Neuroendocrine Regulationof Immunity

8 Feb 2002 9:39 AR AR152-06.tex AR152-06.
SGM LaTeX2e(2001/05/10) P1: GJC

10.1146/annurev.immunol.20.082401.104914
Annu. Rev. Immunol. 2002. 20:12563
DOI: 10.1146/annurev.immunol.20.082401.104914
NEUROENDOCRINE REGULATIONOF IMMUNITY
Jeanette I. Webster, Leonardo Tonelli,

and Esther M. Sternberg
National Institute of Mental Health, Section on Neuroimmune Immunology and Behavior,

Bldg 36, Room 1A 23 (MSC 4020), 36 Convent Drive, Bethesda, Maryland 20892-4020;
e-mail: jwebster@codon.nih.gov; tonellil@irp.nimh.nih.gov; ems@codon.nih.gov
Key Words glucocorticoid, immune response, inammatory/autoimmune disease,
HPA axis, cytokines
I Abstract A reciprocal regulation exists between the central nervous and im-
mune systems through which the CNS signals the immune system via hormonal
and neuronal pathways and the immune system signals the CNS through cytokines.
The primary hormonal pathway by which the CNS regulates the immune system
is the hypothalamic-pituitary-adrenal axis, through the hormones of the neuroen-
docrine stress response. The sympathetic nervous system regulates the function of
the immune system primarily via adrenergic neurotransmitters released through neu-
ronal routes. Neuroendocrine regulation of immune function is essential for survival
during stress or infection and to modulate immune responses in inammatory dis-
ease. Glucocorticoids are the main effector end point of this neuroendocrine system
and, through the glucocorticoid receptor, have multiple effects on immune cells and
molecules. This review focuses on the regulation of the immune response via the
neuroendocrine system. Particular details are presented on the effects of interrup-
tions of this regulatory loop at multiple levels in predisposition and expression of
immune diseases and on mechanisms of glucocorticoid effects on immune cells and
molecules.
GENERAL INTRODUCTION
The immune system has for many years been known to be inuenced by gluco-
corticoids, and glucocorticoids have been used in the treatment of inammatory
diseases since the 1940s. In fact, Kendall, Reichstein, and Hench received the
Nobel Prize for this discovery in 1950 (1). Since then extensive research has
shown the pharmacological effects of glucocorticoids on many aspects of immune
cell function (2, 3). However, until recently the fact that glucocorticoids play an
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Corresponding author.
125
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5 Feb 2002 7:56 AR AR152-06.tex AR152-06.SGM LaTeX2e(2001/05/10) P1: GJC
126 WEBSTER ET AL.
essential physiological role in regulation of the immune system in health and dis-
ease was not fully appreciated. An understanding of the physiological mechanisms
involved in glucocorticoid secretion and their regulation of the immune system
under both normal and disease conditions is fundamental to our understanding of
the pathogenesis of inammatory disease and ultimately for the development of
effective therapies for such diseases.
Recent studies have shown that this physiological regulation of the immune
system by glucocorticoids is only one part of an extensive regulatory network
between the central nervous system (CNS), neuroendocrine system, and immune
system. This network of connections through nerve pathways, hormonal cascades,
and cellular interactions allows the CNS to regulate the immune system locally
at sites of inammation, regionally in immune organs, and systemically though
hormonal routes. In turn through similar connections, the immune system also
regulates the CNS. During inammation, cytokines produced at the inammatory
site can signal to the brain and produce the symptoms of sickness behavior and
fever (4, 5). Cytokines are also expressed in areas of the brain, e.g., glia, neurons,
and macrophages, and play a role in both neuronal cell death (6, 7) and survival
(8). Cytokine-mediated neuronal cell death is thought to play an important role
in several neuro-degenerative diseases, such as neuro-AIDS, Alzheimers, mul-
tiple sclerosis, stroke, and nerve trauma. In addition to this growth-factor role
when expressed within the CNS, cytokines produced in the periphery can func-
tion as hormones and can stimulate the CNS by several mechanisms. They can
pass the blood-brain barrier (BBB) at leaky points, for example at the organum
vasculosum lamina terminalis (OVLT) or median eminence. They may be actively
transported across the BBB in small amounts (9). In addition they can rapidly
signal the CNS through the vagus nerve (10, 11). They can inuence the brain
by activation of second messengers, such as nitric oxide and prostaglandins, after
binding to receptors on endothelial cells (12, 13). While a full understanding of this
bidirectional communication between the CNS and immune systems is important,
this chapter focuses only on the regulation of the immune system by the CNS,
mainly though the neuroendocrine system and the adrenergic system. For further
information on the regulation of the CNS by the immune system see the review by
Mulla & Buckingham (14).
The CNS regulates the immune system through two major mechanisms: (a) the
hormonal stress response and the production of glucocorticoids, and (b) the auto-
nomic nervous systemwith the release of noradrenalin. The CNS can also regulate
the immune system locally via the peripheral nerves with release of neuropeptides
suchas substance Pandlocallyproducedcorticotrophin-releasinghormone (CRH).
This latter mechanism is not the focus of this review; for further information on
these refer to the following articles (15, 16).
The main regulator of the glucocorticoid effect on the immune system is the
hypothalamic-pituitary-adrenal axis (HPA axis) (Figure 1). The main components
of the HPA axis are the paraventricular nucleus (PVN) in the hypothalamus of the
brain, the anterior pituitary gland located at the base of the brain, and the adrenal
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NEUROENDOCRINE REGULATION OF IMMUNITY 127
Figure 1 Diagram of the routes of communication between the brain and immune system,
including the HPA axis, sympathetic nervous system, and cytokine feedback to the brain.
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128 WEBSTER ET AL.
glands. CRH is secreted from the PVN of the hypothalamus into the hypophyseal
portal blood supply and stimulates the expression of adrenocorticotropin hormone
(ACTH) in the anterior pituitary gland. ACTHthen circulates in the bloodstreamto
the adrenal glands where it induces the expression and release of glucocorticoids.
The HPA axis is subject to regulation both from within the central nervous sys-
tem and from the periphery. Glucocorticoids, themselves, feed back to negatively
regulate the HPA axis, exerting their negative feedback at the hypothalamic and
pituitary level. The HPAaxis can also be regulated by other factors such as the sym-
pathetic nervous system, cytokines, and other neuropeptides, such as arginine va-
sopressin (AVP) (17). CRHis also negatively regulated by ACTHand itself, as well
as by other neuropeptides and neurotransmitters in the brain, e.g., -aminobutyric
acid-benzodiazopines (GABA-BDZ) and opioid peptide systems. CRH is posi-
tively regulated by serotonergic, cholinergic, and histaminergic systems (18).
The connections between the neuroendocrine system and immune system pro-
vide a nely tuned regulatory system required for health. Disturbances at any
level of the HPA axis or glucocorticoid action lead to an imbalance of this system
and enhanced susceptibility to infection and inammatory or autoimmune disease.
Overstimulation of the HPAaxis with excessive amounts of circulating glucocorti-
coids and overall suppression of immune responses lead to enhanced susceptibility
to infection, whereas understimulation results in lower circulating levels of glu-
cocorticoids and susceptibility to inammation. Dysregulation may also occur at
the molecular level and in this instance would result in glucocorticoid resistance
at a molecular level leading to enhanced susceptibility to inammation. A detailed
understanding, therefore, by which the CNS and neuroendocrine systems regu-
late the immune system at the systemic, anatomical, cellular, and molecular levels
will inform not only the pathogenesis and treatment of inammatory/autoimmune
conditions and infectious disease but also conditions predisposing to susceptibility
and resistance to these illnesses.
EVIDENCE FOR ROLE OF ENDOGENOUS
GLUCOCORTICOIDS IN REGULATION
OF IMMUNE FUNCTION
Changes in the levels of circulating glucocorticoids, such as during exercise and
with circadian rhythms, are associated with changes in cytokine levels and pro-
duction by leukocytes (1923). Such studies provide circumstantial evidence that
physiological uctuations in glucocorticoid levels, in the range of those seen with
circadian variations or stress, are associated with altered immune function. How-
ever, animal models have provided the strongest proof that endogenous glucocor-
ticoids are essential physiological regulators of the immune response and inam-
matory/autoimmune disease.
Inbred rat strains, in which altered neuroendocrine responsiveness is associ-
ated with differential susceptibility and resistance to autoimmune/inammatory
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disease, provide a naturalistic, genetically uniform system that can be systemi-
cally manipulated to test the role of neuroendocrine regulation of various aspects
of immunity. Lewis (LEW/N) rats are an inbred strain of rats that are highly sus-
ceptible to development of a wide range of autoimmune/inammatory diseases
in response to a variety of antigenic or proinammatory stimuli. Largely histo-
compatible Fischer (F344/N) rats are relatively resistant to these same illnesses
after exposure to the same dose of antigens. These two strains also show related
differences in HPA axis responsiveness, with inammatory-susceptible LEW/N
exhibiting a blunted response, compared to inammatory-resistant F344/N rats
with an excessive HPA response compared to outbred rats (2428). Differences in
the expression of hypothalamic CRH (26), pro-opiomelanocortin (POMC) (28),
corticosterone-binding globulin (CBG) (27), and glucocorticoid receptor (GR)
expression and activation (27, 29, 30) have been shown in these two rat strains.
