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Vol. 23 / Nm 4/ Octubre-Diciembre 2004: 328-338

Toll-like receptors and human pathology

E. Snchez*, G. Orozco*, and J. Martn
Instituto de Parasitologa y Biomedicina Lpez-Neyra, CSIC, Granada.
* The authors have contributed equally to this work.


Recibido: 8 Noviembre 2004

Aceptado: 1 Diciembre 2004

El sistema inmunitario innato desarroll uno de los meca- The innate immune system has evolved one of the mecha-
nismos de reconocimiento frente a las infecciones microbianas y nisms of recognition of microbial infection and initiation of host
el inicio de defensa del hospedador. ste mecanismo est basado defence. This is based on the recognition of molecular patterns
en el reconocimiento de patrones moleculares presentes en los that are present in microbial components or endogenous ligands.
distintos componentes microbianos as como en determinados These patterns are recognized, among other, through the Toll-like
ligandos endgenos. Estos patrones son reconocidos, entre otros receptors (TLRs), which activate inflammatory reactions and are
receptores, a travs de los llamados receptores Toll-like (TLRs), critical in the initiation of adaptive immune responses. The func-
los cuales son responsables de la activacin de reacciones infla- tion of TLRs in various human diseases has been investigated by
matorias y tienen un papel crtico en el inicio de la respuesta inmu- the study of several polymorphisms in genes that participate in
nitaria innata. La funcin de los TLRs en varias enfermedades TLR signalling. These studies have suggested that several disea-
humanas ha sido investigada a travs del estudio de polimorfis- ses, including infectious, autoimmune, atherosclerosis and inflam-
mos de genes que participan en la sealizacin a travs de TLR. matory airway diseases are affected by the TLR function. The futu-
Estos estudios sugieren que varias enfermedades, incluidas enfer- re studies in this field will continue to improve the understanding
medades infecciosas, autoinmunitarias, ateroesclerosis e infla- of the pathogenesis and aetiology of these diseases and they will
matorias de las vas respiratorias estn afectadas por la funcin as well reveal information about therapeutic options.
de estos TLR. Los futuros estudios en este campo continuarn
aumentando el conocimiento de la patognesis y etiologa de estas KEY WORDS: Toll-like receptors / Genetic polymorphism / Infec-
enfermedades as como revelarn informacin sobre las distintas tious diseases / Autoimmunity / Atherosclerosis / Inflamma-
opciones teraputicas. tory airway diseases.

PALABRAS CLAVE: Receptores tipo toll / Polimorfismo genti-

co / Enfermedades infecciosas / Autoinmunidad / Ateroscle-
rosis / Enfermedades inflamatorias de las vas respiratorias.

