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Revisin
Toll-like receptors and human pathology
Instituto de Parasitologa y Biomedicina Lpez-Neyra, CSIC, Granada.
RESUMEN
El sistema inmunitario innato desarroll uno de los meca-
nismos de reconocimiento frente a las infecciones microbianas y
el inicio de defensa del hospedador. ste mecanismo est basado
en el reconocimiento de patrones moleculares presentes en los
distintos componentes microbianos as como en determinados
ligandos endgenos. Estos patrones son reconocidos, entre otros
receptores, a travs de los llamados receptores Toll-like (TLRs),
los cuales son responsables de la activacin de reacciones infla-
matorias y tienen un papel crtico en el inicio de la respuesta inmu-
nitaria innata. La funcin de los TLRs en varias enfermedades
humanas ha sido investigada a travs del estudio de polimorfis-
mos de genes que participan en la sealizacin a travs de TLR.
Estos estudios sugieren que varias enfermedades, incluidas enfer-
medades infecciosas, autoinmunitarias, ateroesclerosis e infla-
matorias de las vas respiratorias estn afectadas por la funcin
de estos TLR. Los futuros estudios en este campo continuarn
aumentando el conocimiento de la patognesis y etiologa de estas
enfermedades as como revelarn informacin sobre las distintas
opciones teraputicas.
PALABRAS CLAVE: Receptores tipo toll / Polimorfismo genti-
co / Enfermedades infecciosas / Autoinmunidad / Ateroscle-
rosis / Enfermedades inflamatorias de las vas respiratorias.
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Inmunologa
Vol. 23 / Nm 4/ Octubre-Diciembre 2004: 328-338
E. Snchez*, G. Orozco*, and J. Martn
* The authors have contributed equally to this work.
RECEPTORES TIPO TOLL Y PATOLOGA HUMANA
Recibido: 8 Noviembre 2004
Aceptado: 1 Diciembre 2004
ABSTRACT
The innate immune system has evolved one of the mecha-
nisms of recognition of microbial infection and initiation of host
defence. This is based on the recognition of molecular patterns
that are present in microbial components or endogenous ligands.
These patterns are recognized, among other, through the Toll-like
receptors (TLRs), which activate inflammatory reactions and are
critical in the initiation of adaptive immune responses. The func-
tion of TLRs in various human diseases has been investigated by
the study of several polymorphisms in genes that participate in
TLR signalling. These studies have suggested that several disea-
ses, including infectious, autoimmune, atherosclerosis and inflam-
matory airway diseases are affected by the TLR function. The futu-
re studies in this field will continue to improve the understanding
of the pathogenesis and aetiology of these diseases and they will
as well reveal information about therapeutic options.
KEY WORDS: Toll-like receptors / Genetic polymorphism / Infec-
tious diseases / Autoimmunity / Atherosclerosis / Inflamma-
tory airway diseases.
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INTRODUCTION
Innate immunity is the first-line of host defence of
multicellular organisms that rapidly operates to limit infection
upon exposure to infectious agents. Accumulating evidence
indicates that activation of the innate immune system is a
prerequisite for the induction of acquired immunity,
particularly for the induction of a T helper 1 (Th1)-cell
response(1, 2). Toll-like receptors (TLRs) play a crucial role
in innate immunity, through their ability to bind pathogen-
associated molecular patterns (PAMPs)(3). The receptors of
the innate immune system that recognise PAMPs are called
pattern-recognition receptors (PRR)(4). PRRs are expressed
on the cell surface, activate signalling pathways that induce
antimicrobial effector responses and inflammation upon
recognition of PAMPs. Therefore TLRs control multiple
functions and activate signals that are critically involved
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,
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
demonstrated for TLR3 in responses to poly(I:C) (double-
stranded viral RNA)(9), TLR5 for responses to flagellin and
flagellated bacteria(10), and TLR9 for mediating responses
to CpG bacterial DNA(11). On the contrary, TLR2 and TLR4
have a broad specificity for the recognition of microbial
patterns. TLR2 is responsible for the recognition of Gram-
positive bacteria (peptidoglycan, lipoteichoic acid) (12),
mycobacterial species(13, 14), protozoan parasites(15, 16), as well
as microbial lipoproteins, glycoproteins, glycolipids, and
nonenteric LPS(17-21). TLR4 recognizes LPS(22, 23), the LPS
mimetic drug Taxol(24), the fusion protein of respiratory
syncytical virus (RSV)(25), as well as fungal ligands(26, 27).
TLRs can also dimerise upon interaction with the proper
ligand. Dimers consisting of TLR4-TLR4, TLR2-TLR6 and
TLR1-TLR2 have been described(28). The Drosophila protein
Toll was originally described as a type I transmembrane
receptor that controls the dorsal-ventral patterning of the
fly embryo(29). Toll signalling has been identified as an
essential element of an effective anti-fungal immune response
in the fly(30). Several studies have identified mammalian
homologs of Toll, proteins now referred to as Toll-like
receptors (TLR) (31-33). TLRs are grouped into the same
gene family based on their sequence similarity. Eleven
mammalian members have been described, namely TLR1
to TLR11. All of them are type I transmembrane proteins
that show peculiar structural features. Several leucine-rich
repeats (LRRs) are present in the extracellular domain of
E. SNCHEZ, G. OROZCO, J. MARTN
IL-1RI TLR4 TLR3
MyD88
MyD88-
independent TRIF
pathway
IRAK 4 IRAK 1
TRAF6
MKK IKK
IKK IKK
complex
IKK
JnK
IB IB
Degradation
NF-B
AP-1 NF-B Nucleus
Figure 1. The TLR signalling pathway.
the molecule(31). TLRs cross the cytoplasmatic membrane
once, and their intracellular portion is extremely similar to
the cytoplasmatic domain of the IL-1R and related molecules,
which is designated Toll-IL-1R or TIR domain(34). By contrast,
the extracellular region of the TLRs and IL-1R differs
markedly: the extracellular region of TLRs contains LRRs
motifs, whereas the extracellular region of IL-1R contains
three immunoglobulin-like domains.
Upon ligand binding, TLRs (homo- hetero-) dimerise
and undergo a conformational change required for the
recruitment of downstream signalling molecules. After TLR
ligation, the adaptor molecule myeloid-differentiation
primary-response protein 88 (MyD88) is recruited to the
cytoplasmatic TIR domain, where it facilitates the association
of IL-1R-associated kinase 4 (IRAK4) with the receptor
complex (Fig. 1). The binding of MyD88 to IRAK4 facilitates
IRAK4-mediated phosphorylation of crucial residue/s in
the kinase-activation loop of IRAK1, which induces the
kinase activity of IRAK1. Activated IRAK1 then
autophosphorylates, and this enables tumour-necrosis factor
(TNF)-receptor-associated factor 6 (TRAF6) to bind to the
complex. The IRAK1-TRAF6 complex then disengages from
the receptor and interacts with another preformed complex
consisting of transforming growth factor- (TGF-)-activated
kinase (TAK1), TAK1-binding protein 1 (TAB1) and TAB2
or TAB3. Next, IkB kinases (IKKs) are activated, and
phosphorylate the inhibitor of NF-kB (IkB). This
phosphorylation leads to the degradation of IkB and
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TOLL-LIKE RECEPTORS AND HUMAN PATHOLOGY VOL. 23 NUM. 4/ 2004

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

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of the Asp299Gly mutation failed to demonstrate an association
of this polymorphism with the frequency or severity of
documented meningococcal disease(8, 47).
