The immunomodulatory effect of green tea (Camellia sinensis) leaves extract on immunocompromised Wistar rats infected by Candida albicans

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1 Veterinry World, EISSN: Avilble t RESEARCH ARTICLE Open Access The immunomodultory effect of green te (Cmelli sinensis) leves extrct on immunocompromised Wistr rts infected by Cndid lbicns Retno P. Rhyu 1, Remit A. Prsetyo 2, Djoko A. Purwnto 3, Utri Kresnodi 4, Regin P. D. Iskndr 5 nd Muhmmd Rubinto 6 1. Deprtment of Orl nd Mxillofcil Pthology, Fculty of Dentl Medicine, Universits Airlngg, Surby, Indonesi; 2. Instlltion of Orl nd Dentl Helth, Dr. Soetomo Hospitl, Surby, Indonesi; 3. Deprtment of Phrmceuticl Chemistry, Fculty of Phrmcy, Universits Airlngg, Surby, Indonesi; 4. Deprtment of Prosthodontics, Fculty of Dentl Medicine, Universits Airlngg, Surby, Indonesi; 5. Student of Immunology, Postgrdute School, Universits Airlngg, Surby, Indonesi; 6.Deprtment of Periodontics, Fculty of Dentl Medicine, Universits Airlngg, Surby, Indonesi. Corresponding uthor: Retno P. Rhyu, e-mil: -retno-p-r@fkg.unir.c.id Co-uthors: RAP: mitprsetyo@gmil.com, DAP: djokogus@ff.unir.c.id, UK: utri-k@fkg.unir.c.id, MR: rubinto@fkg.unir.c.id, RPDI: regin_pdewi@hotmil.com Received: , Accepted: , Published online: doi: /vetworld How to cite this rticle: Rhyu RP, Prsetyo RA, Purwnto DA, Kresnodi U, Iskndr RPD, Rubinto M (2018) The immunomodultory effect of green te (Cmelli sinensis) leves extrct on immunocompromised Wistr rts infected by Cndid lbicns, Veterinry World, 11(6): Abstrct Bckground nd Aim: The immunocompromised condition is considered defect in the immune system. This condition tends to increse the risk of orl cndidisis, due to the inbility of the immune system to eliminte the dhesion of Cndid lbicns nd leds to systemic cndidisis with mortlity rte of 60%. Green te (Cmelli sinensis) contins potentil ntioxidnt nd immunomodultory which cts s nticncer, ntifungl, nd ntivirus gent. The im of this study ws to invent herbl-bsed medicine, which cts s n immunomodultor nd ntifungl gent to tret fungl infection in immunocompromised ptients. Mterils nd Methods: Thirty-five immunocompromised Wistr rts induced with C. lbicns were divided into 7 groups (n=5): Control group (C+); treted for 4 dys with green te extrct 1.25% (GT 4), epiglloctechin gllte (EGCG) 1% (EGCG 4), EGC 1% (EGC 4); nd treted for 7 dys with green te extrct 1.25% (GT 7), EGCG 1% (EGCG 7), nd EGC 1% (EGC 7). Tongue tissue ws collected nd nlyzed with immunohistochemistry stining using monoclonl ntibody; interleukin (IL)-17A, IL-8, nd humn bet-defensin 2 (HBD)-2. Dt were nlyzed using nlysis of vrince test nd Tukey honest significnt differences test. Results: The expression of IL-17A, IL-8, nd HBD-2 ws significntly incresed (p=0.000) fter green te extrct dministrtion in 7 dys, wheres in 7 dys, the expression of IL-8, IL-17A, nd HBD-2 fter EGCG nd EGC dministrtion did not give significnt result (p>0.005). Conclusion: Within the limits of this study, green te extrct hs the bility s n immunomodultory gent in n immunocompromised ptient infected by C. lbicns through expression ugmenttion of IL-8, IL-17A, nd HBD-2 compred to EGCG nd EGC. Keywords: epiglloctechin gllte, epiglloctechin, green te extrct, immunocompromised, orl cndidisis. Introduction The immune system is n essentil mechnism to ginst microorgnism nd its toxins. The defect in the immune system could led to n immunocompromised condition tht put ptients t high risk of vrious infections of fungl, virl, nd bcteril infections [1]. One of the most common infection is fungl infection, orl cndidisis, which could led to systemic cndidisis with mortlity rte of 60% [1,2]. Copyright: Rhyu, et l. Open