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Molecular Psychiatry (2017) 00, 17

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ORIGINAL ARTICLE
Selective increase of cerebrospinal uid IL-6 during
experimental systemic inammation in humans: association
with depressive symptoms
H Engler1, P Brendt2, J Wischermann2, A Wegner3, R Rhling1, T Schoemberg4, U Meyer5, R Gold6, J Peters2, S Benson1 and
M Schedlowski1

Systemic inammation is accompanied by profound behavioral and mood changes that resemble symptoms of depression.
Findings in animals suggest that pro-inammatory cytokines released by activated immune cells in the periphery evoke these
behavioral symptoms by driving inammatory changes in the brain. However, experimental data in humans are lacking. Here we
demonstrate in healthy male volunteers (10 endotoxin treated, 8 placebo treated) that intravenous administration of low-dose
endotoxin (0.8 ng/kg body weight), a prototypical pathogen-associated molecular pattern that activates the innate immune system,
not only induces a signicant increase in peripheral blood cytokine concentrations (that is, tumor necrosis factor-, interleukin
(IL)-6, IL-10) but also results, with some latency, in a robust and selective increase of IL-6 in the cerebrospinal uid (CSF). Moreover,
we found a strong association between the endotoxin-induced increase of IL-6 in the CSF and the severity of mood impairment,
with larger increases in CSF IL-6 concentration followed by a greater deterioration in mood. Taken together, these ndings suggest
that the appearance of depressive symptoms in inammatory conditions might be primarily linked to an increase in central IL-6
concentration, identifying IL-6 as a potential therapeutic target in mood disorders.

Molecular Psychiatry advance online publication, 31 January 2017; doi:10.1038/mp.2016.264

INTRODUCTION behavioral changes (for example, anhedonia, social withdrawal,


Inammation and immune dysregulation are increasingly recog- decreased activity) reminiscent of human depression, and several
nized as important factors in the etiology and pathophysiology of afferent pathways have been identied through which peripheral
neuropsychiatric disorders.1,2 An extensive body of evidence cytokine signals can reach the brain.20,21 These routes include
particularly supports a bidirectional link between inammation activation of vagal afferent bers projecting to the nucleus of the
and mood disorders.3,4 On the one hand, a substantial proportion solitary tract,22 active transport across the bloodbrain barrier
of patients with major depression or bipolar disorder exhibit signs (BBB) via cytokine-specic saturable transporters23 and diffusion in
of systemic inammation, including increased concentrations of brain areas lacking a BBB such as the circumventricular organs
inammatory mediators (for example, cytokines and acute phase and the choroid plexus (CP).24 Engagement of immune-to-brain
proteins) in the blood or cerebrospinal uid (CSF).59 On the pathways triggers inammatory changes within the brain,
other hand, major depression is highly prevalent in chronic ultimately affecting neuronal activity and neurotransmitter release
inammatory conditions such as rheumatoid arthritis, psoriasis, in brain areas critically involved in mood regulation such as limbic
inammatory bowel diseases and multiple sclerosis,1013 and anti- and cortical regions.4,25,26 Together, these data support the idea
inammatory therapies effectively improve mood in these that peripheral inammatory responses drive inammation in the
patients.14,15 Moreover, a large fraction of patients undergoing brain leading to depressive symptoms. However, while rodent
cytokine therapy for the treatment of cancer or hepatitis C virus models have provided important insights into the cellular and
infection develop depressive symptoms.1618 Finally, acute molecular mechanisms underlying inammation-induced beha-
systemic inammation is accompanied by profound behavioral vioral changes, human emotional states cannot be sufciently
changes (for example, deterioration in mood, anhedonia, cogni- modeled in animals. This calls for translational approaches linking
tive decits, fatigue), commonly referred to as sickness behavior, peripheral inammation and affective symptoms in humans.
that show striking similarities to symptoms of depression.19,20 In healthy humans, systemic inammation can be experimen-
Experimental ndings in animals suggest that cytokines have a tally elicited by administration of puried bacterial endotoxin
key role in mediating the behavioral effects of inammation. (lipopolysaccharide (LPS)).27 LPS is a prototypical pathogen-
Administration of pro-inammatory cytokines such as interleukin associated molecular pattern that activates the innate immune
(IL)-1, IL-6, and tumor necrosis factor (TNF)- to rodents induces system through a Toll-like receptor 4-dependent pathway.

