The

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clinical implications of basic research

Systemic Lupus Erythematosus and the Neutrophil

Xavier Bosch, M.D., Ph.D.
Most physicians can identify B lymphocytes and
T lymphocytes, and perhaps dendritic cells, as the
cells involved in the pathogenesis of systemic
lupus erythematosus (SLE). This systemic autoimmune disease is characterized by the loss of
tolerance to nuclear antigens, the deposition of immune complexes in tissues, and multiorgan involvement. Recent studies, such as those by Lande
et al.1 and Garcia-Romo et al.,2 have pushed the
neutrophil to the forefront of the pathogenesis of
SLE and have provided insight into how the implicated biochemical and cellular events are linked.
The chronic activation of plasmacytoid dendritic cells by circulating immune complexes is
a key, early trigger of autoimmunity in patients
with SLE. These immune complexes provoke the
plasmacytoid dendritic cells to secrete type I interferons. In lupus, the prevalence of circulating
plasmacytoid dendritic cells is markedly reduced
because these cells migrate to the tissues and
remain therein; however, residual, single circulating plasmacytoid dendritic cells can produce
interferon- normally3 and in huge amounts,
which can have a systemic effect. A single plasmacytoid dendritic cell synthesizes around a billion
interferon- molecules in a 12hour period
200 to 1000 times as many as other cell types.4
Genomic studies indicate that around 95% of
children and 70% of adults with SLE have a type I
interferon signature, of which interferon- is a
hallmark. Also characteristic of this disorder is
the expression of neutrophil-specific genes, which
correlates with disease activity. Thus, neutrophilspecific genes are the second most prevalent
peripheral-blood mononuclear-cell transcriptional signature in children with SLE.5 Furthermore,
the presence of neutrophil-specific proteins in
the urine, a surrogate marker of disease activity
in lupus, may be an indicator of their possible
role in its pathogenesis.
The studies by Lande et al. and Garcia-Romo
et al. suggest that a peculiar chromatin-based
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substance that is spewed into the extracellular

matrix as the neutrophil undergoes a unique
form of cell death so-called NETosis represents the link between interferon- production
and neutrophil death. The discovery of this substance, dubbed the neutrophil extracellular trap
(NET), revealed that neutrophils can immobilize
and kill invading microbes by means of NET
formation. In some patients with SLE, the degradation of NETs is impaired owing to DNase I
inhibitors or antibodies to NETs.
Lande et al. observed that the antimicrobial
peptide LL-37 a key mediator of plasmacytoid
dendritic cell activation in psoriasis was expressed at high levels in the blood of persons
with SLE, suggesting that LL-37 is involved in the
immunogenicity of self nucleic acids in immune
complexes. They confirmed that LL-37 and human neutrophil peptide (HNP) are essential for
the immunogenicity of DNA-containing immune
complexes in SLE and that free human DNA entered and activated plasmacytoid dendritic cells
through toll-like receptor 9 when complexed with
LL-37. Likewise, autoantibodies in immune complexes interacted with the Fc surface receptor II
(FcRII) on plasmacytoid dendritic cells and triggered receptor-mediated endocytosis of self DNA.
Self DNAantimicrobial peptide complexes,
LL-37 and HNP, which would seem to be pivotal
components of NETs, activate plasmacytoid dendritic cells to produce interferon- (Fig. 1). Both
antiLL-37 and anti-HNP antibodies activate neutrophils to release NETs; exposure of neutrophils to interferon- in vitro is followed by expression of the LL-37 and HNP peptides. Lande
et al. observed a significant correlation between
high levels of antiLL-37 and anti-HNP antibodies
and anti-DNA antibody titers, suggesting that
neutrophil-derived antimicrobial peptides act as
B-cell autoantigens in conjunction with DNA.
Garcia-Romo et al. also showed that NETs
in SLE contain LL-37, and they went on to show

n engl j med 365;8 nejm.org august 25, 2011

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Clinical Implications of Basic Research

