Omalizumab therapy for bullous pemphigoid.

BACKGROUND: Bullous pemphigoid (BP) responds to a variety of immunosuppressive agents and usually controls, but does not cure, the disease. Omalizumab, Food and Drug Administration-approved for asthma, selectively suppresses the activity of IgE, an important immunoglobulin in the pathogenesis of BP. OBJECTIVE: We wished to determine if systemic omalizumab would have a therapeutic effect in patients with BP. METHODS: We treated 6 patients with BP using omalizumab and followed up their disease for up to 42 months. RESULTS: Although variable, 5 of the 6 patients with BP received therapeutic benefit from systemic omalizumab (the sixth terminated treatment because of intercurrent illness) with less use of other immunosuppressants, inhibition of new bullae, less pruritus, and dramatic decreases in eosinophil counts. None of the patients had untoward side effects from omalizumab. LIMITATIONS: This was an open, uncontrolled study. CONCLUSIONS: Omalizumab neutralizes the activity of IgE in patients with BP and improves the control of their disease activity.

Functional characterization of an IgE-class monoclonal antibody specific for the bullous pemphigoid autoantigen, BP180.

BP180 (collagen XVII) is the target antigen in several autoimmune diseases including bullous pemphigoid (BP). Both IgE and IgG class autoantibodies have been shown to be pathogenic in BP; however, studies designed to elucidate the patho-mechanisms mediated specifically by the IgE-class autoantibodies are limited by the low levels (ng/mL) of IgE in human sera. In this report, we developed mouse IgE class monoclonal antibodies (MAbs) against the immunodominant NC16A domain of the human BP180 protein and characterized two of the resultant MAbs, designated 395A5 and 395D2. Epitope mapping studies revealed that both MAbs target segment 2 of NC16A, as was described for IgE and IgG class BP autoantibodies. Also similar to BP IgE, MAb 395A5 showed indirect immunofluorescence labeling of the basement membrane zone (BMZ) of human skin, stimulated histamine release from mast cells when triggered with NC16A, and induced keratinocyte production of IL-8. The 395D2 MAb was also able to trigger antigen-specific histamine release from mast cells; however, in contrast to BP IgE and 395A5, 395D2 did not label the cutaneous BMZ, nor did it induce IL-8 production in keratinocytes. In summary, these studies underscore the importance of functionally characterizing MAbs generated for use in human disease models. The 395A5 IgE class murine MAb was shown to share several key functional properties with the pathogenically active IgE produced by BP patients. We therefore expect that this MAb will prove to be a useful tool for dissecting the mechanisms used by BP180-NC16A-specific IgE antibodies in the induction of BP skin lesions.

Pregnant women have increased incidence of IgE autoantibodies reactive with the skin and placental antigen BP180 (type XVII collagen).

BP180 (type XVII collagen) is a transmembrane protein expressed in a variety of cell types. It is also the target of autoantibodies in cutaneous autoimmune disease including bullous pemphigoid and pemphigoid gestationis, a disease unique to pregnancy. The purpose of this study was to determine the prevalence and specificity of cutaneous autoantibodies in a cohort of pregnant women. De-identified sera were collected from pregnant women (n=299) and from non-pregnant controls (n=134). Sera were analyzed by ELISA for the presence of IgG and IgE autoantibodies directed against several cutaneous autoantigens. IgE antibodies against the NC16A domain of BP180 were detected in 7.7% of pregnant women, compared to 2.2% of healthy controls (p=0.01). No increase in total or cutaneous autoantigen specific IgG was seen. Total serum IgE was within the normal range. Full-length BP180 was detected by western immunoblot in epidermal, keratinocyte, placental and cytotrophoblast (CTB) cell lysates. Furthermore, flow cytometry and indirect immunofluorescence confirmed the expression of BP180 on the surface of cultured CTBs. Finally, it was demonstrated that IgE antibodies in the pregnancy sera labeled not only cultured CTBs, but also the placental amnion and cutaneous basement membrane zone using indirect immunofluorescence. We conclude that some pregnant women develop antibodies specific for BP180, and that these autoantibodies are capable of binding both CTB and the placental amnion, potentially affecting placental function.

