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Lu Y, You J. Strategy and application of manipulating DCs chemotaxis in disease treatment and vaccine design. Biomed Pharmacother 2023; 161:114457. [PMID: 36868016 DOI: 10.1016/j.biopha.2023.114457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/17/2023] [Accepted: 02/26/2023] [Indexed: 03/05/2023] Open
Abstract
As the most versatile antigen-presenting cells (APCs), dendritic cells (DCs) function as the cardinal commanders in orchestrating innate and adaptive immunity for either eliciting protective immune responses against canceration and microbial invasion or maintaining immune homeostasis/tolerance. In fact, in physiological or pathological conditions, the diversified migratory patterns and exquisite chemotaxis of DCs, prominently manipulate their biological activities in both secondary lymphoid organs (SLOs) as well as homeostatic/inflammatory peripheral tissues in vivo. Thus, the inherent mechanisms or regulation strategies to modulate the directional migration of DCs even could be regarded as the crucial cartographers of the immune system. Herein, we systemically reviewed the existing mechanistic understandings and regulation measures of trafficking both endogenous DC subtypes and reinfused DCs vaccines towards either SLOs or inflammatory foci (including neoplastic lesions, infections, acute/chronic tissue inflammations, autoimmune diseases and graft sites). Furthermore, we briefly introduced the DCs-participated prophylactic and therapeutic clinical application against disparate diseases, and also provided insights into the future clinical immunotherapies development as well as the vaccines design associated with modulating DCs mobilization modes.
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Affiliation(s)
- Yichao Lu
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Jian You
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China; Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, 291 Fucheng Road, Zhejiang 310018, PR China; Zhejiang-California International NanoSystems Institute, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China.
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Herderschee J, Heinonen T, Fenwick C, Schrijver IT, Ohmiti K, Moradpour D, Cavassini M, Pantaleo G, Roger T, Calandra T. High-dimensional immune phenotyping of blood cells by mass cytometry in patients infected with hepatitis C virus. Clin Microbiol Infect 2021; 28:611.e1-611.e7. [PMID: 34474121 DOI: 10.1016/j.cmi.2021.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/18/2021] [Accepted: 08/21/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Chronic hepatitis C virus (HCV) infection affects the immune system. Whether elimination of HCV with direct-acting antivirals (DAA) restores immunity is unclear. We used mass cytometry to get a broad and in-depth assessment of blood cell populations of patients with chronic HCV before and after DAA therapy. METHODS Before and 12 weeks after sustained virological response (SVR12) to DAA therapy, 22 cell populations were analysed by mass cytometry in blood collected from ten healthy control individuals and 20 HCV-infected patients with (ten patients) or without (ten patients) human immunodeficiency virus (HIV) infection. RESULTS HCV infection altered the frequency of 14/22 (64%) blood cell populations. At baseline, the frequencies (median, interquartile range (IQR); control, HCV, HCV/HIV) of intermediate monocytes (1.2, IQR 0.47-1.46; 1.76, IQR 0.83-2.66; 0.78, IQR 0.28-1.77), non-classical monocytes (1.11, IQR 0.49-1.26; 0.9, IQR 0.18-0.99; 0.54, IQR 0.28-1.77), conventional dendritic cells type 2 (0.55, IQR 0.35-0.59; 0.31, IQR 0.16-0.38; 0.19, IQR 0.11-0.36) and CD56dim natural killer cells (8.08, IQR 5.34-9.79; 4.72, IQR 2.59-6.05) 3.61, IQR 2.98-5.07) were reduced by 35% to 65%, particularly in HCV/HIV co-infected patients. In contrast, activated double-negative T cells (0.07, IQR 0.06-0.10; 0.10, IQR 0.09-0.19; 0.19, IQR 0.12-0.25), activated CD4 T cells (0.28, IQR 0.21-0.36; 0.56, IQR 0.33-0.77; 0.40, IQR 0.22-0.53) and activated CD8 T cells (0.23, IQR 0.14-0.42; 0.74, IQR 0.30-1.65; 0.80, IQR 0.58-1.16) were increased 1.4 to 3.5 times. Upon stimulation with Toll-like receptor ligands, the expression of cytokines was up-regulated in 7/9 (78%) and 17/19 (89%) of the conditions in HCV- and HCV/HIV-infected patients, respectively. Most alterations persisted at SVR12. CONCLUSIONS Chronic HCV and HCV/HIV infections induce profound and durable perturbations of innate and adaptive immune homeostasis.
