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Immunol Rev. Author manuscript; available in PMC 2018 November 01.
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Published in final edited form as:

Immunol Rev. 2017 November ; 280(1): 41–56. doi:10.1111/imr.12577.
ALARMINS AND IMMUNITY

De Yang*, Zhen Han, and Joost J. Oppenheim*
Cancer and Inflammation Program, Center for Cancer Research, National Cancer Institute at
Frederick, National Institutes of Health
SUMMARY
More than a decade has passed since the conceptualization of the ‘alarmin’ hypothesis. The
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alarmin family has been expanding in terms of both number and the concept. It has recently
become clear that alarmins play important roles as initiators and participarnts in a diverse range of
physiological and pathophysiological processes such as host defense, regulation of gene
expression, cellular homeostasis, wound healing, inflammation, allergy, autoimmunity, and
oncogenesis. Here we provide a general view on the participation of alarmins in the induction of
innate and adaptive immune responses, as well as their contribution to tumor immunity.
Keywords
Dendritic cells; Alarmin; Damage-associated molecular pattern; Immune response; and Tumor
immunity
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INTRODUCTION
Alarmins are endogenous, constitutively expressed, chemotactic and immune activating
proteins/peptides that are released as a result of degranulation, cell injury or death or in
response to immune induction. Alarmins function as intercellular signals defense by
interacting with chemotactic and pattern recognition receptors (PRRs) to galvanize immune
cells in host defense (1). Only when alarmins are released in excess by severe injuries and
maximal stimulation do they result in the dangerous effects of potentially lethal cytokine
storm. They have therefore also been considered damage-associated molecular patterns
(DAMPs) (2) and this term has been used interchangeably with alarmins. In 2001, Polly
Matzinger proposed that the immune system is geared to respond to DAMPs that resulted
from microbial attack with ensuing cell injury and death (3). DAMPs were very broadly
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defined to include both exogenous pathogen associated molecular patterns (PAMPs) such as
bacterial lipopolysaccharide (LPS), CpG oligodeoxynucleotide, and flagellin and deleterious
endogenous products of damaged and dead cells (3). However, we prefer to identify the
endogenous alarmins as a subset of endogenous DAMPs that interact with PRRs such as
*
Correspondence: Drs. De Yang (Phone: 301-846-6450; Fax: 301-846-7042; yangd@mail.nih.gov) and Joost J. Oppenheim (Phone:
301-846-1552; Fax: 301-846-7042; oppenheij@mail.nih.gov), Rm31-19/21-89, Bldg 560, 1050 Boyles Street, Frederick, MD
21702-1201, USA.
DR. JOOST J. OPPENHEIM (Orcid ID : 0000-0003-0271-7921)
CONFLICT OF INTEREST
The authors have no conflict of interest.
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Toll-like receptors (TLRs) as cytokine-like mediators that participate in host defense and are
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usually not dangerous.
How did we arrive at this alarmin concept? A serendipitous observation initiated this
research. In 1995 we performed a rather simplistic experiment to ensure that interleukin-8
(IL-8), an in vitro neutrophil chemoattractant, was also capable of attracting neutrophils in
vivo. As expected, we observed that upon subcutaneous injection of IL-8 mice developed an
acute inflammatory response characterized by neutrophilic infiltrates at 24 h. However, we
unexpectedly observed that the inflammatory site persisted and at 72 h, was infiltrated only
by mononuclear cells. We therefore hypothesized that neutrophils produced a
chemoattractant for the monocytes/macrophages and predicted it to be a chemokine such as
monocyte chemotactic peptide 1 (MCP-1/CCL2). Fortuitously our lab was joined at that
time for a summer sabbatical by Dr. Oleg Chertov, a Russian biochemist. We asked him to
determine the identity of the neutrophil derived attractant of mononuclear cells. He informed
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us several months later that it was a 1500 Dalton moiety. I informed him this was too small
to be a chemokine and therefore undoubtedly a contaminant. He countered that he had
performed the experiment three times and that the amino acid sequence of this small peptide
identified it as a defensin (4). I asked him “what is a defensin?” Defensins had initially been
identified in 1985 as “antimicrobial peptides” (AMPs) by Robert Lehrer and colleagues (5).
Our data thus indicated they also interacted with inflammatory cells of the host and we
reported our findings that these defensins mobilized cells engaged in host defense in several
papers (4, 6, 7) that were largely ignored until Dr. De Yang joined our laboratory and found
out that human β defensins interacted with the chemokine receptor CCR6 to induce the
migration of immature dendritic cells (DCs) (8). This observation upset the chemokine
research community because it “contaminated” their complicated network of chemokine-
receptor interactions even more. It also upset the microbiologists who were studying the
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natural antibiotic activities of AMPs and were afraid to be outnumbered by immunologists

preempting their studies on AMPs. Suffice it to state that neither discipline has suffered any
interference or decline in their activities based on these observations.
The discovery of defensins’ chemotactic activity was followed by the identification of the
DC-activating property of β defensins (9, 10). Subsequently, other granule-derived AMPs as
well as the now famous high-mobility group box-1 (HMGB1) were shown to have both
chemoattracting and activating effects on leukocytes including DCs and hence the capacity
to induce innate and adaptive immune responses (11–26). This led us in 2004 to propose
considering these endogenous moieties that can chemotactically mobilize and are also able
to activate the immune system as endogenous alarmins (1, 27). Since alarmins are all
constitutively expressed and rapidly released in response to infection and non-programmed
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cell death, they are available as “first responders” and by recruiting and activating leukocytes
including dendritic cells (DCs), alarmins can initiate both innate/inflammatory and adaptive
immune responses (28–34). Since then a plethora of additional host-derived molecules have
been called alarmins. The definition of alarmins has been broadened to include endogenous
moieties generated as a result of non-programmed cell death with the capacity to induce
innate/inflammatory and adaptive immune responses (31, 32, 35–38). Currently, alarmins
include a surprising number of chromatin-binding moieties in addition to HMGB1, such as

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HMGN1, IL-1α, and IL-33, as well as heat shock proteins (HSPs), S100 proteins, ATP, and
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uric acid crystals, which can be classified based on their origin (Table 1).
There are probably a number of alarmins that remain to be identified and little is as yet
known about the clinical role of already identified alarmins. One intriguing example of this
is our recent identification of α-synuclein as an alarmin (39). This protein is located in
vesicles at nerve ends and released in response to microbial invaders, especially in the region
of the gastrointestinal tract. Mutated variants of α-synuclein have been associated with early
onset of familial Parkinson’s disease. The relationship of the alarmin activity of α-synuclein
and how it may cause chronic long term inflammatory CNS damage needs to be clarified.
Alarmins have been shown to participate in diverse processes including antimicrobial

defense, regulation of gene expression, cellular homeostasis, wound healing, inflammation,
allergy, immunity, autoimmunity, and oncogenesis. Below, we will focus on the roles of
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alarmins in the induction of innate and adaptive immune responses in general, as well as
their contribution to tumor immunity.
CONTRIBUTION OF ALARMINS TO INNATE IMMUNE RESPONSES

