Chronic Granulomatous Disease Phagocytes Research Articles

Chronic Granulomatous Disease: a Comprehensive Review.

Chronic granulomatous disease (CGD) is a primary immunodeficiency of phagocyte function due to defective NADPH oxidase (phox). Compared with the common types of CYBB/gp91phox, NCF1/p47phox, and CYBA/p22phox deficiency, NCF4/p40phox deficiency is a mild and atypical form of CGD without invasive bacterial or fungal infections. It can be diagnosed using serum-opsonized E.coli as a stimulus in dihydrorhodamine (DHR) assay. Patients with CYBC1/Eros deficiency, a new and rare form of CGD, present as loss of respiratory burst and gp91phox expression in phagocytes. Neutrophils from patients with CGD are deficient in neutrophil extracellular traps (NETosis), autophagy, and apoptosis. The hyper-activation of NF-ĸB and inflammasome in CGD phagocytes also lead to long-lasting production of pro-inflammatory cytokines and inflammatory manifestations, such as granuloma formation and inflammatory bowel disease-like colitis. Patients with CGD and X-linked female carriers also have a higher incidence of autoimmune diseases. The implementation of antimicrobial, anti-fungal, and interferon-γ prophylaxis has greatly improved overall survival. Residual NADPH oxidase activity is significantly associated with disease severity and the chance of survival of the patient. New therapeutic approaches using immunomodulators for CGD-related inflammatory manifestations are under investigation, including pioglitazone, tamoxifen, and rapamycin. Hematopoietic stem cell transplantation (HSCT) is the curative treatment. Outcomes of HSCT have improved substantially over the last decade with overall survival more than 84-90%, but there are debates about designing optimal conditioning protocols using myeloablative or reduced-intensity regimens. The gene therapy for X-linked CGD using hematopoietic stem and progenitor cells transduced ex vivo by lentiviral vector encoding the human gp91phox gene demonstrated persistence of adequate oxidase-positive neutrophils in a small number of patients. Gene therapy using genome-editing technology such as CRISPR/Cas9 nucleases is a promising approach for patients with CGD in the future.

Downregulation of endothelial nitric oxide synthase (eNOS) and endothelin-1 (ET-1) in a co-culture system with human stimulated X-linked CGD neutrophils.

Phagocytes in patients with chronic granulomatous disease (CGD) do not generate reactive oxidative species (ROS), whereas nitric oxide (NO) production is increased in response to the calcium ionophore A23187 in CGD phagocytes compared with healthy phagocytes. Recently, patients with X-linked CGD (X-CGD) have been reported to show higher flow-mediated dilation, suggesting that endothelial cell function is affected by NO production from phagocytes. We studied NOS3 and EDN1 mRNA and protein expression in human umbilical vein endothelial cells (HUVECs) in a co-culture system with neutrophils from X-CGD patients. HUVECs were co-cultured for 30 minutes with human neutrophils from X-CGD or healthy participants in response to A23187 without cell-to-cell contact. The expression of NOS3 and EDN1 mRNA in HUVECs was quantified by real-time polymerase chain reaction. Moreover, we demonstrated the protein expression of eNOS, ET-1, and NFκB p65, including phosphorylation at Ser1177 of eNOS and Ser536 of NFκB p65. Neutrophils from X-CGD patients showed significantly higher NO and lower H2O2 production in response to A23187 than healthy neutrophils in vitro. Compared with healthy neutrophils, X-CGD neutrophils under A23187 stimulation exhibited significantly increased NO and decreased H2O2, and promoted downregulated NOS3 and EDN1 expression in HUVECs. The total expression and phosphorylation at Ser1177 of eNOS and ET-1 expression were significantly decreased in HUVECs co-cultures with stimulated X-CGD neutrophils. Also, phosphorylation at Ser536 of NFκB p65 were significantly decreased. In conclusions, eNOS and ET-1 significantly down-regulated in co-culture with stimulated X-CGD neutrophils through their excessive NO and the lack of ROS production. These findings suggest that ROS generated from neutrophils may mediate arterial tone affecting eNOS and ET-1 expression via their NO and ROS production.

