ABSTRACT
Delayed-type drug hypersensitivity reactions are major causes of morbidity and mortality. The origin, phenotype and function of pathogenic T cells across the spectrum of severity requires investigation. We leveraged recent technical advancements to study skin-resident memory T cells (TRM) versus recruited T cell subsets in the pathogenesis of severe systemic forms of disease, SJS/TEN and DRESS, and skin-limited disease, morbilliform drug eruption (MDE). Microscopy, bulk transcriptional profiling and scRNAseq + CITEseq + TCRseq supported in SJS/TEN clonal expansion and recruitment of cytotoxic CD8+ T cells from circulation into skin, along with expanded and non-expanded cytotoxic CD8+ skin TRM. Comparatively, MDE displayed a cytotoxic T cell profile in skin without appreciable expansion and recruitment of cytotoxic CD8+ T cells from circulation, implicating TRM as potential protagonists in skin-limited disease. Mechanistic interrogation in patients unable to recruit T cells from circulation into skin and in a parallel mouse model supported that skin TRM were sufficient to mediate MDE. Concomitantly, SJS/TEN displayed a reduced regulatory T cell (Treg) signature compared to MDE. DRESS demonstrated recruitment of cytotoxic CD8+ T cells into skin like SJS/TEN, yet a pro-Treg signature like MDE. These findings have important implications for fundamental skin immunology and clinical care.
ABSTRACT
Importance: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a severe hypersensitivity reaction. Identifying a culprit drug is critical for patient care, yet identification is based on clinical judgment. Data are limited on the accuracy in or approach to identifying a culprit drug. Objective: To evaluate patient allergy list outcomes, current approaches in identifying culprit drugs, and potential methods of improving culprit drug identification. Design, Setting, and Participants: This retrospective cohort study spanned 18 years (January 2000 to July 2018), was conducted at Brigham and Women's Hospital and Massachusetts General Hospital (Boston), and included patients with clinically and histologically confirmed cases of SJS/TEN overlap and TEN. Main Outcomes and Measures: This study descriptively analyzed potential culprits to SJS/TEN, patients' allergy lists, and currently used approaches that led to those lists. It then tested the theoretical contribution of incorporating various parameters to allergy list outcomes. Results: Of 48 patients (29 women [60.4%]; 4 Asian [8.3%], 6 Black [12.5%], 5 Hispanic [10.4%], and 25 White [52.1%] individuals; median age, 40 years [range, 1-82 years]), the mean (SD) number of drugs taken per patient at disease onset was 6.5 (4.7). Physicians labeled 17 patients as allergic to a single culprit drug. Comparatively, 104 drugs were added to allergy lists across all patients. Physicians' approaches relied largely on heuristic identification of high-notoriety drugs and the timing of drug exposure. Use of a vetted database for drug risk improved sensitivity. Algorithm for Drug Causality for Epidermal Necrolysis scoring was discordant in 28 cases, labeling an additional 9 drugs missed by physicians and clearing 43 drugs labeled as allergens by physicians. Human leukocyte antigen testing could have potentially affected 20 cases. Consideration of infection as a culprit was limited. Conclusions and Relevance: The results of this cohort study suggest that currently used approaches to identify culprit drugs in SJS/TEN are associated with overlabeling patients allergic to likely nonculprit drugs and less commonly missed possible culprit drugs. Incorporation of a systematized unbiased approach could potentially improve culprit drug identification, although ultimately a diagnostic test is necessary.
Subject(s)
Stevens-Johnson Syndrome , Adult , Female , Humans , HLA Antigens , Retrospective Studies , Stevens-Johnson Syndrome/diagnosis , Stevens-Johnson Syndrome/etiology , Male , Infant , Child, Preschool , Child , Adolescent , Young Adult , Middle Aged , Aged , Aged, 80 and overABSTRACT
Graft-versus-host disease (GVHD) is a major cause of morbidity and mortality in hematopoietic stem cell transplantation (HSCT). Donor T cells are key mediators in pathogenesis, but a contribution from host T cells has not been explored, as conditioning regimens are believed to deplete host T cells. To evaluate a potential role for host T cells in GVHD, the origin of skin and blood T cells was assessed prospectively in patients after HSCT in the absence of GVHD. While blood contained primarily donor-derived T cells, most T cells in the skin were host derived. We next examined patient skin, colon, and blood during acute GVHD. Host T cells were present in all skin and colon acute GVHD specimens studied, yet were largely absent in blood. We observed acute skin GVHD in the presence of 100% host T cells. Analysis demonstrated that a subset of host T cells in peripheral tissues were proliferating (Ki67+) and producing the proinflammatory cytokines IFN-γ and IL-17 in situ. Comparatively, the majority of antigen-presenting cells (APCs) in tissue in acute GVHD were donor derived, and donor-derived APCs were observed directly adjacent to host T cells. A humanized mouse model demonstrated that host skin-resident T cells could be activated by donor monocytes to generate a GVHD-like dermatitis. Thus, host tissue-resident T cells may play a previously unappreciated pathogenic role in acute GVHD.