A variety of surgical or pharmacological HPA axis interventions in these strains
of rats, as well as in mouse strains, alter the course and severity of inducible
autoimmune/inammatory disease. Thus, in F344/N rats, treatment with the glu-
cocorticoid antagonist RU486 is associated with high mortality and development
of arthritis in response to injection of streptococcal cell walls (25). Approximately
50%of rats die after infection with Salmonella typhimurium, but adrenalectomized
rats suffer 100% lethality after infection with this bacteria (31). Similarly, in mice,
adrenalectomy before infection with CMV virus results in lethality but glucocorti-
coid replacement prevents virus-induced lethality (32). The high rates of mortality
within 1224 h of exposure to this wide range of antigenic, proinammatory, or
infectious stimuli across species and strains in which the HPA axis has been inter-
rupted pharmacologically or surgically, indicates the importance of an intact HPA
axis to protect against septic shock.
It is also possible in animal models to attenuate inammatory disease by re-
constituting the HPA axis, pharmacologically with glucocorticoids, or surgically
by intracerebral fetal hypothalamic tissue transplantation. In LEW/N rats either
treated with low-dose dexamethasone (25) or transplanted intracerebroventricu-
larly with F344/Nhypothalamic tissue (33), arthritis and carageenan inammation
are signicantly attenuated. Experimental allergic encephalomyelitis (EAE) is in-
ducible in LEW/N rats by immunization with myelin basic protein. After initial
immunization these animals experience transient paralysis but then recover to some
extent. During the development of the disease and recovery, the production of en-
dogenous corticosterone increases, which is essential for survival of the animal. If
this endogenous production is interrupted by adrenalectomy, the development of
EAE is fatal. Whereas a subcutaneous steroid implant equivalent to the basal cor-
ticosterone levels does not reduce mortality, a dose equivalent to the EAE-induced
corticosterone levels results in survival rates similar to that of normal animals, but
EAE still develops. If a subcutaneous implant of even higher corticosterone levels
is used, however, the animal will undergo complete remission (34).
Such animal studies showing that interruption of the HPA axis predisposes
to worse inammation, while reconstitution attenuates autoimmune/inammatory
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130 WEBSTER ET AL.
disease, lend support to the role of glucocorticoid imbalance in exacerbation of
human autoimmune, inammatory, allergic, or infectious diseases. Thus, a blunted
HPA axis response to pituitary adrenal axis stimulation with CRH or insulin, or
by psychological stress, has been shown in a variety of autoimmune diseases in-
cluding rheumatoid arthritis, SLE, Sjogrens syndrome, bromyalgia, and chronic
fatigue syndrome, as well as in allergic asthma and atopic dermatitis. Conversely,
in humans, excess chronic stimulation of the hormonal stress response with con-
comitant chronically elevated glucocorticoids, as occurs in chronic stress situations
is associated with an enhanced susceptibility to viral infection, prolonged wound
healing, or decreased antibody production after vaccination (3538). Such stress
is experienced by caregivers of Alzheimers patients, students taking exams, cou-
ples during marital conict, and Army Rangers undergoing extreme exercise and
stress. One important mechanism by which activation of the HPA axis regulates
these immune responses and severity of expression of resultant disease is through
the effects of glucocorticoids at the molecular level though the glucocorticoid re-
ceptor (GR). The next sections describes this important receptor system and its
regulation of target gene expression.
PHARMACOLOGICAL VERSUS PHYSIOLOGICAL
EFFECTS OF GLUCOCORTICOID
When considering the physiological relevance of the effects of glucocorticoids
on immunity, it is important to recognize that glucocorticoids in pharmacologi-
cal doses or forms exert different effects than they do under physiological condi-
tions. Physiological concentrations of glucocorticoids in the range of 350 nmol/l to
950 nmol/l, such as occur during physical or psychological stress, result in mod-
ulation of transcription of genes involved in the inammatory response, whereas
pharmacological doses (higher concentration than physiological) result in a total
suppression of the inammatory response. There are also differences in potency of
immune suppression by synthetic glucocorticoids, such as dexamethasone, versus
the effects on immune response to natural glucocorticoids, such as hydrocorti-
sone. For example, the synthetic glucocorticoid dexamethasone exerts a greater
suppression of IL-12 than does the natural glucocorticoid hydrocortisone, which
is consistent with the greater afnity of dexamethasone than hydrocortisone for
GR (39).
MODULATION OF THE IMMUNE SYSTEM
BY GLUCOCORTICOIDS
There are two receptors for glucocorticoids, the glucocorticoid receptor and the
mineralocorticoid receptor (MR). Corticosterone has a lower afnity for MR
than for GR. Thus, at low levels, glucocorticoids bind preferentially to MR, and
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only at high levels, i.e., during stress, is GR occupied (39, 41). MR and GR, which
are colocalized in some areas of the brain and in lymphocytes, can bind as het-
erodimers to DNA (42, 43), which could have implications for gene transcription
or transrepression. In the brain, MR has been implicated in a proactive mode, in
the prevention of disturbance of homeostasis, whereas GR has been suggested to
work in a reactive mode in the recovery from a disturbance (39, 44). The primary
receptor for glucocorticoids in immune cells is GR. The availability of glucocorti-
coids is also dependent on the expression of 11-hydroxysteroid dehydrogenase,
an enzyme responsible for the conversion of steroids from the active form, e.g.,
cortisol and corticosterone, into an 11-keto inactive form, e.g., cortisone and 11-
dehydrocortisone. Two forms of this enzyme exist. The type I enzyme is expressed
in liver, brain, adipose tissue, lung, and other glucocorticoid-target tissues and cat-
alyzes the regeneration of active glucocorticoids from the inactive 11-keto form.
Conversely, the type II enzyme catalyzes the inactivation of glucocorticoids to the
inert 11-keto form (45).
Glucocorticoid Receptor and Mechanism of Action
The end point tissue effect of glucocorticoids is mediated by GR (NR3C1) (46).
This is a member of the steroid and thyroid hormone receptor superfamily along
with the progesterone, estrogen, mineralocorticoid, and thyroid receptors, and GR
essentially is a ligand-dependent transcription factor. These receptors all have a
similar structure that can be divided into three distinct regions (Figure 2). The
N-terminal domain is involved in transactivation; the middle section is termed
the DNA-binding domain (DBD) and is involved in DNA binding mediated via
two zinc ngers; and the C-terminal domain or ligand-binding domain (LDB) is
responsible for ligand binding as well as being also involved in transactivation,
dimerization, and hsp90 binding (2, 47).
Glucocorticoids circulate in the plasma associated with CBG or albumin. It is
generally thought that glucocorticoids enter the cell by passive diffusion,
Figure 2 Structure of the glucocorticoid receptor.
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132 WEBSTER ET AL.
although there is evidence for an active transport out of the cell. GR is located in
the cytoplasm in the unactivated state in a multiprotein complex containing hsp90
and immunophilins. These are thought to hold the GR in a conformation that is
available to the ligand. Upon ligand binding, GR dissociates from this complex
and translocates to the nucleus where it binds as a homodimer to target elements
or glucocorticoid response elements (GREs) via its zinc ngers of the DBD. The
bound GRhomodimer can then modulate gene expression by modulating the basal
transcription machinery either directly or via cofactors (Figure 3). GR has been
involved in both the upregulation and downregulation of genes. Downregulation of
gene expression can occur via so-called negative glucocorticoid response elements
(nGRE), e.g., the POMC gene, but mostly gene repression by GR occurs via its in-
teraction with other transcription factors such as AP-1 and NFB(2, 48). It is note-
worthy that the reverse can also occur, i.e., AP-1 and NFB are able to repress GR
function.
When GR was rst cloned, two clones for GR were found that differed in the
C terminus (49). This second receptor, GR, is a splice variant of GR that is
identical to GR but is lacking the last 50 amino acids. Instead it has a unique 15
amino acid C terminus. This receptor is located in the nucleus regardless of ligand
Figure 3 Schematic diagram of the mechanisms of action of
the glucocorticoid receptor.
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status, but it can also be found in the cytoplasmcomplexed to hsp90. It does not bind
ligand and does not activate gene transcription but may act as a dominant negative
receptor in vitro by forming transcriptionally inactive heterodimers with GR
(5052). This mechanism of a dominant negative receptor is still under dispute as
other studies have shown no effect of GR on GR-mediated transactivation or
transrepression (5355).