A novel ELISA reveals high frequencies of BP180-specific IgE production in bullous pemphigoid.

Bullous pemphigoid (BP) is a humoral autoimmune disease directed predominantly against the non-collagenous NC16A domain of the BP180 hemidesmosomal protein. Our laboratory has recently shown, using a mouse xenograft model, that passive transfer of IgE autoantibodies from BP sera induces a skin phenotype that recapitulates the early phases of the disease. Herein, we describe the development of a highly specific and sensitive ELISA to detect circulating IgE autoantibodies that recognize BP180-NC16A. Using this assay, we detected NC16A-specific IgE-class autoantibodies in 77% of BP sera. This frequency, which is significantly higher than reported previously, is comparable to that of anti-NC16A IgG autoantibody production. In 3 BP patients monitored over time, the circulating NC16A-specific levels of both IgE and IgG were associated with clinical disease activity; however, patient sera did not always contain high levels of both isotypes. In conclusion, our ELISA provides a highly sensitive and specific tool for the detection of BP180-specific IgE in patient sera. Furthermore, we report that the majority of BP sera contain both IgE and IgG class autoantibodies specific for NC16A and suggest that screening for both isotypes of autoantibodies may provide a better diagnostic value than IgG alone.

A role for IFN-gamma from antigen-specific CD8+ T cells in protective immunity to Listeria monocytogenes.

Whether IFN-gamma contributes to the per-cell protective capacity of memory CD8(+) T cells against Listeria monocytogenes (LM) has not been formally tested. In this study, we generated LM Ag-specific memory CD8(+) T cells via immunization of wild-type (WT) and IFN-gamma-deficient (gamma knockout (GKO)) mice with LM peptide-coated dendritic cells and compared them phenotypically and functionally. Immunization of WT and GKO mice resulted in memory CD8(+) T cells that were similar in number, functional avidity, TCR repertoire use, and memory phenotype. The protective capacity of memory CD8(+) T cells from immunized WT and GKO mice was evaluated after adoptive transfer of equal numbers of WT or GKO cells into naive BALB/c mice followed by LM challenge. The adoptively transferred CD8(+) T cells from GKO donors exhibited a decreased ability to reduce bacterial numbers in the organs of recipient mice when compared with an equivalent number of Ag-matched WT CD8(+) T cells. This deficiency was most evident early (day 3) after infection if a relatively low infectious dose was used; however, transferring fewer memory CD8(+) T cells or increasing the LM challenge dose revealed a more pronounced defect in protective immunity mediated by the CD8(+) T cells from GKO mice. Our studies identified a decrease in Ag-specific target cell lysis in vivo by CD8(+) T cells from GKO mice as the mechanism for the decreased protective immunity after LM challenge. Further studies suggest that the lack of IFN-gamma production by the Ag-specific CD8 T cells themselves diminishes target cell sensitivity to cytolysis, thereby reducing the lytic potency of IFN-gamma-deficient LM-specific memory CD8(+) T cells.

The early acute phase response after burn injury in mice.

In the hours immediately after burn injury, the body enters into an acute phase reaction characterized, in part, by the augmentation of cytokine and acute phase protein production. This reaction has been poorly characterized in the 24 hours immediately after injury. To better understand the early acute phase response, 8- to 10-week-old BALB/C female mice were subjected to a 15% total body surface area (TBSA). Hepatic levels of tumor necrosis factor-alpha, interleukin-1beta, and interleukin-6 were monitored. In addition, the circulating level of serum amyloid A, an acute phase protein, also was measured at the same time points. Tumor necrosis factor-alpha levels peaked 2 hours after burn injury, whereas interleukin-1beta had a biphasic response, increasing 2 hours after injury and again at 12 hours. Interleukin-6 and serum amyloid A were not increased until 12 hours after injury and began to decline at 24 hours. These results demonstrate that within the liver, the acute phase response after burn injury initially involves tumor necrosis factor-alpha and interleukin-1beta, whereas interleukin-6 is not involved until later and that systemic serum amyloid A levels are not increased until interleukin-6 is also increased.

