Department of Dermatology and Cutaneous Biology Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
Department of Computer Science and Engineering, College of Information and Biotechnology, National Institute of Science and Technology, Ulsan, South Korea.
J Clin Invest. 2023 Dec 1;133(23):e166357. doi: 10.1172/JCI166357.
BACKGROUNDPemphigus, a rare autoimmune bullous disease mediated by antidesmoglein autoantibodies, can be controlled with systemic medication like rituximab and high-dose systemic corticosteroids combined with immunosuppressants. However, some patients continue to experience chronically recurrent blisters in a specific area and require long-term maintenance systemic therapy.METHODSSkin with chronic blisters was obtained from patients with pemphigus. Immunologic properties of the skin were analyzed by immunofluorescence staining, bulk and single-cell RNA and TCR sequencing, and a highly multiplex imaging technique known as CO-Detection by indEXing (CODEX). Functional analyses were performed by flow cytometry and bulk RNA-Seq using peripheral blood from healthy donors. Intralesional corticosteroid was injected into patient skin, and changes in chronically recurrent blisters were observed.RESULTSWe demonstrated the presence of skin tertiary lymphoid structures (TLSs) with desmoglein-specific B cells in chronic blisters from patients with pemphigus. In the skin TLSs, CD4+ T cells predominantly produced CXCL13. These clonally expanded CXCL13+CD4+ T cells exhibited features of activated Th1-like cells and downregulated genes associated with T cell receptor-mediated signaling. Tregs are in direct contact with CXCL13+CD4+ memory T cells and increased CXCL13 production of CD4+ T cells through IL-2 consumption and TGF-β stimulation. Finally, intralesional corticosteroid injection improved chronic blisters and reduced skin TLSs in patients with pemphigus.CONCLUSIONThrough this study we conclude that skin TLSs are associated with the persistence of chronically recurrent blisters in patients with pemphigus, and the microenvironmental network involving CXCL13+CD4+ T cells and Tregs within these structures plays an important role in CXCL13 production.TRIAL REGISTRATIONClinicalTrials.gov NCT04509570.FUNDINGThis work was supported by National Research Foundation of South Korea (NRF-2021R1C1C1007179) and Korea Drug Development Fund, which is funded by Ministry of Science and ICT; Ministry of Trade, Industry, and Energy; and Ministry of Health and Welfare (grant RS-2022-00165917).
天疱疮是一种罕见的自身免疫性大疱性疾病，由抗桥粒芯糖蛋白自身抗体介导，可通过利妥昔单抗和大剂量全身皮质类固醇联合免疫抑制剂进行控制。然而，一些患者在特定部位仍持续出现慢性复发性水疱，需要长期维持全身治疗。
从天疱疮患者的慢性水疱皮肤中获取皮肤样本。通过免疫荧光染色、批量和单细胞 RNA 和 TCR 测序以及一种称为通过索引进行的高多重成像技术（CODEX）分析皮肤的免疫特性。使用来自健康供体的外周血通过流式细胞术和批量 RNA-Seq 进行功能分析。向患者皮肤内注射皮质类固醇，观察慢性复发性水疱的变化。
我们证明了在天疱疮患者的慢性水疱中存在带有桥粒芯糖蛋白特异性 B 细胞的皮肤三级淋巴结构（TLS）。在皮肤 TLS 中，CD4+ T 细胞主要产生 CXCL13。这些克隆扩增的 CXCL13+CD4+ T 细胞表现出激活的 Th1 样细胞的特征，并下调与 T 细胞受体介导的信号转导相关的基因。Tregs 与 CXCL13+CD4+记忆 T 细胞直接接触，并通过消耗 IL-2 和刺激 TGF-β 来增加 CXCL13+CD4+T 细胞的 CXCL13 产生。最后，皮损内皮质类固醇注射改善了天疱疮患者的慢性水疱，并减少了皮肤 TLS。
通过这项研究，我们得出结论，皮肤 TLS 与天疱疮患者慢性复发性水疱的持续存在有关，这些结构内涉及 CXCL13+CD4+T 细胞和 Tregs 的微环境网络在 CXCL13 产生中发挥重要作用。
ClinicalTrials.gov NCT04509570。
这项工作得到了韩国国家研究基金会（NRF-2021R1C1C1007179）和韩国药物开发基金的支持，该基金由科学和信息通信技术部、贸易、工业和能源部以及健康和福利部资助（拨款 RS-2022-00165917）。
