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MYCMED-458; No. of Pages 6 Journal de Mycologie Médicale (2014) xxx, xxx—xxx

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ORIGINAL ARTICLE/ARTICLE ORIGINAL

Altered immune responses in patients with chronic mucocutaneous candidiasis ´ ration des re ´ ponses immunitaires chez les patients atteints de Alte ´ o-muqueuse candidose chronique cutane A.R. Khosravi a,*, H. Shokri b, S. Darvishi a a b

Mycology research center, faculty of veterinary medicine, university of Tehran, Azadi street, Tehran, Iran Faculty of veterinary medicine, Amol university of special modern technologies, Amol, Iran

Received 24 April 2013; received in revised form 24 November 2013; accepted 7 January 2014

KEYWORDS Chronic mucocutaneous candidiasis; Cellular immunity; Lymphocyte transformation; Cytokines

Summary Objective. — The purpose of this study was to investigate the lymphocyte transformation responses and cytokine secretion of peripheral blood mononuclear cells (PBMC) from patients with chronic mucocutaneous candidiasis (CMC). Methods. — Phytohaemagglutinin (PHA) mitogen and Candida albicans (C. albicans) antigen proliferation assays were performed by culturing PBMCs in RPMI 1640. The levels of interleukin (IL)-2, IL-10, IL-17 and interferon (IFN)-g present in the supernatant of cultures were determined using enzyme-linked immunosorbent assay (ELISA). Results. — The results showed that most patients (92.3%) had a low proliferative response to C. albicans antigens and PHA. PBMCs from CMC patients produced lower levels of T (h)-1 cytokines IL-2 (78.5  59.8 pg/mL) and IFN-g (115.1  43.3 pg/mL) in response to Candida antigens when compared to controls (Il-2: 177  103.6 pg/mL; IFN-g: 330.3  21.6 pg/mL) (P < 0.05). Conversely, we observed a partial enhancement of IL-10 in the patients (213.7  86.1 pg/mL). Production of IL-17 indicated no significant differences between patients and controls when stimulated by Candida antigens (21.5  8.6 pg/mL versus 32.4  12.2 pg/mL) and PHA (27.7  11.5 pg/mL versus 36.2  9.1 pg/mL), respectively. Conclusion. — These findings suggest that Candida antigens trigger a Th2 instead of Th1 cytokine response in patients with CMC. For better understanding, further studies require on a larger number of patients into the future. # 2014 Elsevier Masson SAS. All rights reserved.

* Corresponding author. E-mail address: [email protected] (A.R. Khosravi). 1156-5233/$ — see front matter # 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.mycmed.2014.01.062

Please cite this article in press as: Khosravi AR, et al. Altered immune responses in patients with chronic mucocutaneous candidiasis. Journal De Mycologie Médicale (2014), http://dx.doi.org/10.1016/j.mycmed.2014.01.062

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MOTS CLÉS Candidose chronique cutanéo-muqueuse ; L’immunité cellulaire lymphocytaire ; Transformation ; Cytokines

Re ´sume ´ Objectif. — Le but de cette étude était d’étudier la transformation lymphocytaire et la sécrétion cytokiniques des cellules mononuclées du sang périphérique (PBMC) chez des patients atteints de candidose chronique cutanéo-muqueuse (CMC). Mate´riel et me ´thodes. — Les tests de prolifération avec la phytohémagglutinine (PHA) et avec les antigènes de Candida albicans (C. albicans) ont été effectués par la culture de PBMCs en RPMI 1640. Les niveaux de l’interleukine (IL) -2, IL-10, l’IL-17 et de l’interféron (IFN) -g présents dans le surnageant des cultures ont été déterminés à l’aide test immuno-enzymatiques (Elisa). Re ´sultats. — Les résultats ont montré que la plupart des patients (92,3 %) avaient une faible réponse proliférative de C. albicans antigènes et à la PHA. Les PBMCs des patients atteints de CMC produisent des niveaux inférieurs de T (h)-1 cytokines IL-2 (78,5  59,8 pg/mL) et L’IFN-g (USD 115,1 millions  43,3 pg/mL) en réponse aux Candida antigènes de Candida comparés aux contrôles (Il-2 : 177  103,6 pg/mL ; IFN-g : 330.3  21,6 pg/mL) ( p < 0,05). Inversement, nous avons observé une amélioration partielle de l’IL-10 chez les patients (213,7  86,1 pg/mL). La production de l’IL-17 ne montrait aucune différence significative entre les patients et les contrôles lorsque stimulé par les antigènes de Candida (21,5  8,6 pg/mL versus 32,4  12,2 pg/mL) et la PHA (27,7  11,5 pg/mL versus 36,2  9,1 pg/mL), respectivement. Conclusion. — Ces résultats suggèrent que les antigènes de Candida déclenchent une production cytokinique Th2 au lieu de Th1 chez des patients avec CMC. Pour une meilleure compréhension, d’autres études ont besoin d’un plus grand nombre de patients dans l’avenir. # 2014 Elsevier Masson SAS. Tous droits réservés.