On the other hand a critical role for TLRs in host defence
against Gram-positive bacteria was strongly suggested by
several experiments in which TLR2-deficient mice were
unable to respond to peptidoglycan and lipoproteins derived
from these organisms (Staphylococcus aureus)(48, 49). Extensive
in vitro data strongly suggest that TLR2 participates in
mycobacterial infection(50-52). Several studies have suggested
that a mutation in the TLR2 gene (Arg753Gln) may predispose
individuals to staphylococcal, Mycobacterium leprae and
Mycobacterium tuberculosis infections(53-56). Underhill et al.(52)
reported that TLR2 is the principal mediator of macrophage
activation in response to mycobacteria and might cause
defective mycobacterial phagocytosis by macrophages,
resulting in an impaired Th1 response characteristic of
patients with lepromatous leprosy. These findings suggest
that this TLR2 polymorphism plays an important role in
defence against Gram-positive infections.
Recently a study has demonstrated that TLR5 recognizes
the flagellin protein, a potent inflammatory stimulus present
in the flagellar structure of many bacteria(10, 57). The author
also suggested that a common TLR5 stop codon polymorphism
is associated with susceptibility to infection with Legionella
pneumophila, a flagellated bacterium(58).
Regarding fungal infection, there is relatively little
evidence that implicate mammalian TLRs in antifungal host
defence. In vitro assays have shown that TLR2 recognizes
zymosan, a yeast cell wall particle, and that TLR4 plays a
role in the induction of cytokines and intracellular signalling
in response to stimulation with Aspergillus fumigatus and
Cryptococcal polysaccharide capsule, respectively(8).
There is evidence for the participation of TLR in host
defence against viral infection. Some studies using a model
of RSV infection of tlr4-deficient C57BL/10ScNcr mice
implicated TLR4 and CD14 in the recognition of RSV fusion
(F) protein(25, 59). TLR4 mutations (Asp299Gly, Thr399Ile) are
associated with an increased risk of severe RSV bronchiolitis(60).
TLR3 is another candidate for viral recognition, arising from
studies using poly (I:C), a synthetic double-stranded RNA
(dsRNA) analogue that is a molecular pattern associated
with viral infection(9). Recent reports also suggest that mouse
TLR7 and human TLR7 and TLR8 may participate in antiviral
host defence(61, 62).
TLRs AND AUTOIMMUNITY
Autoimmune disease is an attack on self-tissues by the
adaptative immune system(63). Systemic autoimmune diseases
E. SNCHEZ, G. OROZCO, J. MARTN
such as rheumatoid arthritis (RA) and systemic lupus
erythematosus (SLE) are characterized by the production
of autoantibodies, including rheumatoid factor (RF), antinuclear
antibodies and antibodies to DNA(64). The production of
circulating antibodies in response to many pathogens depends
on recognition of those pathogens by both T and B cells.
This constraint greatly reduces the risk of autoantibody
production, as T and B cells would have to break their
tolerance to the same self-antigen simultaneously. Some
antigens from pathogens are T-cell-independent, being
lipopolysaccharide (LPS) the best understood of them. LPS
is recognized by TLR4, present on all mouse B cells(38) but
not human B cells(65). High concentrations of LPS stimulate
the proliferation of mouse B cells. But at lower concentrations,
the simultaneous recognition of LPS by antigen receptors
and by TLR4 causes a synergistic signal, which provokes
proliferation and production of circulating antibodies
selectively by bacteria-specific B cells(66, 67).
The mechanisms that lead to autoantibody production
remain relatively obscure, but a report by Leadbetter et al
points to a similar mechanism in which B cells seem to
produce RF independently of T cells(68). In a mouse model
of systemic autoimmune disease, the simultaneous activation
of cell-surface antigen receptors and another toll-like receptor,
TLR9, causes a particular subclass of self-immunoglobulin
(IgG2a) to be recognized by B cells as if it were a pathogen.
This triggers T-cell-independent proliferation of B cells. In
the bloodstream of the autoimmune mice, self-IgG2a
accumulates in complexes with self-DNA. This DNA fails
to be cleared from the bloodstream for unknown reasons.
TLR9 detects bacterial DNA(11). Bacterial and vertebrate
DNAs differ by the absence of CpG methylation in bacteria.
The immune system uses TLR9 to detect the presence of
unmethylated CpG dinucleotides as a signal of infection.
In fact, vertebrate DNA is not completely methylated: only
70-80% of the CpG dinucleotides in vertebrate genomes are
actually methylated. It seems possible that those unmethylated
CpGs might be causing the observed effects. Interestingly,
DNA methylation is decreased in cells from autoimmune
mice and humans(69), which supports the hypothesis that
unmethylated self-DNA may actually be a pathogenic factor
in autoimmunity(70). In addition, drugs that can induce SLE
in humans inhibit CpG methylation(71), strengthening the
link between hypomethylated self-DNA and autoimmunity.
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
than joints, such as blood vessels (72). The finding that
mammalian DNA can stimulate TLR9 when present in
immune complexes was corroborated by Viglianti et al(73).
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Although TLRs are usually thought to be crucial for the
recognition of pathogens, they can also bind to self-antigens,
such as heat shock proteins, fibrinogen and others(74), released
by cells undergoing stress, damage or necrotic death. So,
B cells may simultaneously recognize these self-antigens
through cell-surface antigen receptors and TLRs, provoking
other autoantibodies to nuclear antigens such as self-
DNA itself, in autoimmune diseases that are characterized
by prominent tissue damage.
Recently, another point of view about the role of TLRs
on autoimmunity has been reported(75). In this work, it is
proposed that in healthy individuals, tolerance to self antigens
is maintained by the balanced crosstalk between C-type
lectin receptors (CLRs), which sample specific carbohydrated
structures on self-antigens and induce tolerance(76), and
TLRs, which sense danger signals by PAMPS and induce
immune activation. The normally balanced CLR-TLR crosstalk
can be disturbed by overstimulation of TLRs and/or
understimulation of CLRs, leading to dendritic cell (DC)
maturation, and ultimately autoimmunity. They hypothesize
that disturbed glycosilation of self-antigens might set the
stage for autoimmunity by weakening the capacity of CLRs
to buffer danger signals through TLRs.
Next, we will review some of the most relevant findings
concerning the role of TLRs in some common autoimmune
diseases, such as rheumatoid arthritis (RA), systemic lupus
erythematosus (SLE), type 1 diabetes (T1D), inflammatory
bowel disease (IBD) and multiple sclerosis (MS).
Activation of the innate immune system triggers the
release of proinflammatory cytokines and chemokines
(including TNF-) that can contribute to the initiation and/or
perpetuation of inflammatory responses, such as those seen
in RA. Active infection of the joint stimulates a strong innate
immune response, and such infection commonly culminates
in a destructive arthritis. Although the etiology of RA is
largely unknown, we know that antigen-presenting cells
(APCs) such as macrophages and DCs play an important
role in disease pathogenesis(77-79). APCs are well equipped
with several receptors involved in antigen uptake and
processing, including TLRs. TLR4 is the most investigated
TLR in RA. This receptor interacts with endogenous ligands
released by cells undergoing stress, damage or necrotic
death, which are present in inflamed synovial joints of
patients with RA, activating immune cells to produce factors
that are involved in the breakdown of the cartilage. The
most studied SNPs within the TLR4 gene are Asp299Gly
and Th399Ile, but their role on RA susceptibility is unclear.
