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Restimulation-Induced Apoptosis of T Cells Is Impaired in Patients with X-Linked Lymphoproliferative Disease Caused by SAP Deficiency

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Restimulation-Induced Apoptosis of T Cells Is Impaired in Patients with X-Linked Lymphoproliferative Disease Caused by SAP Deficiency Restimulation-induced apoptosis of T cells is impaired in patients with X-linked lymphoproliferative disease caused by SAP deficiency Andrew L. Snow, … , Jack J. Bleesing, Michael J. Lenardo J Clin Invest. 2009;119(10):2976-2989. https://doi.org/10.1172/JCI39518. Research Article Immunology X-linked lymphoproliferative disease (XLP) is a rare congenital immunodeficiency that leads to an extreme, usually fatal increase in the number of lymphocytes upon infection with EBV. It is most commonly defined molecularly by loss of expression of SLAM-associated protein (SAP). Despite this, there is little understanding of how SAP deficiency causes lymphocytosis following EBV infection. Here we show that T cells from individuals with XLP are specifically resistant to apoptosis mediated by TCR restimulation, a process that normally constrains T cell expansion during immune responses. Expression of SAP and the SLAM family receptor NK, T, and B cell antigen (NTB-A) were required for TCR-induced upregulation of key pro-apoptotic molecules and subsequent apoptosis. Further, SAP/NTB-A signaling augmented the strength of the proximal TCR signal to achieve the threshold required for restimulation-induced cell death (RICD). Strikingly, TCR ligation in activated T cells triggered increased recruitment of SAP to NTB-A, dissociation of the phosphatase SHP-1, and colocalization of NTB-A with CD3 aggregates. In contrast, NTB-A and SHP-1 contributed to RICD resistance in XLP T cells. Our results reveal what we believe to be novel roles for NTB-A and SAP in regulating T cell homeostasis through apoptosis and provide mechanistic insight into the pathogenesis of lymphoproliferative disease in XLP. Find the latest version: https://jci.me/39518/pdf Research article Restimulation-induced apoptosis of T cells is impaired in patients with X-linked lymphoproliferative disease caused by SAP deficiency Andrew L. Snow,1 Rebecca A. Marsh,2 Scott M. Krummey,1 Philip Roehrs,2 Lisa R. Young,3 Kejian Zhang,4 Jack van Hoff,5 Deepali Dhar,1 Kim E. Nichols,6 Alexandra H. Filipovich,2 Helen C. Su,7 Jack J. Bleesing,2 and Michael J. Lenardo1 1Laboratory of Immunology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA. 2Division of Bone Marrow Transplantation/Immune Deficiency, 3Division of Pulmonary Medicine, and 4Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA. 5Department of Hematology/Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA. 6Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA. 7Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA. X-linked lymphoproliferative disease (XLP) is a rare congenital immunodeficiency that leads to an extreme, usually fatal increase in the number of lymphocytes upon infection with EBV. It is most commonly defined molecularly by loss of expression of SLAM-associated protein (SAP). Despite this, there is little understand- ing of how SAP deficiency causes lymphocytosis following EBV infection. Here we show that T cells from individuals with XLP are specifically resistant to apoptosis mediated by TCR restimulation, a process that normally constrains T cell expansion during immune responses. Expression of SAP and the SLAM family receptor NK, T, and B cell antigen (NTB-A) were required for TCR-induced upregulation of key pro-apoptotic molecules and subsequent apoptosis. Further, SAP/NTB-A signaling augmented the strength of the proximal TCR signal to achieve the threshold required for restimulation-induced cell death (RICD). Strikingly, TCR ligation in activated T cells triggered increased recruitment of SAP to NTB-A, dissociation of the phosphatase SHP-1, and colocalization of NTB-A with CD3 aggregates. In contrast, NTB-A and SHP-1 contributed to RICD resistance in XLP T cells. Our results reveal what we believe to be novel roles for NTB-A and SAP in regulating T cell homeostasis through apoptosis and provide mechanistic insight into the pathogenesis of lymphoproliferative disease in XLP. Introduction function of these main molecular mediators can result in uncon- Effective adaptive immunity relies upon the activation and robust trolled lymphoproliferation, autoimmunity, and lymphomagen- clonal expansion of responding T lymphocytes that orchestrate esis in both mice and humans (4, 5). the elimination of infectious pathogens. However, it is critical to X-linked lymphoproliferative disease (XLP) is a rare congeni- constrain the pool of effector T cells that may, if left unchecked, tal immunodeficiency originally described by David Purtilo and inflict damage