In memory of Bertil Ahlgren

List of Papers

This thesis is based on the following papers, which are referred to in the text by their Roman numerals.

I Ahlgren, K.M., Moretti, S., Ardesjö Lundgren, B., Karlsson, I.,

Åhlin, E., Norling, A., Hallgren, Å., Perheentupa, J., Gustafsson, J., Rorsman, F., Crewther, P.E., Rönnelid, J., Bensing, S., Scott, H.S., Kämpe, O., Romani, L., Lobell, A. (2011) Increased IL-17A secretion in response to Candida albi-cans in autoimmune polyendocrine syndrome type 1 and its an-imal model. European Journal of Immunology, (41):235–245

II Oftedal, B.E.V., Kämpe, K., Meager, A., Ahlgren, K.M., Lo-bell, A., Husebye, E.S., Wolff, A.S.B. (2011) Measuring au-toantibodies against IL-17F and IL-22 in autoimmune polyen-docrine syndrome type 1 by radioligand binding assay using fu-sion proteins. Scandinavian Journal of Immunology, (74): 327-333

III Ahlgren, K.M., Fall, T., Landegren, N., von Euler, H., Sundberg, K., Lindblad-Toh, K., Lobell, A., Hedhammar, Å., Andersson, G., Hansson-Hamlin, H., Lernmark, Å., Kämpe, O. Diabetes mellitus in dog - No evidence for a type-1 like pheno-type. Manuscript.

IV Ahlgren, K.M., Wilbe, M., Sundberg, K., Eloranta, M-L., Lindblad-Toh, K., Andersson, G., Lobell, A., Hansson-Hamlin, H., Kämpe, O. Type I Interferon signature in Nova Scotia duck tolling retriever dogs with steroid responsive meningitis-arteritis. Manuscript.

Reprints were made with permission from the respective publishers.

Contents

Introduction ................................................................................................... 11

Background ................................................................................................... 12 The immune system ................................................................................. 12 Cells of the immune system ..................................................................... 12 T cells ....................................................................................................... 12

Central and peripheral T cell tolerance ................................................ 13 CD4+ T cells ........................................................................................ 13

Cytokines .................................................................................................. 15 Interferons ............................................................................................ 16

B cells ....................................................................................................... 17 Autoimmunity .......................................................................................... 17

Autoimmune diseases .......................................................................... 17 Autoimmune disease models .................................................................... 18 1. Autoimmune Polyendocrine Syndrome type 1 as a model disorder .... 18 2. The dog as a model for human disease ................................................. 20

a) Canine Diabetes mellitus ............................................................ 21 b) Canine systemic autoimmune diseases ....................................... 23

Present investigations .................................................................................... 24 Aims of this thesis .................................................................................... 24

Material and methods .................................................................................... 25 Patients ..................................................................................................... 25 Dogs ......................................................................................................... 25 Cell isolation ............................................................................................ 26 Recall assay .............................................................................................. 26 Intracellular cytokine staining .................................................................. 26 Enzyme-linked immunosorbent spot (ELISPOT) .................................... 27 Enzyme-linked immunosorbent assay (ELISA) ....................................... 27 Multiplex bead immunoassay ................................................................... 27 Quantitative Real-Time RT-PCR ............................................................. 28 Immunoprecipitations of radioactively labeled protein ............................ 28 Immunofluorescence ................................................................................ 28 Antibody ELISA (Paper II) ...................................................................... 29 Canine type I IFN assay ........................................................................... 29 Statistical analyses .................................................................................... 29

Results ........................................................................................................... 30 Paper I ...................................................................................................... 30 Paper II ..................................................................................................... 31 Paper III .................................................................................................... 31 Paper IV ................................................................................................... 31

Conclusions and general discussion .............................................................. 33

Summary of the Thesis in Swedish ............................................................... 37 Immunologiska studier av modellsjukdomar i människa och hund ......... 37

Acknowledgements ....................................................................................... 39

References ..................................................................................................... 42

Abbreviations

APS-1 DM SLE PRR TLR TCR Th mTEC AIRE IPEX Treg IL IFN TGF IL-17RA C. albicans APC BCR T1D APECED TSA moDC LADA GAD65 IAA ICA ZnT8A GADA IA2A MIDD MODY pDC IRF NSDTR

Autoimmune polyendocrine syndrome type 1 Diabetes mellitus Systemic lupus erythematosus Pattern Recognition Receptor Toll-like receptor T cell receptor T helper cell Medullary thymic epithelial cell Autoimmune regulator Immune dysregulation, endocrinopathy, enteropathy,X-linked syndrome Regulatory T cell Interleukin Interferon Transforming growth factor Interleukin-17 receptor A Candida albicans Antigen presenting cell B cell receptor Type 1 diabetes mellitus Autoimmune polyendocrinopathy candidiasis-ectodermal dystrophy Tissue-specific self-antigens Monocyte derived dendritic cell Latent autoimmune diabetes of the adult Glutamic acid decarboxylase 65 kDa Insulin autoantibody Cytoplasmic islet cell antibodies ZnT8 autoantibody GAD autoantibody IA-2 autoantibody Maternally inherited diabetes and deafness Maturity-onset diabetes of young people Plasmacytoid dendritic cell Interferon regulatory factor Nova Scotia duck tolling retriever

IMRD ANA SRMA IIF PBMC ELISPOT ELISA RPE ITT MDCK ANOVA RLBA

Immune-mediated rheumatic disease Antinuclear antibody Steroid responsive meningitis-arteritis Indirect Immunofluorescence Peripheral blood mononuclear cells Enzyme-linked immunosorbent spot Enzyme-linked immunosorbent assay R-Phycoerythrin In vitro transcription and translation Madin-Darby canine kidney Analysis of variance Radioligand binding assays

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Introduction

Many different diseases are considered to be of autoimmune origin. Au-toimmunity can lead to pathological changes such as tissue destruction. In this thesis studies focus on human and canine models for autoimmune dis-orders. Autoimmune Polyendocrine Syndrome type 1 (APS-1) is a human multiorgan autoimmune disorder that serves as a model for autoimmune disease. Hallmarks of APS-1 are chronic mucocutaneous candidiasis togeth-er with the autoimmune endocrine disorders hypoparathyroidism and adrenal failure. Dogs are generally considered to be a suitable model for several human diseases, but a careful characterization of the disease of interest is essential. Canine models for autoimmune disorders in this thesis are canine diabetes mellitus (DM) and a canine systemic autoimmune disease resem-bling human Systemic Lupus Erythematosus (SLE). Studies on autoimmune disease mechanisms allow for development of new therapies and for early identification of affected individuals.

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Background

The immune system The immune system has a remarkable ability to eliminate potentially harmful microbes but at the same time to tolerate self. It comprises of receptors that recognises an almost infinite number of antigens. In humans the immune system generates self-specific receptors, which can cause an autoimmune reaction if not controlled. Both central and peripheral tolerance mechanisms are important to control self-reactivity.

The immune system can be divided into innate immunity which reacts with a rapid but nonspecific response to a pathogen, and adaptive immunity which is specific and characterized by immunological memory. Innate im-mune mechanisms are needed to activate adaptive responses. Innate immuni-ty includes phagocytes, antimicrobial peptides, the complement system and pattern recognition receptors (PRRs) such as Toll-like receptors (TLRs)[1]. Adaptive immunity includes lymphocytes, i.e. T and B cells, and cytokines and chemokines are important for regulation of adaptive immunity. Factors of both innate and adaptive immunity contribute to autoimmunity[2].

Cells of the immune system The different cell types in the immune system are derived from a common hematopoietic stem cell in the bone marrow[3,4]. These pluripotent stem cells can form both lymphoid progenitor cells and myeloid progenitor cells[5]. Myeloid progenitor cells can develop into dendritic cells, mono-cytes and macrophages, megakaryocytes, and granulocytes. This thesis will, however, mainly focus on features of cells of the lymphoid lineage which includes T cells, B cells and NK cells.

T cells T cell receptor (TCR) recognition of specific peptides on MHC activates T cells if they receive concomitant co-stimulatory signals. CD4+ T helper (Th) cells recognize peptides loaded on MHC II molecules and CD8+ T cells rec-ognize peptides loaded on MHC I molecules[6]. Upon activation T cells start

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to differentiate into effector T cells (Figure 1). The primary T cell response is followed by generation of memory T cells[7]. These processes are tightly regulated to avoid pathological responses to self-antigens.

Individual lymphocytes carry several copies of a single TCR with a unique antigen-binding site. Somatic DNA recombination generates a diver-sity of receptor genes by combining multiple gene segments and by modify-ing the junctional sequences. Diversity of the TCR due to amino acid se-quence variations at the antigen binding site enables responses to many dif-ferent antigens.

The majority of T cells have TCRs made up of : heterodimers, but a minority carries : TCRs. These two TCR types are structurally similar, but it seems that : TCRs are not restricted to antigen recognition on MHC, i.e. they may bind free antigens[8].

Central and peripheral T cell tolerance Central tolerance develops primarily during perinatal life in the thymus[9]. Thymocytes carrying TCRs that recognize peptides presented on MHC un-dergo positive selection in the thymus. Medullary thymic epithelial cells (mTECs) enable expression of tissue-specific self-antigens, i.e. promiscuous expression, during negative selection[10]. The transcription factor autoim-mune regulator (AIRE) controls the differentiation of mTECs and the pro-miscuous expression of self-antigens[11,12]. Mutations in the AIRE gene cause the disease APS-1[13,14]. Thymocytes expressing TCR with high affinity to intrathymic autoantigens are deleted whereas low affinity thymo-cytes mature and enter the periphery.

Peripheral tolerance mechanisms prevent activation of potentially self-reactive lymphocytes[15]. Anergy, or hyporesponsiveness, is induced when a lymphocyte recognises an antigen without receiving concomitant co-stimulation[16]. Tregs play an important role in the maintenance of immune homeostasis and self-tolerance. Tregs possess the ability to down-regulate T cell responses to foreign antigens, and importantly, to self-antigens. The T cell response can be suppressed by Tregs in different ways, e.g. via CTLA-4:CD80 interactions[17] and by cytokine production. FOXP3 is the key tran-scription factor driving Treg differentiation and mutated FOXP3 gives rise to the X-linked recessive disease immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX). The autoimmune disorders APS-1 and IPEX both exemplify the importance of central and peripheral tolerance mechanisms[18].

CD4+ T cells Based on the pattern of cytokine secretion CD4+ T cells can be divided into Th1 cells, Th2 cells, Th17 cells, Th22 cells and regulatory T (Treg) cells

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(Table 1). Several recent studies however report functional plasticity within the CD4+ effector T cell program[19,20,21,22,23,24]. Lineage differentiation is influenced by the strength of antigenic stimulation and by activated tran-scription factors. The lineage commitment also largely depends on the cyto-kine environment e.g. members of the interleukin (IL)-12 family. IL-12 comprises a p40 unit together with a p35 unit and is pivotal for Th1 differen-tiation. IL-23 is a member of the same family and consist of a p19 subunit and the p40 unit that is common to IL-23 and IL-12. IL-23 promotes diffe-rentiation of Th cells into pathogenic Th17 cells[20,25,26].

