101
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Rheumatoid arthritis and depression: an inflammatory perspective. Lancet Psychiatry 2019; 6:164-173. [PMID: 30366684 DOI: 10.1016/s2215-0366(18)30255-4] [Citation(s) in RCA: 248] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/11/2018] [Accepted: 06/20/2018] [Indexed: 12/13/2022]
Abstract
The coexistence of immune-mediated inflammatory diseases with depression has long been recognised. Data that illustrate the intimate associations between peripheral and brain immune responses raise the possibility of shared pathophysiological mechanisms. These associations include the negative effects of proinflammatory cytokines on monoaminergic neurotransmission, neurotrophic factors, and measures of synaptic plasticity. The evidence supporting this association is accumulating and includes findings from clinical trials of immunomodulatory therapy, indicating that these interventions can provide benefits to mental health independent of improvements in physical disease scores. In this Review, we assess this evidence in relation to rheumatoid arthritis and depression, with a focus on innate immune and molecular responses to inflammation, and discuss the challenges of assessing causation in this population, acknowledging the difficulty of assessing the confounding and contributory effects of pain and fatigue. We also discuss how future clinical and preclinical research might improve diagnosis of depression in people with rheumatoid arthritis and shed light on mechanisms that could be substrates for therapeutic interventions.
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102
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Nazmi A, Field RH, Griffin EW, Haugh O, Hennessy E, Cox D, Reis R, Tortorelli L, Murray CL, Lopez-Rodriguez AB, Jin L, Lavelle EC, Dunne A, Cunningham C. Chronic neurodegeneration induces type I interferon synthesis via STING, shaping microglial phenotype and accelerating disease progression. Glia 2019; 67:1254-1276. [PMID: 30680794 PMCID: PMC6520218 DOI: 10.1002/glia.23592] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/21/2018] [Accepted: 12/28/2018] [Indexed: 12/13/2022]
Abstract
Type I interferons (IFN‐I) are the principal antiviral molecules of the innate immune system and can be made by most cell types, including central nervous system cells. IFN‐I has been implicated in neuroinflammation during neurodegeneration, but its mechanism of induction and its consequences remain unclear. In the current study, we assessed expression of IFN‐I in murine prion disease (ME7) and examined the contribution of the IFN‐I receptor IFNAR1 to disease progression. The data indicate a robust IFNβ response, specifically in microglia, with evidence of IFN‐dependent genes in both microglia and astrocytes. This IFN‐I response was absent in stimulator of interferon genes (STING−/−) mice. Microglia showed increased numbers and activated morphology independent of genotype, but transcriptional signatures indicated an IFNAR1‐dependent neuroinflammatory phenotype. Isolation of microglia and astrocytes demonstrated disease‐associated microglial induction of Tnfα, Tgfb1, and of phagolysosomal system transcripts including those for cathepsins, Cd68, C1qa, C3, and Trem2, which were diminished in IFNAR1 and STING deficient mice. Microglial increases in activated cathepsin D, and CD68 were significantly reduced in IFNAR1−/− mice, particularly in white matter, and increases in COX‐1 expression, and prostaglandin synthesis were significantly mitigated. Disease progressed more slowly in IFNAR1−/− mice, with diminished synaptic and neuronal loss and delayed onset of neurological signs and death but without effect on proteinase K‐resistant PrP levels. Therefore, STING‐dependent IFN‐I influences microglial phenotype and influences neurodegenerative progression despite occurring secondary to initial degenerative changes. These data expand our mechanistic understanding of IFN‐I induction and its impact on microglial function during chronic neurodegeneration.
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Affiliation(s)
- Arshed Nazmi
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Robert H Field
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Eadaoin W Griffin
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Orla Haugh
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Edel Hennessy
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Donal Cox
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Renata Reis
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Lucas Tortorelli
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Carol L Murray
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Ana Belen Lopez-Rodriguez
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Lei Jin
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida
| | - Ed C Lavelle
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Aisling Dunne
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
| | - Colm Cunningham
- School of Biochemistry and Immunology, Trinity College Institute of Neuroscience & Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Republic of Ireland
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103
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Da Mesquita S, Fu Z, Kipnis J. The Meningeal Lymphatic System: A New Player in Neurophysiology. Neuron 2018; 100:375-388. [PMID: 30359603 PMCID: PMC6268162 DOI: 10.1016/j.neuron.2018.09.022] [Citation(s) in RCA: 303] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/30/2018] [Accepted: 09/11/2018] [Indexed: 12/24/2022]
Abstract
The nature of fluid dynamics within the brain parenchyma is a focus of intensive research. Of particular relevance is its participation in diseases associated with protein accumulation and aggregation in the brain, such as Alzheimer's disease (AD). The meningeal lymphatic vessels have recently been recognized as an important player in the complex circulation and exchange of soluble contents between the cerebrospinal fluid (CSF) and the interstitial fluid (ISF). In aging mammals, for example, impaired functioning of the meningeal lymphatic vessels can lead to accelerated accumulation of toxic amyloid beta protein in the brain parenchyma, thus aggravating AD-related pathology. Given that meningeal lymphatic vessels are functionally linked to paravascular influx/efflux of the CSF/ISF, and in light of recent findings that certain cytokines, classically perceived as immune molecules, exert neuromodulatory effects, it is reasonable to suggest that the activity of meningeal lymphatics could alter the accessibility of CSF-borne immune neuromodulators to the brain parenchyma, thereby altering their effects on the brain. Accordingly, in this Perspective we propose that the meningeal lymphatic system can be viewed as a novel player in neurophysiology.
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Affiliation(s)
- Sandro Da Mesquita
- Center for Brain Immunology and Glia (BIG), University of Virginia, Charlottesville, VA 22908, USA; Department of Neuroscience, University of Virginia, Charlottesville, VA 22908, USA.
| | - Zhongxiao Fu
- Center for Brain Immunology and Glia (BIG), University of Virginia, Charlottesville, VA 22908, USA; Department of Neuroscience, University of Virginia, Charlottesville, VA 22908, USA
| | - Jonathan Kipnis
- Center for Brain Immunology and Glia (BIG), University of Virginia, Charlottesville, VA 22908, USA; Department of Neuroscience, University of Virginia, Charlottesville, VA 22908, USA.
