ESAT-6家族在结核病方面的研究进展

结核病（tuberculosis，TB）是一种由结核分枝杆菌（Mycobacterium tuberculosis，MTB）引起的慢性传染病，已成为危害人们身体健康的最严重的疾病之一。现在用于预防结核病感染的唯一疫苗是卡介苗（Bacille Calmette Guerin，BCG），但其免疫保护效果不同地区存在着差异。对患有免疫功能严重损害的患者如AIDS、移植和肿瘤化疗后接种卡介苗，可能会导致严重的播散，所以改善卡介苗和开发新疫苗是必要的。     

结核病疫苗的抗结核免疫机制的研究进展

结核病是由结核分枝杆菌(Mycobacterium Tuberculosis,MTB)所引起的一种慢性传染病,严重危害人类健康,是目前全球范围内,尤以发展中国家为首,是受危害最为严重的慢性传染病之一。目前,预防结核病最常见且有效的疫苗是卡介苗(Bacillus Calmette-Guérin,BCG),但由于其对成人肺部结核保护作用的不确定性,再加上外界因素的改变也使卡介苗难以满足人类预防结核病的迫切需求,因此,新型抗结核疫苗的研发显得格外紧迫和重要。本文将介绍减毒活疫苗VPM1002疫苗,蛋白质/佐剂疫苗H4/H56:IC31疫苗,病毒载体疫苗腺病毒载体疫苗和其他已经进入临床试验的疫苗,以及一些尚在研究的抗结核免疫机制的研究现状,为以后的结核病防治提供参考。     

ag85a-卡介苗重组疫苗的构建、免疫原性及抗结核作用的初步研究

目的构建结核分枝杆菌ag85a-卡介苗重组疫苗,研究其免疫原性及抗结核作用,以期获得结核病预防性或治疗性疫苗。方法通过基因工程重组技术将结核分枝杆菌保护性抗原Ag85A的编码基因与穿梭质粒载体pYUB295重组,采用电穿孔技术导入卡介苗中,应用PCR扩增、PAGE电泳鉴定重组卡介苗。通过ELISA法检测其免疫小鼠血清中特异性抗体,用MTS法分析其脾淋巴细胞增殖指数。通过观察ag85a-卡介苗重组疫苗对结核分枝杆菌感染实验动物半数死亡时间、一定时间内的死亡率、大体病变、T细胞及B细胞免疫功能等指标评价ag85a-卡介苗重组疫苗对结核分枝杆菌感染的预防效果。结果PCR扩增、限制性内切酶酶切、DNA测序鉴定、PAGE电泳表明成功地构建了ag85a基因pYUB295重组质粒,Ag85A蛋白在卡介苗中分泌表达。重组卡介苗免疫原性试验表明：ag85a-卡介苗重组疫苗免疫组小鼠有Ag85A特异性抗体产生,45天时达到最高水平。脾淋巴细胞增殖试验表明刺激指数均达2．0以上,ag85a-卡介苗重组疫苗免疫组小鼠脾淋巴细胞的刺激指数与对照组无明显区别。预防试验表明：ag85a-卡介苗重组疫苗组、卡介苗组与生理盐水对照组比都能延长结核分枝杆菌感染小鼠的半数死亡时间,降低2个月内的死亡率。结核分支杆菌攻击后2个月,处死小鼠时,小鼠脏器大体病变、脏器培养、抗体检测结果及淋巴细胞增殖实验表明：各组间无显著差别。结论正确构建了ag85a-卡介苗重组疫苗,ag85a-卡介苗重组疫苗与卡介苗对结核分枝杆菌感染的预防作用基本相同。     

播散性卡介苗感染与遗传性白细胞介素-12/干扰素γ通路缺陷

卡介苗（BCG）是一种来自牛型结核杆菌的减毒活疫苗,BCG接种后一般不会引起严重反应,极少数情况下,卡介菌会进入血液,发生全身性播散,常可致死,称为播散性卡介苗感染。播散性卡介苗感染是最严重的不良反应,有时具有家族性分布,且临床预后不良者较多。播散性卡介苗感染极其[1]     