Table 1. CD4+ effector T cell subsets

Cell subset Key transcription factors Cytokines

Th1 Tbet IFN- , IL-2Th2 GATA-3 IL-4, IL-5, IL-13, IL-10Treg FOXP3 IL-10, TGF-Th17 ROR t, ROR IL-17A, IL-17F, IL-22, GM-CSFTh22 ROR t, AHR IL-22, IL-13

T-bet is the key transcription factor for Th1 cell lineage commitment[27].

Th1 cells are implicated in the defense to intracellular bacteria by producing interferon (IFN)- that activates macrophages. Th1 cells also produce IL-2 and tumor necrosis factor.

The key transcription factor for Th2 cells is GATA-3 and Th2 cells re-quire IL-4 for differentiation[28]. Th2 cells mediate humoral responses and protection against extracellular parasites through the production of IL-4, IL-5, IL-10 and IL-13. In addition Th2 cells mediate allergic reactions.

Differentiation of the Th17 lineage requires the transcription factors ROR t and ROR [29]. IL-6 and transforming growth factor (TGF)- are required for differentiation of Th17 cells but IL-1 [30] and IL-23[31] can further induce IL-17 expression. Th17 cell development is negatively regu-lated by IL-4, IL-27, IL-2 and IFN- in mice[32,33,34,35,36]. Th17 cells are implicated in protection against infections caused by extracellular bacteria and fungus by production of pro-inflammatory cytokines and recruitment of neutrophil granulocytes to the site of infection. IL-17A, IL-17F and IL-22 are expressed by Th17 cells and subsets of NK cells, : -T cells and NKT cells[37]. Chronic mucocutaneous candidiasis has been associated to muta-tions of the genes encoding IL-17 and the IL-17 receptor (IL-17RA) and defects in the IL-17 signaling pathway[38,39,40,41]. The exact role of IL-17 in antifungal immunity is, however, still controversial because both positive and negative effects have been described[42]. A subset of Th17 cells that express GM-CSF drives autoimmune neuroinflammation in mice[25,26].

It is under debate whether Th22 cells are a unique lineage or a subset of Th17 cells. The proposed Th22 cells reside in the skin, produce IL-22 and are implicated in skin inflammations[43,44,45]. Furthermore it is suggested

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that Th22 cells restrict growth of the commensal Candida albicans (C. albicans)[46]. Indeed C. albicans-specific Th cells that produce IL-22 are found in healthy individuals[46].

Tregs express the transcription factor FOXP3 and contribute to maintain-ing immune homeostasis by secreting suppressive cytokines IL-10 and TGF- . Tregs can withdraw IL-2 from the microenvironment, which leads to cytokine deprivation-induced apoptosis of effector T cells[47]. Another me-chanism is trans-endocytosis of CD80/CD86 via CTLA-4[17]. The Treg and the Th17 cell lineages are able to interconvert depending on the concentra-tions of retinoic acid, IL-6, IL-23 and TGF- [22,24].

Figure 1. Outcomes of T cell activation. Antigen presenting cells (APCs) circulate the body and engulf antigens that are subsequently degraded in endocytic vesicles and loaded as peptides on MHC molecules. Innate immune mechanisms control the activation of antigen-specific immune responses[48,49]. APCs express low levels of MHC and co-stimulatory molecules. Hence, their capacity to activate naïve T cells is limited. As APCs encounter pathogens, their expression of MHC and co-stimulatory molecules increase, they start to produce cytokines and thereby their ability to prime T cells progresses[49]. Activation of transcription factors downstream of the TCR leads to IL-2 expression and clonal expansion. Lineage differentiation depend on antigenic stimuli, activated transcription factors and cytokines.

Cytokines Cytokines play an important role in regulation of immune responses, but are also implicated in autoimmunity[50]. Although very potent, no single cyto-kine can alone cause tissue damage in autoimmunity or antifungal immunity, but instead cytokines are likely secreted in concert with each other and the cytokine milieu determine the outcome of the processes. Chemokines are a family of chemo-attracting cytokines.

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Interleukins can be produced by mononuclear phagocytes and tissue cells but are primarily secreted from APC and T cells and promote T cell differen-tiation and effector functions.

Interferons The interferon system affects both innate and adaptive immunity and it is the first line defense against virus infections [51]. Interferons are divided into three groups characterized by the type of receptor and signal transduction pathway (Table 2).

Type I Interferons In systemic autoimmune diseases type I IFN plays a pivotal role. Type I IFNs include IFN- , IFN- , IFN- , IFN- and IFN- . In humans there are 13 IFN- genes, one IFN- gene and one IFN- gene, located on chromosome 9. The genes encoding type I IFNs lack introns. The main producers of IFN- are the plasmacytoid dendritic cells[52,53]. Patients with SLE display increased serum levels of IFN- which correlates with disease activity and number of organs targeted by disease. An increased expression of type I IFN regulated genes, i.e. an IFN signature, is present in SLE and some other autoimmune diseases[54].

Type II Interferons IFN- is a type II IFN encoded by one gene located on human chromosome 12. IFN- is expressed by activated Th cells and NK cells[55]. IFN- is a Th1 cytokine and contributes to cell-mediated immune responses by activat-ing macrophages and by increasing the antigen processing and antigen pre-senting ability of APCs[56].

Type III Interferons IFN- is the only known Type III IFN at present.

Table 2. Interferons

Type Interferons Receptors

Type I IFN- , IFN- , IFN- , IFN- , IFN- IFNAR1: IFNAR2Type II IFN- IFNGR1: IFNGR2Type III IFN- IL-10R2: IFNLR1

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B cells In lymphoid tissues dendritic cells bind to and activate CD4+ T cells that in turn interact with antigen-specific B cells. Activated B cells subsequently form germinal centers where they continue to receive help from follicular T helper cells and turn into antibody-secreting plasma cells[57]. Each B cell expresses a receptor specific for a particular antigen. Antibodies are secreted B cell receptors (BCRs). Similar to T cells and TCRs, diversity in BCR spe-cificity is enabled by somatic DNA recombination. In addition B cells un-dergo somatic hypermutation after encounter with and activation by an anti-gen. B cells that have become activated can undergo yet another somatic recombination, called isotype switching which confers antibodies of the same antigen specificity with different isotypes.

Immature B cells in the bone marrow are resistant to apoptosis, but their development can be blocked by interactions with self-antigen. Self-reactive mature B cells that cannot undergo receptor editing are susceptible to elimi-nation by apoptosis[58]. However a pool of autoreactive B cells appears in the peripheral lymphoid organs.

Autoimmunity Autoimmunity is characterized by an inappropriate activation of pathogenic T cells, B cells or both against self-antigens. Genetic factors, immune defi-ciencies, hormones and environment can contribute to autoimmunity[59]. Many autoimmune diseases are associated to certain HLA alleles, e.g. type 1 diabetes (T1D) to HLA-DR and -DQ alleles[60]. Immune defects associated with autoimmunity include IgA deficiency, deficiency of com-plement components and regulatory T cell defects[59]. Hormonal and envi-ronmental factors associated with autoimmunity include sex hormones, ul-traviolet radiation[61], infections[62] and pharmaceuticals. Therapeutic IFN- treatment can induce autoimmune thyroiditis[63].

Autoimmune diseases There are more than 80 different autoimmune diseases. They are often clas-sified as organ-specific or systemic. In organ-specific diseases the autoim-mune reactions are localized to isolated organs such as thyroid, adrenals, stomach and pancreas whereas in systemic autoimmunity reactivity is wide-spread in the body. Autoimmune responses engage both T cells, B cells and APCs for recognition of self-antigens. However, one cell type may have a prominent role for causing disease. This is exemplified by the decisive roles of autoantibodies and B cells in SLE and autoreactive T cells in T1D[64].

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Autoimmune disease models

1. Autoimmune Polyendocrine Syndrome type 1 as a model disorder APS-1, or autoimmune polyendocrinopathy-candidiasis-ectodermal dystro-phy (APECED) is a rare autoimmune disease caused by mutations in the AIRE gene which is located on chromosome 21[13,14]. APS-1 serves as a useful model for elucidating the mechanism of central tolerance[65]. More than 50 AIRE mutations have been described in association with APS-1[66]. Functional studies of the AIRE protein have implicated a function as a tran-scription factor (Figure 2).

Figure 2. AIRE controls promiscuous expression of otherwise tissue-specific self-antigens (TSA) in thymus. CD4+ and CD8+ thymocytes that bind peptide-MHC complexes with high affinity will be deleted. Extrathymic AIRE-expressing cells can form longterm contacts with naive autoreactive T cells entering the lymp node. Such interaction leads to deletion of these cells[15].

Diagnosis of APS-1 is based on clinical features (Table 3). The three cardin-al manifestations are chronic mucocutaneous candidiasis, adrenal failure and hypoparathyroidism. In 1990, Ahonen et al. described the clinical presenta-tion in 68 patients, with one to eight different disease components. Although the spectrum varied, most (63%) had three to five disease components[67]. A typical feature of APS-1 patients is autoantibodies to endocrine tissue antigens. In recent years new autoantigens have been discovered[68,69]. Interestingly, anti-cytokine antibodies were recently detected in APS-1 pa-tients[41,70,71,72].

The animal model of APS-1, AIRE-deficient mice, does not display the same repertoire of autoantibodies as APS-1 patients[73]. Furthermore AIRE-

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deficient mice lack spontaneous candidiasis and autoimmune tissue damage[73]. On the other hand AIRE-deficient mice exhibit an exacerbated fungal infection in an actively induced candidiasis model compared to wild-type mice.

Table 3. Clinical signs of Autoimmune Polyendocrine Syndrome type I

Disease manifestations

Mucocutaneous candidiasis

Hypoparathyroidism

Adrenal insufficiency

Diabetes mellitus

Pernicious anemia

Chronic active hepatitis

Growth hormone deficiency

Asplenia

Dental enamel hypoplasia

Autoimmune thyroid disease

Gonadal insufficiency

Vitiligo

Alopecia

Malabsorbtion

Chronic mucocutaneous candidiasis C. albicans is a commensal fungus, usually not causing clinically important infections. In individuals with a compromised immune system the fungi can undergo a phenotypic switch from yeast and start spreading and grow inva-sively as hyphae, causing considerable harm to the host[74]. Patients with APS-1 are not known to be prone to infections by other microorganisms, such as bacteria, but often suffer from chronic mucocutaneous candidiasis, which is characterized as recurrent or persistent superficial infections of skin, mucous membranes and nails by C. albicans[75].

Figure 3. C. albicans as yeast (left) and hyphae (right).

Typically, the C. albicans mucositis is pseudomembranotic, painful and with erosions on the oral and esophageal mucosa and may contribute to develop-ment of oral and squamous cell carcinoma in APS-1 patients[76]. As the

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C. albicans infection usually is the first sign of disease in APS-1, it may be hypothesized that mechanisms involved in the fungal defense or infection drives the development of other manifestations of APS-1.

