A hypothesis for the existence of two types of tuberculosis, reflecting two distinct types of immune failure to control the pathogen, based upon prevalence of mycobacterium-specific IgG subclasses.

Most people infected by Mycobacterium tuberculosis, about 90%, contain the pathogen and are healthy. Most investigators have concluded that pathogen-specific Th1 cells contribute to protection. Pulmonary tuberculosis, the most prevalent form of disease, is associated with destructive granulomas, the formation of which also appears to involve Th1 cells. In what sense then do the two Th1 components of the response, in healthy infected individuals and patients, differ? An insight into this question might provide clues for attaining effective vaccination and better treatment. We approached this question by examining the relative prevalence of different IgG isotypes among anti-mycobacterium-specific antibodies in patients and healthy infected individuals as a surrogate marker for the Th1/Th2 phenotype of the response. Our observations lead us to agree that healthy infected individuals generate a predominant Th1 response. Our observations also lead us to propose that many patients make a similar kind of response as healthy infected individuals, but that this response is too weak to contain the infection. We refer to such individuals as having type I tuberculosis. Other patients appear to have a greater and detrimental Th2 component to their immune response than that of healthy infected individuals. We refer to these individuals as having type II tuberculosis. This proposal that there are two types of tuberculosis, reflecting two distinct types of failure by the immune system, will, if correct, be pertinent to vaccine design, treatment of tuberculosis and in making further progress in our understanding the genetics of susceptibility to M. tuberculosis.

Immune Class Regulation and Its Medical Significance Part II of a Report of a Workshop on Foundational Concepts of Immune Regulation.

We discussed different proposals for how the nature of the Th1/Th2 phenotype of an immune response is determined, and favoured one, the Threshold Hypothesis, as plausible and so useful as the basis for further discussions. The activation of a target CD4 T cell can be facilitated by helper CD4 T cells when the CD4 T cells interact via an antigen-presenting cell. The Threshold Hypothesis states that tentative and robust antigen-mediated CD4 T cell cooperation results in the target CD4 T cell, respectively giving rise, upon activation, to Th1 and Th2 cells. We primarily discussed four topics. We briefly discussed in the background section certain limitations of the Th1/Th2 paradigm in understanding immune class regulation, and the remarkable anti-inflammatory properties of human IgG4 antibody. Secondly, we assessed the role of class II MHC molecules in determining the number of mature CD4 T cells and so affecting the Th1/Th2 phenotype of immune responses. We also discussed the controversial role of CD8 T cells in affecting the Th1/Th2 phenotype of responses to MHC and other antigens, and the potential role of their relative scarcity in neonates in biasing responses towards an antibody, Th2 mode. Lastly, we examined the regulation of the Th1/Th2 phenotype of both primary and ongoing immune responses in the context of the intriguing proposal that antigen initially generates different classes/subclasses of immunity and then selects, by a feedback mechanism, the most effective class. We found this interesting idea difficult to reconcile with various observations.

A Conversation with Cohn on the Activation of CD4 T Cells.

Despite an agreement on most issues surrounding models for how lymphocytes are activated and inactivated, and arising out of the 1970 Two Signal Model of lymphocyte activation, Cohn and I have different perspectives on two critical issues concerning the activation of CD4 T cells. One issue is the origin of the first effector T helper (eTh) cells, postulated by both of us to be required to optimally activate precursor Th (pTh), that is naïve CD4 T cells, to further generate eTh cells. The second issue arises from our agreement that the antigen-dependent CD4 T cell cooperation, that we both postulate is required to activate naïve CD4 T (pTh) cells, most likely is mediated by the operational recognition of linked epitopes. Although agreeing on the centrality of this operational mechanism, we disagree about how it might be realized at the molecular/cellular level. I respond here to issues raised by Cohn concerning these two mechanistic questions, in his response to my recent article on the activation and inactivation of mature CD4 T cells.

The activation and inactivation of mature CD4 T cells: a case for peripheral self-nonself discrimination.