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Affiliation(s)
- Jacobus Herderschee
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Tytti Heinonen
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Craig Fenwick
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Irene T Schrijver
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Khalid Ohmiti
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Cavassini
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giuseppe Pantaleo
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Swiss Vaccine Research Institute, Lausanne, Switzerland
| | - Thierry Roger
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Role of the chemokine receptors CXCR3, CXCR4 and CCR7 in the intramuscular recruitment of plasmacytoid dendritic cells in dermatomyositis. J Neuroimmunol 2018; 319:142-148. [PMID: 29366593 DOI: 10.1016/j.jneuroim.2018.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 10/13/2017] [Accepted: 01/08/2018] [Indexed: 12/18/2022]
Abstract
To explore the possible mechanism implicated in the recruitment of plasmacytoid dendritic cells (pDCs), we investigated the expression of the chemokine receptors CXCR3, CXCR4, and CCR7 on intramuscular and circulating pDCs from patients with dermatomyositis (DM). Using immunohistochemistry, preferential expression of CXCR3, CXCR4 and CCR7 was identified in the perivascular inflammatory infiltrates within the perimysium in DM muscle. Western-blot analysis showed marked up-regulation of expression of CXCR3, CXCR4 and CCR7 in muscle homogenate from patients with DM compared with that in non-diseased controls. Co-localization of CD303+ pDCs with these chemokine receptors was further examined by double immunofluorescence staining, which showed extensive co-localization of CD303 with CXCR3/CXCR4/CCR7 in DM biopsies. Flow cytometry was then used to investigate the proportion of pDCs among the total PBMCs and the expression of CXCR3, CXCR4 and CCR7 on circulating pDCs. The proportion of CD123+CD303+ pDCs in peripheral blood from DM patients was markedly decreased compared to that from polymyositis (PM) patients and normal controls. Significantly increased expression of CXCR3, but not CXCR4 or CCR7, was further identified on circulating pDCs in DM. Correlation analysis showed that the expression of CXCR3 correlated inversely with the frequency of pDCs in peripheral blood. Our findings indicate that the chemokine receptors, CXCR3, CXCR4 and CCR7 may be involved in the recruitment of pDCs from peripheral blood to muscle tissues in DM via different mechanisms, and in which CXCR3 may play an important role under DM conditions.
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Dendritic cell recruitment and activation in autoimmunity. J Autoimmun 2017; 85:126-140. [DOI: 10.1016/j.jaut.2017.07.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/11/2022]
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Keng CT, Sze CW, Zheng D, Zheng Z, Yong KSM, Tan SQ, Ong JJY, Tan SY, Loh E, Upadya MH, Kuick CH, Hotta H, Lim SG, Tan TC, Chang KTE, Hong W, Chen J, Tan YJ, Chen Q. Characterisation of liver pathogenesis, human immune responses and drug testing in a humanised mouse model of HCV infection. Gut 2016; 65:1744-53. [PMID: 26149491 PMCID: PMC5036242 DOI: 10.1136/gutjnl-2014-307856] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 05/11/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE HCV infection affects millions of people worldwide, and many patients develop chronic infection leading to liver cancers. For decades, the lack of a small animal model that can recapitulate HCV infection, its immunopathogenesis and disease progression has impeded the development of an effective vaccine and therapeutics. We aim to provide a humanised mouse model for the understanding of HCV-specific human immune responses and HCV-associated disease pathologies. DESIGN Recently, we have established human liver cells with a matched human immune system in NOD-scid Il2rg(-/-) (NSG) mice (HIL mice). These mice are infected with HCV by intravenous injection, and the pathologies are investigated. RESULTS In this study, we demonstrate that HIL mouse is capable of supporting HCV infection and can present some of the clinical symptoms found in HCV-infected patients including hepatitis, robust virus-specific human immune cell and cytokine responses as well as liver fibrosis and cirrhosis. Similar to results obtained from the analysis of patient samples, the human immune cells, particularly T cells and macrophages, play critical roles during the HCV-associated liver disease development in the HIL mice. Furthermore, our model is demonstrated to be able to reproduce the therapeutic effects of human interferon alpha 2a antiviral treatment. CONCLUSIONS The HIL mouse provides a model for the understanding of HCV-specific human immune responses and HCV-associated disease pathologies. It could also serve as a platform for antifibrosis and immune-modulatory drug testing.