AP-1
GRcan modulate gene expression via interaction with other factors, such as NFB
and AP-1. AP-1 consists of a heterodimer of the oncoproteins c-Fos and c-Jun that
bind to an AP-1 consensus binding site in DNA to activate gene transcription
in response to ligands such as phorbol esters. Although the high-afnity Fos/Jun
heterodimers predominate, the lower-afnity Jun/Jun homodimers are also capable
of binding to the AP-1 site. Glucocorticoids can reduce the DNA-binding ability
of the Fos and Jun complexes by protein-protein interactions and thereby repress
AP-1-mediated gene activation (56, 57) (Figure 4). This can also occur through a
composite GRE. This sequence contains a binding site for the receptor and also
for a nonreceptor factor. For example, GR was shown to repress AP-1 activity at
the composite GRE in the promoter of the plfGgene; this repression was mediated
by the N-terminal domain of GR and could not be mediated by MR (58, 59).
One example of a gene where a composite HRE is involved in the repression
of the gene by glucocorticoids is the hypothalamic hormone CRH. The promoter
of this gene contains an AP-1 site closely located to a GRE, and repression of the
AP-1-activated gene transcription by glucocorticoids has been shown (60). This
could be the mechanism by which glucocorticoids exert their negative feedback
on the hypothalamus to downregulate the HPA axis.
NFB
Glucocorticoids play a role in immunosuppression through their repression of
NFB, which is a major factor involved in the regulation of cytokines and other im-
mune responses. [For comprehensive reviews on NFB, see Baldwin (61), Ghosh
et al. (62), and McKay & Cidlowski (48)]. NFB was originally described as a
dimer of two proteins p65 (RelA) and p50 (NF-B1), but a whole family of these
proteins has now been described. These proteins all contain a highly conserved
300amino acid domain termed the Rel homology domain (RHD), which is impor-
tant for DNAbinding and nuclear translocation and dimerization. The proteins p65
(Rel A), C Rel, and Rel B contain a C-terminal transactivation domain, whereas
p50 (NF-B1) and p52 (NF-B2) are present as precursors (p105 and p100, respec-
tively), which contain a C-terminal IB-like region that is removed by proteolysis.
The ability of these proteins to form various dimer partners and the specicity
of these dimers for different DNA sequences may be fundamental to the cell-
specic responses mediated by NFB. These proteins are present in the cytoplasm
as complexes together with the inhibitory protein IB. This is also now known
to be part of a family of proteins that include IB, IB, IB , IB-R, and the
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134 WEBSTER ET AL.
Figure 4 Schematic diagram of the mechanism(s) by which the glucocorticoid receptor
inhibits the action of NFB and AP-1.
C-termini of p105/p50 and p100/p52. These all contain multiple ankyrin repeats,
which are involved in protein-protein interactions between the IBand NFB, and
a C-terminal PEST sequence, which is a signal for protein degradation (48).
NFB is normally located in the cytoplasm associated with the inhibitor IB
protein. Upon activation, IB is phosphorylated, ubiquinated, and then degraded.
The free NFB can then translocate to the nucleus where it activates gene expres-
sion. NFB can be stimulated by a variety of factors, including proinammatory
cytokines such as TNF- and IL-1, physical or oxidative stress, and bacterial or
viral proteins (48, 63) (Figure 4).
There have been two schools of thought regarding GR-mediated repression of
NFB, and data exist to support both. One is that glucocorticoids via GR induce
the expression of the inhibitory protein IB that then sequesters NFB in the
cytoplasm and prevents it from translocating to the nucleus and inducing gene
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activation (63, 64). This mechanism of repression of NFB by GR may be limited
to certain cell types, particularly monocytes and lymphocytes. The other model
suggests that there is a physical interaction or cross-talk between NFB and GR
that prevents gene expression (63, 6571). In some cases GR-induced transcription
is not required, as the anti-glucocorticoid RU486 is also capable of inhibiting
NFB to some extent (67, 72). The region of the GR required for GR repression of
NFB has been located to the zinc nger region of the DNA-binding region of GR
(63, 67). This region has been further dened as two amino acids in the C-terminal
zinc nger that are absolutely critical for GR-mediated repression of NFB; these
residues are not involved in GR-mediated repression of AP-1 (73). It is plausible
that these two models are not mutually exclusive or that they are dependent on
cell type. One experiment in the A549 pulmonary epithelial cell line has shown
that both these models exist in the same system. In this case, dexamethasone does
induce IB expression, but when protein synthesis and therefore IB production
is blocked, GR is still able to repress NFB-mediated gene activation although not
to the same extent as when protein synthesis is allowed (74).
It has also been suggested that glucocorticoid repression of NFB activity
could be caused by competition between GR and NFB for limited cofactors such
as CREB-binding protein (CBP) and steroid receptor coactivator 1 (SRC-1), as
it has been shown in Cos cells that this repression can be alleviated by excess
cofactor (75). McKay & Cidlowski, however, showed that CBP did not mediate
GRrepression of NFBby a competitive model, but rather that CBP functioned as
an integrator to enhance the physical interaction between GR and NFB (76). The
catalytic subunit of protein kinase A (PKAc) has also been suggested to promote
the cross-talk between GR and NFB (77).
REGULATION OF IMMUNE-RELATED GENES
Glucocorticoids regulate a wide variety of immune cell functions and expression
of immune molecules through the molecular mechanisms described above. Thus,
glucocorticoids modulate cytokine expression, adhesion molecule expression and
immune cell trafcking, immune cell maturation and differentiation, expression
of chemoattractants and cell migration, and production of inammatory mediators
and other inammatory molecules [for reviews see Barnes (78) and Adcock (2)].
Cytokine Expression
Glucocorticoids modulate the transcription of many cytokines. They suppress the
proinammatory cytokines IL-1, IL-2, IL-6, IL-8, IL-11, IL-12, TNF-, IFN- ,
and GM-CSF while upregulating the anti-inammatory cytokines IL-4 and
IL-10.
PROINFLAMMATORY CYTOKINES Glucocorticoids mediate the anti-inammatory
response by downregulating the expression of proinammatory cytokines such
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136 WEBSTER ET AL.
as IL-1, IL-6, and TNF-. Glucocorticoids have been shown to downregulate the
transcription of IL-1, to destabilize IL-1 mRNA (7981), and to downregulate
IL-1 (82). They also upregulate the expression of the decoy IL-1 receptor, IL-1R
II (83).
Glucocorticoids regulate IL-6 production not only directly, but also indirectly,
through their effects on the cytokines that regulate IL-6. IL-1 or TNF induction of
IL-6 is mediated via NFB and by another nuclear factor, NF-IL6, in transfection
studies of these nuclear factors and the IL-6 promoter in HeLa and F9 cells. This
IL-1-induced induction of IL-6 can be inhibited by glucocorticoid-activated GR
via protein-protein interactions at the C-terminal transactivation domain of NFB
(65, 69, 84). This repression does not require protein synthesis and does not affect
the DNA-binding capacity of NFB (69). Glucocorticoids also inhibit expression
of IL-11, a member of the IL-6 cytokine family, by inhibition of gene expression
and by destabilization of mRNA (85).
Evidence for these molecular mechanisms of GC regulation of cytokines has
appeared in vivo in disease states. In rheumatoid arthritis patients, administration
of glucocorticoids leads to a decrease in the release of TNF- into the bloodstream
(86). The LPS-stimulated production of TNF- in monocytes is reduced by gluco-
corticoid treatment. The promoter of TNF- does not contain a typical GRE site,
and so this repression by glucocorticoids may occur via other factors involved in
the regulation of TNF- which have binding sites in the promoter, such as NFB
and AP-1 (87). However, some evidence suggests that the glucocorticoid-mediated
repression of TNF- could occur at the level of translation rather than transcription
(88).
The transcription of other proinammatory cytokines is also affected by gluco-
corticoids. IFN- expression in spleen cells, and blood monocytes is inhibited by
glucocorticoids (89, 90). Dexamethasone inhibits basal IL-8 in airway epithelial
cells by destabilizing the mRNA via new protein synthesis (91). The expression
of the Th1 cytokine IL-12 and its receptor is downregulated by glucocorticoids
(9294). Effects of glucocorticoids on IL-12 are fully discussed in the section on
Th1-Th2 shift.
IL-2 expression in spleen cells is inhibited by glucocorticoids (89), and dexam-
ethasone inhibits the ionomycin- and TPA-induced IL-2 expression in FJ8.1 cells.
With the promoter for IL-2, the dexamethasone-induced repression inhibits the
binding of NFB and reduces the binding of AP-1 to DNA. Glucocorticoids not
only affect the action of cytokines by affecting their expression, but they also can
inhibit their signaling mechanisms. Thus IL-2 signaling via the Jak-STAT cascade
can be inhibited by dexamethasone (95).
Granulocyte-macrophage colony stimulating factor (GM-CSF) is a proinam-
matory mediator. IL-1-stimulated GM-CSF in bronchial epithelial cells is inhib-
ited by dexamethasone by transcriptional mechanisms (96).
ANTIINFLAMMATORY CYTOKINES The major Th2cytokine is IL-10. Inbloodmono-
cytes varying effects of glucocorticoids, both synthetic and natural, on IL-10 have
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been reported that are dependent on the dose. Lowphysiological doses of glucocor-
ticoids suppress IL-10 expression, whereas high pharmacological doses enhance
IL-10 expression (39, 97a).
