Seminars in Immunology 21 (2009) 242–253

Contents lists available at ScienceDirect

Seminars in Immunology
journal homepage: www.elsevier.com/locate/ysmim

Review

Toll-like receptors (TLRs) and Nod-like receptors (NLRs) in inflammatory

disorders
Masayuki Fukata, Arunan S. Vamadevan, Maria T. Abreu ∗
Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, United States

a r t i c l e i n f o a b s t r a c t

Keywords: Toll-like receptors (TLRs) and Nod-like receptors (NLRs) are two major forms of innate immune sensors,
Toll-like receptor which provide immediate responses against pathogenic invasion or tissue injury. Activation of these sen-
Nod-like receptor sors induces the recruitment of innate immune cells such as macrophages and neutrophils, initiates tissue
Inflammation
repair processes, and results in adaptive immune activation. Abnormalities in any of these innate sensor-
mediated processes may cause excessive inflammation due to either hyper responsive innate immune
signaling or sustained compensatory adaptive immune activation. Recent gene association studies appear
to reveal strong associations of NLR gene mutations and development of several idiopathic inflammatory
disorders. In contrast, TLR polymorphisms are less often associated with inflammatory disorders. Nev-
ertheless, TLRs are up-regulated in the affected tissue of most inflammatory disorders, suggesting TLR
signaling is involved in the pathogenesis of chronic and/or idiopathic inflammatory disorders. NLR signal-
ing results in the formation of a molecular scaffold complex (termed an inflammasome) and orchestrates
with TLRs to induce IL-1␤ and IL-18, both of which are important mediators in the majority of inflam-
matory disorders. Therefore, understanding the roles of TLRs and NLRs in the pathogenesis of chronic
and idiopathic inflammatory disorders may provide novel targets for the prevention and/or treatment of
many common and uncommon diseases involving inflammation.
© 2009 Published by Elsevier Ltd.

1. Introduction research on NLRs has been mainly focused on NOD1 and NOD2
while little is known about the role and mechanism of NLR-induced
The innate immune system is our first line of defense against innate immunity. However, polymorphisms or mutations of NLRs
pathogens and tissue injury. It is responsible for initiating immune have been found to be associated with susceptibility to inflam-
responses to resolve infections and repair damaged tissues. Initi- matory disorders suggesting that these molecules are important
ation of the innate immune response is triggered by recognition in inflammation and immunity. More recently, accumulating evi-
of pathogen-associated molecular patterns (PAMPs) or danger- dence suggests that NLRs complement and synergize with TLRs in
associated molecular patterns (DAMPs) by pathogen recognition induction of innate immune responses. Various levels of crosstalk
receptors (PRRs). PRRs are located in both the cell membranes between TLR and NLR pathways have been described. A molec-
and in the cytosol. The most studied PRRs are the Toll-like recep- ular scaffold complex, the inflammasome, requires input from
tors (TLRs) which are localized either to the cell surface or within both pathways and leads to the activation of IL-1␤ and IL-18.
endosomes [1]. Cytoplasmic PRRs include the RNA helicase fam- TLR-mediated NF-␬B activation is required for the production of
ily (retinoic acid inducible gene protein 1, RIG-1 and melanoma pro-IL-1␤ while cleavage of pro-IL-1␤ to its biologically active form
differentiation-associated gene-5, MDA5) and the nucleotide bind- is dependent on NLR-mediated caspase-1 activation [5]. Since IL-1␤
ing and oligomerization domain (NOD)-like receptor (NLR) family has been implicated in the pathogenesis of a myriad of inflam-
[2]. Endogenous cellular products associated with tissue injury matory disorders, it is possible that many idiopathic inflammatory
and self-danger signals such as heat shock proteins and defective disorders may be due in part to TLR and/or NLR-mediated immune
nucleic acids can also be recognized by PRRs [3,4]. responses. Indeed, TLR and NLR mutations have been associated
Since the discovery of TLRs as innate immune receptors two with increased susceptibility to certain inflammatory disorders
decades ago, extensive studies have revealed the structural, cel- such as Nod2 mutations and Crohn’s disease. In this review, we
lular, biochemical, and genetic characteristics of TLRs. In contrast, will discuss recent findings regarding the role of TLRs and NLRs as
innate immune sensors and their possible association with inflam-
matory disorders. Defective TLR and/or NLR function can lead to
∗ Corresponding author. the development of autoimmune or chronic inflammatory diseases
E-mail address: [email protected] (M.T. Abreu). and increase host susceptibility to infectious diseases by failing to

1044-5323/$ – see front matter © 2009 Published by Elsevier Ltd.

doi:10.1016/j.smim.2009.06.005
 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253 243

mount a proper immune response to pathogens, self-danger sig- and MHC class II transactivator (CIITA) [10] (Table 1). Unlike TLRs,
nals, or commensal organisms. NLRs consist of soluble proteins that survey the cytoplasm for the
presence of intracellular pathogens. There are 23 NLR genes in
2. Roles of TLRs and NLRs in regulation of innate and humans and 34 in the mouse genome [5,11,12]. NLRs are character-
adaptive immunity ized by three distinct domains: the ligand-sensing LRRs, the NACHT
domain which is responsible for the capacity of NLRs to oligomerize,
The fundamental purpose of TLRs and NLRs is protection of a host and the effector pyrin domain (PYD), caspase recruitment domain
against pathogens (Table 1). Given the diverse types of microor- family (CARD), or baculoviral IAP repeat (BIR). Each NLR differs in
ganisms in nature and their potential for genetic recombination the make up of its effector domain which mediates signal transduc-
to survive, it is understandable that PRRs are encoded to cover all tion to downstream targets leading to activation of inflammatory
the possible permutations of these microorganisms. TLRs recog- caspases by inflammasomes or NF-␬B by NODs. The BIR is present
nize microbes on the cell surface and in endosomes [6]. To date, in NAIP, CARD is present both in IPAF and in some members of the
10 TLRs (TLR1–10) in humans and 12 TLRs (TLR1–9 and TLR11–13) NALP family, and PYD is present in most NALPs [13].
in mice have been described [7]. TLRs are type-1 transmembrane NOD1 and NOD2 were the first NLRs reported to survey
glycoprotein receptors. The extracellular domain of TLRs contains the cytosol for the presence of the peptidoglycan components
19–25 consecutive leucine-rich repeat (LRR) motifs, each of which is dipeptide ␥-d-glutamyl-meso-dia-minopimelic acid (iE-DAP) and
24–29 amino acids in length, that are involved in ligand binding [8]. muramyl dipeptide (MDP), respectively. NODs drive the activation
The intracellular tail contains a highly conserved region, the Toll- of mitogen-activated protein kinase (MAPK) and NF-␬B via interac-
interleukin-1 receptor (TIR) domain, which mediates downstream tion with serine–threonine kinase RICK (also called Ripk2 or RIP2)
signaling. The recognition of PAMPs by TLRs can result in activation and activation of the kinase TAK1 [2,14–17].
of one of two major signaling pathways. The MyD88-dependent Three human inflammasomes have been described, named from
pathway results in the activation of NF-␬B and activated protein-1 the NLR protein involved: the NALP1 inflammasome, activates
(AP-1) while the TRIF-dependent pathway results in the activation caspase-5 and caspase-1; and the NALP3 and IPAF inflammasomes,
of type I interferons (IFN)s [9]. both of which activate caspase-1. Caspase-1 is required for the pro-
The NLR family consists of a group of cytoplasmic PRRs that cessing and maturation of proinflammatory cytokines of IL-1␤ and
include NODs, NALPs, IL-1␤-converting enzyme (ICE)-protease acti- IL-18 (Fig. 1). During inflammasome activation, NALP3 or NALP1
vating factor (IPAF), neuronal apoptosis inhibitor factors (NAIPs), interact through PYD–PYD homotypic interactions with apoptosis-

Table 1
Toll-like receptors (TLR) and nucleotide olgomerization domain-like receptors (NLR).

TLR Recognized motif NLR Recognized motif

TLR1 Triacyl lipoproteins CIITA

TLR2 NAIP Flagellin
Lipoproteins NOD1 meso-lanthionine
Peptidoglycan meso-DAP
Glycoinositolphospholipids ␥-d-Glu-meso-DAP (iE-DAP)
Zymosan l-Ala-␥-d-Glu-meso-DAP (TriDAP)
Phospholipomannan d-lactyl-l-Ala-␥-Glu-meso-DAP-Gly (FK 156)
Lipoteichoic acid Heptanoly-␥-Glu-meso-DAP-d-Ala (FK565)
Heat shock proteins
Hyaluronan
Viral envelop proteins of measles virus, human NOD2 MurNAc-l-Ala-d-isoGln (muramyldipeptide)
cytomegalovirus, and herpes simplex virus type I
TLR3 Double-stranded RNA, poly IC NLRC3 MurNAc-l-Ala-d-Glu-l-Lys (M-TRILys)
TLR4 Lipopolysaccharide NLRC4 Flagellin (Salmonella, Legionella, Listeria, Pseudomonas)
Flavolipin
Heat shock proteins
Fibrinogen NLRC5
Mannan
Glycoinositolphospholipids NALP1 Muramyldipeptide, Anthrax lethal toxin
Taxol
F protein of respiratory syncytial virus murine NALP2 Muramyldipeptide
retroviral envelope protein
Fibronectin NALP3 Bacterial RNA
Hyaluronic acid Viral RNA
Heparan sulfate Lipopolysaccharide
TLR5 Flagellin Uric acid crystals
TLR6 Diacyl lipopeptides Nigericin
Lipoteichoic acid Maitotoxin
Zymosan Aerolysin
TLR7 Single-stranded RNA NALP4
Imidazoquinoline NALP5
TLR8 Single-stranded RNA NALP6
Imidazoquinoline NALP7
TLR9 Demethylated CpG NALP8
TLR10 Unknown NALP9
TLR11 Uropathogenic bacteria NALP10
TLR12 Unknown NALP11
TLR13 Unknown NALP12
NALP13
NALP14
Refs. [171–196] Refs. [1,138,197–213]
244 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253

Fig. 1. NLRs and inflammasome activation. PYD–PYD and CARD–CARD interactions are required for the activation of caspases. To form an inflammasome, the NACHT domains
are oligomerize. A wide variety of stimuli, including bacterial toxins, ATP, DNA, bacterial RNA, K+ efflux, and crystals such as cilica, asbestos, uric acid, alum can activate
the NALP3 inflammasome. Recognition of PAMPs by TLRs induces pro IL-1␤ synthesis through NF-␬B activation. Activated caspase-1 processes the IL-1␤ precursor into the
mature IL-1␤.

