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Srivastava RK, Sapra L, Bhardwaj A, Mishra PK, Verma B, Baig Z. Unravelling the immunobiology of innate lymphoid cells (ILCs): Implications in health and disease. Cytokine Growth Factor Rev 2023; 74:56-75. [PMID: 37743134 DOI: 10.1016/j.cytogfr.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/09/2023] [Accepted: 09/13/2023] [Indexed: 09/26/2023]
Abstract
Innate lymphoid cells (ILCs), a growing class of immune cells, imitate the appearance and abilities of T cells. However, unlike T cells, ILCs lack acquired antigen receptors, and they also do not undergo clonal selection or proliferation in response to antigenic stimuli. Despite lacking antigen-specific receptors, ILCs respond quickly to signals from infected or damaged tissues and generate an array of cytokines that regulate the development of adaptive immune response. ILCs can be categorized into four types based on their signature cytokines and transcription factors: ILC1, ILC2, ILC3 (including Lymphoid Tissue inducer- LTi cells), and regulatory ILCs (ILCregs). ILCs play key functions in controlling and resolving inflammation, and variations in their proportion are linked to various pathological diseases including cancer, gastrointestinal, pulmonary, and skin diseases. We highlight current advancements in the biology and classification of ILCs in this review. Additionally, we provide a thorough overview of their contributions to several inflammatory bone-related pathologies, including osteoporosis, rheumatoid arthritis, periodontitis, and ankylosing spondylitis. Understanding the multiple functions of ILCs in both physiological and pathological conditions will further mobilize future research towards targeting ILCs for therapeutic purposes.
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Affiliation(s)
- Rupesh K Srivastava
- Translational Immunology, Osteoimmunology & Immunoporosis Lab (TIOIL), Department of Biotechnology, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India.
| | - Leena Sapra
- Translational Immunology, Osteoimmunology & Immunoporosis Lab (TIOIL), Department of Biotechnology, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
| | - Asha Bhardwaj
- Translational Immunology, Osteoimmunology & Immunoporosis Lab (TIOIL), Department of Biotechnology, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
| | | | - Bhupendra Verma
- Department of Biotechnology, All India Institute of Medical Sciences(AIIMS), New Delhi-110029, India
| | - Zainab Baig
- Translational Immunology, Osteoimmunology & Immunoporosis Lab (TIOIL), Department of Biotechnology, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
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Wang C, Du Z, Li R, Luo Y, Zhu C, Ding N, Lei A. Interferons as negative regulators of ILC2s in allergic lung inflammation and respiratory viral infections. J Mol Med (Berl) 2023; 101:947-959. [PMID: 37414870 DOI: 10.1007/s00109-023-02345-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
Group 2 innate lymphoid cells (ILC2s), characterized by a lack of antigen receptors, have been regarded as an important component of type 2 pulmonary immunity. Analogous to Th2 cells, ILC2s are capable of releasing type 2 cytokines and amphiregulin, thus playing an essential role in a variety of diseases, such as allergic diseases and virus-induced respiratory diseases. Interferons (IFNs), an important family of cytokines with potent antiviral effects, can be triggered by microbial products, microbial exposure, and pathogen infections. Interestingly, the past few years have witnessed encouraging progress in revealing the important role of IFNs and IFN-producing cells in modulating ILC2 responses in allergic lung inflammation and respiratory viral infections. This review underscores recent progress in understanding the role of IFNs and IFN-producing cells in shaping ILC2 responses and discusses disease phenotypes, mechanisms, and therapeutic targets in the context of allergic lung inflammation and infections with viruses, including influenza virus, rhinovirus (RV), respiratory syncytial virus (RSV), and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2).
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Affiliation(s)
- Cui Wang
- Institute of Pathogenic Biology, School of Basic Medical Sciences, Hengyang Medical School, University of South China, Hengyang, 421001, China
- Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, 421001, China
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, China
| | - Zhaoxiang Du
- Institute of Pathogenic Biology, School of Basic Medical Sciences, Hengyang Medical School, University of South China, Hengyang, 421001, China
- Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, 421001, China
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, China
| | - Ranhui Li
- Institute of Pathogenic Biology, School of Basic Medical Sciences, Hengyang Medical School, University of South China, Hengyang, 421001, China
- Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, 421001, China
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, China
| | - Ying Luo
- Institute of Pathogenic Biology, School of Basic Medical Sciences, Hengyang Medical School, University of South China, Hengyang, 421001, China
- Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, 421001, China
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, China
| | - Cuiming Zhu
- Institute of Pathogenic Biology, School of Basic Medical Sciences, Hengyang Medical School, University of South China, Hengyang, 421001, China
- Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, 421001, China
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, China
| | - Nan Ding
- Institute of Pathogenic Biology, School of Basic Medical Sciences, Hengyang Medical School, University of South China, Hengyang, 421001, China
- Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, 421001, China
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, China
| | - Aihua Lei
- Institute of Pathogenic Biology, School of Basic Medical Sciences, Hengyang Medical School, University of South China, Hengyang, 421001, China.
