00:00:15;00 Hello.
00:00:16;00 My name is Ruslan Medzhitov.
00:00:17;00 I'm a professor at Yale University School of Medicine, and an Investigator from
00:00:21;17 Howard Hughes Medical Institute.
00:00:23;10 In this lecture, I will discuss inflammation, and I'll give a brief overview of the
00:00:28;21 field of inflammation and its role in both host defense and homeostasis, as well as in pathologies.
00:00:37;19 So, inflammation is an enormously huge field with a lot of details known about some aspects
00:00:44;00 of inflammation.
00:00:45;00 And to be able to summarize it in this short overview, I will use a couple of perspectives
00:00:51;28 that summarize some key features of inflammation, and specifically I will start by putting inflammation
00:01:00;09 in the context of the better-understood and better-defined phenomenon of homeostasis,
00:01:06;15 and I'll show the similarities, parallels, and how the two types of processes
00:01:13;13 interact with each other, causing both beneficial and detrimental outcomes.
00:01:18;07 So, just to remind you, homeostasis maintains stability of biological systems
00:01:25;13 in the face of perturbations.
00:01:27;00 And perturbations could be either external or internal to the system.
00:01:31;15 And inflammation is induced when these perturbations exceed homeostatic capacity of the system.
00:01:37;09 So schematically, this could be summarized as follows.
00:01:40;15 If we imagine the position of this ball as the state of the system, here, in the center
00:01:46;26 -- you can see, in the normal state -- the homeostasis is maintained by keeping
00:01:54;13 the state of the system in the desired position.
00:01:57;22 And when it deviates from that position, homeostatic mechanisms will bring it back.
00:02:02;20 But if perturbation is large enough and the system goes outside of its normal control zone,
00:02:10;06 outside of its normal homeostatic range, then homeostatic capacity is no longer sufficient
00:02:17;08 to keep the system in a desired state, and that's when inflammation is induced,
00:02:22;14 to force the system back into the homeostatic state.
00:02:25;17 That's one way to think about connections between homeostasis and inflammation.
00:02:30;21 So, inflammation is something that forces the system to go back into the homeostatic state,
00:02:36;00 when perturbations are large enough and when they overwhelm homeostatic capacity.
00:02:43;04 In modern terms, we can describe homeostasis using the idea of a control circuit.
00:02:49;22 And this is a very simple but very fundamental concept.
00:02:54;04 So here, what is summarized on this slide is key components of a homeostatic circuit.
00:03:00;26 And whenever we speak about homeostasis, that means that we talk about maintenance of
00:03:08;02 some variable of the system.
00:03:09;09 It could be blood sugar; it could be temperature; it could be sodium; it could be any of the
00:03:15;03 variables of the system that the system cares about and wants to maintain.
00:03:19;11 So, that's what's denoted here as X.
00:03:21;24 And when we refer to homeostasis of this variable, that means we want to keep it close to
00:03:27;26 some desired value.
00:03:29;14 And that's what's called the setpoint value, X' here.
00:03:33;02 So, that is... it is the value of that variable, or the difference of that variable value from
00:03:39;20 the setpoint value, that is monitored by the sensor.
00:03:43;00 The sensor is the component of a homeostatic circuit that monitors the value of the variable
00:03:47;28 the system cares about.
00:03:51;01 And the second essential part of the system is the effector part, and that's the part
00:03:56;24 that can change that value.
00:03:58;26 So, the sensor monitors the value; the effector can change the value.
00:04:02;06 And they need to communicate with each other through a signal that's denoted as C, here.
00:04:07;16 So for example, in the case of systemic homeostasis of blood glucose, X would be the actual concentration
00:04:15;23 of glucose in the blood, X' would be the setpoint value, which is in humans about 5 millimolar,
00:04:22;23 and the sensors would be pancreatic alpha and beta cells that monitor how much glucose
00:04:27;04 we have in the blood.
00:04:28;08 Are you eat, glucose level goes up.
00:04:30;26 Beta cells in the pancreas will detect that and will start producing insulin, which is
00:04:35;06 the example of the signal, shown here, which will go on to act on its effectors,
00:04:41;06 which include skeletal muscle, fat, and liver.
00:04:44;04 And the effect of insulin on these target tissues will be to lower blood glucose level,
00:04:49;04 for example by inducing uptake into those tissues or conversion into glycogen or lipids.
00:04:54;24 If the glucose level is lower than the setpoint value, then alpha cells of the pancreas
00:05:01;08 will detect that, a low lev... a low level, and start producing a different hormone,
00:05:06;05 which is glucagon, which will act exactly, again, on effector cells... effector tissues and organs,
00:05:11;25 for example liver, and cause them to start producing glucose to raise it...
00:05:17;07 to raise the level to the desired value.
00:05:20;06 So, that's how a homeostatic circuit works at... at an organismal level, a tissue level,
00:05:27;10 and a cellular level.
00:05:30;12 Now, the origin of the concept of inflammation goes back to... it can be credited to many people,
00:05:38;14 but the two that I want to highlight here are Rudolf Virchow Elle Metchnikoff,
00:05:44;01 who were contemporaries and colleagues.
00:05:49;01 And so, Virchow, of course, is credited with the development of the modern science of pathology,
00:05:53;25 of cellular pathology.
00:05:56;15 And he was an extremely influential scientist in Europe at the time.
00:06:01;01 And Elle Metchnikoff, of course, is known for his discovery of phagocytes and its...
00:06:07;10 their role in innate immunity.
00:06:09;12 But in the context of inflammation, these two individuals provided very important
00:06:15;15 conceptual contributions.
00:06:16;15 But there was one important difference between them, in that Virchow primarily viewed inflammation
00:06:21;15 as a pathological process, whereas Metchnikoff recognized early on that, in addition to these
00:06:27;17 pathological outcomes of inflammation, that the... the primary reason for an
00:06:34;03 inflammatory response is to provide protection from infections.
00:06:38;24 And he visualized and conceptualized the inflammatory response as being part of a spectrum,
00:06:47;28 where at the base of the spectrum would be what he called "harmony/disharmony balance",
00:06:53;28 and this is what we currently would call homeostasis, but the term homeostasis wasn't coined yet,
00:06:59;22 until 1929.
00:07:00;27 Then, the next level would be physiological inflammation, when inflammation plays
00:07:07;11 beneficial roles in host defense.
00:07:09;20 And then pathological inflammation, and finally immunity.
00:07:13;08 And that... that concept of physiological inflammation and the spectrum of
00:07:18;28 inflammatory response from homeostasis to immunity is actually a very profound insight which was
00:07:25;10 largely forgotten until very recently.
00:07:27;11 And only now we are starting to rediscover and realize these fundamental connections
00:07:32;27 between physiological processes and inflammation.
00:07:38;18 So, taking that, Metchnikoff's idea, and putting it in... looking from different dimensions,
00:07:46;13 we can summarize it as follows, as the spectrum of degrees of deviation from homeostatic states.
00:07:53;06 So here, on the... on the left side, you see the range of conditions of a system that
00:08:00;02 would be within a homeostatic state.
00:08:02;23 If it deviates far enough from that, that's what... what we would call a stress response,
00:08:07;11 or we could also call it a physiological inflammatory response.
00:08:11;07 And if it deviates much further than that, that's what we would call inflammation proper.