The immune system relies on close collaboration of the innate and adaptive limbs to fend off
any dangers (i.e. infection and/or cell damage) to the host. In response to microbial infection
or sterile cell/tissue injury, alarmins/DAMPs are released and initiate innate/inflammatory
immune responses (1, 28, 29, 31). Innate immune responses involve the activation of
resident leukocytes [e.g. macrophages, DCs, mast cells (MCs), etc.], production of
inflammatory mediators (cytokines, chemokines, and lipid metabolites), recruitment of
neutrophils and monocytes/macrophages, and aims to eliminate invading microorganisms
and injured tissues (28, 29).
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Alarmins activate leukocytes

Mammalian α defensins induce degranulation and histamine release by MCs (40, 41).
Human β defensins, synthesized θ defensin, and cathelicidin/LL-37 also activate MCs
leading to degranulation and release of histamine and prostaglandin D2 (14, 42–44). Human
α defensin and cathelicidin/LL-37 activate monocytes/macrophages, resulting in the
production of IL-1, TNFα, IL-8, and CCL2 (15, 16). IL-1α and IL-33 activate MCs and
basophils to induce MC maturation and release of inflammatory mediators including TNFα,
IL-1β, and IL-4 (30, 45, 46). ATP promotes MC degranulation and production of
inflammatory cytokines, chemokines and leukotrienes (47, 48). Uric acid crystals activate
MCs for the production of nitride oxide, IL-1β, and IL-6 (49, 50). Overall, many alarmins
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have the capacity to trigger MCs (and basophils) to produce/release histamine,

prostaglandins, leukotrienes, proinflammatory chemokines and cytokines.
Defensins, cathelicidin, HMGB1 and HSPs have been shown to induce phagocytes
(neutrophils and monocytes/macrophages) to produce a variety of inflammatory mediators
including TNFα, IL-1β, IL-6, IL-8, CCL2, CCL3 and CCL4, leukotriene B4, and nitride
oxide (13, 17, 26, 33, 51–62). Granulysin, ATP, and several S100 proteins also activate
phagocytes to produce inflammatory mediators such as chemokines and cytokines (63–67).

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IL-1α and IL-33 promote the activation of phagocytes, resulting in distinct types of
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inflammatory responses (30, 34, 68–70). Inflammatory mediators produced by phagocytes in

response to various alarmins act collaboratively and orchestrate innate immune responses.
All alarmins identified so far have the capacity to activate DCs. Defensins activate
conventional as well as plasmacytoid DCs either generated from DC progenitors/precursors
in vitro or isolated from blood or skin (9, 10, 71–75). Cathelicidin/LL-37 promotes DC
activation alone or in complex with self or microbial nucleic acids (18, 61, 76–78). EDN
induces the maturation of human and mouse DCs (24, 79). Alarmins of nuclear origin (e.g.
HMGB1, HMGN1, IL-1α, etc.) activate human and mouse conventional (25, 30, 80–82) and
plasmacytoid (83, 84) DCs. HSPs and certain S100 proteins such as S100A8/A9 (also
known as calprotectin or Mrp8/14) have been shown to induce the maturation of bone
marrow-derived and monocyte-derived DCs (67, 85–90). ATP and uric acid crystal stimulate
DC maturation in vitro and in vivo (91–94). DC maturation/activation induced by all
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alarmins is characterized by upregulation of DC surface costimulatory (CD80 and CD86)

and MHC (class I and II) molecules, induction of production of proinflammatory
chemokines and cytokines such as TNFα, IL-1β, IL-6, IL-8, CCL5, IL-10, and IL-12, and
enhancement of the capacity to present antigens to lymphocytes resulting in the induction of
adaptive immune responses. Nevertheless, DC-derived cytokines and chemokines also
contribute to a pool of inflammatory mediators responsible for orchestrating innate immune
responses.
Alarmins participate in the activation of inflammasomes

While most alarmins promote the expression and production of inflammatory cytokines by
tissue resident leukocytes, IL-1β and IL-18, two of the IL-1 superfamily cytokines, are
produced in pro-forms and require cleavage by inflammasome-dependent activation of
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caspase 1 to become bioactive. Activation of caspase 1 requires the activation of several

inflammasomes in macrophages. Inflammasomes are cytosolic molecular complexes
assembled by NACHT, LRR and PYD domains-containing proteins (NLRP), apoptosis-
associated specklike protein (ASC), and caspase 1 (95). Activation of inflammasomes is
critical for innate/inflammatory responses and host defense. Interestingly, several alarmins
have been reported to contribute to the activation of inflammasomes, in particular NLRP3.
Uric acid crystal activates NLRP3 and caspase 1, resulting in the production of active IL-1β
and IL-18 (96). HMGB1 elevates NLRP3 expression to a critical level for inflammasome
formation (97). ATP is a well-known activator of NLRP3 inflammasome (94, 95, 98).
Recently, an α defensin human neutrophil-derived peptide 1 (HNP1) has also been reported
to promote NLRP3 inflammasome activation (52). Activation of NLRP3 inflammasome
causes not only the maturation of IL-1β and IL-18, but also promotes the release of HMGB1
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(95, 99), presumably forming a feedforward loop that amplifies innate immune responses.
Alarmins induce the recruitment of leukocytes

Alarmins chemoattract leukocytes—Recruitment of various leukocytes into danger
sites is an essential step in innate/inflammatory response (28, 29). Many alarmins are
chemotactic factors for diverse types of leukocytes. All vertebrate α- and β-defesnins tested
are chemotactic for immature DCs, neutrophils, monocytes/macrophages, and certain

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subsets of T cells (4, 8, 26, 32, 100–102). Human and mouse cathelicidins induce the
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migration of mast cells, neutrophils, and monocytes (12, 26, 44, 103, 104). EDN, HSPs,
granulysin, S100 proteins, and HMGN1 are chemotactic for immature neutrophils, mast
cells, monocytes, DCs, and NK cells (20, 32, 63, 82, 105–109). HMGB1 can induce the
migration of neutrophils, monocytes/macrophages and DCs (26, 110, 111). IL-33 is
chemotactic for neutrophils and Th2 lymphocytes (112–114). Uric acid can chemoattract
eosinophils (115) while ATP is chemotactic for many leukocytes (116). Given the
importance of chemotactic factors in the induction of leukocyte extravasation and infiltration
(117, 118), alarmins are definitively contributing directly to the infiltration of various
leukocytes into sites of infection or tissue injury. Indeed, it has been shown that many
alarmins induce the recruitment of granulocytes, macrophages, and DCs in vivo (32, 79, 82,
102, 119–122).
Alarmins indirectly promote the recruitment of leukocytes—Activation of various

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leukocytes by alarmins results in the production of many chemokines such as CXCL5,