The establishment of central tolerance to most self-antigens results in a repertoire of mature peripheral lymphocytes specific for foreign and peripheral self-antigens. The framework that single, mature lymphocytes are inactivated by antigen, whereas their activation requires lymphocyte cooperation, accounts for diverse observations and incorporates a mechanism of peripheral tolerance. This framework accounts for the generalizations that the sustained activation by antigen of most B cells and CD8 T cells requires CD4 T helper cells; in the absence of CD4 T cells, antigen can inactivate these B cells and CD8 T cells. In this sense, CD4 T cells are the guardians of the fate of most B cells and CD8 T cells when they encounter antigen. I argue here that the single-lymphocyte/multiple-lymphocyte framework for the inactivation/activation of lymphocytes also applies to CD4 T cells. I consider within this framework a model for the activation/inactivation of CD4 T cells that is consistent with the large majority of contemporary observations, including significant clinical observations. I outline the grounds why I feel this model is more plausible than the contemporary and predominant pathogen-associated molecular pattern (PAMP) and Danger Models for CD4 T cell activation. These models are based upon what I consider the radical premise that self-nonself discrimination does not exist at the level of mature CD4 T cells. I explain why I feel this feature renders the PAMP and Danger Models somewhat implausible. The model I propose, in contrast, is conservative in that it embodies such a process of self-nonself discrimination.

On the mechanism determining the TH1/TH2 phenotype of an immune response, and its pertinence to strategies for the prevention, and treatment, of certain infectious diseases.

It is well recognized that the physiological/pathological consequences of an immune response, against a foreign or a self-antigen, are often critically dependent on the class of immunity generated. Here we focus on how antigen interacts with the cells of the immune system to determine whether antigen predominantly generates Th1 or Th2 cells. We refer to this mechanism as the 'decision criterion' controlling the Th1/Th2 phenotype of the immune response. A plausible decision criterion should account for the variables of immunization known to affect the Th1/Th2 phenotype of the ensuing immune response. Documented variables include the nature of the antigen, in terms of its degree of foreignness, the dose of antigen and the time after immunization at which the Th1/Th2 phenotype of the immune response is assessed. These are quantitative variables made at the level of the system. In addition, the route of immunization is also critical. I describe a quantitative hypothesis as to the nature of the decision criterion, referred to as the Threshold Hypothesis. This hypothesis accounts for the quantitative variables of immunization known to affect the Th1/Th2 phenotype of the immune response generated. I suggest and illustrate how this is not true of competing, contemporary hypotheses. I outline studies testing predictions of the hypothesis and illustrate its potential utility in designing strategies to prevent or treat medical situations where a predominant Th1 response is required to contain an infection, such as those caused by HIV-1 and by Mycobacterium tuberculosis, or to contain cancers.

T cells cooperating in the induction of delayed-type hypersensitivity act via the linked recognition of antigenic determinants.

Culture conditions have been established that allow the induction of delayed-type hypersensitivity (DTH) precursor cells present in a cell population derived from unsensitized spleen cells only when antigen-specific, radioresistant, Thy-1-bearing helper cells are added. This specific cellular cooperation acts via the linked recognition of two determinants on the antigen; thus, cells primed to the protein antigen fowl gamma globulin (FGG) will only allow the induction of DTH reactivity against the second antigen, burro erythrocyte (BRBC), when the conjugate FGG-BRBC is present in the cultures. The requirement for physical linkage between the two antigens has been demonstrated by the observation that DTH to BRBC is induced when the conjugate FGG-BRBC is present and not when BRBC and FGG are given an uncoupled molecules.

Helper T cells are required for the polyclonal stimulation of cytotoxic T cells by concanavalin A.

Concanavalin A stimulation of T-cell cytotoxicity has been shown to be absolutely dependent on helper T-cell collaboration. Thymocytes stimulated with ConA do not differentiate to yield cytotoxic effector cells. However, thymocytes cocultured with irradiated spleen cells as helpers and ConA yield high levels of cytotoxicity. The helper cell bears theta antigens on its surface, is not an adherent cell, and does not require any adherent cell functions in our culture conditions. The ConA-dependent helper cells appear to be polyclonal in specificity. Thus, polyclonal stimulation of cytotoxicity by ConA requires T helper-T precursor collaboration in analogy to antigen-specific T helper-T precursor interactions. Unlike the antigen-specific interacitons, the ConA-driven cytotoxicity does not appear to require linked associative recognition for induction of cytotoxicity.

