Pathogenesis Of Herpetic Stromal Keratitis Research Articles

The immunobiology of corneal HSV-1 infection and herpetic stromal keratitis.

SUMMARYHuman alphaherpesvirus 1 (HSV-1) is a highly successful neurotropic pathogen that primarily infects the epithelial cells lining the orofacial mucosa. After primary lytic replication in the oral, ocular, and nasal mucosal epithelial cells, HSV-1 establishes life-long latency in neurons within the trigeminal ganglion. Patients with compromised immune systems experience frequent reactivation of HSV-1 from latency, leading to virus entry in the sensory neurons, followed by anterograde transport and lytic replication at the innervated mucosal epithelial surface. Although recurrent infection of the corneal mucosal surface is rare, it can result in a chronic immuno-inflammatory condition called herpetic stromal keratitis (HSK). HSK leads to gradual vision loss and can cause permanent blindness in severe untreated cases. Currently, there is no cure or successful vaccine to prevent latent or recurrent HSV-1 infections, posing a significant clinical challenge to managing HSK and preventing vision loss. The conventional clinical management of HSK primarily relies on anti-virals to suppress HSV-1 replication, anti-inflammatory drugs (such as corticosteroids) to provide symptomatic relief from pain and inflammation, and surgical interventions in more severe cases to replace damaged cornea. However, each clinical treatment strategy has limitations, such as local and systemic drug toxicities and the emergence of anti-viral-resistant HSV-1 strains. In this review, we summarize the factors and immune cells involved in HSK pathogenesis and highlight alternate therapeutic strategies for successful clinical management of HSK. We also discuss the therapeutic potential of immunoregulatory cytokines and immunometabolism modulators as promising HSK therapies against emerging anti-viral-resistant HSV-1 strains.

Application of our understanding of pathogenesis of herpetic stromal keratitis for novel therapy

HSV-1 ocular infection can cause herpes stromal keratitis (SK), an immunopathological lesion. Frequent recurrences can lead to progressive corneal scaring which can result in vision impairment if left untreated. Currently, the acute and epithelial forms of SK are usually controlled using anti-viral drugs. However, chronic forms of SK which are inflammatory in nature, require the addition of a topical corticosteroid to the anti-viral treatment regimen. In this review, we highlight the essential events involved in SK pathogenesis which can be targeted for improved therapy. We also examine some approaches which can be combined with the current treatments to effectively control SK.

The inflammasome NLRP3 plays a protective role against a viral immunopathological lesion.

Herpes simplex 1 infection of the eye can cause blindness with lesions in the corneal stroma largely attributable to inflammatory events that include components of both adaptive and innate immunity. Several innate immune responses are triggered by herpes simplex 1, but it is unclear how such innate events relate to the subsequent development of stromal keratitis. In this study, we compared the outcome of herpes simplex 1 ocular infection in mice unable to express NLRP3 because of gene knockout (NLRP3(-/-)) to that of wild-type mice. The NLRP3(-/-) mice developed more-severe and earlier stromal keratitis lesions and had higher angiogenesis scores than did infected wild-type animals. In addition, NLRP3(-/-) mice generated an increased early immune response with heightened chemokines and cytokines, including interleukin-1β and interleukin-18, and elevated recruitment of neutrophils. Increased numbers of CD4(+) T cells were seen at later stages of the disease in NLRP3(-/-) animals. Reduction in neutrophils prevented early onset of the disease in NLRP3(-/-) animals and lowered levels of bioactive interleukin-1β but did not lower bioactive interleukin-18. In conclusion, our results indicate that NLRP3 has a regulatory and beneficial role in herpetic stromal keratitis pathogenesis.