Immune cell deviations in AIRE deficiency AIRE contributes to negative selection of thymocytes by regulating expres-sion of tissue-restricted self-antigens by mTECs. Mutations in AIRE contri-butes to aberrant : -thymocyte selection in thymus; however, the : -thymocytes seem unaffected by mutations in AIRE[77]. Accumulation of DC in the thymus is also dependent on AIRE which contributes to develop-ment and selection of natural Tregs[78]. Indeed mutations in AIRE negative-ly affect the homeostasis and activity of Treg[79,80].

Although AIRE is primarily expressed in thymus, effects of AIRE-mutations can be observed in the periphery. Reduced maturation and im-paired function of monocyte derived DCs (moDC) has been reported[81].

Studies of iNKT cells, another cell type with immunoregulatory func-tions, are however inconclusive. One study claims that the numbers of iNKT cells are not affected by AIRE-mutations[80], while in other studies de-creased number of circulating iNKT cells was demonstrated in APS-1 and AIRE-deficient mice[82,83]. These aberrations may however be secondary to AIRE’s function in the thymus.

2. The dog as a model for human disease The human share environment, many genetic factors and in part life style with the dog. That, in combination with the unique structure of the canine genome, makes the dog an interesting model for genetic studies of complex human diseases[84]. Before using the dog as a model for human disease, a careful characterization of the canine disease is essential. In these studies the aim was to investigate whether dogs with DM could serve as a model for human autoimmune DM and to analyze the expression of type I IFN in dogs with a systemic autoimmune disease resembling human SLE.

Human diabetes mellitus DM is a group of disorders, collectively being a major threat to public health worldwide. In the year 2000 the global prevalence of diabetes for all age-groups was estimated to 2.8% of the population. Recent WHO calculations indicate that almost 3 million deaths per year worldwide are attributable to DM and the numbers of afflicted persons are estimated to be doubled by the year 2030 solely taking into account the demographic changes. In humans the two most common forms are T1D and T2D.

The human forms of DM that are considered to be of autoimmune origin are T1D and latent autoimmune diabetes of the adult (LADA). LADA is a

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slowly progressive form of T1D with onset during adulthood in contrast to T1D, which have a more abrupt onset earlier in life. Their difference in onset may indicate separate disease mechanisms[85]. Autoantibodies in autoim-mune DM are directed to targets in the pancreas (Figure 4). Most prevalent are autoantibodies to the 65 kDa isoform of glutamic acid decarboxylase, (GAD65), the protein tyrosine phosphatase Islet antigen 2 (IA2) and recently identified zinc transporter protein ZnT8[86]. Present at lower frequencies are antibodies to insulin (IAA) and cytoplasmic islet antibodies (ICA). Measur-ing ZnT8 antibodies (ZnT8A), GAD65 antibodies (GADA), Islet antigen 2 antibodies (IA2A), and IAA in combination detects 98% patients at disease onset[86]. GAD65 is an enzyme expressed in brain and pancreas. GAD65 catalyse the decarboxylation of glutamic acid to GABA and CO2[87]. The function of GABA in pancreatic -cells remains to be elucidated, but it has been suggested that GABA has a paracrine suppressive effect on glucagon secretion[88].

T2D is characterized by peripheral insulin resistance and is part of the metabolic syndrome[89]. Other forms of diabetes are secondary forms of diabetes, related to pregnancy, medical disorders or surgical removal of the pancreas. Further, several monogenic forms of diabetes have been identified, such as maternally inherited diabetes and deafness (MIDD), maturity-onset diabetes of young people (MODY)[90] and Wolfram syndrome[91].

Figure 4. The insulin producing -cells are located in pancreatic islets of Langer-hans. To the left binding of monoclonal antibodies to GAD65 in tissue section from canine pancreas is depicted in red. (In blue, nuclear DAPI staining). To the right isolated islets of Langerhans from a euthanized dog.

a) Canine Diabetes mellitus DM develops spontaneously in dogs, but the disease mechanisms have not yet been identified. Like in humans, the disease is complex and includes several subtypes. Diabetes is one of the most common endocrine disorders in dogs[92].

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The clinical symptoms of human and canine DM are similar but the eti-ologies may differ. The diagnosis of canine DM is often based on its clinical signs, including polyuria and polydipsia, a persistent fasting hyperglycemia of more than 8 mmol/l and glycosuria. Prolonged periods of hyperglycemia have a negative effect on many tissues. Capillary epithelial cells in the ret-ina, mesangial cells in the renal glomerolus and neurons and Schwann cells in the peripheral nerves can be damaged in human DM[93]. Similar to hu-man DM, long-term complications have been reported in dogs[94].

Canine DM may be divided into insulin-resistant and insulin-deficient DM. Canine insulin resistance can occur as a consequence of hormonal dis-turbances and can lead to insulin deficiency by means of glucotoxicity. Insu-lin deficiency may additionally be caused by autoimmunity or develop be-cause of -cell loss associated with exocrine pancreatic disease[95]. Autoan-tibodies to canine GAD65, IA2 and recombinant canine proinsulin have been reported at low frequency in English DM dogs[96,97].

Human Systemic Lupus Erythematosus SLE is a human systemic autoimmune disease with a female predominance. It is often relapsing-remitting but also chronic active, and long quiescent disease activity patterns occur[98]. Disease manifestations include cutaneous rash, fever, arthritis, anemia, serositis, glomerulonephritis, pancytopenia and seizures[61,99]. A majority of the patients have autoantibodies to nucleic acid[61]. SLE patient sera containing immune complexes can activate plas-macytoid DCs (pDCs) - the main producers of type I IFN in vivo[100]. In SLE patients pDCs migrate to tissues where IFN- is secreted[101].

Interferon-induced genes in SLE IFNs induce expression of hundreds of genes. Transcriptome analysis by mRNA amplification on hybridization chips can determine genes activated in response to IFNs. This analysis shows that SLE patients have a so-called IFN signature[54]. Some genes are induced by only one IFN, such as IRF1, preferentially induced by IFN- , whereas other genes such as MX1 can be induced by type I and type III IFN. The genes in the IFN signature encodes cytokines, chemokines, membrane receptors, signal transduction proteins, growth factors, apoptotic factors, adhesion molecules and antimicrobial pro-teins[102]. Interferon regulatory factors (IRFs) possess DNA binding do-mains that recognise interferon stimulated response elements, located at the promoter region of interferon inducible genes. Large-scale genetic associa-tion studies have shown that genetic variants of IRF5 is associated with risk of SLE[103,104,105,106] and a recent study showed that IRF5 activation is altered in monocytes from SLE patients[107].

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b) Canine systemic autoimmune diseases Dogs of the breed Nova Scotia duck tolling retriever (NSDTR) have a high incidence of immune-mediated diseases. Some of the dogs develop a condi-tion termed immune-mediated rheumatic disease (IMRD), a disease complex resembling the human autoimmune disease SLE. These dogs may also de-velop anti-nuclear antibodies (ANAs) but do not develop autoAb to double-stranded DNA. In a study of 33 diseased NSDTRs 23 of them were ANA positive[108]. Another condition appearing at higher frequency in NSDTRs than other breeds is called steroid responsive meningitis-arteritis (SRMA), also known as aseptic meningitis[108]. Familial predisposition and a ge-nome-wide association study show that genetic factors are involved in the etiology of disease[109,110].

IMRD Dogs that develop IMRD are usually between two and six years. Clinical signs of IMRD are symmetrical nonerosive polyarthritis, stiffness, mainly after resting and signs of pain from several joints of extremities. A propor-tion of dogs with IMRD are ANA positive, i.e. antinuclear antibodies can be detected in sera from these dogs by indirect immunofluorescence (IIF). Based on this test it is possible to divide ANA-positive dogs into different subgroups, where 25% display a homogeneous fluorescence pattern and 75% speckled staining pattern[111].

SRMA Dogs suffering from SRMA typically display fever, neck pain, stiffness and reluctance to move. Infectious causes to the clinical signs of disease are ruled out by test of the cerebrospinal fluid. The prognosis for young dogs in acute stage of disease is relatively good with early and aggressive anti-inflammatory or immunosuppressive therapy. Age of onset of SRMA is typ-ically between 6 and 18 months with a range from 4 months to 7 years[112].

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Present investigations

Autoimmunity is defined as an inappropriate immune reaction to self-tissue and subsequent tissue damage. Chronic mucocutaneous candidiasis is often the first sign of APS-1 but the underlying mechanisms are not yet clear. Dogs are generally considered to be a suitable model for several immunolog-ical human diseases, but a careful characterization of the disease of interest is essential. The principal aims of this thesis was to gain knowledge about mechanisms involved with autoimmune diseases and to further evaluate the dog as a model for autoimmune diseases.

Aims of this thesis To investigate disease mechanisms of chronic mucocutaneous candidia-

sis in APS-1 (Paper I and II) To investigate if diabetic dogs can be used as model organism for studies

of T1D (Paper III) Develop an assay for measuring canine type I IFN-induced gene tran-

scription and investigate if an IFN signature is present in dogs with sys-temic autoimmunity (Paper IV)

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Material and methods

Here follows a brief description of the material and methods used within the studies. For more detailed information, see Paper I-IV.

Patients

Paper I & II In Paper I and II human APS-1 patients, patients with isolated chronic mu-cocutaneous candidiasis and thyroiditis, and healthy control persons were included. Additionally, AIRE-deficient and wild-type mice were included in Paper I. Peripheral blood mononuclear cells (PBMC) from nine APS-1 pa-tients were included in Paper I, two females and seven males, aged 18-58 years. The mean age at onset was ten years. All patients had chronic muco-cutaneous candidiasis, eight of nine adrenal insufficiencies, seven of nine hypoparathyroidism; five had alopecia, four vitiligo, four malabsorbtion, three nail pitting, three dental enamel hypoplasia, two diabetes, two chronic active hepatitis, two growth hormone deficiency, two gonadal insufficien-cies, two thyroid disease and two had pernicious anemia. The healthy con-trols were sex- and age-matched with each patient. Serum samples from 11 Swedish and 57 Finnish APS-1 patients, and 70 healthy blood donors were used for autoantibody assays in Paper I and serum samples from 25 Norwe-gian APS-1 patients were used in Paper II. All the Swedish/Finnish patients and 21 of 25 Norwegian patients had chronic mucocutaneous candidiasis.

Dogs

Paper III In total dogs from 64 different breeds diagnosed with diabetes, dogs with Addison’s disease, thyroiditis or healthy control dogs were included in the study. Diabetes diagnoses were based on the clinical signs polyuria and polydipsia and a persistent fasting hyperglycaemia >8 mmol/l. Addison’s disease was diagnosed based on clinical signs, hyponatremia, hyperkalemia

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and on ACTH-stimulation test. The thyroiditis dogs had increased levels of thyrotropin-stimulating hormone or autoantibodies to thyreoglobulin or both.

Paper IV All dogs included in Paper IV are of the breed Nova Scotia duck tolling re-triever. Dogs with IMRD showed signs of pain from several joint of extremi-ties, stiffness, mainly after resting and symmetrical nonerosive polyarthritis. Dogs with SRMA displayed fever, neck pain, stiffness and reluctance to move. Cerebrospinal fluid sample analyses were performed for most of SRMA dogs, and ruled out infectious cause of disease. Healthy control dogs had no history of autoimmune disease.

