Sarcoidosis and Autoimmunity: Evidence of Differential Associations with HLA Class II Markers

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Article Information:


Group: 2006
Subgroup: Volume 4, Issue 1, Winter
Date: January 2006
Type: Original Article
Start Page: 13
End Page: 18

Authors:

  • K I Papadopoulos
  • Department of Endocrinology, cGastroenterology and Hepatology Division, Department of Medicine, University of Lund, Malmö University Hospital, Malmö, Sweden
  • R Wassmuth
  • Department of Medicine III, Institute for Clinical Immunology, University of Erlangen-Nürnberg, Germany,
  • T Sponsel
  • Department of Medicine III, Institute for Clinical Immunology, University of Erlangen-Nürnberg, Germany,
  • K Sjöberg
  • Gastroenterology and Hepatology Division, Department of Medicine, University of Lund, Malmö University Hospital, Malmö, Sweden
  • B Hallengren
  • Department of Endocrinology, cGastroenterology and Hepatology Division, Department of Medicine, University of Lund, Malmö University Hospital, Malmö, Sweden

      Correspondence:

      Affiliation: Department of Endocrinology, cGastroenterology and Hepatology Division, Department of Medicine, University of Lund, Malmö University Hospital
      City, Province: Malmö,
      Country: Sweden
      Tel:
      Fax:
      E-mail: kostas@thaistemlife.co.th

Abstract:


Ahigh frequency of endocrine autoim munity and gastrointestinal immune reactivity has been reported in sarcoidosis. The aim of the present study was to determine the immunogenetic background of sarcoidosis focusing on the associated autoim- mune manifestations. Materials and Methods: A total of 66 (38 males, 28 females) and /65 (37 males, 28 females) Cauca- sian patients with documented sarcoidosis diag- nosed at the Department of Pulmonary Medi- cine, Malmö University Hospital were genomi- cally typed for DRB1/DQB1. Results: The frequencies of HLA-DRB1*02 (p=0.004), DRB1*14 (p=0.022), DQB1*0602 (p=0.027), DQB1*0503 (p=0.022), were signifi- cantly increased in the whole group of patients with sarcoidosis as well as in sarcoidosis associ- ated with autoimmune manifestations compared to healthy controls. Conclusions: Significant associations of HLA- DRB1*02 and *14 and DQB1*0602 and *0503 with sarcoidosis were found, particularly apparent in the subgroup with associated autoimmune mani- festations. Different immunogenetic profiles may thus exist in sarcoidosis indicative and/or causative of distinct clinical subgroups. HLA class II presentation of a putative sarcoidosis- specific antigen might be of vital importance in sarcoidosis, deciding the direction of the sarcoid disease and eventual associations with it. Whether the above mentioned HLA class II hap- lotypes and/or their linked genes, alone or in unison with HLA class I, are organ- or disease- specific remains to be determined.

Keywords: Autoimmunity;HLA;Polyglandular Autoimmune Syndromes;Sarcoidosis;Thyroid

Manuscript Body:


Introduction

Sarcoidosis is regarded today as a systemic disorder that can affect virtually all organs of the body. The contraction of the disease seems to require both exposure to an antigenic stimulus and a genetic predisposition to react against this stimulus with an immune reaction, resulting in the pathological hallmark of the disease: the non-caseating granuloma.1 Immune granuloma formation implies a specific, T-cell-mediated response to a persistent, poorly degradable antigen that has previously been processed by macrophages and presented by HLA molecules to antigenspecific-T-cells.1 Indeed, the expansion of oligoclonal T-cell receptor (TCR)-specific T-cells at sites of granulomatous inflammation has been observed, providing evidence for conventional antigen-driven T-cell responses in sarcoidosis.2 Berlin and co-workers suggested that HLA class II presentation of a putative sarcoidosis-specific antigen might be of vital importance in sarcoidosis, deciding the direction of the sarcoid disease.3 Preferential use of specific TCR genes in Scandinavian sarcoidosis patients, associated with specific HLA haplotypes, has been shown.4
HLA class II associations have been studied extensively in sarcoidosis in many ethnic groups. Strong associations have been reported with HLA–DR35, DR5, DR6 and DR85 with a high prevalence of HLA-DR3 and DR4 among females and of -DR5 among males.6 Furthermore, in the Japanese population, associations between the HLA-DR52 group antigen-associated alleles (serologically DR3 encoded by DRB1*03, serologically DR5 encoded by DRB1*11/12, serologically DR6 encoded by DRB1*13/14), DR8 (DRB1*08), and sarcoidosis have been reported several times.6 In Scandinavians, a strong correlation has been established between HLA-DRB1*03 and acute sarcoidosis with good prognosis, and DRB1*02DQB1*0602 and DRB1*14-DQB1*0503 and a chronic form of sarcoidosis.3
A high frequency of endocrine autoimmunity including PGA syndromes, and gastrointestinal immune reactivity has recently been reported by us and others, to occur in patients with sarcoidosis.7 As sarcoidosis has been associated with a number of different HLA specificities depending on the clinical presentation, sarcoidosis may either be a heterogeneous disease or may have a role in the occurrence of various autoimmune diseases. Thus, the aim of the present study was to determine the immunogenetic background of sarcoidosis focusing on the associated autoimmune manifestations.
 