结核分枝杆菌TB10.4抗原的分子生物学特性研究进展

结核病（tuberculosis,TB）这种古老的慢性人兽共患病,4千多年前就已流行于全球,而且至今仍危胁着全球近1/3人口的健康[1]。自1921年诞生且是当前唯一可行的卡介苗（Bacillus Calmette-Gufirin，BCG），是至今接种人数最多、使用范围最广的疫苗之一，但该疫苗的免疫保护效果并不理想，     

卡介苗不良反应的临床特征及预防

卡介苗（BacilleCalmette-Gu6ri，BCG）是儿童基础免疫疫苗之一，出生后即行接种。由于其具有较强的免疫原性，又是唯一诱导产生局部反应的疫苗，接种部位几乎都出现不同程度的红肿、化脓，还偶发淋巴结炎、全身性播散性感染等严重的异常反应，对受种者造成不同程度的健康损害，     

卡介苗对结核分枝杆菌IFN-γ酶联免疫斑点检测法的影响

目的探讨卡介苗（BCG）对结核分枝杆菌IFN-γ酶联免疫斑点（简称Elispot）检测影响,评价Elispot检测在诊断结核分枝杆菌潜伏感染的价值。方法对98例某高校学生同时进行Elispot检测和PPD皮试,其中27例PPD皮试结果和Elis-pot检测均为阴性的受试者进行卡介苗接种。结果 98例受试者中,48例PPD皮试阳性,13例Elispot检测阳性,两种检测结果比较差异有统计学意义。对上述27例受试者接种BCG后PPD皮试结果全转为阳性,Elispot检测仍为阴性。在BCG接种前后,ESAT-6和PoolA作用下IFN-γ分泌水平均无差异;但在BCG作用下,BCG接种后IFN-γ分泌水平显著高于接种前。结论 Elis-pot检测体外IFN-γ应答反应不受卡介苗接种影响,在诊断结核分枝杆菌潜伏感染的价值优于PPD皮试。     

卡介苗接种对实验结核病影响的研究(一)对豚鼠实验结核病的影响

不做结素试验直接接种卡介苗可以简化许多手续,使接种工作能更容易普及推行(尤其在农村)。但首先必须证实卡介苗接种对已感染者及活动性结核病没有不良作用,而后才能施行。因此,研究卡介苗对于结核病的影响是十分迫切需要。关于这个问题文献上各家意见颇为分岐,某些学者报告口服卡介苗对结素阳性者及活动性肺结核病人安全无害,因而主张不做结素试验直接接种;但亦有卡介苗接种促使结核病变恶化甚至引致死亡的报告。在动物实验方面,柳泽曾报告卡介苗对已感染结核病豚鼠无害,但Jankov报告皮内接种可使豚鼠结核病导致严重恶化,Fitzpatrick 在小白鼠实验上亦证明大量卡介苗对实验结核病有不良影响。     

结核分枝杆菌及结核疫苗新作用方式的研究

结核病主要是由结核分枝杆菌引起的传染性疾病，是严重威胁人类健康的重大公共卫生问题。目前，卡介苗仍是唯一被批准应用于人体的预防性疫苗，其对婴幼儿具有较好的保护效果，但对成年人的保护作用存在巨大争议。巨噬细胞和树突状细胞吞噬结核分枝杆菌之后，启动适应性免疫应答，活化的效应性CD4⁺和CD8⁺T细胞通过释放细胞因子和细胞毒作用发挥免疫效应。然而，结核分枝杆菌可通过抑制吞噬溶酶体形成、改变代谢途径、抑制抗原提呈等作用发生免疫逃逸，使其在宿主体内长期存在。近年来，随着多组学的发展，针对结核分枝杆菌感染免疫机制的研究有了一定的进展，但通过接种疫苗对结核病进行防控的结果依然不尽人意。本文重点探讨了结核分枝杆菌和宿主之间的免疫反应以及逃逸机制，并概述了结核疫苗的研发情况，有助于我们利用结核菌感染的免疫学知识对结核病疫苗进行快速高效的研发。     

