Synchrony 2022: The Role of Neuroinflammation in Behavioral Exacerbations in Autism Spectrum Disorder

The BRAIN Foundation (Pleasanton, CA) hosted Synchrony 2022, a medical conference focusing on research for treatments to benefit individuals with neurodevelopmental disorders (NDD), including those with autism spectrum disorders (ASD) [...].

Long COVID Syndrome Presenting as Neuropsychiatric Exacerbations in Autism Spectrum Disorder: Insights for Treatment

COVID-19 causes not only severe respiratory symptoms, but also long-term sequelae, even if the acute-phase symptoms are minor. Neurological and neuropsychiatric symptoms are emerging as major long-term sequalae. In patients with pre-existing behavioral symptoms, such as individuals with autism spectrum disorders (ASD), the emergence of neuropsychiatric symptoms due to long COVID can be difficult to diagnose and manage. Herein, we present three ASD cases who presented with markedly worsening neuropsychiatric symptoms following COVID-19 exposure and subsequent difficulty in managing the post-COVID neuropsychiatric symptoms. Case 1 contracted SARS-CoV-2 during the early stages of the pandemic and treatment targeting COVID-19-induced immune activation was delayed. Case 2 was asymptomatic in the acute stage of a confirmed COVID-19 exposure, but still developed significant neuropsychiatric symptoms. Case 3 demonstrated a difficult course, partly due to pre-existing immune dysregulation and prior use of multiple immunomodulating agents. In cases 1 and 3 for whom serial blood samples were obtained, notable changes in the production of inflammatory and counter-regulatory cytokines by peripheral blood monocytes were observed. The presented cases illustrate the profound effects of COVID-19 on neuropsychiatric symptoms in ASD subjects and the difficulty of managing long-COVID symptoms.

Whole-exome sequencing in a subject with fluctuating neuropsychiatric symptoms, immunoglobulin G1 deficiency, and subsequent development of Crohn's disease: a case report

BACKGROUND

Mutations or polymorphisms of genes that are associated with inflammasome functions are known to predispose individuals to Crohn's disease and likely affect clinical presentations and responses to therapeutic agents in patients with Crohn's disease. The presence of additional gene mutations/polymorphisms that can modify immune responses may further affect clinical features, making diagnosis and management of Crohn's disease even more challenging. Whole-exome sequencing is expected to be instrumental in understanding atypical presentations of Crohn's disease and the selection of therapeutic measures, especially when multiple gene mutations/polymorphisms affect patients with Crohn's disease. We report the case of a non-Hispanic Caucasian female patient with Crohn's disease who was initially diagnosed with pediatric acute-onset neuropsychiatric syndrome with fluctuating anxiety symptoms at 9 years of age. This patient was initially managed with pulse oral corticosteroid treatment and then intravenous immunoglobulin due to her immunoglobulin G1 deficiency. At 15 years of age, she was diagnosed with Crohn's disease, following onset of acute abdomen. Treatment with oral corticosteroid and then tumor necrosis factor-α blockers (adalimumab and infliximab) led to remission of Crohn's disease. However, she continued to suffer from chronic abdominal pain, persistent headache, general fatigue, and joint ache involving multiple joints. Extensive gastrointestinal workup was unrevealing, but whole-exome sequencing identified two autosomal dominant gene variants: NLRP12 (loss of function) and IRF2BP2 (gain of function). Based on whole-exome sequencing findings, infliximab was discontinued and anakinra, an interleukin-1β blocker, was started, rendering marked improvement of her clinical symptoms. However, Crohn's disease lesions recurred following Yersinia enterocolitis. The patient was successfully treated with a blocker of interleukin-12p40 (ustekinumab), and anakinra was discontinued following remission of her Crohn's disease lesions.

CONCLUSION

Loss-of-function mutation of NRLRP12 gene augments production of interleukin-1β and tumor necrosis factor-α, while gain-of-function mutation of IRF2BP2 impairs cytokine production and B cell differentiation. We propose that the presence of these two autosomal dominant variants caused an atypical clinical presentation of Crohn's disease.

Resolution of EEG findings and clinical improvement in a patient with encephalopathy and ESES with a combination of immunomodulating agents other than corticosteroids: A case report

Encephalopathy with electrical status epilepticus in sleep (ESES) syndrome is characterized by a near-continuous spike-and-wave discharges during sleep with marked developmental regression, mainly in speech, and the presence of clinical seizures. Although the etiology ofESES is generally unknown, its resistance to antiseizure medication (ASM), and favorable responses to oral corticosteroids (OCS), support a role for inflammation. However, the prolonged use of OCS results in undesirable side effects and alternative treatment measures are needed. Herein, we present a patient with ESES who revealed responsed to a combination of immunomodulating agents other than OCS. The patient revealed 30, 50, and 100%, reduction in the ESES pattern on EEG with the sequential addition of anakinra (interleukin-1ß inhibitor), intravenous immunoglobulin (IVIg), and sirolimus, an inhibitor of mammalian target of rapamycin (mTOR) respectively, after discontinuation of OCS due to side effects. This combination of immune-modulating agents, that were selected based on monocyte cytokine profiles, also resulted in a gradual improvement of speech and behavioral symptoms. This case indicates a possible use of immunomodulating agents other than OCS for ESES syndrome.

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ESES syndrome can be controlled immunomodulating agents.

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OCS was not requred for maintaing good control of ESES in the presented case.

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Monocyte cytokine profiles may be useful for the selection of immunomodulating agents for treatment of ESES.

Associations between Monocyte and T Cell Cytokine Profiles in Autism Spectrum Disorders: Effects of Dysregulated Innate Immune Responses on Adaptive Responses to Recall Antigens in a Subset of ASD Children

Changes in monocyte cytokine production with toll like receptor (TLR) agonists in subjects with autism spectrum disorders (ASD) were best reflected by the IL-1β/IL-10 ratios in our previous research. The IL-1β/IL-10 based subgrouping (low, normal, and high) of ASD samples revealed marked differences in microRNA expression, and mitochondrial respiration. However, it is unknown whether the IL-1β/IL-10 ratio based subgrouping is associated with changes in T cell cytokine profiles or monocyte cytokine profiles with non-TLR agonists. In ASD (n = 152) and non-ASD (n = 41) subjects, cytokine production by peripheral blood monocytes (PBMo) with TLR agonists and β-glucan, an inflammasome agonist, and T cell cytokine production by peripheral blood mononuclear cells (PBMCs) with recall antigens (Ags) (food and candida Ags) were concurrently measured. Changes in monocyte cytokine profiles were observed with β-glucan in the IL-1β/IL-10 ratio based ASD subgroups, along with changes in T cell cytokine production and ASD subgroup-specific correlations between T cell and monocyte cytokine production. Non-ASD controls revealed considerably less of such correlations. Altered innate immune responses in a subset of ASD children are not restricted to TLR pathways and correlated with changes in T cell cytokine production. Altered trained immunity may play a role in the above described changes.