Cell isolation Venous blood was collected to Sodium-heparinized tubes. In Paper I human PBMC was isolated and in Paper IV dog PBMC was isolated, both using a density centrifugation method. Due to differences in density between human and canine PBMC, Ficoll-Paque PLUS was used for the human samples while Ficoll-Paque Premium 1.084 was used for canine samples (both from GE Healthcare, Uppsala, Sweden).

Recall assay PBMC were cultured in 24-well plates in 37 ºC, 5% CO2 in humidified at-mosphere. Cell density was 2X106 cells/ml. Human PBMC were cultured in TB-1 lymphocyte medium, 1% HS. The cells were stimulated by C. albi-cans, Mycobacterium tuberculosis, Zymosan or peptidoglycan. Cells and supernatants were collected at one, two and three days of culture.

Intracellular cytokine staining Th1 cells were stained for intracellular IFN- and investigated using flow cytometry. Cells were stimulated to produce cytokine and stained for surface molecules CD3 and CD4. After staining of surface molecules cells were permeabilized in order for anti-cytokine mAb to be able to enter cells. Next, after intracellular cytokine staining cells were washed, fixated and analyzed using a FACS Canto II cytometer (BD Biosciences, San Jose, CA).

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Enzyme-linked immunosorbent spot (ELISPOT) Human IL-17A secreting cells were detected using ELISPOT (Mabtech, Nacka, Sweden). The cells were cultured in antibody pre-coated ELISPOT plates for 72 h in the presence of stimulatory antigens. Spots were developed and counted manually in a dissection microscope.

Enzyme-linked immunosorbent assay (ELISA) Based on the quantitative sandwich enzyme immunoassay technique ELISAs were used for measuring the contents of cytokines from cultured cells. Mi-crotiter plates precoated with monoclonal antibodies were used. Standards and samples were added to the plate and cytokine of interest was bound by the immobilized antibodies. After washing unbound molecules, enzyme-linked polyclonal antibodies directed to cytokine of interest were added. Unbound antibody-enzyme reagents were washed off and substrate added. Color, in proportion to the amount of cytokine of interest in samples and standards was developed and measured.

Human IL-17A, murine IFN- , IL-4, IL-10, IL-17A, IL-6 and IL-15 were from R&D systems, Minneapolis, MN. Murine IL-23 ELISA was from eBioscience, Rome, Italy. ELISA was used as a reference method for mea-suring autoantibodies in Paper II.

Multiplex bead immunoassay Cell supernatants were analyzed for multiple cytokines using BMD’s FIDIS Human Cytokine 25-plex kit (BMD, Marne la Valée, France). The method is based on a solid phase sandwich technique in which the spectral properties of different bead regions are monitored to achieve simultaneous measure-ment of multiple cytokines. A solution of beads with different spectral prop-erties conjugated to analyte-specific capture antibodies were mixed and in-cubated with samples, controls and standards for 2 h in filter bottom micro plates. After washing the beads using a vacuum manifold, analyte-specific biotinylated detector antibodies were added and incubated for 1 h. Excessive detector antibodies were then removed and streptavidin conjugated to the fluorescent protein R-Phycoerythrin (RPE) added forming the solid phase sandwich with the immune complexed bead. The beads were then analyzed using the FIDISTM100 instrument. By monitoring the spectral properties of the beads and the amount of associated RPE fluorescence, the concentration of each analyte are determined. Four-parametric curve-fitting were used to calculate cytokine concentrations in the samples.

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Quantitative Real-Time RT-PCR Total RNA was isolated from cells using RNeasy micro or mini kit accord-ing to the manufacturer’s instructions (Qiagen, Hilden, Germany). Reverse transcription was performed with 10 µl or 0.2 µg total RNA random hex-amer primers, dNTPs and Superscript III (Invitrogen, Carlsbad, CA).

Quantitative real time PCR of the cDNA was performed using primers designed based on human or canine DNA sequences. Relative expression to the housekeeping genes GUSB, GAPDH or 18s rRNA was calculated for all samples and qPCR was run on a MyiQ Real-Time PCR Detection System (Bio-Rad Laboratories, Hercules, CA) as previously described[113].

Immunoprecipitations of radioactively labeled protein Plasmids containing genes of interest (encoding human IL-17A, IL-17F, IL-22, hetero and homodimers thereof, human IL-10, and canine and human GAD-65) were used for in vitro transcription and translation (ITT) into 35S labeled proteins. Patient sera, control sera and sera from healthy or diseased dogs were used for immunoprecipitations and subsequently the amount of antibody-bound protein was measured by assaying the radioactivity of preci-pitates. Indices were calculated and serum with an index mean-value plus 3 (Paper I-II) or 4 (Paper III) standard deviations were considered autoantibo-dy-positive.

Figure 5. The principle for immunofluorescent staining. Patient sera or monoclonal antibodies directed to antigen of interest are added to tissue sections on microscope slides. Fluorophore labeled secondary antibodies are added and specific binding assessed in a microscope.

Immunofluorescence Tissue sections of human and canine pancreata were used for autoantibody detection in canine sera. Tissues were snap frozen at harvest and stored in -70º C until cryosectioning. Human pancreata were stained in 3- m sections while 6- m sections were used for canine substrates. Sera and antibodies as

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indicated in Paper III were used for IIF and fluorescence microscope or con-focal microscope was used for assessing autoantibody binding (Figure 5).

Antibody ELISA (Paper II) Immunosorbent plates were coated with IL-17F or IL-22 protein and non-specific binding sites were blocked with BSA (3%). After washing, samples diluted 1:50 were added, in duplicates. After subsequent washing alkaline phosphatase conjugated goat anti-human IgG was added. SIGMAFAST p-nitrophenol phosphate substrate solution was used for visualization of anti-protein binding. Absorbance was read at 405 nm in a spectrophotometer.

Canine type I IFN assay Madin-Darby canine kidney (MDCK) cells are known to be responsive to IFN. Therefore these cells were cultured and stimulated with sera from dogs with IMRD, SRMA and healthy control dogs. After 6 h stimulation the cells were harvested and mRNA isolated. After cDNA synthesis the relative ex-pression of the IFN responsive genes MX1, IFIT10 and CXCL-10 was measured by qPCR.

Statistical analyses Students T test, nonparametric Mann Whitney test, Kruskal-Wallis test and Dunn’s multiple comparisons tests were used. One way analysis of variance (ANOVA) was calculated to determine whether there was a significant dif-ference between groups in Paper III. Correlations of the result of the antibo-dy assays by radioligand binding assays (RLBA) and ELISA were calculated using the Spearman r-test, confidence interval and p-value.

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Results

Paper I

IL-17A secretion in response to Candida albicans is increased in AIRE deficiency In Paper I we found that the IL-17A secretion in response to ex vivo recall stimulation with C. albicans is increased in PBMC from APS-1 patients and in AIRE-deficient mice. None of the control antigens - Mycobacterium tu-berculosis, Zymosan or peptidoglycan - gave rise to increased secretion of IL-17A in APS-1 patients. This shows that the response observed is C. albi-cans-specific. AIRE deficiency appears to promote a strong Th17 response to C. albicans. In contrast, the IL-22 secretion was reduced.

In patients with isolated chronic mucocutaneous candidiasis without AIRE deficiency the IL-17A secretion was unaltered and the IL-22 secretion was reduced.

Recently, it was found that APS-1 patients carry autoantibodies to cyto-kines that are related to the C. albicans-infection[41,70]. We confirmed presence of antibodies to IL-17A, IL-17F and IL-22 by radioligand binding assay and immunoprecipitation. We also investigated whether patients suf-fering from other autoimmune diseases display anti-IL-22 autoantibodies, but found that the anti-IL-22 antibodies are specific to APS-1. We found high titers of anti-IL-22 autoantibodies in 89 % of the APS-1 patients.

Main findings: The IL-17A secretion in response to C. albicans is increased in both

APS-1 patients and its animal model. PBMC from patients suffering from chronic mucocutaneous candidiasis,

with or without AIRE deficiency, secrete less IL-22 than healthy con-trols.

A strong antibody response to IL-22 is seen in almost all APS-1 patients.

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Paper II

Radioligand binding assays based on IL-17F and IL-22 as monomers or dimers can be used for screening of autoantibodies in APS-1 In Paper I autoantibodies were measured by in vitro transcription and trans-lation followed by immunoprecipitation with a radioactively-labeled protein. In Paper II this assay was improved and evaluated in comparison to ELISA. Fusion proteins of the cytokines IL-17F and IL-22 was tested, both as homo- and hetero-dimers because cytokines are small proteins and thus difficult to express in vitro. We found that the assays based on dimeric proteins are highly reproducible with low inter- and intra-variation. The method has high throughput and easy standardization compared to ELISA, thus providing excellent choices for the screening of IL-17F and IL-22 autoantibodies.

Main finding: Screening of autoantibodies to IL-17F and IL-22 can preferably be per-

formed using radioligand-binding assay using fusion proteins of the two cytokines.

Paper III

No evidence for autoimmune disease in diabetic dogs We used four assays to investigate signs of humoral autoimmunity in diabet-ic dogs. Sera from diabetic dogs were tested for islet cell antibodies and GAD65 antibodies using indirect immunofluorescence and in vitro transcrip-tion and translation followed by immunoprecipitation with a radioactively-labeled protein. Among a large cohort of diabetic dogs from many different breeds we found no evidence for humoral autoimmunity.

Main finding: DM in Swedish dogs does not appear to have an autoimmune etiology.

Paper IV

Nova Scotia duck tolling retrievers suffering from steroid responsive meningitis-arteritis exhibit a type I IFN signature IFIT1, MX1 and CXCL10 are examples of IFN-inducible genes. By directly measuring the mRNA expression of these genes in PBMC from diseased and healthy NSDTRs, a higher expression of IFIT1 was detected in dogs suffer-ing from IMRD compared to healthy dogs.

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It is difficult to detect type I IFN directly in blood because the protein le-vels are below the detection limit with current techniques. Therefore indirect methods are used for measuring the type I IFN content in sera or plasma. A novel method for indirect measurement of canine type I IFN was devel-oped. MDCK cells were stimulated with sera from diseased and healthy dogs. IFN-inducible gene expression was measured by real-time PCR by stimulated cells.

Main findings: PBMC from NSDTR suffering from IMRD display a higher mRNA

expression of IFIT1 than healthy control dogs. Sera from NSDTRs suffering from SRMA can induce a higher expres-

sion of the IFN-inducible gene MX1 in cultured cells than sera from healthy dogs, indicating an IFN signature in dogs with SRMA.

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Conclusions and general discussion

The precise sequence of events leading to chronic mucocutaneous candidia-sis is not clear, though much progress in this research area has been achieved in recent years.