卡介苗病2例报告及相关文献复习

卡介苗是一种用来预防儿童结核病的预防接种疫苗,接种后可使儿童产生对结核病的特殊抵抗力,是我国计划免疫的疫苗之一,能有效预防结核病的发生。卡介苗接种的主要对象是新生婴幼儿,卡介苗接种引起异常反应的发生率极低,Lotte对欧洲6国1977～1981年535万接种者的前瞻性研究,     

Isoniazid resistance among Bacillus Calmette Guerin strains: implications on bladder cancer immunotherapy related infections

Bacillus Calmette Guerin (BCG) immunotherapy is widely used for treatment of superficial bladder transitional cell carcinoma. Infectious complications while rare can be serious and severe disseminated infections as well as sepsis has been reported. There are no standard guidelines to direct therapy of these complications. Isoniazid is a commonly and widely used component of the various treatment regimens. Various strains of BCG are used for treatment of bladder cancer as well as vaccinations. These strains have evolved because of repeated subcultures in various laboratories in the world and have been shown to exhibit phenotypic differences in their immunogenicity as well as recently in susceptibility to various antimycobacterial agents. In this article, we review the resistance of BCG strains to various antimycobacterial agents. Some of these strains including the BCG Connaught strain, which is widely used in the United States, Canada and some other parts of the world for bladder cancer therapy exhibit intrinsic resistance to isoniazid. Although the clinical relevance of these differences is unclear, recent studies have questioned the role of isoniazid in treatment of infections after vaccination with these strains. Also, use of isoniazid in combination therapy for these infections may lead to the development of resistance to other antimycobacterial agents. We conclude that isoniazid may not be a suitable agent for empiric treatment of infections related to intravesical immunotherapy for bladder cancer with these strains and further studies are needed to clarify its role.     

Utility of PCR assays for rapid diagnosis of BCG infection in children.

We report Mycobacterium bovis BCG infection in two children vaccinated with BCG (Tokyo strain) on the first day of life. Their diagnoses were made by biopsy of skin lesions and pus from an anterior chest wall abscess, respectively, yielding a positive culture of mycobacteria fully susceptible to rifampicin, isoniazid and ethambutol, but resistant to pyrazinamide. M. bovis BCG was identified by a negative niacin test, absence of nitrate reductase and resistance to pyrazinamide and cycloserine. The diagnoses were further confirmed by a combination of an allele-specific polymerase chain reaction ated strain of Mycobacterium bovis, is the only available vaccine for the prevention of tuberculosis. Although complications are rare after BCG vaccination and the outcome is usually favourable, serious BCG infections can occur. We report two cases of M. bovis BCG infection in children, a 4-year-old immunocompetent girl and an 8-month-old immunodeficient boy. To our knowledge, this is the first report of BCG complications in children in which two recently developed polymerase chain reaction (PCR) based methods were used for rapid identification of M. bovis BCG infection. (PCR) and a multiplex PCR method. Based on the drug susceptibility results, treatment with rifampicin, isoniazid and ethambutol was instituted. One patient (Case 1) improved clinically and is well after treatment. However, the other patient with severe combined immunodeficiency died of disseminated BCG infection in spite of intensive anti-tuberculosis therapy. Although BCG is considered to be a safe vaccine, it should be kept in mind that complications related to BCG do occur.     

