Role of target groups in integrated leprosy programmes.

The introduction of integrated leprosy services into the primary health care set-up has taken away active case-detection in the community and is replaced by passive reporting by the suspected, afflicted individuals. This can only be made operative effectively with intensive IEC activities in the community. A research study involving school-children (219,000) in leprosy work achieved spectacular success in new case-detection, effective monitoring, completion of MDT and coverage of a large number of individuals (750,000). The results evaluated on a representative sample of 20,000 school students (pre- and post-test), showed over 90% success in creating awareness about the cause of the disease, its symptoms, curability by fixed duration MDT and better attitudes and perceptions of the community towards leprosy-affected individuals. It is emphasised that, in view of the experience gained from the study, other more cohesive and disciplined target groups, such as scouts and guides, NCC cadets, NSS volunteers, should be identified for leprosy work throughout the country in a planned and coordinated manner in order to implement and sustain leprosy eradication activities in the near-elimination and post-elimination phases.

Studies on bovine adrenal estrogen sulfotransferase. III. Facile synthesis of 3'-phospho- and 2'-phosphoadenosine 5'-phosphosulfate.

A practical synthesis of 3'-phosphoadenosine 5'-phosphosulfate (IV) in yields of 68-72% from adenosine 2',3'-cyclic phosphate 5'-phosphate (II) is described. Reaction of II with triethylamine-N-sulfonic acid affords adenosine 2',3'-cyclic phosphate 5'-phosphosulfate (III) which, on treatment with ribonuclease-T2, provides IV. Spleen phosphodiesterase, on the other hand, converts III to 2'-phosphoadenosine 5'-phosphosulfate (V). The biological activity of IV, measured by sulfate transfer to [6,7-3H2]estrone as mediated by bovine adrenal estrone sulfotransferase (3'-phosphoadenylyl-sulfate:estrone 3-sulfotransferase, EC 2.8.2.4), is identical with that obtained with a sample of IV prepared by an established biochemical procedure. By contrast, V exhibits approximately one-third the activity of the natural isomer.

IV. Synthesis and assay of analogs of adenosine 3',5'-diphosphate as inhibitors of bovine adrenal estrogen sulfotranferase.

Analogs of adenosine 3',5'-diphosphate are described which aid in the characterization of the inhibition of estrone sulfurylation by 3'-phosphoadenosine 5'-phosphosulfate as mediated by bovine adrenal estrogen sulfotransferase (3'-5'-phosphosulfate:estrone 3-sulphotransferase, EC 2.8.2.4). The facile conversion of ribonucleosides to 2',3'-cyclic phosphate 5'-phosphate in neat pyrophosphoryl chloride is utilized to provide a reliable route to the requisite intermediates for enzymatic regiospecific conversion to ribonucleoside 3',5'- and 2',5'-diphosphates. The importance of the 3'-phosphate ester to inhibition of estrone sulfurylation is confirmed by Ki measurements. Replacement of the 6-amino group by hydrogen or oxygen leads to considerable loss in affinity for the enzyme as does also dimethylation of the exocylic amino group. Alterations in the pyrimidine ring are not well tolerated by the sulfotransferase but modifications in the imidazole ring as in tubercidin (7 -deazaadenosine) and 8-bromoadenosine 3',5'-diphosphate lead to an enhanced affinity. The latter findings are discussed in terms of an hypothesis of stacking of the aromatic ring of the estrogen substrate and the purine moiety and its analogs.

Monocyte derived IL 10 and PGE2 are associated with the absence of Th 1 cells and in vitro T cell suppression in lepromatous leprosy.

Our previous studies had shown that the clinicopathological spectrum in leprosy was associated with discrete T cell subsets in circulation, with tuberculoid patients having antigen-induced Th 1, whereas lepromatous leprosy patients with antigen-specific T cell anergy possessed Th 2 cells. The present study shows that infected monocytes from lepromatous but not tuberculoid leprosy patients released soluble factors (MoF(s)) containing IL-10 and PGE2 which inhibited M. leprae induced in vitro lymphoproliferation of previously sensitised healthy or tuberculoid leprosy subjects. A strong negative correlation was observed between adherent cell derived IL-10 and IL-2 at the level of both the product and cytokine mRNA. Moreover, anti-IL-10 antibodies and indomethacin partially reversed the suppressor effects of MoF(s). Taken together these studies indicate that infected monocytes contribute to the development of T cell anergy by releasing factors that affect regulatory cytokines and T cell subset differentiation in lepromatous leprosy.

