Molecular mechanisms in allergy and clinical immunology

Series editors: WilliamT. Shearer, MD, PhD, Lanny J. Rosenwasser, MD, and Bruce S. Bochner, MD
T regulatory cells in allergy: Novel concepts in
the pathogenesis, prevention, and treatment
of allergic diseases
Mu beccel Akdis, MD, PhD, Kurt Blaser, PhD, and Cezmi A. Akdis, MD Davos, Switzerland
This activity is available for CME credit. See page 32A for important information.
The identication of Tregulatory (T
Reg
) cells as key regulators of
immunologic processes in peripheral tolerance to allergens has
opened an important era in the prevention and treatment of
allergic diseases. Both naturally occurring CD4
1
CD25
1
T
Reg
cells and inducible populations of allergen-specic IL-10
secreting T
R
1 cells inhibit allergen-specic effector cells in
experimental models. Allergen-specic T
Reg
cell responses
contribute to the control of allergic inammation in several
ways. Skewing of allergen-specic effector T cells to a T
Reg
phenotype appears to be a crucial event in the development of
a healthy immune response to allergens and successful outcome
in allergen-specic immunotherapy. The increased levels of
IL-10 and TGF-b produced by T
Reg
cells can potently suppress
IgE production while simultaneously increasing the production
of the noninammatory antibody isotypes IgG4 and IgA,
respectively. T
Reg
cells directly or indirectly suppress effector
cells of allergic inammation, such as mast cells, basophils, and
eosinophils, and contribute to remodeling in asthma and atopic
dermatitis. In addition, mediators of allergic inammation that
trigger cyclic AMPassociated G proteincoupled receptors,
such as histamine receptor 2, might play a role in peripheral
tolerance mechanisms against allergens. Current strategies for
drug development and allergen-specic immunotherapy
exploit these observations with the potential to provide cure for
allergic diseases. (J Allergy Clin Immunol 2005;116:961-8.)
Key words: T regulatory cells, immunotherapy, tolerance, anergy,
IgE, T cells, histamine, IL-10, TGF-b
The initial event responsible for the development of
allergic diseases is the generation of allergen-specic
CD4
1
T
H
cells.
1
Once generated, effector T
H
2 cells
produce IL-4, IL-5, IL-9, and IL-13 and mediate several
regulatory and effector functions. These cytokines induce
the production of allergen-specic IgE by B cells, devel-
opment and recruitment of eosinophils, production of mu-
cus, and contraction of smooth muscles.
1
T
H
1 cells might
also efciently contribute to the effector phase in allergic
diseases
2,3
or dampen allergic inammation, depending
on specic disease model and stage of the inammation.
4
In addition to T
H
1 and T
H
2 cells, a further subtype of
T cells with immunosuppressive function and cytokine
proles distinct from either T
H
1 or T
H
2 cells is termed
regulatory-suppressor T cells (T
Reg
cells, Fig 1).
5-8
T
Reg
cells are able to inhibit the development of allergic T
H
2
responses and play a major role in allergen SIT.
8,9
Subsets
of T
Reg
cells with distinct phenotypes and mechanisms of
action include the naturally occurring, thymus-selected
CD4
1
CD25
1
FoxP3
1
T
Reg
cells and the inducible type 1
T
Reg
cells (T
R
1 cells).
10,11
In addition, subsets of CD8
1
T cells, gd T cells, dendritic cells (DCs), IL-10producing
B cells, natural killer cells, and resident tissue cells, which
might promote the generation of T
Reg
cells, could contrib-
ute to suppressive and regulatory events.
11
During the last
few years, the concept of T
Reg
cells has received general
attention by the scientic community, and excitement
about the possibility of these cells in therapeutic applica-
tions for the treatment of diseases that are associated
with a dysfunction in T-cell regulation has been aug-
mented. As discussed in this review, understanding the
immune mechanisms that prevent disease occurrence in
nonallergic individuals and evidence for healing of altered
regulatory mechanisms in allergic diseases offers promise
for new immune interventions (Table I).
Abbreviations used
CTLA4: Cytotoxic T lymphocyteassociated antigen 4
DC: Dendritic cell
HR: Histamine receptor
SIT: Specic immunotherapy
T
Reg
cell: T regulatory cell
T
R
1: T regulatory type 1
From the Swiss Institute of Allergy and Asthma Research (SIAF).
The authors laboratories are supported by Swiss National Foundation grants
32-100266, 31-65436, and 32-105268 and the Global Allergy and
Asthma European Network (GA
2
LEN).
Received for publication May 3, 2005; revised September 2, 2005; accepted
for publication September 7, 2005.
Available online October 10, 2005.
Reprint requests: Cezmi A. Akdis, MD, Swiss Institute of Allergy and Asthma
Research (SIAF), Obere Strasse 22, CH7270 Davos, Switzerland. E-mail:
akdisac@siaf.unizh.ch.
0091-6749/$30.00
2005 American Academy of Allergy, Asthma and Immunology
doi:10.1016/j.jaci.2005.09.004
961
R
e
v
i
e
w
s
a
n
d
f
e
a
t
u
r
e
a
r
t
i
c
l
e
s
MECHANISMS OF T
Reg
CELL GENERATION
DCs not only control immunity but also maintain
peripheral tolerance, 2 complementary functions that
would ensure the integrity of the organism in an environ-
ment full of pathogens and allergens. The tolerogenic
function of DCs depends on certain maturation stages and
subsets of different ontogenies and can be inuenced by
immunomodulatory agents. The differentiation of thymus-
derived T
Reg
cells does not depend on the interaction
with specialized DCs,
12
whereas a role for DCs in the in-
duction of T
R
1 cells has been supported by several studies.
Immature DCs control peripheral tolerance by inducing
the differentiation of T
R
1-like cells.
13
Related to the pre-
vention and development of asthma, airway DCs control
the pulmonary immune response and determine tolerance
and immunity to newly encountered antigens. Immature
DCs are distributed throughout the lungs and capture aller-
gens and migrate to the T-cell area of mediastinal lymph
nodes within 12 hours.
