Inflammation and hyper-inflammation

Inflammation

As part of the immune response, inflammation plays an important role in defending the body against pathogens, such as viruses, bacteria, fungi, and other parasites. However, the inappropriate activation of inflammatory processes is an underlying contributor to many common pathological conditions. For example, autoimmune conditions arise when our immune system mistakes our cells or tissues for pathogens and attacks them. In addition, studies show that tumor proliferation and metastasis may occur when inflammatory cytokines create a microenvironment conducive to cancer progression.

Acute versus chronic inflammation

Acute inflammation is a short-lived response that is characterized by extravasation of leukocytes, erythrocytes, and plasma components into the injured tissue. If left unchecked, the acute inflammatory process can lead to chronic inflammation. Unlike acute inflammation, chronic inflammation is characterized primarily by tissue infiltration by lymphocytes and macrophages. Chronic inflammation is closely associated with allergy, atherosclerosis, cancer, arthritis, and Alzheimer’s disease, as well as autoimmune diseases. The process of acute inflammation is well defined, but the causes of chronic inflammation and its associated molecular and cellular pathways are still not well understood.

The critical balance between pro- and anti-inflammatory mediators

The overall effect of an inflammatory response is dictated by the balance between pro- and anti-inflammatory mediators. Pro-inflammatory cytokines such as IL-1 beta, IL-6, and TNF alpha are responsible for early responses and amplify inflammatory reactions, whereas anti-inflammatory cytokines, which include IL-4, IL-10, and IL-13, have the opposite effect in that they limit the inflammatory reactions. The increasing complexity of pro- and anti-inflammatory cytokine and chemokine networks has made it crucial to examine them in relevant functional groups rather than individually.

Hyper-Inflammation and the Cytokine Storm

A typical immune response involves production of cytokines that orchestrate the differentiation of lymphocytes based on the type of pathogen being cleared. Ultimately the immune system self-regulates and shuts down once the infection is resolved. In some cases, however, the immune response does not shut down, and there is an overproduction of inflammatory cytokines that causes systemic damage to host cells.

The so-called cytokine storm or cytokine release syndrome (CRS) is characterized by an aggressive pro-inflammatory response in combination with an insufficient an anti-inflammatory response, which results in the loss of homeostasis of the immune response. The key factors identified in the pathology of a cytokine storm are TNF alpha, Interferons, IL-1 beta, MCP-1 (CCL2), and most importantly IL-61.

Activation of mainly T cells or lysis of immune cells induces a release of IFN gamma or TNF alpha. This leads to the activation of macrophages, dendritic cells, other immune cells, and endothelial cells. After activation, these cells further release proinflammatory cytokines. Large amounts of Interleukin 6 (IL-6) are produced by macrophages and endothelial cells, activating T cells and other immune cells and creating a positive feedback-loop that results in a cytokine storm, inducing the release of many more cytokines and chemokines but also upregulating acute phase proteins. The resulting cytokine storm syndromes are heterogeneous but have the described immune dysregulation in common, leading to hyperinflammation, fever, cytopenia, splenomegaly, hepatitis, coagulopathy, and may result in fatal multisystem organ dysfunction.

Infectious diseases associated with a hyperreactive immune system may be caused by different pathogens, such as bacteria (e.g. toxic shock syndrome (TSS)) and viruses (e.g. Influenza, Epstein-Barr Virus, SARS and SARS COV-2)). In addition, the cytokine storm has been described in therapeutic environments such as immunotherapy and CAR-T cell therapy in cancer. Treatment of patients with therapeutic monoclonal antibodies may stimulate a massive cytokine release syndrome leading to life threatening side effects of immunotherapy2. Recently described by Cheng et al., exposure to organic pollutants could elicit a hyper reactive immune response. Exposure to polycyclic aromatic hydrocarbons was linked to increased serum levels of cytokines associated with a cytokine storm3.