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104
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Stapel B, Sieve I, Falk CS, Bleich S, Hilfiker-Kleiner D, Kahl KG. Second generation atypical antipsychotics olanzapine and aripiprazole reduce expression and secretion of inflammatory cytokines in human immune cells. J Psychiatr Res 2018; 105:95-102. [PMID: 30216787 DOI: 10.1016/j.jpsychires.2018.08.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/10/2018] [Accepted: 08/10/2018] [Indexed: 12/21/2022]
Abstract
Schizophrenia and major depression are associated with alterations in peripheral inflammatory markers, and anti-inflammatory therapy has been proposed as a promising add-on approach in the pharmacologic treatment of both disorders. Second-generation atypical antipsychotics are currently first-line drugs in the treatment of schizophrenia and are also used as augmentation strategies in treatment-resistant major depression. Furthermore, these drugs have been reported to exhibit distinct metabolic side effects and to influence inflammatory processes. In this study, we used ex vivo stimulation of primary human peripheral blood mononuclear cells (PBMC) from healthy blood donors with atypical antipsychotics olanzapine or aripiprazole to examine effects on cytokine production independent from metabolic side effects and disease status. Both olanzapine and aripiprazole stimulation decreased mRNA levels of IL-1β, IL-6, and TNF-α and resulted in diminished protein concentrations of IL-6 and TNF-α in conditioned medium of stimulated PBMC. A multiplex approach revealed additional downregulation of IL-2; MIP-1β and IP-10 secretion. Similarly, olanzapine and aripiprazole stimulation of the human monocytic cell line THP-1 resulted in a significant decrease in expression and secretion of IL-1β and TNF-α. Our results suggest that atypical antipsychotics directly influence immune cell function and thereby highlight the importance to factor in potential side effects of drugs routinely used in treatment of schizophrenia and major depression on inflammatory processes when considering anti-inflammatory drug therapy as an additional treatment option.
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Affiliation(s)
- Britta Stapel
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; Department of Cardiology and Angiology, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Irina Sieve
- Department of Cardiology and Angiology, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Christine S Falk
- Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation, IFB-Tx, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | | | - Kai G Kahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
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105
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Duan L, Zhang XD, Miao WY, Sun YJ, Xiong G, Wu Q, Li G, Yang P, Yu H, Li H, Wang Y, Zhang M, Hu LY, Tong X, Zhou WH, Yu X. PDGFRβ Cells Rapidly Relay Inflammatory Signal from the Circulatory System to Neurons via Chemokine CCL2. Neuron 2018; 100:183-200.e8. [PMID: 30269986 DOI: 10.1016/j.neuron.2018.08.030] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 03/30/2018] [Accepted: 08/20/2018] [Indexed: 01/19/2023]
Abstract
Acute infection, if not kept in check, can lead to systemic inflammatory responses in the brain. Here, we show that within 2 hr of systemic inflammation, PDGFRβ mural cells of blood vessels rapidly secrete chemokine CCL2, which in turn increases total neuronal excitability by promoting excitatory synaptic transmission in glutamatergic neurons of multiple brain regions. By single-cell RNA sequencing, we identified Col1a1 and Rgs5 subgroups of PDGFRβ cells as the main source of CCL2. Lipopolysaccharide (LPS)- or Poly(I:C)-treated pericyte culture medium induced similar effects in a CCL2-dependent manner. Importantly, in Pdgfrb-Cre;Ccl2fl/fl mice, LPS-induced increase in excitatory synaptic transmission was significantly attenuated. These results demonstrate in vivo that PDGFRβ cells function as initial sensors of external insults by secreting CCL2, which relays the signal to the central nervous system. Through their gateway position in the brain, PDGFRβ cells are ideally positioned to respond rapidly to environmental changes and to coordinate responses.
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Affiliation(s)
- Lihui Duan
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Xiao-Di Zhang
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Wan-Ying Miao
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Yun-Jun Sun
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Guoliang Xiong
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Qiuzi Wu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Guangying Li
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Ping Yang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Hang Yu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Humingzhu Li
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China; School of Life Science and Technology, ShanghaiTech University, Shanghai 201210, China
| | - Yue Wang
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China; School of Life Science and Technology, ShanghaiTech University, Shanghai 201210, China
| | - Min Zhang
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Li-Yuan Hu
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Xiaoping Tong
- Department of Anatomy and Physiology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wen-Hao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Xiang Yu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China; School of Life Science and Technology, ShanghaiTech University, Shanghai 201210, China.
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106
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Converging pathways in neurodegeneration, from genetics to mechanisms. Nat Neurosci 2018; 21:1300-1309. [PMID: 30258237 DOI: 10.1038/s41593-018-0237-7] [Citation(s) in RCA: 320] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/07/2018] [Indexed: 02/07/2023]
Abstract
Neurodegenerative diseases cause progressive loss of cognitive and/or motor function and pose major challenges for societies with rapidly aging populations. Human genetics studies have shown that disease-causing rare mutations and risk-associated common alleles overlap in different neurodegenerative disorders. Here we review the intricate genotype-phenotype relationships and common cellular pathways emerging from recent genetic and mechanistic studies. Shared pathological mechanisms include defective protein quality-control and degradation pathways, dysfunctional mitochondrial homeostasis, stress granules, and maladaptive innate immune responses. Research efforts have started to bear fruit, as shown by recent treatment successes and an encouraging therapeutic outlook.
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107
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Garré JM, Yang G. Contributions of monocytes to nervous system disorders. J Mol Med (Berl) 2018; 96:873-883. [PMID: 30030568 PMCID: PMC6186399 DOI: 10.1007/s00109-018-1672-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 06/26/2018] [Accepted: 07/10/2018] [Indexed: 12/16/2022]
Abstract
Monocytes are a class of leukocytes derived from progenitors in the bone marrow and are prevalent in the blood stream. Although the main function of monocytes is to provide innate immune defenses against infection and injury, their contributions to the central nervous system (CNS) disorders are increasingly recognized. In this review article, we summarize the molecular and physiological properties of monocytes in relation to other myeloid cells. Primarily, we discuss how monocytes (or leukocytes) may affect neuronal function in diseases that are characterized by dysregulated innate immunity and cognitive dysfunction. Under these pathological conditions, monocytes and monocyte-derived cells (1) fail to remove neurotoxic products from CNS, (2) interact with astrocytes at the periphery-brain interfaces to alter synapse development and plasticity, or (3) infiltrate into the CNS to exacerbate neuroinflammation. Through these cellular mechanisms, we speculate that monocytes and other peripheral immune cells may affect brain functioning and contribute to behavioral and cognitive deficits. Better understanding of neuroimmune interactions will help the development of strategies to ameliorate neuronal and cognitive dysfunction associated with dysregulated innate immunity.
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Affiliation(s)
- Juan Mauricio Garré
- Department of Anesthesiology, Columbia University, New York, NY, 10032, USA.
| | - Guang Yang
- Department of Anesthesiology, Columbia University, New York, NY, 10032, USA.
