EVALUATION OF THE POSSIBLE ROLE OF IL-17 AND ITS RECEPTOR IL-17R IN THE PATHOGENESIS OF ORAL LICHEN PLANUS | ||||
Al-Azhar Journal of Dental Science | ||||
Article 1, Volume 19, Issue 1, January 2016, Page 1-8 | ||||
Document Type: Original Article | ||||
DOI: 10.21608/ajdsm.2016.69612 | ||||
View on SCiNiTO | ||||
Authors | ||||
Amal A Hussine1; Amira Maged Abdel Azim2; Rasha Wagih Mosatafa2; Laila Rashid3 | ||||
1Dept. Oral Medicine, Peridontology and Diagnosis. Faculty of Oral and Dental Medicine, Cairo University, Egypt | ||||
2Dept of Oral Medicine, Periodontolgy and Diagnosis, Faculty of Dental Medicine, Cairo University, Egypt | ||||
3Biochemistry Dept, Faculty of Medicine, Cairo University, Egypt | ||||
Abstract | ||||
Introduction: Oral Lichen Planus (OLP) is considered a T cell mediated disease with unknown etiology. T helper cells appear to play an important role in the pathogenesis of OLP.Interleukin-17 (IL-17) is the signature cytokine of T helper (Th) cells. Recent studies suggested that IL-17 may be involved in the pathogenesis of OLPand homeostasis of tissues beyond the immune system.Interleukin-17 receptor (IL-17R) expression is working in disparate tissuessuch as articular cartilage, bone, meniscus, brain, hematopoietic tissue, kidney, lung, skin and intestine. Aim of the study: This study evaluated the possible correlation between serum and tissue levels of IL-17 as well as the expression of its tissue receptor in order to detect their possible role in the etio-pathogenesis of OLP. Subjects and methods: 20 patients with OLP and 10 healthy volunteers were recruited. Serum and tissue IL-17 levels were assessed by using an Enzyme Linked Immune-Sorbent Assay (ELISA), whileIL-17R gene expression was detected by quantitative real time polymerase chain reaction (qRT-PCR). Results : Results showed that the mean serum and tissue levels of IL-17 as well as mean tissue level of IL-17R in OLP were significantly higher compared to the controls (P value < 0.001),and there was a statistically significant positive (direct) correlation between serum IL-17 andboth tissue level of IL-17 and its tissue receptor. Discussion : This study demonstrated the increased expression of serum and tissue level of IL-17 and IL-17 tissue receptor in OLP patients, suggesting that IL-17 and its receptor in affected tissues may be associated with the pathogenesis of OLP and that IL-17 may be considered an important diagnostic pro-inflammatory cytokine in OLP. Conclusions and recommendations: Further studies are required to investigate the immune-pathologic mechanisms and therapeutic target of IL-17 in OLP. | ||||
Keywords | ||||
Interleukin 17; interleukin 17 receptor; Oral lichen planus | ||||
Full Text | ||||
LP is a relatively common chronic inflammatory muco-cutaneous disease of probable immune based etiology, and involves oral and genital mucosal surfaces, skin, scalp and nails. OLP presents oral mucosal lesions such as white striations, papules, plaques, erythema, blisters or ulcers.
(1) LP is characterized by a T cell mediated immune response against epithelial cells, causing epithelial cell damage and subepithelial persistent accumulation of T lymphocytes. The mechanism involved in this chronic inflammatory disease remains unclear.
(2-4) Cell mediated immunity in OLP may be regulated by various cytokines and their receptors,
(5) so identification of the specificity of T helper cells(Th) is one of the most important steps to reveal pathogenesis and etiology of OLP. * Lecturer at Department of Oral Medicine, Periodontology and Diagnosis, Faculty of Oral and Dental Medicine, Cairo University. ** Prof. at Department of Medical Biochemistry, Faculty of Medicine, Cairo University. Al-Azhar Journal of Dental Science Vol. 19 - No. 1 - January 2016 2
Amal A. Hussine, et al. A.J.D.S. Vol. 19, No. 1 Although cytotoic CD8+T lymphocytes are the majority of intraepithelial lymphocytes and subepithelial lymphocytes in OLP, most lymphocytes in the lamina propria are identified as CD4+ T cells. (5, 6)
CD4+ helper cells have been suggested to play an important role in cytotoxic CD8+T cell activation via T helper cell related cytokine release.