IL-22 has emerged as an important cytokine in protection from fungal in-fections. Healthy individuals carry IL-22-producing Th22 cells specific for C. albicans[46]. We and others have shown that IL-22 secretion is depressed in chronic mucocutaneous candidiasis, either isolated or caused by AIRE-deficiency or STAT1 mutations[70,114,115,116]. This argues for a promi-nent role for IL-22 in antifungal defense regardless of the underlying cause for susceptibility to the disease. In addition, protective immunity to candi-diasis involves an early IL-22 response in mice[117]. IL-22 receptor en-gagement induces STAT3 phosphorylation and thereby release of antimi-crobial peptides. This contributes to antifungal resistance at mucosal surfac-es[117].

The role of Th17 cells in protection vs. pathology to fungal infection re-mains controversial. In Paper I we report a several-fold increase in IL-17A producing cells and secretion of IL-17A in response to C. albicans in PBMC from APS-1 patients. These results were corroborated in a British APS-1 patient group[115]. On the other hand, IL-17A and IL-17 receptor A defi-ciencies are associated to isolated chronic mucocutaneous candidiasis[40]. Reduced IL-17A and IL-17F expression in response to C. albicans has also been reported in isolated chronic mucocutaneous candidiasis patients[39]. STAT3 mutations lead to hyper-IgE syndrome, a condition characterized by chronic mucocutaneous candidiasis and other immune deficiencies. These patients fail to mount a Th17 response[118]. Thus APS-1 patients display an enhanced Th17 response to C. albicans, whereas patient groups with other underlying causes of candidiasis display an impaired Th17 response. It re-mains to establish whether the Th17 cells protect from fungal infection or are involved in the pathology[42].

A feature of chronic mucocutaneous candidiasis in APS-1 is the presence of autoantibodies to IL-22 as observed in Paper I. These antibodies can be the primary cause of candidiasis or a consequence of the enhanced Th17 responses. At present it is not known whether the autoantibodies to IL-22 cause chronic mucocutaneous candidiasis. Prospective studies in infants with APS-1 are required to solve this question.

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Others have reported a normal frequency but an impaired function of Tregs from APS-1 patients[79]. Indeed the frequency of Tregs was unaltered in our study (data not included). In Paper I higher amount of IL-2 from C. albicans-stimulated PBMC from APS-1 patients was observed. Cytokine deprivation-induced apoptosis is a mechanism by which Tregs inhibit T cell responses[47]. I speculate that the increased amount of IL-2 is a conse-quence of impaired Treg-mediated IL-2 deprivation.

In conclusion, IL-22 responses to C. albicans are impaired in patients suf-fering from chronic mucocutaneous candidiasis, whereas the Th17 response to C. albicans is enhanced in APS-1. I hypothesize that IL-22 deficiency has a prominent role in the disease mechanism of chronic mucoutaneous candi-diasis, whereas the increased Th17 response seen in Paper I is related to the AIRE-deficiency. This is supported by the enhanced Th17 responses ob-served in AIRE-deficient mice (Paper I).

In Paper I we report that nearly all APS-1 patients carry autoantibodies to IL-22 and one fifth of the patients carry antibodies to IL-17A or IL-17F. The anti-IL-22 antibodies were specific for APS-1. However the sensitivity and specificity of the autoantibody assays were not determined. In paper II a radioligand binding assay based on hetero- and homo-dimers of IL-22 and IL-17F was developed. We found that the assays based on dimeric proteins are highly reproducible with low inter- and intra-variation. Thus, the assays can be used as diagnostic methods for APS-1.

Several human diseases have an equivalent disease in dogs. Because humans share environment, and in part life style with the dogs they are interesting for use in comparative studies. In Paper III and IV the main aim was to evaluate the dog as a model for autoimmune disease and gain knowledge about dis-ease mechanisms in canine DM and in a systemic autoimmune disease re-sembling human SLE.

Although many studies have characterized canine DM, no consensus has been established for etiological classification of DM in dogs. According to WHO criteria DM in humans can be diagnosed by venous plasma glucose concentration is >11.1 mmol/l 2 h after a 75-g peroral glucose tolerance test or by two fasting glucose measurements >6.1 mmol/l. The diagnosis of ca-nine DM is often based on its clinical signs, including polyuria and polydip-sia, a persistent fasting hyperglycemia of more than 8 mmol/l and glycosuria. DM is more common in middle aged and older dogs, rather than young dogs and most dogs require exogenous insulin therapy [95].

Based on disease pathogenesis a system for classification of DM in dogs was suggested by the Royal Veterinary College in UK, and presented by Catchpole at al, 2005[95]. In this system the disease was divided into insulin deficient diabetes (IDD) and insulin resistant diabetes (IRD). IDD is charac-terized by a progressive loss of -cells. Processes that lead to IDD include

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congenital -cells hypoplasia/abiotrophy, -cells loss associated with exo-crine pancreatic disease, immune-mediated destruction and idiopathic -cells deficiency. IRD result from antagonism of insulin function by other hor-mones. This includes resistance due to diestrous/gestational DM or to other endocrine disorders or iatrogenic effects. Obesity may also contribute to IRD, but is not a primary cause of DM in dogs[95]. In 2009, Fall presented a new classification system in her doctoral thesis[119]. This system was based on new knowledge on causes for DM and included 7 classes:

juvenile diabetes, including -cell hypoplasia and combined -cell defi-ciency and pancreatic acinar atrophy

progesterone-related, i.e. gestational/diestrous diabetes secondary to pancreatitis diabetes caused by endocrine tumors diabetes caused by iatrogenic effects immune-mediated diabetes idiopathic diabetes

In conclusion, DM has several etiologies in dogs. One of the proposed etiol-ogies is immune-mediated DM. Autoimmunity in canine diabetes is however controversial. Antibodies to canine GAD65, IA2 and recombinant canine proinsulin have been reported at low frequency in English diabetic dogs [96,97], while we and others report absence of autoantibodies[120,121].

In autoimmune diseases such as APS-1 and T1D mature B cells turn into plasma cells and produce autoantibodies before clinical manifestations ap-pear[122,123]. These autoantibodies offer a useful diagnostic and potentially predictive disease marker. If the autoantigen is known, radioligand immuno-precipitation assays or immunoglobulin ELISA can be used for measuring the quantity of antibodies in sera. Indirect immunofluorescence (IIF) staining of tissue sections can also detect autoantibodies. This method can be useful if the autoantigen is unknown, but the organ targeted by disease is known. In canine diabetes the clinical picture resembles the human disease, which indi-cates pancreas as the target for a potential autoimmune attack. Therefore we used IIF to look for signs of autoimmunity in canine pancreas. We also used a certified human ICA assay. RLBA for antibodies to human and canine GAD65 was used on a large cohort of diabetic and control dogs from differ-ent breeds. We found however no presence of humoral autoreactivity. Prob-ably, the dogs included in our study suffer from other types of diabetes, in-cluding gestational diabetes[124], combined endocrine and exocrine pan-creatic insufficiency and idiopathic diabetes. However, future studies of cellular responses to islet cell antigens are needed, since autoreactive T cells play an important role in the pathogenesis of human T1D[64,125]. In addi-tion, future studies on histopathology of canine pancreata may shed further light on the etiology of diabetes in dogs.

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Human SLE patients have overproduction of IFN- and treatment with antibodies to IFN- ameliorates disease. This suggests a detrimental role for IFN- in the pathogenesis. Because NSDTR dogs often develop a disease complex resembling SLE, including IMRD and SRMA[108]. It is not known whether IMRD and SRMA are two different diseases or parts of the same disease. A genetic study implies a partially shared genetic background [110].

Increased type I IFN secretion was detected in SRMA dogs by an indirect method in Paper IV. PBMC from IMRD dogs expressed more IFIT1, an IFN-inducible gene. This may suggest a role for type I IFN in the pathogene-sis of systemic autoimmune diseases in NSDTRs. It would be desirable to treat dogs with antibodies to IFN- to confirm this association.

This thesis contributes to increased knowledge about mechanisms in au-toimmune disease in man and dog. In addition the results presented herein can form the basis for future research with the aim to develop new therapies to autoimmune diseases. The results presented in Paper I has in addition increased our understanding of disease mechanisms in chronic mucocutane-ous candidiasis.

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Summary of the Thesis in Swedish

Immunologiska studier av modellsjukdomar i människa och hund Vårt immunförsvar finns för att skydda oss från infektioner orsakade av bak-terier, parasiter och virus. Autoimmunitet kan definieras som en olämplig aktivering av T celler och/eller B celler mot kroppsegen vävnad. Sådan akti-vering kan leda till vävnadsskada och ge upphov till autoimmuna sjukdomar.

Den här avhandlingen beskriver studier av sjukdomsmekanismer i en hu-man och två djurmodeller för autoimmuna sjukdomar. Autoimmunt Polyen-dokrint Syndrom typ 1 (APS-1) är en sjukdom orsakad av mutationer i auto-immune regulator (AIRE)-genen. Den kan yttra sig med flertalet olika sjuk-domssymptom. De tre kardinalsymptomen är kronisk mukokutan kandidain-fektion, binjurebarksvikt och hypoparatyroidism.

Vidare har två sjukdomar i hundar studerats. Dessa sjukdomar, diabetes och systemisk lupus erythematosus (SLE), uppkommer spontant hos hundar och har en motsvarighet i människa. Dock måste noggranna jämförande studier bekräfta likheter för att vi ska kunna använda dessa hund-sjukdomar som sjukdomsmodeller för de humana sjukdomarna. När kunskapen kring mekanismerna i dessa två sjukdomar ökar, ökar vi även möjligheten att be-handla dessa hundar effektivt, vilket kan leda till ökat välbefinnande hos såväl människa som hund.

I APS-1 är det ofta den kroniska eller frekvent återkommande och svår-behandlade kandida-infektionen som är det första tecknet på sjukdom, och uppstår redan i barndomen hos de flesta patienterna. Jag studerade immun-svaret mot kandida i blodceller från a) patienter med APS-1, b) patienter med kronisk mukokutan kandida infektion utan AIRE-mutation och c) friska ålders- och köns-matchade kontroller. Jag fann en förhöjd utsöndring av cytokinet IL-17A i APS-1 patienternas blodceller efter stimulering med kan-dida, jämfört med friska kontroller. Denna ökade utsöndring kunde inte ob-serveras hos patienter med kronisk mukokutan kandida infektion utan AIRE-mutation. En annan signaleringsmolekyl som är viktig vid svampinfektioner, IL-22 var däremot lägre hos patienter än friska. Denna nedreglering var dock inte enbart observerad vid stimulering med kandida, utan även vid stimule-ring med kontrollantigenerna Mycobacterium tuberculosis, Zymosam och peptidoglykan. Patienter med kronisk mukokutan kandidainfektion utan AIRE-mutation hade också låg nivå av IL-22 i våra försök. Detta tyder på att

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IL-22 är viktigt för att skydda mot kronisk mukokutan kandida, och att AIRE mutationer ökar IL-17A-svaret mot kandida.

APS-1 patienter har autoantikroppar mot IL-22, IL-17A och IL-17F. Re-aktiviteten mot IL-22 är stark, förekommer hos 89% av APS-1 patienterna, men inte i friska kontroller eller patienter med andra autoimmuna sjukdomar. I arbete 2 utvecklade vi en förbättrad metod för att mäta förekomst av auto-antikroppar mot IL-22 och IL-17F. Vi fann att genom att använda fusions-protein av IL-17F och IL-22 kan man få en mätmetod som är både reprodu-cerbar och användbar för stort antal prover.