CXCL7, CXCL8, CXCL9, CXCL10, CXCL12, CCL2, CCL3, CCL5, CCL7, CCL8, and
CCL20, which are well-established contributors to the recruitment of leukocytes during the
development of innate immune responses (117, 118, 123). Additionally, some alarmins also
upregulate the expression of adhesion molecules by endothelial cells and leukocytes, for
example, HMGB1 increases endothelial expression of ICAM-1, β1 and β2 integrins (124).
Human β 11efensing 2 has been shown to induce the arrest of Th17 cells on inflamed
endothelial cells in an ICAM-1-dependent manner (125). Additionally, S100A8/A9 reduces
neutrophil rolling and increase leukocyte adhesion by activating β2 integrin (126). Because
upregulation of adhesion molecules on endothelial cells and leukocytes is a prerequisite for
leukocyte extravasation and movement into sites of inflammation (118, 123, 127), alarmins
by upregulating the expression of adhesion molecules on endothelial cells also promote the
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recruitment and infiltration of leukocytes during innate immune responses.
The ultimate goal of innate/inflammatory immune response is to eliminate dangers, such as

invading microbes and/or damaged tissues. This is achieved through a wide range of
mediators that form complex networks involving host release of alarmins in response to
dangers, followed by activation of epithelial cells and leukocytes (MCs, macrophages, DCs,
etc) in local tissues to produce a plethora of inflammatory mediators such as vasoactive
amines and peptides, lipid metabolites (e.g. leukotrienes and prostaglandins), chemokines,
and cytokines, which in turn orchestrate the recruitment of leukocytes (e.g. neutrophils,
monocytes, and DCs) and activation of effectors (e.g. complement, phagocytes, etc) for the
removal or sequestration of the invading pathogens or injured tissues to allow the host to
restore functionality and homeostasis of the tissues. In this context, alarmins are critical as
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the warning signals reporting to the host the appearance of dangers by inducing the
recruitment and activation of various leukocytes that are crucial for the innate/inflammatory
responses. Many alarmins, such as defensins, cathelicidins, EDN, granulysin, and HMGB1
possess direct antimicrobial activities (26, 27, 128, 129) and therefore also contribute to
eliminating pathogens and shaping the host’s microbiota that, in turn, regulates immune
responses and influence infection and inflammatory disorders. One example is cathelicidin.
In patients with atopic dermatitis, a common Th-2 type inflammatory skin disorder, the lack

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of cathelicidin/LL-37 production due to suppression by high levels of IL-4 and IL-13 results
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in greatly reduced defense against vaccinia virus infection (130). Furthermore, it has
recently been found that mouse cathelicidin/CRAMP is produced by pancreatic β-cells in
response to certain short-chain fatty acids generated by gut microbiota, which modulates the
pancreatic inflammation associated with diabetes. Non-obese diabetic (NOD) mice, due to
deficiency in those short chain fatty acids, are defective in CRAMP production (131) and
CRAMP administration to NOD mice dampens the development of autoimmune diabetes in
NOD mice (131). Thus, alarmins in addition to networking with other endogenous host
defense molecules also interact with exogenous agents influencing our host defense.
ALARMIN-SENSING RECEPTORS AND SIGNAL TRANSDUCTION

PATHWAYS
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Many receptors are employed by alarmins to alert host’s immune system (Table 1). It has
become clear that many alarmins use more than one receptors and some receptors are used
by more than one alarmin. For examples, HMGB1 has been reported to use TLR2 (132),
TLR4 (132, 133), RAGE (56, 84, 133), and CXCR4 (121). TLR4 is used by many alarmins
(Table 1). Of particular note, certain alarmins interact with exogenous pathogen-associated
patterns (PAMPs) or endogenous mediators to form complexes that enable the activation of
additional receptors. In this regard, cathelicidin forms complexes with microbial or host
nucleic acids (RNA or DNA) that can trigger TLR7/8 (78) or TLR9 (77, 134), which are
implicated in the inflammatory responses of autoimmune disorders (lupus and psoriasis) and
atherosclerosis. β defensins have also been shown to form complexes with DNA, which
interacts with TLR9 to trigger the activation of plasmacytoid DCs (72). HMGB1 can also
bind to complexes of DNA and anti-DNA autoantibody to activate plasmacytoid DCs via
TLR9, which is thought to initiate/promote the autoimmune systemic lupus erythematosus
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(84). HMGB1, 2, and 3 bind with various nucleic acids in the cytosol and stimulate type I
IFNs and inflammatory cytokines through triggering of TLR3, TLR7, and TLR9, which has
been proposed as means for alarmins to sense viral infection (135). Thus, by binding to a
variety of endogenous or exogenous molecules, alarmins can interact with additional
receptors.
Signal transduction pathways for alarmin-induced leukocyte activation

Alarmins trigger PRRs, such as TLRs, receptor for glycation end-products (RAGE), P2X7,
and NLRP3, and members of the IL-1R family including IL-1R1 and ST2 for the activation
various leukocytes (Fig. 1). IL-1α and IL-33 act on IL-1R1 and ST2, respectively 4 (30, 45,
46). Defensins stimulate TLR4 on conventional DCs or TLR7/8/9 in plasmacytoid DCs for
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the induction of TNFα, IL-6, and IFN production via the activation of transcriptional factors
NF-κB, IRF3 and IRF7 (10, 72, 75). Cathelicidin activates neutrophils, macrophages, DCs,
and fibroblasts using TLR7,8, 9 (77, 78, 134) or P2X7 (55, 136, 137) for the induction of
inflammatory mediators like TNFα, IFNα, COX2, and PGE2. EDN activates conventional
DCs through triggering TLR2 and consequently the activation of NF-κB and multiple
MAPKs, leading to the production of inflammatory cytokines such as TNFα, IL-6, IL-8 (24,
79). Many alarmins act on TLR4 to induce the production of various inflammatory
mediators by macrophages or DCs, including β defensins (10), HSPs (62, 88, 89, 138),

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HMGN1 (82), granulysin (119), S100 A8/A9 (66, 126, 139), and HMGB1 (132, 133).
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Signal transduction through IL-1R1, ST2, and TLR2, TLR3, TLR4, TLR7, TLR8, TLR9,
and RAGE relies on distinct adaptor proteins including MyD88, TRIF, TIRAP, and TRAM
(30, 140, 141). Despite the complexity of receptor usage and distinct receptor-proximal
signaling effect, alarmins triggering TLRs, IL-1R1/ST2 and RAGE converge in the
activation of transcriptional factors such as NF-κB, IRFs, and AP-1, etc., which are
responsible for promoting the transcriptional expression of mediators including many
chemokines and cytokines (Fig. 1).
While most chemokines and cytokines are bioactive after translation and secretion, IL-1β
and IL-18 are produced in macrophages and DCs as pro-forms that require cleavage by
caspase 1 whose activation depends predominantly on the activation of NLRP3
inflammasome (30). The induction of the pro-forms of IL-1β and IL-18 can be promoted by
many mediators including alarmins/DAMPs, PAMPs, and cytokines (29, 30, 33, 67, 70, 95,
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142). The activation of NLRP3 inflammasome requires two steps: upregulation of