IL-4 is a Th2-associated cytokine that is important for the proliferation of
mast cells and attraction of eosinophils to areas of inammation during response
to IgE stimuli or allergic reactions. Dexamethasone downregulates IL-4 mRNA
in mast cells (98, 99) and in lymphocytes (82). The effect of dexamethasone on
IL-4 production in T cells is a matter of some controversy and can be at least
partially explained by consideration of the doses used experimentally. As IL-4
is a Th2-associated cytokine and since glucocorticoids induce a shift from Th1-
Th2 immunity (see later section), one might expect dexamethasone to induce
IL-4 expression. Indeed, in the lymph nodes and spleen of mice IL-4 is induced
in response to physiological concentrations of glucocorticoids both in vivo and in
vitro(100, 101). Onthe other hand, consistent withthe efciencyof glucocorticoids
in the treatment of allergic diseases, data also exist showing that stress levels of
dexamethasone downregulate IL-4 expression in T cells (89).
Cell Adhesion Molecules and Immune Cell Trafcking
Glucocorticoids reduce the trafcking of leukocytes to areas of inammation.
This occurs via the downregulation of protein molecules involved in the attraction
and adhesion of leukocytes to these areas. Dexamethasone inhibits the expression
of intracellular adhesion molecule 1 (ICAM-1), endothelial-leukocyte adhesion
molecule 1 (ELAM-1) (102), and vascular adhesion molecule 1 (VCAM-1) (103).
Glucocorticoids can inhibit the expression of ICAM-1 through inhibition of the
NFB site in the promoter of the ICAM-1 gene (66, 71, 74). Glucocorticoids in-
hibit TNF-induced VCAM-1 expression but not ICAM-1 in bronchial epithe-
lial cells. NFB sites have been identied in the promoter of VCAM-1, and it
has been suggested that glucocorticoid repression of this gene may occur through
GR-mediated repression of NFB (103).
E-selectin is an endothelial cell surface adhesion molecule that is important for
the recruitment of leukocytes fromthe blood. It is upregulated by IL-1 and TNF-
and its expression can be repressed by glucocorticoids. Repression by glucocor-
ticoids does not affect NFB translocation or binding to DNA, which suggests
interference in transcriptional activation of NFB (70). L-selectin is involved in
the attachment of blood leukocytes during inammation, and its expression is de-
creased by glucocorticoid treatment in bone marrow cells and polymorphonuclear
cells (104).
Chemoattractants and Cell Migration
Cytokine-induced neutrophil chemoattractant (CINC)/gro is a chemoattractant for
neutrophils and is therefore important for the accumulation of neutrophils at sites
of inammation. It is also proposed to be a member of the family that includes
IL-8. mRNA for CINC/gro is induced by IL-1 via NFB, and this induction can
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138 WEBSTER ET AL.
be inhibited by glucocorticoids, which prevent the translocation of NFB to the
nucleus and therefore prevent DNA binding and gene transcription (105).
IL-5 is a chemoattractant for eosinophils and is important for the accumula-
tion of eosinophils in inammatory diseases such as asthma. IL-5 mRNA can be
downregulated by glucocorticoids in mast cells (99) and T cells (106). IL-5 can
be induced by TCR and IL-2 by different mechanisms, and both of these can
be repressed by glucocorticoids. The mechanism of glucocorticoid repression of
TCR-induced IL-5 possibly occurs through AP-1 and NFB, but these factors are
not involved in the glucocorticoid repression of IL-2-induced IL-5 (107).
RANTES (regulated upon activation normal T cell expressed and secreted) is a
chemoattractant involved in the recruitment of eosinophils to areas of inamma-
tion. Dexamethasone inhibits mRNAexpression in activated and nonactivated cells
(108, 109). The cytokines monocyte chemoattractant protein 1 (MCP-1), MCP-
2, and MCP-3 are downregulated by dexamethasone (108). Downregulation of
MCP-1 occurs posttranscriptionally by destabilization of the mRNA at the 5
end,
although the exact mechanism is unknown (110).
Eotaxin is an eosinophil chemoattractant involved in the accumulation of eosin-
ophils in the airways in response to allergic stimuli. Eotaxin mRNA is stimulated
by cytokines such as TNF- and IL-1 and this cytokine-induced induction is
repressed by glucocorticoids (111).
Production of Inammatory Mediators
Glucocorticoids also affect the production of inammatory mediators including
prostaglandins and nitric oxide. Glucocorticoids suppress prostaglandin synthesis
at sites of inammation by several mechanisms. The key stages during the synthesis
of prostaglandin are the release of arachadonic acid frommembrane phospholipids,
which is catalyzed by phospholipase A
2
(PLA
2
), and the subsequent conversion to
PGH
2
by the action of cyclooxygenase (COX). There are two isoforms of PLA
2
,
secretory PLA
2
and cytosolic PLA
2
. There are also two COX enzymes; COX-1
is constitutively expressed, and COX-2 is inducible and thought to be involved
in stimuli-induced prostaglandin synthesis. COX-2 induction by inammatory
stimuli is mediated though NF-IL6 and NFBregulatory sequences in its promoter
(112). Glucocorticoids exert their effect by repression of cytosolic PLA
2
and COX-
2 mRNA levels (113115).
Nitric oxide synthase II (NOS II) is the enzyme that produces nitric oxide (NO).
NOhas been implicated in autoimmune and inammatory responses. The promoter
of NOS II contains a binding site for NFB, which is required for the cytokine
induction of this gene. Glucocorticoids repress the cytokine induction of NOS II,
and this repression does not correspond with an induction of the IBgene, thereby
implicating a method of protein-protein interaction for this repression (68). iNOS
is an inducible form of nitric oxide synthase and is another enzyme involved in the
synthesis of nitric oxide. Dexamethasone inhibits transcription of the iNOS gene
in rat hepatocytes by the induction of IB (116).
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Lipocortin 1 (or annexin 1) is expressed in many immune cells and is also
expressed in the neuroendocrine system in the hypothalamus and pituitary. It has
anti-inammatory actions although these mechanisms are not fully understood.
One way in which lipocortin 1 exerts its anti-inammatory action in the periph-
ery is by the inhibition of prostaglandin synthesis via the inhibition of release of
arachadonic acid, although the exact mechanism is not known. Glucocorticoids
have a dual action on lipocortin 1. Lipocortin 1 is normally expressed and local-
ized mainly in the cytoplasm, but it is also localized to the external surface of cell
membranes. Upon glucocorticoid exposure, the amount of lipocortin 1 on the ex-
ternal membrane rapidly increases. This externalization is followed by an increase
in lipocortin 1 synthesis by the cells in response to glucocorticoids (117).
Other Factors Involved in the Inammatory Response
The
2
-adrenoreceptor is involved in the adrenergic control of the immune system
(see later section). Glucocorticoids increase the transcription of the
2
-adrenore-
ceptor in many cell types, including airway epithelial cells. This transcriptional
regulation occurs via a GRE sequence in the promoter of the gene (118, 119).
Other receptors involved in the regulation of the immune system are regulated by
glucocorticoids. The transcription of the NK
1
-receptor, the receptor for substance
P, is inhibited by glucocorticoids probably through an AP-1 site (120). The NK
2
-
receptor is also downregulated by glucocorticoids (121).
EFFECTS ON IMMUNE CELLS
Glucocorticoids, in general, suppress maturation, differentiation, and proliferation
of immune cells involved in all aspects of immunity, including innate, T cell, and
B cell function and chronic allergic reactions.
Innate Immunity
Monocytes are produced in the bone marrow. Once mature they leave, circulate in
the bloodstream, and after a time enter the tissues and become macrophages.
During inammation, circulating monocytes migrate to the inammatory site
where they become activated. Glucocorticoids interfere with the protective and
defense mechanisms of activated macrophages, rather than resident macrophages.
This occurs via their effects on cytokines and other inammatory mediators such
as prostaglandin synthesis (122). Glucocorticoids at pharmacological concentra-
tions induce apoptosis in macrophages and monocytes; and the pro-inammatory
cytokine IL-1 may be involved in prevention of apoptosis, whereas the anti-
inammatory cytokines IL-4 and IL-10 induce apoptosis in these cells (81). Thus,
pharmacological or stress levels of glucocorticoids reduce circulating numbers
of monocytes, inhibit secretion of IL-1, IL-6, TNF-, and monocyte chemotactic
activating factors, and impair synthesis of collagenase, elastase, and tissue plas-
minogen activator (123).
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140 WEBSTER ET AL.
