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Gastrointestinal allergic reactions compromise human health and social economy.

As many as 4~8% of children and 1~2% of adults have the IgE-mediated hypersensitivity to food antigens [16, 17]. The prevalence of food allergy and related disorders has increased rapidly across the world in the last few decades [18]. Research in the area of food allergy has advanced greatly in recent years; however the pathogenesis of food allergy remains unclear [19].The symptoms of food allergy range from slight inconveniences to life-threatening anaphylactic shock reactions [17]. Food allergic reaction involves not only the intestinal tract, but other body systems such as the skin [20], the airway [21] and the cardiovascular system [22]. IgE-mediated food allergy is one of the causes of eosinophil accumulation in the gastrointestinal tract that is a common feature of numerous gastrointestinal disorders [23]. Since the food allergic disorders are common throughout the world, affecting the males and the females of all ages, races and all social classes, they certainly represent a substantial burden of morbidity and health service cost [24, 25].

Oral tolerance maintains the homeostasis in intestinal tissue

Oral tolerance, as characterized by Chase in 1946 [26], refers to a state of active inhibition of immune responses to an antigen by means of prior exposure to that antigen through the oral route. In animal models, oral tolerance appears to be a specific consequence of the immune environment in the intestine, which favors the generation of T regulatory cells [27, 28]. The mechanism of oral tolerance may involve either anergy/deletion of CD4+ T cells, or the induction of regulatory CD4+ T cells (Tregs) that produce immune suppressive cytokines interleukin 10 (IL-10) and/or TGFbeta [29, 30]. Such CD4+ Tregs include CD4+CD25+ cells [31, 32]. It is postulated that a breakdown in oral tolerance or a failure of induction of oral tolerance results in hypersensitivity to food antigens [33]. However, it remains unclear how the established oral tolerance breaks down or fails to develop.

Th2 polarization plays a crucial role in oral tolerance impairment and the initiation of intestinal sensitization

The etiology of food allergy remains unclear; a failure to develop or a breakdown in the maintenance of, oral tolerance may be responsible [27, 28, 34, 35]. The key feature of the disease is a T-helper type 2 (Th2)-predominant allergen-specific immune response, with the production of IgE antibodies specific for the food allergen [1]. Th2 cells are produced when type 2 dendritic cells present antigen to the T cell's receptor for antigen (TCR) [36]. Contrast to Th1 cells which release type 1 cytokines such as IFNγ, the major cytokines secreted by Th2 cells are Th2 cytokines IL-4, IL-5 and IL-13. These cytokines are of major importance because IL-4 and IL-13 induce the production of IgE by B cells [37]. T cell differentiation is a complex process that is regulated by a network of transcription factors [38], including transcription factors T-box expressed in T cells (T-bet) and GATA binding protein 3 (GATA3) that are considered as the master regulators of Th1 and Th2 differentiation, respectively [38, 39]. (Fig 1).

Role of SEB in allergic diseases

Staphylococcus aureus (S. aureus) is consistently found in human’s intestine [40-42]. SEB is one of the enterotoxins produced by S. aureus that has multifaceted functions in the immune regulation [43-45]. SEB induces vigorous activation, proliferation, and cytokine production by T cells that express specific TCR variable beta (Vß) chains. Some investigators associate SEB with inducing the Th1 pattern inflammation [46-48], however, mounting evidence indicates that SEB is also involved in the pathogenesis of allergic diseases [43, 49-52] although the mechanisms have remained unclear. We and others have found that the simultaneous exposure to SEB and food antigens such as ovalbumin (OVA) enhances susceptibility to allergic reactions [43, 53-55]. SEB triggers immune cells to release the Th2 cytokines IL-4, IL-5 and IL-13 [55-58] and enhances antigen-specific immune responses [49, 59]. The primed T cells of antigen specificity would be further and more potently expanded by SEB [60, 61] while naive T cells of the same Vβ specificity would become anergized [62]. CD4+CD25+ Tregs play roles in suppression of the Th2 reactions [63-65]; however, in SEB-involved atopic patients, CD4+CD25+ Tregs demonstrate incompetent inhibitory capability in suppression of the Th2 reactions [66]. SEB would thus be a potent activator of both cellular and humoral arms of the immune system in an antigen-specific manner. SEB increases permeability of the intestinal epithelium leading to enhanced uptake of the co-administered antigen [53]. SEB also induces dendritic cell maturation that may enhance antigen presentation by APCs [67].

