Normal Estrogen, but Low Dehydroepiandrosterone ... - ATS Journals

ORIGINAL RESEARCH Normal Estrogen, but Low Dehydroepiandrosterone Levels, in Women with Pulmonary Mycobacterium avium Complex A Preliminary Study Joshua Danley1, Rebecca Kwait1, Donald D. Peterson1,4, Jocelyn Sendecki 2, Beverly Vaughn 3, Kara Nakisbendi 3, Janet Sawicki 4, and Leah Lande1,4 1 Division of Pulmonary and Critical Care Medicine, and 3Division of Obstetrics and Gynecology, Lankenau Medical Center, Wynnewood, Pennsylvania; 2Division of Biostatistics, Thomas Jefferson University, Philadelphia, Pennsylvania; and 4Lankenau Institute for Medical Research, Wynnewood, Pennsylvania

Abstract Rationale: For unclear reasons, the phenotypical hosts for nontuberculous mycobacterial lung infection are often thin, elderly, white women without underlying lung disease. As these women are usually postmenopausal, we hypothesized that a state of relative hormone deficiency may predispose some women to pulmonary nontuberculous mycobacterial infection. Objectives: To conduct a prospective cross-sectional study to assess for alterations in systemic levels of sex hormones in patients with confirmed pulmonary Mycobacterium avium complex infection compared with healthy control subjects. Methods: Female patients with pulmonary M. avium complex infection (n = 35) were recruited along with similar-aged control subjects (n = 27) without lung disease from the general population of our institution. Levels of dehydroepiandrosterone-sulfate (DHEA-S), estrone, and ultrasensitive estradiol were measured from sampled blood.

Measurements and Main Results: DHEA-S levels of patients with M. avium complex infection were significantly lower than control subjects (mean 33 mg/dl vs. 59 mg/dl, P = 0.001). No significant difference was found in the levels of estrone (mean, 27 pg/ml vs. 28 pg/ml, P = 0.665) or ultrasensitive estradiol (mean, 9 pg/ml vs. 9 pg/ml, P = 0.364). Patients with M. avium complex had a lower body mass index (BMI) than control subjects (mean, 22 vs. 26, P = 0.001). There was no association between levels of DHEA-S, estrone, or estradiol, and BMI or age. Conclusions: Women with M. avium complex infection had lower DHEA-S levels, but not lower estrogen levels, compared with control subjects. There was no relationship between BMI and hormone levels in the study population. Further study of these hormonal effects on immune function in nontuberculous mycobacterial infection is warranted. Keywords: menopause; nontuberculous mycobacteria; body mass index; Th1–Th2 balance; hormones

(Received in original form December 3, 2013; accepted in final form May 8, 2014 ) Funded by the Sharpe-Strumia Research Foundation. Author Contributions: conception and design: D.D.P., J. Sawicki, L.L.; analysis and interpretation: J.D., J. Sendecki, J. Sawicki, L.L.; data acquisition: R.K., B.V., K.N., L.L.; manuscript drafting: J.D., D.D.P., J. Sawicki, L.L. Correspondence and requests for reprints should be addressed to Leah Lande, M.D., Suite 230, MOB West, 100 Lancaster Avenue, Wynnewood, PA 19096. E-mail: [email protected] Ann Am Thorac Soc Vol 11, No 6, pp 908–914, Jul 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201312-422OC Internet address: www.atsjournals.org

Mycobacterium avium complex is the most common pulmonary nontuberculous mycobacterial infection in the United States (1) and is known to cause significant lung disease in otherwise healthy individuals. The incidence of pulmonary M. avium complex infection has been increasing steadily over the last decade for unclear 908

reasons. As many as 80% of cases in individuals without preexisting lung disease occur in women, most of whom are over the age of 55 years (2), white, and thin (3, 4). One of the unanswered questions regarding pulmonary M. avium complex infection is why it occurs disproportionately

in thin, postmenopausal women. Menopause is characterized by a state of relative hormonal deficiency. In the postmenopausal state, as ovarian production of sex hormones declines, the main supply of these hormones is from the adrenal glands, with peripheral conversion into their active form in adipose

