Acta Neuropathol DOI 10.1007/s00401-015-1383-6
CORRESPONDENCE
Therapeutic use of CCR5 antagonists is supported by strong expression of CCR5 on CD8+ T cells in progressive multifocal leukoencephalopathy‑associated immune reconstitution inflammatory syndrome Guillaume Martin‑Blondel · Jan Bauer · Emmanuelle Uro‑Coste · Damien Biotti · Delphine Averseng‑Peaureaux · Nelly Fabre · Hervé Dumas · Fabrice Bonneville · Hans Lassmann · Bruno Marchou · Roland S. Liblau · David Brassat Received: 21 November 2014 / Revised: 23 December 2014 / Accepted: 6 January 2015 © Springer-Verlag Berlin Heidelberg 2015
Therapeutic strategies that modulate the deleterious immune response underlying progressive multifocal leukoencephalopathy-associated immune reconstitution inflammatory syndrome (PML-IRIS) are warranted [5]. Maraviroc, an antagonist of the CCR5 chemokine receptor that entered recently the HIV armamentarium, has been suggested to be beneficial in preventing or treating PMLIRIS [1, 4]. Since chemokine receptors play an important role in inflammatory cell migration, we investigated whether the molecular target of maraviroc is expressed on pathogenic T cells infiltrating PML-IRIS lesions. Paraffinembedded brain specimens of inflammatory PML, obtained through diagnostic stereotactic brain biopsy, were analyzed from five previously described HIV-infected patients who developed PML-IRIS after initiation of antiretroviral R. S. Liblau and D. Brassat: Co-senior authors. Electronic supplementary material The online version of this article (doi:10.1007/s00401-015-1383-6) contains supplementary material, which is available to authorized users.
therapy (ART) [3], and two non-HIV-infected patients who developed PML after chemotherapy or natalizumab, one who developed PML-IRIS, and the other at high risk of PML-IRIS (supplementary table and figure). Biopsies were performed before any steroid therapy and before maraviroc was introduced for the two non-HIV-infected patients to treat or prevent PML-IRIS, with a highly favorable outcome. As a control, we collected brain autopsies from 4 HIV-infected patients who developed classic PML (without IRIS). Consistent with previous reports [3, 6], CD8+ T cells dominate the inflammatory response in HIV-infected as well as non-HIV-infected patients with inflammatory PML (Fig. 1a). In patient 2, CD68+ macrophagic/microglial cells (1,480/mm2), CD20+ B cells (55/mm2) and CD138+ plasma cells (241/mm2) were also present in the biopsied lesion, while in patient 1, who was treated by rituximab, cells of the B cell lineage were totally absent, arguing against a necessary role for B cells and antibodies in the pathogenesis of PML-IRIS (Fig. 1i–k and data not shown). Brain lesions displayed strong infiltration by CCR5+ cells
G. Martin‑Blondel · B. Marchou Department of Infectious and Tropical Diseases, Toulouse University Hospital, Toulouse, France
E. Uro‑Coste Department of Pathology, Toulouse University Hospital, Toulouse, France
G. Martin‑Blondel (*) · R. S. Liblau · D. Brassat INSERM U1043‑CNRS UMR 5282, Centre de Physiopathologie Toulouse-Purpan, Place du Docteur Baylac TSA 40031, 31059 Toulouse Cedex 9, France e-mail: martin‑blondel.g@chu‑toulouse.fr
E. Uro‑Coste INSERM, CRCT U1087, Toulouse, France
G. Martin‑Blondel · E. Uro‑Coste · D. Averseng‑Peaureaux · F. Bonneville · B. Marchou · R. S. Liblau · D. Brassat Université Toulouse III, 31000 Toulouse, France
D. Biotti · D. Averseng‑Peaureaux · N. Fabre · D. Brassat Department of Neurology, Pole des Neurosciences, Toulouse University Hospital, Toulouse, France H. Dumas · F. Bonneville Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