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108
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Markovinovic A, Ljutic T, Béland LC, Munitic I. Optineurin Insufficiency Disbalances Proinflammatory and Anti-inflammatory Factors by Reducing Microglial IFN-β Responses. Neuroscience 2018; 388:139-151. [DOI: 10.1016/j.neuroscience.2018.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 12/14/2022]
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109
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Kummer KK, Kalpachidou T, Mitrić M, Langeslag M, Kress M. Altered Gene Expression in Prefrontal Cortex of a Fabry Disease Mouse Model. Front Mol Neurosci 2018; 11:201. [PMID: 30013462 PMCID: PMC6036252 DOI: 10.3389/fnmol.2018.00201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/18/2018] [Indexed: 11/13/2022] Open
Abstract
Fabry disease is an X-chromosome linked hereditary disease that is caused by loss of function mutations in the α-galactosidase A (α-Gal A) gene, resulting in defective glycolipid degradation and subsequent accumulation of globotriaosylceramide (Gb3) in different tissues, including vascular endothelial cells and neurons in the peripheral and central nervous system. We recently reported a differential gene expression profile of α-Gal A(−/0) mouse dorsal root ganglia, an established animal model of Fabry disease, thereby providing new gene targets that might underlie the neuropathic pain related symptoms. To investigate the cognitive symptoms experienced by Fabry patients, we performed one-color based hybridization microarray expression profiling of prefrontal cortex samples from adult α-Gal A(−/0) mice and age-matched wildtype controls, followed by protein-protein interaction and pathway analyses for the differentially regulated mRNAs. We found that from a total of 381 differentially expressed genes, 135 genes were significantly upregulated, whereas 246 genes were significantly downregulated between α-Gal A(−/0) mice and wildtype controls. Enrichment analysis for downregulated genes revealed mainly immune related pathways, including immune/defense responses, regulation of cytokine production, as well as signaling and transport regulation pathways. Further analysis of the regulated genes revealed a large number of genes involved in neurodegeneration. The current analysis for the first time presents a differential gene expression profile of central nervous system tissue from α-Gal A(−/0) mice, thereby providing novel knowledge on the deregulation and a possible contribution of gene expression to Fabry disease related brain pathologies.
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Affiliation(s)
- Kai K Kummer
- Division of Physiology, Department of Physiology and Medical Physics Medical, University of Innsbruck, Innsbruck, Austria
| | - Theodora Kalpachidou
- Division of Physiology, Department of Physiology and Medical Physics Medical, University of Innsbruck, Innsbruck, Austria
| | - Miodrag Mitrić
- Division of Physiology, Department of Physiology and Medical Physics Medical, University of Innsbruck, Innsbruck, Austria
| | - Michiel Langeslag
- Division of Physiology, Department of Physiology and Medical Physics Medical, University of Innsbruck, Innsbruck, Austria
| | - Michaela Kress
- Division of Physiology, Department of Physiology and Medical Physics Medical, University of Innsbruck, Innsbruck, Austria
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110
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Roselli F, Chandrasekar A, Morganti-Kossmann MC. Interferons in Traumatic Brain and Spinal Cord Injury: Current Evidence for Translational Application. Front Neurol 2018; 9:458. [PMID: 29971040 PMCID: PMC6018073 DOI: 10.3389/fneur.2018.00458] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 05/30/2018] [Indexed: 12/11/2022] Open
Abstract
This review article provides a general perspective of the experimental and clinical work surrounding the role of type-I, type-II, and type-III interferons (IFNs) in the pathophysiology of brain and spinal cord injury. Since IFNs are themselves well-known therapeutic targets (as well as pharmacological agents), and anti-IFNs monoclonal antibodies are being tested in clinical trials, it is timely to review the basis for the repurposing of these agents for the treatment of brain and spinal cord traumatic injury. Experimental evidence suggests that IFN-α may play a detrimental role in brain trauma, enhancing the pro-inflammatory response while keeping in check astrocyte proliferation; converging evidence from genetic models and neutralization by monoclonal antibodies suggests that limiting IFN-α actions in acute trauma may be a suitable therapeutic strategy. Effects of IFN-β administration in spinal cord and brain trauma have been reported but remain unclear or limited in effect. Despite the involvement in the inflammatory response, the role of IFN-γ remains controversial: although IFN-γ appears to improve the outcome of traumatic spinal cord injury, genetic models have produced either beneficial or detrimental results. IFNs may display opposing actions on the injured CNS relative to the concentration at which they are released and strictly dependent on whether the IFN or their receptors are targeted either via administration of neutralizing antibodies or through genetic deletion of either the mediator or its receptor. To date, IFN-α appears to most promising target for drug repurposing, and monoclonal antibodies anti IFN-α or its receptor may find appropriate use in the treatment of acute brain or spinal cord injury.
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Affiliation(s)
- Francesco Roselli
- Department of Neurology, Ulm University, Ulm, Germany.,Department of Anatomy and Cell Biology, Ulm University, Ulm, Germany
| | | | - Maria C Morganti-Kossmann
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Child Health, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, United States
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111
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Rua R, McGavern DB. Advances in Meningeal Immunity. Trends Mol Med 2018; 24:542-559. [PMID: 29731353 PMCID: PMC6044730 DOI: 10.1016/j.molmed.2018.04.003] [Citation(s) in RCA: 198] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/08/2018] [Accepted: 04/09/2018] [Indexed: 12/26/2022]
Abstract
The central nervous system (CNS) is an immunologically specialized tissue protected by a blood-brain barrier. The CNS parenchyma is enveloped by a series of overlapping membranes that are collectively referred to as the meninges. The meninges provide an additional CNS barrier, harbor a diverse array of resident immune cells, and serve as a crucial interface with the periphery. Recent studies have significantly advanced our understanding of meningeal immunity, demonstrating how a complex immune landscape influences CNS functions under steady-state and inflammatory conditions. The location and activation state of meningeal immune cells can profoundly influence CNS homeostasis and contribute to neurological disorders, but these cells are also well equipped to protect the CNS from pathogens. In this review, we discuss advances in our understanding of the meningeal immune repertoire and provide insights into how this CNS barrier operates immunologically under conditions ranging from neurocognition to inflammatory diseases.
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Affiliation(s)
- Rejane Rua
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA
| | - Dorian B McGavern
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA.
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112
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Ewald DR, Sumner SCJ. Human microbiota, blood group antigens, and disease. WILEY INTERDISCIPLINARY REVIEWS. SYSTEMS BIOLOGY AND MEDICINE 2018; 10:e1413. [PMID: 29316320 PMCID: PMC5902424 DOI: 10.1002/wsbm.1413] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/05/2017] [Accepted: 11/09/2017] [Indexed: 12/11/2022]
Abstract
Far from being just "bugs in our guts," the microbiota interacts with the body in previously unimagined ways. Research into the genome and the microbiome has revealed that the human body and the microbiota have a long-established but only recently recognized symbiotic relationship; homeostatic balance between them regulates body function. That balance is fragile, easily disturbed, and plays a fundamental role in human health-our very survival depends on the healthy functioning of these microorganisms. Increasing rates of cardiovascular, autoimmune, and inflammatory diseases, as well as epidemics in obesity and diabetes in recent decades are believed to be explained, in part, by unintended effects on the microbiota from vaccinations, poor diets, environmental chemicals, indiscriminate antibiotic use, and "germophobia." Discovery and exploration of the brain-gut-microbiota axis have provided new insights into functional diseases of the gut, autoimmune and stress-related disorders, and the role of probiotics in treating certain affective disorders; it may even explain some aspects of autism. Research into dietary effects on the human gut microbiota led to its classification into three proposed enterotypes, but also revealed the surprising role of blood group antigens in shaping those populations. Blood group antigens have previously been associated with disease risks; their subsequent association with the microbiota may reveal mechanisms that lead to development of nutritional interventions and improved treatment modalities. Further exploration of associations between specific enteric microbes and specific metabolites will foster new dietary interventions, treatment modalities, and genetic therapies, and inevitably, their application in personalized healthcare strategies. This article is categorized under: Laboratory Methods and Technologies > Metabolomics Translational, Genomic, and Systems Medicine > Translational Medicine Physiology > Mammalian Physiology in Health and Disease.
