SHAPE Society

1. Toll-Like Receptor-4 Is Expressed by Macrophages in
Murine and Human Lipid-Rich Atherosclerotic Plaques and
Upregulated by Oxidized LDL
Xiaoou Helen Xu, MD; Prediman K. Shah, MD; Emmanuelle Faure, PhD; Ozlem Equils, MD;
Lisa Thomas, BS; Michael C. Fishbein, MD; Daniel Luthringer, MD; Xiao-Ping Xu, MD;
Tripathi B. Rajavashisth, PhD; Juliana Yano, BS; Sanjay Kaul, MD; Moshe Arditi, MD
Background—Inflammation is implicated in atherogenesis and plaque disruption. Toll-like receptor 2 (TLR-2) and TLR-4,
a human homologue of drosophila Toll, play an important role in the innate and inflammatory signaling responses to
microbial agents. To investigate a potential role of these receptors in atherosclerosis, we assessed the expression of
TLR-2 and TLR-4 in murine and human atherosclerotic plaques.
Methods and Results—Aortic root lesions of high-fat diet–fed apoE-deficient mice (nϭ5) and human coronary
atherosclerotic plaques (nϭ9) obtained at autopsy were examined for TLR-4 and TLR-2 expression by immunohisto-
chemistry. Aortic atherosclerotic lesions in all apoE-deficient mice expressed TLR-4, whereas aortic tissue obtained
from control C57BL/6J mice showed no TLR-4 expression. All 5 lipid-rich human plaques expressed TRL-4, whereas
the 4 fibrous plaques and 4 normal human arteries showed no or minimal expression. Serial sections and double
immunostaining showed TLR-4 colocalizing with macrophages both in murine atherosclerotic lesions and at the
shoulder region of human coronary artery plaques. In contrast to TLR-4, none of the plaques expressed TLR-2.
Furthermore, basal TLR-4 mRNA expression by human monocyte-derived macrophages was upregulated by ox-LDL
in vitro.
Conclusions—Our study demonstrates that TLR-4 is preferentially expressed by macrophages in murine and human
lipid-rich atherosclerotic lesions, where it may play a role to enhance and sustain the innate immune and inflammatory
responses. Moreover, upregulation of TLR-4 in macrophages by oxidized LDL suggests that TLR-4 may provide a
potential pathophysiological link between lipids and infection/inflammation and atherosclerosis. (Circulation. 2001;
104:3103-3108.)
Key Words: receptors Ⅲ inflammation Ⅲ cells Ⅲ atherosclerosis Ⅲ lipoproteins
Experimental work over the past decade has linked inflam-
mation to atherogenesis and plaque disruption.1–4 The
precise triggers for inflammation are not known but may
include modified lipoproteins and local or distant infections.2
A potential role for infection in the development of athero-
sclerosis has been considered for several decades, but interest
in this topic has recently reemerged because of several recent
observations. Accumulating evidence has implicated specific
infectious agents, including Chlamydia pneumoniae, in the
progression and/or destabilization of atherosclerosis.1–17
Recent studies suggest that chlamydia lipopolysaccharide
(LPS) induces foam-cell formation, whereas its heat-shock
protein (chlamydia HSP60) induces oxidative modification of
LDL.5,18 Chlamydia HSP60 has been implicated in the
induction of deleterious immune responses in human chla-
mydial infection and has been found to colocalize with
infiltrating macrophages in the atheroma lesions.19 Collec-
tively, these data support a potential role for C pneumoniae in
the development and progression of atherosclerosis and
suggest that this organism may indeed play an active role in
atheroma development. Available data, however, also under-
score the current lack of a complete understanding of the
molecular mechanisms that link C pneumoniae infection to
innate immunity and trigger the signals for enhanced inflam-
mation and atherogenesis.
LPS, a major component of the outer surface of Gram-
negative bacteria, activates the proinflammatory transcription
factor nuclear factor (NF)-␬B in endothelial cells and mac-
rophages.20,21 Recently, human Toll-like receptor-4 (TLR-4),
a human homologue of drosophila Toll, has been identified as
Received September 5, 2001; revision received October 11, 2001; accepted October 11, 2001.
