Marys Medicine

The new england journal of medicine established in 1812 october 29, 2009 A Homozygous CARD9 Mutation in a Family with Susceptibility to Fungal Infections Erik-Oliver Glocker, M.D., Andre Hennigs, Mohammad Nabavi, M.D., Alejandro A. Schäffer, Ph.D., Cristina Woellner, M.Sc., Ulrich Salzer, M.D., Dietmar Pfeifer, Ph.D., Hendrik Veelken, M.D., Klaus Warnatz, M.D., Fariba Tahami, M.Sc., Sarah Jamal, M.Sc., Annabelle Manguiat, M.Sc., Nima Rezaei, M.D., Ali Akbar Amirzargar, M.D., Alessandro Plebani, M.D., Nicole Hannesschläger, B.Sc., Olaf Gross, Ph.D., Jürgen Ruland, M.D., and Bodo Grimbacher, M.D.
Chronic mucocutaneous candidiasis may be manifested as a primary immunodefi- The authors' affiliations are listed in the
Appendix. Address reprint requests to ciency characterized by persistent or recurrent infections of the mucosa or the skin Dr. Grimbacher at the Department of Im- with candida species. Most cases are sporadic, but both autosomal dominant in- munology and Molecular Pathology, Royal heritance and autosomal recessive inheritance have been described.
Free Hospital and University College Lon-don, Pond St., London NW3 2QG, United Kingdom, or at Methods
We performed genetic studies in 36 members of a large, consanguineous five-gener- Drs. Glocker and Hennigs contributed
equally to this article.
ation family, in which 4 members had recurrent fungal infections and an addi- tional 3 members died during adolescence, 2 after invasive infection of the brain N Engl J Med 2009;361:1727-35.
with candida species. All 36 family members were enrolled in the study, and 22 had Copyright 2009 Massachusetts Medical Society. blood samples taken for DNA analysis. Homozygosity mapping was used to locate the mutated gene. In the 4 affected family members (patients) and the 18 unaffected members we sequenced CARD9, the gene encoding the caspase recruitment domain- containing protein 9, carried out T-cell phenotyping, and performed functional studies, with the use of either leukocytes from the patients or a reconstituted mu- rine model of the genetic defect.
We found linkage (lod score, 3.6) to a genomic interval on chromosome 9q, includ-
ing CARD9. All four patients had a homozygous point mutation in CARD9, resulting in a premature termination codon (Q295X). Healthy family members had wild-type expression of the CARD9 protein; the four patients lacked wild-type expression, which was associated with low numbers of Th17 cells (helper T cells producing inter- leukin-17). Functional studies based on genetic reconstitution of myeloid cells from Card9−/− mice showed that the Q295X mutation impairs innate signaling from the antifungal pattern-recognition receptor dectin-1.
An autosomal recessive form of susceptibility to chronic mucocutaneous candidi-
asis is associated with homozygous mutations in CARD9.
n engl j med 361;18 october 29, 2009 Downloaded from at BIBLIOTECA DELLA FACOLTA DI MED E CHIRURGIA on October 29, 2009 . Copyright 2009 Massachusetts Medical Society. All rights reserved. Chronic mucocutaneous candidia- has shown that innate antifungal immunity in sis is characterized by impaired clearance mice is controlled by a signaling pathway that of fungal infections and results in coloni- does not involve toll-like receptors. Mice lacking zation and infections of the mucosa or skin, pre- either the C-type lectin receptor dectin-1 (encoded dominantly with Candida albicans.1,2 A variety of by the Clec7a gene) or the intracellular adapter mol- clinical conditions, such as infection with the hu- ecule Card9, which is essential for dectin-1 signal- man immunodeficiency virus or the use of corti- ing, have impaired antifungal immunity.22,23 costeroids, favor the development of chronic mu- We identified a homozygous mutation in CARD9 cocutaneous candidiasis, but the disease may also that results in a loss-of-function mutation due to be a primary immunodeficiency arising from un- a premature stop codon in the coding sequence. known genetic defects.1,3 In chronic mucocutane- Experiments in the murine Card9−/− model showed ous candidiasis, the most common infections are that only wild-type CARD9 — not the mutated hu- due to C. albicans; however, patients may also have man CARD9 gene found in patients — could re- an increased susceptibility to dermatophytes.1,3 Se- store cytokine production in response to the trig- vere complications rarely develop in patients with gering of dectin-1, a pattern-recognition receptor chronic mucocutaneous candidiasis, although re- for fungal cell-wall antigens.