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Affiliation(s)
- D Rose Ewald
- Department of Nutrition, University of North Carolina at Chapel Hill, Kannapolis, NC, 28081
| | - Susan CJ Sumner
- Department of Nutrition, University of North Carolina at Chapel Hill, Kannapolis, NC, 28081
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113
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Patas K, Willing A, Demiralay C, Engler JB, Lupu A, Ramien C, Schäfer T, Gach C, Stumm L, Chan K, Vignali M, Arck PC, Friese MA, Pless O, Wiedemann K, Agorastos A, Gold SM. T Cell Phenotype and T Cell Receptor Repertoire in Patients with Major Depressive Disorder. Front Immunol 2018. [PMID: 29515587 PMCID: PMC5826233 DOI: 10.3389/fimmu.2018.00291] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
While a link between inflammation and the development of neuropsychiatric disorders, including major depressive disorder (MDD) is supported by a growing body of evidence, little is known about the contribution of aberrant adaptive immunity in this context. Here, we conducted in-depth characterization of T cell phenotype and T cell receptor (TCR) repertoire in MDD. For this cross-sectional case–control study, we recruited antidepressant-free patients with MDD without any somatic or psychiatric comorbidities (n = 20), who were individually matched for sex, age, body mass index, and smoking status to a non-depressed control subject (n = 20). T cell phenotype and repertoire were interrogated using a combination of flow cytometry, gene expression analysis, and next generation sequencing. T cells from MDD patients showed significantly lower surface expression of the chemokine receptors CXCR3 and CCR6, which are known to be central to T cell differentiation and trafficking. In addition, we observed a shift within the CD4+ T cell compartment characterized by a higher frequency of CD4+CD25highCD127low/− cells and higher FOXP3 mRNA expression in purified CD4+ T cells obtained from patients with MDD. Finally, flow cytometry-based TCR Vβ repertoire analysis indicated a less diverse CD4+ T cell repertoire in MDD, which was corroborated by next generation sequencing of the TCR β chain CDR3 region. Overall, these results suggest that T cell phenotype and TCR utilization are skewed on several levels in patients with MDD. Our study identifies putative cellular and molecular signatures of dysregulated adaptive immunity and reinforces the notion that T cells are a pathophysiologically relevant cell population in this disorder.
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Affiliation(s)
- Kostas Patas
- Institut für Neuroimmunologie und Multiple Sklerose (INIMS), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Willing
- Institut für Neuroimmunologie und Multiple Sklerose (INIMS), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Cüneyt Demiralay
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Broder Engler
- Institut für Neuroimmunologie und Multiple Sklerose (INIMS), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Andreea Lupu
- Institut für Neuroimmunologie und Multiple Sklerose (INIMS), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.,Immunomodulation Group, Cantacuzino National Research Institute, Bucharest, Romania
| | - Caren Ramien
- Institut für Neuroimmunologie und Multiple Sklerose (INIMS), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Laura Stumm
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Kenneth Chan
- Adaptive Biotechnologies, Seattle, WA, Unites States
| | | | - Petra C Arck
- Experimentelle Feto-Maternale Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Manuel A Friese
- Institut für Neuroimmunologie und Multiple Sklerose (INIMS), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ole Pless
- Fraunhofer IME ScreeningPort, Hamburg, Germany
| | - Klaus Wiedemann
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Agorastos Agorastos
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan M Gold
- Institut für Neuroimmunologie und Multiple Sklerose (INIMS), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.,Charité - Universitätsmedizin Berlin, Humboldt Universität zu Berlin, Berlin Institute of Health (BIH), Klinik für Psychiatrie und Psychotherapie, Campus Benjamin Franklin (CBF), Berlin, Germany
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114
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Leighton SP, Nerurkar L, Krishnadas R, Johnman C, Graham GJ, Cavanagh J. Chemokines in depression in health and in inflammatory illness: a systematic review and meta-analysis. Mol Psychiatry 2018; 23:48-58. [PMID: 29133955 PMCID: PMC5754468 DOI: 10.1038/mp.2017.205] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/02/2017] [Accepted: 08/07/2017] [Indexed: 02/07/2023]
Abstract
Inflammatory illness is associated with depression. Preclinical work has shown that chemokines are linked with peripheral-central crosstalk and may be important in mediating depressive behaviours. We sought to establish what evidence exists that differences in blood or cerebrospinal fluid chemokine concentration discriminate between individuals with depression and those without. Following PRISMA guidelines, we systematically searched Embase, PsycINFO and Medline databases. We included participants with physical illness for subgroup analysis, and excluded participants with comorbid psychiatric diagnoses. Seventy-three studies met the inclusion criteria for the meta-analysis. Individuals with depression had higher levels of blood CXCL4 and CXCL7 and lower levels of blood CCL4. Sensitivity analysis of studies with only physically healthy participants identified higher blood levels of CCL2, CCL3, CCL11, CXCL7 and CXCL8 and lower blood levels of CCL4. All other chemokines examined did not reveal significant differences (blood CCL5, CCL7, CXCL9, CXCL10 and cerebrospinal fluid CXCL8 and CXCL10). Analysis of the clinical utility of the effect size of plasma CXCL8 in healthy individuals found a negative predictive value 93.5%, given the population prevalence of depression of 10%. Overall, our meta-analysis finds evidence linking abnormalities of blood chemokines with depression in humans. Furthermore, we have demonstrated the possibility of classifying individuals with depression based on their inflammatory biomarker profile. Future research should explore putative mechanisms underlying this association, attempt to replicate existing findings in larger populations and aim to develop new diagnostic and therapeutic strategies.
