Adult-onset Still's disease pathophysiology

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Template:Adult-onset Still's disease Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Pathophysiology

Adult-onset Still's disease is an automminue inflammatory arthritis that typically affects adolescents and adults ranging from age 16-40 years. Major etiological mechanisms behind cause a dysfunction of the innate and cellular immunity (limited) leading to activation of effector cells of the disease.

Putative triggers

Although the pathogenesis of adult-onset Still's disease is largerly idiopathic. Triggers of ASOD lead to activation of toll-like receptors (TLR) and activation of immune system. The following triggers may be implicated as factors responsible for generating key pathological processes occurring in adult-onset Still's disease (ASOD):[1][2][3][4][5][6][7][8]

Pathogen-associated molecular patterns (PAMPs)

  • Bacteria
    • Yersinia enterocolitica
    • Chlamydophila pneumoniae
    • Brucella abortus
    • Borrelia burgdorferi
  • Viruses
    • Rubella
    • Echovirus 7
    • Mumps
    • Cytomegalovirus (CMV)
  • Fungi

Danger-associated molecular patterns (DAMPs)

  • Chemicals
  • Toxins
  • Stress

Immune dysfunction

Both innate and adaptive immunity play roles in the pathological evolution of adult-onset Still's disease with the dysfunction occurring in the innate immunity predominating the picture. The following dysfunctions are involved:

Changes in the innate immunity

  • Natural killer cells have been found to be decreased in patients with ASOD. The mechanism underlying dysfunctional NK cells is a defect in IL-18 receptor β phosphorylation.[9]
  • Neutrophil and macrophage activation lie at the heart of pathogenesis of ASOD due to the effects of the proinflammatory interleukin-18 (IL-18) signalling.
  • CD64, a marker of neutrophil activation has been found to be upregulated in active ASOD.[10]
  • Macrophage colony stimulating factor (MCSF), intercellular adhesion molecule-1 (ICAM-1) and calprotectin are elevated and act as markers of active disease.[11][12]

Changes in the adaptive immunity

  • T cell activation has also been shown to play role in the pathogenesis of ASOD with Th1 (cytotoxic) subset prevailing over Th2 CD4+ T cells.
  • Increased number of Th17 cells derived from the differentiation of naieve CD4+ T cells due to to activation by interleukin-1 beta, transforming growth factor-beta and interleukin- 6 is also seen in active ASOD. [13][14]

Role of interleukin-1 beta (IL-1), interleukin-6 (IL-6), interferon-alpha (IFN-alpha) and tumor necrosis factor (TNF-alpha)

Interleukin-i beta plays a key role in producing major characteristic features of adult-onset Still's disease. PAMPs and DAMPs lead to stimulation of protein complex nucleotide-binding oligomerization-domain-(NOD-) like receptor family, pyrin domain containing 3 (NLRP3) inflammasome (expressed in myeloid cells). The consequence of all these trigger-stimulated NOD and NLRP increasing interactions is an increased production of interleukin-1 beta.[15]The following processes are affected by an increased production of this key interleukin of ASOD:

(a) Hypothalamic-pituitary axis influence

Activation of the hypothalmic-pitutary axis by interleukin-1 beta lead to the following changes:

Hormonal

  • An increased secretion of adenocorticotrophic hormone (ACTH) and anti-diuretic hormone (ADH).
  • A decreased secretion of growth hormone (GH) and somatostatin.[16]

Systemic

  • Disturbance of the thalmic temperature regulating centres leading to fever.[17]
  • Fatigue[18]
  • Anorexia[19] 

(b) Liver synthesis and secretion of acute phase proteins

Both interleukin-1 beta, interleukin-6 and interferon-alpha (IFN-alpha) lead to increased production of acute phase reactants by the liver due to inflammatory and oxidative stress occurring during active ASOD. The following acute phase reactant proteins are elevated in ASOD as a result of increased liver production:[20][21]

  • C-reactive protein (CRP)
  • Ferritin  
  • Serum amyloid protein (SAA)

(c) Osteoclasts activation and matrix metalloproteinases (MMPs) synthesis

Interleukin-1 and TNF-alpha have been shown to inhibit chondrogenesis leading to decreased repair process of bone and cartilage in ASOD.[22]

(d) Innate immune system cells activation

Effector cells of the innate immune system such as macrophages and neutrophils are activated mainly due to interleukin-1. The neutrophil to lymphocyte count ratio is increased due to elevated neutrophils.[23]

(e) Increased gene transcription of proinflammatory molecules

The following proinflammatory factors are produced in an increased concentration in ASOD:

  • Inducible nitric oxide synthase (iNOS)[24]
  • Innter leukin 1, 6 and TNF-alpha induced cyclo-oxygenase 2 (COX2)[25]
  • Phospholipase A2[26]
  • Intracellular adhesion molecules[27]
  • Colony-stimulating factors (CSF)[28]

Role of interleukin-18

It is produced by macrophages and monocytes as a consequence of bacterial and viral infections (which are thought to be triggers of ASOD).[29] A defective phosphorylation of IL-18 receptor is though to give rise to this dysfunction.[30]

Role of interleukin-17

Th17 cells lead to an increased production of interleukin-17. The stimulaton of Th17 cells is drived by interleukin-1, transforming growth factor beta (TGF-beta) and interleukin-6.[31][32]

Role of interferon gamma

Imblanced production of interferon-gamma is thought to be associated with ASOD.[33]  Levels of the IFN-γ-induced chemokines, CXCL9, CXCL10 and CXCL11 are increased during active phase of ASOD.[34]

 Reactive hemophagocytic lymphohistiocytosis 

Genetics

Associated Conditions

Gross Pathology

Microscopic Pathology

References

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