14
They express a partially mature
phenotype with an intermediate array of costimulatory
molecules and induce T-cell tolerance.
15
Antigen presen-
tation by partially mature airway DCs that express IL-10
induce the formation of T
R
1-like cells, which inhibit sub-
sequent inammatory responses.
16
Moreover, depletion
and adoptive transfer of pulmonary plasmacytoid DCs
has demonstrated an important role for these cells in
protection from allergen sensitization and asthma de-
velopment in mice.
17
Although molecular mechanisms
of T
Reg
cell generation remain to be elucidated, some
existing therapies for allergic diseases, such as treatment
with glucocorticoids and b
2
-agonists, might function to
promote the numbers and function of IL-10secreting
T
R
1-like cells.
18,19
T
Reg
CELLS IN HEALTHY IMMUNE RESPONSE
TO ALLERGENS
Studies on immune response to allergens in healthy
individuals demonstrated that a peripheral T-cell reper-
toire to allergens exists that recognizes the same T-cell
epitopes as allergic patients.
20-22
Accordingly, active
regulation emerges as a very essential mechanism for
both inducing and maintaining peripheral tolerance to
allergens. The analysis of T-cell subsets specic to various
food or inhaled antigens enables a suitable human model
to investigate how harmless environmental proteins are
recognized and tolerated by the immune system. Single
allergen-specic T cells constitute less than 0.1% of the
whole CD4
1
T-cell repertoire and can be isolated from
the peripheral blood of human subjects according to
their cytokine prole.
22
Freshly puried IFN-g, IL-4,
and IL-10producing allergen-specic CD4
1
T cells dis-
play characteristics of T
H
1, T
H
2, and IL-10secreting T
Reg
cells (T
R
1like cells), respectively.
22
Specic T
R
1 cells
consistently represent the dominant subset against com-
mon environmental allergens in healthy individuals, in
contrast to the high frequency of allergen-specic IL-4
secreting T cells in allergic individuals. T
R
1 cells can act
by secreting cytokines, such as IL-10 and TGF-b, but
contact-dependent signals, such as programmed death-1,
glucocorticoid-induced TNF receptor, membrane TGF-b,
and cytotoxic T lymphocyteassociated antigen 4
(CTLA4), appear to be important in some situations.
10,22
Healthy and allergic individuals exhibit all 3 allergen-
specic subsets in different proportions, indicating that a
change in dominant subset might lead to allergy develop-
ment or recovery. The ratio between specic T
R
1 and
T
H
2 cells determines the development of a healthy or an
FIG 1. The generation of allergen-specic T
Reg
cell response is
an essential step in allergen SIT and natural allergen exposure of
nonallergic individuals. IL-10 and TGF-b secreted from T
Reg
cells
directly or indirectly suppress T
H
2 cells, T
H
1 cells, mast cells,
eosinophils, and basophils and regulate antibody isotypes in
B cells. Red line, Suppression; black line, stimulation.
TABLE I. Denitions of anergy, tolerance, suppression,
and ignorance
Anergy: Clinically, anergy describes the lack of T celldependent,
cutaneous, delayed-type hypersensitivity reactions to common
antigens. Lymphocyte anergy is the failure of T- or B-cell clones
to react to antigenic stimulation as a state of unresponsiveness.
Immunologic ignorance: Lack of immune response development
because of insufcient doses, stability, or inaccessibility of
antigen to the immune system.
Immune suppression: Suppression of the immune response by a
dened molecular mechanism.
Mucosal tolerance: A state of antigen-specic unresponsiveness
after mucosal exposure to antigens.
Suppressor T cell: T cells that block the activation and function
of other effector T lymphocytes, a function that can now be
attributed to T
Reg
cells.
Inducible T
Reg
cells: T
R
1 cells and other T
Reg
subsets, which are
generated in the peripheral immune system.
Natural T
Reg
cells: Thymus-derived, CD4
1
CD25
1
T
Reg
cells.
Tolerance: An induced state of antigen-specic immunologic
unresponsiveness by exposure to antigens in an immunocompetent
individual.
J ALLERGY CLIN IMMUNOL
NOVEMBER 2005
962 Akdis, Blaser, and Akdis
R
e
v
i
e
w
s
a
n
d
f
e
a
t
u
r
e
a
r
t
i
c
l
e
s
allergic immune response. Although in low frequency, the
existence of potential suppressive allergen-specic T
R
1
cells in allergic individuals suggests a possible method
of treatment.
T
Reg
CELLS IN ALLERGEN SIT
Allergen SIT is most efciently used in allergy to insect
venoms and allergic rhinitis.
23,24
Despite its use in clinical
practice for nearly a century, the underlying immunologic
mechanisms are slowly being elucidated.
11,23
Increased
IgG4 isotype antibodies supposedly block IgE-facilitated
allergen presentation.
25
A reduction in the numbers of
mast cells and eosinophils, including the release of medi-
ators,
26,27
is associated with successful allergen SIT.
It appears, however, that the induction of a tolerant
state in peripheral T cells represents an essential step in
allergen SIT (Fig 1).
8,9,28,29
Peripheral T-cell tolerance
is characterized mainly by suppressed proliferative and
cytokine responses against the major allergens and their
T cellrecognition sites.
28
The generation of allergen-
specic T
Reg
cells and increased production of their
suppressive cytokines IL-10 and TGF-b are essential
early events in allergen SIT.
8,9
Targeting pathogenic T cells with vaccines consisting
of synthetic T-cell epitope peptides (peptide immunother-
apy) is another attractive approach for investigation of
peripheral T-cell tolerance in human subjects. To date,
clinical trials of peptide immunotherapy have been
performed in 2 allergies.
30-32
Induction of peripheral tole-
rance directed to whole allergen and increases in IL-10
have been reported.
