a positive regulator of inflammatory cytokine production.

Effects of vitamins, including vitamin A, on HIV/AIDS patients

An estimated 25 million lives have been lost to acquired immune-deficiency syndrome (AIDS) since the immunodeficiency syndrome was first described in 1981. The progress made in the field of treatment in the form of antiretroviral therapy (ART) for HIV disease/AIDS has prolonged as well as improved the quality of life of HIV-infected individuals. However, access to such treatment remains a major concern in most parts of the world, especially in the developing countries. Hence, there is a constant need to find low-cost interventions to complement the role of ART in prevention of HIV infection and slowing clinical disease progression. Nutritional interventions, particularly vitamin supplementation, have the potential to be a low-cost method for being such an intervention by virtue of their modulation of the immune system. Among all the vitamins, the role of vitamin A has been studied most extensively; most observational studies have found that low vitamin A levels are associated with increased risk of transmission of HIV from mother to child. This finding has not been supported by large randomized trials of vitamin A supplementation; on the contrary, these trials have found that vitamin A supplementation increases the risk of mother-to-child transmission (MTCT). There are a number of potential mechanisms that might explain these contradictory findings. One is the issue of reverse causality in observational studies-for instance, advanced HIV disease may suppress release of vitamin A from the liver. This would lead to low levels of vitamin A in the plasma despite the body having enough vitamin A liver stores. Further, advanced HIV disease is likely to increase the risk of MTCT, and hence it would appear that low serum vitamin A levels are associated with increased MTCT. The HIV genome also has a retinoic acid receptor element-hence, vitamin A may increase HIV replication via interacting with this element, thus increasing risk of MTCT. Finally, vitamin A is known to increase lymphoid cell differentiation, which leads to an increase in CCR5 receptors. These receptors are essential for attachment of HIV to the lymphocytes and therefore, an increase in their number is likely to increase HIV replication. Vitamin A supplementation in HIV-infected children, on the other hand, has been associated with protective effects against mortality and morbidity, similar to that seen in HIV-negative children. The risk for lower respiratory tract infection and severe watery diarrhea has been shown to be lower in HIV-infected children supplemented with vitamin A. All-cause mortality and AIDS-related deaths have also been found to be lower in vitamin A-supplemented HIV-infected children. The benefits of multivitamin supplementation, particularly vitamins B, C, and E, have been more consistent across studies. Multivitamin supplementation in HIV-infected pregnant mothers has been shown to reduce the incidence of adverse pregnancy outcomes such as fetal loss and low birth weight. It also has been shown to decrease rates of MTCT among women who have poor nutritional or immunologic status. Further, multivitamin supplementation reduces the rate of HIV disease progression among patients in early stage of disease, thus delaying the need for ART by prolonging the pre-ART stage. In brief, there is no evidence to recommend vitamin A supplementation of HIV-infected pregnant women; however, periodic vitamin A supplementation of HIV-infected infants and children is beneficial in reducing all-cause mortality and morbidity and is recommended. Similarly, multivitamin supplementation of people infected with HIV, particularly pregnant women, is strongly suggested.

Vitamin A supplementation and retinoic acid treatment in the regulation of antibody responses in vivo

Vitamin A (VA, retinol) is essential for normal immune system maturation, but the effect of VA(1) on antibody production, the hallmark of successful vaccination, is still not well understood. In countries where VA deficiency is a public health problem, many children worldwide are now receiving VA along with immunizations against poliovirus, measles, diphtheria, pertussis, and tetanus. The primary goal has been to provide enough VA to protect against the development of VA deficiency for a period of 4-6 months. However, it is also possible that VA might promote the vaccine antibody response. Several community studies, generally of small size, have been conducted in children supplemented with VA at the time of immunization, as promoted by the World Health Organization/UNICEF. However, only a few studies have reported differences in antibody titers or seroconversion rates due to VA. However, VA status was not directly assessed, and in some communities children were often breast fed, another strategy for preventing VA deficiency. Some of the vaccines used induced a high rate of seroconversion, even without VA. In children likely to have been VA deficient, oral polio vaccine seroconversion rate was increased by VA. In animal models, where VA status was controlled and VA deficiency confirmed, the antibody response to T-cell-dependent (TD) and polysaccharide antigens was significantly reduced, congruent with other defects in innate and adaptive immunity. Moreover, the active metabolite of VA, retinoic acid (RA) can potentiate antibody production to TD antigens in normal adult and neonatal animals. We speculate that numerous animal studies have correctly identified VA deficiency as a risk factor for low antibody production. A lack of effect of VA in human studies could be due to a low rate of VA deficiency in the populations studied or low sample numbers. The ability to detect differences in antibody response may also depend on the vaccine-adjuvant combination used. Future studies of VA supplementation and immunization should include assessment of VA status and a sufficiently large sample size. It would also be worthwhile to test the effect of neonatal VA supplementation on the response to immunization given after 6 months to 1 year of age, as VA supplementation, by preventing the onset of VA deficiency, may improve the response to immunizations given later on.

