Figure 2 Functional model of enthesitis

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Figure 2 Functional model of enthesitis Figure 2 | Functional model of enthesitis. a | Enthesitis is initiated during a mechanosensation and immune activation phase involving mechanical and/or infectious stress that leads to the activation of prostaglandin E2 (PGE2) and IL-23, followed by vasodilatation and activation of resident γδ T cells and type 3 innate lymphoid cells (ILCs). b | The subsequent innate inflammatory response is characterized by the release of TNF and IL-17, leading to the influx of immune cells such as polymorphonuclear neutrophils (PMNs). c | Mesenchymal proliferation elicited by IL-17 and IL-22 is characterized by the activation and proliferation of resident mesenchymal stem cells (MSCs) from the perientheseal periosteum. d | New bone formation at entheseal sites (enthesophyte growth) is triggered by hedgehog signalling and parathyroid hormone related-peptide (PTHrP), which contribute to the mineralization of fibrocartilage; bone morphogenic proteins (BMPs) and Wnt proteins induce osteoblast differentiation and enable new bone apposition. Schett, G. et al. (2017) Enthesitis: from pathophysiology to treatment Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2017.188