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Absence of all components of the flagellar export and synthesis machinery differentially alters virulence of Salmonella enterica serovar Typhimurium in models of typhoid fever, survival in macrophages, tissue culture invasiveness, and calf enterocolitis.

In this study, we constructed an flhD (the master flagellar regulator gene) mutant of Salmonella enterica serovar Typhimurium and compared the virulence of the strain to that of the wild-type strain in a series of assays that included the mouse model of typhoid fever, the mouse macrophage survival assay, an intestinal epithelial cell adherence and invasion assay, and the calf model of enterocolitis. We found that the flhD mutant was more virulent than its parent in the mouse and displayed slightly faster net growth between 4 and 24 h of infection in mouse macrophages. Conversely, the flhD mutant exhibited diminished invasiveness for human and mouse intestinal epithelial cells, as well as a reduced capacity to induce fluid secretion and evoke a polymorphonuclear leukocyte response in the calf ligated-loop assay. These findings, taken with the results from virulence assessment assays done on an fljB fliC mutant of serovar Typhimurium that does not produce flagellin but does synthesize the flagellar secretory apparatus, indicate that neither the presence of flagella (as previously reported) nor the synthesis of the flagellar export machinery are necessary for pathogenicity of the organism in the mouse. Conversely, the presence of flagella is required for the full invasive potential of the bacterium in tissue culture and for the influx of polymorphonuclear leukocytes in the calf intestine, while the flagellar secretory components are also necessary for the induction of maximum fluid secretion in that enterocolitis model. A corollary to this conclusion is that, as has previously been surmised but not demonstrated in a comparative investigation of the same mutant strains, the mouse systemic infection and macrophage assays measure aspects of virulence different from those of the tissue culture invasion assay, and the latter is more predictive of findings in the calf enterocolitis model.

Animals↗

Recombinant secretory immunoglobulin A in passive immunotherapy: linking immunology and biotechnology.

The use of monoclonal antibodies has become routine in the research and diagnostic laboratories, but the potential of antibody molecules in public health and medical applications is still far from its maximum. Most infections begin at mucosal surfaces, and this is certainly not only a stroke of good fortune if mother's milk serves as a natural delivery vehicle for antibodies protecting the gastrointestinal tract of nursing infants. Mammary gland or other mucous secretions containing numerous antibody specificities provide an efficient mean to immediately protect a mucosal surface against pathogens, which have never been encountered by the host. From a public health perspective, topical passive immunization of mucosal surfaces with monoclonal antibodies can block entry and transmission of bacteria, viruses, fungi and parasites that infect humans, and thus defeat some key immune evasion strategies designed by many pathogens. The chief antibody on most mucosal surfaces is secretory immunoglobulin A (SIgA), a polypeptide complex comprising dimeric IgA, the connecting J chain, and the secretory component. The molecular stability, tetravalency, and strong anti-inflammatory properties make SIgA particularly well suited to fulfill the function of passive protective immunity when applied exogenously to mucosal surfaces. The review will give an overview of the basic concepts underlying mucosal immunity, present the molecular mechanisms whereby SIgA prevents mucosal infections, cover the last advances in the topic of recombinant SIgA production, and examine how structure-function relationship in SIgA will help designing molecules with novel properties for passive immunotherapy.

Animals↗

Alterations in cell surface membrane components of adapting rat small intestinal epithelium. Studies with lectins after massive proximal jejunoileal resection and jejunoileal transposition.

After proximal resection or transposition of intestinal segments, the small intestinal mucosa of rats was examined with fluorescein-conjugated lectins derived from Ricinus communis and Triticum vulgare (wheat germ). These agglutinins are thought to be specific for the nonreducing end-terminal carbohydrate residues, beta-D-galactose and beta-N-acetyl-D-glucosamine, respectively. After 70% proximal jejunoilealal resection as well as transposition of ileal segments to jejunum, ileal villus cell surface labeling by both lectins was changed to a pattern characteristic of normal rat proximal intestine. Alterations were not detected proximal to the surgical anastomosis after massive resection or in the jejunal segments transposed to ileum. Although the labeling pattern of goblet cell mucin differed in proximal duodenum from the remainder of control small intestine in normal animals, no differences were detected in goblet cell mucin labeling between normal and resected or transposed animals. This study confirms the previously reported differential lectin-labeling patterns of the small intestinal crypt and villus cells and further emphasizes the differences between cell surface carbohydrate and secretory mucins of goblet cells. Furthermore, the changes induced in the cell surface-labeling pattern by massive proximal jejunoileal resection and transposition suggest that cell surface and secretory components may be altered differently during adaptation of the small intestine.