production and assembly (30, 95, 143). The first step is mediated primarily by TLR adaptor
MyD88- or cytokine-driven activation of NF-κB, which promotes the production of NLRP3
(95, 143, 144). Many alarmins can potentially contribute to this step, some of which has
recently been confirmed (97). The second step involves the assembly of NLRP3, ASC, and
pro-caspase 1 into a complex and autocatalytic cleavage of pro-caspase 1 into active caspase
1, which in turn catalyzes IL-1β; and IL-18 processing (30, 95, 143). Several alarmins are
shown to promote this step. ATP via P2X7 causes K+ efflux to promote NLRP3
inflammasome assembly and activation (95, 98, 145) and so do α 15efensing and
cathelicidin (52, 55, 136, 137). Uric acid crystals or even soluble uric acid upon entering
into macrophages causes lysosomal rupture to release proteases such as cathepsin B, which
promote the activation of NLRP3 inflammasome and hence the production of active IL-1β
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and IL-18 (95, 96, 146, 147). Thus, it has been determined that alarmins can provide the
necessary signals for the activation of NLRP3 inflammasome (Fig. 1).
Signal transduction pathways for alarmin-induced leukocyte migration

Leukocyte migration induced by most alarmins can be inhibited by pretreatment of the target
cells with pertussis toxin, a bacterial toxin capable of preventing G proteins from interacting
with GiPCRs on the cell membrane by catalyzing the ADP-ribosylation of the αi subunits of
the heterotrimeric G protein (8, 11, 12, 20, 63, 81, 100, 103, 104, 148). This indicates that
the direct chemotactic effects of many alarmins are mediated by GiPCRs (Fig. 1). β-
defensins use CCR6 (8, 9, 122, 149, 150) and CCR2 (151, 152) to induce the migration of
DCs and monocytes/macrophages. Human and mouse cathelicidins induce the migration of
leukocytes via FPRL1 or its mouse ortholog FPR2 (12, 104), however, human cathelicidin/
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LL-37 induces mast cell migration and degranulation through MrgX2, a GiPCR belonging to
Mas-related gene family (44). Recently, LL-37 has also been reported to induce neutrophil
migration via CXCR2 (153). ATP uses several GiPCRs for inducing the migration of various
target cells, such as P2Y2, P2Y6, and P2Y12 (116).
Receptors other than GiPCRs also participate in alarmin-induced leukocyte migration.

HMGB1-induced migration of neutrophils, monocytes, and DCs is dependent on the

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presence of RAGE (45, 81, 110, 111, 154). While S100A8- and S100A15-induced migration
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of neutrophils and macrophages is mediated by GiPCRs (108, 109), monocyte migration

induced by S100A7 is RAGE-dependent (108). IL-33-induced cell migration is mediated by
ST2 (112, 114).
Since many receptors mediating the chemotactic effects of alarmins are GiPCRs (e.g.
FPRL1, CCR2, CCR6, etc.) whose signaling pathways have been elucidated in some details
(32, 117, 155, 156), it is likely that alarmins trigger similar intracellular signaling pathways
to those of chemoattractants and chemokines (Fig. 1). Briefly, binding of an alarmin with its
GiPCR presumably result in the activation of heterotrimeric G-protein(s) that dissociate into
activated GαI and Gβγ subunits. Activated GαI and GβGγ trigger the activation of two
phospholipase C (PLC). PLCβ, through inducing the generation of diacylglycerol (DAG)
and elevation of cytoplasmic Ca2+, induces the activation of PKC. PLCγ on the other hand
activate PI3K and small GTPases (Rac and Rho), which, in turn, initiates a series of
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reactions that lead to the activation of Akt, ERKs, and LIM domain kinase (LIMK). Finally,
PKC, Akt, Erks, and LIMK act in concert to rearrange cytoskeleton fibers leading to cell
migration. Consistent with this scenario, cathelicidins have been shown to elevate
intracellular Ca2+ in neutrophils, monocytes, and mast cells (12, 103, 104, 157). In addition,
HMGB1-induced migration of glioblastoma cells depends on the activation of ERKs (158).
Defensin-induced cell migration is accompanied by the activation of PI3K-Akt signaling
pathway (159).
CONTRIBUTION OF ALARMINS TO ADAPTIVE IMMUNE RESPONSES

In addition to aiming for the elimination of dangers (microbes or dead/damaged cells), the
innate/inflammatory immune responses also initiate adaptive immune responses by
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promoting antigen uptake, processing, and presentation. This is achieved by the induction of
DC maturation/activation, an essential process for the induction of adaptive immune
response because DCs matured/activated in the peripheral tissues upregulate CCR7
expression that enables DCs to home to draining lymph nodes by interacting with CCL19/21
expressed on high endothelial venules (140, 160, 161). As discussed previously, all alarmins
can promote the maturation/activation of DCs and hence contribute this essential step. Upon
arrival in lymph nodes, matured/activated DCs induce antigen-specific activation, expansion,
and differentiation of naïve CD4+ and CD8+ T cells into helper CD4+ T (Th) and CD8+
cytotoxic lymphocyte (CTL) effector cells (162–164). Matured/activated DCs also pass
intact antigens to follicular DCs for the activation of antigen-specific B cells in the germinal
center, which is facilitated by activated Th cells (140, 161, 165, 166). Effectors (antibodies,
helper T cells, cytotoxic T cells, etc) generated as a result of adaptive immune responses
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work in collaboration with the effectors of the innate immune system including
granulocytes, macrophages, natural killer cells, and complement system to further promote
the elimination of invading pathogens, damaged tissues, or oncogenic cells and to
subsequently initiate tissue repair.
A second line of evidence supporting the capacity of alarmins to promote adaptive immunity
has been obtained by administering alarmins together with antigens to induce antigen-
specific immune responses. Intranasal co-administration of ovalbumin (OVA), an often used

