Evaluation of enzyme immunoassays using purified protein derivative (PPD) and its pooled fractions 3 and 4 for diagnosis of pulmonary tuberculosis

A critical evaluation of two enzyme immunoassays (EIAs) for diagnosis of pulmonary tuberculosis is reported. Purified protein derivative (PPD) or its pooled fractions 3 and 4 were used as antigens for detection of antibodies in sera from 53 patients with active pulmonary tuberculosis and 10 normal healthy individuals. The cut-off point for each EIA was based on the absorbance (mean + 3 SD) of normal sera with the respective antigens. All the normal sera were negative in both the assays. The positivity of tuberculosis patients in either assay was 86.8 per cent. Thus, for serodiagnosis of tuberculosis fractions 3 and 4 of PPD could serve as a good substitute for whole PPD. Sera from 45 leprosy patients were also analysed to assess the specificity of the EIAs. The mean reactivity of tuberculoid leprosy sera was comparable to that of normal sera. The ratio of the mean absorbance of lepromatous leprosy (LL) sera and normal sera was 16.73 with PPD, in comparison to 21.95 for pooled fractions 3 and 4. Out of 10 LL patients 9 (90%) were positive with fractions 3 and 4, in comparison to 10 (100%) with PPD. 71.1 per cent of leprosy patients belonging to different categories were positive in assay based on PPD in comparison to 64.4% in EIA using fractions 3 and 4. The high false positivity of leprosy sera in an assay designed for detection of pulmonary tuberculosis has immense implications in interpretation of results of the assay for diagnostic and epidemiological purposes.     

Cell-mediated immunologic status of healthy members of families with a history of leprosy.

The cell-mediated immune status of 20 apparently healthy children from families with a history of leprosy has been studied. They have been compared with 20 age- and sex-matched controls from families with no history of leprosy. Lymphocyte transformation tests using PHA, PPD and lepromin and skin tests to lepromin, PPD and candida were carried out. No evidence of a depression of cell-mediated immunity in the children from families with leprosy was obtained. The only two children giving a negative Mitsuda lepromin skin test both subsequently developed leprosy in the succeeding 16 months. One was classified histologically as indefinite lepromatous and the other as borderline lepromatous. This emphasizes the practical significance of a negative lepromin skin test in an endemic leprosy area as a prognosis of clinical lepromatous leprosy.     

Antibodies to a synthetic analog of phenolic glycolipid-I of Mycobacterium leprae in healthy household contacts of patients with leprosy

Fifty-four household contacts of lepromatous patients, 39 household contacts of tuberculoid patients, and 99 control persons were examined with an enzyme-linked immunosorbent assay for their antibody responses to phenolic glycolipid-I (PGL-I) of Mycobacterium leprae using a synthetic analog (PGL-ISA) with the same terminal sugar epitope, namely, O-(3, 6-di-O-methyl-beta-D-glucopyranosyl)-(1----4)-O-(alpha-L-rhamnopyranosyl )-(1----9)-oxynonanoyl-BSA. This study was conducted in the Gurage area of Ethiopia in 15 households with a leprosy patient and 15 matched control households. Household contacts with more than 1 year of exposure to a lepromatous patient had antibodies to PGL-ISA significantly more often (19 of 34 persons) than did household contacts with less than 1 year of exposure to a lepromatous patient (4 of 20 persons), household contacts of tuberculoid patients (8 of 39 persons), and persons without exposure to leprosy in the household (33 of 99 persons). No significant association was found between the prevalence of antibodies to PGL-ISA in the household contacts and disease activity in the lepromatous index patients at the time of examination; nor was there a significant association between antibody responses and age or sex of the contacts. The increased prevalence of antibodies to M. leprae antigen in healthy persons with more than 1 year of contact with a lepromatous patient provides further evidence that subclinical infection in leprosy is common, and is related to the type of leprosy in the index patient. The fact that antibodies to PGL-ISA were detected in one third of the persons without household exposure to leprosy emphasizes the necessity to always include comparable controls from the same endemic area in studies of leprosy contacts.     