Skin complications of Bacillus Calmette-Guérin immunization

PURPOSE OF REVIEW: Bacillus Calmette-Guerin (BCG) vaccination has been performed since 1921, and remains the best method of preventing severe infections caused by Mycobacterium tuberculosis. Tuberculosis, in its various forms, remains a public health problem, and more than 100 countries continue BCG vaccination in an effort to control the disease. Since the initiation of BCG vaccination, numerous complications have been reported. In this review we will focus on the cutaneous complications of BCG vaccination. RECENT FINDINGS: Recent case reports detail the development of large keloids, and also of juvenile sarcoidosis after BCG vaccination. Adverse outcomes from inadvertent intradermal injection of the forearm and from revaccination with BCG have also been reported. Other recently described skin complications subsequent to BCG vaccination include lupus vulgaris, delayed granuloma formation, cutaneous BCG infection in immune disorders, anterior chest wall mass, acute erythroderma with multiple skin abscesses, ulceration at the BCG site during Kawasaki disease, fixed drug eruption, and cutaneous abscesses following mesotherapy. SUMMARY: BCG vaccination will continue to be a key method of preventing severe tuberculosis infections for the foreseeable future. The World Health Organization currently recommends BCG vaccination for all infants living in tuberculosis endemic areas. As such, it is important for health care providers to recognize the routinely anticipated cutaneous findings of the vaccination, in addition to complications relating to the injection. Subsequent care of these skin complications is of paramount importance to the health of these patients.     

A case with severe combined immunodeficiency diagnosed with disseminated BCG infection by detecting specific RD gene deletion

Because the Bacillus Calmette-Guérin (BCG) prevents infants from contracting miliary tuberculosis and tuberculosis meningitis, BCG vaccination is recommended for those under 6 months old in Japan. Complications such as favorable local inflammatory reactions including redness, induration, and abscess formation may occur, but severe adverse effects such as osteomyelitis, periostitis, and disseminated BCG infection are generally rare. We report an 11-month-old boy with severe combined immunodeficiency dying of serious disseminated BCG infection despite anti-tuberculosis therapy and blood stem cell transplantation. He was vaccinated with disseminated BCG infection at 4 months before severe combined immunodeficiency diagnosis was confirmed by specific RD gene deletion based on allele-specific polymerase chain reaction. Although BCG is considered safe, we should keep in mind that subjects with immunological deficiency may suffer severe BCG complications.     

Bacillus Calmette-Guérin immunization in infants born to HIV-1-seropositive mothers

During the prospective follow-up of 64 babies at risk for perinatal HIV-1 infection because their mothers were seropositive, and of 130 control babies whose mothers were seronegative, we studied the occurrence of complications of bacillus Calmette-Guérin (BCG) immunization and its ability to induce cutaneous reactivity to tuberculin. Babies born both to HIV-1-positive and HIV-1-negative mothers received BCG immunization during their first month of life according to the Expanded Programme on Immunization (EPI) recommendations. Local and regional complications of BCG vaccine were looked for at 3, 6 and 9 months after inoculation. A tuberculin skin test was performed at 6 or 9 months of age. Most babies born to HIV-1-positive mothers were later classified as infected or uninfected according to their clinical condition and/or serological status at 18 months of age. The mean duration of the follow-up was 36 months (range 30-40 months). No chronic or deep ulcerations at the site of injection or disseminated forms of BCG infection were observed. The frequency of BCG-related lymphadenitis in the group of HIV-1-infected children (24%) did not differ significantly from the group of uninfected children (19%; Fisher test: P = 0.73). In contrast, the tuberculin skin test responses were positive less often in the group of HIV-1-infected children (33%) than in the uninfected group (83%; Fisher test: P = 0.007). Because BCG vaccine appears to be safe--even when given to perinatally infected babies--continuation of the BCG immunization policies of the EPI is justified, especially in view of the growing incidence of tuberculosis as a complication of HIV infection.     

Persistence and boosting of bacille Calmette-Guérin-induced delayed-type hypersensitivity.