Variations in Mitochondrial Respiration Differ in IL-1ß/IL-10 Ratio Based Subgroups in Autism Spectrum Disorders

Autism spectrum disorder (ASD)⁷ is associated with multiple physiological abnormalities, including immune dysregulation, and mitochondrial dysfunction. However, an association between these two commonly reported abnormalities in ASD has not been studied in depth. This study assessed the association between previously identified alterations in cytokine profiles by ASD peripheral blood monocytes (PBMo) and mitochondrial dysfunction. In 112 ASD and 38 non-ASD subjects, cytokine production was assessed by culturing purified PBMo overnight with stimuli of innate immunity. Parameters of mitochondrial respiration including proton-leak respiration (PLR), ATP-linked respiration (ALR), maximal respiratory capacity (MRC), and reserve capacity (RC) were measured in peripheral blood mononuclear cells (PBMCs). The ASD samples were analyzed by subgrouping them into high, normal, and low IL-1ß/IL-10 ratio groups, which was previously shown to be associated with changes in behaviors and PBMo miRNA expression. MRC, RC, and RC/PLR, a marker of electron transport chain (ETC) efficiency, were higher in ASD PBMCs than controls. The expected positive associations between PLR and ALR were found in control non-ASD PBMCs, but not in ASD PBMCs. Higher MRC, RC, RC/PLR in ASD PBMCs were secondary to higher levels of these parameters in the high and normal IL-1ß/IL-10 ratio ASD subgroups than controls. Associations between mitochondrial parameters and monocyte cytokine profiles differed markedly across the IL-1ß/IL-10 ratio based ASD subgroups, rendering such associations less evident when ASD samples as a whole were compared to non-ASD controls. Our results indicate for the first time, an association between PBMC mitochondrial function and PBMo cytokine profiles in ASD subjects. This relationship differs across the IL-1ß/IL-10 ratio based ASD subgroups. Changes in mitochondrial function are likely due to adaptive changes or mitochondrial dysfunction, resulting from chronic oxidative stress. These results may indicate alteration in molecular pathways affecting both the immune system and mitochondrial function in some ASD subjects.

Serum microRNAs in ASD: Association With Monocyte Cytokine Profiles and Mitochondrial Respiration

Our previous research has shown that purified peripheral blood monocytes (PRMo) from individuals who are diagnosed with autism spectrum disorders (ASDs) and have innate immune abnormalities reveal altered interleukin-1ß (IL-1ß)/IL-10 ratios. We also found, in separate studies, that microRNA (miRNA) expression in PBMo and mitochondrial respiration in peripheral blood mononuclear cells (PBMCs) differed in the IL-1ß/IL-10-based ASD subgroups. This study explored whether serum miRNAs are associated with both altered innate immune responses and changes in mitochondrial respiration as a link of regulatory mechanisms for these two common abnormalities in ASD subjects. Serum miRNA levels were examined by high-throughput deep sequencing in ASD and non-ASD control sera with concurrent measurement of PBMo cytokine production and mitochondrial respiration by PBMCs. ASD samples were examined as a whole group and with respect to the previously defined IL-1ß/IL-10-based ASD subgroups (high, normal, and low groups). Serum miRNA levels differed between the overall ASD sera (N = 116) and non-ASD control sera (N = 35) and also differed across the IL-1ß/IL-10-based ASD subgroups. Specifically, miRNA levels were increased and decreased in eight and nine miRNAs, respectively, in the high-ratio ASD subgroup (N = 48). In contrast, the low- (N = 25) and normal- (N = 43) ratio ASD subgroups only showed decreased miRNAs levels (18 and 10 miRNAs, respectively). Gene targets of the altered miRNAs in the high and/or low IL-1β/IL-10 ratio ASD subgroups were enriched in pathways critical for monocyte functions and metabolic regulation. Gene targets of the altered miRNAs in all the ASD subgroups were enriched in pathways of neuronal development and synaptic plasticity, along with cell proliferation/differentiation. ASD subgroup-specific associations were observed between serum miRNA expression and IL-1ß/IL-10 ratios, mitochondrial respiration, and monocyte cytokine profiles (IL-10, CCL2, and TNF-α). In summary, our results indicate that serum levels of select miRNAs may serve as promising biomarkers for screening and monitoring changes in innate immunity and mitochondrial respiration in ASD.

Hematopoietic Stem Cell Transplant for the Treatment of X-MAID

We report outcomes after hematopoietic stem cell transplant for three patients with X-MAID, including 1 patient from the originally described cohort and two brothers with positive TREC newborn screening for SCID who were found to have a T-B-NK+ SCID phenotype attributable to X-linked moesin associated immunodeficiency (X-MAID). A c.511C>T variant in moesin was identified via exome sequencing in the older of these siblings in the setting of low lymphocyte counts and poor proliferative responses consistent with SCID. He received reduced intensity conditioning due to CMV, and was transplanted with a T-depleted haploidentical (maternal) donor. His post-transplant course was complicated by hemolytic anemia, neutropenia, and sepsis. He had poor engraftment, requiring a 2nd transplant. His younger brother presented with the same clinical phenotype and was treated with umbilical cord blood transplant following myeloablative conditioning, has engrafted and is doing well. The third case also presented with severe lymphopenia in infancy, received a matched related bone marrow transplant following myeloablative conditioning, has engrafted and is doing well. These cases represent a novel manifestation of non-radiosensitive X-linked form of T-B-NK+ SCID that is able to be detected by TREC based newborn screening and effectively treated with HCT.

