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Slaney ED, Modica R, Woolnough L, Kafisheh D, Bell-Brunson DH, Elder M. Case Report: Refractory macrophage activation syndrome requiring high-dose anakinra, emapalumab, and etoposide therapy in early-onset systemic juvenile idiopathic arthritis associated with adenoviremia. Front Pediatr 2024; 11:1336554. [PMID: 38322244 PMCID: PMC10845352 DOI: 10.3389/fped.2023.1336554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024] Open
Abstract
Macrophage activation syndrome (MAS) is a life-threatening condition characterized by the excessive stimulation of macrophages and T lymphocytes, provoked by infections, malignancy, and autoimmune or autoinflammatory conditions such as systemic juvenile idiopathic arthritis (sJIA). Clinical signs of sJIA may include high-spiking, quotidian fevers, lymphadenopathy, hepatosplenomegaly, and a salmon-colored migratory, evanescent rash. By contrast, MAS is characterized by unremitting fevers and diffuse, fixed, maculopapular rashes. In addition to hepatosplenomegaly and lymphadenopathy, patients with MAS may also have clinical signs of coagulopathy, as well as cardiac, lung, renal, and central nervous system dysfunction. The empiric treatment for MAS is initially high-dose IV corticosteroids, but usually requires addition of immunomodulators such as tacrolimus or a biologic such as Anakinra to control. The addition of immunotherapies for MAS has improved patient outcomes. We present a 2-year-old male patient with a history of early-onset sJIA, who presented with MAS refractory to corticosteroids and anakinra triggered by adenoviremia that required addition of emapalumab to control. We believe this is the first reported case of a combination of immunosuppressive therapy of emapalumab, etoposide, anakinra, tacrolimus, and corticosteroids used in the successful treatment of infection-induced MAS in early-onset sJIA. Given the lack of treatment guidelines and approved therapies for MAS, alternative strategies should be considered for patients with an intractable course.
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Affiliation(s)
| | - Renee Modica
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Leandra Woolnough
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Dina Kafisheh
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Denise Heather Bell-Brunson
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Melissa Elder
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
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2
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Nguyen TH, Kumar D, Prince C, Martini D, Grunwell JR, Lawrence T, Whitely T, Chappelle K, Chonat S, Prahalad S, Briones M, Chandrakasan S. Frequency of HLA-DR +CD38 hi T cells identifies and quantifies T-cell activation in hemophagocytic lymphohistiocytosis, hyperinflammation, and immune regulatory disorders. J Allergy Clin Immunol 2024; 153:309-319. [PMID: 37517575 PMCID: PMC10823038 DOI: 10.1016/j.jaci.2023.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/13/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Quantifying T-cell activation is essential for the diagnosis and evaluation of treatment response in various hyperinflammatory and immune regulatory disorders, including hemophagocytic lymphohistiocytosis. Plasma soluble IL-2 receptor (sIL-2R) is a well-established biomarker for evaluating systemic T-cell activation. However, the limited availability of sIL-2R testing could result in delayed diagnosis. Furthermore, high sIL-2R levels may not always reflect T-cell activation. OBJECTIVES To address these limitations, this study investigated whether cell surface markers of T-cell activation, HLA-DR, and CD38, as assessed by flow cytometry, could be used to quantify systemic T-cell activation in a variety of inflammatory disease states and examine its correlation with sIL-2R levels. METHODS Results for sIL-2R, CXCL9, and ferritin assays were obtained from patient's medical records. Frequency of HLA-DR+CD38high(hi) T-cells was assessed in different T-cell subsets using flow cytometry. RESULTS In this study's cohort, activation in total CD8+ T (r = 0.65; P < .0001) and CD4+ (r = 0.42; P < .0001) T-cell subsets significantly correlated with plasma sIL-2R levels. At the disease onset, the frequency of HLA-DR+CD38hi T cells in CD8+ T (r = 0.65, P < .0001) and CD4+ T (r = 0.77; P < .0001) effector memory (TEM) compartments correlated strongly with sIL-2R levels. Evaluation of T-cell activation markers in follow-up samples also revealed a positive correlation for both CD4+ TEM and CD8+ TEM activation with sIL-2R levels; thus, attesting its utility in initial diagnosis and in evaluating treatment response. The frequency of HLA-DR+CD38hi T-cells in the CD8+ TEM compartment also correlated with plasma CXCL9 (r = 0.42; P = .0120) and ferritin levels (r = 0.32; P = .0037). CONCLUSIONS This study demonstrates that flow cytometry-based direct T-cell activation assessed by HLA-DR+CD38hi T cells accurately quantifies T-cell activation and strongly correlates with sIL-2R levels across a spectrum of hyperinflammatory and immune dysregulation disorders.
