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Peyer's patch

Peyer's patches are specialized lymphoid tissues embedded in the mucosa and submucosa of the small intestine, primarily in the distal ileum, serving as critical components of the gut-associated lymphoid tissue (GALT) that initiate and regulate immune responses to luminal antigens.^[1] These patches consist of multiple lymphoid follicles surrounded by follicle-associated epithelium (FAE) containing microfold (M) cells, which facilitate the sampling and transcytosis of antigens from the intestinal lumen to underlying immune cells.^[2] Named after the Swiss anatomist Johann Conrad Peyer who first described them in 1677, they represent the primary inductive sites for mucosal immunity in the gut.^[1] Structurally, Peyer's patches feature B cell-rich germinal centers within follicles, parafollicular T cell zones, and a subepithelial dome region densely populated with dendritic cells and macrophages, enabling coordinated antigen presentation and lymphocyte activation.^[3] Their numbers peak during adolescence, with approximately 100–200 patches in humans, nearly half concentrated in the distal 25 cm of the terminal ileum where they form a protective ring against pathogens.^[1]^[4] Functionally, these tissues promote the production of secretory IgA antibodies for immune tolerance to harmless commensal bacteria while mounting defenses against invading pathogens such as Salmonella typhi and Shigella flexneri, which exploit M cells for entry.^[2] Dysregulation in Peyer's patch function, often linked to genetic factors like NOD2 mutations, contributes to inflammatory conditions including Crohn's disease.^[3] Beyond antigen sampling, Peyer's patches interact with the enteric nervous system and microbiota to maintain intestinal homeostasis, influencing both innate and adaptive immunity through Th1/Th2 polarization and regulatory T cell induction.^[3] Their role extends to oral tolerance mechanisms, preventing excessive immune reactions to food antigens, and they are implicated in the pathogenesis of infections like HIV-1 and prion diseases due to their accessibility to luminal threats.^[2] With age, the size and activity of Peyer's patches decline, reflecting broader immunosenescence in the mucosal immune system.^[1]

Anatomy

Location and Morphology

Peyer's patches are organized aggregates of lymphoid follicles situated in the lamina propria and submucosa of the small intestine, forming a key component of the gut-associated lymphoid tissue (GALT). These structures are absent in the duodenum and large intestine, with sparse distribution in the jejunum and a primary concentration along the antimesenteric wall of the distal ileum. Specifically, over 46% of Peyer's patches are located within the terminal 25 cm of the ileum, where they often coalesce to form a continuous lymphoid ring visible on the mucosal surface.^[3] In humans, the total number of Peyer's patches is approximately 30-40, varying by individual and peaking during adolescence. Each patch typically appears as an elongated oval elevation on the intestinal mucosa, measuring 2-5 cm in length and 1-2 cm in width, with the largest patches found in the ileum. These macroscopic features make them distinguishable during endoscopic or postmortem examination as raised, whitish areas devoid of villi over the follicle-associated epithelium.^[1]^[5] In species variations, rodents exhibit a higher relative density; for instance, mice possess 6-12 patches, while rats and other rodents can have up to 100 or more, reflecting differences in intestinal length and immune demands.^[3]^[4]

Cellular and Tissue Composition

Peyer's patches exhibit a distinctive layered structure, with the follicle-associated epithelium (FAE) forming a specialized dome-shaped layer that overlies clusters of lymphoid follicles embedded in the lamina propria and extending into the submucosa. Unlike the surrounding villous epithelium, the FAE lacks goblet cells, resulting in reduced mucus production, but is enriched with microfold (M) cells that constitute approximately 10% of its epithelial cells. These M cells are characterized by microfolds on their apical surface and play a key role in the structural interface between the intestinal lumen and underlying immune tissues.^[3]^[6]^[7] The primary cellular components of Peyer's patches are lymphocytes, which dominate the lymphoid follicles and interfollicular regions. B lymphocytes comprise the majority, accounting for 57-70% of the leukocyte population, particularly concentrating in germinal centers where they undergo maturation and differentiation into plasma cells. T lymphocytes represent 20-36% of cells, primarily residing in interfollicular zones, with subsets including CD4+ helper T cells (approximately 70-82% of T cells) and CD8+ cytotoxic T cells (18-35%). Additional populations include dendritic cells (0.6-10%), macrophages (<5%), and plasma cells, which are abundant in the lamina propria and contribute to local immunoglobulin production. Each Peyer's patch typically harbors 10^6 to 10^8 lymphocytes, varying by species and age.^[3]^[6]^[8] Specialized features of the tissue include the subepithelial dome region beneath the FAE, which is densely populated with antigen-presenting cells such as dendritic cells and macrophages, facilitating interactions with transported luminal contents. Vascular elements are prominent, with a high density of capillaries and high endothelial venules in the lamina propria and submucosa supporting lymphocyte recruitment and migration via adhesion molecules like MAdCAM-1. Enteric glial cells are also increased in number within Peyer's patches, forming networks that aid in coordinating immune cell dynamics and maintaining tissue homeostasis.^[2]^[4]^[9]