Det har föreslagits att hundar med diabetes ofta lider av autoimmun dia-betes, dvs typ 1 diabetes. Jag letade efter markörer för autoimmunitet, men kunde ej påvisa sådana, trots att fyra väl utprovade och allmänt vedertagna metoder användes på ett material som innefattande ett stort antal diabetiska och kontrollhundar. Detta tyder på att hundar med diabetes har en annan etiologi, expempelvis idiopatisk diabetes, dräktighetsdiabetes eller diabetes orsakad av exokrin och endokrin bukspottkörtelsjukdom.

I vårt immunförsvar är typ I interferon viktigt för skydd mot virusinfek-tioner, men i den humana sjukdomen SLE är typ I interferon kopplat till sjukdomsmekanismen. Patienter med SLE har ökad koncentration av typ I interferon i blodet. Hundar av rasen Nova Scotia duck tolling retrievers (även kallade Tollare) får ofta någon av de immunmedierade sjukdomarna immune-mediated rheumatic disease (IMRD) eller steriod responsive me-ningitis-arteritis (SRMA). SRMA debuterar vanligtvis redan vid 6 - 18 må-naders ålder, medan IMRD vanligen debuterar något senare, vid 2 - 6 års ålder. Vissa Tollare får SRMA och utvecklar senare IMRD. Detta sjukdoms-komplex kan liknas vid den humana sjukdomen SLE. Jag utvecklade en me-tod för att indirekt mäta interferon i serum från hundar. Jag fann att Tollare med SRMA har högre nivå av typ I interferon i serum. Vidare studier behövs för att följa upp dessa resultat.

Denna avhandling bidrar till ökad kunskap om mekanismer i autoimmuna sjukdomar, i människa och hund. Dessa kunskaper har inte bara bidragit till ökad förståelse för de studerade sjukdomarna, utan kan också ligga till grund för vidare forskning med syfte att utveckla nya behandlingar mot autoimmu-na sjukdomar. Resultaten i delarbete 1 har även bidragit till ökad förståelse om sjukdomsmekanismer vid kroniska svampinfektioner.

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Acknowledgements

The work with this thesis was carried out at the Department of Medical Sciences, Uppsala University. I want to express my gratitude to all of you that in various ways helped me along the way. Some of you I will mention here.

My supervisor Anna Lobell, for introducing me to the field of cellular im-munology, for endurance, for being an excellent supervisor, for sharing many many laughters with me. You have inspired me and taught me a lot!

Professor Olle Kämpe, for accepting me as a PhD student. Thank you for your great generosity and for sharing your deep scientific knowledge!

Professor Luigina Romani, I am grateful for your expertise, your support and encouragement. Thank you for a fruitful collaboration!

Past and present members of the Systemic autoimmunity-group, plus And-ers Rönnblom, for scientific discussions on Mondays and SLE and interferon guidance. Especially thanks to Maija-Leena Eloranta, for sharing your deep knowledge within the interferon-field, and for always being so nice and cheerful!

Göran Andersson, Gerli Rosengren Pielberg, Helene Hamlin and my co-supervisor Kerstin Lindblad-Toh, for scientific input for my canine re-search. All nice dog researchers and LUPA members for interesting and joyful research meetings in Europe and Baltimore. Especially Nina Sund-berg and Maria Wilbe for nice collaborations.

Tove Fall, Henrik von Euler, Johan Rönnelid, Erik Åhlin and all other co-authors, for fruitful collaborations!

Anna-Stina Höglund, for teaching me confocal microscopy. Professor Sherry Mowbray for useful advices early in my studies and a fruitful project before my PhD studies began.

Åsa Hallgren for support, both scientific and personal. You are a first class pedagogue and outstanding interpreter of research data and mood swings!

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Present and past members of lab 21. Mohammad Alimohammadi, for help and for being such a nice and social person. Brita Ardesjö-Lundgren, for a lot of help, and it was great to inherit your closet! Magnus Isaksson, for clinical expertise and sampling, Frida Dalin for running in stadsskogen and Nils Landegren for helping me out of the DM-swamp I almost got stuck in, Pernilla, Mina, Casey & Sophie -thanks for all nice time together at lab and outside.

Anna-Stina Sahlqvist, thanks for introducing me to lab 21, for your friend-ship, a NYC week-end, chats in my closet (skrubbsnack), running, parties and much more!

Anna-Malin Linde (fd Hermansson), my life-line to the lab during my ma-ternal leave. Anna Norling and Iulia Karlsson, I appreciate all the help I’ve had and the very pleasant company during many exhausting hours in cell-lab.

Present and past members of professor Syvänens group for being nice, helpful and friendly. Annika Ahlford, Johanna Sandling, Jessica Nor-dlund and Anna Kiialainen for giving the word smart its both meanings! Sofia and Edvard for your friendly concern! And Jessica -thanks for lin-guistic expertise and cheerful company late nights at work!

Dhana, Cecile, Margareta, Malin, Peter, Birgitta, Susanne, Siv, Reza, Anette, Gunnar, Eva Hagforsen, Lillebil, Anna Foyer, it-Lena and it-Anders and all other helpful people at the research department for help and creating a nice atmosphere.

Elina Hjertström, you are a real friend! I wouldn’t have come this far with-out you, I really mean it. I have had so much fun with you!! Thank you for all your help!

Vännerna; Sofia & David, kära grannar på Apelgatan och Ling, Anna B-M, Lollo och Eleonore med familjer för att ni är precis lagom in-tresserade av min forskning.

Alla mina släktingar i Uppsala, speciellt Madeleine, Roine, Dan, Hasse & Birgitta, Maj och Birgit för stöd, boende, blod, barnvakt, äpplen, kärlek och trygghet.

Mina släktingar på min mans sida, speciellt svärmor Rita de la Noe och svärfar Kenneth Nilsson för att jag fått komma till Dalarna och ladda batte-rierna, och tack Björn Nilsson för att jag fick träffa din bror.

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Min fina mor Sara, som helhjärtat stöttat mig genom doktorandtiden och kommit och avlastat de tyngsta veckorna! Din kärlek gör mig trygg. Tack mamma!

Min avlidne far Bertil, den här boken är din! Minnet av dig hjälpte mig på vägen. Ditt intresse för forskning (och dina insulinsprutor) inspirerade mig redan som barn, även om vägen till doktorstiteln långt ifrån varit spikrak. Du är den finaste människan jag någonsin mött och jag saknar dig!

Min storebror Björn Ahlgren, för att du alltid varit så duktig, hjälpsam och en bra förebild! Tack också till din härliga familj!

Karl-Johan! Tack för all uppmuntran, stöd och ditt tålamod, och för att du hjälpt mig tro på mig själv och min förmåga! Miranda, för att du är den du är och ger mitt liv utanför forskningen mening!

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References

1. Medzhitov R (2001) Toll-like receptors and innate immunity. Nat Rev Immunol 1: 135-145.

2. Atassi MZ, Casali P (2008) Molecular mechanisms of autoimmunity. Autoimmunity 41: 123-132.

3. Adolfsson J, Månsson R, Buza-Vidas N, Hultquist A, Liuba K, et al. (2005) Identification of Flt3+ Lympho-Myeloid Stem Cells Lacking Erythro-Megakaryocytic Potential: A Revised Road Map for Adult Blood Lineage Commitment. Cell 121: 295-306.

4. Iwasaki H, Akashi K (2007) Hematopoietic developmental pathways: on cellular basis. Oncogene 26: 6687-6696.

5. Iwasaki H, Akashi K (2007) Myeloid Lineage Commitment from the Hematopoietic Stem Cell. Immunity 26: 726-740.

6. Call ME, Wucherpfennig KW (2005) THE T CELL RECEPTOR: Critical Role of the Membrane Environment in Receptor Assembly and Function. Annual Review of Immunology 23: 101-125.

7. Pepper M, Jenkins MK (2011) Origins of CD4(+) effector and central memory T cells. Nat Immunol 12: 467-471.

8. Schrum AG, Turka LA, Palmer E (2003) Surface T-cell antigen receptor expression and availability for long-term antigenic signaling. Immunological Reviews 196: 7-24.

9. Guerau-de-Arellano M, Martinic M, Benoist C, Mathis D (2009) Neonatal tolerance revisited: a perinatal window for Aire control of autoimmunity. J Exp Med 206: 1245-1252.

10. Derbinski J, Gabler J, Brors B, Tierling S, Jonnakuty S, et al. (2005) Promiscuous gene expression in thymic epithelial cells is regulated at multiple levels. J Exp Med 202: 33-45.

11. Derbinski J, Schulte A, Kyewski B, Klein L (2001) Promiscuous gene expression in medullary thymic epithelial cells mirrors the peripheral self. Nat Immunol 2: 1032-1039.

12. Yano M, Kuroda N, Han H, Meguro-Horike M, Nishikawa Y, et al. (2008) Aire controls the differentiation program of thymic epithelial cells in the medulla for the establishment of self-tolerance. J Exp Med 205: 2827-2838.

13. Consortium F-GA (1997) An autoimmune disease, APECED, caused by mutations in a novel gene featuring two PHD-type zinc-finger domains. Nat Genet 17: 399-403.

14. Nagamine K, Peterson P, Scott HS, Kudoh J, Minoshima S, et al. (1997) Positional cloning of the APECED gene. Nat Genet 17: 393-398.

15. Gardner JM, Devoss JJ, Friedman RS, Wong DJ, Tan YX, et al. (2008) Deletional tolerance mediated by extrathymic Aire-expressing cells. Science 321: 843-847.

16. Fathman CG, Lineberry NB (2007) Molecular mechanisms of CD4+ T-cell anergy. Nat Rev Immunol 7: 599-609.

43

17. Qureshi OS, Zheng Y, Nakamura K, Attridge K, Manzotti C, et al. (2011) Trans-endocytosis of CD80 and CD86: a molecular basis for the cell-extrinsic function of CTLA-4. Science 332: 600-603.

18. Michels AW, Gottlieb PA (2010) Autoimmune polyglandular syndromes. Nat Rev Endocrinol 6: 270-277.

19. Dardalhon V, Awasthi A, Kwon H, Galileos G, Gao W, et al. (2008) IL-4 inhibits TGF-beta-induced Foxp3+ T cells and, together with TGF-beta, generates IL-9+ IL-10+ Foxp3(-) effector T cells. Nat Immunol 9: 1347-1355.

20. Hirota K, Duarte JH, Veldhoen M, Hornsby E, Li Y, et al. (2011) Fate mapping of IL-17-producing T cells in inflammatory responses. Nat Immunol 12: 255-263.

21. Kurschus FC, Croxford AL, Heinen AP, Wortge S, Ielo D, et al. (2010) Genetic proof for the transient nature of the Th17 phenotype. Eur J Immunol 40: 3336-3346.

22. Mucida D, Park Y, Kim G, Turovskaya O, Scott I, et al. (2007) Reciprocal TH17 and regulatory T cell differentiation mediated by retinoic acid. Science 317: 256-260.

