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Updates on Candida Immunology

2018 MSGERC Biennial MeetingPlenary Lectures on ”Candida”September 26, 2018

Michail S. Lionakis, MD, ScD

Chief, Fungal Pathogenesis SectionLaboratory of Clinical Immunology & MicrobiologyNational Institute of Allergy & Infectious Diseases

0 20 806040 100

COLONIZED HUMANS NON-COLONIZED HUMANS

COMMENSAL STATEINFECTION

MUCOCUTANEOUS CANDIDIASIS SYSTEMICCANDIDIASIS

NOT LIFE-THREATENING

≈ 75% of all women → vaginitis≈ 25% of antibiotic-treated women → vaginitis

≈ 90% of AIDS patients → oral thrush

LIFE-THREATENING

SURVIVAL

The Disease Burden of Candidiasis in Humans

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CANDIDIASIS

MUCOSAL

T lymphocytes

SYSTEMIC

Neutrophils Macrophages

CANDIDIASIS

MUCOSAL

T lymphocytes

SYSTEMIC

Neutrophils Macrophages

IL-17 Signaling is Important for Anti-Candida Mucosal Host Defense

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Chronic Mucocutaneous Candidiasis

in Humans with Inborn Errors of

Interleukin-17 ImmunityAnne Puel,1*‡ Sophie Cypowyj,2* Jacinta Bustamante,1 Jill F. Wright,3 Luyan Liu,1 Hye Kyung Lim,2

Mélanie Migaud,1 Laura Israel,1 Maya Chrabieh,1 Magali Audry,2 Matthew Gumbleton,4 Antoine

Toulon,5 Christine Bodemer,5 Jamila El-Baghdadi,6 Matthew Whitters,3 Theresa Paradis,3 Jonathan

Brooks,3 Mary Collins,3 Neil M. Wolfman,3 Saleh Al-Muhsen,7 Miguel Galicchio,8 Laurent Abel,1,2†

Capucine Picard,1,9,10†Jean-Laurent Casanova1,2,7,10‡

www.sciencemag.org SCIENCE VOL 332 1 APRIL 2011

Inherited IL-17RC deficiency in patients

with chronic mucocutaneous candidiasisYun Ling, Sophie Cypowyj, Caner Aytekin, Miguel Galicchio, Yildiz Camcioglu, Serdar Nepesov,

Aydan Ikinciogullari, Figen Dogu, Aziz Belkadi, Romain Levy, Mélanie Migaud, Bertrand Boisson,

Alexandre Bolze, Yuval Itan, Nicolas Goudin, Julien Cottineau, Capucine Picard, Laurent Abel,

Jacinta Bustamante, Jean-Laurent Casanova, Anne Puel

www.jem.org JEM VO 212 27 APRIL 2015

IL-17 Signaling is Important for Anti-CandidaMucosal Host Defense in Mice and Humans

Conti et al., J Exp Med. 2009

Holland, NEJM, 2009; Lionakis & Levitz. Annu Rev Immunol, 2018

IL-17–Mediated Protection via Generation of Anti-Candida Antimicrobial Peptides

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CANDIDIASIS

MUCOSAL

T lymphocytes

SYSTEMIC

Neutrophils Macrophages

The Clinical Observations

Although ICU patients share clinical and microbiological risk factors for candidiasis,

only a small minority develops the infection

Among infected patients, the outcome of candidiasis varies greatly

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The Hypothesis

Variation in immune function-related genes modulates the risk of developing candidiasis

and worse outcome after infection

Bench to Bedside Study of Systemic

Candidiasis

Can we identify patients with specific

host genetics that are at higher risk for

the infection?- Sample size, replication, functional analyses,

frequency

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Macrophages

Qian et al., J Immunol. 1994

Phagocytes but not Lymphocytes are Critical in Host Defense against Systemic Candidiasis

Per

cen

t su

rviv

al

Neutrophils

0 2 4 6 8 10 12 140

20

40

60

80

100

Days post-infection

Perc

en

t su

rviv

al

Neutropenic

Non-neutropenic

Unpublished data

MONOCYTESMACROPHAGES

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Lionakis & Levitz. Annu Rev Immunol. 2018

Candida Yeasts Are Effectively Picked up by Macrophages Early After Infection in the Kidney

Macrophages (CX3CR1)dTomato-Candida

2 hrs post-infection

Lionakis et al., J Clin Invest. 2013

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Macrophages Wrap Around Candida Hyphae Early After Infection in the Kidney

Macrophages (CX3CR1)dTomato-Candida

2 hrs post-infectionLionakis et al., J Clin Invest. 2013

CX3CR1 is Protectiveagainst Systemic Candidiasis

Lionakis et al., J Clin Invest, 2013

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Targeted Immunogenetic Approaches:

CX3CR1-M280

Cx3cr1 is important for macrophage survival and protects from death after systemic candidiasis (MICE)

The CX3CR1-M280 mutation impairs human monocyte survival and is a risk factor for systemic candidiasis

(HUMANS)

Lionakis et al., J Clin Invest, 2013; Collar et al, JCI Insight, 2018

NEUTROPHILS

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Red: dTomato-C. albicans

Green: Cx3cr1(macrophages)

Grey: Ly6G(neutrophils)

unpublished

47 67

Phagosome

Cytoplasm

1o

granule

2o

granule

GECG

MPOPR3Defensins

LactoferrinCD11b

40

Candida

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4767

e- O2-

HOCl

H2O2

Phagosome

NADPH

NADP+

Cytoplasm

GECGGECG

40

Candida

4767

e- O2-

HOCl

H2O2

Phagosome

NADPH

NADP+

Cytoplasm

40

~5% of CGD Patients Develop Invasive

Candidiasis

Winkelstein et al., Medicine. 2000

Candida

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4767

e- O2-

HOCl

H2O2

Phagosome

NADPH

NADP+

40

~5% of Patients with Complete MPO

Deficiency Develop Invasive Candidiasis

Parry et al., Ann Intern Med. 1981

Candida

Non-oxidative Cytotoxic anti-CandidaMechanisms of Neutrophils are Largely Unknown