Subject(s)
Graft vs Host Disease/immunology , Hematopoietic Stem Cell Transplantation , Skin Diseases/immunology , Skin/immunology , T-Lymphocytes/immunology , Adult , Allografts , Animals , Antigen-Presenting Cells/immunology , Antigen-Presenting Cells/pathology , Female , Graft vs Host Disease/pathology , Humans , Interferon-gamma/immunology , Interleukin-17/immunology , Male , Mice , Mice, Inbred NOD , Mice, SCID , Prospective Studies , Skin/pathology , Skin Diseases/pathology , T-Lymphocytes/pathologyABSTRACT
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are potentially life-threatening, immune-mediated adverse reactions characterized by widespread erythema, epidermal necrosis, and detachment of skin and mucosa. Efforts to grow and develop functional international collaborations and a multidisciplinary interactive network focusing on SJS/TEN as an uncommon but high burden disease will be necessary to improve efforts in prevention, early diagnosis and improved acute and long-term management. SJS/TEN 2019: From Science to Translation was a 1.5-day scientific program held April 26-27, 2019, in Vancouver, Canada. The meeting successfully engaged clinicians, researchers, and patients and conducted many productive discussions on research and patient care needs.
Subject(s)
Health Services Needs and Demand/organization & administration , Patient Care Team/organization & administration , Stevens-Johnson Syndrome/therapy , Congresses as Topic , Global Burden of Disease , Global Health , Humans , International Cooperation , Pharmacogenetics/organization & administration , Registries/statistics & numerical data , Stevens-Johnson Syndrome/epidemiology , Stevens-Johnson Syndrome/etiology , Translational Research, Biomedical/organization & administrationSubject(s)
Angiomatosis/etiology , Graft vs Host Disease/etiology , Skin Diseases, Vascular/etiology , Skin/pathology , Adrenergic beta-Antagonists/therapeutic use , Angiogenesis Inhibitors/pharmacology , Angiogenesis Inhibitors/therapeutic use , Angiomatosis/pathology , Angiomatosis/therapy , Graft vs Host Disease/drug therapy , Graft vs Host Disease/pathology , Humans , Mechanistic Target of Rapamycin Complex 1/antagonists & inhibitors , Sirolimus/pharmacology , Sirolimus/therapeutic use , Skin/blood supply , Skin Diseases, Vascular/pathology , Skin Diseases, Vascular/therapy , Vascular Endothelial Growth Factor A/antagonists & inhibitorsABSTRACT
During that past two decades, advances in techniques for generating in vitro immune-suppressive dendritic cells (DCs) have heralded the use of these pro-tolerogenic DCs as therapeutics against transplant rejection and autoimmune diseases. In transplantation, previous dogma assumed that systemically administered therapeutic DCs bearing donor antigens (Ags) control the anti-donor response by directly interacting with anti-donor T cells in vivo. However, recent evidence indicates that the exogenously-administered therapeutic DCs instead function as Ag-transporting cells that transfer donor Ags to recipient's Ag-presenting cells (APCs) for presentation to T cells. In secondary lymphoid organs, presentation of acquired donor Ags by recipient's quiescent DCs triggers deficient activation and eventual apoptosis of donor-specific effector T cells, leading to a relative increase in the percentage of donor-specific regulatory T cells. This chapter describes the methodology to generate in vitro immune-suppressive DCs that are resistant to maturation, and to assess in vivo both their survival and their ability to regulate donor-specific T cells in a mouse model.
