Table Of ContentThe Value of BCG and TNF in
Autoimmunity
The Value of BCG and TNF in
Autoimmunity
Denise L. Faustman
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LIST OF CONTRIBUTORS
AlexanderS.Burn,MD
DepartmentofRadiology,HartfordHospital,Hartford,Connecticut,USA
PaulBurn,PhD
SanfordSchoolofMedicine,TheUniversityofSouthDakota,SiouxFalls,South
Dakota,USA
SabrinaC.Burn
SanfordSchoolofMedicine,TheUniversityofSouthDakota,SiouxFalls,South
Dakota,USA
CarlaButtinelli,MD
TheCenterforExperimentalNeurologicalTherapies,S.AndreaHospital-site,
NESMOSDepartmentandDepartmentofNeurologyandPsychiatry,“Sapienza”
UniversityofRome,Italy
StefaniaCannoni,MD,PhD
TheCenterforExperimentalNeurologicalTherapies,S.AndreaHospital-site,
NESMOSDepartmentandDepartmentofNeurologyandPsychiatry,“Sapienza”
UniversityofRome,Italy
NataliaE.Castillo,MD
BethIsraelDeaconessMedicalCenter,HarvardMedicalSchool,Boston,MA
GiuliaCoarelli,MD
TheCenterforExperimentalNeurologicalTherapies,S.AndreaHospital-site,
NESMOSDepartmentandDepartmentofNeurologyandPsychiatry,“Sapienza”
UniversityofRome,Italy
DeniseL.Faustman,MD,PhD
Director,ImmunobiologyLaboratory,MassachusettsGeneralHospital&Associate
Professor,HarvardMedicalSchool,Boston,Massachusetts02129,USA
EugenFeist,MD
DepartmentofRheumatologyandClinicalImmunology,Charité-Universitätsmedizin
Berlin,Charitéplatz1,D-10117Berlin,Germany
MehmetKaraci,MD
BEUGeneralHospitalAssistantProfessorofMedicine,BulentEcevitUniversity,
SchoolofMedicine,DepartmentofPediatrics.Kozlu,Zonguldak-Turkey
DanielA.Leffler,MD,MS
BethIsraelDeaconessMedicalCenter,HarvardMedicalSchool,Boston,MA
CarloPozzilli,MD
TheCenterforExperimentalNeurologicalTherapies,S.AndreaHospital-site,
NESMOSDepartmentandDepartmentofNeurologyandPsychiatry,“Sapienza”
UniversityofRome,Italy
x ListofContributors
GiovanniRistori,MD,PhD
TheCenterforExperimentalNeurologicalTherapies,S.AndreaHospital-site,
NESMOSDepartmentandDepartmentofNeurologyandPsychiatry,“Sapienza”
UniversityofRome,Italy
SilviaRomano,MD,PhD
TheCenterforExperimentalNeurologicalTherapies,S.AndreaHospital-site,
NESMOSDepartmentandDepartmentofNeurologyandPsychiatry,“Sapienza”
UniversityofRome,Italy
GrahamA.W.Rook,BAMBBChirMD
CentreforClinicalMicrobiology,DepartmentofInfection,andtheNationalInstitute
forHealthResearch(NIHR)andUCLHospitalsBiomedicalResearchCentre,
UniversityCollegeLondon(UCL),London,UK
MarcoSalvetti,MD
TheCenterforExperimentalNeurologicalTherapies,S.AndreaHospital-site,
NESMOSDepartmentandDepartmentofNeurologyandPsychiatry,“Sapienza”
UniversityofRome,Italy
BhagirathSingh,PhD,FRSC,FCAHS
CentreforHumanImmunologyandDepartmentofMicrobiologyandImmunology,
andRobartsResearchInstitute,UniversityofWesternOntario,London,Ontario
N6A5C1Canada
TorPaaskeUtheim,MD,PhD
ActingGroupLeader,DepartmentofMedicalBiochemistry,OsloUniversity
Hospital,Kirkeveien166,0407Oslo,Norway
NicolaVanacore,MD
TheCenterforExperimentalNeurologicalTherapies,S.AndreaHospital-site,
NESMOSDepartmentandDepartmentofNeurologyandPsychiatry,“Sapienza”
UniversityofRome,Italy
INTRODUCTION
Since its introduction as a tuberculosis vaccine in 1921, bacillus
Calmette-Guérin (BCG) continues to thrive as new uses emerge in dis-
parate fields of immunology. BCG contains the avirulent tuberculosis
strain Mycobacterium bovis, and its main appeal for the potential pur-
pose of treating autoimmunity is its induction of the cytokine tumor
necrosis factor (TNF). This book is the work of participants in a con-
ference, “BCG and TNF Signaling in Autoimmunity,” which was held
in London, England on October 19, 2013. The conference was held
with three purposes in mind: to bring together for the first time
researchers working on BCG and TNF for the treatment and preven-
tion of human autoimmune diseases; to advance research by sharing
animal and human findings and best practices; and to discuss how
ongoing collaboration can facilitate clinical trials. Many of the investi-
gators in attendance had never met before.