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model antigen, and α-defensins enhances both humoral and cell-mediated OVA-specific
immune responses in mice (6, 26). For β-defensins, engineered expression of mouse β-
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defensin 2 in a mouse leukemia cell line confers immunogenicity on the cell line, leading to
the generation of protective immunity against the same tumor without the expression of
mouse β-defensin 2 upon implantation into syngeneic immunocompetent mice (167). The
generation protective immunity appears to be induced by activating DCs and relies on the
presence of both NK and CD8 T cells, establishing induction of tumor-specific adaptive
immune responses by β-defensin 2 (167). The capacity of β-defensins to induce adaptive
immune responses have also been corroborated by the fact that DNA vaccination of certain
β-defensins fused to a tumor or HIV antigen promoted the generation of antigen-specific
systemic and mucosal immune responses (9, 10, 168). Co-administration of OVA and
cathelicidin/mouse CRAMP induces the recruitment of monocytes and neutrophils via one
of the cathelicidin receptor FPR2 and promotes OVA-specific humoral and cell-mediated
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immune responses (104). Additionally, co-administration of OVA and HMGB1 (80), EDN
(79), and HMGN1(82) have all been shown to promote generation of OVA-specific
antibodies and cytokines derived from activated T cells, such as TNFα, IL-4, IL-5, IL-10,
IL-13, and IFNγ. Furthermore, it has also been shown that S100A8/A9 participates in the
development of autoreactive CD8+ effectors by signaling through TLR4 (139).
The third line of evidence demonstrating the important roles of alarmins in the development
of adaptive immune responses comes from studies using knockout cells or mice with
deletion of a given alarmin or its receptor. Necrotic fibroblasts induce inflammatory
responses and can activate macrophages and DCs, however, necrotic Hmgb1−/− fibroblasts
have significantly lower immunostimulating capacity, pointing to the essential role of
HMGB1 in the induction of immune responses (17, 80). The alarmin EDN uses TLR2 as its
receptor for the activation DCs as well as induction of immune responses (24, 79). The
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capacity of EDN to induce OVA-specific immune responses is greatly compromised in mice

with TLR2 deletion, demonstrating the importance of EDN for the induction of adaptive
immune response (79). Hmgn1−/− mice, in comparison with littermate-matched Hmgn1+/+
control, manifest remarkably reduced antigen-specific immune responses, establishing the
essential contribution of HMGN1 to the induction of adaptive immunity (82). It has recently
been shown that CRAMP promotes mouse DC maturation based on the use of FPR2 (169)
and the knockout of either FPR2 or CRAMP not only hamper the maturation of mouse DCs,
but also inhibits OVA-specific immune responses in a model of airway inflammation and
allergy, solidifying the notion that cathelicidin contributes to the induction of adaptive
immune responses (169, 170).
Not only do alarmins contribute to the induction of adaptive immune responses, it has
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gradually become clear that alarmins also participate in determining the types of adaptive
immune responses. Human α defensins promote both Th1 and Th2 types of immune
response when given together with antigens (6, 7). Cathelicidin also enhances both Th1 and
Th2 responses (104, 169, 170). HMGB1 is capable of inducing the generation of protective
antitumor immune responses (80), which is known to be dependent on the production of
IFNγ by Th1 cells and the generation of CTLs. Granulysin promotes OVA specific immune
responses with predominant elevation of IFNγ, but not IL-4 or IL-13, in a TLR4-dependent
manner (119). HMGN1 preferentially induces a Th1-polarized immune response, leading to

Yang et al. Page 10
the production of TNFα and IFNγ, but not IL-4, IL-5, or IL-13 (82). S100A8/A9 is also a
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Th1-promoting alarmin (139). A common property of all the alarmins capable of inducing
Th1-type immune responses is their use of TLR4 as a receptor for the activation of DCs to
generate IL-12 (25, 80, 82, 119), a cytokine critical for the polarization of Th1 response
(171). Therefore, HMGB1, HMGN1, S100A8/A9, and granulysin are Th1-polarizing
alarmins. In contrast, two alarmins including EDN and IL-33, have been shown to
preferentially promote Th2 type immune responses. EDN induces OVA-specific immune
responses characterized by the elevation of IL-4, IL-5, IL-6, IL-10, and IL-13, but not IFNγ,
typical of Th2-polarized immune response (79). Administration of IL-33 to mice induces, in
a ST2-dependent manner, elevation of serum IL-5, IL-33, and IgE, as well as eosinophilia
and splenomegaly, and airway inflammation, typical of Th2-polarized immune response
(172). IL-33 also promotes the production of TSLP another cytokine important for Th2
polarization, in an intestinal mematode infection model (173). IL-33 is crucial for
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upregulating IL-5 and IL-13 by Th2 cells by activating the transcription factor GATA3 (37,
174). Mice lacking either IL-33 or its receptor ST2 show diminished Th2 cytokine
production and reduced Th2-polarized immune responses (37, 174–176) Therefore, IL-33
participates in the polarization of Th2 response.
The contribution of various alarmins to the development of Th1 and Th2 dichotomy is likely
to be more complex. Recently, it has been shown that certain alarmins can also manifest
regulatory roles. Mice lacking the S100A8/A9 expression manifest more severe allergic
contact dermatitis in comparison with wild-type mice owing at least in part to accelerated
maturation of DCs, suggesting that S100A8/A9 has a regulatory function in adaptive
immunity (126). IL-33 is also reported to contribute to the clonal expansion of CTLs in a
model of viral infection (177). A number of alarmins including HMGB1 and IL-33 have also
been shown to promote wound repair, which apparently requires dampening of immune
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responses (30, 31, 37, 38, 174). Overall, alarmins play important roles in the development of
innate/inflammatory and adaptive immune responses.
Given the prominent roles of alarmins in innate/inflammatory and adaptive immune

responses, the availability, activity, and signaling of alarmins must be intricately regulated.
The best studied example is HMGB1. First, the activities of HMGB1 is regulated by redox
states. The reduced form is chemotactic (120), however, breakage of the intramolecular
disulfide bond between Cys23 and Cys45 or oxidation of the free thiol group of Cys106 to
sulfonate destroys its cell-activating activity (57, 120, 178). It should be mentioned that
HMGN1, in contrast, should not be subject to such redox regulation because it lacks Cys
residue. Consequently, HMGN1 is not inactivated at inflammatory sites. Second, HMGB1
can bind to CD24, which, through mobilizing Siglec-10 (Siglec-G in mice), counters
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HMGB1-induced DC activation through TLR4 (179). Third, the N-terminal domain of

thrombomodulin can bind to HMGB1 and thrombin to facilitate thrombin-mediated
degradation of HMGB1 (180, 181). Finally, T-cell immunoglobulin domain and mucin
domain 3 (TIM-3), a checkpoint inhibitor expressed on DCs in tumors, has been shown to
bind HMGB1, which functions to prevent HMGB1 from interacting with nucleic acids and
hence inhibiting the efficacy of antitumor DNA vaccines or chemotherapy (182). The
detailed mechanisms that negatively regulate the availability/activity of other alarmins
remain largely undetermined.

Yang et al. Page 11
ALARMINS AND TUMOR IMMUNITY

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Tumor formation is accompanied by leukocyte infiltration and innate/inflammatory

responses, which leads to either induction of antitumor immunity or promotion of tumor
progression and metastasis by fostering tumor growth and concomitant immunosuppression
(183). Given their diverse effects on leukocytes and immune system, alarmins can be
envisaged to play complex roles in cancer immunity (Table 2).
HMGN1
HMGN1 preferentially induces Th1-polarized immune responses (82) and has recently been
shown to promote the development of protective antitumor immunity (184, 185). EG7
mouse thymoma expressing ovalbumin (OVA) as a surrogate tumor-associated antigen
(TAA) was found to grow much faster in HMGN1-deficient mice than littermate-matched
controls (185). Additionally, HMGN1−/− mice exhibited a higher incidence of spontaneous
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formation of multiple malignant tumors than their HMGN1+/+ littermates (186).