Adjuvants are required to induce sensitization in animal models

Adjuvants are substances that are added to vaccines or with antigens to improve the immune responses. Such adjuvants work by speeding the differentiation of lymphocytes. We induce intestinal sensitization in animal models using pertussis toxins/vaccines as adjuvants together with antigens ([3-6, 68-72]. Cholera toxins [1], Freund's adjuvant [73], etc are also commonly used with antigens in developing allergic animal models. Microbe-derived toxins or their components are commonly used as adjuvants. They more likely induce Th1 reactions if used alone [74, 75)] but enhance both Th1 and Th2 or Th2 reactions when used together with antigens [76, 77]. Similar to the adjuvants mentioned above, SEB has been shown to facilitate the development of either Th1 reactions [46-48] or Th2 allergic disorders [49-52].

Role of TIM1 and TIM4 in regulation of immune function

The family of TIMs has been described in the mice recently, and their homologous molecules have been identified in the human, monkey, and rodent [78]. TIM1 is encoded by a gene identified as an 'atopy susceptibility gene' (Havcr1) and is expressed on CD4+ T cells after activation. It is preferentially expressed in T helper type 2 (Th2) but not Th1 cells. TIM1 has been identified as being important in asthma and allergy susceptibility although it also associates with the hygiene theory because it is the receptor of the hepatitis A virus [79-82]. TIM1 plays an important role in the activation of Th2 cells and the inhibition of the peripheral tolerance [83, 84]. On the other hand, TIM4 is expressed by APCs; it is the ligand for TIM1. In vitro stimulation of CD4+ T cells with a TIM-1-specific monoclonal antibody and T cell receptor ligation enhanced T cell proliferation; in Th2 cells, such costimulation greatly enhanced synthesis of interleukin 4 but not interferon-gamma [83]. In vivo administration of either the soluble TIM1-immunoglobulin (TIM1-Ig) fusion protein or the TIM4-Ig fusion protein resulted in hyperproliferation of T cells, and TIM4-Ig costimulated T cell proliferation mediated by CD3 and CD28 in vitro. These data suggest that the TIM1-TIM4 interaction is involved in regulating T cell proliferation [34]. Although SEB can bind to the TCR to activate T cells directly, SEB also promotes dendritic cell maturation as shown by increased expression of CD40, CD80 and CD86 [67]; Our previous study indicates that SEB also increases the TIM4 expression in the intestinal APCsand increase the histone acetylation at lysine 9 (an indicator of gene transcription).

Specific gaps in existing knowledge in the field of food allergy research

We know that antigens interact with immune cells and induce the immune reactions; it has been unclear what decides the outcome of immune reactions in the gut: immune-tolerance or hypersensitivity [16-18]. While the growing evidence indicates that SEB plays roles in the regulation of both Th1 and Th2 inflammation, the mechanisms have to be understood [46, 47, 50, 51]. Emerging evidence strongly suggests a critical role of the TIM1 and TIM4 interaction in regulation of Th1/Th2 balance [34, 35, 83, 84]. However, the role of TIM1 and TIM4 in the immune mechanisms of food allergy in the intestine has not been investigated. We have established a murine model of intestinal Th2 sensitization and food allergy by concurrent exposure to SEB (microbial product) and OVA (food antigen). By using this model system, we will investigate the role of TIM1 and TIM4 interaction in the immunopathogenesis of intestinal food allergy. Both in vitro and in vivo approaches will be used in our studies.