ports on invasive infections with candida species — Cryptococcus neoformans or Histoplasma capsula- tum — have been published.4-6 Research conducted in the eight decades since Study Participants
the first report on primary chronic mucocutane- We enrolled 36 members of a large, consanguin- ous candidiasis appeared7 has shown that it is a eous Iranian family in the study. Blood samples heterogeneous syndrome that may be accompa- were obtained for DNA analysis, and the partici- nied by endocrine and inflammatory disorders, pants were classified as likely to be affected or including hypothyroidism and adrenocortical fail- likely to be unaffected according to the results of ure.2 Most cases of chronic mucocutaneous can- physical examination and microbiologic culture. didiasis are sporadic, but multiplex families with Laboratory personnel were unaware of the clas- dominant8-12 and recessive13,14 inheritance have sification of the samples. The participants pro- been described.
vided written informed consent on forms approved Recurrent and severe candidiasis can have a by local ethics committees. DNA samples from 50 defining role in primary immunodeficiencies. The healthy Iranian donors and 180 healthy white do- autoimmune polyendocrinopathy–candidiasis– nors of other nationalities were used as controls.
ectodermal dystrophy (APECED) syndrome is caused by biallelic mutations in AIRE, the auto- Genotyping and Analysis
immune regulator gene. Heterozygous mutations DNA samples from five family members deemed in the signal transducer and activator of transcrip- likely to be affected and eight deemed likely to be tion 3 gene (STAT3) cause the hyper-IgE syndrome, unaffected were genotyped with use of the Affyme- another multisystem disorder in which candidi- trix 250k NspI single-nucleotide-polymorphism asis is a common clinical feature.17-20 Genetic link- (SNP) mapping array, as described previously.24 age of an autosomal dominant candidiasis–thy- Genotypes of the SNP arrays were assigned with roiditis syndrome to chromosome 2 has been the use of the Bayesian Robust Linear Modeling reported,12 and candidiasis associated with a low and Mahalanobis (BRLMM) distance method, expression of intercellular adhesion molecule 1 which was implemented as described in the Geno- (ICAM-1) has been traced to chromosome 11,21 but typing Console software and introduced as an in both cases the causative genes remain un- improvement over the RLMM method.25 To further evaluate one region on chromosome We undertook genetic studies of a large, con- 9 that was suggestive of linkage, four microsat- sanguineous Iranian family with multiple cases of ellite markers were genotyped on 13 available chronic mucocutaneous candidiasis to determine samples, as described previously.26 Single-mark- whether a mutated gene was associated with this er lod scores were computed with Fast link27-29; form of nonsyndromic candidiasis. Recent work multipoint lod scores were computed with Su- n engl j med 361;18 october 29, 2009 Downloaded from at BIBLIOTECA DELLA FACOLTA DI MED E CHIRURGIA on October 29, 2009 . Copyright 2009 Massachusetts Medical Society. All rights reserved. A Homozygous CARD9 Mutation in a Family with Susceptibility to Fungal Infections perlink.30,31 (For details on the use of the BRLMM affected by chronic mucocutaneous candidiasis method, Fastlink, and Superlink, see the Supple- through a presumably autosomal recessive mode mentary Appendix, available with the full text of of inheritance. Recurrent fungal infections were this article at diagnosed clinically in eight family members, three of whom died in early adolescence — two molecular genetics and t-cell phenotyping
with proven and one with presumed invasive can- DNA from the study participants was isolated, dida infection of the brain. None of the eight in- and coding regions of CARD9 (Ensembl number, fected patients had unusual bacterial or viral in- ENSG00000187796) were amplified and se- fections, suggesting that the host defense against quenced. Total RNA was isolated and transcribed these pathogens was normal.
into complementary DNA (cDNA). SYBR green- The index patient (Patient 2B2) was a 19-year- based real-time polymerase-chain-reaction quan- old man who had had oral candidiasis (thrush) tification of CARD9 was performed with the use since the age of 3 years. Candida infection was of standard curves. Screening for the Q295X mu- confirmed with the use of microbiologic testing, tation with the use of restriction-enzyme diges- and prophylaxis with ketoconazole was ongoing. tion was carried out in heterozygous and homozy- He was otherwise healthy.