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Innate immunity is the first-line of host defence of IL-1RI TLR4 TLR3
multicellular organisms that rapidly operates to limit infection MyD88
upon exposure to infectious agents. Accumulating evidence MyD88-
independent TRIF
indicates that activation of the innate immune system is a pathway
prerequisite for the induction of acquired immunity, IRAK 4 IRAK 1
particularly for the induction of a T helper 1 (Th1)-cell TRAF6
response(1, 2). Toll-like receptors (TLRs) play a crucial role
in innate immunity, through their ability to bind pathogen- MKK IKK
associated molecular patterns (PAMPs)(3). The receptors of complex
the innate immune system that recognise PAMPs are called JnK
pattern-recognition receptors (PRR)(4). PRRs are expressed IB IB
on the cell surface, activate signalling pathways that induce
antimicrobial effector responses and inflammation upon NF-B
recognition of PAMPs. Therefore TLRs control multiple
functions and activate signals that are critically involved AP-1 NF-B Nucleus
in the initiation of adaptative immune responses(5, 6). Different
TLRs appear to recognise specific microbial products
(PAMPs), including lipopolysaccharide, bacterial lipoproteins,
peptidoglycan and bacterial DNA(7). Numerous studies, Figure 1. The TLR signalling pathway.
conducted mainly in vitro, have led to the identification of
a large number of different ligands for each member of the
TLR family(7, 8). Recognition of a single ligand has been the molecule(31). TLRs cross the cytoplasmatic membrane
demonstrated for TLR3 in responses to poly(I:C) (double- once, and their intracellular portion is extremely similar to
stranded viral RNA)(9), TLR5 for responses to flagellin and the cytoplasmatic domain of the IL-1R and related molecules,
flagellated bacteria(10), and TLR9 for mediating responses which is designated Toll-IL-1R or TIR domain(34). By contrast,
to CpG bacterial DNA(11). On the contrary, TLR2 and TLR4 the extracellular region of the TLRs and IL-1R differs
have a broad specificity for the recognition of microbial markedly: the extracellular region of TLRs contains LRRs
patterns. TLR2 is responsible for the recognition of Gram- motifs, whereas the extracellular region of IL-1R contains
positive bacteria (peptidoglycan, lipoteichoic acid) (12), three immunoglobulin-like domains.
mycobacterial species(13, 14), protozoan parasites(15, 16), as well Upon ligand binding, TLRs (homo- hetero-) dimerise
as microbial lipoproteins, glycoproteins, glycolipids, and and undergo a conformational change required for the
nonenteric LPS(17-21). TLR4 recognizes LPS(22, 23), the LPS recruitment of downstream signalling molecules. After TLR
mimetic drug Taxol(24), the fusion protein of respiratory ligation, the adaptor molecule myeloid-differentiation
syncytical virus (RSV)(25), as well as fungal ligands(26, 27). primary-response protein 88 (MyD88) is recruited to the
TLRs can also dimerise upon interaction with the proper cytoplasmatic TIR domain, where it facilitates the association
ligand. Dimers consisting of TLR4-TLR4, TLR2-TLR6 and of IL-1R-associated kinase 4 (IRAK4) with the receptor
TLR1-TLR2 have been described(28). The Drosophila protein complex (Fig. 1). The binding of MyD88 to IRAK4 facilitates
Toll was originally described as a type I transmembrane IRAK4-mediated phosphorylation of crucial residue/s in
receptor that controls the dorsal-ventral patterning of the the kinase-activation loop of IRAK1, which induces the
fly embryo(29). Toll signalling has been identified as an kinase activity of IRAK1. Activated IRAK1 then
essential element of an effective anti-fungal immune response autophosphorylates, and this enables tumour-necrosis factor
in the fly(30). Several studies have identified mammalian (TNF)-receptor-associated factor 6 (TRAF6) to bind to the
homologs of Toll, proteins now referred to as Toll-like complex. The IRAK1-TRAF6 complex then disengages from
receptors (TLR) (31-33). TLRs are grouped into the same the receptor and interacts with another preformed complex
gene family based on their sequence similarity. Eleven consisting of transforming growth factor- (TGF-)-activated
mammalian members have been described, namely TLR1 kinase (TAK1), TAK1-binding protein 1 (TAB1) and TAB2
to TLR11. All of them are type I transmembrane proteins or TAB3. Next, IkB kinases (IKKs) are activated, and
that show peculiar structural features. Several leucine-rich phosphorylate the inhibitor of NF-kB (IkB). This
repeats (LRRs) are present in the extracellular domain of phosphorylation leads to the degradation of IkB and

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TABLE I. Polymorphisms in TLRs genes and their relationship with human pathologies

