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Association of TNFSF4 Polymorphisms with Vogt-Koyanagi-Harada and Behcet’s Disease in Han Chinese

Scientific Reports volume 6, Article number: 37257 (2016) | Download Citation


To investigate whether single nucleotide polymorphisms (SNPs) of the Tumor Necrosis Factor Superfamily 4 (TNFSF4) gene are associated with Vogt–Koyanagi–Harada (VKH) and Behcet’s disease (BD) in a Chinese Han population. A two-stage case control study was carried out in 1331 VKH, 938 BD and 1752 healthy controls. Ten TNFSF4 SNPs, including rs1234314, rs1234315, rs2205960, rs704840, rs2795288, rs844654, rs12039904, rs10912580, rs844665, and rs844644, were genotyped using the PCR-restriction fragment length polymorphism method. Genotype and allele frequencies were analyzed between cases and healthy controls using the X2 or Fisher’s exact test and p values were corrected for multiple comparisons. We observed a significantly increased frequency of the TT genotype of rs1234315 in BD patients (Pc = 1.44 × 10−5, OR = 1.734, 95% CI = 1.398–2.151). The frequency of the TT genotype of rs12039904 was significantly higher in patients with VKH disease as compared to controls (Pc = 4.62 × 10−5, OR = 1.959, 95% CI = 1.483–2.588). Analysis of clinical manifestations in VKH disease and BD did not show an association with the TNFSF4 gene polymorphisms. The study suggests that the TNFSF4 gene may be involved in the susceptibility to VKH disease and BD in Han Chinese.


Vogt-Koyanagi-Harada (VKH) disease and Behcet’s disease (BD) are two of the most common uveitis entities in China, manifesting as bilateral panuveitis and can lead to serious visual impairment1,2,3. Although the etiologic pathways or mechanisms of VKH disease and BD remain unclear, many studies have indicated that an autoimmune response following cutaneous injury or a viral infection may trigger an inappropriate and overactive T cell-mediated autoimmune disease, which leads to tissue damage in individuals with a certain genetic background4,5,6. Earlier studies showed that a number of human leukocyte antigen (HLA) and non-HLA genes are associated with VKH disease and BD7,8,9,10,11,12,13. However, the susceptibility genes identified thus far do not yet completely explain the genetic pathogenesis of VKH disease and BD.

Recently, several SNPs in a Tumor necrosis factor superfamily-4 (TNFSF4) have been shown to be shared risk factors for several immune-related diseases, including systemic lupus erythematosus (SLE), primary Sjögren’s syndrome (SS) and systemic sclerosis (SS)14,15,16,17,18,19,20,21,22. TNFSF4, also known as OX40L, is expressed on antigen-presenting cells (APC), T cells, B cells, natural killer (NK) cells, macrophages, dendritic cells and vascular endothelial cells23. Moreover, TNFSF4 with its unique receptor OX40 as a co-stimulatory signal can activate CD4+ T cells24.

Previous studies have shown the important role of TNFSF4 in the development of autoimmune diseases. The association of TNFSF4 polymorphisms with BD and VKH disease has however not been investigated and was therefore the subject of the study presented here. Our results show that polymorphisms of rs1234315 of TNFSF4 are associated with susceptibility to ocular BD, whereas rs12039904 is associated with susceptibility to VKH disease in a Han Chinese population.


Clinical features of patients with BD and VKH disease

The demographics and clinical characteristics of the enrolled BD and VKH disease patients in the study are displayed in Tables 1 and 2. The genotype and allele frequencies of the ten SNPs did not deviate from the Hardy-Weinberg equilibrium in the controls. The primers and restriction enzymes used for RFLP analysis of the TSFNF4 gene are shown in Table 3.

Table 1: Clinical Features of BD Patients used for the first and second stage study.
Table 2: Clinical Features of VKH Syndrome Patients used for the first and second stage study.
Table 3: Primers and Restriction Enzymes Used for RFLP Analysis of the TSFNF4 Gene.

Associations of the TNFSF4 gene polymorphisms with susceptibility to BD

In the first stage of this case-control study, ten SNPs of the TNFSF4 gene were successfully genotyped in 394 BD patients and 606 normal controls. The frequencies of the rs1234315 genotype CC and C allele were significantly lower in patients with BD (Bonferroni Pca = 1.68 × 10−4, OR = 0.484, 95% CI = 0.352–0.664; Pca = 5.91 × 10−3, OR = 0.676, 95% CI = 0.564–0.809; respectively) (Table 4). To confirm this result, another 544 BD patients and another set of 413 normal controls were used to replicate the association between SNP rs1234315 and BD. Increased frequencies of the rs1234315 genotype C allele was observed in BD patients (Pc = 1.07 × 10−3, OR = 0.682, 95% CI = 0.568–0.818) as compared to the control group (Table 5). The combined data of the two studies showed a significant association of SNP rs1234315 with BD (Pccombined = 1.60 × 10−6, OR = 0.688, 95% CI = 0.606–0.780) (Table 5). We could not detect a significant association between the other nine SNPs and BD (Table 4).

