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Licensed Unlicensed Requires Authentication Published by De Gruyter January 11, 2017

Activation of the tryptophan/serotonin pathway is associated with severity and predicts outcomes in pneumonia: results of a long-term cohort study

  • Marc A. Meier , Manuel Ottiger , Alaadin Vögeli , Christian Steuer , Luca Bernasconi , Robert Thomann , Mirjam Christ-Crain , Christoph Henzen , Claus Hoess , Werner Zimmerli , Andreas Huber , Beat Mueller and Philipp Schuetz EMAIL logo



As part of the immune defense during infection, an increase in enzyme activity of indoleamine 2,3-dioxygenase (IDO) leads to a breakdown of tryptophan to kynurenine. In previous animal studies, therapeutic antagonism of IDO resulted in reduced sepsis mortality. We investigated the prognostic ability of tryptophan, serotonin, kynurenine and IDO (represented by the ratio of kynurenine/tryptophan) to predict adverse clinical outcomes in patients with community-acquired pneumonia (CAP).


We measured tryptophan, serotonin and kynurenine on admission plasma samples from CAP patients included in a previous multicenter trial by liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). We studied their association with inflammation (C-reactive protein), infection (procalcitonin) and clinical outcome.


Mortality in the 268 included patients was 45% within 6 years of follow-up. IDO and kynurenine showed a strong positive correlation with markers of infection (procalcitonin) and inflammation (C-reactive protein) as well as sepsis and CAP severity scores. Tryptophan showed similar, but negative correlations. In a multivariate regression analysis adjusted for age and comorbidities, higher IDO activity and lower tryptophan levels were strongly associated with short-term adverse outcome defined as death and/or ICU admission within 30 days with adjusted odds ratios of 9.1 [95% confidence interval (CI) 1.4–59.5, p=0.021] and 0.11 (95% CI 0.02–0.70, p=0.021). Multivariate analysis did not reveal significant associations for kynurenine and serotonin.


In hospitalized CAP patients, higher IDO activity and lower tryptophan levels independently predicted disease severity and short-term adverse outcome. Whether therapeutic modulation of IDO has positive effects on outcome needs further investigation.

Corresponding author: Prof. Dr. med. Philipp Schuetz, MD, MPH, University Department of Medicine, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland, Phone: 0041 62 838 68 12, Fax: 0041 62 838 98 73


We are thankful for all patients, patients’ relatives and all local general practitioners who participated in this study. In particular, we thank the emergency department, medical clinic, and central laboratory staff of the University Hospital Basel and the Cantonal Hospitals Aarau, Liestal, Lucerne, and Muensterlingen, and the ‘Buergerspital’ Solothurn for their assistance and technical support. Finally, we acknowledge our ProHOSP Study Group for their important support.

  1. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission. PS, MC-C, and BM created the concept and design, wrote the protocol and initiated the initial ProHOSP study. MM and PS drafted the present manuscript and performed the statistical analyses. CS, AH, and LB performed laboratory measurements of p180-Kit. All authors contributed to the data acquisition, interpretation and drafting of the analyses, critical review for important content, and final approval of the manuscript. PS had full access to all data and takes responsibility for the accuracy of the data analysis and the integrity of the work.

    The ProHOSP Study Group included: U. Schild, K. Regez, R. Bossart, C. Blum, M. Wolbers, S. Neidert, I. Suter, H.C. Bucher, F. Mueller, A. Chaudry, J. Haeuptle, R. Zarbosky, R. Fiumefreddo, M. Wieland, C. Nussbaumer, A. Christ, R. Bingisser, and K. Schneider (University Hospital Basel, Basel, Switzerland); T. Bregenzer, D. Conen, A. Huber, and J. Staehelin (Kantonsspital Aarau, Aarau, Switzerland); W. Zimmerli, C. Falconnier, and C. Bruehl-hardt (Kantonsspital Baselland, Liestal, Switzerland); C. Henzen and V. Briner (Kantonsspital Luzern, Luzern, Switzerland); T. Fricker, C. Hoess, M. Krause, I. Lambinon, and M. Zueger (Kantonsspital Muensterlingen, Muensterlingen, Switzerland); and R. Thomann, R. Schoenenberger, and R. Luginbuehl (Buergerspital Solothurn, Solothurn, Switzerland).

  2. Research funding: This study was supported in part by the Swiss National Science Foundation (SNSF Professorship, PP00P3_150531/1) and the Research Council of the Kantonsspital Aarau (1410.000.044). The initial trial was funded by the Swiss National Science Foundation (grant SNF 3200BO-116177/1), Santé Suisse, the Gottfried and Julia Bangerter-Rhyner Foundation and BRAHMS Biomarkers.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.

  5. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.


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Received: 2016-10-11
Accepted: 2016-11-1
Published Online: 2017-1-11
Published in Print: 2017-6-27

©2017 Walter de Gruyter GmbH, Berlin/Boston

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