Immunogenetics of Infection and Inflammation in the Gastrointestinal and Urogenital Tracts Sander Ouburg IMMUNOGENETICS OF INFLAMMATION AND INFECTION IN THE GASTROINTESTINAL AND UROGENITAL TRACTS The work described in this thesis was performed at the VU University Medical Center, Laboratory of Immunogenetics (Head: Prof. A.S. Peña, MD, PhD, FRCP, AGAF) of the Department of Pathology (Head: Prof. C.J.L.M. Meijer), in collaboration with the Department of Gastroenterology (Head: Prof. C.J.J. Mulder, MD, PhD). This thesis was enrolled in the research line “Immunogenetics of Infectious Diseases” (Project-leader: Dr. S.A. Morré). The work described in this thesis was financially supported by AstraZeneca Nederland BV. Publication of this thesis was financially supported by: AstraZeneca Nederland BV Greiner Bio-One BV bioMérieux Benelux BV Microbiome Ltd. BMD BioMedical Diagnostics SA – Ani Labsystems Ltd. Oy Medac GmbH – Oxoid BV Roche Diagnostics Netherlands Goffin Meyvis Analytical & Medical Systems Eric Ouburg Marga van Putten Herman & Ria Pleijster Cover design: Sander Ouburg Druk: Gildeprint Drukkerijen B.V. - www.gildeprint.nl Lay out: Sander Ouburg ISBN-10: 90-9021321-X ISBN-13: 978-90-9021321-7 © Sander Ouburg, Mijdrecht, Nederland 2006. All rights reserved. Any part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or otherwise, with written permission from the publisher. VRIJE UNIVERSITEIT IMMUNOGENETICS OF INFLAMMATION AND INFECTION IN THE GASTROINTESTINAL AND UROGENITAL TRACTS ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. L.M. Bouter, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de faculteit der Geneeskunde op maandag 18 december 2006 om 10.45 uur in de aula van de universiteit, De Boelelaan 1105 door Sander Ouburg geboren te Amsterdam promotoren: prof.dr. A.S. Peña prof.dr. C.J.J. Mulder copromotoren: dr. S.A. Morré dr. E.C. Klinkenberg-Knol I am among those who think that science has great beauty. A scientist in his laboratory is not only a technician: he is also a child placed before natural phenomena which impress him like a fairy tale. Marie Curie French (Polish-born) chemist & physicist (1867 - 1934) Table of Contents Contents Introduction 11 Aims and Outline 31 Part I Inflammation and Infection of the gastrointestinal tract 35 Aims and Outline 37 Chapter 1 41 Polymorphisms in the immune regulatory genes IL-1B & IL-1RN and the bacterial sensing genes CD14 & TLR4 are associated with Barrett oesophagus Chapter 2 53 The toll-like receptor 4 (TLR4) Asp299Gly polymorphism is associated with colonic localisation of Crohn's disease without a major role for the Saccharomyces cerevisiae mannan-LBP-CD14-TLR4 pathway Chapter 3 63 The role of the bacterial CpG sensing toll-like receptor 9 (TLR9) in Dutch 6 Caucasians and Spanish Galicians patients with Crohn’s disease: evidence for genetic heterogeneity Chapter 4 71 CD14 and TLR4 gene polymorphisms in Galician patients with Crohn’s disease: genetic and environmental interactions Chapter 5 83 Combined carriership of TLR9-1237*C and CD14-260*T alleles enhances the risk of developing chronic relapsing pouchitis Table of contents Part II Inflammation and Infection of the urogenital tract 97 Aims and Outline 99 Chapter 6 103 The first strong genetic susceptibility marker for Chlamydia trachomatis infections: The interleukin 1 receptor antagonist IL-1RN +2018 T>C gene polymorphism Chapter 7 109 The CD14 functional gene polymorphism –260 C>T is not involved in either the susceptibility to Chlamydia trachomatis infection or the development of tubal pathology Chapter 8 123 Host inflammatory response and development of complications of Chlamydia trachomatis genital infection in CCR5 deficient mice and subfertile women with the CCR5delta32 gene deletion Chapter 9 141 Do host genetic traits in the bacterial sensing system play a role in the development of Chlamydia trachomatis-associated tubal pathology in subfertile women? 7 General Discussion 153 Summary 189 Samenvatting 197 Addendum 207 Curriculum Vitae 208 Curriculum Vitae in English 209 Publications 210 Author affiliations 212 Acknowledgments 216 Table of Contents 8 All truths are easy to understand once they are discovered; the point is to discover them Galileo Galilei Italian astronomer & physicist (1564 - 1642) IMMUNOGENETICS OF INFLAMMATION AND INFECTION IN THE GASTROINTESTINAL AND UROGENITAL TRACTS Sander Ouburg 10 If life gives us rocks, it's our choice whether to build a bridge or a wall Anonymous Introduction Partially based on A candidate gene approach of immune mediators effecting the susceptibility to and severity of upper gastrointestinal tract diseases in relation to Helicobacter pylori