(6) It is well accepted that two CD4+ helper T cells subsets namely Th1 and Th2 are associated with immunopathogenesis of OLP. Th1 and Th2 cells are identified by their signature cytokines interferon gamma (IFN γ) and IL-4 respectively.
(5, 7) Recently, Th 17 cells (IL-17 producing CD4 T cells) have been discovered as a unique subset of T helper cells that develop along with a pathway that distinct from the Th1 and Th2 differentiation pathways. Th17 cells are characterized by the production of potent pro-inflammatory cytokines IL-17, IL-17 f, IL-21, IL-22 and IL-26, which suggests that these cells function as pleiotropic pro-inflammatory T helper cells.
(8, 9) IL-17 (also referred as IL-17A) is the signature cytokine of T helper 17 cells, which are considered a key T cell subset involved in the etiology of autoimmune and inflammatory disorders such as Lupus Erythematosis, Multiple Sclerosis, Rheumaroid Arthritis and tumor microenvironments.
(10, 11, 12) The human IL-17A gene is a protein of 150 amino acids with a molecular weight of 15 KDa and is secreted as disulfide linked homodimer of 30-35 KDa glyco-proteins.
(13) There were five related cytokines identified (B, C, D, E, F), that share 20- 50% homology to IL- 17A. IL-17A has been designated A to indicate that it is the essential member of the IL-17 cytokines family.
(14) IL-17 has been shown to signal through the IL- 17R molecule and promoting production of tumor necrosis factor alpha (TNF-α), IL-1ß IL-6, IL-8 and granulocyte colony stimulating factor (G-CSF).
(15-17) Thus, IL-17A functions as a pro-inflammatory cytokine which can activate different cells such as epithelial, endothelial, fibroblast, chondrocyte and osteoblast producing numerous inflammatory molecules including cytokines, chemokines, defensins and MMPs.
(14, 18) The receptor for IL-17A (IL-17R) is a single pass-transmembrane protein of approximately 130 KDa, while the IL-17A cytokine expressed only by T cells, its receptor is expressed in all tissues examined. The activation of the receptor by IL- 17A generally results in the induction of other proinflammatory cytokines through activation of NK-Kß.
(19) Although it is accepted that OLP is a localized disease, an increasing number of studies indicate that many significant changes in peripheral blood are implicated in the pathogenesis.
(20, 21, 22)Several previous investigations focused on the alteration of T lymphocyte subsets in the peripheral blood of OLP lesions.
(22) Some studies found the presence of IL-17 in the local lesion of OLP, suggesting its role in local environments.
(23) Other studies detected the serum and saliva levels of IL-17 in OLP patients, but found no significant difference compared to healthy groups.
(24) The aim of this study was to investigate possible correlation between serum and tissue levels ofIL- 17 as well as the expression of its tissue receptor in order to detect their possible role in the etiopathogenesisof OLP. SUBJECTS AND METHODS I. Study Population The entire study sample comprised 30 individuals;
20 oral lichen planus (OLP) patients were selected, in addition, 10 age and sex matched healthy normal volunteer individuals free from any systemic diseasewere recruited as control subjects. A.J.D.S. Vol. 19, No. 1 EVALUATION OF THE POSSIBLE ROLE OF IL-17 AND ITS RECEPTOR 3 II. Inclusion and exclusion criteria All subjects participated in this study were selected from the Outpatient Clinic, Department of Oral Medicine, Oral Diagnosis and Periodontology, Faculty of Oral and Dental Medicine, Cairo University, between February 2014 and December 2014. A detailed medical history of each subject was obtained according to the detailed questionnaire of the modified Cornell Medical Index.
