Circulating cytokine profiles in leprosy patients

BACKGROUND: Leprosy is a chronic infectious disease caused by Mycobacterium leprae which is an obligate intracellular pathogen. It is characterised by a broad spectrum of clinical forms dictated by the patient's immune response to the organism. The tuberculoid pole has good cell mediated immunity to M. leprae, with few lesions and bacilli while the lepromatous pole has poor immunity coupled with extensive involvement and greater bacillary load. METHODS: We studied serum levels of interferon gamma and interleukin 6 in 100 patients of untreated leprosy, compared them with 30 age and sex matched normal healthy controls and co-related them with different parts of the spectrum and reactional episodes. The purpose of this study was to delineate the role of cytokines and their clinical implications in the leprosy spectrum and during reactional episodes. RESULTS: We observed that mean cytokine levels were significantly higher in the patient group as compared to the controls. In the non reactional patient group, pure neuritic leprosy patients showed highest levels of INFgamma which were directly proportional to the extent of nerve involvement. Lepromatous leprosy patients had the highest levels of IL6. Bacteriological index demonstrated a negative and positive corelation with INFgamma and IL 6 levels respectively. Type I and Type II reactional patients had higher levels of INFgamma and IL 6 respectively as compared to nonreactional patients. CONCLUSIONS: Our results suggest that pure neuritic leprosy and borderline tuberculoid patients in type I reaction are at greatest risk for nerve and tissue damage. Thus cytokines have the potential to play a significant role in classification, prognosis and treatment of leprosy.     

Cytokines in leprosy, I. Serum cytokine profile in leprosy

Background Leprosy is a chronic infectious disease characterized by a broad spectrum of clinical forms depending on the patient's immune response, in particular cell-mediated immune response. Methods Cytokines can play a role in the cell-mediated immune response. Serum levels of interferon-gamma (IFN-γ), interleukin-2 (IL-2), interleukin-2 receptor (IL-2R), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-α), and interleukin-1beta (IL-1β) were measured by enzyme-linked immunosorbent assay (ELISA) in 55 untreated leprosy patients and 35 reactional leprosy patients, in addition to 20 age- and sex-matched healthy controls. Results Leprosy patients showed significantly higher serum levels of the studied cytokines (except IL-2) compared with healthy controls. When the two poles were compared, tuberculoid leprosy (TT) patients showed significantly higher levels of IFN-γ and TNF-α with significant negative correlations with the bacterial index (BI), whereas lepromatous leprosy (LL) patients showed significantly higher serum levels of IL-2R, IL-10, and IL-1β with significant positive correlations with the BI. Both type I and type II reactional patients showed significantly higher serum IFN-γ, IL-2R, and IL-1β, in addition to IL-10 in type II reactional patients, compared with nonreactional leprosy patients. When compared with each other, type I reactional patients showed increased levels of IFN-γ, whereas type II reactional patients showed increased levels of IL-10. Conclusions In leprosy patients, both IFN-γ and TNF-α are immunoprotective, whereas IL-2R, IL-10, and IL-1β are immunosuppressive. Our results indicate that type I reaction, with increased levels of IFN-γ, is a cell-mediated immune response, whereas type II reaction, with increased levels of IL-10, is essentially an immune complex disease.     

T regulatory cells (TREG)(TCD4+CD25+FOXP3+) distribution in the different clinical forms of leprosy and reactional states

BACKGROUND

Leprosy is characterized histologically by a spectrum of different granulomatous skin lesions, reflecting patients'' immune responses to Mycobacterium leprae. Although CD4+CD25+ FoxP3+ T regulatory cells are pivotal in the immuneregulation, presence, frequency, and distribution of Tregs in leprosy, its reactional states have been investigated in few studies.

OBJECTIVES

This study aimed to verify the frequency and distribution of regulatory T cells in different clinical forms and reactional states of leprosy.

METHODS

We performed an immunohistochemical study on 96 leprosy cases [Indeterminate (I): 9 patients; tuberculoid tuberculoid: 13 patients; borderline tuberculoid: 26 patients; borderline borderline: 3 patients; borderline lepromatous: 8 patients; lepromatous lepromatous: 27 patients; reversal reaction: 8 patients; and erythema nodosum leprosum: 2 patients].

