Alcohol and the immune system Gyongyi Szabo, MD PhD University of Massachusetts Medical School RSA 2008.

Alcohol and the immune system

Gyongyi Szabo, MD PhDUniversity of Massachusetts

Medical School

RSA 2008

http://www.ephidrina.org/alcohol/history.html

-The first brew was probably date palm wine, originating in Mesopotamia. - We know that the ancient Egyptians were drinkers, because they invented the first straws, for drinking beer that still contained wheat-husks. - Some of Egyptian texts refer to the social problems associated with drunkenness, so they were no strangers to recreational drinking. - The Babylonians, in the world's first legal text, included a law regulating drinking houses.

Heiroglyph from Memphis, the capital of ancient Egypt, drawn in approximately 3700BC:depicts a temple priest called Ruma showing typical clinical signs of paralytic poliomyelitis.

Infectious Disease in History

Ancient times:

Koch's postulates :

i. The agent must be present in every case of the disease. ii. The agent must be isolated from the host & grown in vitro. iii. The disease must be reproduced when a pure culture of the agent is inoculated into a healthy susceptible host. iv. The same agent must be recovered once again from the experimentally infected host.

’Germ theory' of disease was introduced in the 1880s byRobert Koch & Louis Pasteur

Louis Pasteur (1822-1895)Robert Koch (1843-1910)

Koch observed:-Significant mortality of alcoholics during the cholera epidemics of 1884.-Showed that rats experimentally treated with alcohol were more susceptible to cholera.

Sir William Osler:-“ The most potent predisposing factor is perhaps the lowered resistance to alcohol” - in pneumonia.Principles and Practice of Medicine (1909)

1849-1919

Alcohol, inflammation and immune response

Clinical observations

• Reduced antimicrobial defense– Increased incidence of bacterial pneumonias– Increased incidence of M. tuberculosis infection– Suscepibility to infection with Listeria monocytogenes

• Reduced anti-viral immunity– Increased susceptibility to HIV infection– Higher rate of chronic hepatitis C viral (HCV) infection

and accelerated liver injury in alcoholics

• Increased inflammatory pathway activation– Increased post-trauma immunosuppression

• Higher rate of major complications, prolonged disease course

Pathogens

Immune response

BacteriaVirusesFungiParasites, etc

Pathogen elimination

Innate immunityNeutrophils

Monocytes/MacrophagesDendritic cells

Natural killer cellsInterferonsInterleukinsCytokinesChemokinesReactive oxygen substances

Adaptive immunity

T lymphocytesCD4+CD8+

Regulatory T cells

Humoral Cellular

B lymphocytesantibodies

Immune response to pathogens

Host cell

CD4+Th cell

B cell

CD8+CTL

MHCClass I

Th1 cytokines(IL-2, IFN-)

TCR

TCR

Th2 cytokines(IL-4, IL-5, IL-10)

DendriticCell

MHC Class II

Monocyte

Macrophage

NKcellIFN-

antibodies

Adaptive immunity Innate immunity

PhagocytosisReactive oxygen radicals

Cytokines(TNF, IL-1, IL-6, IL-10)

ChemokinesInterferons

PMNL

TLR2/6

TLR2/1

TLR5Flagellin

Triacyl peptides Diacyl

PeptidesZymosan

TLR4LPS

DNA

TLR3dsDNA

TLR9 TLR7/8Endosome

CpG ssRNA

MyD88

NF-B

Pro-inflammatory cytokines

IRAK-1

TRAF6

IBCytoplasm

Nucleus

Extracellular space

IRF7

IRF7

MyD88

TRIF

Type I IFNs

IRF3

IRF3 IRF3

TRAM

Toll-like receptors in pathogen recognition

Adaptive immunity Antigen presentation and T cell

activation

Microbes Viral products

CytokinesEtc.

Th1

Th2IL-12, IL-18, IL-6, IL-8,

TNF-, IL-10

CD8+MHC Class I

Naïve Th0CD4+

Co-stimulatory signals

MHC Class IICD80, CD86

MonocytesDendritic cells

APC T cells

IFNIL- 2

IL-10IL- 4

Alcohol reduces host antimicrobial defense

– Increased incidence of bacterial pneumonias• Pneumococcus, Klebsiella, Hemophilus

influenzae, Legionella, other Gram negative organisms

– Increased incidence of infection with

Pneumococcus

Klebsiella

M. tuberculosis

Listeria monocytogenes

Alcohol use and M. tuberculosis

• Acute and chronic alcohol predisposes to TB disease through alterations of the specific and non-specific immune response to MTB.

