RHEUMATOLOGY
Rheumatology 2015;54:363368 doi:10.1093/rheumatology/keu341 Advance Access publication 29 August 2014
Concise report TLR2/TLR4-dependent exaggerated cytokine production in hyperimmunoglobulinaemia D and periodic fever syndrome Monique Stoffels1,2, Johanna Jongekrijg1,2, Thijs Remijn1,2, Nina Kok1,2, Jos W. M. van der Meer1,2 and Anna Simon1,2
Methods. Peripheral blood mononuclear cells from HIDS patients and healthy donors were incubated with several stimuli. Cytokine concentrations were detected by ELISA. To analyse mRNA and protein expression, we performed quantitative RT-PCR and western blot, respectively. Results. We observed significant differences in cytokine production when cells were incubated with ligands for Toll-like receptor 2 (TLR2), TLR4 and nucleotide-binding oligomerization domain-containing 2 (NOD2). The increased ratio between active and inactive caspase-1 protein in HIDS patients could explain why these cells are more easily triggered to secrete IL-1b. This is apparently not regulated at the transcriptional level, since expression levels of caspase-1 and IL-1b mRNA were similar in patients and controls. Both anakinra and tocilizumab treatment resulted in decreased inflammation, both ex vivo as well as in vivo. Conclusion. The increased cytokine secretion in HIDS is specific for TLR2, TLR4 and NOD2 ligation. Although IL-1b is important in the HIDS pathology, our data suggest it is a multicytokine disease. A more rigorous clinical trial is required to determine whether IL-6 receptor blockade may be considered in patients not responding to anakinra treatment. Key words: periodic fever, autoinflammatory syndrome, anakinra, tocilizumab, mevalonate kinase deficiency, hyper-IgD syndrome.
Introduction Hereditary autoinflammatory syndromes are diseases characterized by lifelong recurrent episodes of systemic inflammation. One of these is hyperimmunoglobulinaemia D and periodic fever syndrome (HIDS), an autosomal 1 Department of Internal Medicine, Radboud University Medical Center and 2Nijmegen Institute for Infection, Inflammation and Immunity (N4i), Nijmegen, The Netherlands.
Submitted 29 January 2014; revised version accepted 27 June 2014. Correspondence to: Anna Simon, Department of Internal Medicine, 463, UMC St Radboud, PO Box 9101, 6500 HB Nijmegen, The Netherlands. E-mail: [email protected]
recessively inherited disorder that is part of the spectrum of phenotypes associated with mevalonate kinase (MK) deficiency (MKD) [1, 2]. This spectrum encompasses HIDS and mevalonic aciduria (MA), both autoinflammatory disorders in which the episodes are characterized by symptoms that can include fever, abdominal pain, diarrhoea, skin rash and lymphadenopathy [3]. More severe MA is also characterized by symptoms such as cerebellar ataxia and mental retardation. Recently cases of disseminated superficial actinic porokeratosis and retinitis pigmentosa have been added to the spectrum [4, 5]. MKD is caused by mutations in the MVK gene, resulting in decreased activity of MK in the isoprenoid pathway, in
! The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected]
BASIC SCIENCE
Objective. The autoinflammatory hyperimmunoglobulinaemia D and periodic fever syndrome (HIDS) is characterized by recurrent episodes of fever and inflammation. As part of the mevalonate kinase deficiency spectrum, it is caused by MVK mutations, resulting in decreased mevalonate kinase activity in the isoprenoid pathway. Although IL-1b is considered a major cytokine in its pathogenesis, IL-1 blockade is not successful in a proportion of patients. We aimed to further characterize the pro-inflammatory cytokine profile of HIDS.
Downloaded from http://rheumatology.oxfordjournals.org/ at Cornell University Library on July 19, 2015
Abstract
Monique Stoffels et al.
Methods Patients and controls Fifteen clinically and genetically confirmed HIDS patients (see supplementary Table S1, available at Rheumatology Online) and 37 unrelated healthy controls were included in the study. The study was approved by the Committee on Research Involving Human Subjects (Arnhem-Nijmegen region) and written informed consent was obtained according to the Declaration of Helsinki before venous blood was collected and processed.