AnnalsATS Volume 11 Number 6 | July 2014

ORIGINAL RESEARCH tissue (5, 6). A number of studies have described the role of two such hormones, estrogen and dehydroepiandrosterone (DHEA), in modulating the immune response to different microbial pathogens (7–12). DHEA is a lipophilic circulating prohormone. Its production in the zona reticularis of the adrenal glands leads to the production of androstenedione, which is then converted to estrone in peripheral adipose tissue. Its sulfated ester, DHEA-S, is the hydrophilic storage form bound to albumin in the bloodstream. DHEA-S is converted to DHEA by the enzyme sulphatase, and this reaction occurs mainly in peripheral tissues (5). DHEA is the primary source of sex steroids in women after menopause. DHEA levels are known to be variable in the elderly but overall to decline with age (13). Plasma levels of DHEA have been found to be significantly reduced in patients with active

M. tuberculosis (14), and plasma DHEA levels correlated positively with the in vitro production of IFN-g by mycobacterialstimulated peripheral blood mononuclear cells (15). In a mouse model of M. tuberculosis infection, administration of DHEA and androstenedione to mice with active M. tuberculosis resulted in a reduction in bacterial counts and improved survival (8). In several other studies, DHEA has been shown to have a stimulatory effect on the Th1 response to foreign antigens (8–10, 12). In an attempt to better understand why only certain postmenopausal women are susceptible to pulmonary nontuberculous mycobacterial infections, we conducted a prospective cross-sectional study to assess whether systemic levels of estrogen and DHEA are altered in women with pulmonary Mycobacterium avium complex infection as compared with levels in healthy women.

Methods Study Population

This research study was conducted over a 104-week period between July 2010 and June 2012. Subjects with M. avium complex lung disease were recruited from the Lankenau Medical Center Division of Pulmonary Medicine. All patients seen in the Lankenau Medical Center Pulmonary Division between the ages of 50 and 89 years were screened by the nurse study coordinator for postmenopausal status and for the diagnosis of M. avium complex, and those that met the 2007 American Thoracic Society/Infectious Disease Society of America criteria for the diagnosis of pulmonary M. avium complex disease were selected (16). Clinical and demographic information was obtained on all patients through both chart review and patient questionnaires, which were filled out by patients with the aid of study personnel.

Table 1. Study population

Age, mean (SD), yr BMI, mean (SD) Race White, n (%) Black, n (%) Tobacco use Total, n (%) Former smoker, n Current smoker, n Average pack-years, mean (SD) NTM treatment status Current antibiotic treatment, n (%) Prior antibiotic treatment, n (%) Never treated, n (%) Coexisting lung disease Total, n (%) COPD, n Asthma, n Bronchiectasis, n History of pneumonia, n Pneumothorax, n Lung cancer, n History of HRT use, n (%) Medical comorbidities Hypertension, n Hyperlipidemia, n Coronary artery disease, n Atrial fibrillation, n Hypothyroid, n Diabetes, n Gastroesophageal reflux disease, n Osteopenia/osteoporosis, n

Control Subjects (n = 27)

Patients with Mycobacterium avium Complex (n = 35)

P Value

69 (8) 26 (5)

72 (10) 22 (5)

0.242 0.001

26 (96) 1 (4)

34 (97) 1 (3)

1.0000

8 (30) 8 0 7 (5)

15 (43) 14 1 15 (15)

0.305

N/A N/A N/A

17 (48) 9 (26) 9 (26)

2 (7) 0 0 0 1 1 0 10 (37)

18 (51) 0 5 4 11 1 1 20 (59)

8 8 0 1 4 0 4 3

14 11 2 3 7 0 10 10

0.543

,0.001

0.124 0.435 1.00 0.500 0.626 0.742 0.235 0.122

Definition of abbreviations: BMI = body mass index; COPD = chronic obstructive pulmonary disease; HRT = hormone replacement therapy; N/A = not applicable; NTM = nontuberculous mycobacteria.

Danley, Kwait, Peterson, et al.: Low DHEA Levels in Patients with M. avium Complex

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ORIGINAL RESEARCH Table 2. Serum hormone levels Patients with Mycobacterium avium Complex (n = 35)

Control Subjects (n = 27)

Ultrasensitive estradiol, pg/ml Estrone, pg/ml DHEA-S, mg/dl

n

Mean (SD)

n

Mean (SD)

26 26 15

9 (8) 28 (17) 59 (22)

30 32 15

9 (9) 27 (13) 33 (20)

P Value*

0.364 0.665 0.001

Definition of abbreviation: DHEA-S = dehydroepiandrosterone-sulfate. *t Test on log-transformed biomarkers.

