Inflammatory and effector activities of cells of the monocyte/macrophage lineage

Monocyte/macrophages play various roles in T cell-mediated inflammatory diseases because they function as accessory cells for T cell activation, as pro-inflammatory cells, as effector cells that mediate tissue damage, and as anti-inflammatory cells that promote wound healing/tissue repair (Figure 6). There is strong evidence that

deregulation of monocyte/macrophage functions could be responsible for disease development. For instance,

pro-inflammatory activated monocyte/macrophages are cardinal

inflammatory cells implicated into the pathogenesis of RA and MS.

Human monocytes constitute between 3% and 7% of peripheral blood leukocytes. Monocytes are members of the human mononuclear phagocyte

system, which is important for non-specific defence against pathogenic organisms and tumor surveillance, and which exerts immunoregulatory functions like accessory activities and cytokine production. Monocytes derive from progenitor cells in the bone marrow, circulate in the blood as monocytes for 1-3 days before entering tissue to differentiate into locoregional-specific and heterogeneous cells, such as alveolar macrophage of the lung, as macrophages or DCs in connective tissue (261), and as microglial cells in the CNS(262). In inflammatory conditions, monocyte production is increased in the bone marrow and after release into circulation monocytes are rapidly recruited to sites of injury and infection where they differentiate into inflammatory macrophages(263). The term monocyte/macrophages broadly used in this thesis refers to cells that undergo a transition from a quiescent to an inflammatory phenotype and consequently represents somewhat a heterogeneous cell population. The classical immunophenotypic marker for monocytes is CD14, the receptor for complexes of lipopolysaccharides (LPS) and LPS-binding protein(264).

Human peripheral blood monocytes are not a homogeneous population, but differ in their phenotypes and functions. Human monocytes could be divided into two major populations by the presence or absence of CD16, the low affinity Fc-gamma receptor III(63). The CD14⁺/CD16⁺ subpopulation of monocytes represents approximately 10% of total blood monocytes. In comparison to main subpopulation of CD14⁺⁺ (so-called “classical”) monocytes, this subpopulation is characterized by enhanced expression of MHC class II determinants, and increased ability to produce

pro-Figure 6. The diverse functions of monocyte/macrophages (Mφ).

Monocyte/macrophages are capable of many functional activities and contribute both to the initiation of cell-mediated immune response and to the effector limb of those responses. During the course of the response, monocyte/macrophages can display, at different times, both inflammatory and anti-inflammatory activities. (From (3)).

inflammatory cytokines (TNF, IL-1β, IL-6) following stimulation by TLRs agonists(265;266). The CD14⁺/CD16⁺ subset of peripheral blood monocytes is also thought to be a transitional stage in the development of monocytes to either macrophages or DCs(267-269). Consistent with this notion, an expansion of the CD14⁺/CD16⁺ population has been found in septicemia(270) and other infectious or inflammatory disorders(267). However, the latter phenotypic switch is still controversial in RA(271;272) while it has been so far not identified in MS(273;274).

Monocytes selectively home to different tissues, presumably under the influence of chemokines or other tissue-specific homing factors(275). Upon entry into a tissue, maturing monocyte/macrophages migrate into the parenchyma, the environment of which significantly influences the function of macrophages such that macrophages localized in different tissues display different patterns of function(276;277). Upon inflammatory insult to the tissue, resident tissue macrophages can contribute to the innate immune response by expression of a wide variety of inflammatory and effector activities, the pattern of which is differentially regulated by the microenvironment of the different tissues. Moreover, macrophages priming is a very effective first step towards full-scale activation. Upon priming, cells are educated by an initial insult(278), and thus prepared for subsequent second insults, in such a manner that the priming alters or modulates cell response to the secondary stimulation.