associated speck-like protein-containing CARD (ASC), resulting in phocytes, its specific role in innate immunity as a PRR has yet to be
its activation [18]. Subsequently, the CARD domain of ASC interacts determined.
with the CARD domain of caspase-1 and mediates its activation. TLR- and NLR-mediated signaling also plays an important role
NALP1 may also activate caspase-5 directly through its C-terminal in the activation of the adaptive immune system by inducing proin-
CARD domain. In contrast, NALP3 does not simultaneously activate flammatory cytokines and up-regulating costimulatory molecules
caspase-5, but can recruit a second capsase-1 through the CARD on antigen-presenting cells. In humans, TLR- and NLR-mediated
domain of CARD inhibitor of NF-␬B activating ligand (CARDINAL), IL-1␤ promotes the expansion of Th17-type helper T cells [25,26].
a component of the NALP3 inflammasome [19]. IPAF and NAIP have In contrast, the NALP3 inflammasome directs a humoral adaptive
been shown to recognize flagellin. The IPAF inflammasome can immune response. Inflammasomes activated by monosodium urate
on its own sense PAMPs because it possesses a CARD domain at (MSU), silica dust, or alum may induce Th2 type immune responses
the N-terminus and thus may directly activate caspase-1 without via NALP3, ASC, and caspase-1 [27–29]. In addition to its effect
ASC recruitment [20]. The BIR domain of NAIP is considered to be on IL-1␤ and IL-18 expression, inflammasome-mediated signaling
inhibitory, thus NAIP may function as a negative modulator of IPAF may induce IL-33, which is a potent inducer of IL-4, IL-5, and IL-
in the recognition of flagellin. 13 favoring Th2 polarization [30]. These findings demonstrate the
Class II transactivator (CIITA) is a transcriptional activator, which importance of the inflammasome in linking innate immunity to
regulates major histocompatibility complex class (MHC) II genes adaptive immunity.
[21,22]. CIITA consists of an N-terminal transcriptional activation Perhaps the most important NLR in the induction of adaptive
domain that is essential for MHC gene transactivation, a mid-region immunity is CIITA. CIITA is responsible for MHC class II expres-
containing the NACHT domain, and a C-terminal LRR domain that sion on antigen-presenting cells [31]. Loss-of-function mutations
affects nuclear translocation and self-association [22,23]. CIITA also in CIITA results in type II bare lymphocyte syndrome (BLS) [21,22].
carries a CARD-like domain in the N-terminal region, while CIITA BLS is a hereditary disorder of MHC-II deficiency and patients with
lacks CARD activity [24]. Although CIITA plays a critical role in BLS suffer from severe primary immunodeficiency and a short-
antigen presentation and development of antigen-specific T lym- ened life expectancy due to repeated pathogenic infections in early
 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253 245

childhood. Based on our own experimental animal data and recent Symptoms include skin rash, severe arthritis and chronic polymor-
findings, most TLRs and some of the NLRs are expressed by T cells, phonuclear meningitis leading to neurologic damage. MWS is a rare
suggesting direct roles of TLRs and NLRs on establishment of T cell- autosomal dominant disease that causes sensorineural deafness,
mediated adaptive immune responses [32–35]. Therefore, the roles recurrent hives, and can lead to amyloidosis. MWS patients often
of TLRs and NLRs appear to be beyond the scope of classical innate have episodic fever, chills and painful joints. FCAS is associated with
immunity. the development of fevers, skin lesions, arthalgia and conjunctivitis
following exposure to cold. PAPA is characterized by the accumula-
3. TLRs and NLRs: genetic association with inflammatory tion of sterile, pyogenic, neutrophil-rich material in the joints and
disorders disfiguring skin lesions. The majority of disease-associated mutants
are clustered within the highly conserved NACHT domain of NALP3
With the completion of the Human Genome Project, genome- and are thought to result in spontaneous caspase-1 activation with
wide association studies have identified allelic variants within NLR IL-1␤ production [19]. In fact, increased secretion of IL-1␤ has been
and TLR encoding genes associated with inflammatory disorders observed in macrophages from these patients [46]. Moreover, over-
(Table 2). The most impressive discovery was Nod2 mutations as expression of mutant NALP3 proteins induces spontaneous IL-1␤
a genetic risk factor for Crohn’s disease. A higher frequency of one secretion [47]. IL-1␤ is therefore the major mediator of inflamma-
of three mutations (R702W, G908R, and L1007insC) near or within tion in these syndromes. Furthermore, subsets of individuals have
the NOD2 LRR region was identified in patients with Crohn’s disease demonstrated a dramatic response to the IL-1R antagonist IL-1Ra
[36,37]. This discovery has significantly improved the understand- [48,49]. Variants of NALP1 have been implicated in the susceptibil-
ing of the pathogenesis of Crohn’s disease. Polymorphisms in the ity to several autoimmune diseases, including vitiligo, autoimmune
intronic region of Nod1 have also been associated with the age of thyroid disease, Addison’s disease, rheumatoid arthritis, psoria-
IBD onset [38]. sis, pernicious anemia and systemic lupus erythematosus (SLE)
The Crohn’s disease-associated Nod2 variants have also been [50].
linked to an increased incidence of graft-versus-host disease Microbial exposure in childhood has been suggested to pro-
(GVHD) and increased mortality in patients undergoing allogenic tect against the development of atopic diseases [51]. This idea can
bone-marrow transplantation [39,40]. Although the mechanism be explained by the association of genetic variants of NLRs with
involved remains unclear, abnormal innate immune responses to allergic disorders. NOD1 polymorphisms are associated with the
translocated intestinal flora might be of importance since the development of atopic eczema, asthma, and increased serum IgE
increased mortality associated with GVHD was not seen after concentration [52,53]. This polymorphism affects the expression
decontamination of the gut microflora [39]. On the other hand, The of specific Nod1 splicing variants [52]. Since the corresponding
D299G SNP in TLR4 has been associated with a lower rate of acute isoforms of NOD1 displayed an impaired response to pepti-
allograft rejection after transplantation [41]. Missense mutations doglycan in vitro [54], it is possible that defective detection
in NOD2 also underlie Blau syndrome [42], and early onset of sar- of peptidoglycan by non-functional Nod1 splicing variants may
coidosis [43]. The mutation in NOD2 occurs in the NOD-domain. contribute to the onset of asthma. Several polymorphisms and
Blau syndrome is a rare life-long disorder initiated in childhood and haplotypes in NOD2/CARD15 have been associated both posi-
characterized by skin rash, uveitis, and recurrent arthritis which can tively and negatively with development of asthma in a German
evolve toward camptodactyly. Blau syndrome does not involve the cohort, suggesting multiple roles of NOD2 in the pathogenesis
digestive tract, but as in Crohn’s disease, granulomas are associated of asthma [55]. In addition, an association of polymorphisms in
with inflammatory lesions. CD14, a co-receptor of TLR4, and a risk for developing asthma
Genetic variants of other NLRs have been identified in hereditary have been reported in children [56–58]. Polymorphisms in TLR2
periodic fever syndrome, which causes periodic (episodic) fever and TLR10 also appear to influence the risk of developing asthma
without any infectious cause. The hereditary periodic fevers include [59,60].
familial Mediterranean fever (FMF), chronic neurogenic cutaneous Autoimmune diseases are a major component of inflammatory
and articular syndrome (CINCA), Muckle-Wells syndrome (MWS), disorders. In general, the pathogenesis of autoimmune diseases
familial cold autoinflammatory syndrome (FCAS), and pyogenic is associated with a misdirected immune response to self-tissues.
sterile arthritis with pyoderma gangrenosum and acne (PAPA) Several studies have tried to identify TLR and NLR encoding gene
[44,45]. CINCA is caused by mutations in the CINAS1 gene encoding disease susceptibility genes for autoimmune diseases. However, no
NALP3 and is a rare periodic fever syndrome. It causes uncontrolled association has been found between TLR gene polymorphisms and
inflammation in multiple parts of the body starting in the newborn. major autoimmune diseases such as rheumatoid arthritis (RA) or
systemic lupus erythematosus (SLE) [61–64]. There are few reports
describing possible genetic associations of TLRs and autoimmune-
Table 2
mediated diseases. For the most part, the exact physiological role
Genetic associations of TLR and NLR to inflammatory disorders.
played by the TLR polymorphism is unknown. The common TLR2
TLR/NLR Inflammatory disorder Arg to Gln polymorphism at position 753 (Arg753Gln) is associated
TLR2 Asthma, acute rheumatic fever, Lepromatous leprosy with the pathogenesis of acute rheumatic fever [65]. SNP R677W of
TLR4 Asthma, Crohn’s disease, ulcerative colitis TLR2 was found to be associated with lepromatous leprosy in Asian
TLR10 Asthma, atopic eczema, increased serum IgE people [66]. The TLR4 polymorphism Asp299Gly is associated with
NOD1 Asthma, atopic eczema, increased serum IgE, IBD (Crohn’s disease
Crohn’s disease and ulcerative colitis [67]. This SNP occurs within
and Ulcerative colitis)
NOD2 Atopic dermatitis, Blau syndrome, Crohn’s disease, early-onset the extracellular domain of TLR4; thus the decrease in response
sarcoidosis, graft-versus-host disease (GVHD) is most likely mediated by a decrease in recognition of ligands.
NALP1 Vitiligo, autoimmune thyroid disease, Addison’s disease, RA, Although, TLRs and NLRs are crucial regulators of both innate as
psoriasis, SLE well as adaptive immunity, fewer associations of gene polymor-
NALP3 Hereditary periodic fever syndromes [familial Mediterranean
fever (FMF), chronic neurogenic cutaneous and articular
phisms with autoimmune diseases imply genetic abnormalities of
syndrome (CINCA), Muckle-Wells syndrome (MWS), familial cold TLRs and NLRs are not a direct cause of most autoimmune diseases.
autoinflammatory syndrome (FCAS), and pyogenic sterile arthritis Epigenetic association of TLRs and NLRs to autoimmune diseases
with pyoderma gangrenosum and acne (PAPA)] and other inflammatory diseases will be discussed in the next
Refs. [37,42,44,50,52,140,214–223]
section.
246 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253