Vitamin A supplementation increases ratios of proinflammatory to anti-inflammatory cytokine responses in pregnancy and lactation

Vitamin A supplementation reduces child mortality in populations at risk of vitamin A deficiency and may also reduce maternal mortality. One possible explanation for this is that vitamin A deficiency is associated with altered immune function and cytokine dysregulation. Vitamin A deficiency in pregnancy may thus compound the pregnancy-associated bias of cellular immune responses towards Th-2-like responses and exacerbate susceptibility to intracellular pathogens. We assessed mitogen and antigen-induced cytokine responses during pregnancy and lactation in Ghanaian primigravidae receiving either vitamin A supplementation or placebo. This was a double-blind, randomized, placebo-controlled trial of weekly vitamin A supplementation in pregnant and lactating women. Pregnancy compared to postpartum was associated with a suppression of cytokine responses, in particular of the proinflammatory cytokines interferon (IFN)-gamma and tumour necrosis factor (TNF)-alpha. Mitogen-induced TNF-alpha responses were associated with a decreased risk of peripheral parasitaemia during pregnancy. Furthermore, vitamin A supplementation was significantly associated with an increased ratio of mitogen-induced proinflammatory cytokine (IFN-gamma) to anti-inflammatory cytokine (IL-10) during pregnancy and in the postpartum period. The results of this study indicate that suppression of proinflammatory type 1 immune responses and hence immunity to intracellular infections, resulting from the combined effects of pregnancy and vitamin A deficiency, might be ameliorated by vitamin A supplementation.

Total serum immunoglobulin M levels are affected by immunomodulators in seabream (Sparus aurata L.)

Immunoglobulin M (IgM) is a major component of the teleost humoral immune system. Despite the significance of IgM levels as an immune parameter, there are relatively few studies on changes induced in its total levels in serum. This study examines the effects of several immunomodulators (vitamin A, chitin, yeast cells or levamisole, which act as immunostimulants, and crowding, hypoxia or anaesthetics, which act as stressors) upon the total serum IgM levels of non-immunized gilthead seabream (Sparus aurata L.). Total serum IgM levels of fish fed with the assayed immunostimulant-supplemented diets were statistically higher than those in fish fed a non-supplemented diet, especially in the case of levamisole. On the other hand, serum IgM levels of fish subjected to different stressors were not affected by crowding, hypoxia or certain anaesthetics. However, benzocaine and a narcotic dose of 2-phenoxyethanol provoked a great reduction, while quinaldine sulphate increased IgM levels to a significant degree. These results show how the seric IgM levels can be differently affected by some immunomodulators and the important role they may play in the regulation of total circulating IgM levels in seabream. The possibility of using total serum IgM for assessing immunostimulation, disease diagnosis and stress symptoms during fish farming is discussed.

US youths in the early stages of HIV disease have low intakes of some micronutrients important for optimal immune function

OBJECTIVE

We examined the association between micronutrient intakes and human immunodeficiency virus (HIV) infection in youths who were at increased nutritional risk because of the demands of growth and disease as well as poor dietary habits.

DESIGN

This was a cross-sectional study to collect dietary intake data using the Block Food Frequency Questionnaire (98.2). Anthropometric, biochemical, clinical, and sociodemographic data were available.Subjects/Setting Participants included 264 HIV-infected and 127 HIV-uninfected adolescents and young adults from the Reaching for Excellence in Adolescent Care and Health network, a multisite observational study on HIV progression. Statistical analyses CD4(+) T cells were stratified for HIV-infected youths: >/=500, 200 to 499, and <200 cells/microL. Micronutrient intakes were compared by presence of HIV infection, using two-sample Student's t tests. Categoric analyses used chi(2) test. Generalized linear regression determined predictors of vitamins A, C, and E; iron; and zinc intakes.

RESULTS

Almost half (49.0%) of the HIV-infected participants had CD4(+) T cells >/=500 cells/microL. After controlling for other factors, HIV-infected participants with CD4(+) T cells >/=500 had decreased iron intake (P<.05) and tended to be associated with lower intakes of vitamins C and E (P<.10) compared with those with more advanced disease and HIV-uninfected youths. Among those youths with CD4(+) T cells between 200 and 499 cells/microL, a high anxiety score was associated with a sixfold increase in vitamin A intake as compared with those with a low score.Applications/conclusions Given the increased micronutrient requirements, nutrition counseling with HIV-infected youths should focus on early increase of intake of foods rich in micronutrients to improve growth, slow disease progression, and increase survival.