Recent advances

We recent found that a significant increase in TIM4 expression in human DCs was observed in response to SEB stimulation via Toll-like receptor (TLR)2 and nucleotide-binding oligomerization domain (NOD)1 pathway. Coculture SEB-conditioned DCs with naïve CD4 T cells induced Th2 responses that could be abolished using TLR2 or NOD1 or TIM4 or TIM1 with counterpart antibodies or RNA interference. The results demonstrate that Staphylococcus aureus derived SEB promotes the TIM4 production in human DCs. The interaction between TIM4 and TIM1 drives naïve CD4 T cells to develop to Th2 cells [85]. In another study, we determined the role of TIM-4, a recently identified member of cell surface molecules, in the pathogenesis of intestinal allergy in a murine model. We report that TIM-4 as well as costimulatory molecules were up-regulated in intestinal mucosal dendritic cells by in vitro or in vivo exposure to SEB. SEB-conditioned intestinal dendritic cells loaded with a food macromolecule ovalbumin (OVA) induced potent OVA-specific Th2 lymphocyte responses in vitro and such Th2 responses were inhibited completely by TIM-4 blockade. In vivo exposure to both SEB and OVA resulted in OVA-specific Th2 differentiation and intestinal allergic responses including increased serum immunoglobulin E and Th2 cytokine levels, activation of OVA-specific Th2 cells detected both ex vivo and in situ, and mast cell degranulation. Of importance, in vivo abrogation of TIM-4 or its cognate ligand TIM-1 by using a polyclonal antibody remarkably dampened Th2 differentiation and intestinal allergy. This study thus identifies TIM-4 as a novel molecule critically required for the development of intestinal allergy [86]. We have taken a further step in this series of study. In a project with animal model, mouse bone marrow-derived DCs (BMDCs) were generated and exposed to cholera toxin (CT) or/and peanut extract (PE) for 24 hours and then adoptively transferred to naive mice. After re-exposure to specific antigen PE, the mice were killed; intestinal allergic status was determined. The results showed that Increased expression of TIM4 and costimulatory molecules was detected in BMDCs after concurrent exposure to CT and PE. Adoptively transferred CT/PE-conditioned BMDCs resulted in the increases in serum PE-specific IgE and skewed T(H)2 polarization in the intestine. Oral challenge with specific antigen PE induced mast cell activation in the intestine. Treating with Toll-like receptor 4 small interfering RNA abolished increased expression of TIM4 and costimulatory molecules by BMDCs. Pretreatment with anti-TIM1 or anti-TIM4 antibody abolished PE-specific Th2 polarization and allergy in the intestine. We conclude that concurrent exposure to microbial product CT and food antigen PE increases TIM4 expression in DCs and promotes DC maturation, which plays an important role in the initiation of PE-specific Th2 polarization and allergy in the intestine. Modulation of TIM4 production in DCs represents a novel therapeutic approach for the treatment of peanut allergy [87].

References:

1. Cardoso CR, Provinciatto PR, Godoi DF, Ferreira BR, Teixeira G, Rossi MA, Cunha FQ, Silva JS. IL-4 regulates susceptibility to intestinal inflammation in murine food allergy. Am J Physiol Gastrointest Liver Physiol. 2009; 296: G593-600.

2. Berin MC, Mayer L. Immunophysiology of experimental food allergy. Mucosal Immunol. 2009;2:24-32.

3. Yang PC, Berin MC, Yu LC, Conrad DH, Perdue MH. Enhanced intestinal transepithelial antigen transport in allergic rats is mediated by IgE and CD23 (FcepsilonRII). J Clin Invest. 2000;106:879-86.

4. Yang PC, Berin MC, Yu L, Perdue MH. Mucosal pathophysiology and inflammatory changes in the late phase of the intestinal allergic reaction in the rat. Am J Pathol. 2001;158:681-90.

5. Yang PC, Berin MC, Perdue MH. Enhanced antigen transport across rat tracheal epithelium induced by sensitization and mast cell activation. J Immunol. 1999; 163: 2769-76.

6. Yang PC, Jury J, Soderholm J, Mckay DM, Sherman P, Perdue MH. Chronic psychological stress in rats induces intestinal sensitization to luminal antigens. Am J Pathol 2006; 168:104-14.

7. Yang M, Yang C, Nau F, Pasco M, Juneja LR, Okubo T, Mine Y. Immunomodulatory effects of egg white enzymatic hydrolysates containing immunodominant epitopes in a BALB/c mouse model of egg allergy. J Agric Food Chem. 2009;57:2241-8.