Elevated Mitochondrial Reactive Oxygen Species and Cellular Redox Imbalance in Human NADPH-Oxidase-Deficient Phagocytes.

Chronic granulomatous disease (CGD) is caused by mutations in genes that encode the NADPH-oxidase and result in a failure of phagocytic cells to produce reactive oxygen species (ROS) via this enzyme system. Patients with CGD are highly susceptible to infections and often suffer from inflammatory disorders; the latter occurs in the absence of infection and correlates with the spontaneous production of inflammatory cytokines. This clinical feature suggests that NADPH-oxidase-derived ROS are not required for, or may even suppress, inflammatory processes. Experimental evidence, however, implies that ROS are in fact required for inflammatory cytokine production. By using a myeloid cell line devoid of a functional NADPH-oxidase and primary CGD cells, we analyzed intracellular oxidants, signs of oxidative stress, and inflammatory cytokine production. Herein, we demonstrate that phagocytes lacking a functional NADPH-oxidase, namely primary CGD phagocytes and a gp91phox-deficient cell line, display elevated levels of ROS derived from mitochondria. Accordingly, these cells, despite lacking the major source of cellular ROS, display clear signs of oxidative stress, including an induced expression of antioxidants and altered oxidation of cell surface thiols. These observed changes in redox state were not due to abnormalities in mitochondrial mass or membrane integrity. Finally, we demonstrate that increased mitochondrial ROS enhanced phosphorylation of ERK1/2, and induced production of IL8, findings that correlate with previous observations of increased MAPK activation and inflammatory cytokine production in CGD cells. Our data show that elevated baseline levels of mitochondria-derived oxidants lead to the counter-intuitive observation that CGD phagocytes are under oxidative stress and have enhanced MAPK signaling, which may contribute to the elevated basal production of inflammatory cytokines and the sterile inflammatory manifestations in CGD.

Excessive Nitric Oxide Production of CGD Neutrophils Induces the Down-Regulation of NOS3 and EDN1 Expression in Human Endothelial Cells

Introduction: Chronic granulomatous disease (CGD) is an inherited immunodeficiency due to a mutation in genes that encode the subunits of NADPH oxidase of phagocytes. Phagocytes of CGD can not generate the reactive oxidative species (ROS), whereas nitric oxide (NO) production of CGD phagocytes is increased in response to calcium ionophore, A23187, compared with that of phagocytes from healthy subjects. Recently, X-linked CGD (X-CGD) patients showed lower oxidative stress and higher flow-mediated dilation, suggesting that endothelial cell function is affected by NO production of phagocytes. We studied the effects of NO on the regulation of endothelial gene expression related to dilator and constrictive effect of blood vessels, such as NOS3 and EDN1 using neutrophils from X-CGD patients.Methods: Eighteen X-CGD patients and 18 age-matched healthy male subjects were enrolled in this study from 2009 to 2013. NO production of phagocytes was assessed by flow cytometry using DAF2/DA fluorescent probe. Human umbilical vein endothelial cells (HUVECs) were co-cultured with human neutrophils of X-CGD or healthy subjects in response to calcium ionophore,A23187 without cell to cell contact using the Transwell-permeable support systems. The expression of endothelial NOS3 and EDN1 mRNA gene in HUVECs were quantified by real-time PCR.Results: Neutrophils of X-CGD patients showed significantly higher production of NO in response to A23187 for 30 to 60 minutes than those of normal subjects detected by flow cytometric analyses. NO concentration artificially generated by NO donor was significantly decreased by ROS produced by xanthine and xanthine oxidase. Similarly, neutrophils from healthy subjects, but not from X-CGD stimulated with A23187 induced the decrease in the concentration of NO. These results strongly suggest that the lack of ROS generation in CGD neutrophils leads to the increase of NO production in response to A23187. HUVECs were incubated with NO generation system, ROS generation system alone or with both systems. The expression of NOS3 and EDN1 was significantly decreased depending on the concentration of extracellular NO. In contrast, both NOS3 and EDN1 expression was significantly up-regulated under the ROS generation system without NO. Next, HUVECs were incubated by X-CGD neutrophils or by control neutrophils with or without A23187 for 30 minutes using the wells divided by membrane (0.45μm) to prevent cell to cell contact. Both NOS3 and EDN1 expression of HUVECs incubated with X-CGD neutrophils was significantly down-regulated under A23187 stimulation compared with normal neutrophils (112±117 vs. 34.5±39.9, n=8, p<0.05, 0.94± 0.24 vs. 0.61±0.24, n=5, p<0.05, respectively).Conclusion: This study demonstrated that the stimulated X-CGD neutrophils induced the decreased endothelial NOS3 and EDN1 gene expression through the excessive generation of NO due to the lack of ROS production. These findings suggest that ROS generated by phagocytes may modulate arterial tone affecting the amount of NO, a potent vasodilator molecule produced by endothelial cells. DisclosuresNo relevant conflicts of interest to declare.