Information was collected on patient age, racial background, smoking history, past medical history, pulmonary disease history, and medications. Subjects were excluded if they were receiving hormone replacement therapy at the time of the study, if they had underlying severe chronic obstructive pulmonary disease (COPD), or if they had a history of malignancy. A total of 48 patients with M. avium complex lung infection were screened for the study, and 13 patients were excluded for the following reasons: current hormone therapy use (3), severe COPD (2), history of breast cancer (1), history of skin cancer (1), patient refused blood draw (2), age greater than 90 years (3), or patient not meeting the 2007 American Thoracic Society/ Infectious Disease Society of America criteria for M. avium complex infection (1). A total of 35 patients with M. avium complex infection were included in the final analysis. Female postmenopausal control subjects between the ages of 50 and 89 years with no known lung disease or history of cancer, and who were not receiving hormonal therapy, were selected from the general medical and gynecologic population of our institution. One hundred thirty-five control subjects were randomly screened. Of these, 108 were excluded for the following reasons: current hormone therapy use (48), premenopausal status (38), diagnosis of COPD (9), diagnosis of cancer (6), unable to provide blood sample (2), age less than 50 or greater than 89 years (5). A total of 27 control subjects were included in the final analysis.

of ultrasensitive estradiol, estrone, and DHEA-S levels. Because DHEA-S levels have been shown to be relatively stable throughout the day and are not subject to significant circadian variation, no attempt was made to perform blood draws at exactly the same time of day in all subjects, although all blood draws were performed in the morning hours (17, 18). The protocol and consent forms for this study were approved by the Main Line Health Institutional Review Board.

factor and BMI by treatment group. The relationship of BMI and hormones by group were initially assessed graphically. The plots of Estrone and DHEA-S suggested a potential interaction between BMI and group, which was then tested using linear regression modeling. These interaction terms were found to be nonsignificant for all three hormones, and BMI-adjusted geometric means produced from main effects models were reported.

Statistical Methods

Results

Summary statistics were calculated for study population characteristics by treatment group. Means and SDs were reported for continuous variables, and counts and frequencies were reported for categorical variables. t Tests were used to test for group differences between age and body mass index (BMI). Because of its nonnormal distribution, a Wilcoxon test was used to test for differences in average smoking pack-years. Fisher exact test was used for all categorical comparisons. Summary statistics (n, mean, and SD) were calculated for ultrasensitive estradiol, estrone, and DHEA-S. Because of the heavy skew in these factors, data were log-transformed before inferential analyses. Pearson product moment correlation coefficient was calculated between each log-transformed

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The study population consisted of female patients with pulmonary M. avium complex and control subjects of similar age with no statistical difference in age, race, medical comorbidities, or tobacco history between the groups (Table 1). The BMI of subjects with M. avium complex was significantly lower than that of control subjects (22 vs. 26, P = 0.001). Although the M. avium complex group had twice the number of average pack-years of smoking as the control group, this was not a significant difference. Patients with M. avium complex had a higher incidence of coexisting lung disease (51 vs. 7%, P , 0.001), with the majority reporting a history of pneumonia (Table 1). Because history was self-

Table 3. Correlations with body mass index by group Patients with Mycobacterium avium Complex

Control Subjects

Measurement of Serum Hormone Levels

After obtaining informed consent from patients with M. avium complex and control subjects, blood was drawn and sent to Quest Diagnostics for the measurement

Study Population

Ultrasensitive estradiol Estrone DHEA-S

n

R

P Value

n

R

P Value

26 26 15

0.296 0.330 20.180

0.143 0.100 0.521

30 32 15

0.266 0.346 0.328

0.155 0.053 0.233

Definition of abbreviation: DHEA-S = dehydroepiandrosterone-sulfate.