From the Atherosclerosis Research Center, Burns and Allen Research Institute, Division of Cardiology (X.H.X., P.K.S., X.-P.X., T.B.R., J.Y., S.K.),
the Division of Pediatric Infectious Diseases, Steven Spielberg Pediatric Research Center (E.F., O.E., L.T., M.A.), the Department of Pathology, UCLA
School of Medicine (M.C.F.), and the Department of Pathology, Cedars-Sinai Medical Center (D.L.), Los Angeles, Calif.
Correspondence to Moshe Arditi, MD, Cedars-Sinai Medical Center, Division of Pediatric Infectious Diseases, 8700 Beverly Blvd, Room 4220, Los
Angeles, CA 90048. E-mail moshe.arditi@cshs.org
© 2001 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
3103

2. the signaling receptor for endotoxin22 as well as human and
chlamydial HSP60.23,24
Currently, more than 10 human TLRs have been identified,
and at least 10 human homologues of drosophila Toll have
been sequenced. Whereas TLR-4 is used by enteric Gram-
negative bacteria and LPS, TLR-2 is used by Gram-positive
bacterial, mycobacterial, fungal, and spirochetal cell-wall
components.25,26 TLRs are evolutionarily conserved innate
immune receptors that recognize pathogen-associated molec-
ular patterns and contain a common intracytoplasmic domain
that conveys signals by molecules that are shared by
interleukin-1 receptor signaling to activate the NF-␬B path-
way and release inflammatory cytokines.21,27 Because TLR-2
and TLR-4 play an important role in the innate immune and
inflammatory responses, we investigated the expression of
these receptors in murine aortic and human coronary athero-
sclerotic plaques. Here, we report preferential expression of
TLR-4 in lipid-rich and macrophage-infiltrated murine and
human atherosclerotic plaques. In vitro studies demonstrated
basal expression of TLR-4 by macrophages, which was
upregulated by oxidized LDL (ox-LDL). These findings
suggest a potential role for TLR-4 in lipid-mediated proin-
flammatory signaling in atherosclerosis. Because TLR-4 is
the receptor that recognizes chlamydial antigens such as
chlamydia LPS and HSP60, it may provide a potential
molecular link between chronic infection, inflammation, and
atherosclerosis.
Methods
Preparation of Mouse Tissue
Apolipoprotein E (apoE)–deficient mice (C57BL/6J strain, 5 weeks
old, 18 to 20 g) obtained from Jackson Laboratory (Bar Harbor, Me)
(nϭ5) were fed a high-fat, high-cholesterol (atherogenic) diet con-
taining 42% (wt/wt) fat and 0.15% cholesterol from 6 weeks of age
through the duration of the experiment. After anesthesia with
eflurane, the mice were euthanized at 26 weeks of age, and their
hearts and proximal aortas were excised and embedded in OCT
compound (Tissue-Tek), frozen on dry ice, and then stored at Ϫ70°C
until sectioning. Serial sections 10 ␮m thick were collected on slides
for immunohistochemistry as described earlier.28
Preparation of Human Tissue and Human
Monocyte-Derived Macrophages
Human coronary artery specimens from 9 autopsy cases were
collected within 24 hours of death, fixed with 10% formalin
overnight, and embedded in paraffin. Five of the 9 coronary artery
specimens included lipid-rich plaques containing a well-defined lipid
core covered by a fibrous cap, and the other 4 of the 9 specimens
included fibrous plaques, which contained mostly extracellular
matrix without a lipid core. Normal mammary artery specimens were
also obtained from 4 additional autopsy cases. Sections 5 ␮m thick
were cut and applied to slides for both hematoxylin-eosin and
immunohistochemical staining. Peripheral-blood monocytes were
isolated from whole blood of normal human subjects by Ficoll-Paque
density gradient centrifugation. Monocyte-derived macrophages
were cultured in RPMI 1640 containing 10% FCS, 100 U/mL
penicillin, 100 ␮g/mL streptomycin, and 0.25 ␮g/mL amphotericin
B for 5 days as described earlier.29
Immunohistochemistry
Frozen sections of the apoE-deficient mouse aortic root were fixed
with acetone for 5 minutes at room temperature and then immuno-
stained with rabbit anti–hTLR-4 immune serum (1:100, obtained
from Dr Ruslan Medzhitov, Yale University) according to the
instructions on Dako’s immunostaining kit. Rat anti–mouse macro-
phage antibodies (1:500, Serotec) were used as macrophage marker.