Adaptation, Physiological↗

[Detection of secretory immunoglobulin A in cervical secretion and in cervicovaginal irrigation fluids].

Secretory immunoglobulin A (S-IgA) is an essential part of local immune system of female genital tract. Accordingly the estimation of S-IgA in female genital secretions is important for judgement of immunologic problems in female genital tract. The estimation of S-IgA was carried out by means of an antiserum against human secretory component (anti SC) and S-IgA standard. It was used the single radial immunodiffusion according to Mancini and co-workers. Our results refer to changes in the quantity of S-IgA locally produced in the mucous membranes of female genital tract correlated to the menstrual cycle. The essential results are a decrease of S-IgA in midcycle in cervical mucus and vaginal fluids as well as of fertile and sterile patients.

Adult↗

[Histopathological and immunohistochemical studies on mucous cysts].

The present study investigated the histopathology, histochemistry of mucopolysaccharides, and immunohistochemistry of oral mucous cysts. The materials were obtained from ninety cases that were histopathologically diagnosed as oral mucous cysts at the Department of Oral Pathology, Meikai University School of Dentistry. Mucopolysaccharide staining was done with PAS, alcian blue (AB, pH 2.5) and high iron diamine (HID). Immunohistochemical studies were focused on secretory component (SC), lactoferrin (Lf), alpha-amylase (Am), IgA, lysozyme (Ly), and keratin (Kr). The following results were obtained: 1. Histopathological findings. (1) Retention and/or retention-like type cysts occurred in was twenty-six cases and the extravasation type in sixty-four cases. (2) Cases showing epithelial lining of the cystic wall were only eight in number, and many cystic walls were contained granulation tissue (fifty cases). (3) As for inflammation of the cystic wall, the degree was slight, and infiltrated cells were mainly macrophages (so-called mucinophages) and lymphocytes. (4) Regarding adjoining salivary glands, acinar cells showed atrophic changes, and hypertrophy of mucous acinar cells was evident. Many ducts showed dilatation, and stromal connective tissue showed fibrosis and hyalinization. 2. Histochemical findings on mucopolysaccharides. (1) Mucous materials in cystic cavity, mucous acinar cells, and secretory materials in ductal lumens were intensely stained by PAS and AB. But stainability with AB was less than that with PAS staining. Serous acinar cells and ductal epithelium were negative to PAS and AB staining. (2) Stainability of the above with HID was less than at with PAS or AB. Cystic walls were not stained by HID. Mucous acinar cells reactive with HID were intensely stained, but the number of the positive cells was limited when compared with the numbers of PAS-and AB-positive cells. 3. Immunohistochemical findings. (1) As for mucous materials in the cystic cavity, reactions for Sc, Am, IgA, and Ly were all positive, whereas those for Lf and Kr were negative. (2) Staining of cystic walls was generally weak: the walls were negative for IgA, Ly and Kr showed and borderline or slightly positive for Sc, Lf, and Am. (3) Mucous acinar cells were negative for all markers examined in this study, but serous acinar cells and/or demilunes were markedly positive for Sc, Ly, and Am. (4) In ductal epithelial cells, Ly and Kr were negative, but IgA was borderline or slightly positive. Sc and Am gave intensely positive staining. (5) Secretory materials in ductal lumens, Sc were intensely positive for Lf, and Ly; slightly or moderately positive for IgA; and slightly positive or negative for Am.(ABSTRACT TRUNCATED AT 400 WORDS)

Glycosaminoglycans↗

Immunoglobulins coat microorganisms of skin surface: a comparative immunohistochemical and ultrastructural study of cutaneous and oral microbial symbionts.