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Affiliation(s)
- S P Leighton
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - L Nerurkar
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - R Krishnadas
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - C Johnman
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - G J Graham
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - J Cavanagh
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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115
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Interferon-ɣ mediated signaling in the brain endothelium is critical for inflammation-induced aversion. Brain Behav Immun 2018; 67:54-58. [PMID: 28864260 DOI: 10.1016/j.bbi.2017.08.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 01/09/2023] Open
Abstract
Systemic inflammation elicits malaise and a negative affective state. The mechanism underpinning the aversive component of inflammation include cerebral prostaglandin synthesis and modulation of dopaminergic reward circuits, but the messengers that mediate the signaling between the peripheral inflammation and the brain have not been sufficiently characterized. Here we investigated the role of interferon-ɣ (IFN-ɣ) in the aversive response to systemic inflammation induced by a low dose (10μg/kg) of lipopolysaccharide (LPS) in mice. LPS induced IFN-ɣ expression in the blood and deletion of IFN-ɣ or its receptor prevented the development of conditioned place aversion to LPS. LPS induced expression of the chemokine Cxcl10 in the striatum of normal mice, but this induction was absent in mice lacking IFN-ɣ receptors or Myd88 in blood brain barrier endothelial cells. Furthermore, inflammation-induced aversion was blocked in mice lacking Cxcl10 or its receptor Cxcr3. Finally, mice with a selective deletion of the IFN-ɣ receptor in brain endothelial cells did not develop inflammation-induced aversion, demonstrating that the brain endothelium is the critical site of IFN-ɣ action. Collectively, these findings show that circulating IFN-ɣ that binds to receptors on brain endothelial cells and induces Cxcl10, is a central link in the signaling chain eliciting inflammation-induced aversion.
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116
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Boff D, Fagundes CT, Russo RC, Amaral FA. Innate Immunity and Inflammation: The Molecular Mechanisms Governing the Cross-Talk Between Innate Immune and Endothelial Cells. IMMUNOPHARMACOLOGY AND INFLAMMATION 2018:33-56. [DOI: 10.1007/978-3-319-77658-3_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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117
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Menard C, Pfau ML, Hodes GE, Kana V, Wang VX, Bouchard S, Takahashi A, Flanigan ME, Aleyasin H, LeClair KB, Janssen WG, Labonté B, Parise EM, Lorsch ZS, Golden SA, Heshmati M, Tamminga C, Turecki G, Campbell M, Fayad ZA, Tang CY, Merad M, Russo SJ. Social stress induces neurovascular pathology promoting depression. Nat Neurosci 2017; 20:1752-1760. [PMID: 29184215 PMCID: PMC5726568 DOI: 10.1038/s41593-017-0010-3] [Citation(s) in RCA: 663] [Impact Index Per Article: 82.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/27/2017] [Indexed: 02/07/2023]
Abstract
Studies suggest that heightened peripheral inflammation contributes to the pathogenesis of major depressive disorder. We investigated the effect of chronic social defeat stress, a mouse model of depression, on blood-brain barrier (BBB) permeability and infiltration of peripheral immune signals. We found reduced expression of the endothelial cell tight junction protein claudin-5 (Cldn5) and abnormal blood vessel morphology in nucleus accumbens (NAc) of stress-susceptible but not resilient mice. CLDN5 expression was also decreased in NAc of depressed patients. Cldn5 downregulation was sufficient to induce depression-like behaviors following subthreshold social stress whereas chronic antidepressant treatment rescued Cldn5 loss and promoted resilience. Reduced BBB integrity in NAc of stress-susceptible or mice injected with adeno-associated virus expressing shRNA against Cldn5 caused infiltration of the peripheral cytokine interleukin-6 (IL-6) into brain parenchyma and subsequent expression of depression-like behaviors. These findings suggest that chronic social stress alters BBB integrity through loss of tight junction protein Cldn5, promoting peripheral IL-6 passage across the BBB and depression.
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Affiliation(s)
- Caroline Menard
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Département de psychiatrie et neurosciences, Faculté de médecine and CERVO Brain Research Centre, Université Laval, Quebec City, QC, Canada
| | - Madeline L Pfau
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Georgia E Hodes
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Veronika Kana
- Department of Oncological Sciences, Tisch Cancer Institute and Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Victoria X Wang
- Department of Radiology, Translational and Molecular Imaging Institute at Mount Sinai, New York, NY, USA
| | - Sylvain Bouchard
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aki Takahashi
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- University of Tsukuba, Tsukuba, Japan
| | - Meghan E Flanigan
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hossein Aleyasin
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine B LeClair
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William G Janssen
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Benoit Labonté
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric M Parise
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zachary S Lorsch
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sam A Golden
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mitra Heshmati
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carol Tamminga
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Gustavo Turecki
- Douglas Mental Health University Institute and McGill University, Montreal, QC, Canada
| | - Matthew Campbell
- Smurfit Institute of Genetics, Trinity College Dublin, Dublin 2, Ireland
| | - Zahi A Fayad
- Department of Radiology, Translational and Molecular Imaging Institute at Mount Sinai, New York, NY, USA
| | - Cheuk Ying Tang
- Department of Radiology, Translational and Molecular Imaging Institute at Mount Sinai, New York, NY, USA
| | - Miriam Merad
- Department of Oncological Sciences, Tisch Cancer Institute and Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Scott J Russo
- Fishberg Department of Neuroscience and the Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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118
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Muller PA, Mucida D. Spineless Behavior of CX3CR1 + Monocytes in Response to Infection. Immunity 2017; 47:12-14. [PMID: 28723545 DOI: 10.1016/j.immuni.2017.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Sickness in mammals can lead to cognition deficits, although the underlying mechanisms remain elusive. In a recent Nature Medicine article, Garré et al. (2017) report that sickness-induced cortical dendritic spine loss and impaired memory formation is mediated by CX3CR1+ monocyte-derived TNF-α.
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Affiliation(s)
- Paul A Muller
- Laboratory of Mucosal Immunology, The Rockefeller University, 1230 York Ave, New York, NY 10065, USA.
| | - Daniel Mucida
- Laboratory of Mucosal Immunology, The Rockefeller University, 1230 York Ave, New York, NY 10065, USA.
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119
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Blackmore S, Hernandez J, Juda M, Ryder E, Freund GG, Johnson RW, Steelman AJ. Influenza infection triggers disease in a genetic model of experimental autoimmune encephalomyelitis. Proc Natl Acad Sci U S A 2017; 114:E6107-E6116. [PMID: 28696309 PMCID: PMC5544260 DOI: 10.1073/pnas.1620415114] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system. Most MS patients experience periods of symptom exacerbation (relapses) followed by periods of partial recovery (remission). Interestingly, upper-respiratory viral infections increase the risk for relapse. Here, we used an autoimmune-prone T-cell receptor transgenic mouse (2D2) and a mouse-adapted human influenza virus to test the hypothesis that upper-respiratory viral infection can cause glial activation, promote immune cell trafficking to the CNS, and trigger disease. Specifically, we inoculated 2D2 mice with influenza A virus (Puerto Rico/8/34; PR8) and then monitored them for symptoms of inflammatory demyelination. Clinical and histological experimental autoimmune encephalomyelitis was observed in ∼29% of infected 2D2 mice. To further understand how peripheral infection could contribute to disease onset, we inoculated wild-type C57BL/6 mice and measured transcriptomic alterations occurring in the cerebellum and spinal cord and monitored immune cell surveillance of the CNS by flow cytometry. Infection caused temporal alterations in the transcriptome of both the cerebellum and spinal cord that was consistent with glial activation and increased T-cell, monocyte, and neutrophil trafficking to the brain at day 8 post infection. Finally, Cxcl5 expression was up-regulated in the brains of influenza-infected mice and was elevated in cerebrospinal fluid of MS patients during relapse compared with specimens acquired during remission. Collectively, these data identify a mechanism by which peripheral infection may exacerbate MS as well as other neurological diseases.