ORIGINAL RESEARCH reported, this may in fact not be an accurate reflection of clinical disease. Neither group had received hormone replacement therapy in the recent past, nor was there any statistical difference in prior hormone replacement therapy use between the two groups. Of the patients with M. avium complex, 48% were actively undergoing therapy for M. avium complex infection at the time of the study, 26% had undergone prior M. avium complex therapy, and 26% had never been treated for their M. avium complex infection. Serum Hormone Levels

Serum testing measured levels of ultrasensitive estradiol, estrone, and DHEAS. There was no significant difference in ultrasensitive estradiol or estrone levels between the M. avium complex and control groups (Table 2). DHEA-S levels, however, were 44% lower in the M. avium complex group as compared with the control group (59 vs. 33 mg/dl, P = 0.001). No Correlation between Hormone Levels and BMI

Within each group, there was no correlation demonstrated between ultrasensitive estradiol, estrone, or DHEA-S and BMI (Table 3). The correlation between estrone and BMI within the M. avium complex group was marginally significant, although not strongly correlated (R = 0.35, P = 0.053). Impact of BMI

Figures 1A–1C illustrate the relationships between BMI and hormones for M. avium complex and control groups. The relationship between BMI and ultrasensitive estradiol level appear nearly identical between the control and M. avium complex groups (Figure 1A). The relationships between BMI and estrone also appear fairly similar regarding group, although with a slight difference in slope. By contrast, the relationship between BMI and DHEA-S by group appears potentially quite different, with a positive relationship between BMI and DHEA-S in the M. avium complex group but a negative relationship in the control group. Linear regression models were run to test whether the BMI–hormone relationships were different by group; in all three cases these were found to be nonsignificant (P = 0.882, P = 0.691, and P = 0.142, respectively). It was noted that BMI can have an effect on hormone

Figure 1. Serum ultrasensitive estradiol, estrone, and dehydroepiandrosterone-sulfate (DHEA-S) as a function of body mass index (BMI) by group. (A) Relationship between BMI and log(ultrasensitive estradiol) by group; (B) relationship between BMI and log(estrone) by group; (C) relationship between BMI and log(DHEA-S) by group. Solid blue circles and solid blue line = patients with Mycobacterium avium complex (MAC); open orange squares and dashed orange line = control subjects.

expression, so linear regression models were used to produce BMI-adjusted hormone means by group (Table 4). As


with the unadjusted test of serum hormones (Table 2), there were no significant differences between M. avium 911

ORIGINAL RESEARCH Table 4. Geometric means of body mass index adjusted hormones by group

Ultrasensitive estradiol Estrone DHEA-S

Control Subjects, Geometric Mean (95% CI)

Patients with Mycobacterium avium Complex, Geometric Mean (95% CI)

P Value

5.44 (3.49, 8.47) 20.73 (16.52, 26.02) 53.47 (39.43, 72.49)

5.45 (3.61, 8.21) 26.38 (21.54, 32.31) 28.91 (21.32, 39.20)

0.9953 0.1352 0.0127

Definition of abbreviation: CI = confidence interval; DHEA-S = dehydroepiandrosterone-sulfate.

complex and control groups by ultrasensitive estradiol and estrone, but when adjusted for BMI, DHEA-S remained significantly higher in control group than in subjects with M. avium complex (54 vs. 29, P = 0.0127).

Discussion To date, there is an incomplete understanding of the mechanisms of susceptibility of middle-aged and elderly women without preexisting lung disease to pulmonary nontuberculous mycobacterial infection (i.e., why only a small percentage of individuals who are exposed to nontuberculous mycobacteria in the environment develop clinically apparent disease). One of the unanswered questions about pulmonary nontuberculous mycobacterial disease is why it occurs disproportionately in postmenopausal women as opposed to men. In men aged 65 to 75 years, the contribution of adrenal DHEA to the total androgen pool has been measured at 40%, with the remainder of their androgens being of testicular origin (19). Therefore, the comparable decrease in serum DHEA levels observed in both sexes with aging may be less significant in men who, on average, continue to receive a supply of testicular sex steroids throughout their lifetime. The low BMI status of the patients with nontuberculous mycobacterial disease in this study is consistent with the observations made by others (2–4, 20, 21). Because the phenotype of susceptible women appears to include postmenopausal status and thin body habitus (2–4, 20, 21), the hypothesis of a hormonal deficiency as a predisposing factor for pulmonary nontuberculous mycobacterial infection is compelling. This study is the first to examine levels of sex hormones in women with nontuberculous mycobacterial lung disease. 912