Development and History

Historical Discovery

Peyer's patches, organized aggregates of lymphoid follicles in the small intestine, were first systematically described by the Swiss anatomist and physician Johann Conrad Peyer in 1677. In his treatise Exercitationes de Glandulis intestini tenuis, Peyer detailed these structures as prominent nodules or "intestinal glands" visible on the mucosal surface of the ileum, noting their distribution and potential glandular function, though he did not fully elucidate their lymphoid nature.^[3] Earlier, vague observations of intestinal lymphoid structures had been made, such as by Italian anatomist Marco Aurelio Severino in 1645, who mentioned aggregated follicles, but these lacked the precision and focus of Peyer's work.^[3] By the mid-19th century, microscopic analysis advanced the understanding of these nodules. In 1850, Swiss physician Rudolph Oskar Ziegler, in his inaugural dissertation Ueber die solitären und Peyerschen Follikel, examined Peyer's patches closely and identified them as lymphoid tissue composed of follicles, distinguishing them from mere digestive glands and emphasizing their role in the intestinal immune system. This clarification marked a shift from anatomical curiosity to recognition as part of the lymphatic apparatus. The eponym "Peyer's patches" gained widespread use in anatomical literature by the early 1900s, with no significant disputes over attribution, as Peyer's foundational description remained unchallenged.^[10] Twentieth-century technological progress, particularly electron microscopy in the 1960s and 1970s, revealed finer structural details. Specialized epithelial cells overlying the patches, now known as microfold (M) cells, were first characterized in 1974 by Robert L. Owen and Albert L. Jones, who described their unique morphology with short microfolds rather than microvilli and their capacity for transepithelial transport of luminal contents. This discovery illuminated the patches' interface with the gut lumen. Concurrently, in the 1980s, immunologist Allan M. Mowat and colleagues integrated Peyer's patches into the concept of gut-associated lymphoid tissue (GALT), establishing them as key inductive sites for mucosal immunity through seminal studies on antigen handling and lymphocyte responses.

Embryonic and Postnatal Development

Peyer's patches originate during embryonic development through the coordinated interaction of lymphoid tissue inducer (LTi) cells with stromal organizer cells, mediated by lymphotoxin-β receptor (LTβR) signaling. In mice, the initial clustering leading to Peyer's patch formation begins around embryonic day 16.5 (E16.5), marking the onset of these gut-associated lymphoid tissues in the small intestine.^[11]^[12] In humans, Peyer's patches emerge around 14-16 weeks of gestation, with the fetal small intestine containing an average of 60 such structures by week 30, reflecting early establishment of mucosal immune surveillance.^[13]^[3] Key molecular signals drive follicle initiation during this phase, including retinoic acid, which promotes LTi cell adhesion and differentiation; interleukin-7 (IL-7), essential for LTi cell survival and proliferation via the IL-7 receptor α; and receptor activator of nuclear factor kappa-B ligand (RANKL), which supports stromal cell organization and lymphoid clustering.^[14]^[15] These pathways ensure the spatial and temporal patterning of nascent follicles, independent of microbial influences in the sterile fetal environment. Postnatally, Peyer's patches undergo rapid expansion in infancy, driven by exposure to luminal antigens that stimulate follicle growth and immune cell recruitment.^[16] This maturation is heavily influenced by the microbiota, which provides signals for full structural and functional development; in germ-free animals, Peyer's patches are absent or severely underdeveloped, with fewer than 10% of normal IgA-producing B cells and reduced follicle numbers. Follicle density peaks by puberty, after which involution occurs with aging, with a reduction in size and activity due to diminished stromal support and immune cell attrition. Species differences are notable in Peyer's patch organization: in rodents, they form a continuous band along the antimesenteric small intestine, facilitating broad antigen sampling, whereas in humans, they appear as discrete patches, typically 30-40 in number, concentrated in the ileum.^[17]