Establishment of stable, cell-mediated immunity that makes "susceptible" mice resistant to Leishmania major.

Cell-mediated, but not antibody-mediated, immune responses protect humans against certain pathogens that produce chronic diseases such as leishmaniasis. Effective vaccination against such pathogens must therefore produce an immunological "imprint" so that stable, cell-mediated immunity is induced in all individuals after natural infection. BALB/c mice "innately susceptible" to Leishmania major produce antibodies after substantial infection. In the present study, "susceptible" mice injected with a small number of parasites mounted a cell-mediated response and acquired resistance to a larger, normally pathogenic, challenge. This vaccination strategy may be applicable in diseases in which protection is dependent on cell-mediated immunity.

A valid ELISPOT assay for enumeration of ex vivo, antigen-specific, IFNgamma-producing T cells.

We describe an ELISPOT technique for the detection of antigen specific IFNgamma-producing T cells. The technique is performed on spleen cells plated directly ex vivo into ELISPOT trays without an in vitro pre-culture step. Thus, the assay is likely to reflect the in vivo activity of the cells. We have found that very high cell densities (at least 10(6) cells/well) are required for optimal detection of spot forming cells, and only at a high density of cells is the number of spots detected linearly related to the number of primed cells plated. If lower numbers of antigen primed cells are used, then unprimed spleen cells from syngeneic mice can be added to the well to increase the cell density. Under these conditions, we find that the number of spots is linearly proportional to the number of primed cells plated, even if these are well below a million cells/well. Experiments with MHC congenic mice indicate that the high density of spleen cells required to obtain optimal spot formation reflects a requirement for an MHC restricted function, probably efficient antigen presentation to T cells. The formation of IFNgamma spots is antigen dependent and abrogated by depleting the antigen primed cells of T cells. We conclude that this linear assay can be used to efficiently detect ex vivo antigen-specific IFNgamma-producing T cells.

Prospects for low dose BCG vaccination against tuberculosis.

Efficacious vaccination against fast growing pathogens results in a rapid, secondary immune response on natural infection; this provides protection to the vaccinated individual in the race between developing effective immunity and the rapid multiplication of the pathogen. In certain chronic diseases, due to slow growing pathogens, cell-mediated immunity alone can contain the infection, and yet an antibody response is sometimes induced, at the expense of the cell-mediated response, upon natural infection. Such situations arise in leprosy and the leishmaniases and most probably in tuberculosis. AIDS and syphilis. In these cases, the purpose of vaccination must be to ensure that a stable, protective, cell-mediated immune response is inevitably induced upon natural infection. We believe we have developed a general strategy for causing a pathogen-specific imprint upon the immune system so that a stable, protective, cell-mediated response is inevitably induced in all individuals upon natural infection. BALB/c mice are "susceptible" to Leishmania major in the sense that they mount a non-protective antibody response on substantial infection, and consequently suffer chronic and progressive disease. We have demonstrated that infection with low doses of parasites induces only cellular immunity, and establishes the desired imprint. Mice exposed to low doses and challenged some months later with a substantial, normally pathogenic dose of parasites, mount a stable, protective, cell-mediated response and the vaccinated "susceptible" mice withstand the infection. We have recently managed to achieve a similar lock of the immune response of BALB/c mice to BCG into a cell-mediated mode by low-dose exposure.(ABSTRACT TRUNCATED AT 250 WORDS)

Towards a strategy of universally efficacious vaccination against pathogens uniquely susceptible to cell-mediated attack.