Table 4: Frequencies of alleles and genotypes of TNFSF4 polymorphisms in BD, VKH patients and controls in first stage study.
Table 5: Frequencies of alleles and genotypes of rs1234315 polymorphisms in BD patients and controls in second stage and combined results.

TNFSF4 gene confers susceptibility to VKH disease

Ten SNPs were genotyped in a total of 395 VKH patients and 606 healthy controls in the first-stage study. The frequency of the TT genotype of rs12039904 in VKH patients (Pcb = 4.74 × 10−3, OR = 2.494, 95% CI = 1.532–4.060) was significantly higher than that in normal controls (Table 4). Based on this result, we performed a confirmatory study with another set of 936 VKH patients and 1146 normal subjects. The result again demonstrated a significantly higher frequency of the rs12039904 genotype TT in patients with VKH (Pc = 0.034, OR = 1.746, 95% CI = 1.244–2.452) (Table 6). The combined data of the two studies in VKH showed that the TT genotype and T allele of rs12039904 were significantly increased (Pccombined = 4.62 × 10−5, OR = 1.959, 95% CI = 1.483–2.588; Pccombined = 3.48 × 10−5, OR = 1.325, 95% CI = 1.183–1.485) as compared to normal controls (Table 6). Genotype and allele frequencies of the other nine SNPs did not reveal a significant difference between the VKH patients and normal controls (Table 4).

Table 6: Frequencies of alleles and genotypes of rs12039904 polymorphisms in VKH patients and controls in second stage and combined results.


In the present study, we show that TNFSF4 gene polymorphisms are associated with both BD and VKH disease, although each disease is associated with a separate locus. The T allele and TT genotype of rs1234315 of TNFSF4 was increased in BD, whereas the T allele and TT genotype of rs12039904 confers risk to VKH disease.

TNFSF4 is mostly expressed on CD4+ T cells, where it plays a role in the stimulation of IL-17 production and inhibition of IL-10 production25,26,27. TNFSF4 activates CD4+ T cells when bound to its receptor TNFRSF4 as a potent co-stimulatory signal28. In addition to CD4+ T cells effects, the co-stimulatory signal inhibits the formation of Foxp3+ regulatory T cells29. Recently, Zhou demonstrated a modification of cytokine production in PBMC in Lupus Nephritis patients after treatment with anti-OX40 monoclonal antibody30. Moreover, higher serum TNFSF4 levels have been demonstrated in SLE patients as compared to controls, suggesting a role for this molecule as a disease marker31. In addition, OX40 activating antibody prolonged and exacerbated disease in a model of experimental autoimmune uveitis by upregulating IL-7Rα expression in the activated T-cell population32. Taken together, these findings suggest alink between a genetic variant in the TNFSF4 gene and autoimmune disease30,31,32,33.

VKH disease and BD are both immune mediated diseases resulting from an aberrant reaction following environmental triggers in a genetically predisposed individual34,35,36,37. In the past, we have reported various immune response related genes to be involved in the susceptibility to both BD and VKH disease, including CD40, JAK2, STAT4, STAT338, 39, 40, 41. To date, the genetic background of BD and VKH disease is however not yet completely clear. Recent studies showed that certain polymorphisms of TNFSF4 increased the risk of autoimmune diseases, such as for instance SLE, SS and primary Sjögren’s syndrome14,15,16,17,18,19,20,21,22. A polymorphism of rs1234315 was reported to be involved in the susceptibility to SLE in European and Asian (including Chinese Han) patients and also in Sjögren’s syndrome14,15,16,17,18,22. In our study, rs1234315 was observed to be associated with BD, whereby the risk T allele was the minor allele in BD patients, which is similar to the association observed in Chinese SLE patients16,18. Our finding that the rs12039904 of TNFSF4 is associated with VKH disease is similar to findings in European SLE and SS patients, that reported a significant association with the T allele and the TT genotype of rs1203990414,15. We were not able to confirm earlier reported associations in BD or VKH diseases with other TNFSF4 polymorphisms, whereby rs1234314, rs2205960 and rs844644 showed an association with SLE and SS, and rs704840, rs2795288, rs844654, rs10912580 and rs844665 showed an association with SLE13,14,15,16,17,19,20,21. This indicates that the pathogenesis of BD and VKH is different from these other autoimmune mediated diseases. The reason why rs1234315 was associated with BD but not with VKH, and that rs12039904 had a significant association with VKH but not with BD is not yet clear but may be due to the fact that both diseases are caused by different pathogenic pathways each leading to serious intraocular inflammation. BD is thought to be caused by an aberrant inflammatory response against microbial antigens, whereas VKH is a disease mediated by an autoimmune response directed against melanocyte antigens42,43.

