metabolism, infection and immunity in inborn errors of ... · metabolism, infection and immunity in...

National Institutes of Health

U.S. Department of Health and Human Services

NATIONAL HUMAN GENOME RESEARCH INSTITUTE

Metabolism, Infection and Immunity

in Inborn Errors of Metabolism

Peter J. McGuire MS, MD

Physician-Scientist

Immunometabolism Unit

No conflicts of interest to declare

Medschoolwatercooler.blogspot.com

Acute metabolic decompensation

in IEM

• Defined as a functional deterioration in metabolic status

• Are disease specific

• Can be life threatening

• Can be associated with long-term complications

• Triggers include dietary indiscretion, insufficient calories, infection

• Infection associated with increased morbidity (McGuire et al., 2013)

unstable

stable

Metabolichomeostasis

Outline

• What is the immune system and why is it

important?

• Infection and IEM

• Immune function in IEM

Why is the immune system

important? • Protects us against

Bacteria Viruses Fungi

Cancer Parasites Pollution

The immune system has

multiple lines of defense

The immune system is

composed of organs and

cells Organs Cells

The immune system has many different type of cells

Bone graft

Multipotential stem cell

Hematopoietic stem cell

Platelets

Macrophage

Erythrocytes

Eosinophil

Neutrophil

Megakaryocyte

Mast cell

Basophil

T lymphocyte

Natural killer cell

Dendritic cell

B lymphocyte

Lymphoid progenitor cell

Myeloid progenitor

cell

Monocyte

Marrow

Bone

How does the immune system

protect us?

• Body learns to defend

itself by:

– Natural infection

– Vaccination

vaccina on

YYYYYY

YYY

infec on

Y Y Y Y Y

YYYYYY

YYY

YYYYYY

YYY

YYYYYY

YYY

YYYYYY

YYY

YYYYYY

YYY

“Immunememory”

Y

T-cellsandB-cells

Protec vean bodies

Key:

Weeks Years Days Years

Y Y Y

How does the immune system

protect us?

Why study immune function in

metabolic disorders?

• Because:

– Infection is bad for patients

with IEM

• Our question:

– Does having a IEM affect

immune function?

Infection is bad for patients with IEM

• Point #1: Infection increases

caloric requirements

– For every 1° C of fever, metabolic

rate can increase 10% or more

– Problem: need more calories, but

you don’t feel like eating; ability to

generate energy


• Point #2: Infection can cause increased breakdown

Muscle Fat


• Point #3: Infection can inhibit metabolism – ammonia metabolism

CPS1 enzyme

McGuire et al., 2014

Sickness

Behaviors

Infection

Sac

Sac

spf-ash controls

spf-ash controls

spf-ash Controls

4-6 week old

Day 0

Day 1

Day 2

Day 3

Day 4

Day 5

A B

N= 5 N= 5

Euthanize

Inhalation based infection

Contr

ol

Infe

cted

0

50

100

150

CP

S1 e

nzym

e a

cti

vit

y

(co

ntr

ol ra

tio

)

Contr

ol

Infe

cted

80

85

90

95

100

105

110

OT

C e

nzym

e a

cti

vit

y

(co

ntr

ol ra

tio

)


• Point #3: Infection can inhibit metabolism - fatty acid oxidation

Longchainacyl-coA

CPT1a

Longchainacylcarni ne

Longchainacyl-coA

CACT

Longchainacylcarni ne

ETFDHI

IIIII

IV

V

CPT2

Acetyl-coA

β-oxida on

ETFA/B

e-e-e- e

-

e-e-

e- e-e-

e-

TCAcycle

Ketones

MitochondriaLong chain fats

Metabolomics

13C-palmitate oxidation breath testing

Tarasenko et al (in preparation)

Time (min)

Perc

en

t d

ose o

xid

ized

0 30 60 90 120

150

0

20

40

60

80

Infection

Control

Contr

ol

Infe

cted

0.0

0.5

1.0

1.5

CP

T2 m

RN

A

(co

ntr

ol ra

tio

)

Contr

ol

Infe

cted

0.0

0.5

1.0

1.5

AC

AD

VL

mR

NA

(c

on

tro

l ra

tio

)

Contr

ol

Infe

cted

0.0

0.5

1.0

1.5

AC

AD

L m

RN

A

(co

ntr

ol ra

tio

)

Contr

ol

Infe

cted

0.0

0.5

1.0

1.5

CA

CT

mR

NA

(c

on

tro

l ra

tio

)

Contr

ol

Infe

cted

0.0

0.5

1.0

1.5

HA

DH

A m

RN

A

(co

ntr

ol ra

tio

)