• Alcohol use predisposes to a more severe form of TB• Heavy alcohol use (>3 drinks/day) was associated

with an increased risk of TB

Alcohol feeding increases susceptibility to Listeria

Monocytogenes

Alcohol Clin Exp Res. 1993 Feb;17(1):75-85

Liver enzyme levels in mice 5 days after infection(5 mice/group)

AS

T

Bacterial colony counts in livers and spleens(5 mice/group)

Nu

mb

er o

f co

lon

ies/

gram

of

tiss

ue

Human data: mortality from listeric meningitis or sepsis is 10.7% in non-alcoholics and 24% in alcoholics

Experimental data in mice

• Image Removed – Awaiting Copyright Permissions

Chronic alcohol feeding increases susceptibility to respiratory syncytial

virus infection in mice

Increased virusreplication

after alcohol feeding

Increased early Type I Interferon

production after alcohol feeding

Chronic alcohol feeding increases susceptibility to influenza virus infection

in mice

Increased lethality and magnitude of

infection

Progressive loss of CD8+ T cell function

with prolonged alcohol

The Journal of Immunology, 2008, 181: 641-648.

Increased lung injury and neutrophil infiltration

Impairment of pulmonary host defense from alcohol abuse

OropharynxSaliva production, poor dentationBacterial pathogen colonization Glottis

Consciousness, cough reflexAspiration

Airspaces/Innate Immunity Alveolar macrophages Neutrophils

Adhesion molecules, ChemotaxisPhagocytosis, antimicrobial activity

Cytokines (TNF, IL-12, GM-CSF)Chemokines (MIP2/IL-8/CINC/Gro-

Bone marrow PMNL response to infection

Adaptive ImmunityCellular immunity Humoral immunityT cell proliferation B cell numbersInflammatory cytokines Airspace levels ofIFN, IL-17 IgG and IgG1Anti-inflammatory Cytokines (IL-10)

AirwaysMucosiliary function

Happel & Nelson 2005

Treatment options for alcohol-induced immune defects in

pneumonia

• Antibiotics

• G-CSF administration to alcohol-fed mice with Klebsiella pneumoniae infection– Increased PMNL recruitment to lungs– Increased pulmonary host defense

• Replacement of the reduced glutathione levels with N-acetylcystein feeding reversed decreased alveolar macrophage phagocytosis in the lung.

Alcohol use and Human Immunodeficiency Virus infection

• Association between alcohol use and risk of being infected with HIV

• Incidence of alcohol abuse among HIV-infected individuals is greater than the population as a whole

• 82% if HIV positive patients consume alcohol and 41% met criteria for alcoholism (Michigan test)

• Miami HIV-infected Drug Abuser Study >60% of HIV+ patients reported heavy alcohol use

• Fong described a heavy alcohol user patient who developed accelerated HIV progression to AIDS in a 3-months period.

Alcohol Clin Exp Res. 2006 Oct;30(10):1781-90

The adverse effects of alcohol on the HIV-infected patient as it relates to immunity and disease progression are poorly understood.

Chronic alcohol worsens infection with Simian Immunodeficiency

Virus

• Increased viral load• Decreased circulating

CD4+/CD8+ lymphocyte ratio• Increased lymphocyte

proliferation• Increased muscle TNF

mRNA expression at 10 months after infection

• More rapid development of end-stage disease

Alcohol Clin Exp Res. 2006 Oct;30(10):1781-90.

Percent survival as a function of days after SIV inoculation inmacaques receiving ethanol or sucrose. Statistical difference by Lifetest,p<0.05.

Image Removed – Awaiting Copyright Permissions

Alcohol and trauma

• Alcohol abuse has a detrimental outcome on traumatic injury.

• Alcohol abuse is estimated in nearly 50% of burn and trauma admissions

• Decreased survival • Higher number of complications including

– infection, sepsis, pneumonia, prolonged hospitalization

http://www.photovault.com/Link/Health/Emergency/Paramedics/HEPVolume01.html

J Trauma 64:230-240.Alcohol 28:137-149.

Alcohol Clin Exp Res 31:704-715.