MicroRNA expression changes in association with changes in interleukin-1ß/interleukin10 ratios produced by monocytes in autism spectrum disorders: their association with neuropsychiatric symptoms and comorbid conditions (observational study)

BACKGROUND

MicroRNAs (miRNAs) play a major role in regulating immune responses at post-transcriptional levels. Previously, we have reported fluctuating interlukine-1ß (IL-1ß)/IL-10 ratios produced by peripheral blood monocytes (PBMo) in some patients with autism spectrum disorders (ASD). This study examined whether changes in miRNA expression by PBMo are associated with changes in IL-1ß/IL-10 ratios and how such changes are associated with ASD clinical features.

METHODS

miRNA expression by purified PBMo from ASD subjects (N = 69) and non-ASD controls (N = 27) were determined by high-throughput sequencing. Cytokine production by PBMo in responses to stimuli of innate immunity, and behavioral symptoms [assessed by aberrant behavioral checklist (ABC)] were also evaluated at the same time of sample obtainment.

RESULTS

As a whole, there was no difference in miRNA expression between ASD and control non-ASD PBMo. However, when ASD cells were subdivided into 3 groups with high, normal, or low IL-1ß/IL-10 ratios as defined in the "Results" section, in comparison with the data obtained from non-ASD controls, we observed marked changes in miRNA expression. Namely, over 3-fold changes in expression of miR-181a, miR-93, miR-223, miR-342, and miR-1248 were observed in ASD PBMo with high or low IL-1ß/IL-10 ratios, but not in ASD PBMo with normal ratios. These miRNAs that had altered in expression are those closely associated with the regulation of key signaling pathways. With changes in IL-1ß/IL-10 ratios, we also observed changes in the production of cytokines (IL-6, TNF-α, and TGF-ß) other than IL-1ß/IL-10 by ASD PBMo. The association between behavioral symptoms and cytokine levels was different when ASD cells exhibit high/low IL-1ß/IL-10 ratios vs. when ASD cells exhibited normal ratios. Non-IgE-mediated food allergy was also observed at higher frequency in ASD subjects with high/low IL-1ß/IL-10 ratios than with normal ratios.

CONCLUSIONS

Changes in cytokine profiles and miRNA expression by PBMo appear to be associated with changes in ASD behavioral symptoms. miRNAs that are altered in expression in ASD PBMo with high/low IL-1ß/IL-10 ratios are those associated with inflammatory responses. Changes in IL-1ß/IL-10 ratios along with changes in miRNA expression may serve as biomarkers for immune-mediated inflammation in ASD.

Marked improvement of neuropsychiatric symptoms following control of allergy symptoms with the use of humanized murine anti-IgE antibody (omalizumab) in 2 patients with severely limited expressive language

Flare-up of allergic rhinitis has been implicated in worsening neuropsychiatric symptoms such as hyperactivity and anxiety in the general population, mostly supported by epidemiological data. However, it is unknown how such respiratory allergy symptoms affect behavioral symptoms in patients with intellectual disability and limited expressive language. These patients may express more severe behavioral symptoms partly due to frustration and anxiety, being under-diagnosed and undertreated secondary to a lack of proper communication means. Herein, we present two cases of patients with severely limited expressive language , in whom we observed marked improvement in behavioral symptoms and even cognitive activity following control of their symptoms of allergic rhinitis with the use of omalizmab, a humanized anti-IgE antibody. The presented cases indicate that clinicians need to be aware of profound effects of allergy rhinitis on neuropsychiatric symptoms in individuals with limited expressive language.

Cytokine profiles by peripheral blood monocytes are associated with changes in behavioral symptoms following immune insults in a subset of ASD subjects: an inflammatory subtype?

BACKGROUND

Some children with autism spectrum disorders (ASD) are characterized by fluctuating behavioral symptoms following immune insults, persistent gastrointestinal (GI) symptoms, and a lack of response to the first-line intervention measures. These children have been categorized as the ASD-inflammatory subtype (ASD-IS) for this study. We reported a high prevalence of non-IgE mediated food allergy (NFA) in young ASD children before, but not all ASD/NFA children reveal such clinical features of ASD-IS. This study addressed whether behavioral changes of ASD-IS are associated with innate immune abnormalities manifested in isolated peripheral blood (PB) monocytes (Mo), major innate immune cells in the PB.

METHODS

This study includes three groups of ASD subjects (ASD-IS subjects (N = 24), ASD controls with a history of NFA (ASD/NFA (N = 20), and ASD/non-NFA controls (N = 20)) and three groups of non-ASD controls (non-ASD/NFA subjects (N = 16), those diagnosed with pediatric acute onset-neuropsychiatric syndrome (PANS, N = 18), and normal controls without NFA or PANS (N = 16)). Functions of purified PB Mo were assessed by measuring the production of inflammatory and counter-regulatory cytokines with or without stimuli of innate immunity (lipopolysaccharide (LPS), zymosan, CL097, and candida heat extracts as a source of β-lactam). In ASD-IS and PANS subjects, these assays were done in the state of behavioral exacerbation ('flare') and in the stable ('non-flare') condition. ASD-IS children in the 'flare' state revealed worsening irritability, lethargy and hyperactivity.

RESULTS

'Flare' ASD-IS PB Mo produced higher amounts of inflammatory cytokines (IL-1β and IL-6) without stimuli than 'non-flare' ASD-IS cells. With zymosan, 'flare' ASD-IS cells produced more IL-1β than most control cells, despite spontaneous production of large amounts of IL-1ß. Moreover, 'flare' ASD-IS Mo produced less IL-10, a counterregulatory cytokine, in response to stimuli than 'non-flare' cells or other control cells. These changes were not observed in PANS cells.

CONCLUSIONS

We observed an imbalance in the production of inflammatory (IL-1ß and IL-6) and counterregulatory (IL-10) cytokines by 'flare' ASD-IS monocytes, which may indicate an association between intrinsic abnormalities of PB Mo and changes in behavioral symptoms in the ASD-IS subjects.