Neutrophils are involved in the tissue damage that occurs during the innate
inammatory phase of inammatory disease. In response to injury, neutrophils
migrate out of the circulating bloodstream, extravasate between endothelial cells,
and move to the site of inammation. Glucocorticoids affect the activation of
neutrophils and also the functions of neutrophils, such as chemotaxis, adhesion,
transmigration, apoptosis, and phagocytosis (123, 124). Glucocorticoid regulation
of these functions in neutrophils is due to numerous components including regula-
tion of cytokines. However, lipocortin 1 also plays a pivotal role in glucocorticoid-
induced responses. Glucocorticoids have a dual effect on neutrophils. On one
hand pharmacological doses are inhibitory and suppress the inammatory response
caused by neutrophil activation and migration. On the other hand, neutrophils are
required for the response to bacterial infections, and as such their circulating num-
bers are increased by pharmacological doses of glucocorticoids through inhibition
of apoptosis (124).
Th1-Th2
Glucocorticoids induce a shift from a Th1 to a Th2 pattern of immunity. Th1
immunity or cellular immunity is characterized by the expression of proinamma-
tory cytokines, such as IFN- , IL-2, and TNF-, which lead to the differentiation
of macrophages, natural killer cells (NK cells), and cytotoxic T cells that are in-
volved in phagocytosis and destruction of invading bacteria or foreign bodies.
Th2 immunity or humoral immunity is characterized by the production of anti-
inammatory cytokines such as IL-4, IL-10, and IL-13, resulting in the differenti-
ation of eosinophils, mast cells, and B cells, which lead to an antibody-mediated
defense against foreign antigens. The main inducer of Th1 immunity is IL-12.
This can induce the expression of IFN- and inhibit the expression of IL-4, which
plays a critical role in the immune response. [For a detailed review on IL-4, see
Nelms et al. (125)].
As previously mentioned, glucocorticoids can affect the transcription of many
cytokines, generally upregulating antiinammatory cytokines and downregulating
proinammatory cytokines, thereby causing a shift from Th1 to Th2 immunity.
The glucocorticoid-induced shift of Th1 to Th2 may be due mainly to down-
regulation of the Th1 cytokines, thus allowing dominant expression of the Th2
cytokines (126, 127). They modulate the expression of IL-12 or its receptor, and
this regulation of IL-12 is thought to be a major mechanism by which glucocor-
ticoids mediate the Th1-Th2 shift (94). This glucocorticoid-mediated downreg-
ulation of IL-12 occurs by inhibition of Stat4 phosphorylation in the signaling
cascade downstream of IL-12, and this inhibition is mediated by GR. This is spe-
cic for the Th1-mediated immunity because phosphorylation of Stat6, which
is involved in the signal cascade from IL-4, is not affected by glucocorticoids
(93). Glucocorticoids downregulate the IL-12 receptor 1- and 2-chains, but
this downregulation occurs after 3 days of treatment, whereas the inhibition of
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Stat4 phosphorylation is seen within 2 h, suggesting that IL-12 receptor
downregulation occurs in response to prolonged glucocorticoid exposure (92, 93).
Several other neural factors besides glucocorticoids can also induce a Th1-Th2
shift; these neural factors include the sympathetic neuropeptides, noradrenalin,
and adrenalin (94).
Glucocorticoids differentially affect the survival of Th1 and Th2 cells. Th2
NK1.1
+
Tcells, which produce IL-4, are resistant to dexamethasone-induced apop-
tosis, and this resistance may be due to the expression of the proto-oncogene Bcl-2
(128).
Alterations in Th1-Th2 immunity are characteristic of some autoimmune dis-
eases. Rheumatoid arthritis, multiple sclerosis (MS), and type I diabetes mellitus
are examples of autoimmune diseases in which there is a shift toward Th1-mediated
immunity with an excess of IL-12 and TNF- production. Systemic lupus erythe-
matosus (SLE) is shifted toward Th2-mediated immunity with an excess of IL-10
production (94). In situations where there is an excess of glucocorticoid produc-
tion, e.g., in animal models with a hyperactive HPAaxis (F344/Nrats) or in women
in the third trimester of pregnancy, there is a relative resistance to Th1-associated
autoimmune diseases. Conversely, animals with a lack of glucocorticoids or a hy-
poactive HPA axis (LEW/N rats) are susceptible to Th1-associated autoimmune
diseases (94, 129). LEW/N rats are susceptible to EAE, a Th1-mediated autoim-
mune disease. Spontaneous recovery of these animals is correlated with an increase
in glucocorticoids, whereas adrenalectomy results in fatal regression of the disease
but can be reversed by administration of glucocorticoids, indicating the shift from
Th1 to Th2 immunity (34).
Allergy
Eosinophils are critical in the response to allergic stimuli, and glucocorticoids
both systemically and topically applied are effective in the treatment of these
diseases. Pharmacological doses of glucocorticoids reduce the circulating numbers
of eosinophils probably through many factors including IL-5, IL-3, and GM-CSF.
Glucocorticoids also sequester eosinophils in primary and secondary lymphoid
tissues, induce apoptosis, and inhibit the recruitment of eosinophils to areas of
inammation (123, 130, 131).
Basophils are the least abundant circulating leukocyte but are important in IgE-
mediated allergic inammation. Their activation leads to the synthesis and release
of lipid mediators such as leukotriene C4 (LTC4), which induces changes in muscle
and vascular tissue. Glucocorticoids reduce circulating numbers of basophils, im-
pair histamine and leukotriene release, and inhibit basophil migration (123, 131).
Mast cells are important for the mediation of inammatory disease particularly
in response to IgE. Glucocorticoid treatment results in a decrease in mast cells in
airways, but the mechanism for this is not certain, and a direct inhibitory effect on
mediator release has been disproven (132, 133).
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142 WEBSTER ET AL.
Resident Tissue Immune Cells
Dendritic cells are involved in antigen presentation, and this could assist in the
Th1-Th2 shift. Glucocorticoids reduce the number of dendritic cells in an animal
model and also in human nasal mucosa after topical glucocorticoid application
(134, 135). Epithelial cells are involved in inammation in asthmatic airways,
and they are also a target for glucocorticoid therapy in this disease. As described
earlier, glucocorticoids inhibit the expression of cytokines, chemoattractants, and
mediators of inammation in the epithelial cells of the airways. Glucocorticoids
reduce the inammatory mediatorinduced leakage of plasma proteins into the
alveolar bronchi (136). Interestingly, endothelial cells of the airways show the
highest expression of GRin human lung (137). Mucosal cells secrete mucus during
inammation. Glucocorticoids act directly on these cells and inhibit the expression
of MUC2 and MUC5AC, the genes that encode mucin (138, 139). Glucocorticoids
also inhibit mucus secretion via their inhibition of inammatory mediators.
Effects of Glucocorticoids on Lymphocyte Selection
at the Cellular and Immune Organ Level
Glucocorticoids play an important role in lymphocyte selection via several mech-
anisms, including apoptosis and thymocyte differentiation during development.
APOPTOSIS Apoptosis is a mechanism of programmed cell death, which is neces-
sary for a homeostasis to exist between cell death and proliferation. For a reviewon
apoptosis, see King&Cidlowski (140). Glucocorticoids induce G1arrest andapop-
tosis in lymphoid cells. There appear to be two mechanisms for glucocorticoid-
mediated apoptosis in thymocytes, one for proliferating thymocytes and one for
nonproliferating thymocytes. Although separate mechanisms, these two pathways
do share some common features such as the activation of GR and the activation of
caspases. The mechanism of glucocorticoid-mediated cell cycle arrest and apop-
tosis is not fully understood, but some cell cycle genes, e.g., c-myc, cyclin D3, and
Cdk4, are regulated by glucocorticoids (140, 141). Glucocorticoids upregulate the
expression of the cyclin-dependent kinase inhibitor, p57
Kip2
, which is important in
this glucocorticoids-mediated cell cycle arrest (142).
In T cells, glucocorticoid-induced apoptosis is dependent on protein synthesis,
but there is also evidence that it is dependent on repression of genes, such as
c-myc. Comparison of the glucocorticoid-sensitive T-cell line 6TG1.1 and the
glucocorticoid-resistant variant ICR27TK.3, which contains GR that is incapable
of gene activation, indicates that repression of AP-1-induced gene activity is not
involved in glucocorticoid-induced apoptosis in these cells. DNAfragmentation in
the sensitive 6TG1.1 cells was inhibited by cyclohexamide, indicating that protein
synthesis is required for glucocorticoid-induced apoptosis. Because inhibitory IB
molecule is inducedbydexamethasone inthese cells andbecause c-myc is regulated
by NFB, it has been suggested that glucocorticoid-induced apoptosis could occur
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by repression of gene transcription of the c-myc gene via glucocorticoid-induced
transcription of IB or another similar inhibitory factor (64).
Glucocorticoid-mediated apoptosis has also been described in monocytes. This
occurs via the death receptor, CD95, a cascade for apoptosis that does not occur in
Tcells or thymocytes inresponse toglucocorticoids. Inmonocytes, glucocorticoids
increase the expression of membrane CD95 and the ligand, CD95L, and also
enhance their release. This activates a cascade involving caspase 8 and caspase 3
to induce apoptosis (143).