23. Veldhoen M, Uyttenhove C, van Snick J, Helmby H, Westendorf A, et al. (2008) Transforming growth factor-beta 'reprograms' the differentiation of T helper 2 cells and promotes an interleukin 9-producing subset. Nat Immunol 9: 1341-1346.

24. Zhou L, Lopes JE, Chong MM, Ivanov, II, Min R, et al. (2008) TGF-beta-induced Foxp3 inhibits T(H)17 cell differentiation by antagonizing RORgammat function. Nature 453: 236-240.

25. Codarri L, Gyulveszi G, Tosevski V, Hesske L, Fontana A, et al. (2011) RORgammat drives production of the cytokine GM-CSF in helper T cells, which is essential for the effector phase of autoimmune neuroinflammation. Nat Immunol 12: 560-567.

26. El-Behi M, Ciric B, Dai H, Yan Y, Cullimore M, et al. (2011) The encephalitogenicity of T(H)17 cells is dependent on IL-1- and IL-23-induced production of the cytokine GM-CSF. Nat Immunol 12: 568-575.

27. Szabo SJ, Kim ST, Costa GL, Zhang X, Fathman CG, et al. (2000) A novel transcription factor, T-bet, directs Th1 lineage commitment. Cell 100: 655-669.

28. Zheng W, Flavell RA (1997) The transcription factor GATA-3 is necessary and sufficient for Th2 cytokine gene expression in CD4 T cells. Cell 89: 587-596.

29. Ivanov, II, McKenzie BS, Zhou L, Tadokoro CE, Lepelley A, et al. (2006) The orphan nuclear receptor RORgammat directs the differentiation program of proinflammatory IL-17+ T helper cells. Cell 126: 1121-1133.

30. Acosta-Rodriguez EV, Napolitani G, Lanzavecchia A, Sallusto F (2007) Interleukins 1beta and 6 but not transforming growth factor-beta are essential for the differentiation of interleukin 17-producing human T helper cells. Nat Immunol 8: 942-949.

31. Wilson NJ, Boniface K, Chan JR, McKenzie BS, Blumenschein WM, et al. (2007) Development, cytokine profile and function of human interleukin 17-producing helper T cells. Nat Immunol 8: 950-957.

32. Batten M, Li J, Yi S, Kljavin NM, Danilenko DM, et al. (2006) Interleukin 27 limits autoimmune encephalomyelitis by suppressing the development of interleukin 17-producing T cells. Nat Immunol 7: 929-936.

33. Harrington LE, Hatton RD, Mangan PR, Turner H, Murphy TL, et al. (2005) Interleukin 17-producing CD4+ effector T cells develop via a lineage distinct from the T helper type 1 and 2 lineages. Nat Immunol 6: 1123-1132.

44

34. Laurence A, Tato CM, Davidson TS, Kanno Y, Chen Z, et al. (2007) Interleukin-2 signaling via STAT5 constrains T helper 17 cell generation. Immunity 26: 371-381.

35. Park H, Li Z, Yang XO, Chang SH, Nurieva R, et al. (2005) A distinct lineage of CD4 T cells regulates tissue inflammation by producing interleukin 17. Nat Immunol 6: 1133-1141.

36. Stumhofer JS, Laurence A, Wilson EH, Huang E, Tato CM, et al. (2006) Interleukin 27 negatively regulates the development of interleukin 17-producing T helper cells during chronic inflammation of the central nervous system. Nat Immunol 7: 937-945.

37. Kolls JK, Lindén A (2004) Interleukin-17 Family Members and Inflammation. Immunity 21: 467-476.

38. Conti HR, Shen F, Nayyar N, Stocum E, Sun JN, et al. (2009) Th17 cells and IL-17 receptor signaling are essential for mucosal host defense against oral candidiasis. J Exp Med 206: 299-311.

39. Eyerich K, Foerster S, Rombold S, Seidl HP, Behrendt H, et al. (2008) Patients with chronic mucocutaneous candidiasis exhibit reduced production of Th17-associated cytokines IL-17 and IL-22. J Invest Dermatol 128: 2640-2645.

40. Puel A, Cypowyj S, Bustamante J, Wright JF, Liu L, et al. (2011) Chronic mucocutaneous candidiasis in humans with inborn errors of interleukin-17 immunity. Science 332: 65-68.

41. Puel A, Doffinger R, Natividad A, Chrabieh M, Barcenas-Morales G, et al. (2010) Autoantibodies against IL-17A, IL-17F, and IL-22 in patients with chronic mucocutaneous candidiasis and autoimmune polyendocrine syndrome type I. J Exp Med 207: 291-297.

42. Zelante T, De Luca A, Bonifazi P, Montagnoli C, Bozza S, et al. (2007) IL-23 and the Th17 pathway promote inflammation and impair antifungal immune resistance. Eur J Immunol 37: 2695-2706.

43. Duhen T, Geiger R, Jarrossay D, Lanzavecchia A, Sallusto F (2009) Production of interleukin 22 but not interleukin 17 by a subset of human skin-homing memory T cells. Nat Immunol 10: 857-863.

44. Eyerich S, Eyerich K, Pennino D, Carbone T, Nasorri F, et al. (2009) Th22 cells represent a distinct human T cell subset involved in epidermal immunity and remodeling. J Clin Invest 119: 3573-3585.

45. Trifari S, Kaplan CD, Tran EH, Crellin NK, Spits H (2009) Identification of a human helper T cell population that has abundant production of interleukin 22 and is distinct from TH-17, TH1 and TH2 cells. Nat Immunol 10: 864-871.

46. Liu Y, Yang B, Zhou M, Li L, Zhou H, et al. (2009) Memory IL-22-producing CD4+ T cells specific for Candida albicans are present in humans. Eur J Immunol 39: 1472-1479.

47. Pandiyan P, Zheng L, Ishihara S, Reed J, Lenardo MJ (2007) CD4+CD25+Foxp3+ regulatory T cells induce cytokine deprivation-mediated apoptosis of effector CD4+ T cells. Nat Immunol 8: 1353-1362.

48. Banchereau J, Steinman RM (1998) Dendritic cells and the control of immunity. Nature 392: 245-252.

49. Schnare M, Barton GM, Holt AC, Takeda K, Akira S, et al. (2001) Toll-like receptors control activation of adaptive immune responses. Nat Immunol 2: 947-950.

50. Moudgil KD, Choubey D (2011) Cytokines in autoimmunity: role in induction, regulation, and treatment. J Interferon Cytokine Res 31: 695-703.

51. Sen GC (2001) Viruses and interferons. Annu Rev Microbiol 55: 255-281.

45

52. Fitzgerald-Bocarsly P (1993) Human natural interferon-alpha producing cells. Pharmacol Ther 60: 39-62.

53. Rönnblom L, Ramstedt U, Alm GV (1983) Properties of human natural interferon-producing cells stimulated by tumor cell lines. Eur J Immunol 13: 471-476.

54. Crow MK, Wohlgemuth J (2003) Microarray analysis of gene expression in lupus. Arthritis Res Ther 5: 279-287.

55. Samuel CE (2001) Antiviral actions of interferons. Clin Microbiol Rev 14: 778-809, table of contents.

56. Hu X, Ivashkiv LB (2009) Cross-regulation of Signaling Pathways by Interferon- : Implications for Immune Responses and Autoimmune Diseases. Immunity 31: 539-550.

57. Pape KA, Catron DM, Itano AA, Jenkins MK (2007) The Humoral Immune Response Is Initiated in Lymph Nodes by B Cells that Acquire Soluble Antigen Directly in the Follicles. Immunity 26: 491-502.

58. Goodnow CC, Vinuesa CG, Randall KL, Mackay F, Brink R (2010) Control systems and decision making for antibody production. Nat Immunol 11: 681-688.

59. Shoenfeld Y, Isenberg DA (1989) The mosaic of autoimmunity. Immunol Today 10: 123-126.

60. Sanjeevi CB, Sedimbi SK, Landin-Olsson M, Kockum I, Lernmark Å, et al. (2008) The Risk Conferred by HLA-DR and DQ for Type 1 Diabetes in 0–35-Years Age Group are Different in Different Regions of Sweden. Annals of the New York Academy of Sciences 1150: 106-111.

61. Rahman A, Isenberg DA (2008) Systemic lupus erythematosus. N Engl J Med 358: 929-939.

62. Ercolini AM, Miller SD (2009) The role of infections in autoimmune disease. Clin Exp Immunol 155: 1-15.

63. Gota C, Calabrese L (2003) Induction of clinical autoimmune disease by therapeutic interferon-alpha. Autoimmunity 36: 511-518.

64. Martin S, Wolf-Eichbaum D, Duinkerken G, Scherbaum WA, Kolb H, et al. (2001) Development of type 1 diabetes despite severe hereditary B-lymphocyte deficiency. N Engl J Med 345: 1036-1040.

65. Mathis D, Benoist C (2007) A decade of AIRE. Nat Rev Immunol 7: 645-650. 66. Peterson P, Peltonen L (2005) Autoimmune polyendocrinopathy syndrome type

1 (APS1) and AIRE gene: new views on molecular basis of autoimmunity. J Autoimmun 25 Suppl: 49-55.

67. Ahonen P, Myllarniemi S, Sipila I, Perheentupa J (1990) Clinical variation of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in a series of 68 patients. N Engl J Med 322: 1829-1836.

68. Alimohammadi M, Björklund P, Hallgren A, Pöntynen N, Szinnai G, et al. (2008) Autoimmune polyendocrine syndrome type 1 and NALP5, a parathyroid autoantigen. N Engl J Med 358: 1018-1028.

69. Alimohammadi M, Dubois N, Sköldberg F, Hallgren Å, Tardivel I, et al. (2009) Pulmonary autoimmunity as a feature of autoimmune polyendocrine syndrome type 1 and identification of KCNRG as a bronchial autoantigen. Proc Natl Acad Sci U S A 106: 4396-4401.

70. Kisand K, Boe Wolff AS, Podkrajsek KT, Tserel L, Link M, et al. (2010) Chronic mucocutaneous candidiasis in APECED or thymoma patients correlates with autoimmunity to Th17-associated cytokines. J Exp Med 207: 299-308.

46

71. Meager A, Visvalingam K, Peterson P, Moll K, Murumagi A, et al. (2006) Anti-interferon autoantibodies in autoimmune polyendocrinopathy syndrome type 1. PLoS Med 3: e289.

72. Meloni A, Furcas M, Cetani F, Marcocci C, Falorni A, et al. (2008) Autoantibodies against type I interferons as an additional diagnostic criterion for autoimmune polyendocrine syndrome type I. J Clin Endocrinol Metab 93: 4389-4397.

73. Pöntynen N, Miettinen A, Arstila TP, Kämpe O, Alimohammadi M, et al. (2006) Aire deficient mice do not develop the same profile of tissue-specific autoantibodies as APECED patients. J Autoimmun 27: 96-104.

74. Antachopoulos C, Walsh TJ, Roilides E (2007) Fungal infections in primary immunodeficiencies. Eur J Pediatr 166: 1099-1117.