J. Bauer · H. Lassmann Center for Brain Research, Medical University of Vienna, Vienna, Austria
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Acta Neuropathol
Fig. 1 Histopathology of HIVinfected PML-IRIS patients (left row), patient 1 (middle row) and patient 2 (right row). Bars c–k 50 µm, l–n 25 µm. a Density of CCR5+, CD3+ and CD8+ cells in brain lesions from inflammatory PML brain lesions (/mm2). b Percentage of CD8+ T cells expressing CCR5. c–e Staining for SV40 showing JC virusinfected cells (arrowheads). f–h Staining for CD3 revealing strong T cell infiltration in all cases. i–k Staining for CD138 showing the presence of plasma cells in the HIV-infected PMLIRIS patients and in patient 2 but not in the Rituximab-treated patient 1. l–n Double staining for CD8 (green) and CCR5 (red) showing that in all patients most CD8 cells in perivascular space (white arrowhead in panel m) and parenchyma express CCR5. The red arrowheads in l, m and n indicate the presence of CD8− CCR5+ cells
(Fig. 1a). Confocal fluorescence staining showed that the vast majority of the perivascular and parenchymal CD8+ T cells express CCR5, representing 93.7 ± 2.5 % of CD8+ T cells in HIV-infected PML-IRIS patients, and 93.8 ± 6.2 % of CD8+ T cells in the non-HIV-infected patients (Fig. 1b, l–n). CD8+ T cells accounted for 88 and 70 % of CCR5+ cells in HIV-infected PML-IRIS patients and in non-HIVinfected patients, respectively. Indeed, CD4+ T cells and macrophagic/microglial cells also expressed CCR5, albeit at weaker levels than CD8+ T cells (data not shown). While brain lesions of classic PML cases also displayed some CCR5+ cells, the weak staining prevented faithful counting. We show here that brain lesion-infiltrating CD8+ T cells, the likely drivers of tissue damage, highly express CCR5 in HIV-infected and non-HIV-infected patients developing inflammatory forms of PML. The CCR5/CCL5 axis is
13
implicated in T cell activation and in leukocyte trafficking to the brain in the setting of neurotropic infections and in experimental models of multiple sclerosis (MS) as well as in human MS [2, 7]. We hypothesize that CCR5 antagonists might prevent and/or treat the deleterious inflammatory reaction that occurs during immune recovery in PML patients, by interfering with the activation and/or migration of CCR5-expressing activated CD8+ T cells. We therefore introduced maraviroc in the two non-HIV-infected patients with inflammatory PML. Maraviroc might have participated to the favorable outcome in the first case of PML-IRIS, and prevention of clinical worsening related to IRIS in the second case while this natalizumab-treated MS patient underwent plasmapheresis. Because CD8+ T cells in PML-IRIS lesions of HIV-infected patients also express CCR5, we propose that including maraviroc in HIV-infected patients with PML at the initiation of ART
Acta Neuropathol
might reduce the IRIS burden. In this context, the optimal duration of maraviroc treatment still has to be determined. Building on these observations, our results suggest that CCR5 antagonists can mitigate the deleterious immune response underlying PML-IRIS, deserving further clinical trials. Acknowledgments We thank Dr. V. Sazdovitch, Paris, France, for providing some tissue samples. This work was supported by the French National Institute for Medical Research (INSERM), the Agence Nationale pour la Recherche sur le Sida et les hépatites virales (ANRS), the Association pour la Recherche sur la Sclérose en Plaques (ARSEP), the Collège des Universitaires de Maladies Infectieuses et Tropicales (CMIT) and the Best-MS network, a FP7 network, Grant agreement No: 305477.