The effect of antigen presenting cells on the cytokine profiles of stable and reactional lepromatous leprosy patients.

In view of varied reports on the Th1/Th2 paradigm in leprosy, we used a novel real time (RT) fluorogenic reverse transcriptase based PCR (RT-PCR) to measure cytokine expression in peripheral blood cells from lepromatous leprosy patients with stable disease and those suffering from erythema nodosum leprosum (ENL/Type II) reactions. To evaluate the role of accessory cells in Th cell differentiation, co-expression of Th cytokines interferon gamma (IFNgamma) and interleukin (IL) 4 and regulatory cytokines IL 10 and IL 12 was compared in antigen stimulated peripheral blood mononuclear cells (PBMC), cultures containing T cells reconstituted with autologous monocytes (MO) and cultures containing T cells reconstituted with autologous dendritic cells (DC). 7/8 stable lepromatous leprosy patients showed co-expression of both IFNgamma and IL 4, suggesting a Th0 or a combination of Th1 + Th2 subsets in PBMC. The RT-PCR demonstrated that stable lepromatous patients and patients in ENL had significantly higher levels of IFNgamma mRNA molecules compared to IL 4. In fact, 5/8 ENL patients had undetectable levels of IL 4 mRNA, with a skewing of the cytokine response towards a Th1-like profile. Consistent with this. IL 12p40 mRNA molecules were significantly higher in the PBMC of ENL patients compared to stable lepromatous patients (P < 0.01). Reconstitution of purified T cells with autologous DC and MO from the stable lepromatous group resulted in down regulation of IL 4 (P < 0.03 for DC and P < 0.02 for MO) and IL 10 (P < 0. 01 for DC and P < 0.02 for MO), and a consequent skewing towards a Th1 profile similar to that seen in ENL patients. The fact that accessory cells could alter the cytokine profile in the reconstituted cultures suggests that they may play a role in determining Th subset differentiation in chronic diseases, and may influence the immunological stability of such diseases.

In situ characterization of cellular infiltrates in lupus vulgaris indicates lesional T-cell activation.

Skin biopsy specimens from nine patients with lupus vulgaris were examined in situ by means of monoclonal antibodies directed against phenotypes of lymphocyte subsets, Langerhans cells, HLA-DR antigens, and interleukin 2 receptor. The epidermis showed prominent changes, including intense expression of HLA-DR on keratinocytes, increase in epidermal cell layers, moderate to high Langerhans cell hyperplasia, and infiltration by CD3+ pan-T cells as well as CD8+ (cytotoxic/suppressor) and CD4+ (helper/inducer) T cells. The predominant lymphocyte in the dermal granulomas was the activated CD3+ T cell, expressing major histocompatibility complex class II antigens and interleukin 2 receptor. CD4+ and CD8+ cells were randomly distributed among the epithelioid cells, which showed intense staining for major histocompatibility complex class II antigens. In all except two patients, the CD4+ population was greater than that of the CD8+ cells. CD1+ Langerhans cells were scattered in moderate numbers in the dermal granulomas. Acid-fast bacilli were conspicuously absent in the biopsy specimens. These features suggest that T-cell activation and Langerhans cell hyperplasia are prominent features of dermal tuberculosis.

Synthesis of substituted thiobenzoxazoles/benzothiazoles: inhibition of cellular respiratory and monoamine oxidase activities and anticonvulsant property.