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Affiliation(s)
- Choong Tat Keng
- Institute of Molecular and Cell Biology, Singapore, Singapore
| | - Ching Wooen Sze
- Department of Microbiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Dahai Zheng
- Institute of Molecular and Cell Biology, Singapore, Singapore
| | - Zhiqiang Zheng
- Institute of Molecular and Cell Biology, Singapore, Singapore
| | | | - Shu Qi Tan
- Department of Obstetrics & Gynaecology, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - Sue Yee Tan
- Institute of Molecular and Cell Biology, Singapore, Singapore
| | - Eva Loh
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Megha Haridas Upadya
- Department of Microbiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chik Hong Kuick
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Hak Hotta
- Division of Microbiology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Seng Gee Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore Department of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
| | - Thiam Chye Tan
- Department of Obstetrics & Gynaecology, KK Women's and Children's Hospital, Singapore, Singapore Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Kenneth T E Chang
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Wanjin Hong
- Institute of Molecular and Cell Biology, Singapore, Singapore
| | - Jianzhu Chen
- Interdisciplinary Research Group in Infectious Diseases, Singapore-Massachusetts Institute of Technology Alliance for Research and Technology, Singapore, Singapore The Koch Institute for Integrative Cancer Research and Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Yee-Joo Tan
- Institute of Molecular and Cell Biology, Singapore, Singapore Department of Microbiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Qingfeng Chen
- Institute of Molecular and Cell Biology, Singapore, Singapore Department of Microbiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore Interdisciplinary Research Group in Infectious Diseases, Singapore-Massachusetts Institute of Technology Alliance for Research and Technology, Singapore, Singapore
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Tomer S, Chawla YK, Duseja A, Arora SK. Dominating expression of negative regulatory factors downmodulates major histocompatibility complex Class-II expression on dendritic cells in chronic hepatitis C infection. World J Gastroenterol 2016; 22:5173-82. [PMID: 27298560 PMCID: PMC4893464 DOI: 10.3748/wjg.v22.i22.5173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/26/2016] [Accepted: 05/04/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To elucidate the molecular mechanisms leading to development of functionally impaired dendritic cells (DCs) in chronic hepatitis C (CHC) patients infected with genotype 3 virus. METHODS This prospective study was conducted on the cohorts of CHC individuals identified as responders or non-responders to antiviral therapy. Myeloid DCs were isolated from the peripheral blood of each subject using CD1c (BDCA1)(+) DC isolation Kit. Monocytes from healthy donor were cultured with DC growth factors such as IL-4 and GM-CSF either in the presence or absence of hepatitis C virus (HCV) viral proteins followed by LPS stimulation. Phenotyping was done by flowcytometry and gene expression profiling was evaluated by real-time PCR. RESULTS Non-responders [sustained virological response (SVR)-ve] to conventional antiviral therapy had significantly higher expression of genes associated with interferon responsive element such as IDO1 and PD-L1 (6-fold) and negative regulators of JAK-STAT pathway such as SOCS (6-fold) as compared to responders (SVR+ve) to antiviral therapy. The down-regulated genes in non-responders included factors involved in antigen processing and presentation mainly belonging to major histocompatibility complex (MHC) Class-II family as HLA-DP, HLA-DQ (2-fold) and superoxide dismutase (2-fold). Cells grown in the presence of HCV viral proteins had genes down-regulated for factors involved in innate response, interferon signaling, DC maturation and co-stimulatory signaling to T-cells, while the genes for cytokine signaling and Toll-like receptors (4-fold) were up-regulated as compared to cells grown in absence of viral proteins. CONCLUSION Underexpressed MHC class-II genes and upregulated negative regulators in non-responders indicate diminished capacity to present antigen and may constitute mechanism of functionally defective state of DCs.
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Probable involvement of p11 with interferon alpha induced depression. Sci Rep 2016; 6:17029. [PMID: 26821757 PMCID: PMC4731785 DOI: 10.1038/srep17029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 10/23/2015] [Indexed: 12/16/2022] Open
Abstract
Depression is one of the major side effects of interferon alpha (IFN-α) treatment, but the molecular mechanism underlying IFN-α-induced depression remains unclear. Several studies have shown that the serotonin receptors 5-HTR1b and 5-HTR4 play key roles in the anti-depression effects associated with p11 (S100A10). We investigated the effects of IFN-α on the regulation of p11, 5-HTR1b and 5-HTR4 in mice and human neuroblastoma cells (SH-sy5y). We found that intraperitoneal injection with IFN-α in Balb/c mice resulted in an increased immobility in FST and TST, and potently lowered the protein levels of p11, 5-HTR1b and 5-HTR4 in the hippocampus or cingulate gyrus. IFN-α significantly down-regulated the protein levels of p11, 5-HTR1b and 5-HTR4 in SH-sy5y cells, in a time- and dose-dependent manner. Our study revealed that over-expression of p11 could prevent the IFN-α-induced down-regulation of 5-HTR1b and 5-HTR4. The results indicated that IFN-α treatment resulted in p11 down-regulation, which subsequently decreased 5-HTR1b and 5-HTR4 in vitro or in vivo. Our findings suggested that p11 might be a potential regulator on 5-HTR1b and 5-HTR4 as well as a predictor of or a therapeutic target for IFN-α-induced depression.
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Increased proportions of dendritic cells and recovery of IFNγ responses in HIV/HCV co-infected patients receiving ART. Hum Immunol 2015; 77:29-34. [PMID: 26455474 DOI: 10.1016/j.humimm.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 07/29/2015] [Accepted: 10/05/2015] [Indexed: 12/24/2022]
Abstract
Dendritic cell (DC) numbers and functions can be affected by HIV and HCV disease, but the effects of antiretroviral therapy (ART) on DC and the implications of these changes are unclear. We examined circulating DC in samples from Indonesian patients beginning ART with advanced HIV disease and documented mild/moderate HCV hepatitis. Frequencies of myeloid and plasmacytoid DC increased after 6 months on ART, but frequencies of DC producing IL-12 or IFNα following stimulation with TLR agonists (CL075, CpG) did not change. IFNγ responses to CL075, HCV and other antigens rose over this period. Hence increased IFNγ responses during ART may be associated with increased DC frequencies rather than changes in their functional capacity.
