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Paneth Cell Hyperplasia and Metaplasia in Necrotizing Enterocolitis

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Paneth Cell Hyperplasia and Metaplasia in Necrotizing Enterocolitis 0031-3998/11/6903-0217 Vol. 69, No. 3, 2011 PEDIATRIC RESEARCH Printed in U.S.A. Copyright © 2011 International Pediatric Research Foundation, Inc. Paneth Cell Hyperplasia and Metaplasia in Necrotizing Enterocolitis PATRYCJA J. PUIMAN, NANDA BURGER-VAN PAASSEN, MAAIKE W. SCHAART, ADRIANUS C.J.M. DE BRUIJN, RONALD R. DE KRIJGER, DICK TIBBOEL, JOHANNES B. VAN GOUDOEVER, AND INGRID B. RENES Department of Neonatology [P.J.P., N.B.-P., M.W.S., A.C.J.M.B., J.B.G., I.B.R.], Department of Pediatric Surgery [M.W.S., D.T.], Erasmus MC-Sophia Children’s Hospital, Rotterdam 3015 GJ, The Netherlands; Department of Pathology [R.R.K.], Erasmus MC-Josephine Nefkens Institute, Rotterdam 3015 GJ, The Netherlands ABSTRACT: Paneth cell dysfunction has been suggested in necro- with term infants, and up to 200-fold lower than in adults (18). tizing enterocolitis (NEC). The aim of this study was to i) study In the premature infant, who is often exposed to nosocomial Paneth cell presence, protein expression, and developmental changes pathogens and has delayed colonization with beneficial com- in preterm infants with NEC and ii) determine Paneth cell products mensals, this phenomenon could result in higher susceptibility and antimicrobial capacity in ileostomy outflow fluid. Intestinal to bacterial infection and inflammation. tissue from NEC patients (n ϭ 55), preterm control infants (n ϭ 22), Although Paneth cell dysfunction in necrotizing enteroco- and term controls (n ϭ 7) was obtained during surgical resection and at stoma closure after recovery. Paneth cell abundance and protein litis (NEC) has been suggested (19), little is known about expression were analyzed by immunohistochemistry. RNA levels of Paneth cell abundance and function in preterm infants at risk Paneth cell proteins were determined by real-time quantitative RT- for NEC. NEC is the most common gastrointestinal disease in PCR. In ileostomy outflow fluid, Paneth cell products were quanti- premature infants with mortality rates up to 50% for infants fied, and antimicrobial activity was measured in vitro. In acute NEC, needing surgery (20,21). Risk factors for NEC are prematu- Paneth cell abundance in small intestinal tissue was not significantly rity, very low birth weight, enteral formula feeding, and different from preterm controls. After recovery from NEC, Paneth bacterial colonization (22–24). However, the underlying eti- cell hyperplasia was observed in the small intestine concomitant with ology and the impact of the innate immune system on the elevated human alpha-defensin 5 mRNA levels. In the colon, meta- development of NEC require further investigation. plastic Paneth cells were observed. Ileostomy fluid contained Paneth We hypothesized that preterm infants with acute NEC have cell proteins and inhibited bacterial growth. In conjunction, these fewer Paneth cells compared with control patients, and that data suggest an important role of Paneth cells and their products in various phases of NEC. (Pediatr Res 69: 217–223, 2011) Paneth cell numbers are up-regulated during recovery from NEC, thereby enhancing the innate immune response. Our aim was i) to study Paneth cell presence, Paneth cell protein aneth cells, named after Joseph Paneth (1), play a signif- expression, and disease-related changes in Paneth cell num- Picant role in the innate immune response. Localized at the bers over time in premature infants with NEC compared with base of the crypts of Lieberku¨hn, Paneth cells are abundant in control patients and ii) to measure Paneth cell products in the ileum and are only occasionally found in the proximal ileostomy outflow fluid during NEC recovery and to deter- colon (2). Paneth cells have defensive functions including 1) mine the bactericidal activity of ileal outflow fluid. protection of stem cells in response to invading microbes (3,4); 2) eradication of ingested pathogens (5–7); 3) regulation of the composition, distribution, and number of commensal METHODS bacteria in the intestinal lumen (8,9); and 4) induction of Study population. Premature infants who underwent bowel resection for cytokine secretion, immune cell recruitment, and chloride NEC between August 2003 and September 2009 were eligible for the study. secretion to flush the intestinal crypts of pathogens (10,11). NEC was diagnosed and staged according to the criteria of Bell et al. (25). Paneth cells execute their functions by production of anti- Diagnosis was confirmed during surgery and by histopathological evaluation of resected intestinal tissue. Samples of both ends of the resected intestine microbial proteins/peptides such as lysozyme (12,13), secre- represented macroscopically vital tissue and were collected