4. Epigenetic involvement of TLRs and NLRs in response by TLR4 stimulation with OVA sensitization is dependent
inflammatory disorders on doses of the TLR4 ligand LPS [91]. Paradoxically, PBMC in patients
with asthma have reduced expression and response to TLR4 [92].
TLR signaling stimulated by extrinsic PAMPs and self-DAMPs has Therefore, the roles of TLR4 signaling in the induction of airway
been demonstrated to be involved in and to be a prerequisite for the inflammation in patients with asthma are probably more compli-
development of various inflammatory disorders. In general, expres- cated than our expectation.
sion of some of the TLRs is up-regulated in the lesion of the specific Evidence demonstrating altered expression of TLRs in many
inflammatory diseases. Increased expression of TLR2 and TLR4 in types of cells in the lung in patients with chronic obstructive pul-
intestinal macrophages has been reported in patients with IBD [68]. monary disease (COPD) suggests that TLR activation contributes to
Peripheral blood mononuclear cells (PBMCs) from Behcet’s disease the development of COPD [93–95]. The respiratory tract is mor-
have increased expression of TLR4 [69,70]. B cells in patients with phologically unique as it has a closed space in the efferent end
SLE have increased expression of TLR9 [71]. RA synovial fibrob- and is open to the external environment at the afferent naso-oral
lasts express increased levels of most TLRs that are more prone side. Innate immunity plays crucial roles to protect the terminal
to activation by diverse TLR ligands when compared with syn- respiratory tract against a variety of pathogens. To maintain the
ovial fibroblasts from non-RA patients, suggesting that TLRs may be aseptic condition of the terminal airway, the alveolar macrophages
involved in persistent inflammation and joint destruction [72,73]. monitor microbial invasion into the alveoli and provide protec-
Recently, the importance of IL-17 producing Th17 type T helper tion to the host by initiating inflammatory responses though innate
cells induced by TLR signaling in the pathogenesis of autoim- immune receptors, TLRs and NLRs. Airway epithelial cells and alve-
mune diseases has been highlighted by striking data in a mouse olar type II cells express TLRs [96–99], and airway epithelial cells
model of multiple sclerosis (MS) induced by injection of myelin can up-regulate TLR expression during infection [100]. The alveo-
oligodendrocyte glycoprotein (MOG). MS is an organ-specific lar macrophages also express functional TLRs [101,102]. Interesting
autoimmune condition, in which the immune system attacks the animal data demonstrate involvement of both MyD88-dependent
central nervous system, leading to demyelination of the oligoden- TLR4 signaling and inflammasome activation in cigarette-induced
drocytes surrounding the axons of the nerves. MyD88-deficient lung inflammation [103]. In this study, absence of TLR4, MyD88,
mice do not develop experimental MS in a model of autoimmune or IL-1R1 abrogated neutrophil recruitment to the lung and bron-
encephalomyelitis [74,75]. In this model, MyD88-deficient mice do choalveolar lavage (BAL) showed with low expression of IL-1␤, KC,
not generate MOG-specific Th17 cells and have fewer Th1 cells com- IL-6 and MMP-9.
pared to the controls, suggesting MyD88-dependent TLR signaling Asbestos and silica microparticles have been shown to acti-
is required for the disease associated Th17 cell generation. This vate the NALP3 inflammasome [104–106]. Silica and asbestos dust
highlights a role of TLRs in the pathogenesis of MS. The deficiency of are particularly potent inducers of inflammation in the lungs.
IL-17 or the use of IL-17-blocking antibodies prevented the devel- Macrophages are unable to efficiently eliminate the microparticles
opment of the disease or diminished its severity [76]. Recently, we of silica and asbestos. Therefore, inhaling finely ground crystalline
have shown T cells from MyD88−/− mice do not induce wasting silica or asbestos dust in small quantities over time can lead to
disease in the T cell adoptive transfer IBD model, due to defective the inflammatory conditions of silicosis and asbestosis, respectively
differentiation into Th17 type effector cells [32]. Up-regulation of [107]. Interestingly, pulmonary inflammation is greatly reduced in
IL-17 has been demonstrated in human IBD mucosa, active lesions NALP3-deficient mice after in vivo inhalation of asbestos or sil-
in the central nervous system in patients with MS, and synovial fluid ica, suggesting a role of NALP3 inflammasomes in silica-mediated
of RA patients [77–80,81]. Anti-IL-17 therapies are also effective in pulmonary inflammation [104,105].
the collagen-induced arthritis (CIA) model [82,83]. These results Gout is caused by abnormal purine metabolism and is associated
indicate that TLR-mediated IL-17 production may be a universal with deposition of monosodium urate (MSU) crystals in joints and
factor important in the development of autoimmune or idiopathic periarticular tissues. Similarly, pseudogout arises from deposition
chronic inflammatory disorders. of calcium pyrophosphate dihydrate crystals. It has been shown that
Evidence has indicated that TLRs play a role in the development MSU and calcium pyrophosphate dihydrate crystals activate the
of allergic diseases through induction of Th2 responses. However, NALP3 inflammasome resulting in the production of active IL-1␤
regulation of TLR-mediated immune activation directing the Th2 and IL-18 [108]. High levels of circulating uric acid (hyperuricemia)
cytokine induction has still been unclear. Abnormal innate immune have been associated with various inflammatory diseases including
responses in the skin have been seen in patients with atopic der- multiple sclerosis, hypertension, and cardiovascular diseases [109].
matitis. In fact, patients with atopic dermatitis have an enhanced The importance of IL-1 in the pathology of gout and pseudogout is
susceptibility to bacterial skin infections, especially with Staphylo- supported by clinical trials of the IL-1R antagonist IL-1Ra in patients
coccus aureus. Macrophages from patients with atopic dermatitis with acute gout [110,111].
express significantly less TLR2, and have a reduced capacity to pro- There is increasing data to support a role for TLRs in
duce pro-inflammatory cytokines including IL-6, IL-8 and IL-1␤ immune complex-mediated glomerulonephritis [112,113]. TLR7
upon TLR2 stimulation, compared to macrophages from healthy has emerged as a key regulator of autoantibody production in
controls [84]. this regard. TLR7 ligand-containing antigens bind to specific self-
Animal studies have revealed that TLR4 may promote air- reactive naive B cells. Immune complexes containing RNPs and
way sensitization [85–87]. TLR4-deficient C3H/HeJ mice exhibited ssRNA induce DC maturation and type I IFN production, and
less airway inflammation after intranasal OVA challenge when up-regulate TLR7 in B cells inducing anti-RNP IgG2a and IgG2b
compared with control mice [86]. The other study directly demon- autoantibodies [114].
strated a requirement for TLR4 signaling in the induction of
Th2 airway inflammation by OVA sensitization in intranasally 5. Role of TLRs and NLRs in inflammatory bowel diseases
immunized mice with LPS-depleted OVA [85]. In addition, this
TLR4-mediated Th2 response to OVA is MyD88-dependent [87]. Given the complexity of the bacterial flora in the human intes-
TLR2 appears to exert similar immunologic effects as TLR4 on air- tine, careful regulation of TLR signaling must take place in order to
way sensitization in the same mouse asthma model [88], while avoid an inappropriate inflammatory response. One of the emerging
the TLR9 signal has been shown to inhibit OVA-induced aller- themes of research in innate immunity in the gut is the impor-
gic airway inflammation [88–90]. The induction of Th2 immune tant role of TLR signaling in maintenance of intestinal homeostasis.
 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253 247

Fig. 2. Endoscopic images of Crohn’s disease (left) and ulcerative colitis (right) exemplifying the distribution and characteristics of the inflammation.

Inflammatory bowel diseases (IBDs) such as ulcerative colitis and With respect to NLRs, strong association of Nod2 gene muta-
Crohn’s disease are characterized by chronic intestinal inflamma- tions and Crohn’s disease was discovered almost simultaneously
tion induced by the commensal flora (Fig. 2). Since inflammatory in 2001 using two distinct strategies [37,130]. This discovery over-
bowel disease is associated with inappropriate inflammation in the turned the prevailing theory that inflammatory bowel disease
presence of seemingly normal commensal bacteria, several groups pathogenesis resulted from aberrant adaptive immunity to the
have studied expression of TLRs and NLRs in human and murine new point of view that NLR mutations resulted in defective innate
IBD in hopes of identifying how bacterial sensing contributes to immunity. Most mutations were found in the LRR region of the
IBD pathogenesis. Almost all of the TLRs, TLR1 through TLR9, are molecule. The 3020insC frameshift mutation results in a protein
expressed in intestinal epithelial cells as well as in other types of that is unable to sense the natural ligand MDP [12,131]. This results
cells in the intestine [115–118]. Increased expression of multiple in impaired responses by macrophages to ligands [132,133]. These
TLRs has been found in the tissue from patients with inflammatory observations are counterintuitive when considering an inflamma-
bowel disease but it is difficult to make a causal link between these tory disorder. However, more recently mice with a knock-in of the
observations and the development of inflammatory bowel disease human frameshift mutation have increased inflammation, in partic-
since inflammatory cytokines can up-regulate expression of TLRs ular increased production of the inflammasome-generated IL-1␤, in
on intestinal epithelial cells [119,120]. response to DSS [134].
Perhaps more importantly, several TLR polymorphisms have The mechanism by which Nod2 mutations confer an increased
been found in patients with inflammatory bowel disease. The susceptibility to Crohn’s disease is unknown. Dendritic cells from
strongest TLR association with inflammatory bowel disease is the patients with Crohn’s disease carrying Nod2 mutations produced
TLR4 polymorphism, Asp299Gly, in patients with Crohn’s disease reduced levels of IL-12 and did not up-regulate co-stimulatory
and to a lesser extent ulcerative colitis [67]. Several meta-analyses molecules in response to MDP plus TLR ligands [135]. Besides
have found the odds ratio for association between TLR4 and Crohn’s antigen-presenting cells, NOD2 is also expressed in Paneth cells
disease to be approximately 1.5 [120–123]. Depending on the study, [136], which are localized in the bottom of the crypt of the small
the Asp299Gly TLR4 association in Crohn’s disease is associated intestine, most abundantly in the terminal ileum. This distribution
with colonic disease or with stricturing disease [122,124,125]. of Paneth cells is corresponds to the most frequently affected site
In addition to TLR4, lesser associations have been found between of the gut by Crohn’s disease. Furthermore, homozygosity of NOD2
TLR9, TLR2 and inflammatory bowel disease. The −1237C polymor- mutations in Crohn’s disease is associated with more severe disease
phism of TLR9 has been found as a disease susceptibility gene in and fibrostenosis in the terminal ileum [137].
Crohn’s disease [126]. This polymorphism of TLR9 was significantly Defective production of anti-microbial peptide, ␣-defensins
higher in Crohn’s disease patients with at least one NOD2 muta- (HD5, HD6) mainly secreted by Paneth cells, has been observed
tion (odds ratio 1.60) and with the rs1004819 IL-23R variant [127]. in Crohn’s disease patients with NOD2 mutations [138,139]. These
The R753Q polymorphism of TLR2 has been implicated in ulcerative results suggest that defective anti-microbial peptide and subse-
colitis [128]. In particular, the R80T and R753G polymorphisms are quent regional microbial overgrowth is, at least in part, involved in
associated with a greater risk of pancolitis. A study using intestinal the pathogenesis of Crohn’s disease caused by Nod2 mutations. An
epithelial cell lines expressing the R753Q variant of TLR2 found that in vitro study further supports this idea; a NOD2-deficient intestinal
this mutation resulted in defective production of trefoil factor 3, a epithelial monolayer showed reduced ability to resist Salmonella
trophic growth factor important in epithelial repair [129]. growth [140]. In addition, other susceptibility genes for Crohn’s dis-
248 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253