RESULTS

FoxP3-positive cells were present in 100% of the cases with an average density of 2.82% of the infiltrate. Their distribution was not related to granulomatous structures or special locations. There was a statistically significant increment of FoxP3 expression in patients with leprosy reversal reactions when compared with patients presenting with type I leprosy (P= 0.0228); borderline tuberculoid leprosy (P = 0.0351) and lepromatous leprosy (P = 0.0344).

CONCLUSIONS

These findings suggest that Tregs play a relevant role in the etiopathogenesis of leprosy, mainly in type I leprosy reaction.     

Mast cells in leprosy and leprosy reaction

BACKGROUND: Mast cells can be visualized in routine, acid-fast-staining, paraffin tissue section as metachromatic staining cells, and can be activated to release inflammatory mediators which play a role in the cell-mediated immune response. METHODS: Skin biopsy tissues were taken from the most active skin lesion of each leprosy patient at the time of diagnosis (nonreactional group) and at the time of reaction (reactional group) during the years 1994-1997 in the leprosy clinic at the Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand. Mast cells were identified by metachromatic staining (purple) in Fite's stain sections and reported as the average number of cells per high power field in three compartments: at the center and periphery of the granuloma and in the interstitium. The data were analyzed in three groups: nonreactional group, type I, and type II leprosy reactions. The mast cell count of each group and each compartment of the section, expressed as the mean +/- standard error, was compared. RESULTS: A total of 95 persons were included in the study, but 108 tissue sections were obtained due to nine cases having more than one section. Of these patients, 63 cases (66.32%) had no reaction, 19 cases (20%) had type I reaction, and 13 cases had type II reaction. There was no difference in age and sex among these groups. The mast cell count in the interstitium was higher than that within the granuloma, both at the center and at the periphery, in every type, and the count in this area reduced significantly in leprosy reactions, both type I and type II, compared with the nonreactional group. CONCLUSIONS: The change in the average mast cell number in nonreactional leprosy and leprosy reactions may indicate the important role of mast cells in dynamic changes in the cell-mediated immune response in leprosy and leprosy reactions.     

Erythema nodosum leprosum: reactional leprosy

The different clinical forms of leprosy are mainly related to the variety of immunological responses to the infection. Thus, lepromatous leprosy occurs in patients with a poor cell-mediated immunity to Mycobacterium leprae, whereas tuberculoid leprosy is associated with a high resistance to leprosy bacillus. Intermediate forms, including borderline tuberculoid leprosy, borderline lepromatous leprosy, and borderline leprosy, are a continuous and unstable spectrum of the disease. Leprosy reactions are rare and not well-known states that interrupt the usual chronic course and clinical stability of patients with leprosy. They are expressions of immunological perturbations. Attending to the clinical and histopathological manifestations, leprosy reactions may be separated in 2 or 3 different variants: reverse reaction (type I), erythema nodosum leprosum (type II), erythema polymorphous (type II) and Lucio's phenomenon, mainly considered a type II reaction, but sometimes designated type III. Type I leprosy reaction, also named "upgrading reaction," occurs in borderline leprosy states and is associated with a shift toward the tuberculoid pole. Type II reaction usually occurs in lepromatous leprosy, and there are 3 different clinical variants, including erythema nudosum leprosum, erythema polymorphous-like reaction, and Lucio's phenomenon.     

Thyroid function in leprosy

Thyroid function tests were carried out in 43 cases of leprosy. The study subjects included cases of tuberculoid, borderline and lepromatous leprosy and those with lepra reaction. The parameters studied included serum cholesterol, protein bound Iodine, serum T3 level and serum T4 levels. The levels of serum cholesterol and protein bound Iodine were normal in all the four groups of leprosy patients. However, the mean serum T3 and T4 were low in all the four groups. The difference in the levels of serum T3 was statistically significant only in the lepra reaction group. The levels of T4 were statistically significantly decreased in borderline leprosy, lepromatous leprosy and in lepra reaction.     