8. Srivastava KD, Qu C, Zhang T, Goldfarb J, Sampson HA, Li XM. Food Allergy Herbal Formula-2 silences peanut-induced anaphylaxis for a prolonged posttreatment period via IFN-gamma-producing CD8+ T cells. J Allergy Clin Immunol. 2009;123:443-51.

9. Matheson MC, Walters EH, Simpson JA, Wharton CL, Ponsonby AL, Johns DP, Jenkins MA, Giles GG, Hopper JL, Abramson MJ, Dharmage SC. Relevance of the hygiene hypothesis to early vs. late onset allergic rhinitis. Clin Exp Allergy. 2009;39:370-8.

10. Yazdanbakhsh M, Kremsner PG, van Ree R. Allergy, parasites, and the hygiene hypothesis. Science. 2002; 296: 490-4.

11. Kramer MS, Matush L, Bogdanovich N, Dahhou M, Platt RW, Mazer B. The low prevalence of allergic disease in Eastern Europe: are risk factors consistent with the hygiene hypothesis? Clin Exp Allergy. 2009;39:708-16.

12. Sheikh A, Strachan DP. The hygiene theory: fact or fiction? Curr Opin Otolaryngol Head Neck Surg. 2004; 12: 232-6.

13. Eisenbarth SC, Piggott DA, Huleatt JW, Visintin I, Herrick CA, Bottomly K. Lipopolysaccharide-enhanced, toll-like receptor 4-dependent T helper cell type 2 responses to inhaled antigen. J Exp Med. 2002;196:1645-51.

14. Rosenthal la, Moss mh. Lipopolysaccharide-enhanced, Toll-like Receptor 4–dependent T Helper Cell Type 2 Responses to Inhaled Antigen. PEDIATRICS 2004; 114: 527-528

15. Reed CE, Milton DK. Endotoxin-stimulated innate immunity: A contributing factor for asthma. J Allergy Clin Immunol. 2001;108:157-66.

16. Sicherer SH, Leung DY. Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2008. J Allergy Clin Immunol. 2009; 123: 319-27.

17. Sampson HA. Food allergy-accrurately identifying clinical reactivity. Allergy. 2005; 60 Suppl 79: 19-24.

18. Bishoff S, Crowe SE. Gastrointestinal food allergy: new insights into pathophysiology and clinical perspectives. Gastroenterology 2005; 128: 1089-113.

19. Cox HE. Food allergy as seen by an allergist. J Pediatr Gastroenterol Nutr. 2008;47 Suppl 2:S45-8.

20. Bath-Hextall F, Delamere FM, Williams HC. Dietary exclusions for improving established atopic eczema in adults and children: systematic review. Allergy. 2009;64:258-64.

21. Krogulska A, Wasowska-Królikowska K, Polakowska E, Chrul S. Cytokine profile in children with asthma undergoing food challenges. J Investig Allergol Clin Immunol. 2009; 19: 43-8.

22. Helbling A, Hurni T, Mueller UR, Pichler WJ. Incidence of anaphylaxis with circulatory symptoms: a study over a 3-year period comprising 940,000 inhabitants of the Swiss Canton Bern. Clin Exp Allergy. 2004;34:285-90.

23. Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). J Allergy Clin Immunol. 2004;113:11-28.

24. Guest JF, Valovirta E. Modelling the resource implications and budget impact of new reimbursement guidelines for the management of cow milk allergy in Finland. Curr Med Res Opin. 2008;24:1167-77.

25. Keil T. Epidemiology of food allergy: what's new? A critical appraisal of recent population-based studies. Curr Opin Allergy Clin Immunol. 2007;7:259-63.

26. Chase M W. Inhibition of experimental drug allergy by prior feeding of the sensitizing agent. Proc Soc Exp Biol Med 1946;61:257–259

27. Nowak-Wegrzyn A, Fiocchi A. Rare, medium, or well done? The effect of heating and food matrix on food protein allergenicity. Curr Opin Allergy Clin Immunol. 2009;9:234-7.

