Tuberculous spondylitis following intravesical Bacillus Calmette-Guérin therapy for bladder cancer surgically treated through the anterior approach.

Intravesical BCG therapy is commonly used to treat superficial bladder cancer. Although various complications associated with this therapy have been reported, tuberculous spondylitis is uncommon. Here, we report a rare case of tuberculous spondylitis that occurred after intravesical BCG therapy for bladder cancer. A man in his 80s received BCG immunotherapy for bladder cancer and developed low back pain after treatment. Remarkably, he presented with neurological symptoms. Spondylitis was suspected on imaging. CT-guided biopsy was performed to confirm the diagnosis. Consequently, Mycobacterium bovis was identified as the causative pathogen by multiplex PCR. Multidrug therapy, administered for several months, was ineffective. Therefore, surgery was performed through an anterior approach. The symptoms, including low back pain, improved and postoperative C reactive protein tests were within the normal range. Tuberculous spondylitis following BCG therapy should be considered in cases with a history of bladder cancer treatment.

Urocytological evaluation of pemphigus patients on long term cyclophosphamide therapy: A cross sectional study.

BACKGROUND: Cyclophosphamide therapy is associated with several urological complications including urinary bladder malignancy. Data on urologic complications of chronic cyclophosphamide therapy for dermatologic conditions is not available. OBJECTIVES: To study the urocytological profile of pemphigus patients on long-term cyclophosphamide therapy. MATERIALS AND METHODS: In a cross-sectional study, consecutive patients who had received cyclophosphamide therapy for pemphigus for more than 12 months were included. All patients were subjected to urinalysis including microscopy, culture, and urine cytology. Immunocytochemical staining for cytokeratin 20 (CK-20) on urine sediments and ELISA (enzyme-linked immunosorbent assay) for nuclear membrane protein-22 (NMP-22) were performed in all cases. In patients with urinary symptoms, microscopic hematuria, or those detected with abnormal urine sediment cytology, NMP-22, and CK-20 positivity, cystoscopy, and other relevant investigations were also done. RESULTS: A total of 44 patients (43 of pemphigus vulgaris and one of pemphigus foliaceus) were recruited. Mean duration of cyclophosphamide intake was 2.9 ± 1.7 years (range 1-8 years) with a mean cumulative dose of 53 ± 28.4 g (range 6.5-141 g). Twenty-one cases (47.7%) each were asymptomatic and symptomatic with episodic urinary symptoms [of which two had urinary tract infection (UTI)] and two patients had gross hematuria. Urine cytology revealed mild urothelial nucleomegaly with hyperchromasia in four patients. However, CK-20 and NMP-22 were negative in all samples. Cystoscopy was performed in 21 cases and did not reveal any sign of bladder malignancy. LIMITATIONS: A relatively small sample size and lack of long-term follow-up were limitations. CONCLUSIONS: In our study, no serious urologic complications were found in pemphigus cases on chronic cyclophosphamide therapy.

Primary tuberculosis of glans penis after intravesical Bacillus Calmette Guerin immunotherapy.

A 55-year-old male with carcinoma in situ of urinary bladder was treated with weekly intravesical injections of Bacillus Calmette Guerin (BCG) vaccine. Three days after the sixth injection, he developed low grade fever and multiple grouped punched out, 2-3 mm ulcers around meatus and corona glandis. In addition, multiple, firm, indurated, nontender papules and few deeper nodules were present on the proximal part of glans penis, along with bilateral enlarged, matted and nontender inguinal lymph nodes. There was no history suggestive of sexually transmitted diseases and high risk behavior. Chest X-ray was within normal limits, and Mantoux, Venereal Disease Research Laboratory (VDRL) and HIV antibody tests were negative. The biopsy from the penile ulcer revealed epithelioid cell granuloma with Langhans giant cells. Fine needle aspiration cytology from the lymph node also revealed epithelioid cell granuloma and acid fast bacilli on Ziehl Neelsen's stain. The tissue biopsy grew Mycobacterium tuberculosis. The BCG immunotherapy was stopped and patient was treated with four drug antitubercular therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide in standard daily doses along with pyridoxine. The edema resolved and the ulcers started healing within 2 weeks, and at 6 weeks after starting antitubercular therapy almost complete healing occurred. To the best of our knowledge, we describe the first case of an Indian patient with BCG induced primary tuberculosis of penis after immunotherapy for carcinoma urinary bladder and review the previously described cases to increase awareness of this condition in dermatologists and venereologists.

Programa de Formación de Epidemiología de Campo: período 2001-2004

Contiene: estudios de brotes epidémicos, evaluación de un sistema de vigilancia, publicaciones e informes, conferencias científicas.

[Study on recombinant BCG].