Thymus dependent lymphocytes in leprosy. I. T lymphocyte subpopulations defined by monoclonal antibodies

Monoclonal antibodies recognizing different human T lymphocyte subpopulations were used to characterize peripheral blood T lymphocytes in patients with leprosy. An increase in the suppressor T lymphocyte subpopulation was seen only in lepromatous leprosy (BL-LL) patients. In contrast, patients who had erythema nodosum leprosum (ENL) showed a disturbance in immunoregulation seen as a decrease of the suppressor cell percentage and manifested by an increase in in vitro lymphoproliferative responses to both PPD and PHA. This imbalance was seen to normalize as patients improved clinically. There was no deviation from the normal values of the total T lymphocyte population. It is suggested, therefore, that ENL may be associated with an acute imbalance of T lymphocyte subpopulations. Since the suppressor T lymphocyte identified by the mononuclear antibody used is antigen nonspecific, the significance of these suppressor cells in the pathogenesis of leprosy remains unclear.     

Immunochemotherapy with interferon-gamma and multidrug therapy for multibacillary leprosy

Treatment for multibacillary leprosy is presently performed with a multidrug therapy (MDT) scheme maintained for 2 years. Leprosy treatment however can benefit from the reduction of length. The lack of interferon-gamma (IFN-gamma) production by lepromatous leprosy (LL) patients' lymphocytes lead us to use this cytokine in the treatment of multibacillary leprosy associated with MDT in the treatment of multibacillary leprosy, and monitor several clinical and immunological parameters during the course of treatment. A total of 20 multibacillary leprosy patients were evaluated, 10 treated with MDT alone, and 10 treated with MDT + 10 daily doses of 2 x 10(6) international units (IU) of recombinant human IFN-gamma/m2 followed by 10 daily doses of 10(7) IU IFN-gamma/m2, intramuscularly, during the first 20 days of MDT. IFN-gamma was well tolerated and did not cause any increase in the rate of leprosy reactions development during treatment. Decrease of bacillary load, fall of anti-Mycobacterium leprae IgG serum antibodies, changes of histological pattern, as well as changes in lymphocyte proliferation assay in response to mitogens (PHA or PWM), M. leprae antigen or PPD was similar in both groups of patients. Among several soluble immunological markers measured before and 30 days after beginning of treatment, levels of soluble IL-2R receptor increased in patients treated with MDT plus IFN-gamma whereas decreased in patients treated with MDT alone. Soluble ICAM-1 levels decreased in the MDT group but did not change in the MDT + IFN-gamma treated patients. Soluble CD4 and soluble CD8 markers did not change significantly in either group of patients. Neopterin, a marker of macrophage activation, increased in all but one patient treated with MDT + IFN-gamma but in none treated with MDT alone, indicating that IFN-gamma was active in vivo. Our findings indicate that despite being able to promote macrophage activation in multibacillary leprosy patients a short course of systemically administered IFN-gamma is not able to change the clinical course of a long standing disease such as leprosy.     

An evaluation of the immune state in leprosy.

An evaluation of the immune state in leprosy was done by the application of a system of graft-versus-host reaction. Peripheral blood lymphocytes obtained from patients with different forms of leprosy and from normal healthy individuals were injected intravenously into the irradiated mice. The rate of blast transformation of the donor cells was measured by the radio-active thymidine uptake. The number of cells labelled with tritiated-thymidine was much higher in the normal individuals and patients with tuberculoid leprosy than in the patients with lepromatous leprosy with the borderline group placed in between the two. However, following successful treatment with DDS, an increased responsiveness and active DNA synthesis could be observed in the previously less responsive lepromatous lymphocytes.     

