Respuesta de la vacuna MycobacteriumHabana en pacientes con lepra lepromatosa y sus convivientes.Un estudio piloto

Se llevó a cabo una vacunación a dosis única con Mycobactericem habana, con 31 casos de lepra lepromatosa que recibieron 1-5 mg (1'5 mg = 6'27 x 108 bacilos) y 36 convivientes con 1'5, 2'0, 2'5 mg de vacuna intradérmica. La du ración del estudio fue de 18 semanas. La vacunación indujo conversión a la lepromina en el 100 por ciento de los casos lepromatosos y convivientes de lepromina negativos y aumento del 100 por ciento en contactos lepromina positivos, estable durante las 15 semanas de duración del seguimiento, El incremento máximo en la reactividad a la lepromina se obtuvo con 1'5 mg de vacuna, probablemente la dosis máxima admisible. Además, la vacunación de los no vacuna BCG previa reveló un valor promedio superior de incremento de la lepromina. Los cambios en la vacunación local incluyen induración, ulceración, picazón dolorosa y linfodenopatías periféricas, todas remitieron espontáneamente a las 15 semanas. Los efectos secundarios sistémicos resultaron ser pyrexia, ENL, ictericia con una frecuencia no superior a lo observado con otras vacunas. Estos efectos secundarios sistémicos eran fácilmente controlables y no se acompañaban de deterioro ocular o nervioso. Las investigaciones analíticas tipo perfil de seguridad, revelaron un incremento en el valor promedio de la cantidad de (hemoglobina) Hb por ciento, RBC (hematíes) y PCV en los convivientes y de PCV en pacientes lepromatosos, post-vacunación. También se observaron alteraciones en las funciones hepáticas en los pacientes con lepra lepromatosa. Por lo tanto, M. habana parece útil en estimular CMI específica contra M. leprae como evidencia la reactividad incrementada a la lepromina (AU)

Detection of Mycobacterium leprae DNA by polymerase chain reaction in the blood of individuals, eight years after completion of anti-leprosy therapy.

Thirty eight patients with indeterminate leprosy (HI), at least 4 to 6 years after discharge from multibacillary (MB) or paucibacillary (PB) schemes of anti leprosy multidrug therapy (MDT), were submitted to traditional diagnostic procedures for leprosy and to polymerase chain reaction (PCR) analysis of different clinical samples for detection of Mycobacterium leprae DNA. No significant difference was observed for any of the parameters analyzed between PB or MB schemes of treatment and no indications were found for more efficient outcome of HI using the MB scheme. Remarkably, 18 (54.5%) of the individuals were PCR positive in at least one of the samples: positivity of PCR was highest in blood samples and four individuals were PCR positive in blood and some other sample. Upon comparison of PCR results with clinical and histopathological parameters, no correlation was found between PCR-positivity and eventual relapse. This is the first report on detection of M. leprae DNA in PB patients, more than half a decade after completion of MDT, suggesting that live bacilli are present and circulating much longer than expected, although reinfection of the individuals can not be excluded. Overall, we feel that because of the high sensitivity of the assay, extreme care should be taken about association of PCR results, efficacy of treatment and disease status.

Analise da conversao da reacao de mitsuda nas formas multibacilares da hanseniase / An analysis of mitsuda reactions conversion in multi-bacillar forms of hansen's disease