Immunomodulation with corticosteroids and levamisole in leprosy as gauged by in vivo lepromin and in vitro CMI responses

Corticosteroids and Levamisole are known to be immuno suppressive and immuno stimulating agents respectively. Their effects on polar types of leprosy, tuberculoid and lepromatous have been studied using in vivo lepromin and in vitro lymphocyte count, rosette formation, L.T.T. and L.M.I.T. parameters. Immunosuppressive effect of corticosteroids on tuberculoid leprosy is marked with reduced and negative lepromin sensitivity but same does not hold true with other in vitro C.M.I. tests. Similar results are obtained with levamisole exhibiting its ineffectiveness in lepromin conversion in lepromatous cases although some improvement is observed in other in vitro C.M.I. tests. Evaluation of the results showed: lack of correlation between in vivo lepromin and in vitro other C.M.I. parameters with corticosteroids and levamisole lepromin sensitivity has some unknown influence other than thymic factors, prolonged corticosteroid therapy may produce permanent immunosuppression in tuberculoid cases making them more vulnerable towards lepromatous pole and lepromin sensitivity is more reliable, stable and easy to perform.     

Cojedes: a leprosy hyperendemic state

Background Leprosy is a chronic infectious disease produced by Mycobacterium leprae. In 1997 Venezuela reached the goal of elimination of leprosy as a public health problem (according to the World Health Organization a prevalence rate of ≤1/10,000 inhabitants), but five states still had prevalence rates over that goal. For this study we selected Cojedes State, where prevalence rates remain over the elimination goal. Objective Evaluate the real leprosy situation in high‐prevalence areas of Cojedes State. Materials and methods Seven communities of Cojedes State were selected because they had the highest historic prevalence, as well as the highest prevalence in the year to be studied (1997). Results A rank correlation using Spearman’s test comparing historical prevalence rates (1946–1996) and detection rates (1998–2004) gave a statistically significant P < 0.05 value. Diagnosed leprosy cases were as follows: age: 3.2% under 15 years old; sex: male/female rates between 60% and 91.66% males. The highest number of cases were paucibacillary forms: indeterminate leprosy (33.07%) and borderline tuberculoid leprosy (32.28%); tuberculoid leprosy (7.00%); and multibacillary cases (lepromatous leprosy, LL) were only 2.36%. Bacteriologically, 18.52 patients were M. leprae positive. At the moment of diagnosis, 96.6% showed no disabilities, 3.4% showed grade I disabilities, and there were no grade II or III disabilities. Conclusion This study confirms that several communities in Cojedes State have extremely high leprosy rates.     

Serological pattern of hepatitis B virus markers (HBsAg, anti-HBs, IgM anti-HBc and HBV specific DNA polymerase) in leprosy patients

Sera of 134 lepromatous (LL/BL) and 57 tuberculoid (TT/BT) leprosy patients were analysed for four HBV markers. HBsAg was detected in 6.71% of lepromatous and 3.5% of tuberculoid sera. The per cent positivity of lepromatous and tuberculoid sera for anti-HBs antibodies was 30.59% and 35.08%, respectively. The positivity of normal sera for HBsAg and anti-HBs was 3.60% and 21.69%, respectively. The difference in the positivity of three groups of sera (lepromatous, tuberculoid and normal) for HBsAg or anti-HBs was not statistically significant. Anti-HBc (IgM) antibodies were detected in 6% of lepromatous sera. HBV-specific DNA-polymerase activity was found in 22.22% of HBsAg positive (but anti-HBc negative) sera, and 66.66% of anti-HBc positive (but HBsAg negative) sera. The pattern of acute HBV infection in leprosy patients followed the typical pattern prevalent in the normal population.     

Alpha-1-antitrypsin in leprosy

Estimation of Alpha-1-antitrypsin (AAT) levels was carried out in 52 patients of various types of leprosy. Fifty age and sex matched healthy individuals served as controls. The mean level of AAT in controls was 290.12 +/- 59.56 mg/dl. In patients of tuberculoid leprosy (TT), borderline tuberculoid leprosy (BT) and borderline leprosy (BB), the AAT levels were found to be 284 +/- 47.03, 314.37 +/- 31.56 and 324.44 +/- 32.05 mg/dl respectively. These were statistically insignificantly raised when compared with controls. In borderline lepromatous leprosy (BL), lepromatous leprosy without erythema nodosum leprosum (LL without ENL) and in LL with ENL there was a statistically significant rise in AAT levels. The maximum levels of AAT were observed in patients of LL with ENL (mean 500.8 +/- 93.44 mg/dl. P less than 0.001).     