30-32
Complete allergens with full
T-cell repertoires are apparently necessary because multi-
ple T-cell epitopes are recognized individually by differ-
ent patients as a result of the large diversity of major
histocompatibility antigens and T-cell receptors. The
generation of novel fusion proteins that combine major
allergens offers advantages over T cell peptidebased
immunotherapy because these vaccines can be designed
to comprise the complete repertoire of T-cell epitopes
without binding IgE.
33
As a promising model for other
allergies, single-dose administration of a hybrid vaccine
that combines 2 major allergens of bee venom, phospho-
lipase A
2
and hyaluronidase, prevents IgE development
on exposure to native allergen in mice.
33
T
Reg
CELL RESPONSE TO ALLERGENS IS
ASSOCIATED WITH REGULATION OF
ANTIBODY ISOTYPES
Howdifferent subsets of T
Reg
cells cross-talk to Bcells,
which leads to regulation of antibody production, is an
essential question. CD4
1
CD25
1
CD69
2
T
Reg
cells can
migrate to germinal centers and negatively regulate T
celldependent B-cell antibody production in mice.
34
In
humans the serum levels of specic IgE and IgG4 anti-
bodies delineate allergic and normal immunity to aller-
gen. Although peripheral tolerance was demonstrated in
specic T cells, the capacity of B cells to produce speci-
c IgE and IgG4 antibodies was not abolished during
allergen SIT.
28
In fact, specic serum levels of both iso-
types increased during the early phase of treatment.
The increase in antigen-specic IgG4 levels was more
pronounced, and the ratio of specic IgE to IgG4
decreased by 10- to 100-fold. A similar change in specic
isotype ratio was observed in SIT of various allergies.
Moreover, IL-10, which is induced and increasingly se-
creted by SIT, counterregulates antigen-specic IgE and
IgG4 antibody synthesis.
8
IL-10 is a potent suppressor
of both total and allergen-specic IgE, whereas it simul-
taneously increases IgG4 production.
8
IL-10 has 2 major
effects on B cells, which could result in the shift in bal-
ance as observed. IL-10 decreases e transcript expression
and therefore production of IgE when added to PBMCs
during the rst 3 days of culture. However, IL-10 induces
further upregulation of IgE production when added to
already committed B cells.
35
Furthermore, IL-10 enhances
g4 transcript expression and IgG4 production induced by
IL-4.
35
Thus IL-10 not only generates tolerance in T cells,
it also regulates specic isotype formation and skews the
specic response from an IgE- to an IgG4-dominated phe-
notype (Fig 1). In healthy individuals antibody response
to Der p 1 is characterized by specic IgA and IgG4
levels, small amounts of IgG1, and almost undetectable
IgE antibodies in serum.
9
House dust mite SIT did not
signicantly change specic IgE levels after 70 days of
treatment; however, a signicant increase in specic
IgA, IgG1, and IgG4 levels was observed.
9
The increase
of specic IgA and IgG4 levels in serum coincides with
increased TGF-b and IL-10 levels, respectively.
Although further studies are required, this might account
for the role of IgA and TGF-b, as well as IgG4 and
IL-10, in mucosal immune responses to allergens in
healthy individuals.
8,36
These ndings suggest a regula-
tory function in addition to the well-known suppressor
function of T
Reg
cells.
T
Reg
CELL RESPONSE TO ALLERGENS IS
ASSOCIATED WITH SUPPRESSION OF
EFFECTOR CELLS
Despite the fact that a denite decrease in IgE antibody
levels and IgE-mediated skin sensitivity normally requires
several years of SIT, most patients are protected against
bee stings already at an early stage of bee venom SIT. The
reason for this is that effector cells of allergic inamma-
tion, such as mast cells, basophils, and eosinophils, require
T-cell cytokines for priming, survival, and activity,
37
which are not efciently provided by suppressed T
H
2
cells (Fig 1). T
Reg
cells generated by SIT might efciently
modulate the thresholds for mast cell and basophil acti-
vation and decrease IgE-mediated histamine release.
38,39
In
addition, IL-10 reduces proinammatory cytokine release
from mast cells,
40
downregulates eosinophil function and
activity, and suppresses IL-5 production by human resting
T
H
0 and T
H
2 cells.
41
Development of IgE response to
J ALLERGY CLIN IMMUNOL
VOLUME 116, NUMBER 5
Akdis, Blaser, and Akdis 963
R
e
v
i
e
w
s
a
n
d
f
e
a
t
u
r
e
a
r
t
i
c
l
e
s
helminths has been commonly observed, although there
is no typically accompanying allergic diseases. IL-10
producing B cells were suggested as an underlying
mechanism for the prevention of anaphylaxis during
Schistosoma mansoni infection, suggesting the control
of mast cell degranulation threshold by IL-10.
42
Helminth infections are also accompanied by high levels
of helminth-specic IgG4 as a link for IL-10, peripheral
tolerance, and suppression of allergic reactions.
43
HISTAMINE RECEPTOR 2 AS A KEY PLAYER
IN PERIPHERAL TOLERANCE
Many established G proteincoupled receptor systems
have been successfully exploited by the pharmaceutical
industry to become the target for approximately 40%of the
currently available drugs.
44
As a small-molecular-weight
monoamine that binds to 4 different G proteincoupled
receptors, histamine has been demonstrated to regulate
several essential events in the immune response.
45,46
The expression of these receptors on different cells and
cell subsets is regulated, and apparently diverse effects
of histamine on immune regulation are due to differential
expression of these receptors and their distinct intracellu-
lar signals. Histamine receptor (HR) 2 is coupled to aden-
ylate cyclase, and studies in different species and several
human cells demonstrated that inhibition of characteristic
features of the cells by primarily cyclic AMP formation
dominates in HR2-dependent effects of histamine.
47
Histamine actively participates in the function and
activity of DC precursors, as well as their immature and
mature forms. In the differentiation process of DCs from
monocytes, HR1, HR3, and HR4 act as positive stimuli
that increase antigen-presentation capacity, proinam-
matory cytokine production, and T
H
1 priming activity.