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Schulz S, Landi A, Garg R, Wilson JA, van Drunen Littel-van den Hurk S. Indolamine 2,3-dioxygenase expression by monocytes and dendritic cell populations in hepatitis C patients. Clin Exp Immunol 2015; 180:484-98. [PMID: 25605587 DOI: 10.1111/cei.12586] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 12/31/2014] [Accepted: 01/09/2015] [Indexed: 12/24/2022] Open
Abstract
Dendritic cells (DCs) play an important role in the induction of the primary immune response to infection. DCs may express the tryptophan-catabolizing enzyme indolamine2,3-dioxygenase (IDO), which is an inducer of immune tolerance. Because there is evidence that chronic hepatitis C virus (HCV) infection leads to functional impairment of certain DC populations, we analysed IDO expression in DCs and monocytes from chronically infected and recovered HCV patients. The IDO1 and -2 expression was increased significantly in the monocytes of chronic HCV patients but, interestingly, not in those from recovered patients. The myeloid DCs from chronically infected HCV patients also showed enhanced IDO1 expression, while no change in either IDO1 or -2 was found for plasmacytoid DCs. Up-regulation of IDO1 gene expression was confirmed by the presence of enhanced kynurenine/tryptophan ratios in the plasma from chronic HCV patients. Increased IDO1 and -2 expression was also observed in monocytes from healthy donors infected with an adapted mutant of the HCV JFH-1 strain ex vivo, confirming a direct effect of HCV infection. These changes in IDO expression could be prevented by treatment with the IDO inhibitor 1-methyl tryptophan (1-mT). Furthermore, maturation of monocyte-derived DCs from chronically infected HCV patients, as well as well as monocyte-derived DCs infected ex vivo with HCV, was impaired, but this was reversed by 1-mT treatment. This suggests that IDO inhibitors may be used to treat chronic HCV patients in vivo, in conjunction with current therapies, or to activate DCs from patients ex vivo, such that they can be administered back as a DC-based therapeutic vaccine.
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Affiliation(s)
- S Schulz
- VIDO-InterVac, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - A Landi
- Li Ka Shing Institute of Virology, Medical Microbiology and Immunology, University of Alberta, Edmonton, Alberta, Canada
| | - R Garg
- VIDO-InterVac, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - J A Wilson
- Microbiology and Immunology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - S van Drunen Littel-van den Hurk
- VIDO-InterVac, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Microbiology and Immunology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Ma L, Zhou Y, Zhang Y, Li Y, Guo Y, He Y, Wang J, Lian J, Hao C, Moorman JP, Yao ZQ, Zhou Y, Jia Z. Role of A20 in interferon-α-mediated functional restoration of myeloid dendritic cells in patients with chronic hepatitis C. Immunology 2015; 143:670-8. [PMID: 24965710 DOI: 10.1111/imm.12350] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 06/12/2014] [Accepted: 06/23/2014] [Indexed: 01/01/2023] Open
Abstract
Hepatitis C virus (HCV) infection is a global health problem characterized by a high rate of chronic infection, which may in part be due to a defect in myeloid dendritic cells (mDCs). This defect appears to be remedied by treatment with interferon-α (IFN-α) -based antiviral therapies; however, the molecular mechanisms underlying mDC dysfunction in HCV infection and restoration by IFN-α treatment are unclear. The ubiquitin-editing protein A20 plays a crucial role in controlling the maturation, cytokine production and immunostimulatory function of mDCs. We propose that the expression of A20 correlates with the function of mDCs during HCV infection and IFN-α therapy. In this study, we observed that A20 expression in mDCs isolated from chronically HCV-infected subjects was significantly higher than healthy subjects or subjects achieving sustained virological responses (SVR) following antiviral treatment. Notably, A20 expression in mDCs from HCV patients during IFN-α treatment was significantly lower than for untreated patients, SVR patients, or healthy subjects. Besides, A20 expression in mDCs stimulated by polyI:C differed between HCV patients and healthy subjects, and this difference could be abrogated by the treatment with IFN-α in vitro. Additionally, A20 expression by polyI:C-activated mDCs, with or without IFN-α treatment, negatively correlated with the expression of HLA-DR, CD86 and CCR7, and the secretion of interleukin-12 (IL-12), but positively associated with the production of IL-10. Importantly, silencing A20 expression using small interfering RNAs increased the production of IL-12 in mDCs of chronically HCV-infected individuals. These findings suggest that A20 plays a crucial role in negative regulation of innate immune responses during chronic viral infection.