Peripheral blood (PB) monocytes from subjects with autism spectrum disorders (ASD) and fluctuating behavioral symptoms following immune insults reveal similar innate immune responses to those observed in pediatric acute onset neuropsychiatric disorders (PANS). (HUM1P.325)

ASD is a behaviorally defined syndrome and encompasses markedly heterogeneous subjects. Some ASD subjects reveal markedly fluctuating behavioral symptoms following immune insults and persistent gastrointestinal (GI) symptoms; categorized as the ASD-inflammatory subtype (ASD-IS) (N=20) in this study. Cyotkine production by purified PB monocytes from ASD-IS subjects in response to TLR2/6, TLR4, TLR7/8, and Dectin 1 agonists were assessed in comparison with cells from control ASD subjects with and without non-IgE mediated food allergy (NFA) (ASD/NFA N=16, ASD/non-NFA children; N=18), non-ASD controls (non-ASD/NFA; N=13, normal controls; N=12, non-ASD/PANS N=18). ASD-IS subjects had no siblings diagnosed with ASD and ASD-IS children are noted to have a higher frequency of recurrent sinopulmonary infection than ASD/non-ASD controls; 8/20 ASD-IS children were diagnosed with antibody deficiency syndrome (ADS). ASD-IS PB monocytes produced higher levels of IL-1β, IL-6, and IL-12 with or without stimuli. In addition, decrease in production of IL-10 and sTNFRII with TLR2/6 and TLR7/8 agonists was more striking than normal control monocytes. Monocytes from ASD/NFA, ASD/non-NFA, or non-ASD/NFA subjects did not reveal such tendencies. However, cytokine production by PANS monocytes revealed similar tendencies. Aberrant innate immune responses detected in PB monocytes may be associated with markedly fluctuating neuropsychiatric symptoms observed in ASD-IS and PANS subjects.

Oral tolerance in patients with food protein induced enterocolitis syndrome (FPIES); Evidence of impaired induction of oral tolerance in FPIES patients with persistent reaction to multiple foods (123.9)

Treatment for FPIES is the avoidance of offending food, i.e., a restricted diet (RD). While most FPIES children are good responders to the RD (FPIES-GR), some are not (FPIES-poor responders: FPIES-PR) with persistent non-IgE mediated reactivity to multiple foods. This study assessed production of counter-regulatory cytokines crucial for oral tolerance by peripheral blood mononuclear cells (PBMCs) in FPIES-PR (N=18, 0.6 -4.8 yr), FPIES-GR (N=22, 1.1-5.9 yr), and normal control (N=19, 1.0-5.7 yr) children after FPIES children were on the RD. PBMCs were stimulated with agonists of toll like receptors (TLRs) and representative luminal antigens (Ags) (soy, cow’s milk, and wheat proteins, and candida Ag). Microarray analysis of PB moncytes was also performed on samples from some of these children. FPIES-PR children revealed more severe clinical features including failure to thrive, intolerance to probiotics, and anaphylaxis like reaction to rice than FPIES-GR children (p<0.005). FPIES-PR PBMCs produced less sTNFRII and IL-10 both with TLR agonists and without a stimulus than the control groups. FPIRS-PR cells also produced less IL-6 with a TLR4 agonist and without a stimulus than normal controls (p<0.05). Such changes were not observed in FPIES-GR cells. FPIES-PR PBMCs produced less TGF-β with and without luminal Ag than PFIES-GR PBMCs. Taken together, FPIES-PR children may have impaired production of counter-regulatory cytokines that are crucial for oral tolerance.

Autoimmune regulator (AIRE) contributes to Dectin-1-induced TNF-α production and complexes with caspase recruitment domain-containing protein 9 (CARD9), spleen tyrosine kinase (Syk), and Dectin-1

BACKGROUND

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) syndrome is a complex immunologic disease caused by mutation of the autoimmune regulator (AIRE) gene. Autoimmunity in patients with APECED syndrome has been shown to result from deficiency of AIRE function in transcriptional regulation of thymic peripheral tissue antigens, which leads to defective T-cell negative selection. Candidal susceptibility in patients with APECED syndrome is thought to result from aberrant adaptive immunity.

OBJECTIVE

To determine whether AIRE could function in anticandidal innate immune signaling, we investigated an extrathymic role for AIRE in the immune recognition of β-glucan through the Dectin-1 pathway, which is required for defense against Candida species.

METHODS

Innate immune signaling through the Dectin-1 pathway was assessed in both PBMCs from patients with APECED syndrome and a monocytic cell line. Subcellular localization of AIRE was assessed by using confocal microscopy.

RESULTS

PBMCs from patients with APECED syndrome had reduced TNF-α responses after Dectin-1 ligation but in part used a Raf-1-mediated pathway to preserve function. In the THP-1 human monocytic cell line, reducing AIRE expression resulted in significantly decreased TNF-α release after Dectin-1 ligation. AIRE formed a transient complex with the known Dectin-1 pathway components phosphorylated spleen tyrosine kinase and caspase recruitment domain-containing protein 9 after receptor ligation and localized with Dectin-1 at the cell membrane.

CONCLUSION

AIRE can participate in the Dectin-1 signaling pathway, indicating a novel extrathymic role for AIRE and a defect that likely contributes to fungal susceptibility in patients with APECED syndrome.

Immunological characterization and transcription profiling of peripheral blood (PB) monocytes in children with autism spectrum disorders (ASD) and specific polysaccharide antibody deficiency (SPAD): case study

Introduction

There exists a small subset of children with autism spectrum disorders (ASD) characterized by fluctuating behavioral symptoms and cognitive skills following immune insults. Some of these children also exhibit specific polysaccharide antibody deficiency (SPAD), resulting in frequent infection caused by encapsulated organisms, and they often require supplemental intravenous immunoglobulin (IVIG) (ASD/SPAD). This study assessed whether these ASD/SPAD children have distinct immunological findings in comparison with ASD/non-SPAD or non-ASD/SPAD children.

Case description

We describe 8 ASD/SPAD children with worsening behavioral symptoms/cognitive skills that are triggered by immune insults. These ASD/SPAD children exhibited delayed type food allergy (5/8), treatment-resistant seizure disorders (4/8), and chronic gastrointestinal (GI) symptoms (5/8) at high frequencies. Control subjects included ASD children without SPAD (N = 39), normal controls (N = 37), and non-ASD children with SPAD (N = 12).