- Hunan Provincial Key Laboratory for Special Pathogens Prevention and Control, University of South China, Hengyang, 421001, China.
- Hunan Province Cooperative Innovation Center for Molecular Target New Drug Study, University of South China, Hengyang, 421001, China.
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Korchagina AA, Koroleva E, Tumanov AV. Innate Lymphoid Cell Plasticity in Mucosal Infections. Microorganisms 2023; 11:461. [PMID: 36838426 PMCID: PMC9967737 DOI: 10.3390/microorganisms11020461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Mucosal tissue homeostasis is a dynamic process that involves multiple mechanisms including regulation of innate lymphoid cells (ILCs). ILCs are mostly tissue-resident cells which are critical for tissue homeostasis and immune response against pathogens. ILCs can sense environmental changes and rapidly respond by producing effector cytokines to limit pathogen spread and initiate tissue recovery. However, dysregulation of ILCs can also lead to immunopathology. Accumulating evidence suggests that ILCs are dynamic population that can change their phenotype and functions under rapidly changing tissue microenvironment. However, the significance of ILC plasticity in response to pathogens remains poorly understood. Therefore, in this review, we discuss recent advances in understanding the mechanisms regulating ILC plasticity in response to intestinal, respiratory and genital tract pathogens. Key transcription factors and lineage-guiding cytokines regulate this plasticity. Additionally, we discuss the emerging data on the role of tissue microenvironment, gut microbiota, and hypoxia in ILC plasticity in response to mucosal pathogens. The identification of new pathways and molecular mechanisms that control functions and plasticity of ILCs could uncover more specific and effective therapeutic targets for infectious and autoimmune diseases where ILCs become dysregulated.
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Affiliation(s)
| | | | - Alexei V. Tumanov
- Department of Microbiology, Immunology and Molecular Genetics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229, USA
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Forte D, Pellegrino RM, Trabanelli S, Tonetti T, Ricci F, Cenerenti M, Comai G, Tazzari P, Lazzarotto T, Buratta S, Urbanelli L, Narimanfar G, Alabed HBR, Mecucci C, La Manna G, Emiliani C, Jandus C, Ranieri VM, Cavo M, Catani L, Palandri F. Circulating extracellular particles from severe COVID-19 patients show altered profiling and innate lymphoid cell-modulating ability. Front Immunol 2023; 14:1085610. [PMID: 37207201 PMCID: PMC10189636 DOI: 10.3389/fimmu.2023.1085610] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
Introduction Extracellular vesicles (EVs) and particles (EPs) represent reliable biomarkers for disease detection. Their role in the inflammatory microenvironment of severe COVID-19 patients is not well determined. Here, we characterized the immunophenotype, the lipidomic cargo and the functional activity of circulating EPs from severe COVID-19 patients (Co-19-EPs) and healthy controls (HC-EPs) correlating the data with the clinical parameters including the partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) and the sequential organ failure assessment (SOFA) score. Methods Peripheral blood (PB) was collected from COVID-19 patients (n=10) and HC (n=10). EPs were purified from platelet-poor plasma by size exclusion chromatography (SEC) and ultrafiltration. Plasma cytokines and EPs were characterized by multiplex bead-based assay. Quantitative lipidomic profiling of EPs was performed by liquid chromatography/mass spectrometry combined with quadrupole time-of-flight (LC/MS Q-TOF). Innate lymphoid cells (ILC) were characterized by flow cytometry after co-cultures with HC-EPs or Co-19-EPs. Results We observed that EPs from severe COVID-19 patients: 1) display an altered surface signature as assessed by multiplex protein analysis; 2) are characterized by distinct lipidomic profiling; 3) show correlations between lipidomic profiling and disease aggressiveness scores; 4) fail to dampen type 2 innate lymphoid cells (ILC2) cytokine secretion. As a consequence, ILC2 from severe COVID-19 patients show a more activated phenotype due to the presence of Co-19-EPs. Discussion In summary, these data highlight that abnormal circulating EPs promote ILC2-driven inflammatory signals in severe COVID-19 patients and support further exploration to unravel the role of EPs (and EVs) in COVID-19 pathogenesis.