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Affiliation(s)
- Li Ma
- Department of Infectious Diseases, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
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O’Connor KS, George J, Booth D, Ahlenstiel G. Dendritic cells in hepatitis C virus infection: key players in the IFNL3-genotype response. World J Gastroenterol 2014; 20:17830-8. [PMID: 25548481 PMCID: PMC4273133 DOI: 10.3748/wjg.v20.i47.17830] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 07/14/2014] [Accepted: 07/24/2014] [Indexed: 02/06/2023] Open
Abstract
Recently, single nucleotide polymorphisms, in the vicinity of the interferon lambda 3 (IFNL3) gene have been identified as the strongest predictor of spontaneous and treatment induced clearance of hepatitis C virus (HCV) infection. Since then, increasing evidence has implicated the innate immune response in mediating the IFNL3 genotype effect. Dendritic cells (DCs) are key to the host immune response in HCV infection and their vital role in the IFNL3 genotype effect is emerging. Reports have identified subclasses of DCs, particularly myeloid DC2s and potentially plasmacytoid DCs as the major producers of IFNL3 in the setting of HCV infection. Given the complexities of dendritic cell biology and the conflicting current available data, this review aims to summarize what is currently known regarding the role of dendritic cells in HCV infection and to place it into context of what is know about lambda interferons and dendritic cells in general.
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Zekri ARN, Bahnassy AA, Mohamed WS, Alam EL-Din HM, Shousha HI, Zayed N, Eldahshan DH, Abdel-Aziz AO. Dynamic interplay between CXCL levels in chronic hepatitis C patients treated by interferon. Virol J 2013; 10:218. [PMID: 23816271 PMCID: PMC3707769 DOI: 10.1186/1743-422x-10-218] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 05/17/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Combined pegylated interferon-α and ribavirin therapy has sustained virological response (SVR) rates of 54% to 61%. Pretreatment predictors of SVR to interferon therapy have not been fully investigated yet. The current study assesses a group of chemokines that may predict treatment response in Egyptian patients with chronic HCV infection. PATIENTS AND METHODS CXCL5, CXCL9, CXCL11, CXCL12, CXCL 13, CXCL 16 chemokines and E-Cadherin were assayed in 57 chronic HCV patients' sera using quantitative ELISA plate method. All studied patients were scheduled for combined pegylated interferon alpha and ribavirin therapy (32 patients received pegylated interferon α 2b, and 25 patients received pegylated interferon α 2a). Quantitative hepatitis C virus RNA was done by real time RT-PCR and HCV genotyping by INNOLIPAII. RESULTS There was no significant difference (p > 0.05) in baseline HCV RNA levels between responders and non-responders to interferon. A statistically significant difference in CXCL13 (p = 0.017) and E-Cadherin levels (P = 0.041) was reported between responders and nonresponders at week 12. Significant correlations were found between changes in the CXCL13 levels and CXCL9, CXCL16, E-cadherin levels as well as between changes in E-cadherin levels and both CXCL16 and ALT levels that were maintained during follow up. Also, significant changes have been found in the serum levels of CXCL5, CXCL13, and CXCL16 with time (before pegylated interferon α 2 a and α 2 b therapy, and at weeks 12 and 24) with no significant difference in relation to interferon type and response to treatment. CONCLUSION Serum levels of CXCL13 and E-Cadherin could be used as surrogate markers to predict response of combined PEG IFN-α/RBV therapy, especially at week 12. However, an extended study including larger number of patients is needed for validation of these findings. CLINICAL TRIAL NO NCT01758939.
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Affiliation(s)
- Abdel-Rahman N Zekri
- Virology and Immunology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, 1st Kasr El-Aini st, Cairo, Egypt
| | - Abeer A Bahnassy
- Pathology Department, National Cancer Institute, Cairo University, 1st Kasr El-Aini st, Cairo, Egypt
| | - Waleed S Mohamed
- Virology and Immunology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, 1st Kasr El-Aini st, Cairo, Egypt
| | - Hanaa M Alam EL-Din
- Virology and Immunology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, 1st Kasr El-Aini st, Cairo, Egypt
| | - Hend I Shousha
- Tropical Medicine Department, Faculty of Medicine, Cairo University, Kasr El-Aini st, Cairo, Egypt
| | - Naglaa Zayed
- Tropical Medicine Department, Faculty of Medicine, Cairo University, Kasr El-Aini st, Cairo, Egypt
| | - Dina H Eldahshan
- Clinical Pathology Department, Faculty of Medicine, Benisuef University, Cairo, Egypt
| | - Ashraf Omar Abdel-Aziz
- Tropical Medicine Department, Faculty of Medicine, Cairo University, Kasr El-Aini st, Cairo, Egypt
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Self AA, Losikoff PT, Gregory SH. Divergent contributions of regulatory T cells to the pathogenesis of chronic hepatitis C. Hum Vaccin Immunother 2013; 9:1569-76. [PMID: 23732899 DOI: 10.4161/hv.24726] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Hepatitis C virus, a small single-stranded RNA virus, is a major cause of chronic liver disease. Resolution of primary hepatitis C virus infections depends upon the vigorous responses of CD4(+) and CD8(+) T cells to multiple viral epitopes. Although such broad CD4(+) and CD8(+) T-cell responses are readily detected early during the course of infection regardless of clinical outcome, they are not maintained in individuals who develop chronic disease. Purportedly, a variety of factors contribute to the diminished T-cell responses observed in chronic, virus-infected patients including the induction of and biological suppression by CD4(+)FoxP3(+) regulatory T cells. Indeed, a wealth of evidence suggests that regulatory T cells play diverse roles in the pathogenesis of chronic hepatitis C, impairing the effector T-cell response and viral clearance early during the course of infection and suppressing liver injury as the disease progresses. The factors that affect the generation and biological response of regulatory T cells in chronic, hepatitis C virus-infected patients is discussed.