Only recently have human sweat glands been demonstrated to secrete immunoglobulins (Ig), paralleling Ig secretion in mucosal epithelia. It is well established that Ig protect mucosal membranes against infections by binding to surface structures of microorganisms. In view of these findings immunohistochemical studies were performed to determine if microbes on the skin surface are coated by Ig as proposed for mucosal bacteria and fungi. Smear preparations from the skin and oral cavity rich in micro-organisms were subjected to immunoperoxidase staining using anti-secretory component (SC), -IgA, -IgM, -IgG antibodies. An immunogold labeling technique of microbial suspensions of sweat and saliva was adapted to correlate the results on an ultrastructural level. Negative controls included unsuccessful staining for IgA in preparations obtained from an IgA-deficient patient as well as nonreactivity of subcultured microorganisms for all Ig classes or SC. Smear preparations from both the oral cavity and skin surface exhibited labeling of bacterial or fungal elements with anti-IgA, -IgM, -IgG, and -SC antibodies. Skin bacteria revealed a lower number of reactive microbes as compared to saliva. Staining intensity for the different Ig classes exhibited intra- and interindividual variations. Immunoelectronmicroscopically, Ig and SC could be detected either directly along the cell wall of coccal, coryneform, and fungal elements or on floccular and fimbrial material adhering to the bacterial surface. It is concluded that secretory Ig of the skin cover surface structures of microorganisms and thus modify their adhesional and/or infectious properties, resembling humoral surface immunity on mucous membranes.

Adult↗

Electrophoretic isolation and partial characterization of a glycoprotein of the submandibular glands of the mouse.

A protein has been isolated from the water-extract of the submandibular glands of the mouse, after Biogel P-300 column passage, followed by preparative polyacrylamide gel electrophoresis at pH 4.3 and subsequently at pH 8.9, designated the AM1 protein. The isolated protein was electrophoretically pure in 7.5, 10 and 15% polyacrylamide gels both at pH 4.3 and at pH 8.9. Likewise, by electrophoresis in 15% sodium dodecyl sulfate-polyacrylamide gel only one protein band could be detected. Of the total amount of the water-extractable submandibular proteins the recovery of this protein component comprised 3 to 5 per cent. The molecular weight was estimated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis to be 28 000, both in 7.5 and 15% gel. The isoelectric point was determined by isoelectric focusing in 4.8% polyacrylamide slabgel to be 4.85. The amino acid analysis showed that the ratio of acidic amino acids (Glx plus Asx) to basic amino acids (Lys plus Arg) is 2.3. The glycoprotein consists of protein for 77.4 per cent and of carbohydrate for 22.6 per cent. The molar ratio of the carbohydrates was GlcNH2:GalNH2:Man:Gal:Glc:Fuc:sialic acid = 22.0:1.3:3.0:1.7:10.0:2.6:0.3. The glycoprotein was not secreted from the submandibular glands by stimulation with cholinergic (acetylcholin) or adrenergic (noradrenalin) drugs both in vitro and in vivo. So, it appeared that this glycoprotein could be characterized as a cellular, non-secretory component of these salivary glands.

Amino Acids↗

A solid phase, direct competition, radioimmunoassay for quantitation of secretory IgA in human serum.

A solid phase radioimmunoassay is described for measurement of secretory IgA (sIgA) in human serum. The assay is based on direct competition between sIgA in serum and purified labelled milk sIgA for anti-secretory-component antibodies coated on disposable plastic cups. The assay is relatively rapid, reproducible and of adequate sensitivity. A wide range of sIgA concentrations (5--120 microgram/ml) can be tested with the same dilution of human serum. The arithmetic mean +/- S.D. of the serum sIgA levels of 120 random blood donors (both sexes) was 10.9 +/- 4.6 microgram/ml. Compared to previously published methods and results of quantitation of sIgA in human sera, the present assay is an improvement which should yield interesting data in human hepatic physiopathology.

Blood Proteins↗

Antibodies against Aspergillus fumigatus in bronchial secretions from patients without aspergillosis.

Antibodies to Aspergillus fumigatus were investigated by indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA) in bronchial secretions (BS) and sera from 40 patients with neoplasia, lung infiltrates of non-fungal aetiology or chronic bronchitis. By IIF, IgG aspergillus antibodies were found in 23 samples of BS (58%) (titre range 10-40) and in all 40 sera (titre range 10-1280). IgA aspergillus antibodies were detected in 33 samples of BS (83%) (titre range 10-160) and in 33 sera (83%) (titre range 10-40). IgM aspergillus antibodies occurred in 2 samples of BS (5%) (titre 10 and 40) compared with 35 sera (88%) (titre range 10-40). Antibodies with secretory component (SC) were detected in 20 of 39 BS samples tested (51%) (titre range 10-160). Significantly higher levels of IgA antibodies were detected by ELISA in BS than in serum (2p less than 0.05) and, conversely, significantly higher levels of IgG antibodies were found in serum than in BS (2p less than 0.001). Low levels of antibodies with SC were also detected in BS by ELISA. These results suggest that aspergillus antibodies are produced within the bronchopulmonary system in patients without aspergillosis.