Our study has several limitations. We showed that rs1234315 SNP or rs12039904 of TNFSF may play a role in the susceptibility for BD and VKH but we cannot rule out that other as yet not identified SNPs in the TNFSF4 gene may also be associated with these two uveitis entities. Further studies should be performed to investigate whether TNFSF4 is also involved in the pathogenesis of other uveitis entities. The effect of the polymorphisms on the biological function or expression of TNFSF is not yet known and we can therefore only speculate on the exact mechanism by which rs1234315 of TNFSF4 exerts its role in the pathogenesis of BD as well as how rs12039904 affects VHK development.

In conclusion, this study shows an association between polymorphisms of rs1234315 of TNFSF4 with susceptibility to ocular BD, and rs12039904 with susceptibility to VKH in Chinese Han. These data add to the existing knowledge concerning the complex pathogenesis of BD and VKH disease.

Materials and Methods

Study population

All patients and healthy controls were recruited from the Zhongshan Ophthalmic Center (Guangzhou, China) and the First Affiliated Hospital of Chongqing Medical University (Chongqing, China) were enrolled from April 2005 to June 2014 and were all Han Chinese. The investigated patients and healthy controls gave a written informed consent before collection of blood. This study was approved by the local ethics research committee at the Chongqing Medical University and was conducted according to the Declaration of Helsinki Principles.

In the first-stage study of this case-control study, 394 BD patients, 395 VKH patients and 606 healthy controls were enrolled to identify susceptible SNPs (Pc < 0.05) in the TNFSF4 gene. In the second-stage, another 544 BD and 413 healthy individual, and another 936 VKH and 1166 controls were added to replicate the susceptible SNPs found in the first-stage study. The diagnosis of BD was based on the criteria of the International Study Group for BD44. VKH disease was diagnosed according to the First International Workshop criteria45. Clinical characteristics of BD and VKH patients were summarized in Tables 1 and 2. If the diagnosis was in doubt, the patients were excluded from the study.

DNA extraction and genotyping

Genomic DNA was extracted from blood samples by using the QIAamp DNA Blood Mini Kit (Qiagen, Valencia, California, USA).The proper primers of rs1234314, rs1234315, rs2205960, rs704840, rs2795288, rs844654, rs12039904, rs10912580, rs844665, and rs844644 for amplifying target DNA sequence by polymerase chain reaction- restriction fragment length polymorphism (PCR-RFLP) are depicted in Table 3. Digestion products were separated on 3–5% agarose gels which were stained with GoldView TM (SBS Genetech Beijing, China) following electrophoresis. Five percent of all samples were randomly selected to check the accuracy of genotyping by the Sangon Biotechnology Company (Shanghai, China).

Statistical Analysis

The X2 test was used to check whether the data conformed to the Hardy-Weinberg (HWE) principle. Statistical analysis was performed using SPSS 17.0 software (SPSS, Inc, Chicago, Illinois, USA). The frequencies of genotypes and alleles were evaluated using a case-control study design and significance was tested using the Pearson X2 test. The patterns of linkage disequilibrium of the SNPs of TNFSF4 were compared using Haploview 4.0 (Daly Lab at the Broad Institute, Cambridge, Massachusetts, USA). P values were corrected for multiple comparisons using the Bonferroni correction by multiplying obtained p values with the number of analyses performed. A Bonferroni corrected P values <0.05 was considered to be statistically significant.

Additional Information

How to cite this article: Lu, S. et al. Association of TNFSF4 Polymorphisms with Vogt-Koyanagi-Harada and Behcet’s Disease in Han Chinese. Sci. Rep. 6, 37257; doi: 10.1038/srep37257 (2016).

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This work was supported by Natural Science Foundation Major International (Regional) Joint Research Project (81320108009), Key Project of Natural Science Foundation (81130019), National Natural Science Foundation Project (31370893, 81200678), Basic Research program of Chongqing (cstc2013jcyjC10001), Fundamental and Advanced Research Program of Chongqing (cstc2015jcyjA10022), Science and Technology Project of Chongqing Municipal Education Commission (KJ1500236), Chongqing Key Laboratory of Ophthalmology (CSTC, 2008CA5003), National Key Clinical Specialties Construction Program of China, Key Project of Health Bureau of Chongqing (2012–1–003), Research fund for Traditional Chinese Medicine of Chongqing Health and Family Planning Commission (ZY201401013).

Author information

Author notes

    • Sha Lu
    •  & Shengfang Song

    These authors contributed equally to this work.


  1. Department of Ophthalmology, Yongchuan Hospital, Chongqing Medical University, Chongqing, P R China

    • Sha Lu
    • , Shengfang Song
    •  & Hua Li
  2. The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, and Chongqing Eye Institute, Chongqing, P R China

    • Shengping Hou
    •  & Peizeng Yang


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S.L., S.S. and P.Y. conceived the idea and designed the experiments. S.L. and H.L. performed the experiments, S.L. and H.L. analyzed the data. S.L., S.H. and P.Y. wrote the manuscript. S.L. prepared tables. All authors reviewed the manuscript.

Competing interests

The authors declare no competing financial interests.

Corresponding author

Correspondence to Peizeng Yang.

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