Contr

ol

Infe

cted

0.0

0.5

1.0

1.5

ET

FA

mR

NA

(c

on

tro

l ra

tio

)

A B

VL

CA

D (

co

ntr

ol ra

tio

)

Contr

ol PR8

0.0

0.5

1.0

1.5

2.0

2.5

LC

AD

(co

ntr

ol ra

tio

)

Contr

ol PR8

0.0

0.5

1.0

1.5

HA

DH

A (

co

ntr

ol ra

tio

)

Contr

ol PR8

0.0

0.5

1.0

1.5

VLCAD

b-actin

LCAD

HADHA

Control Infected

Infection decreases components of

hepatic fatty acid oxidation


mRNA protein

Acute metabolic decompensation

in IEM: FAO Long chain acyl-coA

CPT1a

Long chain acylcarnitine

Long chain acyl-coA

CACT

Long chain acylcarnitine

ETFDH I

II III

IV

V

CPT2

Acetyl-coA

β-oxidation

ETFA/B

e-

e-

e- e-

e- e-

e- e-

e- e-

TCA cycle

Ketones

Mitochondria


• Point #3: Infection can inhibit metabolism - pyruvate dehydrogenase

13C-Pyruvate

13C-Pyruvate

AcetylcoA+13CO2

TCA

PDH

13C-Lactate13C-Alanine

ALT LDH

Mitochondria

Hyperpolarized 13C-pyruvate:

assessment of in vivo pyruvate dehydrogenase

Contr

olPo

lyI:C 2 ho

urs

Poly I:C

3 da

ys

0

100

200

300

400

Co

ntr

ol % Lac/Pyr

Ala/Pyr

P<0.01

P<0.01

Figure 7: Poly I:C results in increased Lactate/Pyruvate and Alanine/Pyruvate.

Hyperpolarized 13C-pyruvate was injected by tail vein and alanine and lactate production

were measured by MR spectroscopy.



• Point #3: Infection can inhibit metabolism – mitochondria


Pairfed

Infected

0

100

200

300

400

500

AS

T (

U/L

)

Pair f

ed

Infected

0

50

100

150

AL

T (

U/L

)Day 0

Day 5

P<0.01P<0.01

Contr

ol Inf

ected

0.0

0.5

1.0

1.5

mtD

NA

(co

ntr

ol ra

tio

)

Figure 2: Influenza causes (A) hepatitis and (B) mtDNA depletion

in B6 mice. Mice were infected with PR8 influenza and euthanized

on Day 5.

A B

P=0.03

Co

mp

lex I / t

ub

ulin

rati

o

Contr

ol

2 hours

72 h

ours0.0

0.5

1.0

1.5 P = 0.04

Co

mp

lex II / tu

bu

lin

rati

o

Contr

ol

2 hours

72 h

ours0.0

0.5

1.0

1.5P <0.01

Contr

ol

2 hours

72 h

ours0.0

0.5

1.0

1.5

Figure 6: Poly I:C results in (A) PDH phosphorylation and

depletion and (B) respiratory chain complex depletion after 72

hours by immunoblot.

Co

mp

lex III / t

ub

ulin

rati

o

Contr

ol

2 hou

rs

72 ho

urs

0.0

0.5

1.0

1.5P <0.01

Co

mp

lex V

/ t

ub

ulin

rati

o

Contr

ol

2 hou

rs

72 ho

urs

0.0

0.5

1.0

1.5P = 0.02

Figure 6: Poly I:C results in (A) PDH phosphorylation and

depletion and (B) respiratory chain complex depletion after 72

hours by immunoblot.


• Point #4: The immune response may be

part of the problem - cytokines

PBS

TNF

!IL-

1"

IL-2

IL-6

IFN!

IFN"

IFN#

0.0

0.5

1.0

1.5

NA

GS

/b-a

ctin

(co

ntr

ol ra

tio

)

PBS

TNF

!IL-

1"

IL-2

IL-6

IFN!

IFN"

IFN#

0.0

0.5

1.0

1.5

CP

S1

/b-a

ctin

(co

ntr

ol ra

tio

)

PBS

TNF

!IL-

1"

IL-2

IL-6

IFN!

IFN"

IFN#

0.0

0.5

1.0

1.5

OT

C/b

-ac

tin

(co

ntr

ol ra

tio

)

A B C

0 ng/m

L0.1

ng/m

L1 n

g/mL

10 ng

/mL

0.0

0.5

1.0

Am

mo

nia

me

tab

olis

m

(co

ntr

ol ra

tio

)

IL-1b

0 ng/m

L0.1

ng/m

L1 n

g/mL

10 ng

/mL

0.0

0.5

1.0

Am

mo

nia

me

tab

olis

m

(co

ntr

ol ra

tio

)

IL-6

0 ng/m

L0.1

ng/m

L1 n

g/mL

10 ng

/mL

0.0

0.5

1.0

Am

mo

nia

me

tab

olis

m

(co

ntr

ol ra

tio

)

TNFa

0 ng/m

L0.1

ng/m

L1 n

g/mL

10 ng

/mL

0.0

0.5

1.0

Am

mo

nia

me

tab

olis

m

(co

ntr

ol r

atio

) IL-6

TNFα

IL-1β

A B C D

E F G H

I

Cytokines produced as part of the immune response inhibit

ammonia metabolism in human liver cells.