75. Eyerich K, Eyerich S, Hiller J, Behrendt H, Traidl-Hoffmann C (2010) Chronic mucocutaneous candidiasis, from bench to bedside. Eur J Dermatol 20: 260-265.

76. Rautemaa R, Hietanen J, Niissalo S, Pirinen S, Perheentupa J (2007) Oral and oesophageal squamous cell carcinoma--a complication or component of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED, APS-I). Oral Oncol 43: 607-613.

77. Tuovinen H, Pöntynen N, Gylling M, Kekalainen E, Perheentupa J, et al. (2009) gammadelta T cells develop independently of Aire. Cell Immunol 257: 5-12.

78. Lei Y, Ripen AM, Ishimaru N, Ohigashi I, Nagasawa T, et al. (2011) Aire-dependent production of XCL1 mediates medullary accumulation of thymic dendritic cells and contributes to regulatory T cell development. J Exp Med 208: 383-394.

79. Laakso SM, Laurinolli TT, Rossi LH, Lehtoviita A, Sairanen H, et al. (2010) Regulatory T cell defect in APECED patients is associated with loss of naive FOXP3(+) precursors and impaired activated population. J Autoimmun 35: 351-357.

80. Wolff AS, Oftedal BE, Kisand K, Ersvaer E, Lima K, et al. (2010) Flow cytometry study of blood cell subtypes reflects autoimmune and inflammatory processes in autoimmune polyendocrine syndrome type I. Scand J Immunol 71: 459-467.

81. Pöntynen N, Strengell M, Sillanpaa N, Saharinen J, Ulmanen I, et al. (2008) Critical immunological pathways are downregulated in APECED patient dendritic cells. J Mol Med (Berl) 86: 1139-1152.

82. Lindh E, Rosmaraki E, Berg L, Brauner H, Karlsson MC, et al. (2010) AIRE deficiency leads to impaired iNKT cell development. J Autoimmun 34: 66-72.

83. Mi QS, Deng ZB, Joshi SK, Wang ZZ, Zhou L, et al. (2006) The autoimmune regulator (Aire) controls iNKT cell development and maturation. Nat Med 12: 1100.

84. Lindblad-Toh K, Wade CM, Mikkelsen TS, Karlsson EK, Jaffe DB, et al. (2005) Genome sequence, comparative analysis and haplotype structure of the domestic dog. Nature 438: 803-819.

85. Hirschhorn JN (2003) Genetic epidemiology of type 1 diabetes. Pediatr Diabetes 4: 87-100.

86. Wenzlau JM, Juhl K, Yu L, Moua O, Sarkar SA, et al. (2007) The cation efflux transporter ZnT8 (Slc30A8) is a major autoantigen in human type 1 diabetes. Proc Natl Acad Sci U S A 104: 17040-17045.

87. Soltani N, Qiu H, Aleksic M, Glinka Y, Zhao F, et al. (2011) GABA exerts protective and regenerative effects on islet beta cells and reverses diabetes. Proceedings of the National Academy of Sciences 108: 11692-11697.

47

88. Franklin IK, Wollheim CB (2004) GABA in the endocrine pancreas: its putative role as an islet cell paracrine-signalling molecule. J Gen Physiol 123: 185-190.

89. Vaxillaire M, Froguel P (2008) Monogenic diabetes in the young, pharmacogenetics and relevance to multifactorial forms of type 2 diabetes. Endocr Rev 29: 254-264.

90. (2003) Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 26: s5-s20.

91. Ganie MA, Bhat D (2009) Current developments in Wolfram syndrome. J Pediatr Endocrinol Metab 22: 3-10.

92. Fall T, Hamlin HH, Hedhammar Å, Kämpe O, Egenvall A (2007) Diabetes mellitus in a population of 180,000 insured dogs: incidence, survival, and breed distribution. J Vet Intern Med 21: 1209-1216.

93. Brownlee M (2005) The Pathobiology of Diabetic Complications: A Unifying Mechanism. Diabetes 54: 1615-1625.

94. Morgan MJ, Vite CH, Radhakrishnan A, Hess RS (2008) Clinical peripheral neuropathy associated with diabetes mellitus in 3 dogs. Can Vet J 49: 583-586.

95. Catchpole B, Ristic JM, Fleeman LM, Davison LJ (2005) Canine diabetes mellitus: can old dogs teach us new tricks? Diabetologia 48: 1948-1956.

96. Davison LJ, Herrtage ME, Catchpole B (2011) Autoantibodies to recombinant canine proinsulin in canine diabetic patients. Res Vet Sci 91: 58-63.

97. Davison LJ, Weenink SM, Christie MR, Herrtage ME, Catchpole B (2008) Autoantibodies to GAD65 and IA-2 in canine diabetes mellitus. Vet Immunol Immunopathol 126: 83-90.

98. Barr SG, Zonana-Nacach A, Magder LS, Petri M (1999) Patterns of disease activity in systemic lupus erythematosus. Arthritis Rheum 42: 2682-2688.

99. Pego-Reigosa JM, Isenberg DA (2008) Psychosis due to systemic lupus erythematosus: characteristics and long-term outcome of this rare manifestation of the disease. Rheumatology (Oxford) 47: 1498-1502.

100. Lövgren T, Eloranta ML, Båve U, Alm GV, Rönnblom L (2004) Induction of interferon-alpha production in plasmacytoid dendritic cells by immune complexes containing nucleic acid released by necrotic or late apoptotic cells and lupus IgG. Arthritis Rheum 50: 1861-1872.

101. Rönnblom L, Alm GV, Eloranta ML (2011) The type I interferon system in the development of lupus. Semin Immunol 23: 113-121.

102. Meyer O (2009) Interferons and autoimmune disorders. Joint Bone Spine 76: 464-473.

103. Graham RR, Kyogoku C, Sigurdsson S, Vlasova IA, Davies LR, et al. (2007) Three functional variants of IFN regulatory factor 5 (IRF5) define risk and protective haplotypes for human lupus. Proc Natl Acad Sci U S A 104: 6758-6763.

104. Kelly JA, Kelley JM, Kaufman KM, Kilpatrick J, Bruner GR, et al. (2008) Interferon regulatory factor-5 is genetically associated with systemic lupus erythematosus in African Americans. Genes Immun 9: 187-194.

105. Shin HD, Sung YK, Choi CB, Lee SO, Lee HW, et al. (2007) Replication of the genetic effects of IFN regulatory factor 5 (IRF5) on systemic lupus erythematosus in a Korean population. Arthritis Res Ther 9: R32.

106. Sigurdsson S, Goring HH, Kristjansdottir G, Milani L, Nordmark G, et al. (2008) Comprehensive evaluation of the genetic variants of interferon regulatory factor 5 (IRF5) reveals a novel 5 bp length polymorphism as strong risk factor for systemic lupus erythematosus. Hum Mol Genet 17: 872-881.

48

107. Stone RC, Feng D, Deng J, Singh S, Yang L, et al. (2011) IRF5 activation in monocytes of SLE patients is triggered by circulating autoantigens independent of type I IFN. Arthritis & Rheumatism: n/a-n/a.

108. Hansson-Hamlin H, Lilliehöök I (2009) A possible systemic rheumatic disorder in the Nova Scotia duck tolling retriever. Acta Vet Scand 51: 16.

109. Anfinsen KP, Berendt M, Liste FJ, Haagensen TR, Indrebo A, et al. (2008) A retrospective epidemiological study of clinical signs and familial predisposition associated with aseptic meningitis in the Norwegian population of Nova Scotia duck tolling retrievers born 1994-2003. Can J Vet Res 72: 350-355.

110. Wilbe M, Jokinen P, Truve K, Seppala EH, Karlsson EK, et al. (2010) Genome-wide association mapping identifies multiple loci for a canine SLE-related disease complex. Nat Genet 42: 250-254.

111. Hansson-Hamlin H, Lilliehook I, Trowald-Wigh G (2006) Subgroups of canine antinuclear antibodies in relation to laboratory and clinical findings in immune-mediated disease. Vet Clin Pathol 35: 397-404.

112. Cizinauskas S, Jaggy A, Tipold A (2000) Long-term treatment of dogs with steroid-responsive meningitis-arteritis: clinical, laboratory and therapeutic results. J Small Anim Pract 41: 295-301.

113. Marta M, Andersson A, Isaksson M, Kämpe O, Lobell A (2008) Unexpected regulatory roles of TLR4 and TLR9 in experimental autoimmune encephalomyelitis. Eur J Immunol 38: 565-575.

114. Cheng SC, van de Veerdonk FL, Lenardon M, Stoffels M, Plantinga T, et al. (2011) The dectin-1/inflammasome pathway is responsible for the induction of protective T-helper 17 responses that discriminate between yeasts and hyphae of Candida albicans. J Leukoc Biol 90: 357-366.

115. Ng WF, von Delwig A, Carmichael AJ, Arkwright PD, Abinun M, et al. (2010) Impaired T(H)17 responses in patients with chronic mucocutaneous candidiasis with and without autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. J Allergy Clin Immunol 126: 1006-1015, 1015 e1001-1004.

116. van de Veerdonk FL, Plantinga TS, Hoischen A, Smeekens SP, Joosten LA, et al. (2011) STAT1 mutations in autosomal dominant chronic mucocutaneous candidiasis. N Engl J Med 365: 54-61.

117. De Luca A, Zelante T, D'Angelo C, Zagarella S, Fallarino F, et al. (2010) IL-22 defines a novel immune pathway of antifungal resistance. Mucosal Immunol 3: 361-373.

118. Milner JD, Brenchley JM, Laurence A, Freeman AF, Hill BJ, et al. (2008) Impaired T(H)17 cell differentiation in subjects with autosomal dominant hyper-IgE syndrome. Nature 452: 773-776.

119. Fall T (2009:45) Characterisation of Diabetes Mellitus in Dogs. Uppsala: Swedish University of Agricultural Sciences. 2009:2045 p.

120. Alejandro R, Feldman EC, Shienvold FL, Mintz DH (1988) Advances in canine diabetes mellitus research: etiopathology and results of islet transplantation. J Am Vet Med Assoc 193: 1050-1055.

121. Fall T, Hedhammar A, Wallberg A, Fall N, Ahlgren KM, et al. (2010) Diabetes mellitus in elkhounds is associated with diestrus and pregnancy. J Vet Intern Med 24: 1322-1328.

122. Bärmeier H, McCulloch D, Neifing J, Warnock G, Rajotte R, et al. (1991) Risk for developing Type 1 (insulin-dependent) diabetes mellitus and the presence of islet 64K antibodies. Diabetologia 34: 727-733.

123. Gorsuch AN, Spencer KM, Lister J, McNally JM, Dean BM, et al. (1981) Evidence for a long prediabetic period in type I (insulin-dependent) diabetes mellitus. Lancet 2: 1363-1365.

49

124. Fall T, Johansson Kreuger S, Juberget A, Bergström Å, Hedhammar Å (2008) Gestational diabetes mellitus in 13 dogs. J Vet Intern Med 22: 1296-1300.

125. Monti P, Heninger AK, Bonifacio E (2009) Differentiation, expansion, and homeostasis of autoreactive T cells in type 1 diabetes mellitus. Curr Diab Rep 9: 113-118.