The progress of study on recombinant BCG was stated briefly. And then our studies on recombinant BCG were mentioned. Recombinant BCG secreting alpha antigen-fused merozoite surface protein 1 (MSP 1) was prepared and tested for its ability to control infections of Plasmodium yoelii. Result turned out it controlled the infection better than recombinant MSP 1 mixed with Freund incomplete adjuvant did. Recombinant BCG secreting excess amounts of antigen 85 complex A controlled infection of Mycobacterium leprae. Addition of recombinant BCG secreting alpha antigen-fused IL-2 to peritoneal exudate cells induced IFN-gamma resulting in killing bladder cancer cells more efficiently than parental BCG did.

[Study on recombinant BCG to prevent infections of intracellular pathogens].

Studies on recombinant BCG (rBCG) which my group carried out so far were reviewed. Recombinant BCG which secreted alpha antigen-fused foreign antigen was constructed and tested for its ability to induce protective immunity. Thus, rBCG secreting merozoite surface protein 1 (MSP1) of Plasmodium yoelii efficiently protected the infection more than recombinant MSP 1 mixed with artificial adjuvant RAS or IFA did. rBCG which secreted excess amounts of antigen 85 complex A inhibited the multiplication of M. leprae in the footpads of mice. rBCG which secreted alpha antigen-fused IL-2 stimulated peritoneal exudate cells of mice resulting in enhancing killing a bladder cancer cell line in vitro.

The Bcg host-resistance gene.

In the mouse, resistance and susceptibility to intracellular growth of mycobacteria in macrophages is controlled by the Bcg (Nramp1) gene, which has been cloned and shown to encode a macrophage phagosomal membrane protein with a putative transporter function. In the homologous human NRAMP1 gene, a total of 11 polymorphisms have been identified, which are being used to test for the linkage of NRAMP1 alleles with human responses to mycobacteria, including susceptibility to tuberculosis and leprosy, as well as BCG immunotherapy in bladder cancer.

Role of a bacillus Calmette-Guérin fibronectin attachment protein in BCG-induced antitumor activity.

Intravesical Mycobacterium bovis bacillus Calmette-Gu*erin (BCG) is the treatment of choice for superficial bladder cancer. Previous studies showed that attachment of BCG to fibronectin within the bladder was necessary for mediation of the antitumor response. Further studies identified a bacterial receptor, fibronectin attachment protein (FAP), as an important mediator of BCG attachment to fibronectin. In vitro studies showed that a stable BCG/fibronectin interaction was dependent on FAP binding to fibronectin; however, no role for FAP in the attachment of BCG in vivo has been characterized. We now report the cloning of the M. bovis BCG FAP (FAP-B) and demonstrate an important role for FAP in the in vivo attachment of BCG to the bladder wall and in the induction of BCG-mediated antitumor activity. The predicted amino acid sequence for FAP-B shows 61% and 71% homology, respectively, with Mycobacterium avium FAP (FAP-A) and Mycobacterium leprae FAP (FAP-L). Rabbit polyclonal antibodies against Mycobacterium vaccae FAP (FAP-V) reacted with all 3 recombinant FAP proteins on Western blots. Functional studies show FAP-B to bind fibronectin via the highly conserved attachment regions previously identified for FAP-A and FAP-L and also to competitively inhibit attachment of BCG to matrix fibronectin. In vivo studies show FAP to be a necessary protein for the stable attachment of BCG to the bladder wall. Moreover, stable binding of BCG via FAP was shown to be necessary for the expression of BCG-induced antitumor activity. Our results demonstrate a biological role for FAP in the mediation of BCG-induced antitumor activity.

Ability of lymphokine-activated killer cells to lyse mycobacteria-infected cells.

Lymphokine-activated killer (LAK) cells were generated by interleukin-2 activation of peripheral blood lymphocytes obtained from lepromatous leprosy (LL) patients and healthy individuals. The ability of LAK cells to lyse targets (macrophages and T-24, a bladder carcinoma cell line) infected with mycobacteria (Mycobacterium leprae and mycobacterial strain ICRC) was assessed in a 51 chromium-release assay. It was observed that LAK cells generated from LL patients and healthy individuals could preferentially lyse M. leprae or ICRC-pulsed macrophages and T-24 cells, compared to non-pulsed targets. The ability of LAK cells to kill intracellular mycobacteria was demonstrated in colony forming assays. These results indicate a promising role for LAK cells in immunotherapy of leprosy.

Evolution of cellular and humoral response against Tuberculin and antigen 85 complex during intravesical treatment with BCG of superficial bladder cancer.

Prophylactic treatment with Bacillus Calmette-Guerin (BCG) is an established and effective therapy of bladder cancer. The antitumor effect of BCG seems to be largely related to cellular immunological mechanisms, although its precise mode of action is unknown. Antitumor response of BCG seems to be initiated by the attachment of BCG to bladder wall via Fibronectin (FN). The cellular immune response against Tuberculin PPD and the major secreted BCG antigen (Fibronectin-binding AG 85 complex) has been tested in a control group of 20 untreated bladder tumor patients and before and after 6 weekly intravesical BCG instillations in a group of 20 superficial bladder tumor patients. A major increase in the lymphoproliferative response against PPD and AG 85 was observed in respectively 66% and 57% of the treated patients. In contrast, no detectable antibody response (IgA, IgM, IgG) was observed against AG 85 complex after BCG treatment. On the other hand, antibodies against Tuberculin increased in 13 of 20 patients. This study seems to demonstrate a specific cellular immune activation against AG 85 Fibronectin-binding complex during BCG treatment of superficial bladder tumors. Humoral response against the AG 85 is not activated after BCG treatment. Further studies are needed to elucidate the role of AG 85 in the cellular intravesical penetration of BCG. Presence or absence of cellular response against this antigen could be of clinical value.

