Environmental factors are the main contributors to type 1 diabetes (T1D) pathogenesis, yet they remain unidentified. Enteroviruses are proposed candidate triggers due to temporal correlations between infection and T1D autoimmunity and to detection of viral proteins in diseased islets. However, such correlations are not universal and may be relatively uncommon. Furthermore, evidence of a cause-effect relationship is lacking, as infection of non-obese diabetic mice with Coxsackie enteroviruses can either trigger or blunt disease. The proposed mechanisms are either non-antigen-specific (i.e. β-cell destruction and release of sequestered antigens, islet inflammation) or antigen-specific (i.e. epitope mimicry, by which immune responses to enteroviruses may be diverted against homologous β-cell antigens). The case for the latter mechanisms is even less stringent, as there is little evidence of promiscuous antigen recognition at the single T-cell level. Other infectious agents may thus be implicated. Demonstration of their role will require fulfilling the Koch's postulates, namely isolation of the agent preferentially in T1D patients, including before disease onset; and T1D induction when the agent is inoculated into mice. The same is needed for cross-reactive T cells to support epitope mimicry mechanisms. Generation of alternative (humanized) mouse models that could be challenged with candidate microbes is needed. Keywords: antigen, autoimmunity, enterovirus, epitope, NOD mouse, T cells
Date submitted 22 March 2013; date of final acceptance 22 May 2013
The Role of Environmental Factors in Type 1 Diabetes PathogenesisType 1 diabetes (T1D) is a multifactorial disease in which environmental triggers act on a genetic background of predisposition to engender islet autoimmunity, leading to β-cell destruction and insulin dependency. What is the relative role of genetic and environmental factors in T1D pathogenesis? Several lines of evidence converge to support the predominant role of the latter [1]. First, a dealt of susceptible alleles have been identified at different genetic loci. While three of them, namely alleles at the DQB1, INS variable number of tandem repeats (VNTR) and PTPN22 loci carry disease odds ratios >2, all the other predisposing alleles identified confer a more modest risk. Even the DQ2 and/or DQ8 haplotypes which are more strongly associated with T1D are found in a large (∼75%) proportion of T1D patients, yet also in healthy individuals. Second, the T1D concordance between monozygotic twin pairs in which one sibling is affected is rather incomplete (∼30-65%) [2,3]. Third, migrant studies document that T1D incidence adapts to that of the hosting region rather than to that of origin [4]. Fourth, comparison between regions with the same genetic background and different environmental exposures shows largely discordant T1D prevalence. One paradigmatic example is given by urbanized Finland and the nearby rural Russian Republic of Karelia, which host genetically similar human populations, yet display a ∼sixfold ...