Although Radstake et al find an association between Asp299Gly
polymorphism and RA(80), other reports show no association(81,
82). It is worth noting that the frequency of TLR4 Asp299Gly
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VOL. 23 NUM. 4/ 2004
heterozygous is of 17% in Radstakes manuscript, which is
considerable higher that the reported in most studies.
It has been reported that synovial cells express low levels
of both TLR2 and TLR9(83). The former is up-regulated by
exposure to peptidoglycans (PG), which is consistent with
this PAMP contributing to the development of RA. Synovial
fibroblasts from RA patients cultured with PGs increased
their expression of intercellular adhesion molecule 1 (ICAM-
1) and various metalloproteinases, and produced the
proinflammatory cytokines IL-6 and IL-8. This is consistent
with the evidence that PG injected intraarticularly induces
inflammation(84). Recently, it has been reported that the
nominal antigen-independent, polyclonal activation of
preactivated T cells via TLR2 has a pivotal role in the initiation
and perpetuation of pathogen-induced chronic inflammatory
joint disease(85).
Deng et al. demonstrated that intraarticular injection of
bacterial DNA induces an inflammatory arthritis(86, 87). They
showed that CpG DNA, recognised by TLR9, triggers TNF
production, facilitating the development of CpG mediated
arthritis. This was followed by a study by Zeuner et al
documenting that suppressive oligodeoxynucleotides
specifically inhibited the immune activation induced by
CpG DNA, blocked production of TNF, and thereby
prevented development of RA(88).
A typical characteristic of SLE is the presence of
autoantibodies against self-antigens, including nucleic acids.
Signalling through TLR9 might be responsible for that(68).
This hypothesis has been supported by Anders et al, who
found that CpG-oligodeoxynucleotides (CpG-ODN) or E.
coli DNA aggravate renal disease in MRLlpr/lpr mice, a murine
model for SLE(89). CpG-DNA increased serum levels of DNA
autoantibodies of the IgG2a isotype in the MRLlpr/lpr mice,
caused massive proteinuria, and worsened renal pathology.
Injected exogenous DNA or ODN bound to TLR9-positive
macrophages and DC in glomeruli and renal interstitium
of MRLlpr/lpr mice caused enhanced renal chemokine and
chemokine receptor expression. Thus activation of TLR9 by
unmethylated synthetic or E. coli DNA triggers exacerbation
of autoimmune lupus nephritis.
TLR4 is believed to recognize, in addition to microbial
constituents, host-derived molecules(74). A recent publication
followed this idea by showing that cell surface-expressed
GP (a paralogue of the human HSP90, which has been linked
to active SLE) as a ligand of TLR2 and TLR4 leads to a
MyD88-dependent development of lupus-like autoimmune
disease in mice, independent from lymphocyte activity(90).
Polymorphisms of TLR4 and TLR2 have been studied
concerning SLE predisposition and severity, but no association
has been found(81).
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Recently, the important role of TLR3 in the development
of T1D has been shown(91). Wen et al found that treatment
with poly (I:C), a synthetic dsRNA that can stimulate immune
responses similar to those produced by viral infections, plus
immunization with whole insulin-protein induced a high
incidence of diabetes in B6/RIP-B7.1 mice. This effect is
performed through TLR3 recognition of poly (I:C). When
they investigated TLR expression in pancreatic islets in
humans, TLR3 showed the highest expression level in all
the individuals studied.
Of note, Asp299Gly and Thr399Ile polymorphisms of
the TLR4 gene have been shown association with reduced
prevalence of diabetic neuropathy in patients with T2D(92).
Primary human intestinal epithelial cells (IECs) of normal
mucosa constitutively express TLR2, TLR3, TLR4 and TLR5
and their expression is selectively altered in patients with
IBD(93). TLR4 is strongly up-regulated in both Crohns disease
and ulcerative colitis, while the expression of TLR2 and
TLR5 remains unchanged. Furthermore, the expression of
TLR3 in the intestinal epithelium is down-regulated in active
Crohns disease, but not in ulcerative colitis. These results
suggest that IBD may be associated with distinctive changes
in selective TLR expression in the intestinal epithelium.
Interestingly, a recent study by Kobayashi et al., using
multiple genetic manipulations of the myeloid cell-specific
deletion of Stat3 mouse model, showed that enterocolitis is
significantly improved in TLR4/Stat3 double-deficient
mice(94). Furthermore, polymorphisms in TLR genes have
shown association with IBD. TLR4 Asp299Gly polymorphism
is associated with both Crohns disease and ulcerative
colitis(95); Thr399Ile mutation in the TLR4 gene is associated
with ulcerative colitis(96) and a promoter SNP in the TLR9
gene is associated with Crohns disease(97).
Activation of APCs through TLR9 is also important in
the development of MS(98). TLR4 is necessary for LPS-induced
oligodendrocyte injury in the central nervous system(99).
In mice, a transcriptional activation of TLR2 has been
associated with the clinical course of experimental autoimmune
encephalomyelitis(100). Nevertheless, Asp299Gly and Thr399Ile
polymorphisms in TLR4 do not predispose to the development
of MS(101).
TLRs AND ATHEROSCLEROSIS
Atherosclerosis is a consequence of a complicated
inflammatory process with immune reactions at the initiation
and progression of this disease. Evidence is accumulating
that shows expression of TLRs on a variety of cells, including
cells of the arterial wall(102). Human endothelial cells in normal
arteries express TLR4 and low levels of TLR2(103, 104) and in
E. SNCHEZ, G. OROZCO, J. MARTN
the atherosclerotic plaque, expression of TLR2 and TLR4
has been described in macrophages and endothelial cells(105).
It is now clear that endogenous ligands are also able to
activate immune responses through TLRs. The extra domain
A of cellular fibronectin (in vivo experiments have demonstrated
that this domain is expressed in injured arteries), chlamydial
LPS or human heat shock protein 60 (hsp60) are endogenous
ligands of TLR4 that have been involved in the induction of
atherosclerosis(106-108). The expression of innate immune
receptors in healthy arteries and atherosclerotic plaques,
and the presence of these ligands in atherosclerotic and
injured arteries, suggest that the TLR are involved in the
development and progression of atherosclerotic disease(109).
Recently, the Asp299Gly TLR4 polymorphism has been
associated with atherosclerosis progression. In a case-control
study it was found that subjects with the Asp299Gly allele
had lower levels of some of the inflammatory cytokines,
acute-phase reactants, soluble adhesion molecules, and other
mediators of inflammation; also this allele was associated
with a decreased risk of atherosclerosis(110). Another study
in patients with acute coronary syndromes confirm previous
results, since the Asp299Gly allele was associated with a
decreased risk of acute coronary events independently of
standard coronary risk factors (OR 0.41; 95% CI 0.18-0.95;
P= 0.037)(111). Both results suggest that this TLR4 polymorphism
protects against the progression of atherosclerosis disease.
But conflicting results have also been reported. A study
found no difference in the frequency of TLR4 polymorphisms
in patients requiring carotid endarterectomy, compared to
controls(112) and another study suggested that predisposition
to and progression of coronary artery stenosis are not related
to this TLR4 polymorphism(113), although Gly299 allele carriers
had a greater reduction in cardiovascular events when treated
with pravastatin(114).
The role of TLRs in the cardiac function has also been
demonstrated in tlr2-knockout mice. This study suggests
that TLR2 is involved in cardiac remodelling after myocardial
infarction(115).