Vitamin A levels and immunity in humans

In animal studies, vitamin A deficiency induces a shift from type 2 (humoral) to type 1 (cellular) cytokines; there are no similar data for humans. Control of human immunodeficiency virus (HIV) and Mycobacterium tuberculosis infections requires type 1 cytokine (cellular) immunity. These infections and vitamin A deficiency are highly prevalent in Africa. We therefore examined the interactions among serum vitamin A levels, immune parameters, HIV infection status, Mycobacterium bovis BCG vaccine scarring (as an indicator of a type 1 cytokine profile), and clinical findings for 70 hospitalized children in Malawi, Africa. Directly conjugated monoclonal antibodies and flow cytometry were used to assess cell-specific cytokine production by peripheral blood monocytes and lymphocyte subpopulations. The statistical techniques employed included nonparametric statistics and logistic regression analyses. Thirty percent of the participants had severe vitamin A deficiency (<10 microg/dl), 34% had moderate deficiency (10 to <20 microg/dl), and 36% had normal levels (> or = 20 microg/dl). Vitamin A levels were lower for HIV-positive than for HIV-negative children (median, 10 and 17 microg/dl, respectively). Vitamin A-deficient children (<20 microg/dl) were more likely than non-vitamin A-deficient children to have higher proportions of natural killer (NK) cells (median, 8.3 and 5.2%, respectively) and lower ratios of interleukin-10-producing monocytes to tumor necrosis factor alpha-producing monocytes after induction (median, 1.0 and 2.3, respectively). Vitamin A-deficient children were also more likely than non-vitamin A-deficient children to exhibit respiratory symptoms (47% versus 12%) and visible BCG vaccine scars (83% versus 48%), which are indicative of a type 1 response to vaccination. Vitamin A status did not vary with gender, age, incidence of malaria parasitemia, blood culture positivity, or rates of mortality (6% of vitamin A-deficient children died versus 20% of non-vitamin A-deficient children). Lower vitamin A levels were associated with a relative type 1 cytokine dominance and proportionately more NK cells, both of which may be somewhat beneficial to persons who are exposed to HIV, M. tuberculosis, or other type 1 pathogens.

The role of vitamin A in enhancing humoral immunity produced by antirabies vaccine

We tested the effects of vitamin A supplementation on the antibody titre of 40 healthy volunteers (age range: 10-35 years), who had received a complete course of antirabies vaccine (5 injections over 30 days). After determining the baseline serum vitamin A status of 80 volunteers, 20 pairs were matched for serum vitamin A level, body mass index, age, sex and socioeconomic status. One person from each pair was randomly assigned to an experimental or control group. The experimental group received vitamin A and antirabies vaccine. Controls received only the vaccine. The experimental group had significantly greater (2.1 times) serum antirabies titre than controls. This finding is an important step towards improving the economy of dosage of antirabies vaccines.

Immunobiology of mild micronutrient deficiencies

Nutrition is a critical determinant of the outcome of host microbe interactions through a modulation of the immune response. Besides macronutrient malnutrition, deficiencies of several macronutrients also influence immune homeostasis and thus affect infection-related morbidity and mortality. Deficiencies of micronutrients like vitamin A, iron and zinc are widely prevalent among populations living in developing countries. Besides their severe deficiencies, subclinical deficiencies are known to impair biological functions in the host, immune function being one of them. The effects of these micronutrients on various immune mechanisms are briefly reviewed in this article.

No strong long-term effect of vitamin A supplementation in infancy on CD4 and CD8 T-cell subsets. A community study from Guinea-Bissau, West Africa

The World Health Organization recommends that 100,000 IU of vitamin A be given to infants between 6 and 12 months of age at the same time as measles vaccination in order to prevent vitamin A deficiency. In the present study, our aim was to assess the effect of vitamin A supplementation on T-cell subsets in a randomized factorial design, seeking a possible modifying effect of measles vaccination. Three hundred children were allocated either to two doses of measles vaccine at 6 and 9 months of age or to poliomyelitis vaccine at age 6 months and measles vaccine at age 9 months. Within each group, infants were to receive two doses of vitamin A or two doses of placebo at 6 and 9 months of age. We found no significant effect of vitamin A supplementation on CD4 and CD8 T-cell subsets at 3 and 9 months after supplementation. We found no effect of measles vaccine and no interaction between vitamin A supplementation and measles vaccine. Based on these observations, vitamin A supplementation does not seem to have a strong long-term effect on CD4 and CD8 T-cell subsets in infants without clinical vitamin A deficiency.