00:08:16;23 And so this... any deviation from a normal state, therefore, can be... can lead to
00:08:22;07 the induction of the inflammatory response.
00:08:24;18 So, the causes of inflammation from that perspective can be summarized as follows.
00:08:32;09 In the center here, in the middle, you can see that loss of homeostasis per se is sufficient
00:08:36;27 to lead to inflammation as... as I just mentioned.
00:08:41;02 But in addition, there could be exogenous perturbations that can lead to loss of homeostasis.
00:08:48;11 And the two major types of such perturbations will be pathogens (during infection)
00:08:53;25 as well as toxins and allergens and virulence factors produced by pathogens.
00:08:59;02 So, both pathogens and... and toxins can cause loss of inflammation... loss of homeostasis
00:09:06;14 that... and that can lead to inflammation.
00:09:09;10 But in addition, the immune system developed two pre-emptive mechanisms to trigger a protective
00:09:15;04 inflammatory response, even before pathogens or allergens can cause damage to the system.
00:09:22;07 And there are two fundamental ways that the immune system detects these inducers of inflammation.
00:09:27;10 At the top here, what I call structural feature recognition is the property of the
00:09:32;17 innate immune system to detect invariant structures associated with microbial cells.
00:09:40;03 This is sometimes called the pattern recognition system, where receptors of the immune system
00:09:46;10 detect conserved structures that have found in most microbes, for example we lipopolysaccharides
00:09:53;10 of the cell wall or peptidoglycans, lipoteichoic acids, and so on.
00:09:58;07 And detection of these structures is sufficient to trigger inflammation.
00:10:02;23 On the other hand, allergens and toxins and virulence factors, they're extremely diverse.
00:10:07;00 There... there are many different types and there is no way to detect them all based on
00:10:11;08 structural features, because they don't share any structural features.
00:10:15;09 And the strategy of recognition here is what I would call a functional feature recognition,
00:10:20;16 because what is detected is not specific structures but rather specific biochemical activities,
00:10:27;02 such as protease activities, lipase activities, lipid binding, membrane perturbations,
00:10:33;25 pore formation, and so on.
00:10:35;16 Those functional features are detected by that system, and that also can lead to inflammation.
00:10:40;13 And that type of strategy is particularly important in allergic inflammation.
00:10:46;07 So, based on these ideas, we now can summarize how the immune system operates based on
00:10:53;20 the simple logic of the control circuits.
00:10:57;05 So, we know that the immune system... one of the major functions of the immune system
00:11:01;18 is to detect pathogens and to provide a protective response against them by, for example,
00:11:09;01 destroying them or expelling them from the organism.
00:11:14;00 To do so, the immune system has to have two essential components.
00:11:17;04 It has to have a pathogen-sensing component, or pathogen-sensing cells, and it has to have
00:11:25;10 antimicrobial effector cells, and sensor and effector cells have to communicate with
00:11:31;06 each other through a signal, and once the effector receives the signal from the sensor, it elicits
00:11:36;22 a response that leads to defense from the pathogen.
00:11:40;02 So, that's a very simplified view of the immune system.
00:11:45;13 And the signals that are involved in communication between sensors and effectors are what contributes
00:11:51;02 to this enormous complexity of inflammation and understanding of the immunity.
00:11:57;10 There are many different types of signals in the context of inflammation.
00:12:01;28 The signals are usually called inflammatory mediators.
00:12:06;13 And two major types of inflammatory mediators are signals called chemokines and cytokines.
00:12:14;14 Chemokines are short polypeptides that are produced upon infection by sensor cells
00:12:24;05 that detect pathogens or tissue damage.
00:12:27;08 And what chemokines do is they recruit effector cells to the site of infection.
00:12:33;15 For example, macrophages that function as sensor cells, when they detect bacterial pathogens,
00:12:40;04 will produce chemokines that will recruit neutrophils to the site of infection,
00:12:43;24 and then neutrophils will take care of the pathogens.
00:12:47;11 The second type of inflammatory mediators are cytokines.
00:12:50;26 And this is a... again, a very diverse group of signals that belong to different structural families,
00:12:56;14 but basically what cytokines do... they... they, again, are produced by sensor cells
00:13:01;14 when they detect infection, and they activate effector cells to elicit various
00:13:09;16 antimicrobial functions.
00:13:11;25 So, with this in mind, we now can summarize much of the inflammation and diversity of inflammation
00:13:22;02 into these simple and universal components of the inflammatory pathway.
00:13:28;00 Any type of inflammation includes these four universal components.
00:13:31;12 There is always some type of an inducer of inflammation, for example, pathogen, toxin,
00:13:36;22 tissue damage, or loss of homeostasis.
00:13:39;13 There are sensors that detect the inducers.
00:13:42;19 These include various types of cells of the innate immune system, such as macrophages
00:13:48;04 and mast cells, but also various types of sensory neurons.
00:13:54;27 And the sensor cells produce inflammatory mediators, which include cytokines, chemokines,
00:14:01;15 as well as bioactive amines like histamine, peptides, like bradykinin, as well as
00:14:07;28 lipid mediators called eicosanoids, which include, for example, prostaglandins.
00:14:13;07 And these mediators then act on various target tissues.
00:14:16;25 And almost any tissue in the body can be a target for different types of inflammatory mediators.
00:14:23;01 So here, I'm showing liver, vasculature, epithelial cells, and neutrophils.
00:14:30;21 When mediators act on these effector cells, they cause appropriate changes in their
00:14:36;16 state and their function, or in their positioning.
00:14:39;02 Again, chemokines can recruit neutrophils to the site of infection.
00:14:44;11 Cytokines acting on hepatocytes sites or vascular endothelium will cause their activation,
00:14:52;21 changing protein secretion or permeability of the epithelium.
00:14:56;02 And in the case of mucosal epithelium, they can change the production of antimicrobial
00:15:02;21 peptides or mucus.
00:15:04;21 So, this is this inflammatory pathway.
00:15:08;00 And as you... as you may notice, there is... this is very much related to... it's the
00:15:17;21 same kind of a control circuit we just discussed for homeostasis, where we have a sensor,
00:15:23;26 a signal that connects sensor to the effector, and the effector.
00:15:28;06 The only difference is that in this case what is monitored is not a homeostatic variable,
00:15:33;15 but rather some inducer of inflammation, such as a pathogen or toxin.
00:15:38;22 So, there are these clear parallels between homeostatic and inflammatory control circuits.
00:15:45;04 The reason for that has to do with the fundamental importance of these type of control circuits.
00:15:50;02 They're everywhere, from engineering systems to biological systems.
00:15:55;04 And again, the differences between them are related to the types of inducers that are...
00:16:03;18 that are detected by sensors, or homeostatic variables detected by homeostatic sensors.
00:16:10;07 But we should also keep in mind that sometimes the differences between homeostatic and inflammatory
00:16:16;10 control circuits can be arbitrary, because inflammatory mediators used by homeostatic...
00:16:21;16 by inflammatory circuits can also have some homeostatic functions, and homeostatic signals
00:16:29;11 used by homeostatic circuits can participate in regulation of the inflammatory response.
00:16:37;10 There are actually two different designs... versions of the control circuits.
00:16:45;24 Here on the top is the control circuit I just mentioned.
00:16:48;19 That's the simplest one, where you just have sensor and an effector, and the signal
00:16:52;24 that connects them.