In vitro cytokine production Peripheral blood mononuclear cells (PBMCs) were isolated by density centrifugation using Ficoll-Paque Plus (GE Healthcare Bio-Sciences, Uppsala, Sweden). Cells were incubated with various stimuli for 24 h at 37 C in RPMI 1640 medium (Dutch modification; Invitrogen, Paisley, UK) supplemented with 50 mg/ml gentamicin (Centrafarm, Etten-Leur, The Netherlands), 1 mM sodium pyruvate and 2 mM GlutaMAX (Invitrogen). To assess inflammasome activation, PBMCs were stimulated for 3 h with 1 mg/ml lipopolysaccharide (LPS; Sigma, St Louis, MO, USA; Escherichia coli serotype 055:B5) followed by 15 min of 1 mM adenosine triphosphate (ATP) stimulation.
Cytokine assays Cytokine concentrations in supernatants were measured using commercial ELISAs from R&D Systems (Abingdon, UK) or Sanquin (Amsterdam, The Netherlands).
364
For measurement of intracellular cytokine concentrations the remaining cells were three times freezethawed. Cellular debris was removed by centrifugation before measuring cytokine concentrations by ELISA. CRP levels were measured using an Aeroset 2.0 analyser (Abbott Diagnostics, Santa Clara, CA, USA; normal reference 50% reduction of cytokine secretion compared with LPS stimulation. CRP in this patient decreased markedly after initiation of treatment (arrow). Controls are shown in green. (B) Ex vivo stimulated PBMCs from two untreated patients (P1: red bars, MVK V377I/I268T; P2: blue bars, MVK H20P/V377I) and control PBMCs (white bars). One month after initiation of tocilizumab treatment, ex vivo cytokine secretion is in the normal range (dashed bars). HIDS: hyperimmunoglobulinaemia D and periodic fever syndrome; LPS: lipopolysaccharide; PBMC: peripheral blood mononuclear cell; ND: not determined. NOD2 ligation and involves not only IL-1b but also other pro-inflammatory cytokines. The increased ratio between active and inactive caspase-1 protein in HIDS patients provides an explanation of why these cells are more
www.rheumatology.oxfordjournals.org
easily triggered to secrete IL-1b. The driving role of IL1b in HIDS pathology may be questioned as we provide data in favour of a multicytokine disease. IL-6 receptor blockade may be considered in patients not responding
367
Monique Stoffels et al.
to anakinra treatment, but this needs a more rigorous clinical trial. Rheumatology key messages The increased cytokine response in hyper-IgD and periodic fever syndrome (HIDS) patients is specific for TLR4, TLR2 and NOD2 ligation. . In addition to IL-1, other cytokines have a driving role in the pathogenesis of HIDS. .
Acknowledgements We thank our patients and volunteers.
Disclosure statement: The authors have declared no conflicts of interest.
Supplementary data Supplementary data are available at Rheumatology Online.
References 1 Dinarello CA, Simon A, van der Meer JW. Treating inflammation by blocking interleukin-1 in a broad spectrum of diseases. Nat Rev Drug Discov 2012;11:63352. 2 Stoffels M, van der Meer JW, Simon A. Mevalonate kinase deficiency nomenclature. Rheumatol Int 2014;34:2956. 3 Stoffels M, Simon A. Hyper-IgD syndrome or mevalonate kinase deficiency. Curr Opin Rheumatology 2011;23: 41923. 4 Siemiatkowska AM, van den Born LI, van Hagen PM et al. Mutations in the mevalonate kinase (MVK) gene cause nonsyndromic retinitis pigmentosa. Ophthalmology 2013; 120:2697705. 5 Zhang SQ, Jiang T, Li M et al. Exome sequencing identifies MVK mutations in disseminated superficial actinic porokeratosis. Nat Genet 2012;44:115660. 6 Bodar EJ, Kuijk LM, Drenth JP et al. On-demand anakinra treatment is effective in mevalonate kinase deficiency. Ann Rheum Dis 2011;70:21558. 7 De Leo L, Marcuzzi A, Decorti G et al. Targeting farnesyltransferase as a novel therapeutic strategy for mevalonate
368