1
Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; 2Clinic for Anesthesiology and
Intensive Care Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; 3Department of Orthopedic and Trauma Surgery, University Hospital Essen,
University of Duisburg-Essen, Essen, Germany; 4Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; 5Institute of Pharmacology
and Toxicology, University of Zurich-Vetsuisse, Zurich, Switzerland and 6Department of Neurology, St Josef-Hospital, Ruhr University, Bochum, Germany. Correspondence:
Professor H Engler, Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, Essen D-45122,
Germany.
E-mail: harald.engler@uk-essen.de
Received 12 August 2016; revised 3 November 2016; accepted 14 December 2016
Endotoxin-induced CSF IL-6 and depressive symptoms
H Engler et al
2
Intravenous injection of endotoxin rapidly leads to increased Langen, Germany) and was stored in endotoxin-free borosilicate tubes
cytokine concentrations in the circulation, and this is accompanied (Pyroquant Diagnostik, Mrfelden-Waldorf, Germany) at 20 C until use.
by affective symptoms, such as negative mood, anhedonia and Additional blood and CSF samples were collected 1, 2, 3, 4, 6 and 24 h after
social disconnection resembling human depression.2832 A recent the injection. Heart rate and arterial blood pressure were continuously
positron emission tomographic study has provided initial evi- recorded (Siemens SC 9000 XL, Drger Medical, Lbeck, Germany), and
body temperature was measured every 30 min with a tympanic thermo-
dence that LPS administration might also be associated with
meter (Genius 2, Covidien, Tullamore, Ireland). After collection of the 6-h
inammatory changes in the human brain,33 but this has not been sample, participants were transferred to a hospital ward room where they
conrmed by biochemical ndings. Moreover, the temporal stayed overnight under medical surveillance. On the next day (that is, 24 h
dynamics and molecular signature of the central inammatory after LPS/placebo injection), a nal blood and CSF sample were collected,
response and its potential association with behavioral symptoms and catheters were removed. After a neurological examination, partici-
are unknown. pants were discharged and instructed to refrain from physical activity for
One feasible approach of measuring inammatory responses in 7 days. A medical follow-up was conducted 1 week after the study.
the human central nervous system is the analysis of cytokines in
the CSF, which is produced in the CP and exchanges with brain Cytokine and CRP concentrations
interstitial uid. CSF can be safely obtained by lumbar puncture Blood was drawn into tubes containing either EDTA or clot activator
and CSF cytokine concentrations are clinically used as markers of (S-Monovette, Sarstedt, Nmbrecht, Germany) and CSF was collected in
central inammation. In the present study, we simultaneously pyrogen-free polypropylene tubes (Falcon, BD Biosciences, Heidelberg,
assessed plasma and CSF cytokine responses to low-dose Germany). Plasma/serum and cell-free CSF were obtained by centrifugation
endotoxin administration in healthy volunteers over a period of (2000 g, 10 min, 4 C) and were stored at 80 C until analysis. Concentra-
24 h and explored the potential associations between peripheral tions of TNF-, IL-6, IL-10 and IL-1 in plasma and CSF were measured by
and central cytokine levels as well as mood changes. We enzyme-linked immunosorbent assay (ELISA) (Human Quantikine ELISA,
hypothesized that experimental endotoxemia would result in R&D Systems, Minneapolis, MN, USA) according to the manufacturers
protocols. The sensitivity of the assays was 0.11 pg ml 1 for TNF-,
increased cytokine concentrations both in the circulation and CSF. 0.70 pg ml 1 for IL-6, 0.09 pg ml 1 for IL-10 and 0.14 pg ml 1 for IL-1.
Furthermore, we expected to nd positive associations between Mean inter- and intra-assay coefcients of variation were 10%. As IL-1
CSF levels of pro-inammatory cytokines and the severity of was below the limit of detection in the majority of plasma and CSF
depressive symptoms. samples, IL-1 data are not presented. Serum concentration of CRP was
measured by ELISA (CRP high-sensitive ELISA, IBL International, Hamburg,
Germany) according to the manufacturers instructions. The sensitivity of
MATERIALS AND METHODS the assay was 0.02 mg l 1 and mean interassay and intra-assay coefcients
Participants of variation were o 7%.
Eighteen healthy male volunteers with a mean age of 27.8 1.2 years
(range: 2042 years) and a mean body mass index of 24.6 0.6 kg/m2 Cell counts
(range: 20.428.4 kg/m2), all of Caucasian ethnicity, were recruited by Complete blood counts, including white blood cell differential, were