Role of miR-155 in the Pathogenesis of Herpetic Stromal Keratitis

Ocular infection with herpes simplex virus 1 can result in a chronic immunoinflammatory stromal keratitis (SK) lesion that is a significant cause of human blindness. A key to controlling SK lesion severity is to identify cellular and molecular events responsible for tissue damage and to manipulate them therapeutically. Potential targets for therapy are miRNAs, but these are minimally explored especially in responses to infection. Here, we demonstrated that Mir155 expression was up-regulated after ocular herpes simplex virus 1 infection, with the increased Mir155 expression occurring mainly in macrophages and CD4(+) T cells and to a lesser extent in neutrophils. In vivo studies indicated that Mir155 knockout mice were more resistant to herpes SK with marked suppression of T helper cells type 1 and 17 responses both in the ocular lesions and the lymphoid organs. The reduced SK lesion severity was reflected by increased phosphatidylinositol-3,4,5-trisphosphate 5-phosphatase 1 and interferon-γ receptor α-chain levels in activated CD4(+) T cells in the lymph nodes. Finally, in vivo silencing of miR-155 by the provision of antagomir-155 nanoparticles to herpes simplex virus 1-infected mice led to diminished SK lesions and corneal vascularization. In conclusion, our results indicate that miR-155 contributes to the pathogenesis of SK and represents a promising target to control SK severity.

Who Pays the Toll for Solving the Enigma of Corneal Herpes?

In herpetic stromal keratitis (HSK), herpes simplex virus type-1 DNA fragments and herpes simplex virus-immunoglobulin G immune complexes are present in corneas long after the infective virus has disappeared. These viral components are highly immunogenic and potentiate the production of proinflammatory cytokines and chemokines via Toll-like receptors expressed on corneal cells and macrophages. In addition, angiogenic factors, such as the vascular endothelium growth factor and the tissue-damaging enzyme, matrix metalloproteinase 9, are induced by corneal cells and macrophages through the recognition of these viral components in the pathogenesis of HSK. Upon neovascularization, robust infiltration of leukocytes via leaky new vessels is elicited. Activated polymorphonuclear leukocytes (PMNs) secrete hydrogen peroxide and myeloperoxidase, which inhibit viral growth. PMNs also produce tumor necrosis factor, monokine-induced by interferon-γ (CXCL9), and nitric oxide. These factors provide a local environment that can induce the differentiation of peripheral CD4* T cells to induce Th1-predominant immunopathology. Thus, strategies developed to alter these pathways should lead to new preventative and therapeutic measures for the treatment of HSK.

Translationally Controlled Tumour Protein (TCTP) is present in human cornea and increases in herpetic keratitis

BackgroundTranslationally Controlled Tumour protein is a multifunctional calcium binding protein which has an important role in apoptosis, calcium levels balance and immunological response. The aim of this study was to evaluated the presence and distribution of TCTP in healthy human corneas and to identify and characterize the presence and distribution of this protein in human normal cornea. Since recent studies suggest that apoptosis, calcium levels and immunological mechanisms play a role in the pathogenesis of herpetic stromal keratitis, we studied TCTP expression in this disease.MethodsWe evaluated the expression of TCTP at both RNA messanger and protein level by using reverse transcriptase analysis, immunoblotting and immunohistochemistry in 10 healthy samples cornea: four obtained after penetrating keratoplasty and six from eyes enucleated for other pathologies. Finally, we analysed by immunohistochemistry ten paraffin-embedded samples of Herpes simplex virus keratitis collected at Siena Department of Human Pathology and Oncology: 5 had clinically quiescent disease and 5 had active corneal inflammation.ResultsReverse transcriptase and immunoblotting demonstrated TCTP expression in cornea as a 22,000 Da molecular weight band corresponding to the molecular weight of this protein. Immunohistochemically, all the layers of normal corneal epithelium showed TCTP cytoplasmic expression. TCTP was, also, observed in keratocytes and in the endothelium. In Herpes simplex virus keratitis samples, strong expression of TCTP was evident in stromal cells, in the inflammatory infiltrate and in neo-vessels.ConclusionsIn this preliminary study we demonstrated, for the first time, the presence of TCTP in human cornea, suggesting a potential role in the pathogenesis of herpes virus keratitis.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/3306813447428149

Herpetic keratitis: Herpes simplex virus versus host

AbstractHerpes simplex virus type 1 (HSV‐1) is an endemic virus worldwide that causes ocular disease in a limited but significant number of infected persons. Corneal HSV‐1 infection is clinically classified into herpetic epithelial keratitis (HEK) and herpetic stromal keratitis (HSK). HEK is an acute inflammation and results from viral toxicity of infected corneal epithelial cells. In contrast, HSK is characterized as a chronic immunopathogenic disease in which tissue injury and eventually blindness is due to the complex interplay between cells of the innate and adoptive immune response to viral antigens expressed in the corneal tissue. Studies performed on the experimental HSK mouse model greatly improved our understanding of the pathogenesis of HSK. This talk will recapitulate current insights on the virus‐host interactions involved in the initiation and perpetuation of herpetic keratitis in mice and men.