Discussion and Evaluation

We assessed their innate and adaptive immune responses, by measuring the production of pro-inflammatory and counter-regulatory cytokines by peripheral blood mononuclear cells (PBMCs) in responses to agonists of toll like receptors (TLR), stimuli of innate immunity, and T cell stimulants. Transcription profiling of PB monocytes was also assessed. ASD/SPAD PBMCs produced less proinflammatory cytokines with agonists of TLR7/8 (IL-6, IL-23), TLR2/6 (IL-6), TLR4 (IL-12p40), and without stimuli (IL-1ß, IL-6, and TNF-α) than normal controls. In addition, cytokine production of ASD/SPAD PBMCs in response to T cell mitogens (IFN-γ, IL-17, and IL-12p40) and candida antigen (Ag) (IL-10, IL-12p40) were less than normal controls. ASD/non-SPAD PBMDs revealed similar results as normal controls, while non-ASD/SPAD PBMCs revealed lower production of IL-6, IL-10 and IL-23 with a TLR4 agonist. Only common features observed between ASD/SPAD and non-ASD/SPAD children is lower IL-10 production in the absence of stimuli. Transcription profiling of PB monocytes revealed over a 2-fold up (830 and 1250) and down (653 and 1235) regulation of genes in ASD/SPAD children, as compared to normal (N = 26) and ASD/non-SPAD (N = 29) controls, respectively. Enriched gene expression of TGFBR (p < 0.005), Notch (p < 0.01), and EGFR1 (p < 0.02) pathways was found in the ASD/SPAD monocytes as compared to ASD/non-SPAD controls.

Conclusions

The Immunological findings in the ASD/SPAD children who exhibit fluctuating behavioral symptoms and cognitive skills cannot be solely attributed to SPAD. Instead, these findings may be more specific for ASD/SPAD children with the above-described clinical characteristics, indicating a possible role of these immune abnormalities in their neuropsychiatric symptoms.

Children with autism spectrum disorders experiencing neuropsychiatric symptoms, cognitive skills, and gastrointestinal symptoms exhibit distinct innate immune abnormalities and transcriptional profiles in peripheral blood monocytes (47.7)

ASD is considered a behavioral syndrome associated with multiple genetic and environmental factors. This study focuses on a subset of ASD children characterized by fluctuating behavioral symptoms and cognitive skills, triggered by immune insults, in addition to chronic GI symptoms (ASD-immune subtype; ASD-IS). The study included ASD-IS (N=19), control ASD (N=29), and normal control (N=26) children. We evaluated production of pro-inflammatory and counter-regulatory cytokines by peripheral blood mononuclear cells (PBMCs) in response to agonists of toll like receptors (TLRs), polyclonal T cell stimulants, and recall antigens (Ags), and transcriptional profiles of PB monocytes. ASD-IS PBMCs produced less pro-inflammatory (IL-1β, IL-6, IL-12, and IL-23) and counter-regulatory (IL-10 and sTNFRII) cytokines with TLR agonists and less Th1 cytokines (IFN-γ and TNF-α) with recall Ags than control cells. ASD-IS PBMC also produced higher amounts of CCL2 than controls. Transcript profiles of ASD-IS monocytes were distinguished by altered mRNA expression (&gt;2x) in &gt;900 genes compared with either ASD or normal controls. Among these, 392 genes overlapped in the two control groups, including genes regulating TLR signaling, inflammatory responses, cell migration/adhesion, chemokines (CCL2 and CCL7), and genes associated with risks for autism, sychizophrenia, and depression. Our findings indicate a role of innate immunity in the puzzling clinical features observed in ASD-IS children.

Age-dependent changes in peripheral blood dendritic cell subsets in normal children and children with specific polysaccharide antibody deficiency (SPAD)

Myeloid and plasmacytoid dendritic cells (MDC/PDC) play crucial roles in bridging adaptive and innate immunity by affecting development of both cellular and humoral immunity. The immune system evolves after birth as reflected in dynamic changes in numbers and functions of various immune cells with age. However, age-associated changes in DC subsets in children have not been elucidated despite the fact that such normative data are crucial for evaluating alternations of DC subsets in various pediatric diseases. This study addressed age-associated changes in DC subsets and CD40/86 expression on PDC (markers of maturation/activation) in 50 healthy children in comparison with 25 children with specific polysaccharide antibody deficiency (SPAD). Our results revealed age-dependent decrease of PDC numbers (p < 0.0001), although there was no age-associated changes in CD40/CD86 expression. MDC1/MDC2 numbers did not reveal such linear age-dependent changes and MDC1/PDC ratio reached around 2 as typically seen in young adults after 10 years of age. In contrast, SPAD patients did not reveal such age-associated changes and showed decreased fluorescence intensity of CD86 in PDC cells. These results indicate lineage specific, age-dependent changes in DC subsets in normal children and possible altered development of these cells in SPAD children, emphasizing the importance of age-appropriate controls.

Autism spectrum disorders and allergy: observation from a pediatric allergy/immunology clinic

IgE-mediated allergic diseases (e.g., allergic rhinoconjunctivitis, atopic asthma and food allergy) are prevalent (up to 30%) in the general population and are increasing in developed countries. In infants and young children, non-IgE-mediated food allergy is also prevalent. In addition to easily recognized organ-specific symptoms, allergic diseases can cause neuropsychiatric symptoms, such as irritability and hyperactivity, in otherwise healthy individuals. This is also likely to occur in children with autism spectrum disorder (ASD). Moreover, the discomfort and pain associated with allergic diseases could aggravate behavioral symptoms in ASD children. Allergic conditions are easily treatable; however, ASD children may be underdiagnosed and/or undertreated for allergic and other common childhood diseases, in part due to their impaired communication skills. Practicing physicians should be aware of the potential impact of allergic diseases on behavioral symptoms and cognitive activity in ASD children. However, they also need to be aware that certain symptoms often attributed to 'allergy' by caregivers may not be immune mediated and should understand that behavioral symptoms can also be affected by many non-IgE-mediated causes.

Aberrant responses to TLR agonists in pediatric IBD patients; the possible association with increased production of Th1/Th17 cytokines in response to candida, a luminal antigen

Toll like receptors (TLR) regulate innate immune responses sensing byproducts of intestinal microbiota. We examined responses to TLR agonists in children with inflammatory bowel disease (IBD). Peripheral blood mononuclear cells (PBMC) obtained from children with IBD [Crohn's disease (CD, n = 10), ulcerative colitis (UC, n = 10)], children with non-IgE-mediated food allergy (NFA, n = 20), and controls (n = 15) were tested for their production of proinflammatory and counter-regulatory cytokines with TLR agonists in comparison with their cytokine production against milk protein and candida. IBD patients were all in the inactive state. IBD PBMC produced more IL-6 with all the TLR agonists tested than controls. CD PBMC produced more counter-regulatory cytokines with TLR agonists, while UC PBMC produced more IL-1ss and IL-10 with TLR 7/8 agonist than controls. Cytokine production by NFA PBMC did not differ from controls. CD but not UC PBMC produced more IFN-gamma and IL-17 with candida. Aberrant responses to TLR agonists may be associated with increase in IFN-gamma/IL-17 production against candida in CD children.