public advertisement and underwent an extensive screening and safety determined with a Sysmex KX-N21 hematology analyzer (Sysmex Europe,
procedure consisting of a physical examination, a structured personal Norderstedt, Germany). CSF cell counts were obtained using a Sysmex
interview and the measurement of blood and clinical chemistry param- XE-500 Automated Hematology System (Sysmex Europe).
eters (that is, complete blood cell count, C-reactive protein (CRP), coagula-
tion factors, liver enzymes and renal parameters). General exclusion criteria
were any preexisting or current physical or psychiatric illness, body mass Albumin and IgG concentrations
index o18 or 29 kg/m2, current medications, smoking, regular alcohol Serum and CSF albumin and immunoglobulin (IgG) concentrations were
use (44 drinks per week) and anxiety and/or depression scores exceeding determined by nephelometry on a Beckman Coulter IMMAGE Immuno-
published cutoffs of the Hospital Anxiety and Depression Scale.34 chemistry System (Beckman Coulter, Krefeld, Germany). The CSF (mg l 1)
Participants were instructed to refrain from excessive exercise for 48 h to serum (g l 1) ratios of albumin and IgG served as indices to evaluate the
before testing. The study was conducted in accordance with the Declaration integrity of the BBB, with increases in these ratios indicating increased
of Helsinki and was approved by the Institutional Ethics Review Board permeability.
of the Medical Faculty of the University of Duisburg-Essen (Approval
No. 13-5408-BO). Signed informed consent was obtained and subjects
received nancial compensation for their participation in the study. Mood assessment
Normal mood (euthymia) and depressed mood (dysthymia) were assessed
before (baseline) as well as 1, 2, 3, 4, 6 and 24 h after endotoxin or placebo
Study design injection with two ve-item subscales of the state version of the
The study was conducted in the Clinic of Anesthesiology and Intensive standardized and validated State-Trait Anxiety Depression Inventory.35
Care Medicine, University Hospital Essen and was supervised by a senior
anesthesiologist, with a neurosurgeon as an independent monitor.
Subjects were randomly assigned to receive either endotoxin (N = 10) or Statistical analysis
placebo (N = 8). Randomization was conducted using a web-based tool Data analysis was performed using SPSS 22.0 (SPSS, Chicago, IL, USA) and
(www.randomizer.org). Upon arrival at the study site, participants rst the level of signicance was set at Po0.05. Normality of residuals was
underwent a neurological check-up and were then prepared for the study. examined using the ShapiroWilk test and data were log-transformed
On each arm, an intravenous catheter was inserted into a forearm vein for when necessary. Group differences in behavioral and physiological
repeated blood collection and LPS/placebo injection, respectively. Subse- measures were analyzed by repeated-measures analysis of variance
quently, a local anesthetic (Scandicain 1%, AstraZeneca, Wedel, Germany) (ANOVA) with LPS as between-subject factor and time as within-
was injected subcutaneously at the lumbar L3/4 interspace and a catheter subject factor. GreenhouseGeisser correction was performed when the
(IntraLong Set, 27 G catheter, Pajunk Geisingen, Germany) was inserted assumption of sphericity was violated. If ANOVA revealed a signicant
into the intrathecal space for serial CSF collection. After a resting period of LPS time interaction, independent samples t-tests (two-tailed) were
30 min, a rst blood and CSF sample were obtained (baseline). Thirty computed to compare LPS and placebo groups at the different sampling
minutes later, subjects received in a randomized and double-blinded points. Only interaction effects are reported. A priori power calculations
manner an intravenous injection of either endotoxin (0.8 ng kg 1 of body using G*Power 3.1 (Faul et al.36) revealed sufcient statistical power
weight; reference standard endotoxin from Escherichia coli, lot H0K354; (483%) to detect medium effect sizes (f = 0.25) in repeated-measures
United States Pharmacopeia, Rockville, MD, USA) or placebo (sterile, ANOVAs for plasma/CSF cytokines and mood parameters, which were the
pyrogen-free isotonic NaCl solution, B Braun Melsungen, Melsungen, primary readouts. The Spearmens rank correlation coefcient (Spearmans
Germany). LPS had been subjected to a microbial safety testing routine by ; one tailed) was used to explore potential associations between cytokine
the German Federal Agency for Sera and Vaccines (Paul-Ehrlich Institute, concentrations and behavioral measures within the endotoxin group. The