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Affiliation(s)
- Ayssa A Self
- Department of Medicine; Rhode Island Hospital and the Warren Alpert Medical School of Brown University; Providence, RI USA
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Losikoff PT, Self AA, Gregory SH. Dendritic cells, regulatory T cells and the pathogenesis of chronic hepatitis C. Virulence 2012; 3:610-20. [PMID: 23076334 PMCID: PMC3545943 DOI: 10.4161/viru.21823] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hepatitis C virus (HCV) is a small, enveloped RNA virus and a major cause of chronic liver disease. Resolution of primary HCV infections depends upon the vigorous responses of CD4+ and CD8+ T cells to multiple viral epitopes. Although such broad-based responses are readily detected early during the course of infection regardless of clinical outcome, they are not maintained in individuals who develop chronic disease. Ostensibly, a variety of factors contribute to the diminished T cell responses observed in chronic, HCV-infected patients including impaired dendritic cell function and the induction of CD4+FoxP3+ regulatory T cells. Overwhelming evidence suggests that the complex interaction of dendritic cells and regulatory T cells plays a critical role in the pathogenesis of chronic hepatitis C.
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Affiliation(s)
- Phyllis T Losikoff
- Department of Medicine, Rhode Island Hospital and the Warren Alpert Medical School at Brown University, Providence, RI, USA
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Kanto T, Inoue M, Oze T, Miyazaki M, Sakakibara M, Kakita N, Matsubara T, Higashitani K, Hagiwara H, Iio S, Katayama K, Mita E, Kasahara A, Hiramatsu N, Takehara T, Hayashi N. Dynamics of regulatory T cells and plasmacytoid dendritic cells as immune markers for virological response in pegylated interferon-α and ribavirin therapy for chronic hepatitis C patients. J Gastroenterol 2012; 47:169-78. [PMID: 21947705 DOI: 10.1007/s00535-011-0466-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 08/03/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND For the treatment of chronic hepatitis C, a combination of pegylated interferon-α (PEG-IFNα) and ribavirin has been widely used as a standard of care. Enhancement of immune response against hepatitis C virus (HCV) is known to be involved in the efficacy of the combination therapy. Our aim was to elucidate whether or not the frequency or function of blood cells is related to the outcome of the therapy. METHODS Sixty-seven chronic hepatitis C patients with high viral load of HCV genotype 1 infection who underwent 48 weeks of PEG-IFNα2b and ribavirin therapy were examined. During the treatment, frequencies of myeloid or plasmacytoid dendritic cells, Th1, Th2 cells, NK cells, and regulatory T cells were phenotypically determined. RESULTS Among the patients enrolled, 29 showed a sustained virological response (SVR), 18 a transient response (TR) and 17 no response (NR). The clinical and immunological markers were compared between the SVR and non-SVR patients, including TR and NR. Based on clinical, histological, immunological parameters, and cumulative dosage of PEG-IFNα2b and ribavirin, multivariate analyses revealed that higher platelet counts and higher regulatory T cell frequency at week 12 are indicative of SVR. Even in patients who attained complete early virological response at week 12, multivariate analyses disclosed that higher platelet counts and higher plasmacytoid dendritic cell frequency are indicative of SVR. CONCLUSIONS In PEG-IFNα and ribavirin combination therapy for chronic hepatitis C patients, the increments of regulatory T cells and plasmacytoid dendritic cell frequency are independently related to favorable virological response to the therapy.
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Affiliation(s)
- Tatsuya Kanto
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan.
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16
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Plasmacytoid dendritic cells in HIV infection. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 762:71-107. [PMID: 22975872 DOI: 10.1007/978-1-4614-4433-6_3] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Plasmacytoid dendritic cells (pDCs) are innate immune cells that are specialized to produce interferon-alpha (IFNα) and participate in activating adaptive immune responses. Although IFNα inhibits HIV-1 (HIV) replication in vitro, pDCs may act as inflammatory and immunosuppressive dendritic cells (DCs) rather than classical antigen-presenting cells during chronic HIV infection in vivo, contributing more to HIV pathogenesis than to protection. Improved understanding of HIV-pDC interactions may yield potential new avenues of discovery to prevent HIV transmission, to blunt chronic immune activation and exhaustion, and to enhance beneficial adaptive immune responses. In this chapter we discuss pDC biology, including pDC development from progenitors, trafficking and localization of pDCs in the body, and signaling pathways involved in pDC activation. We focus on the role of pDCs in HIV transmission, chronic disease progression and immune activation, and immunosuppression through regulatory T cell development. Lastly, we discuss potential future directions for the field which are needed to strengthen our current understanding of the role of pDCs in HIV transmission and pathogenesis.