gous healthy family members as well as in healthy Patient 2B1, a sibling of Patient 2B2, had had intermittent thrush since early childhood. Seizures T-cell phenotyping, regulatory T-cell staining, developed suddenly, with loss of consciousness, and detection of Th17 cells (helper T cells pro- when he was 18 years old. Hydrocephalus devel- ducing interleukin-17) were performed in accor- oped, and he died of candida meningitis at the dance with protocols published previously.32-36 Ex- age of 19 years.
tracts of peripheral-blood mononuclear cells from Patient 2M, the mother of Patients 2B1 and 2B2, patients with a deficiency of the CARD9 protein was 50 years old at the time of our study and had were stained with a polyclonal goat anti-CARD9 had vaginal candidiasis since the age of 42 years. antibody. (Details of these procedures are avail- In addition to being infected with C. albicans, she able in the Supplementary Appendix.) had a 5-year history of dermatophytosis of her hands and neck. She also had intermittent aph- Retroviral Transduction of Human CARD9
thous lesions, type 2 diabetes mellitus, and neph- CARD9 cDNA was generated from human periph- Patient 1M, the sister of Patient 2M, had had eral-blood mononuclear cells and cloned into a oral and vaginal candidiasis since early childhood. retroviral expression vector (based on murine stem- She also had tinea corporis on her chest and neck. cell virus) expressing green fluorescent protein.37 She was otherwise healthy.
The Q295X mutation was introduced with the use Patient 5F, the affected brother of Patients 1M of site-directed mutagenesis. Retroviruses were and 2M, had had dermatophytosis since child- generated by transfecting the Phoenix ecotropic- hood, with little improvement in response to local packaging cell line and were used to infect bone treatment. Both of his daughters were given a post- marrow cells as described previously.37 Bone mar- mortem diagnosis of invasive candida infection. row cells were differentiated into macrophages The older daughter (Patient 5G1) had a ventricu- and stimulated with either curdlan, a selective dec- lar septal defect during infancy and had a geo- tin-1 agonist, or ultrapure lipopolysaccharide. Con- graphic tongue, which is suggestive of chronic centrations of tumor necrosis factor α (TNF-α) in candidiasis. A unilateral paresthesia developed the supernatants were analyzed with the use of when she was 13 years old, and she died from what an enzyme-linked immunosorbent assay.22,23,38 was vaguely defined as a brain tumor, with se- vere skull destruction, at the age of 15 years. Her sister (Patient 5G2) had recurrent, severe, refractory thrush starting in early childhood. At Patients' Medical History
15 years of age, a severe headache and fevers de- The pedigree (Fig. 1A) for the consanguineous veloped, followed by diplopia. A brain tumor was Iranian family shows that multiple members were suspected, but candida meningoencephalitis was n engl j med 361;18 october 29, 2009 Downloaded from at BIBLIOTECA DELLA FACOLTA DI MED E CHIRURGIA on October 29, 2009 . Copyright 2009 Massachusetts Medical Society. All rights reserved. affected family members (see the Supplementary Appendix for the definition of phenocopy).
Cell Counts and T-Cell Phenotyping
In Patients 1M, 2M, and 5F, complete blood counts
were within the normal range, as were total counts of CD3+ T cells, CD4+ T cells, CD8+ T cells, mem- Family 3 Family 4 Family 5 ory T cells, follicular helper T cells, effector mem- ory T cells, regulatory T cells, B cells, and natural killer cells (for results see Table S1 in the Supple- mentary Appendix). Basal levels of serum im- 1G1 1G2 1B1 2B1 2G2 2G1 2B2 munoglobulin were also normal. In Patient 2B2, the results of a delayed-type hypersensitivity skin test were negative for tuberculin but positive for Wild Type
AIRE was shown to be of wild-type sequence in Patient 2B2. The absence of a specific immuno- logic disorder led us to use a positional cloning approach to identify the patients' underlying ge- netic defect.