(20) All subjects were free from any systemic disease and did not receive any medication either topical or systemic that could cause lichenoid reaction during the 3 months prior to the specimen collection. Moreover, patients with suspected restoration-related reaction were excluded from this study. All patients had oral symptoms, and every case was clinically diagnosed as erosive lichen planus (ELP) or atrophic lichen planus(ALP). Duration of the disease ranged from 2 to 3 months with periods of remission and exacerbation. The lesions were bilaterally selected and extended to involve the buccal mucosa, labial mucosa, and tongue which varied from one patient to another. Diagnosis was confirmed by histopathologic examination according to the World Health Organization’s (WHO’s) clinicopathological diagnostic criteria for LP.
(21) III. Ethical procedures: All subjects were informed about the detailed procedure and they were given written approval consent to sign. Patients were treated after the samples had been collected. The study was performed between February 2014 and December 2014. The thirty selected participants were divided into two groups as follow:- Group A: It included 20 patients suffering from OLP, 3 males and 12 females. Their ages ranged from 36-48 years. Group B: It included 10 medically free subjects as controls, 4 males and 11 females. Their ages ranged from 35-42 years. VI. Collection of samples i. Serum sample collection Peripheral venous blood samples (5 ml) were obtained by standardvenipuncture from subjects using plain tubes. Samples were centrifuged. The clarifying supernatant was filtered and stored at −20 °C until assayed. Serum IL-17 level was determined using a special kit (Human IL-17, ELISA Crokit ko13207p, South Korea) with ELISA assay according to manufacturer’s instructions. ii. Tissue samples. 20 OLP lesion specimens were biopsied from selected patients, and 10 normal oral mucosa (NOM) tissues were collected from healthy volunteers receiving ortho-gnathic surgery. IL-17protein in tissue levels were assessed using same ELISA kit. Real-time RT-PCR: Detection of tissue IL-17 receptor gene expression by Quantitative real time polymerase chain reaction (qRT-PCR). Total RNA was extracted from frozen tissue samples using the RN easy Mini Kit (Qiagen Inc) following the manufacturer’s protocol, extracted RNA was quantified by spectrophotometry. The RNA integrity was assessed using agarose gel electrophoresis and ethidium bromide staining. 2 μg of total RNA were reverse transcribed in 0.05 M Tris–HCl pH 8.3, 40 mM KCl, 7 mM MgCl2 buffer containing 0.05 μg of random hexamers, 1 mM dNTPs mix, 0.05 U/l RNase inhibitor and 200 U/l murineleukemia virus reverse transcriptase 4
Amal A. Hussine, et al. A.J.D.S. Vol. 19, No. 1 M-MLV. Samples were incubated for 10 min at 70˚C and then 60 min at 37 C. Inactivation of the reverse transcriptase was achieved by heating the samples at 95C for 10 min. Real-time RT-PCR for quantitative assessment of mRNA expression was performed on step one plus (Applied Biosystems, USA), reaction contained SYBR Green Master Mix (Applied Biosystems), gene-specific forward and reverse primers (10 μM), cDNA and nuclease-free water. The sequences of PCR primer pairs used for each gene are shown in Table 1. With cycling conditions (10 min at 95°C followed by 40 cycles of 15 s at 95°C and 60 s at 60°C). The level of expression of each target gene was normalized relative to the expression of GAPDH mRNA in that sample using the ΔCt method. Relative differences in gene expression among groups were determined using the comparative Ct (ΔΔCt) method and fold expression was calculated as 2
−ΔΔCt, where ΔΔCt represents ΔCt values normalized relative to the mean ΔCt of control samples (R). TABLE (1) Primer sequences used for RT-PCR(25) Primer Sequence IL-17