00:16:54;21 There is another type of a circuit which has an additional component in between.
00:17:00;12 And that's what's called a controller or integrating unit.
00:17:04;04 So, here we have a sensor that monitors an inflammatory inducer or homeostatic variable.
00:17:11;21 It produces a signal that then acts on the controller, and then the controller does
00:17:15;23 some type of a computation, and then sends a second signal to the effector.
00:17:19;28 This type of a design is particularly prevalent in both immune and nervous systems.
00:17:28;02 In the case of the immune system, the control... the role of a controller is typically played
00:17:31;17 by a lymphocyte.
00:17:33;03 And in the case of the nervous system, it's played by various types of interneurons.
00:17:39;04 So, sensor cells, again, after detecting the inducer, produce one signal, and then
00:17:46;24 the controller produces a second signal.
00:17:48;20 And these two types of signals are distinct in the immune system, as we will discuss.
00:17:55;10 So from that perspective, we can summarize the entire operation of the immune system
00:18:02;00 as... as connections between pathogen sensors and effectors.
00:18:09;11 And there are three types of disconnections.
00:18:11;17 The simplest one is shown at the top, where the sensor and the effector is the same entity,
00:18:17;10 the same cell.
00:18:19;16 The sensor would be, for example, a receptor, and the effector would be, for example,
00:18:24;05 an antimicrobial enzyme.
00:18:27;11 The second type is when the sensor produces a signal that acts on the effector,
00:18:32;07 as we just discussed.
00:18:33;16 And the third type when there is a lymphocyte in between.
00:18:36;22 And the first two types belong entirely to the domain of the innate immune system,
00:18:41;22 and the second... the... the third one, it can be either innate or adaptive immune system,
00:18:48;07 depending on the type of lymphocyte involved.
00:18:50;26 So, we will go through the different versions of these circuits to illustrate how they operate
00:18:58;09 in the context of infection.
00:18:59;25 So, the simplest one is when a cell like a macrophage encounters a pathogen, like a bacterium, phagocytoses then kills it.
00:19:08;13 So in this case, the sensor would be receptors that detect the microbe, and the effectors
00:19:13;17 would be phagocytic machinery and lysosomal enzymes that will kill the microbe.
00:19:17;24 So, that's the simplest one.
00:19:19;16 And more... more commonly, when macrophages detect pathogens, they will produce a signal
00:19:25;27 that will connect them to the effector, such as a neutrophil, and it will either recruit...
00:19:31;22 recruit or activate neutrophils.
00:19:33;05 And neutrophils are specialized in killing bacteria fungi, and they will proceed to do so.
00:19:39;16 And then the system operates in this manner to provide protection from infection.
00:19:47;14 And finally, the third system... the third design would be when cells... sensor cells
00:19:52;25 like macrophages again detect pathogens, then they produce cytokines that act on, now...
00:19:58;12 on lymphocytes first.
00:20:00;23 And then lymphocytes -- that could involve T cells or different types of innate versions
00:20:08;02 of T cells that I'll describe in a second -- which then produce the second-order cytokines.
00:20:13;21 In this case, a first-order cytokine would be IL-12 produced by macrophages, which acts
00:20:18;11 on lymphocytes, and causes lymphocytes to produce second-order cytokine
00:20:22;08 such as interferon-gamma,
00:20:24;08 which will then act on effector cells -- that will be macrophages -- and cause them to
00:20:28;23 become activated to kill bacteria.
00:20:30;23 So, this design is actually... it captures most of the operation of the immune system.
00:20:37;28 And most of the complexity comes from the generation of lymphocytes and their
00:20:42;24 functional heterogeneities.
00:20:44;12 So, we will now... we'll go quickly through different components of these systems,
00:20:49;15 starting with sensors.
00:20:51;04 There are several cell types that can function as sensors in the inflammatory and immune
00:20:56;15 pathways.
00:20:57;15 These include macrophages, mast cells, epithelial cells, dendritic cells, and plasmacytoid dendritic cells.
00:21:05;10 So, these are different sensor cells that have different types of specializations.
00:21:11;06 Macrophages, mast cells, and epithelial cells are kind of general-purpose sensors.
00:21:16;13 They detect a large variety of pathogens and other types of inflammatory inducers.
00:21:24;23 Dendritic cells are specialized on activating T cells.
00:21:28;07 And plasmacytoid dendritic cells are specialized on antiviral responses.
00:21:33;21 The lymphocyte part is... that's where a lot of complexity comes in.
00:21:40;11 They can be... there are two versions of circuits, depending on what kind of lymphocyte is used.
00:21:46;20 And broadly speaking, there are innate lymphocytes that participate in the innate immune system,
00:21:52;15 and lymphocytes involved in the adaptive immune system, which are T and B cells.
00:21:57;22 The innate lymphocytes, again, come in two versions.
00:22:00;04 There are so-called innate lymphoid cells, which are... have been relatively
00:22:04;16 recently discovered.
00:22:05;16 They don't have T cell receptor.
00:22:07;26 They reside in tissues and they respond to cytokines produced by sensor cells,
00:22:13;15 and in turn produce cytokines that affect effectors.
00:22:16;07 Then there are inmate-like lymphocytes that have T cell receptor, but it's not a random receptor;
00:22:23;05 it's invariant, so it's designed to detect very specific subsets of antigens.
00:22:29;10 And finally, the adaptive immune system of course has antigen receptors, T cell receptor
00:22:35;00 and immunoglobulin receptor for B cells, and these are the most complicated cells of the
00:22:41;21 immune system because of the way that they develop and because of the way that
00:22:46;02 their receptors are assembled, and all the additional steps that are involved to make the cells functional,
00:22:51;18 because their receptors are generated at random.
00:22:55;15 Again, when lymphocytes detect cytokines, they respond by producing cytokines.
00:23:02;03 And what's summarized here are some of the types of cytokines that... on the left side,
00:23:07;21 that act on lymphocytes and the different types of lymphocytes
00:23:12;24 and the second-order cytokines produced by lymphocytes.
00:23:16;02 And then these things... cytokines produced by lymphocytes and, again, act on the effector cells,
00:23:21;07 which are... examples are shown here: macrophages, neutrophils, basophils, eosinophils,
00:23:27;06 mast cells, and epithelial cells.
00:23:30;06 Depending on the type of cytokine produced, there would be different type of change
00:23:33;18 in these cells, effector cell types.
00:23:37;06 And in addition to these specialized effectors of the innate immune system, practically
00:23:43;06 any cell in the body can be an effector, because most cells express receptors for at least
00:23:48;15 some of the cytokines produced by lymphocytes.
00:23:52;10 So, now we will quickly go over... with these concepts in mind, we will go over some of
00:24:01;00 the key features of the inflammatory response.
00:24:04;08 And we have to start with one of the oldest notions in the field of inflammation,
00:24:11;05 which is the cardinal signs of inflammation.
00:24:13;10 These were first defined by a Roman physician, Cornelius Celsus, in the first century AD.
00:24:22;12 He defined them as redness and swelling with heat and pain.
00:24:27;25 That was his description of how to diagnose inflammation.
00:24:33;10 And much later, Rudolph Virchow added a fifth cardinal sign of inflammation, which is disturbance
00:24:39;14 of function or loss of function of tissues.
00:24:42;22 The four cardinal signs described by Celsus are a consequence of the changes that
00:24:49;09 occur during acute inflammation.