Immune regulation in trauma

J Trauma 64:230-240.Alcohol 28:137-149.Alcohol Clin Exp Res 31:704-715

Image Removed – Awaiting Copyright Permissions

Alcohol and trauma

J Trauma. 2008;64:230 –240.

Moderate alcohol consumption and immunity

• Moderate drinkers were more resistant than abstainers to common cold virus (non-smokers)

• Wine consumption, especially red wine, decreases the incidence of common cold

• Moderate wine or beer consumption was associated with lower levels of systemic inflammatory markers in three different European areas (Germany, Scotland, France)

• After moderate alcohol consumption there is a decrease in TNF induced adhesion in monocytes to endothelial cells

• Beer down-regulates activated peripheral mononuclear cells Most studies show an anti-inflammatory effect of acute, moderate consumption of

alcoholic beverages.

Alcohol and TNF a master regulator of inflammatory

responses

• Dose-dependent inhibition of TNF production in monocytes

• Inhibits TNF converting enzyme (TACE) - reversible

• Acute in vivo alcohol inhibits LPS-induced TNF in the serum or lung

•Increased serum and monocyte TNF in alcoholic hepatitis•Increased TNF producion by Kupffer cells in the liver•Increased TNF production by human monocytes

Acute (moderate)

Opposite effects

Chronic (excessive)

Toll-like receptor 4 signaling

TLR4CD14 MD-2

LPS

TBK-1

IKKi

IRF3

IRF3 IRF3IFNß

TRAM

TRIFMyD88

TIRAP

IRAK1/4TRAF6

MAPK

IkB

NF-B

NF-BAP-1

Inflammatory genes

TNFα

Toll-like receptor 4 signaling

TLR4CD14 MD-2

LPS

TBK-1

IKKi

IRF3

IRF3 IRF3IFNß

TRAM

TRIFMyD88

TIRAP

IRAK1/4TRAF6

MAPK

IkB

NF-B

NF-BAP-1

Inflammatory genes

TNFα

- transiently-formed, dynamic plasma membrane microdomains enriched in sphingolipids and cholesterol (Mouritsen OG et al., 2004)

- represent ~30-50% of the plasma membrane

- platforms for various cellular events, such as membrane trafficking and signaling

- GPI-linked proteins and Src-family kinases, are constitutively expressed in rafts, while others, like T cell receptors, associate with rafts upon engagement with specific ligands for the purpose of signal transduction

- lipid rafts play a pivotal role in lymphocyte and monocyte/macrophage functions and may interfere with TLR-mediated signaling

Razaqq TM et al., 2004; Schmitz, 2002; Triantafilou M, 2003; Dai Q, 2005

Lipid rafts

Acute alcohol treatment disrupts TLR4 recruitment into lipid rafts

Szabo et al, J. Immunol, 2007

Opposite effects of acute and chronic alcohol on monocyte TNF production

Acute alcohol also inhibits while chronic alcohol increases activation of NF-B, a nuclear regulatory

factor in TNF regulation.J Immunol. 2007 178:7686-93

Inflammation

TLR4

Pro-inflammatoryTNF, IL-1 Anti-

inflammatoryIL-10

LPS

Acute alcohol

Inflammation

TLR4

Pro-inflammatory

TNF

Anti-inflammatory

LPS

Chronic alcohol

Alcohol Clin Exp Res. 2006 Apr;30(4):720-30.

Mechanisms of alcoholic liver injury

PMNL HepatocyteAlcohol

Gut

Endotoxin(LPS)

Kupffer Cell

IL-8MCP-1 Stellate Cell

TNFROSTGF

Collagen

TLR4

NADPHNF-kBAP-1

Adachi et al, Gastro 1995;108:218-224.

Kupffer cell activation in alcoholic liver disease

TNF

Courtesy of L. Nagy (Cleveland Cilinic)J Gastroenterol Hepatol. 2007 Jun;22 Suppl 1:S53-6

Hepatitis C and Alcohol Use

• 30% of alcoholic patients with liver disease are HCV infected (Rosman AS,1996, Am.J.Gastroenerology)

• USA: 70% of HCV infected patients have alcohol use/abuse history (Schiff ER, 1999, Am.J.Med)

• Clinical progression and liver disease with alcohol use is accelerated in HCV(Tanaka T, 2000, Alcohol Clin.Exp.Res)

• Prolonged alcohol use is an independent risk factor for HCV progression (Regev A, 1999 Alcohol Clin.Exp.Res)