Protein biomarkers for Cytokine Storm or Cytokine Release Syndrome in the ProcartaPlex Multiplex Cytokine Assay

TargetTypeRole associated with cytokine release syndrome (CRS)
G-CSF (CSF-3)Cytokine (Colony-Stimulating Factors)CRS, cytokine profile associated with sHLH and severe COVID-19
GM-CSFCytokine (Colony-Stimulating Factors)Inflammatory cytokine released during CRS4, stimulates IL-65
IFN alphaCytokine (Interferon), pro-inflammatoryKey player in CRS, innate immunity to viruses
IFN gammaCytokine (Interferon), pro-inflammatoryKey mediator of CRS, described in SARS patients6, potential marker to predict COVID-19 outcome, potential therapeutic target7
IL-1 betaCytokine, pro-inflammatoryPlays a central role in CRS, is considered a potential target for COVID-197
IL-2Cytokine, pro-inflammatoryReleased during CRS4, stimulates IL-65
IL-4Cytokine, anti-inflammatoryImportant for homeostasis in the immune response, stimulates IL-65
IL-5CytokineMain biomarker for sepsis, involved in CRS and has a role in influenza infection induced CRS8
IL-6Cytokine, pro-inflammatoryKey mediator of CRS, potential therapeutic target, blocking IL-6 potentially beneficial for patients with severe inflammation in the lungs due to CRS, increased plasma levels in ICU vs. non-ICU patients for COVID199
IL-8 (CXCL8)Chemokine (CXC type), pro-inflammatoryCRS in SARS patients6, chemoattractant for various immune cells
IL-10Cytokine, anti-inflammatoryImportant for homeostasis in the immune response, stimulates IL-65
IL-12p70Cytokine, pro-inflammatoryPlays a role in CRS
IL-13Cytokine, immunoregulatorySecreted by NK cells, plays a role in MAS10
IL-17A (CTLA-8)Cytokine, pro-inflammatoryPlays a role in CRS provoked by TSS11, increased level in PAH exposure associated cytokine storm3
IL-18Cytokine, pro-inflammatoryInvolved in CRS in SARS patients6
IP-10 (CXCL10)Chemokine (CXC type)CRS associated with sHLH, and severity of COVID-1912, increased plasma levels in ICU vs. non-ICU patients9
MCP-1 (CCL2)Chemokine (CC type)Central role in CRS, associated with sHLH; CRS in SARS patients9 and severity of COVID-1912, increased plasma levels in ICU vs. non-ICU patients9
MIP-1 alpha (CCL3)Chemokine (CC type)Cytokine profile associated with sHLH and severity of COVID-1912; increased plasma levels in ICU vs. non-ICU patients9, potential marker to predict COVID-19 disease severity/outcome
MIP-1 beta (CCL4)Chemokine (CC type)Biomarker for sepsis and CRS in general
TNF alphaTumor necrosis factorCentral role in CRS, blocking TNF alpha potentially beneficial for patients with severe inflammation in the lung due to CRS, increased plasma levels in ICU vs. non-ICU patients9
TNF betaTumor necrosis factorCRS in SARS patients6, plays a role in the TNF-dominated response to superantigens leading to STSS13
Abbreviations–COVID-19: Coronavirus disease 2019, ICU: Intensive care unit, MAS: Macrophage activation syndrome, PAH: Polycyclic aromatic hydrocarbons, sHLH: Secondary haemophagocytic lymphohistiocytosis, SARS: Severe acute respiratory syndrome, STSS: Streptococcal toxic shock syndrome

Study other immune biomarkers with Procartaplex Preconfigured Panels

Since many different causes and pathologic conditions for the induction of a cytokine storm do exist, and not all syndromes involving cytokine release result in the same pathogenic cytokine profile, it is of great interest to analyze the level of a broader panel of immunomodulatory markers to get the whole picture of a patient’s immune status. For studying a broader set of biomarkers, we recommend the following ProcartaPlex Preconfigured Panels:

Panel NameCat. No.Analytes
Human Cytokine Assays
Immune Monitoring 65-Plex Human ProcartaPlex PanelEPX650-10065-901APRIL, BAFF, BLC (CXCL13), CD30, CD40L, ENA-78 (CXCL5), Eotaxin (CCL11), Eotaxin-2 (CCL24), Eotaxin-3 (CCL26), FGF-2, Fractalkine (CX3CL1), G-CSF (CSF-3), GM-CSF, GRO alpha (CXCL1), HGF, IFN alpha, IFN gamma, IL-10, IL-12p70, IL-13, IL-15, IL-16, IL-17A (CTLA-8), IL-18, IL-1 alpha, IL-1 beta, IL-2, IL-20, IL-21, IL-22, IL-23, IL-27, IL-2R, IL-3, IL-31, IL-4, IL-5, IL-6, IL-7, IL-8 (CXCL8), IL-9, IP-10 (CXCL10), I-TAC (CXCL11), LIF, MCP-1 (CCL2), MCP-2 (CCL8), MCP-3 (CCL7), M-CSF, MDC, MIF, MIG (CXCL9), MIP-1 alpha (CCL3), MIP-1 beta (CCL4), MIP-3 alpha (CCL20), MMP-1,NGF beta, SCF, SDF-1 alpha, TNF beta, TNF alpha, TNF-RII, TRAIL, TSLP, TWEAK, VEGF-A
Cytokine/Chemokine/Growth Factor Convenience 45-Plex Human ProcartaPlex Panel 1EPXR450-12171-901BDNF, EGF, Eotaxin (CCL11), FGF-2, GM-CSF, GRO alpha (CXCL1), HGF, IFN gamma, IFN alpha, IL-1RA, IL-1 beta, IL-1 alpha, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8 (CXCL8), IL-9, IL-10, IL-12p70, IL-13, IL-15, IL-17A (CTLA-8), IL-18, IL-21, IL-22, IL-23, IL-27, IL-31, IP-10 (CXCL10), LIF, MCP-1 (CCL2), MIP-1 alpha (CCL3), MIP-1 beta (CCL4), NGF beta, PDGF-BB, PlGF-1, RANTES (CCL5), SCF, SDF-1 alpha, TNF alpha, TNF beta, VEGF-A, VEGF-D
Cytokine & Chemokine Convenience 34-Plex Human ProcartaPlex Panel 1AEPXR340-12167-901Eotaxin (CCL11), GM-CSF, GRO alpha (CXCL1), IFN alpha, IFN gamma, IL-1 beta, IL-1 alpha, IL-1RA, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8 (CXCL8), IL-9, IL-10, IL-12p70, IL-13, IL-15, IL-17A (CTLA-8), IL-18, IL-21, IL-22, IL-23, IL-27, IL-31, IP-10 (CXCL10), MCP-1 (CCL2), MIP-1 alpha (CCL3), MIP-1 beta (CCL4), RANTES (CCL5), SDF-1 alpha, TNF alpha, TNF beta
Inflammation 20-Plex Human ProcartaPlex PanelEPX200-12185-901E-selectin (CD62E), GM-CSF, ICAM-1, IFN alpha, IFN gamma, IL-1 alpha, IL-1 beta, IL-4, IL-6, IL-8 (CXCL8), IL-10, IL-12p70, IL-13, IL-17A (CTLA-8), IP-10 (CXCL10), MCP-1 (CCL2), MIP-1 alpha (CCL3), MIP-1 beta (CCL4), P-Selectin, TNF alpha
Mouse Cytokine Assays
Immune Monitoring 48-Plex Mouse ProcartaPlex PanelEPX480-20834-901BAFF, BTC, ENA-78, Eotaxin (CCL11), G-CSF, GM-CSF, GRO alpha (CXCL1), IFN alpha, IFN gamma, IL-10, IL-12p70, IL-13, IL-15, IL-17A, IL-18, IL-19, IL-1 alpha, IL-1 beta, IL-2, IL-22, IL-23, IL-25 (IL-17E), IL-27, IL-28, IL-2Ra, IL-3, IL-31, IL-33, IL-33R, IL-4, IL-5, IL-6, IL-7, IL-7Ra, IL-9, IP-10 (CXCL10), Leptin, LIF, MCP-1 (CCL2), MCP-3 (CCL7), M-CSF, MIP-1 alpha (CCL3), MIP-1 beta (CCL4), MIP-2 alpha (CXCL2), RANKL, RANTES, TNF alpha, VEGF-A
Cytokine & Chemokine Convenience 36-Plex Mouse ProcartaPlex Panel 1AEPXR360-26092-901BAFF, BTC, ENA-78, Eotaxin (CCL11), G-CSF, GM-CSF, GRO alpha (CXCL1), IFN alpha, IFN gamma, IL-10, IL-12p70, IL-13, IL-15, IL-17A, IL-18, IL-19, IL-1 alpha, IL-1 beta, IL-2, IL-22, IL-23, IL-25 (IL-17E), IL-27, IL-28, IL-2Ra, IL-3, IL-31, IL-33, IL-33R, IL-4, IL-5, IL-6, IL-7, IL-7Ra, IL-9, IP-10 (CXCL10), Leptin, LIF, MCP-1 (CCL2), MCP-3 (CCL7), M-CSF, MIP-1 alpha (CCL3), MIP-1 beta (CCL4), MIP-2 alpha (CXCL2), RANKL, RANTES, TNF alpha, VEGF-A