Accelerated CD8+ T-cell memory and prime-boost response after dendritic-cell vaccination.

Efficient boosting of memory T-cell numbers to protective levels generally requires a relatively long interval between immunizations. Decreasing this interval could be crucial in biodefense and cancer immunotherapy, in which rapid protective responses are essential. Here, we show that vaccination with peptide-coated dendritic cells (DCs) generated CD8+ T cells with the phenotype and function of memory cells within 4-6 d. These early memory CD8+ T cells underwent vigorous secondary expansion in response to a variety of booster immunizations, leading to elevated numbers of effector and memory T cells and enhanced protective immunity. Coinjection of CpG oligodeoxynucleotides, potent inducers of inflammation that did not alter the duration of DC antigen display, prevented the rapid generation of memory T cells in wild-type mice but not in mice lacking the interferon (IFN)-gamma receptor. These data show that DC vaccination stimulates a pathway of accelerated generation of memory T cells, and suggest that events of inflammation, including the action of IFN-gamma on the responding T cells, control the rate of development of memory CD8+ T cells.

Ethanol and burn injury: estrogen modulation of immunity.

A good deal of clinical evidence supports the idea that ethanol exposure is a causative factor in the occurrence of burn or other traumatic injury. In addition, more recent evidence reveals that individuals who sustain injury while under the influence of ethanol suffer from increased morbidity and mortality compared with those with comparable injuries who did not consume ethanol. Many of the complications seen in ethanol-exposed, burn-injured subjects result from depressed immune responses, which render the host unable to fight off infectious organisms. Both injury and ethanol exposure independently affect cellular immune responses, including delayed-type hypersensitivity and splenocyte proliferative responses, and the combined insult of ethanol exposure and injury acts in conjunction to increase further the magnitude and duration of immunosuppression. It is interesting that these immune responses can be restored experimentally in male, but not in female, mice by administration of low, proestrous levels of estrogen. The complexity of the responses after injury in ethanol-exposed subjects is multiplied when the sex of the subjects is added to the equation. This is due, in part, to the effect of the combined insult of injury and ethanol on the production of gonadal steroid hormones in males and females and the direct effects of those hormones on cytokine gene expression in sensitive cell types such as the macrophage. Evidence seems to indicate that cellular immune responses after ethanol exposure and burn injury differ in kinetics and magnitude for male and female subjects, and, hence, the therapeutic interventions to treat burn-injured patients should take into account both sex and ethanol exposure.

Elevated monocyte chemoattractant protein-1 levels following thermal injury precede monocyte recruitment to the wound site and are controlled, in part, by tumor necrosis factor-alpha.

In previous studies, mice given a full-thickness scald injury had an influx of neutrophils into the skin that followed a local increase in a neutrophil chemoattractant. Because macrophages are known to infiltrate the wound area after neutrophils and are essential for normal wound repair, studies were designed to characterize the time course of macrophage accumulation in the wound and to identify the factor(s) responsible for this influx. A macrophage infiltrate into the wound was observed at 4 days post-injury and persisted through at least 10 days. This influx was preceded by an initial fourfold increase in dermal monocyte chemoattractant protein-1 levels at 24 hours post-injury (p < 0.05). This elevation in monocyte chemoattractant protein-1 was enhanced at 4 and 10 days postburn resulting in a sixfold increase over baseline (p < 0.01). Levels of tumor necrosis factor-alpha, a proinflammatory cytokine known to induce chemokine production, were elevated at 90 minutes after injury in burn- versus sham-injured groups (p < 0.05). Furthermore, administration of tumor necrosis factor-alpha neutralizing antibody in vivo reduced the dermal levels of monocyte chemoattractant protein-1 seen at 10 days postburn by 57% (p < 0.01); however, macrophage accumulation was not altered. Thus, elevated systemic TNF-alpha levels may influence the local chemokine milieu following burn injury.