Role of Toll-like receptors in the pathogenesis of herpetic stromal keratitis in cats

Role of Toll-like receptors in the pathogenesis of herpetic stromal keratitis in cats

Immunological Aspects of Herpetic Stromal Keratitis

Herpetic stromal keratitis (HSK) is an immune reaction related to herpes simplex virus (HSV) corneal infection, and has many important immunological aspects. CD4+ T lymphocytes, especially Th1 cells, are the principal mediators for HSK. In addition, neutrophils and antigen-presenting cells play vital roles in HSK. CD8+ T lymphocytes, B cells, and natural killer cells all participate in the pathogenesis of HSK under certain circumstances. Many molecules are involved in the pathogenesis of HSK. Th1 cytokines such as interleukin 2 (IL-2), IL-12 and interferon γ, and inflammatory cytokines such as IL-1α and IL-6 are especially important ones. Among various chemokines that take part in HSK, MIP-1α is one of the most important aggravating factors. Vaccination therapy against HSK has been developed; glycoprotein D is a particularly promising candidate. However, the possibility of HSK exacerbation due to vaccination is the final problem to be solved before vaccination can be clinically applied to HSK. Molecular mimicry theory and bystander activation theory are the two new autoimmune theories that have been advocated. Since genuine autoimmune HSK without HSV growth can hardly be the case in clinical practice, some part of these new theories remains controversial. In the future, better understanding of the pathogenesis of HSK is essential to resolve the paradox between suppressing the immune reaction to avoid corneal scarring and preventing viral proliferation.

Who (What) Pays Toll for the Development of Herpetic Stromal Keratitis (HSK)

In the herpetic stromal keratitis (HSK), HSV DNA fragments and HSV-IgG immune complexes (HSV-IC) are present in most of the corneas long after infective virus has disappeared. These viral components are highly immunogenic and potentiate production of proinflammatory cytokines and chemokines via Toll-like receptors (TLRs) expressed on the corneal cells and macrophages. In addition angiogenic factors, such as vascular endothelium growth factor (VEGF) and the tissue damaging enzyme matrix metalloproteinase 9 (MMP-9) deeply involved in the pathogenesis of HSK, are also induced by corneal cells and macrophages through the recognition of these viral components. These processes elicited by residual viral DNA and HSV-IC are likely one of the sustained driving force in the development of HSK. Hence, strategies developed to alter these pathways should lead to new preventative and therapeutic measures.

Topical antisense-oligonucleotides targeting IFN-gamma mRNA improve incidence and severity of herpetic stromal keratitis by cytokine specific and sequence unspecific effects

Corneal infection with herpes simplex virus-1 (HSV) can cause an inflammatory eye disease termed herpetic stromal keratitis (HSK). Interferon-gamma (IFN-gamma) is known to be involved in the development of this disease. In this study, antisense oligonucleotides targeting IFN-gamma mRNA (IFN-gamma-ASON) were investigated for their effects in experimental HSK. Splenic cells were used to examine the efficacy of IFN-gamma-ASON to decrease IFN-gamma- release into the cell culture supernatants as measured by ELISA. Mice were corneally infected with 10(5) PFU HSV, and IFN-gamma-ASON were given subepithelially. Alternatively, mice were infected without any further treatment, received only buffer, or received control oligonucleotides (CON) to observe substance specific effects. The animals were followed up clinically for the signs of herpetic keratitis. On days 14 and 28 post infection (p.i.), animals were sacrificed, and eyes were collected for histological analysis. On day 7 p.i., infectious virus particles in the eyes were determined by a plaque assay. While IFN-gamma-ASON diminished the content of IFN-gamma in a concentration-dependent manner in vitro, CON showed no significant effects. Whereas buffer-treated and only infected mice showed severe necrotizing keratitis on day 14 p.i., this was abolished after treatment with IFN-gamma-ASON, even after 28 and 52 days. CON-treated mice also showed an improved HSK on day 14, but not on day 28. The incidence of the disease was also clearly diminished after treatment with IFN-gamma-ASON at all time points examined. The number of inflammatory cells in both the central and the peripheral cornea were strongly reduced after the application of IFN-gamma-ASON as compared to the controls. In contrast, the infectious viral particles in eyes at day 7 p.i. did not differ between the four groups. Topical treatment with IFN-gamma-ASON induced a long-term improvement of the course and the incidence of HSK in the murine model. IFN-gamma seems to be involved in a proinflammatory manner during the pathogenesis of HSK, while the antiviral defense against HSV was not affected by this topical cytokine inhibition. Unspecific CON induced a transient and cytokine independent improvement of HSK.