A distinct pattern of mRNA expression by monocytes is found in a subset of children with autism spectrum disorders (ASD) who present with recurrent infection, repeated loss of cognitive skills, and persistent gastrointestinal (GI) symptoms. (51.16)

A subset of ASD children (ASD Test Group) characterized by repeated loss of cognitive skills triggered by infection and frequent persistent GI symptoms were studied. We evaluated mRNA expression by peripheral blood (PB) monocytes in ASD test group (N=20, median 8 y) , ASD controls(N=22, median 7.6 y) , and normal control children (N=10, median 5.5 y) as well as the mothers of the ASD test (N=19) and ASD control (N=22) groups. We found that 568 genes were up-regulated and 72 genes were down-regulated (&gt;2 fold) in the ASD test group versus 469 up-regulated and 57 down-regulated in the control groups. Only the ASD control group displayed up-regulation of CCL7 and CCL2 and down-regulation of IL-6 and CD86. The ASD test group mothers revealed up-regulation of 175 genes including CCL7 and down-regulation of 57 genes as compared to the ASD control mothers. The ASD test group also revealed decreased spontaneous production of IL-6 and IL-1β by PB mononuclear cells compared to controls. The 16/20 ASD test group children with persistent GI symptoms revealed up-regulation of CCL7 (&gt;5 fold) and CCL2 and down-regulation of inflammatory mediators (IL-6, IL-23, IL-1α/IL-1β, CD86, and other chemokines) as compared to ASD and normal controls. Our results indicate a distinct pattern of mRNA expression in PB monocytes in the ASD subset with characteristic clinical features. Interestingly, CCL7 and CCL2 are up-regulated in the brain in various neurodegenerative disorders.

Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report

Autism spectrum disorders (ASDs) are common and clinically heterogeneous neurodevelopmental disorders. Gastrointestinal disorders and associated symptoms are commonly reported in individuals with ASDs, but key issues such as the prevalence and best treatment of these conditions are incompletely understood. A central difficulty in recognizing and characterizing gastrointestinal dysfunction with ASDs is the communication difficulties experienced by many affected individuals. A multidisciplinary panel reviewed the medical literature with the aim of generating evidence-based recommendations for diagnostic evaluation and management of gastrointestinal problems in this patient population. The panel concluded that evidence-based recommendations are not yet available. The consensus expert opinion of the panel was that individuals with ASDs deserve the same thoroughness and standard of care in the diagnostic workup and treatment of gastrointestinal concerns as should occur for patients without ASDs. Care providers should be aware that problem behavior in patients with ASDs may be the primary or sole symptom of the underlying medical condition, including some gastrointestinal disorders. For these patients, integration of behavioral and medical care may be most beneficial. Priorities for future research are identified to advance our understanding and management of gastrointestinal disorders in persons with ASDs.

Food allergy and autism spectrum disorders: is there a link?

Gastrointestinal (GI) symptoms are common comorbidities in children with autism spectrum disorders (ASDs). Parents often attribute these GI symptoms to food allergy (FA), although an evaluation for IgE-mediated FA is often unrevealing. Our previous studies indicated a high prevalence of non-IgE-mediated FA in young children with ASDs. Therefore, non-IgE-mediated FA may account for some but not all GI symptoms observed in children with ASDs. This raises the question of what treatment measures are applicable to ASD children with GI symptoms. A wide variety of dietary supplements and dietary intervention measures for ASD children have been promoted by medical professionals practicing complementary and alternative medicine despite the lack of rigorous scientific validation in most instances. This review summarizes possible (or proposed) etiologies of GI symptoms in ASD children and discusses risks and possible benefits of intervention measures promoted by complementary and alternative practitioners, with emphasis on FA.

Children with autism spectrum disorders (ASD) characterized by frequent viral infection and subsequent loss of cognitive skills differ in mRNA expression of peripheral blood monocytes from other ASD children (136.7)

We have reported presence of an ASD subset distinguished by recurrent loss of previously acquired cognitive skills with worsening behavioral symptoms triggered by infection (typically viral), which may be associated with altered TLR responses important for neuro-immune interactions involving IL-1β. This study assessed gene expression of peripheral blood (PB) monocytes in this ASD subset (ASD-test group, N=14, median 7.8 yr) in comparison with control ASD (N=11, median 6.8 yr) and normal children (N=5, median 8yr). Both the ASD groups regressed at the onset of ASD and had high frequency of non-IgE mediated food allergy. The ASD test group also had lower IL-10 production with recall antigens than 24 normal controls. Microarray analysis revealed difference of mRNA expression (two fold or more) of 1593 genes in the ASD-test group and 2704 genes ASD-controls as compared to normal controls. IL-1 pathway related genes were over-represented in the ASD-test group (p=0.002) while IL-2, IL-3, IL-9, α-integrin (all p&lt;0.05), and TNF-α pathway (p=0.001) genes were over-represented in the ASD-control group (GeneSpring GX). Among 844 genes belonging to both the ASD groups, IL-2 and IL-3 pathway related genes were enriched (p&lt;0.05). Our results indicate notable difference in the ASD test and control groups at the level of mRNA expression in PB monocytes, supporting our previous results. Partly funded by Jonty Foundation and ARI.

Impact of innate immunity in a subset of children with autism spectrum disorders: a case control study

Background

Among patients with autism spectrum disorders (ASD) evaluated in our clinic, there appears to be a subset that can be clinically distinguished from other ASD children because of frequent infections (usually viral) accompanied by worsening behavioural symptoms and/or loss/decrease in acquired skills. This study assessed whether these clinical features of this ASD subset are associated with atopy, asthma, food allergy (FA), primary immunodeficiency (PID), or innate immune responses important in viral infections.

Methods

This study included the ASD children described above (ASD test, N = 26) and the following controls: ASD controls (N = 107), non-ASD controls with FA (N = 24), non-ASD controls with chronic rhinosinusitis/recurrent otitis media (CRS/ROM; N = 38), and normal controls (N = 43). We assessed prevalence of atopy, asthma, FA, CRS/ROM, and PID. Innate immune responses were assessed by measuring production of proinflammatory and counter-regulatory cytokines by peripheral blood mononuclear cells (PBMCs) in response to agonists of Toll-like receptors (TLRs), with or without pre-treatment of lipopolysaccharide (LPS), a TLR4 agonist.