Introduction Chronic mucocutaneous candidiasis (CMC) is a primary immunodeficiency disease presenting with debilitating, persistent and refractory infections of the skin, nails and mucosal tissues by Candida species; in particular Candida albicans in the majority of the cases [28]. Several clinical features of CMC have been described, some of which are associated with endocrinopathies or autoimmune diseases, such as hypothyroidism and hypoparathyroidism [4]. Patients with CMC rarely develop disseminated or invasive candidiasis, suggesting a defect in the host defense limited to superficial candidal infections [13,17]. Several reports have shown that the defects are almost exclusively in the cellular branch of the immune system, mainly the specific responses to antigens of Candida species [26]. The balance between T helper (Th)1 and Th2 cytokines is important in the initiation of the type of immune response. A Th1 cytokine response is associated with resistance to candidiasis, whereas a Th2 response results in susceptibility to infection [24]. Some CMC patients present serum factors that inhibit the proliferative responses of peripheral blood mononuclear cells (PBMC) from Candida-sensitized normal subjects [3]. Durandy et al. [10] demonstrated that infection with C. albicans leads to an accumulation of mannan (a Candida polysaccharide antigen). This causes activation of suppressor T-cells capable of inhibiting both the proliferation and the activation of T-helper cells. It is generally accepted that defense mechanisms encompass macrophages, cytotoxic lymphocytes and natural killer (NK) cells. For activation of these cells, pro-inflammatory cytokines such as interferon (IFN)-g and tumor necrosis factor (TNF)-a are major mediators, whereas anti-inflammatory cytokines, such as interleukin (IL)-4 and IL-10, antagonize the cellular anti-candidal defense [23]. Moreover, other recent studies demonstrated deficient production and secretion of IL-2 by PBMC in response to Candida antigen [21]. It has also been revealed that other cytokines can influence the

balance of cytokines produced, as is the case with IFNg, which stimulate Th1 responses. Specifically, the pro-inflammatory IL-17—producing Th17 subset is implicated in protection against Candida at epithelial surfaces [7]. Due to the several controversial aspects of CMC, we assessed the pro- and anti-inflammatory cytokine responses in a whole-blood culture model after stimulation with C. albicans antigens and phytohaemagglutinin (PHA) mitogen in patients with CMC.

Patients and methods Patients and sample collection The CMC patient group consisted of 13 cases (5 male and 8 female) between 6 and 17 years of age, representing clinical criteria for persistent and refractory candidiasis of skin, nails and mucosal tissues. Thirteen patients presented oral thrush, 5 had nail lesions, 13 trunk skin involvement, 3 scalp skin involvement, 4 oesophageal lesions and 1 conjunctivitis. During the study, the CMC patients did not suffer from other concurrent disorders or acute infections. In all patients, endocrinopathy was excluded as judged by absence of clinical manifestations and laboratory evidence of autoimmune endocrinopathy. The control group consisted of 13 age- and sex-matched healthy individuals. Ethical approval was granted by Ethical Committee of Imam Khomeini Hospital, Tehran, Iran. After obtaining informed consent, blood samples were obtained from both patients and controls at the same time, using 2 ml glass tubes containing lithium heparin (Becton Dickinson, Franklin Lakes, NJ).