Role of Stat4-Mediated Signal Transduction Events in the Generation of Aggressor CD4+T Cells in Herpetic Stromal Keratitis Pathogenesis

Ocular infection with herpes simplex virus (HSV) causes a vision-impairing inflammatory reaction called herpetic stromal keratitis. In murine models, herpetic stromal keratitis lesions appear to be immunopathologic, mediated by CD4(+) T cells of Th1 phenotype. To provide insight about cytokine networks and signaling events involved in the development of aggressor CD4(+) T cells, ocular HSV infection was followed in mice deficient in Stat4 (Stat4(-/-) mice), the signal transducer for the cytokine interleukin-12 (IL-12). After ocular HSV infection of Stat4(-/-) and control BALB/c mice, clinical, histologic, and immunologic analyses were carried out. Further, to evaluate the involvement of Stat4 in the development of this aggressor population, naive CD4(+) T cells from Stat4(-/-) and BALB/c mice were adoptively transferred to C.B-17 SCID mice 1 day after corneal infection. Although Stat4(-/-) mice demonstrated increased susceptibility to lethal encephalitis and facial lesions, interestingly, these mice had less severe stromal keratitis in comparison to control animals. Adoptive transfer of naive CD4(+) T cells from Stat4(-/-) mice failed to produce disease in infected SCID recipients. The data imply a significant role of Stat4-mediated signaling events in the generation of an aggressor CD4(+) T cell population in stromal keratitis pathogenesis.

B7-H1 (CD274) inhibits the development of herpetic stromal keratitis (HSK)

The co-signaling molecule B7-H1 (CD274) functions as both a co-inhibitor through programmed death-1 (PD-1) receptor and a co-stimulator via an as-yet-unidentified receptor on T cells. We investigated the physiological role of endogenous B7-H1 in the pathogenesis of herpetic stromal keratitis (HSK) caused by herpes simplex virus type 1 (HSV-1). Following HSV-1 infection of the cornea of mice, B7-H1 expression was up-regulated in the CD11b + macrophage population in the draining lymph nodes (dLN) and in the inflamed cornea. In addition, HSV-1 infection significantly increased PD-1 expression on CD4 + T cells in the dLN and inflamed cornea. The administration of antagonistic B7-H1 monoclonal antibody resulted in the proliferation of HSV-specific CD4 + T cells that secreted interferon (INF)- γ, and inhibited the apoptosis of HSV-specific CD4 + T cells, which exaggerated HSK. These results strongly suggest that the B7-H1 may be involved in suppression of the development of HSK.

Involvement of IL-6 in the paracrine production of VEGF in ocular HSV-1 infection

Following ocular HSV-1 infection, neovascularisation of the avascular cornea is a critical event in the pathogenesis of herpetic stromal keratitis. This present study evaluates the role of proinflammatory cytokines such as IL-6 in corneal angiogenesis following virus infection. Both in vivo and in vitro data indicate that IL-6 produced from virus-infected cells can stimulate noninfected resident corneal cells and other inflammatory cells in a paracrine manner to secrete VEGF, a potent angiogenic factor. Antibody neutralisation of IL-6 resulted in a significant decrease in the number of VEGF producing cells in the cornea. Thus, our results further demonstrate the close relationship between proinflammatory cytokines and VEGF-induced corneal neovascularisation.

Role of matrix metalloproteinase-9 in angiogenesis caused by ocular infection with herpes simplex virus.