Current Concepts of Hyperinflammation in Chronic Granulomatous Disease

Chronic granulomatous disease (CGD) is the most common inherited disorder of phagocytic functions, caused by genetic defects in the leukocyte nicotinamide dinucleotide phosphate (NADPH) oxidase. Consequently, CGD phagocytes are impaired in destroying phagocytosed microorganisms, rendering the patients susceptible to bacterial and fungal infections. Besides this immunodeficiency, CGD patients suffer from various autoinflammatory symptoms, such as granuloma formation in the skin or urinary tract and Crohn-like colitis. Owing to improved antimicrobial treatment strategies, the majority of CGD patients reaches adulthood, yet the autoinflammatory manifestations become more prominent by lack of causative treatment options. The underlying pathomechanisms driving hyperinflammatory reactions in CGD are poorly understood, but recent studies implicate reduced neutrophil apoptosis and efferocytosis, dysbalanced innate immune receptors, altered T-cell surface redox levels, induction of Th17 cells, the enzyme indolamine-2,3-dioxygenase (IDO), impaired Nrf2 activity, and inflammasome activation. Here we discuss immunological mechanisms of hyperinflammation and their potential therapeutic implications in CGD.

Chronic Granulomatous Disease: Lessons from a Rare Disorder

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency with X-linked or autosomal recessive inheritance involving defects in genes encoding phox proteins, which are the subunits of the phagocyte NADPH oxidase. This results in failure to produce superoxide anion and downstream antimicrobial oxidant metabolites and to activate antimicrobial proteases. Affected patients are susceptible to severe, life-threatening bacterial and fungal infections and excessive inflammation characterized by granulomatous enteritis resembling Crohn's disease and genitourinary obstruction. Early diagnosis of CGD and rapid treatment of infections are critical. Prophylaxis with antibacterial and mold-active antifungal agents and the administration of interferon-γ has significantly improved the natural history of CGD. Currently, the only cure is allogeneic hematopoietic cell transplant (HCT), although there remains controversy as to which patients with CGD should get a transplant. Allele-based HLA typing of alternative donors, improved supportive care measures, and use of reduced toxicity conditioning have resulted in event-free survival (EFS) of at least 80% even with an unrelated donor and even better when the patient has no active infections/inflammation. Gene correction of CGD would eliminate the risks of graft-versus-host disease (GVHD) and the immunoablative chemotherapy required for allogeneic HCT. Based on gene therapy trials in patients with SCID-X1, ADA-SCID, and the early experience with CGD, it is clear that at least some degree of myeloablation will be necessary for CGD as there is no inherent selective growth advantage for gene-corrected cells. Current efforts for gene therapy focus on use of lentivector constructs, which are thought to be safer from the standpoint of insertional mutagenesis and more efficient in transducing hematopoietic stem cells (HSCs).