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Vermi W, Soncini M, Melocchi L, Sozzani S, Facchetti F. Plasmacytoid dendritic cells and cancer. J Leukoc Biol 2011; 90:681-90. [PMID: 21730085 DOI: 10.1189/jlb.0411190] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Cancer develops in a complex microenvironment comprising cancer cells, stromal cells, and host immune cells with their soluble products. The counteracting host-protective and tumor-promoting roles of different immune cell populations have been elegantly clarified in the last decade by pertinent genetically modified mouse models. Among cells with a potential role in cancer immunity, PDCs might represent important players as a result of their capacity to bring together innate and adaptive immunity. This review summarizes current knowledge about the role of PDCs in cancer immunity. PDCs have been documented in primary and metastatic human neoplasms; however, the clinical significance of this finding is still unknown. Once into the tumor bed, PDCs can be hijacked by the tumor microenvironment and lose their propensity to produce the required amount of endogenous I-IFN. However, when properly reprogrammed (i.e., by TLR agonists), PDCs might mediate tumor rejection in a clinical setting. Tumor rejection, at least partially, is driven by I-IFN and seems to require a cross-talk with other innate immune cells, including IFN DCs. The latter evidence, although still limited to skin cancers, can provide a leading model for developing adjuvant immune therapy for other neoplasms. To this end, the generation of appropriate mouse models to modulate the frequency and activation state of murine PDCs will also be of remarkable importance.
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Affiliation(s)
- William Vermi
- Department of Pathology, University of Brescia, Brescia, Italy.
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Hammond T, Lee S, Watson MW, Flexman JP, Cheng W, Price P. Decreased IFNγ production correlates with diminished production of cytokines by dendritic cells in patients infected with hepatitis C virus and receiving therapy. J Viral Hepat 2011; 18:482-92. [PMID: 20529204 DOI: 10.1111/j.1365-2893.2010.01331.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Toll-like receptor (TLR) expression and the signalling pathways that lead to the production of accessory cytokines by antigen-presenting cells (APCs) both have potential to limit T-cell responses to viral antigens. Here, expression of TLR and retinoic acid inducible gene I (RIG-I) and responses evoked through these proteins were evaluated in patients chronically infected with HCV, before and during pegylated interferon-α (IFNα) and ribavirin therapy. Expression of TLR2, 3, 4, 7, 9 and RIG-I on APCs and cytokine production by DCs were measured by flow cytometry. Production of IL-12 by myeloid dendritic cells (mDCs), IFNα by plasmacytoid cells (pDCs) and IFNγ by peripheral blood mononuclear cells was measured after stimulation with TLR ligands. IFNγ ELISpot responses to HCV and CMV antigens declined on therapy. TLR and RIG-I expression on mDCs, pDCs, B cells and monocytes was either similar or higher in patients than that in controls and generally increased during therapy. Therapy impaired IL-12 and IFNα production by DCs and reduced production of IFNγ by PBMCs after stimulation with ligands for TLR3, TLR7/8, TLR9 and RIG-I. This was independent of whether patients attained a sustained virological response. HCV disease and interferon-based therapy reduced IFN-γ responses to HCV antigens and TLR agonists. This was not accompanied by reduced expression of pertinent TLR but correlated with diminished production of co-stimulatory cytokines by DCs stimulated via TLR.
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Affiliation(s)
- T Hammond
- School of Pathology and Laboratory Medicine, University of Western Australia, WA, Australia
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Dolganiuc A, Szabo G. Dendritic cells in hepatitis C infection: can they (help) win the battle? J Gastroenterol 2011; 46:432-47. [PMID: 21327958 DOI: 10.1007/s00535-011-0377-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 12/13/2010] [Indexed: 02/04/2023]
Abstract
Infection with hepatitis C virus (HCV) is a public health problem; it establishes a chronic course in ~85% of infected patients and increases their risk for developing liver cirrhosis, hepatocellular carcinoma, and significant extrahepatic manifestations. The mechanisms of HCV persistence remain elusive and are largely related to inefficient clearance of the virus by the host immune system. Dendritic cells (DCs) are the most efficient inducers of immune responses; they are capable of triggering productive immunity and maintaining the state of tolerance to self- and non-self antigens. During the past decade, multiple research groups have focused on DCs, in hopes of unraveling an HCV-specific DC signature or DC-dependent mechanisms of antiviral immunity which would lead to a successful HCV elimination strategy. This review incorporates the latest update in the current status of knowledge on the role of DCs in anti-HCV immunity as it relates to several challenging questions: (a) the phenotype and function of diverse DC subsets in HCV-infected patients; (b) the characteristics of non-human HCV infection models from the DCs' point of view; (c) how can in vitro systems, ranging from HCV protein- or peptide-exposed DC to HCV protein-expressing DCs, and in vivo systems, ranging from HCV protein-expressing transgenic mice to HCV-infected non-human primates, be employed to dissect the role of DCs in triggering/maintaining a robust antiviral response; and (d) the prospect of DC-based strategy for managing and finding a cure for HCV infection.