Com o objetivo de verificar o percentual de conversao imunologica atraves da reacao de Mitsuda e realizar a analise de fatores envolvidos nesse processo, selecionou-se ex-pacientes portadores de hanseniase atendidos na Fundacao Alfredo da Matta (Manaus-AM), com as seguintes caracteristicas: forma clinica multibacilar, reacao de Mitsuda negativo no diagnostico, alta por cura no periodo de 1989 a 1993, sem tratamento especifico anterior e que fizeram uso de esquemas poliquimioterapicos (PQT) com regularidade. Os participantes foram dispostos em dois grupos conforme esquema PQT: 22 haviam feito uso do esquema da OMS (PQT/OMS), isto e, ate negativacao baciloscopica, e 24 utilizaram o esquema de duracao fixa (PQT/DF), com ingestacao de 24 doses. Todos foram reavaliados, em 1997, atraves de exame clinico-dermatoneurologico, baciloscopia da pele, grau de incapacidade e aplicacao de novo reacao de Mitsuda com posterior leitura. Constatou-se que entre os individuos classificados como portadores de hanseniase Virchowiana nao ocorreu nenhuma variacao de resposta imunologica celular, medida pela reacao de Mitsuda. Entretanto, nas demais formas e principalmente nos pacientes que fizeram uso de PQT/DF, a conversao ocorreu com maior frequencia a medida que o paciente, na classificacao de Ridley e Jopling, estava mais proximo do polo imunocompetente. Em relacao ao Indice Baciloscopico verificou-se que a negativacao baciloscopica precoce pode ter enterferido na conversao da Reacao de Mitsuda. A correlacao dos dados retrospectivos e os obtidos na reavalicao contemporanea permitiu concluir que estas conversoes, embora frequentes, nao estao relacionadas com o esquema poliquimioterapico utilizado, a presenca ou nao de reacao reversa ou com o grau de incapacidade induzido pela hanseniase.

Immunotherapy of lepromin-negative borderline leprosy patients with low-dose Convit vaccine as an adjunct to multidrug therapy; a six-year follow-up study in Calcutta.

The present report, which describes management of lepromin-negative borderline leprosy patients with low-dose Convit vaccine, is an extension of our earlier study on the treatment of lepromatous leprosy patients with low-dose Convit vaccine as an adjunct to multidrug therapy (MDT). The test Group I, consisting of 50 lepromin-negative, borderline leprosy patients, were given low-dose Convit vaccine plus MDT. The control group II consisted of 25 lepromin-negative, borderline leprosy patients given BCG vaccination plus MDT and 25 lepromin-negative, borderline leprosy patients given killed Mycobacterium leprae (human) vaccine plus MDT. The control group III consisted of 50 lepromin-positive, borderline leprosy patients not given any immunostimulation but given only MDT. Depending upon the lepromin unresponsiveness, the patients were given one to four inoculations of the various antileprosy vaccines and were followed up every 3 months for 2 years for clinical, bacteriological and immunological outcome. All patients belonging to the test and control groups showed clinical cure and bacteriological negativity within 2 years. However, immunologic potentiation, assessed by lepromin testing and the leukocyte migration inhibition test (LMIT), was better in the test patients receiving low-dose Convit vaccine plus MDT than in the control patients receiving BCG vaccine plus MDT or killed M. leprae vaccine plus MDT or MDT alone. But the capacity of clearance bacteria (CCB) test from the lepromin granuloma showed poor bacterial clearance in the test patients. However, there was no relapse during 6 years of follow up. Two mid-borderline (BB) patients had severe reversal reactions with lagophthalmos and wrist drop during immunotherapy despite being given low-dose Convit vaccine.

Evaluation of cell mediated immunity in healthy contacts of leprosy.

The cell mediated immunity (CMI) was studied in 50 healthy contacts of leprosy patients and 50 age & sex matched non-contact controls by lepromin test and leucocyte migration inhibition (LMI) test using phytohaemagglutinin (PHA) and lepromin and its association with other risk factors in contacts was assessed. The lepromin positivity correlated well with LMI results. There was no difference in CMI in I, II and III degree of contacts. Amongst direct contacts lepromin test was positive in 67 per cent as compared to 92 per cent in indirect contacts while in LMIT migration index (MI) was significantly increased (0.66 +/- 0.20) in direct contacts. MI was also significantly increased (0.73 +/- 0.20) contacts of less than two years duration which decreased to 0.51 +/- 0.18 in contacts of more than five years duration. Lepromin positivity also increased from 60 per cent to 100 per cent in these contacts. The specific CMI was significantly suppressed in contacts of LL patients (MI:0.74 +/- 0.21) and BL patients (MI: 0.61 +/- 0.01) as compared to healthy controls. B.C.G. vaccinated individuals showed better CMI response. The findings in the study showed specific unresponsiveness to lepromin in LMI in leprosy contacts of less than two years duration, direct contacts, contacts of lepromatous spectrum of index patients and contacts not vaccinated with B.C.G. emphasizing that CMI status is an important parameter in identifying the contact population at the greater risk of acquiring leprosy.