The conflicting reports do not exclude, however,
involvement of TLR4 in atherosclerosis; the lack of association
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
within genes in these pathways, other than TLR4, are important
in the pathogenesis of coronary artery disease; other candidate
genes have been associated with coronary atherosclerosis
or acute coronary syndromes, such as the genes encoding
CD14(116, 117), IL-6(118) or MyD88(119).
In conclusion, these data support the concept that an
efficient innate immune defence against bacteria and associated
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long-term intravascular inflammatory stress are involved
in the development of atherosclerosis.
TLRs IN INFLAMMATORY AIRWAY DISEASES
The role of TLR proteins in inflammatory airway diseases,
such as asthma and allergy is being intensively studied.
These studies are based on two contradictory lines of reasoning.
First, exposure to LPS increases the severity of asthma. A
study on people sensitive to house dust mite allergen showed
that the severity of their asthma correlated more closely
with levels of LPS than with those of the allergen itself(120).
People with allergic asthma are also more sensitive to the
bronchoconstrictive effects of inhaled endotoxin(121) than are
non-asthmatics. Thus, LPS can exacerbate asthma, probably
by increasing the extent of airway inflammation, through
its recognition by TLRs. In contrast to its exacerbating effect
on asthma, exposure to LPS and other TLR ligands in early
childhood may, paradoxically, decrease the incidence of
asthma later in life (122, 123). The essence of the hygiene
hypothesis(124) is the idea that exposure to specific infections,
or perhaps endotoxins, drives the maturing immune system
in infancy/childhood towards a Th1 phenotype, and away
from the Th2 phenotype associated with atopy. Since TLRs
are implicitly involved in responses to many pathogen-
related molecules, they may be critical receptor pathways
involved in maturation of the normal adult immune system.
There is some evidence for this hypothesis, albeit indirect,
since polymorphisms in CD14, the correceptor involved in
LPS signalling via TLR4, correlate with IgE levels(125). It is
clear that LPS can either exacerbate or diminish the severity
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
during the initial phase of immune activation determines
the polarization of the adaptative immune response and
may play a role in the initiation of Th2-mediated immune
disorders, such as asthma(126). These results may also be
explained by the finding that high doses of LPS activate the
CD4+ CD25+ T regulatory (Treg) cells that may prevent
the activation of pathogenic T cell clones(127). On the contrary,
low doses of LPS activate DCs that in conjunction with IL-
6 production, release T cells from the inhibitory effect of the
Treg cells(128), thereby leading to the activation of the pathogenic
T cell clones.
The importance of TLRs in allergic diseases is less well
understood. Studies of polymorphisms in TLR genes have
the potential to advance our understanding of the response
to endotoxin and the pathogenesis of allergic disease. The
best-studied polymorphism is the Asp299Gly amino acid
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substitution of TLR4. This SNP is associated with differences
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
Thr399Ile polymorphisms in TLR4 gene have been shown
to be associated with a modified response to endotoxin in
asthmatic patients(129). On the other hand, other studies
analysing TLR4 polymorphisms-asthma associations have
yielded heterogeneous results. Raby et al.(130) found no
evidence that genetic variation in TLR4 contributes to asthma
susceptibility. Yang et al.(113) could confirm the previously
observed lack of association of TLR4 polymorphisms with
asthma. Nevertheless, their findings suggest that genetically
determined hyporesponsiveness to endotoxin may increase
atopy severity. These findings are consistent with the known
ability of LPS to exacerbate existing asthma and to decrease
atopy and suggest that the Asp299Gly polymorphism is
predictive of airway and atopic responses in a specific subset
of the population.
Polymorphisms mapping to other TLRs genes have been
studied in relation to asthma and allergy susceptibility, but
not as widely as the TLR4 genetic variants. Regarding to the
TLR2 gene, -16934A/T genetic variation is a major determinant
of the susceptibility to asthma and allergies in children of
farmers (131). Furthermore, SNPs in TLR6, TLR9 and TLR10
genes have shown association with asthma(132-134). Recently,
Noguchi et al.(135) screened the 5 flanking and coding regions
of TLR2, TLR3, TLR4 and TLR9 for polymorphisms. They
found 16 variants, even though none of the alleles or haplotypes
were associated with asthma or total IgE levels in a Japanese
population.
CONCLUDING REMARKS
TLRs are a family of transmembrane receptors, some of
which have been clearly demonstrated to play a key role in
innate immunity. The first focus of research was on the TLR
signalling pathway. The identified LPS signalling mediators
may be important pharmacological targets, and the future
identification of all the component of the LPS signalling
cascade will be an invaluable platform for designing
therapeutical interventions. Also, the effect of various TLR
polymorphisms on disease progression becomes better
understood, a patients genotypic profile will comprise an
increasingly important factor in the consideration of various
therapeutic options. Future studies will need to address the
biological importance of the known differences in TLR
function, including expression patterns, ligand specificities
and the relationships among TLR signalling, genetic
polymorphism and human disease.
Inmunol 80p 18/1/05 10:08 Pgina 335
INMUNOLOGA
CORRESPONDENCE TO:
Javier Martn MD, PhD
Instituto de Parasitologa y Biomedicina Lpez Neyra, CSIC
Parque Tecnolgico de Ciencias de la Salud.
Avenida del Conocimiento s/n
18100 Armilla (Granada), Spain.
Phone: 34-958-181669. Fax: 34-958- 181633
E-mail: martin@ipb.csic.es
REFERENCES
1. Medzhitov R. Toll-like receptors and innate immunity. Nat Rev
Immunol 2001;1:135-145.
2. Akira S, Takeda K, Kaisho T. Toll-like receptors: critical proteins
linking innate and acquired immunity. Nat Immunol 2001;2:675-
680.
3. Takeda K, Kaisho T, Akira S. Toll-like receptors. Annu Rev Immunol
2003;21:335-376.
4. Janeway CA, Jr. Approaching the asymptote? Evolution and
revolution in immunology. Cold Spring Harb Symp Quant Biol
1989;54:1-13.
5. Medzhitov R, Janeway CA, Jr. Decoding the patterns of self and
nonself by the innate immune system. Science 2002;296:298-300.
6. Iwasaki A, Medzhitov R. Toll-like receptor control of the adaptive
immune responses. Nat Immunol 2004;5:987-995.
7. Lien E, Ingalls RR. Toll-like receptors. Crit Care Med 2002;30:1-11.
8. Qureshi ST, Medzhitov R. Toll-like receptors and their role in
experimental models of microbial infection. Genes Immun 2003;4:87-
94.
9. Alexopoulou L, Holt AC, Medzhitov R, Flavell RA. Recognition
of double-stranded RNA and activation of NF-kappaB by Toll-
like receptor 3. Nature 2001;413:732-738.
10. Hayashi F, Smith KD, Ozinsky A, Hawn TR, Yi EC, Goodlett DR,
et al. The innate immune response to bacterial flagellin is mediated
by Toll-like receptor 5. Nature 2001;410:1099-1103.
11. Hemmi H, Takeuchi O, Kawai T, Kaisho T, Sato S, Sanjo H, et al. A
Toll-like receptor recognizes bacterial DNA. Nature 2000;408:740-745.
12. Schwandner R, Dziarski R, Wesche H, Rothe M, Kirschning CJ.
Peptidoglycan- and lipoteichoic acid-induced cell activation is
mediated by toll-like receptor 2. J Biol Chem 1999;274:17406-17409.
13. Means TK, Lien E, Yoshimura A, Wang S, Golenbock DT, Fenton
MJ. The CD14 ligands lipoarabinomannan and lipopolysaccharide
differ in their requirement for Toll-like receptors. J Immunol
1999;163:6748-6755.
