Alcohol and the immune

system

Gyongyi Szabo, MD PhD

University of Massachusetts
Medical School

RSA 2008
 -The first brew was probably date palm wine,
originating in Mesopotamia.
- We know that the ancient Egyptians were
drinkers, because they invented the first
straws, for drinking beer that still contained
wheat-husks.
- Some of Egyptian texts refer to the social
problems associated with drunkenness, so they
were no strangers to recreational drinking.
- The Babylonians, in the world's first legal
text, included a law regulating drinking houses.

http://www.ephidrina.org/alcohol/history.html
 Infectious Disease in History

Ancient times:
Heiroglyph from
Memphis, the capital of
ancient Egypt, drawn in
approximately 3700BC:
depicts a temple priest
called Ruma showing
typical clinical signs of
paralytic poliomyelitis.
 ’Germ theory' of disease
was introduced in the 1880s by
Robert Koch & Louis Pasteur

Louis Pasteur (1822-1895)

Robert Koch (1843-1910)

Koch's postulates :
i. The agent must be present in every case of the disease.
ii. The agent must be isolated from the host & grown in
vitro.
iii. The disease must be reproduced when a pure culture of
the agent is inoculated into a healthy susceptible host.
iv. The same agent must be recovered once again from the
experimentally infected host.
 Koch observed:
-Significant mortality of alcoholics
during the cholera epidemics of
1884.
-Showed that rats experimentally
treated with alcohol were more
susceptible to cholera.

Sir William Osler:

-“ The most potent predisposing
factor is perhaps the lowered
resistance to alcohol” - in
pneumonia.
Principles and Practice of Medicine
(1909)

1849-1919
Alcohol, inflammation and immune response
Clinical observations

• Reduced antimicrobial defense

– Increased incidence of bacterial pneumonias
– Increased incidence of M. tuberculosis infection
– Suscepibility to infection with Listeria monocytogenes

• Reduced anti-viral immunity

– Increased susceptibility to HIV infection
– Higher rate of chronic hepatitis C viral (HCV) infection and
accelerated liver injury in alcoholics

• Increased inflammatory pathway activation

– Increased post-trauma immunosuppression
• Higher rate of major complications, prolonged disease course
 Bacteria
Pathogens Viruses
Fungi
Parasites, etc

Immune response

Adaptive immunity Innate immunity

Neutrophils
Monocytes/Macrophages
Humoral Cellular Dendritic cells
T lymphocytes Natural killer cells
B lymphocytes CD4+
antibodies CD8+ Interferons
Regulatory T cells Interleukins
Cytokines
Chemokines
Reactive oxygen
substances
Pathogen elimination
 Immune response to pathogens
Adaptive immunity Innate immunity
antibodies

B cell Dendritic PMNL

TCR Cell
Monocyte
Th2 cytokines Phagocytosis
(IL-4, IL-5, IL-10) CD4+ MHC Class II
Reactive oxygen radicals
Cytokines
Th cell (TNF, IL-1, IL-6, IL-10)
Th1 cytokines
(IL-2, IFN-) NK Chemokines
Interferons
IFN- cell
Macrophage
TCR
CD8+
CTL Host cell
MHC
Class I
 Toll-like receptors in pathogen recognition
Extracellular space
LPS TLR4 Flagellin
Triacyl
TLR5 peptidesDiacyl
TLR2/1 Peptides
CpG ssRNA dsDNA Zymosan
TLR9 TLR7/8 TLR3 TLR2/6
Endosome MyD88
MyD88 IRAK-1
TRIF TRAF6
TRAM

Cytoplasm IRF3 IB

IRF7 NF-B
Nucleus
IRF7 IRF3 IRF3 Pro-inflammatory
Type I IFNs DNA cytokines
 Adaptive immunity
Antigen presentation and T cell activation
IFN
Th1 IL- 2
CD8+
MHC Class II
MHC Class I
CD80, CD86
Microbes Naïve Th0
Viral products APC CD4+
T cells
Cytokines
Etc.
Co-stimulatory
signals

Monocytes Th2 IL-10

IL-12, IL-18, IL- 4
Dendritic cells IL-6, IL-8,
TNF-,
IL-10
 Alcohol reduces host antimicrobial defense
– Increased incidence of bacterial pneumonias
• Pneumococcus, Klebsiella, Hemophilus influenzae,
Legionella, other Gram negative organisms