As stated above, cells belonging to the monocyte/macrophage lineage are heterogeneous and as such are engaged in a variety of activities that may appear opposing in nature: pro-inflammatory versus anti-inflammatory activities, immunogenic versus tolerogenic activities, and tissue-destructive versus tissue-restorative activities(13;279-281). To date, monocyte/macrophage heterogeneity is likely to reflect the plasticity and versatility of these cells in response to exposure to microenvironmental signals. In this respect, it is assumed that five types of monocyte/macrophage activation occurs(13) as depicted in Figure 7. Besides these different mechanisms, the process that control monocyte/macrophage activation in chronic/sterile inflammation, while not completely well understood, might be elicited by direct cellular contact with activated T lymphocytes.

3.2.1. Cells of the monocyte/macrophage lineage in rheumatoid arthritis

Monocyte/macrophages play a pivotal role in RA(230;282;283). Indeed, they are numerous in the inflamed synovial lining membrane and at the cartilage-pannus junction. Extensive investigations have identified the monocyte/macrophage as the only cell type in the synovium whose number correlates with disease severity(282). This is in accordance with the premise that monocyte/macrophages are the main producers of TNF and IL-1β, which levels strongly correlate with disease symptoms and with joint damage(58;230;282). It has been hypothesized that in addition

Figure 7. Innate and acquired immune activation of monocyte/macrophages. a) The innate immune activation (antigen non-specific, T cell-independent) of monocyte/macrophages is triggered by microbial stimul and results in the production of pro- and anti-inflammatory mediators including cytokines, upregulation of antigen presentation capacity and promotion of the phagocytosis and endocytosis of host and exogenous ligands. b) The humoral activation and phagocytosis of monocyte/macrophages that are mediated by the occupancy of Fc and complement receptors trigger a cytolytic activity and production of pro-and anti-inflammatory cytokines. c) The classical activation which is mediated by the priming stimulus IFNγ, followed by exposure to TH1 cytokines such as IFNγ or other activators, including TNF and LPS (e,g. in intracellular killing of phagocytosed pathogens), gives rise to the production of pro-inflammatory cytokines and mediators that subsequently direct microbicidal activity, tissue damage and cellular immunity. d) The alternative immunologic activation that is promoted by IL-4 and IL-13 enhances endocytotic antigen uptake and presentation, in response to parasitic and extracellular pathogens and has been proposed to be a way to attenuate excessive inflammation. e) The deactivation (switch-off) of already activated monocyte/macrophages is triggered by the uptake of apoptotic cells or lysosomal storage of host molecules. This active process that could be of innate or acquired origin generates anti-inflammatory responses in which cytokines and glucocorticosteroids are potent modulators of activation. Pathogens can deactivate monocyte/macrophages by various mechanisms.

(Adapted from (13)).

to the infiltration from the circulation, the subsequent possible local proliferation of monocyte/macrophages may contribute to the local hyperplasia exhibited in inflamed joints(284).

However, it is unlikely that monocyte/macrophages occupy a causal position in the pathogenesis of RA, except for their function as APCs in the hypothesis of a primary autoimmune disorder(285). At the inflammatory site, monocyte/macrophages show clear signs of activation, such as over expression of MHC class II, and possess broad pro-inflammatory, destructive, and remodeling capacities. Monocyte/macrophages act as amplifiers of local and systemic inflammation in both the acute and the chronic phases of RA(283;286-288). Locally, monocyte/macrophages are implicated in recruitment and activation/differentiation of neighboring/inflammatory cells, secretion of matrix-degrading enzymes, and neovascularization. While monocyte/macrophage activation is most obvious within the rheumatoid joint, “presynovial” activation, has been evidenced, although unclear in its extent(286;289). One hypothesis imply that initiation of the autoimmune response is non-specific and depends solely on the presence of misplaced peripherally activated pro-inflammatory monocyte/macrophages, which come into the target organ as a result of their activation status.

Peripheral monocyte/macrophage activation is characterized overall by gene activation with a pattern closely resembling the synovial activation pattern, including the spontaneous production of inflammatory mediators, such as TNF, IL-1, and IL-6(290;291), enhanced levels of adhesion molecules(292;293) and increased phagocytic activity(294). In addition to local effects, the observation of a peripheral blood monocytosis(295;296), and both quantitative and qualitative alterations of myelomonocytic cells in the bone marrow in RA patients(297) emphasize the importance of monocyte/macrophages in this disease. Thus at the systemic level, monocyte/macrophages might amplify disease via the development of bone marrow differentiation abnormalities, and chronic activation of circulating monocytes.