In contrast, HR2 acts as a suppressive molecule for anti-
gen-presentation capacity, suppresses IL-12 production,
enhances IL-10 production, and induces IL-10producing
T cells (Fig 2).
48,49
It has been demonstrated that differential patterns of HR
expression on T
H
1 and T
H
2 cells determine reciprocal
T-cell responses after histamine stimulation.
45
T
H
1 cells
show predominant, but not exclusive, expression of
HR1, whereas T
H
2 cells show increased expression of
HR2. Histamine enhances T
H
1-type responses by trigger-
ing HR1, whereas both T
H
1- and T
H
2-type responses are
negatively regulated by HR2.
45
In mice deletion of HR1
results in suppression of IFN-g and dominant secretion
of T
H
2 cytokines (IL-4 and IL-13). HR2-deleted mice
show upregulation of both T
H
1 and T
H
2 cytokines. In ad-
dition, increased IL-10 production in both DCs and T cells
through HR2 might account for an important regulatory
mechanism in the control of allergen-specic T cells
through histamine.
50
In accordance with this phenome-
non, histamine supports the suppressive effect of TGF-b
on particularly T
H
2 cells through HR2.
51
Thus histamine
and HR2 promote the development of peripheral tolerance
during SIT in several pathways. Histamine induces the
production of IL-10 by DCs
48
and T
H
2 cells and sup-
presses both T
H
1 and T
H
2 cytokines.
45,50
In addition,
histamine enhances the suppressive activity of TGF-b
on T cells (Fig 2).
51
Whether this pathway is defective
in chronic allergic individuals and might act as a target
for possible treatment modalities remains to be elucidated.
Because of the same signal transduction patterns, b
2
-
adrenergic receptors and some other G proteincoupled
receptors might function similarly to HR2 in humans.
52
LINKS BETWEEN IMMUNOLOGIC
IGNORANCE, IMMUNE SUPPRESSION,
ANERGY, AND T
Reg
CELLS
Peripheral T-cell tolerance is characterized by func-
tional inactivation of the cell to antigen encounter, which
remains alive for an extended period of time in an
unresponsive state. The overall evaluation of the studies
on T-cell unresponsiveness suggest that anergy, immuno-
logic ignorance, and suppression are not entirely distinct
but rather represent linked mechanisms possibly involving
the same molecular events (Fig 3 and Table I).
T
Reg
cells, mucosal IgA, and
immunologic ignorance
The mucosal surfaces of the respiratory, gastrointesti-
nal, and urogenital tracts, covering a total of 300 m
2
in
contact with the external environment, represent major
sites of antigen exposure. Discriminating between patho-
genic antigens, toward which a protective immune
response has to be established, and harmless antigens,
such as food, airborne antigens, or the commensal bacte-
rial ora that should be ignored, is the most challenging
FIG 2. Suppressive functions of histamine by HR2. HR2 is highly
expressed on T
H
2 cells and negatively regulates T-cell proliferation
and IL-4 and IL-13 production. T cells are more efciently sup-
pressed by TGF-b in the presence of histamine through HR2. HR1
on T
H
1 cells enhances IFN-g and proliferation and increases effec-
tor functions and tissue injury. Red line, Suppression; black line,
differentiation. APC, Antigen-presenting cell.
J ALLERGY CLIN IMMUNOL
NOVEMBER 2005
964 Akdis, Blaser, and Akdis
R
e
v
i
e
w
s
a
n
d
f
e
a
t
u
r
e
a
r
t
i
c
l
e
s
task of the mucosal immune system. Induction of mucosal
tolerance or immunologic ignorance of harmless environ-
mental proteins, as well as infectious agents, by secretory
IgA antibodies are 2 main mechanisms.
53
The association
between serum and mucosal secretory IgA levels and the
development of allergy has been recently questioned.
Antigen-specic secretory IgA antibodies in the gut
were decreased in a mouse model of food allergy, suggest-
ing a role for secretory IgA in peripheral tolerance to
foods. Peyers patch CD3
1
cells were primarily involved
by favoring IgA production through the release of IL-10
and TGF-b, and low IL-10 production in Peyers patches
favored the symptoms of food allergy.
54
In another study
allergen-specic secretory IgA was found to protect sensi-
tized children from allergic symptoms during the rst 2
years of life, suggesting a possible preventive role of
secretory IgA against the development of allergy.
55
In
addition, increases in allergen-specic IgA levels have
been reported in SITs performed through the sublingual
or subcutaneous routes.
9,56
T
Reg
cells, remodeling in asthma, and
immunologic ignorance
Remodeling in asthma, which might be the conse-
quence of excessive repair processes after repeated airway
injury, includes increased deposition of several extracel-
lular matrix proteins in the reticular basement membrane
and bronchial mucosa, as well as increases in airway
smooth muscle mass, goblet-cell hyperplasia, and new
blood vessel formation.
57
Consequently, the airway wall
in asthma is usually characterized by increased thickness
and markedly and permanently reduced airway caliber.
A major T
Reg
cytokine, TGF-b, in particular, is a potent
regulator of broblast and myobroblast function and
controls the production of several extracellular matrix pro-
teins, including collagens, proteoglycans, and tenascin.
58
Other cell types involved in allergic inammation as
potential sources of TGF-b include eosinophils, macro-
phages, mast cells, neutrophils, endothelial and epithelial
cells, and smooth muscle cells and broblasts them-
selves.
58
TGF-b interacts with several other cytokines,
such as activin for the efciency of remodeling response.
59
The thickening of the subepithelial lamina reticularis
in bronchial asthma has been related to an increase in
broblasts in correlation with TGF-b expression.
60
Sup-
porting these ndings, therapeutic treatment of mice with
anti-TGF-b antibody signicantly reduced peribron-
chiolar extracellular matrix deposition, airway smooth
muscle cell proliferation, and mucus production in the
lung.