14. Tsuji S, Matsumoto M, Takeuchi O, Akira S, Azuma I, Hayashi
A, et al. Maturation of human dendritic cells by cell wall skeleton
of Mycobacterium bovis bacillus Calmette-Guerin: involvement
of toll-like receptors. Infect Immun 2000;68:6883-6890.
15. Campos MA, Almeida IC, Takeuchi O, Akira S, Valente EP, Procopio
DO, et al. Activation of Toll-like receptor-2 by glycosyl-
phosphatidylinositol anchors from a protozoan parasite. J Immunol
2001;167:416-423.
16. Ouaissi A, Guilvard E, Delneste Y, Caron G, Magistrelli G, Herbault
N, et al. The Trypanosoma cruzi Tc52-released protein induces
human dendritic cell maturation, signals via Toll-like receptor 2,
and confers protection against lethal infection. J Immunol
2002;168:6366-6374.
E. SNCHEZ, G. OROZCO, J. MARTN
17. Aliprantis AO, Yang RB, Mark MR, Suggett S, Devaux B, Radolf
JD, et al. Cell activation and apoptosis by bacterial lipoproteins
through toll-like receptor-2. Science 1999;285:736-739.
18. Brightbill HD, Libraty DH, Krutzik SR, Yang RB, Belisle JT, Bleharski
JR, et al. Host defense mechanisms triggered by microbial lipoproteins
through toll-like receptors. Science 1999;285:732-736.
19. Sugawara S, Yang S, Iki K, Hatakeyama J, Tamai R, Takeuchi O,
et al. Monocytic cell activation by Nonendotoxic glycoprotein
from Prevotella intermedia ATCC 25611 is mediated by toll-like
receptor 2. Infect Immun 2001;69:4951-4957.
20. Opitz B, Schroder NW, Spreitzer I, Michelsen KS, Kirschning CJ,
Hallatschek W, et al. Toll-like receptor-2 mediates Treponema
glycolipid and lipoteichoic acid-induced NF-kappaB translocation.
J Biol Chem 2001;276:22041-22047.
21. Werts C, Tapping RI, Mathison JC, Chuang TH, Kravchenko V, Saint
Girons I, et al. Leptospiral lipopolysaccharide activates cells through
a TLR2-dependent mechanism. Nat Immunol 2001;2:346-352.
22. Chow JC, Young DW, Golenbock DT, Christ WJ, Gusovsky F. Toll-
like receptor-4 mediates lipopolysaccharide-induced signal
transduction. J Biol Chem 1999;274:10689-10692.
23. Hirschfeld M, Ma Y, Weis JH, Vogel SN, Weis JJ. Cutting edge:
repurification of lipopolysaccharide eliminates signaling through
both human and murine toll-like receptor 2. J Immunol 2000;165:618-
622.
24. Kawasaki K, Akashi S, Shimazu R, Yoshida T, Miyake K, Nishijima
M. Mouse toll-like receptor 4.MD-2 complex mediates
lipopolysaccharide-mimetic signal transduction by Taxol. J Biol
Chem 2000;275:2251-2254.
25. Kurt-Jones EA, Popova L, Kwinn L, Haynes LM, Jones LP, Tripp
RA, et al. Pattern recognition receptors TLR4 and CD14 mediate
response to respiratory syncytial virus. Nat Immunol 2000;1:398-
401.
26. Shoham S, Huang C, Chen JM, Golenbock DT, Levitz SM. Toll-
like receptor 4 mediates intracellular signaling without TNF-alpha
release in response to Cryptococcus neoformans polysaccharide
capsule. J Immunol 2001;166:4620-4226.
27. Wang JE, Warris A, Ellingsen EA, Jorgensen PF, Flo TH, Espevik
T, et al. Involvement of CD14 and toll-like receptors in activation
of human monocytes by Aspergillus fumigatus hyphae. Infect
Immun 2001;69:2402-2406.
28. Ozinsky A, Underhill DM, Fontenot JD, Hajjar AM, Smith KD,
Wilson CB, et al. The repertoire for pattern recognition of pathogens
by the innate immune system is defined by cooperation between
toll-like receptors. Proc Natl Acad Sci U S A 2000;97:13766-13771.
29. Hashimoto C, Hudson KL, Anderson KV. The Toll gene of Drosophila,
required for dorsal-ventral embryonic polarity, appears to encode
a transmembrane protein. Cell 1988;52:269-279.
30. Lemaitre B, Nicolas E, Michaut L, Reichhart JM, Hoffmann JA.
The dorsoventral regulatory gene cassette spatzle/Toll/cactus
controls the potent antifungal response in Drosophila adults. Cell
1996;86:973-983.
31. Rock FL, Hardiman G, Timans JC, Kastelein RA, Bazan JF. A family
of human receptors structurally related to Drosophila Toll. Proc
Natl Acad Sci U S A 1998;95:588-593.
32. Chaudhary PM, Ferguson C, Nguyen V, Nguyen O, Massa HF,
Eby M, et al. Cloning and characterization of two Toll/Interleukin-
1 receptor-like genes TIL3 and TIL4: evidence for a multi-gene
receptor family in humans. Blood 1998;91:4020-4027.
335
Inmunol 80p 18/1/05 10:08 Pgina 336
TOLL-LIKE RECEPTORS AND HUMAN PATHOLOGY
33. Takeuchi O, Kawai T, Sanjo H, Copeland NG, Gilbert DJ, Jenkins
NA, et al. TLR6: A novel member of an expanding toll-like receptor
family. Gene 1999;231:59-65.
34. Gay NJ, Keith FJ. Drosophila Toll and IL-1 receptor. Nature
1991;351:355-356.
35. Akira S, Takeda K. Toll-like receptor signalling. Nat Rev Immunol
2004;4:499-511.
36. Kawai T, Adachi O, Ogawa T, Takeda K, Akira S. Unresponsiveness
of MyD88-deficient mice to endotoxin. Immunity 1999;11:115-122.
37. O'Brien AD, Rosenstreich DL, Scher I, Campbell GH, MacDermott
RP, Formal SB. Genetic control of susceptibility to Salmonella
typhimurium in mice: role of the LPS gene. J Immunol 1980;124:20-
24.
38. Poltorak A, He X, Smirnova I, Liu MY, Van Huffel C, Du X, et al.
Defective LPS signaling in C3H/HeJ and C57BL/10ScCr mice:
mutations in Tlr4 gene. Science 1998;282:2085-2088.
39. Qureshi ST, Lariviere L, Leveque G, Clermont S, Moore KJ, Gros
P, et al. Endotoxin-tolerant mice have mutations in Toll-like receptor
4 (Tlr4). J Exp Med 1999;189:615-625.
40. Bihl F, Lariviere L, Qureshi ST, Flaherty L, Malo D. LPS-
hyporesponsiveness of mnd mice is associated with a mutation
in Toll-like receptor 4. Genes Immun 2001;2:56-59.
41. Woods JP, Frelinger JA, Warrack G, Cannon JG. Mouse genetic
locus Lps influences susceptibility to Neisseria meningitidis
infection. Infect Immun 1988;56:1950-1955.
42. Arbour NC, Lorenz E, Schutte BC, Zabner J, Kline JN, Jones M, et
al. TLR4 mutations are associated with endotoxin hyporesponsiveness
in humans. Nat Genet 2000;25:187-191.
43. Lorenz E, Mira JP, Frees KL, Schwartz DA. Relevance of mutations
in the TLR4 receptor in patients with gram-negative septic shock.
