D.W. Rosenthal

Biologic IgG level in primary immunodeficiency disease: The IgG level that protects against recurrent infection

overfocused on the medical needs of their own children rather than the nutritional and social needs of the children and their classmates. In contrast, schools were less positive, relating to training needs, institutional and personal liability, and responsibility, although some schools were positive about the option. Even with an overall broadly positive response from parents and schools (although the proportion of schools responding was disappointing), the proposed system could not currently be put into action. This is because epinephrine is a prescription medication. However, legislation can be changed, and precedents have been set in related areas such as external automatic defibrillation. Our study has limitations because of sampling bias. The families recruited had a high rate of having 2 EAIs available at home and at school and a lower rate of having used of EAIs to treat anaphylaxis in schools, compared with the available literature. A lower number of schools reported experience of anaphylaxis in a student. A lower than average number of severe reactions may reflect the local availability of specialized allergy care. These findings may suggest that the life experience of children with food allergy who receive their care from a regional allergy unit is different from the life experience where such expertise is not so available. The proposed system has the potential to save the United Kingdom National Health Service a significant amount of money. Parents of children with food allergy are more sensitive to the societal cost of their children’s food allergies than many people give them credit for, whereas schools mostly identified major needs for staff retraining and liability coverage if the system were to be introduced. The projected cost savings from the new model of provision could meet some of these costs. Laura Norton, MB Audrey Dunn Galvin, MA Jonathan O’Brien Hourihane, MD From Child Health, University of Southampton, United Kingdom; and Pediatrics and Child Health, University College Cork, Cork, Ireland. E-mail: J.Hourihane@ucc.ie. Disclosure of potential conflict of interest: J. O. Hourihane has received speaker fees from Novartis, Numico, and Menarini; has received research funding from the European Commission; has received a project grant from the Irish Lung Foundation; has received research support from Numico plc; has served as an expert witness in an opinion case of immunodeficiency; has served as a Paediatric section board member for the European Academy of Allergology and Clinical Immunology; has served as a board member for the Clemens von Pirquet Foundation; and has received travel support from Menarini, DPC, Merck, Sharp, and Dohme. The rest of the authors have declared that they have no conflict of interest.

Recurrent respiratory papillomatosis: a complex defect in immune responsiveness to human papillomavirus‐6 and ‐11

Bonagura VR, Hatam LJ, Rosenthal DW, DeVoti JA, Lam F, Steinberg BM, Abramson AL. Recurrent respiratory papillomatosis: a complex defect in immune responsiveness to human papillomavirus‐6 and ‐11. APMIS 2010; 118: 455–470.

Activating killer cell immunoglobulin-like receptors 3DS1 and 2DS1 protect against developing the severe form of recurrent respiratory papillomatosis

The polymorphic killer cell immunoglobulin-like receptors (KIR) control natural killer (NK) cell response against viral infection and tumor transformation. Here we investigated if select KIR genes are associated with recurrent respiratory papillomatosis (RRP), a rare disease of the larynx and upper airway caused by human papillomaviruses (HPV)-6/11. DNA from 66 RRP patients and 195 healthy controls were characterized for KIR and HLA gene polymorphism. Patients lacking activating KIR genes 3DS1 and 2DS1 were more common in severe RRP compared with mild-moderate RRP (78.8% vs 48.5%, p = 0.019). Further, patients carrying any of the known susceptible HLA-DRB1/DQB1 alleles were more frequently negative for KIR3DS1 (p = 0.006), KIR2DS1 (p = 0.003) or KIR2DS5 (p = 0.004) compared with controls carrying any of these HLA allotypes. Nearly 80% of the patients with severe disease were missing the protective HLA-DQB1*0602 allele as well as both KIR3DS1 and KIR2DS1 genes. Phenotyping of papilloma-infiltrating mononuclear-cells revealed an elevated numbers of NK cells and CD57(+)CD4(+) T cells in KIR3DS1(-)KIR2DS1(-) patients compared with patients carrying either one or both of these KIRs. Our data suggest that NK cells expressing activating receptors KIR3DS1 and KIR2DS1 may be necessary to trigger an effective early immune response against HPV-infected targets to establish resistance to RRP development.