Materials and Methods

Patients: A total of 66 (38 males, 28 females) and /65 (37 males, 28 females) Caucasian patients were genomically typed for DRB1/DQB1 (median age at diagnosis of sarcoidosis 30.5/31 years, range 16-75; median observation time 126/120 months, range 1-468; steroid treatment 24/23 of 66/65, 35.4/36.4%, median treatment time 42/48 months, range 2-420). Those patients had documented sarcoidosis diagnosed at the Department of Pulmonary Medicine, Malmö University Hospital between January 1980 and December 1991. The diagnosis of sarcoidosis was based on histological or clinical, biochemical and radiological evidence.8 No distinction was made between patients with acute or chronic sarcoidosis. The patients with sarcoidosis were divided into two subgroups according to the presence (N=34) or absence (N=32) of autoimmune manifestations7 and were compared to each other and to the control group. The autoimmune manifestations such as thyroid autoimmunity and gastrointestinal immune reactivity, (gluten immune reactivity and gastric autoimmunity) were defined as present when seropositivity was detected for microsomal/thyroglobulin, gluten IgA/IgG and H+/K+ ATPase antibodies respectively and/or corresponding clinical disease was diagnosed according to our previous studies.7 In the case of thyroid autoimmunity, patients with clinical thyroid disease, Graves´ disease and autoimmune (Hashimoto) thyroiditis (verified by serological studies and/or fine-needle biopsy) were classified as clinical autoimmune thyroid disease (ATD). ATD was described according to the original diagnosis, e.g. patients with hypothyroidism following treatment for Graves' disease were classified as hyperthyroidism.
Controls: The control population consisted of 82 healthy, age and gender matched Caucasian blood donors originating from the same area in southern Sweden (Malmö) as the patients, but unrelated to them.HLA typing: HLA genotyping for HLADRB1 and -DQB1 was carried out using sequence-specific oligonucleotide probes to analyze enzymatically-amplified locus-specific DNA. The primer sequences were taken from literature.9,10 After the enzymatic amplification, the PCR products were hybridized with non-radioactively labelled sequence-specific oligonucleotides to differen-tiate HLA-DRB1 and, DQB1 variants as previously described in detail11 following established protocols.12-14 All HLA class II specificities and alleles were differentiated to the extent given below.Statistical analysis. For the immunogenetic analyses, odds ratios (ORs) were calculated according to Woolf’s method as cross-product ratios of a 2x2 contingency table [OR= (axb)/(cxd)].15,16 Haldane’s correction for the odds ratio was used when either all patients were positive or all controls negative for a particular specificity or allele.17 The level of significance was assessed by Yates corrected χ2 analysis, or Fisher’s exact test where appropriate. Generally, the given p-values were not corrected to avoid a conservative bias in this exploratory study. The etiologic or preventive fraction (EF/PF) was calculated using the odds ratio as an approximation of relative risk and taking the percentage of exposed controls as exposure proportion in the general population as described.16The study was approved by the Ethics Committee of the Medical Faculty, University of Lund.
ResultsThe distribution of the HLA-DRB1 and DQB1 specificities and alleles defined by genotyping in 66 and 65 patients respectively and in 82 controls are summarized in tables 1 and 2. The frequencies of HLA-DRB1*02 (p=0.004, EF 0.32), DRB1*14 (p=0.022, EF 0.1), DQB1*0303 (p=0.011, EF 0.11), DQB1*0503 (p=0.022, EF 0.1), DQB1*0602 (p=0.027, EF 0.24), and DQB1*0603 (p=0.034, EF 0.11) were significantly increased in the whole group of patients with sarcoidosis compared to healthy controls.Isolated sarcoidosis (Table 1,2). HLADQB1*0303 (p=0.02, EF 0.12) was increased compared to healthy controls.Autoimmune manifestations in patients with sarcoidosis (Table 1,2). Patients with autoimmune manifestations, when compared to controls, were found to have a significantly increased frequency of HLA-DRB1*02 (p=0.0057, EF 0.38), DRB1*14 (p=0.025, EF 0.11), DQB1*0303 (p=0.025, EF 0.11), DQB1*0503 (p=0.025, EF 0.11), DQB1*0602 (p=0.042, EF 0.27) and DQB1*0603 (p=0.047, EF 0.11).
 