Infection by some intracellular parasites is contained only by cell-mediated immunity, and yet antibody is produced at the expense of the cell-mediated response upon natural infection, leading to chronic or fatal disease. Effective vaccination must therefore generate an immunological imprint ensuring a strong and stable cell-mediated response upon infection. Such diseases include leprosy, tuberculosis, the leishmaniasis and AIDS (Kaplan and Cohn (1986) Int. Rev. Exp. Pathol. 28, 45-78; Surcel et al. (1994) Immunology 81, 171-176; Pearson et al. (1983) Rev. Infect. Dis. 5, 907-927; Clerici and Shearer (1993) Immunol. Today 14, 107-111). BALB/C mice are susceptible to Leishmania major, a protozoan that causes cutaneous leishmaniasis in man, by the criterion that substantial infection results in antibody production and progressive disease (Locksley and Scott (1991) Immunoparasitology Today, A58-A61; J.N. Menon and P.A. Bretscher, unpublished data). Infection of BALB/C mice with very few parasites results in an exclusive cell-mediated, Th1-like response and resistance to an ordinarily pathogenic, high dose challenge. This resistance is associated with a strong and stable cell-mediated response (Bretscher et al. (1992) Science 257, 539-542; J.N. Menon and P.A. Bretscher, unpublished data). The generation of this Th1 imprint by low dose infection has been achieved with three very different strains of the parasite. There is a similar dependency of susceptibility and resistance on relative parasite dose in 'susceptible' and 'resistant' mice and in mice of 'intermediate susceptibility'. For example, 'resistant' mice are resistant to substantial infection but succumb to infection with very high doses of parasites. We therefore propose that infection of a genetically diverse population with a very low dose of viable parasites, that does not induce antibody in any individual, will either induce cell-mediated immunity and contain the parasite, or the parasite will grow until it reaches the threshold required to induce cell-mediated immunity, thereby generating the required imprint. Low dose infection may thus constitute universally efficacious vaccination. The pertinence of these observations to improving the efficacy of BCG vaccination against tuberculosis is discussed.

Immunosuppressive therapy in systemic lupus erythematosus.

The therapeutic efficacy of immunosuppressive therapy in lupus and lupus nephritis in particular, is reviewed. We have tried to resolve the paradox between the observed immunostimulatory effects of cyclophosphamide and cyclosporin A in vivo and our concept of an immunosuppressive agent.

A two-step, two-signal model for the primary activation of precursor helper T cells.

I present here a new model for the primary activation of precursor helper T cells. Observations demonstrate that the immune system learns not to respond to extrathymic, organ-specific self-antigens because of their early appearance in development. The immune system thus discriminates between peripheral self-antigens and foreign antigens and, when mature, usually makes an immune response against only the latter. Contemporary models for the activation and inactivation of T helper (Th) function do not account for such discrimination. The model proposed here is consistent with contemporary findings and incorporates a mechanism of peripheral self-nonself discrimination.

Regulation of the class of immune response induced by antigen. I. Specific T cells switch the in vivo response from a cell-mediated to humoral mode.

Unprimed murine spleen cells, when administered intravenously to irradiated recipients together with antigen for 7 days, are induced to display either DTH reactivity or to mount a humoral (IgM and IgG) response. The class induced depends on the number of spleen cells given to the irradiated host. A low number of cells does not support the induction of any response, a medium number only gives rise to substantial DTH reactivity, whereas a high number only mounts a humoral (IgM and IgG) response. Observations show that the higher number of T cells in a large inoculum of spleen cells, compared to the number present in a medium one, is responsible for the absence of DTH reactivity and the mounting of a humoral response. This finding suggests that the induction of DTH precursor cells may occur when fewer antigen-specific helper-T-cell-dependent signals are generated than the number of signals required to induce B-cell precursors of the IgM and IgG classes. This possibility is favored by further observations. The administration of in situ irradiated, primed helper T cells to mice reconstituted with a medium number of normal spleen cells, results both in the specific suppression of the DTH response that occurs in the absence of these primed cells and in the mounting of a humoral response.

Significance and mechanisms of cellular regulation of the immune response.