Antibodies to HIV-1 in sera from patients with mycobacterial infections

Sera from 478 persons (348 leprosy patients, 33 tuberculosis patients, 29 healthy contacts of leprosy patients, 38 normal healthy Indians, and 30 normal healthy Europeans) were screened for anti-HIV-1 IgG antibodies by ELISA. None was positive. In addition, 132 samples (from 43 leprosy patients, 21 tuberculosis patients, 5 healthy contacts of leprosy patients, 33 normal healthy Indians, and 30 normal healthy Europeans) were also tested by Western blot assay for anti-HIV-1 IgG antibodies. Only 1 of the 63 healthy subjects expressed a prominent p17 band. One or more bands were found in 44 (leprosy patients 33/43, tuberculosis patients 7/21, and leprosy contacts 4/5) of the remaining 69 sera. Antibody to the HIV-1-specific antigen p24 was expressed by 17 of these subjects (14/43 leprosy patients, 1/21 tuberculosis patients, and 2/5 leprosy contacts), either as a single band or in combination with other bands. This raises the possibility of a common antigenic pattern between HIV-1 and mycobacteria, especially Mycobacterium leprae.     

Involvement of nitric oxide in the development of tuberculin anergy in patients with pulmonary tuberculosis]

The production of nitric oxide (NO) and the magnitude of an antigen-specific proliferative response of the human lymphocytes stimulated by M. tuberculosis antigen [a purified protein derivative (PPD)] were investigated. PPD-reactive T lymphocytes were found in the peripheral blood of healthy donors. Normal values (mean values, the range of the minimum and maximum values) of PPD-induced proliferation and NO production were determined. Patients with pulmonary tuberculosis were found to have different levels of PPD-stimulated proliferation and NO production. The lymphocytes are shown to preserve their PPD reactivity in patients with normal NO production whereas the PPD-induced proliferative response was significantly decreased in those with high NO production. Patients with reduced tuberculin reactivities and high NO production were less responsive to treatment. The findings suggest that nitric oxide is involved in the development of tuberculin anergy with pulmonary tuberculosis.     

Correlation of nitric oxide and atrial natriuretic peptide changes with altered cGMP homeostasis in liver cirrhosis.

BACKGROUND: Cyclic GMP (cGMP) concentration is increased in plasma of patients with liver cirrhosis. Three possible mechanisms may contribute: increased cGMP synthesis by soluble (activated by nitric oxide), or particulate (activated by atrial natriuretic peptide (ANP)) guanylate cyclase or increased release from cells. AIM: The aim of this work was to analyze the possible contributors to increased plasma cGMP and to assess whether changes in the parameters of the system vary with the degree of liver disease (Child Pugh score) or by the presence of ascites. METHODS: We measured cGMP in plasma and lymphocytes, soluble guanylate cyclase activation by nitric oxide in lymphocytes, nitrates and nitrites and ANPs (activator of particulate guanylate cyclase) in plasma. We analyzed the correlation between changes in different parameters to discern which parameters contribute to increased plasma cGMP. RESULTS: The plasma content of nitrates+nitrites, ANP and cGMP are increased. Activation of soluble guanylate cyclase by nitric oxide is increased in patients while basal cGMP in lymphocytes is decreased. CONCLUSIONS: Both increased ANP and increased activation of soluble guanylate cyclase by nitric oxide contribute to increased plasma cGMP in patients. The concentrations of ANP and cGMP in plasma increase with the degree of disease and are higher in patients with ascites.     

Biochemical, immunological and genetic studies in leprosy. II. Profile of immunoglobulins, complement components and C-reactive protein in sera of leprosy patients and healthy controls.

Various classes of immunoglobulins (IgA, IgM, IgG, IgD and IgE), complement components (C3 and C4) and C-reactive protein (CRP) were estimated in sera from normal healthy controls and leprosy (lepromatous and tuberculoid) patients from Ethiopia. Higher levels of IgA, IgM, IgG and IgD were found in lepromatous leprosy compared with normal healthy people while in tuberculoid leprosy only IgM, IgG and IgD levels were increased. Borderline leprosy patients showed increase in IgG level only. Although an increase in IgE was noted in lepromatous leprosy, it was not significant; the variations in IgE levels could be due to different socioeconomic background and exposure to intestinal parasites. C3 component was significantly reduced in leprosy patients compared with healthy controls while no difference in C4 component was observed. The results point towards an involvement of the "alternate pathway". A positive test against C-reactive protein antiserum was given by about 20% of the normal healthy controls while more than 60% lepromatous and tuberculoid leprosy patients were CRP positive. The results are discussed in relation to the status of immunoglobulins and complement components in leprosy and possible factors (environmental and genetic) which might affect them.     