28. Mowat AM. Anatomical basis of tolerance and immunity to intestinal antigens. Nat Rev Immunol. 2003;3:331-41.

29. Shiokawa A, Tanabe K, Tsuji NM, Sato R, Hachimura S. IL-10 and IL-27-producing dendritic cells capable of enhancing IL-10 production of T cells are induced in oral tolerance. Immunol Lett. 2009; PMID: 19446579.

30. Perruche S, Zhang P, Liu Y, Saas P, Bluestone JA, Chen W. CD3-specific antibody-induced immune tolerance involves transforming growth factor-beta from phagocytes digesting apoptotic T cells. Nat Med. 2008;14:528-35.

31. Ochi H, Abraham M, Ishikawa H, Frenkel D, Yang K, Basso AS, Wu H, Chen ML, Gandhi R, Miller A, Maron R, Weiner HL. Oral CD3-specific antibody suppresses autoimmune encephalomyelitis by inducing CD4+ CD25- LAP+ T cells. Nat Med. 2006;12:627-35.

32. Pandiyan P, Zheng L, Ishihara S, Reed J, Lenardo MJ. CD4+CD25+Foxp3+ regulatory T cells induce cytokine deprivation-mediated apoptosis of effector CD4+ T cells. Nat Immunol. 2007;8:1353-62.

33. Wanich N, Nowak-Wegrzyn A, Sampson HA, Shreffler WG. Allergen-specific basophil suppression associated with clinical tolerance in patients with milk allergy. J Allergy Clin Immunol. 2009;123:789-94.

34. Meyers JH, Chakravarti S, Schlesinger D, Illes Z, Waldner H, Umetsu SE, Kenny J, Zheng XX, Umetsu DT, DeKruyff RH, Strom TB, Kuchroo VK. TIM-4 is the ligand for TIM-1, and the TIM-1-TIM-4 interaction regulates T cell proliferation. Nat Immunol. 2005;6:455-64.

35. Meyers JH, Sabatos CA, Chakravarti S, Kuchroo VK. The TIM gene family regulates autoimmune and allergic diseases. Trends Mol Med. 2005; PMID: 16002337

36. Strober W. Vitamin A rewrites the ABCs of oral tolerance. Mucosal Immunol. 2008;1:92-5.

37. Pesce JT, Ramalingam TR, Wilson MS, Mentink-Kane MM, Thompson RW, Cheever AW, Urban JF Jr, Wynn TA. Retnla (relmalpha/fizz1) suppresses helminth-induced th2-type immunity. PLoS Pathog. 2009;5:e1000393.

38. Timmermans F, Velghe I, Vanwalleghem L, De Smedt M, Van Coppernolle S, Taghon T, Moore HD, Leclercq G, Langerak AW, Kerre T, Plum J, Vandekerckhove B. Generation of T cells from human embryonic stem cell-derived hematopoietic zones. J Immunol. 2009;182:6879-88.

39. Charles N, Watford WT, Ramos HL, Hellman L, Oettgen HC, Gomez G, Ryan JJ, O'Shea JJ, Rivera J. Lyn kinase controls basophil GATA-3 transcription factor expression and induction of Th2 cell differentiation. Immunity. 2009;30:533-43.

40. Lundequist B, Nord CE, Winberg J. The composition of the faecal microflora in breastfed and bottle fed infants from birth to eight weeks. Acta Paediatr Scand. 1985;74:45-51.

41. Sepp E, Julge K, Vasar M, Naaber P, Bjorksten B, Mikelsaar M. Intestinal microflora of Estonian and Swedish infants. Acta Paediatr. 1997;86:956-61.

42. Lindberg E, Nowrouzian F, Adlerberth I, Wold AE. Long-time persistence of superantigen-producing Staphylococcus aureus strains in the intestinal microflora of healthy infants. Pediatr Res. 2000;48:741-7.

43. Ganeshan K, Neilsen CV, Hadsaitong A, Schleimer RP, Luo X, Bryce PJ. Impairing oral tolerance promotes allergy and anaphylaxis: a new murine food allergy model. J Allergy Clin Immunol. 2009;123:231-238.

