title: A role for muscarinic receptors in neutrophil extracellular trap formation and levamisole-induced autoimmunity.
abstract: Levamisole, an anthelmintic drug with cholinergic properties, has been implicated in cases of drug-induced vasculitis when added to cocaine for profit purposes. Neutrophil extracellular trap (NET) formation is a cell death mechanism characterized by extrusion of chromatin decorated with granule proteins. Aberrant NET formation and degradation have been implicated in idiopathic autoimmune diseases that share features with levamisole-induced autoimmunity as well as in drug-induced autoimmunity. This study's objective was to determine how levamisole modulates neutrophil biology and its putative effects on the vasculature. Murine and human neutrophils exposed to levamisole demonstrated enhanced NET formation through engagement of muscarinic subtype 3 receptor. Levamisole-induced NETosis required activation of Akt and the RAF/MEK/ERK pathway, ROS induction through the nicotinamide adenine dinucleotide phosphate oxidase, and peptidylarginine deiminase activation. Sera from two cohorts of patients actively using levamisole-adulterated cocaine displayed autoantibodies against NET components. Cutaneous biopsy material obtained from individuals exposed to levamisole suggests that neutrophils produce NETs in areas of vasculitic inflammation and thrombosis. NETs generated by levamisole were toxic to endothelial cells and impaired endothelium-dependent vasorelaxation. Stimulation of muscarinic receptors on neutrophils by cholinergic agonists may contribute to the pathophysiology observed in drug-induced autoimmunity through the induction of inflammatory responses and neutrophil-induced vascular damage.
authors.affiliation: Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), and.
authors.forename: Carmelo
authors.initials: C
authors.lastname: Carmona-Rivera
authors.affiliation: Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), and.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Purmalek
authors.affiliation: Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), and.
authors.forename: Erica
authors.initials: E
authors.lastname: Moore
authors.affiliation: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA.
authors.forename: Meryl
authors.initials: M
authors.lastname: Waldman
authors.affiliation: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Walter
authors.affiliation: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA.
authors.forename: H Martin
authors.initials: HM
authors.lastname: Garraffo
authors.affiliation: National Institute on Drug Abuse (NIDA), National Institutes of Health, Baltimore, Maryland, USA.
authors.forename: Karran A
authors.initials: KA
authors.lastname: Phillips
authors.affiliation: National Institute on Drug Abuse (NIDA), National Institutes of Health, Baltimore, Maryland, USA.
authors.forename: Kenzie L
authors.initials: KL
authors.lastname: Preston
authors.affiliation: Division of Rheumatology, UCSF, San Francisco, California, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Graf
authors.affiliation: Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), and.
authors.forename: Mariana J
authors.initials: MJ
authors.lastname: Kaplan
authors.affiliation: Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), and.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Grayson
mesh_terms: D000818:Animals; D001323:Autoantibodies / Q000378:metabolism; D015551:Autoimmunity; D002478:Cells, Cultured; D003042:Cocaine / Q000009:adverse effects* / Q000494:pharmacology*; D004340:Drug Contamination; D065206:Extracellular Traps; D006801:Humans; D007978:Levamisole / Q000009:adverse effects*; D051379:Mice; D009504:Neutrophils / Q000187:drug effects* / Q000378:metabolism; D000076342:Protein-Arginine Deiminases / Q000378:metabolism; D017382:Reactive Oxygen Species / Q000378:metabolism; D043587:Receptor, Muscarinic M3 / Q000378:metabolism*; D015398:Signal Transduction
chemical_list: D001323:Autoantibodies; D017382:Reactive Oxygen Species; D043587:Receptor, Muscarinic M3; D007978:Levamisole; D000076342:Protein-Arginine Deiminases; D003042:Cocaine