Microscopic findings of delayed reactions elicited by the skin test reagent Leprosin A derived from M. leprae

Punch biopsies taken 12, 24, 48, and 72 hours after skin testing with Leprosin A have been used to prepare ultrathin sections for the identification and enumeration of infiltration cells. The study was performed on small numbers of both healthy persons and leprosy patients with various forms of the disease living in India. Similar cells were found to infiltrate both positive and negative responses to the skin test reagent, although there were quantitative differences. The most striking findings were the absence of the expected basophils and an infiltration of eosinophils which proceeded to degranulate. This was especially noticeable in a healthy leprosy contact and in patients at the tuberculoid end of the leprosy spectrum, whether or not they produced positive skin reactions to Leprosin A. In patients at the lepromatous end of the spectrum, infiltrates were largely neutrophils.     

Immunologic defects in leprosy patients. II. Interleukin 1, interleukin 2, and interferon production in leprosy patients.

The capabilities of monocytes and lymphocytes in peripheral blood mononuclear leukocytes (PBML) to produce interleukin-1 (IL-1), IL-2, and interferon (IFN), respectively, were evaluated in various types and treatments of leprosy patients. IL-1 production in response to lipopolysaccharide was significantly lower in LL, BL, BB, and BT patients than in normal controls. However, there were no differences in IL-1 levels between TT patients and normal controls. The percentages of nonspecific-esterase-positive cells adhering to the plastic surfaces were not different in LL, BB and TT patients when compared to normal controls. However, they were significantly higher in BT and BL patients than in normal controls. When PBML from leprosy patients were stimulated with concanavalin-A (ConA) for IL-2 production, there were no differences in the IL-2 levels in treated BL/LL, untreated BL/LL, treated BT/TT, and untreated BT/TT patients compared to normal controls. Similar results were obtained when PBML were stimulated with phytohemagglutinin-P (PHA-P). However, when purified protein derivative (PPD) was used as the stimulating agent, there were significantly lower IL-2 levels in treated BL/LL, untreated BL/LL, treated BT/TT, and untreated BT/TT patients when compared to normal controls. There were also lower IL-2 levels in untreated BL/LL and BT/TT patients compared to treated BL/LL and BT/TT patients, respectively. PBML were stimulated with PHA-P or ConA for IFN production.(ABSTRACT TRUNCATED AT 250 WORDS)     

A study of the immunological effects of cimetidine in patients with lepromatous leprosy

To test the capacity of cimetidine to enhance cellular immunity in patients with lepromatous leprosy (LL), cimetidine was given for one month to 29 inactive LL patients and 3 active LL patients. Immune function was monitored with skin tests (lepromin, PPD, candida, and trichopytin), lymphocyte transformation tests (phytohemagglutinin, BCG, and Dharmendra lepromin), and quantitation of peripheral blood lymphocyte subpopulations. A small but significant "booster" response to PPD was the only change observed in the study of patients with inactive disease, and leprosy-related reactions did not occur. In the few active LL patients studied, neither immune enhancement nor leprosy-related reactions were observed. The results of this investigation suggest that cimetidine can be used safely in patients with inactive lepromatous leprosy.     