Antibodies, Fungal↗

Binding and transepithelial transport of immunoglobulins by intestinal M cells: demonstration using monoclonal IgA antibodies against enteric viral proteins.

M cells of intestinal epithelia overlying lymphoid follicles endocytose luminal macromolecules and microorganisms and deliver them to underlying lymphoid tissue. The effect of luminal secretory IgA antibodies on adherence and transepithelial transport of antigens and microorganisms by M cells is unknown. We have studied the interaction of monoclonal IgA antibodies directed against specific enteric viruses, or the hapten trinitrophenyl (TNP), with M cells. To produce monospecific IgA antibodies against mouse mammary tumor virus (MMTV) and reovirus type 1, Peyer's patch cells from mucosally immunized mice were fused with myeloma cells, generating hybridomas that secreted virus-specific IgA antibodies in monomeric and polymeric forms. One of two anti-MMTV IgA antibodies specifically bound the viral surface glycoprotein gp52, and 3 of 10 antireovirus IgA antibodies immunoprecipitated sigma 3 and mu lc surface proteins. 35S-labeled IgA antibodies injected intravenously into rats were recovered in bile as higher molecular weight species, suggesting that secretory component had been added on passage through the liver. Radiolabeled or colloidal gold-conjugated mouse IgA was injected into mouse, rat, and rabbit intestinal loops containing Peyer's patches. Light microscopic autoradiography and EM showed that all IgA antibodies (antivirus or anti-TNP) bound to M cell luminal membranes and were transported in vesicles across M cells. IgA-gold binding was inhibited by excess unlabeled IgA, indicating that binding was specific. IgG-gold also adhered to M cells and excess unlabeled IgG inhibited IgA-gold binding; thus binding was not isotype-specific. Immune complexes consisting of monoclonal anti-TNP IgA and TNP-ferritin adhered selectively to M cell membranes, while TNP-ferritin alone did not. These results suggest that selective adherence of luminal antibody to M cells may facilitate delivery of virus-antibody complexes to mucosal lymphoid tissue, enhancing subsequent secretory immune responses or facilitating viral invasion.

Animals↗

Monoclonal antibodies against ovine IgA purified from lung lavage fluid.

Ovine secretory IgA (sIgA) has been purified to relative homogeneity by ammonium sulphate precipitation (to 40 per cent w/v) of lung lavage fluid from 3- or 12-month-old lambs, followed by molecular sieve chromatography on a Sephacryl S300 matrix. Three peaks A, B and C with molecular sizes corresponding to 550,000, 400,000 and 165,000 respectively were eluted from the column. Immunoelectrophoresis, radial immunodiffusion and enzyme-linked immunosorbent assays (ELISAs) with class specific antiserum confirmed that peak B contained only IgA. Polyacrylamide gel electrophoresis of peak B under reducing conditions resolved three subunits corresponding to secretory component, heavy and light chains. Hybridomas generated by fusing spleen cells from IgA-primed Balb/C mice with murine myeloma (Sp2/0) were screened for IgA-specific monoclonal antibodies against a panel of ovine IgG2, IgG1, IgA and IgM. One particular clone, F3-4B4, identified as murine IgG1, was monospecific against ovine IgA with no cross reactivity against bovine immunoglobulins. This hybridoma was successfully tested as a serological probe by ELISA profiling to locate IgA containing fractions in the course of immunoglobulin purification from biological fluids.

Animals↗

Increased plasma IgA, sIgA, and C3- and IgA-containing immune complexes with renal glomerular deposits in diabetic rats.