Subjects with M. avium complex were found to have significantly lower levels of DHEA sulfate compared with control subjects, and this finding was independent of age and BMI. What is unclear is whether low DHEA levels predispose women to pulmonary M. avium complex infection or whether chronic M. avium complex infection suppresses DHEA levels. Low DHEA levels in women as they age may predispose them to pulmonary M. avium complex infection through a blunted immune response to mycobacteria, or, alternatively, the mycobacterial infection may be suppressing DHEA levels. This question has been partially addressed by D’Attilio and colleagues (22), who reported that cells treated with supernatants from peripheral blood mononuclear cells of patients with tuberculosis had suppressed DHEA secretion. These peripheral blood mononuclear cells produced factors that inhibited DHEA production by adrenal cell lines, even in the absence of further mycobacterial stimulation. Bozza and colleagues (14) found that men with tuberculosis had decreased DHEA levels when compared with healthy control subjects. Those patients with the lowest DHEA activity were also noted to have the most severe disease. Lymphokine assays of peripheral blood mononuclear cells from these patients showed decreased production of IFN-g and suppressed lymphoproliferation in general. When the peripheral blood mononuclear cells were treated with DHEA, they showed significantly greater IFN-g production than untreated control subjects. Several studies have helped shed light on the role that DHEA-S plays in immune modulation. Hernandez-Pando and colleagues (8) showed the immunostimulatory effects of DHEA in an established BALB/c mouse model of M. tuberculosis infection. Mice with M. tuberculosis that were treated with DHEA favored a Th1 over a Th2 response with increased

production of IL-2, IL-1a, and tumor necrosis factor-a and decreased production of IL-4. Furthermore, mice in the treatment group had a tendency to form a more robust granulomatous response for a longer period of time. The control group developed significantly more pneumonic symptoms at an earlier stage and of greater severity than the DHEA-treated group. In another study, Suzuki et al (9) exposed T lymphocytes from healthy adults to DHEA and then stimulated the cells with mitogens or antigen. Activated CD41 T cells in the presence of DHEA produced a significantly greater amount of IL-2 than activated cells in the absence of hormone. Additionally, CD81 cells showed enhanced cytotoxicity when stimulated in the presence of DHEA-exposed CD41 cells. The increased production of IL-2 in the setting of DHEA appeared to preferentially promote a Th1, cell-mediated immune response (8–10, 12). An unexpected finding in our study was that women with M. avium complex lung disease did not have lower estradiol or estrone levels compared with control subjects, suggesting that estrogen itself may not be playing a significant role in immune function in pulmonary M. avium complex infection. A thin body habitus has been observed in a significant proportion of elderly women with pulmonary M. avium complex infection (4, 20). After menopause, most endogenous estrogen is produced by conversion of androstenedione, secreted by the adrenal cortex, to estrone by peripheral adipose tissue. A murine study by Tsuyuguchi and colleagues (7) suggested that estrogen may be protective against intrapulmonary M. avium complex infection. However, in this study, there was no correlation between BMI and estradiol or estrone levels in postmenopausal women, and estrogen levels in patients with M. avium complex were not significantly different from levels in similar-aged control subjects.


ORIGINAL RESEARCH There is no clear association in the literature between DHEA levels and obesity in human adults. Obese women have been reported to have normal DHEA levels (23). Obese children showed significantly increased DHEA-S levels compared with normal-weight children, yet these levels did not change when the children lost weight, suggesting a lack of association between DHEA and weight loss (24). In a randomized trial of postmenopausal women with low DHEA levels who were treated with DHEA supplementation for 2 years with subsequent restoration of DHEA levels to premenopausal levels, there was no difference in BMI, peak volume of oxygen consumed per minute, muscle strength, or insulin sensitivity after treatment (25). Therefore, the difference in BMI in our patients with M. avium complex and control patients was unlikely to be the reason for the lower DHEA levels in the patients with M. avium complex. Furthermore, in our correlation analysis, we found no relationship between BMI and DHEA levels in either patients with M. avium complex or control subjects. The small sample size was a weakness of this study; however, even with this small sample, a significant difference was found in DHEA levels between subjects with M. avium complex infection and control subjects. In addition, because DHEA