Altered Modulation of Soluble Guanylate Cyclase by Nitric Oxide in Patients with Liver Disease

The glutamate–nitric oxide–cGMP pathway is impaired in brain in vivo in animal models of chronic moderate hyperammonemia either with or without liver failure. The impairment occurs at the level of activation of soluble guanylate cyclase by nitric oxide (NO). It has been suggested that the impairment of this pathway may be responsible for some of the neurological alterations found in hyperammonemia and hepatic encephalopathy. Soluble guanylate cyclase is also present in lymphocytes. Activation of guanylate cyclase by NO is also altered in lymphocytes from hyperammonemic rats or from rats with portacaval anastomosis. We assessed whether soluble guanylate cyclase activation was also altered in human patients with liver disease. We studied activation of soluble guanylate cyclase in lymphocytes from 77 patients with liver disease and 17 controls. The basal content of cGMP in lymphocytes was decreased both in patients with liver cirrhosis and in patients with chronic hepatitis. In contrast, cGMP concentration was increased in plasma from patients with liver disease. Activation of guanylate cyclase by NO was also altered in liver disease and was higher in lymphocytes from patients with cirrhosis or hepatitis than that in lymphocytes from controls. Successful treatment with interferon of patients with hepatitis C reversed all the above alterations. Altered modulation of soluble guanylate cyclase by NO in liver disease may play a role in the neurological and hemodynamic alterations in these patients.     

Biochemical, immunological and genetic studies in leprosy. I. Changes in serum lactate dehydrogenase isoenzymes, creatine phosphokinase and aldolase activity in different forms of leprosy.

Serum lactate dehydrogenase isoenzymes, creatine phosphokinase and aldolase activity were determined in healthy control subjects and in lepromatous and tuberculoid leprosy patients from Ethiopia. Sera from lepromatous patients showed a higher total LDH activity compared with control subject. The values for tuberculoid leprosy patients were similar to those of controls. Sera from normal healthy controls showed a higher proportion of LDH-H form (72%) while lepromatous leprosy patient's sera exhibited a higher proportion of LDH-M form (55%). Tuberculoid leprosy patients showed a pattern similar to that of healthy controls. A possible significance of these observations is discussed. No significant variations were observed in fructose-1,6-diphosphate aldolase activity within the different types of disease and controls. Although creatine phosphokinase levels in different types of leprosy decreased significantly from those of normal healthy, it falls within the reported variation of the activity in normal sera.     

The tuberculin specificity in humans of Mycobacterium tuberculosis antigen 5

Mycobacterium tuberculosis antigen 5 is a protein antigen limited in distribution to M. tuberculosis and M. bovis and capable of eliciting typical delayed tuberculin skin test reactions in humans. A single large batch of this antigen was purified by immunoabsorbent affinity chromatography and used to skin test patients with tuberculosis and other mycobacterial infections and healthy persons in general populations in geographic areas where nonspecific tuberculin reactivity is frequently encountered. Antigen 5 was found to be no more specific as a tuberculin antigen than PPD. If the available data are accepted, then either a disparity in antigen recognition by antibody and T lymphocytes may exist or the widely accepted hypothesis attributing nonspecific tuberculin reactivity to antigenic cross reactivity with other mycobacteria may be incorrect.     

Serodiagnosis of tuberculosis by radioimmunoassay

Mycobacteria antigens derived from whole cells and cell walls of M. tuberculosis and M. bovis (BCG) and soluble purified protein derivative (PPD) prepared from M. tuberculosis were used in solid phase radioimmunoassays to measure the amount of reactive IgG antibody in serums from 54 patients with active (culture-positive) tuberculosis (Group I), 6 patients with inactive (culture-negative) tuberculosis (Group II), 15 healthy subjects who were skin test positive to PPD (Group III), and 30 healthy persons who were PPD skin test negative (Group IV). Patients with active tuberculosis had statistically larger (p less than 0.001) amounts of IgG antibody to M. tuberculosis whole cells, cell walls, and PPD and to BCG whole cells and cell walls when compared with the amount of antibody in serums from healthy subjects who were PPD skin test negative. However, no significant differences were detected in the mean antibody response or frequency of positive antibody responses between patients with active disease and those in clinical remission. Moreover, significant amounts of antibody were detected in 7 to 20% of healthy, tuberculin-reactive subjects. On the basis of these results, it is unlikely that antibody assays alone will prove useful in the diagnosis of this disease.     

Decreased expression of zeta molecules by T lymphocytes is correlated with disease progression in human immunodeficiency virus-infected persons.