TLR SNP Disease Association

TLR2 Arg753Gln Staphylococcal, Mycobacterium leprae and Mycobacterium Tuberculosis infection Yes (53-56)
-16934 A/T Asthma and allergies Yes (131)
-196 to 174 del, Asthma No (135)
-191 G/A, 597 T/C,
1350 T/C
TLR3 -7 A/C, +71 C/A, Asthma No (135)
Leu412Phe, 1377 C/T
TLR4 Asp299Gly Response to inhaled endotoxin, Gram negative sepsis, severe RSV bronchiolitis, Yes (42-46, 60, 80, 92,
rheumatoid artritis, diabetic neuropathy, Crohns disease, ulcerative colitis, 95, 110, 111)
Meningococcal disease, rheumatoid artritis, systemic lupus erythematosus, No (8, 47, 81, 82, 101,
multiple sclerosis, atherosclerosis, asthma 112, 113, 130)
Thr399Ile Response to inhaled endotoxin, severe RSV bronchiolitis, diabetic neuropathy, Yes (42, 60, 92, 96)
ulcerative colitis
Rheumatoid artritis, systemic lupus erythematosus, multiple sclerosis, asthma No (81, 101, 130)
TLR5 392 Stop Legionella pneumophila infection Yes (58)
TLR6 Ser249Pro Asthma Yes (132)
TLR9 -1237 C/T Crohns disease, asthma Yes (97, 133)
TLR10 +1031 G/A, +2322 G/A Asthma Yes (134)

consequently the release of NF-kB to the nucleus(35). MyD88 mouse strain is exquisitely sensitive to progressive overwhelming
is essential for responses against a broad range of microbial infection by Salmonella typhimurium(37), extensive studies led
components. However, a closer study of MyD88-deficient to the identification of tlr4 as the gene encoded by Lps, with
cells has revealed the existence of MyD88-dependent and C3H/HeJ mice harbouring a spontaneous point mutation
independent pathways, both of which mediate signalling (Pro712His) in the cytoplasmic signalling domain (38, 39).
in response to LPS(36). Two other mouse strains bear mutations of tlr4; C57BL10/ScN
Due to the fact that TLRs are clearly at the top of the and its subline C57BL10/ScNCr carry a genomic deletion
immune-system pyramid, great efforts have been made to and do not express TLR4, while motor neuron degeneration
elucidate their possible role on human diseases. Here, we (mnd) mutant mice have a large insertion within exon 2 that
review some of the findings that have arisen from these results in an aberrantly spliced transcript predicting a truncated
investigations, relating to infectious diseases, autoimmunity, protein(40). Relative to mice bearing a wild-type TLR4, C3H/HeJ
atherosclerosis and inflammatory airway diseases (Table I). and C57BL10/Sc mutant mice have also been shown to
develop prolonged bacteremia after experimental infection
with Neisseria meningitidis, another Gram-negative bacteria
TLRs AND INFECTIOUS DISEASES recognized for its exuberant production of LPS(41). The role
Recognition of microbial non-self plays a crucial role in of TLR4 seems clear in response to Gram-negative LPS in
host defence. This recognition strategy is based on the detection mice, and several groups have studied the effect of the two
of PAMPs that are essential products of microbial physiology, cosegregating missense mutations (Asp299Gly and Thr399Ile)
unique to microbes and recognised by PRRs. The TLRs are on humans at risk for sepsis. These polymorphisms have
a part of this innate immune defence. The role of the TLR been associated with a blunted physiological response to
family in host defence against microbes bearing one or more inhaled endotoxin(42), for this observation the Asp299Gly
of these PAMPs has been confirmed by experimental assays allele has been associated with a predisposition with Gram-
with mice bearing spontaneous or genetically engineered negative sepsis(43-46). The biological significance of the Asp299Gly
defects of various TLR signalling components(8). Regarding and Thr399Ile has been demonstrated by transfection of THP-
Gram-negative infection genetic differences in susceptibility 1 cells with either the wild-type or the mutant allele of the
to LPS are well established; C3H/HeJ and C57BL/10ScCR TLR4 gene(46). Although these data support the relevance of
mice strains are hyporesponsive to LPS. Since the C3H/HeJ TLR4 to human LPS responsiveness, a retrospective analysis