The gamma-carboxyglutamic acid domain of human factor VIIa is essential for its interaction with cell surface tissue factor.

Previous studies indicated that both plasma-derived and recombinant human factor VIIa specifically interacted with tissue factor on the surface of a human bladder carcinoma cell line (J82). In the presence of calcium ions, factor VIIa interacted with approximately 300,000 binding sites/cell with a dissociation constant (Kd) of 3.25 nM (Sakai, T., Lund-Hansen, T., Paborsky, L., Pedersen, A. H., and Kisiel, W. (1989) J. Biol. Chem. 264, 9980-9988). In this study, we compare recombinant human factor VIIa and a preparation of recombinant human factor VIIa lacking the gamma-carboxyglutamic acid domain (GD-rVIIa) with respect to their interaction with J82 cell surface tissue factor. Interaction of GD-rVIIa with J82 monolayers at 37 degrees C was specific, saturable, and exhibited a hyperbolic profile. Scatchard plots of the binding data obtained at 37 degrees C indicated a single class of binding sites for GD-rVIIa with a Kd value of 2.5 nM. GD-rVIIa interacted with about 10,000 binding sites/cell. In contrast to the tissue factor-specific binding observed for intact factor VIIa, specific binding of GD-rVIIa to the J82 cell surface was neither influenced by calcium nor blocked by prior incubation of the cells with polyclonal anti-tissue factor apoprotein IgG. In addition, cell-bound GD-rVIIa failed to activate human factor X. These results indicate that the gamma-carboxyglutamic acid domain of factor VIIa is essential for its interaction with cell surface tissue factor.

Plasminogen activator regulation by transforming growth factor-beta in normal and neoplastic human urothelium.

Plasminogen activators (PA) are thought to participate in the invasive and metastatic processes of malignancies and are known to be modulated by certain growth factors (Danø, K; Andreasen, P.A.; Grondahl-Hansen, J.; Kristensen, P.; Nielsen, L.S.; Skriver, L. Adv. Cancer Res. 44:139-266; 1985 and Laiho, M.; Keski-Oja, J. Cancer Res. 49:2533-2553; 1989). This report describes the effect of TGF-beta on the regulation of secreted PA activity produced by human fetal urothelium and neoplastic urothelial cell lines. Epidermal growth factor was previously shown to induce substantially different effects on PA production by normal versus neoplastic urothelial (Dubeau, L.; Jones, P.A.; Rideout, W.M.; Laug, W.E. Cancer Res. 48:5552-5556; 1988). This report demonstrates that log phase normal urothelium, but not transformed cells, responded to TGF-beta (1-10 ng/mL) by diminishing the total secreted PA activity. Northern and western analyses showed that the reduction in protease activity resulted from an increased level of plasminogen activator inhibitor-1 (PAI-1) mRNA and protein. Additionally, northern analysis of total mRNA levels at varying cell densities demonstrated modulation of tPA, PAI-1, and TGF-beta transcripts in normal urothelial cells as a function of growth in vitro, suggesting the presence of an intact regulatory pathway to control extracellular proteolysis.

Survey of the human acetylator polymorphism in spontaneous disorders.

There is ample evidence that the human acetylator phenotypes are associated with drug induced phenomena. It is principally the slow acetylators who exhibit toxic adverse effects because of their relative inability to detoxify the original drug compounds. In rare instances, however, it is the rapid acetylators who are at a disadvantage. In the matter of association of spontaneous disease with either acetylator phenotype, there are two groups of disorders to consider. First, disorders in which carcinogenic amines are known to be an aetiological factor. This is because these amines are substrates for the polymorphic N-acetyltransferase activity and hence there is a possible rational basis for searching for an association. Secondly, other disorders where searches for associations are based more on hunches. In the first group there is a definite statistical association between cancer of the bladder and the slow acetylator phenotype. In prevalence studies the slow phenotype is 39% more associated with bladder cancer than is the rapid phenotype. On the basis of the evidence now available it is not possible to say whether this association is because slow acetylators develop the disease more frequently or whether they survive longer. In the second group the relevant studies show (1) a greatly increased prevalence of slow acetylators in Gilbert's disease; (2) a confirmed association between the rapid acetylator phenotype and diabetes; (3) a possible association between the rapid acetylator phenotype and breast cancer; (4) a possible association between the slow acetylator phenotype and leprosy in Chinese patients; (5) an earlier age of onset of thyrotoxicosis (Graves' disease) in slow acetylators than in rapid acetylators; (6) no evidence of an association between either phenotype and spontaneous systemic lupus erythematosus.