Arch Intern Med 2002;162:1028-1032.
44. Agnese DM, Calvano JE, Hahm SJ, Coyle SM, Corbett SA, Calvano
SE, et al. Human toll-like receptor 4 mutations but not CD14
polymorphisms are associated with an increased risk of gram-
negative infections. J Infect Dis 2002;186:1522-1525.
45. Child NJ, Yang IA, Pulletz MC, de Courcy-Golder K, Andrews
AL, Pappachan VJ, et al. Polymorphisms in Toll-like receptor 4
and the systemic inflammatory response syndrome. Biochem Soc
Trans 2003;31:652-653.
46. Schwartz DA. The genetics of innate immunity. Chest 2002;121:62S-
68S.
47. Read RC, Pullin J, Gregory S, Borrow R, Kaczmarski EB, di Giovine
FS, et al. A functional polymorphism of toll-like receptor 4 is not
associated with likelihood or severity of meningococcal disease.
J Infect Dis 2001;184:640-642.
48. Takeuchi O, Hoshino K, Kawai T, Sanjo H, Takada H, Ogawa T,
et al. Differential roles of TLR2 and TLR4 in recognition of
gram-negative and gram-positive bacterial cell wall components.
Immunity 1999;11:443-451.
49. Takeuchi O, Hoshino K, Akira S. Cutting edge: TLR2-deficient
and MyD88-deficient mice are highly susceptible to Staphylococcus
aureus infection. J Immunol 2000;165:5392-5396.
50. Lien E, Sellati TJ, Yoshimura A, Flo TH, Rawadi G, Finberg RW,
et al. Toll-like receptor 2 functions as a pattern recognition receptor
for diverse bacterial products. J Biol Chem 1999;274:33419-33425.
51. Means TK, Wang S, Lien E, Yoshimura A, Golenbock DT, Fenton
MJ. Human toll-like receptors mediate cellular activation by
Mycobacterium tuberculosis. J Immunol 1999;163:3920-3927.
336
VOL. 23 NUM. 4/ 2004
52. Underhill DM, Ozinsky A, Smith KD, Aderem A. Toll-like receptor-
2 mediates mycobacteria-induced proinflammatory signaling in
macrophages. Proc Natl Acad Sci U S A 1999;96:14459-14463.
53. Lorenz E, Mira JP, Cornish KL, Arbour NC, Schwartz DA. A novel
polymorphism in the toll-like receptor 2 gene and its potential
association with staphylococcal infection. Infect Immun 2000;68:6398-
6401.
54. Ogus AC, Yoldas B, Ozdemir T, Uguz A, Olcen S, Keser I, et al.
The Arg753GLn polymorphism of the human toll-like receptor
2 gene in tuberculosis disease. Eur Respir J 2004;23:219-223.
55. Kang TJ, Chae GT. Detection of Toll-like receptor 2 (TLR2) mutation
in the lepromatous leprosy patients. FEMS Immunol Med Microbiol
2001;31:53-58.
56. Ben-Ali M, Barbouche MR, Bousnina S, Chabbou A, Dellagi K.
Toll-like receptor 2 Arg677Trp polymorphism is associated with
susceptibility to tuberculosis in Tunisian patients. Clin Diagn Lab
Immunol 2004;11:625-626.
57. Smith KD, Ozinsky A. Toll-like receptor-5 and the innate immune
response to bacterial flagellin. Curr Top Microbiol Immunol
2002;270:93-108.
58. Hawn TR, Verbon A, Lettinga KD, Zhao LP, Li SS, Laws RJ, et
al. A common dominant TLR5 stop codon polymorphism abolishes
flagellin signaling and is associated with susceptibility to legionnaires'
disease. J Exp Med 2003;198:1563-1572.
59. Haynes LM, Moore DD, Kurt-Jones EA, Finberg RW, Anderson
LJ, Tripp RA. Involvement of toll-like receptor 4 in innate immunity
to respiratory syncytial virus. J Virol 2001;75:10730-10737.
60. Tal G, Mandelberg A, Dalal I, Cesar K, Somekh E, Tal A, et al.
Association between common Toll-like receptor 4 mutations and
severe respiratory syncytial virus disease. J Infect Dis 2004;189:2057-
2063.
61. Hemmi H, Kaisho T, Takeuchi O, Sato S, Sanjo H, Hoshino K, et
al. Small anti-viral compounds activate immune cells via the TLR7
MyD88-dependent signaling pathway. Nat Immunol 2002;3:196-
200.
62. Jurk M, Heil F, Vollmer J, Schetter C, Krieg AM, Wagner H, et
al. Human TLR7 or TLR8 independently confer responsiveness
to the antiviral compound R-848. Nat Immunol 2002;3:499.
63. Ermann J, Fathman CG. Autoimmune diseases: genes, bugs and
failed regulation. Nat Immunol 2001;2:759-761.
64. Hahn BH. Antibodies to DNA. N Engl J Med 1998;338(19):1359-
68.
65. Bourke E, Bosisio D, Golay J, Polentarutti N, Mantovani A. The
toll-like receptor repertoire of human B lymphocytes: inducible
and selective expression of TLR9 and TLR10 in normal and
transformed cells. Blood 2003;102:956-963.
66. Coutinho A, Moller G. Immune activation of B cells: evidence for
one non-specific triggering signal not delivered by the Ig receptors.
Boll Ist Sieroter Milan 1974;53:131-143.
67. Cooke MP, Heath AW, Shokat KM, Zeng Y, Finkelman FD, Linsley
PS, et al. Immunoglobulin signal transduction guides the specificity
of B cell-T cell interactions and is blocked in tolerant self-reactive
B cells. J Exp Med 1994;179:425-438.
68. Leadbetter EA, Rifkin IR, Hohlbaum AM, Beaudette BC, Shlomchik
MJ, Marshak-Rothstein A. Chromatin-IgG complexes activate B
cells by dual engagement of IgM and Toll-like receptors. Nature
2002;416:603-607.
69. Richardson B, Scheinbart L, Strahler J, Gross L, Hanash S, Johnson
Inmunol 80p 18/1/05 10:08 Pgina 337
INMUNOLOGA
M. Evidence for impaired T cell DNA methylation in systemic
lupus erythematosus and rheumatoid arthritis. Arthritis Rheum
1990;33:1665-1673.
70. Krieg AM. CpG DNA: a pathogenic factor in systemic lupus
erythematosus? J Clin Immunol 1995;15:284-292.
71. Sun S, Beard C, Jaenisch R, Jones P, Sprent J. Mitogenicity of DNA
from different organisms for murine B cells. J Immunol 1997;159:3119-
3125.
72. van Zeben D, Breedveld FC. Prognostic factors in rheumatoid
arthritis. J Rheumatol Suppl 1996;44:31-33.
73. Viglianti GA, Lau CM, Hanley TM, Miko BA, Shlomchik MJ,
Marshak-Rothstein A. Activation of autoreactive B cells by CpG
dsDNA. Immunity 2003;19:837-847.
74. Tsan MF, Gao B. Endogenous ligands of Toll-like receptors. J
Leukoc Biol 2004;76:514-519.
75. t Hart BA, van Kooyk Y. Yin-Yang regulation of autoimmunity
by DCs. Trends Immunol 2004;25:353-359.
76. Geijtenbeek TB, van Vliet SJ, Engering A, t Hart BA, van Kooyk
Y. Self- and nonself-recognition by C-type lectins on dendritic
cells. Annu Rev Immunol 2004;22:33-54.
