AsthMatic Inflammation and Neurocircuitry Activation (MINA)

Asthma is characterized by airway inflammation, bronchial hyperresponsiveness and airflow
obstruction. The development of symptoms in patients with asthma is initiated by exposure to
a variety of airborne substances including aeroallergens. The inhalation of these allergens
by asthmatic subjects initiates a series of complex, interactive immune events through
activation of cell bound IgE, which serve to further existing airway inflammation, intensify
underlying airway hyperresponsiveness and cause airflow obstruction. Although the immune
events and processes associated with these reactions are largely localized to the airways
themselves, a variety of other factors can contribute to the ongoing allergic response in
either an enhancing or inhibitory manner. The regulation and modulation of these inflammatory
actions is a key determinant to the eventual severity of asthma.

The initial step in the activation of the allergic airway response is the ability of inhaled
allergen to activate IgE molecules on the pulmonary mast cell to release stored mediators and
generate synthesis of new products, which can acutely contract airway smooth muscle. The mast
cell also is capable of generating a variety of cytokines, which, in turn, can cause
persistence and progression of the allergic response by furthering the underlying
inflammation. In addition to mast cell activation, inhaled allergens are capable of
stimulating resident lymphocytes in the lung. It is proposed that these allergen-responsive
lymphocytes belong to a subpopulation of T helper cells (Th2), which are capable of
generating a variety of cytokines, i.e. interleukin (IL)-4, IL-5, and IL-13. These Th2
cytokines can activate the local inflammatory response and can also serve to initiate events
outside the lung, which can then further promote the persistence of the allergic inflammatory
response.

To illustrate the means by which newly generated lung mediators can affect allergic
inflammation, investigators have shown that inhaled allergen is associated with enhanced bone
marrow generation of eosinophils. This enhanced bone marrow production of eosinophils is
associated with bone marrow cell generation of IL-5, which causes terminal differentiation of
eosinophils and their release into the circulation. Presumably, these recently generated
eosinophils enter the circulation and are recruited to the lung where they may further the
development of eosinophilic inflammation and the severity of asthma.

Other factors also influence the development and intensity of the allergic inflammatory
response to inhaled allergen. In preliminary studies, the investigators have found that the
stress associated with the final examination period in college students will enhance the
eosinophilic inflammatory response to inhaled allergen. In addition, the investigators have
found that during the final examination period, and independent of an allergen challenge,
circulating eosinophils increase. Moreover, Marin and colleagues (2009) studied children with
asthma over a two-year period and found that mononuclear cells from children who reported
persistent life stress coupled with an acute stressful event produced elevated levels of
asthma-promoting cytokines compared to asthmatic children without chronic stress or healthy
controls. These findings suggest that the persistent stress associated with an acute stressor
may promote allergic inflammatory events and that these processes include regulation of
eosinophil numbers and recruitment to the lung.

From these studies, the investigators have evidence to suggest that stress-related events can
influence allergic inflammation and, presumably, that these peripheral responses are
regulated by central nervous system (CNS) events. Although stress-related events can modulate
inflammatory processes, the mechanisms and CNS-site of this activity are poorly understood.
It is proposed that areas of the brain are activated by stress and that these areas of
activation may represent sites in the CNS that integrate information concerning the internal
state of the body and signal the generation of modulating factors in the enhancement or
inhibition of the allergic airway inflammation. To visualize these potential sites of CNS
activation in asthma, it is possible to use neuroimaging techniques, such as positron
emission tomography (PET) or functional magnetic resonance imaging (fMRI). The investigators
have completed two prior studies that used fMRI to evaluate the central mechanisms associated
with allergic inflammation, and in both studies, the anterior insula was identified as a
region activated by asthma-related emotional cues that predicted the subsequent development
of airway inflammation (e.g. Rosenkranz, M et al (2005) Proceedings of the National Academy
of Science 102, 13319-13324.). In addition, the investigators have completed a study using
PET to evaluate the neural mechanisms through which stress along contributes to
asthma-related inflammation in individuals with high and low levels of chronic stress. This
study corroborated our findings using fMRI, showing involvement of the insula, and also
revealed new mechanisms involving IL-1β/IL-17 as a potential pathway linking through which
stress-reactivity primes airway inflammation.