Results

Non-IgE mediated FA was equally prevalent in both ASD test and ASD control groups, occurring at higher frequency than in the non-ASD controls. Allergic rhinitis, atopic/non-atopic asthma, and atopic dermatitis were equally prevalent among the study groups except for the CRS/ROM group in which non-atopic asthma was more prevalent (52.6%). CRS/ROM and specific polysaccharide antibody deficiency (SPAD) were more prevalent in the ASD test group than in the ASD control, FA, and normal control groups: 23.1% vs. < 5% for CRS/ROS and 19.2% vs. < 1% for SPAD. However, CRS/ROM patients had the highest prevalence of SPAD (34.2%). When compared to ASD and normal case controls, PBMCs from 19 non-SPAD, ASD test group children produced: 1) less IL-1β with a TLR7/8 agonist, less IL-10 with a TLR2/6 agonist, and more IL-23 with a TLR4 agonist without LPS pre-treatment, and 2) less IL-1β with TLR4/7/8 agonists with LPS pre-treatment. These are cytokines associated with the neuro-immune network.

Conclusion

Clinical features of the ASD test group were not associated with atopy, asthma, FA, or PID in our study but may be associated with altered TLR responses mediating neuro-immune interactions.

Monozygous twins with a microdeletion syndrome involving BTK, DDP1, and two other genes; evidence of intact dendritic cell development and TLR responses

We report for the first time monozygous twins with a microdeletion syndrome involving genes coding for Bruton's tyrosine kinase (Btk) and deafness-dystonia peptide 1 (DDP1), and two other genes. Apart from its essential role in B cell development, Btk is indicated to affect signaling mediated by toll like receptors (TLRs) and development of dendritic cells (DCs) but results are conflictive. The twins revealed normal numbers of plasmacytoid and myeloid DCs (pDCs and mDCs). Moreover, BTK null cells from these patients exhibited robust responses to TLR agonists, normal natural killer (NK) cell activity, and normal pDC functions.

CONCLUSION

Our results do not indicate the essential role of Btk in TLR signaling and DC development.

Adjunctive treatment of disseminated Mycobacterium avium complex infection with interferon alpha-2b in a patient with complete interferon-gamma receptor R1 deficiency

We report adjunct treatment of (interferon) IFN-alpha2b (Intron-A) in a patient with complete interferon-gamma receptor R1 (IFNGR1) deficiency suffering from disseminated infection with Mycobacterium avium complex (MAC) resistant to multiple anti-mycobacterial agents. A low dose of IFN-alpha2b (3 x 10(6) units/m(2) three times weekly subcutaneously) successfully attenuated progressive hepatosplenomegaly and abdominal/retroperitoneal/pelvic lymphadenopathy, although the patient continued to be mycobacteremic. This is the first report of a complete IFNGR1 deficiency treated with adjuvant IFN-alpha2b for disseminated MAC infection.

Fetal sensitization to cow's milk protein and wheat: cow's milk protein and wheat-specific TNF-alpha production by umbilical cord blood cells and subsequent decline of TNF-alpha production by peripheral blood mononuclear cells following dietary intervention

We present a case of fetal sensitization to cow's milk protein (CMP) and wheat, resulting in non-IgE mediated food allergy (NFA). Fetal sensitization was indicated by onset of NFA symptoms shortly after birth and CMP/wheat-specific tumor necrosis factor-alpha (TNF-alpha) production by cord blood mononuclear cells. Following dietary intervention, we observed a decline of TNF-alpha production by peripheral blood mononuclear cells with stimuli of these dietary proteins (DPs) but recurrence of reactivity was observed following viral gastroenteritis, while interleukin-10 production with these DPs persisted during his first 5 yr of life. This finding may indicate active suppressive mechanisms for maintaining oral tolerance.

Association between TLR4 SNPs (Asp299Gly/Thr399Ile) and non-IgE mediated food allergy (NFA) with or without recurrent otitis media (OM) and chronic rhinosinusitis (CRS). (44.25)

Co-segragating missense mutations of Asp299Gly and Thr399Ile in TLR4 are found in 10% of general population. Heterozygousity of these mutations is implicated with hyporesponsiveness to a TLR4 agonist (LPS). This study addressed the association between heterozygousity of these TLR4 alleles and NFA with or without recurrent OM/CRS. The study included 203 children: inflammatory bowel disease (IBD; N=11 median 14.5 y), OM/CRS/no NFA (N=21, median 7.3 y), NFA alone (N=64, median 3.8 y), OM/CRS+NFA (N=30, median 5.5 y) and controls (N=78, median 6.9 y). Production of proinflammatory cytokines (TNF-α, IL-1ß, IL-6, and IL-12) by peripheral blood mononuclear cells and TLR2 Arg753Gln allele were also assessed. In this study, 20/203 (9.85%) and 7/203 (3.4%) subjects were heterozygous for TLR4 Asp299Gly/Thr399Ile and TLR2 Arg753Gln alleles, respectively. Heterozygousity of these TLR4 alleles were associated with OM/CRS+NFA (57.1% vs 9.7%, p&lt;0.00001), IgE mediated FA (p&lt;0.001), and atopy (p&lt;0.02) but not with OM/CRS/no NFA or IBD. Such an association was not found in TLR2 Arg753Gln allele. LPS responses did not differ irrespective with these TLR2/4 mutated alleles. Among 21 children with OM/CRS/no NFA, 16 revealed other immunodeficiencies. Thus individuals heterozygous for TLR4 Asp299Gly/Thr399Ile alleles may be predisposed to OM/CRS/NFA and possibly IgE mediated FA.

Funded by Jonty Foundation.