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of the Asp299Gly mutation failed to demonstrate an association such as rheumatoid arthritis (RA) and systemic lupus
of this polymorphism with the frequency or severity of erythematosus (SLE) are characterized by the production
documented meningococcal disease(8, 47). of autoantibodies, including rheumatoid factor (RF), antinuclear
On the other hand a critical role for TLRs in host defence antibodies and antibodies to DNA(64). The production of
against Gram-positive bacteria was strongly suggested by circulating antibodies in response to many pathogens depends
several experiments in which TLR2-deficient mice were on recognition of those pathogens by both T and B cells.
unable to respond to peptidoglycan and lipoproteins derived This constraint greatly reduces the risk of autoantibody
from these organisms (Staphylococcus aureus)(48, 49). Extensive production, as T and B cells would have to break their
in vitro data strongly suggest that TLR2 participates in tolerance to the same self-antigen simultaneously. Some
mycobacterial infection(50-52). Several studies have suggested antigens from pathogens are T-cell-independent, being
that a mutation in the TLR2 gene (Arg753Gln) may predispose lipopolysaccharide (LPS) the best understood of them. LPS
individuals to staphylococcal, Mycobacterium leprae and is recognized by TLR4, present on all mouse B cells(38) but
Mycobacterium tuberculosis infections(53-56). Underhill et al.(52) not human B cells(65). High concentrations of LPS stimulate
reported that TLR2 is the principal mediator of macrophage the proliferation of mouse B cells. But at lower concentrations,
activation in response to mycobacteria and might cause the simultaneous recognition of LPS by antigen receptors
defective mycobacterial phagocytosis by macrophages, and by TLR4 causes a synergistic signal, which provokes
resulting in an impaired Th1 response characteristic of proliferation and production of circulating antibodies
patients with lepromatous leprosy. These findings suggest selectively by bacteria-specific B cells(66, 67).
that this TLR2 polymorphism plays an important role in The mechanisms that lead to autoantibody production
defence against Gram-positive infections. remain relatively obscure, but a report by Leadbetter et al
Recently a study has demonstrated that TLR5 recognizes points to a similar mechanism in which B cells seem to
the flagellin protein, a potent inflammatory stimulus present produce RF independently of T cells(68). In a mouse model
in the flagellar structure of many bacteria(10, 57). The author of systemic autoimmune disease, the simultaneous activation
also suggested that a common TLR5 stop codon polymorphism of cell-surface antigen receptors and another toll-like receptor,