00:24:52;07 And these are local changes due to alterations in the local vasculature, as we will discuss next.
00:25:01;15 So, this is what typically happens during the most common types of inflammatory responses,
00:25:06;27 when you have a mild infection or papercut or some other splinter or some other injury
00:25:15;03 to the epithelial surfaces.
00:25:18;04 So, microbes or damage to the tissue are detected by sensor cells such as macrophages, dendritic cell,
00:25:28;27 and mast cells, as I just mentioned.
00:25:31;24 And once they detect microbes or tissue damage, these cells start producing inflammatory mediators
00:25:37;00 such as cytokines and chemokines.
00:25:40;00 And one of the effects of these inflammatory mediators, locally, within the tissue,
00:25:44;07 is to act on the local microvasculature.
00:25:47;26 And specifically, they... by acting on postcapillary venules, they cause several characteristic
00:25:54;26 changes of the endothelium of the venules.
00:25:59;04 They cause vasodilation, so there is increased blood flow.
00:26:03;13 And increased blood flow causes heat and redness.
00:26:07;20 And it causes increased vascular permeability, so that plasma starts going from the
00:26:15;02 inside of blood vessels into extravascular spaces within tissues.
00:26:19;12 And that causes swelling, or edema.
00:26:23;12 And together the edema, and effects of inflammatory mediators, also can cause pain.
00:26:29;13 So, redness, swelling, heat, and pain are all [results] of these vascular changes
00:26:35;09 that occur locally.
00:26:37;04 Another important change that happens is that endothelium within postcapillary venules becomes
00:26:42;19 activated, in the sense that it now becomes... acquires adhesive properties such that neutrophils
00:26:51;09 and monocytes and other cell types that go through blood vessels... normally, they would
00:26:56;13 pass through.
00:26:57;16 But when... if there is a local inflammation, the local endothelium becomes sticky, so that
00:27:03;02 these cells now adhere or attach to endothelium, and ultimately they crawl through the endothelial wall
00:27:11;06 into the tissue.
00:27:13;00 And that's the process called extravasation.
00:27:16;01 And the point of that process is to deliver the circulating effector cells to
00:27:21;05 the site of infection.
00:27:22;05 And actually, Elle Metchnikoff was the first to recognize that that's the point of vascular
00:27:27;08 changes during inflammation.
00:27:30;00 So, once neutrophils and other effector cells get to the site of the inflammation,
00:27:35;00 where inflammation is induced, they will then seek out pathogens and will destroy them or
00:27:41;21 repair the damaged tissue.
00:27:44;27 Another important point that was realized probably in the last decade or so is that
00:27:55;11 once inflammation accomplished its goal, which is elimination of pathogens, for example,
00:28:02;23 that is not enough to get back to the normal state.
00:28:06;25 If you just eliminated the cause of inflammation, it doesn't mean that the system automatically
00:28:11;08 goes back by default into homeostatic state.
00:28:14;22 There is another phase between inflammation and homeostatic state -- that's called resolution --
00:28:19;20 that needs to be actively engaged.
00:28:22;24 This is analogous to a situation if you have, for example, a broken pipe and there's flooding
00:28:27;15 in the system.
00:28:28;15 The cause of the mess would be the broken pipe, so let's say you fix the pipe.
00:28:32;13 That doesn't mean that the system is now back into its original state.
00:28:36;11 Now you have all the water on the floor and you need to get rid of it to return actively
00:28:40;20 back to homeostatic state.
00:28:42;04 So, that's what resolution does.
00:28:44;09 After inflammation accomplishes its goal, there's a lot of mess within the tissue --
00:28:50;11 there are many dead cells, there is destroyed extracellular matrix, and all of that has to be cleaned up
00:28:57;26 and changed back to the original state.
00:29:01;04 And of course this is something that requires a highly orchestrated and regulated process.
00:29:08;06 And that's what resolution does.
00:29:10;06 And resolution of inflammation is a very important but still not fully understood process,
00:29:16;21 but it's... it's well recognized now that it's an active process -- it's not just
00:29:22;00 passive cessation of inflammation -- and that it's needed to restore the homeostatic state.
00:29:27;23 An additional important point to understand about inflammation is that there are
00:29:35;13 not just different types of inflammation based on the causes, but there are also different modalities
00:29:40;04 of inflammation.
00:29:41;04 And they are historically defined as acute and chronic modalities of the inflammatory response.
00:29:49;12 So they, as the names imply, acute and chronic inflammation obviously differ in duration.
00:29:54;16 Acute inflammation can last from hours to days, and chronic inflammation typically
00:30:01;02 can last from weeks to months to years.
00:30:06;22 But more importantly, it's not just the kinetics of the response, but more importantly
00:30:11;21 acute and chronic inflammation are qualitatively distinct.
00:30:17;20 And the common causes of chronic inflammation include failure to eliminate the inflammatory inducer,
00:30:23;05 for example, if there is a persistent infection.
00:30:27;04 It's a failure of resolution of inflammation.
00:30:31;17 And in some cases it could be a positive feedback, such that the consequence of the inflammatory response,
00:30:37;22 for example, collateral tissue damage, may also be a cause for a secondary inflammatory response.
00:30:44;03 And potentially that can sustain the inflammatory state.
00:30:49;07 The qualitative differences between acute and chronic inflammation have to do with
00:30:53;16 the types of cells involved.
00:30:54;27 It's mostly neutrophils and eosinophils in acute inflammation, but mostly lymphocytes
00:31:01;19 in chronic inflammation, as well as macrophages.
00:31:05;13 And there are many other differences related to the type of the mechanism used to...
00:31:12;19 to deal with a persistent inflammatory inducer that's used during chronic inflammation.
00:31:18;01 Like other defenses, inflammation always operates at a cost.
00:31:23;01 And these costs can be divided into distinct categories.
00:31:27;06 The first class of causes of... the first type of costs of inflammation has to do with
00:31:35;14 intentional suppression of physiological functions that are lower priority than the inflammatory response
00:31:43;00 and that are somehow incompatible with the inflammatory response.
00:31:47;24 For example, if you're sitting on the couch and watching TV and there is a fire,
00:31:52;24 then watching TV, as a function, would be incompatible with dealing with the fire.
00:31:57;28 And it also would be obviously lower priority than dealing with the fire.
00:32:02;08 So, you will intentionally stop watching TV, so that would be a cost, but it's a low cost
00:32:07;17 compared to the benefit of putting away the fire.
00:32:12;05 And then the second type of course is unintentional cost.
00:32:16;10 That is, it's not something you want, but it's something you can't avoid.
00:32:21;03 It's unintentional and unavoidable costs, such as collateral tissue damage.
00:32:24;20 So, when you're putting out the fire and putting water on it, you will cause perhaps some
00:32:30;26 collateral damage to the rest of the room.
00:32:33;21 So, these are two different types of costs.
00:32:36;17 And the sum of these two costs has to be lower than the benefit provided by inflammation
00:32:40;15 for... for... for the system to be evolutionarily stable.
00:32:45;20 So, inflammation can be pathological, therefore, for several reasons.
00:32:51;17 And what's important to understand is that even an appropriately controlled inflammatory response
00:32:57;06 operates at the expense of other functions.
00:33:00;04 So, it's often said that inflammation is beneficial but when dysregulated can be pathological.