on host tissues. Programmed cell death via apopto- colleagues in 1975 (6). Its prevalence, estimated at 2–3 per 106 sis plays an integral role in expunging effector T cells at 2 distinct males, may be underreported due to failure to recognize the dis- phases of the immune response (1). As foreign antigens are success- order prior to EBV infection (7, 8). XLP is usually diagnosed in fully eliminated and T cell growth cytokines such as IL-2 dissipate, childhood or adolescence upon presentation of EBV-associated an intrinsic pathway of apoptosis triggered by cytokine withdrawal fulminant infectious mononucleosis (FIM)/hemophagocytic causes a major contraction phase of the T cell response, culling all lymphohistiocytosis (HLH) (in ~60% of cases), lymphoprolif- but the small fraction of T cells that later constitute immunologi- erative disease (LPD) including lymphoma, and/or hypo-/dys- cal memory. At the peak of the immune response, when antigen gammaglobulinemia (9). The massive expansion of reactive T and IL-2 are still abundant, restimulation through the TCR also cells as well as EBV+ B cells that accompanies EBV-associated deletes effector T cells. This autoregulatory program of restimu- FIM is fatal in over 90% of patients that progress to that stage, lation-induced cell death (RICD) constitutes a built-in negative underscoring the severity of the disease (10). XLP commonly feedback mechanism to preclude overt lymphoproliferation and results from deficiency of SLAM-associated protein (SAP), also immunopathology and maintain homeostasis (1). We and others designated XLP1, caused by mutations in the SH2D1A gene on have shown that RICD is executed through the action of multiple chromosome Xq24-25 (11–13). SAP is an Src homology 2 (SH2) biochemical pathways, including both death receptor signals (e.g., domain adapter protein involved in the intracellular signaling FAS-FASL) as well as pro-apoptotic Bcl-2 family proteins targeting of the signaling lymphocyte activation molecule (SLAM) family the mitochondria (e.g., BIM) (2, 3). Genetic defects that impair the of immunomodulatory receptors. Loss of SAP causes intrinsic defects in lymphocyte function including cytokine production, Conflict of interest: The authors have declared that no conflict of interest exists. cytotoxicity, T cell–dependent humoral immune responses, and Citation for this article: J. Clin. Invest. 119:2976–2989 (2009). doi:10.1172/JCI39518. NKT cell development (14, 15). However, none of these defects 2976 The Journal of Clinical Investigation http://www.jci.org Volume 119 Number 10 October 2009 research article adequately explain the rapid, lethal phenotype associated with article; doi:10.1172/JCI39518DS1). Pt3 and Pt4 were brothers. Pt1 FIM in affected XLP children. Many of these defects are recapitu- received a bone marrow transplant before this research began and lated in SAP-deficient mice (16–19). Analogous to XLP, severe T therefore was not included in subsequent analyses. cell expansion with associated mortality occurs in SAP-knockout SH2D1A genomic DNA sequencing detected a gross deletion mice challenged with murine γ herpesvirus-68 or chronic lym- spanning exons 2–4 in Pt1, exons 1–4 in Pt2, and an insertional phocytic choriomeningitis virus (17, 19, 20). This connection mutation in Pt3 and Pt4 (195_196insT), resulting in a frame shift between SAP deficiency and massive T cell lymphocytosis, and and predicted premature stop codon (A66fsX67). Both mutations how it might relate to the particular susceptibility to lethal EBV- resulted in a SAP-null phenotype, based on complete absence of associated FIM, is not well understood. SAP protein in immunoblots of patient T cell lysates (Figure 1A). Given that LPD is a characteristic feature of congenital disorders Sequence analysis of carrier 1 (Cr1, the mother of Pt3 and Pt4) of lymphocyte apoptosis, we conjectured that altered lymphocyte confirmed her obligate carrier state, although total SAP protein homeostasis may also contribute to XLP-related LPD. Chen et al. expression was comparable to control lysates. Intracellular flow recently observed a survival advantage for SAP-knockout murine cytometry also failed to detect SAP expression in these patients CD8+ T cells 48 hours after primary stimulation, which they char- (Supplemental Figure 1). Clinical immunodiagnostic phenotyping acterized as a defect in activation-induced cell death (AICD) (21). of these patients revealed various hallmarks of XLP disease relat- As Strasser and colleagues recently pointed out, the term “AICD” ed to SAP deficiency, including low numbers of CD27+ memory is broadly used to refer to any form of lymphocyte death after B cells, poor Ab responses to vaccination, impaired CTL/NK cell antigen stimulation and does not distinguish between the pos- cytolytic activity, and absence of NKT cells.
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