Monocyte/macrophage sensitization can be detrimental in RA synovitis, which is characterized by only low production of IFNγ by T lymphocyte(66;298;299), but ample production of various monocyte-derived cytokines(300). Indeed, it is well supported that subthreshold concentrations of IFNγ are capable to up-regulate the sensitivity (i.e. priming) of monocyte/macrophages to a subsequent second stimulus. Therefore the low concentration of locally produced IFNγ, may prime the synovial monocyte/macrophages to a subsequent non-IFN-type stimulus (for example TNF or cell-cell contact), explaining the over activity of such cells in RA synovitis.

3.2.2. Cells of the monocyte/macrophage lineage in multiple sclerosis

Infiltrates of inflammatory cells in the CNS, as well as the production of pro- and anti-inflammatory cytokines and chemokines, all have proposed roles in MS disease pathogenesis and

severity(301;302). In this regard, inflammation is believed to be an initial feature of MS followed by demyelination(303). The early MS lesion is characterized by the presence of large numbers of activated T lymphocytes and monocyte/macrophages, implicating these cells as possible mediators in the formation of inflammatory lesions(304-311). In MS, monocyte/macrophages are thought to be responsible for cellular pathology and tissue damage, while T lymphocytes are thought to orchestrate the process(208;312-315). The key role for monocyte/macrophages was illustrated in EAE. In EAE, a systemic depletion of monocyte/macrophages or a treatment by CNI-1493, a macrophage inhibiting agent, protects animals from EAE(316-319). These studies suggest that the infiltration of monocyte/macrophages into the brain parenchyma is essential for the development of new lesions in EAE and MS. In this context, during MS, recruitment of T lymphocytes across the BBB is facilitated by monocyte/macrophages(320-322).

Monocyte/macrophages together with microglial cells, a brain resident monocytic cell type, are competent presenters of antigen and can effectively activate or reactivate infiltrating T cells recruited to the inflamed CNS to promote myelin-specific T cell responses. Alternatively, monocyte/macrophages can digest CNS myelin in response to signals produced by the infiltrating myelin-specific T cells. Otherwise, in the aberrant response to infection paradigm, an essential signal for autoimmunity may originate from the presence of pro-inflammatory molecules by activated monocyte/macrophages that initiate locally tissue damage directly and so generate autoantigens(323;324). The sequence initiating autoimmunity would begin with monocyte/macrophages, putatively derived from acute or chronic peripheral infections, penetrating the BBB(323).

Monocyte/macrophages are an important sources of cytokines(306;325-327) and secrete inflammatory and potentially cytopathic mediators toxic to myelin and oligodendrocytes in the inflammatory milieu, such as TNF(328). Importantly, IL-12, that shifts the immune response towards a TH1 profile and facilitates TNF and IL-6 secretion, is another cytokine predominantly secreted by monocyte/macrophages(329;330). Monocyte/macrophages secrete as well IL-10, a TH2-related cytokine that counteracts many of the TH1 cytokines and could be therefore beneficial in MS(331).

Because monocyte/macrophages secrete several cytokines implicated in the pathogenesis of MS (as reviewed in ref. (332)) this argue for their importance in the pathogenesis of MS. On the other hand, monocyte/macrophages can damage the myelin sheath by mediating antibody-dependent cytotoxicity against oligodendrocytes after the binding of pathogenic autoantibodies directed against myelin- or oligodendrocyte-specific antigens. In consequence monocyte/macrophages may contribute to the induction, perpetuation and resolution of inflammatory observed in patients with MS. Noticeably, the CD14⁺/CCR2⁺ subset of peripheral blood monocytes might correct the presumed TH1/TH2 balance

and may therefore possibly play an important role in the shift from the active disease state to a state of remission(333).