00:33:05;01 We should appreciate that even perfectly controlled inflammatory responses operate at a cost,
00:33:09;21 and sometimes these costs can manifest as symptoms that we may refer to as a disease.
00:33:17;08 The second reason for pathology of inflammation is when the response is excessive and...
00:33:24;26 either in magnitude or in duration.
00:33:27;01 And the third cost would be when the response is induced when it shouldn't be induced,
00:33:30;26 for example when it's mistargeted against something that is not harmful.
00:33:37;22 And this is summarized in this schematic.
00:33:41;24 When inflammation causes swelling, pain, fever, mucus overproduction, coughing, sneezing, diarrhea,
00:33:47;11 these are all defenses.
00:33:49;26 These are all manifestations of defenses.
00:33:51;25 They are protective from different types of noxious challenges, but obviously all of them
00:33:57;17 are processes that come at a cost.
00:34:01;15 We do feel ill when we experience those reactions, even though they are protective.
00:34:07;06 And what makes it worse is when they're protective but excessive.
00:34:11;08 Then they would be clearly just pathological.
00:34:15;13 And so these are two different outcomes that need to be distinguished: when pathology is
00:34:19;23 due to excessive response versus when pathology is simply the cost we have to pay for a normal response.
00:34:27;03 And then the third type of pathological outcome is more obvious.
00:34:31;06 It's when there is a... just collateral tissue damage or a mistargeted response.
00:34:36;09 So, when we put it this way, it's clear that the three types of pathological outcomes
00:34:42;01 are very different.
00:34:43;05 And... for example, you don't want to interfere with the first one, you want to dial down
00:34:47;16 the second one, and you want to stop the third one.
00:34:50;24 And the challenge is to be able to distinguish which one they belong to so that we know
00:34:55;19 what to do with them.
00:34:57;08 So, the take-home messages in this brief overview is that inflammation is normally
00:35:03;20 a protective response to infection and injury and other... and loss of tissue homeostasis,
00:35:10;06 that it's induced when homeostatic capacity is overwhelmed, and that all of the diversity and complexity
00:35:18;08 of inflam... of inflammation can be summarized in terms of the inflammatory pathway that
00:35:22;22 consists of inducers, sensors that detect them, mediators they produce, and the effectors
00:35:28;10 that eliminate the inducers.
00:35:32;02 And inflammation is normally followed by a resolution phase, which returns the system
00:35:36;12 to homeostasis.
00:35:39;16 And an inflammatory response always operates at a cost to incompatible lower-priority functions.
00:35:48;16 And inflammation can cause pathology when it's excessive, inappropriately induced,
00:35:53;05 or due to collateral damage.
00:35:55;22 And that completes this overview.
00:35:59;02 I will discuss in the next talk some specific examples of inflammation in the context of
00:36:08;08 inflammatory diseases.
00:36:09;27 And thank you for your attention.

00:00:15;00 Hello.
00:00:16;00 My name is Ruslan Medzhitov.
00:00:17;00 I'm a professor at Yale University School of Medicine and an Investigator of the
00:00:22;00 Howard Hughes Medical Institute.
00:00:23;13 And in this lecture, I will discuss our recent study on the effect of inflammation in acute illness
00:00:30;11 and the role of disease tolerance in surviving acute illness.
00:00:39;11 As I discussed in the introductory lecture, the costs of inflammation can be broken down
00:00:44;01 into two categories.
00:00:45;10 The first is the intentional suppression of lower priority functions that are incompatible
00:00:51;00 with the goals of the response.
00:00:53;17 And the second type of costs are unintentional but unavoidable loss of function, for example,
00:01:00;05 due to collateral damage.
00:01:02;22 And the sum of these two costs has to be lower than the benefit provided by the inflammation
00:01:07;18 in order to... for the system to evolve the way it is.
00:01:12;28 And this relation between the cost and benefit is what's really essential for understanding
00:01:17;14 many biological functions and their deviations into pathological states.
00:01:22;11 So, every biological trait can be characterized by some benefit it provides and some cost
00:01:28;14 at which it operates.
00:01:30;10 And this can be schematically shown as follows.
00:01:32;26 So, if we plot benefit versus cost for a system, for a biological trait to evolve the benefit
00:01:41;06 has to be higher than the cost.
00:01:43;03 So, any trait that would be in the green triangle part of the plot, where the benefit is higher
00:01:48;27 than the cost, would be evolutionary acceptable.
00:01:54;01 And anything in the red triangle, where the cost is higher than the benefit, would be
00:01:57;25 eliminated by natural selection.
00:02:00;28 And as you can see, the higher the benefit of the trait the higher is the acceptable cost.
00:02:07;27 And this view is from the evolutionary perspective.
00:02:11;14 So, all evolution cares about is that the benefit is higher than the cost.
00:02:17;22 And the same plot from the patient or physician perspective would look like this.
00:02:22;21 Here, again, anything that is in the upper-left triangle, where the benefit is higher than
00:02:29;16 the cost, would be a fair game from evolutionary perspective.
00:02:32;27 But as you move to the right side, when the cost becomes higher and higher, because benefit
00:02:38;09 is high, then this would be associated with conditions we would often refer to as
00:02:44;19 pathological or disease conditions.
00:02:46;09 So, if you're a patient and you're having an acute infection, there are ongoing
00:02:52;07 immune and inflammatory responses, but at the same time you feel very ill as a consequence of
00:02:56;21 these responses.
00:02:59;04 This would be a situation in the upper-right corner, where the benefit is still higher
00:03:04;24 than the cost, but the cost is so high that it makes us feel sick.
00:03:10;03 And it is this position on the plot, on the upper-right corner, where trades that provide
00:03:19;00 very high benefit will have very high acceptable costs.
00:03:22;22 And some diseases can be due to these types of trades, with very high benefits coming
00:03:28;28 with the high costs.
00:03:30;08 And that's the situation we've been interested in investigating.
00:03:34;13 What kind of mechanisms operate when the cost of the response is so high that it makes you
00:03:39;10 feel ill, and you're in fact close to the... to the condition where it could be life-threatening?
00:03:48;01 And one famous set of conditions like this is associated with acute illness.
00:03:53;23 And what's been known for... for a long time is that, during acute illness,
00:03:58;19 humans and other animals experience what's known as sickness behaviors.
00:04:04;04 And these are stereotypical responses that include loss of appetite, social withdrawal,
00:04:11;06 fatigue, altered sleep patterns, cessation of grooming, and suppression of libido.
00:04:17;10 And why they all happen and why there's this particular combination of behaviors is
00:04:23;12 not very clear, but it's clear that they occur in all animals studied.
00:04:28;24 They've even been observed in insects.
00:04:31;23 And it's been concluded, decades ago, that these are not just debilitations of
00:04:40;18 normal behaviors, but rather these are motivated behaviors.
00:04:43;21 In other words, they occur with a purpose.
00:04:46;14 There is some intentional induction of these responses.
00:04:50;26 But what the purpose of these responses is... is... has been less clear.
00:04:54;28 And that's what we investigated in this study I will describe today.
00:04:59;14 So, we were particularly interested in understanding the phenomenon of disease-induced anorexia.
00:05:09;23 We are all familiar with this phenomenon.
00:05:11;19 When you have acute infection, like flu infection or a severe cold, your appetite goes away.
00:05:18;01 You don't want to eat.
00:05:19;02 You want to sleep a lot.