61
In some respects airway remodeling might repre-
sent a continuum from inammation to scarring, but it
could also be a protective response to altered airway im-
munology caused by ongoing cellular activation and tissue
damage. There is clear evidence that lamina reticularis
thickening starts very early, even at the time of rst diag-
nosis,
62
suggesting that a barrier between activated epithe-
lium or mucosal allergens and inner tissues (ie, immune
system cells) occurs with the aim of downregulation of
the allergen-induced inammatory response.
Taken together, increased subepithelial lamina reticu-
laris thickness and mucosal IgA production against aller-
gens might be related to T
Reg
cells, which attempt to
decrease the amount of allergen exposure and play a role
in immunologic ignorance (Fig 3).
T
Reg
cells and anergy: Active suppression of
T-cell costimulation by IL-10
The term anergy was rst coined by Von Pirquet in
1908 to describe the loss of delayed-type hypersensitivity
to tuberculin in individuals infected with measles virus.
63
The term has been clinically adopted to describe negative
FIG 3. Involvement of T
Reg
cells in immunologic ignorance and
anergy. A, increased subepithelial lamina reticularis thickness
and mucosal IgA production might lead to immunologic ignorance
by decreasing the amount of allergen entrance to the submucosal
immune system cells in the lungs. B, IL-10 secreted from T
Reg
cells
induces DCs to develop into IL-10producing DCs and blocks T-cell
costimulation signals and leads to an anergic status.
J ALLERGY CLIN IMMUNOL
VOLUME 116, NUMBER 5
Akdis, Blaser, and Akdis 965
R
e
v
i
e
w
s
a
n
d
f
e
a
t
u
r
e
a
r
t
i
c
l
e
s
tuberculin skin test results in conditions in which they
were expected to be positive. In 1980, the term anergy
was used to describe the specic inactivation of B cells
in mice by high doses of antigen.
64
It was subsequently
used for T cells to describe a phenomena in which antigen
presentation to T-cell clones in the absence of professional
antigen-presenting cells induced a hyporesponsive state,
affecting subsequent IL-2 production and proliferation
on restimulation.
65
Inhibition of T-cell costimulatory mol-
ecules at the cell surface or their intracellular signal trans-
duction has been repeatedly reported to play an important
role in T-cell unresponsiveness. The interaction between
B7 and CD28 might determine whether a T-cell response
develops. Blocking antibodies to B7-2 inhibit the develop-
ment of specic IgE, pulmonary eosinophilia, and airway
hyperresponsiveness in mice.
66
CTLA4 seems to act on
endogenous inhibitors of T-cell activation, and CTLA4-
Ig, a soluble fusion protein, has also been effective in
blocking airway hyperresponsiveness in mice.
67
Further-
more, cytokine production by memory-effector T cells,
particularly those of the T
H
2 subset, is highly dependent
on costimulation through the inducible costimulator/B7RP1
(inducible costimulator ligand) pathway. Blockage
68
or
genetic disruption
69
of this costimulatory pathway mark-
edly reduced allergen-induced asthma in mice, suggesting
a promising approach for the treatment of allergic disease
in human subjects.
One mechanismof direct T-cell suppression by IL-10 is
due to the inhibition of CD28 costimulation (Fig 3). IL-10
does not affect the proliferative responses of T cells that
were stimulated with anti-CD3. In contrast, IL-10 signi-
cantly inhibits the anti-CD28stimulated proliferation.
70
Thus IL-10 suppresses only those T cells that have low
numbers of T-cell receptors triggered and that require
CD28 for proliferation.
70
Ligation of IL-10 receptor at
the time of CD28 stimulation inhibits tyrosine phospho-
rylation of CD28.
70
As a consecutive event for signal
transduction, the association of CD28 with the phosphati-
dylinositol 3kinase p85 molecule is inhibited by IL-10.
Taken together, after a century of its rst use, the term an-
ergy is immunologically dened in the context of IL-10
secreting T
R
1 cells. Containment and cure of tuberculosis
requires an effective cell-mediated immune response, and
its absence during severe forms of active tuberculosis
infection in parallel to tuberculin skin test negativity has
been demonstrated to be related to IL-10mediated
peripheral tolerance.
71
Accordingly, T-cell response in
IL-10mediated peripheral tolerance functions in the
same way as the original denition of anergy because
costimulatory signals are suppressed, and T cells receive
a weak signal only through the T-cell receptor without
costimulation (Fig 3).
CONCLUSION
Peripheral T-cell tolerance is a key immunologic
mechanism in healthy immune response to self-antigens
and noninfectious nonself-antigens. This phenomenon is
clinically well documented in allergy, autoimmunity,
transplantation, cancer, and infection. There is growing
evidence supporting the role for T
Reg
cells, immuno-
suppressive cytokines, or both as a mechanism by which
allergen SIT and healthy immune response to allergens
is mediated. T
Reg
cells contribute to the control of allergen-
specic immune responses in 5 major ways (Fig 4):
(1) suppression of antigen-presenting cells that support
the generation of effector T
H
2 and T
H
1 cells; (2) suppres-
sion of T
H
2 and T
H
1 cells; (3) regulatory function on B
cells by suppression of allergen-specic IgE and induction
of IgG4, IgA, or both; (4) suppression of mast cells, baso-
phils, and eosinophils; and (5) interaction with resident tis-
sue cells and remodeling. In addition to the treatment of
established allergy, it is essential to consider prophylactic
approaches before initial sensitization has taken place.
Preventive and therapeutic vaccines that induce T
Reg
responses can be developed. Allergen-specic T
Reg
cells
might in turn dampen both the T
H
1 and T
H
2 cells and
cytokines, ensuring a well-balanced immune response.
However, it has to be considered that T
Reg
cells might
not always be responsible for benecial effects because
several studies have shown that they could be responsible
for the chronicity of infections and tumor tolerance. T
Reg
cell populations have proved possible but difcult to
grow, expand, and clone in vitro. A crucial area for future
studies is the identication of drugs, cytokines, or costi-
mulatory molecules that induce in vivo growth while
preserving the suppressor function of T
Reg
cells.