8 Henneman L, Schneiders MS, Turkenburg M, Waterham HR. Compromised geranylgeranylation of RhoA and Rac1 in mevalonate kinase deficiency. J Inherit Metab Dis 2010;33:62532. 9 Kuijk LM, Beekman JM, Koster J et al. HMG-CoA reductase inhibition induces IL-1beta release through Rac1/ PI3K/PKB-dependent caspase-1 activation. Blood 2008; 112:356373. 10 Kuijk LM, Mandey SH, Schellens I et al. Statin synergizes with LPS to induce IL-1beta release by THP-1 cells through activation of caspase-1. Mol Immunol 2008;45: 215865. 11 Mandey SH, Kuijk LM, Frenkel J, Waterham HR. A role for geranylgeranylation in interleukin-1b secretion. Arthritis Rheum 2006;54:36905. 12 Marcuzzi A, Crovella S, Pontillo A. Geraniol rescues inflammation in cellular and animal models of mevalonate kinase deficiencyIn Vivo 2011;25:8792. 13 Pontillo A, Paoluzzi E, Crovella S. The inhibition of mevalonate pathway induces upregulation of NALP3 expression: new insight in the pathogenesis of mevalonate kinase deficiency. Eur J Hum Genet 2010;18:8447. 14 Simon A, Drewe E, van der Meer JW et al. Simvastatin treatment for inflammatory attacks of the hyperimmunoglobulinemia D and periodic fever syndrome. Clin Pharmacol Ther 2004;75:47683. 15 Bodar EJ, van der Hilst JC, van Heerde W et al. Defective apoptosis of peripheral-blood lymphocytes in hyper-IgD and periodic fever syndrome. Blood 2007;109: 24168. 16 de Koning HD, Schalkwijk J, van der Ven-Jongekrijg J et al. Sustained efficacy of the monoclonal anti-interleukin-1 beta antibody canakinumab in a 9-month trial in Schnitzler’s syndrome. Ann Rheum Dis 2013;72: 16348. 17 Bodar EJ, van der Hilst JC, Drenth JP, van der Meer JW, Simon A. Effect of etanercept and anakinra on inflammatory attacks in the hyper-IgD syndrome: introducing a vaccination provocation model. Neth J Med 2005;63: 2604. 18 van der Burgh R, Nijhuis L, Pervolaraki K et al. Defects in mitochondrial clearance predispose human monocytes to interleukin-1b hypersecretion. J Biol Chem 2014;289: 500012. 19 Yu L, Wang L, Chen S. Endogenous toll-like receptor ligands and their biological significance. J Cell Mol Med 2010;14:2592603.
www.rheumatology.oxfordjournals.org
Downloaded from http://rheumatology.oxfordjournals.org/ at Cornell University Library on July 19, 2015
Funding: This study was supported by a Vidi grant (017.106.386 to A.S.) from the Netherlands Organization for Scientific Research (NWO).
kinase deficiency: in vitro and in vivo approaches. Pharmacol Res 2010;61:50610.
Rheumatology 2015;54:363368 doi:10.1093/rheumatology/keu341 Advance Access publication 29 August 2014
Concise report TLR2/TLR4-dependent exaggerated cytokine production in hyperimmunoglobulinaemia D and periodic fever syndrome Monique Stoffels1,2, Johanna Jongekrijg1,2, Thijs Remijn1,2, Nina Kok1,2, Jos W. M. van der Meer1,2 and Anna Simon1,2
Methods. Peripheral blood mononuclear cells from HIDS patients and healthy donors were incubated with several stimuli. Cytokine concentrations were detected by ELISA. To analyse mRNA and protein expression, we performed quantitative RT-PCR and western blot, respectively. Results. We observed significant differences in cytokine production when cells were incubated with ligands for Toll-like receptor 2 (TLR2), TLR4 and nucleotide-binding oligomerization domain-containing 2 (NOD2). The increased ratio between active and inactive caspase-1 protein in HIDS patients could explain why these cells are more easily triggered to secrete IL-1b. This is apparently not regulated at the transcriptional level, since expression levels of caspase-1 and IL-1b mRNA were similar in patients and controls. Both anakinra and tocilizumab treatment resulted in decreased inflammation, both ex vivo as well as in vivo. Conclusion. The increased cytokine secretion in HIDS is specific for TLR2, TLR4 and NOD2 ligation. Although IL-1b is important in the HIDS pathology, our data suggest it is a multicytokine disease. A more rigorous clinical trial is required to determine whether IL-6 receptor blockade may be considered in patients not responding to anakinra treatment. Key words: periodic fever, autoinflammatory syndrome, anakinra, tocilizumab, mevalonate kinase deficiency, hyper-IgD syndrome.
Introduction Hereditary autoinflammatory syndromes are diseases characterized by lifelong recurrent episodes of systemic inflammation. One of these is hyperimmunoglobulinaemia D and periodic fever syndrome (HIDS), an autosomal 1 Department of Internal Medicine, Radboud University Medical Center and 2Nijmegen Institute for Infection, Inflammation and Immunity (N4i), Nijmegen, The Netherlands.