The conditions known to favor the induction of delayed-type hypersensitivity (DTH), IgM and IgG antibody production, can be accounted for on the postulate that their precursors require the formation of different numbers of inductive complexes between their receptors, antigen, and the antigen-specific factor derived from helper T cells. The postulate that DTH precursors require the least, IgM B cells an intermediate number, and IgG precursors the most, accounts for the following facts: i) antigens with few foreign sites, for which there are relatively few helper T cell clones, induce only DTH; ii) medium doses of antigens that bear many foreign sites induce a humoral response; whereas iii) low doses that do not result in efficient collaboration induce DTH; and iv) high doses that partially block collaboration also lead to the induction of DTH. Furthermore, the conditions under which unresponsiveness can be induced at the humoral level in immunological competent animals are just those that give rise to the induction of DTH; the induction of a humoral response is also known to result in unresponsiveness at the DTH level. Therefore it seems very likely that these unresponsive states reflect the cellular regulation responsible for the exclusiveness between the induction of DTH and humoral immunity observed in the whole animal. Theoretically, this exclusiveness is due to the action of regulatory T cells. The biological significance of the way in which the induction of different classes is regulated is discussed. Experimental evidence is described that tests the following predictions: i) the class of response induced is due to the action of suppressor and repressor T cells, and ii) it is the number of inductive complexes formed that determines the class of response induced; DTH precursors require the least number and IgG precursors the most.

A cascade of T-T interactions, mediated by the linked recognition of antigen, in the induction of T cells able to help delayed-type hypersensitivity responses.

Previous work has shown that specific helper T cells are required for the primary induction of delayed-type hypersensitivity (DTH). Conditions are defined here under which the primary induction by antigen of precursor helper T cells only occurs in the presence of specific, irradiated effector T cells, demonstrating that the induction of helper T cells requires T-T cooperation. The interaction between precursor and effector helper T cells is mediated by the recognition of epitopes that must be physically linked to one another. In more detail, hapten-Ficoll conjugates and xenogeneic red blood cells induce medium-density but not low-density cultures of unprimed murine spleen cells to express antigen-specific DTH. Low-density cultures do not support the induction of DTH unless they are supplemented with specific irradiated helper T cells. These helper T cells are themselves induced when antigen is added to medium-density but not low-density cultures. Precursor helper T cells in low-density cultures are only induced by antigen in the presence of additional specific irradiated T cells. Further experiments were directed at analyzing the nature of this T-T interaction. Irradiated hapten-primed T cells help the induction of precursor helper T cells specific for burro red blood cells (BRBC) in the presence of haptenated BRBC and chicken red blood cells (CRBC), but do not help in the presence of haptenated CRBC and BRBC. These experiments demonstrate that the interaction between precursor and effector T cells is mediated by the linked recognition of antigen. These findings show that the induction of precursor cells for both DTH reactivity, and those T cells able to help in the induction of DTH, require specific helper T cells. It is further shown that the induction of T cells able to help in the induction of helper precursor cells takes place in medium-density but not low-density cultures. In order words, antigen, when added to medium-density cultures of normal spleen cells, induces T cells able to mediate DTH, and T cells able to help in the induction of these helper T cells, whereas antigen induces none of these T cells when added to low-density cultures unless appropriate specific helper T cells are added.(ABSTRACT TRUNCATED AT 400 WORDS)

A strategy to improve the efficacy of vaccination against tuberculosis and leprosy.

The pathogens responsible for leprosy, tuberculosis and the leishmaniases can induce different classes of immunity, but protection is provided only by a cell-mediated response. Here, Peter Bretscher proposes a strategy to achieve an immunological imprint that ensures a stable cell-mediated response upon natural infection.

An hypothesis to explain why cell-mediated immunity alone can contain infections by certain intracellular parasites and how immune class regulation of the response against such parasites can be subverted.

Cells with a low density of parasite-specific antigens on their surface are postulated to be susceptible to a cell-mediated attack but not to effector mechanisms normally activated following the binding of specific antibody to the infected cell. It is further postulated that such infected cells normally induce a cell-mediated response, and that cells infected with slow-growing intracellular parasites have a low density of parasite-specific antigens on their surface. Despite these general postulates, cell-mediated immunity is not invariably induced following natural infection by certain slow-growing parasites, such as those responsible for leprosy, tuberculosis, and the leishmaniases, and antibody can be induced that is exclusive of a strong, cell-mediated response. It is proposed that certain events in such cases subvert the normal regulatory processes that control the class of immunity induced. In these cases, the parasite-infected cells, bearing a low representation of parasite antigens, induce antibody even though they are not susceptible to antibody-dependent effector mechanisms, and so they are not eliminated. In this case, chronic infection and uncontrolled growth of the parasite occurs, often with fatal consequences.