77. Barrera P, Blom A, van Lent PL, van Bloois L, Beijnen JH, van
Rooijen N, et al. Synovial macrophage depletion with clodronate-
containing liposomes in rheumatoid arthritis. Arthritis Rheum
2000;43:1951-1959.
78. Burmester GR, Stuhlmuller B, Keyszer G, Kinne RW. Mononuclear
phagocytes and rheumatoid synovitis. Mastermind or workhorse
in arthritis? Arthritis Rheum 1997;40:5-18.
79. Thomas R, Davis LS, Lipsky PE. Rheumatoid synovium is enriched
in mature antigen-presenting dendritic cells. J Immunol 1994;152:2613-
2623.
80. Radstake TR, Franke B, Hanssen S, Netea MG, Welsing P, Barrera
P, et al. The Toll-like receptor 4 Asp299Gly functional variant is
associated with decreased rheumatoid arthritis disease susceptibility
but does not influence disease severity and/or outcome. Arthritis
Rheum 2004;50:999-1001.
81. Sanchez E, Orozco G, Lopez-Nevot MA, Jimenez-Alonso J, Martin
J. Polymorphisms of toll-like receptor 2 and 4 genes in rheumatoid
arthritis and systemic lupus erythematosus. Tissue Antigens
2004;63:54-57.
82. Kilding R, Akil M, Till S, Amos R, Winfield J, Iles MM, et al. A
biologically important single nucleotide polymorphism within
the toll-like receptor-4 gene is not associated with rheumatoid
arthritis. Clin Exp Rheumatol 2003;21:340-342.
83. Kyburz D, Rethage J, Seibl R, Lauener R, Gay RE, Carson DA, et
al. Bacterial peptidoglycans but not CpG oligodeoxynucleotides
activate synovial fibroblasts by toll-like receptor signaling. Arthritis
Rheum 2003;48:642-650.
84. Liu ZQ, Deng GM, Foster S, Tarkowski A. Staphylococcal
peptidoglycans induce arthritis. Arthritis Res 2001;3:375-380.
85. Sobek V, Birkner N, Falk I, Wurch A, Kirschning CJ, Wagner H,
et al. Direct Toll-like receptor 2 mediated co-stimulation of T cells
in the mouse system as a basis for chronic inflammatory joint
disease. Arthritis Res Ther 2004;6:433-446.
86. Deng GM, Nilsson IM, Verdrengh M, Collins LV, Tarkowski A.
Intra-articularly localized bacterial DNA containing CpG motifs
induces arthritis. Nat Med 1999;5:702-705.
87. Deng GM, Tarkowski A. The features of arthritis induced by CpG
motifs in bacterial DNA. Arthritis Rheum 2000;43:356-364.
E. SNCHEZ, G. OROZCO, J. MARTN
88. Zeuner RA, Ishii KJ, Lizak MJ, Gursel I, Yamada H, Klinman DM,
et al. Reduction of CpG-induced arthritis by suppressive
oligodeoxynucleotides. Arthritis Rheum 2002;46:2219-2224.
89. Anders HJ, Vielhauer V, Eis V, Linde Y, Kretzler M, Perez de Lema
G, et al. Activation of toll-like receptor-9 induces progression of
renal disease in MRL-Fas(lpr) mice. Faseb J 2004;18:534-536.
90. Liu B, Dai J, Zheng H, Stoilova D, Sun S, Li Z. Cell surface expression
of an endoplasmic reticulum resident heat shock protein gp96
triggers MyD88-dependent systemic autoimmune diseases. Proc
Natl Acad Sci U S A 2003;100(26):15824-9.
91. Wen L, Peng J, Li Z, Wong FS. The effect of innate immunity on
autoimmune diabetes and the expression of Toll-like receptors on
pancreatic islets. J Immunol 2004;172:3173-3180.
92. Rudofsky G, Jr., Reismann P, Witte S, Humpert PM, Isermann B,
Chavakis T, et al. Asp299Gly and Thr399Ile genotypes of the TLR4
gene are associated with a reduced prevalence of diabetic neuropathy
in patients with type 2 diabetes. Diabetes Care 2004;27:179-183.
93. Cario E, Podolsky DK. Differential alteration in intestinal epithelial
cell expression of toll-like receptor 3 (TLR3) and TLR4 in inflammatory
bowel disease. Infect Immun 2000;68:7010-7017.
94. Kobayashi K, Inohara N, Hernandez LD, Galan JE, Nunez G,
Janeway CA, et al. RICK/Rip2/CARDIAK mediates signalling
for receptors of the innate and adaptive immune systems. Nature
2002;416:194-199.
95. Franchimont D, Vermeire S, El Housni H, Pierik M, Van Steen
K, Gustot T, et al. Deficient host-bacteria interactions in inflammatory
bowel disease? The toll-like receptor (TLR)-4 Asp299gly
polymorphism is associated with Crohn's disease and ulcerative
colitis. Gut 2004;53:987-992.
96. Torok HP, Glas J, Tonenchi L, Mussack T, Folwaczny C.
Polymorphisms of the lipopolysaccharide-signaling complex in
inflammatory bowel disease: association of a mutation in the Toll-
like receptor 4 gene with ulcerative colitis. Clin Immunol 2004;112:85-
91.
97. Torok HP, Glas J, Tonenchi L, Bruennler G, Folwaczny M, Folwaczny
C. Crohn's disease is associated with a toll-like receptor-9
polymorphism. Gastroenterology 2004;127:365-366.
98. Ichikawa HT, Williams LP, Segal BM. Activation of APCs through
CD40 or Toll-like receptor 9 overcomes tolerance and precipitates
autoimmune disease. J Immunol 2002;169:2781-2787.
99. Lehnardt S, Lachance C, Patrizi S, Lefebvre S, Follett PL, Jensen
FE, et al. The toll-like receptor TLR4 is necessary for
lipopolysaccharide-induced oligodendrocyte injury in the CNS.
J Neurosci 2002;22:2478-2486.
100.Zekki H, Feinstein DL, Rivest S. The clinical course of experimental
autoimmune encephalomyelitis is associated with a profound and
sustained transcriptional activation of the genes encoding toll-
like receptor 2 and CD14 in the mouse CNS. Brain Pathol 2002;12:308-
319.
101.Reindl M, Lutterotti A, Ingram J, Schanda K, Gassner C,
Deisenhammer F, et al. Mutations in the gene for toll-like receptor
4 and multiple sclerosis. Tissue Antigens 2003;61:85-88.
102.de Kleijn D, Pasterkamp G. Toll-like receptors in cardiovascular
diseases. Cardiovasc Res 2003;60:58-67.
103.Frantz S, Kobzik L, Kim YD, Fukazawa R, Medzhitov R, Lee RT,
et al. Toll4 (TLR4) expression in cardiac myocytes in normal and
failing myocardium. J Clin Invest 1999;104:271-280.
104.Faure E, Equils O, Sieling PA, Thomas L, Zhang FX, Kirschning
337
Inmunol 80p 18/1/05 10:08 Pgina 338
TOLL-LIKE RECEPTORS AND HUMAN PATHOLOGY
CJ, et al. Bacterial lipopolysaccharide activates NF-kappaB through
toll-like receptor 4 (TLR-4) in cultured human dermal endothelial
cells. Differential expression of TLR-4 and TLR-2 in endothelial
cells. J Biol Chem 2000;275:11058-11063.
105.Edfeldt K, Swedenborg J, Hansson GK, Yan ZQ. Expression of
toll-like receptors in human atherosclerotic lesions: a possible
pathway for plaque activation. Circulation 2002;105:1158-1161.