Subject(s)
Antigens/immunology , Dendritic Cells/immunology , Immune Tolerance , T-Lymphocytes, Regulatory/immunology , Animals , Antigen Presentation/immunology , Autoimmune Diseases/immunology , Autoimmune Diseases/therapy , Dendritic Cells/transplantation , HumansABSTRACT
Mycosis fungoides (MF), the most common cutaneous T cell lymphoma (CTCL) is a malignancy of skin-tropic memory T cells. Most MF cases present as early stage (stage I A/B, limited to the skin), and these patients typically have a chronic, indolent clinical course. However, a small subset of early-stage cases develop progressive and fatal disease. Because outcomes can be so different, early identification of this high-risk population is an urgent unmet clinical need. We evaluated the use of next-generation high-throughput DNA sequencing of the T cell receptor ß gene (TCRB) in lesional skin biopsies to predict progression and survival in a discovery cohort of 208 patients with CTCL (177 with MF) from a 15-year longitudinal observational clinical study. We compared these data to the results in an independent validation cohort of 101 CTCL patients (87 with MF). The tumor clone frequency (TCF) in lesional skin, measured by high-throughput sequencing of the TCRB gene, was an independent prognostic factor of both progression-free and overall survival in patients with CTCL and MF in particular. In early-stage patients, a TCF of >25% in the skin was a stronger predictor of progression than any other established prognostic factor (stage IB versus IA, presence of plaques, high blood lactate dehydrogenase concentration, large-cell transformation, or age). The TCF therefore may accurately predict disease progression in early-stage MF. Early identification of patients at high risk for progression could help identify candidates who may benefit from allogeneic hematopoietic stem cell transplantation before their disease becomes treatment-refractory.
Subject(s)
Genes, T-Cell Receptor beta , High-Throughput Nucleotide Sequencing/methods , Mycosis Fungoides/genetics , Mycosis Fungoides/immunology , Skin Neoplasms/genetics , Skin Neoplasms/immunology , Cellular Microenvironment , Clone Cells , Exome/genetics , Female , Gene Expression Regulation, Neoplastic , Humans , Lymphoma, T-Cell, Cutaneous/genetics , Lymphoma, T-Cell, Cutaneous/immunology , Lymphoma, T-Cell, Cutaneous/pathology , Male , Middle Aged , Multivariate Analysis , Mycosis Fungoides/pathology , Prognosis , Progression-Free Survival , Skin/pathology , Skin Neoplasms/pathologyABSTRACT
Although rare, Stevens-Johnson syndrome and toxic epidermal necrolysis remain among the most devastating of acute conditions involving the skin. In the past 30 years, tremendous progress has been made in understanding the causes and pathobiology of this often life-threatening condition. Su et al demonstrate associations between IL 15 serum levels and the outcome of patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. Their findings provide ideas for further investigations that may help us better understand the role of cytokines in this T-cell mediate disease and provides clues to possible new therapies.
Subject(s)
Acute Disease , Stevens-Johnson Syndrome , Cytokines , Humans , Interleukin-15 , SkinABSTRACT
Tissue-resident memory T (TRM) cells persist indefinitely in epithelial barrier tissues and protect the host against pathogens. However, the biological pathways that enable the long-term survival of TRM cells are obscure. Here we show that mouse CD8+ TRM cells generated by viral infection of the skin differentially express high levels of several molecules that mediate lipid uptake and intracellular transport, including fatty-acid-binding proteins 4 and 5 (FABP4 and FABP5). We further show that T-cell-specific deficiency of Fabp4 and Fabp5 (Fabp4/Fabp5) impairs exogenous free fatty acid (FFA) uptake by CD8+ TRM cells and greatly reduces their long-term survival in vivo, while having no effect on the survival of central memory T (TCM) cells in lymph nodes. In vitro, CD8+ TRM cells, but not CD8+ TCM cells, demonstrated increased mitochondrial oxidative metabolism in the presence of exogenous FFAs; this increase was not seen in Fabp4/Fabp5 double-knockout CD8+ TRM cells. The persistence of CD8+ TRM cells in the skin was strongly diminished by inhibition of mitochondrial FFA ß-oxidation in vivo. Moreover, skin CD8+ TRM cells that lacked Fabp4/Fabp5 were less effective at protecting mice from cutaneous viral infection, and lung Fabp4/Fabp5 double-knockout CD8+ TRM cells generated by skin vaccinia virus (VACV) infection were less effective at protecting mice from a lethal pulmonary challenge with VACV. Consistent with the mouse data, increased FABP4 and FABP5 expression and enhanced extracellular FFA uptake were also demonstrated in human CD8+ TRM cells in normal and psoriatic skin. These results suggest that FABP4 and FABP5 have a critical role in the maintenance, longevity and function of CD8+ TRM cells, and suggest that CD8+ TRM cells use exogenous FFAs and their oxidative metabolism to persist in tissue and to mediate protective immunity.