Access. This rticle is distributed under the terms of the Cretive Commons Attribution 4.0 Interntionl License ( by/4.0/), which permits unrestricted use, distribution, nd reproduction in ny medium, provided you give pproprite credit to the originl uthor(s) nd the source, provide link to the Cretive Commons license, nd indicte if chnges were mde. The Cretive Commons Public Domin Dediction wiver ( cretivecommons.org/publicdomin/zero/1.0/) pplies to the dt mde vilble in this rticle, unless otherwise stted. Cndid lbicns is prt of the indigenous microbil flor in humns nd cn be found in the orl cvity, nd is unique mong opportunistic pthogens becuse it is prt of the norml microbil flor of the host [1,3]. C. lbicns hs been shown to ply n importnt role in orl cndidisis, denture stomtitis, nd severe periodontitis. In immunocompromised ptients, mucosl immunity is not ble to eliminte the dhesion of C. lbicns. The prevlence of orl cndidisis tends to increse long with immunocompromised ptients, such s humn immunodeficiency virus (HIV), dibetes mellitus, itrogenic infections, nd cncer [4]. The condition cuses impired phgocytosis effect of polymorphonucler cells, nd mcrophges decrese the qulity nd quntity of cytokines [5]. C. lbicns infection triggers differentition of T helper (Th) cell into Th17 to produce Interleukin 17 (IL-17) through ctivtion IL-23 tht ws produced by dendritic cells. Veterinry World, EISSN:

2 IL-17A plys n importnt role in mobiliztion nd fungicidl ctivity of neutrophil [5,6]. In ddition, ctivtion of IL-17A through receptor IL-17R in epithelil induce the relese of humn bet-defensin 2 (HBD-2). HBD-2 is prt of innte immunity system tht plys role in recruitment nd ctivtion of neutrophil to phgocyte ginst C. lbicns [7]. The resistnce to ntifungl gents tends to increse nowdys nd cuses filure of tretment. Therefore, innovtion is needed to enhnce the effectivity of ntifungl gents. The common nti-fungl gents grdully become more unffordble for some Indonesins. Therefore, it is required to seek solution to tret orl cndidisis in immunocompromised ptients properly. Current reserches which re supported by Ministry of Technology nd Higher Eduction tend to use more nturl ingredients. Herbl bsed medicines could be the proper solution to tret some diseses. In ddition, herbl medicines re bundntly provided in nture, ffordble, hve low toxicity level, nd re recognized sfe by Food nd Drug Administrtion (FDA) [8]. Ctechin tht contined in green te could hve higher biovilbility when bsorbed orlly. One of the nturl ingredients tht re widely consumed by Indonesins is Cmelli sinensis (green te), which is known to ct s potent ntioxidnt. It contins ctechins tht consist of epictechin (EC), epiglloctechin (EGC), EC gllte, nd EGC gllte (EGCG). It is reported tht ctechin in green te hs the bility s ntioxidnt, nticncer, ntifungl, nd ntivirus [9]. EGCG nd EGC ct s n immunomodultor by influencing the prolifertion of lymphocyte T nd cytokines production. Green te extrct enhnces lymphoblst to induce the production of lymphocytes, while EGCG stimultes the production of IL-1α, IL-1β, monocytes, nd lymphocytes [10]. The EGCG nd EGC dministered orlly could suppress inflmmtion, inhibit prolifertion nd pro-inflmmtion cytokines, s well s, inhibit the ctivtion of NF-кB [11]. This condition leds to lower level of IL-8 which plys s chemottrctnt nd neutrophil recruitment. The ctive component is responsible for biologicl effects such s immunomodultor, nti-tumor ctivity, nd ntimicrobil [12]. It is possible tht green te possesses immunomodultory effect ginst orl cndidisis in immunocompromised ptients. However, further investigtion is needed to study the immunomodultory effect of green te extrct, EGCG, EGC through