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Affiliation(s)
- Thinh H Nguyen
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Deepak Kumar
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Chengyu Prince
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta
| | - Dylan Martini
- Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University School of Medicine, Atlanta; Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta
| | - Taylor Lawrence
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta
| | - Trenton Whitely
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta
| | - Karin Chappelle
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Sampath Prahalad
- Department of Pediatrics, Emory University School of Medicine, Atlanta; Pediatric Rheumatology, Children's Healthcare of Atlanta, Atlanta
| | - Michael Briones
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorder Center, and the Divisions of Children's Healthcare of Atlanta, Atlanta; Department of Pediatrics, Emory University School of Medicine, Atlanta.
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Dillemans L, De Somer L, Neerinckx B, Proost P. A review of the pleiotropic actions of the IFN-inducible CXC chemokine receptor 3 ligands in the synovial microenvironment. Cell Mol Life Sci 2023; 80:78. [PMID: 36862204 PMCID: PMC11071919 DOI: 10.1007/s00018-023-04715-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/09/2023] [Accepted: 02/01/2023] [Indexed: 03/03/2023]
Abstract
Chemokines are pivotal players in instigation and perpetuation of synovitis through leukocytes egress from the blood circulation into the inflamed articulation. Multitudinous literature addressing the involvement of the dual-function interferon (IFN)-inducible chemokines CXCL9, CXCL10 and CXCL11 in diseases characterized by chronic inflammatory arthritis emphasizes the need for detangling their etiopathological relevance. Through interaction with their mutual receptor CXC chemokine receptor 3 (CXCR3), the chemokines CXCL9, CXCL10 and CXCL11 exert their hallmark function of coordinating directional trafficking of CD4+ TH1 cells, CD8+ T cells, NK cells and NKT cells towards inflammatory niches. Among other (patho)physiological processes including infection, cancer, and angiostasis, IFN-inducible CXCR3 ligands have been implicated in autoinflammatory and autoimmune diseases. This review presents a comprehensive overview of the abundant presence of IFN-induced CXCR3 ligands in bodily fluids of patients with inflammatory arthritis, the outcomes of their selective depletion in rodent models, and the attempts at developing candidate drugs targeting the CXCR3 chemokine system. We further propose that the involvement of the CXCR3 binding chemokines in synovitis and joint remodeling encompasses more than solely the directional ingress of CXCR3-expressing leukocytes. The pleotropic actions of the IFN-inducible CXCR3 ligands in the synovial niche reiteratively illustrate the extensive complexity of the CXCR3 chemokine network, which is based on the intercommunion of IFN-inducible CXCR3 ligands with distinct CXCR3 isoforms, enzymes, cytokines, and infiltrated and resident cells present in the inflamed joints.
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Affiliation(s)
- Luna Dillemans
- Laboratory of Molecular Immunology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium
| | - Lien De Somer
- Laboratory of Immunobiology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium
| | - Barbara Neerinckx
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Paul Proost
- Laboratory of Molecular Immunology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium.
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Planas R, Felber M, Vavassori S, Pachlopnik Schmid J. The hyperinflammatory spectrum: from defects in cytotoxicity to cytokine control. Front Immunol 2023; 14:1163316. [PMID: 37187762 PMCID: PMC10175623 DOI: 10.3389/fimmu.2023.1163316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Cytotoxic lymphocytes kill target cells through polarized release of the content of cytotoxic granules towards the target cell. The importance of this cytotoxic pathway in immune regulation is evidenced by the severe and often fatal condition, known as hemophagocytic lymphohistiocytosis (HLH) that occurs in mice and humans with inborn errors of lymphocyte cytotoxic function. The clinical and preclinical data indicate that the damage seen in severe, virally triggered HLH is due to an overwhelming immune system reaction and not the direct effects of the virus per se. The main HLH-disease mechanism, which links impaired cytotoxicity to excessive release of pro-inflammatory cytokines is a prolongation of the synapse time between the cytotoxic effector cell and the target cell, which prompts the former to secrete larger amounts of cytokines (including interferon gamma) that activate macrophages. We and others have identified novel genetic HLH spectrum disorders. In the present update, we position these newly reported molecular causes, including CD48-haploinsufficiency and ZNFX1-deficiency, within the pathogenic pathways that lead to HLH. These genetic defects have consequences on the cellular level on a gradient model ranging from impaired lymphocyte cytotoxicity to intrinsic activation of macrophages and virally infected cells. Altogether, it is clear that target cells and macrophages may play an independent role and are not passive bystanders in the pathogenesis of HLH. Understanding these processes which lead to immune dysregulation may pave the way to novel ideas for medical intervention in HLH and virally triggered hypercytokinemia.