Cell separation and cell cultures Peripheral blood mononuclear cells (PBMCs) were obtained by centrifugation on Ficoll-Hypaque. The cells were washed twice with RPMI 1640 (Gibco, Grand Island, N.Y.), the number of viable lymphocytes was determined by trypan blue

Please cite this article in press as: Khosravi AR, et al. Altered immune responses in patients with chronic mucocutaneous candidiasis. Journal De Mycologie Médicale (2014), http://dx.doi.org/10.1016/j.mycmed.2014.01.062

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staining, and the cells were counted on a hemocytometer. The cells were resuspended in RPMI 1640 with 20% fetal calf serum (FCS) at a concentration of 105 cells per mL. Mitogen proliferation assay was performed by incubating 105 PBMCs in RPMI 1640 supplemented with penicillin (100 U/ mL), streptomycin (100 mg/mL), L-glutamine, and 20% FCS. The cells were cultured in triplicate for 72 h with PHA (1 mg/ mL; Sigma, St. Louis, Mo.) at 37 8C in 5% CO2. After 72 h, they received a 6-h pulse with 0.5 mCi of [3H]thymidine (Sigma) and were then harvested and washed on glass filters. [3H]thymidine incorporation was measured in a liquid scintillation counter (Beckman). Antigen proliferation assay was also performed in triplicate with 2  105 PBMCs per microwell cultured with C. albicans antigens (Hollister-Stier, Spokane, Wash.) which had been dialyzed against RPMI 1640, filter sterilized, and titrated against control PBMCs. An optimal dilution of 1:4 was used in all subsequent studies. Cells were cultured for 5 to 7 days at 37 8C in 5% CO2. At the end of the incubation, the cells received a 6-h pulse of [3H]thymidine and were then harvested and counted as described above. The results were presented as stimulation index (SI).

plate was then washed once with a buffered detergent wash solution, 100 mL of a rabbit polyclonal anti-human cytokine antibody was added to each well, and the plate was incubated for 1 h at 24 8C. The plate was washed, 100 mL of an anti-rabbit antibody conjugated to horseradish peroxidase (HRP) was added to each well, and the plate was incubated for 1 h. After washing four times, an HRP substrate solution was added for 1 h. The reaction was stopped by adding 5% sulfuric acid to each well, and the plate was read at 490 nm. The values were calculated by comparison with the standard curve.

Cytokine assay

The controversial reports of cellular immune response of CMC patients reflect the clinical and immunological variability of these patients [28]. Due to the dominant role of the cellular compartment of the immune system in the defense against fungi, several parameters of the cell-mediated immunity such as T lymphocyte proliferation and cytokine secretion in patients with CMC were investigated. The lymphocyte transformation responses were evaluated after stimulation with PHA and C. albicans antigens. In this study, most patients (12/13; 92.3%) revealed a low proliferative response to Candida antigens (Fig. 1). The proliferative response to PHA was also below the lower normal limit in 12 of 13 patients tested (Fig. 2). These proportions were different in relation to the control group: as 9 and 8 of them showed low stimulation indices (SIs) against Candida antigens and PHA, respectively (Table 1). Despite the depressed proliferative response from PBMC to Candida antigens, most patients presented the same specific immune response, failing to recognize PHA, as observed previously [15,18]. It should be noted that serum from the patients suppressed both mitogen- and antigen-induced lymphocyte proliferation. De Moraes-Vasconcelos et al. [9] studied eight CMC patients without endocrinopathies, who showed low normal proliferative response to PHA and impaired response to Candida antigens. Durandy et al. [10] demonstrated that infection with C. albicans leads to an accumulation of mannan (a Candida polysaccharide antigen). This causes activation of suppressor T cells capable of inhibiting both the proliferation and the activation of T-helper cells. The analysis of mean IL-10 production by PBMC of the patients showed lower levels than those found for the control group; i.e. 157.9  103.1 pg/mL in the patients and 173.2  94.1 pg/mL in the controls, when stimulated by PHA (Table 1). In addition, production of IL-10 was not significantly altered in the patients (213  74 pg/ml) when compared to the controls (205.05  123.16 pg/mL) upon Candida antigens stimulus. The secretion of IL-2 (Figs. 3 and 4) and IFN-g (Figs. 5 and 6) revealed significantly lower levels than those found for the control group; i.e. 78.5  59.8 pg/mL in the patients and 177  103.6 pg/mL

Quantification of cytokines in the supernatant was obtained by stimulation of 5  105 cells/mL in RPMI/10% AB serum in 24-well plates with PHA 1 mg/mL and C. albicans antigens 1 mg/mL. The supernatant samples were harvested 24 h after PHA stimulation and 72 h after Candida stimulation, according to preliminary experiments in which harvesting time was determined (data not shown). The supernatants were stored in aliquots at 70 8C until quantification of cytokines. The amounts of IL-2, IL-10, IL-17 and IFN-g present in the supernatant of cultures were determined using human enzymelinked immunosorbent assay (ELISA) kits (BioSource International, Camarillo, Calif.). Briefly, 100 mL of supernatant or human cytokine standard was added in duplicate to each well of a plate precoated with anti-human cytokine monoclonal antibody, and the plate was incubated for 1 h at 24 8C. The C (control)