Genetic Linkage Analysis
Analysis of the SNP genotypes showed a region of Figure 1. Pedigree of an Iranian Family with Chronic Mucocutaneous
perfect segregation on chromosome 9 (137.5 to 138.8 Mbp in human genome build 36), provided In Panel A, circles d FIGURE: enote female family members; squares m 2nd members; solid circles and squares patients with chronic mucocutaneous that Patient 1B1's episode of candida infection candidiasis, who were homozygous for the Q2 4-C 95X mutation; half-solid cir- was the result of a phenocopy. This finding was cles and squares me ARTIST: gous for the Q295X muta- confirmed by genotyping four microsatellite mark- tion; open circles and squares health Combo y members with wild-type CARD9, and ers, yielding a peak multipoint lod score of 3.6 double horizontal lines conAUTHOR, PLEASE NOTE:
sanguinity in a marrie d couple. A slash denotes (see the Supplementary Appendix).
a deceased famil Figure has been redrawn and type has been reset.
y member. Asterisks indicate family members whose sam- Please check carefully.
ples were sequenced. In Panel B, the sequence at the top is for a healthy There were 121 genes in the maximal linkage family member with wild-type CARD9. The middle sequence, obtained from interval defined by the microsatellite markers Patient 1M, is characteristic of a person with a homozygous CARD9 muta- D9S2157 (135.0 Mbp) and D9S1838 (139.8 Mbp). tion, in which a single-nucleotide exchange (C→T) in exon 6 of CARD9 re- Among these 121 genes, 41 are located in the per- sults in a premature stop codon (Q295X). The bottom sequence, from Pa- fectly segregating 1.3-Mbp subinterval suggested tient 1G1, is characteristic of a healthy heterozygous person.
by the SNP data. After exploring the literature, we identified CARD9 — which is among the 41 identified during surgery. She died 6 months af- ideally located genes (see Table S2 in the Supple- ter the onset of symptoms.
mentary Appendix) — as a functional candidate None of the patients with invasive fungal in- because Card9−/− mice are susceptible to fungal in- fections had a condition or took any medication fections (for details, see the Supplementary Ap- that predisposed them to infection. The three de- pendix).22,39 ceased patients could not be enrolled in the study because of the lack of available tissue samples. Homozygous Mutations in CARD9
Patient 1B1, a child of Patient 1M and a cousin We sequenced CARD9 in the four affected patients of the index patient (Patient 2B2), had had one mild and 18 other relatives and identified in all affected episode of candida infection in adulthood. In our persons a single homozygous point mutation from genetic analysis, we considered Patient 1B1 to be C to T in exon 6 at codon 295, resulting in a pre- affected. We found that the episode of infection in mature termination codon (Q295X). Patient 1B1 Patient 1B1 was the result of a phenocopy, which and his healthy relatives had either a heterozygous is consistent with the fact that it was clinically Q295X mutation or wild-type alleles only (Fig. 1B).
much milder than the infections in all the other To assess the frequency of this previously un- n engl j med 361;18 october 29, 2009 Downloaded from at BIBLIOTECA DELLA FACOLTA DI MED E CHIRURGIA on October 29, 2009 . Copyright 2009 Massachusetts Medical Society. All rights reserved. A Homozygous CARD9 Mutation in a Family with Susceptibility to Fungal Infections known genetic abnormality in CARD9 and to ex- clude the possibility of a genetic variation, we ex- amined the affected site in 50 unrelated healthy Iranians and 180 unrelated healthy white subjects +/+ mouse) 9−/− mouse)
by means of a sequencing assay or a restriction- (Card Unrelated healthy
enzyme assay. None of the 230 controls had the control family membe
family membe
family membe
Q295X mutation in CARD9.
CARD9 mRNA Levels and Protein Expression
Among CARD9 wild-type cells, average levels of
CARD9 mRNA were highest in monocytes, followed by granulocytes, B cells and T cells, and the co- lon-cell line HT-29. The peripheral-blood mono- Figure 2. Western Blot Detection of CARD9 in Peripheral-Blood Mono-
nuclear cells from our patients still had substan- nuclear Cells.
tial levels of mutated CARD9 mRNA, thereby Macrophages from FIGURE: Card9 wild-type mice (Card9+/+) and Car 2nd d9 knockout escaping nonsense-mediated RNA decay (see the mice (Card9−/−) were used as positive and negative controls (lanes 1 and 2), respectively. The blot in lane 4 is from Rela 4-C tive 4F, that in lane 5 from To examine the effect of the CARD9 Q295X mu- Relative 2G2, and th ARTIST: phate dehydrogenase (GAPDH) was Combo used as a loading control.