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Affiliation(s)
- Stephen Blackmore
- Department of Animal Sciences, University of Illinois Urbana-Champaign, Urbana, IL 61801
| | - Jessica Hernandez
- Department of Animal Sciences, University of Illinois Urbana-Champaign, Urbana, IL 61801
| | - Michal Juda
- Department of Animal Sciences, University of Illinois Urbana-Champaign, Urbana, IL 61801
| | - Emily Ryder
- Neuroscience Program, University of Illinois Urbana-Champaign, Urbana, IL 61801
| | - Gregory G Freund
- Department of Animal Sciences, University of Illinois Urbana-Champaign, Urbana, IL 61801
- Department of Pathology, University of Illinois Urbana-Champaign, Urbana, IL 61801
| | - Rodney W Johnson
- Department of Animal Sciences, University of Illinois Urbana-Champaign, Urbana, IL 61801
- Neuroscience Program, University of Illinois Urbana-Champaign, Urbana, IL 61801
- Division of Nutritional Sciences, University of Illinois Urbana-Champaign, Urbana, IL 61801
| | - Andrew J Steelman
- Department of Animal Sciences, University of Illinois Urbana-Champaign, Urbana, IL 61801;
- Neuroscience Program, University of Illinois Urbana-Champaign, Urbana, IL 61801
- Division of Nutritional Sciences, University of Illinois Urbana-Champaign, Urbana, IL 61801
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120
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Wekerle H. Brain Autoimmunity and Intestinal Microbiota: 100 Trillion Game Changers. Trends Immunol 2017; 38:483-497. [DOI: 10.1016/j.it.2017.03.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 02/17/2017] [Accepted: 03/31/2017] [Indexed: 02/07/2023]
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121
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Filiano AJ, Gadani SP, Kipnis J. How and why do T cells and their derived cytokines affect the injured and healthy brain? Nat Rev Neurosci 2017; 18:375-384. [PMID: 28446786 PMCID: PMC5823005 DOI: 10.1038/nrn.2017.39] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The evolution of adaptive immunity provides enhanced defence against specific pathogens, as well as homeostatic immune surveillance of all tissues. Despite being 'immune privileged', the CNS uses the assistance of the immune system in physiological and pathological states. In this Opinion article, we discuss the influence of adaptive immunity on recovery after CNS injury and on cognitive and social brain function. We further extend a hypothesis that the pro-social effects of interferon-regulated genes were initially exploited by pathogens to increase host-host transmission, and that these genes were later recycled by the host to form part of an immune defence programme. In this way, the evolution of adaptive immunity may reflect a host-pathogen 'arms race'.
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Affiliation(s)
- Anthony J Filiano
- Center for Brain Immunology and Glia, Department of Neuroscience, School of Medicine, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Sachin P Gadani
- Center for Brain Immunology and Glia, Department of Neuroscience, School of Medicine, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Jonathan Kipnis
- Center for Brain Immunology and Glia, Department of Neuroscience, School of Medicine, University of Virginia, Charlottesville, Virginia 22908, USA
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122
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Blank T, Prinz M. Type I interferon pathway in CNS homeostasis and neurological disorders. Glia 2017; 65:1397-1406. [PMID: 28519900 DOI: 10.1002/glia.23154] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 04/01/2017] [Accepted: 04/04/2017] [Indexed: 01/12/2023]
Abstract
Type I interferons (IFNs), IFN-α and IFN-β, represent the major effector cytokines of the host immune response against viruses and other intracellular pathogens. These cytokines are produced via activation of numerous pattern recognition receptors, including the Toll-like receptor signaling network, retinoic acid-inducible gene-1 (RIG-1), melanoma differentiation-associated protein-5 (MDA-5) and interferon gamma-inducible protein-16 (IFI-16). Whilst the contribution of type I IFNs to peripheral immunity is well documented, they can also be produced by almost every cell in the central nervous system (CNS). Furthermore, IFNs can reach the CNS from the periphery to modulate the function of not only microglia and astrocytes, but also neurons and oligodendrocytes, with major consequences for cognition and behavior. Given the pleiotropic nature of type I IFNs, it is critical to determine their exact cellular impact. Inappropriate upregulation of type I IFN signaling and interferon-stimulated gene expression have been linked to several CNS diseases termed "interferonopathies" including Aicardi-Goutieres syndrome and ubiquitin specific peptidase 18 (USP18)-deficiency. In contrast, in the CNS of mice with virus-induced neuroinflammation, type I IFNs can limit production of other cytokines to prevent potential damage associated with chronic cytokine expression. This capacity of type I IFNs could also explain the therapeutic benefits of exogenous type I IFN in chronic CNS autoimmune diseases such as multiple sclerosis. In this review we will highlight the importance of a well-balanced level of type I IFNs for healthy brain physiology, and to what extent dysregulation of this cytokine system can result in brain 'interferonopathies'.
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Affiliation(s)
- Thomas Blank
- Institute of Neuropathology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Prinz
- Institute of Neuropathology, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,BIOSS Centre for Biological Signalling Studies, University of Freiburg, Freiburg, Germany
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123
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CX3CR1 + monocytes modulate learning and learning-dependent dendritic spine remodeling via TNF-α. Nat Med 2017; 23:714-722. [PMID: 28504723 PMCID: PMC5590232 DOI: 10.1038/nm.4340] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 04/11/2017] [Indexed: 02/07/2023]
Abstract
Impaired learning and cognitive function often occurs during systemic infection or inflammation. Although activation of the innate immune system has been linked to the behavioral and cognitive effects that are associated with infection, the underlying mechanisms remain poorly understood. Here we mimicked viral immune activation with poly(I:C), a synthetic analog of double-stranded RNA, and longitudinally imaged postsynaptic dendritic spines of layer V pyramidal neurons in the mouse primary motor cortex using two-photon microscopy. We found that peripheral immune activation caused dendritic spine loss, impairments in learning-dependent dendritic spine formation and deficits in multiple learning tasks in mice. These observed synaptic alterations in the cortex were mediated by peripheral-monocyte-derived cells and did not require microglial function in the central nervous system. Furthermore, activation of CX3CR1highLy6Clow monocytes impaired motor learning and learning-related dendritic spine plasticity through tumor necrosis factor (TNF)-α-dependent mechanisms. Taken together, our results highlight CX3CR1high monocytes and TNF-α as potential therapeutic targets for preventing infection-induced cognitive dysfunction.