Colors were developed with the Dako AES substrate system. Smooth
muscle cells were stained by a mouse anti-actin antibody conjugated
with alkaline phosphatase (1:50, Sigma). Colors were developed
with a Vector Red Alkaline Phosphatase Substrate Kit I. Rabbit IgG
or rabbit serum was used as a negative control.
For human atherosclerotic plaques, after deparaffinization in
graded alcohol, sections were immunostained with rabbit anti–
human TLR-4 and TLR-2 antiserum (1:100) raised against extracel-
lular peptide domains of TLR-4 and TLR-2 as previously de-
scribed.21 Preincubation of the anti–TLR-4 antiserum with TLR-4
peptide (FKEIRHKLTLRNNFDLSLNVMKT) was used to demon-
strate specificity of the stain, and rabbit IgG or rabbit serum instead
of primary antibody was used as negative control.
Double Immunohistochemistry
Double immunostaining of human atherosclerotic plaques was per-
formed with Dako’s Doublestain System kit. After TLR-4 immuno-
staining, 3,3Ј-diaminobenzidine was used as the peroxidase chromo-
genic substrate. Mouse monoclonal anti–human CD68 antibody (360
␮g/mL, 1:20 dilution; Dako, Derma) for macrophages and mouse
monoclonal anti–human ␣-actin antibody (100 ␮g/mL, 1:100 dilu-
tion; Dako, Derma) for smooth muscle cells were used with fast red
as the alkaline phosphatase chromogenic substrate.
Preparation and Modification of Lipoproteins
Human native LDL (Sigma) was dialyzed against isotonic PBS (pH
7.4) to remove EDTA by use of Slide-A-Lyzer cassette 10 000
MWCO (Pierce). Ox-LDL was prepared as described previously.30
In brief, oxidation of LDL was performed by incubating 0.1 mg of
LDL protein/mL with 5 ␮mol/L CuSO4 for 24 hours at 37°C. All
reagents were endotoxin-free. LPS levels of LDL preparations were
confirmed with a chromogenic Limulus assay and contained Ͻ0.3 pg
of LPS/␮g LDL protein. The extent of oxidation of the lipoprotein
preparations was determined by the thiobarbituric acid–reactive
substance (TBARS) assay.31 The ox-LDL had 20 to 25 nmol/L
TBARS/mg cholesterol.
Reverse Transcription–Polymerase Chain Reaction
Total RNA was isolated from resting and native LDL–, ox-LDL–
stimulated human monocyte–derived macrophages with an RNA
Stat60 isolation reagent (Tel-test “B” Inc) according to the manu-
facturer’s instructions and treated with RNase-free DNase I. For the
reverse transcription (RT) reaction, the MMLV preamplification
system (Life Technologies, Inc) was applied. Polymerase chain
reaction (PCR) amplification was performed with Taq gold polymer-
ase (Perkin Elmer) for 32 cycles at 95°C for 45 seconds, 54°C for 45
seconds, and 72°C for 1 minute (for TLR-2 and TLR-4). The
oligonucleotide primers used for RT-PCR were TLR-2, 5Ј-
GCCAAAGTCTTGATTGATTGG and 5Ј-TTGAAGTTCTC-
CAGCTCCTG; for TLR-4, 5Ј-TGGATACGTTTCCTTATAAG and
5Ј-GAAATGGAGGCACCCCTTC-5Ј as described earlier.32
GAPDH primers were obtained from Clontech.
Results
TLR-4 Is Expressed in Atherosclerotic Lesions of
ApoE-Deficient Mice
In all 5 apoE-deficient mice, TLR-4 immunoreactivity was
observed in the aortic root atherosclerotic lesions, which
colocalized with macrophage immunoreactivity (Figure 1).
TLR-4 staining was absent in the normal vessels obtained
from control C56BL/6J mice. Mouse IgG staining was
negative, and preincubation of the tissue sections with the
specific peptide against which the anti–TLR-4 antiserum was
generated completely blocked the TLR-4 staining in the
apoE-deficient vessels, indicating the specific nature of the
3104 Circulation December 18/25, 2001

3. TLR-4 immunostaining. No TLR-2 immunoreactivity was
observed (data not shown) in normal or atherosclerotic
lesions.