SAPHO osteomyelitis and sarcoid dermatitis in a patient with DiGeorge syndrome

We report the development and spontaneous resolution of annular erythematous skin lesions consistent with sarcoid dermatitis in a child with DiGeorge syndrome (DGS) carrying the 22q11.2 microdeletion. The skin lesion developed after she was treated with isoniazid (INH) following exposure to active tuberculosis (TB). After resolution of the skin lesions, this child developed sterile hyperplastic osteomyelitis consistent with SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) osteomyelitis in her right mandible triggered by an odontogenic infection. This child had congenital heart disease, dysmorphic facies, recurrent sinopulmonary infection, gastroesophageal reflux disease, scoliosis, reactive periostitis, and developmental delay. She had a low CD4 and CD8 T cell count with a normal 4/8 ratio, but normal cell proliferation and T cell cytokine production in response to mitogens. When she was presented with sterile osteomyelitis of right mandible, she revealed polyclonal hypergammaglobulinemia with elevated erythrocyte sedimentation rate (ESR)/angiotensin converting enzyme (ACE) levels, but negative CRP. Autoimmune and sarcoidosis workup was negative. Inflammatory parameters gradually normalized following resolution of odontogenic infection and with the use of non-steroidal anti-inflammatory drugs (NSAIDs). The broad clinical spectrum of DGS is further expanded with the development of autoimmune and inflammatory complications later in life. This case suggests that patients with the DGS can present with unusual sterile inflammatory lesions triggered by environmental factors, further broadening the clinical spectrum of this syndrome.

Cerebrospinal fluid and serum markers of inflammation in autism

Systemic immune abnormalities have no known relevance to brain dysfunction in autism. In order to find evidence for neuroinflammation, we compared levels of sensitive indicators of immune activation: quinolinic acid, neopterin, and biopterin, as well as multiple cytokines and cytokine receptors, in cerebrospinal fluid and serum from children with autism, to control subjects with other neurologic disorders. In cerebrospinal fluid from 12 children with autism, quinolinic acid (P = 0.037) and neopterin (P = 0.003) were decreased, and biopterin (P = 0.040) was elevated, compared with control subjects. In sera from 35 persons with autism, among cytokines, only tumor necrosis factor receptor II was elevated compared with controls (P < 0.02). Decreased quinolinic acid and neopterin in cerebrospinal fluid are paradoxical and suggest dysmaturation of metabolic pathways and absence of concurrent infection, respectively, in autism. Alternatively, they may be produced by microglia but remain localized and not expressed in cerebrospinal fluid.

Evaluation of an association between gastrointestinal symptoms and cytokine production against common dietary proteins in children with autism spectrum disorders

OBJECTIVE

To evaluate an association between cytokine production with common dietary proteins as a marker of non-allergic food hypersensitivity (NFH) and gastrointestinal (GI) symptoms in young children with autism spectrum disorders (ASD).

STUDY DESIGN

Peripheral blood mononuclear cells (PBMCs) were obtained from 109 ASD children with or without GI symptoms (GI [+] ASD, N = 75 and GI (-) ASD, N = 34], from children with NFH (N = 15), and control subjects (N = 19). Diarrhea and constipation were the major GI symptoms. We measured production of type 1 T-helper cells (Th1), type 2 T-helper cells (Th2), and regulatory cytokines by PBMCs stimulated with whole cow's milk protein (CMP), its major components (casein, beta-lactoglobulin, and alpha-lactoalbumin), gliadin, and soy.

RESULTS

PBMCs obtained from GI (+) ASD children produced more tumor necrosis factor-alpha (TNF-alpha)/interleukin-12 (IL-12) than those obtained from control subjects with CMP, beta-lactoglobulin, and alpha-lactoalbumin, irrespective of objective GI symptoms. They also produced more TNF-alpha with gliadin, which was more frequently observed in the group with loose stools. PBMCs obtained from GI (-) ASD children produced more TNF-alpha/IL-12 with CMP than those from control subjects, but not with beta-lactoglobulin, alpha-lactoalbumin, or gliadin. Cytokine production with casein and soy were unremarkable.

CONCLUSION

A high prevalence of elevated TNF-alpha/IL-12 production by GI (+) ASD PBMCs with CMP and its major components indicates a role of NFH in GI symptoms observed in children with ASD.

Dysregulated innate immune responses in young children with autism spectrum disorders: their relationship to gastrointestinal symptoms and dietary intervention

OBJECTIVE

Our previous study indicated an association between cellular immune reactivity to common dietary proteins (DPs) and excessive proinflammatory cytokine production with endotoxin (lipopolysaccharide, LPS), a major stimulant of innate immunity in the gut mucosa, in a subset of autism spectrum disorder (ASD) children. However, it is unclear whether such abnormal LPS responses are intrinsic in these ASD children or the results of chronic gastrointestinal (GI) inflammation secondary to immune reactivity to DPs. This study further explored possible dysregulated production of proinflammatory and counter-regulatory cytokines with LPS in ASD children and its relationship to GI symptoms and the effects of dietary intervention measures.

METHODS

This study includes ASD children (median age 4.8 years) on the unrestricted (n = 100) or elimination (n = 77) diet appropriate with their immune reactivity. Controls include children with non-allergic food hypersensitivity (NFH; median age 2.9 years) on the unrestricted (n = 14) or elimination (n = 16) diet, and typically developing children (median age 4.5 years, n = 13). The innate immune responses were assessed by measuring production of proinflammatory (TNF-alpha, IL-1beta, IL-6, and IL-12) and counter-regulatory (IL-1ra, IL-10, and sTNFRII) cytokines by peripheral blood mononuclear cells (PBMCs) with LPS. The results were also compared to T-cell responses with common DPs and control T-cell mitogens assessed by measuring T-cell cytokine production.

RESULTS

ASD and NFH PBMCs produced higher levels of TNF-alpha with LPS than controls regardless of dietary interventions. However, only in PBMCs from ASD children with positive gastrointestinal (GI(+)) symptoms, did we find a positive association between TNF-alpha levels produced with LPS and those with cow's milk protein (CMP) and its major components regardless of dietary interventions. In the unrestricted diet group, GI(+) ASD PBMCs produced higher IL-12 than controls and less IL-10 than GI(-) ASD PBMCs with LPS. GI(+) ASD but not GI(-) ASD or NFH PBMCs produced less counter-regulatory cytokines with LPS in the unrestricted diet group than in the elimination diet group. There was no significant difference among the study groups with regard to cytokine production in responses to T-cell mitogens and other recall antigens.

CONCLUSION

Our results revealed that there are findings limited to GI(+) ASD PBMCs in both the unrestricted and elimination diet groups. Thus our findings indicate intrinsic defects of innate immune responses in GI(+) ASD children but not in NFH or GI(-) ASD children, suggesting a possible link between GI and behavioral symptoms mediated by innate immune abnormalities.