CXCL9 in UC e235

Review Clin Ter 2018; 169 (5):e235-241. doi: 10.7417/CT.2018.2085

CXCL9 in ulcerative colitis G. Elia1 , G. Guglielmi2

1Department of Clinical and Experimental Medicine, University of Pisa; 2Operative Unit of Preventive and Occupational Medicine, University Hospital of Pisa, Pisa, Italy

Abstract on Type-1 helper (Th1) cells, as well as chemokine (C-C motif) receptor (CCR)5. The aim of this narrative review is to highlight the role of CXCL9 CXCL9, CXCL10 and CXCL11 are in Ulcerative Colitis (UC), in order to understand the mechanism commonly produced by local cells in inflammatory lesions underlying the inflammation in UC and to investigate also if Th1- and are able to attract Th1 cells; then both CXCR3 and its chemokines could be useful as a marker of disease. It was shown that ligands have a central role in the recruitment of inflamma- chemokine (C-X-C motif) receptor (CXCR)3 and its ligand chemokine, tory cells (2). induced by (IFN)-γ(MIG)/ chemokine (C-X-C CXCL9 is a small known as MIG. CXCL9 is motif) ligand 9 (CXCL)9, are highly overexpressed both in the inte- a T-cell chemoattractant, which is induced by IFN-γ. It is stinal mucosa of mice with experimental colitis and in patients with closely related to two other CXC chemokines called CX- UC (specifically, in lymphocytes, and epithelial cells). CL10 and CXCL11, whose genes are located near the gene In epithelial colonic cells CXCL9 expression is increased by IFN-γ. for CXCL9 on human chromosome 4 (3, 4). MIG has an important role in the recruitment of mononuclear cells and Therefore high level of CXCL9 revealed in peripheral granulocytes, so in maintaining the inflammation in UC. Since serum liquids, can be considered as a marker of host immune re- CXCL9 levels are related with UC disease activity, it could be a marker sponse, especially of that involving Th1 cells (5, 6). for the responsiveness of patients to treatments. It has been recently Indeed recruited Th1 lymphocytes increase IFN-γ and suggested that blocking CXCL9 may be a potentially effective therapy (TNF)-α production that stimulates for moderately-to-severely active UC. Clin Ter 2018; 169(5):e235-241. CXCL9 secretion from several cells of the inflamed site, doi: 10.7417/CT.2018.2085 leading to an amplification feedback loop (5, 6). An increase of serum CXCL9 (as well as that of other Key words: CXCR3, CXCL9, ulcerative colitis Th1 chemokines) and/or of the tissue expressions in different organ specific of autoimmune diseases has been reported by various studies. Actually this has been found in several specific autoim- mune diseases such as: autoimmune thyroiditis (7-12), Gra- Introduction ves’ disease (13, 14) Graves’ ophthalmopathy (15-18), type 1 diabetes (19-23), or systemic rheumatological disorders, like CXCL9, and CXCR3 rheumatoid arthritis (24), systemic lupus erythematosus (25, 26), systemic sclerosis (27-30), psoriasis or psoriatic arthritis

Chemokine (C-X-C motif) receptor (CXCR)3 is a Gαi (31-33), sarcoidosis (34, 35), HCV-related cryoglobulinemia protein-coupled receptor belonging to CXC chemokine re- (36-41), other HCV immune mediated disorders (11, 42-47), ceptor family, with two isoforms: CXCR3-A and CXCR3-B; other disorders, and also in cancers (48-69). both binding CXC chemokines, monokine induced by in- terferon (IFN)-γ(MIG)/ chemokine (C-X-C motif) ligand 9 (CXCL)9, (IFN)-γ-inducible protein 10 (IP-10)/CXCL10 Ulcerative colitis and IFN-inducible T-cell α chemoattractant (I-TAC)/CX- CL11. CXCR3-B binds also chemokine CXCL4 (1). Ulcerative colitis (UC) belongs to the inflammatory CXCR3 is expressed by different cells, such as acti- bowel diseases (IBD) and it is characterized by a chronic vated T lymphocytes and Natural Killer (NK) cells, some inflammatory condition normally involving colon and rec- epithelial and endothelial cells. CXCR3 is highly expressed tum (70, 71).