Table 1. Frequency of HLA-DRB1 alleles in patients with isolated sarcoidosis and sarcoidosis associated with autoimmune manifestations and in 82 healthy control subjects.

Allele Control subjects Sarcoidosis        
     Total       Isolated
 Autoimmune manifestations      

 n=82 (%) n=66 (%)  χ2
 OR
P n=32 (%)
n=34 (%)  χ2
OR  P
 DRB1*01  23 (28) 11 (16.7)
       5 (15.6)  6 (17.6)      
 DRB1*02  20 (24.4)
32 (48.5)
 8.29  2.9  0.004  14(43.8)
 18 (52.9)  7.65  3.5 0.0057
 DRB1*03  26 (31.7)  13(19.7)        8 (25)  5 (14.7)      
 DRB1*04  35 (42.7)  20(30.3)        10(31.3)  10 (29.4)      
 DRB1*07  8 (9.8)  12(18.2)        6 (18.8)  6 (17.6)      
 DRB1*08  8 (9.8)  5 (7.6)        2 (6.3)  3 (8.8)      
 DRB1*09  1 (1.2)
1 (1.5)
       0 (0)
1 (2.9)
     
 DRB1*11  18 (22)
7 (10.6)
       4 (12.5)
3 (8.8)
     
 DRB1*12  3 (3.7)
6 (9.1)
       3 (9.4)
3 (8.8)
     
 DRB1*13  11 (13.4)
9 (13.6)
       5 (15.6)
4 (11.8)
     
 DRB1*14  1 (1.2)
7 (10.6)
 6.3
9.6
0.022
 3 (9.4)   
4 (11.8)
6.48
10.8
0.025

OR: odds ratio, χ2: chi-square value, p-values compared to control subjects; AM= Autoimmune manifestations

Table 2. Frequency of HLA-DQB1 alleles in patients with isolated sarcoidosis and sarcoidosis associated
with autoimmune manifestations and in 82 healthy control subjects.

Allele Control
subjects
Sarcoidosis                      
  n=82 (%)

Totaln

=65 (%)

χ2 
OR p

Isolated

n=31 (%)

χ2 
OR P n=34(%) χ2 
OR P
DQB1*0201  
33(40.2) 20 (30.8)       10 (32.3)       10 (29.4)      
 DQB1*0301   
31(37.8)
19 (29.2)
      10 (32.3)
      9 (26.5)
     
 DQB1*0302   25(30.5)
13 (20)
      7 (22.6)
      6 (17.6)
     
 DQB1*0303     
1(1.2) 
 8 (12.3)  7.67
 11.4
0.011a
4(12.9)
7.26
12
0.02e
4(11.8)
6.48
10.8
0.025f
 DQB1*0402
 8(9.8)  3 (4.6)        1 (3.2)        2 (5.9)      
 DQB1*0501  
22(26.8)
10 (15.4)
      4 (12.9)
      6 (17.6)
     
 DQB1*0502   
1(1.2)
3 (4.6)
      2 (6.5)
      1 (2.9)
     
 DQB1*0503
 1(1.2)  7 (10.8)  6.58   9.8  0.022b  3(9.7)
 
 
4(11.8)
6.48
10.8
 0.025g
 DQB1*0601
 0(0)  1(1.5)        0 (0)        1 (2.9)      
 DQB1*0602  19(23.2)  27(41.5)  4.87  2.4  0.027c  12(38.7)        15(44.1)  4.13  2.6  0.042h
 DQB1*0603  3(3.7)  9(13.8)  5.04  4.2  0.034d  4 (12.9)        5 (14.7)  4.77  4.5  0.047i
 DQB1*0604  8(9.8)  1 (1.5)        1 (3.2)        0 (0)      

OR: odds ratio, χ2: chi-square value, p: p-values in a-i compared to healthy controls; AM= Autoimmune
manifestations