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Figure 1 Lymphocyte transformation test using Candida albicans antigens in patients with chronic mucocutaneous candidiasis and controls. ` nes de CanTransformation lymphocytaire utilisant les antige dida albicans chez des patients atteints de candidose chronique ˆ les. ´ o-muqueuse et des contro cutane

Statistics One-way analysis of variance (ANOVA) test was used for multiple group comparisons followed by Tukey post-hoc for group-wise comparisons. P value < 0.05 was considered statistically significant.

Results and discussion

Please cite this article in press as: Khosravi AR, et al. Altered immune responses in patients with chronic mucocutaneous candidiasis. Journal De Mycologie Médicale (2014), http://dx.doi.org/10.1016/j.mycmed.2014.01.062

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Figure 3 The level of IL-2 using stimulated cells with Candida albicans antigens in patients with chronic mucocutaneous candidiasis and controls. ` nes de Niveau de l’IL-2 en stimulant les cellules avec les antige Candida albicans chez les patients atteints de candidose chro´ o-muqueuse et des contro ˆ les. nique cutane

in the controls for IL-2, and 115.1  43.3 pg/mL in the patients and 330.3  121.6 pg/mL in the controls for IFNg, when stimulated by Candida antigens (P < 0.05). The mean levels of production of IL-2 and IFN-g after stimulation with PHA were not different between patient (172  106.5 and 315.8  116.9 pg/mL) and control groups (219.4  127.8 and 379  141.3 pg/mL), respectively (Table 1). Our results demonstrated significant alterations in the patterns of cytokine production seen in patients with CMC; specifically in response to C. albicans antigens, representing

a significant decrease in the production of Th1 cytokines including IL-2 and IFN-g. In contrast, the production of the anti-inflammatory cytokine IL-10 tended to be higher in CMC patients. A similar lack of responses was also noted in proliferation assay. Our data are in accordance with those of Gravenor et al. [14] demonstrating higher IL-10 levels and deficient IL-2 production in CMC patients after C. albicans stimulation. In a comprehensive study conducted by Lilic and

Table 1 The levels of cytokines production of peripheral blood mononuclear cells from patients with mucocutaneous candidiasis and controls stimulated with Candida albicans antigens and phytohaemagglutinin mitogn (pg/mL). ´ es du sang pe ´ riphe ´ rique de patients atteints de candidose cutane ´ oNiveau de production des cytokines par les cellules mononucle ˆ les stimule ´ s avec les antige ` nes de Candida albicans et la phytohe ´ magglutinine (pg/mL). muqueuse et de contro Data SI

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Patient 4.1 Control 37 PHA Patient 51.8 Control 186.7

3 6.3 14.6 39.1 43.3

4 1.3 17.8 48.8 41.1

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21.2 2.3 4.8 1.1 2.6 7.29 43.31 3.21 27.14 6.23 95.9 81.3 113 79.6 141.9 41.2 268.9 117.8 198.9 57.9

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10 17.4 3.3 11.4 18.56 42.3 27.8 79.3 140.3

11 14.3 15.11 31.2 73.4

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IL-10 CA

Patient Control PHA Patient Control

346 163.9 214.4 181.1 315.4 184.4 458.3 131.5 311.3 98.3 112.8 201.8 285.4 196.8 87.4 196.4

192.3 198.4 95.3 129

163.4 219.3 59.6 231.5

372.6 301.5 298.5 315.8

291.3 353 349.9 306.6

195.7 57.2 87.5 59.6

275.1 199 192.1 201.3

87.4 107.6 121.3 119.6

197.6 52.6 45.2 71.5

97.9 87.5 79.5 51.3

IL-2

CA

109.7 63.2 27.5 79 197.4 87.3 119.7 74.3 216.4 97.2 132.1 307.3 248.4 121.5 109.2 92.4

0 69.2 25.6 157.2

198.3 151.3 331.1 191.6

57.6 315.4 219.8 429.5

107.5 125.3 199.4 161.2

0 155.4 0 201.9

179.8 401.3 101.9 499.8

53.3 181.9 89.3 212.3

63.1 112.7 219.7 99.4

82 309.4 301.6 327.6

IFN-g CA

121.6 81.4 195.6 181.3 329.3 314.2 297.6 417.1 329.6 275.6 291.2 491.3 497 301.9 333.2 561.7