00:05:20;17 And we asked why is it that we don't eat when we are very sick.
00:05:25;18 And to model that, we studied an infection with a bacterial pathogen called
00:05:32;18 Listeria monocytogenes, which is a very common bacterium that causes food poisoning.
00:05:39;11 And what we did... here, we infected mice with a sublethal dose of Listeria and monitored
00:05:47;18 their food consumption.
00:05:49;09 And as you can see, the red line is mice that are infected with Listeria, and as you
00:05:55;18 can see there is a very profound suppression of food consumption.
00:05:59;28 And go on... into this anorexic state until they start recovering from infection,
00:06:06;26 at which point they will regain food consumption.
00:06:11;08 And we asked, why is it that they don't eat?
00:06:13;21 What would happen if they are forced to eat?
00:06:17;27 And to address that, we fed the mice with the same amount of the same type of food
00:06:24;15 that they normally consume.
00:06:26;16 And we only provided them about 20 percent of normal daily caloric intake.
00:06:32;26 So, it's just a small fraction of what they would normally eat.
00:06:36;28 And we used, in this case, a dose of Listeria that kills 50 percent of mice -- so it's called
00:06:43;02 lethal dose 50 or LD50 -- which is shown in the black line.
00:06:47;25 These are mice that are control mice.
00:06:51;15 And then the experimental mice were given food.
00:06:54;03 And as you can see, all of them died within 10 days, indicating that eating during bacterial infection
00:07:01;17 can be lethal.
00:07:03;13 And that result actually is not new.
00:07:05;02 It was first reported in 1979 with a similar model, with Listeria infection, that force-feeding
00:07:11;08 during infection can be... it can lead... can increased... it can increase lethality.
00:07:16;28 So, then we asked, what is it in the food that causes this effect?
00:07:21;14 And we tested, separately, proteins, carbohydrates, and fats.
00:07:26;19 And found that the effect of the... this effect of feeding was due to carbohydrates,
00:07:32;22 specifically due to glucose, because if we would just give mice glucose at the time of the... of the infection,
00:07:39;25 then 100% of them would succumb to infection.
00:07:45;07 And that was very interesting because it indicated that just glucose -- that simple metabolite,
00:07:50;07 an essential metabolite -- is sufficient to cause such a dramatic effect on survival.
00:07:56;24 And then we asked, what would happen if we do the opposite manipulation, if we
00:08:02;20 prevent glucose utilization?
00:08:04;21 And to do so, we used a metabolite derivative called 2-deoxyglucose, or 2DG, which is
00:08:12;02 a glucose variant that can be taken into the cells but cannot be metabolized, so it
00:08:16;18 prevents glucose utilization even if glucose is present in the system.
00:08:22;00 And when we gave mice 2DG twice a day, by injecting it either intraperitoneally or
00:08:29;01 giving it orally or giving it intravenously... it didn't matter which route we used.
00:08:35;16 And as you can see in the blue line here, 100% of mice now could survive this infection
00:08:41;12 that otherwise would kill 50% of mice.
00:08:44;04 So, that was very exciting because it indicated that blocking glucose utilization can
00:08:50;03 protect mice from infection, and giving them glucose can promote mortality.
00:08:57;22 Then we asked whether this is something unique to Listeria or can be generalized to
00:09:02;20 other types of bacterial infections.
00:09:05;28 And to address this, we used a common model of bacterial sepsis that is caused by...
00:09:12;21 not by live bacteria but by specific a bacterial component called lipopolysaccharide, or LPS,
00:09:19;17 which is present in all gram-negative bacteria and which is well-known to induce a very dramatic
00:09:25;20 inflammatory response.
00:09:27;07 So, inflammation caused by gram-negative infections is in large part due to LPS.
00:09:32;24 So, if we just use LPS instead of live pathogens, then we simplify the system and
00:09:38;04 eliminate all the variations due to pathogenicity of different bacteria.
00:09:44;21 And as you can see here, we... when we give an LD50 dose of LPS, which is the line
00:09:50;22 in the middle, we have about 50% of mice that would succumb to sepsis.
00:09:56;11 Then, if we give them either a control -- PBS, phosphate... phosphate-buffered saline,
00:10:03;22 a physiological solution -- or give them food, you can see that there's a dramatic difference
00:10:08;01 in survival.
00:10:09;01 So, mice that received food, most of them would die.
00:10:13;09 And then we asked if this effect, again, is due to glucose.
00:10:16;19 And we performed, again, a similar experiment, giving either glucose or 2DG.
00:10:23;24 And as you can see, now 100% of mice that received glucose would die from LPS sepsis,
00:10:31;00 and 100% would survive if they are given 2-deoxyglucose.
00:10:34;17 So, this was very exciting because this is a very simple manipulation.
00:10:38;22 We're just using either glucose or anti-glucose.
00:10:43;01 And we have this profound, 100% effect on survival in a condition that is
00:10:51;05 otherwise intractable.
00:10:52;16 It's uhh... sepsis is a very complex disease that has a very high mortality rate,
00:11:00;11 and there are still very few treatment options for sepsis.
00:11:02;28 So, we were very excited to see that such a simple manipulation can have such a dramatic
00:11:07;18 effect on survival.
00:11:09;28 Interestingly, these effects of glucose and 2-deoxyglucose were not due to changes in
00:11:17;04 the magnitude of the inflammatory response.
00:11:20;14 So, if we measure the major inflammatory cytokines, including TNF, IL-6, or acute-phase proteins
00:11:28;13 such as serum amyloid protein, you can see that, regardless of whether it's
00:11:33;19 a control mouse or a mouse given glucose or 2DG, the level of inflammatory response was the same.
00:11:39;14 So the fact that mice given glucose died and mice given 2DG survived is not due to changes
00:11:46;02 in the inflammatory response.
00:11:48;04 So, then we asked, what is it due to?
00:11:50;28 And of course, when mice don't eat they undergo a fasting metabolic state.
00:11:57;21 And we then asked whether this fasting metabolism is the one that matters, rather than the inflammation
00:12:03;12 itself.
00:12:05;06 And just to remind you, what happens during fasting is that glucose level goes down and
00:12:12;07 therefore insulin level goes down.
00:12:14;19 And most organs switch from using glucose to switching... to using fatty acids produced...
00:12:23;15 released from adipose tissue.
00:12:25;13 And only brain continues to use glucose, initially.
00:12:28;12 So, during initial stages of fasting, free fatty acids, or FFA, would be released from
00:12:34;27 adipose tissue by a process called lipolysis, or release of fatty acids.
00:12:40;06 And then fatty acids will become main fuel for most organs.
00:12:44;02 And... while brain will continue to use glucose.
00:12:47;24 And then, if fasting is prolonged, then some fatty acids will go into liver and will
00:12:53;15 be converted into a different metabolite called... called ketones, such as beta-hydroxybutyrate,
00:12:59;04 or BHOB here.
00:13:02;06 And this fasting metabolic switch into ketogenesis -- production of ketones -- is controlled
00:13:08;18 by a nuclear receptor called PPAR-alpha, shown here.
00:13:13;06 So, what PPAR-alpha does during this prolonged fasting... it detects fatty acids that are
00:13:19;14 delivered from the adipose tissue and induces enzymes that generate ketones from fatty acids.
00:13:28;06 And the point of that is that ketones now can be used by the brain.