Immune response to influenza vaccine in healthy elderly: lack of association with plasma beta-carotene, retinol, alpha-tocopherol, or zinc

Immunity and nutritional status are compromised with age, yet the relationship between them is unclear. Immune responses and plasma micronutrient levels of 61 healthy elderly (mean 81 years) and 27 young (mean 27 years) were assessed before and after immunization with trivalent influenza vaccine (FLU). FLU-induced proliferation and IFN-gamma levels of elderly were lower than young before and after immunization. Proliferation and IFN-gamma levels increased after immunization of young, but not elderly. FLU-induced IL-6 and IL-10 levels did not change after immunization of either group. While antibody titers to all three FLU components increased after vaccination of young and elderly, post-vaccination titers of elderly were lower than young. Although plasma retinol and zinc levels of young and elderly were similar before and after vaccination, elderly had higher plasma beta-carotene and alpha-tocopherol levels at both assessments that increased after vaccination. Importantly, plasma micronutrient levels were comparable for elderly with or without intact (titers >/=40 and fourfold rise post-vaccination) antibody responses after vaccination. These results suggest that differences in these plasma micronutrients (1) are not required to observe decreased FLU responses of healthy elderly compared to young and (2) are not associated with differences in antibody responses among healthy elderly.

Chronic marginal vitamin A status affects the distribution and function of T cells and natural T cells in aging Lewis rats

Although both vitamin A (VA) deficiency and aging are independently associated with alterations in immune function, the effects of marginal VA status or VA supplementation on the immune system during aging were not studied. A long-term dietary study was conducted in a rat model of aging to quantify changes in T-cell populations in blood and spleen, including T-cells bearing a marker of natural killer (NKT) cells. The study included nine treatment groups [three levels of dietary VA: marginal (0.35 RE/kg diet), control (4.0 RE/kg diet), and supplemented (50 RE/kg diet); and three age groups: young (2-3 mo), middle-aged (8-10 mo), and old 20-22 mo); diets were fed continuously from weaning to the end of the study period. CD3(+)/CD4(+) T-cells decreased in percentage and number in blood with age, CD8(+) cells increased (%), and the CD4/CD8 ratio decreased. Conversely, aging was associated with increased NKT cells (phenotype CD3(intermediate)/NKR-P1(+)). Based on regression analysis of flow cytometry data, the phenotype of most NKT cells was CD3(intermediate)/NKR-P1(+)/CD28(-). NKT cells, which are most likely of extrathymic origin, accounted for most of the decrease in the CD4/CD8 ratio. Marginal VA status, particularly in older rats, was associated with increases in the percentage of CD8(+) T cells, percentage and number of NKT cells, and peripheral blood cell anti-CD3epsilon-stimulated proliferative response, and decreases in the CD4/CD8 T-cell ratio and splenic cell interleukin-2 production. These differences and the reciprocal changes observed for NKT cells vs. T- and classical NK cells in aging VA-marginal rats suggest that low VA status during aging may increase the risk of infectious or neoplastic diseases that require a normal balance of T-cell or NK-cell responses.

Vitamin A administered with measles vaccine to nine-month-old infants does not reduce vaccine immunogenicity

After a report of reduced seroconversion to measles in infants, aged 6 mo, given vitamin A with their measles vaccination, serious concerns were raised regarding the safety of the WHO's recommendation that infants be supplemented with vitamin A at the time of measles immunization. To determine the impact of coadministered vitamin A on the antibody response to measles vaccine given to infants aged 9 mo, the more common age for immunization in developing countries, we conducted a randomized, double-blind, placebo-controlled trial in an urban slum community in Delhi. Infants (618) were randomly allocated to receive 30 mg vitamin A or a placebo with the measles immunization. Antibodies to measles were measured by ELISA in serum samples obtained at before (baseline) and 12 wk after immunization. Overall, the seroconversion rates did not differ between vitamin A (89.5%) and placebo (87.6%) groups. There were no significant differences in the geometric mean titers in the two groups (ratio of geometric means, 1.19; 95% confidence interval, 0.97-1.46). Among malnourished infants, the geometric mean titer was significantly greater in the vitamin A group compared to the placebo group (ratio of geometric means, 1.57; 95% confidence interval, 1. 18-2.0), but seroconversion rates did not differ. There were no differences in seroconversion rates and geometric mean titers in the two study groups among the well-nourished children. These results indicate that 30 mg vitamin A does not reduce the immune response to the coadministered vaccine and, therefore, can be continued to be given safely in public health programs.

Chronic marginal vitamin A status reduces natural killer cell number and function in aging Lewis rats

Natural killer (NK) cells function in the regulation of immune responses and in the surveillance of malignant or other abnormal cells. Little is known of the effects of chronic marginal vitamin A (VA) status or VA supplementation, or their interaction with age, on NK cell number and cytolytic activity. We have conducted a two-factor (diet, age) study in which male Lewis rats were fed AIN-93M diet, modified to contain either 0.3 (designated marginal), 4.0 (control) or 50 (supplemented) mg retinol equivalents (RE)/kg diet, from the time of weaning until the ages of 2.5 mo (young), 8-10 mo (middle-aged) or 18-20 mo (old). Natural killer cells were identified and quantified in peripheral blood mononuclear cells (PBMC) and spleen with the use of flow cytometry, and NK cell cytotoxicity was assayed. The number and percentage of PBMC NK cells increased with age (P < 0.0001 by two-way ANOVA). For all age groups, values were lowest in rats with marginal VA status (P < 0.0001 vs. controls). NK cell lytic activity also declined with age (P = 0. 0003). As a result, NK cell lytic efficiency (lytic activity per NK cell) decreased markedly with age (P < 0.0001). Regardless of the donor's age or VA status, PBMC NK cell cytotoxicity doubled (100 +/- 25% increase) after exposure to interferon-alpha (5 x 10(5) U/L for 1 h before assay), indicating that IFN-stimulated lytic activity was related directly to basal NK cell activity. If the relationships observed in this animal model can be applied to humans, these data suggest that elderly people consuming diets chronically low in VA may be at increased risk for infectious or neoplastic diseases.