Forward primer :5′-GCTCCAGAAGGCCC TCAGACT-3′ Reverse primer : 5′-CCAGCTTTCCCTCCGCATTGA-3′ IL-17 R A Forward: 5′-AGACACTCCAGAACCAATTCC-3′, Reverse: 5′-TCTTAGAGTTGCTCTCCACCA-3′, GAPDH Forward: 5`-AGA GAT ATC CCT CTG TG ATC-3` Reverse: 5`-TAC CCC AAA GTT ATC TCA GG-3`′ V. Statistical Analysis: Quantitative data were presented as mean, median, standard deviation (SD), range (Minimum – Maximum) and 95% Confidence interval (95% CI) for the mean values. Data were explored for normality by checking the data distribution and using Kolmogorov-Smirnov and Shapiro-Wilk tests. IL-17 levels data showed parametric distribution. Student’s t-test was used to compare between the two groups. Pearson’s correlation coefficient was used to determine the correlation between IL-17 levels in serum, tissue and tissue receptor. ROC (Receiver Operating Characteristic) curve was constructed to determine the cut-off values of IL-17 for detection of OLP. Areas under the ROC curve (AUCs), sensitivity, specificity, predictive values and diagnostic accuracy was calculated. The significance level was set at P ≤ 0.05. Sta
tistical analysis was performed with IBM
® SPSS® Statistics Version 20 for Windows. Comparison between the two groups In serum, tissues as well as tissue receptor, study group showed statistically significantly higher mean IL-17 level than control group ( Table 2, figure 1)). Correlation between serum and receptor IL-17 levels There was a statistically significant positive (direct) correlation between serum and receptor IL-17 levels (
r = 0.940, P-value <0.001) i.e. an increase in serum level of IL-17 is associated with an increase in receptor level of IL-17 (Fig. 2). Correlation between serum and tissue IL-17 levels There was a statistically significant positive (direct) correlation between serum and tissue IL-17 levels (
r = 0.862, P-value <0.001) i.e. an increase in serum level of IL-17 is associated with an increase in tissue level of IL-17 (Fig. 3). Correlation between receptor and tissue IL-17 levels There was a statistically significant positive (direct) correlation between receptor and tissue IL-17 levels (
r = 0.828, P-value <0.001) i.e. an increase in receptor level of IL-17 is associated with an increase in tissue level of IL-17 (Fig.4). ®
IBM Corporation, NY, USA. ®SPSS, Inc., an IBM Company. A.J.D.S. Vol. 19, No. 1 EVALUATION OF THE POSSIBLE ROLE OF IL-17 AND ITS RECEPTOR 5 TABLE (2) Descriptive statistics and results of Student’s t-test for comparison between IL-17 serum, tissue levels as well as IL-17 tissue receptor levels in the two groups Group Mean SD Median Minimum Maximum 95% CI Lower
P-value bound Upper bound Serum Study 113.3 21.5 107.0 67.4 162.8 103.2 123.4 <0.001* Control 25.5 6.7 24.1 18.2 40.6 20.8 30.3 Receptor Study 9.6 2.8 10.1 4.9 13.7 8.3 10.9 <0.001* Control 1.1 0.1 1.0 0.9 1.3 1.0 1.2 Tissue Study 142.6 26.5 142.7 97.3 201.3 130.2 155.0 <0.001* Control 43.4 8.3 41.7 33.4 61.2 37.5 49.4 *: Significant at P ≤ 0.05 FIG (1) Bar chart representing mean and standard deviation values of IL-17 levels in the two groups FIG (3) Scatter diagram representing positive correlation between serum and tissue levels of IL-17 FIG (2) Scatter diagram representing positive correlation between serum and receptor levels of IL-17 FIG (4) Scatter diagram representing positive correlation between receptor and tissue levels of IL-17 6
Amal A. Hussine, et al. A.J.D.S. Vol. 19, No. 1 ROC curve analysis (Cut-off values) ROC curve analysis of serum, receptor and tissue levels of IL-17 in the present study showed cut-off values of 40.6, 1.3 and 61.2 pg/ml, respectively. DISCUSSION The pathogenesis of OLP still remains poorly understood although it is characterized by a T cell mediated immune response against epithelial cells causing epithelial cell damage and subepithelial infiltration of T lymphocytes.