Physiology

Immune Surveillance Mechanism

Peyer's patches function as sentinel sites within the gut-associated lymphoid tissue (GALT), enabling continuous immune surveillance of the intestinal lumen by sampling gut microbiota, food antigens, and potential pathogens. Specialized microfold (M) cells in the overlying follicle-associated epithelium facilitate the transcytosis of these luminal contents into the underlying lymphoid follicles, allowing resident immune cells to monitor for threats while maintaining homeostasis. This baseline monitoring ensures that the mucosal immune system remains vigilant against microbial dysbiosis or invasive pathogens without immediate effector activation.^[2] Naive B and T lymphocytes recirculate into Peyer's patches primarily through high endothelial venules (HEVs), where they undergo selective homing mediated by adhesion molecules and chemokines such as CCL19 and CCL21. Once inside, these lymphocytes patrol the subepithelial dome and follicular regions for approximately 12-24 hours, scanning antigen-presenting cells for cognate antigens before egressing if no match is found. This dynamic recirculation supports ongoing surveillance and allows for the recruitment of diverse lymphocyte populations to sustain immune readiness.^[3]^[18] A key aspect of this surveillance is the promotion of oral tolerance to commensal microbes and dietary antigens, primarily through the induction of regulatory T cells (Tregs). In Peyer's patches, Tregs suppress excessive inflammatory responses and foster immune homeostasis by interacting with dendritic cells and other antigen-presenting cells. This tolerance mechanism prevents aberrant reactions to harmless luminal components, ensuring long-term coexistence with the microbiota.^[3] Surveillance in Peyer's patches integrates with broader systemic immunity via efferent lymphatic vessels that drain activated lymphocytes and signals to mesenteric lymph nodes (MLNs). This connectivity allows local detections to propagate to distant lymphoid sites, coordinating adaptive responses across the body when necessary. The intestinal tract, harboring an estimated 10^13 to 10^14 microbial cells, underscores the scale of this monitoring, with Peyer's patches processing a representative fraction through M cell-mediated uptake to balance tolerance and defense.^[3]^[19]

Antigen Sampling and Response

Peyer's patches facilitate antigen sampling primarily through microfold (M) cells located in the follicle-associated epithelium, which actively transport luminal antigens via transcytosis to underlying immune cells. These M cells engulf antigens at their apical surface using receptors such as glycoprotein 2 (GP2) and release them basolaterally into subepithelial pockets, where they are captured by dendritic cells (DCs) and macrophages in the subepithelial dome. Recent studies have shown that microbiota-derived signals, such as the pyruvate-GPR31 axis, promote dendrite protrusion from DCs to M cells, enhancing antigen uptake efficiency.^[20]^[21] This process enables efficient uptake of particulate antigens, including bacteria and viruses, initiating mucosal immune responses without compromising the epithelial barrier.^[22] Antigens delivered by M cells drive B cell activation within the germinal centers of Peyer's patches, where B cells undergo proliferation, somatic hypermutation, and class-switch recombination to produce immunoglobulin A (IgA)-secreting plasma cells. These germinal center reactions are induced by chronic exposure to microbial antigens, leading to the generation of high-affinity IgA antibodies that home to the intestinal lamina propria. Predominantly, the output consists of dimeric IgA, which is transported across the epithelium via the polymeric immunoglobulin receptor (pIgR) to form secretory IgA in the gut lumen, neutralizing pathogens and maintaining microbiota balance.^[4] CD4+ T follicular helper (Tfh) cells provide essential support for B cell maturation in Peyer's patches by migrating into germinal centers and secreting cytokines like interleukin-21 (IL-21), which drive IgA class switching and affinity maturation. This T cell-dependent process amplifies the adaptive response, with activated lymphocytes trafficking to mesenteric lymph nodes (MLNs) for further expansion and differentiation. In the MLNs, the response intensifies, enabling systemic coordination of mucosal immunity.^[23]^[24] Homeostatic balance in antigen responses is maintained by Foxp3+ regulatory T cells (Tregs), which suppress excessive activation in Peyer's patches to prevent inflammation against commensals. These Tregs localize to germinal centers, modulating Tfh activity and promoting tolerance. The gut microbiota further shapes responses through Toll-like receptor (TLR) signaling, where microbial ligands activate pathways like MyD88-dependent TLR2 and TLR5 to enhance Treg differentiation and regulate IgA production. Phagocytes in Peyer's patches acquire microbiota-induced transcriptional programs that support maturation and antigen processing.^[25]^[26]^[27] Recent research has explored therapeutic modulation of these responses; for instance, CD122-targeted IL-2 therapy induces selective apoptosis of B cells in Peyer's patches by engaging the IL-2 receptor beta chain, reducing germinal center activity without broadly depleting systemic immunity. This approach, demonstrated in murine models, highlights potential for fine-tuning mucosal responses in autoimmune or inflammatory conditions.^[28]