Dr. Bhagirath Singh of the University of Western Ontario began
the meeting, speaking about the prevention of type 1 diabetes in rodent
models by immunotherapy with mycobacterial adjuvants. Dr. Singh
has performed abundant work on the prevention and treatment of type
1 diabetes in two animal models—the non-obese diabetic (NOD)
mouse and the biobreeding (BB) rat. His research has shown that
immunotherapy using BCG or complete Freund’s adjuvant (CFA)
reverses insulitis and increases insulin production if given to pre-
diabetic mice or even diabetic mice with new-onset autoimmunity.
Some of the possible mechanisms include the induction of innate
immune cells and regulatory T cells, as well as downregulation or
death of pathogenic T cells. The data in support of BCG’s synergy
with the host’s innate immune response of TNF induction were pre-
sented from many angles. A review of Dr. Singh’s groundbreaking
studies over the past 15(cid:1)20 years sheds historical light on the utility of
BCG for type 1 diabetes in rodents.
Dr. Graham Rook of University College London is one of the pio-
neers of the concept that the infectious environment protects people
from autoimmunity. The developed countries have witnessed huge
xii Introduction
increases in the prevalence of a wide range of chronic inflammatory
disorders, including allergies and autoimmune diseases. The increases
in these diseases occur against a backdrop of economic development
and urbanization in which direct exposure to infectious agents has
receded. Exposure to infectious diseases (e.g., tuberculosis) has immu-
noregulatory roles through the induction of TNF and the upregulation
of regulatory T cells. Dr. Rook views “old friends” as naturally occur-
ring organisms that have co-evolved with humans and led to long-term
health benefits. These organisms have almost been eliminated from the
urban environment. Obviously, the ongoing global trials with BCG are
one such attempt to reintroduce infectious agents that might allow
better immune system development.
Dr. Eugen Feist of Charité University of Medicine in Berlin discov-
ered that human Sjögren’s syndrome is associated with a genetic defect
in the immunoproteasomes. The defect traces to a deficiency in one of
the proteins (LMP2) that forms a catalytic subunit of the proteasome.
As a consequence, defective proteasomes are thwarted in two key roles:
processing of the transcription factor NF-κB and processing of pro-
teins for T cell education. Intact proteasomes are needed to liberate
NF-κB from its chaperone molecule in the cytoplasm. Once liberated
by TNF stimulation, NF-κB normally migrates to the nucleus to tran-
scribe pro-survival genes. The defective proteasome leaves autoreactive
T cells, but not healthy T cells, selectively vulnerable to TNF-induced
death, as seen in mouse models of Sjögren’s syndrome. This provides
the rationale for future testing of BCG in human clinical trials of
Sjögren’s syndrome. Following the discovery that diabetes- and
Sjögren’s-affected mice have proteasome defects, Sjögren’s syndrome
was the first human autoimmune disease in which the protein defect
(leading to defective proteasome function for T cell education and
altered T cells with NF-κB defects) was identified. Over the last 15
years, these data have buttressed similar autoimmune animal data, and
now broader human autoimmune diseases show proteasome defects.
Dr. Mehmet Karaci of Turkey’s Bülent Ecevit University per-
formed a case-control epidemiological study on children with type 1
diabetes. The study found that children with at least two BCG vaccina-
tions, especially with the first vaccination in early infancy, was protec-
tive against the development of type 1 diabetes. In contrast, children
with 0(cid:1)1 vaccinations developed the disease at the same rate as
Introduction xiii
children in the general pediatric population. There was no relationship
between vaccination date and age at diagnosis. This research builds on
animal studies showing that CFA treatment of NOD mice prevents
onset of type 1 diabetes, especially multi-dosing. Dr. Karaci’s data
shows that multiple doses of BCG, with the first dose in the neonatal
period, are most protective. The findings align with animal data on the
critical time period for infectious disease exposures that trigger TNF
(and even with recent data showing that latent maternal tuberculosis
infection may influence fetal immune development) and suggest the
potential of BCG for type 1 diabetes prevention.
Dr. Giovanni Ristori, an expert on multiple sclerosis (MS), opened
his talk with the historical point that the use of BCG or immune adju-
vants in animal models of MS dates back to the 1950s. His presenta-
tion then turned to his present-day human clinical trial using BCG in
this disease. Dr. Ristori and his colleagues at the Sapienza University
of Rome have conducted the most advanced clinical trials of BCG in
patients with autoimmunity, in this case with MS. In a placebo-
controlled trial, they found that BCG prevented progression of MS in
patients with a single clinical episode suggestive of MS and a baseline
gadolinium (Gd)-enhanced MRI scan supporting a diagnosis of MS.