Furthermore, EG7-bearing HMGN1−/− mice generated fewer OVA-specific CTLs than EG7-
bearing HMGN1+/+ mice, suggesting that HMGN1 contributed to the generation of tumor-
specific CTL response and anti-tumor immune protection, a conclusion supported by the fact
that HMGN1-expressing EG7 tumors grew more slowly than control EG7 tumors. HMGN1-
stimulated protective antitumor immunity relied on T cells because it was abolished by
depletion of CD4+ and CD8+ T cells. Mice DNA-vaccinated with a construct directing the
expression of HMGN1-gp100 fusion protein indeed induced gp100-specific immune
responses and resistant to challenge with mouse B16 melanoma, providing additional
support for the crucial role of HMGN1 in the generation of antitumor immunity (185).
HMGB1
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HMGB1 can also promote Th1-polarized immune response and has been implicated in anti-
tumor immune responses (80, 187, 188). HMGB1 enables the TLR4-dependent activation of
dendritic cells, which promotes antigen cross-presentation to CTLs favoring the
development of anticancer immune responses in mouse tumor models and human patients
(189). In addition, injection of a monoclonal neutralizing antibody specific for HMGB1
abolishes the immunogenicity of anthracycline-treated CT26 or EG7 cells in vivo (190).
However, recent studies suggest that HMGB1 can also promote tumor progression,
metastasis, and formation of immunosuppressive tumor microenvironment by promoting
inflammation (191, 192) or interacting with TIM-3 (182). Thus, HMGB1 acts as both a
tumor suppressor and an oncogenic factor in tumorigenesis and cancer therapy depending on
the context and the study conditions, as well as HMGB1 location and modification as
recently reviewed (193).
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Defensins
Human α defensins was shown a long time ago to enhance the antibody response as well as
immunoprotection to a syngeneic mouse B cell lymphoma, providing perhaps the earliest
hint that alarmin can promote antitumor immune responses (7). Upon delivery by DNA
vaccination in the form of defensin-TAA fusion, β defensin 2 and 3 promote antitumor
immunity toward multiple mouse B-cell lymphomas, in part, through targeting and

Yang et al. Page 12
activating DCs (9, 10). In addition, mice inoculated with a syngeneic leukemia engineered to
express mouse β-defensin 2 induces the generation of protective antitumor immunity
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dependent on NK and CD8 T cells (167). Therefore, defensins, at least the ones tested, have
the capacity to induce the generation of protective antitumor immune responses. However, it
has gradually been shown that a number of human cancers of squamous keratinocytes (e.g.
cervical, esophageal, salivary gland, head and neck carcinoma, colon, etc) show elevated
expression of β-defensin 2 and/or 3 (194–199). Both β-defensin 2 and 3 promotes tumor cell
proliferation and/or invasion (194, 197, 198). β-defensin 3 upregulation can be triggered by
either epidermal growth factor or human papillomavirus (199) and its promotion of tumor
cell proliferation involve the activation of NF-κB (198). In contrast, human β-defensin 1 has
been shown to inhibit the proliferation of several types of cancer cells (200, 201). There are
6 α defensins and more than 30 β-defensins in humans (202), and their contributions to
tumor immunity require further investigation.
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IL-1α
IL-1α, upon synthesis, translocates to the nucleus to function as a transcriptional factor to
regulate gene expression (30, 70, 142). IL-1α is known to inhibit the proliferation of many
cancer cells via regulating metabolism, cell cycle, and inducing apoptosis (30, 70, 203–205).
Overexpression of IL-1α on the surface of fibrosarcoma or lymphoma cells promotes their
destruction by inducing the generation of protective immunity and memory via promoting
the recruitment of macrophages, NK, and CD8+ T cells into the tumor tissues (70, 206). In
contrast, IL-1α has also been shown to promote oncogenesis of several types of tumors via
enhancing angiogenesis (207), tumor-associated chronic inflammatory response (208), and
keratinocyte transformation (209). The non-alarmin, IL-1β has been shown to have only
tumor promoting activity. IL-1α can either promote the generation of antitumor immunity or
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enhance tumor progression (34, 70).
IL-33
IL-33 is a nuclear alarmin that primarily induces Th2-polarized immune response, and
would be predicted to promote tumor progression by inducing Th2-polarized tumor
microenvironment. It seems fitting that IL-33 promotes tumorigenesis by recruiting MCs
(210) or enhancing the generation and function of MDSCs (211). IL-33 also facilitates
oncogenesis of several types of tumors through promoting epithelial cell proliferation (212,
213) and/or transformation (214, 215). Surprisingly, overexpression of IL-33 in 4T1 and
Lewis lung carcinoma cells promotes the generation of antitumor immunity depending on
the activation and recruitment of CTL and NK cells (216, 217). In addition, IL-33-ST2 axis
has antitumor effect on CT26 colon carcinoma since knockdown of ST2 promoted CT26
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growth in vivo (218). Furthermore, systemic administration of IL-33 inhibits the growth of
established mouse melanoma by promoting DC recruitment and activation in the tumor
tissues (219). Thus, IL-33 can ameliorate or promote tumor immunity depending on the
context.
HSPs
Induction of antitumor CTL responses requires TAAs to be transferred to DCs for cross-
presentation (220). HSPs such as HSP70, HSP90, gp96, and calreticulin are critical for TAA

Yang et al. Page 13
cross-presentation using CD91 as the receptor (220–223). In addition, purified HSPs

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stimulate DC maturation (86–90) and generation of Th1-polarized antitumor immunity (88,