for histology and tory phospholipase-A2 (sPLA2) (14), and human ␣-defensins real-time quantitative RT-PCR (real time qRT-PCR). (HD5 and Ϫ6) (15,16). In the human fetal intestine, Paneth Approximately 3–5 wk after surgery, when infants received an enteral intake of at least 100 mL ⅐ kg ⅐ d, enterostomy outflow fluid was collected cells are present from 20 wk of gestation; however, HD5 and Ϫ6 mRNAs are expressed from 13.5 wk onward (17,18). Both Paneth cell numbers and HD5 and Ϫ6 mRNA expression are Abbreviations: A-NEC, acute phase of necrotizing enterocolitis; CFU, col- lower in premature infants at 24 wk of gestation compared ony forming units; HD, human defensins; LGG, Lactobacillus rhamnosus GG; NEC, necrotizing enterocolitis; NEC-R, stoma reanastomosis after ne- crotizing enterocolitis; post-NEC stricture, stricture formation after acute Received June 8, 2010; accepted October 14, 2010. phase of necrotizing enterocolitis; preterm CO, preterm control patients; Correspondence: Ingrid B. Renes, Ph.D., Erasmus MC, Lab Pediatrics, Rmnr. Ee preterm CO-R, stoma reanastomosis in preterm control patient; qRT-PCR, 1575A, Dr. Molewaterplein 50, Rotterdam 3015 GE, The Netherlands; e-mail: [email protected] real-time quantitative PCR; sPLA2, secretory phospholipase-A2; term CO, Supported, in part, by Danone. term control patient 217 218 PUIMAN ET AL. every 3 h for 24 h and immediately stored at Ϫ20°C. After full recovery, anti-rabbit or anti-mouse antibodies and Luminol Enhancer (Pierce, Thermo patients underwent a second surgical procedure when eligible for reanasto- Fisher Scientific, Inc., Rockford, IL). Western blots were analyzed using mosis (i.e. stoma closure). To allow proper reanastomosis, tissue was re- densitometry. sected, which was collected for histology. Antimicrobial assay. Escherichia coli (E. coli), Lactococcus lactis (L. Patients who underwent surgery for resection of post-NEC strictures, as a lactis), and Lactobacillus rhamnosus (LGG) were grown overnight in LB result of obstructive fibrotic intestinal tissue that developed during nonsurgi- medium, GM17 medium, and MRS medium (BD, Franklin Lakes, NJ), cal therapy for NEC, were also included. These samples were not subjected to respectively, at 37°C. The pooled antimicrobial protein fractions (100 ␮g) surgical manipulation or exposed to the extra-abdominal environment and are were added to 200 ␮L of bacterial cultures of 2 ϫ 107 colony forming units thus representative for the effects of NEC only. Moreover, samples were taken (CFUs)/mL and incubated for 1h at 37°C. A 10Ϫ4 dilution was prepared, and from both the proximal and distal part of the resected intestine. 100 ␮L of the suspension was plated. After overnight incubation at 37°C, Finally, both preterm and term neonates who underwent resection for CFUs were counted. Bacterial growth inhibition was analyzed by calculating developmental defects or diseases other than NEC were included as control the number of CFUs in comparison with untreated bacteria. patients, and intestinal tissue was collected as described earlier. Infants Statistical analysis. Comparisons between patient groups were made using diagnosed with cystic fibrosis were excluded. The study protocol was ap- ANOVA with a post hoc Tukey t test for normally distributed data or the proved by the “Central Committee on Research involving Human Subjects” Kruskal-Wallis test followed by Dunn’s Multiple Comparison test for not- (The Hague, the Netherlands), and written informed consent was obtained normally distributed data. Protein and mRNA levels of antimicrobial proteins from the parents. were determined using the Mann Whitney test. Analyses were performed Histology and immunohistochemistry. Intestinal tissues were fixed in 4% using GraphPad Prism version 5.0 (GraphPad Software, San Diego, CA). (wt/vol) paraformaldehyde in PBS for 24 h at 4°C and processed for light Significance was defined at p Ͻ 0.05. microscopy. Five micrometer-thick sections were cut and deparaffinized through a graded series of xylol-ethanol. For histology, tissue samples were stained with hematoxylin and eosin. To determine Paneth cell-specific ex- pression of lysozyme, trypsin, and HD5, immunohistochemistry was per- RESULTS formed as described previously (26,27). Antibodies used were anti-human lysozyme (Dako, Glostrup, Denmark), anti-human trypsin (MAB 1482; Mil- Study population. A total of 84 infants were included in the lipore, Billerica, MA), and anti-human HD5 (HyCult Biotechnology, Uden, the Netherlands). Secondary antibodies applied were biotinylated horse anti- study. Patient characteristics are shown in Table 2. Forty-nine mouse IgG diluted (Vector Laboratories, Burlingame, England) and biotinyl- preterm infants underwent bowel resection for stage III acute ated goat anti-rabbit IgG (Vector Laboratories). Detection was performed NEC, further referred to as A-NEC.
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