tation at the protein level, we assessed the ex- AUTHOR, PLEASE NOTE:
pression of CARD9 in peripheral-blood mononu- Figure has been redrawn and type has been reset.
clear cells from the patients, using Western man protein can complement the murine mu Please check carefully. tation.
blotting. As compared with unrelated healthy con- Expression of the human mutant CARD9 Q295X trols and homozygous or heterozygous healthy did not increase TNF-α production, on stimulation family members, patients with the homozygous with dectin-1, above the level in uninfected cells or Q295X mutation completely lacked expression of those transduced with green fluorescent protein the wild-type CARD9 protein (Fig. 2), indicating only, showing that CARD9 Q295X is a loss-of-func- the detrimental consequences of the mutation. tion mutation (Fig. 3B).
However, expression of the truncated CARD9 (amino acid positions 1 through 294) protein can- Homozygous Q295X Mutations and Th17 Cells
not be ruled out, since the polyclonal antibody Since Th17 cells40 are important for antifungal im- used is directed against the C-terminal part of munity and Card9−/− mice have an impairment in Th17 polarization,22,38 we compared Th17 cells in our four patients with those in family members effect of CARD9 Q295X on Signal
with wild-type CARD9 and nine healthy controls. The mean proportion of Th17 cells in the four af- Primary bone marrow cells from Card9-deficient fected patients was significantly lower than that mice were retrovirally transduced with human in healthy controls (mean, 0.2% of CD4+CD45RO+ wild-type and mutated (Q295X) CARD9, differenti- interleukin-17 +interferon-γ − cells; P = 0.004) (Fig. ated into macrophages in vitro, and analyzed with 4). Healthy controls and family members with the use of flow cytometry (see the Supplementary wild-type CARD9 had an average of 1.2% Th17 Appendix). We then stimulated the transduced or cells ex vivo.
nontransduced cells with the β-glucan prepara- tion curdlan as a specific and selective agonist for dectin-1 or with the TLR4 ligand lipopolysaccha- ride and measured TNF-α production to test in- Pattern-recognition receptors of the innate im- nate immune cell activation.38 As is consistent with mune system bind components of microbes and previous data, Card9−/− cells showed severe defects initiate intracellular signal cascades that result in in dectin-1–triggered TNF-α production, although the activation of transcription factors, up-regula- they responded normally to stimulation with li- tion of defense-associated target genes, and release popolysaccharide (Fig. 3A).22 Expression of human of cytokines. Dectin-1 is a transmembrane pattern- full-length CARD9 corrected the dectin-1 signal- recognition receptor that senses the β-glucan ing defect in Card9−/− cells, indicating that the hu- component of fungal cell walls.23,41-43 On ligand n engl j med 361;18 october 29, 2009 Downloaded from at BIBLIOTECA DELLA FACOLTA DI MED E CHIRURGIA on October 29, 2009 . Copyright 2009 Massachusetts Medical Society. All rights reserved. Figure 3. Analysis of the Functional Defect and Genetic
Reconstitution of the Card9
Q295X Mutation.
Bone-marrow–derived macrophages from wild-type mice and Card9−/− mice were stimulated for 16 hours with both the dectin-1 agonist curdlan (300 μg per mil iliter) and the tol -like-receptor agonist lipopolysaccharide (LPS, 100 ng per mil iliter) (Panel A). The concentration of secreted tu-mor necrosis factor (TNF-α) was determined in the cel supernatant with the use of an enzyme-linked immuno- sorbent assay. To examine the effect of mutated CARD9 Q295X on signal transduction (Panel B), we cloned hu-man wild-type CARD9 complementary DNA (cDNA) and mutated CARD9 Q295X cDNA into a retroviral expression vector. Using these constructs, we retroviral y transduced primary bone marrow cel s from Card9−/− mice with either wild-type CARD9 or the mutated CARD9 Q295X. To es- tablish a control, we transduced bone marrow cel s from Card9+/+ wild-type mice and Card9−/− mice with a control vector only. The transduced bone marrow cel s were then differentiated into macrophages in vitro. After stimulation of the macrophages with curdlan for 16 hours, the con-centration of secreted TNF-α was determined. The mac- rophages of Card9−/− mice transduced with human wild-type CARD9 secreted as much TNF-α upon stimulation with curdlan as did the control macrophages of wild-type Card9+/+ mice with the control vector. In contrast with these cel s, the macrophages of Card9−/− mice transduced wild-type
cells with
with wild-
with mutated human CARD9 Q295X or with a control control vector cells CARD9
(Q295X) vector
vector only did not respond with increased secretion of cells with mutated
TNF-α upon stimulation with curdlan, a finding showing cells with control vector
that CARD9 Q295X is a loss-of-function mutation that cannot correct the dectin-1/Card9 signaling pathway in the cel s of Card9−/− mice. T bars indicate standard devia- AUTHOR: sends signals through an im tions in three independent experiments.