Klebsiella

Pneumococcus
– Increased incidence of infection with
M. tuberculosis

Listeria monocytogenes
Alcohol use and M. tuberculosis

• Acute and chronic alcohol predisposes to TB disease

through alterations of the specific and non-specific
immune response to MTB.
• Alcohol use predisposes to a more severe form of TB
• Heavy alcohol use (>3 drinks/day) was associated with an
increased risk of TB
Alcohol feeding increases susceptibility to
Listeria Monocytogenes
Human data: mortality from listeric meningitis or sepsis is
10.7% in non-alcoholics and 24% in alcoholics

Experimental data in mice

Liver enzyme levels in mice 5 days after infection Bacterial colony counts in livers and spleens
(5 mice/group) (5 mice/group)

Number of colonies/gram of tissue

• Image Removed – Awaiting
AST

Copyright Permissions

Alcohol Clin Exp Res. 1993 Feb;17(1):75-85

 Chronic alcohol feeding increases susceptibility
to respiratory syncytial virus infection in mice
Increased early
Type I Interferon
production after alcohol feeding
Increased virus
replication
after alcohol feeding
 Chronic alcohol feeding increases susceptibility
to influenza virus infection in mice

Increased lethality Increased lung injury Progressive loss of CD8+

and magnitude of and neutrophil T cell function with
infection infiltration prolonged alcohol

The Journal of Immunology, 2008, 181: 641-648.

 Impairment of pulmonary host defense
from alcohol abuse
Oropharynx
Saliva production, poor dentation
Bacterial pathogen colonization Glottis
Consciousness, cough reflex
Aspiration
Airways
Mucosiliary function

Airspaces/Innate Immunity
Alveolar macrophages Neutrophils
Adhesion molecules, Chemotaxis
Phagocytosis, antimicrobial activity
Cytokines (TNF, IL-12, GM-CSF)
Chemokines (MIP2/IL-8/CINC/Gro-
Bone marrow PMNL response to infection

Adaptive Immunity
Cellular immunity Humoral immunity
T cell proliferation B cell numbers
Inflammatory cytokines Airspace levels of
IFN, IL-17 IgG and IgG1
Anti-inflammatory
Cytokines (IL-10)

Happel & Nelson 2005

 Treatment options for alcohol-
induced immune defects in pneumonia

• Antibiotics

• G-CSF administration to alcohol-fed mice with Klebsiella

pneumoniae infection
– Increased PMNL recruitment to lungs
– Increased pulmonary host defense

• Replacement of the reduced glutathione levels with N-

acetylcystein feeding reversed decreased alveolar
macrophage phagocytosis in the lung.
 Alcohol use and Human
Immunodeficiency Virus infection
• Association between alcohol use and risk of being infected
with HIV
• Incidence of alcohol abuse among HIV-infected individuals is
greater than the population as a whole
• 82% if HIV positive patients consume alcohol and 41% met
criteria for alcoholism (Michigan test)
• Miami HIV-infected Drug Abuser Study >60% of HIV+
patients reported heavy alcohol use
• Fong described a heavy alcohol user patient who developed
accelerated HIV progression to AIDS in a 3-months period.

The adverse effects of alcohol on the HIV-infected

patient as it relates to immunity and disease
progression are poorly understood.

Alcohol Clin Exp Res. 2006 Oct;30(10):1781-90

 Chronic alcohol worsens infection with
Simian Immunodeficiency Virus

• Increased viral load

• Decreased circulating
Image Removed – Awaiting CD4+/CD8+ lymphocyte ratio
Copyright Permissions • Increased lymphocyte
proliferation
• Increased muscle TNF mRNA
expression at 10 months after
infection
• More rapid development of end-
stage disease
Percent survival as a function of days after SIV
inoculation in
macaques receiving ethanol or sucrose.
Statistical difference by Lifetest,
p<0.05.
Alcohol Clin Exp Res. 2006 Oct;30(10):1781-90.
 Alcohol
and trauma

• Alcohol abuse has a detrimental outcome on

traumatic injury.
• Alcohol abuse is estimated in nearly 50% of
burn and trauma admissions
• Decreased survival
• Higher number of complications including
– infection, sepsis, pneumonia, prolonged
hospitalization

J Trauma 64:230-240.
Alcohol 28:137-149.
Alcohol Clin Exp Res 31:704-715.
http://www.photovault.com/Link/Health/Emergency/Paramedics/HEPVolume01.html
Immune regulation in trauma

Image Removed – Awaiting

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J Trauma 64:230-240.
Alcohol 28:137-149.
Alcohol Clin Exp Res 31:704-715
 Alcohol and trauma

J Trauma. 2008;64:230 –240.