is associated with susceptibility to infection with Legionella TLR9, causes a particular subclass of self-immunoglobulin
pneumophila, a flagellated bacterium(58). (IgG2a) to be recognized by B cells as if it were a pathogen.
Regarding fungal infection, there is relatively little This triggers T-cell-independent proliferation of B cells. In
evidence that implicate mammalian TLRs in antifungal host the bloodstream of the autoimmune mice, self-IgG2a
defence. In vitro assays have shown that TLR2 recognizes accumulates in complexes with self-DNA. This DNA fails
zymosan, a yeast cell wall particle, and that TLR4 plays a to be cleared from the bloodstream for unknown reasons.
role in the induction of cytokines and intracellular signalling TLR9 detects bacterial DNA(11). Bacterial and vertebrate
in response to stimulation with Aspergillus fumigatus and DNAs differ by the absence of CpG methylation in bacteria.
Cryptococcal polysaccharide capsule, respectively(8). The immune system uses TLR9 to detect the presence of
There is evidence for the participation of TLR in host unmethylated CpG dinucleotides as a signal of infection.
defence against viral infection. Some studies using a model In fact, vertebrate DNA is not completely methylated: only
of RSV infection of tlr4-deficient C57BL/10ScNcr mice 70-80% of the CpG dinucleotides in vertebrate genomes are
implicated TLR4 and CD14 in the recognition of RSV fusion actually methylated. It seems possible that those unmethylated
(F) protein(25, 59). TLR4 mutations (Asp299Gly, Thr399Ile) are CpGs might be causing the observed effects. Interestingly,
associated with an increased risk of severe RSV bronchiolitis(60). DNA methylation is decreased in cells from autoimmune
TLR3 is another candidate for viral recognition, arising from mice and humans(69), which supports the hypothesis that
studies using poly (I:C), a synthetic double-stranded RNA unmethylated self-DNA may actually be a pathogenic factor
(dsRNA) analogue that is a molecular pattern associated in autoimmunity(70). In addition, drugs that can induce SLE
with viral infection(9). Recent reports also suggest that mouse in humans inhibit CpG methylation(71), strengthening the
TLR7 and human TLR7 and TLR8 may participate in antiviral link between hypomethylated self-DNA and autoimmunity.
host defence(61, 62). Although we do not know how rheumatoid factors are
involved in diseases, a high titre at diagnosis correlates with
the severity of both later RA and disease in tissues other
TLRs AND AUTOIMMUNITY than joints, such as blood vessels (72). The finding that
Autoimmune disease is an attack on self-tissues by the mammalian DNA can stimulate TLR9 when present in
adaptative immune system(63). Systemic autoimmune diseases immune complexes was corroborated by Viglianti et al(73).