In human immunodeficiency virus type 1 (HIV-1) infection, functional activities of T lymphocytes are impaired. Analogous to tumor-infiltrating T lymphocytes from cancer patients, in whom poor proliferative responses are associated with fewer zeta molecules, this study compared expression of CD3zeta molecules by T lymphocytes from HIV-infected persons and healthy controls. Flow cytometry and immunoblotting revealed significantly diminished zeta expression by CD3, CD4, and CD8 T lymphocytes from AIDS patients but not from persons without AIDS. zeta-mRNA levels were also decreased in cells from AIDS patients. CD3zeta expression correlated significantly with CD4 cell counts and HIV-1 RNA levels; impaired expression of CD3zeta molecules appeared to be reversible upon virus load reduction following highly active antiretroviral treatment (HAART). Thus, reduced expression of CD3zeta molecules by T lymphocytes from HIV-infected persons correlates with disease status. Investigations into CD3zeta expression by subpopulations of peripheral T lymphocytes and by T lymphocytes in lymphoid tissues will contribute to the understanding of immune reconstitution of HIV-infected patients following HAART.     

IgM antibodies to native phenolic glycolipid-I in contacts of leprosy patients in Venezuela: epidemiological observations and a prospective study of the risk of leprosy

In a randomized, double-blind vaccine trial in Venezuela, about 29,000 contacts of leprosy patients have been vaccinated with either a mixture of heat-killed Mycobacterium leprae and BCG or BCG alone, and are being re-surveyed annually to detect new cases of leprosy. All contacts had a serum sample collected at the time of entry into the trial, and 13,020 of these sera have been analyzed for antibodies to phenolic glycolipid-I (PGL-I). Antibody levels have been related to various characteristics of the contacts and to their risk of developing leprosy in the following 4 years. A strong association was found between PGL-I antibody level and the risk of developing leprosy, in spite of possible modification of the incidence rate induced by vaccination. Antibody levels were higher in females than in males, and declined progressively with age. Household contacts had higher levels than did non-household contacts, and levels were higher in individuals from the state in Venezuela which has the highest incidence of the disease. No substantial differences were found in antibody levels between contacts of multibacillary and paucibacillary patients, which may in part reflect the influence of treatment, and there was no clear association with the presence of BCG or lepromin scars or with skin-test responses to PPD and leprosy soluble antigen. The assay of antibodies to PGL-I seems unlikely to provide a sensitive or specific test for infection with M. leprae, and measuring PGL-I antibody levels as a screening procedure to identify those at high risk of developing leprosy is unlikely to be particularly useful in most leprosy control programs. Such assays may be useful for the epidemiological monitoring of changes in the intensity of infection with M. leprae in a community and for the study of carefully defined groups of contacts during some phases of control programs.     

Antigen-specific and persistent tuberculin anergy in a cohort of pulmonary tuberculosis patients from rural Cambodia

Purified protein derivative (PPD) skin testing is used to identify persons infected with Mycobacterium tuberculosis (Mtb) and to assess cell-mediated immune responses to Mtb. However, lack of skin induration to intradermal injection of PPD or PPD anergy is observed in a subset of patients with active tuberculosis (TB). To investigate the sensitivity and persistence of PPD reactivity and its in vitro correlates during active TB disease and after successful chemotherapy, we evaluated the distribution of skin size induration after intradermal injection of PPD among 364 pulmonary TB patients in Cambodia. A subset of 25 pulmonary TB patients who had a positive skin reaction to mumps and/or candida antigens showed persistent anergy to PPD after successful completion of TB therapy. Strikingly, in vitro stimulation of T cells from persistently anergic TB patients with mumps but not PPD resulted in T cell proliferation, and lower levels of IL-2 and IFN-gamma and higher levels of IL-10 were detected in PPD-stimulated cellular cultures from PPD-anergic as compared with PPD-reactive pulmonary TB patients. These results show that anergy to PPD is antigen-specific and persistent in a subset of immunocompetent pulmonary TB patients and is characterized by antigen-specific impaired T cell proliferative responses and a distinct pattern of cytokine production including reduced levels of IL-2.