106.Okamura Y, Watari M, Jerud ES, Young DW, Ishizaka ST, Rose J,
et al. The extra domain A of fibronectin activates Toll-like receptor
4. J Biol Chem 2001;276:10229-10233.
107.Kalayoglu MV, Byrne GI. A Chlamydia pneumoniae component
that induces macrophage foam cell formation is chlamydial
lipopolysaccharide. Infect Immun 1998;66:5067-5072.
108.Ohashi K, Burkart V, Flohe S, Kolb H. Cutting edge: heat shock
protein 60 is a putative endogenous ligand of the toll-like receptor-
4 complex. J Immunol 2000;164:558-561.
109.Vink A, De Kleijn DP, Pasterkamp G. Functional role for toll-
like receptors in atherosclerosis and arterial remodeling. Curr
Opin Lipidol 2004;15(5):515-521.
110.Kiechl S, Lorenz E, Reindl M, Wiedermann CJ, Oberhollenzer F,
Bonora E, et al. Toll-like receptor 4 polymorphisms and atherogenesis.
N Engl J Med 2002;347:185-192.
111.Ameziane N, Beillat T, Verpillat P, Chollet-Martin S, Aumont MC,
Seknadji P, et al. Association of the Toll-like receptor 4 gene
Asp299Gly polymorphism with acute coronary events. Arterioscler
Thromb Vasc Biol 2003;23:61-64.
112.Beutler B, Beutler E. Toll-like receptor 4 polymorphisms and
atherogenesis. N Engl J Med 2002;347:1978-1980; author reply
1978-1980.
113.Yang IA, Holloway JW, Ye S. TLR4 Asp299Gly polymorphism is
not associated with coronary artery stenosis. Atherosclerosis
2003;170:187-190.
114.Boekholdt SM, Agema WR, Peters RJ, Zwinderman AH, van der
Wall EE, Reitsma PH, et al. Variants of toll-like receptor 4 modify
the efficacy of statin therapy and the risk of cardiovascular events.
Circulation 2003;107:2416-2421.
115.Shishido T, Nozaki N, Yamaguchi S, Shibata Y, Nitobe J, Miyamoto
T, et al. Toll-like receptor-2 modulates ventricular remodeling
after myocardial infarction. Circulation 2003;108:2905-2910.
116.Shimada K, Watanabe Y, Mokuno H, Iwama Y, Daida H, Yamaguchi
H. Common polymorphism in the promoter of the CD14 monocyte
receptor gene is associated with acute myocardial infarction in
Japanese men. Am J Cardiol 2000;86:682-684.
117.Hubacek JA, Rothe G, Pit'ha J, Skodova Z, Stanek V, Poledne R,
et al. C(-260)-->T polymorphism in the promoter of the CD14
monocyte receptor gene as a risk factor for myocardial infarction.
Circulation 1999;99:3218-3220.
118.Georges JL, Loukaci V, Poirier O, Evans A, Luc G, Arveiler D, et
al. Interleukin-6 gene polymorphisms and susceptibility to
myocardial infarction: the ECTIM study. Etude Cas-Temoin de
l'Infarctus du Myocarde. J Mol Med 2001;79:300-305.
119.Bjorkbacka H, Kunjathoor VV, Moore KJ, Koehn S, Ordija CM,
Lee MA, et al. Reduced atherosclerosis in MyD88-null mice links
elevated serum cholesterol levels to activation of innate immunity
signaling pathways. Nat Med 2004;10:416-421.
120.Michel O, Kips J, Duchateau J, Vertongen F, Robert L, Collet H,
338
VOL. 23 NUM. 4/ 2004
et al. Severity of asthma is related to endotoxin in house dust. Am
J Respir Crit Care Med 1996;154:1641-1646.
121.Michel O, Duchateau J, Sergysels R. Effect of inhaled endotoxin
on bronchial reactivity in asthmatic and normal subjects. J Appl
Physiol 1989;66:1059-1064.
122.Braun-Fahrlander C, Riedler J, Herz U, Eder W, Waser M, Grize
L, et al. Environmental exposure to endotoxin and its relation to
asthma in school-age children. N Engl J Med 2002;347:869-877.
123.Gehring U, Bischof W, Fahlbusch B, Wichmann HE, Heinrich J.
House dust endotoxin and allergic sensitization in children. Am
J Respir Crit Care Med 2002;166:939-944.
124.Warner JO. Worldwide variations in the prevalence of atopic
symptoms: what does it all mean? Thorax 1999;54:46-51.
125.Baldini M, Lohman IC, Halonen M, Erickson RP, Holt PG, Martinez
FD. A Polymorphism in the 5' flanking region of the CD14 gene
is associated with circulating soluble CD14 levels and with total
serum immunoglobulin E. Am J Respir Cell Mol Biol 1999;20:976-
983.
126.Redecke V, Hacker H, Datta SK, Fermin A, Pitha PM, Broide DH,
et al. Cutting edge: activation of Toll-like receptor 2 induces a Th2
immune response and promotes experimental asthma. J Immunol
2004;172:2739-2743.
127.Caramalho I, Lopes-Carvalho T, Ostler D, Zelenay S, Haury M,
Demengeot J. Regulatory T cells selectively express toll-like receptors
and are activated by lipopolysaccharide. J Exp Med 2003;197:403-
411.
128.Pasare C, Medzhitov R. Toll pathway-dependent blockade of
CD4+CD25+ T cell-mediated suppression by dendritic cells. Science
2003;299:1033-1036.
129.Werner M, Topp R, Wimmer K, Richter K, Bischof W, Wjst M, et
al. TLR4 gene variants modify endotoxin effects on asthma. J
Allergy Clin Immunol 2003;112:323-330.
130.Raby BA, Klimecki WT, Laprise C, Renaud Y, Faith J, Lemire M,
et al. Polymorphisms in toll-like receptor 4 are not associated with
asthma or atopy-related phenotypes. Am J Respir Crit Care
Med 2002;166:1449-1456.
131.Eder W, Klimecki W, Yu L, von Mutius E, Riedler J, Braun-Fahrlander
C, et al. Toll-like receptor 2 as a major gene for asthma in children
of European farmers. J Allergy Clin Immunol 2004;113:482-488.
132.Tantisira K, Klimecki WT, Lazarus R, Palmer LJ, Raby BA,
Kwiatkowski DJ, et al. Toll-like receptor 6 gene (TLR6): single-
nucleotide polymorphism frequencies and preliminary association
with the diagnosis of asthma. Genes Immun 2004;5:343-346.
133.Lazarus R, Klimecki WT, Raby BA, Vercelli D, Palmer LJ, Kwiatkowski
DJ, et al. Single-nucleotide polymorphisms in the Toll-like receptor
9 gene (TLR9): frequencies, pairwise linkage disequilibrium, and
haplotypes in three U.S. ethnic groups and exploratory case-control
disease association studies. Genomics 2003;81:85-91.
134.Lazarus R, Raby BA, Lange C, Silverman EK, Kwiatkowski DJ,
Vercelli D, et al. TOLL-like receptor 10 genetic variation is associated
with asthma in two independent samples. Am J Respir Crit Care
Med 2004;170:594-600.
135.Noguchi E, Nishimura F, Fukai H, Kim J, Ichikawa K, Shibasaki
M, et al. An association study of asthma and total serum
immunoglobin E levels for Toll-like receptor polymorphisms in
a Japanese population. Clin Exp Allergy 2004;34:177-183.