Several 2-(substituted alkoxy/hydrazinocarbonyl acetanilidothio)benzoxazoles/benzothiazoles were synthesized and characterized by their sharp melting points, elemental analyses, and IR spectra. All thiobenzoxazoles/benzothiazoles possessed low anticonvulsant activity, which was reflected by the 10-40% protection afforded by these compounds against pentylenetetrazol-induced convulsions. All thiobenzoxazoles/benzothiazoles inhibited selectively the nicotinamide adenine dinucleotide (NAD)-dependent oxidation of pyruvate, DL-isocitrate, and alpha-ketoglutarate by rat brain homogenates. NAD-independent oxidation of succinate remained unaltered. All 2-(substituted hydrazinocarbonyl acetanilidothio)benzoxazoles/benzothiazoles inhibited monoamine oxidase activity of rat brain homogenates. Greater monoamine oxidase inhibition was observed with thiobenzothiazoles than with the corresponding thiobenzoxazoles/benzothiazoles was found to be unrelated with their ability to inhibit cellular respiratory and monoamine oxidase activities of rat brain homogenates.

Synthesis of 2-(4-arylthiosemicarbazidocarbonylthio)benzthiazoles and their monoamine oxidase inhibitory and anticonvulsant properties.

Ten 2-(4-arylthiosemicarbazidocarbonylthio)benzthiazoles were synthesized, characterized, and evaluated for their monoamine oxidase inhibitory and anticonvulsant activities. All substituted benzthiazoles inhibited activity of monoamine oxidase in rat brain homogenate where the degree of enzyme inhibition was higher with kynuramine as compared to tyramine and 5-hydroxytryptamine as the substrates. All substituted benzthiazoles possessed measurable anticonvulsant activity against pentylenetetrazol-induced convulsions.

Trend of antimicrobial resistance in Neisseria gonorrhoeae at New Delhi, India.

We aim to monitor the trends of antimicrobial resistance in Neisseria gonorrhoeae and to compare the results of antimicrobial sensitivity by disc diffusion and minimum inhibitory concentration (MIC). Two hundred and eleven confirmed strains of N. gonorrhoeae were subjected to antimicrobial sensitivity testing by disc diffusion using penicillin, tetracycline, ciprofloxacin and ceftriaxone from 1995 to June 1999. Penicillinase-producing Neisseria gonorrhoeae (PPNG) were detected by lodometric method. Minimum inhibitory concentration was determined by E test. A low level of penicillin resistance and PPNG detected in 1996 was maintained over the years. Significant increasing trend of tetracycline and ciprofloxacin resistance with high MIC i.e. 2-96 microg/ml and 1-32 microg/ml respectively were found. Ceftriaxone was found to be the drug of choice, being 100% sensitive. Comparison of resistance pattern by the 2 tests showed satisfactory agreement. Emergence of penicillin, quinolone and tetracyline resistance in N. gonorrhoeae isolates from a major STD centre at New Delhi indicates the need for increased awareness, prudent use of antimicrobials, and evaluation of new antimicrobials for the treatment of gonorrhoea.

PIP: This study determined the prevalence of antimicrobial resistance by Neisseria gonorrhoeae, including penicillinase-producing gonorrhea (PPNG) strains, and monitored the trends. It further compared the results of antimicrobial sensitivity by disc diffusion and minimum inhibitory concentration (MIC). A total of 211 confirmed gonorrhea strains were subjected to antimicrobial sensitivity testing by disc diffusion using penicillin, tetracycline, ciprofloxacin, and ceftriaxone from 1995 to June 1999. PPNG strains were detected by lodometric method, and an E test method of 55 strains isolated in 1997-98 determined MIC. Statistical analysis of the results indicates that a low level of penicillin resistance and PPNG detected in 1996 was maintained over the years. In addition, a significant increasing trend of tetracycline and ciprofloxacin resistance with high MIC was found. Ceftriaxone, being 100% sensitive, was found to be the drug of choice. Moreover, comparison of resistance pattern by the two tests showed satisfactory agreement. Findings indicate the need for increased awareness, prudent use of antimicrobials, and evaluation of new antimicrobials for the treatment of gonorrhea.

Increasing trend of HIV seropositivity in a sexually transmitted diseases centre and epidemiology of HIV seropositive individuals.