Correspondence: Giusy Elia, Department of Clinical and Experimental Medicine, University of Pisa, Via Savi, 10, 56126, Pisa, Italy Phone: +39-050-992318; Fax: +39-050-553235. E-mail: [email protected]

Copyright © Società Editrice Universo (SEU) ISSN 1972-6007 e236 G. Elia

Typical symptomatology includes diarrhea mixed with The crucial role of CD4 T-cells in the pathogenesis of blood and mucus (that lasts for weeks), and it could be follo- human IBD has been shown by another study that suggests wed by abdominal pain, that ranges from a mild discomfort a higher percentage of CXCR3 expression on mesenteric to painful abdominal cramping (72). lymph node (MLN) CD4 T-cells isolated from inflamed The diagnosis of UC is mainly based on endoscopy, intestinal tissue in IBD (90). which usually reveals signs of inflammation of the colon A further study has been conducted on 8 controls and (73). Ulcerative colitis pathology usually involves distortion on 11 patients affected by UC in the distal part of the colon, of crypt architecture, crypt inflammation, crypt abscess, and before and during topical treatment with corticosteroids, in haemorrhages and inflammatory cells in the lamina propria order to investigate the expression of CXC-chemokines (91). (LP) (74). Perfusates (before as well after 7 and 28 days of treatment), It is an autoimmune disease characterized by T cells and pinch biopsies (before and after 28 days of treatment) infiltrating the colon (75-78). Patients may have comorbi- were collected by colonoscopy. High levels of growth related dities that lead to symptoms and complications outside the oncogene (GRO)-α, (IL)-8, and CXCL9 were colon. The incidence of these extraintestinal manifestations detected in perfusates with respect to controls. GRO-α and was between 6 and 47 % (79); among them: osteoporosis, MIG decreased in responders during treatment with corti- aphthous ulcer, iritis or uveitis, seronegative arthritis, costeroids. Epithelial cells and granulocytes too, expressed ankylosing spondylitis, erythema nodosum, autoimmune GRO-α and CXCL9 (91). hemolytic anemia, etc. Moreover a possible link between The mRNA expression of eighty-eight genes from IBD or its therapy with glucocorticoids and osteonecrosis various biological contexts on colon biopsies of patients has been reported by a clinical study (80). affected by Crohn’s disease (CD), and UC, were evaluated Therapy’s goals are to induce and maintain remission, in order to determine new susceptibility genes involved on reducing the risk of complications. The treatment depends UC disease. A CXCL9 overexpression was observed in the on the severity of the symptoms. Mesalazine is the mainstay colon tissue of 3/5 CD and 3/3 UC patients compared to of treatment in mild to moderate disease (81). healthy controls. SNP genotyping for the 77147452G-->A Therapy with corticosteroids followed by transition to polymorphism of the CXCL9 gene on 114 pediatric patients a steroid-sparing agent with a thiopurine, anti-TNF agent, affected by IBD and 120 ethnically matched unaffected or adhesion molecule inhibitor usually is administered in adults detected a minor allele frequency of 20.3% in CD patients with failed 5-Aminosalycilate therapy or with severe patients compared to 31.3% in controls (p=0.016). Remar- disease (82, 83). kably, children with homozygosity for the wild-type allele Monoclonal antibodies are the last pharmacotherapeutic had a significant earlier onset of CD than heterozygous option before surgery and, despite all the above mentioned the- individuals (11.1 versus 13.8 years) (92). rapies, 10-15% of patients required proctocolectomy (84). Development of dextran sulfate sodium (DSS)-induced UC is characterized by a clinical course of relapse and colitis was investigated in CXCR3 (-/-) mice in order to remission. A crucial step in the development and progres- evaluate wether CXCR3 knock-out mice would have im- sion of the disease is the infiltration of leukocytes in the paired cellular transport thereby attenuating the course of colon, where chemokines and their receptors orchestrate colitis (93). Their results demonstrated an attenuated DSS- the tissue-specific and cell type-selective trafficking of induced colitis in CXCR3 (-/-) mice (at macroscopic and leukocytes (85, 86). microscopic level), with a lower recruitment, as The objective of this narrative review is to evaluate the well as a decreased IFN-γ production (93); therefore sug- role of CXCL9 in UC. The presentation of data has been gesting the important role played by CXCR3 in recruiting reported according to the International Narrative Systematic pro-inflammatory cells to the colon during colitis. These Assessment (INSA) tool (87). findings suggested that CXCR3 could be a therapeutic target to reduce pro-inflammatory cells recruitment in the CXCR3 and CXCL9 in ulcerative colitis inflamed colon. A further study examined peripheral blood immature In a first study, human epithelial, and intraepithelial lym- plasma cells and their mechanisms of migration into in- phocytes (IEL) lineages were used to study epithelial che- flamed sites in UC, reporting a significative higher number moattractants for IEL (88). Pre-stimulation of the epithelium of these cells in patients with active UC and active CD, than with IFN-γ significantly improved the induced IEL chemota- in healthy controls. The proportion of immature plasma cells xis by the epithelial-conditioned medium. Chemotaxis was correlates in a positive manner with clinical activities of significantly inhibited by using antibodies against CXCL10, UC and CD. Many peripheral blood immature plasma cells or CXCL9. Chemokine CXCL10 and CXCL9 were detected were positive for CXCR3, CXCR4, CCR9; and CCR10 and in high amounts in epithelial-conditioned media stimulated mRNA levels of Th1 chemokines were higher in colonic mu- with IFN-γ. These results showed that epithelial cells, under cosa of inflamed IBD respect to controls. CXCR3-positive IFN-γ stimulation, produce chemoattractants (CXCL10 and immature plasma cells in the inflamed colonic mucosa CXCL9) for IEL (88). of UC has been evidenced by Immunofluorescence too. In a second study, it has been shown that CXCR3- Therefore this study suggested that increased numbers of mediated chemotaxis of human T cells (in UC, and other immature plasma cells could migrate across the CXCR3 autoimmune diseases) is regulated by a Gi- and phospholi- axis to inflammatory UC sites and then may be involved in pase C-dependent pathway and not via activation of MEK/ the pathogenesis of UC (94). p44/p42 MAPK nor Akt/PI-3 kinase (89). CXCL9 in UC e237