Estrogen regulation of immune responses after injury.

There is a naturally occurring gender difference in immune responses which persists after traumatic injury. Physiological levels of 17beta-estradiol (E(2)) are immunostimulatory, whereas high pregnancy and superphysiological levels are immunosuppressive. In contrast, at all concentrations, testosterone suppresses immune responses. Evidence from this laboratory and others suggest that the gender difference in immune responses after injury is mediated in part by alterations in the circulating levels of gonadal steroid hormones through modulation of production of inflammatory and immunoregulatory cytokines, including interleukin-6 (IL-6). Aberrant production of IL-6 is known to be an important mediator of immunity after injury. Since E(2) is a critical regulator of IL-6 production and overall immune function, it suggests gender specific therapies should be considered for the treatment of patients.

Interleukin-4 treatment restores cellular immunity after ethanol exposure and burn injury.

BACKGROUND: Previous studies from this laboratory showed that the suppression of cell-mediated immunity after the combined injury of ethanol exposure and burn is mediated by increased presence of the proinflammatory cytokine interleukin (IL)-6. IL-4 is a T-helper cell type 2 lymphocyte-derived cytokine that serves to down-regulate the inflammatory response. Therefore, the goal of this study was to evaluate the effects of ethanol exposure and burn injury on lymphocyte production of IL-4 and to determine whether administration of IL-4 could improve cellular immunity after ethanol exposure and burn injury through modulation of IL-6 levels. METHODS: Mice were subjected to a 15% total body-surface area burn (or sham) injury 30 min after being given a single dose of alcohol (or saline) designed to achieve a blood alcohol level of 100 mg/dl. Thirty minutes after burn, mice were treated with IL-4 (or vehicle) and were killed 24 hr later. RESULTS: Lymphocytes from ethanol/burn mice secreted significantly less IL-4 in comparison to all other groups of mice (p < 0.05). Administration of IL-4 resulted in a complete restoration of the delayed-type hypersensitivity (p < 0.01) and splenocyte proliferative responses (p < 0.05) and a significant reduction in circulating and splenic macrophage-derived IL-6 (p < 0.05). Addition of IL-4 (100 or 300 pg/ml) to cultures generated from ethanol/burn and vehicle mice resulted in a complete restoration of splenocyte proliferation and a concomitant attenuation of macrophage IL-6 production. CONCLUSIONS: These studies suggest that the loss of lymphocyte production of IL-4 after ethanol exposure and burn injury may contribute to the exaggerated production of IL-6, a known mediator of immune suppression after injury. Moreover, the administration of IL-4 may be beneficial for patients with injuries that are characterized by a dysregulated inflammatory response.

Influence of alcohol and gender on immune response.

Decades of research have shown that women's and men's immune systems function differently. During the reproductive years, women have a stronger immune response than men. This gender difference is believed to be controlled by differences in the blood levels of gonadal steroid hormones--including the female hormone, estrogen, which stimulates immune responses, and the male hormone, testosterone, which is immunosuppressive. In both males and females, alcohol exposure suppresses immune responses; however, it is unclear whether there are significant gender differences in this suppression. Chronic exposure to alcohol alters the production of this same set of hormones (i.e., estrogen and testosterone), and hence alcohol's effects on immunity could involve an indirect mechanism in which alcohol alters hormone levels and, in turn, the hormones regulate immune responses. This article discusses evidence that these hormonal changes play a role in the regulation of the immune response following alcohol exposure in males and females. In addition, the article considers the possible reasons why it takes less time and lower doses of alcohol exposure to cause liver damage in females than in males.