11,539 STD clinic attenders and 20,897 antenatal clinic (ANC) attenders at a New Delhi hospital were screened for HIV antibodies by ELISA over a 3-year period. Results were confirmed by Western Blot. A low HIV seropositivity rate (1 per 1000) with an increasing trend in 1993 (4 per 1000) was observed in the STD attenders as against 0.1 per 1000 in the normal control populations. Most of the STD attenders including all the HIV seropositives had heterosexual contact with female sex workers. Both the HIV seropositive ANC attenders acquired the infection through blood transfusion. Thirteen of 23 HIV positive STD attenders had genital lesions, 5 having ulcerative and 8 having nonulcerative STD. Their clinical presentation did not differ from the HIV negative cases but the therapeutic response in 4 was altered. None had signs of symptoms of ARC/AIDS. Two out of 6 spouses and a 2-year-old child of HIV seropositive patients were seropositive. Increasing HIV seropositivity observed in this study reflects the changing situation in the country and highlights the importance of improvement of surveillance, early diagnosis and combined approaches to the management and control of STDs and HIV.

PIP: Although India's Sexually Transmitted Diseases (STD) Control Program has been in existence for 40 years, it was not until the acquired immunodeficiency syndrome (AIDS) epidemic that a serious attempt was made to strengthen the program and collect data on conditions responsible for the spread of human immunodeficiency virus (HIV). In this study, 11,539 individuals attending the Regional STD Teaching, Training, and Research Center in New Delhi during a 3-year period and 20,897 antenatal clinic patients at a New Delhi hospital were screened for HIV. The overall HIV seropositivity rate was 2.0/1000 among STD clinic attenders, but there was an increase from 1.0/1000 in 1990 to 4.1/1000 in 1993. The overall rate for antenatal patients was 0.1/1000. Heterosexual transmission, largely through contact with commercial sex workers, was the source of HIV transmission in almost half of the 23 infected STD clients. The 2 HIV-1 cases involving pregnant women were acquired through blood transfusion. 13 of the HIV-infected STD clients had genital lesions and, in 4 of these cases, the response to treatment was compromised (i.e., no response or a slow response). Two out of 6 spouses and a 2-year-old child of HIV-infected subjects were also seropositive. Although the incidence of HIV was small in this New Delhi study, increasing interactions with Bombay, where HIV incidence is at 35% of commercial sex workers, may change this situation.

Post-kala-azar dermal leishmaniasis: a case report strikingly resembling lepromatous leprosy.

An adult man with post-kala-azar dermal leishmaniasis who had lessons distributed in a manner strikingly similar to lepromatous leprosy is described. He was mistakenly treated with multidrug therapy as recommended by the WHO Expert Committee on leprosy. All investigations including slit-skin smears, histopathology, culture for Leishmania donovani and an indirect fluorescent antibody test to confirm post-kala-azar dermal leishmaniasis proved futile. The diagnosis was ultimately based on the previous history of kala-azar, the absence of other disorders which were ruled out by relevant laboratory tests and the good therapeutic response to sodium antimony gluconate. The epidemiological significance of this case and the salient points to distinguish this condition from leprosy are discussed.

Multiple cutaneous nerve abscesses on a healed tuberculoid patch.

A case of healed tuberculoid leprosy (TT) with multiple superficial nerve abscesses involving the whole cutaneous network on the patch is reported. To the best of our knowledge multiple cutaneous nerve abscesses involving the entire subcutaneous plexus on a TT patch is a very uncommon observation.

Persistent reaction in paucibacillary leprosy: case reports.

Three patients of histopathologically confirmed borderline-tuberculoid leprosy showing no acid-fast bacilli and with lesions confined to the face, 2 on the cheek and 1 on the forehead, were given multidrug therapy as recommended by the WHO for paucibacillary cases. Within 3 months the lesions showed signs of upgrading (or reversal) reaction which was substantiated by histopathology. In 1 patient the facial nerve was affected leading to facial palsy. The lymphocyte transformation test did not show a significant rise. All 3 patients were given oral prednisolone for periods varying between 5 and 7 months, but the response was poor except in 1 patient in whom the facial palsy responded favourably. Injections of sodium antimony gluconate tried in 1 patient after stoppage of steroids did not control the reaction. After 18 months of regular follow-up during therapy, the cutaneous reaction in the patient with facial nerve involvement subsided leaving significant atrophy. However, in the other 2 patients the skin lesion persisted with clinical and histopathological evidence of upgrading reaction. The reasons for the unnatural persistence of reaction in these patients is not clear.