00:13:33;00 And the second thing that PPAR-alpha does, it controls expression of a fasting hormone
00:13:38;02 called FGF21.
00:13:39;15 So, we thought that it's... these PPAR-alpha-regulated processes that are activated during fasting
00:13:47;06 might be involved in controlling survival because when we eat, or consume food or glucose,
00:13:54;12 that would induce insulin production, and insulin will suppress all these processes.
00:13:58;20 It will suppress lipolysis and it will suppress ketogenesis.
00:14:03;00 And we thought that maybe that's why glucose kills and 2-deoxyglucose leads to...
00:14:09;09 promotes survival.
00:14:10;26 So, to test that, we first examined whether, indeed, glucose will prevent these PPAR-alpha-regulated
00:14:20;19 outcomes, such as hydroxybutyrate production and FGF21 expression.
00:14:26;06 And indeed, as you can see on the left side, this is measurement of non-esterified fatty acids,
00:14:32;28 or free fatty acids.
00:14:34;04 So, they are released during fasting.
00:14:35;19 You can see in the black line the fatty acid level in the... in the plasma go up.
00:14:42;25 And later, beta-hydroxybutyrate starts going up and the fasting hormone FGF21 is also
00:14:49;27 strongly induced.
00:14:52;04 But if we give mice glucose, then all these responses are shut down, and none of them happen.
00:14:58;21 And then we asked whether they... this is what contributes to differential survival
00:15:03;13 from feeding.
00:15:05;01 So to address that, we used mice that are deficient PPAR-alpha, where neither ketogenesis
00:15:11;23 nor FGF21 expression can be induced.
00:15:14;19 And we used, also, FGF21 knockout mice.
00:15:18;09 And as you can see in the left panel, both of these mice now succumb to sub-lethal doses
00:15:25;12 of LPS that are survived 100% by control mice.
00:15:30;13 So, that suggested both FGF21 and PPAR-alpha are necessary for survival.
00:15:36;00 And in the absence of PPAR-alpha, on the right panel you can see that there is no production
00:15:40;26 of beta-hydroxybutyrate.
00:15:45;13 But the level of inflammation in all three conditions was the same.
00:15:48;19 So, as you can see in the lower panel, the level of TNF in... in the serum in all three
00:15:55;23 mouse strains was the same.
00:15:59;26 So, what we found also is that glucose supplementation increased, and 2-deoxyglucose decreased oxidative
00:16:09;14 stress in the midbrain area during LPS sepsis.
00:16:13;28 And by performing PET scans to follow where glucose goes during sepsis, we found that,
00:16:20;12 following LPS challenge, the... this area of midbrain was the... showed the
00:16:27;22 greatest difference in glucose consumption.
00:16:29;12 So, there was increased glucose uptake into the... this particular brain area that...
00:16:34;16 where we also saw increased oxidative stress.
00:16:39;08 And so what we concluded from that is that fasting metabolism and ketogenic programs
00:16:45;14 are required for survival of LPS sepsis.
00:16:50;12 And what we noticed also is that the death from sepsis was preceded by seizures or convulsions.
00:16:57;01 And it's also well-known that ketogenic diet is used to treat epilepsy.
00:17:02;01 And all these pieces of the puzzle together led us to ask whether anti-epileptic drugs
00:17:08;04 could be protective from sepsis, which was a very far-fetched idea.
00:17:12;17 But we tested it and, to our surprise and delight, we found that, indeed, the anti-epileptic drug
00:17:20;01 valproic acid could rescue mice from lethal sepsis.
00:17:25;24 And interestingly, the second anti-epileptic drug, called Keppra, did not have such an effect.
00:17:31;06 And that is very informative for us because these two drugs have very different
00:17:34;08 mechanisms of action.
00:17:37;02 So, we then tested whether valproic acid can protect upstream or downstream of the effect
00:17:45;22 of glucose.
00:17:47;10 And what we found was that valproic acid protected against LPS sepsis even in PPAR-alpha knockout mice,
00:17:57;12 which as you remember cannot produce ketone bodies.
00:18:02;12 So... as if valproic acid substitutes to the protective effect of ketones.
00:18:08;01 But 2-deoxyglucose cannot protect PPAR-alpha knockout mice from LPS sepsis because it acts
00:18:13;04 upstream of PPAR-alpha.
00:18:15;17 So, that indicated that valproic acid has its effect very downstream in the fasting pathway,
00:18:22;22 at the same level, perhaps, as ketone bodies.
00:18:26;19 And the conclusion to this part is that during sepsis -- endotoxin sepsis, LPS sepsis --
00:18:37;05 LPS induces inflammatory cytokines, and which of these is most important here is...
00:18:41;16 is not clear, and probably several of them can lead to similar effects of increasing
00:18:47;20 generation of reactive oxygen species in the midbrain area.
00:18:51;25 And glucose promotes this effect and 2DG inhibits it.
00:18:57;08 And ketones also inhibit that effect.
00:18:59;20 And consumption of food or glucose prevents ketogenesis and therefore interferes with
00:19:07;02 the protective effect from... protection from this damage by ROS.
00:19:12;22 And during fasting, a PPAR-alpha-dependent mechanism generates ketones, which lead to
00:19:19;00 reduced ROS production and adaptation to the stress of inflammation, and survival, ultimately.
00:19:26;10 And we think one of the effects, common targets, here, could be histone deacetylase... deacetylases,
00:19:33;11 because both ketones and valproic acid are known to inhibit histone deacetylases.
00:19:38;27 And this is something we are currently testing.
00:19:41;05 So, that's the part of the study that had to do with bacterial infection and bacterial sepsis,
00:19:49;01 where we found that eating during bacterial infection or sepsis interferes with
00:19:55;02 this normal protective effect of fasting metabolism, and therefore the anorexia that we feel
00:20:01;08 when we have infections has to do with promoting these types of protective mechanisms
00:20:09;22 associated with fasting metabolism.
00:20:13;12 And then we... what we found here, therefore, is that this increased glucose level, if it
00:20:21;06 goes above some upper threshold level, can be deadly in the context of bacterial sepsis.
00:20:30;05 And another recent study examined the role of glucose in a very different model,
00:20:35;16 where they looked at the lower threshold level, where they used mice which are unable to
00:20:41;20 produce glucose from the liver.
00:20:44;19 And this was... this... and that also leads to mortality.
00:20:47;20 This was a study by Miguel Soares from Instituto Gulbenkian in Lisbon, where they found that
00:20:53;23 there is also a lower boundary for the glucose level.
00:20:58;10 So, both upper boundary and lower boundary, if they're exceeded in the glucose level,
00:21:03;06 can lead to mortality.
00:21:04;19 So, it's important to keep that in mind, that it's not an excess or depletion; it's a maintenance
00:21:12;00 of the... the right amount of glucose that is required for survival.
00:21:17;00 And this is not surprising, of course, because glucose is still essential for many cells,
00:21:21;25 especially neuronal cells, for survival.
00:21:29;01 And... well, we found this very dramatic effect of glucose and 2-deoxyglucose on
00:21:35;27 bacterial infection in sepsis.
00:21:37;06 We then asked whether this is more a general phenomenon and whether it applies to all infections.
00:21:44;16 And to address that, we used a mouse model of influenza infection, where mice are infected
00:21:52;02 with the flu virus.