Molecular Psychiatry (2017), 1 7 2017 Macmillan Publishers Limited, part of Springer Nature.
Endotoxin-induced CSF IL-6 and depressive symptoms
H Engler et al
3
BenjaminiHochberg procedure was used to control for the false discovery QIgG: F(6,96) = 0.73, P = 0.63; Figure 2a). Furthermore, leukocyte
rate (q = 0.05) in multiple comparisons. counts in the CSF did not signicantly differ between treatment
groups at 2 and 6 h after injection, indicating that administration
of low-dose LPS did not result in leukocyte inltration into the CSF
RESULTS (F(1,16) = 0.33, P = 0.86; Figure 2b).
Sample characteristics
Ten subjects were injected with endotoxin (0.8 ng kg 1) and eight Mood changes
subjects served as controls, receiving placebo. Demographic and Participants who had received endotoxin exhibited pronounced
clinical characteristics of the two treatment groups are shown in
mood changes, whereas placebo-injected subjects did not show
Table 1. Groups did not signicantly differ in age and body mass
these behavioral symptoms (Figure 3). Specically, administration
index. Hematological parameters, inammatory markers, coagula-
of LPS resulted in worsened mood as evident from a signicant
tion factors and liver and renal parameters as well as Hospital
increase in dysthymia (F(6,96) = 2.50, P = 0.027), with the largest
Anxiety and Depression Scale anxiety and depression scores were
effects observed at 3 h after LPS injection. Although euthymia
within normal range, without evidence for group differences at
scores showed a slight decrease in LPS compared with placebo-
baseline.
injected subjects over time, no signicant time group interaction
was found (F(6,96) = 0.44, P = 0.85).
Inammatory response
Low-dose endotoxin administration induced an acute systemic Relationship between cytokine and mood changes
inammatory response as evident from a signicant elevation in
To explore the potential associations between the endotoxin-
body temperature (F(6,96) = 11.2, P o 0.001; Figure 1a), a pro-
induced increase in CSF IL-6 concentration and the deterioration
nounced leukocytosis (F(6,96) = 8.9, P o0.001; Figure 1b) and a
in mood, we additionally performed correlation analyses between
signicant rise in serum CRP levels (F(3,48) = 159.93, P o 0.001;
CSF IL-6 levels and dysthymia scores from 2 to 6 h after LPS
Figure 1c) as well as signicant increases in plasma concentrations
injection. Dysthymia scores showed strong positive correlations
of TNF- (F(6,96) = 65.76, P o 0.001), IL-6 (F(6,96) = 26.18, P o 0.001)
with CSF IL-6 concentrations across all time points investigated
and IL-10 (F(6,96) = 21.91, P o 0.001; Figure 1d). The increase in
(Supplementary Table S1). Correlations between 2 h CSF IL-6 and
plasma cytokines was transient, peaking at 2 h after LPS injection,
3 h dysthymia score (Spearmans = 0.759) as well as between 3 h
and rapidly declining thereafter. The endotoxin-induced cytokine
CSF IL-6 and 6 h dysthymia score (Spearmans = 0.817) remained
response in the CSF markedly differed from that in the peripheral
signicant after false discovery rate correction for multiple
blood (Figure 1e). First, a signicant increase in CSF cytokines
comparisons (Po 0.05; one tailed). No signicant correlations
was found only for IL-6 (F(6,96) = 4.62, P = 0.005), whereas
between plasma cytokine concentrations and dysthymia scores
CSF concentrations of TNF- (F(6,96) = 1.54, P = 0.17) and IL-10
were found.