121.6 482.2 210.2 499.3

89.6 385.6 385.6 363.5

98.6 471.1 412.7 509.1

161.3 312.4 175.6 215.3

59.9 185.4 95.6 304.3

124.6 512.8 271.6 617.2

79.3 275.1 295.6 307.8

119.3 112.6 379.4 201.2

61.4 198.5 491.7 215.6

11.4 33.2 17.2 49.2

15 21.3 13.3 37

23.1 14.5 52.4 39.1

23 32.1 35.4 40.1

37.5 42.1 39.1 41.8

21.2 25 23.3 33.3

10.2 21.5 20.1 25.6

19.2 39.7 25.1 50.8

13.3 46 15.1 22.3

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IL-17 CA

Patient Control PHA Patient Control

32.2 21.4 41.3 25.6

29.4 57.8 23.2 43

14.3 27.1 25.2 35.3

29.5 39.4 32.1 27.5

SI: stimulation index; CA: Candida albicans antigens; PHA: phytohaemagglutinin.

Please cite this article in press as: Khosravi AR, et al. Altered immune responses in patients with chronic mucocutaneous candidiasis. Journal De Mycologie Médicale (2014), http://dx.doi.org/10.1016/j.mycmed.2014.01.062

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Gravenor [22] on a larger number of patients with CMC, it was demonstrated increased IL-10 production in response to Candida antigens in all patients. This was paralleled by decreased values of IL-2 and IFN-g. As IL-10 is a potent anti-inflammatory cytokine which counteracts the actions of IFN-g, the IFN-g/IL-10 ratio is considered to be important in defense against C. albicans [27]. Therefore, the greater release of IL-10 in CMC patients further contributes to a reduced IFN-g/IL-10 ratio and is likely to also be involved in the defective activation of anti-candidal mechanisms. Low IL-2 and IFN-g production in response to C. albicans antigens could largely explain impaired cell-mediated immunity previously reported in these patients [9,18]. It is likely that low IL-2 and IFN-g levels are the results of decreased Th1 cell numbers. Differences in some studies may in part depend on the type of C. albicans antigens used to stimulated responses [16]. It is important to mention that the sera of

Figure 6 The level of IFN-g using stimulated cells with phytohaemagglutinin (PHA) in patients with chronic mucocutaneous candidiasis and controls. ` s stimulation des cellules avec phytohe ´Niveau de l’IFN-g apre magglutinine (PHA) chez les patients atteints de candidose ´ o-muqueuse et des contro ˆ les. chronique cutane

the patients clearly modulated immune reactivity, suppressing the production of Th1-type but not Th2-type cytokines. The fact that little patients secreted adequate concentrations of the Th1 cytokines can be a consequence of the heterogeneity of the disease or, on the other hand, of the clinical status at the time of evaluation. Considering that these defects are not consistently found in CMC patients, they are unlikely to be the only or the main underlying cause of susceptibility to persistent Candida infections. The defective IFN-g release appeared to be rather specific for candidal stimulation. Microbial components stimulate IFN-g production through intermediary release of monocyte products such as IL-12 and IL-18, while PHA directly stimulates T lymphocytes [2]. Thus, the difference between Candida and PHA stimulation suggests that the defect in CMC patients may be localized at the level of monocytes. Th17 cells that produce IL-17 are crucial in protection against oral or mucocutaneous candidiasis [7,8]. Indeed, the natural Th17 memory repertoire includes many C. albicans — specific Th17 cells, which trigger the production of neutrophil-recruiting and -activating cytokines and chemokines, pro-inflammatory cytokines, and anti-microbial peptides in many cell types [1,12,20]. As illustrated in Table 1, production of IL-17 showed no significant differences between patients and controls when stimulated by Candida antigens (21.5  8.6 pg/mL versus 32.4  12.2 pg/mL) and PHA (27.7  11.5 versus 36.2  9.1 pg/mL), respectively. Little is known about the defects underlying susceptibility to Candida in patients with autosomal dominant CMC (related to Th17). In a previous study, investigators found defective Th17 responses in patients with this disorder [5]. The exact role of these cells in anti-Candida immunity is not fully understood, with evidence to suggest both a positive [6] and negative [29] role, although it is becoming clear that cytokines secreted by these cells, most notably IL-17, play a significant role in antifungal immunity. IL-17 acts on epithelial cells and neutrophils, functioning as a bridge between the adaptive and innate immune responses. Its effects on epithelial cells include induction of anti-microbial peptides, matrix metalloproteases and other inflammatory mediators. The importance of the