REFERENCES
1. Romagnani S. Immunologic inuences on allergy and the TH1/TH2
balance. J Allergy Clin Immunol 2004;113:395-400.
FIG 4. T
Reg
cells contribute to the control of allergen-specic
immune responses in 5 major ways: (1) suppression of antigen-
presenting cells (APC) that support the generation of effector T
H
2
and T
H
1 cells; (2) suppression of T
H
2 and T
H
1 cells; (3) suppression
of allergen-specic IgE and induction of IgG4, IgA, or both; (4) sup-
pression of mast cells, basophils, and eosinophils; and (5) interac-
tion with resident tissue cells and remodeling.
J ALLERGY CLIN IMMUNOL
NOVEMBER 2005
966 Akdis, Blaser, and Akdis
R
e
v
i
e
w
s
a
n
d
f
e
a
t
u
r
e
a
r
t
i
c
l
e
s
2. Trautmann A, Akdis M, Kleemann D, Altznauer F, Simon HU, Graeve T,
et al. T cell-mediated Fas-induced keratinocyte apoptosis plays a key path-
ogenetic role in eczematous dermatitis. J Clin Invest 2000;106:25-35.
3. Trautmann A, Schmid-Grendelmeier P, Kru ger K, Crameri R, Akdis M,
Akkaya A, et al. T cells and eosinophils cooperate in the induction of
bronchial epithelial apoptosis in asthma. J Allergy Clin Immunol 2002;
109:329-37.
4. Finotto S, Neurath MF, Glickman JN, Qin S, Lehr HA, Green FH, et al.
Development of spontaneous airway changes consistent with human
asthma in mice lacking T-bet. Science 2002;295:336-8.
5. Chen Y, Kuchroo VK, Inobe J, Haer DA, Weiner HL. Regulatory T cell
clones induced by oral tolerance: suppression of autoimmune encephalo-
myelitis. Science 1994;265:1237-40.
6. Powrie F, Correa-Oliveira R, Mauze S, Coffman RL. Regulatory interac-
tions between CD45RB
high
and CD45RB
low
CD41 T cells are important
for the balance between protective and pathogenic cell-mediated immu-
nity. J Exp Med 1994;179:589-600.
7. Groux H, OGarra A, Bigler M, Rouleau M, Antonenko S, de Vries JE,
et al. A CD41 T-cell subset inhibits antigen-specic T-cell responses
and prevents colitis. Nature 1997;389:737-42.
8. Akdis CA, Blesken T, Akdis M, Wuthrich B, Blaser K. Role of inter-
leukin 10 in specic immunotherapy. J Clin Invest 1998;102:98-106.
9. Jutel M, Akdis M, Budak F, Aebischer-Casaulta C, Wrzyszcz M, Blaser
K, et al. IL-10 and TGF-b cooperate in regulatory T cell response to
mucosal allergens in normal immunity and specic immunotherapy.
Eur J Immunol 2003;33:1205-14.
10. Robinson DS, Larche M, Durham SR. Tregs and allergic disease. J Clin
Invest 2004;114:1389-97.
11. Akdis CA, Blaser K, Akdis M. Genes of tolerance. Allergy 2004;59:
897-913.
12. Jordan MS, Riley MP, von Boehmer H, Caton AJ. Anergy and suppres-
sion regulate CD4(1) T cell responses to a self peptide. Eur J Immunol
2000;30:136-44.
13. Jonuleit H, Schmitt E, Schuler G, Knop J, Enk AH. Induction of inter-
leukin 10-producing, nonproliferating CD4(1) T cells with regulatory
properties by repetitive stimulation with allogeneic immature human
dendritic cells. J Exp Med 2000;192:1213-22.
14. Vermaelen KY, Carro-Muino I, Lambrecht BN, Pauwels RA. Specic
migratory dendritic cells rapidly transport antigen from the airways to
the thoracic lymph nodes. J Exp Med 2001;193:51-60.
15. Lambrecht BN, Pauwels RA, Fazekas De St Groth B. Induction of rapid
T cell activation, division, and recirculation by intratracheal injection of
dendritic cells in a TCR transgenic model. J Immunol 2000;164:2937-46.
16. Akbari O, DeKruyff RH, Umetsu DT. Pulmonary dendritic cells produc-
ing IL-10 mediate tolerance induced by respiratory exposure to antigen.
Nat Immunol 2001;2:725-31.
17. de Heer HJ, Hammad H, Soullie T, Hijdra D, Vos N, Willart MA, et al.
Essential role of lung plasmacytoid dendritic cells in preventing asth-
matic reactions to harmless inhaled antigen. J Exp Med 2004;200:
89-98.
18. Peek EJ, Richards DF, Faith A, Lavender P, Lee TH, Corrigan CJ, et al.
Interleukin-10-secreting regulatory T cells induced by glucocorticoids
and beta2-agonists. Am J Respir Cell Mol Biol 2005;33:105-11.
19. Karagiannidis C, Akdis M, Holopainen P, Woolley NJ, Hense G,
Ruckert B, et al. Glucocorticoids upregulate FOXP3 expression and reg-
ulatory T cells in asthma. J Allergy Clin Immunol 2004;114:1425-33.
20. Carballido JM, Carballido-Perrig N, Terres G, Heusser CH, Blaser K.
Bee venom phospholipase A
2
-specic T cell clones from human allergic
and non-allergic individuals: cytokine patterns change in response to the
antigen concentration. Eur J Immunol 1992;22:1357-63.
21. Ebner C, Schenk S, Najaan N, Siemann U, Steiner R, Fischer GW, et al.
Nonallergic individuals recognize the same T cell epitopes of Bet v 1, the
major birch pollen allergen, as atopic patients. J Immunol 1995;154:
1932-40.
22. Akdis M, Verhagen J, Taylor A, Karamloo F, Karagiannidis C, Crameri
R, et al. Immune responses in healthy and allergic individuals are char-
acterized by a ne balance between allergen-specic T regulatory 1 and
T helper 2 cells. J Exp Med 2004;199:1567-75.