and Epstein-Barr virus infections Sander Ouburg, J. Bart A. Crusius, Elly C. Klinkenberg-Knol, Chris J.J. Mulder, A. Salvador Peña & Servaas A. Morré European Journal of Gastroenterology and Hepatology 2005; 17 (11): pp. 1213 - 1224 & The true ligand of the NOD2 receptor is peptidoglycan instead of lipopolysaccharide: a schematic representation of ligand-receptor interactions and NF-kappa B activation Servaas A. Morré, Sander Ouburg, Elly C. Klinkenberg-Knol, Chris J.J. Mulder & A. Salvador Peña Gastroenterology 2004; 126 (1): pp. 371 - 373 Introduction 12 There is nothing like looking, if you want to find something. You certainly usually find something, if you look, but it is not always quite the something you were after. J.R.R. Tolkien (English writer, 1892 – 1973) to the thesis Introduction to the thesis astrointestinal diseases can be affected by a wide range of pathological conditions, from simple passing infections to severe chronic inflammation. G The chronic inflammatory conditions can have a severe impact of the patient’s lifestyle and / or quality of life. Many patients require life long medication, changes in life style, or in severe cases require surgical intervention. Barrett oesophagus, a condition predisposing to the development of oesophageal cancer, and Inflammatory Bowel Disease (IBD) are two of these chronic inflammatory conditions. Chlamydia trachomatis is the most prevalent sexually transmitted bacterium around the world and the leading cause of bacteria related blindness. Due to its mostly asymptomatic course of infection, infected persons are at increased risk of spreading the disease and of developing late complications. Furthermore infected persons are at increased risk of acquiring other STDs, such as HIV1. Clear differences in the course of these inflammatory processes and infections have been described, however the aetiopathogenesis remains currently unknown. In order to be able to better treat patients and to potentially prevent disease, or at least severe complications, many questions need to be addressed, including: Why do some people acquire infection while others exposed to the same pathogen do not? Why do some people develop complications or more severe inflammations, while others do not? Since inflammation is a defensive mechanism of the immune system: does regulation of the immune system play a role in the aetiopathogenesis of these diseases? Does recognition or lack thereof, of pathogens influence the course of infection? 13 These are questions that this thesis will try to address. Contents 1. Introduction 2. Gastrointestinal diseases 3. Urogenital diseases 4. Genetic variation in the immune system 1. Introduction The human body remains one of the humankinds biggest scientific puzzles. Although science progresses at a rapid pace due to the current high rate of technological development, relatively little is known about the complex mechanisms and biological interactions that make life possible. One of the big mysteries that remain is the human immune system. The immune system is very versatile and efficient at dealing with most pathogens. Unfortunately, the more complex something is, the more difficult it is to understand and the more easily something can go wrong. Approximately 5% of the human genome is thought to be structurally variable2. Genetic variation in genes encoding the immune system may help to create a more flexible immune Introduction system, however these variations may also result in aberrant immune responses. In order to gain a better understanding of the immune system, the way it works and the way it is regulated, we studied mucosal infections in two distinct organ systems, the gastrointestinal tract and the urogenital tract. 2. Gastrointestinal diseases 2.1 Barrett oesophagus 2.2 Crohn’s Disease 2.3 Pouchitis The human gastrointestinal tract is a very complex system, interlinking several organs, each with its own specific biological functions and mechanisms. Apart from being the digestive system providing the body with essential nutrients, the gastrointestinal tract plays an important role in the immune system. On the one hand it provides a homeostatic balance with the intestinal flora3, on the other hand it forms a immune barrier against (food-borne) pathogens. Due to its complexity, the gastrointestinal system is capable of responding to changing patterns in both diet and immune stimuli. However the complexity makes the gastrointestinal tract also vulnerable to factors that may influence key processes that deregulate the gastrointestinal system. 2.1 Barrett oesophagus Barrett Oesophagus (BO) is an inflammatory condition of the oesophagus and patients have