References 1. Giacomini PS, Rozenberg A, Metz I, Araujo D, Arbour N, Bar-Or A (2014) Maraviroc and JC virus-associated immune reconstitution inflammatory syndrome. N Engl J Med 370:486–488 2. Glass WG, Hickey MJ, Hardison JL, Liu MT, Manning JE, Lane TE (2004) Antibody targeting of the CC chemokine ligand 5
results in diminished leukocyte infiltration into the central nervous system and reduced neurologic disease in a viral model of multiple sclerosis. J Immunol 172:4018–4025 3. Martin-Blondel G, Bauer J, Cuvinciuc V, Uro-Coste E, Debard A, Massip P, Delisle MB, Lassmann H, Marchou B, Mars LT et al (2013) In situ evidence of JC virus control by CD8+ T cells in PML-IRIS during HIV infection. Neurology 81:964–970 4. Martin-Blondel G, Cuzin L, Delobel P, Cuvinciuc V, Dumas H, Alvarez M, Massip P, Marchou B (2009) Is maraviroc beneficial in paradoxical progressive multifocal leukoencephalopathyimmune reconstitution inflammatory syndrome management? Aids 23:2545–2546 5. Martin-Blondel G, Delobel P, Blancher A, Massip P, Marchou B, Liblau RS, Mars LT (2011) Pathogenesis of the immune reconstitution inflammatory syndrome affecting the central nervous system in patients infected with HIV. Brain 134:928–946 6. Metz I, Radue EW, Oterino A, Kumpfel T, Wiendl H, Schippling S, Kuhle J, Sahraian MA, Gray F, Jakl V et al (2012) Pathology of immune reconstitution inflammatory syndrome in multiple sclerosis with natalizumab-associated progressive multifocal leukoencephalopathy. Acta Neuropathol 123:235–245 7. Trebst C, Staugaitis SM, Tucky B, Wei T, Suzuki K, Aldape KD, Pardo CA, Troncoso J, Lassmann H, Ransohoff RM (2003) Chemokine receptors on infiltrating leucocytes in inflammatory pathologies of the central nervous system (CNS). Neuropathol Appl Neurobiol 29:584–595
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CORRESPONDENCE
Therapeutic use of CCR5 antagonists is supported by strong expression of CCR5 on CD8+ T cells in progressive multifocal leukoencephalopathy‑associated immune reconstitution inflammatory syndrome Guillaume Martin‑Blondel · Jan Bauer · Emmanuelle Uro‑Coste · Damien Biotti · Delphine Averseng‑Peaureaux · Nelly Fabre · Hervé Dumas · Fabrice Bonneville · Hans Lassmann · Bruno Marchou · Roland S. Liblau · David Brassat Received: 21 November 2014 / Revised: 23 December 2014 / Accepted: 6 January 2015 © Springer-Verlag Berlin Heidelberg 2015
Therapeutic strategies that modulate the deleterious immune response underlying progressive multifocal leukoencephalopathy-associated immune reconstitution inflammatory syndrome (PML-IRIS) are warranted [5]. Maraviroc, an antagonist of the CCR5 chemokine receptor that entered recently the HIV armamentarium, has been suggested to be beneficial in preventing or treating PMLIRIS [1, 4]. Since chemokine receptors play an important role in inflammatory cell migration, we investigated whether the molecular target of maraviroc is expressed on pathogenic T cells infiltrating PML-IRIS lesions. Paraffinembedded brain specimens of inflammatory PML, obtained through diagnostic stereotactic brain biopsy, were analyzed from five previously described HIV-infected patients who developed PML-IRIS after initiation of antiretroviral R. S. Liblau and D. Brassat: Co-senior authors. Electronic supplementary material The online version of this article (doi:10.1007/s00401-015-1383-6) contains supplementary material, which is available to authorized users.