TLR-4 Is Expressed in Human Coronary Plaques
The human coronary atherosclerotic plaques were classified
into lipid-rich plaques containing a well-defined lipid core
covered by a fibrous cap (nϭ5) and fibrous plaques that
contained mostly extracellular matrix without a lipid core
(nϭ4). Strong TLR-4 expression (brown staining) was ob-
served around the lipid core and at the shoulder of lipid-rich
plaques, where it colocalized with macrophage immunoreac-
tivity (Figure 2). Incubation of the antiserum with the peptide
used to generate the primary antibody blocked TLR-4 immu-
noreactivity, confirming the specificity of the anti–TLR-4
antiserum. Double staining showed close spatial colocaliza-
tion of TLR-4 expression with macrophage immunoreactivity
(Figure 2). No TLR-4 immunoreactivity or macrophage
immunoreactivity was found in fibrous plaques that demon-
strated strong smooth muscle ␣-actin immunoreactivity (Fig-
ure 2). Normal mammary arteries showed only minimal or no
TLR-4 expression (Figure 2). TLR-2 immunoreactivity was
absent in all plaques, whereas control staining was positive in
THP-1 cells (data not shown).
TLR-4 mRNA Regulation by Ox-LDL
Cultured human monocyte-derived macrophages were stim-
ulated with native LDL or ox-LDL for 5 hours, RT-PCR for
TLR-2 and TLR-4 was performed, and relative intensity was
calculated by densitometry as described earlier.32 RT-PCR
showed basal TLR-2 and TLR-4 mRNA expression by
macrophages. The TLR-4 mRNA was upregulated by ox-
LDL in a dose-dependent manner up to 3-fold, whereas native
LDL had no effect. TLR-2 mRNA was not upregulated by
ox-LDL (Figure 3).
Discussion
Although precise triggers for inflammation in atherosclerosis
are not fully understood, hypercholesterolemia, modified
lipoproteins, and infection with organisms such as C pneu-
moniae and others have all been implicated. There is now
evidence that C pneumoniae infection can accelerate the
Figure 1. TLR-4 immunoreactivity is seen
within atherosclerotic plaque, in lipid core
of plaque of aortic sinus of apoE-deficient
mouse (A). B and C, Immunoreactivity of
macrophages and smooth muscle cells,
respectively, in serial section of aortic
sinus. Note close spatial localization of
macrophage immunoreactivity and TLR-4
immunoreactivity. D, Rabbit IgG staining
for negative control. E, There is no immu-
noreactivity of TLR-4 in nonatherosclerotic
aortic sinus of C57BL/6J mouse.
Figure 2. Photomicrographs showing
immunohistochemical evidence for TLR-4
expression in human atherosclerotic lipid-
rich plaques but not in fibrous plaques. A,
Atherosclerotic plaque stained with rabbit
anti–human TLR-4 antiserum (brown stain-
ing); B, negative control where primary
antibody was replaced by rabbit IgG; C,
TLR-4 immunoreactivity (brown); D, double
immunostain with TLR-4 brown and mac-
rophages red to demonstrate colocaliza-
tion. E, F, and G, Higher-magnification
view of macrophage immunoreactivity
(red), TLR-4 immunoreactivity (brown), and
macrophage plus TLR-4 immunoreactivity
(red and brown), respectively. Fibrous
plaques showed no immunoreactivity for
TLR-4 (H) or macrophages (J) but showed
only smooth muscle cell ␣-actin immuno-
reactivity (red) without TLR-4 immunoreac-
tivity (brown) on double staining in I. K,
Negative control with preabsorption of
antiserum with peptide; L, normal mam-
mary artery showing only minimal immuno-
reactivity to TLR-4 along endothelial
border.
Xu et al TLR-4 and Atherosclerosis 3105

4. progression and facilitate the induction of atherosclerosis in
cholesterol-fed rabbits and genetically modified atheroscle-
rosis-prone mice.33–37 The concept of C pneumoniae–induced
atherogenesis is further strengthened by the finding that
antibiotic therapy against chlamydia prevents acceleration of
atherosclerosis in the rabbit model.33 Ingalls et al38 have
suggested LPS, and Kol et al39,40 have implicated HSP60, as
the triggers for chlamydia-induced inflammatory responses.