T cell reactivity against antigen 85 but not against the 18- and 65-kD heat shock proteins in the early stages of acquired immunity against Mycobacterium leprae.

T cell proliferation and interferon-gamma (IFN-gamma) production of peripheral blood mononuclear cells (PBMC) from 20 household contacts were tested against the 18- and 65-kD heat shock proteins from Mycobacterium leprae (ML18 and ML65 respectively) and antigen 85 from Myco. bovis bacille Calmette-Guérin (BCG) (Ag 85) during a 12-months follow-up study. Among the eight contacts that became positive, eight showed positive reactivity against Ag 85, 5/8 against ML65 and 4/8 against ML18 at the end of the study. Of the 16 contacts who were lepromin-positive either at first or second testing, all responded to Ag 85, 11 to ML 65, but only eight reacted to ML18 antigen. Contacts who were lepromin-positive at first testing developed responses to ML18 only at second testing. In contrast, among the four contacts that remained lepromin-negative during the follow up, three proliferated to Ag 85 either at first or second testing, but only one produced IFN-gamma against Ag 85 at the end of the study. These results demonstrated that T cell reactivity and particularly IFN-gamma secretion against Ag 85, but not against ML18 and ML65, might be a predominant mechanism in the early stages of acquired protective immunity against Myco. leprae.

IL-6 production in response to purified mycobacterial heat-shock proteins and to antigen 85 in leprosy.

IL-6 production was examined in PBMC cultures from healthy leprosy contacts and from leprosy patients stimulated with the purified mycobacterial 18-, 65-, and 70-kDa heat-shock proteins (hsp) and the secreted fibronectin-binding antigen 85 (Ag85). In lepromin-negative contacts, the 70-kDa hsp was the only antigen capable of eliciting significant IL-6 production. In lepromin-positive contacts, Ag85, the 65- and the 70-kDa hsp induced substantial IL-6 titers. IL-6 levels induced with the 70-kDa antigen were about fourfold higher than with the 65-kDa hsp or with Ag85. The 18-kDa antigen did not induce any IL-6 in these healthy contacts. PBMC from tuberculoid leprosy patients produced even more elevated levels of IL-6, and PBMC from lepromatous leprosy patients produced extremely high levels of IL-6. All antigens were capable of inducing IL-6 in leprosy patients. Highest levels were found in cultures stimulated with the 65-kDa hsp, and lowest levels were in cultures stimulated with the 18-kDa hsp.

Serum tumor necrosis factor and interleukin 1 in leprosy and during lepra reactions.

Tumor necrosis factor--alpha (TNF), one of the mediators of septic shock, has a role in the immunopathological complications of several infections. However, its role in leprosy is yet unclear. In this study, serum TNF and IL-1 levels in 64 patients spread over the spectrum of leprosy [lepromatous leprosy (LL), 30; borderline lepromatous, 12; borderline borderline, 8; and borderline tuberculoid-tuberculoid leprosy, 14] were measured at the time of admission. Elevated levels of TNF ranging from 15 to 4500 pg/ml were detected in lepromatous leprosy cases (399 +/- 189) and low levels ranging from 15 to 160 pg/ml were detected in the tuberculoid form of leprosy. Patients undergoing type 1 and type 2 lepra reactions also exhibited high TNF levels of 15-2100 pg/ml. Of the 14 clinically healthy individuals studied, 3 showed TNF levels of 15, 50, and 58 pg/ml. Interleukin 1-beta (IL-1) levels were found to be significantly higher in LL cases (70-5000 pg/ml) (328 +/- 184) in comparison to other groups or normal controls (9 +/- 3). The coefficient of correlation between TNF and IL-1 levels was statistically significant in LL and reaction cases (r = 0.96, P less than 0.001). These patients were followed up as outpatients for a period of 1 year. It was observed that 4 out of 8 patients with TNF levels greater than 100 pg/ml went into lepra reactions between 2 and 6 months after entry into the study, whereas only 5 out of 56 with less than 100 pg/ml went into mild lepra reactions (chi 2 = 9.7, P less than 0.01). Determination of TNF and IL-1 levels thus seems to have a prognostic significance in terms of lepra reaction in patients.