REG F eptor tyrosine-based activation mot (ITAM), which becomes phospho 4-Crylated by Src eral antifungal pattern-recognition receptors and family k ARTIST: ts Enon inases (proto-oncog stimulating proinflammatory responses. Since es), leading to the recruitmen Combot and activation of murine Card9 deficiency results in susceptibili- the spleen tyrosine kinase (Syk).44,45 AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.
ty to fungal infections,22,39 this signaling path- Dectin-1–Syk engages CARD9, Please check carefully. which together way seems to be conserved between mice and
with B-cell leukemia–lymphoma 10 (BCL10) and humans.
mucosa-associated lymphoid tissue 1 (MALT1) Our study shows that a homozygous point mu- forms an intracellular signaling complex that in tation in CARD9, resulting in a premature termi- cells recognizing fungi leads to the activation of nation codon and a loss of function in the adapter the transcription factor nuclear factor κB and mi- protein CARD9, is associated with a susceptibil- togen-activated protein kinases.22,46-48 This signal- ity to fungal infections, as evidenced by a chronic ing pathway is operative in myeloid cells and pro- mucocutaneous candidiasis phenotype. In the motes the production of key cytokines, including family in our study, two members died from a interleukin-1β, interleukin-6, and interleukin-23, fungal infection and a third presumably died from which are required to control antifungal immune a similar cause. Further studies may clarify wheth- responses.24,38,49-52 Apart from dectin-1, the C-type er human CARD9 deficiency accounts only for re- lectins dectin-2 and macrophage-inducible C-type current mucosal infections or also accounts for lectin (MINCLE) may also recognize fungi, en- an increased susceptibility to severe invasive fun- gage the ITAM adapter FcRγ for Syk activation, gal infections. In this consanguineous family, we and transmit signals through the CARD9 path- cannot exclude the possibility that a second ge- way.23,53-55 Thus, CARD9 plays a central role in netic defect may have contributed to a more severe antifungal defense by receiving signals from sev- phenotype in the deceased family members.
n engl j med 361;18 october 29, 2009 Downloaded from at BIBLIOTECA DELLA FACOLTA DI MED E CHIRURGIA on October 29, 2009 . Copyright 2009 Massachusetts Medical Society. All rights reserved. A Homozygous CARD9 Mutation in a Family with Susceptibility to Fungal Infections CARD9−/− patients had significantly reduced num- bers of Th17 cells, further supporting the notion that CARD9-mediated signaling contributes to Th17-cell differentiation. Th17 cells and their pro- duction of interleukin-17 have been shown to play a pivotal role in mucosal host defense against candidiasis in mice.56,57 Moreover, Eyerich et al. reported decreased numbers of Th17 cells in two sporadic cases of chronic mucocutaneous candidi- asis,58 but the role of these cells in human anti- Patients with CMC
fungal immunity remains elusive. If the lack of Th17 cells and their cytokines were critical for the pathogenesis of mucosal candidiasis, one could Figure 4. Proportion of Interleukin-17–Producing
speculate that in patients with a low total CD4 5RO+ Cel s Glocker
That Were Negative foRETAKE
r Interfero 1st
count, such as in the low-CD4 syndrome, an- n in Four Patients with a Homozygous Muta-
other rare primary immunodeficiency, or in pa- tion in CARD9 as Compared with Unrelated Healthy
tients with the acquired immunodeficiency syn- drome, the lack of CD4 differentiation into Th17 Cells were surface-stained f H/T cells is critical for maintaining the mucosal host then subjected to intracellular staining for interleu- AUTHOR, PLEASE NOTE:
kin-17 and interferon-γ. CMC denotes chronic mucocu- defense against candida. Patients with the hy- Figure has been redrawn and type has been reset.