ease, such as ATG16L1, IL-23R and IRGM are also involved in innate cally block signaling of TLRs and NLRs. Often the strategy has been
immune deficiency and further suggest defective anti-microbial to inhibit or augment their downstream products such as block-
immune processing is the central pathogenesis of Crohn’s disease. ing antibodies to TNF-␣ or IL-1␤. Depending on the disease state,
Failure to control intestinal microbes may lead to inappropriate exogenous recombinant cytokines such as IFN-␤ are used to treat
alternative immune responses in an attempt to control enteric flora, MS or IFN-␣ for hepatitis C; it is conceivable that activation of
but may also lead to inflammation and tissue destruction. Pheno- the underlying TLR or NLR pathway may be used in the future.
typic variations of the disease, such as inflammatory, fibrostenotic, One common way in which TLR signaling is used to advantage is
or perforating disease, are probably due to the type of genetic muta- as adjuvants for vaccines. A table of TLR-based strategies is listed
tions, grade of the anti-microbial defect, grade of compensatory below (Table 3). Most common vaccines use adjuvants to increase
adaptive immune responses, and environmental factors including the adaptive immune response to the antigen. In the future, very
the enteric flora. specific TLR ligands such as CpG DNA will be added to common
As a testament to the notion that defective innate immunity vaccines.
underpins some of the pathogenesis of Crohn’s disease, we and We have studied blocking Abs to TLR4 in acute and chronic
others have described that patients carrying Nod2 polymorphisms DSS colitis. Perhaps not surprisingly, acute inflammation is damp-
have increased levels of antibodies against luminal microbes such ened but it also results in delayed epithelial repair [148]. Another
as anti-Saccharomyces cerevisiae and anti-CBir, an antibody against avenue that has been very effective in the treatment of actinic ker-
a Clostridial flagellin [141,142]. These data suggest that defective atoses and anal warts is the TLR7/8 ligand imiquimod. It is generally
handling of the luminal flora plays a role in inflammatory bowel believed that the imiquimod boosts the innate immune response
disease. What is clear in animal models is that TLR signaling is to the damaged tissue in these neoplastic lesions. Case reports of
essential for epithelial repair [143,144]. To the extent that inflam- autoimmunity resulting from imiquimod therapy urge some cau-
matory bowel disease may be partially due to defective epithelial tion [113,149].
healing, polymorphisms in TLRs may contribute to susceptibility One significant advance in the development of TLR targeted ther-
to inflammatory bowel disease by both impairing the ability to kill apy is TLR9 agonist against allergic diseases. In general, allergic
commensal bacteria and causing an epithelial repair defect. reactions are thought to result from an excess Th2 immune response
Although the focus has been the Nod2 gene as an NLR related to against environmental stimuli. Since most TLR agonists induce Th1
inflammatory bowel disease, recent evidence suggests that NALP3 type immune responses, inhibiting production of Th2 cytokines,
is also involved in inflammatory bowel disease [145]. European some of the TLR agonist is expected to shift the Th2 hyper reactiv-
investigators have found NLRP3 SNPs are associated with a 1.78 ity to Th1 in patients with active allergy. The effectiveness of this
odds ratio of Crohn’s disease. Moreover, they observed a significant approach has been reported in patients with allergy to ragweed,
association between SNPs and NLRP3 expression and IL-1␤ pro- with the expected shift in Th2/Th1 ratio [150,151]. Clinical trials
duction. Future studies will elucidate whether inhibiting IL-1 will of a CpG-ODN (1018ISS) have demonstrated both safety and phar-
be effective in Crohn’s disease. macological activity in asthmatic patients when administered by
inhalation [152]. In another study, R848 (resiquimod), a synthetic
6. Possible therapeutic strategies for inflammatory ligand for TLR7 and TLR8, effectively shifted the Th2 response of
disorders by targeting TLRs and NLRs allergen specific human CD4+ T cells into a protective Th1 response,
suggesting the therapeutic potential of this compound for allergy
TLR agonists are being developed for the treatment of cancer, [153]. Efficacy of TLR7 agonists has also been shown in a mouse
allergic diseases, viral infections, and as adjuvants for vaccines model of asthma [154].
against cancer and infectious diseases [146]. In addition, devel- As we discussed so far, TLRs are up-regulated in the lesions
opment of antagonists to TLRs is expected given the role of of inflammatory diseases. Therefore, blocking TLR signaling is
inappropriate TLR stimulation in chronic idiopathic inflammatory expected to be a novel strategy. There is now considerable evidence
and autoimmune diseases (Table 3). that self-recognition through TLR can occur and can contribute sig-
Clearly the TLR and NLR pathways are essential for normal nificantly to sterile inflammation and autoimmunity [155]. In this
human homeostasis. Even polymorphisms in these proteins do not regard, TLR4 antagonists are currently being developed [156].
result in radical changes in susceptibility to infection. By design, In contrast to TLRs, the effect of NLR agonist or antagonist has
there is redundancy in the function of TLRs and NLRs. Severe infec- not yet been tested. Nevertheless, IL-1␤ and IL-18, the final products
tions occur in humans born with mutations in IRAK, for instance of inflammasome activation, have been implicated in the patho-
[147]. For this reason, we must be careful in trying to systemi- genesis of many autoimmune diseases [157–161]. Recombinant

Table 3
Toll-like receptor (TLR) therapeutics currently in development.

TLR target Potential therapeutic agent Company Mechanism of action Indication

TLR3 Ampligen Bioclones Agonist Ovarian cancer

TLR4 CRX-675, CRX-527 Corixa Agonist Allergic rhinitis

TLR4 E5564 Eisai Antagonist Sepsis, Complications after CABG
TLR7 ANA245, ANA975 Anadys Agonist HCV, HBV, hepatocellular carcinoma
TLR7/8 Imiquimod 3M Agonist Superficial basal cell carcinoma, Actinic keratosis, HPV, genital warts
TLR9 CPG7909 Coley Agonist Non-small cell lung cancer, melanoma, refractory B cell non-Hodgkin’s
lymphoma
TLR9 CPG10101 Coley Agonist HCV
TLR9 AVE7279, AVE0675 Coley Agonist Asthma
TLR9 1018ISS Dynavax Agonist HBV, ragweed allergy
TLR9 HYB2055, HYB2903 Hybridon Agonist Renal cell carcinoma
TLR9 IMO-2055 Idera pharmaceuticals Agonist Renal cell carcinoma
Refs. [224–227]

CABG, coronary artery bypass graft surgery: HBV, hepatitis B virus: HCV, hepatitis C virus: HPV, human papilloma virus.
 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253 249

human IL-Ra has been shown to be beneficial in patients with active [19] Agostini L, Martinon F, Burns K, et al. NALP3 forms an IL-l beta-processing
rheumatoid arthritis as well as gout [110,162–164]. Although IL- inflammasome with increased activity in Muckle-Wells autoinflammatory
disorder. Immunity 2004;20(3):319–25.
1␤ blocking by IL-1Ra has been less effective in RA compared to [20] Sidiropoulos PI, Goulielmos G, Voloudakis GK, Petraki E, Boumpas DT.
anti-TNF-␣ therapy [165], targeting therapies to upstream signaling Inflammasomes and rheumatic diseases: evolving concepts. Ann Rheum Dis
molecules including NLR-mediated inflammasomes may improve 2008;67(10):1382–9.
[21] Steimle V, Otten LA, Zufferey M, Mach B. Complementation cloning of an MHC
efficacy of current biological therapy for many autoimmune dis- class II transactivator mutated in hereditary MHC class II deficiency (or bare
eases. lymphocyte syndrome). Cell 1993;75(1):135–46.
Finally, several reports have demonstrated efficacy of TLRs and [22] Reith W, Mach B. The bare lymphocyte syndrome and the regulation of MHC
expression. Annu Rev Immunol 2001;19:331–73.
NOD2 antagonist for prevention of murine models of IBD [166–170]. [23] Linhoff MW, Harton JA, Cressman DE, Martin BK, Ting JPY. Two distinct
Notably, the inhibitory effects of these agonists are observed when domains within CIITA mediate self-association: involvement of the GTP-
administered prior to induction of intestinal inflammation. A sub- binding and leucine-rich repeat domains. Mol Cell Biol 2001;21(9):3001–11.