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Affiliation(s)
- Raquel Planas
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
- Department of Cell Biology, Physiology and Immunology, University of Barcelona, Barcelona, Spain
| | - Matthias Felber
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Stefano Vavassori
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Jana Pachlopnik Schmid
- Division of Immunology, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Immunology, University of Zurich, Zurich, Switzerland
- *Correspondence: Jana Pachlopnik Schmid,
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Morales J, Pawle RH, Akkilic N, Luo Y, Xavierselvan M, Albokhari R, Calderon IAC, Selfridge S, Minns R, Takiff L, Mallidi S, Clark HA. DNA-Based Photoacoustic Nanosensor for Interferon Gamma Detection. ACS Sens 2019; 4:1313-1322. [PMID: 30973005 DOI: 10.1021/acssensors.9b00209] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Tracking protein levels in the body is vital in both research and medicine, where understanding their physiological roles provides insight into their regulation in homeostasis and diseases. In medicine, protein levels are actively sampled since they continuously fluctuate, reflecting the status of biological systems and provide insight into patient health. One such protein is interferon gamma, a clinically relevant protein with immunoregulatory functions that play critical roles against infection. New tools for continuously monitoring protein levels in vivo are invaluable in monitoring real-time conditions of patients to allow better care. Here, we developed a DNA-based nanosensor for the photoacoustic detection of interferon gamma. This work demonstrates how we transformed a simple DNA motif, receptors, and a novel phthalocyanine dye into a proof-of-concept photoacoustic nanosensor for protein detection. Surface plasmon resonance kinetic analysis demonstrated that the nanosensor is responsive and reversible to interferon gamma with an affinity in the nanomolar range, KD1 = 167 nM and KD2 = 316 nM. As a reporter, our design includes a novel phthalocyanine-based photoacoustic dye that stacks in a J-aggregate, causing a 22.5% increase in signal. Upon receptor binding, the DNA structure bends to induce phthalocyanine dye stacking, resulting in a 55% increase in photoacoustic signal in the presence of 10 μM interferon gamma. This proof-of-concept nanosensor is a novel approach to the development of a photoacoustic sensor and may be adapted for other proteins of interest in the future for in vivo tracking.
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Affiliation(s)
- Jennifer Morales
- Department of Bioengineering, Northeastern University, Boston, Massachusetts 02115, United States,
| | - Robert H. Pawle
- Akita Innovations LLC, Billerica, Massachusetts 01862, United States,
| | - Namik Akkilic
- Department of Pharmaceutical Sciences, Northeastern University, Boston, Massachusetts 02115, United States,
| | - Yi Luo
- Department of Pharmaceutical Sciences, Northeastern University, Boston, Massachusetts 02115, United States,
| | - Marvin Xavierselvan
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States,
| | - Rayan Albokhari
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States,
| | - Isen Andrew C. Calderon
- Department of Bioengineering, Northeastern University, Boston, Massachusetts 02115, United States,
| | - Scott Selfridge
- Akita Innovations LLC, Billerica, Massachusetts 01862, United States,
| | - Richard Minns
- Akita Innovations LLC, Billerica, Massachusetts 01862, United States,
| | - Larry Takiff
- Akita Innovations LLC, Billerica, Massachusetts 01862, United States,
| | - Srivalleesha Mallidi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States,
| | - Heather A. Clark
- Department of Bioengineering, Northeastern University, Boston, Massachusetts 02115, United States,
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, Massachusetts 02115, United States
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Brisse E, Matthys P, Wouters CH. Understanding the spectrum of haemophagocytic lymphohistiocytosis: update on diagnostic challenges and therapeutic options. Br J Haematol 2016; 174:175-87. [PMID: 27292929 DOI: 10.1111/bjh.14144] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The cytokine storm syndrome 'haemophagocytic lymphohistiocytosis' (HLH) is an under-recognized hyperinflammatory disorder, causing high morbidity and mortality risk in children and adults. It can be subdivided into a primary, genetic form and a secondary, acquired form that complicates diverse infections, malignancies and autoimmune or autoinflammatory disorders. Both subtypes present with the same spectrum of non-specific symptoms, making accurate diagnosis and rapid treatment initiation challenging. In the last decade, increased awareness and international collaborative efforts fuelled a marked progress in diagnostic protocols and novel treatment strategies for HLH and new diagnostic guidelines are being tailored to specific secondary HLH subtypes. Therapy is gradually shifting its focus from overall immunosuppression towards targeting specific cytokines, cell types or signalling pathways underlying pathophysiology. Nevertheless, continued research efforts remain indispensable to customize therapy to individual patient needs.
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Affiliation(s)
- Ellen Brisse
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Patrick Matthys
- Laboratory of Immunobiology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Carine H Wouters
- Laboratory of Paediatric Immunology, KU Leuven, University Hospital Gasthuisberg, Leuven, Belgium
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