Immune Dysregulation and Tumor-Associated Gene Changes in Recurrent Respiratory Papillomatosis : A Paired Microarray Analysis

Recurrent respiratory papillomas (RRP) are benign airway tumors, caused primarily by human papillomaviruses (HPV) types 6 and 11.The disease is characterized by multiple recurrences after surgical removal, with limited effective therapy. To identify novel targets for future therapy, we established transcriptional profiles for actively growing papillomas compared with autologous, clinically normal, laryngeal epithelia (adjacent tissue). Total ribonucleic acid (RNA) from 12 papillomas and 12 adjacent tissues were analyzed by microarray, and the matched sets of tissues compared by paired t test, to identify differentially expressed genes in papilloma tissues while minimizing variations intrinsic to individual patients. Quantitative polymerase chain reaction (PCR) was used to confirm the relative expression levels for a subset of genes. Within the 109 differentially expressed transcripts whose expression varied at least three-fold were two large groups of genes with related functions. The first group consisted of 18 genes related to host defense, including both innate and adaptive immunity. The second group contained 37 genes that likely contribute to growth of papillomas as benign tumors, since the altered pattern of expression also had been reported previously in many cancers. Our results support our previous studies that document a systemic TH2-like adaptive immune response in RRP, and suggest that there is a role for altered innate immunity in RRP as well. We propose that HPV 6 and 11 infection establishes a tumorigenic microenvironment characterized by alteration of both innate inflammatory signals and adaptive immune responses that prevent effective TH1-like response, in conjunction with altered expression of numerous genes that regulate cellular growth and differentiation.

Immune Suppression in Premalignant Respiratory Papillomas: Enriched Functional CD4+Foxp3+ Regulatory T-cells And PD-1/PD-L1/L2 Expression

Purpose: Respiratory papillomas, caused by human papillomaviruses types 6 and 11 (HPV6/11), are premalignant lesions with potential for malignant conversion. The cytokine and chemokine micromilieu of papillomas is TH2-like with a marked absence of IFN-γ expression. To illuminate why patients with recurrent respiratory papillomatosis (RRP) fail to effectively control their disease, we further investigated the suppressive cellular microenvironment in papillomas. Experimental Design: CD4+CD25+CD127low/−Foxp3+ regulatory T cells (Treg) and CD4+CD25−CD127low/−Foxp3− T cells within papillomas were characterized and isolated. Their suppressor function was measured by inhibition of peripheral blood mononuclear cell (PBMC) proliferation. Expression of PD-1, CD69, and Helios was identified on these T cells. PD-L1, PD-L2, CCL17, and CCL22 mRNA was also identified in papillomas by quantitative PCR. Results: Functional Tregs were markedly enriched in papillomas and strongly inhibited anti-CD3 and anti-CD28 antibody activated PBMC proliferation. The natural Treg marker Helios was reduced on Tregs from papillomas, indicating that the majority of Tregs in papillomas are adaptive. The majority of the papilloma-derived CD4+ T cells expressed the CD4+CD25−CD127low/−Foxp3−PD1+CD69+ phenotype and failed to suppress PBMC proliferation, suggesting that they are chronically activated and exhausted. The Treg-attracting chemokine CCL22 was equally expressed by all laryngeal tissues examined. However, CCL17 was robustly expressed by papillomas compared with unaffected laryngeal tissues from RRP patients and individuals without RRP. PD-L1 was elevated in papillomas compared with control laryngeal tissues. Conclusions: Papilloma CD4+ T cells are enriched with functional Tregs, and the adaptive Helios− Treg fraction was increased within the TH2-like papilloma micromilieu. CD4+CD25−CD127low/−Foxp3− T-cells failed to suppress PBMC proliferation and may be exhausted. The PD-1/PDL-1 pathway may represent an additional immunosuppressive mechanism that contributes to defective HPV6/11 clearance in RRP. Clin Cancer Res; 18(7); 1925–35. ©2012 AACR.