Is TNFα a Potential Target for the Treatment of Colitis in Chronic Granulomatous Disease?

Background: Chronic granulomatous disease (CGD) is an immmunodeficiency and hyperinflammation disorder. Sterile hyperinflammation in the colon, CGD colitis, contributes significantly to the morbidity of patients. Presently available treatment options for CGD colitis include corticosteroids and interferon γ. Overshooting tumor necrosis factor α (TNFα) production in CGD phagocytes has been proposed as a mechanism contributing to hyperinflammation. In this study, we have investigated whether a deletion or suppression of TNFα resulted in a diminution of the hyperinflammation in a murine CGD model. Methods: For genetic deletion experiments, wild-type (N = 6), CGD (=Nox 2 [gp91phox]-deficient, N = 6), and CGD/TNFα–deficient mice (N = 6) were injected intradermally with β-glucan to induce hyperinflammation. For pharmacological experiments, CGD mice were treated with the TNFα scavenger sTNFR2-Fc (Ethanercept) before β-glucan injection. Seven days later, the severity of inflammation was assessed on hematoxylin and eosin–stained slides of ear sections by a histological score (from 0 to 4, with 4 being the most severe inflammation). Results: The β-glucan generated a mild inflammatory score in the wild-type mice (mean score 1.5 ± 0.5), whereas CGD mice showed severe inflammation (mean 3.5 ± 0.2). Genetic deletion or pharmacological inhibition of TNFα did not decrease the severity of inflammation in CGD mice: histological scores for CGD/TNFα-deficient mice and for sTNFR2-Fc-treated CGD mice were 3.7 ± 0.3, and 3.7 ± 0.4, respectively. In both TNFα suppressed mice, a hyperinflammatory syndrome associated with necrotic lesions was observed. Conclusions: Neither genetic deletion of TNFα nor treatment with a TNFα scavenger prevented skin hyperinflammation in CGD mice. Thus, unlike as previously suggested, TNFα probably does not represent a potential target for the treatment of CGD hyperinflammation. However, our results were obtained in skin hyperinflammation and future research will have to investigate the similarities and differences between hyperinflammation in the skin and the colon. The authors report no conflicts of interest.

IFN-γIs Effective in Reducing Infections in the Mouse Model of Chronic Granulomatous Disease (CGD)

Chronic granulomatous disease (CGD) is a genetic disorder characterized by recurrent bacterial and fungal infections and tissue granuloma formation. CGD phagocytes are unable to generate superoxide because of mutations in any of four proteins of the phagocyte NADPH oxidase. Prophylactic recombinant human interferon-gamma (IFN-gamma) has been shown to reduce the frequency and severity of infections in CGD patients, but its mechanism(s) remains undefined, and its benefit has been questioned. We investigated the prophylactic effect of IFN-gamma in the mouse model of the major autosomal recessive (p47(phox)) form of CGD. In a prospective, randomized, placebo-controlled study, we compared IFN-gamma, 20,000 U administered subcutaneously (s.c.) three times weekly, to placebo in 118 p47(phox-/-) mice. By 6 weeks of study, there were 3 infections in the IFN-gamma group compared with 13 infections in the placebo group (77% reduction in infections, p<0.01). By 18 months of study, there were 7 infections in the IFN-gamma group compared with 18 infections in the placebo group (39% reduction in infections, p<0.01). Two animals receiving IFN-gamma had seizures after 7 months in the study. No other toxicities were observed. Peripheral blood phagocytes from IFN-gamma treated p47(phox-/-) mice produced no superoxide, excluding restoration of the oxidative burst as a mechanism for the IFN-gamma effect. There were no differences in either peritoneal macrophage nitrate production or thioglycollate-induced peritoneal exudate between treatment groups. This animal model demonstrates a prophylactic benefit of IFN-gamma similar to that seen in humans and provides an opportunity to investigate the mechanism(s) of action for IFN-gamma in CGD.