therapy (ART) [3], and two non-HIV-infected patients who developed PML after chemotherapy or natalizumab, one who developed PML-IRIS, and the other at high risk of PML-IRIS (supplementary table and figure). Biopsies were performed before any steroid therapy and before maraviroc was introduced for the two non-HIV-infected patients to treat or prevent PML-IRIS, with a highly favorable outcome. As a control, we collected brain autopsies from 4 HIV-infected patients who developed classic PML (without IRIS). Consistent with previous reports [3, 6], CD8+ T cells dominate the inflammatory response in HIV-infected as well as non-HIV-infected patients with inflammatory PML (Fig. 1a). In patient 2, CD68+ macrophagic/microglial cells (1,480/mm2), CD20+ B cells (55/mm2) and CD138+ plasma cells (241/mm2) were also present in the biopsied lesion, while in patient 1, who was treated by rituximab, cells of the B cell lineage were totally absent, arguing against a necessary role for B cells and antibodies in the pathogenesis of PML-IRIS (Fig. 1i–k and data not shown). Brain lesions displayed strong infiltration by CCR5+ cells
G. Martin‑Blondel · B. Marchou Department of Infectious and Tropical Diseases, Toulouse University Hospital, Toulouse, France
E. Uro‑Coste Department of Pathology, Toulouse University Hospital, Toulouse, France
G. Martin‑Blondel (*) · R. S. Liblau · D. Brassat INSERM U1043‑CNRS UMR 5282, Centre de Physiopathologie Toulouse-Purpan, Place du Docteur Baylac TSA 40031, 31059 Toulouse Cedex 9, France e-mail: martin‑blondel.g@chu‑toulouse.fr
E. Uro‑Coste INSERM, CRCT U1087, Toulouse, France
G. Martin‑Blondel · E. Uro‑Coste · D. Averseng‑Peaureaux · F. Bonneville · B. Marchou · R. S. Liblau · D. Brassat Université Toulouse III, 31000 Toulouse, France
D. Biotti · D. Averseng‑Peaureaux · N. Fabre · D. Brassat Department of Neurology, Pole des Neurosciences, Toulouse University Hospital, Toulouse, France H. Dumas · F. Bonneville Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
J. Bauer · H. Lassmann Center for Brain Research, Medical University of Vienna, Vienna, Austria
13
Acta Neuropathol
Fig. 1 Histopathology of HIVinfected PML-IRIS patients (left row), patient 1 (middle row) and patient 2 (right row). Bars c–k 50 µm, l–n 25 µm. a Density of CCR5+, CD3+ and CD8+ cells in brain lesions from inflammatory PML brain lesions (/mm2). b Percentage of CD8+ T cells expressing CCR5. c–e Staining for SV40 showing JC virusinfected cells (arrowheads). f–h Staining for CD3 revealing strong T cell infiltration in all cases. i–k Staining for CD138 showing the presence of plasma cells in the HIV-infected PMLIRIS patients and in patient 2 but not in the Rituximab-treated patient 1. l–n Double staining for CD8 (green) and CCR5 (red) showing that in all patients most CD8 cells in perivascular space (white arrowhead in panel m) and parenchyma express CCR5. The red arrowheads in l, m and n indicate the presence of CD8− CCR5+ cells
(Fig. 1a). Confocal fluorescence staining showed that the vast majority of the perivascular and parenchymal CD8+ T cells express CCR5, representing 93.7 ± 2.5 % of CD8+ T cells in HIV-infected PML-IRIS patients, and 93.8 ± 6.2 % of CD8+ T cells in the non-HIV-infected patients (Fig. 1b, l–n). CD8+ T cells accounted for 88 and 70 % of CCR5+ cells in HIV-infected PML-IRIS patients and in non-HIVinfected patients, respectively. Indeed, CD4+ T cells and macrophagic/microglial cells also expressed CCR5, albeit at weaker levels than CD8+ T cells (data not shown). While brain lesions of classic PML cases also displayed some CCR5+ cells, the weak staining prevented faithful counting. We show here that brain lesion-infiltrating CD8+ T cells, the likely drivers of tissue damage, highly express CCR5 in HIV-infected and non-HIV-infected patients developing inflammatory forms of PML. The CCR5/CCL5 axis is