(26, 27)Interleukin-17 family consists of cytokines that are secreted by Th- 17 cells and have an important role in the regulation of mucous and epithelial immune responses.
(28) There is increasing evidence that IL-17 is a critical pro-inflammatory cytokine in human autoimmune diseases, and it has previously been demonstrated to stimulate the expression of TNF-α and IL-6 in several cell types including keratinocytes, fibroblasts, endothelial cells and macrophages, as well as inducing the production of several chemokines, such as CCL-20 and CXCL-8
(8). High levels of IL-17 and Th17 cells can provoke an inflammatory response and are correlated with autoimmune diseases such as inflammatory bowel disease, rheumatoid arthritis, multiple sclerosis and psoriasis.
(29,30) TABLE (3) Sensitivity, specificity, predictive values, diagnostic accuracy, Area under the ROC curve (AUC), 95% confidence interval (95% CI) of serum and tissue IL-17 levels IL-17 (pg/ml) Cut-off Sensitivity %
Specificity % +PV% -PV% Diagnostic accuracy % AUC 95% CI Serum 40.6 100.0 100.0 100.0 100.0 100.0 1.000 0.884 – 1.000 Receptor 1.3 100.0 100.0 100.0 100.0 100.0 1.000 0.884 – 1.000 Tissue 61.2 100.0 100.0 100.0 100.0 100.0 1.000 0.884 – 1.000 +PV: Positive Predictive Value, -PV: Negative Predictive Value At these cut-off values, the diagnostic accuracy of IL-17 as a marker for detecting OLP is 100.0%. Results of ROC curve analysis are presented in Table (3) A previous study demonstrated that Th1 and Th17 were scattered in lamina propria of local lesions in OLP, in addition, there was increased proportions of circulating Th1 and Th17 cells,
(31) which correlates closely with our findings of increased IL-17 in serum and tissue with increased expression of IL-17R in the local lesions, indicating that IL-17 mediates immune response in OLP. Recent studies have suggested that different lichenoid tissue reaction/ interface dermatitis disorder, including lichen planus and psoriasis, may share a common inflammatory signaling pathway
(32) which supports our research studying the IL-17 and its receptor expression in local lesions of OLP correlating them with serum IL-17 levels. In a study done by Ruilu et al,
(33) they observed a large number of IL-17 + cells located in the sub
epithelial lymphocytic infiltrate in the OLP lesions and showed increased higher mRNA expression of IL- 17 in OLP lesions compared to the normal tissues. In our study we investigated these findings by measuring IL-17 itself in local environment to prove whether mRNA completed its transduction A.J.D.S. Vol. 19, No. 1 EVALUATION OF THE POSSIBLE ROLE OF IL-17 AND ITS RECEPTOR 7 pathway and gave its final product IL-17. In addition, we measured IL-17R in the local lesions to be sure that IL-17 will perform its action. In the present study, it was found that there is a statistically significant relation between the increases of IL-17 in serum of patient than in normal individual. These findings are also consistent with the published study by Piccinni and his colleagues who also found an elevated mRNA expression of IL-17, together with other TH-17 type molecules in OLP lesions compared to healthy mucosa.
(33 )Moreover, the presence of Th17 was also identified in another study conducted by Xie et al
(31) Overexpression of IL-17 in OLP lesions highlighted its potent pro-inflammatory properties which may induce profound biological effects and play an important role in the formation and progress of the disease, especially that our study not only found an increase in the local lesion, but also in serum of the patients. This phenomenon indicated that the overexpression of IL-17 in OLP lesions attributes not only to the lymphocytic infiltration, but also to other unknown regulatory mechanisms, which is recommended for further exploration. Finding possible techniques and materials that control and decrease IL-17 serum levels may open new horizons to the treatment of such medical condition other than corticosteroids with their side | ||||
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