The significance of vitamin A and carotenoid status in persons infected by the human immunodeficiency virus

Hyporetinemia is associated with increased childhood morbidity and mortality that is reversible with vitamin A supplementation. Although vitamin A deficiency is otherwise rare in developed countries, the prevalence of hyporetinemia in human immunodeficiency virus (HIV)-infected persons is up to 29%. Hyporetinemic HIV-infected patients have a 3.5-5-fold increased risk of death. Furthermore, HIV-infected patients with very low or very high intake of vitamin A and beta-carotene (a vitamin A precursor) have greater rates of disease progression than do patients with intermediate intake. In developing countries up to 60% of HIV-infected pregnant women are hyporetinemic. In such women the relative risk of perinatal HIV transmission may be increased more than fourfold. These data indicate that vitamin A deficiency is common in HIV-infected patients in the developed world and strongly suggest that vitamin A supplementation may be especially useful in adjunctive therapy for HIV-infected pregnant women who reside in the developing world.

The effect of zinc and vitamin A supplementation on immune response in an older population

OBJECTIVE

To determine if either supplemental vitamin A, zinc, or both increases cell-mediated immune response in an older population.

DESIGN

A double-blind, randomized, controlled trial of supplementation with vitamin A and zinc.

SETTING

Casa Di Riposo Roma III, a public home for older people in Rome, Italy.

SUBJECTS

The health and nutritional status of 178 residents were evaluated. One hundred thirty-six residents agreed to participate in the trial and were randomized into four treatment groups, and 118 of these residents completed the trial.

INTERVENTION

The four treatments consisted of: (1) Vitamin A (800 micrograms retinol palmitate); (2) Zinc (25 mg as zinc sulfate); (3) Vitamin A and Zinc (800 micrograms retinol palmitate and 25 mg as zinc sulfate); (4) Placebo capsules containing starch.

MAIN OUTCOME MEASUREMENTS

Immune tests-counts of leucocytes, lymphocytes, T-cell subsets, and lymphocyte proliferative response to mitogens-were measured before and after supplementation.

RESULTS

Zinc increased the number of CD4 + DR + T-cells (P = .016) and cytotoxic T-lymphocytes (P = .005). Subjects treated with vitamin A experienced a reduction in the number of CD3 + T-cells (P = .012) and CD4 + T-cells (P = .012).

CONCLUSIONS

These data indicate that zinc supplementation improved cell-mediated immune response, whereas vitamin A had a deleterious effect in this older population. Further research is needed to clarify the clinical significance of these findings.

Retinol (vitamin A) is a cofactor in CD3-induced human T-lymphocyte activation

Immunomodulatory effects of different retinoids have been demonstrated, both in vivo and in vitro, in different cellular lineages including human and murine thymocytes, human lung fibroblasts, Langerhans' cells, tumoral cells and natural killer (NK) cells; however, any attempt to demonstrate the effect of retinoids on human peripheral blood mononuclear cells (PBMC) resulted in negative results. In the present work, it is shown that retinol and retinoic acid induce a marked increase of proliferation on human PBMC from 32 unrelated healthy individuals, which had previously been stimulated with anti-CD3 antibodies 48 hr before. Serum-free medium, specific retinoid concentration (10(-7) M) and a particular timing of retinol addition to the cultures (48 hr after CD3 stimulation) was necessary clearly to detect this retinol-enhancing effect. The increased proliferative response is specifically mediated via the clonotipic T-cell receptor-CD3 complex and correlates with the up-regulation of certain adhesion/activation markers on the T-lymphocyte surface: CD18, CD45RO and CD25; also Th1-type of cytokines (interleukin-2 and interferon-gamma) are found concordantly increased after retinoid costimulation, both measured by a direct protein measurement and by a specific mRNA increase. In addition, it is shown that the in vitro retinol costimulation is only present in immunodeficient patients who have no defect on CD3 molecules and activation pathway. The fact that retinol costimulate lymphocytes only via CD3 (and not via CD2 or CD28) and the lack of response enhancement in immunodeficients with impaired CD3 activation pathway indicates that retinoids may be used as therapeutic agents in immune system deficiencies that do not affect the clonotypic T-cell receptor.