(F(6,96) = 0.36, P = 0.91) remained unaffected. Second, the
endotoxin-induced increase of IL-6 in the CSF was time delayed
relative to the increase of IL-6 in the circulation, with signicant DISCUSSION
group differences between 3 and 6 h after injection, and IL-6 levels
We believe our study demonstrates for the rst time that
in the CSF continued to increase even after the peripheral IL-6
intravenous administration of low-dose endotoxin in humans
response had already vanished.
not only evokes peripheral pro- and anti-inammatory cytokine
responses but also results in a robust and selective increase of IL-6
BBB integrity and CSF cell counts in the CSF, suggesting that the molecular signature of the
Both the CSF/serum albumin (QAlb) and the CSF/serum IgG (QIgG) inammatory response substantially differs between the periph-
ratios were within normal range in all subjects and were not eral and central compartments. Moreover, we found a strong
affected by endotoxin administration (QAlb: F(6,96) = 0.50, P = 0.81; association between the endotoxin-induced increase of IL-6 in the
CSF and the severity of mood changes, showing that higher CSF
Table 1. Demographic and clinical characteristics IL-6 concentrations were followed by a greater deterioration
in mood.
Variable Placebo Endotoxin P-value One intriguing nding of the present study was the selective
(N = 8) (N = 10) increase of IL-6 in the CSF, while CSF concentrations of other key
cytokines such as TNF-, IL-1 and IL-10 remained unaffected.
Age (years) 30.2 1.9 25.8 1.1 0.07 Similar observations have been made in hepatitis C virus patients
BMI (kg/m2) 24.9 0.8 24.7 1.0 0.92
under cytokine therapy, exhibiting increased CSF concentrations
WBC count (103 l 1) 5.7 0.5 5.6 0.6 0.91
Hematocrit (%) 42.3 1.2 42.2 0.8 0.96 of IL-6 but not of TNF- and IL-1 after chronic IFN-/ribavirin
CRP (mg l 1) 0.51 0.16 0.59 0.24 0.34 treatment.37 Our data in healthy subjects extend and corroborate
TNF- (pg ml 1) 1.30 0.42 1.28 0.29 0.96 these ndings and strengthen the notion that in humans there is
IL-6 (pg ml 1) 2.50 0.38 3.22 1.06 0.57 no one-to-one translation between cytokine changes in the
IL-10 (pg ml 1) 0.29 0.07 0.47 0.11 0.20 systemic circulation and the CSF. Hence, our ndings differ from
Fibrinogen (mg dl 1) 210 9 209 8 0.94 those in rodents where peripheral LPS administration (intrave-
INR 1.01 0.01 1.02 0.01 0.58 nously or intraperitoneally) increased concentrations of various
GGT (U l 1) 25 7 20 3 0.47
Serum creatinine 1.08 0.03 1.01 0.04 0.15
cytokines, including TNF-, IL-1 and IL-6, in both circulation and
(mg dl 1) brain.3840 However, the latter effects emerged in response to
HADS Anxiety Score 3.9 1.2 3.0 1.0 0.51 much higher (104- to 106-fold) endotoxin doses and may have
HADS Depression Score 2.9 0.6 1.6 0.4 0.12 been accompanied by disruption of the BBB. In addition, cytokine
analyses in animals were carried out in brain tissue and not in CSF,
Abbreviations: BMI, body mass index; CRP, C-reactive protein; GGT, gamma
leaving the possibility that these differences in human and animal
glutamyl transpeptidase; HADS, Hospital Anxiety and Depression Scale; IL,
interleukin; INR, International Normalized Ratio; TNF, tumor necrosis factor; ndings might be related to differences in sampling sites. This
WBC, white blood cell. Data are presented as mean s.e.m. issue needs further investigation and calls for comparative time-
course studies assessing in parallel cytokine proles in peripheral