90, 220, 224). Furthermore, it has recently been shown that exogenous HSP70 triggers the
secretion of endogenous HSP70 to tumor cell surface, which sensitizes cancer cells for CTL-
mediated killing (225). Therefore, HSPs are primarily alarmins that promote the generation
of protective antitumor immunity. In fact, autologous tumor-derived HSPs [e.g. HSP96-
peptide complex (HSPPC-96), HSPPC-70, etc) have been evaluated as tumor vaccines in a
variety of phase I-III trials over a wide range of cancers, with clinical benefit in some
melanoma patients (226).
ATP
ATP induces DC maturation (91, 92) and inflammasome activation (94, 95, 98) and
consequently promotes the generation of antitumor immunity (94). This is supported by a
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recent report showing that knockout of P2X7 in mice, the major receptor mediating the
effect of ATP on the activation of DCs and inflammasome (32, 92, 94, 95), reduces
antitumor immunity and accelerates the progression of B16 melanoma and CT26 colon
carcinoma (227). However, ATP upon release into extracellular space is rapidly converted
into adenosine, a well-established immunosuppressor (228–230) and oncogenic promoter
(230). Indeed, blockade of A2A, one the four adenosine receptors, or knockout of CD73, an
ecto-5′-nucleotidase critical for the conversion of ATP to adenosine, promotes antitumor
immunity based on IFNγ, NK cells, and CTLs, and inhibit oncogenesis, tumor growth, and
metastasis (231–233).
S100 proteins
S100A8/A9 induces apoptosis of diverse types of human and mouse tumor cell lines via
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Zn2+ chelation and induction of reactive oxygen species (234, 235). Together with its DC-
activating activity, S100A8/A9 may play a role in tumor immunity. However, S100A8/A9
promotes tumor growth by inhibit the differentiation of DCs and macrophages and enhance
MDSC production, recruitment and infiltration (236, 237). S100A9-deficient (also lacking
S100A8 expression) mice generates potent antitumor immune responses to reject implanted
tumors (237). S100A8/A9 produced by lung phagocytes in response to tumors promotes
MDSC recruitment by inducing serum amyloid protein A3, which facilitates metastasis of
Lewis lung carcinoma and B16 melanoma into the lung. Overall, S100 A8/A9 appear to
suppress the generation of antitumor immunity.
The roles of alarmins in tumor immunity are very complicated, primarily depending on their
receptor usage and effects on non-leukocytes and leukocytes. HMGB1 primarily promotes
the generation of antitumor immunity by signaling through TLR4 (189, 190), however, it
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predominantly promote tumor progression by interacting with RAGE (238) or TIM-3 (182).
For β defensins, they differentially regulate the proliferation of oral squamous cell
carcinoma and prostate cancer cells and therefore might function as proto-oncogene or as a
tumor suppressor in those tumors (239, 240). All alarmins participate in the initiation of
innate/inflammatory immune responses and their effects on cancer immunity depend largely
on the balance of inducing protective immune responses versus fostering
immunosuppression. Overall, alarmins preferentially promote Th1-polarized immune

Yang et al. Page 14
responses mediate antitumor immunity, whereas alarmins enhance the recruitment of

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immunosuppressive MDSCs or Tregs may contribute to tumor growth.
Given the critical roles of NK, CTL, and IFNγ in protective immunity against cancers, Th1-
polarizing alarmins (e.g. HMGB1, HMGN1, and HSPs, etc) are potentially good candidates
to be used for designing immunotherapies for cancers. Based on the critical roles of
HMGN1 in the development of protective antitumor immunity (184, 185), we further
investigated whether HMGN1 could be harnessed for the treatment of growing tumors in a
therapeutic vaccination approach. We have developed a therapeutic ‘cocktail’ (termed
‘TheraVac’) consisting of HMGN1, the TLR7/8 ligand R848, and an inhibitor of
immunosuppression (e.g. Cytoxan, anti-CTLA-4, or anti-PD-L1). HMGN1 and R848
synergized in activating DCs to produce IL-12 (Nie, et al., submitted). TheraVac cured a
number of large (≥1 cm in diameter) established tumors, namely CT26 (colon), Renca
(kidney), EG7 (thymoma), and Hepa1-6 (hepatoma) in mice. Treatment with TheraVac
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resulted in augmented infiltration of effector T cells into the tumor tissue (Han, et al., in
press and Nie, et al., submitted). The cured mice showed specific protective antitumor
immunity. This therapeutic regimen also caused migration of tumor-infiltrating dendritic
cells from tumors to home to draining lymph nodes (Nie, et al., submitted). Hepa1-6-bearing
mice treated with TheraVac, generated increased Hepa1-6-specific CTLs in the draining
lymph nodes and showed greatly upregulated expression of CXCL9, CXCL10, and IFN-γ
and elevated infiltration of T lymphocytes in tumor tissues (Han, et al., in press). The
successful use of HMGN1 in TheraVac to cure large tumors with the genearation of long-
term memory further solidify the idea that HMGN1 predominantly promotes the generation
of protective antitumor immunity.
CONCLUSIONS AND PERSPECTIVES

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Alarmins are multifunctional endogenous molecules that are sensed by host immune system
and contribute to host defense. Since they are constitutively available they are first reactors
to infectious and traumatic insults. Based on their chemotactic leukocyte-recruiting and DC-
activating capacities, they initiate not only innate but also adaptive immune responses. The
key ability of alarmins to activate DC to mature enables these cells to migrate and deliver
their antigenic contents to the T lymphocytes in draining lymph nodes resulting in the
adaptive immunity and T cell dependent long term immune memory. Since preformed
alarmins can be found bound to cell chromatin, in cell granules, vesicles, and even the
cytosol, any nucleated cell can be a source. Alarmins are released by dead and dying cells
and in response to a variety of inflammatory stimulants. Alarmins target not only
chemotactic GiPCR, but a variety of activating receptors expressed by many cell types.
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Thus, alarmins are ubiquitous warning signals.
As previously indicated we propose that numerous molecules with alarmin activities remain
to be identified. Some of them are well known markers/promulgators inflammation. One or
more of the classical proinflammatory “acute phase proteins” are probably alarmins. For
example, serum amyloid A (SAA) is chemotactic for dendritic cells and other leucocytes
(241) and also activates DCs (242), and can therefore be considered an alarmin. Similarly,
some components generated by the complement cascade such as C3a and C5a have both

Yang et al. Page 15
chemotactic (243) and activating (244) effects on leucocytes and are therefore likely to be
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alarmins. These considerations enable us to expand and redefine our view of some well-
known proinflammatory intercellular signals. These age-old alarmins together with our
identification of α-synuclein, a product of nerve cells, a novel alarmin conveys the message
that a broad array of molecules engages in this means of host defense. Of course one may
ask what can you do with this information? Hopefully, identification of the receptors and
downstream signal transducers of alarmins may lead to the identification of antagonistic
inhibitors and agonists, with the capacity to modulate alarmins and potential therapeutic
applicability.
Acknowledgments
This research was supported in part by the Intramural Research Program of NIH, Frederick National Lab, Center
for Cancer Research, Cancer and Inflammation Program. The content of this publication does not necessarily reflect
Author Manuscript
the views or policies of the Department of Health and Human Services, nor does mention of trade names,
commercial products, or organizations imply endorsement by the U.S. Government. The publisher or recipient
acknowledges right of the U.S. Government to retain a nonexclusive, royalty-free license in and to any copyright
covering the article.
The authors thank Ms. Sharon Livingstone for her excellent managerial assistance in preparing this manuscript.
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Yang et al. Page 28
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Figure 1.
Signaling pathways triggered by alarmins. Alarmins produced in response to danger (injury
or infection) engage primarily pattern-recognition receptors (PRRs) and Gαi protein-
coupled receptors (GiPCRs) for inducing leukocyte activation and recruitment, respectively.
Most alarmins triggers Toll-like recetpors, IL-1R1, ST2, or receptor for advanced glycation
endproducts (RAGE) for the activation of various transcription factors (TFs) such as NF-κB,
IFN-responsive factors (IRFs) that, after nuclear relocation, coordinately promote the
transcription of proinflammatory chemokines and cytokines including pro-IL-1β and pro-
IL-18. Some alarmins (e.g. uric acid) internalized as phagocytic vacuoles disrupt lysosome
upon fusion, leading to the release of proteases (e.g. cathepsin B) to promote the
oligomerization and assembly of NLRP3 inflammasome. Several alarmins (e.g. ATP,
Author Manuscript
cathelicidin, defensins) activate the purinergic receptor P2X7 to induce K+ efflux, which
also promotes the oligomerization and assembly of NLRP3 inflammasome. Oligomerization
and assembly of NLRP3 inflammasome trigger the cleavage of pro-caspase 1 into active
caspase 1 (CASP1) that are responsible for the maturation of IL-1β and IL-18. Most
alarmins also interact with GiPCRs (e.g. CCR6, CCR2, P2Ys, etc) to activate
phospholipases (PLCβ or PLCγ). PLCβ or PLCγ induce the activation of PI3K, the small
GTPases (Rac and Rho), Akt, Erks, LIMK, and PKC, which coordinately promote cell
migration.
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Yang et al. Page 29
Table 1
Major Categories, Receptors, and Biological Effects of Alarmins