13
implicated in T cell activation and in leukocyte trafficking to the brain in the setting of neurotropic infections and in experimental models of multiple sclerosis (MS) as well as in human MS [2, 7]. We hypothesize that CCR5 antagonists might prevent and/or treat the deleterious inflammatory reaction that occurs during immune recovery in PML patients, by interfering with the activation and/or migration of CCR5-expressing activated CD8+ T cells. We therefore introduced maraviroc in the two non-HIV-infected patients with inflammatory PML. Maraviroc might have participated to the favorable outcome in the first case of PML-IRIS, and prevention of clinical worsening related to IRIS in the second case while this natalizumab-treated MS patient underwent plasmapheresis. Because CD8+ T cells in PML-IRIS lesions of HIV-infected patients also express CCR5, we propose that including maraviroc in HIV-infected patients with PML at the initiation of ART
Acta Neuropathol
might reduce the IRIS burden. In this context, the optimal duration of maraviroc treatment still has to be determined. Building on these observations, our results suggest that CCR5 antagonists can mitigate the deleterious immune response underlying PML-IRIS, deserving further clinical trials. Acknowledgments We thank Dr. V. Sazdovitch, Paris, France, for providing some tissue samples. This work was supported by the French National Institute for Medical Research (INSERM), the Agence Nationale pour la Recherche sur le Sida et les hépatites virales (ANRS), the Association pour la Recherche sur la Sclérose en Plaques (ARSEP), the Collège des Universitaires de Maladies Infectieuses et Tropicales (CMIT) and the Best-MS network, a FP7 network, Grant agreement No: 305477.
References 1. Giacomini PS, Rozenberg A, Metz I, Araujo D, Arbour N, Bar-Or A (2014) Maraviroc and JC virus-associated immune reconstitution inflammatory syndrome. N Engl J Med 370:486–488 2. Glass WG, Hickey MJ, Hardison JL, Liu MT, Manning JE, Lane TE (2004) Antibody targeting of the CC chemokine ligand 5
results in diminished leukocyte infiltration into the central nervous system and reduced neurologic disease in a viral model of multiple sclerosis. J Immunol 172:4018–4025 3. Martin-Blondel G, Bauer J, Cuvinciuc V, Uro-Coste E, Debard A, Massip P, Delisle MB, Lassmann H, Marchou B, Mars LT et al (2013) In situ evidence of JC virus control by CD8+ T cells in PML-IRIS during HIV infection. Neurology 81:964–970 4. Martin-Blondel G, Cuzin L, Delobel P, Cuvinciuc V, Dumas H, Alvarez M, Massip P, Marchou B (2009) Is maraviroc beneficial in paradoxical progressive multifocal leukoencephalopathyimmune reconstitution inflammatory syndrome management? Aids 23:2545–2546 5. Martin-Blondel G, Delobel P, Blancher A, Massip P, Marchou B, Liblau RS, Mars LT (2011) Pathogenesis of the immune reconstitution inflammatory syndrome affecting the central nervous system in patients infected with HIV. Brain 134:928–946 6. Metz I, Radue EW, Oterino A, Kumpfel T, Wiendl H, Schippling S, Kuhle J, Sahraian MA, Gray F, Jakl V et al (2012) Pathology of immune reconstitution inflammatory syndrome in multiple sclerosis with natalizumab-associated progressive multifocal leukoencephalopathy. Acta Neuropathol 123:235–245 7. Trebst C, Staugaitis SM, Tucky B, Wei T, Suzuki K, Aldape KD, Pardo CA, Troncoso J, Lassmann H, Ransohoff RM (2003) Chemokine receptors on infiltrating leucocytes in inflammatory pathologies of the central nervous system (CNS). Neuropathol Appl Neurobiol 29:584–595
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