A high prevalence of Kaposi's sarcoma (KS) is seen in diabetic patients. It is unknown if the physiological conditions of diabetes contribute to KS development. We found elevated levels of viral lytic gene expression when Kaposi's sarcoma-associated herpesvirus (KSHV)-infected cells were cultured in high-glucose medium. To demonstrate the association between high glucose levels and KSHV replication, we xenografted telomerase-immortalized human umbilical vein endothelial cells that are infected with KSHV (TIVE-KSHV cells) into hyperglycemic and normal nude mice. The injected cells expressed significantly higher levels of KSHV lytic genes in hyperglycemic mice than in normal mice. We further demonstrated that high glucose levels induced the production of hydrogen peroxide (H 2 O 2 ), which downregulated silent information regulator 1 (SIRT1), a class III histone deacetylase (HDAC), resulting in the epigenetic transactivation of KSHV lytic genes. These results suggest that high blood glucose levels in diabetic patients contribute to the development of KS by promoting KSHV lytic replication and infection.
IMPORTANCEMultiple epidemiological studies have reported a higher prevalence of classic KS in diabetic patients. By using both in vitro and in vivo models, we demonstrated an association between high glucose levels and KSHV lytic replication. High glucose levels induce oxidative stress and the production of H 2 O 2 , which mediates the reactivation of latent KSHV through multiple mechanisms. Our results provide the first experimental evidence and mechanistic support for the association of classic KS with diabetes. K aposi's sarcoma (KS) is a vascular neoplasia etiologically associated with Kaposi's sarcoma-associated herpesvirus (KSHV) infection (1). KSHV establishes a lifelong persistent latent infection following acute infection. Reactivation of the latent virus into productive lytic replication plays a pivotal role in the initiation and progression of KS, as viral load positively correlates with KS progression. Indeed, treatment of KS patients with antiherpesvirus drugs effectively leads to regression of KS tumors (2-6).Unlike iatrogenic or AIDS-associated KS, classic KS occurs predominantly in elderly men of Mediterranean or Jewish descent who have no apparent immune suppression (7). The exact cause of the development of classic KS remains undefined. Asthma, allergies in males, topical corticosteroid use, and infrequent bathing have been suggested to be risk factors for classic KS (8,9). Multiple studies have also documented a high prevalence of classic KS in patients with diabetes mellitus (10-13), a metabolic syndrome that manifests with elevated levels of blood glucose and episodic ketoacidosis, due to either a lack of insulin (type 1 diabetes) or cellular resistance to insulin (type 2 diabetes). High levels of KSHV DNA and seropositivity have been seen in diabetic patients (14-16). However, no study has ever determined if diabetes is the cause or an effect of KS and whether high glucose levels play ...