Clinical Relevance

Associated Pathologies

Peyer's patches can serve as lead points for intussusception, particularly in pediatric cases, where hypertrophy or enlargement of these lymphoid structures contributes to the telescoping of the intestine. In children, enlarged Peyer's patches due to lymphoid hyperplasia, often following viral infections, are a common cause of idiopathic intussusception, accounting for the majority of cases without identifiable pathologic lead points (which occur in 5-10%).^[29]^[30] In inflammatory bowel disease, Peyer's patches exhibit hyperplasia in Crohn's disease, characterized by increased lymphoid follicle size and density, which may initiate aphthoid ulcers at these sites. A 2022 study demonstrated elevated numbers of enteric glial cells within Peyer's patches and the surrounding lamina propria in patients with ileal Crohn's disease, correlating with enhanced intestinal permeability and contributing to fibrotic strictures common in this condition.^[31]^[32]^[33] In contrast, celiac disease is associated with atrophy of the small intestinal mucosa and villous blunting due to chronic inflammation, with immune activation potentially involving Peyer's patches.^[34] Peyer's patches are implicated in autoimmune conditions such as rheumatoid arthritis through gut microbiota alterations that promote differentiation of T follicular helper cells in these patches, contributing to systemic autoantibody responses in experimental models.^[35] Age-related involution of Peyer's patches, marked by reduced follicle-associated epithelium and impaired M cell function, contributes to immunosenescence by diminishing mucosal immune surveillance and IgA responses in the elderly.^[36]^[37] In prion diseases like scrapie, early hyperplasia of Peyer's patches occurs, facilitating prion uptake via M cells and subsequent accumulation on follicular dendritic cells, as observed in experimental models of bovine spongiform encephalopathy.^[38]^[39] Congenital absence or underdevelopment of Peyer's patches is rare and observed in primary immunodeficiencies such as X-linked agammaglobulinemia, resulting from mutations in the BTK gene that arrest B cell maturation and lead to recurrent bacterial infections due to impaired mucosal immunity.^[40]

Interactions with Pathogens and Therapeutics

Peyer's patches serve as primary entry points for various pathogens in the gastrointestinal tract, where microfold (M) cells facilitate antigen sampling and invasion. Salmonella typhi, the causative agent of typhoid fever, preferentially invades M cells overlying Peyer's patches, leading to bacterial translocation into underlying lymphoid tissues and systemic dissemination.^[41]^[42] Similarly, Yersinia enterocolitica exploits dendritic cells within Peyer's patches to evade immune detection and promote bacterial survival and replication following initial uptake by M cells.^[43]^[44] Norovirus, a major cause of gastroenteritis, replicates efficiently in the follicle-associated epithelium (FAE) of Peyer's patches, particularly in macrophages and dendritic cells, enabling viral spread and persistent infection.^[45]^[46] Oral vaccines leverage Peyer's patches to elicit robust mucosal immunity, as these structures are key inductive sites for secretory IgA production. The oral poliovirus vaccine (OPV), for instance, induces strong intestinal immunity by replicating in Peyer's patch-associated cells, generating T-cell and B-cell responses that prevent viral dissemination.^[47]^[48] Peyer's patches are also targeted by adjuvants in mucosal vaccine formulations to enhance antigen uptake via M cells, promoting both local IgA and systemic responses for protection against enteric pathogens.^[49]^[50] Therapeutic strategies increasingly focus on modulating Peyer's patch function to treat inflammatory conditions. Anti-tumor necrosis factor (TNF) therapies, such as infliximab, reduce inflammation in Crohn's disease by suppressing proinflammatory cytokine production.^[51] Nanoparticle-based delivery systems exploit M cells in Peyer's patches for targeted transport of gut-specific drugs, enabling controlled release and minimizing systemic exposure in conditions like inflammatory bowel disease.^[52]^[53] Recent research highlights Peyer's patches in broader neuro-immune interactions, particularly in Parkinson's disease pathogenesis. Studies indicate pathological alpha-synuclein aggregates can be taken up by immune cells in the gut and transported via vagal afferents to the brain, contributing to neuroinflammation and disease progression.^[54] Additionally, microbiota modulation using probiotics targets Peyer's patches to restore immune function in inflammatory bowel disease (IBD), with specific strains enhancing B-cell subsets and IgA production to maintain epithelial integrity.^[55]^[56] Dysbiosis induced by antibiotics disrupts Peyer's patch homeostasis, leading to lymphoid atrophy and compromised barrier function. Early-life antibiotic exposure, for example, impairs germinal center formation in Peyer's patches and increases intestinal permeability, heightening susceptibility to infections.^[57]^[58]

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