Immune cells “text”

each other by cytokines

May be innocent

bystanders (e.g. liver)

CPS1 liver cells

cytokines PB

S

TNFα

IL-1βIL

-2IL

-6

IFNαIF

NβIF

Nγ

0.0

0.5

1.0

1.5N

AG

S/b

-ac

tin

(co

ntr

ol r

atio

)

PBS

TNFα

IL-1βIL

-2IL

-6

IFNαIF

NβIF

Nγ

0.0

0.5

1.0

1.5

CP

S1

/b-a

ctin

(co

ntr

ol r

atio

)

PBS

TNFα

IL-1βIL

-2IL

-6

IFNαIF

NβIF

Nγ

0.0

0.5

1.0

1.5

OT

C/b

-ac

tin

(co

ntr

ol r

atio

)

A B C



part of the problem.

cytokines

PolyI:C

TNFα

IL12/18

IFNγKC

NK

T

HSC

PolyI:C

TNFα

IL12/18

IFNγKC

NK

T

HSC

Clodronate


part of the problem – immune cells



part of the problem.

cytokines

Contr

olPo

lyI:C 2 ho

urs

Poly I:C

3 da

ys

0

100

200

300

400

Figure 7: Poly I:C results in increased Lactate/Pyruvate and Alanine/Pyruvate.

Hyperpolarized 13C-pyruvate was injected by tail vein and alanine and lactate production

were measured by MR spectroscopy.


CD

11

b

F4/80

3.05% 0.053%

CD

11

b

F4/80


• Point #5: What do we see clinically with infection?

McGuire et al., 2013

Oth

erDie

t

Infe

ctio

n0

1

2

3

4

5

6

7

Ho

sp

ital d

ays

*

Oth

erDie

t

Infe

ctio

n0

20

40

60

80

100IV

scaven

gers

(%

HA

even

ts ) *

A B

Summary:

hospital admissions

hospital days

Ammonul use

Immune function in IEM

• Since infection can be very

serious...

– How well does the immune

system function in patients with

IEM?

– Can patients with IEM be

protected from illnesses by

vaccination?

Immune function and IEM

• What do we know? Not much,

but…

– Immune cells don’t like high levels

of toxins

– Immune cells don’t like nutritional

deficiencies

– Certain IEM enzyme deficiencies

are also present in immune organs

and cells

Immune function and IEM:

toxins

Wajner et al. (1999)


nutritional deficiencies PrimaryNutrientDeficiency ImmuneSystem ImmuneResponseProteinCalorieDeficiency Thymicatrophy,↓lymph

nodes/tonsils/T-cells,↑

IgA,↑/-IgG

↓Skinreactivity,↓cytokineresponse,might

respondtovaccines,riskof

infectionProteindeficiency(kwashiorkor) AlteredT-cellsubsets,↑

IgA,↑/-IgG

↓Skinreactivity,↓

cytokineresponse,might

respondtovaccines,riskofinfection

Zinc Lymphopenia,thymicatrophy,alteredT-cell

subsets

↓Skinreactivity,↓cytokineresponse

Iron T-celldefects,↓IgG,↓phagocyticactivity

↓Cytokineresponse,riskofinfection

Copper Lymphopenia ReducedIL-2response

Selenium ↓Antioxidantdefense ↑Viralvirulence

VitaminA Lymphopenia,↓mucosalbarrier

↓T-cellresponse(TH2),↓phagocyticcellandNK

function

VitaminE ↓Antioxidantdefense,↑IgElevels

↑PGE2production,↑viralvirulence

VitaminC ↓Plasmaglutathione ↓Phagocytefunction,riskofinfections

Arginine ↓T-cellproliferation,↓

TCR

Riskofinfections

Citrulline Seearginine Seearginine


enzymes in immune cells

Naive Ac vated

T-reg

Th17

Th1

Th2

Memory

FAO Glycolysis/Glutaminolysis

FAO

FAO

Glycolysis

Glycolysis

Glycolysis

T-cells need fatty acid oxidation to function!

Immune function and IEM

• What don’t we know? A lot…

– How well do immune cells from patients

with IEM function?