Reactional states and neuritis in multibacillary leprosy patients following MDT with/without immunotherapy with Mycobacterium w antileprosy vaccine.

A vaccine based on autoclaved Mycobacterium w was administered, in addition to standard multidrug therapy (MDT), to 157 untreated, bacteriologically positive, lepromin negative multibacillary leprosy patients, supported by a well matched control group of 147 patients with similar type of disease, who received a placebo injection in addition to MDT. The MDT was given for a minimum period of 2 years and continued until skin smear negativity, while the vaccine/placebo was given at 3-monthly intervals up to a maximum of eight doses. The incidence of type 2 reaction and neuritis during treatment and follow-up showed no statistically significant difference in the vaccine and placebo groups. The incidence of type 1 reaction (mild in most cases), however, was higher in the vaccine group (P = 0.041, relative risk ratio 1.79), considering LL, BL and BB leprosy types together, and considerably higher (P = 0.009) in LL type, probably because of confounding due to higher number of patients with previous history of reaction in this group. The occurrence of reactions and neuritis in terms of single or multiple episodes was similar in the vaccine and placebo groups. The association of neuritis and reactions, as well as their timing of occurrence (during MDT or follow-up), was also similar in the two groups, with more than 90% of occurrences taking place during MDT. The incidence of reversal reaction was significantly higher among the males in the vaccine group (34.5% versus 8.3%, P = 0.019). Patients with high initial BI (4.1-6.0) showed higher incidence of reactions (70.3%) as compared to those with medium (2.1-4.0) and low (0.3-2.0) BI where the reactions were observed with a frequency of 56.1% and 38.8%, respectively. However, unlike reactions, neuritis incidence did not seem to be affected by initial BI to the same extent in the vaccine group, with frequencies of 35.3%, 36.3% and 25.9% in the three mentioned BI ranges. Overall, the vaccine did not precipitate reactional states and neuritis over and above that observed with MDT alone.

Dysregulation of IL-4 expression in lepromatous leprosy patients with and without erythema nodosum leprosum.

In order to increase our understanding of the immunological basis of erythema nodosum leprosum (ENL), we studied Th-like cytokine profiles in 130 leprosy patients, employing both the conventional and a novel, real-time, fluorogenic reverse transcriptase-based PCR (RT-PCR). The concomitant expression of both Th-like cytokines, interferon-gamma and IL-4, and the regulatory cytokines, IL-10 and IL-12, was studied in the peripheral blood cells of leprosy patients with and without ENL. In the conventional RT-PCR, varied cytokine profiles were observed in individual patients of all clinical types. Fifty-three percent of lepromatous patients without ENL and 59% of tuberculoid leprosy patients showed co-expression of IFN gamma and IL-4, indicating a non-polarized Th 0 pattern. Of the 36 patients with ENL, 58% demonstrated a polarized Th 1 pattern, with only 30% expressing both cytokines. Semiquantitative RT-PCR indicated a lower expression of IL-4 compared to that of IFN gamma in the lepromatous patients without ENL; the difference was even greater among those with ENL. The sensitive, real-time PCR confirmed the down-regulation of IL-4 and IL-10, with absence of IL-4 in half of the patients, resulting in skewing of the cytokine response toward a Th 1-like profile.

Mycobacterium w vaccine, a useful adjuvant to multidrug therapy in multibacillary leprosy: a report on hospital based immunotherapeutic clinical trials with a follow-up of 1-7 years after treatment.