[24] Nickerson K, Sisk TJ, Inohara N, et al. Dendritic cell-specific MHC class II
set of patients with Crohn’s disease showed decreased expression of
transactivator contains a caspase recruitment domain that confers potent
mucosal TLR3 [118], and Crohn’s disease associated Nod2 mutations transactivation activity. J Biol Chem 2001;276(22):19089–93.
are considered as loss of function mutation [132,133], stimulation [25] Rao DA, Tracey KJ, Pober JS. IL-1 alpha and IL-1 ss are endogenous medi-
of TLR3 or NOD2 signaling in the mucosa can be a new therapeu- ators linking cell injury to the adaptive alloimmune response. J Immunol
2007;179:6536–46.
tic strategy for patients with Crohn’s disease carrying decreased [26] Acosta-Rodriguez EV, Napolitani G, Lanzavecchia A, Sallusto F. Interleukins 1
expression of TLR3 or Nod2 mutations, respectively. Therefore, the beta and 6 but not transforming growth factor-beta are essential for the dif-
ying and yang of TLR signaling will need to be taken into account ferentiation of interleukin 17-producing human T helper cells. Nat Immunol
2007;8(9):942–9.
as we move forward to design therapeutics. [27] Eisenbarth SC, Colegio OR, O’Connor W, Sutterwala FS, Flavell RA. Crucial
role for the Nalp3 inflammasome in the immunostimulatory properties of
aluminium adjuvants. Nature 2008;453(7198), 1122–U1113.
7. Concluding remarks [28] Li HF, Willingham SB, Ting JPY, Re F. Cutting edge: inflammasome activa-
tion by alum and alum’s adjuvant effect are mediated by NLRP3. J Immunol
The discovery of the TLR and NLR pathways has provided an 2008;181(1):17–21.
[29] Kool M, Soullie T, van Nimwegen M, et al. Alum adjuvant boosts adaptive
extraordinary window into the workings of our immune system. immunity by inducing uric acid and activating inflammatory dendritic cells. J
Their discovery helps to resolve our understanding of common and Exp Med 2008;205(4):869–82.
uncommon human diseases from atherosclerosis and gout to Blau [30] Schmitz J, Owyang A, Oldham E, et al. IL-33, an interleukin-1-like cytokine
that signals via the IL-1 receptor-related protein ST2 and induces T helper
syndrome and Crohn’s disease. In the next phase, investigators will
type 2-associated cytokines. Immunity 2005;23(5):479–90.
try to capitalize on their findings by manipulating these pathways [31] Mach B, Steimle V, MartinezSoria E, Reith W. Regulation of MHC class II genes:
to treat disease. lessons from a disease. Annu Rev Immunol 1996;14:301–31.
[32] Fukata M, Breglio K, Chen A, et al. The myeloid differentiation factor 88
(MyD88) is required for CD4(+) T cell effector function in a murine model
References of inflammatory bowel disease. J Immunol 2008;180(3):1886–94.
[33] Caron G, Duluc D, Fremaux I, et al. Direct stimulation of human T cells via TLR5
[1] Kawai T, Akira S. Innate immune recognition of viral infection. Nat Immunol and TLR7/8: flagellin and R-848 up-regulate proliferation and IFN-gamma
2006;7(2):131–7. production by memory CD4(+) T cells. J Immunol 2005;175(3):1551–7.
[2] Inohara N, Chamaillard M, McDonald C, Nunez G. NOD–LRR proteins: role [34] Caramalho I, Lopes-Carvalho T, Ostler D, et al. Regulatory T cells selectively
in host–microbial interactions and inflammatory disease. Annu Rev Biochem express toll-like receptors and are activated by lipopolysaccharide. J Exp Med
2005;74:355–83. 2003;197(4):403–11.
[3] Matzinger P. The danger model: a renewed sense of self. Science [35] Zarember KA, Godowski PJ. Tissue expression of human Toll-like recep-
2002;296(5566):301–5. tors and differential regulation of Toll-like receptor mRNAs in leukocytes in
[4] Shi Y, Evans JE, Rock KL. Molecular identification of a danger signal that alerts response to microbes, their products, and cytokines. J Immunol 2002;168(2):
the immune system to dying cells. Nature 2003;425(6957):516–21. 554–61.
[5] Kanneganti TD, Lamkanfi M, Kim YG, et al. Pannexin-1-mediated recognition [36] Hugot JP, Chamaillard M, Zouali H, et al. Association of NOD2 leucine-
of bacterial molecules activates the cryopyrin inflammasome independent of rich repeat variants with susceptibility to Crohn’s disease. Nature
Toll-like receptor signaling. Immunity 2007;26(4):433–43. 2001;411(6837):599–603.
[6] Kawai T, Akira S. TLR signaling. Cell Death Differ 2006;13(5):816–25. [37] Ogura Y, Bonen DK, Inohara N, et al. A frameshift mutation in NOD2 associated
[7] O’Neill LAJ. How Toll-like receptors signal: what we know and what we don’t with susceptibility to Crohn’s disease. Nature 2001;411(6837):603–6.
know. Curr Opin Immunol 2006;18(1):3–9. [38] McGovern DPB, Hysi P, Ahmad T, et al. Association between a complex
[8] Bowie A, O’Neill LAJ. The interleukin-1 receptor/Toll-like receptor super- insertion/deletion polymorphism in NOD1 (CARD4) and susceptibility to
family: signal generators for pro-inflammatory interleukins and microbial inflammatory bowel disease. Hum Mol Genet 2005;14(10):1245–50.
products. J Leukoc Biol 2000;67(4):508–14. [39] Elmaagacli AH, Koldehoff M, Hindahl H, et al. Mutations in innate immune
[9] Creagh EM, O’Neill LAJ. TLRs, NLRs and RLRs: a trinity of pathogen sensors that system NOD2/CARD 15 and TLR-4 (Thr399Ile) genes influence the risk for
co-operate in innate immunity. Trends Immunol 2006;27(8):352–7. severe acute graft-versus-host disease in patients who underwent an allo-
[10] Ting JPY, Kastner DL, Hoffman HM. CATERPILLERs, pyrin and hereditary geneic transplantation. Transplantation 2006;81(2):247–54.
immunological disorders. Nat Rev Immunol 2006;6(3):183–95. [40] Granell M, Urbano-Ispizua A, Arostegui JI, et al. Effect of NOD2/CARD15
[11] Harton JA, Linhoff MW, Zhang JH, Ting JPY. Cutting edge: CATERPILLER: a large variants in T-cell depleted allogeneic stem cell transplantation. Haematol-
family of mammalian genes containing CARD, pyrin, nucleotide-binding, and Hematol J 2006;91(10):1372–6.
leucine-rich repeat domains. J Immunol 2002;169(8):4088–93. [41] Palmer SM, Burch LH, Davis RD, et al. The role of innate immunity in acute
[12] Inohara N, Ogura Y, Fontalba A, et al. Host recognition of bacterial muramyl allograft rejection after lung transplantation. Am J Respir Crit Care Med
dipeptide mediated through NOD2. Implications for Crohn’s disease. J Biol 2003;168(6):628–32.
Chem 2003;278(8):5509–12. [42] Miceli-Richard C, Lesage S, Rybojad M, et al. CARD15 mutations in Blau syn-
[13] Martinon F, Tschopp J. Inflammatory caspases and inflammasomes: master drome. Nat Genet 2001;29(1):19–20.
switches of inflammation. Cell Death Differ 2007;14:10–22. [43] Kanazawa N, Okafuji I, Kambe N, et al. Early-onset sarcoidosis and CARD15
[14] Chamaillard M, Philpott D, Girardin SE, et al. Gene-environment interaction mutations with constitutive nuclear factor-kappa B activation: common
modulated by allelic heterogeneity in inflammatory diseases. Proc Natl Acad genetic etiology with Blau syndrome. Blood 2005;105(3):1195–7.
Sci USA 2003;100(6):3455–60. [44] Rosenstiel P, Till A, Schreiber S. NOD-like receptors and human diseases.
[15] Ogura Y, Saab L, Chen FF, et al. Genetic variation and activity of mouse Microbes Infect 2007;9(5):648–57.
Nod2, a susceptibility gene for Crohn’s disease small star, filled. Genomics [45] Church LD, Churchman SM, Hawkins PN, McDermott MF. Hereditary
2003;81(4):369–77. auto-inflammatory disorders and biologics. Springer Semin Immunopathol
[16] Windheim M, Lang C, Peggie M, Plater LA, Cohen P. Molecular mechanisms 2006;27(4):494–508.
involved in the regulation of cytokine production by muramyl dipeptide. [46] Masters SL, Lobito AA, Chae JJ, Kastner DL. Recent advances in the molecular
Biochem J 2007;404:179–90. pathogenesis of hereditary recurrent fevers. Curr Opin Allergy Clin Immunol
[17] Park JH, Kim YG, McDonald C, et al. RICK/RIP2 mediates innate immune 2006;6(6):428–33.
responses induced through Nod1 and Nod2 but not TLRs. J Immunol [47] Dowds TA, Masumoto J, Zhu L, Inohara N, Nunez G. Cryopyrin-induced
2007;178(4):2380–6. interleukin 1 beta secretion in monocytic cells—enhanced activity of
[18] Martinon F, Tschopp J. Inflammatory caspases: linking an intracellular innate disease-associated mutants and requirement for ASC. J Biol Chem
immune system to autoinflammatory diseases. Cell 2004;117(5):561–74. 2004;279(21):21924–8.
250 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253