Retinoids as Ig isotype-switch modulators. The role of retinoids in directing isotype switching to IgA and IgG1 (IgE) in association with IL-4 and IL-5

The role of retinoids was analyzed in directing isotype switching to IgA and IgG1 (IgE) by LPS-stimulated murine mu(+)B-cells in the presence of two Th2-type cytokines, IL-4 and IL-5. All trans retinoic acid (RA) enhanced the production of IgA at high concentrations (10-100 nM) in the presence of IL-5. Addition of IL-4 to the system modulated the IgA response in a dose-dependent manner. Namely, IL-4 inhibited the response at concentrations higher than 250 u/ml, but showed slight enhancement at lower concentrations (130 u/ml). IL-4 alone, which is considered to be an IgE isotype-switch inducer, strongly enhanced the IgG1 and IgE responses. Addition of IL-5 to the system showed a synergistic effect which could be attenuated by addition of low concentrations of RA (about 1 nM). Thus, the presence of switch modulators such as IL-4 and IL-5, their concentration ratios, and concentrations of retinoids are crucial factors in initiating and directing isotype switching to IgA and IgG1 (IgE).

Surgically significant nutritional supplements

This is not an exhaustive study of all nutritional supplements that patients may be taking. The most frequently used and those potentially most detrimental or most beneficial for surgical patients have been chosen for review of pertinent effects. It is essential to ask patients specifically about supplements or unusual dietary habits that may affect their surgical outcome prior to their invasive procedure and to keep in mind the supplements that may improve their outcome.

Sensitization of mice to paraphenylenediamine and structurally-related compounds: adjuvant effects of vitamin A supplementation

Allergic contact dermatitis from moderate and weak contact sensitizers is generally studied with guinea pigs, since they are readily sensitized to contact allergens. Mice, by contrast, are poor responders to weak contact allergens. However, the variety of in vitro murine systems as well as murine specific reagents make mice the preferable species. With the use of vitamin A supplementation, 2 protocols were developed which sensitized CBA/J female mice to paraphenylenediamine. Mice were sensitized by 5 daily topical applications to shaven dorsal skin. Alternately, mice were sensitized by 2 intraperitoneal injections of antigen pulsed spleen cells. Sensitization to paraphenylenediamine was determined by ear swelling following topical application. Vitamin A supplementation was found to be essential for optimum response. Lymph node and spleen cells from sensitized mice were capable of proliferating to paraphenylenediamine in vitro. With the use of vitamin A supplementation and intraperitoneal injection, CBA/J mice were also sensitized to a number of compounds structurally related to paraphenylenediamine, including the ortho- and meta-derivatives of paraphenylenediamine, as well as hydroquinone and resorcinol. These new protocols, combined with vitamin A supplementation, expand the use of mice to study moderate sensitizers with minimal animal utilization.

An arm immersion model of compromised skin (I). Influence on irritation reactions

Patch testing and safety evaluation processes to assess the allergic or irritant potential of substances are usually performed on normal skin. However, the reactivity of compromised skin may be different. Consequently, it is important to have a test procedure which acts as a model for compromised skin and which reproduces on the target sites the cumulative insult which results from repeated exposure, working temperatures, hydration and the action of surfactants. The procedure described uses regular immersion of forearm skin in an aqueous solution of sodium dodecyl sulphate until an identifiable alteration of skin condition is produced. In this first report, the model system has been described in detail and the influence of skin compromise on the response to 3 irritants, citral, sodium dodecyl sulphate and nonanoic acid, has been assessed. The irritation potential of the materials varied, but each irritant produced a greater degree of reaction on skin compromised to be within the normal clinical range one might expect from housework.

Neuron-specific enolase and glial fibrillary acidic protein in vitamin-A-induced mouse myeloschisis: an immunohistochemical study

In an effort to establish the appropriate timing of myeloschisis repair, changes in the exposed neural tissue were studied during fetal development. Neuron-specific enolase (NSE) and glial fibrillary acidic protein (GFAP) were examined immunohistochemically in mice with vitamin-A-induced myeloschisis. As in the normally developing lumbosacral spinal cord, NSE was already expressed in the cytoplasm of neurons in the basal plate of the neural plaque in 16-day-old embryos. GFAP became positive at day 17 both in normal embryos and at the outer border of the plaques in dysraphic embryos. Expression of both NSE and GFAP in normal controls was unchanged in intensity and localization during later fetal development. In contrast, the expression of GFAP increased during later development in the neural plaque of dysraphic animals and suggests a progressive gliosis of tissue with the passage of time. The expression of NSE in the plaque did not change during this time. These results suggest that the neural plaque retains intact neurons in the face of progressive gliosis. Moreover, the results suggest that repair of the myeloschisis should start before irreversible changes are established by progressive gliosis.