Please cite this article in press as: Khosravi AR, et al. Altered immune responses in patients with chronic mucocutaneous candidiasis. Journal De Mycologie Médicale (2014), http://dx.doi.org/10.1016/j.mycmed.2014.01.062

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Th17 response in mucosal immunity to Candida infections is underlined by several recent studies linking defects in the Th17 response and production of IL-17 to cases of CMC [11,25]. This link is further supported by the finding that in cases of autoimmunity with neutralizing antibodies to Th17 cytokines (IL-17A, IL-17F, and IL-22), there is an increased incidence of CMC [19]. Despite this, the report that IL-17 may play a deleterious role in anti-Candida immunity suggests that the situation may be far more complex in vivo [11]. In conclusion, our data suggest that altered cytokine production may be an important mechanism underlying increased susceptibility to Candida infections seen in patients with CMC. Our findings of an impaired ability to produce Il-2, IL-17 and IFN-g and a mild production of IL-10 suggest that in patients with CMC, Candida antigens seem unable to trigger adequate production of Th1 cytokines, but instead trigger increased production of Th2 cytokines. However, even though our findings support this scenario, further studies addressing production of other cytokines characteristic of a Th1 or Th2 type response are needed to confirm this bias.

[10]

[11]

[12]

[13]

[14]

[15]

[16]

Disclosure of interest The authors have not supplied their declaration of conflict of interest.

[17]

Acknowledgments

[18]

This work was supported by the Research council of the university of Tehran. The authors would like to thanks all patients who participated in this study.

[19]

[20]

References [1] Acosta-Rodriguez EV, Rivino L, Geginat J, Jarrossay D, Gattorno M, Lanzavecchia A, et al. Surface phenotype and antigenic specificity of human interleukin 17-producing T helper memory cells. Nat Immunol 2007;8:639—46. [2] Ahn HJ, Maruo S, Tomura M, Mu J, Hamaoka T, Nakanishi K. A mechanism underlying synergy between IL-12 and IFN-gammainducing factor in enhanced production of IFN-gamma. J Immunol 1997;159:2125—31. [3] Anaissie EJ, McGinnis MR, Pfaller MA. Clinical mycology. In: Sobel JD, editor. Fungal infections of the genitourinary tract. . 1st ed., Philadelphia: Churchill Livingstone; 2003. p. 496—9. [4] Coleman R, Hay RJ. Chronic mucocutaneous candidosis associated with hypothyroidism: a distinct syndrome? Br J Dermatol 1997;136:24—9. [5] Conti HR, Gaffen SL. Host responses to Candida albicans: Th17 cells and mucosal candidiasis. Microb Infect 2010;12:518—27. [6] Conti HR, Shen F, Nayyar N, Stocum E, Sun JN, Lindemann MJ, et al. Th17 cells and IL-17 receptor signaling are essential for mucosal host defense against oral candidiasis. J Exp Med 2009; 206:299—311. [7] Curtis MM, Way SS. Interleukin-17 in host defence against bacterial, mycobacterial and fungal pathogens. Immunology 2009;126:177—85. [8] de Beaucoudrey L, Puel A, Filipe-Santos O, Cobat A, Ghandil P, Chrabieh M, et al. Mutations in STAT3 and IL12RB1 impair the development of human IL-17—producing T cells. J Exp Med 2008;205:1543—50. [9] De Moraes-Vasconcelos D, Orii NM, Romano CC, Iqueoka RY, Da S, Duarte AJ. Characterization of the cellular immune function

[21]

[22] [23]

[24]

[25]

[26]