Submitted 29 January 2014; revised version accepted 27 June 2014. Correspondence to: Anna Simon, Department of Internal Medicine, 463, UMC St Radboud, PO Box 9101, 6500 HB Nijmegen, The Netherlands. E-mail: [email protected]
recessively inherited disorder that is part of the spectrum of phenotypes associated with mevalonate kinase (MK) deficiency (MKD) [1, 2]. This spectrum encompasses HIDS and mevalonic aciduria (MA), both autoinflammatory disorders in which the episodes are characterized by symptoms that can include fever, abdominal pain, diarrhoea, skin rash and lymphadenopathy [3]. More severe MA is also characterized by symptoms such as cerebellar ataxia and mental retardation. Recently cases of disseminated superficial actinic porokeratosis and retinitis pigmentosa have been added to the spectrum [4, 5]. MKD is caused by mutations in the MVK gene, resulting in decreased activity of MK in the isoprenoid pathway, in
! The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected]
BASIC SCIENCE
Objective. The autoinflammatory hyperimmunoglobulinaemia D and periodic fever syndrome (HIDS) is characterized by recurrent episodes of fever and inflammation. As part of the mevalonate kinase deficiency spectrum, it is caused by MVK mutations, resulting in decreased mevalonate kinase activity in the isoprenoid pathway. Although IL-1b is considered a major cytokine in its pathogenesis, IL-1 blockade is not successful in a proportion of patients. We aimed to further characterize the pro-inflammatory cytokine profile of HIDS.
Downloaded from http://rheumatology.oxfordjournals.org/ at Cornell University Library on July 19, 2015
Abstract
Monique Stoffels et al.
Methods Patients and controls Fifteen clinically and genetically confirmed HIDS patients (see supplementary Table S1, available at Rheumatology Online) and 37 unrelated healthy controls were included in the study. The study was approved by the Committee on Research Involving Human Subjects (Arnhem-Nijmegen region) and written informed consent was obtained according to the Declaration of Helsinki before venous blood was collected and processed.
In vitro cytokine production Peripheral blood mononuclear cells (PBMCs) were isolated by density centrifugation using Ficoll-Paque Plus (GE Healthcare Bio-Sciences, Uppsala, Sweden). Cells were incubated with various stimuli for 24 h at 37 C in RPMI 1640 medium (Dutch modification; Invitrogen, Paisley, UK) supplemented with 50 mg/ml gentamicin (Centrafarm, Etten-Leur, The Netherlands), 1 mM sodium pyruvate and 2 mM GlutaMAX (Invitrogen). To assess inflammasome activation, PBMCs were stimulated for 3 h with 1 mg/ml lipopolysaccharide (LPS; Sigma, St Louis, MO, USA; Escherichia coli serotype 055:B5) followed by 15 min of 1 mM adenosine triphosphate (ATP) stimulation.
Cytokine assays Cytokine concentrations in supernatants were measured using commercial ELISAs from R&D Systems (Abingdon, UK) or Sanquin (Amsterdam, The Netherlands).
364
For measurement of intracellular cytokine concentrations the remaining cells were three times freezethawed. Cellular debris was removed by centrifugation before measuring cytokine concentrations by ELISA. CRP levels were measured using an Aeroset 2.0 analyser (Abbott Diagnostics, Santa Clara, CA, USA; normal reference 50% reduction of cytokine secretion compared with LPS stimulation. CRP in this patient decreased markedly after initiation of treatment (arrow). Controls are shown in green. (B) Ex vivo stimulated PBMCs from two untreated patients (P1: red bars, MVK V377I/I268T; P2: blue bars, MVK H20P/V377I) and control PBMCs (white bars). One month after initiation of tocilizumab treatment, ex vivo cytokine secretion is in the normal range (dashed bars). HIDS: hyperimmunoglobulinaemia D and periodic fever syndrome; LPS: lipopolysaccharide; PBMC: peripheral blood mononuclear cell; ND: not determined. NOD2 ligation and involves not only IL-1b but also other pro-inflammatory cytokines. The increased ratio between active and inactive caspase-1 protein in HIDS patients provides an explanation of why these cells are more
www.rheumatology.oxfordjournals.org
easily triggered to secrete IL-1b. The driving role of IL1b in HIDS pathology may be questioned as we provide data in favour of a multicytokine disease. IL-6 receptor blockade may be considered in patients not responding
367
Monique Stoffels et al.
to anakinra treatment, but this needs a more rigorous clinical trial. Rheumatology key messages The increased cytokine response in hyper-IgD and periodic fever syndrome (HIDS) patients is specific for TLR4, TLR2 and NOD2 ligation. . In addition to IL-1, other cytokines have a driving role in the pathogenesis of HIDS. .