In this report, we demonstrate that herpes simplex virus (HSV) infection of the cornea results in the upregulation of the matrix-degrading metalloproteinase enzyme MMP-9. This enzyme was shown to contribute to the neovascularization process that occurs in the corneal stroma in response to HSV infection. The likely source of MMP-9, at least initially after infection, was neutrophils that were signaled to invade the cornea soon after infection. Corneal infiltrating neutrophils were shown to express MMP-9, and preventing the neutrophil response with specific mAb diminished MMP-9 expression as well as the extent of angiogenesis. Further supporting a role for MMP-9 in HSV-induced corneal angiogenesis was the observation that inhibition of MMP-9 with the specific inhibitor TIMP-1 resulted in reduced angiogenesis. In addition, angiogenesis was diminished in ocularly infected MMP-9 knockout mice. Our results demonstrate that MMP-9 is involved in angiogenesis caused by HSV. Since angiogenesis appears to represent a vital step in the pathogenesis of herpetic stromal keratitis, these results indicate that targeting MMP-9 for inhibition should prove useful for the therapy of herpetic stromal keratitis.

Role of matrix metalloproteinase-9 in angiogenesis caused by ocular infection with herpes simplex virus

In this report, we demonstrate that herpes simplex virus (HSV) infection of the cornea results in the upregulation of the matrix-degrading metalloproteinase enzyme MMP-9. This enzyme was shown to contribute to the neovascularization process that occurs in the corneal stroma in response to HSV infection. The likely source of MMP-9, at least initially after infection, was neutrophils that were signaled to invade the cornea soon after infection. Corneal infiltrating neutrophils were shown to express MMP-9, and preventing the neutrophil response with specific mAb diminished MMP-9 expression as well as the extent of angiogenesis. Further supporting a role for MMP-9 in HSV-induced corneal angiogenesis was the observation that inhibition of MMP-9 with the specific inhibitor TIMP-1 resulted in reduced angiogenesis. In addition, angiogenesis was diminished in ocularly infected MMP-9 knockout mice. Our results demonstrate that MMP-9 is involved in angiogenesis caused by HSV. Since angiogenesis appears to represent a vital step in the pathogenesis of herpetic stromal keratitis, these results indicate that targeting MMP-9 for inhibition should prove useful for the therapy of herpetic stromal keratitis.

Contribution of vascular endothelial growth factor in the neovascularization process during the pathogenesis of herpetic stromal keratitis.

This report analyzes the role of vascular endothelial growth factor (VEGF)-induced angiogenesis in the immunoinflammatory lesion stromal keratitis induced by ocular infection with herpes simplex virus (HSV). Our results show that infection with replication-competent, but not mutant, viruses results in the expression of VEGF mRNA and protein in the cornea. This a rapid event, with VEGF mRNA detectable by 12 h postinfection (p.i.) and proteins detectable by 24 h p.i. VEGF production occurred both in the virus-infected corneal epithelium and in the underlying stroma, in which viral antigens were undetectable. In the stroma, VEGF was produced by inflammatory cells; these initially were predominantly polymorphonuclear leukocytes (PMN), but at later time points both PMN and macrophage-like cells were VEGF producers. In the epithelium, the major site of VEGF-expressing cells in early infection, the infected cells themselves were usually negative for VEGF. Similarly, in vitro infection studies indicated that the cells which produced VEGF were not those which expressed virus. Attesting to the possible role of VEGF-induced angiogenesis in the pathogenesis of herpetic stromal keratitis were experiments showing that VEGF inhibition with mFlt(1-3)-immunoglobulin G diminished angiogenesis and the severity of lesions after HSV infection. These observations are the first to evaluate VEGF-induced angiogenesis in the pathogenesis of stromal keratitis. Our results indicate that the control of angiogenesis represents a useful adjunct to therapy of herpetic ocular disease, an important cause of human blindness.

Herpes simplex virus-induced keratitis: Evaluation of the role of molecular mimicry in lesion pathogenesis. Deshpande SP, Lee S, Zheng M, Song B, Knipe D, Kapp JA, Rouse BT. J Virology 2001;75:3077–3088.