Moderate alcohol consumption and immunity

• Moderate drinkers were more resistant than abstainers to

common cold virus (non-smokers)
• Wine consumption, especially red wine, decreases the
incidence of common cold
• Moderate wine or beer consumption was associated with
lower levels of systemic inflammatory markers in three
different European areas (Germany, Scotland, France)
• After moderate alcohol consumption there is a decrease in
TNF induced adhesion in monocytes to endothelial cells
• Beer down-regulates activated peripheral mononuclear cells

Most studies show an anti-inflammatory effect of

acute, moderate consumption of alcoholic beverages.
 Alcohol and TNF
a master regulator of inflammatory responses

Acute (moderate) Chronic (excessive)

• Dose-dependent inhibition of
TNF production in monocytes
• Inhibits TNF converting
enzyme (TACE) - reversible
• Acute in vivo alcohol inhibits
LPS-induced TNF in the
serum or lung
•Increased serum and monocyte
TNF in alcoholic hepatitis
•Increased TNF producion by
Kupffer cells in the liver
•Increased TNF production by
human monocytes

Opposite effects
 Toll-like receptor 4 signaling

LPS

TLR4
CD14
MD-2
TIRAP TRAM

IRAK1/4
TRAF6
MyD88 TRIF TBK-1
IkB IKKi
MAPK NF-B
IRF3
Inflammatory genes
IFNß
AP-1 NF-B IRF3 IRF3
TNFα
 Toll-like receptor 4 signaling

LPS
TLR4
CD14
MD-2
TIRAP TRAM

IRAK1/4
TRAF6
MyD88 TRIF TBK-1
IkB IKKi
MAPK NF-B
IRF3
Inflammatory genes
IFNß
AP-1 NF-B IRF3 IRF3
TNFα
Lipid rafts
- transiently-formed, dynamic plasma membrane
microdomains enriched in sphingolipids and
cholesterol (Mouritsen OG et al., 2004)

- represent ~30-50% of the plasma membrane

- platforms for various cellular events, such as

membrane trafficking and signaling

- GPI-linked proteins and Src-family kinases, are

constitutively expressed in rafts, while others, like T
cell receptors, associate with rafts upon engagement
with specific ligands for the purpose of signal
transduction

- lipid rafts play a pivotal role in lymphocyte and

monocyte/macrophage functions and may interfere
with TLR-mediated signaling

Razaqq TM et al., 2004; Schmitz, 2002; Triantafilou M,

2003; Dai Q, 2005
Acute alcohol treatment disrupts TLR4
recruitment into lipid rafts

Szabo et al, J. Immunol, 2007

 Opposite effects of acute and chronic alcohol
on monocyte TNF production

Acute alcohol also inhibits while chronic alcohol

increases activation of NF-B, a nuclear regulatory
factor in TNF regulation.
J Immunol. 2007 178:7686-93
Acute alcohol Chronic alcohol

LPS LPS

TLR4 TLR4

Pro- Anti-
inflammatory inflammatory
TNF, IL-1 Anti- Pro-
inflammatory inflammatory
IL-10 TNF

Inflammation Inflammation

Alcohol Clin Exp Res. 2006 Apr;30(4):720-30.

 Mechanisms of alcoholic liver injury

PMNL Hepatocyte
Alcohol
TNF
ROS Collagen
IL-8 TGF Gut
MCP-1 Stellate Cell

NADPH
NF-kB
AP-1
Endotoxin
TLR4
(LPS)
Kupffer Cell Adachi et al, Gastro 1995;108:218-224.
 Kupffer cell activation in
alcoholic liver disease

TNF

Courtesy of L. Nagy (Cleveland Cilinic)

J Gastroenterol Hepatol. 2007 Jun;22 Suppl 1:S53-6
 Hepatitis C and Alcohol Use
• 30% of alcoholic patients with liver disease are HCV
infected (Rosman AS,1996, Am.J.Gastroenerology)
• USA: 70% of HCV infected patients have alcohol use/abuse
history (Schiff ER, 1999, Am.J.Med)