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccination may induce persistent and booster purified protein derivative (PPD) responses that complicate tuberculosis screening efforts. OBJECTIVES: To investigate the effects of BCG vaccination on serial PPD tests and to study correlations between persistent delayed-type hypersensitivity and other potential surrogate markers of protective immunity. DESIGN: Cohort study. SETTING: Midwestern urban university. PARTICIPANTS: 69 healthy adults. INTERVENTIONS: BCG vaccination, blood samples drawn for immunologic studies, and PPD tests done sequentially over 1 to 3 years. MEASUREMENTS: Serial PPD induration, lymphoproliferation, and interferon-gamma responses. RESULTS: 10% of participants (95% CI, 4% to 20%) had persistent PPD responses of 15 mm or greater, and 3% (CI, 0% to 10%) demonstrated PPD boosting of 15 mm or greater 1 to 3 years after BCG vaccination. Intradermal BCG vaccination induced a larger number of persistent responses that were 10 mm or greater than did percutaneous BCG vaccination (12 of 46 participants compared with 1 of 23 participants; P = 0.05). Persistent and boosted delayed-type hypersensitivity correlated with mycobacterial-specific lymphoproliferation and interferon-gamma responses. CONCLUSIONS: Previous BCG vaccination reduces the predictive value of serial PPD testing. The lowest PPD predictive values will occur in persons without known tuberculosis exposure who were vaccinated recently or many times with intradermal BCG. In addition, BCG-related persistence and boosting of delayed-type hypersensitivity responses correlate with other potential surrogate markers of protective mycobacterial immunity.     

Bacillus Calmette-Guérin (BCG) Infection Following Intravesical BCG Administration as Adjunctive Therapy For Bladder Cancer: Incidence,Risk Factors,and Outcome in a Single-Institution Series and Review of the Literature

Bacillus Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for superficial bladder cancer. Although generally well tolerated, BCG-related infectious complications may occur following instillation. Much of the current knowledge about this complication comes from single case reports, with heterogeneous diagnostic and therapeutic approaches and no investigation on risk factors for its occurrence. We retrospectively analyzed 256 patients treated with intravesical BCG in our institution during a 6-year period, with a minimum follow-up of 6 months after the last instillation. We also conducted a comprehensive review and pooled analysis of additional cases reported in the literature since 1975. Eleven patients (4.3%) developed systemic BCG infection in our institution, with miliary tuberculosis as the most common form (6 cases). A 3-drug antituberculosis regimen was initiated in all but 1 patient, with a favorable outcome in 9/10 cases. There were no significant differences in the mean number of transurethral resections prior to the first instillation, the time interval between both procedures, the overall mean number of instillations, or the presence of underlying immunosuppression between patients with or without BCG infection. We included 282 patients in the pooled analysis (271 from the literature and 11 from our institution). Disseminated (34.4%), genitourinary (23.4%), and osteomuscular (19.9%) infections were the most common presentations of disease. Specimens for microbiologic diagnosis were obtained in 87.2% of cases, and the diagnostic performances for acid-fast staining, conventional culture, and polymerase chain reaction (PCR)-based assays were 25.3%, 40.9%, and 41.8%, respectively. Most patients (82.5%) received antituberculosis therapy for a median of 6.0 (interquartile range: 4.0–9.0) months. Patients with disseminated infection more commonly received antituberculosis therapy and adjuvant corticosteroids, whereas those with reactive arthritis were frequently treated only with nonsteroidal antiinflammatory drugs (p < 0.001 for all comparisons). Attributable mortality was higher for patients aged ≥65 years (7.4% vs 2.1%; p  = 0.091) and those with disseminated infection (9.9% vs 3.0%; p = 0.040) and vascular involvement (16.7% vs 4.6%; p = 0.064). The scheduled BCG regimen was resumed in only 2 of 36 patients with available data (5.6%), with an uneventful outcome. In the absence of an apparent predictor of the development of disseminated BCG infection after intravesical therapy, and considering the protean variety of clinical manifestations, it is essential to keep a high index of suspicion to initiate adequate therapy promptly and to evaluate carefully the risk-benefit balance of resuming intravesical BCG immunotherapy.     