taneous candidiasis. per-IgE syndrome, who lack Th17 cells because Please check carefully.
of heterozygous mutations in STAT3, also have recurrent candidiasis.18,20 Whether Th17 cells Unfortunately, we were unable to study viable are also implicated in the pathogenesis of candidi- cells from the family members in vitro because asis in APECED is currently being studied. The of logistical constraints. However, to understand phenotype of susceptibility to fungal infections in the function of the human mutated CARD9 gene, human CARD9 deficiency serves as another ex- we used an in vivo model with cells from Card9−/− ample of a rare primary immunodeficiency that mice and showed that the truncated human gives insight into the signaling pathways involved CARD9 protein fails to correct the dectin-1 sig- in immune regulation.
naling defect. In contrast, the human wild-type Supported in part by a European Commission Marie Curie CARD9 protein restores the dectin-1–Card9 path- Excellence Grant (MEXT-CT-2006-042316); the young investiga- way in murine Card9−/− macrophages.
tor award of 2008 from the European Society for Immunodefi- ciencies; the Intramural Research Program of the National Insti- In Card9−/− mice, stimulation of dendritic cells tutes of Health (NIH), National Library of Medicine; a Max Eder with the cell-wall component zymosan or whole Program Grant from Deutsche Krebshilfe (to Dr. Ruland); and C. albicans cells results in a considerable reduction Sonderforschungsbereich grants from the Deutsche Forschungs- gemeinschaft (to Dr. Ruland). in the release of cytokines, including interleukin-2, No potential conflict of interest relevant to this article was interleukin-6, interleukin-10, and TNF-α, and de- reported.
creased numbers of Th17 cells, which are impli- We thank Judy Levin and Charlotte Holden of the NIH for administrative support and encouragement and Dr. Hans Stauss cated in adaptive antifungal immunity.22,38 All for his critical reading of an earlier version of this article.
The authors' affiliations are as follows: the Department of Immunology and Molecular Pathology, Royal Free Hospital and University College London, London (E.-O.G., C.W., F.T., S.J., A.M., B.G.); the Departments of Rheumatology and Clinical Immunology (A.H., U.S., K.W.) and Hematology and Oncology (D.P., H.V.), University Hospital Freiburg, Freiburg, Germany; Semnan University of Medi- cal Science, Semnan, Iran (M.N.); the National Center for Biotechnology Information, National Institutes of Health, Department of Health and Human Services, Bethesda, MD (A.A.S.); the Growth and Development Research Center, Center of Excellence for Pediatrics, Children's Medical Center (N.R.), and the Immunogenetic Laboratory, Department of Immunology (A.A.A.), School of Medicine, Teh- ran University of Medical Sciences, Tehran, Iran; Clinica Pediatrica, Università di Brescia and Istituto Medicina Molecolare Angelo No- civelli, Spedali Civili, Brescia, Italy (A.P.); Medizinische Klinik 3, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (N.H., O.G., J.R.); and the Laboratory of Signaling in the Immune System, Helmholtz Zentrum München — German Research Center for Environmental Health, Neuherberg, Germany (J.R.).
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Microsoft word - community%20social%20service%20agencies-updates2%20nashville%20(autosaved)[1].doc

Community Social Service Agencies – Middle Tennessee State Contacts IN-SCHOOL/AFTER-SCHOOL Bedford County Schools – Special Education Dept. (Shelbyville) • Provides services to students with a wide variety of disabilities (Learning Disabilities, ADHD, Emotionally Disturbed, Speech and Language, etc.). The range of services can vary from consultation to self-contained in a special education classroom.


A PSYCHOBIOLOGICAL MODEL OF TEMPERAMENT AND CHARACTER: TCI My heart leaps up when I A rainbow in the sky: CLONINGER'IN PSIKOBIYOLOJIK MIZAÇ (HUY) VE KARATER So was it when my life be- So is it now I am a man: So be it when I shall grow Cloninger kiflili¤in iki temel bilefleni olan mizaç ve karakterdeki normal ve anormal varyas- yonlar› aç›klayan boyutsal bir psikobiyolojik kiflilik modeli gelifltirmifltir. Cloninger, mizac›n