Discussion

In sarcoidosis a strong correlation has been established between HLA-DRB1*03-DQB1*0201 and good prognosis and DRB1*02-DQB1*0602 and DRB1*14-DQB1*0503 and a chronic form of the disease in Scandinavians, British and Dutch.3,18 In our cohort, we observed an increased frequency of HLA-DRB1*02 and DRB1*14 as well as their linked DQB1 alleles, DQB1*0602 and DQB1*0503 compared to the controls. Furthermore, we observed a significant association with DQB1*0603 similar to the over-representation of DQB1*0603 and DQB1*0604 described among alleles of affected first degree relatives of German patients with sarcoidosis.19 We have not been able to account for the increase of DQB1*0303 allele observed in all our patients with sarcoidosis (groups and subgroups, albeit not always significant). Further analyses are needed to elucidate this point. The association of HLADRB1*02/*14 and their linked DQB1* 0602/ *0503 alleles remained significant for the group with autoimmune manifestations as well as for the group of gastrointestinal immune reactivity (data not shown) but was not seen in isolated sarcoidosis.

Moreover, in the face of the sarcoidosis protective haplotype HLA-DRB1*03, DQB1*0201 we have previously described two unrelated Scandinavian female patients with the association of PGA syndrome type III, coeliac disease and sarcoidosis20,21 in whom the HLA haplotypes were almost identical (common: A1, B8, Cw7, DR3, DQ2). It has been postulated that the increased risk towards the development of sarcoidosis might be independently exerted by the HLA A1, 3/B7, 8/Cw7 haplotype via a complex immunopathogenetic pathway or that class I and II may play complementary roles.22,23 When this HLA class I haplotype is present, the direction towards persistent sarcoidosis might require the presence of HLA class II DRB1*02,*14 and DQB1*0602, *0503. Those individuals may thus develop a disordered immune activation in the face of chronic sarcoidosis, leading to serological abnormalities without evidence of clinical disease as in our patients with sarcoidosis and evidence of gastrointestinal immune reactivity.24 This is possibly due to the long latency that precedes the clinical onset of autoimmune diseases in genetically predisposed individuals who maintain the function of the

HLA-DRB1/DQB1 in Sarcoidosis 17

organ almost intact for a variable length of time, despite the presence of a variety of circulating autoantibodies directed against that organ, as for example in pre-IDDM.25 If instead the protective alleles DRB1*01/04, DRB1*03/DQB1*201 are present, then the sarcoid disease may be mild and resolving but since those alleles confer susceptibility to endocrine autoimmune disease, clinical endocrine autoimmune disease may develop possibly favoured by the above mentioned complex immunopathogenetic pathway or by other known and unknown factors whose genes are included at the HLA-DRB3, like TNF-α, lymphotoxin-α, I-κ-B-like protein, and HLA-B-associated transcript 1 loci.18 Ultimately it may seem as in the face of the HLA class I A1, 3/B7, 8/Cw7 haplotype, the immune system has to choose between the Scylla of chronic sarcoidosis and the Charybdes of endocrine autoimmune disease!
On the other hand, DRB1*02 has, apart from chronic sarcoidosis, even been associated with several other diseases involving the lungs, such as tuberculosis,26 extrinsic allergic alveolitis,27 Goodpasture’s syndrome28 and allergic bronchopulmonary asperigillosis.29 To a lesser extent, similar associations have been observed for DR6 (DRB1*14).3032 Whether these examples of DRB1*02/*14associations with various diseases affecting the lung as a target organ might indicate an organ- rather than a disease-specificity for DRB1*02 or DRB1*02-linked genes, remains to be determined.In conclusion, significant associations of HLA-DRB1*02 and *14 and DQB1*0602 and *0503 with sarcoidosis were found, particularly apparent in the subgroup with associated autoimmune manifestations. Different immunogenetic profiles may thus exist in sarcoidosis indicative and/or causative of distinct clinical subgroups. HLA class II presentation of a putative sarcoidosis-specific antigen might be of vital importance in sarcoidosis, deciding the direction of the sarcoid disease and eventual associations with it. Whether the above mentioned HLA class II haplotypes and/or their linked genes, alone or in unison with HLA class I, are organ- or disease- specific remains to be determined.

Acknowledgements

The authors express their gratitude to ALF medel, City of Malmö and to Jan-Åke Nils-son, statistician, Malmö University Hospital, Malmö.

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