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Affiliation(s)
- Angela Dolganiuc
- Department of Medicine, University of Massachusetts Medical School, 364 Plantation Street, LRB-270-H, Worcester, MA 01605, USA.
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Lin Q, Fang D, Hou X, Le Y, Fang J, Wen F, Gong W, Chen K, Wang JM, Su SB. HCV peptide (C5A), an amphipathic α-helical peptide of hepatitis virus C, is an activator of N-formyl peptide receptor in human phagocytes. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2011; 186:2087-94. [PMID: 21228351 PMCID: PMC7385933 DOI: 10.4049/jimmunol.1002340] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The hepatitis C virus (HCV) nonstructural 5A, a phosphorylated zinc metalloprotein, is an essential component of the HCV replication complex. An amphipathic α-helical peptide (HCV peptide [C5A]) derived from nonstructural 5A membrane anchor domain possesses potent anti-HCV and anti-HIV activity in vitro. In this study, we aimed to investigate the potential of HCV peptide (C5A) to regulate host immune responses. The capacity of HCV peptide (C5A) in vitro to induce migration and calcium mobilization of human phagocytes and chemoattractant receptor-transfected cells was investigated. The recruitment of phagocytes in vivo induced by HCV peptide (C5A) and its adjuvant activity were examined. The results revealed that HCV peptide (C5A) was a chemoattractant and activator of human phagocytic leukocytes by using a G-protein coupled receptor, namely formyl peptide receptor. In mice, HCV peptide (C5A) induced massive phagocyte infiltration after injection in the air pouch or the s.c. region. HCV peptide (C5A) also acted as an immune adjuvant by enhancing specific T cell responses to Ag challenge in mice. Our results suggest that HCV peptide (C5A) derived from HCV regulates innate and adaptive immunity in the host by activating the formyl peptide receptor.
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Affiliation(s)
- Qing Lin
- The State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Dan Fang
- The State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xinwei Hou
- Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Yingying Le
- Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Jiazhu Fang
- The State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Feng Wen
- The State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Wanghua Gong
- Basic Research Program, Science Applications International Corporation-Frederick, Frederick, MD 21702
| | - Keqiang Chen
- Laboratory of Molecular Immunoregulation, Cancer and Inflammation Program, Center for Cancer Research, National Cancer Institute at Frederick, Frederick, MD 21702
| | - Ji Ming Wang
- Laboratory of Molecular Immunoregulation, Cancer and Inflammation Program, Center for Cancer Research, National Cancer Institute at Frederick, Frederick, MD 21702
| | - Shao Bo Su
- The State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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Trafficking properties of plasmacytoid dendritic cells in health and disease. Trends Immunol 2010; 31:270-7. [PMID: 20579936 DOI: 10.1016/j.it.2010.05.004] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 05/04/2010] [Accepted: 05/06/2010] [Indexed: 12/29/2022]
Abstract
Plasmacytoid dendritic cells (PDCs) represent a subset of circulating leukocytes characterized by the ability to release high levels of type I interferon (IFN). Under homeostatic conditions PDCs are confined to primary and secondary lymphoid organs. This is consistent with the restricted profile of functional chemotactic receptors expressed by circulating PDCs (i.e. CXCR4 and ChemR23). Accumulation of PDCs in non-lymphoid tissue is, however, observed in certain autoimmune diseases, allergic reactions and tumors. Indeed, PDCs are now considered to be involved in the pathogenesis of diseases characterized by a type I IFN-signature and are considered as a promising target for new intervention strategies. Here, current knowledge of the molecular mechanisms involved in the recruitment of PDCs under homeostatic and pathological conditions are summarized.
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Gonzalez VD, Landay AL, Sandberg JK. Innate immunity and chronic immune activation in HCV/HIV-1 co-infection. Clin Immunol 2010; 135:12-25. [PMID: 20100670 DOI: 10.1016/j.clim.2009.12.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Revised: 12/09/2009] [Accepted: 12/16/2009] [Indexed: 02/07/2023]
Abstract
Innate immune responses are critical in the defense against viral infections. NK cells, myeloid and plasmacytoid dendritic cells, and invariant CD1d-restricted NKT cells mediate both effector and regulatory functions in this early immune response. In chronic uncontrolled viral infections such as HCV and HIV-1, these essential immune functions are compromised and can become a double edged sword contributing to the immunopathogenesis of viral disease. In particular, recent findings indicate that innate immune responses play a central role in the chronic immune activation which is a primary driver of HIV-1 disease progression. HCV/HIV-1 co-infection is affecting millions of people and is associated with faster viral disease progression. Here, we review the role of innate immunity and chronic immune activation in HCV and HIV-1 infection, and discuss how mechanisms of innate immunity may influence protection as well as immunopathogenesis in the HCV/HIV-1 co-infected human host.
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Affiliation(s)
- Veronica D Gonzalez
- Center for Infection Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 14186 Stockholm, Sweden
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