The role of CXCR3 chemokines has been also studied curcumin in human IBD and in experimental colitis (98). in the pathogenesis of pediatric IBD by comparing inflam- An overexpression of IL-33 and its receptor ST2 in matory molecules expression in colon samples obtained clinical colitis tissue has been previously shown. A study from active UC and CD patients, in comparison with those conducted on BALB/c mice demonstrated that IL-33 and of controls. In this study three children were involved, each ST2 are the primary early genes induced after a DSS-induced with UC and CD (both in the active and remission phase), experimental ulcerative colitis. Diarrhea and DSS-induced and their controls, and through microarray was investigated colon inflammation were indeed impaired in ST2(-/-) the inflammatory gene expression in the mucosa. They also BALB/c mice, while worsen in wild-type mice after treat- carried out a real-time reverse transcription polymerase chain ment with exogenous recombinant IL-33. It has also been reaction and an immunohistochemical study involving six seen a reduced and augmented expression of CXCL9 and children from each group, in order to examine the expres- CXCL10, and inflammatory (IL-4, IL-13, IL-1, sion of CXCL9, 10, 11, CXCR3, matrix metalloproteinase IL-6, IL-17) in vivo. The effect of exacerbation of recom- (MMP)-1, -3, -7, and -10. Microarray analysis revealed a binant IL-33 treatment in DSS-induced acute colitis was higher expression of Th1 chemokines genes in the active abolished in IL-4(-/-) BALB/c mice (99). phase of CD that has been confirmed by real-time reverse For the treatment of UC it has been also successfully used transcription polymerase chain reaction too. An enhanced VSL#3, that is a mixture of 8 different probiotic bacteria. A expression of Th1 chemokines in the LP and in epithelial study investigated about the stimulation of human dendritic cells too has been showed by immunohistochemical analy- cells with LPS, VSL#3, or a combination of both, showing sis; CXCR3-positive cells were shown in the LP too. These that this leads to their maturation and to the induction of results suggested the crucial role played by CXCR3 axis different CXCR3 chemokines. It is interesting that a set components and MMP in the mucosal damage in pediatric of LPS-induced chemokines, among which CXCL9 and IBD (95). CXCL10, were suppressed by VSL#3 (100). Experimental models of colitis in mice were used to analyze the molecular events implicated in the develop- ment of IBD. Conclusion One study used global models of gene expression from two sets of pediatric IBD and two models of colitis in mice The importance of cytokines and chemokines in the to compare directly the genomic signatures of murine and pathogenesis of different and/or associated autoimmune human IBDs. Comparing the two pediatric data sets of IBD diseases has been shown by many studies (20, 39, 46, 101- microarrays, it has been found that 83 genes were expressed 118). in a similar manner between pediatric CD and UC. Microar- In this review we focused on CXCR3 and its ligand ray data showed common signatures among pediatric IBD chemokine CXCL9. It was shown that CXCR3 and its li- and experimental colitis, that include an up-regulation of gand chemokine MIG, are higly overexpressed both in the CXCL9 and S100A8 and a cytokine-cytokine receptor path- intestinal mucosa of mice with experimental colitis and in way dysregulation (96). Commensal microbes are necessary patients with UC (specifically, in lymphocytes, macrophages for a healthy intestinal immune system. The mechanism by and epithelial cells). In epithelial colonic cells CXCL9 ex- which these microbes establish and maintain gut immune pression is increased by IFN-γ. CXCL9 has an important role responses is unknown. A study reported an involvement of in the recruitment of mononuclear cells and granulocytes, the gut immune receptor leucine-rich repeat (LRR) C19 in so in maintaining the inflammation in UC. host-microbiota interactions. The LRRC19 deficiency not Since serum CXCL9 levels are related with UC disea- only damages the immune system of the intestine, but also se activity, it could be a marker for the responsiveness of reduces inflammatory responses in the intestinal tissues. It patients to treatments. It has been recently suggested that was showed a pivotal role of LRRC19-associated chemok- blocking CXCL9 may be a potentially effective therapy for ines CCL6, CCL9, CXCL9, and CXCL10 in immune cell moderately-to-severely active UC. recruitment and intestinal inflammation (97).

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