Male Sprague-Dawley rats were fasted 18 h and given streptozocin (STZ; 60 mg/kg body wt i.p.). The resultant diabetes mellitus, not treated with insulin, was associated with persistent manifoldly increased plasma IgA levels, as measured by single-radial immunodiffusion after reduction with dithiothreitol and alkylation with iodoacetamide. Also observed were concurrent increases in plasma levels of secretory IgA (sIgA) and of C3- and IgA-containing immune complexes (C3-IgA-CIC). After 104 days without insulin treatment, six of the diabetic rats were given daily injections of 2 U of insulin for 11 days. Insulin treatment was associated with a precipitous decrease in plasma levels of IgA, sIgA, and C3-IgA-CIC. Cessation of insulin treatment resulted in restoration of greatly increased levels of all three IgA-containing species. Histoimmunofluorescence studies of kidneys from untreated rats with diabetes of 192-324 days revealed glomerular capillary wall and mesangial deposits reacting strongly with anti-IgA (alpha-chain-specific) antiserum. Kidneys from two of the diabetic rats (324 days) were tested with anti-rat C3 and anti-rat secretory component (SC) antisera, and they reacted positively. Control kidneys from normal rats examined simultaneously were negative. The concurrent changes in plasma levels of three IgA-containing species in the untreated STZ-induced diabetic rat and the demonstration of abnormal immunoreactive IgA-containing renal glomerular deposits make this experiment an attractive model for studying the possible role of disturbed IgA metabolism in the pathogenesis of diabetic nephropathy.

Animals↗

The regulation of growth hormone secretion from the isolated rat anterior pituitary in vitro. The role of adenosine 3':5'-cyclic monophosphate.

1. The release of growth hormone from isolated fragments of rat anterior pituitary tissue incubated in vitro was studied by employing a double-antibody radioimmunoassay. 2. In the absence of added stimuli, two phases of hormone release could be distinguished, an early phase of 2h duration and a subsequent late phase. In the early phase, hormone release was rapid but could be significantly decreased by calcium depletion and by 2,4-dinitrophenol whereas the rate of release in the late phase was uninfluenced by these incubation conditions. These results have been interpreted as indicating the existence of a secretory component in the early phase of release. 3. In subsequent experiments, the effects of various agents on the rate of hormone output during the late phase of incubation were investigated. Hormone release was increased by theophylline and by dibutyryl cyclic AMP (N(6)-2'-O-dibutyryl-adenosine 3':5'-cyclic monophosphate), the response to both of these agents being related to the concentration of the stimulant employed. 4. The stimulation of growth hormone output by theophylline was significantly decreased by calcium deprivation and by 2,4-dinitrophenol. The response to dibutyryl cyclic AMP was diminished by 2,4-dinitrophenol, iodoacetate and 2-deoxyglucose but not by malonate or colchicine. 5. Arginine, beta-hydroxybutyrate, albumin-bound palmitate and variation in the glucose concentration of the incubation medium over a wide range were without any statistically significant effect on the rate of hormone release from either control pituitary fragments or those subject to secretory stimulation by dibutyryl cyclic AMP. 6. It is suggested that the regulation of growth hormone secretion is mediated by cyclic AMP (adenosine 3':5'-cyclic monophosphate). The secretion observed in response to cyclic AMP requires the presence of ionized calcium and a source of metabolic energy but is independent of pituitary protein synthesis de novo. The integrity of the glycolytic pathway of glucose metabolism appears to be essential for cyclic AMP-stimulated growth hormone secretion to occur.

Animals↗

Lavage and nipple aspiration of breast ductal fluids: a source of biomarkers for environmental mutagenesis.

The acquisition of breast ductal fluid by nipple aspiration and ductal lavage are simple noninvasive procedures to sample breast tissue. Nipple aspiration fluid (NAF) obtained with gentle suction and a simple syringe-adapted apparatus may evaluate the secretory components that bathe the ductal epithelial cells. Evaluations have included the quantification of soluble markers (carcinoembryonic antigen and prostatic-specific antigen), DNA amplification, protein gel electrophoresis, and mutagenesis assays. It has been suggested that environmental mutagens in the breast ductal system may contribute to carcinogenesis. The feasibility of mutagenesis assays on NAF has been limited by the small size of the samples obtained. Three small clinical studies detected mutagens in 6-14% of the samples using the Salmonella Ames assay. Ductal lavage collects more of a cellular aspirate from the ductal system utilizing a microcatheter. Early studies on ductal lavage fluid have included cytology and methylation-specific PCR. Ductal lavage in a high-risk group has identified cellular atypia in 21% of those sampled. Samples obtained through the nipple, by aspiration or lavage, are the proteinaceous secretions from the ductal system and ductal epithelial cells. The fluid represents the cellular events and the dynamic secretory process of the breast and may include potential initiators of the carcinogenesis process in the cellular microenvironment. Fluid obtained by ductal lavage may allow for more detailed studies of the role of mutagens in breast cancer.