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Affiliation(s)
- Dorian Forte
- Department of Medical and Surgical Sciences (DIMEC), Institute of Hematology ‘Seràgnoli’, University of Bologna, Bologna, Italy
| | - Roberto Maria Pellegrino
- Department of Chemistry, Biology and Biotechnology, Biochemistry and Molecular Biology Section, University of Perugia, Perugia, Italy
| | - Sara Trabanelli
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Ludwig Institute for Cancer Research, Lausanne Branch, Lausanne, Switzerland
| | - Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Ospealiero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Ricci
- Immunohematology and blood bank, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mara Cenerenti
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Ludwig Institute for Cancer Research, Lausanne Branch, Lausanne, Switzerland
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Tazzari
- Immunohematology and blood bank, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Tiziana Lazzarotto
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sandra Buratta
- Department of Chemistry, Biology and Biotechnology, Biochemistry and Molecular Biology Section, University of Perugia, Perugia, Italy
| | - Lorena Urbanelli
- Department of Chemistry, Biology and Biotechnology, Biochemistry and Molecular Biology Section, University of Perugia, Perugia, Italy
| | - Ghazal Narimanfar
- Department of Medical and Surgical Sciences (DIMEC), Institute of Hematology ‘Seràgnoli’, University of Bologna, Bologna, Italy
| | - Husam B. R. Alabed
- Department of Chemistry, Biology and Biotechnology, Biochemistry and Molecular Biology Section, University of Perugia, Perugia, Italy
| | - Cristina Mecucci
- Department of Medicine and Surgery, Center for Hemato-Oncology Research (C.R.E.O.), University of Perugia, Perugia, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carla Emiliani
- Department of Chemistry, Biology and Biotechnology, Biochemistry and Molecular Biology Section, University of Perugia, Perugia, Italy
| | - Camilla Jandus
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Ludwig Institute for Cancer Research, Lausanne Branch, Lausanne, Switzerland
| | - Vito Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Ospealiero-Universitaria di Bologna, Bologna, Italy
| | - Michele Cavo
- Department of Medical and Surgical Sciences (DIMEC), Institute of Hematology ‘Seràgnoli’, University of Bologna, Bologna, Italy
- Istituto di Ematologia “Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Lucia Catani
- Department of Medical and Surgical Sciences (DIMEC), Institute of Hematology ‘Seràgnoli’, University of Bologna, Bologna, Italy
- Istituto di Ematologia “Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- *Correspondence: Lucia Catani,
| | - Francesca Palandri
- Istituto di Ematologia “Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Cervantes O, Talavera IC, Every E, Coler B, Li M, Li A, Li H, Adams Waldorf K. Role of hormones in the pregnancy and sex-specific outcomes to infections with respiratory viruses. Immunol Rev 2022; 308:123-148. [PMID: 35373371 PMCID: PMC9189035 DOI: 10.1111/imr.13078] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 01/13/2023]
Abstract
Pregnant women infected with pathogenic respiratory viruses, such as influenza A viruses (IAV) and coronaviruses, are at higher risk for mortality, hospitalization, preterm birth, and stillbirth. Several factors are likely to contribute to the susceptibility of pregnant individuals to severe lung disease including changes in pulmonary physiology, immune defenses, and effector functions of some immune cells. Pregnancy is also a physiologic state characterized by higher levels of multiple hormones that may impact the effector functions of immune cells, such as progesterone, estrogen, human chorionic gonadotropin, prolactin, and relaxin. Each of these hormones acts to support a tolerogenic immune state of pregnancy, which helps prevent fetal rejection, but may also contribute to an impaired antiviral response. In this review, we address the unique role of adaptive and innate immune cells in the control of pathogenic respiratory viruses and how pregnancy and specific hormones can impact their effector actions. We highlight viruses with sex-specific differences in infection outcomes and why pregnancy hormones may contribute to fetal protection but aid the virus at the expense of the mother's health.