23. Till SJ, Francis JN, Nouri-Aria K, Durham SR. Mechanisms of immuno-
therapy. J Allergy Clin Immunol 2004;113:1025-35.
24. Nelson HS. Advances in upper airway diseases and allergen immuno-
therapy. J Allergy Clin Immunol 2005;115:676-84.
25. Nouri-Aria KT, Wachholz PA, Francis JN, Jacobson MR, Walker SM,
Wilcock LK, et al. Grass pollen immunotherapy induces mucosal and
peripheral IL-10 responses and blocking IgG activity. J Immunol 2004;
172:3252-9.
26. Creticos PS, Adkinson NF Jr, Kagey-Sobotka A, Proud D, Meier HL,
Naclerio RM, et al. Nasal challenge with ragweed pollen in hay fever
patients. Effect of immunotherapy. J Clin Invest 1985;76:2247-53.
27. Rak S, Lowhagen O, Venge P. The effect of immunotherapy on
bronchial hyperresponsiveness and eosinophil cationic protein in pollen-
allergic patients. J Allergy Clin Immunol 1988;82:470-80.
28. Akdis CA, Akdis M, Blesken T, Wymann D, Alkan SS, Muller U, et al.
Epitope-specic T cell tolerance to phospholipase A2 in bee venom
immunotherapy and recovery by IL-2 and IL-15 in vitro. J Clin Invest
1996;98:1676-83.
29. Akdis CA, Blaser K. IL-10-induced anergy in peripheral T cell and
reactivation by microenvironmental cytokines: two key steps in specic
immunotherapy. FASEB J 1999;13:603-9.
30. Mu ller UR, Akdis CA, Fricker M, Akdis M, Bettens F, Blesken T, et al.
Successful immunotherapy with T cell epitope peptides of bee venom
phospholipase A
2
induces specic T cell anergy in bee sting allergic
patients. J Allergy Clin Immunol 1998;101:747-54.
31. Marcotte GV, Braun CM, Norman PS, Nicodemus CF, Kagey-Sobotka
A, Lichtenstein LM, et al. Effects of peptide therapy on ex vivo T-cell
responses. J Allergy Clin Immunol 1998;101:506-13.
32. Oldeld WL, Larche M, Kay AB. Effect of T-cell peptides derived from
Fel d 1 on allergic reactions and cytokine production in patients sensitive
to cats: a randomised controlled trial. Lancet 2002;360:47-53.
33. Kussebi F, Karamloo F, Rhyner C, Schmid-Grendelmeier P, Salagianni
M, Mannhart C, et al. A major allergen gene-fusion protein for potential
usage in allergen-specic immunotherapy. J Allergy Clin Immunol 2005;
115:323-9.
34. Lim HW, Hillsamer P, Kim CH. Regulatory T cells can migrate to
follicles upon T cell activation and suppress GC-Th cells and GC-Th
cell-driven B cell responses. J Clin Invest 2004;114:1640-9.
35. Jeannin P, Lecoanet S, Delneste Y, Gauchat JF, Bonnefoy JY. IgE versus
IgG4 production can be differentially regulated by IL-10. J Immunol
1998;160:3555-61.
36. Sonoda E, Matsumoto R, Hitoshi Y, Ishii T, Sugimoto M, Araki S, et al.
Transforming growth factor beta induces IgA production and acts addi-
tively with interleukin 5 for IgA production. J Exp Med 1989;170:
1415-20.
37. Walker C, Virchow J-C, Bruijnzeel PLB, Blaser K. T cell subsets and
their soluble products regulate eosinophilia in allergic and nonallergic
asthma. J Immunol 1991;146:1829-35.
38. Treter S, Luqman M. Antigen-specic T cell tolerance down-regulates
mast cell responses in vivo. Cell Immunol 2000;206:116-24.
39. Shim YK, Kim BS, Cho SH, Min KU, Hong SJ. Allergen-specic
conventional immunotherapy decreases immunoglobulin E-mediated
basophil histamine releasability. Clin Exp Allergy 2003;33:52-7.
40. Marshall JS, Leal-Berumen I, Nielsen L, Glibetic M, Jordana M.
Interleukin (IL)-10 Inhibits long-term IL-6 production but not preformed
mediator release from rat peritoneal mast cells. J Clin Invest 1996;97:
1122-8.
41. Schandane L, Alonso-Vega C, Willems F, Gerard C, Delvaux A, Velu T,
et al. B7/CD28-dependent IL-5 production by human resting T cells is
inhibited by IL-10. J Immunol 1994;152:4368-74.
42. Mangan NE, Fallon RE, Smith P, van Rooijen N, McKenzie AN, Fallon
PG. Helminth infection protects mice from anaphylaxis via IL-10-
producing B cells. J Immunol 2004;173:6346-56.
43. Fischer P, Bonow I, Supali T, Ruckert P, Rahmah N. Detection of laria-
specic IgG4 antibodies and larial DNA, for the screening of blood
spots for Brugia timori. Ann Trop Med Parasitol 2005;99:53-60.
44. Wilson S, Bergsma DJ. Orphan G-protein-coupled receptors: novel drug
targets for the pharmaceutical industry. Drug Des Discov 2000;17:
105-14.
45. Jutel M, Watanabe T, Klunker S, Akdis M, Thomet OAR, Malolepszy J,
et al. Histamine regulates T-cell and antibody responses by differential
expression of H1 and H2 receptors. Nature 2001;413:420-5.
46. Akdis CA, Blaser K. Histamine in the immune regulation of allergic
inammation. J Allergy Clin Immunol 2003;112:15-22.
47. Del Valle J, Gantz I. Novel insights into histamine H2 receptor biology.
Am J Physiol 1997;273:G987-96.