Failure of Gamma Interferon but Not Interleukin-10 Expression in Response to Human Papillomavirus Type 11 E6 Protein in Respiratory Papillomatosis

ABSTRACT Recurrent respiratory papillomatosis (RRP) is a chronic, debilitating disease of the upper airway caused by human papillomavirus type 6 (HPV-6) or HPV-11. We describe responses of peripheral blood mononuclear cells (PBMC) and T cells from RRP patients and controls to the HPV-11 early proteins E6 and E7. PBMC were exposed in vitro to purified E6 or E7 proteins or transduced with fusion proteins containing the first 11 amino acids of the human immunodeficiency virus type 1 protein tat fused to E6 or E7 (tat-E6/tat-E7). TH1-like (interleukin-2 [IL-2], gamma interferon [IFN-γ], IL-12, and IL-18), and TH2-like (IL-4 and IL-10) cytokine mRNAs were identified by reverse transcription-PCR, and IFN-γ and IL-10 cytokine-producing cells were identified by enzyme-linked immunospot assay. These studies show that HPV-11 E6 skews IL-10-IFN-γ expression by patients with RRP toward greater expression of IL-10 than of IFN-γ. In addition, there is a general cytokine hyporesponsiveness to E6 that is more prominent for TH1-like cytokine expression by patients with severe disease. Patients showed persistent IL-10 cytokine expression by the nonadherent fraction of PBMC when challenged with E6 and tat-E6, and, in contrast to controls, both T cells and non-T cells from patients expressed IL-10. However, E7/tat-E7 cytokine responses in patients with RRP were similar to those of the controls. In contrast, E6 inhibited IL-2 and IL-18 mRNA expression that would further contribute to a cytokine microenvironment unfavorable to HPV-specific, T-cell responses that should control persistent HPV infection. In summary, E6 is the dominant inducer of cytokine expression in RRP, and it induces a skewed expression of IL-10 compared to the expression of IFN-γ.

Papillomavirus-Specific CD4+ T Cells Exhibit Reduced STAT-5 Signaling and Altered Cytokine Profiles in Patients with Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) is caused by human papillomavirus type 6 (HPV-6) or HPV-11. Specific HLA-DR haplotypes DRB1*01:02 and DRB1*03:01 are associated with the development of RRP, disease severity, and Th2-like responses to HPV early proteins. Th1-like responses to HPV proteins have been shown to be protective in animal models. Therefore, we investigated the hypothesis that RRP patients have dysfunctional Th1-like, HPV-specific T cell responses. Using MHC class II tetramers, we identified immunogenic peptides within HPV-11 early proteins. Two distinct peptides (E6113–132 and E21–20) contained DRB1*01:02- or DRB1*03:01-restricted epitopes, respectively. An additional peptide (E2281–300) contained an epitope presented by both alleles. Peptide binding, tetramer, and proliferation assays identified minimal epitopes within these peptides. These epitopes elicited E2/E6-specific CD4+ T cell responses in RRP patients and healthy control subjects, allowing the isolation of HPV-specific T cell lines using tetramers. The cytokine profiles and STAT signaling of these tetramer-positive T cells were measured to compare the polarization and responsiveness of HPV-specific T cells from patients with RRP and healthy subjects. HPV-specific IFN-γ secretion was substantially lower in T cells from RRP patients. HPV-specific IL-13 secretion was seen at modest levels in T cells from RRP patients and was absent in T cells from healthy control subjects. HPV-specific T cells from RRP patients exhibited reduced STAT-5 phosphorylation and reduced IL-2 secretion, suggesting anergy. Levels of STAT-5 phosphorylation and IFN-γ secretion could be improved through addition of IL-2 to HPV-specific T cell lines from RRP patients. Therapeutic vaccination or interventions aimed at restoring Th1-like cytokine responses to HPV proteins and reversing anergy could improve clinical outcomes for RRP patients.