44. Heriazon A, Zhou P, Borojevic R, Foerster K, Streutker CJ, Ng T, Croitoru K. Regulatory T cells modulate staphylococcal enterotoxin B-induced effector T-cell activation and acceleration of colitis. Infect Immun. 2009; 77: 707-13.

45. Deshmukh HS, Hamburger JB, Ahn SH, McCafferty DG, Yang SR, Fowler VG Jr. Critical role of NOD2 in regulating the immune response to Staphylococcus aureus. Infect Immun. 2009;77:1376-82.

46. Dionne S, Laberge S, Deslandres C, Seidman EG.Modulation of cytokine release from colonic explants by bacterial antigens in inflammatory bowel disease. Clin Exp Immunol. 2003; 133: 108-14.

47. Lu J, Wang A, Ansari S, Hershberg RM, McKay DM. Colonic bacterial superantigens evoke an inflammatory response and exaggerate disease in mice recovering from colitis. Gastroenterology. 2003;125:1785-95.

48. Spiekermann GM, Nagler-Anderson C. Oral administration of the bacterial superantigen staphylococcal enterotoxin B induces activation and cytokine production by T cells in murine gut-associated lymphoid tissue. J Immunol. 1998;161:5825-31.

49. Chung SH, Nam KH, Kweon MN. Staphylococcus aureus accelerates an experimental allergic conjunctivitis by Toll-like receptor 2-dependent manner. Clin Immunol. 2009; 131: 170-7.

50. Kedzierska A, Kaszuba-Zwoinska J, Slodowska-Hajduk Z, Kapinska-Mrowiecka M, Czubak M, Thor P, Wojcik K, Pryjma J. SEB-induced T cell apoptosis in atopic patients--correlation to clinical status and skin colonization by Staphylococcus aureus. Arch Immunol Ther Exp (Warsz). 2005; 53:63-70.

51. Suh YJ, Yoon SH, Sampson AP, Kim HJ, Kim SH, Nahm DH, Suh CH, Park HS. Specific immunoglobulin E for staphylococcal enterotoxins in nasal polyps from patients with aspirin-intolerant asthma. Clin Exp Allergy. 2004; 34: 1270-5.

52. Lehmann HS, Heaton T, Mallon D, Holt PG. Staphylococcal enterotoxin-B-mediated stimulation of interleukin-13 production as a potential aetiologic factor in eczema in infants. Int Arch Allergy Immunol. 2004;135:306-12.

53. Yang PC, Wang CS, An ZY. A murine model of ulcerative colitis: induced with sinusitis-derived Superantigen and food allergen. BMC Gastroenterol 2005; 5: 6.

54. Yang PC, Liu T, Wang BQ, Zhang TY, An ZY, Zheng PY, Tian DF. Rhinosinusitis derived Staphylococcal enterotoxin B possibly associates with pathogenesis of ulcerative colitis. BMC Gastroenterol. 2005;5:28

55. Dhaliwal W, Kelly P, Bajaj-Elliott M. Differential effects of Staphylococcal enterotoxin B-mediated immune activation on intestinal defensins. Clin Exp Immunol. 2009;156:263-70.

56. Ardern-Jones MR, Black AP, Bateman EA, Ogg GS. Bacterial superantigen facilitates epithelial presentation of allergen to T helper 2 cells. Proc Natl Acad Sci U S A. 2007 27; 104:5557-62.

57. Liu T, Wang BQ, Zheng PY, He SH, Yang PC. Rhinosinusitis derived Staphylococcal enterotoxin B plays a possible role in pathogenesis of food allergy. BMC Gastroenterol. 2006 18;6:24.

58. Hellings PW, Hens G, Meyts I, Bullens D, Vanoirbeek J, Gevaert P, Jorissen M, Ceuppens JL, Bachert C. Aggravation of bronchial eosinophilia in mice by nasal and bronchial exposure to Staphylococcus aureus enterotoxin B. Clin Exp Allergy. 2006;36:1063-71.