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124
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Schnöder TM, Eberhardt J, Koehler M, Bierhoff HB, Weinert S, Pandey AD, Nimmagadda SC, Wolleschak D, Jöhrens K, Fischer T, Heidel FH. Cell autonomous expression of CXCL-10 in JAK2V617F-mutated MPN. J Cancer Res Clin Oncol 2017; 143:807-820. [PMID: 28233092 DOI: 10.1007/s00432-017-2354-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 01/27/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE Myeloproliferative neoplasms (MPN) are clonal disorders of hematopoietic stem- and progenitor cells. Mutation of Janus-Kinase 2 (JAK2) is the most frequent genetic event detected in Philadelphia-negative MPN. In advanced phases, the clinical hallmark of the disease is a striking inflammatory syndrome. So far, the cellular and molecular basis of inflammation is not fully understood. We, therefore, sought to investigate the relationship of activating JAK2 mutation and aberrant cytokine expression in MPN. METHODS Cytokine array was performed to identify Jak2V617F-related cytokine expression and secretion. CXCL10 mRNA expression was analyzed by qPCR in peripheral blood cells. To exclude paracrine/autocrine stimulation as a potential mechanism, we generated Ba/F3-EpoR-JAK2WT or EpoR-JAK2V617F cells lacking CXCL10 receptor. Pharmacologic inhibition of JAK2 kinase was achieved by JAK-Inhibitor treatment. Signaling pathways and downstream effectors were characterized by Western blotting, immunofluorescence microscopy, luciferase reporter assays, qPCR, and chromatin-immunoprecipitation studies. RESULTS We identified CXCL10 as the most highly induced cytokine in JAK2-mutated cell lines. In MPN patients, CXCL10 is highly expressed in JAK2V617F but not JAK2WT MPN or healthy donor controls. Moreover, CXCL10 expression correlates with JAK2V617F allelic burden. High CXCL10 correlates with the presence of clinical risk factors but not with clinical symptoms and quality of life. Pharmacologic inhibition of mutated JAK2 kinase inhibits CXCL10 expression. NFκB signaling is activated downstream of JAK2V617F receptor and directly induces CXCL10 expression. CONCLUSIONS Our data provide first evidence for a link between oncogenic JAK2V617F signaling and cell intrinsic induction of CXCL10 induced by activated NFkB signaling.
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Affiliation(s)
- Tina M Schnöder
- Innere Medizin II, Hämatologie und Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
- Leibniz Institute on Aging, Fritz-Lipmann-Institute, Jena, Germany
| | - Judith Eberhardt
- Department of Hematology and Oncology, Otto-von-Guericke University Medical Center, Magdeburg, Germany
| | - Michael Koehler
- Department of Hematology and Oncology, Otto-von-Guericke University Medical Center, Magdeburg, Germany
| | - Holger B Bierhoff
- Leibniz Institute on Aging, Fritz-Lipmann-Institute, Jena, Germany
- Department of Genetics, Friedrich-Schiller-University, Jena, Germany
| | - Sönke Weinert
- Department of Cardiology, Otto-von-Guericke University Medical Center, Magdeburg, Germany
| | - Akhilesh Datt Pandey
- Department of Hematology and Oncology, Otto-von-Guericke University Medical Center, Magdeburg, Germany
| | - Subbaiah Chary Nimmagadda
- Department of Hematology and Oncology, Otto-von-Guericke University Medical Center, Magdeburg, Germany
| | - Denise Wolleschak
- Department of Hematology and Oncology, Otto-von-Guericke University Medical Center, Magdeburg, Germany
| | - Korinna Jöhrens
- Institut für Pathologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Fischer
- Department of Hematology and Oncology, Otto-von-Guericke University Medical Center, Magdeburg, Germany
- Collaborative Research Cluster 854 (CRC854), Medical Faculty, University Hospital Magdeburg, Magdeburg, Germany
| | - Florian H Heidel
- Innere Medizin II, Hämatologie und Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
- Leibniz Institute on Aging, Fritz-Lipmann-Institute, Jena, Germany.
- Collaborative Research Cluster 854 (CRC854), Medical Faculty, University Hospital Magdeburg, Magdeburg, Germany.
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125
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The opioid antagonist, β-funaltrexamine, inhibits lipopolysaccharide-induced neuroinflammation and reduces sickness behavior in mice. Physiol Behav 2017; 173:52-60. [DOI: 10.1016/j.physbeh.2017.01.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 11/20/2022]
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126
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Gene expression patterns associated with neurological disease in human HIV infection. PLoS One 2017; 12:e0175316. [PMID: 28445538 PMCID: PMC5405951 DOI: 10.1371/journal.pone.0175316] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/23/2017] [Indexed: 12/01/2022] Open
Abstract
The pathogenesis and nosology of HIV-associated neurological disease (HAND) remain incompletely understood. Here, to provide new insight into the molecular events leading to neurocognitive impairments (NCI) in HIV infection, we analyzed pathway dysregulations in gene expression profiles of HIV-infected patients with or without NCI and HIV encephalitis (HIVE) and control subjects. The Gene Set Enrichment Analysis (GSEA) algorithm was used for pathway analyses in conjunction with the Molecular Signatures Database collection of canonical pathways (MSigDb). We analyzed pathway dysregulations in gene expression profiles of patients from the National NeuroAIDS Tissue Consortium (NNTC), which consists of samples from 3 different brain regions, including white matter, basal ganglia and frontal cortex of HIV-infected and control patients. While HIVE is characterized by widespread, uncontrolled inflammation and tissue damage, substantial gene expression evidence of induction of interferon (IFN), cytokines and tissue injury is apparent in all brain regions studied, even in the absence of NCI. Various degrees of white matter changes were present in all HIV-infected subjects and were the primary manifestation in patients with NCI in the absence of HIVE. In particular, NCI in patients without HIVE in the NNTC sample is associated with white matter expression of chemokines, cytokines and β-defensins, without significant activation of IFN. Altogether, the results identified distinct pathways differentially regulated over the course of neurological disease in HIV infection and provide a new perspective on the dynamics of pathogenic processes in the course of HIV neurological disease in humans. These results also demonstrate the power of the systems biology analyses and indicate that the establishment of larger human gene expression profile datasets will have the potential to provide novel mechanistic insight into the pathogenesis of neurological disease in HIV infection and identify better therapeutic targets for NCI.
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127
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Pikor NB, Cupovic J, Onder L, Gommerman JL, Ludewig B. Stromal Cell Niches in the Inflamed Central Nervous System. THE JOURNAL OF IMMUNOLOGY 2017; 198:1775-1781. [DOI: 10.4049/jimmunol.1601566] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 10/19/2016] [Indexed: 11/19/2022]
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128
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Klein RS, Garber C, Howard N. Infectious immunity in the central nervous system and brain function. Nat Immunol 2017; 18:132-141. [PMID: 28092376 DOI: 10.1038/ni.3656] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/02/2016] [Indexed: 11/09/2022]
Abstract
Inflammation is emerging as a critical mechanism underlying neurological disorders of various etiologies, yet its role in altering brain function as a consequence of neuroinfectious disease remains unclear. Although acute alterations in mental status due to inflammation are a hallmark of central nervous system (CNS) infections with neurotropic pathogens, post-infectious neurologic dysfunction has traditionally been attributed to irreversible damage caused by the pathogens themselves. More recently, studies indicate that pathogen eradication within the CNS may require immune responses that interfere with neural cell function and communication without affecting their survival. In this Review we explore inflammatory processes underlying neurological impairments caused by CNS infection and discuss their potential links to established mechanisms of psychiatric and neurodegenerative diseases.