Retinoid repletion of vitamin A-deficient mice restores IgG responses

Vitamin A-deficient (A-) mice produce poor IgG antibody responses due to a helper T cell dysfunction. We performed retinoid repletion studies to determine the minimum dietary retinyl acetate dose and the most active retinoid for supporting immune function. Dietary retinyl acetate repletion at 2 (R2 group) or 4 (R4 group) microgram/g diet restored serum retinol in A- mice to vitamin A-sufficient (A+) control levels within 24 h. However, in R4 mice, liver retinyl palmitate was restored about twofold faster than in R2 mice; liver retinyl palmitate reached A+ control levels by d 30 in R4 mice but not in R2 mice. We challenged the mice with antigen 24 h post repletion; the R4 mice gave an IgG1 response equal to that of A+ controls, but the R2 mice were comparable with the A- controls. We also compared four retinoids for IgG1 response restoration in vitro; 1 nmol/L retinoic acid fully repleted A- cell IgG1 responses and helper T cell frequencies to the unsupplemented A+ control levels. Retinoic acid was at least 10-fold more active than retinyl acetate or retinaldehyde, and 100-fold more active than retinol. Collectively, our results suggest that retinoic acid is probably the physiologically important metabolite for sustaining IgG immune responses in vivo. We discuss the possible relationship between liver retinyl palmitate levels and availability of retinoic acid to support immune function.

In vivo and in vitro studies on the effects of vitamin A on the chemiluminescent response of murine peritoneal exudate cells

Retinoids are known to enhance macrophage function and enhance bacterial clearance during experimental infection. The purpose of these experiments was to determine if one indicator of macrophage activation, chemiluminescence (CL), was enhanced by retinoids. Peritoneal exudate cells (PEC) harvested from mice injected intraperitoneally for 5 days with retinol palmitate (25, 125, or 250 U/g body wt./d) showed significantly enhanced chemiluminescence (CL) when exposed to opsonized zymosan. A direct dose-response effect was observed, in that the more retinol palmitate was injected, the more CL was observed. The same dose of retinol palmitate injected subcutaneously did not result in enhanced CL. In vitro incubation of murine PEC with physiological concentrations of retinol palmitate or retinoic acid for 1, 6 or 24 h did not result in enhanced CL. The reasons for the effect of the route of administration of retinol palmitate are unknown, but may include poor absorption from the site of subcutaneous injection or an adjuvant effect when injected intraperitoneally due to the particulate nature of the water-dispersible retinol palmitate preparation.

[Vitamin A: an indirect factor in the prevention of cancer]

Although vitamin A intervenes essentially in the mechanism of sight, its possible role in the prevention and treatment of cancer is widely discussed. Epidemiological studies have demonstrated a correlation between vitamin A deficiency and an increase in the frequency of cancers in man. Several hypotheses have been put forward concerning the mechanism of interaction between vitamin A and cancer on the basis of experimental models showing that vitamin A exerts a protective action against spontaneous or induced neoplasias in animals. The toxicological aspects of vitamin A administration and the relevance of these experimental results to human oncology are discussed.

Effects of specific nutrients on the immune response. Selected clinical applications

The importance of diet in multiple aspects of the immune response is inescapable. Although only a few trials have attempted to apply knowledge derived from in-vitro and animal data to humans, the ability to modulate or "reset" the immune response by manipulating dietary intake will surely continue to be studied in the future. The role of various nutrients in immunity is reviewed and clinical applications are noted.

Enhancement of specific antitumor immunity in mice fed a diet enriched in vitamin A acetate

Age-matched male CBA mice on a conventional or a vitamin A acetate (VAOAc)-rich diet were immunized with irradiated cloned 3-methylcholanthrene- or Harvey sarcoma virus-induced (McSa-1 or HT3-2.1) sarcoma cells and then challenged with viable corresponding or unrelated (non-crossreacting) syngeneic sarcoma cells. The survival of the specifically immunized mice on the VAOAc diet was significantly prolonged in comparison with all control groups of mice as assessed by using logrank tests. Moreover, the specific immunization markedly decreased the incidence of tumors after the McSa-1 (but not HT3-2.1) challenge in a group of mice on the VAOAc diet (5% tumor incidence) compared with the equivalent group on the control diet (50% tumor incidence). Neither the VAOAc diet nor in vivo immunization alone or combined influenced natural killer cell activity. Specific T-cell-mediated cytotoxicity after in vivo priming and in vitro boosting with sarcoma cells was increased in VAOAc-fed mice. However, the marginal increase in cytotoxicity does not in itself explain the strikingly increased resistance to tumor transplants in preimmunized mice on the VAOAc diet in comparison with preimmunized mice on the control diet. The results indicate that a diet enriched in VAOAc can modify the ability of the immune system of a mouse to respond effectively to tumor antigens and can influence whether a tumor grows or regresses.