2017 Macmillan Publishers Limited, part of Springer Nature. Molecular Psychiatry (2017), 1 7
Endotoxin-induced CSF IL-6 and depressive symptoms
H Engler et al
4

Figure 1. Low-dose endotoxin administration induces a systemic and central inammatory response. (a) Body temperature, (b) white blood
cell (WBC) counts, (c) serum C-reactive protein (CRP) concentration, (d) plasma and (e) cerebrospinal uid (CSF) concentrations of tumor
necrosis factor (TNF)-, interleukin (IL)-6 and IL-10 before and after intravenous injection of endotoxin (0.8 ng kg 1 lipopolysaccharide; N = 10)
or placebo (N = 8). Means and s.e.m. are shown. Repeated-measure analysis of variance with post hoc independent t-tests, *P 0.05; **P 0.01;
***P 0.001.

blood, CSF and brain tissue of animals challenged with more increase of IL-6 in the CSF relative to its rise in the circulation.
moderate doses of LPS. However, IL-6 levels in the CSF continued to increase while the
Several mechanisms may lead to the endotoxin-induced plasma IL-6 response had already vanished, suggesting that other
increase of IL-6 concentration in the CSF. Given that the integrity mechanisms might be involved as well. Studies in animals have
of the bloodCSF barrier (BCSFB)/BBB was apparently not affected shown that CP epithelial cells, forming the BCSFB, express both
in our LPS-treated subjects, blood-borne IL-6 may have entered Toll-like receptor 4 and cytokine receptors at the basolateral
the CSF either by diffusion from brain areas with incomplete BBB (blood-facing) side, and stimulation of these receptors by
such as the circumventricular organs and the CP or by active circulating LPS or cytokines can trigger IL-6 synthesis in these
transport across the BBB/BCSFB via cytokine-specic transport cells, ultimately leading to its secretion into the CSF.4245 Thus
molecules. Such saturable transport systems have been described local production of IL-6 in the CP may represent an additional
not only for IL-6 but also for other cytokines.41 As both diffusion mechanism contributing to the endotoxin-induced increase of IL-6
and active transport require time, this might explain the delayed in the CSF. Finally, as the CSF exchanges with brain interstitial

Molecular Psychiatry (2017), 1 7 2017 Macmillan Publishers Limited, part of Springer Nature.
Endotoxin-induced CSF IL-6 and depressive symptoms
H Engler et al
5

Figure 2. Low-dose endotoxin administration does not affect bloodcerebrospinal uid barrier/bloodbrain barrier integrity and
cerebrospinal uid (CSF) cell counts. (a) CSF/serum albumin quotient, (b) CSF/serum immunoglobulin G (IgG) quotient and (c) leukocyte
numbers in the CSF before and after intravenous injection of endotoxin (0.8 ng kg 1 lipopolysaccharide; N = 10) or placebo (N = 8). Means and
s.e.m. are shown. Repeated-measure analysis of variance.