Flow cytometric analysis of the granulocyte respiratory burst: a comparison study of fluorescent probes

Chronic granulomatous disease (CGD) is a rare recessive disorder caused by defects in the NADPH oxidase enzyme complex of phagocytes (neutrophils, eosinophils and monocytes). CGD phagocytes fail to produce superoxide and other reactive oxygen species following cell activation (Malech, 1993). The products of oxidase activation can be measured in individual cells by flow cytometry using specific fluorescent probes that increase fluorescence upon oxidation (Trinkle et al., 1987). This approach can be used to confirm a diagnosis of CGD, and to detect the normal/abnormal phagocyte mixture that characterizes the X-linked CGD carrier state. Three fluorescent probes have been described as useful for this purpose: 2′7′-dichlorofluorescin diacetate (DCF) (Bass et al., 1983), 5,6-carboxy-2′7′-dichlorofluorescein diacetate, bis(acetoxymethyl) ester (C-DCF) (Hockenbery et al., 1993) and dihydrorhodamine 123 (DHR) (Rothe et al., 1988; Kinsey et al., 1987). A direct comparison between these three probes has not been reported. In this study we performed a direct comparison between these three probes, evaluating their ability in flow cytometric analysis to maximize fluorescent separation between activated CGD patient and normal granulocytes. Using a whole blood technique with phorbol myristate acetate (PMA) as an activator, it was found that DHR loaded normal granulocytes had a fluorescence intensity which, upon activation, was 48-fold higher than that of C-DCF loaded granulocytes and seven-fold higher than DCF loaded granulocytes ( P < 0.001). Use of sodium azide to decrease the catabolism of H 2O 2 enhanced the fluorescence of DCF by 140%, C-DCF by 45% and DHR by 25%, suggesting that DCF is primarily sensitive to H 2O 2. DCF and DHR were then evaluated for sensitivity in the detection of small percentages of normal cells in a CGD/normal granulocyte mixture. Normal sub-populations as small as 0.1% could clearly be distinguished using DHR, while DCF was insensitive at this level. Based on these findings, we used DHR in an effort to detect normal granulocytes in a CGD patient following therapeutic granulocyte transfusion. We were able to detect normal granulocytes in the circulation for up to 18 h after transfusion. With these data we show that DHR is the most sensitive flow cytometric indicator for the detection of oxygen reactive species in activated granulocytes and is the best probe for evaluating CGD patients and carriers. In addition, our data suggest that DHR is a useful tool for monitoring circulating normal granulocytes in CGD patients following transfusion, and potentially will be a sensitive probe for assessing the success of such future technologies as gene therapy for CGD.

Baculovirus mediated expression of human phagocytic cell oxidase cytochrome b558 in sf9 insect cells.

Chronic granulomatous disease (CGD) results from deficient production of components of the phagocyte NADPH oxidase. Most commonly affected is cytochrome b558, a heterodimer composed of a 22-kDa protein (p22phox) noncovalently bound to a 91-kDa transmembrane glycoprotein (gp91phox). CGD phagocytes lack both p22phox and gp91phox peptides when either gene is affected, suggesting that both peptides must be produced for individual subunit stability. Both genes have been cloned, but eukaryotic expression of recombinant gp91phox has not been reported. To investigate the stability and interaction of cytochrome b558 subunits, we introduced p22phox and gp91phox cDNA into recombinant baculoviruses. Recombinant gp91phox (rgp91phox) and p22phox (rp22phox) were detected individually and together in the same cells by in situ immunofluorescence and by SDS-PAGE immunoblotting of membranes from sf9 cells infected with baculovirus constructs. Formation of rp22phox/rgp91phox complexes was demonstrated by coprecipitation using subunit-specific antibodies. This study demonstrates for the first time that cDNA encoding either subunit is capable of initiating production of stable recombinant cytochrome b558 subunits in eukaryotic cells.