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Although TLRs are usually thought to be crucial for the heterozygous is of 17% in Radstakes manuscript, which is
recognition of pathogens, they can also bind to self-antigens, considerable higher that the reported in most studies.
such as heat shock proteins, fibrinogen and others(74), released It has been reported that synovial cells express low levels
by cells undergoing stress, damage or necrotic death. So, of both TLR2 and TLR9(83). The former is up-regulated by
B cells may simultaneously recognize these self-antigens exposure to peptidoglycans (PG), which is consistent with
through cell-surface antigen receptors and TLRs, provoking this PAMP contributing to the development of RA. Synovial
other autoantibodies to nuclear antigens such as self- fibroblasts from RA patients cultured with PGs increased
DNA itself, in autoimmune diseases that are characterized their expression of intercellular adhesion molecule 1 (ICAM-
by prominent tissue damage. 1) and various metalloproteinases, and produced the
Recently, another point of view about the role of TLRs proinflammatory cytokines IL-6 and IL-8. This is consistent
on autoimmunity has been reported(75). In this work, it is with the evidence that PG injected intraarticularly induces
proposed that in healthy individuals, tolerance to self antigens inflammation(84). Recently, it has been reported that the
is maintained by the balanced crosstalk between C-type nominal antigen-independent, polyclonal activation of
lectin receptors (CLRs), which sample specific carbohydrated preactivated T cells via TLR2 has a pivotal role in the initiation
structures on self-antigens and induce tolerance(76), and and perpetuation of pathogen-induced chronic inflammatory
TLRs, which sense danger signals by PAMPS and induce joint disease(85).
immune activation. The normally balanced CLR-TLR crosstalk Deng et al. demonstrated that intraarticular injection of
can be disturbed by overstimulation of TLRs and/or bacterial DNA induces an inflammatory arthritis(86, 87). They
understimulation of CLRs, leading to dendritic cell (DC) showed that CpG DNA, recognised by TLR9, triggers TNF
maturation, and ultimately autoimmunity. They hypothesize production, facilitating the development of CpG mediated
that disturbed glycosilation of self-antigens might set the arthritis. This was followed by a study by Zeuner et al
stage for autoimmunity by weakening the capacity of CLRs documenting that suppressive oligodeoxynucleotides
to buffer danger signals through TLRs. specifically inhibited the immune activation induced by
Next, we will review some of the most relevant findings CpG DNA, blocked production of TNF, and thereby
concerning the role of TLRs in some common autoimmune prevented development of RA(88).
diseases, such as rheumatoid arthritis (RA), systemic lupus A typical characteristic of SLE is the presence of
erythematosus (SLE), type 1 diabetes (T1D), inflammatory autoantibodies against self-antigens, including nucleic acids.
bowel disease (IBD) and multiple sclerosis (MS). Signalling through TLR9 might be responsible for that(68).
Activation of the innate immune system triggers the This hypothesis has been supported by Anders et al, who
release of proinflammatory cytokines and chemokines found that CpG-oligodeoxynucleotides (CpG-ODN) or E.
(including TNF-) that can contribute to the initiation and/or coli DNA aggravate renal disease in MRLlpr/lpr mice, a murine
perpetuation of inflammatory responses, such as those seen model for SLE(89). CpG-DNA increased serum levels of DNA
in RA. Active infection of the joint stimulates a strong innate autoantibodies of the IgG2a isotype in the MRLlpr/lpr mice,
immune response, and such infection commonly culminates caused massive proteinuria, and worsened renal pathology.
in a destructive arthritis. Although the etiology of RA is Injected exogenous DNA or ODN bound to TLR9-positive
largely unknown, we know that antigen-presenting cells macrophages and DC in glomeruli and renal interstitium
(APCs) such as macrophages and DCs play an important of MRLlpr/lpr mice caused enhanced renal chemokine and
role in disease pathogenesis(77-79). APCs are well equipped chemokine receptor expression. Thus activation of TLR9 by
with several receptors involved in antigen uptake and unmethylated synthetic or E. coli DNA triggers exacerbation
processing, including TLRs. TLR4 is the most investigated of autoimmune lupus nephritis.
TLR in RA. This receptor interacts with endogenous ligands TLR4 is believed to recognize, in addition to microbial
released by cells undergoing stress, damage or necrotic constituents, host-derived molecules(74). A recent publication
death, which are present in inflamed synovial joints of followed this idea by showing that cell surface-expressed
patients with RA, activating immune cells to produce factors GP (a paralogue of the human HSP90, which has been linked
that are involved in the breakdown of the cartilage. The to active SLE) as a ligand of TLR2 and TLR4 leads to a
most studied SNPs within the TLR4 gene are Asp299Gly MyD88-dependent development of lupus-like autoimmune
and Th399Ile, but their role on RA susceptibility is unclear. disease in mice, independent from lymphocyte activity(90).
Although Radstake et al find an association between Asp299Gly Polymorphisms of TLR4 and TLR2 have been studied
polymorphism and RA(80), other reports show no association(81, concerning SLE predisposition and severity, but no association
82). It is worth noting that the frequency of TLR4 Asp299Gly has been found(81).