– Do patients with IEM develop immune

protection following vaccination?

Vaccination in IEM

• Regular childhood vaccinations are

recommended including influenza (Barshop

and Summar, 2008)

• Childhood vaccines are not associated

with adverse events (Klein et al, 2011 and Morgan

et al, 2011)

• Do patients with IEM respond? (Brady, 2005)

Flu season

Seasonality of elevated blood ammonia H

A e

ven

ts

August

Sep

tem

ber

Oct

ober

Nove

mber

Dec

ember

Januar

y

Febru

ary

Mar

ch

Apri

l

May

June

July

0

5

10

15

20

Infection

Diet

Peter McGuire (unpublished data)

Do IEM patients respond to

influenza vaccines?

Esposito et al (2013)

www.nationaljewish.org

The NIH MINI Study: Metabolism,

Infection, and Immunity in Inborn Errors

of Metabolism (NCT01780168)

Participant travel and lodging is provided

Our focus

• To learn how

inborn errors of

metabolism may

affect the function

of the immune

system and vice

versa

Metabolism

Immunity

IEM

MINI Study Participants

Who can participate?

To be in the study a person must:

• Be at least 2 years of age

• Have a biochemically

confirmed diagnosis of an IEM

or related disorder

We can not enroll anyone who:

• Is under 2 years of age

• Is being treated for an

intercurrent infection with

antibiotics, has evidence of an

acute infection, or has acute

decompensation

• Has received another vaccine

or immune modulating drug

within the past 6 months

• Is currently living in a hospital

• Does not have a local / regular

physician to manage their IEM

How can I participate?

• At the NIH Clinical Center

– Out-patient

– In-patient +/- outpatient

• Samples only

America’s Research Hospital

Travel and lodging arranged and covered by NIH

Meals covered by NIH

Children’s Inn at NIH


• Participating as an out-patient

– Immune profiling

• Immune cell populations and function, total antibodies,

antibodies to childhood vaccinations, inflammation markers,

offer vaccination for flu, hep A and pneumococcal disease

– Nutritional profiling

• Dietary analysis; body composition; bone density

– Address patient needs

• Dentistry, Neurology, Physical Medicine and Rehabilitation,

Endocrinology, Immunology, etc.


• Participating as an in-patient +/- out-patient

– Immune profiling

• Immune cell populations and function, total antibodies,

antibodies to childhood vaccinations, inflammation markers,

offer vaccination for flu, hep A and pneumococcal disease

– Nutritional profiling

• Dietary analysis; body composition; bone density; energy

expenditure

– Address patient needs

• Dentistry, Neurology, Physical Medicine and Rehabilitation,

Endocrinology, etc.

How can I participate? • Participating as samples only

– Blood- during infectious illnesses (e.g. Flu) and well

states

– Cord blood – humanized mouse models

– Tissues that result from a medical procedure

including, but not limited to, liver, tonsil, spleen

samples

– Liver Tissue Collection and Distribution System –

University of Minnesota

What is the status of the immune

system in IEM?

What have we found? Screening (Children N=38)

• Ear infections (>4/yr) 18%

• Sinus infections (>2/yr) 18%

• Antibiotics with little effect 13%

• Pneumonia (>2/yr) 8%

• Growth failure 47%

• IV antibiotics 45%

• ICU admission for infection 21%

• Delayed recovery 50%

• Persistent thrush/fungal 13%

• Deep seated infection 13%

• History of immunodeficiency 13%

• Immune evaluation 15%

• IVIG treatment 8%

• Prophylactic antibiotics 29%

What have we found? Laboratory findings

• Subsets of patients with:

– Absent MMR, pneumococcal,

varicella titers

– Absent EBV, CMV titers

– Low immunoglobulins

– Abnormal white blood cell numbers

– Abnormal response to influenza

– Overproduction of cytokines

No s

timulu

sLP

S0

1

2

3

IL-8

(c

on

tro

l ra

tio

)Control

PA pt.

No s

timulu

sSEB

0

1

2

3

4

TN

Fa

(co

ntr

ol ra

tio

)

Control

PA pt.

Summary

• The immune system is important for vaccination

and protection against infection

• Infection is detrimental to patients with IEM

• Subsets of patients with IEM may have immune

dysfunction – Toxicity

– Metabolic dysfunction

– Nutritional perturbations

www.genome.gov/mini

MINI Study contact information

Principal Investigator

Peter J. McGuire MS, MD

Study Coordinator

Janet Shiffer, NP

Telephone

301-451-9145

Website

http://www.genome.gov/mini

Email

[email protected]

Thank you

Any questions?

metabolism, infection and immunity in inborn errors of ... · metabolism, infection and immunity in...

Documents