Subject(s)
CD8-Positive T-Lymphocytes/cytology , CD8-Positive T-Lymphocytes/metabolism , Fatty Acids, Nonesterified/metabolism , Immunologic Memory/immunology , Lipid Metabolism , Animals , Biological Transport , CD8-Positive T-Lymphocytes/immunology , Cell Survival , Fatty Acid-Binding Proteins/deficiency , Fatty Acid-Binding Proteins/metabolism , Female , Humans , Mice , Neoplasm Proteins/deficiency , Neoplasm Proteins/metabolism , Oxidation-Reduction , Psoriasis , Skin/cytology , Skin/immunology , Skin/virology , Vaccinia/immunology , Vaccinia/prevention & control , Vaccinia virus/immunologyABSTRACT
Focal dermal hypoplasia (FDH) is an X-linked dominant disease characterized by dermal thinning and fat herniation with other ectodermal and mesodermal abnormalities. There is limited literature regarding the symptomatology and progression of skin, hair, and nail disease. The risk of bone fragility has not been explored either. This cross-sectional survey-based study explored these gaps in knowledge and provides direction for future avenues of research in FDH.
Subject(s)
Bone Diseases/complications , Bone Diseases/pathology , Focal Dermal Hypoplasia/complications , Focal Dermal Hypoplasia/pathology , Adolescent , Child , Child, Preschool , Cross-Sectional Studies , Female , Hair , Humans , Infant , Male , Middle Aged , Nails , SkinABSTRACT
Successful engraftment of organ transplants has traditionally relied on preventing the activation of recipient (host) T cells. Once T-cell activation has occurred, however, stalling the rejection process becomes increasingly difficult, leading to graft failure. Here we demonstrate that graft-infiltrating, recipient (host) dendritic cells (DCs) play a key role in driving the rejection of transplanted organs by activated (effector) T cells. We show that donor DCs that accompany heart or kidney grafts are rapidly replaced by recipient DCs. The DCs originate from non-classical monocytes and form stable, cognate interactions with effector T cells in the graft. Eliminating recipient DCs reduces the proliferation and survival of graft-infiltrating T cells and abrogates ongoing rejection or rejection mediated by transferred effector T cells. Therefore, host DCs that infiltrate transplanted organs sustain the alloimmune response after T-cell activation has already occurred. Targeting these cells provides a means for preventing or treating rejection.
Subject(s)
Dendritic Cells/immunology , Graft Rejection/immunology , T-Lymphocytes/immunology , Animals , Heart Transplantation , Kidney Transplantation , Lymphocyte Activation , Mice , TransplantsABSTRACT
The immune response against transplanted allografts is one of the most potent reactions mounted by the immune system. The acute rejection response has been attributed to donor dendritic cells (DCs), which migrate to recipient lymphoid tissues and directly activate alloreactive T cells against donor MHC molecules. Here, using a murine heart transplant model, we determined that only a small number of donor DCs reach lymphoid tissues and investigated how this limited population of donor DCs efficiently initiates the alloreactive T cell response that causes acute rejection. In our mouse model, efficient passage of donor MHC molecules to recipient conventional DCs (cDCs) was dependent on the transfer of extracellular vesicles (EVs) from donor DCs that migrated from the graft to lymphoid tissues. These EVs shared characteristics with exosomes and were internalized or remained attached to the recipient cDCs. Recipient cDCs that acquired exosomes became activated and triggered full activation of alloreactive T cells. Depletion of recipient cDCs after cardiac transplantation drastically decreased presentation of donor MHC molecules to directly alloreactive T cells and delayed graft rejection in mice. These findings support a key role for transfer of donor EVs in the generation of allograft-targeting immune responses and suggest that interrupting this process has potential to dampen the immune response to allografts.
Subject(s)
Allografts/immunology , Dendritic Cells/immunology , Dendritic Cells/metabolism , Exosomes/metabolism , Immune Tolerance/immunology , Animals , Cell Movement , Graft Rejection , Graft Survival , Heart Transplantation , Major Histocompatibility Complex/immunology , Male , Mice , Mice, Inbred BALB C , Mice, Inbred C3H , Mice, Inbred C57BL , Skin Transplantation , Spleen/metabolism , T-Lymphocytes/cytology , Transplantation, HomologousABSTRACT
Cell proliferation is commonly assayed in the laboratory for research purposes, but is increasingly used clinically to gauge tumor aggressiveness and potentially guide care. Therefore, both researchers and clinicians should have a basic understanding of techniques used to assess cell proliferation. Multiple cell proliferation assays exist, and the choice of method depends on the laboratory resources available, the types of cells/tissues to be studied, and the specific experimental goals. In this article, we identify four overarching categories of cell proliferation assays that signify various stages of the cell cycle: nucleoside-analog incorporation, cell cycle-associated protein detection, use of cytoplasmic proliferation dyes, and indirect measures of cell proliferation. Each method has strengths and limitations that should guide the dermatology investigator's choice of assay.