[27] [28] [29]

of patients with chronic mucocutaneous candidiasis. Clin Exp Immunol 2001;123:247—53. Durandy AA, Fischer A, LeDeist F, Drouchet E, Griscelli C. Mannan-specific and mannan-induced T-cell suppressive activity in patients with chronic mucocutaneous candidiasis. J Clin Immunol 1987;7:400—9. Eyerich K, Foerster S, Rombold S, Seidl HP, Behrendt H, Hofmann H, et al. Patients with chronic mucocutaneous candidiasis exhibit reduced production of Th17-associated cytokines IL-17 and IL-22. J Invest Dermatol 2008;128:2640—5. Fouser LA, Wright JF, Dunussi-Joannopoulos K, Collins M. Th17 cytokines and their emerging roles in inflammation and autoimmunity. Immunol Rev 2008;226:87—102. Germain M, Gourdeau M, Hebert J. Case report: familial chronic mucocutaneous candidiasis complicated by deep candida infection. Am J Med Sci 1994;307:282—3. Gravenor I, Robson N, Abinun M, Cant AJ, Lilic D.In: 10th Meeting of the European Society for Immunodeficiencies 2002, Weimar, Germany; 2002. Hong R, Clement LT, Gatti RA, Kirkpatrick CH. Disorders of the T cell system. In: Stiehm ER, editor. Immunologic disorders in infants and children. Philadelphia: Saunders; 1996. p. 339—408. Kanarek DAM. ContribuicËaÄo para o estudo da CandidõÂase MucocutaÃ-nea CroÃnica: Aspectos clõÂnicos e avaliacËaÄo da funcËaÄo imune mediada por linfoÂcitos T e macroÂfagos. [Dissertation]. SaÄo Paulo (SP): University of de SaÄo Paulo; 1997. Kauffman CA, Shea MJ, Frame PT. Invasive fungal infections in patients with chronic mucocutaneous candidiasis. Arch Int Med 1981;141:1076—9. Kirkpatrick CH. Chronic mucocutaneous candidiasis. J Am Acad Dermatol 1994;31:S14—7. Kisand K, Boe Wolff AS, Podkrajsek KT, Tserel L, Link M, Kisand KV, et al. Chronic mucocutaneous candidiasis in APECED or thymoma patients correlates with autoimmunity to Th17-associated cytokines. J Exp Med 2010;207:299—308. Korn T, Bettelli E, Oukka M, Kuchroo VK. IL-17 and Th17 cells. Annu Rev Immunol 2009;27:485—517. Lilic D, Cant AJ, Abinun M, Calvert JE, Spickett GP. Chronic mucocutaneous candidiasis. I. Altered antigen-stimulated IL-2, IL-4, IL-6 and interferon-gamma (IFN-g) production. Clin Exp Immunol 1996;105:205—12. Lilic D, Gravenor I. Immunology of chronic mucocutaneous candidiasis. J Clin Pathol 2001;54:81—3. Mathews H, Witek-Janusek L. Host defenses against oral, esophageal and gastrointestinal candidiasis. In: Calderone RA, editor. Candida and candidiasis. Washington DC: ASM Press; 2002. p. 179—92. Netea MG, van der Graaf CA, Vonk AG, Verschueren I, van der Meer JW, Kullberg BJ. The role of Toll-like Receptor (TLR) 2 and TLR4 in the host defense against disseminated candidiasis. J Infect Dis 2002;185:1483—9. Ng WF, von Delwig A, Carmichael AJ, Arkwright PD, Abinun M, Cant AJ, et al. Impaired TH17 responses in patients with chronic mucocutaneous candidiasis with and without autoimmune polyendocrinopathycandidiasis-ectodermal dystrophy. J Allergy Clin Immunol 2010;126:1006—15. Podzorski RP, Gray GR, Nelson RD. Different effects of native Candida albicans mannan and mannan-derived oligosaccharides on antigenstimulated lymphoproliferation in vitro. J Immunol 1990;144:707—16. Romani L. Immunity to Candida albicans: Th1, Th2 cells and beyond. Curr Opin Microbiol 1999;2:363—7. Willium J, Berger D, Timothy G. Andrews diseases of skin; clinical dermatology. Saunders: Elsevier; 2006. Zelante T, De Luca A, Bonifazi P, Montagnoli C, Bozza S, Moretti S, et al. IL-23 and the Th17 pathway promote inflammation and impair antifungal immune resistance. Eur J Immunol 2007; 37:2695—706.

Please cite this article in press as: Khosravi AR, et al. Altered immune responses in patients with chronic mucocutaneous candidiasis. Journal De Mycologie Médicale (2014), http://dx.doi.org/10.1016/j.mycmed.2014.01.062

Altered immune responses in patients with chronic mucocutaneous candidiasis.

The purpose of this study was to investigate the lymphocyte transformation responses and cytokine secretion of peripheral blood mononuclear cells (PBM...
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