J ALLERGY CLIN IMMUNOL
VOLUME 116, NUMBER 5
Akdis, Blaser, and Akdis 967
R
e
v
i
e
w
s
a
n
d
f
e
a
t
u
r
e
a
r
t
i
c
l
e
s
48. Mazzoni A, Young HA, Spitzer JH, Visintin A, Segal DM. Histamine
regulates cytokine production in maturing dendritic cells, resulting in
altered T cell polarization. J Clin Invest 2001;108:1865-73.
49. van der Pouw Kraan TC, Snijders A, Boeije LC, de Groot ER, Alewijnse
AE, Leurs R, et al. Histamine inhibits the production of interleukin-12
through interaction with H2 receptors. J Clin Invest 1998;102:1866-73.
50. Osna N, Elliott K, Khan MM. Regulation of interleukin-10 secretion by
histamine in TH2 cells and splenocytes. Int Immunopharmacol 2001;1:
85-96.
51. Kunzmann S, Mantel P-Y, Wohlfahrt JG, Akdis M, Blaser K, Schmidt-
Weber CB. Histamine enhances TGF-beta1-mediated suppression of Th2
responses. FASEB J 2003;17:1089-95.
52. Goleva E, Dunlap A, Leung DY. Differential control of TH1 versus TH2
cell responses by the combination of low-dose steroids with beta2-
adrenergic agonists. J Allergy Clin Immunol 2004;114:183-91.
53. Macdonald TT, Monteleone G. Immunity, inammation, and allergy in
the gut. Science 2005;307:1920-5.
54. Frossard CP, Hauser C, Eigenmann PA. Antigen-specic secretory IgA
antibodies in the gut are decreased in a mouse model of food allergy.
J Allergy Clin Immunol 2004;114:377-82.
55. Bottcher MF, Haggstrom P, Bjorksten B, Jenmalm MC. Total and
allergen-specic immunoglobulin A levels in saliva in relation to the
development of allergy in infants up to 2 years of age. Clin Exp
Allergy 2002;32:1293-8.
56. Bahceciler NN, Arikan C, Taylor A, Akdis M, Blaser K, Barlan IB, et al.
Impact of sublingual immunotherapy on specic antibody levels in asth-
matic children allergic to house dust mites. Int Arch Allergy Immunol
2005;136:287-94.
57. Bousquet J, Jacot W, Vignola AM, Bachert C, Van Cauwenberge P.
Allergic rhinitis: a disease remodeling the upper airways? J Allergy
Clin Immunol 2004;113:43-9.
58. Duvernelle C, Freund V, Frossard N. Transforming growth factor-beta
and its role in asthma. Pulm Pharmacol Ther 2003;16:181-96.
59. Rosendahl A, Checchin D, Fehniger TE, ten Dijke P, Heldin CH, Sideras
P. Activation of the TGF-beta/activin-Smad2 pathway during allergic
airway inammation. Am J Respir Cell Mol Biol 2001;25:60-8.
60. Hoshino M, Nakamura Y, Sim JJ. Expression of growth factors and re-
modelling of the airway wall in bronchial asthma. Thorax 1998;53:21-7.
61. McMillan SJ, Xanthou G, Lloyd CM. Manipulation of allergen-induced
airway remodeling by treatment with anti-TGF-b antibody: effect on the
Smad signaling pathway. J Immunol 2005;174:5774-80.
62. Laitinen LA, Laitinen A, Haahtela T. Airway mucosal inammation even
in patients with newly diagnosed asthma. Am Rev Respir Dis 1993;147:
697-704.
63. Pirquet V. Das Verhalten der kutaanen Tuberkulin-reaktion wahrend der
Masern. Mu nch Med Wochenschr 1908;34:1297-300.
64. Nossal GJ, Pike BL. Clonal anergy: persistence in tolerant mice of
antigen-binding B lymphocytes incapable of responding to antigen or
mitogen. Proc Natl Acad Sci U S A 1980;77:1602-6.
65. Lamb JR, Skidmore BJ, Green N, Chiller JM, Feldman M. Induction of
tolerance in inuenza virus-immune T lymphocyte clones with synthetic
peptides of inuenza hemagglutinin. J Exp Med 1983;157:1434-47.
66. Haczku A, Takeda K, Redai I, Hamelmann E, Cieslewicz G, Joetham A,
et al. Anti-CD86 (B7.2) treatment abolishes allergic airway hyperrespon-
siveness in mice. Am J Respir Crit Care Med 1999;159:1638-43.
67. Van Oosterhout AJ, Hofstra CL, Shields R, Chan B, Van Ark I, Jardieu
PM, et al. Murine CTLA4-IgG treatment inhibits airway eosinophilia and
hyperresponsiveness and attenuates IgE upregulation in a murine model
of allergic asthma. Am J Respir Cell Mol Biol 1997;17:386-92.
68. Gonzalo JA, Tian J, Delaney T, Corcoran J, Rottman JB, Lora J, et al.
ICOS is critical for T helper cell-mediated lung mucosal inammatory
responses. Nat Immunol 2001;2:597-604.
69. Dong C, Juedes AE, Temann UA, Shresta S, Allison JP, Ruddle NH,
et al. ICOS co-stimulatory receptor is essential for T-cell activation
and function. Nature 2001;409:97-101.
70. Akdis CA, Joss A, Akdis M, Faith A, Blaser K. A molecular basis for T
cell suppression by IL-10: CD28-associated IL-10 receptor inhibits
CD28 tyrosine phosphorylation and phosphatidylinositol 3-kinase
binding. FASEB J 2000;14:1666-9.
71. Boussiotis VA, Tsai EY, Yunis EJ, Thim S, Delgado JC, Dascher CC,
et al. IL-10-producing T cells suppress immune responses in anergic
tuberculosis patients. J Clin Invest 2000;105:1317-25.
J ALLERGY CLIN IMMUNOL
NOVEMBER 2005
968 Akdis, Blaser, and Akdis
R
e
v
i
e
w
s
a
n
d
f
e
a
t
u
r
e
a
r
t
i
c
l
e
s