In situ T regulatory cells and Th17 cytokines in paired samples of leprosy type 1 and type 2 reactions.

Leprosy is a complex chronic, infectious dermato-neurological disease that affects the skin and peripheral nerves especially during immuno-inflammatory episodes known as type 1/T1R and type 2/T2R reactions. This study investigated the in situ expression of CD25+Foxp3+ Treg cells and TGF-ß1, IFN-γ, IL-17 in leprosy T1R and T2R. Tregs were evaluated in 114 skin biopsies from 74 leprosy patients: 56 T1R (28-paired reaction-free/reactional biopsies, 28 unpaired T1R), 18 T2R (12 paired reaction-free/reactional biopsies, 6 unpaired T2R). Double CD25+Foxp3+immunostained Treg cells obtained by automated platform (Ventana BenchMark XT, Roche, Mannheim, Germany) were counted (Nikon Eclipse E400 2mm2). Cytokine expression was evaluated by immunostaining in 96 biopsies (48 paired reaction-free/reactional lesions, 24 T1R, 24 T2R) using rabbit polyclonal anti human TGF-ß1, IFN-γ, IL-17 antibodies (Santa Cruz Biotechnology CA, USA). Treg cell counts in leprosy reactional lesions were higher compared to reaction-free (p = 0.002). Treg numbers were higher in T1R compared to paired unreactional T1R lesions (p = 0.001). Similar frequency of Treg was seen in paired reactional versus unreactional T2R lesions. Higher expression of TGF-ß, IFN-γ and IL-17 was seen in T2R lesions compared to T1R and reaction-free lesions. The increase in Treg cells during T1R suggests a suppressive role to control the exacerbated cellular immune response during T1R that can cause tissue and nerve damage. Evidences of upregulated Treg cells in TR1, which usually occurs in patients with Th1-Th17 immunity and the indications of the expression of Th17/IL-17 in T2R, which develops in patients with Th2-Treg profile, suggest plasticity of Treg-Th17 cells populations and a potential role for these cell populations in the immunopathogenesis of leprosy reactions.

Mast cell heterogeneity and anti-inflammatory annexin A1 expression in leprosy skin lesions.

Mast cells (MCs) have important immunoregulatory roles in skin inflammation. Annexin A1 (ANXA1) is an endogenous anti-inflammatory protein that can be expressed by mast cells, neutrophils, eosinophils, monocytes, epithelial and T cells. This study investigated MCs heterogeneity and ANXA1 expression in human dermatoses with special emphasis in leprosy. Sixty one skin biopsies from 2 groups were investigated: 40 newly diagnosed untreated leprosy patients (18 reaction-free, 11 type 1 reaction/T1R, 11 type 2 reaction/T2R); 21 patients with other dermatoses. Tryptase/try+ and chymase/chy + phenotypic markers and toluidine blue stained intact/degranulated MC counts/mm2 were evaluated. Try+/chy+ MCs and ANXA1 were identified by streptavidin-biotin-peroxidase immunostaining and density was reported. In leprosy, degranulated MCs outnumbered intact ones regardless of the leprosy form (from tuberculoid/TT to lepromatous/LL), leprosy reactions (reactional/reaction-free) and type of reaction (T1R/T2R). Compared to other dermatoses, leprosy skin lesions showed lower numbers of degranulated and intact MCs. Try+ MCs outnumbered chy+ in leprosy lesions (reaction-free/reactional, particularly in T2R), but not in other dermatoses. Compared to other dermatoses, ANXA1 expression, which is also expressed in mast cells, was higher in the epidermis of leprosy skin lesions, independently of reactional episode. In leprosy, higher MC degranulation and differential expression of try+/chy+ subsets independent of leprosy type and reaction suggest that the Mycobacterium leprae infection itself dictates the inflammatory MCs activation in skin lesions. Higher expression of ANXA1 in leprosy suggests its potential anti-inflammatory role to maintain homeostasis preventing tissue and nerve damage.

Coorte multicêntrica de pacientes com hanseníase tratada com terapiade dose única: resultados de três anos de seguimento e perspectiva emsáude pública no Brasil / SINGLE LESION LEPROSY PACIENTS MULTICENTRIC COHORT TREATED WITH SINGLE DOSE DRUG THERAPY: FINDINGS ON THREE-YEAR FOLLOW-UP AND PUBLIC HEALTH PERSPECTIVE IN BRAZIL