59. Matsui K, Nishikawa A. Effects of the macrolide antibiotic, midecamycin, on Staphylococcus aureus product-induced Th2 cytokine response in patients with atopic dermatitis. J Interferon Cytokine Res. 2004;24:197-201.

60. Soos, J. M., J. Schiffenbauer, H. M. Johnson. Treatment of PL/J mice with the superantigen, staphylococcal enterotoxin B, prevents development of experimental allergic encephalomyelitis. J. Neuroimmunol 1993; 43:39.

61. Schiffenbauer, J., H. M. Johnson, E. J. Butfiloski, L. Wegrzyn, J. M. Soos. Staphylococcal enterotoxins can reactivate experimental allergic encephalomyelitis. Proc. Natl. Acad. Sci. USA1993; 90:8543.

62. Kawabe, Y., A. Ochi. 1991. Programmed cell death and extrathymic reduction of Vβ8+ CD4+ T cells in mice tolerant to Staphylococcus aureus enterotoxin B. Nature 1991; 349: 245.

63. Ring S, Oliver SJ, Cronstein BN, Enk AH, Mahnke K. CD4(+)CD25(+) regulatory T cells suppress contact hypersensitivity reactions through a CD39, adenosine-dependent mechanism. J Allergy Clin Immunol. 2009; PMID: 19427686.

64. Ozdemir C, Akdis M, Akdis CA. T regulatory cells and their counterparts: masters of immune regulation. Clin Exp Allergy. 2009;39:626-39.

65. Suto A, Nakajima H, Kagami SI, Suzuki K, Saito Y, Iwamoto I. Role of CD4(+) CD25(+) regulatory T cells in T helper 2 cell-mediated allergic inflammation in the airways. Am J Respir Crit Care Med. 2001;164:680-7.

66. Provoost S, Maes T, van Durme YM, Gevaert P, Bachert C, Schmidt-Weber CB, Brusselle GG, Joos GF, Tournoy KG. Decreased FOXP3 protein expression in patients with asthma. Allergy. 2009; PMID: 19392991

67. Yoon S, Bae KL, Shin JY, Yoo HJ, Lee HW, Baek SY, Kim BS, Kim JB, Lee HD. Analysis of the in vivo dendritic cell response to the bacterial superantigen staphylococcal enterotoxin B in the mouse spleen. Histol Histopathol. 2001; 16: 1149-59.

68. Cameron HL, Yang PC, Perdue MH. Glucagon-like peptide-2-enhanced barrier function reduces pathophysiology in a model of food allergy. Am J Physiol Gastrointest Liver Physiol. 2003;284:G905-12.

69. Yu LC, Montagnac G, Yang PC, Conrad DH, Benmerah A, Perdue MH.Intestinal epithelial CD23 mediates enhanced antigen transport in allergy: evidence for novel splice forms.Am J Physiol Gastrointest Liver Physiol. 2003; 285: G223-34.

70. Yu LC, Yang PC, Berin MC, Di Leo V, Conrad DH, McKay DM, Satoskar AR, Perdue MH. Enhanced transepithelial antigen transport in intestine of allergic mice is mediated by IgE/CD23 and regulated by interleukin-4. Gastroenterology. 2001;121:370-81.

71. Berin MC, Kiliaan AJ, Yang PC, Groot JA, Taminiau JA, Perdue MH. Rapid transepithelial antigen transport in rat jejunum: impact of sensitization and the hypersensitivity reaction. Gastroenterology. 1997;113:856-64.

72. Berin MC, Yang PC, Ciok L, Waserman S, Perdue MH. Role for IL-4 in macromolecular transport across human intestinal epithelium. Am J Physiol. 1999;276:C1046-52.

73. Strid J, Thomson M, Hourihane J, Kimber I, Strobel S. A novel model of sensitization and oral tolerance to peanut protein. Immunology. 2004;113:293-303.

74. Sanchez AE, Aquino G, Ostoa-Saloma P, Laclette JP, Rocha-Zavaleta L. Cholera toxin B-subunit gene enhances mucosal immunoglobulin A, Th1-type, and CD8+ cytotoxic responses when coadministered intradermally with a DNA vaccine. Clin Diagn Lab Immunol. 2004;11:711-9.

