Increase of tissue factor expression on the surface of peripheral monocytes of patients with chronic spontaneous urticaria

概要

Accepted Article

DR. RYO

SAITO (Orcid ID : 0000-0002-1927-8147)

PROF. MICHIHIRO

Article type

HIDE (Orcid ID : 0000-0001-6183-6467)

: Letter to the Editor

Title;

Increase of tissue factor expression on the surface of peripheral monocytes of patients with chronic
spontaneous urticaria

To the Editor,
The involvement of the coagulation cascade has been demonstrated in the pathogenesis of chronic spontaneous
urticaria (CSU) by a number of observations, including successful treatment of CSU with anticoagulants1,2). We
previously reported that blood coagulation potential is elevated in CSU, and that histamine and agonists for
toll-like receptors (TLRs) may synergistically induce tissue factor (TF) expression on vascular endothelial
cells3,4). Immunohistochemical staining revealed TF expression by eosinophils in the lesion of CSU5). However,
monocytes are considered to be the main source of TF in the blood, causing clot formation6). We here
investigated the level of TF expression on monocytes in the blood of patients with CSU, and the potential of TF

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on monocytes to trigger the extrinsic coagulation cascade and consequential inter-cellular gap formation of
vascular endothelial cells.
Peripheral Blood Mononuclear Cells (PBMC) were obtained from 79 patients and 10 healthy donors.

No

statistical differences were detected between the groups in terms of age and sex by the Mann Whitney test and
the Chi-square test, respectively (Table S1). Clinical features of patients with CSU are summarized in Table S2.
Based on the cytometric analysis, TF expression on monocytes in CSU patients was significantly higher than
that in healthy donors (Fig 1a). We then investigated TF expression on monocytes in response to TLR agonists
and/or histamine in vitro. Monocytes were stimulated with various TLR agonists and/or histamine. As shown in
Fig 1b, c, monocytes from normal donors stimulated by agonists for TLR 1,2,4,5 enhanced both TF mRNA and
TF protein expressions, whereas those by agonists for TLR 3,6,7,8,9 and histamine did not.
Considering the association of Helicobacter pylori infection and CSU in many reported cases, we initially
studied the effect of Lipopolysaccharide (LPS), which derives from Gram-negative bacteria and activates TLR4,
on the TF expression of monocytes. The expression of TF mRNA and cell surface TF protein by the monocytes
from normal donors increased in response to LPS stimulation in a dose-dependent manner (Fig S1a, b). To test if
the LPS-induced TF of monocytes have procoagulant activity, monocytes isolated from normal donors were
stimulated with LPS and measured for their TF activity. TF activity assay showed an enhanced activity of TF in
an LPS-dose-dependent manner from the range of 0.1 pg/mL to 100 pg/mL (Fig 1e).
To evaluate the effect of TF of monocytes on vascular permeability, we performed impedance analysis, which
reflects the area of cellular adhesion and morphology the electrodes as Cell Index (CI)4). In Fig. 2, the black line
shows the decrease of CI, which reflects inter-cellular gap formation of histamine- and LPS-treated human
umbilical vein epithelial cells (HUVECs) cultured on the electrodes in the presence of factor VIII-deficient
plasma (positive control). A decrease of CI was also observed in the presence of sufficient numbers of
TF-expressing monocytes from normal donors (104 cells / well). However, CI did not decrease in the presence of

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Accepted Article

a lower number of monocytes (103 cells /well) treated with LPS and factor VIII-deficient plasma, or in the
presence of a large numbers of unstimulated monocytes (103 cells or 104 cells /well) and factor VIII-deficient
plasma. Moreover, a CI decrease was not observed in the presence of LPS-activated monocytes and factor
X-deficient plasma.
These results suggest that LPS increased TF expression on monocytes resulting in the activation of factor
X-dependent, but factor VIII-independent, coagulation cascade followed by the gap formation of vascular
endothelial cells. Because of the increase of the intrinsic coagulation potential in CSU3), the activation of factor
X and II in the common pathway of coagulation, and the induction of vascular endothelial cells gap formation by
these factors may be further enhanced in CSU.
Autoantibodies against IgE or its receptor (FcɛRI) on mast cells are known to be involved in the pathogenesis of
CSU. Moreover, the presence of histamine-releasing factors has also been reported in the plasm of patients with
CSU

7,8).