Both chlamydia infection41 and its LPS have been shown to
induce foam-cell formation in monocytes.18 Persistence of
LPS and/or HSP-60 in the atheroma either within intact C
pneumoniae–infected cells or in the subendothelial space
after cell lysis may promote atherosclerosis by continued
macrophage activation. Indeed, circulating chlamydial LPS–
specific immune complexes have been detected in patients
with coronary heart disease.42 To date, however, the precise
molecular mechanisms by which infections such as C pneu-
moniae contribute to the progression of atherosclerosis and
the links among lipids, microbial antigens, and innate im-
mune and inflammatory responses are not well understood.
Activation of monocytes/macrophages is an important
initial step in the cascades of events leading to many
inflammatory diseases, including atherosclerosis. The recent
findings that TLR-4 is the signaling LPS receptor and also
recognizes HSP60 provided a new impetus in elucidating the
role of TLR-4 in various inflammatory diseases. Furthermore,
a recent study showed that saturated fatty acids, but not
unsaturated fatty acids, induce NF-␬B activation and expres-
sion of cyclooxygenase-2 through the TLR-4 receptor as
well.43
In this study, we show for the first time that the proinflam-
matory signaling receptor TLR-4 is expressed in lipid-rich,
macrophage-infiltrated atherosclerotic lesions of mice and
humans and that TLR-4 mRNA in cultured macrophages is
upregulated by ox-LDL but not native LDL. Together, these
findings raise the possibility that enhanced TLR-4 expression
may play a role in inflammation in atherosclerosis, supporting
the emerging paradigm.1,44–46
Cells of the innate immune system, such as macrophages,
have the ability to recognize common and conserved struc-
tural components of microbial origin by pattern recognition
receptors. The human homologue of drosophila Toll, TLR-4,
is a pattern recognition receptor that activates NF-␬B and
upregulates a variety of inflammatory genes in response to
microbial pathogens.47 TLRs play a fundamental role in the
activation of innate immune responses and pathogen recog-
nition. Activation of NF-␬B is essential for the regulation of
a variety of genes involved in the inflammatory and prolif-
erative responses of cells critical to atherogenesis.48,49 Both
NF-␬B and genes regulated by NF-␬B are expressed in
atherosclerotic lesions.49 Because NF-␬B activation leads to
transcription of a number of proinflammatory genes involved
in atherothrombosis, it is tempting to speculate that infectious
agents and chlamydial antigens, such as LPS and/or HSP-60,
Figure 3. Cultured human monocyte-derived macrophages were stimulated with either native LDL or ox-LDL with different doses for 5
hours. Expression of TLR-2 (347 bp) and TLR-4 (548 bp) mRNA was analyzed by RT-PCR. RT-PCR analysis of GAPDH expression was
used as control. Graph shows relative intensity of each band (relative to GAPDH), which was measured by densitometry with Kodak ID
image analysis software (Kodak, EDAS 290). TLR-4 mRNA is upregulated by ox-LDL but not by native LDL, whereas neither native LDL
nor ox-LDL regulated TLR-2 mRNA.
3106 Circulation December 18/25, 2001

5. might contribute to enhanced and chronic inflammation by
signaling through the TLR-4 receptor, which is upregulated
by ox-LDL.
Our findings of increased expression of TLR-4 induced by
ox-LDL suggest a potential mechanism for the synergistic
effects of hypercholesterolemia and infection in acceleration
of atherosclerosis observed in experimental models35,36 and
human epidemiological observations.50 Thus, these findings
provide additional new insights into the link among lipids,
infection/inflammation, and atherosclerosis.
In summary, we observed that human TLR-4 but not
TLR-2 is expressed in murine and human lipid-rich athero-
sclerotic plaques, including areas infiltrated by macrophages.
Furthermore, we show that ox-LDL but not native LDL
induces upregulation of TLR-4 expression in macrophages.
Given that TLR-4 plays a critical role in inflammatory and
immune signaling, upregulated TLR-4 may participate in the
inflammatory responses linking lipids to chronic infection,
inflammation, and atherosclerosis. Improved understanding
of the molecular mechanisms driving TLR-4 overexpression
and signaling and the role of the resulting chronic inflamma-
tion during atherosclerosis may provide new targets for
antiatherogenic therapy.
Acknowledgment
This study was supported by NIH grants HL-51087 and AI-50699 to
Dr Arditi.
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