Cellular immune activation in cerebrospinal fluid from ugandans with cryptococcal meningitis and immune reconstitution inflammatory syndrome

David B Meya, Samuel Okurut, Godfrey Zziwa, Melissa A Rolfes, Melander Kelsey, Steve Cose, Moses Joloba, Prossy Naluyima, Brent E Palmer, Andrew Kambugu, Harriet Mayanja-Kizza, Paul R Bohjanen, Michael A Eller, Sharon M Wahl, David R Boulware, Yuka C Manabe, Edward N Janoff, David B Meya, Samuel Okurut, Godfrey Zziwa, Melissa A Rolfes, Melander Kelsey, Steve Cose, Moses Joloba, Prossy Naluyima, Brent E Palmer, Andrew Kambugu, Harriet Mayanja-Kizza, Paul R Bohjanen, Michael A Eller, Sharon M Wahl, David R Boulware, Yuka C Manabe, Edward N Janoff

Abstract

Background: Human immunodeficiency virus (HIV)-associated cryptococcal meningitis (CM) is characterized by high fungal burden and limited leukocyte trafficking to cerebrospinal fluid (CSF). The immunopathogenesis of CM immune reconstitution inflammatory syndrome (IRIS) after initiation of antiretroviral therapy at the site of infection is poorly understood.

Methods: We characterized the lineage and activation status of mononuclear cells in blood and CSF of HIV-infected patients with noncryptococcal meningitis (NCM) (n = 10), those with CM at day 0 (n = 40) or day 14 (n = 21) of antifungal therapy, and those with CM-IRIS (n = 10).

Results: At diagnosis, highly activated CD8(+) T cells predominated in CSF in both CM and NCM. CM-IRIS was associated with an increasing frequency of CSF CD4(+) T cells (increased from 2.2% to 23%; P = .06), a shift in monocyte phenotype from classic to an intermediate/proinflammatory, and increased programmed death ligand 1 expression on natural killer cells (increased from 11.9% to 61.6%, P = .03). CSF cellular responses were distinct from responses in peripheral blood.

Conclusions: After CM, T cells in CSF tend to evolve with the development of IRIS, with increasing proportions of activated CD4(+) T cells, migration of intermediate monocytes to the CSF, and declining fungal burden. These changes provide insight into IRIS pathogenesis and could be exploited to more effectively treat CM and prevent CM-IRIS.

Keywords: HIV; cell activation; cerebrospinal fluid; cryptococcal meningitis; cryptococcus; immune responses.

© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America.

Figures

Figure 1.
Figure 1.
Flow cytometry gating strategy for cerebrospinal fluid (CSF) cells. Analytic gating of the flow cytometry data. A, White blood cells in CSF were separated from cryptococcal cells using a CD45 gate. B, Neutrophils and debris were separated from CD45+ cells on the basis of forward-scatter area (FSC-A) and side-scatter area (SSC-A). C, Broad natural killer (NK) cell gate, monocyte gate, and lymphocyte populations were selected. D, CD3+ T-cell subset populations were identified. E, NK-cell subsets were then identified based on differential expression of CD16/56. F, Monocyte subsets were defined based on differential CD14/16 expression. G, Activation by HLA-DR expression on T cells, here showing expression on CD4+ T cells. H, HLA-DR expression on NK cells, showing expression on the CD56bright subset. I, Programmed death ligand 1 (PD-L1) expression on NK cells, showing expression on CD56bright subset. J, PD-L1 expression on monocytes, showing expression on classic monocytes.
Figure 2.
Figure 2.
Study flow diagram. Distribution of subjects with suspected meningitis and etiology of meningitis in a nested cohort of human immunodeficiency virus-infected subjects in the Cryptococcal Optimal Antiretroviral Timing (COAT) trial and Neurological Outcomes on ART (NOAT) study in Mulago National Referral Hospital, Kampala, Uganda. Abbreviations: CM, cryptococcal meningitis; CSF, cerebrospinal fluid; EBV, Epstein-Barr virus; IRIS, with immune reconstitution inflammatory syndrome.
Figure 3.
Figure 3.
Cellular activation in cerebrospinal fluid (CSF) among subjects with cryptococcal meningitis (CM) and noncryptococcal meningitis (NCM). Activation of CD4+, CD8+, and natural killer (NK) cells in CSF is shown by HLA-DR expression and programmed death ligand 1 (PD-L1) expression on monocytes and NK cells. CSF was analyzed with flow cytometry at day 0 and day 14 of CM treatment among subjects with CM (n = 21) or NCM (n = 16) at meningitis diagnosis.
Figure 4.
Figure 4.
Cell phenotype and activation in matched blood and cerebrospinal fluid (CSF) at diagnosis of cryptococcal meningitis with immune reconstitution inflammatory syndrome (CM-IRIS). Cell lineages in the CSF and peripheral blood compartments (top panel) and monocyte subsets (middle panel) are shown for 6 subjects at the diagnosis of CM-IRIS. The frequency of natural killer cells (not shown) was similar. Bottom panel shows HLA-DR expression on T cells and programmed death ligand 1 (PD-L1) expression on monocyte subsets.

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Source: PubMed

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