[48] Goldbach-Mansky R, Dailey NJ, Canna SW, et al. Neonatal-onset multisystem [79] Tzartos JS, Friese MA, Craner MJ, et al. Interleukin-17 production in central
inflammatory disease responsive to interleukin-1 beta inhibition. N Engl J Med nervous system-infiltrating T cells and glial cells is associated with active
2006;355(6):581–92. disease in multiple sclerosis. Am J Pathol 2008;172(1):146–55.
[49] Hoffman HM, Rosengren S, Boyle DL, et al. Prevention of cold-associated acute [80] Cho ML, Yoon CH, Hwang SY, et al. Effector function of type II collagen-
inflammation in familial cold autoinflammatory syndrome by interleukin-1 stimulated T cells from rheumatoid arthritis patients—cross-talk between T
receptor antagonist. Lancet 2004;364(9447):1779–85. cells and synovial fibroblasts. Arthritis Rheum 2004;50(3):776–84.
[50] Jin Y, Mailloux CM, Gowan K, et al. NALP1 in vitiligo-associated multiple [81] Ziolkowska N, Koc A, Luszczykiewicz G, et al. High levels of IL-17 in rheumatoid
autoimmune disease. N Engl J Med 2007;356(12):1216–25. arthritis patients: IL-15 triggers in vitro IL-17 production via cyclosporin A-
[51] Holt PG, Sly PD. Interactions between respiratory tract infections and atopy sensitive mechanism. J Immunol 2000;164(5):2832–8.
in the aetiology of asthma. Eur Respir J 2002;19(3):538–45. [82] Nakae S, Nambu A, Sudo K, Iwakura Y. Suppression of immune induc-
[52] Hysi P, Kabesch M, Moffatt MF, et al. NOD1 variation, immunoglobulin E and tion of collagen-induced arthritis in IL-17-deficient mice. J Immunol
asthma. Hum Mol Genet 2005;14(7):935–41. 2003;171(11):6173–7.
[53] Eder W, Klimecki W, Yu L, et al. Association between exposure to farming, [83] Lubberts E, Koenders MI, Oppers-Walgreen B, et al. Treatment with a neutral-
allergies and genetic variation in CARD4/NOD1. Allergy 2006;61(9):1117–24. izing anti-murine interleukin-17 antibody after the onset of collagen-induced
[54] Girardin SE, Jehanno M, Mengin-Lecreulx D, et al. Identification of the crit- arthritis reduces joint inflammation, cartilage destruction, and bone erosion.
ical residues involved in peptidoglycan detection by Nod1. J Biol Chem Arthritis Rheum 2004;50(2):650–9.
2005;280(46):38648–56. [84] Niebuhr M, Lutat C, Draing C, Kapp A, Werfel T. Impaired TLR-2 expression and
[55] Weidinger S, Klopp N, Rummler L, et al. Association of CARD15 polymorphisms TLR-2 mediated cytokine secretion in macrophages from patients with atopic
with atopy-related traits in a population-based cohort of Caucasian adults. dermatitis. Allergy 2008;63:45.
Clin Exp Allergy 2005;35(7):866–72. [85] Eisenbarth SC, Piggott DA, Huleatt JW, et al. Lipopolysaccharide-enhanced,
[56] Woo JG, Assa’ad A, Heizer AB, Bernstein JA, Hershey GKK. The-159C → T poly- toll-like receptor 4-dependent T helper cell type 2 responses to inhaled anti-
morphism of CD14 is associated with nonatopic asthma and food allergy. J gen. J Exp Med 2002;196(12):1645–51.
Allergy Clin Immunol 2003;112(2):438–44. [86] Dabbagh K, Dahl ME, Stepick-Biek P, Lewis DB. Toll-like receptor 4 is required
[57] Leung T-f, Tang NLS, Wong GWK, Fok T-F. CD14 and toll-like receptors: poten- for optimal development of Th2 immune responses: role of dendritic cells. J
tial contribution of genetic factors and mechanisms to inflammation and Immunol 2002;168(9):4524–30.
allergy. Curr Drug Targets-Inflamm Allergy 2005;4(2):169–75. [87] Piggott DA, Eisenbarth SC, Xu L, et al. MyD88-dependent induction of allergic
[58] Woodcock A, Forster L, Matthews E, et al. Control of exposure to mite allergen Th2 responses to intranasal antigen. J Clin Invest 2005;115(2):459–67.
and allergen-impermeable bed covers for adults with asthma. N Engl J Med [88] Redecke V, Hacker H, Datta SK, et al. Cutting edge: activation of toll-like recep-
2003;349(3):225–36. tor 2 induces a Th2 immune response and promotes experimental asthma. J
[59] Eder W, Klimecki W, Yu LZ, et al. Toll-like receptor 2 as a major gene for asthma Immunol 2004;172(5):2739–43.
in children of European farmers. J Allergy Clin Immunol 2004;113(3):482–8. [89] Banerjee B, Kelly KJ, Fink JN, et al. Modulation of airway inflammation by
[60] Lazarus R, Raby BA, Lange C, et al. TOLL-like receptor 10 genetic variation is immunostimulatory CpG oligodeoxynucleotides in a murine model of allergic
associated with asthma in two independent samples. Am J Respir Crit Care aspergillosis. Infect Immun 2004;72(10):6087–94.
Med 2004;170(6):594–600. [90] Yamamoto K, Kawamura I, Ito J, Mitsuyama M. Modification of allergic inflam-
[61] Hur JW, Shin HD, Park BL, et al. Association study of Toll-like receptor 9 gene mation in murine model of rhinitis by different bacterial ligands: involvement
polymorphism in Korean patients with systemic lupus erythematosus. Tissue of mast cells and dendritic cells. Clin Exp Allergy 2006;36(6):760–9.
Antigens 2005;65(3):266–70. [91] Dong L, Li HJ, Wang SJ, Li YL. Different doses of lipopolysaccharides regu-
[62] Sanchez E, Orozco G, Lopez-Nevot MA, Jimenez-Alonso J, Martin J. Polymor- late the lung inflammation of asthmatic mice via TLR4 pathway in alveolar
phisms of toll-like receptor 2 and 4 genes in rheumatoid arthritis and systemic macrophages. J Asthma 2009;46(3):229–33.
lupus erythematosus. Tissue Antigens 2004;63(1):54–7. [92] Lun SWM, Wong CK, Ko FWS, Hui DSC, Lam CWK. Expression and functional
[63] Sheedy FJ, Marinou I, O’Neill LAJ, Wilson AG. The Mal/TIRAP S180L and TLR4 analysis of Toll-like receptors of peripheral blood cells in asthmatic patients:
G299D polymorphisms are not associated with susceptibility to, or severity implication for immunopathological mechanism in asthma. J Clin Immunol
of, rheumatoid arthritis. Ann Rheum Dis 2008;67(9):1328–31. 2009;29(3):330–42.
[64] Steer S, Fisher SA, Fife M, et al. Development of rheumatoid arthritis is not [93] Droemann D, Goldmann T, Tiedje T, et al. Toll-like receptor 2 expression is
associated with two polymorphisms in the Crohn’s disease gene CARD15. decreased on alveolar macrophages in cigarette smokers and COPD patients.
Rheumatology (Oxford) 2003;42(2):304–7. Respir Res 2005:6.
[65] Berdeli A, Celik HA, Ozyurek R, Dogrusoz B, Aydin HH. TLR-2 gene Arg753Gln [94] Pons J, Sauleda J, Regueiro V, et al. Expression of Toll-like receptor 2 is up-
polymorphism is strongly associated with acute rheumatic fever in children. regulated in monocytes from patients with chronic obstructive pulmonary
Journal of Molecular Medicine-JMM 2005;83(7):535–41. disease. Respir Res 2006:7.
[66] Kang TJ, Chae GT. Detection of Toll-like receptor 2 (TLR2) mutation in the [95] Sarir H, Henricks PAJ, van Homelingen AH, Nijkamp FP, Folkerts G. Cells,
lepromatous leprosy patients. FEMS Immunol Med Microbiol 2001;31(1): mediators and Toll-like receptors in COPD. Eur J Pharmacol 2008;585(2–3):
53–8. 346–53.
[67] Franchimont D, Vermeire S, El Housni H, et al. Deficient host–bacteria [96] Platz J, Beisswenger C, Dalpke A, et al. Microbial DNA induces a
interactions in inflammatory bowel disease? The toll-like receptor (TLR)-4 host defense reaction of human respiratory epithelial cells. J Immunol
Asp299Gly polymorphism is associated with Crohn’s disease and ulcerative 2004;173(2):1219–23.
colitis. Gut 2004;53(7):987–92. [97] Sha Q, Truong-Tran AQ, Plitt JR, Beck LA, Schleimer RP. Activation of air-
[68] Hausmann M, Kiessling S, Mestermann S, et al. Toll-like receptors 2 way epithelial cells by toll-like receptor agonists. Am J Respir Cell Mol Biol
and 4 are up-regulated during intestinal inflammation. Gastroenterology 2004;31(3):358–64.
2002;122(7):1987–2000. [98] Armstrong L, Medford ARL, Uppington KM, et al. Expression of functional toll-
[69] Kirino Y, Takeno M, Watanabe R, et al. Association of reduced heme like receptor-2 and -4 on alveolar epithelial cells. Am J Respir Cell Mol Biol
oxygenase-1 with excessive Toll-like receptor 4 expression in peripheral blood 2004;31(2):241–5.
mononuclear cells in Behcet’s disease. Arthritis Res Ther 2008;10(1). [99] Guillot L, Le Goffic R, Bloch S, et al. Involvement of toll-like receptor 3 in
[70] Do JE, Kwon SY, Park S, Lee ES. Effects of vitamin D on expression of Toll-like the immune response of lung epithelial cells to double-stranded RNA and
receptors of monocytes from patients with Behcet’s disease. Rheumatology influenza A virus. J Biol Chem 2005;280(7):5571–80.
(Oxford) 2008;47(6):840–8. [100] Soong G, Reddy B, Sokol S, Adamo R, Prince A. TLR2 is mobilized into an apical
[71] Migita K, Miyashita T, Maeda Y, et al. Toll-like receptor expression in lupus lipid raft receptor complex to signal infection in airway epithelial cells. J Clin
peripheral blood mononuclear cells. J Rheumatol 2007;34(3):493–500. Invest 2004;113(10):1482–9.
[72] Brentano F, Schorr O, Gay RE, Gay S, Kyburz D. RNA released from necrotic [101] Fernandez S, Jose P, Avdiushko MG, Kaplan AM, Cohen DA. Inhibition of IL-
synovial fluid cells activates rheumatoid arthritis synovial fibroblasts via Toll- 10 receptor function in alveolar macrophages by toll-like receptor agonists. J
like receptor 3. Arthritis Rheum 2005;52(9):2656–65. Immunol 2004;172(4):2613–20.
[73] Kim KW, Cho ML, Lee SH, et al. Human rheumatoid synovial fibroblasts [102] Haeberle HA, Takizawa R, Casola A, et al. Respiratory syncytial virus-
promote osteoclastogenic activity by activating RANKL via TLR-2 and TLR-4 induced activation of nuclear factor-kappa B in the lung involves alveolar
activation. Immunol Lett 2007;110(1):54–64. macrophages and toll-like receptor 4-dependent pathways. J Infect Dis
[74] Marta M, Andersson A, Isaksson M, Kampe O, Lobell A. Unexpected regulatory 2002;186(9):1199–206.
roles of TLR4 and TLR9 in experimental autoimmune encephalomyelitis. Eur [103] Doz E, Noulin N, Boichbt E, et al. Cigarette smoke-induced pulmonary inflam-
J Immunol 2008;38(2):565–75. mation is TLR4/MyD88 and IL-1R1/MyD88 signaling dependent. J Immunol
[75] Lampropoulou V, Hoehlig K, Roch T, et al. TLR-activated B cells suppress T 2008;180(2):1169–78.
cell-mediated autoimmunity. J Immunol 2008;180(7):4763–73. [104] Dostert C, Petrilli V, Van Bruggen R, et al. Innate immune activation
[76] Fitzgerald DC, Ciric B, Touil T, et al. Suppressive effect of IL-27 on encephal- through Nalp3 inflammasome sensing of asbestos and silica. Science
itogenic Th17 cells and the effector phase of experimental autoimmune 2008;320(5876):674–7.
encephalomyelitis. J Immunol 2007;179(5):3268–75. [105] Cassel SL, Eisenbarth SC, Iyer SS, et al. The Nalp3 inflammasome is essential for
[77] Nielsen OH, Kirman I, Rudiger N, Hendel J, Vainer B. Upregulation of the development of silicosis. Proc Natl Acad Sci USA 2008;105(26):9035–40.
interleukin-12 and -17 in active inflammatory bowel disease. Scand J Gas- [106] Hornung V, Bauernfeind F, Halle A, et al. Silica crystals and aluminum salts
troenterol 2003;38(2):180–5. activate the NALP3 inflammasome through phagosomal destabilization. Nat
[78] Fujino S, Andoh A, Bamba S, et al. Increased expression of interleukin 17 in Immunol 2008;9(8):847–56.
inflammatory bowel disease. Gut 2003;52(1):65–70. [107] Wagner GR. Asbestosis and silicosis. Lancet 1997;349(9061):1311–5.
 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253 251