Viruses are often suspected triggering factors for causing autoimmunity reactions. One of the favored mechanisms to explain the role of viruses in the genesis of autoimmunity is molecular mimicry. The immunoinflammatory blinding disease of herpetic stromal keratitis (HSK) that follows ocular infection with herpes simplex virus (HSV) is suggested to result from a CD4 (+) T-cell response to a UL6 peptide of HSV that cross-reacts with a corneal autopeptide shared with the immunoglobulin G2a (b) (IgG2a (b)) isotype. This report reevaluates the molecular mimicry hypothesis to explain HSK pathogenesis. The results failed to reveal cross-reactivity between the UL6 and IgG2ab peptides or between peptide reactive T cells and HSV antigens. Also, animals infected with HSV failed to develop responses that reacted with either peptide, and infection with a recombinant vaccinia UL6 vector failed to cause HSK, in spite of generating UL6 reactivity. Other lines of evidence also failed to support the molecular mimicry hypothesis, such as the failure to affect HSK severity upon tolerization of susceptible BALB/c and B-cell-deficient mice with IgG2ab or UL6 peptides. An additional study system revealed that HSK could be induced in mouse strains that were unable to produce CD4 (+) T-cell responses to any detectable HSV antigens. The authors conclude that their results cast doubt on the molecular mimicry hypothesis as an explanation for the pathogenesis of HSK, and indicate that if autoimmunity is involved its likely proceeds via a bystander activation mechanism.—Thomas J. Liesegang

Herpes simplex virus-induced keratitis: evaluation of the role of molecular mimicry in lesion pathogenesis.

Viruses are suspected but usually unproven triggering factors in autoimmunity. One favored mechanism to explain the role of viruses in the genesis of autoimmunity is molecular mimicry. An immunoinflammatory blinding lesion called herpetic stromal keratitis (HSK) that follows ocular infection with herpes simplex virus (HSV) is suggested to result from a CD4(+) T-cell response to a UL6 peptide of HSV that cross-reacts with a corneal autopeptide shared with the immunoglobulin G2a(b) (IgG2a(b)) isotype. The present report reevaluates the molecular mimicry hypothesis to explain HSK pathogenesis. Our results failed to reveal cross-reactivity between the UL6 and IgG2a(b) peptides or between peptide reactive T cells and HSV antigens. More importantly, animals infected with HSV failed to develop responses that reacted with either peptide, and infection with a recombinant vaccinia UL6 vector failed to cause HSK, in spite of generating UL6 reactivity. Other lines of evidence also failed to support the molecular mimicry hypothesis, such as the failure to affect HSK severity upon tolerization of susceptible BALB/c and B-cell-deficient mice with IgG2a(b) or UL6 peptides. An additional study system revealed that HSK could be induced in mouse strains, such as the OT2 x RAG1(-/-) mice (T cell receptor transgenic recognizing OVA(323-339)) that were unable to produce CD4(+) T-cell responses to any detectable HSV antigens. Our results cast doubt on the molecular mimicry hypothesis as an explanation for the pathogenesis of HSK and indicate that if autoimmunity is involved its likely proceeds via a bystander activation mechanism.

Increased severity of herpes simplex virus type 1-induced keratitis in Hox A5 transgenic mice

Purpose. Herpes simplex virus type 1 is a major cause of stromal keratitis and blindness in humans. Understanding of the role of host genes in the pathogenesis of herpes stromal keratitis is limited. We used a transgenic mouse model to examine the effect of a host gene, Hox A5 (which binds to the TAATGARAT sequence in the promoter regions of HSV-1 immediate early genes and increases HSV-1 replication), on the pathogenesis of HSV-1 induced stromal keratitis. Methods. Corneas of wildtype and Hox A5 transgenic mice were infected with HSV-1 strain F following corneal scarification. Clinical severity of keratitis was evaluated using slit-lamp biomicroscopy. Histologic severity of keratitis was determined by light microscopic evaluation and by computerized morphometry. Ocular viral replication was measured via plaque assay. Results. Clinical lesions of stromal keratitis were more severe at 17 and 23 days post infection in Hox A5 transgenic mice than in wildtype mice. Histological evaluation and morphometric analysis confirmed that keratitis lesions were more severe in the transgenic mice. HSV-1 replication was approximately 100-fold greater in the corneas of transgenic mice than in wildtype mice. Conclusions. Our results demonstrate that a host gene (Hox A5) can increase ocular replication of HSV-1 and alter the pathogenesis of herpetic stromal keratitis.