Impfung gegen Tuberkulose

Efforts over the last two decades have led to a rich research and development pipeline of tuberculosis (TB) vaccines. Although none of the candidates has so far successfully completed the clinical trial pipeline, many are in advanced stages of clinical assessment. These vaccines aim at prevention of active TB with most being considered for pre-exposure with recent additions for postexposure or multistage administration. Some therapeutic vaccines are also in the stage of clinical assessment. Preexposure vaccination with the licensed TB vaccine BCG (Bacillus Calmette-Guérin) prevents severe forms of TB in children but not in adolescents and adults. The current vaccine pipeline does not include strategies which prevent or eliminate infection with the causative agent Mycobacterium tuberculosis (Mtb). In a best-case scenario they are quantitatively superior to BCG in preventing active TB over prolonged periods of time, ideally lifelong in the face of latent Mtb infections. Qualitatively superior vaccines should be capable of preventing or eliminating Mtb infections and in this way eliminate the risk of TB reactivation. The time is now ripe to exploit radically new strategies to achieve this goal.     

Safety of biologic therapies during pregnancy in women with rheumatic disease

Inflammatory rheumatic diseases frequently affect women of childbearing age. Biologic therapy during pregnancy is an important topic that is yet unresolved. The majority of documented experiences are in case series, case reports, or registries. Tumor necrosis factor (TNF) inhibitors are now better known. Some evidence suggests that it is possible that differences between drugs regarding safety are associated with the structure and capacity to cross the placenta, but we are not aware of any study that supports unequivocally this statement. Most of the monoclonal antibodies are actively transferred to fetal circulation using the neonatal Fc receptor. Although this transfer does not appear to be associated with the risk of miscarriage, stillbirth, or congenital abnormality, the rate of premature births and lower birth weight may be increased. During fetal development, the neonatal period, and childhood, the immune system is constantly maturing. The ability to produce cytokines in response to infectious stimulus remains low for years, but is similar to that of an adult around the age of 3 years owing to the adaptive nature of the newborn’s immune system as a result of exposure to microbes. Therefore, exposure to TNF inhibitors may have serious consequences on the newborn, such as severe infections or allergic reactions. Regarding the former, an anecdotal case report described a fatal case of disseminated bacillus Calmette-Guérin (BCG) infection in an infant born to a mother taking infliximab for Crohn’s disease. Although the baby was born and progressed well initially, he died at 4.5 mo after he was vaccinated with BCG. Fortunately, serious infections do not appear to be frequent in newborns exposed to in utero biologic therapy. However, very limited short-term experiences are available regarding complications in an exposed fetus, and no data are available about long-term implications on the child’s developing immune system. Therefore, we must be aware of potential complications in later years. Although the clinical data to date are promising, no firm conclusions can be drawn about the safety of biologic drugs during pregnancy, and, without further evidence, guidelines that suggest these drugs should be avoided at the time of conception cannot yet be changed.     

Anti-tuberculosis drug susceptibility testing of Mycobacterium bovis BCG Tokyo strain.

SETTING: The Mycobacterium bovis bacille Calmette-Guérin (BCG) vaccine is the only vaccine against tuberculosis (TB), owing to its valuable protective effects and low virulence. However, it can occasionally cause systemic infection in immunocompromised hosts. Isoniazid (INH), rifampicin (RMP), streptomycin (SM) and ethambutol (EMB) are known to be effective anti-tuberculosis drugs and are used for the treatment of BCG infections. Unfortunately, there are few studies of the susceptibility of BCG vaccine strains to these drugs. OBJECTIVE: To measure the minimum inhibitory concentrations (MICs) of BCG Tokyo vaccine products for anti-tuberculosis drugs and assess vaccine safety in terms of drug susceptibility. DESIGN: We measured the MIC for one seed and five product lots of BCG Tokyo strain for INH, RMP, SM and EMB using Middlebrook 7H11 agar plates. RESULTS: The MIC results for INH were 0.06 and 0.125 mg/ml for the product and seed lots, respectively. The MIC results for RMP, SM and EMB were 0.25-0.5, 0.25 and 2-4 microg/ml, respectively. CONCLUSION: Our results indicate that the BCG Tokyo strain was susceptible to the major anti-tuberculosis drugs and treatable even in cases of severe adverse events, including systemic infection.