EFFECTS OF GLUCOCORTICOIDS ON THYMOCYTE DIFFERENTIATION AND SELECTION
During the process of thymocyte differentiation, immature CD4
CD8
thymo-
cytes rearrange the gene locus of the T cell receptor (TCR) to express pre-TCR.
These then divide and begin to express CD4
+
and CD8
+
and rearrange the gene
of TCR to express mature / TCR but at low levels. These CD4
+
CD8
+
low
TCR cells then undergo selection, either positive or negative selection. Precisely
what factors determine positive versus negative selection is not understood. In
vitro in the presence of glucocorticoids alone, thymocytes/hybridomas undergo
glucocorticoid-mediated apoptosis, whereas in the absence of glucocorticoids and
the presence of activated TCR, these cells undergo activated-mediated apopto-
sis. Culture in the presence of both results in survival, and this balance between
glucocorticoids and TCR has been termed mutual antagonism. To explain how
selection occurs, it has been proposed that where the CD4
+
CD8
+
low TCR thy-
mocytes do not recognize self-antigen/major histocompatability complex (MHC),
there is a greater ratio of GRto TCRstimulation, and these cells will die of neglect
through glucocorticoid-mediated apoptosis. If these thymocytes strongly recog-
nize self-MHC, with a resultant higher ratio of TCR to GR activation, then these
cells will die by negative selection through activated-mediated apoptosis. If there
is an intermediate recognition of the MHC, a balance exists between the GR and
TCR activation, and these cells will be selected by positive selection and will
further differentiate into mature CD4
+
or CD8
+
thymocytes (144, 145). Evidence
for this mutual antagonism has been provided by studies in which inhibiting glu-
cocorticoids results in thymocytes with a low-to-moderate avidity for self-MHC
being forced into activated-mediated apoptosis (negative selection), rather than
being rescued and undergoing positive selection as would occur in the presence
of glucocorticoids (146). Furthermore, in these conditions thymocytes that do not
recognize self-MHC are rescued rather than undergoing glucocorticoid-mediated
apoptosis (147).
Thymocyte selection is active during fetal and neonatal period, but the levels
of glucocorticoids circulating in the fetus are low because some level of pro-
tection from maternal glucocorticoids is provided by the placenta that contains
high levels of the GC-catabolizing enzyme 11-hydroxysteroid dehydrogenase.
This apparent lack of glucocorticoids in the fetus and the necessity of them for
thymocyte differentiation has led to the hypothesis that there may be local produc-
tion of glucocorticoids in the thymus during development (145). Indeed, cultured
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144 WEBSTER ET AL.
thymic epithelium cells do produce pregnenolone and deoxycorticosterone, and
this production can be increased by ACTH. This production of glucocorticoids
was specic to thymic epithelium cells and was not observed in cultures of thymo-
cytes, macrophages, or dendritic cells. The P450 hydroxylase enzymes involved
in the production of glucocorticoids, specically corticosterone from cholesterol,
have been shown in thymic epithelium cells (144, 145, 148). Murine thymus also
contains all the enzymes required for the production of glucocorticoids from
cholesterol (149).
In hybridomas, activated-mediated apoptosis is caused by the upregulation of
the ligand for Fas, Fas ligand (FasL). Glucocorticoids prevent this upregulation
of FasL, probably by the glucocorticoid-induced leucine zipper (GILZ) gene,
but do not interfere with Fas itself. Another mechanism by which glucocorti-
coids may inhibit activated-mediated apoptosis is the activation of glucocorticoid-
induced TNFR family related (GITR), which can inhibit CD3-mediated but not
Fas-mediated apoptosis. In some diseases there could be a shift in this balance.
Thus, in cases where glucocorticoids are overexpressed, this balance could be
shifted such that a higher level of activated TCR cells survive and thus a greater
population of thymocytes that recognize self could survive (145). Indeed, in au-
toimmune disease models in animals and in patients with the autoimmune disease
multiple sclerosis, there is a higher basal level of glucocorticoids (145, 150).
The involvement of glucocorticoids in thymocyte differentiation and selection
is still a matter of some controversy. Generation of transgenic antisense mice for
the 3
untranslated region of GR under the control of a T cellspecic promoter

led to mice with a twofold reduction of GR mRNA and protein. The thymus of
transgenic homozygotes were 90%smaller than controls, and there was a decrease
in CD4
+
CD8
+
thymocytes and a secondary decrease in CD4
+
CD8
and CD4
CD8
+
thymocytes, which indicates the necessity of glucocorticoids in thymocyte
development and differentiation (144, 145). However, in similar transgenics under
the control of a different promoter (a neurolament promoter), GR levels were
decreased in all tissues, and there was an associated increase in circulating ACTH
and corticosterone. Unlike the T cellspecic antisense animals, no difference
in CD4
+
CD8
+
thymocytes was found (151). In the GR knockin mice, which
are decient in dimerization and are therefore unable to activate gene transcrip-
tion by GR, the thymocyte population was described as being normal although
glucocorticoid-mediated apoptosis was reduced and no extensive analysis was
performed (152).
Recently, GRknockout mice have been described that die at birth [day 19 of em-
bryogenesis (E19)]. However, during embryogenesis, i.e., up to E18, these animals
have apparently normal thymocyte populations and Tcell development, suggesting
that GR in this case in not necessary for the entire process of T cell development
and differentiation (153, 154). The reason for these differences between animal
models is not completely clear, but one signicant difference between these dif-
ferent transgenic animals and knockin animals may result from secondary effects
of the disrupted HPA axis (145).
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DISRUPTION OF THE HPA AXIS AND DISEASE
Animal Models
Animal models have been useful in understanding the pathogenesis of autoim-
mune/inammatory disease. Many animal models exist in which a blunted HPA
axis response has been associated with susceptibility to autoimmune/inammatory
diseases. These include the obese strain (OS) chicken as a model for autoimmune
thyroiditis (155), certain mouse lupus (SLE) models (156, 157), and the inbred
rat strains, LEW/N and F344/N rats, as described earlier. For a review on these
and other animal models for inammatory diseases, refer to Jafarian-Tehrani &
Sternberg (158). It should be noted, however, that many genes and many chromo-
some regions, each with small effect, contribute to susceptibility to autoimmune
diseases, such as SLE (158a) and inammatory arthritis (158b). While some of
these linkage regions contain genes that regulate the HPA axis (158c), many are
unrelated or unknown. Such genetic linkage and segregation studies also indi-
cate that environmental factors play a large role in variance of disease expression.
Thus, many different genetic and environmental factors contribute to autoimmune
susceptibility in addition to HPA or neuroendocrine factors.
Human Diseases
HPA axis responsiveness differs greatly among individuals. Even in healthy in-
dividuals considerable intra-individual variability appears in HPA axis responses.
Normal healthy volunteers have been subgrouped into high or low responders de-
pending on the response of their HPA axis to stimuli (159, 160). Disruptions in the
HPA axis or glucocorticoid response could occur at many levels, including at the
levels of the hypothalamus, pituitary, or adrenals, with changes in the expression
of CRH, ACTH or cortisol, or changes in the sensitivity of the system to stimuli
or suppressive factors. Once cortisol reaches its target tissue, there are then many
steps to inducing gene activation, including entry into the cell, binding to GR,
dimerization, translocation to the nucleus, and interaction with cofactors and the
basal transcription machinery. It is conceivable that interruption of any of these
pathways could result in a defective HPA axis or glucocorticoid response leading
either to a lack of glucocorticoid production or to glucocorticoid resistance and
resultant enhanced autoimmune/inammatory disease. Depending on the specic
defect, patients might or might not respond to exogenous glucocorticoid therapy.
For further reading on glucocorticoid resistance syndromes, see the recent review
by Kino & Chrousos (161).
Disruptions in the HPA Axis or Glucocorticoid Response
Leading to Glucocorticoid Sensitivity and Resistance
HPA AXIS In patient populations it is often difcult to dissect where a problem
lies within the HPA axis, as many of its regulatory components cannot be directly
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146 WEBSTER ET AL.
measured in blood. Furthermore, inammatory illness itself stimulates the HPA
axis and alters its regulation (162, 163). Since CRH cannot be measured directly
in peripheral venous blood, CRH responsiveness must be deduced by measuring
levels of ACTHand cortisol, which can be directly measured in peripheral blood. A
blunted HPAaxis resulting in lowlevels of glucocorticoids or a lowglucocorticoid
response to HPAaxis stimulation has been implicated in a number of inammatory
diseases, including rheumatoid arthritis (164167), systemic lupus erythematosus
(SLE) (168), Sjogrens syndrome (169), allergic asthma and atopic skin disease
(170), and chronic fatigue syndrome (171, 172). Patients with bromyalgia have
a low 24-h urinary free cortisol and a reduced response in the secretion of cortisol
to HPA axis challenge (173). In patients with multiple sclerosis and a high plasma
basal cortisol level, a normal HPA axis response to oCRH but a reduced HPA axis
response to AVP were observed (150).