S-100 as a useful auxiliary diagnostic aid in tuberculoid leprosy

BACKGROUND: The diagnosis of tuberculoid leprosy is often difficult on hematoxylin and eosin (H&E) due to the absence of demonstrable nerve destruction. This study evaluates the utility of S-100 staining in identifying nerve fragmentation and differentiation of tuberculoid leprosy from other cutaneous granulomatous diseases. METHODS: Fifty cases of leprosy including 38 borderline tuberculoid (BT), two tuberculoid (TT), and 10 indeterminate leprosy (IL) were studied. Eleven controls of non-lepromatous cutaneous granulomatous lesions were included. S-100 was used for identifying the following dermal nerve patterns: infiltrated (A), fragmented (B), absent (C), and intact (D) nerves. RESULTS: On H&E, only 18/38 (47.4%) BT cases and 1/2 (50%) TT cases revealed neural inflammation. On S-100 staining of BT cases, 28/38 (73.7%) showed pattern B followed by patterns C and A in 8/38 (21.1%) and 2/38 (5.3%) cases, respectively. Both the TT cases showed pattern B. Only intact nerves (D) were seen in all the control cases. S-100 identified nerve damage in 4/10 (40%) IL cases. The patterns A, B, and C had sensitivity, specificity, and positive and negative predictive values of 100% in diagnosing tuberculoid (BT + TT) leprosy. CONCLUSIONS: S-100 is superior to H&E in identifying nerve fragmentation (p < 0.01). It also aids the differential diagnosis of tuberculoid leprosy.     

Bedside urinalysis in untreated leprosy patients

The study included 53 patients of untreated leprosy attending University Hospital, Banaras Hindu University during study period of 1 1/2 years. The various types of leprosy included 9,14,16 and 14 cases of tuberculoid, borderline, lepromatous and leprosy with type II reaction respectively. Majority of the patients were below the age of 49 years with male preponderance. 66.04% of patients came from the rural area. Painful micturation (dysuria) (13.20%) was the commonest urinary complaint recorded on enquiry. Specific gravity of urine did not show any change. Abnormal proteinuria was noted in 16.98%, 11.32%, 7.54% and 3.77% of patients of leprosy with reaction, lepromatous, borderline and tuberculoid group respectively. Significant haematuria, pyuria and epithelial cells were noted in all the groups. Haematuria was recorded in focal segmental Glomerulonephritis (GN), mesangioproliferative and diffuse endocapillary Glomerulonephritis (GN) incidence of which was 7.89%, 7.89% and 5.26% respectively in the biopsy tissue. Significant pyuria was noticed in all the groups except minimal change GN.     

麻风患者甲皱微循环的研究

应用自制的毛细血管镜,对瘤型、界线类和结核样型麻风共56例,进行甲皱微循环观察.发现麻风患者除临床上有皮肤和神经病变外,约80%的病例有毛细血管拌形态上的异常.血液流态亦有较明显的改变.这些变化主要见于瘤型麻风,界线类和结核样型麻风依次减轻.而瘤型麻风晚期又比早期为重.经分析.作者认为甲皱微循环的异常主要取决于麻风的病型和病期.而与爪手畸形的关系不大.     

Lucio leprosy with lucio phenomenon

Leprosy is one of the commonly seen disease in any dermatology outpatient department in our country. India accounts for a major portion of the leprosy patients in the world. All types of the disease, such as tuberculoid, borderline, lepromatous, neuritic and indeterminate leprosy, are seen. However, "lucio leprosy" which is considered a special type of lepromatous leprosy characterised by diffuse involvement has not been reported from India. We are presenting here two cases of "lucio leprosy" with "lucio phenomenon", the lucio phenomenon being a special type of lepra reaction seen in lucio leprosy.     

Associations between human leukocyte antigens and leprosy in the Turkish population

Leprosy is a chronic infection caused by an intracellular microorganism. Genetic predisposition to both disease susceptibility and to host immunological response has been postulated for many years. The aim of this study was to determine whether there is HLA-linked susceptibility to leprosy and its different types. HLA-class I (A, B, C) and II (DR, DQ) antigen frequencies in 80 patients with leprosy (35 borderline lepromatous, 25 lepromatous, 15 borderline tuberculoid, five tuberculoid) were compared with those in 120 healthy individuals. HLA-class I antigens A9, A10, A32, B5, B21, Bw4, Bw6, Cw1, Cw2 and HLA-class II antigens DR9, DR10, DRw52, DQ1, DQ3 were found to be significantly more frequent in patients with leprosy, whereas HLA-class I antigens A3, B44, B49 and HLA-class II antigen DQ5 were so in controls. However, there was no significant difference in HLA-class I and II antigen frequencies between subtypes of leprosy. HLA-A null antigen was found to have weak expression in patients with leprosy. In conclusion, factors other than HLA-class I and class II antigens may have a more critical role in the pathophysiology of leprosy infection in man.     