[Effect of vitamin A on immunogenesis]

Experiments made on mice, rats and rabbits have shown that administration of vitamin A promotes an increase in the weight of the lymphoid organs, thymus and spleen and stimulates production of the antibody-forming cells by the spleen, as well as that of serum antibodies during immunization with different antigens: sheep red blood cells, influenza virus, tetanus and staphylococcal toxoids. The possible mechanisms that underlie vitamin A action are discussed.

Rat liver microsomes catalyse mannosyl transfer from GDP-D-mannose to retinyl phosphate with high efficiency in the absence of detergents

In the absence of detergent, the transfer of mannose from GDP-mannose to rat liver microsomal vesicles was highly stimulated by exogenous retinyl phosphate in incubations containing bovine serum albumin, as measured in a filter binding assay. Under these conditions 65% of mannose 6-phosphatase activity was latent. The transfer process was linear with time up to 5min and with protein concentration up to 1.5mg/0.2ml. It was also temperature-dependent. The microsomal uptake of mannose was highly dependent on retinyl phosphate and was saturable against increasing amounts of retinyl phosphate, a concentration of 15mum giving half-maximal transfer. The uptake system was also saturated by increasing concentrations of GDP-mannose, with an apparent K(m) of 18mum. Neither exogenous dolichyl phosphate nor non-phosphorylated retinoids were active in this process in the absence of detergent. Phosphatidylethanolamine and synthetic dipalmitoylglycerophosphocholine were also without activity. Several water-soluble organic phosphates (1.5mm), such as phenyl phosphate, 4-nitrophenyl phosphate, phosphoserine and phosphocholine, did not inhibit the retinyl phosphate-stimulated mannosyl transfer to microsomes. This mannosyl-transfer activity was highest in microsomes and marginal in mitochondria, plasma and nuclear membranes. It was specific for mannose residues from GDP-mannose and did not occur with UDP-[(3)H]galactose, UDP- or GDP-[(14)C]glucose, UDP-N-acetyl[(14)C]-glucosamine and UDP-N-acetyl[(14)C]galactosamine, all at 24mum. The mannosyl transfer was inhibited 85% by 3mm-EDTA and 93% by 0.8mm-amphomycin. At 2min, 90% of the radioactivity retained on the filter could be extracted with chloroform/methanol (2:1, v/v) and mainly co-migrated with retinyl phosphate mannose by t.l.c. This mannolipid was shown to bind to immunoglobulin G fraction of anti-(vitamin A) serum and was displaced by a large excess of retinoic acid, thus confirming the presence of the beta-ionone ring in the mannolipid. The amount of retinyl phosphate mannose formed in the bovine serum albumin/retinyl phosphate incubation is about 100-fold greater than in incubations containing 0.5% Triton X-100. In contrast with the lack of activity as a mannosyl acceptor for exogenous dolichyl phosphate in the present assay system, endogenous dolichyl phosphate clearly functions as an acceptor. Moreover in the same incubations a mannolipid with chromatographic properties of retinyl phosphate mannose was also synthesized from endogenous lipid acceptor. The biosynthesis of this mannolipid (retinyl phosphate mannose) was optimal at MnCl(2) concentrations between 5 and 10mm and could not be detected below 0.6mm-MnCl(2), when synthesis of dolichyl phosphate mannose from endogenous dolichyl phosphate was about 80% of optimal synthesis. Under optimal conditions (5mm-MnCl(2)) endogenous retinyl phosphate mannose represented about 20% of dolichyl phosphate mannose at 15min of incubation at 37 degrees C.

Reactivity of vitamin A derivatives and analogues with vitamin A antibodies

Vitamin A antibodies were obtained using retinoic acid conjugated to human serum albumin as an immunogen. The following constraints governed the reactivity of vitamin A analogues with such an anti-serum. The stereochemistry of the side chain is relatively unimportant, and 9- and 13-cis retinal react almost as well as all-trans retinal. The nature of the ring is important; all of the compounds that react readily carry a beta-ionic ring; all of the compounds bearing an aromatic ring react poorly; the two compounds that display intermediate reactivity have non-aromatic 6- and 5-membered rings, respectively.

Vitamin A antibodies: application to radioimmunoassay

A radioimmunoassay for serum vitamin A is described which can detect as little as 1 ng of retinol. The statistical characteristics of this assay are presented and its use in a nutritional experiment is discussed.

[Vitamin A and cancer (author's transl)]

During the past decade, an increasing number of publications have been dealing with the experimental and clinical activity of vitamin A on epithelial neoplasms. Many studies suggest that vitamin A and its analogs may be able to interfere with chemical carcinogenesis and to modify favorably the immune status of tumor bearers by mechanisms incompletely known. The use of vitamin A and of its analogs have been shown to enhance the effects of surgery, radiation therapy and chemotherapy in the treatment of epithelial cancer, possibly because they appear to destabilize lysosomal membranes and contribute to maintenance of the differenciated state in epithelial tissues. The potential role of such substances in preventing neoplastic transformation deserves further study.