Recommended reading and references

  1. Tisoncik JR, Korth MJ, Simmons CP, Farrar J, Martin TR, Katze MG. 2012. Into the Eye of the Cytokine Storm. Microbiol Mol Biol Rev. 76(1):16-32.
  2. Shimabukuro-Vornhagen A, Gödel P, Subklewe M, Stemmler HJ, Schlößer HA, Schlaak M, Kochanek M, Böll B, von Bergwelt-Baildon MS. 2018. Cytokine release syndrome. J Immunother Cancer. 6(1):56.
  3. Cheng Z, Huo X, Dai Y, Lu X, Hylkema MN, Xu X. 2020. Elevated expression of AhR and NLRP3 link polycyclic aromatic hydrocarbon exposure to cytokine storm in preschool children. Environ Int. 139:105720.
  4. Eastwood D, Bird C, Dilger P, Hockley J, Findlay L, Poole S, Thorpe SJ, Wadhwa M, Thorpe R, Stebbings R. 2013. Severity of the TGN1412 trial disaster cytokine storm correlated with IL-2 release. Br J Clin Pharmacol. 76(2):299-315.
  5. Yiu HH, Graham AL, Stengel RF. 2012. Dynamics of a cytokine storm. PLoS One. 7(10):e45027.
  6. Huang KJ, Su IJ, Theron M, Wu YC, Lai SK, Liu CC, Lei HY. 2005. An Interferon-g-Related Cytokine Storm in SARS patients. J Med Virol. 75(2):185-94.
  7. Shi Y, Wang Y, Shao C, Huang J, Gan J, Huang X, Bucci E, Piacentini M, Ippolito G, Melino G. 2020. COVID-19 infection: the perspectives on immune responses. Cell Death Differ. 27(5):1451-1454.
  8. Guo XJ, Thomas PG. 2017. New fronts emerge in the influenza cytokine storm. Semin Immunopathol. 39(5):541-550.
  9. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. 2020. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 395(10223):497-506.
  10. Vandenhaute J, Wouters CH, Matthys P. 2020. Natural Killer Cells in Systemic Autoinflammatory Diseases: A Focus on Systemic Juvenile Idiopathic Arthritis and Macrophage Activation Syndrome. Front Immunol. 10:3089.
  11. Szabo PA, Goswami A, Mazzuca DM, Kim K, O'Gorman DB, Hess DA, Welch ID, Young HA, Singh B, McCormick JK, Haeryfar SM. 2017. Rapid and Rigorous IL-17A Production by a Distinct Subpopulation of Effector Memory T Lymphocytes Constitutes a Novel Mechanism of Toxic Shock Syndrome. Immunopathology. J Immunol. 198(7):2805-2818.
  12. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. 2020. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 395(10229):1033-1034.
  13. Emgård J, Bergsten H, McCormick JK, Barrantes I, Skrede S, Sandberg JK, Norrby-Teglund A. 2019. MAIT Cells Are Major Contributors to the Cytokine Response in Group A Streptococcal Toxic Shock Syndrome. Proc Natl Acad Sci. 116(51):25923-25931.
  14. Liu Q, Zhou YH, Yang ZQ. 2016. The cytokine storm of severe influenza and development of immunomodulatory therapy. Cell Mol Immunol.  13(1):3-10.
  15. Weaver LK, Behrens EM. 2017. Weathering the storm: Improving therapeutic interventions for cytokine storm syndromes by targeting disease pathogenesis. Curr Treatm Opt Rheumatol. 3(1):33-48.
  16. Francois B, Jeannet R, Daix T, Walton AH, Shotwell MS, Unsinger J, Monneret G, Rimmelé T, Blood T, Morre M, Gregoire A, Mayo GA, Blood J, Durum SK, Sherwood ER, Hotchkiss RS. 2018. Interleukin-7 restores lymphocytes in septic shock: the IRIS-7 randomized clinical trial. JCI Insight. 3(5).
  17. Thevarajan I, Nguyen THO, Koutsakos M, Druce J, Caly L, van de Sandt CE, Jia X, Nicholson S, Catton M, Cowie B, Tong SYC, Lewin SR, Kedzierska K. 2020. Breadth of concomitant immune responses prior to patient recovery: a case report of non-severe COVID-19. Nat Med. 26(4):453-455.
  18. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B. 2020. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 395(10229):1054-1062.
  19. Moore JB, June CH. 2020. Cytokine release syndrome in severe COVID-19. Science. 368(6490):473-474.

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