[108] Martinon F, Petrilli V, Mayor A, Tardivel A, Tschopp J. Gout-associated uric acid [137] Seiderer J, Schnitzler F, Brand S, et al. Homozygosity for the CARD15 frameshift
crystals activate the NALP3 inflammasome. Nature 2006;440(7081):237–41. mutation 1007fs is predictive of early onset of Crohn’s disease with ileal steno-
[109] Kutzing MK, Firestein BL. Altered uric acid levels and disease states. J Pharma- sis, entero-enteral fistulas, and frequent need for surgical intervention with
col Exp Ther 2008;324(1):1–7. high risk of re-stenosis. Scand J Gastroenterol 2006;41(12):1421–32.
[110] McGonagle D, Tan AL, Madden J, Emery P, McDermott MF. Success- [138] Voss E, Wehkamp J, Wehkamp K, et al. NOD2/CARD15 mediates induc-
ful treatment of resistant pseudogout with anakinra. Arthritis Rheum tion of the antimicrobial peptide human beta-defensin-2. J Biol Chem
2008;58(2):631–3. 2006;281(4):2005–11.
[111] McGonagle D, Tan AL, Shankaranarayana S, et al. Management of treatment [139] Wehkamp J, Harder J, Weichenthal M, et al. NOD2 (CARD15) mutations
resistant inflammation of acute on chronic tophaceous gout with anakinra. in Crohn’s disease are associated with diminished mucosal alpha-defensin
Ann Rheum Dis 2007;66:1683–4. expression. Gut 2004;53(11):1658–64.
[112] Patole PS, Pawar RD, Lichtnekert J, et al. Coactivation of Toll-like receptor-3 and [140] Hisamatsu T, Suzuki M, Reinecker HC, et al. CARD15/NOD2 functions as an
-7 in immune complex glomerulonephritis. J Autoimmun 2007;29(1):52–9. antibacterial factor in human intestinal epithelial cells. Gastroenterology
[113] Pawar RD, Patole PS, Wornle M, Anders HJ. Microbial nucleic acids pay a Toll 2003;124(4):993–1000.
in kidney disease. Am J Physiol-Renal Physiol 2006;291(3):F509–16. [141] Devlin SM, Yang H, Ippoliti A, et al. NOD2 variants and antibody response to
[114] Ehlers M, Ravetch JV. Opposing effects of Toll-like receptor stimulation induce microbial antigens in Crohn’s disease patients and their unaffected relatives.
autoimmunity or tolerance. Trends Immunol 2007;28(2):74–9. Gastroenterology 2007;132(2):576–86.
[115] Melmed G, Thomas LS, Lee N, et al. Human intestinal epithelial cells [142] Henckaerts L, Pierik M, Joossens M, et al. Mutations in pattern recognition
are broadly unresponsive to toll-like receptor 2-dependent bacterial lig- receptor genes modulate seroreactivity to microbial antigens in patients with
ands: implications for host–microbial interactions in the gut. J Immunol inflammatory bowel disease. Gut 2007;56(11):1536–42.
2003;170(3):1406–15. [143] Fukata M, Michelsen KS, Eri R, et al. Toll-like receptor-4 is required for
[116] Otte JM, Cario E, Podolsky DK. Mechanisms of cross hyporesponsiveness to intestinal response to epithelial injury and limiting bacterial translocation
Toll-like receptor bacterial ligands in intestinal epithelial cells. Gastroenterol- in a murine model of acute colitis. Am J Physiol Gastrointest Liver Physiol
ogy 2004;126(4):1054–70. 2005;288(5):G1055–1065.
[117] Rock FL, Hardiman G, Timans JC, Kastelein RA, Bazan JF. A family of human [144] Rakoff-Nahoum S, Paglino J, Eslami-Varzaneh F, Edberg S, Medzhitov R. Recog-
receptors structurally related to Drosophila Toll. Proc Natl Acad Sci USA nition of commensal microflora by toll-like receptors is required for intestinal
1998;95(2):588–93. homeostasis. Cell 2004;118(2):229–41.
[118] Cario E, Podolsky DK. Differential alteration in intestinal epithelial cell expres- [145] Villani AC, Lemire M, Fortin G, et al. Common variants in the NLRP3 region
sion of toll-like receptor 3 (TLR3) and TLR4 in inflammatory bowel disease. contribute to Crohn’s disease susceptibility. Nat Genet 2009;41(1):71–6.
Infect Immun 2000;68(12):7010–7. [146] Romagne F. Current and future drugs targeting one class of innate immunity
[119] Abreu MT, Arnold ET, Thomas LS, et al. TLR4 and MD-2 expression is regulated receptors: the Toll-like receptors. Drug Discov Today 2007;12(1–2):80–7.
by immune-mediated signals in human intestinal epithelial cells. J Biol Chem [147] Picard C, Puel A, Bonnet M, et al. Pyogenic bacterial infections in humans with
2002;277(23):20431–7. IRAK-4 deficiency. Science 2003;299(5615):2076–9.
[120] Suzuki M, Hisamatsu T, Podolsky DK. Gamma interferon augments the intra- [148] Ungaro R, Fukata M, Hsu D, et al. A novel Toll-like receptor 4 antagonist anti-
cellular pathway for lipopolysaccharide (LPS) recognition in human intestinal body ameliorates inflammation but impairs mucosal healing in murine colitis.
epithelial cells through coordinated up-regulation of LPS uptake and expres- Am J Physiol Gastrointest Liver Physiol 2009;296(6):G1167–79 [Epub 2009
sion of the intracellular Toll-like receptor 4-MD-2 complex. Infect Immun April 1169].
2003;71(6):3503–11. [149] Pawar RD, Patole PS, Ellwart A, et al. Ligands to nucleic acid-specific
[121] Browning BL, Huebner C, Petermann I, et al. Has toll-like receptor 4 been toll-like receptors and the onset of lupus nephritis. J Am Soc Nephrol
prematurely dismissed as an inflammatory bowel disease gene? Association 2006;17(12):3365–73.
study combined with meta-analysis shows strong evidence for association. [150] Tulic MK, Fiset PO, Christodoulopoulos P, et al. Amb a 1-immunostimulatory
Am J Gastroenterol 2007;102(11):2504–12. oligodeoxynucleotide conjugate immunotherapy decreases the nasal inflam-
[122] Brand S, Staudinger T, Schnitzler F, et al. The role of Toll-like receptor 4 matory response. J Allergy Clin Immunol 2004;113(2):235–41.
Asp299Gly and Thr399Ile polymorphisms and CARD15/NOD2 mutations in [151] Creticos PS, Schroeder JT, Hamilton RG, et al. Immunotherapy with a ragweed-
the susceptibility and phenotype of Crohn’s disease. Inflamm Bowel Dis toll-like receptor 9 agonist vaccine for allergic rhinitis. N Engl J Med
2005;11(7):645–52. 2006;355(14):1445–55.
[123] De Jager PL, Franchimont D, Waliszewska A, et al. The role of the Toll recep- [152] Gauvreau GM, Hessel EM, Boulet LP, Coffman RL, O’Byrne PM. Immunostimu-
tor pathway in susceptibility to inflammatory bowel diseases. Genes Immun latory sequences regulate interferon-inducible genes but not allergic airway
2007;8(5):387–97. responses. Am J Respir Crit Care Med 2006;174(1):15–20.
[124] Ouburg S, Mallant-Hent R, Crusius JB, et al. The toll-like receptor 4 (TLR4) [153] Brugnolo F, Sampognaro S, Liotta F, et al. The novel synthetic immune
Asp299Gly polymorphism is associated with colonic localisation of Crohn’s response modifier R-848 (Resiquimod) shifts human allergen-specific CD4+
disease without a major role for the Saccharomyces cerevisiae mannan-LBP- TH2 lymphocytes into IFN-gamma-producing cells. J Allergy Clin Immunol
CD14-TLR4 pathway. Gut 2005;54(3):439–40. 2003;111(2):380–8.
[125] Hume GE, Fowler EV, Doecke J, et al. Novel NOD2 haplotype strengthens the [154] Moisan J, Camateros P, Thuraisingam T, et al. TLR7 ligand prevents allergen-
association between TLR4 Asp299Gly and Crohn’s disease in an Australian induced airway hyperresponsiveness and eosinophilia in allergic asthma by
population. Inflamm Bowel Dis 2008;14(5):585–90. a MYD88-dependent and MK2-independent pathway. Am J Physiol-Lung Cell
[126] Hong J, Leung E, Fraser AG, et al. TLR2,TLR4 and TLR9 polymorphisms and Mol Physiol 2006;290(5):L987–95.
Crohn’s disease in a New Zealand Caucasian cohort. J Gastroenterol Hepatol [155] Barrat FJ, Meeker T, Gregorio J, et al. Nucleic acids of mammalian origin can
2007;22(11):1760–6. act as endogenous ligands for toll-like receptors and may promote systemic
[127] Török HP, Glas J, Endres I, et al. Epistasis between Toll-like receptor-9 polymor- lupus erythematosus. J Exp Med 2005;202(8):1131–9.
phisms and variants in NOD2 and IL23R modulates susceptibility to Crohn’s [156] Rossignol DP, Wasan MM, Choo E, et al. Safety, pharmacokinetics, pharma-
disease. Am J Gastroenterol 2009. codynamics, and plasma lipoprotein distribution of eritoran (E5564) during
[128] Pierik M, Joossens S, Van Steen K, et al. Toll-like receptor-1, -2, and -6 polymor- continuous intravenous infusion into healthy volunteers. Antimicrob Agents
phisms influence disease extension in inflammatory bowel diseases. Inflamm Chemother 2004;48(9):3233–40.
Bowel Dis 2006;12(1):1–8. [157] Schiff MH. Role of interleukin 1 and interleukin 1 receptor antagonist in the
[129] Podolsky D, Gerken G, Eyking A, Cario E. Colitis-associated variant of TLR2 mediation of rheumatoid arthritis. Ann Rheum Dis 2000;59(Suppl. 1):i103–8.
Causes impaired mucosal repair because of TFF3 Deficiency. Gastroenterology [158] Naik V, Khadavi N, Naik MN, et al. Biologic therapeutics in thyroid-
2009. associated ophthalmopathy: translating disease mechanism into therapy.
[130] Hugot JP, Chamaillard M, Zouali H, et al. Association of NOD2 leucine- Thyroid 2008;18(9):967–71.
rich repeat variants with susceptibility to Crohn’s disease. Nature [159] Glaser RL, Goldbach-Mansky R. The spectrum of monogenic autoinflamma-
2001;411(6837):599–603 [comment]. tory syndromes: understanding disease mechanisms and use of targeted
[131] Girardin SE, Boneca IG, Viala J, et al. Nod2 is a general sensor of pep- therapies. Curr Allergy Asthma Rep 2008;8(4):288–98.
tidoglycan through muramyl dipeptide (MDP) detection. J Biol Chem [160] Carroll HP, Paunovic V, Gadina M. Signalling, inflammation and arthri-
2003;278(11):8869–72. tis—crossed signals: the role of interleukin-15 and-18 in autoimmunity.
[132] Netea MG, Ferwerda G, de Jong DJ, et al. The frameshift mutation in Nod2 Rheumatology (Oxford) 2008;47(9):1269–77.
results in unresponsiveness not only to Nod2-but also Nod1-activating pep- [161] Boraschi D, Dinarello CA. IL-18 in autoimmunity: review. Eur Cytokine Netw
tidoglycan agonists. J Biol Chem 2005;280(43):35859–67. 2006;17(4):224–52.
[133] Li J, Moran T, Swanson E, et al. Regulation of IL-8 and IL-1beta expression [162] Karanikolas G, Charalambopoulos D, Vaiopoulos G, et al. Adjunctive anakinra
in Crohn’s disease associated NOD2/CARD15 mutations. Hum Mol Genet in patients with active rheumatoid arthritis despite methotrexate, or lefluno-
2004;13(16):1715–25. mide, or cyclosporin-A monotherapy: a 48-week, comparative, prospective
[134] Maeda S, Hsu LC, Liu H, et al. Nod2 mutation in Crohn’s disease potentiates study. Rheumatology (Oxford) 2008;47(9):1384–8.
NF-kappaB activity and IL-1beta processing. Science 2005;307(5710):734–8. [163] Bresnihan B, Alvaro-Gracia JM, Cobby M, et al. Treatment of rheumatoid
[135] Kramer M, Netea MG, de Jong DJ, Kullberg BJ, Adema GJ. Impaired dendritic cell arthritis with recombinant human interleukin-1 receptor antagonist. Arthritis
function in Crohn’s disease patients with NOD2 3020insC mutation. J Leukoc Rheum 1998;41(12):2196–204.
Biol 2006;79(4):860–6. [164] Cohen S, Hurd E, Cush J, et al. Treatment of rheumatoid arthritis with anakinra,
[136] Lala S, Ogura Y, Osborne C, et al. Crohn’s disease and the NOD2 gene: a role a recombinant human interleukin-1 receptor antagonist, in combination
for paneth cells. Gastroenterology 2003;125(1):47–57. with methotrexate—results of a twenty-four-week, multicenter, random-
252 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253