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Affiliation(s)
- Robyn S Klein
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neuroscience, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charise Garber
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nicole Howard
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
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129
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Troy NM, Bosco A. Respiratory viral infections and host responses; insights from genomics. Respir Res 2016; 17:156. [PMID: 27871304 PMCID: PMC5117516 DOI: 10.1186/s12931-016-0474-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 11/10/2016] [Indexed: 01/23/2023] Open
Abstract
Respiratory viral infections are a leading cause of disease and mortality. The severity of these illnesses can vary markedly from mild or asymptomatic upper airway infections to severe wheezing, bronchiolitis or pneumonia. In this article, we review the viral sensing pathways and organizing principles that govern the innate immune response to infection. Then, we reconstruct the molecular networks that differentiate symptomatic from asymptomatic respiratory viral infections, and identify the underlying molecular drivers of these networks. Finally, we discuss unique aspects of the biology and pathogenesis of infections with respiratory syncytial virus, rhinovirus and influenza, drawing on insights from genomics.
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Affiliation(s)
- Niamh M Troy
- Telethon Kids Institute, The University of Western Australia, Subiaco, Australia
| | - Anthony Bosco
- Telethon Kids Institute, The University of Western Australia, Subiaco, Australia.
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130
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Söderholm S, Fu Y, Gaelings L, Belanov S, Yetukuri L, Berlinkov M, Cheltsov AV, Anders S, Aittokallio T, Nyman TA, Matikainen S, Kainov DE. Multi-Omics Studies towards Novel Modulators of Influenza A Virus-Host Interaction. Viruses 2016; 8:v8100269. [PMID: 27690086 PMCID: PMC5086605 DOI: 10.3390/v8100269] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 09/13/2016] [Accepted: 09/22/2016] [Indexed: 12/20/2022] Open
Abstract
Human influenza A viruses (IAVs) cause global pandemics and epidemics. These viruses evolve rapidly, making current treatment options ineffective. To identify novel modulators of IAV–host interactions, we re-analyzed our recent transcriptomics, metabolomics, proteomics, phosphoproteomics, and genomics/virtual ligand screening data. We identified 713 potential modulators targeting 199 cellular and two viral proteins. Anti-influenza activity for 48 of them has been reported previously, whereas the antiviral efficacy of the 665 remains unknown. Studying anti-influenza efficacy and immuno/neuro-modulating properties of these compounds and their combinations as well as potential viral and host resistance to them may lead to the discovery of novel modulators of IAV–host interactions, which might be more effective than the currently available anti-influenza therapeutics.
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Affiliation(s)
- Sandra Söderholm
- Institute of Biotechnology, University of Helsinki, Helsinki 00014, Finland.
- Finnish Institute of Occupational Health, Helsinki 00250, Finland.
| | - Yu Fu
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki 00014, Finland.
| | - Lana Gaelings
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki 00014, Finland.
| | - Sergey Belanov
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki 00014, Finland.
| | - Laxman Yetukuri
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki 00014, Finland.
| | - Mikhail Berlinkov
- Institute of Mathematics and Computer Science, Ural Federal University, Yekaterinburg 620083, Russia.
| | - Anton V Cheltsov
- Q-Mol L.L.C. in Silico Pharmaceuticals, San Diego, CA 92037, USA.
| | - Simon Anders
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki 00014, Finland.
| | - Tero Aittokallio
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki 00014, Finland.
- Department of Mathematics and Statistics, University of Turku, Turku 20014, Finland.
| | | | - Sampsa Matikainen
- Finnish Institute of Occupational Health, Helsinki 00250, Finland.
- Department of Rheumatology, Helsinki University Hospital, University of Helsinki, Helsinki 00015, Finland.
| | - Denis E Kainov
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki 00014, Finland.
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131
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Abstract
In this issue of Immunity, Prinz and colleagues (2016) describe an unexpected mechanism underlying the role of type I interferon in the initiation of cognitive impairment and sickness behavior during viral infection through induction of chemokine CXCL10 in central nervous system epithelial and endothelial cells.
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132
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Sun L, Wang X, Zhou Y, Zhou RH, Ho WZ, Li JL. Exosomes contribute to the transmission of anti-HIV activity from TLR3-activated brain microvascular endothelial cells to macrophages. Antiviral Res 2016; 134:167-171. [PMID: 27496004 DOI: 10.1016/j.antiviral.2016.07.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/01/2016] [Indexed: 12/17/2022]
Abstract
Human brain microvascular endothelial cells (HBMECs), the major cell type in the blood-brain barrier (BBB), play a key role in maintaining brain homeostasis. However, their role in the BBB innate immunity against HIV invasion of the central nervous system (CNS) remains to be determined. Our early work showed that TLR3 signaling of HBMECs could produce the antiviral factors that inhibit HIV replication in macrophages. The present study examined whether exosomes from TLR3-activated HBMECs mediate the intercellular transfer of antiviral factors to macrophages. Primary human macrophages could take up exosomes from TLR3-activated HBMECs. HBMECs-derived exosomes contained multiple antiviral factors, including several key IFN-stimulated genes (ISGs; ISG15, ISG56, and Mx2) at mRNA and protein levels. The depletion of exosomes from TLR3-activated HBMECs culture supernatant diminished HBMECs-mediated anti-HIV activity in macrophages. In conclusion, we demonstrate that exosomes shed by HBMECs are able to transport the antiviral molecules to macrophages. This finding suggests the possibility that HIV nonpermissive BBB cells (HBMECs) can help to restore the antiviral state in HIV-infected macrophages, which may be a defense mechanism against HIV neuroinvasion.
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Affiliation(s)
- Li Sun
- School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China
| | - Xu Wang
- State Key Laboratory of Virology, Wuhan University, Wuhan, 430071, China; Department of Pathology and Laboratory Medicine, Temple University, Lewis Katz School of Medicine, Philadelphia, PA, 19140, USA
| | - Yu Zhou
- Department of Pathology and Laboratory Medicine, Temple University, Lewis Katz School of Medicine, Philadelphia, PA, 19140, USA
| | - Run-Hong Zhou
- School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China
| | - Wen-Zhe Ho
- School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China; State Key Laboratory of Virology, Wuhan University, Wuhan, 430071, China; Department of Pathology and Laboratory Medicine, Temple University, Lewis Katz School of Medicine, Philadelphia, PA, 19140, USA.
| | - Jie-Liang Li
- Department of Pathology and Laboratory Medicine, Temple University, Lewis Katz School of Medicine, Philadelphia, PA, 19140, USA.
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