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Origin Example Receptor Biological effects

Granule-derived Defensins (α, β) CCR2, CCR6, TLR4 Antimicrobial
Leukocyte recruitment
Cathelicidin (LL37/CRAMP) FPRL1, TLR7,8,9, P2X7, EGFR, MrgX2, CXCR2 DC and Mϕ activation
Promotion of immune responses
EDN TLR2
Granulysin TLR4
Nuclear HMGB1 CXCR4, RAGE, TLR2,4,9 Regulating gene transcription

HMGN1 TLR4 DC and Mϕ activation
IL-1α IL-1R
IL-33 ST2
Cytoplasmic HSP60,70,90,96 TLR2,4, CD91 Cell homeostasis

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S100 proteins RAGE, TLR4 DC and Mϕ activation

ATP P2Y2,6,12, P2X1,3,7
Uric acid P2X7
Abbreviations used in the table: CRAMP, cathelin-related antimicrobial peptide; EDN, eosinophil-derived neurotoxin; HMGB1, high-mobility
group box 1 protein; HMGN1, high-mobility group nucleosome-binding domain 1 protein; TLR, Toll-like receptor; CCR, CC chemokine receptor;
FPRL1, formyl peptide receptor-like 1; EGFR, epidermal growth factor receptor; MrgX2, Mas-related gene X2; CXCR, CXC chemokine receptor;
RAGE, receptor for advanced glycation end-products; Mϕ, macrophage.
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Yang et al. Page 30
Table 2
Effects of Alarmins on Tumor Immunity

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Alarmin Promotor of tumor immunity Inhibitor of tumor immunity

HMGN1 Th1 immune response HMGN1 knockout
Tumor-specific CTLs
Antitumor immune protection
HMGB1 Th1 immune response Angiogenesis
Tumor-specific CTLs Interacting with TIM-3
TAA cross-presentation Tumor relapse in Tlr4* patients
IL-1α Anti-proliferative Angiogenesis
Th1 immune response Tumor-associated inflammation
Tumor-specific CTLs Keratinocyte transformation
NK and CTL infiltration
IL-33 Antitumor immune response Th2 immune response
NK and CTL infiltration ST2 knockout
Tumor cell proliferation
MDSC generation & recruitment
Defensins Th1 immune response Tumor cell proliferation
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Tumor-specific CTLs Tumor-associated inflammation

NK and CTL infiltration
HSPs Th1 immune response
Tumor-specific CTLs
TAA cross-presentation
CTL-mediated killing
S100A8/A9 Tumor cell apoptosis DC and Mϕ differentiation
MDSC generation & recruitment
Tumor metastasis
S100A8 knockout
ATP Antitumor immune response Rapid conversion to adenosine
P2X7 knockout
Abbreviation used in the table: CTL, cytotoxic T lymphocyte; TAA, tumor-associated antigen; Tlr4*, mutated Tlr4 gene; TIM-3, T-cell
immunoglobulin and mucin-domain containing-3; MDSC, myeloid-derived suppressor cell; Mϕ, macrophage.
Author Manuscript
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ALARMINS AND IMMUNITY

usually not dangerous.

natural antibiotic activities of AMPs and were afraid to be outnumbered by immunologists

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

Alarmins have been shown to participate in diverse processes including antimicrobial

CONTRIBUTION OF ALARMINS TO INNATE IMMUNE RESPONSES

Alarmins activate leukocytes

have the capacity to trigger MCs (and basophils) to produce/release histamine,

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

inflammatory responses (30, 34, 68–70). Inflammatory mediators produced by phagocytes in

alarmins is characterized by upregulation of DC surface costimulatory (CD80 and CD86)

Alarmins participate in the activation of inflammasomes

caspase 1 to become bioactive. Activation of caspase 1 requires the activation of several

Alarmins induce the recruitment of leukocytes

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

Alarmins indirectly promote the recruitment of leukocytes—Activation of various

leukocytes by alarmins results in the production of many chemokines such as CXCL5,

recruitment and infiltration of leukocytes during innate immune responses.

The ultimate goal of innate/inflammatory immune response is to eliminate dangers, such as

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

ALARMIN-SENSING RECEPTORS AND SIGNAL TRANSDUCTION

Signal transduction pathways for alarmin-induced leukocyte activation

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

142). The activation of NLRP3 inflammasome requires two steps: upregulation of

Signal transduction pathways for alarmin-induced leukocyte migration

Receptors other than GiPCRs also participate in alarmin-induced leukocyte migration.

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

of neutrophils and macrophages is mediated by GiPCRs (108, 109), monocyte migration

CONTRIBUTION OF ALARMINS TO ADAPTIVE IMMUNE RESPONSES

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

capacity of EDN to induce OVA-specific immune responses is greatly compromised in mice

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

Given the prominent roles of alarmins in innate/inflammatory and adaptive immune

HMGB1-induced DC activation through TLR4 (179). Third, the N-terminal domain of

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

ALARMINS AND TUMOR IMMUNITY

Tumor formation is accompanied by leukocyte infiltration and innate/inflammatory

formation of multiple malignant tumors than their HMGN1+/+ littermates (186).

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

enhance tumor progression (34, 70).

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

cross-presentation using CD91 as the receptor (220–223). In addition, purified HSPs

stimulate DC maturation (86–90) and generation of Th1-polarized antitumor immunity (88,

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

responses mediate antitumor immunity, whereas alarmins enhance the recruitment of

immunosuppressive MDSCs or Tregs may contribute to tumor growth.

CONCLUSIONS AND PERSPECTIVES

Thus, alarmins are ubiquitous warning signals.

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

as T-cell chemoattractant proteins released from interleukin-8-stimulated neutrophils. J Biol Chem.

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Immunol Rev. Author manuscript; available in PMC 2018 November 01.

Immunol Rev. Author manuscript; available in PMC 2018 November 01.

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