Single skin lesion, paucibacillary (SSL-PB) leprosy is considered an early diseasemanifestation. This study evaluated the clinical outcome of a cohort of 259 newlydiagnosed SSL-PB treated with one dose of rifampicin, ofloxacin, minocycline (ROM)and followed-up for three-years. Patients were recruited from the North, Central Westand Southeast regions in Brazil (1997-2001). The result expected with ROM therapywas disappearance or the reduction of lesion size. Manifestations that required additional intervention were considered as poor clinical outcome: type-1 reaction (T1R) with orwithout neuritis, neuritis alone, increase in lesion size and shift from paucibacillary tomultibacillary. The incidence of poor clinical outcome was calculated by personmonthand with the Kaplan-Meier methods. 61.8% of the participants were females,mean age 32.2, and 67.2% had borderline tuberculoid (BT) or tuberculoid forms. T1Rwas the predominant event; shift from paucibacillary to multibacillary was rare. 92.0%of the volunteers shown no events during the first year, the same occurring to 80.6%of them after 3 years of clinical monitoring. The probability of remaining event-freewas highest among those 40 years old or younger. Poor outcome predominated amongBT patients. Extended monitoring of SSL-PB leprosy cases under minimal therapyprovided valuable case management information for reference centers.

Lesão única paucibacilar (SSL-PB) é considerada manifestação clínica inicial dahanseníase. Este estudo avaliou resultado clínico de coorte de 259 pacientes SSL-PBrecém-diagnosticados, tratados com esquema de dose única Rifampicina, Ofloxacina,Minociclina (ROM) e acompanhados por 3 anos (1997-2001) nas regiões Norte,Centro-Oeste e Sudeste. O resultado esperado do tratamento ROM compreendedesaparecimento ou diminuição da lesão. O desfecho foi definido como qualquerevento clínico com indicação de terapia adicional: reação tipo 1 (T1R) com ou semneurite, neurite, aumento de tamanho de lesão e mudança de paucibacilar paramultibacilar. Estas manifestações foram consideradas eventos clínicos desfavoráveis,calculados por densidade de incidência (pessoa-tempo) e por Kaplan-Meier. 61,8%dos participantes eram mulheres (32,2 média idade), 67,2% borderline-tuberculoide(BT) e tuberculoide. T1R foi o desfecho predominante; mudança de paucibacilar paramultibacilar foi rara. 92,0% não apresentaram eventos desfavoráveis no primeiro anoe 80,6% ao final de três anos de monitoramento clínico. Participantes com idade d?40 anos tiveram maior probabilidade de permanecerem sem evento e evolução clínicadesfavorável predominou entre pacientes BT. Monitoramento prolongado de hanseníaselesão-única PB tratados com esquema mínimo forneceu dados importantes sobremanejo clínico para os centros de referência.

Single lesion leprosy pacients multicentric cohort treated with single dose drug therapy: findings on three year follow up and public health perspective in Brazil

Single skin lesion, paucibacillary (SSL PB) leprosy is considered an early disease manifestation. This study evaluated the clinical outcome of a cohort of 259 newly diagnosed SSL PB treated with one dose of rifampicin, ofloxacin, minocycline (ROM) and followed up three years. Patients were recruited from the North, Central West and Southeast regions in Brazil (1997-2001). The result expected with ROM therapy was disappearance or the reduction of lesion size. Manifestations that required additional intervention were considered as poor clinical outcome: type 1 reaction (T1R) with or without neuritis, neuritis alone, increase in lesion size and shift from paucibacillary to multibacillary. The incidence of poor clinical outcome was calculated by person month and with the Kaplan Meier methods. 61,8 percent of the participants were females, mean age 32.2 and 67,2 percent had borderline tuberculoid (BT) or tuberculoid forms. TIR was the predominant event; shift from paucibacillary to multibacillary was rare. 92 percent of the volunteers shown no events during the first year, the same occurring to 80,6 percent of them after 3 years of clinical monitoring. The probability of remaining event free was highest among those 40 years old or younger. Poor outcome predominated among BT patients. Extended monitoring of SSL PB leprosy cases under minimal therapy provided valuable case management information for reference centers.

Mycobacterium leprae DNA associated with type 1 reactions in single lesion paucibacillary leprosy treated with single dose rifampin, ofloxacin, and minocycline.

Leprosy affects skin and peripheral nerves, and acute inflammatory type 1 reactions (reversal reaction) can cause neurologic impairment and disabilities. Single skin lesion paucibacillary leprosy volunteers (N = 135) recruited in three Brazilian endemic regions, treated with single-dose rifampin, ofloxacin, and minocycline (ROM), were monitored for 3 years. Poor outcome was defined as type 1 reactions with or without neuritis. IgM anti-phenolic glycolipid I, histopathology, Mitsuda test, and Mycobacterium leprae DNA polymerase chain reaction (ML-PCR) were performed at baseline. chi(2) test, Kaplan-Meir curves, and Cox proportional hazards were applied. The majority of volunteers were adults with a mean age of 30.5 +/- 15.4 years; 44.4% were ML-PCR positive. During follow-up, 14.8% of the patients had a poor clinical outcome, classified as a type 1 reaction. Older age (> or = 40 years), ML-PCR positivity, and lesion size > 5 cm were associated with increased risk. In multivariate analysis, age (> or = 40 years) and ML-PCR positivity remained baseline predictors of type 1 reaction among monolesion leprosy patients.