Berberine rescues PANoptosis-Driven hemophagocytic lymphohistiocytosis via cardiolipin-mediated mitochondrial stabilization.

Pyroptosis, apoptosis, and necroptosis can converge through a unified inflammatory cell death pathway termed PANoptosis, which plays a pivotal role in the pathogenesis of diverse inflammatory disorders. The isoquinoline alkaloid berberine (BBR) is known to suppress pyroptosis and NLRP3 inflammasome activation, yet its impact on the broader process of PANoptosis remains undefined. In this study, PANoptosis was induced in murine macrophages using poly(I:C) and LPS, and mechanistic insights were investigated by immunoblotting, immunofluorescence, and co-immunoprecipitation. The therapeutic potential of BBR was further evaluated both in vitro and in a mouse model of hemophagocytic lymphohistiocytosis (HLH) in vivo. We identified mitochondrial permeabilization as an early and essential event in PANoptosis. The translocation of gasdermin D N-terminal (GSDMD-NT), gasdermin E N-terminal (GSDME-NT), and phosphorylated mixed lineage kinase domain-like pseudokinase (p-MLKL) to mitochondria disrupted mitochondrial integrity in a manner dependent on cardiolipin synthesis. Notably, BBR inhibited this translocation, thereby preventing mitochondrial permeabilization, preserving mitochondrial function, and suppressing the formation of Z-DNA. In addition, BBR blocked PANoptosome assembly and attenuated the activation of downstream PANoptotic signaling cascades. In vivo, intraperitoneal administration of BBR significantly reduced systemic inflammation and protected the liver, lungs, and kidneys from HLH-associated damage, effects that correlated with diminished PANoptotic activation and Z-DNA accumulation in target organs. Together, these findings uncover a previously unrecognized mitochondrial mechanism underlying PANoptosis execution and demonstrate that BBR can effectively inhibit this process. Our results highlight BBR as a promising therapeutic candidate for the treatment of PANoptosis-driven inflammatory diseases including HLH.