75. Fedele G, Stefanelli P, Spensieri F, Fazio C, Mastrantonio P, Ausiello CM. Bordetella pertussis-infected human monocyte-derived dendritic cells undergo maturation and induce Th1 polarization and interleukin-23 expression. Infect Immun. 2005;73:1590-7.

76. Boyd AP, Ross PJ, Conroy H, Mahon N, Lavelle EC, Mills KH. Bordetella pertussis adenylate cyclase toxin modulates innate and adaptive immune responses: distinct roles for acylation and enzymatic activity in immunomodulation and cell death. J Immunol. 2005; 175: 730-8.

77. Holmgren J, Adamsson J, Anjuere F, et al. Mucosal adjuvants and anti-infection and anti-immunopathology vaccines based on cholera toxin, cholera toxin B subunit and CpG DNA. Immunol Lett. 2005;97:181-8.

78. McIntire JJ, Umetsu DT, DeKruyff RH. TIM-1, a novel allergy and asthma susceptibility gene. Springer Semin Immunopathol. 2004;25:335-48.A78

79. Umetsu DT, McIntire JJ, DeKruyff RH. TIM-1, hepatitis A virus and the hygiene theory of atopy: association of TIM-1 with atopy. J Pediatr Gastroenterol Nutr. 2005;40 Suppl 1:S43.

80. Monney, L., C. A. Sabatos, J. L. Gaglia, A. Ryu, H. Waldner, T. Chernova, S. Manning, E. A. Greenfield, A. J. Coyle, R. A. Sobel, et al Th1-specific cell surface protein Tim-3 regulates macrophage activation and severity of an autoimmune disease. Nature 2002; 415:536.

81. Kuchroo, V. K., D. T. Umetsu, R. H. DeKruyff, G. J. Freeman. The TIM gene family: emerging roles in immunity and disease. Nat. Rev. Immunol 2003; 3:454.

82. McIntire JJ, Umetsu SE, Akbari O, Potter M, Kuchroo VK, Barsh GS, Freeman GJ, Umetsu DT, DeKruyff RH. Identification of Tapr (an airway hyperreactivity regulatory locus) and the linked Tim gene family. Nat Immunol. 2001; 2: 1109-16.

83. Umetsu SE, Lee WL, McIntire JJ, Downey L, Sanjanwala B, Akbari O, Berry GJ, Nagumo H, Freeman GJ, Umetsu DT, DeKruyff RH. TIM-1 induces T cell activation and inhibits the development of peripheral tolerance. Nat Immunol. 2005; 6: 447-54.

84. Khademi M, Illes Z, Gielen AW, Marta M, Takazawa N, Baecher-Allan C, Brundin L, Hannerz J, Martin C, Harris RA, Hafler DA, Kuchroo VK, Olsson T, Piehl F, Wallstrom E. T Cell Ig- and mucin-domain-containing molecule-3 (TIM-3) and TIM-1 molecules are differentially expressed on human Th1 and Th2 cells and in cerebrospinal fluid-derived mononuclear cells in multiple sclerosis. J Immunol. 2004; 172: 7169-76.

85. Liu T, He SH, Zheng PY, Zhang TY, Wang BQ, Yang PC. Staphylococcal enterotoxin B increases TIM4 expression in human dendritic cells that drives naïve CD4 T cells to differentiate into Th2 cells. Mol Immunol. 2007;44:3580-7.

86. Yang PC, Xing Z, Berin CM, Soderholm JD, Feng BS, Wu L, Yeh C. TIM-4 expressed by mucosal dendritic cells plays a critical role in food antigen-specific Th2 differentiation and intestinal allergy. Gastroenterology. 2007; 133: 1522-33.

87. Feng BS, Chen X, He SH, Zheng PY, Foster J, Xing Z, Bienenstock J, Yang PC. Disruption of T-cell immunoglobulin and mucin domain molecule (TIM)-1/TIM4 interaction as a therapeutic strategy in a dendritic cell-induced peanut allergy model. J Allergy Clin Immunol. 2008;122:55-61.