ADRENAL GLANDS Isolated glucocorticoid deciency (IGD) is an autosomal re-
cessive disorder, characterized by adrenocortical but not mineralocorticoid de-
ciency. Patients generally have low, undetectable cortisol levels that do not increase
with treatment with exogenous ACTH. Also, the endogenous ACTH levels are
high. Seventeen-point mutation and frameshifts in the receptor for ACTH have
been identied that lead to this condition (174176). Thus, this disease results
because defective ACTH receptors render the adrenal gland incapable of sens-
ing the high ACTH levels that continue to be secreted by the pituitary. Thus,
despite high levels of ACTH, little or no cortisol is produced. Novel mutations
in the ACTH receptor have also been described in a patient with ACTH hyper-
sensitivity syndrome. In this case the patient had normal cortisol levels but low,
undetectable ACTH levels (177). There have been some reports of patients with
IGD developing autoimmune disease, such as organ-specic autoimmunity and
autoimmune-mediated hypothroidism (178, 179).
CORTISOL BINDING GLOBULIN (CBG) The level of CBG in the blood limits the
amount of free cortisol available. Changes in the expression of this protein or
in its binding capacity could thus also affect the availability of cortisol. In New
World primates, the lower levels of CBGand the lower afnity of cortisol for CBG
have been associated with the higher circulating levels of glucocorticoids, which
have been suggested to compensate for target organ resistance present in these
mammals (180). In some patients with long-standing Crohns disease, a partial
or complete resistance to steroids has been described; this resistance could be
due to the increased expression of CBG in these patients, thereby limiting the
bioavailability of glucocorticoids (181).
11-HYDROXYSTEROID DEHYDROGENASE This enzyme catalyzes the conversion
between an active glucocorticoid and inactive glucocorticoid (45) as described ear-
lier. Thus, changes in this enzyme could result in differences in circulating or tissue
glucocorticoid concentrations. In obese men, an impairment in the conversion of
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the inactive cortisone to the active cortisol was noted, indicating an impairment
in the type I 11-hydroxysteroid dehydrogenase and resulting in a drop in plasma
cortisol levels (182). A decrease in 11-hydroxysteroid dehydrogenase mRNA in
ulcerative colitis has also been demonstrated (183).
GLUCOCORTICOID RECEPTOR Glucocorticoid resistance has been associated with
mutation of GR. This has been particularly studied in relation to familial gluco-
corticoid resistance, a hereditary condition caused by a mutation in the GR with
associated decreased number of receptors, decreased afnity or stability of the
receptor, and a decrease in translocation of the receptor to the nucleus. To date the
molecular defects of four families and one sporadic case have been determined.
These include three different point mutations in the ligand-binding domain, one
in the hinge region, and a deletion in the ligand-binding domain. [For a review see
Kino & Chrousos (161)].
Amutation in the GRmay not be the only mechanismby which a change in this
gene could affect the sensitivity to glucocorticoids. A polymorphism in codon 363
of GRhas been described and associated with an increased sensitivity to glucocor-
ticoids (184). On the other hand, ve polymorphisms in GR (including the one in
codon 363) have been described in a normal population, and they cannot be cor-
related with glucocorticoid resistance (185). Furthermore, there are patients with
glucocorticoid resistance with no mutation detectable in GR, indicating that other
defects in the steps in the pathway leading to gene activation by glucocorticoids
could result in glucocorticoid resistance (186). The GR has several phosphoryla-
tion sites of which the function is unclear. Mutation of these phosphorylation sites
results in reduced transactivation capability of GR of a minimal promoter and re-
duces the stability of the GRprotein (187). Such changes as in the phosphorylation
status of GR could have profound effects on GR function and be one method by
which glucocorticoid resistance could occur.
GR has been proposed to act as a negative regulator of GR function. Thus,
variations in the level of GR and GR could also be associated with apparent glu-
cocorticoid resistance, both initial and acquired. Glucocorticoid-resistant asthma
has been associated with a higher expression of GR on the peripheral blood
lymphocytes (188, 189). GR expression is induced by cytokine treatment (190);
thus as inammatory disease progresses and cytokines are produced, induced GR
expression could lead to exacerbation or development of glucocorticoid-resistant
disease states (189). Increased expression of GR has been shown in mononuclear
blood cells from patients with glucocorticoid-resistant ulcerative colitis compared
to similar cells from patients with glucocorticoid-sensitive disease (191). A pa-
tient with generalized glucocorticoid resistance and chronic lymphoid leukemia
has been described as having a decreased GR number and a reduced afnity for
dexamethasone. This has been shown to be due not to a mutation in the GRbut to a
redistribution of GR to GR with a reduced expression of GR and an increased
expression of GR (192). Finally, a polymorphism in exon 9 of the human GR
gene has been found to be associated with rheumatoid arthritis. This polymorphism
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148 WEBSTER ET AL.
increases the stability of GR and thus alters glucocorticoid sensitivity (193).
Taken together, these studies suggest that a variety of pre- and posttranslational
changes in both forms of the GR are associated with autoimmune/inammatory
diseases.
COFACTORS Although to date a mutation in a cofactor has not been found asso-
ciated with glucocorticoid resistance, a recent study into the glucocorticoid hy-
persensitive state associated with HIV-1 infection is worthy of comment. This
hypersensitive state is specic to the immune system, the brain, musculoskeletal
system, and fat and liver with maintenance of an intact HPA system. A HIV-1 ac-
cessory protein, virion-associated protein (Vpr), is able to act as a transcriptional
activator to aid the replication of the HIV-1 virus. This protein contains a nuclear
receptor binding motif (LXXLL) that binds directly to GR and cooperatively en-
hances transcription via SRC1a and p300/CBP cofactors (161, 194). Recently, two
sisters have been described with resistance to multiple steroids, and this may be
due to a cofactor defect (195).
TRANSPORT PROTEINS A group of ABC transmembrane transporters, MDR pro-
teins, have been suggested to be involved in the active transport of glucocorticoids
out of cells. Evidence exists that these proteins can transport glucocorticoids (196,
197; J. I. Webster, J. Carlstedt-Duke, unpublished data). These proteins are nor-
mally expressed in the blood-brain barrier, and knockout mice have been generated
for the mouse mdr1a. In these knockout mice, an increase in the amount of dexam-
ethasone present in the brain indicates that this protein is involved in the regulation
of brain glucocorticoids (198, 199). These proteins have been identied through
their involvement in the multidrug resistance phenotype (200). Recently, it was
shown that patients with inammatory bowel disease whom medical therapy had
failed had an increase in the expression of the human MDR1 (ABCB1) (201).
This raises the possibility that these proteins may be another component that could
affect the effectiveness of glucocorticoid therapy by reducing the concentration
of the hormone within the cells and thus reducing the ligand availability for the
GR. The novel orphan receptor PXR is involved in the upregulation of MDR1
(202). Because PXR itself is activated by glucocorticoids among many other lig-
ands (203), this could possibly represent another mechanism by which acquired
glucocorticoid resistance may develop.
OTHER NEUROENDOCRINE FACTORS
AFFECTING IMMUNE FUNCTION
While this review has been focused on the HPA axis and glucocorticoid regulation
of immunity and autoimmune/inammatory disease, many other neural and neu-
roendocrine pathways connect with and regulate the immune system at multiple
levels. These include the sympathetic nervous system and adrenergic factors and
the peripheral nervous system and neuropeptides released by peripheral nerves.
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Adrenergic Factors
The adrenergic sympathetic nervous system modulates local immune responses
[for a comprehensive review of this topic, see Madden et al. (204)]. Noradren-
ergic sympathetic nerve bers run from the CNS to primary and secondary lym-
phoid organs, such as the thymus, spleen, and lymph nodes. These nerve terminals
make synaptic-like connections with neighboring immune cells releasing nora-
drenalin (205). The primary neurotransmitter released from sympathetic nerves,
noradrenalin, exerts its effect at the target tissues through its receptor, the adren-
ergic receptor. Numerous cells of the immune system including lymphocytes and
macrophages express adrenoreceptors. These are G-protein coupled receptors that
can be divided into two subgroupsthe - and -adrenergic receptors. These can
be further subdivided into
1
-,
2
-,
1
-,
2
-, and
3
-adrenergic receptors. The most
important receptor in terms of the immune system is the
2
-adrenergic receptor.
Expression of - and -adrenergic receptors on T and Blymphocytes, neutrophils,
mononuclear cells, and NK cells has been described. Activation of
2
-adrenergic
receptors results in an increase in cyclic AMP concentrations, which can modulate
cytokine expression, i.e., decreasing TNF- and increasing IL-8 (94). It was orig-
inally thought that noradrenalin activated the
2
-adrenergic receptor resulting in
suppressed lymphocyte function. However, more recent data suggest that it mod-
ulates B cell function to protect against or aid progression of immune disease. If
-adrenergic receptors are present on immune cells, then activation of these recep-
tors will lead to the activation of a different signaling cascade and the activation of
MAP kinases. Activation of this cascade has different effects on cellular activity
of immune cells than does activation via the 2 adrenergic receptor (206208).