Acknowledgements We thank our patients and volunteers.
Disclosure statement: The authors have declared no conflicts of interest.
Supplementary data Supplementary data are available at Rheumatology Online.
References 1 Dinarello CA, Simon A, van der Meer JW. Treating inflammation by blocking interleukin-1 in a broad spectrum of diseases. Nat Rev Drug Discov 2012;11:63352. 2 Stoffels M, van der Meer JW, Simon A. Mevalonate kinase deficiency nomenclature. Rheumatol Int 2014;34:2956. 3 Stoffels M, Simon A. Hyper-IgD syndrome or mevalonate kinase deficiency. Curr Opin Rheumatology 2011;23: 41923. 4 Siemiatkowska AM, van den Born LI, van Hagen PM et al. Mutations in the mevalonate kinase (MVK) gene cause nonsyndromic retinitis pigmentosa. Ophthalmology 2013; 120:2697705. 5 Zhang SQ, Jiang T, Li M et al. Exome sequencing identifies MVK mutations in disseminated superficial actinic porokeratosis. Nat Genet 2012;44:115660. 6 Bodar EJ, Kuijk LM, Drenth JP et al. On-demand anakinra treatment is effective in mevalonate kinase deficiency. Ann Rheum Dis 2011;70:21558. 7 De Leo L, Marcuzzi A, Decorti G et al. Targeting farnesyltransferase as a novel therapeutic strategy for mevalonate
368
8 Henneman L, Schneiders MS, Turkenburg M, Waterham HR. Compromised geranylgeranylation of RhoA and Rac1 in mevalonate kinase deficiency. J Inherit Metab Dis 2010;33:62532. 9 Kuijk LM, Beekman JM, Koster J et al. HMG-CoA reductase inhibition induces IL-1beta release through Rac1/ PI3K/PKB-dependent caspase-1 activation. Blood 2008; 112:356373. 10 Kuijk LM, Mandey SH, Schellens I et al. Statin synergizes with LPS to induce IL-1beta release by THP-1 cells through activation of caspase-1. Mol Immunol 2008;45: 215865. 11 Mandey SH, Kuijk LM, Frenkel J, Waterham HR. A role for geranylgeranylation in interleukin-1b secretion. Arthritis Rheum 2006;54:36905. 12 Marcuzzi A, Crovella S, Pontillo A. Geraniol rescues inflammation in cellular and animal models of mevalonate kinase deficiencyIn Vivo 2011;25:8792. 13 Pontillo A, Paoluzzi E, Crovella S. The inhibition of mevalonate pathway induces upregulation of NALP3 expression: new insight in the pathogenesis of mevalonate kinase deficiency. Eur J Hum Genet 2010;18:8447. 14 Simon A, Drewe E, van der Meer JW et al. Simvastatin treatment for inflammatory attacks of the hyperimmunoglobulinemia D and periodic fever syndrome. Clin Pharmacol Ther 2004;75:47683. 15 Bodar EJ, van der Hilst JC, van Heerde W et al. Defective apoptosis of peripheral-blood lymphocytes in hyper-IgD and periodic fever syndrome. Blood 2007;109: 24168. 16 de Koning HD, Schalkwijk J, van der Ven-Jongekrijg J et al. Sustained efficacy of the monoclonal anti-interleukin-1 beta antibody canakinumab in a 9-month trial in Schnitzler’s syndrome. Ann Rheum Dis 2013;72: 16348. 17 Bodar EJ, van der Hilst JC, Drenth JP, van der Meer JW, Simon A. Effect of etanercept and anakinra on inflammatory attacks in the hyper-IgD syndrome: introducing a vaccination provocation model. Neth J Med 2005;63: 2604. 18 van der Burgh R, Nijhuis L, Pervolaraki K et al. Defects in mitochondrial clearance predispose human monocytes to interleukin-1b hypersecretion. J Biol Chem 2014;289: 500012. 19 Yu L, Wang L, Chen S. Endogenous toll-like receptor ligands and their biological significance. J Cell Mol Med 2010;14:2592603.
www.rheumatology.oxfordjournals.org
Downloaded from http://rheumatology.oxfordjournals.org/ at Cornell University Library on July 19, 2015
Funding: This study was supported by a Vidi grant (017.106.386 to A.S.) from the Netherlands Organization for Scientific Research (NWO).
kinase deficiency: in vitro and in vivo approaches. Pharmacol Res 2010;61:50610.