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Affiliation(s)
- Orlando Cervantes
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Irene Cruz Talavera
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Emma Every
- University of Washington School of Medicine, Spokane, Washington, United States of America
| | - Brahm Coler
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, United States of America
| | - Miranda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Department of Biological Sciences, Columbia University, New York City, New York, United States of America
| | - Amanda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
- Case Western Reserve, Cleveland, Ohio, United States of America
| | - Hanning Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Kristina Adams Waldorf
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, United States of America
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Abstract
The lung is the primary site of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced immunopathology whereby the virus enters the host cells by binding to angiotensin-converting enzyme 2 (ACE2). Sophisticated regeneration and repair programs exist in the lungs to replenish injured cell populations. However, known resident stem/progenitor cells have been demonstrated to express ACE2, raising a substantial concern regarding the long-term consequences of impaired lung regeneration after SARS-CoV-2 infection. Moreover, clinical treatments may also affect lung repair from antiviral drug candidates to mechanical ventilation. In this review, we highlight how SARS-CoV-2 disrupts a program that governs lung homeostasis. We also summarize the current efforts of targeted therapy and supportive treatments for COVID-19 patients. In addition, we discuss the pros and cons of cell therapy with mesenchymal stem cells or resident lung epithelial stem/progenitor cells in preventing post-acute sequelae of COVID-19. We propose that, in addition to symptomatic treatments being developed and applied in the clinic, targeting lung regeneration is also essential to restore lung homeostasis in COVID-19 patients.
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Affiliation(s)
- Fuxiaonan Zhao
- Department of Basic Medicine, Haihe Clinical School, Tianjin Medical University, Tianjin, China
| | - Qingwen Ma
- Department of Basic Medicine, Haihe Clinical School, Tianjin Medical University, Tianjin, China
| | - Qing Yue
- Department of Basic Medicine, Haihe Clinical School, Tianjin Medical University, Tianjin, China
| | - Huaiyong Chen
- Department of Basic Medicine, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin Institute of Respiratory Diseases, Tianjin Haihe Hospital, Tianjin, China
- Department of Basic Medicine, Haihe Hospital, Tianjin University, Tianjin, China
- Tianjin Key Laboratory of Lung Regenerative Medicine, Tianjin, China
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Comprehensive Analysis of the ILCs and Unconventional T Cells in Virus Infection: Profiling and Dynamics Associated with COVID-19 Disease for a Future Monitoring System and Therapeutic Opportunities. Cells 2022; 11:cells11030542. [PMID: 35159352 PMCID: PMC8834012 DOI: 10.3390/cells11030542] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/28/2021] [Accepted: 02/02/2022] [Indexed: 02/04/2023] Open
Abstract
This review is a comprehensive analysis of the effects of SARS-CoV-2 infection on Unconventional T cells and innate lymphoid cells (ILCs). COVID-19 affected patients show dysregulation of their adaptive immune systems, but many questions remain unsolved on the behavior of Unconventional cells and ILCs during infection, considering their role in maintaining homeostasis in tissue. Therefore, we highlight the differences that exist among the studies in cohorts of patients who in general were categorized considering symptoms and hospitalization. Moreover, we make a critical analysis of the presence of particular clusters of cells that express activation and exhausted markers for each group in order to bring out potential diagnostic factors unconsidered before now. We also focus our attention on studies that take into consideration recovered patients. Indeed, it could be useful to determine Unconventional T cells’ and ILCs’ frequencies and functions in longitudinal studies because it could represent a way to monitor the immune status of SARS-CoV-2-infected subjects. Possible changes in cell frequencies or activation profiles could be potentially useful as prognostic biomarkers and for future therapy. Currently, there are no efficacious therapies for SARS-CoV-2 infection, but deep studies on involvement of Unconventional T cells and ILCs in the pathogenesis of COVID-19 could be promising for targeted therapies.
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Diamond MS, Kanneganti TD. Innate immunity: the first line of defense against SARS-CoV-2. Nat Immunol 2022; 23:165-176. [PMID: 35105981 PMCID: PMC8935980 DOI: 10.1038/s41590-021-01091-0] [Citation(s) in RCA: 249] [Impact Index Per Article: 124.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/03/2021] [Indexed: 02/03/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus (SARS-CoV)-2, continues to cause substantial morbidity and mortality. While most infections are mild, some patients experience severe and potentially fatal systemic inflammation, tissue damage, cytokine storm and acute respiratory distress syndrome. The innate immune system acts as the first line of defense, sensing the virus through pattern recognition receptors and activating inflammatory pathways that promote viral clearance. Here, we discuss innate immune processes involved in SARS-CoV-2 recognition and the resultant inflammation. Improved understanding of how the innate immune system detects and responds to SARS-CoV-2 will help identify targeted therapeutic modalities that mitigate severe disease and improve patient outcomes.
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Affiliation(s)
- Michael S Diamond
- Department of Medicine, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
- The Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
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