A vaccine based on autoclaved Mycobacterium w was administered, in addition to standard multidrug therapy (MDT), to 156 bacteriologically positive, lepromin negative multibacillary leprosy patients compared to a well matched control group of 145 patients with a similar type of disease who received a placebo injection in addition to MDT. The MDT was given for a minimum period of 2 years and continued until skin smear negativity, while the vaccine was given at 3-month intervals up to a maximum of eight doses. The fall in clinical scores and bacteriological indices was significantly more rapid in vaccinated patients, from 6 months onward until years 2 or 3 of therapy. However, no difference was observed in the fall in bacteriological index in the two groups from year 4 onwards. The number of LL and BL patients released from therapy (RFT) following attainment of skin smear negativity, after 24-29 months of treatment was 84/133 (63.1%) in vaccinated and 30/120 (25.0%) in the placebo group; the difference was highly statistically significant (P < 0.0001). In all, 90.2% patients (146/162) converted from lepromin negativity to positivity in the vaccine group, as against 37.9% (56/148) in the placebo group. The average duration of lepromin positivity maintained following eight doses of vaccine administered over 2 years was 3.016 years in the vaccine and 0.920 years in the placebo group. Histological upgrading after 2 years of treatment in the LL type was observed in 34/84 (40.5%) cases in the vaccine and 5/85 (5.9%) cases in the placebo group, the difference being statistically significant (P < 0.001). The incidence of type 1 reactions was significantly higher (30.5%) in the vaccine group than (19.7%) in the placebo group (P = 0.0413); the difference was mainly observed in LL type (P = 0.009). The incidence of type 2 reactions was similar (31.8 and 34.6%) in vaccine and placebo groups. The vaccine did not precipitate neuritis or impairments over and above that encountered with MDT alone. After 5 years of follow-up following RFT, no incidence of bacteriological or clinical relapses was observed in both groups.

Immunotherapy with Mycobacterium w vaccine decreases the incidence and severity of type 2 (ENL) reactions.

Immunotherapy with Mycobacterium w (M.w) vaccine was given to 45 patients with multibacillary (MB) leprosy; 41 similarly classified patients served as controls. All patients received standard multidrug therapy (MDT). Incidence, severity and frequency of type 2 (ENL) reactional episodes were monitored in both groups in a follow-up extending up to 4 years. Reactions were seen in fewer vaccinated (10/37) BL and LL patients than in the control group (12/34). A total of 20 episodes were recorded in the vaccine group as against 29 in the controls, 75% of reactions were mild in vaccinated and 51.72% were mild in the control group patients, and 3 patients in the control group had more than 3 reactional episodes. None of the vaccinated patients showed this. No additional incidence of neuritis were seen among vaccinated individuals during reactional episodes.

Reversal reaction in multibacillary leprosy patients following MDT with and without immunotherapy with a candidate for an antileprosy vaccine, Mycobacterium w.

Immunotherapy with a candidate for an antileprosy vaccine, Mycobacterium w, was given in addition to standard multidrug therapy (MDT) to 53 multibacillary lepromin negative patients belonging to BB, BL and LL types of leprosy (vaccine group). An equal control group received MDT and injections of micronized starch as placebo. Both the vaccine and placebo were administered intradermally every 3 months. The patients were evaluated at determined intervals by clinical, bacteriological and histopathological parameters and lepromin testing. Reactional episodes were analysed with reference to incidence, onset, frequency and severity during and after release from treatment (RFT). Incidence of reversal reaction (RR) was marginally higher in the vaccine group (22.6% vaccine group vs 15% control group). All cases with a history of downgrading type 1 reaction developed RR during therapy. Most episodes occurred within the 1st year of the commencement of therapy--50% developing within 3 months. Late reversal reaction (after RFT) were observed in 3.8% of cases in both groups, and 50% of the reactors in the control group and 33% in the vaccine group had repeated reactional episodes. Incidence of neuritis associated with RR as well as isolated neuritis was similar in both groups.

Association of oral cysticercosis and post kala azar dermal leishmaniasis.

Oral cysticercosis affecting the tongue in association with post kala azar dermal leishmaniasis in an adult man is presented. The features that helped to distinguish oral cysticercosis from other conditions endemic in that area are briefly discussed.

Oral cysticercosis.

A 35-year-old Indian male with nodules in the tongue, lower lip and subcutaneous tissues and convulsions of recent onset is presented. Surgical excision of the nodules confirmed the clinical diagnosis of cysticercosis and relieved the lingual discomfort. This is the 26th case of oral cysticercosis being reported.