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Recently, the important role of TLR3 in the development the atherosclerotic plaque, expression of TLR2 and TLR4
of T1D has been shown(91). Wen et al found that treatment has been described in macrophages and endothelial cells(105).
with poly (I:C), a synthetic dsRNA that can stimulate immune It is now clear that endogenous ligands are also able to
responses similar to those produced by viral infections, plus activate immune responses through TLRs. The extra domain
immunization with whole insulin-protein induced a high A of cellular fibronectin (in vivo experiments have demonstrated
incidence of diabetes in B6/RIP-B7.1 mice. This effect is that this domain is expressed in injured arteries), chlamydial
performed through TLR3 recognition of poly (I:C). When LPS or human heat shock protein 60 (hsp60) are endogenous
they investigated TLR expression in pancreatic islets in ligands of TLR4 that have been involved in the induction of
humans, TLR3 showed the highest expression level in all atherosclerosis(106-108). The expression of innate immune
the individuals studied. receptors in healthy arteries and atherosclerotic plaques,
Of note, Asp299Gly and Thr399Ile polymorphisms of and the presence of these ligands in atherosclerotic and
the TLR4 gene have been shown association with reduced injured arteries, suggest that the TLR are involved in the
prevalence of diabetic neuropathy in patients with T2D(92). development and progression of atherosclerotic disease(109).
Primary human intestinal epithelial cells (IECs) of normal Recently, the Asp299Gly TLR4 polymorphism has been
mucosa constitutively express TLR2, TLR3, TLR4 and TLR5 associated with atherosclerosis progression. In a case-control
and their expression is selectively altered in patients with study it was found that subjects with the Asp299Gly allele
IBD(93). TLR4 is strongly up-regulated in both Crohns disease had lower levels of some of the inflammatory cytokines,
and ulcerative colitis, while the expression of TLR2 and acute-phase reactants, soluble adhesion molecules, and other
TLR5 remains unchanged. Furthermore, the expression of mediators of inflammation; also this allele was associated
TLR3 in the intestinal epithelium is down-regulated in active with a decreased risk of atherosclerosis(110). Another study
Crohns disease, but not in ulcerative colitis. These results in patients with acute coronary syndromes confirm previous
suggest that IBD may be associated with distinctive changes results, since the Asp299Gly allele was associated with a
in selective TLR expression in the intestinal epithelium. decreased risk of acute coronary events independently of
Interestingly, a recent study by Kobayashi et al., using standard coronary risk factors (OR 0.41; 95% CI 0.18-0.95;
multiple genetic manipulations of the myeloid cell-specific P= 0.037)(111). Both results suggest that this TLR4 polymorphism
deletion of Stat3 mouse model, showed that enterocolitis is protects against the progression of atherosclerosis disease.
significantly improved in TLR4/Stat3 double-deficient But conflicting results have also been reported. A study
mice(94). Furthermore, polymorphisms in TLR genes have found no difference in the frequency of TLR4 polymorphisms
shown association with IBD. TLR4 Asp299Gly polymorphism in patients requiring carotid endarterectomy, compared to
is associated with both Crohns disease and ulcerative controls(112) and another study suggested that predisposition
colitis(95); Thr399Ile mutation in the TLR4 gene is associated to and progression of coronary artery stenosis are not related
with ulcerative colitis(96) and a promoter SNP in the TLR9 to this TLR4 polymorphism(113), although Gly299 allele carriers
gene is associated with Crohns disease(97). had a greater reduction in cardiovascular events when treated
Activation of APCs through TLR9 is also important in with pravastatin(114).
the development of MS(98). TLR4 is necessary for LPS-induced The role of TLRs in the cardiac function has also been
oligodendrocyte injury in the central nervous system(99). demonstrated in tlr2-knockout mice. This study suggests
In mice, a transcriptional activation of TLR2 has been that TLR2 is involved in cardiac remodelling after myocardial
associated with the clinical course of experimental autoimmune infarction(115).
encephalomyelitis(100). Nevertheless, Asp299Gly and Thr399Ile The conflicting reports do not exclude, however,
polymorphisms in TLR4 do not predispose to the development involvement of TLR4 in atherosclerosis; the lack of association
of MS(101). in some studies provide additional evidence against the
importance of TLR4 polymorphism in either cardiac or
carotid artery stenosis(112, 114). It is possible that polymorphisms
TLRs AND ATHEROSCLEROSIS within genes in these pathways, other than TLR4, are important
Atherosclerosis is a consequence of a complicated in the pathogenesis of coronary artery disease; other candidate
inflammatory process with immune reactions at the initiation genes have been associated with coronary atherosclerosis
and progression of this disease. Evidence is accumulating or acute coronary syndromes, such as the genes encoding
that shows expression of TLRs on a variety of cells, including CD14(116, 117), IL-6(118) or MyD88(119).
cells of the arterial wall(102). Human endothelial cells in normal In conclusion, these data support the concept that an
arteries express TLR4 and low levels of TLR2(103, 104) and in efficient innate immune defence against bacteria and associated