levels may be influenced by several other confounding conditions, this study is only able to report that individuals with M. avium complex infection have lower DHEA levels than similar-aged healthy control subjects but is unable to prove such an association. Of the 18 patients with M. avium complex who reported a history of underlying lung disease, the majority had received a prior diagnosis of asthma, bronchiectasis, or pneumonia. These are all common diagnoses in patients with M. avium complex infection, both because M. avium complex infection itself can lead to bronchiectasis, airflow obstruction, and recurrent pneumonias and also because patients are often misdiagnosed with these other entities before their diagnosis of M. avium complex infection. Further study of the role of DHEA as an immunoregulator should be pursued. Low DHEA levels may potentially serve as a marker for women who may be predisposed to developing pulmonary M. avium complex infection. Furthermore, suppression of DHEA levels in patients with active mycobacterial infection may further down-regulate their immune response to the infection through the mechanisms discussed above. In either case, DHEA should be considered for study as a potential alternative therapy or supplement to the current long-term antibiotic treatment regimens or as

References 1 Bodle EE, Cunningham JA, Della-Latta P, Schluger NW, Saiman L. Epidemiology of nontuberculous mycobacteria in patients without HIV infection, New York City. Emerg Infect Dis 2008;14: 390–396. 2 Chalermskulrat W, Gilbey JG, Donohue JF. Nontuberculous mycobacteria in women, young and old. Clin Chest Med 2002;23:675–686. 3 Prince DS, Peterson DD, Steiner RM, Gottlieb JE, Scott R, Israel HL, Figueroa WG, Fish JE. Infection with Mycobacterium avium complex in patients without predisposing conditions. N Engl J Med 1989;321: 863–868. 4 Kim RD, Greenberg DE, Ehrmantraut ME, Guide SV, Ding L, Shea Y, Brown MR, Chernick M, Steagall WK, Glasgow CG, et al. Pulmonary nontuberculous mycobacterial disease: prospective study of a distinct preexisting syndrome. Am J Respir Crit Care Med 2008; 178:1066–1074. 5 Bovenberg SA, van Uum SHM, Hermus ARMM. Dehydroepiandrosterone administration in humans: evidence based? Neth J Med 2005;63:300–304. 6 Buford TW, Willoughby DS. Impact of DHEA(S) and cortisol on immune function in aging: a brief review. Appl Physiol Nutr Metab 2008;33: 429–433. 7 Tsuyuguchi K, Suzuki K, Matsumoto H, Tanaka E, Amitani R, Kuze F. Effect of oestrogen on Mycobacterium avium complex pulmonary infection in mice. Clin Exp Immunol 2001;123:428–434.

a preventative strategy against disease recurrence. The current antibiotic regimens for pulmonary M. avium complex infection are difficult to tolerate and do not address the common clinical challenge of disease recurrence after the completion of a prolonged course of antibiotics. It is therefore of vital importance that the mechanism of disease susceptibility of these women be further elucidated. To our knowledge, this is the first clinical investigation of the levels of sex hormones in women with pulmonary M. avium complex infection. Although there are several pulmonary disorders hypothesized to be influenced by sex hormones, none have been directly tested in a clinical study such as this one. Our finding of a correlation between low DHEA levels and pulmonary M. avium complex infection could serve as an important and novel paradigm regarding hormonal effects on immune function and inflammation in the lung. n Author disclosures are available with the text of this article at www.atsjournals.org. Acknowledgment: The authors thank Olarae Giger, Ph.D., Director, Microbiology Laboratory, Lankenau Medical Center, for assistance in data collection and L. Greenspon, M.D., S. Gregory, M.D., T. Meyer, M.D., and C. Kuntz, M.D. for invaluable support and discussions.