At the six month follow-up, 45.5% of vaccinated subjects versus 75%
of placebo subjects developed one or more new Gd-enhanced lesions.
No adverse events were reported. At five years, more than half of
BCG recipients remained relapse-free versus 30% of placebo subjects.
This Phase II BCG clinical trial demonstrates the feasibility and safety
of administering BCG after the first demyelinating episode. In addition
to launching a Phase III trial, Dr. Ristori and colleagues are eager to
explore the mechanisms underlying the long-term beneficial effects of
BCG vaccination in MS patients.
I was pleased to speak about my research group’s findings from a
Phase I clinical trial that evaluated multi-dosing of BCG for the treat-
ment of type 1 diabetes. Our early work showed that TNF-inducers
like BCG and CFA can help to reverse type 1 diabetes (including the
remarkable regeneration of insulin-producing cells of the pancreas)
even in NOD mice with advanced disease. These data came after years
of studying the biochemical mechanism by which this occurs: through
TNF and NF-κB signaling errors in mouse and human diabetes and
other autoimmune diseases.
xiv Introduction
Our findings in the mouse model led us to introduce BCG for
treatment of advanced type 1 diabetes in humans in a randomized,
placebo-controlled, proof-of-concept clinical trial. We found that
multi-dose BCG in patients with advanced disease (mean duration of
disease: 15 years) had the following salutary effects: a large increase in
dead insulin-autoreactive T cells entering the circulation; induction of
regulatory T cells, a rare subtype of T lymphocyte that helps maintain
tolerance to self-antigens; and, most importantly, a transient rise in
production of C-peptide (a marker of insulin production). This was the
first demonstration of a resurgence of β-islet cell function in what was
long considered to be a dead pancreas. It was also the first evidence
that the pathogenic CD8 T cells could be killed directly.
Following these main presentations, Dr. Paul Burn of the
University of South Dakota’s Sanford School of Medicine discussed
some of the difficulties that have hampered success in type 1 diabetes
clinical trials. Dr. Daniel Leffler of Beth Israel Deaconess Medical
Center spoke to the advantages of testing novel therapies in celiac dis-
ease. Because celiac disease is often considered a more benign autoim-
mune disease than some of the life-threatening autoimmune diseases
like type 1 diabetes or multiple sclerosis, it makes a poor candidate for
trials using heavy-duty immunosuppressive drugs. Since the BCG vac-
cine is safe and has an impeccable safety record, it may be a plausible
clinical trial drug candidate for interventional trials where safety is of
utmost importance.
Dr. Tor Paaske Utheim, an ophthalmologist from Oslo University
Hospital, spoke about the compelling rationale for studying BCG for
the treatment of Sjögren’s syndrome, which features an autoimmune
attack against exocrine glands (with hallmark symptoms of dry eye
and dry mouth) and systemic manifestations including severe fatigue.
Dry eye is not trivial in nature, for it can lead to infections, corneal
abrasions, and, potentially, blindness. The ability to study dry eye with
relative ease is one of Sjögren’s foremost advantages for future clinical
trials with BCG. In addition, since both the Sjögren’s-affected NOD
mouse and humans with Sjögren’s syndrome have underlying protea-
some defects that predict drug efficacy with BCG/TNF induction,
Sjögren’s is a prime candidate for human clinical trials.
In conclusion, participants in the conference came away with a
heightened sense of the promise of BCG as a safe and potentially
Introduction xv
efficacious treatment for a wide range of autoimmune disorders. Each
investigator arrived at the value of BCG from a different vantage
point. All converged on the concept that BCG and its induction of
TNF will be valuable in both the prevention and the treatment of mul-
tiple autoimmune diseases, and that strengthening collaborations will
advance the field.
Denise L. Faustman, MD, PhD
Director of Immunobiology & Associate Professor of Medicine,
Massachusetts General Hospital and Harvard Medical School
Conferenceparticipants(lefttoright):Dr.KenCoppieters,Type1DiabetesCenter,NovoNordiskA/S,Søborg,
Denmark;Dr.TorPaaskeUtheim,OsloUniversityHospital,Oslo,Norway;Dr.EugeneFeist,Departmentof
Rheumatology, Charity Hospital and University of Berlin, Berlin, Germany; Professor Graham A. Rook,
University College London, London, UK; Dr. Mehmet Karaci, Department of Pediatrics, Bülent Ecevit
University,Turkey;Dr.DeniseFaustman,HarvardMedicalSchoolandMassachusettsGeneralHospital,Boston,
Massachusetts, USA; Mr. Robert Glenister, autoimmune patient advocate, Johannesburg, South Africa; Dr.
Daniel Leffler, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts,
USA; Dr. Bhagirath Singh, University of Western Ontario, London, Ontario, Canada; Dr. Giovanni Ristori,
Sapienza University of Rome, Rome, Italy; Dr. Paul Burn, Sanford School of Medicine, University of South
Dakota,SiouxFalls,SouthDakota,USA.