Furthermore, there appear to be regional difference in the effects of noradrenalin
on immune function. Noradrenalin in the thymus is thought to play a role in mod-
ulation of thymocyte proliferation and differentiation, whereas in the spleen and
lymph nodes it is thought to be involved in enhancement of the primary antibody
response (205).
Sex Hormones
The role of sex hormones, particularly estrogen, in the modulation of the im-
mune system is an extensive and important area of research that is not reviewed
here [for further reading, see Jansson & Holmdahl (209)]. It is noteworthy that
there is a greatly increased riskin the range of two- to tenfold higher female-to-
male ratioof developing many autoimmune/inammatory diseases such as SLE,
rheumatoidarthritis, andmultiple sclerosis inwomencomparedtomen. Regulation
of the immune system by estrogens is of particular importance during pregnancy.
In this case a balance between glucocorticoid and estrogen regulation probably
plays a role in suppression of the maternal immune system to prevent rejection
of the fetus (209). Animal models have provided evidence for the importance of
in vivo modulation of the immune system by the estrogen receptor (210, 211).
There are two receptors for estrogens. Estrogen receptor (ER) was the rst to
be described (212). A second independent gene was identied in 1996 and termed
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150 WEBSTER ET AL.
ER (213). Knockout mice have shown that both estrogen receptors are important
in a gender-specic manner for thymus development and atrophy (214). In addi-
tion, tamoxifen, an estrogen receptor antagonist, has some inhibitory effects on
inammation in LEW/Nfemale rats (215). Sex hormone regulation of the immune
system also varies with aging; for example, expression of IL-6 is under the control
of sex hormones such as estrogen and testosterone. In postmenopausal women and
postandropausal men, the loss of regulation of IL-6 results in increased concen-
trations of IL-6 that is associated with the increased occurrence of inammatory
diseases with old age such as rheumatoid arthritis, bowel disease, and osteoporosis
(84).
CONCLUSION
In summary there are multiple neuro-anatomical, hormonal, and molecular mech-
anisms by which the CNS regulates immune function and plays a role in suscepti-
bility to and pathogenesis of autoimmune/inammatory disease. We have focused
here on the HPA axis and glucocorticoids, the nal effector end point of the HPA
axis in regulating immunity. It is clear that even in the case of a single hormone,
there are many potential mechanisms at gene, protein, receptor, signaling, and cell
function levels where dysregulation could lead to disease. Given the many different
hormonal and nerve pathways that regulate immunity, each with its own specic
molecular end points, the potential mechanisms for pathogenesis of autoimmune
disease(s) resulting from disruptions in these interactions is large. Nonetheless, a
thorough understanding at all levels of the means by which the CNS and immune
systems communicate will provide many new insights into the bidirectional reg-
ulation of these systems and the disruptions in these communications that lead to
disease. Ultimately this understanding will inform new avenues of therapy.
ACKNOWLEDGMENTS
The authors would like to thank Melanie Vacchio for critically reading the manu-
script and for useful discussions.
Visit the Annual Reviews home page at www.annualreviews.org
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P1: FRK
February 1, 2002 12:47 Annual Reviews AR152-FM
Annual Review of Immunology
Volume 20, 2002
CONTENTS
FRONTISPIECE, Charles A. Janeway, Jr. xiv
A TRIP THROUGH MY LIFE WITH AN IMMUNOLOGICAL THEME,
Charles A. Janeway, Jr. 1
THE B7 FAMILY OF LIGANDS AND ITS RECEPTORS: NEW PATHWAYS
FOR COSTIMULATION AND INHIBITION OF IMMUNE RESPONSES,
Beatriz M. Carreno and Mary Collins 29
MAP KINASES IN THE IMMUNE RESPONSE, Chen Dong, Roger J. Davis,
and Richard A. Flavell 55
PROSPECTS FOR VACCINE PROTECTION AGAINST HIV-1 INFECTION
AND AIDS, Norman L. Letvin, Dan H. Barouch, and David C. Monteori 73
T CELL RESPONSE IN EXPERIMENTAL AUTOIMMUNE
ENCEPHALOMYELITIS (EAE): ROLE OF SELF AND CROSS-REACTIVE
ANTIGENS IN SHAPING, TUNING, AND REGULATING THE
AUTOPATHOGENIC T CELL REPERTOIRE, Vijay K. Kuchroo,
Ana C. Anderson, Hanspeter Waldner, Markus Munder, Estelle Bettelli,
and Lindsay B. Nicholson 101
NEUROENDOCRINE REGULATION OF IMMUNITY, Jeanette I. Webster,
Leonardo Tonelli, and Esther M. Sternberg 125
MOLECULAR MECHANISM OF CLASS SWITCH RECOMBINATION:
LINKAGE WITH SOMATIC HYPERMUTATION, Tasuku Honjo, Kazuo
Kinoshita, and Masamichi Muramatsu 165
INNATE IMMUNE RECOGNITION, Charles A. Janeway, Jr. and Ruslan
Medzhitov 197
KIR: DIVERSE, RAPIDLY EVOLVING RECEPTORS OF INNATE AND
ADAPTIVE IMMUNITY, Carlos Vilches and Peter Parham 217
ORIGINS AND FUNCTIONS OF B-1 CELLS WITH NOTES ON THE ROLE
OF CD5, Robert Berland and Henry H. Wortis 253
E PROTEIN FUNCTION IN LYMPHOCYTE DEVELOPMENT, Melanie
W. Quong, William J. Romanow, and Cornelis Murre 301
LYMPHOCYTE-MEDIATED CYTOTOXICITY, John H. Russell and
Timothy J. Ley 323
SIGNAL TRANSDUCTION MEDIATED BY THE T CELL ANTIGEN
x
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P1: FRK
February 1, 2002 12:47 Annual Reviews AR152-FM
CONTENTS xi
RECEPTOR: THE ROLE OF ADAPTER PROTEINS, Lawrence E. Samelson 371
INTERACTION OF HEAT SHOCK PROTEINS WITH PEPTIDES AND
ANTIGEN PRESENTING CELLS: CHAPERONING OF THE INNATE AND
ADAPTIVE IMMUNE RESPONSES, Pramod Srivastava 395
CHROMATIN STRUCTURE AND GENE REGULATION IN THE IMMUNE
SYSTEM, Stephen T. Smale and Amanda G. Fisher 427
PRODUCING NATURES GENE-CHIPS: THE GENERATION OF PEPTIDES
FOR DISPLAY BY MHC CLASS I MOLECULES, Nilabh Shastri, Susan
Schwab, and Thomas Serwold 463
THE IMMUNOLOGY OF MUCOSAL MODELS OF INFLAMMATION, Warren
Strober, Ivan J. Fuss, and Richard S. Blumberg 495
T CELL MEMORY, Jonathan Sprent and Charles D. Surh 551
GENETIC DISSECTION OF IMMUNITY TO MYCOBACTERIA: THE HUMAN
MODEL, Jean-Laurent Casanova and Laurent Abel 581
ANTIGEN PRESENTATION AND T CELL STIMULATION BY DENDRITIC
CELLS, Pierre Guermonprez, Jenny Valladeau, Laurence Zitvogel, Clotilde
Th ery, and Sebastian Amigorena 621
NEGATIVE REGULATION OF IMMUNORECEPTOR SIGNALING, Andr e
Veillette, Sylvain Latour, and Dominique Davidson 669
CPG MOTIFS IN BACTERIAL DNA AND THEIR IMMUNE EFFECTS,
Arthur M. Krieg 709
PROTEIN KINASE C IN T CELL ACTIVATION, Noah Isakov and Amnon
Altman 761
RANK-L AND RANK: T CELLS, BONE LOSS, AND MAMMALIAN
EVOLUTION, Lars E. Theill, William J. Boyle, and Josef M. Penninger 795
PHAGOCYTOSIS OF MICROBES: COMPLEXITY IN ACTION, David
M. Underhill and Adrian Ozinsky 825
STRUCTURE AND FUNCTION OF NATURAL KILLER CELL RECEPTORS:
MULTIPLE MOLECULAR SOLUTIONS TO SELF, NONSELF
DISCRIMINATION, Kannan Natarajan, Nazzareno Dimasi, Jian Wang,
Roy A. Mariuzza, and David H. Margulies 853
INDEXES
Subject Index 887
Cumulative Index of Contributing Authors, Volumes 120 915
Cumulative Index of Chapter Titles, Volumes 120 925
ERRATA
An online log of corrections to Annual Review of Immunology
chapters (if any, 1997 to the present) may be found
at http://immunol.annualreviews.org/
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8 Feb 2002 9:39 AR AR152-06.tex AR152-06.

SGM LaTeX2e(2001/05/10) P1: GJC

Jeanette I. Webster, Leonardo Tonelli,

National Institute of Mental Health, Section on Neuroimmune Immunology and Behavior,

untranslated region of GR under the control of a T cellspecic promoter

A, Okret S. 2000. Glucocorticoid effects

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