• Ongoing moderate alcohol consumption affects hepatic inflammatory activity (Day CP, 2001 Gut)

• IFN therapy is ineffective in patients with ongoing alcohol use (Newmann A.U, 1998, Science)

p< .001

010

30

50

70

Pro

life

rati

o n (

cpm

x 10- 3

)

Control DC

Control DC+alcohol

HCV DC

HCV DC+alcohol

p< .001 p< .01

p< .022

Additive inhibition of dendritic cell allostimulatory capacity

by HCV infection and alcohol treatment

Dolganiuc et at. Alcoholism: Clin. & Exp. Research, 2003

HCV DC

Control DC

0

0.25

0.5

0.75

1

1.25

HCV DC+alcohol

All

osti

mu

lato

ry c

apac

ity

*

**

02

46

81012141618

20

T cells

DC (TT)

DC (TT)

Et-DC(TT)

43 ±

2.3

%

Th

ymid

ine

in

corp

ora

tio

n

(cp

m x

10-3

)

+ T cells

Th

ymid

ine

in

corp

ora

tio

n

(cp

m x

10-3

)

Dendritic cells (X 104/well)T cells: 2x 105/well

I-DC

EtOH-I-DC

0

10

20

30

40

*

*

*

1 2 4

Ethanol inhibits myeloid dendritic cell antigen presentation and T cell

activation

J Immunol 173:3398-3407.

Adaptive immunity Antigen presentation and T cell

activation

Microbes Viral products

CytokinesEtc.

Th1 IL-12, IL-10

Naïve Th0CD4+

Co-stimulatory signals

MHC Class IICD80, CD86

APC

Antigen-specific T cell proliferation

Th2Naïve Th0

CD4+

Co-stimulatory signals

MHC Class IICD80, CD86

APC

Low IL-12, High IL-10

T cell anergy

Alcohol consumption inhibits dendritic cell antigen presentation in

mice-Alcohol feeding in mice resulted in decreased : -bone marrow-derived DC generation- expression of the co-stimulatory molecules, CD80, CD86 on DCs- induction of T cell proliferation-IL-12 production

J. Leukoc. Biol. 79: 941–953;

Increased:- IL-10 production

Image Removed – Awaiting Copyright Permissions

Image Removed – Awaiting Copyright Permissions

Chronic alcohol exposure affects dendritic cell functions in the skin

• Decreased numbers and migration of Langerhans cells and dermal dendritic cells in mice after 4-8 weeks of alcohol feeding

Alcohol Clin Exp Res, Vol 32, No 3, 2008: pp 1–12

Image Removed – Awaiting Copyright Permissions

Immature DC

Mature (stimulatory) DC

High intracellular MHC IILow CD 80, 86, 54Low CD83Endocytosis, FcR

Inhibitory DC

High surface MHC IIHigh CD80, 86, 54High CD83Low endocytosis, FcRHigh IL-12, low IL-10IFNT cell priming, activation

High Surface MHC IIReduced CD80, 86Low IL-12 High IL-10Reduced T cell activationT cell anergy

Alcohol

Alcohol use affects adaptive immunity in humans

• B cell defects:– Polyclonal hyperglobulinemia– Immunoglobulin A deposition in tissues

• Increased percentage of activated CD8+ T cell

• Shift from “naïve” (CD45RA+) to the “memory” phenotype of T cells (CD45RO+) - both in CD4+ and CD8+ population

Clin Exp Immunol 103:304-310.

Adaptive immunity - animal data

• 4-6 weeks alcohol feeding decreased the splenic, thymic and bone marrow T cell populations

• Increased CD4/CD8 T cell ratios• Increased memory/naïve T cell

ratios• Abnormal antigen-specific

responses

Clin Exp Immunol 103:304-310.

Methods Mol Biol. 2008;447:277-94.

Antigen presentation &Induction of adaptive

immunity

Alcohol impairs innate and adaptive immunity

Inflammatory response

Pathogen eliminationAdaptive immune responses

Pro-inflammatory cytokines

NF-B activation

T cell proliferationIL-12Co-stimulatory molecules

Change in Th1/Th2 cytokine profile (?)

T cellCD4+

APCPathogen

Summary

Alcohol use, both acute and chronic, results in generalized and organ-specific immune defects.

Nature Reviews Immunology 2, 205-209, 2002