We presume that plasma leakage caused by the activation of the coagulation cascade triggered by TF

expressed on either endothelial cells or monocytes allows these factors to move out to the extravascular space
and encounter dermal mast cells, which then degranulate and cause massive vascular hyperpermeability and
wheal formation. It is still unclear if these factors activate dermal mast cells only in the skin. Skin specific
molecules, such as mas-related G-protein coupled receptor member X2 (MRGPRX2) expressed by mast cells
only in the skin, may also be necessary for wheal formation in urticaria. In any case, it is noteworthy that TF
expression on endothelial cells, but not monocytes may be inhibited by H1-antihistamines, and thus, may
account for the pathomechanism of CSU refractory to H1-antihistamines.
An association of chronic infection and CSU has been described for a long time, and the eradication of
Helicobacter pylori may bring about resolution of urticaria 9). In this study, LPS and FLA-ST, more efficiently

enhanced TF expression than Pam3CSK4 and HKLM. Since LPS and FLA-ST are components of gram-negative
bacteria, and HKLM is from gram-positive bacteria, the effect of chronic infection of gram-negative bacteria,

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such as Helicobacter pylori, may be more dominant than that of gram-negative bacteria in the pathogenesis of

antihistamine-resistant CSU via the induction of TF expression on monocytes.
Development of acute urticaria after bacterial or viral infection is commonly experienced in clinical practices 10).
However, in most cases, it disappears within a few weeks. Therefore, there are likely to be other causal
mechanisms underlying the pathogenesis of the chronic stage of spontaneous urticaria. Since the activation of
TLRs transduces various cascades of the cells, other stimuli that share intracellular signal transductions with
TLRs that induce monocyte TF expression may also contribute to the histamine-resistant or partially resistant
CSU.

In conclusion, monocyte TF expression is enhanced in CSU patients compared to healthy donors. It may be
induced by agonists for TRL-1,2,4,5 so as to trigger the exogenous coagulation pathway and vascular
hyperpermeability in a histamine-independent manner. Consequently, TF expression on monocytes may be
utilized as a marker for CSU pathological conditions, and as a therapeutic target for severe and refractory CSU.

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References;
1.

2.

3.

4.

5.

6.

7.

8.

Asero R. Plasma D-dimer levels and clinical response to ciclosporin in severe chronic spontaneous
urticaria. J Allergy Clin Immunol 2015; 135: 1401-3.
Parslew R, Pryce D, Ashworth J, Friedmann PS. Warfarin treatment of chronic idiopathic urticaria and
angioedema. Clin Exp Allergy 2000; 30: 1161-5.
Takeda T, Sakurai Y, Takahagi S, Kato J, Yoshida K, Yoshioka A, et al. Increase of coagulation
potential in chronic spontaneous urticaria. Allergy 2011; 66: 428-33.
Yanase Y, Morioke S, Iwamoto K, Takahagi S, Uchida K, Kawaguchi T, et al. Histamine and Toll-like
receptor ligands synergistically induce endothelial cell gap formation by the extrinsic coagulating
pathway. J Allergy Clin Immunol 2018; 141: 1115-1118.e7
Cugno M, Marzano AV, Tedeschi A, Fanoni D, Venegoni L, Asero R. Expression of Tissue Factor by
Eosinophils in Patients with Chronic Urticaria. Int Arch Allergy Immunol 2009; 148: 170-74.
Giesen PLA, Rauch U, Bohrmann B, Kling D, Roque M, Fallon JT, et al. Blood-borne tissue factor:
Another view of thrombosis. Proc Natl Acad Sci 2002; 96: 2311–5.
Bossi F, Frossi B, Radillo O, Cugno M, Tedeschi A, Riboldi P, et al. Mast cells are critically involved
in serum-mediated vascular leakage in chronic urticaria beyond high-affinity IgE receptor stimulation.
Allergy Eur J Allergy Clin Immunol 2011; 66: 1538–45.
Cugno M, Tedeschi A, Frossi B, Bossi F, Marzano A V., Asero R. Detection of low-molecular-weight
mast cell–activating factors in serum from patients with chronic spontaneous urticaria. J Investig
Allergol Clin Immunol 2016; 26: 310–3.

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9.

10.

Kim, HJ, Kim, Y‐J, Lee, HJ, et al. Systematic review and meta‐analysis: Effect of Helicobacter pylori
eradication on chronic spontaneous urticaria. Helicobacter. 2019; 00: e12661.
Kulthanan K, Chiawsirikajorn Y, Jiamton S. Acute urticaria: Etiologies, clinical course and quality of
life. Asian Pacific J Allergy Immunol. 2008; 26: 1–9.

Acknowledgement;

This work was supported by Takeda Science Foundation 2018, Japanese Society of Allergology, Clinical
Research Support Program, and JSPS KAKENHI (Grant-in-Aid for Scientific Research(C)) Grant Number
18K08298, 18K12061, GSK Japan Research Grant 2019.

Conflict of interest; none declared. ...

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