Hormone profile in leprosy

Hormone profile were carried out in 35 male cases of leprosy. They were divided into tuberculoid leprosy, borderline leprosy, lepromatous leprosy and lepra reaction. Serum testosterone, follicle-stimulating hormone, Luteinizing hormone, and Oestradiol level were measured in these cases of leprosy. It was observed that serum testosterone were significantly low in lepromatous leprosy (P less than 0.001) and lepra reaction (P less than 0.01). The serum levels of follicle-stimulating hormone and luteinizing hormone were significantly high in lepromatous leprosy (P less than 0.02) and lepra reaction (P less than 0.05). Serum Oestradiol was raised in approx. 60% cases in borderline leprosy, lepromatous leprosy and lepra reaction.     

Glucose tolerance test in leprosy

Glucose tolerance test was carried out in 43 cases of leprosy. They included cases of tuberculoid, borderline, lepromatous leprosy and those with lepra reaction. It was observed that normal curve was common in tuberculoid leprosy. Flat glucose tolerance curve was observed in borderline and lepromatous leprosy. However, the diabetic curve was common in Lepra reaction. Fasting blood sugar was low in lepromatous leprosy and it tended to be marginally high in lepra reaction. Normal GTT response was observed in those with duration of disease between 0-6 months, flat curves in those with duration of disease between 7-12 months while diabetic curve was more common in those with disease duration of more than 2 years.     

Evaluation of audiovestibular status in leprosy

One hundred twenty five cases of lepromatous leprosy and 25 cases of tuberculoid leprosy were investigated for audiovestibular status. Impaired hearing was detected in 52 percent and vestibular hypofuction in 7.2 per cent of lepromatous cases. Conductive deafness was due to eustachian tube catarrh secondary to atrophic rhinitis associated with the disease. The perceptive deafness and vestibular hypofuction were due to end organ lesion probably due to E.N.L. reaction. The vestibulococlear nerve involvement was considered to be unlikely. In tuberculoid leprosy derangement in hearing was not observed in any cases.     

LDH isozymes with anomalous bands in semen of leprosy patients

Activity of LDH isozymes was evaluated electrophoretically on 7% acrylamide gel in semen of 37 leprosy patients (15 with borderline, 12 with borderline tuberculoid and ten with lepromatous leprosy) and ten fertile men of 30-45 years of age. Significantly lower activities were recorded of LDH1 in all categories of leprosy patients. Similarly, lowering of LDH2 activity was noticed in borderline and lepromatous cases only, lowering of LDH4 activity in lepromatous cases only and LDH5 activity was lowered in borderline leprosy patients. Lowest activity of LDH3 and absence of LDHx were found in lepromatous leprosy. However, in borderline tuberculoid patients, LDH3 and LDHx were significantly higher. This exceptional increase in activity was found to be due to presence of additional (anomalous) isozymes bands of LDH3, LDHx and LDH4 in 25% of borderline tuberculoid patients. Additional bands of LDH3 have also been located in 40% of the borderline leprosy patients.     

Adreno-cortical function in leprosy

Adreno cortical function was carried out in 43 cases of leprosy. These cases were further divided into tuberculoid, borderline, lepromatous and Lepra reaction. Serum and urinary electrolyte, urinary 17-Ketosteroid and 17-Ketogenic steroid and plasma cortisol levels were measured to assess the adrenocortical status in these different forms of leprosy. It was observed that these parameters were within normal limit in tuberculoid leprosy except low value of urinary 17-Ketogenic steroid. The borderline and Lepromatous leprosy cases revealed low values of urinary sodium, potassium and 17-Ketogenic steroid and high level of serum potassium. However, the cases of lepra reaction revealed low value of serum and urinary sodium and potassium, urinary 17-Ketogenic steroid. The basal plasma cortisol level was high in this group but it was statistically insignificant.