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Targeted Immunogenetic Approaches:

CXCR1-T276

Cxcr1 is important for neutrophil killing and protects from death after systemic candidiasis (MICE)

The CXCR1-T276 mutation impairs human neutrophil killing and is a risk factor for systemic candidiasis

(HUMANS)

Swamydas et al., Science Transl Med, 2016

TAGAP, CD58, LCE4A-C1orf68

Unbiased Approaches:

GWAS

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Other important examples:

The Clinical Observations

A surge of small molecule inhibitors for treatment of autoimmune and neoplastic

conditions

Predictable and non-predictable effects on anti-Candida immunity

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The Hypothesis

Novel iatrogenic risk factors for candidiasis

The Hypothesis

Novel iatrogenic risk factors for candidiasis- Fostamatinib (SYK inhibitor)- Avacopan (C5AR1 inhibitor)- Danirixin (CXCR2 inhibitor)

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CARD9 is centrally positioned in antifungal immune pathways

Lionakis & Netea, PLoS Pathog, 2013; Lionakis & Levitz, Annu Rev Immunol, 2018

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CARD9 deficiency results in decreased neutrophil accumulation in the CSF

Drummond et al, PLoS Pathog, 2015

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The CARD9-/- Infected CSF is not Chemotactic to Neutrophils ex vivo

Card9-/- Mice Develop Uncontrolled Fungal Brain Infection

Card9-/-

Card9+/+

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CARD9+/+

200x

CARD9-/-

200x

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Card9 is Required for Neutrophil Accumulation in the Fungal-Infected Brain

0 24 720

20000

40000

60000

hours post-infection

# n

eu

tro

ph

ils/b

rain

********

Card9-/-

Card9+/+No defect in neutrophil:- Production in bone

marrow- Egress in blood- Survival- Cell-intrinsic

chemotaxis

No defect in the kidney, no defect in staphylococcal brain infection

Drummond et al, PLoS Pathog, 2015

A Model of Microglial Engagement for CNS Protective Antifungal Immunity

Drummond et al, under revision

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Microglia-Mediated Production of IL-1 and CXCL1 is CARD9-Dependent

ng

/g tis

sue

Frequency of pro-IL-1/CXCL1 positive microglia determined by intracellular flow cytometry after 4 hour incubation with Brefeldin A +/- additional stimulation

CXCL1 is not induced in the CARD9-/- infected CSF

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SYK-CARD9 are centrally positioned in antifungal immune pathways

Lionakis & Netea, PLoS Pathog, 2013; Lionakis & Levitz, Annu Rev Immunol, 2018

39 trials in ClinicalTrials.gov- RA- Lymphomas- Solid tumors- Autoimmune

cytopenias

CXCR2 is Critical for Neutrophil Recruitment and Function During Systemic Candidiasis

Swamydas et al, in preparation

0 2 4 6 8 100

20

40

60

80

100

Day post infection

Perc

en

t su

rviv

al

Cxcr2+/+

Cxcr2 -/-

P=0.0033

Opsonized Unopsonized0

50

100

150

Killin

g c

ap

acit

y (

co

mp

are

d t

o W

T)

Cxcr2+/+

***P=0.0001

Cxcr2-/-

*** ***

HYPHAE

10 trials in ClinicalTrials.gov (COPD, severe lung viral infections)

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C5AR1 is Critical for Macrophage Killing During Systemic Candidiasis

Desai et al, in preparation

0 10 20 300

50

100

days post infection

Perc

en

t su

rviv

al C5ar1

+/+

C5ar1-/-

P < 0.0001

C5a

r1+/

+

C5a

r1-/-

0

50

100

150

no

rmalized

Can

did

a

killin

g (

%)

**

6 trials in ClinicalTrials.gov (ANCA vasculitis, HUS, Glomerulonephritis)66 trials of eculizumab in ClinicalTrials.gov (HUS, Glomerulonephritis, kidney transplantation, PNH, HSCT)

Take Home MessagesPhagocytes are crucial for immunity during systemic candidiasis

- Early neutrophil recruitment- Early monocyte/macrophage-Candida contact - Non-oxidative killing mechanisms

Individualized host genetics affect the risk of systemic candidiasis and may provide the platform for personalized risk stratification and prognostication strategies in humans

- Chemokine/cytokine signaling, PRRs, type I interferon genes

Basic immunology studies may uncover novel iatrogenic risk factors for candidiasis in patients treated with small molecule inhibitors for autoimmunity/malignancies.

Future needs: tissue-specific responses, non-albicans Candida

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Acknowledgements

• FPS– Rebecca

Drummond

– Timothy Break

– Mandy Collar

– Lekha Swamydas

– Jigar Desai

– Vas Oikonomou

– Elise Ferre

– Monica Schmitt

– Mike Abers

– Greg Constantine

– Ahnika Kline

• iPSCs– Colleen Sweeney

– Harry Malech

Thank you!

• Candidalysin mutants

– Julian Naglik

– Bernie Hube

• Collaborators– Yasmine Belkaid

– Kat Mayer-Barber

– Phil Murphy

– Brian Kelsall

– Warren Strober

– Tobias Hohl

– Gordon Brown

– Yoichiro Iwakura

– Sergio Lira

– Brian Schaefer

• Candidemia cohorts

– John Perfect

– Melissa Johnson

– Mihai Netea