incresing expression of IL-8, IL-17A, nd HBD-2. This im of this study ws to develop nturl bsed immunomodultor nd nti-fungl gent to tret fungl infection in immunocompromised ptients. Mterils nd Methods Ethicl pprovl This study hs been pproved by the Commission of Ethicl Clernce, Fculty of Dentl Medicine, Universits Airlngg, Surby, Indonesi (No. 306/ HRECC.FODM/XXI/2017). Animls The reserch ws post-test only control group design using Wistr rts s n niml model. The criteri of rts were helthy, 3 months old, nd weighing round 250 g. This study using 35 immunocompromised Wistr rts induced with C. lbicns, which re divided into 7 groups (n=5): Control group (C+); treted with green te extrct concentrtion 1.25% for 4 (GT 4) nd 7 (GT 7) dys; EGCG 1% for 4 (EGCG 4) nd 7 (EGCG 7) dys; nd treted EGC 1% for 4 (EGC 4) nd 7 (EGC 7) dys. Experimentl design This study ws conducted in Integrted Reserch nd Testing Lbortory Biochemistry Fculty of Medicine, Universits Airlngg. Immunocompromised condition ws induced by Dexmethsone 0.8 mg/kg nd Tetrcycline 12 mg/kg intrperitonelly for 7 dys. Blood serums were collected on dy 1 nd 7 to mesure the immunocompromised condition through blood test. The immunocompromised rts were then induced with C. lbicns, by inoculting 0.1 ml sline suspension which contins C. lbicns to tongue tissue using cotton rolls in ll groups for 6 times in dy Tretment groups were treted with green te extrct, EGCG nd EGC until 16 nd 19 dys, respectively, bsed on its group tretment. Preprtion of green te extrct Two nd hlf grm of dried green te lef ws mixed into 200 ml of boiling distilled wter for 30 min. After being rested nd filtered, the extrct ws freeze-dried to preserve the component substnces green te extrct with concentrtion of 1.25% ws mde by mixed 12.5 mg of dried green te extrct with 100 ml of distilled wter for 30 min. It ws followed by filtering the extrct. Preprtion of EGCG nd EGC extrct The EGC nd EGC powder ws obtined from Xi n Rongsheng Biotechnology Co., Ltd, Xi n, PRC. There were 2.5 g of EGCG nd EGC powder in 250 ml sterilized distilled wter needed to mke 1% EGCG nd EGC solution. The solution ws double filtered 30 min fter mixture to gin cler EGCG nd EGC solution. Immunohistochemistry ssy (IHC) The rts were decpitted using combintion of Ketmine nd Xylzine (100 mg/kg nd 10 mg kg/bb) intrmusculr injection. C+ group ws terminted on dy 13; while GT 4, EGC 4, nd EGCG 4 groups were terminted on dy 16; nd green te 7, EGCG 7, nd EGC 7 were terminted on dy 19. Tongue tissues were collected nd nlyzed using IHC stining using monoclonl ntibody of IL-17A, IL-8, nd HBD-2 from Snt Cruz Biotech (Snt Cruz Biotechnology Inc., Dlls, Texs, USA) nd exmined under Veterinry World, EISSN:

3 Olympus digitl microscope (Olympus Co., Tokyo, Jpn) t 400 mgnifiction. Sttisticl nlysis The dt were nlyzed using SPSS softwre version (SPSS Inc., Chicgo, USA) with ANOVA nd post hoc Tukey honest significnt differences (HSD) test. Results c Figure-1: Immunohistochemistry of interleukin-8 expression (blck rrow) in tongue tissue (400 ) in the group which treted with green te extrct (), epiglloctechin (EGC) gllte (b) nd EGC (c) on dy 7. Figure-2: The men of interleukin-8 expression level fter treted with green te extrct, epiglloctechin (EGC) gllte, nd EGC. The IHC results of IL-8 expression re showed in Figure-1. Men of ech group for IL-8 expression ws shown in Figure-2. ANOVA results showed tht the expression of IL-8 ws significntly different for ech group (p=0.000). Tukey HSD test results in 4 dys showed there ws significnt difference expression between GT 4 group compred to EGCG4 (p=0.011) nd EGC4 (p=0.000) groups. However, there ws no significnt difference of IL-8 expression between EGCG 4 nd EGC 4 