• Clinical progression and liver disease with alcohol use is

accelerated in HCV(Tanaka T, 2000, Alcohol Clin.Exp.Res)
• Prolonged alcohol use is an independent risk factor for HCV
progression (Regev A, 1999 Alcohol Clin.Exp.Res)
• Ongoing moderate alcohol consumption affects hepatic
inflammatory activity (Day CP, 2001 Gut)
• IFN therapy is ineffective in patients with ongoing alcohol
use (Newmann A.U, 1998, Science)
 Additive inhibition of dendritic cell
allostimulatory capacity
by HCV infection and alcohol treatment

p< .001
p< .001 p< .01

Allostimulatory capacity
70
Proliferation (cpmx10-3)

1.25
p< .022 *
50 1
0.75 **
30
0.5

10 0.25
0 0
Control Control DC HCV HCV DC Control HCV HCV DC
DC +alcohol DC +alcohol DC DC +alcohol

Dolganiuc et at. Alcoholism: Clin. & Exp. Research, 2003

 Ethanol inhibits myeloid dendritic cell
antigen presentation and T cell activation

40 I-DC 20

Thymidine incorporation

43 ± 2.3%
EtOH-I-DC 18
30
16
14

(cpm x 10-3)
incorporation
(cpm x 10-3)
Thymidine

12
20 * 10
8
* 6
10
* 4
2
0 0
1

Dendritic cells (X 104/well) T DC DC Et-DC

T cells: 2x 105/well cells (TT) (TT) (TT)
J Immunol 173:3398-3407.
+ T cells
 Adaptive immunity
Antigen presentation and T cell activation

IL-12, Antigen-specific T
IL-10 cell proliferation
MHC Class II
Th1
CD80, CD86
Naïve Th0
APC CD4+

Microbes Co-stimulatory
Viral products signals
Cytokines
Etc. MHC Class II
CD80, CD86
Naïve Th0
APC CD4+ Th2
Co-stimulatory
signals
T cell anergy
Low IL-12,
High IL-10
 Alcohol consumption inhibits dendritic cell
antigen presentation in mice
-Alcohol feeding in mice resulted in
decreased :
Image Removed – -bone marrow-derived DC generation
- expression of the co-stimulatory
Awaiting Copyright molecules, CD80, CD86 on DCs
Permissions - induction of T cell proliferation
-IL-12 production

Increased:
- IL-10 production
Image Removed – Awaiting
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J. Leukoc. Biol. 79: 941–953;

 Chronic alcohol exposure affects dendritic
cell functions in the skin

• Decreased numbers and

migration of Langerhans cells
Image Removed – Awaiting and dermal dendritic cells in
mice after 4-8 weeks of
Copyright Permissions alcohol feeding

Alcohol Clin Exp Res, Vol 32, No 3, 2008: pp 1–12

 Mature (stimulatory) DC
High surface MHC II
High CD80, 86, 54
High CD83
Low endocytosis, FcR
High IL-12, low IL-10
IFN
Immature DC T cell priming, activation

Alcohol
Inhibitory DC
High intracellular MHC High Surface MHC II
II Reduced CD80, 86
Low CD 80, 86, 54 Low IL-12
Low CD83 High IL-10
Endocytosis, FcR Reduced T cell activation
T cell anergy
 Alcohol use affects adaptive
immunity in humans

• B cell defects:
– Polyclonal hyperglobulinemia
– Immunoglobulin A deposition in tissues

• Increased percentage of activated CD8+ T

cell

• Shift from “naïve” (CD45RA+) to the

“memory” phenotype of T cells (CD45RO+)
- both in CD4+ and CD8+ population

Clin Exp Immunol 103:304-310.

 Adaptive immunity - animal data

• 4-6 weeks alcohol feeding decreased

the splenic, thymic and bone marrow
T cell populations
• Increased CD4/CD8 T cell ratios
• Increased memory/naïve T cell
ratios
• Abnormal antigen-specific responses

Clin Exp Immunol 103:304-310.

Methods Mol Biol. 2008;447:277-94.
Alcohol impairs innate and adaptive immunity

APC T cell
Pathogen CD4+

Inflammatory response Antigen presentation &

Induction of adaptive immunity

T cell proliferation
Pro-inflammatory IL-12
cytokines Co-stimulatory molecules
NF-B activation
Change in Th1/Th2 cytokine profile (?)

Pathogen elimination
Adaptive immune responses
Summary

Alcohol use, both

acute and chronic,
results in
generalized and
organ-specific
immune defects.

Nature Reviews Immunology 2, 205-209, 2002