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long-term intravascular inflammatory stress are involved substitution of TLR4. This SNP is associated with differences
in the development of atherosclerosis. in LPS responsiveness in humans, demonstrating that gene-
sequence changes can alter the ability of the host to respond
to environmental stress(42). In addition, Asp299Gly and
TLRs IN INFLAMMATORY AIRWAY DISEASES Thr399Ile polymorphisms in TLR4 gene have been shown
The role of TLR proteins in inflammatory airway diseases, to be associated with a modified response to endotoxin in
such as asthma and allergy is being intensively studied. asthmatic patients(129). On the other hand, other studies
These studies are based on two contradictory lines of reasoning. analysing TLR4 polymorphisms-asthma associations have
First, exposure to LPS increases the severity of asthma. A yielded heterogeneous results. Raby et al.(130) found no
study on people sensitive to house dust mite allergen showed evidence that genetic variation in TLR4 contributes to asthma
that the severity of their asthma correlated more closely susceptibility. Yang et al.(113) could confirm the previously
with levels of LPS than with those of the allergen itself(120). observed lack of association of TLR4 polymorphisms with
People with allergic asthma are also more sensitive to the asthma. Nevertheless, their findings suggest that genetically
bronchoconstrictive effects of inhaled endotoxin(121) than are determined hyporesponsiveness to endotoxin may increase
non-asthmatics. Thus, LPS can exacerbate asthma, probably atopy severity. These findings are consistent with the known
by increasing the extent of airway inflammation, through ability of LPS to exacerbate existing asthma and to decrease
its recognition by TLRs. In contrast to its exacerbating effect atopy and suggest that the Asp299Gly polymorphism is
on asthma, exposure to LPS and other TLR ligands in early predictive of airway and atopic responses in a specific subset
childhood may, paradoxically, decrease the incidence of of the population.
asthma later in life (122, 123). The essence of the hygiene Polymorphisms mapping to other TLRs genes have been
hypothesis(124) is the idea that exposure to specific infections, studied in relation to asthma and allergy susceptibility, but
or perhaps endotoxins, drives the maturing immune system not as widely as the TLR4 genetic variants. Regarding to the
in infancy/childhood towards a Th1 phenotype, and away TLR2 gene, -16934A/T genetic variation is a major determinant
from the Th2 phenotype associated with atopy. Since TLRs of the susceptibility to asthma and allergies in children of
are implicitly involved in responses to many pathogen- farmers (131). Furthermore, SNPs in TLR6, TLR9 and TLR10
related molecules, they may be critical receptor pathways genes have shown association with asthma(132-134). Recently,
involved in maturation of the normal adult immune system. Noguchi et al.(135) screened the 5 flanking and coding regions
There is some evidence for this hypothesis, albeit indirect, of TLR2, TLR3, TLR4 and TLR9 for polymorphisms. They
since polymorphisms in CD14, the correceptor involved in found 16 variants, even though none of the alleles or haplotypes
LPS signalling via TLR4, correlate with IgE levels(125). It is were associated with asthma or total IgE levels in a Japanese
clear that LPS can either exacerbate or diminish the severity population.
of asthma, depending on the timing of LPS exposure and
whether the disease or its exacerbations result primarily
from LPS or allergens. In addition, the type of TLR stimulation CONCLUDING REMARKS
during the initial phase of immune activation determines TLRs are a family of transmembrane receptors, some of
the polarization of the adaptative immune response and which have been clearly demonstrated to play a key role in
may play a role in the initiation of Th2-mediated immune innate immunity. The first focus of research was on the TLR
disorders, such as asthma(126). These results may also be signalling pathway. The identified LPS signalling mediators
explained by the finding that high doses of LPS activate the may be important pharmacological targets, and the future
CD4+ CD25+ T regulatory (Treg) cells that may prevent identification of all the component of the LPS signalling
the activation of pathogenic T cell clones(127). On the contrary, cascade will be an invaluable platform for designing
low doses of LPS activate DCs that in conjunction with IL- therapeutical interventions. Also, the effect of various TLR
6 production, release T cells from the inhibitory effect of the polymorphisms on disease progression becomes better
Treg cells(128), thereby leading to the activation of the pathogenic understood, a patients genotypic profile will comprise an
T cell clones. increasingly important factor in the consideration of various
The importance of TLRs in allergic diseases is less well therapeutic options. Future studies will need to address the
understood. Studies of polymorphisms in TLR genes have biological importance of the known differences in TLR
the potential to advance our understanding of the response function, including expression patterns, ligand specificities
to endotoxin and the pathogenesis of allergic disease. The and the relationships among TLR signalling, genetic
best-studied polymorphism is the Asp299Gly amino acid polymorphism and human disease.

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