Adult↗

A study of secretory immunoglobulin A on membranous epithelial cells (M cells) and adjacent absorptive cells of rabbit Peyer's patches.

Secretory immunoglobulin A (SIgA) on the surface of the membranous epithelial cell (M cell) is present in Peyer's patches, an important element of gut-associated lymphoid tissue (GALT). Little information about this immunoglobulin exists except for its scantiness inferred from electron microscopic examination of the relatively thin layer of glycocalyx on the cell surface. This study was undertaken to investigate SIgA on the M cell surface by immunohistochemical observations of specimens from 16-week-old rabbits, using anti-IgA antibody specifically directed to alpha-chain and anti-SIgA antibody specific to both alpha-chain and secretory component (SC). Areas of strongly positive reaction with these antibodies were demonstrable by electron, as well as light microscopy in the glycocalyx layer and on microfolds of M cells, contrasting with the glycocalyx layer and microvilli of the adjacent absorptive cells. The findings were suggestive of an abundant presence of SIgA in the glycocalyx layer and on microfolds of M cells. The results suggested the participation of SIgA on M cell surfaces through a mechanism in which M cells take up intestinal antigens, although the precise role of SIgA on M cells remains unclear.

Animals↗

[Importance of secretory IgA in human body fluids. I. Development of an enzyme immunoassay for secretory IgA].

This paper describes an enzyme-immunoassay for the quantitative estimation of secretory IgA(S-IgA). As solid phase a monoclonal antibody against human secretory component was used, a polyclonal peroxidase labeled anti-IgA serum as conjugate. Thus, the method was specific for S-IgA. The test was done in microtiter plates, the upper limit was 0.5 ng S-IgA/ml. The standards of our test system ran in normal ranges, the coefficients of variation were 6.9% in the within-day-test and 12.2% in the day-to-day-test. The described test system is effective and sensitive. It is suitable for clinical use.

Antibodies, Monoclonal↗

Chromatographic separation and purification of secretory IgA from human milk.

Defatted and decaseinated human milk was concentrated and was fractionated on a preparative DEAE cellulose column. Elution with various concentrations of sodium chloride in Tris-HCl buffer (pH 8.0, 0.01 M) resulted in fractions that were rich in either secretory immunoglobulin A (SIgA) (0.1 M NaCl) or free secretory component (SC) (0.05 M NaCl). The fractions, which were eluted with 0.10 M NaCl from the preparative column, were further fractionated on a G-200 Sephadex column. Repeated fractionation on this column resulted in a single purified fraction, which contained very high SIgA activity and showed immunological cross-reaction with both SC and serum IgA. Additional studies indicated that this fraction was homogeneous as shown by immunoprecipitin and disc gel electrophoresis. Injection of this purified SIgA into rabbits resulted in the production of monospecific antisera.

Chromatography, DEAE-Cellulose↗

Immunological study of histologically non-involved jejunum during Crohn's disease: evidence for reduced in vivo secretion of secretory IgA.

We studied the local humoral immunity of histologically non-involved jejunum in patients with Crohn's disease. Normal subjects and patients with ulcerative colitis served as controls. Jejunal fluid samples were collected during segmental jejunal perfusion, under an occluding balloon and the in vivo jejunal secretion of the following proteins was determined: albumin, orosomucoid, transferrin, alpha 2-macroglobulin, secretory component, monomeric and polymeric IgA, IgG, and IgM. The densities and number of IgA-, IgG-, and IgM-containing cells in the lamina propria of the jejunum were measured on perendoscopic biopsies. Jejunal secretion of polymeric IgA and the density of IgA-containing plasma cells in the lamina propria were significantly lower in patients with Crohn's disease than in both control groups. This abnormal intestinal immune response, which was not correlated to the activity of the disease, might be involved in its pathogenesis.

Adolescent↗