groups (p=0.495). The expression of IL-8 in dy 7 ws higher thn in dy 4. Tukey HSD test result showed greter expression of IL-8 in b GT 7 group compred to EGCG 7(p=0.000) nd EGC 7 (p=0.000) groups. The expression of IL-8 between EGCG 7 nd EGC 7 groups did not show significnt difference (p=0.394). The expression of IL-17A is shown in Figure-3, nd the men is shown in Figure-4. The expression of IL-17A ws significntly different in ech group (p=0.000). Tukey HSD test results in 4 dys showed there ws significnt difference between GT 4 group compred to EGCG 4 (p=0.010) nd EGC4 (p=0.000) groups. Menwhile, the comprison of IL-17A expression between EGCG 4 nd EGC 4 did not show significnt difference (p=0.076). The expression of IL-17A on dy 7 is higher thn on dy 4. HSD test result showed higher expression of IL-17A in GT 7 group compred to EGCG 7 (p=0.000) nd EGC 7 (p=0.000) groups. The expression of IL-17A between EGCG 7 nd EGC 7 groups did not show significnt difference (p=0.110). The expression of HBD-2 is shown in Figure-5, while the mens re shown in Figure-6. The expression of HBD-2 ws significntly different for ech group (p= Tukey HSD test result showed no significnt difference in HBD-2 expression in GT 4 group compred to EGCG 4 group (p=0.080) but showed significnt difference if compred to EGC 4 group (p=0.023). The expression of HBD-2 between EGCG 4 nd EGC4 groups did not show ny significnt difference (p=0.998). The expressions of HBD-2 in dy 7 re greter thn on dy 4. Tukey HSD test result showed tht the expression of HBD-2 in GT 7 group ws significntly different compred to EGCG 7 (p=0.000) nd EGC 7 (p=0.001) groups. Menwhile, the expression of HBD-2 between EGCG 7 nd EGC 7 groups did not show significnt difference (p=0.998). Discussion The current mngement of orl cndidisis is not effective enough, especilly for immunocompromised individuls, due to high risk of recurrence. Therefore, djunctive therpy is needed to get better result. Recently, pproximtely 80% of ntimicrobil, crdiovsculr, immunosuppressive, nd nticncer drugs re of plnt origin. It is widely ccepted tht more thn 80% of drug substnces re either directly derived from nturl products or developed from nturl compound [13]. One of the plnts tht hve therpeutic effect is green te (Cmelli Sinensis). Green te extrct is known to hve nti-oxidnt nd ntifungl properties [14]. Prevlence of orl cndidisis tends to increse ech yer s incresing number of the immunocompromised ptient due to dibetes mellitus, prolonged consumption immunosuppressnt nd ntibiotic, trnsplnt orgn recipient, cncer survivor, nd ptient with HIV/AIDS [15]. Prolonged nd irrtionl usge of nti-fungl (zole) is believed to contribute to the higher prevlence of orl cndidisis, which leds Veterinry World, EISSN:

4 c Figure-3: Immunohistochemistry of interleukin-17a expression (Blck rrow) in tongue tissue (400 ) of the group with green te extrct (), epiglloctechin (EGC) gllte (b), EGC (c) on dy 7. Figure-4: Interleukin-17A expression level fter treted with green te extrct, epiglloctechin (EGC) gllte, nd EGC. to tretment filure [16]. Therefore, innovtion to enhnce nti-fungl effectivity is needed. In immunocompetent ptients, every microorgnism including fungi is controlled by the immune response, whether specific or non-specific. The immune system of immunocompromised ptient fils to eliminte the dhesion of Cndid tht leds to orl cndidisis [6]. Severl ntifungl gents, nysttin, nd zole re reported to be resistnt to orl cndidisis. Menwhile, improper tretment of orl cndidisis my led to systemic infection of Cndid tht increses mortlity rte to 60% [17]. Green te extrct which contins EGCG nd EGC is considered s n herbl-bsed therpy for orl cndidisis. Green te extrct is generlly