Figure 1. Activation of Plasmacytoid Dendritic Cells by Neutrophils in Systemic Lupus Erythematosus (SLE).
Release of neutrophil extracellular traps (NETs) by neutrophils and the activation of plasmacytoid dendritic cells direct the chronic
interferon- production observed in SLE. Type I interferons prime the neutrophils for NETosis, with translocation of LL-37 to the surface.
NETosis begins by the binding of surface LL-37 by antiLL-37 autoantibodies. NETs released from dying neutrophils are taken up by plasmacytoid dendritic cells as a NET-associated LL-37DNA immune complex, together with antiLL-37 or anti-DNA autoantibodies. NET-associated self DNA engages toll-like receptor 9 (TLR9) in endosomes, leading to interferon release and additional neutrophil priming. Moreover,
neutrophil-derived antimicrobial peptides such as LL-37 are used as B-cell autoantigens in combination with DNA. As a result, abundant
NET creation may also prompt autoreactive B-cell activation, possibly through the capacity of NETs to engage B-cell receptors and TLR9
in B cells, leading to the release of antiLL-37 and anti-DNA autoantibodies. IFNAR denotes type I interferon- receptor.

that immune complexes harboring anti-ribonucleoprotein autoantibodies bonded with FcRIIA

on neutrophils undergoing death by NETosis,
resulting in the production of reactive oxygen

species. They observed that, ultimately, these

events led to the activation of plasmacytoid dendritic cells and thus the robust secretion of
interferon-.

n engl j med 365;8 nejm.org august 25, 2011

759

The New England Journal of Medicine

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Clinical Implications of Basic Research

These findings suggest that, in SLE, anti-self

antibodies activate neutrophils, which in turn
release NETs containing complexes of DNA and
antimicrobial peptide. These complexes activate
plasmacytoid dendritic cells, leading to inter
feron- release and exacerbation or perpetuation of inflammation and disease. The molecular basis of NET formation remains unclear,
although it is known that reactive oxygen species
trigger the activation of neutrophil enzymes and
their relocation to the nucleus to initiate DNA
unwinding, upon which NET formation depends.
Increased production of reactive oxygen species,
such as the superoxide anion and hydrogen peroxide, is associated with SLE, as shown by oxidative protein modifications, lipid peroxidation,
and lipoprotein oxidation.
Might the suppression of NET formation as a
result of scavenging of reactive oxygen species
halt chronic autoimmunity in patients with SLE?
Diphenylene iodonium (a potent inhibitor of
NADPH oxidase that prevents oxygen-derived
free-radical generation in neutrophils) profoundly impairs NET formation. Glutathione, a hydrogen peroxide scavenger, inhibits neutrophil death;
catalase, which reduces hydrogen peroxide to
water, delays normal neutrophil apoptosis.1
Specific interference in the signaling of tolllike receptors might also become an attractive
treatment goal in SLE, for which the therapy often includes nonspecific, toxic immunosuppressive drugs. For instance, hydroxychloroquine,

which inhibits signaling by means of the tolllike receptors 3, 7, 8, and 9, is effective in SLE,
and the inhibition of toll-like receptors 7 and
9 mitigates manifestation of the disease in lupusprone mice.3
It remains to be shown whether NETosis may
serve as a biomarker or predictor of tissue damage in SLE and whether enhanced NETosis,
which has already been shown to occur in some
vasculitides, is a factor in other autoimmune
diseases associated with autoantibody production, interferon signatures, or vascular damage,
such as in Sjgrens syndrome, rheumatoid arthritis, or inflammatory myopathies.
Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.
From the Department of Internal Medicine, Hospital Clinic,
University of Barcelona, Institut dInvestigacions Biomdiques
August Pi i Sunyer, Barcelona.
1. Lande R, Ganguly D, Facchinetti V, et al. Neutrophils acti-

vate plasmacytoid dendritic cells by releasing self-DNA-peptide

complexes in systemic lupus erythematosus. Sci Transl Med 2011;
3:73ra19.
2. Garcia-Romo GS, Caielli S, Vega B, et al. Netting neutrophils
are major inducers of type I IFN production in pediatric systemic lupus erythematosus. Sci Transl Med 2011;3:73ra20.
3. Lahita RG, ed. Systemic lupus erythematosus. 5th ed. Boston:
Elsevier, 2011.
4. Obermoser G, Pascual V. The interferon-alpha signature of
systemic lupus erythematosus. Lupus 2010;19:1012-9.
5. Villanueva E, Yalavarthi S, Berthier CC, et al. Netting neutrophils induce endothelial damage, infiltrate tissues, and expose
immunostimulatory molecules in systemic lupus erythematosus.
J Immunol 2011;187:538-52.
Copyright 2011 Massachusetts Medical Society.

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n engl j med 365;8 nejm.org august 25, 2011

The New England Journal of Medicine

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Copyright 2011 Massachusetts Medical Society. All rights reserved.