Abstract Background Acute severe ulcerative colitis (ASUC), a severe and potentially life-threatening manifestation of ulcerative colitis (UC) affects up to 25% of patients over their lifetime and requires urgent medical intervention. T cell subsets and myeloid cells play a critical role in the pathogenesis of mucosal inflammation. In this study, we aimed to perform an unbiased analysis of mucosal immune cell populations in patients with ASUC and to identify ASUC-specific cell type alterations. Methods Ten adult ASUC patients (defined by the Truelove and Witts criteria), 7 patients with active UC (not fulfilling ASUC criteria), and 5 normal volunteers (NV) were recruited (Fig. 1A). Intestinal mononuclear cells were isolated from endoscopically obtained intestinal biopsies and analyzed by single-cell RNA-sequencing (scRNA-seq). Linear mixed-effects models were applied to compare lineage-normalized cell type fractions across groups, while adjusting for relevant covariates including age, sex, and body mass index. Results Unsupervised clustering of 127,795 cells, expressing 38,224 unique genes, identified 45 distinct cell types (Fig. 1B). Among the salient findings specific to lymphoid cells, re-clustering of the T cell/NK cell compartment identified 9 cell subsets (Fig. 1C-D). Notably, TH17 cells (RORA, CTSH, CXCR6, and CCL20) and cycling TH17 cells (MKI67, PCLAF, SMC4, NUSAP1, and RRM2) were significantly enriched in patients with ASUC compared to those with active UC (adjusted P=0.019 and P=0.027, respectively) and NV (adjusted P<0.001 for both) (Fig. 1E-F). Among myeloid cells, of the 11 delineated subsets, patients with ASUC showed a significant reduction in lineage-normalized fractions of type 2 conventional dendritic cells (cDC2s) (CD1C, FCER1A) relative to both active UC and NV (adjusted P=0.017 for both) (Fig. 1G). Additionally, a cluster of CD14+ monocytes (CD14, FCN1, and LYZ) was significantly elevated in patients with ASUC compared to NV (adjusted P=0.032). Conclusion Elevated TH17 cell frequencies distinguish ASUC from UC. While further investigations, including protein-level validation of transcriptomic data and an assessment of the impact of cellular perturbation on treatment outcome, are ongoing, these findings shed light on a potentially underappreciated role for TH17-polarized T cells in ASUC.
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