In the research described here, these two experimental paradigms will be merged to 1)
determine the contribution of the IL-1β/IL-17 pathway in response of emotion neural circuitry
provoked by airway inflammation in the absence of bronchoconstriction and 2) to determine the
neural mechanisms and impact of acute stress on the airway inflammatory response to whole
lung allergen challenge.

Inclusion Criteria:

- Male or female with no health concerns that might affect the outcome of the study,

- Physician diagnosis of asthma for at least six months prior to screening,

- FEV1 > or equal to 70% at baseline AND 12% reversibility OR PC20 response to
methacholine < or equal to 16.0 mg/ml.

- Skin test positive to house dust mite (D. farinae), short ragweed or cat hair

- Asthma medications consisting of only inhaled short-acting B-agonist taken as needed,

- At least a 20% decrease in FEV1 during the immediate response following inhaled
antigen challenge (historical data up to 5 years old will satisfy this criteria),

- Safety laboratory assessments within normal ranges (labs to include CBC with
differential, PT, PTT and platelet count),

- Women of child-bearing potential (WCBP) must have a negative urine pregnancy test
(urine HCG) within 48 hours of the methacholine challenge, within 48 hours of the
inhaled allergen challenge and on the day of the segmental allergen challenge, as well
as fMRI and PET scans. WCBP must agree to use a reliable method of birth control for
the duration of the study (reliable methods of birth control can include abstinence,
barrier methods, oral contraceptives, injection contraceptives or skin absorption
contraceptives).

- In the opinion of the investigator, capable and willing to grant written informed
consent and cooperate with study procedures and requirements.

- Ability to tolerate a simulated fMRI and PET brain scanning session, and

- Ability to give valid informed consent to participate by signing and dating a written
consent form.

Exclusion Criteria:

- Psychotropic medication use that might affect function of neurocircuitry implicated in
our hypotheses (at the discretion of the PI),

- Needle phobia or claustrophobia,

- Unable to distinguish colors used in Stroop task,

- Night shift work,

- Major health problems such as autoimmune disease, heart disease, type I and II
diabetes, uncontrolled hypertension or lung diseases other than asthma. The listed
health problems are definitive exclusion but decisions regarding major health problems
not listed will be based upon the judgment of the investigator,

- History of a diagnosed Bipolar Disorder, Schizophrenia, or Schizoaffective Disorder,

- History of serious head trauma or seizure disorder (can be included at the discretion
of the PI),

- No pre-existing chronic infectious disease,

- Any condition for which, in the opinion of the investigator, transient oxyhemoglobin
desaturation is inadvisable,

- Pregnant or lactating females or has a planned pregnancy during the course of the
study,

- Medication other than for asthma, allergies or contraception (at the discretion of the
PI),

- Inhaled corticosteroids or oral corticosteroids within 1 month of screening,

- Upper or lower respiratory infection within 1 month of screening,

- Unstable asthma as indicated by self-report of increased symptoms or increased
beta-agonist use over the 2 weeks preceding the screening visit,

- Currently receiving immunotherapy,

- Current smokers (defined as smoked within the last year) or a former smoker with a
history of >5 pack years,

- Obesity as defined by a Body Mass Index (BMI) >35 or at the discretion of the
principal investigator or co-investigator. Subjects with a BMI between 30 and 35 will
be evaluated on a case by case basis by the PI or Co-I to determine eligibility.

- Use of an investigational drug within 30 days of entering the study. This criteria
will be reviewed on a case by case basis by the principal investigator or
co-investigator to determine appropriate washout period. Appropriate wash out period
may be greater than 30 days depending on the half-life of the investigational drug,

- History of noncompliance with medical regiments or subjects who are considered
unreliable including those with a psychiatric history that, in the opinion of the
investigator, may interfere with the conduct of study procedures.