and/or showing resistance to conventional antidepressant med-


ication. In this regard, humanized monoclonal antibodies against
the IL-6 receptor (IL-6R) could be one adjunct treatment option54
as they inhibit the binding of IL-6 to the soluble and membrane-
bound forms of the IL-6R, thereby blocking IL-6 signal transduc-
tion. Such trials are currently actively being pursued in patients
with major depressive disorder (for example, NCT02473289 at
ClinicalTrials.gov), but at present, no clinical data are available as
to whether these biologicals effectively reduce depressive
symptoms. However, anti-IL-6R antibody therapy in rheumatoid
arthritis patients signicantly improved fatigue, indicating bene-
cial effects on behavioral outcomes.55
Of note, CSF IL-6 concentration also gradually increased in the
placebo group, although this increase was considerably less
pronounced compared with the LPS group and not associated
with any mood changes. The observed increase of IL-6 concentra-
tion in the CSF samples of placebo-treated subjects presumably
reects local IL-6 production at the catheter insertion site rather
than changes in overall CSF IL-6 concentration. Such effects on
Figure 3. Systemic inammation is accompanied by mood changes.
IL-6 levels owing to local cytokine production have been
Scores for (a) euthymia and (b) dysthymia before and after
intravenous injection of endotoxin (0.8 ng kg 1 lipopolysaccharide; documented in blood samples collected via indwelling venous
N = 10) or placebo (N = 8). Means and s.e.m. are shown. Repeated- catheters for an extended period of time5658 and may also occur
measure analysis of variance with post hoc independent t-tests, in CSF samples collected via indwelling spinal catheters. Our
*P 0.05; **P 0.01. ndings in the CSF of placebo-treated subjects thereby conrm
earlier ndings in untreated healthy volunteers showing a similar
increase in CSF IL-6 concentrations after spinal catheterization,
while CSF levels of TNF-, IL-1 and IL-10 remained unaffected.59
uid, IL-6 produced by brain residential cells (for example,
Contamination of the CSF samples with locally produced IL-6 at
microglia, astrocytes, neurons) may have reached the CSF through
the later time points might also explain the absence of mood
the brainCSF interface.
changes in the placebo group. One approach of investigating this
Another interesting nding was the strong association between
issue in future studies could be to discard the rst drops of CSF,
the endotoxin-induced rise of IL-6 in the CSF and the severity of likely containing locally produced IL-6, before collecting the actual
mood impairment, showing that a larger increase in CSF IL-6 sample for analyses.
concentration was followed by a greater deterioration in mood. The study has several strengths but also some limitations that
This not only extends previous ndings from human endotoxemia warrant consideration. A notable strength is that plasma and CSF
and typhoid vaccination studies reporting correlations between cytokine concentrations were concurrently and repeatedly
circulating IL-6 levels and changes in negative affect4650 but is assessed in the same individuals over a period of 24 h, taking
also in line with clinical observations showing that patients with into account the temporal dynamics of the inammatory
major depressive disorder exhibit elevated levels of IL-6 in response. Furthermore, unlike cytokine therapy studies that have
peripheral blood and CSF.5,5153 Based on the present experi- been carried out in antivirally treated hepatitis C virus patients, our
mental ndings and considering the clinical evidence of increased experiments were conducted in healthy volunteers under
peripheral and CSF IL-6 levels in depressed patients, IL-6 might be standardized laboratory conditions, eliminating potentially con-
a promising therapeutic target in the treatment of depression, founding factors such as underlying disease or medication. One
particularly in patients exhibiting signs of systemic inammation limitation of the study is the relatively small sample size, which

2017 Macmillan Publishers Limited, part of Springer Nature. Molecular Psychiatry (2017), 1 7
Endotoxin-induced CSF IL-6 and depressive symptoms
H Engler et al
6
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CONFLICT OF INTEREST 24 Vitkovic L, Konsman JP, Bockaert J, Dantzer R, Homburger V, Jacque C. Cytokine
signals propagate through the brain. Mol Psychiatry 2000; 5: 604615.
The authors declare no conict of interest.
25 Engler H, Doenlen R, Engler A, Riether C, Prager G, Niemi MB et al. Acute
amygdaloid response to systemic inammation. Brain Behav Immun 2011; 25:
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ACKNOWLEDGMENTS 26 Poon DC, Ho YS, Chiu K, Wong HL, Chang RC. Sickness: from the focus on cyto-
We thank Ursula Brecklinghaus and Alexandra Kornowski for excellent technical kines, prostaglandins, and complement factors to the perspectives of neurons.
assistance and Bettina Lschner and Dr Ingo Spreitzer (Paul-Ehrlich-Institute, Langen, Neurosci Biobehav Rev 2015; 57: 3045.
Germany) for endotoxin safety testing. This work was supported by an internal 27 Schedlowski M, Engler H, Grigoleit JS. Endotoxin-induced experimental systemic
research grant from the Medical Faculty of the University of Duisburg-Essen (IFORES) inammation in humans: a model to disentangle immune-to-brain communica-
awarded to HE. tion. Brain Behav Immun 2014; 35: 18.
28 Reichenberg A, Yirmiya R, Schuld A, Kraus T, Haack M, Morag A et al. Cytokine-
associated emotional and cognitive disturbances in humans. Arch Gen Psychiatry
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