00:21:54;04 And in this case, we are giving a sub-lethal dose of flu.
00:21:57;10 And then we follow, again, the food consumption.
00:21:59;26 And just like with bacterial infection, you can see that mice, when they...
00:22:03;19 at the peak of infection, they stop eating.
00:22:06;16 And then as they start recovering from infection, they... they resume food consumption.
00:22:13;02 And we asked again, what would happen if we feed them at the time when they are anorexic?
00:22:20;07 And what we found was very surprising, and opposite to what we expected and opposite
00:22:24;19 to what we found with bacterial infection.
00:22:27;14 As you can see here, if we feed the mice, they actually survive better compared to mice
00:22:32;21 that received control PBS solution.
00:22:36;26 And if we just give them glucose, they also do better.
00:22:40;01 And glucose partially protects from mortality.
00:22:42;14 And we think the... the rest of the protection is provided by sodium.
00:22:50;06 And when we ask the question, the converse question, what 2DG will do, we found that
00:22:56;05 2DG actually was lethal in the context of viral infection.
00:23:00;16 As shown here in the blue line, when mice are given 2DG in the context of viral infection,
00:23:07;04 they all died 100%.
00:23:09;22 Interestingly, this difference in survival was not due to tissue damage that was normally
00:23:16;27 caused by flu virus.
00:23:18;11 So, this is a lung pathology.
00:23:21;06 On the left side is the control and on the right side is 2DG-treated mice, and they're
00:23:26;02 basically the same.
00:23:27;10 There is no difference in the degree of tissue damage caused by the virus.
00:23:31;12 And also there is the same level of hemorrhage, edema, and inflammatory infiltrates.
00:23:37;08 So, that did not explain 100% differences in survival.
00:23:43;06 And also, there was no difference in the magnitude of the inflammatory response, as shown on
00:23:49;27 the left side by measuring interferon-alpha in the plasma.
00:23:55;02 And interestingly and importantly, there's no difference, also, in viral burden.
00:23:59;05 If we measure the amount of viruses during infection, they are similar between
00:24:04;18 control and 2DG-treated mice.
00:24:06;07 And again, 2DG-treated mice are the ones that succumb 100% to this infection.
00:24:12;22 So, what we then noticed, by performing other measurements on these mice, is that
00:24:22;07 the death from viral inflammation caused by either flu virus or some mimics of viral infection
00:24:29;22 was associated with decline in vital functions, such as heart rate, respiratory rate,
00:24:35;00 and so on.
00:24:36;00 And that suggested that there perhaps is a failure of the autonomic control centers that
00:24:40;16 reside in the brainstem.
00:24:43;08 And moreover, when we performed PET scans on these mice, again we found that
00:24:48;09 glucose was preferentially taken into the brainstem area during viral inflammation.
00:24:54;14 And remember, during bacterial inflammation it was preferentially taken into the midbrain area.
00:24:59;24 So, that was puzzling but suggested a possible scenario where viral infection somehow interfaces
00:25:08;09 with glucose metabolism, and the only type of connection that we could find in the prior literature
00:25:15;02 that would suggest the mechanism had to do with endoplasmic reticulum stress,
00:25:21;02 or ER stress.
00:25:22;02 So, ER stress is normally induced by unfolded protein response in the endoplasmic reticulum,
00:25:29;16 and it leads to adaptation to the unfolded protein accumulation through induction of
00:25:35;24 chaperones and various proteases and so on.
00:25:38;06 And that leads to resolution of the ER stress.
00:25:40;13 However, if ER stress is excessive, then the second branch of the pathway is induced by
00:25:49;04 leading to transcriptional induction of a transcription factor called CHOP that
00:25:56;15 leads to cell death through apoptosis.
00:26:00;15 And because glucose availability can also impact on protein glycosylation in the ER,
00:26:05;10 it can also lead to ER stress.
00:26:07;14 So, when cells are deprived of glucose, that can lead to ER stress.
00:26:14;21 And viral infection can also lead to ER stress.
00:26:17;15 So we thought, perhaps these two conditions may somehow conspire to trigger excessive
00:26:24;13 ER stress, leading to induction of this transcription factor, CHOP, leading to neuronal damage in
00:26:30;24 the brainstem.
00:26:33;11 And we tested whether CHOP is indeed induced under those conditions anywhere in the brain
00:26:38;08 and found that, indeed, when mice have viral inflammation -- in this case induced by
00:26:44;24 a viral mimic called poly(I:C) -- either alone or together with 2DG, and then we monitored
00:26:52;02 CHOP expression by Western blot, and we found that it was only induced in hindbrain area,
00:26:59;04 and only when mice received both poly(I:C) and 2DG.
00:27:04;17 And then we tested whether CHOP is involved in mortality caused by infection and 2DG.
00:27:12;18 And to test that, we used either wild-type or CHOP-deficient mice.
00:27:17;12 The gene name for CHOP is Ddit3, so those are Ddit3 knockout mice in open... open symbols.
00:27:25;08 And as you can see, wild type mice that received poly(I:C) and 2DG die 100%; that's the blue triangles.
00:27:32;23 And CHOP-deficient mice receiving the same combination of poly(I:C) and 2DG survive 100%,
00:27:40;10 indicating that, indeed, this particular transcription factor is a critical mediator of mortality
00:27:46;03 from viral infection combined with 2DG.
00:27:50;24 And again, as shown on the right slide, there was no difference in the inflammatory response,
00:27:55;07 as measured here by interferon-alpha in the serum.
00:27:59;12 So, the summary for this part is, during viral infection, or more generally during
00:28:05;03 viral inflammation, because we could find the same exact phenomenon with just using poly(I:C),
00:28:10;26 there is a production of type-1 interferons -- interferon alpha and beta -- and that leads
00:28:15;28 to activation of the unfolded protein response, or UPR, combined with glucose consumption
00:28:29;00 in the brainstem area.
00:28:31;27 Why it's specifically brainstem that's affected in this manner we don't know.
00:28:35;22 It's a very interesting question which we hope to understand someday.
00:28:41;13 But what happens in the context of this response with metabolites is that glucose ameliorates
00:28:48;07 this response -- it prevents induction of CHOP and neuronal dysfunction and... and death --
00:28:55;19 whereas 2DG exacerbates it and leads to CHOP induction and subsequent loss of function
00:29:03;20 of the brainstem and autonomic control centers, resulting in death.
00:29:09;06 So, these are two very different effects of metabolism on bacterial and viral inflammation.
00:29:16;26 And all of it could be tied down to utilization of glucose or block of glucose utilization.
00:29:25;09 And it's completely independent of pathogenicity.
00:29:29;04 It's independent of pathogen burden.
00:29:32;00 And it's independent on the magnitude of inflammation.
00:29:34;25 So, this is what we refer to as being able to tolerate a given level of inflammation,
00:29:41;09 rather than controlling the level of inflammation.
00:29:44;19 So, this study was done by three very talented scientists in my group -- shown from right to left,
00:29:52;17 Andrew Wang, Sarah Huen, and Harding Luan
00:29:57;09 -- and two talented technicians -- Cuiling and Shuang -- who helped with the study,
00:30:03;15 and... as well as Carmen Booth and Jean-Dominique Gallezot, who are...
00:30:08;27 helped with pathology and PET scans.
00:30:11;20 And our funding is shown at the bottom of this slide.
00:30:15;27 And thank you for your attention.