recognized s sfe by the FDA Sfety of the USA [8], becuse of green te tht is trditionlly consumed s food relies on tht history of food use s evidence of sfety. This study showed tht IL-8 is incresed on dy 4 nd 7 fter treted green te extrct. Green te extrct showed higher IL-8 expression compre to EGCG nd EGC due to green te extrct contins vrious ctive components which synergisticlly increse IL-8 expression. IL-8 is importnt due to chemo-ttrctnt b properties which recruit neutrophils for phgocytosis to inhibit C. lbicns colony formtion. A previous study by Steubesnd et l. [18] showed orl dministrtion of EGCG nd EGC could inhibit the synthesis of pro-inflmmtion cytokines nd the ctivtion of NF-κB which leds to decresing IL-8 expression nd incresing HBD-2. Vrious components contin in green te extrct work synergisticlly to enhnce the expression of IL-17A nd IL-8 which ply s chemottrctnt to relese HBD-2. The expression of IL-17A is shown in Figure-4 fter treted with green te extrct ws significntly different in ech group (p=0.000). Menwhile, the comprison of IL-17A expression between the group treted with EGCG nd EGC did not show significnt difference (p=0.076) in dy-7 is higher thn on dy-4. There is the IL-17A ply vitl role in mobiliztion nd ctivity of neutrophils ginst infection, nd it will be expressed by the ctivity of Th17 through RORγt nd increses the number of neutrophils to inhibit orl cndidisis, even in immunocompromised ptients [19,20]. Green te extrct contins flvonoids which hve n immunomodultory effect, thus enhnce IL-2 production which ctivtes the prolifertion nd differentition of T cells differentite into Th1 nd Th2, Th1 cells secrete vrious cytokines Interferon gmm (IFN-γ) to ctivte mcrophges [21]. Flvonoid contined in green te extrct enhnces prolifertion of lymphocytes could ffect CD4+ cells to ctivte Th17 nd produces IL-17A [22]. It is followed by epithelil induction through IL-17R, which ctivtes the synthesis of HBD-2, IL-8, nd G-CSF. Deficiency of IL-17A led to neutrophil deficiency which increses the risk of systemic C. lbicns infection. The non-specific immune response is triggered s α-mnnns binds to C. lbicns cell wll. The binding stimultes specific immune response through Th17. The ctivity of Th17 cells through inducing Treg will reduce expression of Dectin-2 in C. lbicns [23]. These conditions stimulte the expression of vrious mrkers such s RORγt, IL-17A, nd HBD- 2, s well s the number of neutrophils. A sufficient number of C. lbicns might be incresed nd initite orl cndidisis. Green te extrct, EGC, nd EGCG inhibit Cndid biofilm formtion nd preformed biofilm. Higher EGCG concentrtion is reported to be substntil for in vivo ctivity of C. lbicns protesome chymotrypsin-like. Protesome ctivities disturb cellulr metbolism nd yest structure [15]. In C. lbicns infection, mcrophges relese vrious pro-inflmmtion cytokines supported by IL-23 such s IL-17A, IL-21, nd IL-22, nd would trigger differentition of Th into Th1, Th2, nd Th17. IL-17A is the most prominent cytokines relesed by Th17 tht ws ctivted by IL-23. It is beneficil to trigger epithelil to secrete ntimicrobil peptides nd recruit neutrophils for phgocytosis, C. lbicns in prticulr [10,12]. In certin condition, there would be declined secretion of IL-17 due to such mechnism by C. lbicns to void Veterinry World, EISSN:

5 b to tretment with EGC nd EGCG. The results show tht green te extrct gives better immunomodultory effect, compred to EGC nd EGCG. It is concluded tht green te extrcts possess immunomodultory effect ginst C. lbicns infection in immunocompromised ptients by incresing the expression of IL-8, IL-17A, nd HBD-2. the host immune response. HBD-2 expressions re higher in green te extrct group compred to EGC nd EGCG. Higher expression HBD-2 in green te extrct group due to its bility to ctivte HBD-2 relese s effector molecules in orl mucosl innte immunity. HBD-2 is prt of mucosl primry defense mechnism ginst C. lbicns through severl mechnisms in the cell membrne, such s binding ions C2+ nd Mg2+ [24]; consequently, there would be ion nd peptide exchnge tht interfere the stbility of C. lbicns membrne. Instbility of membrne lekge would led to poptosis of C. lbicns. This shows tht vrious components contined in green te extrct work synergisticlly nd simultneously to increse IL-8 nd IL-17A expressions. Lck of HBD-2 leds to reduce recruitment nd ctivtion of neutrophils nd ffects its phgocytic bility ginst C. lbicns. Mirmón et l. [25] stted tht orl cndidisis cn be cured in immunocompromised individuls. Decresing number of HBD-2 stimultes reduce the ctivity nd recruitment of neutrophil moreover lower phgocytosis ctivity ginst C. lbicns. Conclusion c Figure-5: Immunohistochemistry of humn betdefensin-2 expression (blck rrow) (400 ) of the group treted with green te extrct (), epiglloctechin (EGC) gllte (b), EGC (c) on dy 7. Figure-6: Humn bet-defensin-2 expression level fter treted with green te extrct, epiglloctechin (EGC) gllte, nd EGC. The expressions of IL-17A, IL-8, nd HBD-2 re higher fter treted with green te extrct, compred Authors Contributions All uthors prticipted eqully in the study pln nd design. RAP, UK, nd RPDI collected the smples from the frms nd prepred the niml models. RPR nd DAP ssisted in the lbortory work. MR crried out the sttisticl nlysis of dt nd reporting the results. All uthors collborted in writing, revising, nd improvement of the rticle for publiction. Acknowledgments The present study received finncil support from The Ministry of Reserch nd Higher Eduction of The Republic of Indonesi under the PDUPT scheme with Grnt No. 018/SP2H/LT/DRPM/II/2016. Competing Interests The uthors declre tht they hve no competing interests. References 1. Sgng, G. (2011) Fungl infections in immunocompromised ptients. Mycoses, 54(4): Gow, N.A. nd Hube, B. (2012) Importnce of the Cndid lbicns cell wll during commenslism nd infection. Curr. Opin. Microbiol., 15(4): Fidel, P.L. Jr. (2011) Cndid-host interctions in HIV disese: Implictions for orophryngel cndidisis. Adv. Dent. Res., 23(1): Willims, D. nd Lewis, M. (2011) Pthogenesis nd tretment of orl cndidosis. J. Orl Microbiol., 3(57): Myer, F.L., Duncn, W.D. nd Hube, B. (2013) Cndid lbicns pthogenicity mechnisms. Virulence, 4(2): Smeekens, S.P., vn de Veerdonk, F.L., Kullberg, B.J. nd Nete, M.G. (2013) Genetic susceptibility to Cndid infections. EMBO Mol. Med., 5(6): Hernández-Sntos, N. nd Gffen, S.L. (2012) Th17 cells in immunity to Cndid lbicns. Cell Host Microbe, 11(5): Abdel-Rhmn, A., Anyngwe, N., Crlcci, L., Csper, S., Dnm, R.P., Enongene, E., Erives, G., Fbricnt, D., Gudi, R., Hilms, C.J. nd Hines, F. (2011)The sfety nd regultion of nturl products used s foods nd food ingredients. Toxicol. Sci., 123(2): Tnk, T., Mtsuo, Y. nd Kouno, I. (2013) Biochemicl nd physicochemicl chrcteristics of green te polyphenols. In: Junej, L.R., Kpoor, M.P., Okubo, T. nd Ro, T.P., editors. Green Te Polyphenols, Nutrceuticls of Modern Life. CRC Press, Boc Rton. p Wu, D., Wng, J., Pe, M. nd Meydni, S.N. (2012) Green te EGCG, T cells, nd T cell-medited utoimmune diseses. Mol. Aspects Med., 33(1): Di Lorenzo, C., Dell Agli, M., Sngiovnni, E., Dos Sntos, A., Uberti, F., Moro, E., Bosisio, E. nd Restni, P. (2013) Correltion between ctechin content nd NF-κB inhibition by infusions of green nd blck te. Plnt Foods Hum. Nutr., 68(2): Kumr, V. nd Shrm, A. (2010) Neutrophils: Veterinry World, EISSN:

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