ized, double-blind, placebo-controlled trial. Arthritis Rheum 2002;46(3): [194] Uematsu S, Akira S. Toll-like receptors (TLRs) and their ligands. Handb Exp
614–24. Pharmacol 2008;(183):1–20.
[165] Fleischmann R, Stern R, Iqbal I. Anakinra: an inhibitor of IL-1 for the treatment [195] Underhill DM, Ozinsky A, Hajjar AM, et al. The Toll-like receptor 2 is recruited
of rheumatoid arthritis. Exp Opin Biol Ther 2004;4(8):1333–44. to macrophage phagosomes and discriminates between pathogens. Nature
[166] Obermeier F, Dunger N, Strauch UG, et al. Contrasting activity of cytosin- 1999;401(6755):811–5.
guanosin dinucleotide oligonucleotides in mice with experimental colitis. Clin [196] Wyllie DH, Kiss-Toth E, Visintin A, et al. Evidence for an accessory pro-
Exp Immunol 2003;134(2):217–24. tein function for Toll-like receptor 1 in anti-bacterial responses. J Immunol
[167] Rachmilewitz D, Katakura K, Karmeli F, et al. Toll-like receptor 9 signaling 2000;165(12):7125–32.
mediates the anti-inflammatory effects of probiotics in murine experimental [197] Shaw MH, Reimer T, Kim YG, Nunez G. NOD-like receptors (NLRs):
colitis. Gastroenterology 2004;126(2):520–8. bona fide intracellular microbial sensors. Curr Opin Immunol 2008;20(4):
[168] Vijay-Kumar M, Aitken JD, Sanders CJ, et al. Flagellin treatment pro- 377–82.
tects against chemicals, bacteria, viruses, and radiation. J Immunol [198] Akira S, Uematsu S, Takeuchi O. Pathogen recognition and innate immunity.
2008;180(12):8280–5. Cell 2006;124(4):783–801.
[169] Vijay-Kumar M, Wu H, Aitken J, et al. Activation of toll-like receptor 3 [199] Tanabe T, Chamaillard M, Ogura Y, et al. Regulatory regions and criti-
protects against DSS-induced acute colitis. Inflamm Bowel Dis 2007;13(7): cal residues of NOD2 involved in muramyl dipeptide recognition. Embo J
856–64. 2004;23(7):1587–97.
[170] Watanabe T, Asano N, Murray PJ, et al. Muramyl dipeptide activation of [200] Inohara N, Nunez G. NODs: intracellular proteins involved in inflammation
nucleotide-binding oligomerization domain 2 protects mice from experimen- and apoptosis. Nat Rev Immunol 2003;3(5):371–82.
tal colitis. J Clin Invest 2008;118(2):545–59. [201] Ting JPY, Lovering RC, Alnemri ES, et al. The NLR gene family: a standard
[171] Alexopoulou L, Holt AC, Medzhitov R, Flavell RA. Recognition of double- nomenclature. Immunity 2008;28(3):285–7.
stranded RNA and activation of NF-kappaB by Toll-like receptor 3. Nature [202] Tattoli I, Carneiro LA, Jehanno M, et al. NLRX1 is a mitochondrial
2001;413(6857):732–8. NOD-like receptor that amplifies NF-kappa B and JNK pathways by
[172] Asea A, Rehli M, Kabingu E, et al. Novel signal transduction pathway utilized inducing reactive oxygen species production. Embo Reports 2008;9(3):
by extracellular HSP70: role of toll-like receptor (TLR) 2 and TLR4. J Biol Chem 293–300.
2002;277(17):15028–34. [203] Barnich N, Aguirre JE, Reinecker HC, Xavier R, Podolsky DK. Membrane
[173] Campos MA, Almeida IC, Takeuchi O, et al. Activation of Toll-like receptor-2 recruitment of NOD2 in intestinal epithelial cells is essential for nuclear factor-
by glycosylphosphatidylinositol anchors from a protozoan parasite. J Immunol kappa B activation in muramyl dipeptide recognition. J Cell Biol 2005;170(1):
2001;167(1):416–23. 21–6.
[174] Gomi K, Kawasaki K, Kawai Y, Shiozaki M, Nishijima M. Toll-like receptor [204] Uehara A, Sugawara Y, Kurata S, et al. Chemically synthesized pathogen-
4-MD-2 complex mediates the signal transduction induced by flavolipin, associated molecular patterns increase the expression of peptidoglycan
an amino acid-containing lipid unique to Flavobacterium meningosepticum. recognition proteins via Toll-like receptors, NOD1 and NOD2 in human oral
J Immunol 2002;168(6):2939–43. epithelial cells. Cell Microbiol 2005;7(5):675–86.
[175] Hajjar AM, O’Mahony DS, Ozinsky A, et al. Cutting edge: functional inter- [205] Hsu LC, Ali SR, McGillivray S, et al. A NOD2–NALP1 complex mediates
actions between toll-like receptor (TLR) 2 and TLR1 or TLR6 in response to caspase-1-dependent IL-1 beta secretion in response to Bacillus anthracis
phenol-soluble modulin. J Immunol 2001;166(1):15–9. infection and muramyl dipeptide. Proc Natl Acad Sci USA 2008;105(22):
[176] Heil F, Hemmi H, Hochrein H, et al. Species-specific recognition of single- 7803–8.
stranded RNA via toll-like receptor 7 and 8. Science 2004;303(5663): [206] Girardin SE, Boneca IG, Carneiro LA, et al. Nod1 detects a unique
1526–9. muropeptide from gram-negative bacterial peptidoglycan. Science
[177] Hemmi H, Takeuchi O, Kawai T, et al. A Toll-like receptor recognizes bacterial 2003;300(5625):1584–7.
DNA. Nature 2000;408(6813):740–5. [207] Windheim M, Lang C, Peggie M, Plater LA, Cohen P. Molecular mechanisms
[178] Johnson GB, Brunn GJ, Kodaira Y, Platt JL. Receptor-mediated monitoring of involved in the regulation of cytokine production by muramyl dipeptide.
tissue well-being via detection of soluble heparan sulfate by Toll-like receptor Biochem J 2007;404(2):179–90.
4. J Immunol 2002;168(10):5233–9. [208] Boyden ED, Dietrich WF. Nalp1b controls mouse macrophage susceptibility to
[179] Kawasaki K, Akashi S, Shimazu R, et al. Mouse toll-like receptor 4,MD-2 com- anthrax lethal toxin. Nat Genet 2006;38(2):240–4.
plex mediates lipopolysaccharide-mimetic signal transduction by Taxol. J Biol [209] Chamaillard M, Hashimoto M, Horie Y, et al. An essential role for NOD1 in
Chem 2000;275(4):2251–4. host recognition of bacterial peptidoglycan containing diaminopimelic acid.
[180] Kurt-Jones EA, Popova L, Kwinn L, et al. Pattern recognition receptors TLR4 Nat Immunol 2003;4(7):702–7.
and CD14 mediate response to respiratory syncytial virus. Nat Immunol [210] Ferwerda G, Girardin SE, Kullberg BJ, et al. NOD2 and toll-like receptors
2000;1(5):398–401. are nonredundant recognition systems of Mycobacterium tuberculosis. Plos
[181] Massari P, Henneke P, Ho Y, et al. Cutting edge: immune stimulation by Pathogens 2005;1(3):279–85.
neisserial porins is toll-like receptor 2 and MyD88 dependent. J Immunol [211] Franchi L, McDonald C, Kanneganti TD, Amer A, Nunez G. Nucleotide-
2002;168(4):1533–7. binding oligomerization domain-like receptors: intracellular pattern recog-
[182] Ohashi K, Burkart V, Flohe S, Kolb H. Cutting edge: heat shock protein 60 is nition molecules for pathogen detection and host defense. J Immunol
a putative endogenous ligand of the toll-like receptor-4 complex. J Immunol 2006;177(6):3507–13.
2000;164(2):558–61. [212] Heinzelmann M, Polk HC, Chernobelsky A, Stites TP, Gordon LE. Endotoxin and
[183] Okamura Y, Watari M, Jerud ES, et al. The extra domain A of fibronectin acti- muramyl dipeptide modulate surface receptor expression on human mononu-
vates Toll-like receptor 4. J Biol Chem 2001;276(13):10229–33. clear cells. Immunopharmacology 2000;48(2):117–28.
[184] Opitz B, Schroder NW, Spreitzer I, et al. Toll-like receptor-2 mediates Tre- [213] Viala J, Chaput C, Boneca IG, et al. Nod1 responds to peptidoglycan deliv-
ponema glycolipid and lipoteichoic acid-induced NF-kappaB translocation. J ered by the Helicobacter pylori cag pathogenicity island. Nat Immunol
Biol Chem 2001;276(25):22041–7. 2004;5(11):1166–74.
[185] Ozinsky A, Underhill DM, Fontenot JD, et al. The repertoire for pattern [214] Becker CE, O’Neill LAJ. Inflammasomes in inflammatory disorders: the
recognition of pathogens by the innate immune system is defined by coop- role of TLRs and their interactions with NLRs. Semin Immunopathol
eration between toll-like receptors. Proc Natl Acad Sci USA 2000;97(25): 2007;29(3):239–48.
13766–71. [215] Fischer M, Ehlers M. Toll-like receptors in autoimmunity. Year Immunol
[186] Rassa JC, Meyers JL, Zhang Y, Kudaravalli R, Ross SR. Murine retroviruses acti- 2008;1143:21–34.
vate B cells via interaction with toll-like receptor 4. Proc Natl Acad Sci USA [216] Kanczkowski W, Ziegler CG, Zacharowski K, Bornstein SR. Toll-like
2002;99(4):2281–6. receptors in endocrine disease and diabetes. Neuroimmunomodulation
[187] Scheibner KA, Lutz MA, Boodoo S, et al. Hyaluronan fragments act as 2008;15(1):54–60.
an endogenous danger signal by engaging TLR2. J Immunol 2006;177(2): [217] Raschi E, Borghi MO, Grossi C, et al. Toll-like receptors: another player in the
1272–81. pathogenesis of the anti-phospholipid syndrome. Lupus 2008;17(10):937–42.
[188] Schwandner R, Dziarski R, Wesche H, Rothe M, Kirschning CJ. Peptidoglycan- [218] Dowds TA, Masumoto J, Chen FF, et al. Regulation of cryopyrin/Pypaf1 signal-
and lipoteichoic acid-induced cell activation is mediated by toll-like receptor ing by pyrin, the familial Mediterranean fever gene product. Biochem Biophys
2. J Biol Chem 1999;274(25):17406–9. Res Commun 2003;302(3):575–80.
[189] Smiley ST, King JA, Hancock WW. Fibrinogen stimulates macrophage [219] Kanneganti TD, Lamkanfi M, Nunez G. Intracellular NOD-like receptors in host
chemokine secretion through toll-like receptor 4. J Immunol 2001;167(5): defense and disease. Immunity 2007;27:549–59.
2887–94. [220] Kullberg BJ, Ferwerda G, de Jong DJ, et al. Crohn’s disease patients homozygous
[190] Takeuchi O, Hoshino K, Kawai T, et al. Differential roles of TLR2 and TLR4 in for the 3020insC NOD2 mutation have a defective NOD2/TLR4 cross-tolerance
recognition of Gram-negative and Gram-positive bacterial cell wall compo- to intestinal stimuli. Immunology 2008;123(4):600–5.
nents. Immunity 1999;11(4):443–51. [221] Petrilli V, Dostert C, Muruve DA, Tschopp J. The inflammasome: a dan-
[191] Takeuchi O, Kawai T, Muhlradt PF, et al. Discrimination of bacterial lipoproteins ger sensing complex triggering innate immunity. Curr Opin Immunol
by Toll-like receptor 6. Int Immunol 2001;13(7):933–40. 2007;19(6):615–22.
[192] Takeuchi O, Sato S, Horiuchi T, et al. Cutting edge: role of Toll-like recep- [222] Rosenstiel P, Jacobs G, Till A, Schreiber S. NOD-like receptors: ancient sentinels
tor 1 in mediating immune response to microbial lipoproteins. J Immunol of the innate immune system. Cell Mol Life Sci 2008;65(9):1361–77.
2002;169(1):10–4. [223] Weidinger S, Klopp N, Rummler L, et al. Association of NOD1 polymor-
[193] Termeer C, Benedix F, Sleeman J, et al. Oligosaccharides of Hyaluronan activate phisms with atopic eczema and related phenotypes. J Allergy Clin Immunol
dendritic cells via toll-like receptor 4. J Exp Med 2002;195(1):99–111. 2005;116(1):177–84.
 M. Fukata et al. / Seminars in Immunology 21 (2009) 242–253 253

[224] Lahiri A, Das P, Chakravortty D. Engagement of TLR signaling as adjuvant: [226] Schmidt C. Toll-like receptor therapies compete to reduce side effects. Nat
towards smarter vaccine and beyond. Vaccine 2008;26(52):6777–83. Epub Biotechnol 2006;24(3):230–1.
2008 October 6777. [227] Jasani B, Navabi H, Adams M. Ampligen: a potential toll-like 3 receptor adju-
[225] Barrat FJ, Coffman RL. Development of TLR inhibitors for the treatment of vant for immunotherapy of cancer. Vaccine 2009;27(25–26):3401–4. Epub
autoimmune diseases. Immunol Rev 2008;223:271–83. 2009 February 3405.