8 Hernandez-Pando R, De La Luz Streber M, Orozco H, Arriaga K, Pavon L, Al-Nakhli SA, Rook GA. The effects of androstenediol and dehydroepiandrosterone on the course and cytokine profile of tuberculosis in BALB/c mice. Immunology 1998;95:234–241. 9 Suzuki T, Suzuki N, Daynes RA, Engleman EG. Dehydroepiandrosterone enhances IL2 production and cytotoxic effector function of human T cells. Clin Immunol Immunopathol 1991;61:202–211. 10 Angerami M, Suarez G, Pascutti MF, Salomon H, Bottasso O, Quiroga MF. Modulation of the phenotype and function of Mycobacterium tuberculosis-stimulated dendritic cells by adrenal steroids. Int Immunol 2013;25:405–411. 11 Santucci N, D’Attilio L, Kovalevski L, Bozza V, Besedovsky H, del Rey A, Bay ML, Bottasso O. A multifaceted analysis of immuneendocrine-metabolic alterations in patients with pulmonary tuberculosis. PLoS ONE 2011;6:e26363. 12 Daynes RA, Araneo BA, Dowell TA, Huang K, Dudley D. Regulation of murine lymphokine production in vivo. III. The lymphoid tissue microenvironment exerts regulatory influences over T helper cell function. J Exp Med 1990;171:979–996. 13 Shufelt C, Bretsky P, Almeida CM, Johnson BD, Shaw LJ, Azziz R, Braunstein GD, Pepine CJ, Bittner V, Vido DA, et al. DHEA-S levels and cardiovascular disease mortality in postmenopausal women: results from the National Institutes of Health—National Heart, Lung, and Blood Institute (NHLBI)-sponsored Women’s Ischemia Syndrome Evaluation (WISE). J Clin Endocrinol Metab 2010;95: 4985–4992.


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ORIGINAL RESEARCH 14 Bozza VV, D’Attilio L, Mahuad CV, Giri AA, del Rey A, Besedovsky H, Bottasso O, Bay ML. Altered cortisol/DHEA ratio in tuberculosis patients and its relationship with abnormalities in the mycobacterialdriven cytokine production by peripheral blood mononuclear cells. Scand J Immunol 2007;66:97–103. 15 Bottasso O, Bay ML, Besedovsky H, del Rey A. Immunoendocrine alterations during human tuberculosis as an integrated view of disease pathology. Neuroimmunomodulation 2009;16:68–77. 16 Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, Holland SM, Horsburgh R, Huitt G, Iademarco MF, et al.; ATS Mycobacterial Diseases Subcommittee; American Thoracic Society; Infectious Disease Society of America. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007;175:367–416. [Published erratum appears in Am J Respir Crit Care Med 175:744–745.] 17 Hucklebridge F, Hussain T, Evans P, Clow A. The diurnal patterns of the adrenal steroids cortisol and dehydroepiandrosterone (DHEA) in relation to awakening. Psychoneuroendocrinology 2005;30:51–57. 18 Ostrowska Z, Zwirska-Korczala K, Pardela M, Drozdz M, Kos-Kudla B, Buntner B. Circadian variations of androstenedione, dehydroepiandrosterone sulfate and free testosterone in obese women with menstrual disturbances. Endocr Regul 1998;32:169–176. 19 Labrie F. DHEA, important source of sex steroids in men and even more in women. Prog Brain Res 2010;182:97–148.

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20 Kartalija M, Ovrutsky AR, Bryan CL, Pott GB, Fantuzzi G, Thomas J, Strand MJ, Bai X, Ramamoorthy P, Rothman MS, et al. Patients with nontuberculous mycobacterial lung disease exhibit unique body and immune phenotypes. Am J Respir Crit Care Med 2013; 187:197–205. 21 Iseman MD. The Theodore E. Woodward Award. Mycobacterium avium and slender women: an unrequited affair. Trans Am Clin Climatol Assoc 1998;109:199–202, discussion 203–204. 22 D’Attilio L, Bozza VV, Santucci N, Bongiovanni B, D´ıdoli G, Radcliffe S, Besedovsky H, del Rey A, Bottasso O, Bay ML. TGF-b neutralization abrogates the inhibited DHEA production mediated by factors released from M. tuberculosis-stimulated PBMC. Ann N Y Acad Sci 2012;1262:1–9. 23 Zumoff B. Hormonal abnormalities in obesity. Acta Med Scand Suppl 1988;723:153–160. 24 Reinehr T, Kulle A, Wolters B, Lass N, Welzel M, Riepe F, Holterhus PM. Steroid hormone profiles in prepubertal obese children before and after weight loss. J Clin Endocrinol Metab 2013;98: E1022–E1030. 25 Nair KS, Rizza RA, O’Brien P, Dhatariya K, Short KR, Nehra A, Vittone JL, Klee GG, Basu A, Basu R, et al. DHEA in elderly women and DHEA or testosterone in elderly men. N Engl J Med 2006;355: 1647–1659.