An isoelectric focusing method for the study of the humoral response against the antigen 85 complex of Mycobacterium bovis BCG in the different forms of leprosy.

Isoelectric focusing was used to separate the three components of the antigen 85 complex of Mycobacterium bovis BCG. Antibody responses of leprosy patients against each Mycobacterium bovis BCG. Antibody responses of leprosy patients against each component were quantitated by densitometric analysis of immunoblot assays. The 85A component was recognized by 40% (8/20) of the lepromin positive and negative healthy subjects, by 76% (19/25) of the tuberculoid and by 96% (24/25) of the lepromatous leprosy sera. In contrast, the 85B component was not stained by the control sera, nor by the tuberculoid leprosy sera but by 64% (16/25) of the lepromatous leprosy sera. The results suggest that antigen 85B contains one or several epitopes that are specifically recognized by sera of lepromatous leprosy patients only.

Multibacillary leprosy presenting as a solitary skin lesion; report of three cases and its significance in control programs.

Three patients with solitary skin lesions showing the cardinal signs of leprosy were seen and clinically classified among the paucibacillary cases. Initially, they were treated with two drugs (rifampin and dapsone) as recommended by the WHO Expert Committee. On the first visit of their follow-up, they were seen to be histopathologically either in the borderline (BB) or borderline lepromatous (BL) group, and acid-fast bacilli were demonstrated in the sections. Later they were put on three drugs (rifampin, dapsone and clofazimine) as given for multibacillary cases, and therapeutically they also behaved like bacilliferous leprosy. Such cases are rare and the reasons for the occurrence are not clear. Further studies on the subtle relationship between the local host factors and the virulence of the organisms grown from these lesions may offer an explanation. In light of these cases and previous reports of even lepromatous leprosy presenting as a single skin lesion, field workers--including both medical and paramedical workers--should carefully perform and interpret slit-skin smears from clinically diagnosed paucibacillary cases so that such unusual presentations of the disease are treated appropriately and not missed.

A reaçao de Mitsuda seriada na identificaçao das formas reacionais tuberculóide e dimorfa da hanseníase / ?

Estudou-se a reaçao de Mitsuda em 37 pacientes portadores de hanseníase, sendo 18 da forma tuberculóide reacional e 19 da forma dimorfa reacional, sob o ponto de vista clínico, histológico e baciloscópico, com leituras realizadas aos 30, 60, 90, e 120 dias, com o objetivo de se tentar identificar uma forma da outra. A maioria dos pacientes tuberculóides reacionais apresentou reaçao de Mitsuda positiva +. As reaçoes de Mitsuda diminuíram com o tempo nos dois grupos, sendo mais persistentes no grupo tuberculóide reacional. A baciloscopia aos 30 dias foi negativa ou houve presença de raros bacilos em 77,78 por cento dos casos tuberculóides reacionais. Conclui-se que os tuberculóides reacionais possuem uma maior capacidade de clareamento bacilar que os dimorfos reacionais e que a reaçao de Mitsuda pode ser útil na identificaçao dessas duas formas e, inclusive, sugerir sua evoluçao quanto ao diagnóstico e quanto à terapêutica