Neutrophil-mediated solubilization of the subendothelial matrix: oxidative and nonoxidative mechanisms of proteolysis used by normal and chronic granulomatous disease phagocytes.

Both normal and chronic granulomatous disease (CGD) neutrophils were able to degrade the subendothelial matrix secreted by human endothelial cells via an elastase-dependent process. In the absence of the plasma antiproteinase, alpha-1-proteinase inhibitor (alpha-1-PI), normal neutrophils protect their released elastase from inactivation by using the chlorinated oxidants hypochlorous acid and endogenous N-chloroamines to suppress the antiproteinase's activity. In contrast, CGD neutrophils were unable to generate either class of chlorinated oxidant or to inactivate the porcine pancreatic elastase inhibitory capacity of alpha-1-PI unless the cells were supplemented with exogenous hydrogen peroxide. Despite the reliance of normal neutrophils on chlorinated oxidants to inactivate alpha-1-PI, neutrophils triggered in the presence of agents that block the generation of these reactive species continued to degrade the subendothelial matrix at a suppressed but significant rate in the presence of a 50-fold excess of the antiproteinase. The continued solubilization of the matrix by normal neutrophils was not due to the incomplete inhibition of oxidant generation because triggered CGD neutrophils were also able to degrade the matrix in the presence of excess alpha-1-PI. If CGD neutrophils were stimulated in the presence of an exogenous source of H2O2 and alpha-1-PI, the proteolytic potential of the cells was identical to that observed with normal stimulated neutrophils. We conclude that normal neutrophils can enhance their ability to degrade the subendothelial matrix by oxidatively protecting elastase from inactivation by alpha-1-PI but both normal and CGD neutrophils possess non-oxidatively linked mechanisms for sequestering and using elastase to mediate proteolytic effects in the presence of native antiproteinase.

Evaluation of Opsonic and Leukocyte Function With a Spectrophotometric Test in Patients With Infection and With Phagocytic Disorders

Abstract Paraffin oil droplets containing Oil Red O and coated with Escherichia coli lipopolysaccharide were ingested rapidly by human peripheral blood phagocytes only if they were pretreated with normal serum. This property formed the basis of a screening test in which lipopolysaccharide-coated particles were opsonized with patients’ serums and then were added to autologous leukocytes suspended in two portions, one of which contained nitroblue tetrazolium. After these incubations the cells were washed and extracted with dioxane. Oil Red O and nitroblue tetrazolium formazan in the dioxane extracts were spectrophotometrically assayed, thereby providing simultaneous determinations of the initial rates of ingestion and nitroblue tetrazolium reduction. The test differentiated opsonically-deficient serums and chronic granulomatous disease phagocytes from normals. Serums from individuals with bacterial infections had supernormal opsonic activity, and leukocytes from these patients had increased rates of nitroblue tetrazolium reduction in response to ingestion.

CHRONIC GRANULOMATOUS DISEASE: CORRELATION BETWEEN PATHOGENESIS AND CLINICAL FINDINGS

Chronic granulomatous disease (CGD) results from a failure of patients' phagocytic cells to kill ingested bacteria. The inability to kill intraphagocytic microorganisms leads to granuloma formation and abscesses throughout the reticuloendothelial system. Thus, the clinical picture of CGD is characterized by suppurative lymphadenitis, hepatosplenomegaly, pneumonia, and hematologic evidence of chronic infection. The bactericidal defect which characterizes CGD phagocytes appears to be due to their inability to generate hydrogen peroxide (H2O2). The organisms which infect patients are those which require phagocytic production of H2O2 for death–staphylococci and gram-negative enterics. There are simple means of confirming a clinical diagnosis of CGD, and prolonged therapy with specific antibiotics may therefore suppress the frequency of such serious infections.