INTiRNATIONAI. JOIIRNAI. OP Li i'ioSY^ Volume 70, Number 1

Printed in the U.S.A.( ISSN 01 -IS-916X)

CURRENT LITERATURE

This depari n tent carnes selected ab.stracts of . articles publishecl in c u rent medicaijonrnals dealin,, with leprosy' and olheis ntvcobaclerial diseases.

General and Historical

Chen, X. S., Li, W. Z., Jiang, X., Zhu, C.B. and Ye, G. Y. Studies of mode of de-tection of leprosy in China during theyears 1981-1998. Lepr. Rev. 72302-310.

Along with the nationwide economic re-form initiated in the early 1980s and therapid decrease of leprosy endemic after theinmplementation of multi-drug therapy(MDT), the leprosy program changed from`vertical' to 'horizontal'. An evolution inthe mode of detection of leprosy cases hasconsequently taken place. Based on the na-tionwide registration of newly detectedcases, the profile of patients at detection hasbeen studied. The proportions of cases cor-rected significantly with calendar years indetection by dermatological clinics, contactchecks, `chie survey' and mass survey,showing a significam increase in percentageof cases detected through dermatologicalclinics and contact checks, and decreasesthrough `clue survey' and mass survey. De-tecilon of cases through dermatologicalclinics and voluntary reporting have be-come the main modes of case-finding dur-ing 1997-1998, accounting for 37.3% and28.6%, respectively, where contact checkaccounts for only 9.1 %. In arcas with goocldermatological services, a significantlyhigher proportion (75.9%) of cases was de-tected through dermatological clinics,where voluntary reporting and `clue survey'were the main modes of detection in en-demic arcas. As regarás con!irmation of di-agnosis, the great majority of cases wereconfirmed by leprosy units, even thoughthey were detected in various other situa-tions. Only 6.5% of leprosy cases were de-tected and subsequently confirmed by doc-tors in dermatologic clinics. The presentmodes of detection and their relation to de-

mographical, epidemiological, clinicai fac-tors and health services are discussed. Thisstudy emphasizes the cardinal importanteof the dermatological clinics in the detec-tion of leprosy cases in China at the presenttime and hence the need to strengthen thetraining of doctors in these clinics, whilecontinuously encourage their involvementin leprosy control.—Authors' Abstract

Chen, S., Zhang, L., Wang, Z., Zhou, J.,Liu, Y. and Mao, C. Experiences from acollaborative project on the preventionof clisability in leprosy patients in Shan-dong Province, the People's Republic ofChina. Lepr. Rev. 72 (2001) 330-336.

Shandong Province (present population89 million) in the People's Republic ofChina established a leprosy control pro-gram in 1955. Between that year and theend of 1999, allowing for death and migra-tion, the cumulative number of cases regis-tered was 53,618, including 120 cases onmultiple drug therapy (MDT) and 18,248who had completed satisfactory courses ofdapsone monotherapy and/or MDT. Of thislatter group, 9500 cases (52%) sufferedfrom visible disabilities (grade 2 of theWHO classification). Prevalence and inci-dence rates of leprosy have decreased dra-matically since 1955 and, on average, only50-70 new cases are now being detectedannually in the entire province. Leprosy isthus no longer a public health problem, butthe existente of such a large number of pa-tients with grade 2 disabilities is clearly amatter of serious concern. This paper de-scribes a pilot project to investigate the po-tential of health personnel in the leprosyprogram and the dermatology and sexuallytransmitted cliseases services to (a) preveni

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58^ International Journal otLeprosy^ 2002

deterioration of existing disabilities in ex-patients through self-care and (h) preventnew neuritis in patients on MDT throughearly detection and the use of steroids.—Authors' Abstract

Dequeker, j., Fabry, G. and Vanopden-bosch, L. Hieronymus Bosch(1450-1516): paleopathology of the me-dieval disabled and its relation to thebone and joint decade 2000-2010. Isr.Med. Assoc. J. 3 (2001) 864-871.

Background: At the start of the Bone andJoint Decade 2000-2010, a paleopathologicstudy of the physicaliy disabled may yieldinformation and insight on the prevalenceof crippling disorders and attitudes towardsthe afil icted in the past compared to today.Objective: To analyze "The procession ofthe Cripples," a representative drawing of31 disabied individuais by HieronymusBosch in 1500. Methods: Three special-ists—a rheumatologist, an orthopedic sur-geon and a neurologist—anaiyzed eachcase by problem-solving means and clinicaireasoning in order to forn'mlate a consensuson the most likely diagnosis. Results: Thisiconographic study of crippies in the six-teenth century reveals that the most com-mon crippling disorder was not a neuralform of leprosy, but rather that other disor-ders were also prevalent, such as congenitalmaiformation, dry gangrene due to ergo-tism, post-traumatic amputations, infectiousdiseases (Pott's, syphilis), and even simula-tors. The drawings show characteristic cop-ing patterns and different kinds of crutchesand aids. Conclusion: A correct clinicai di-agnosis can be reached through the collabo-ration of a rheumatologist, an orthopedistand a neurologist. The Bone and JointDecade Project, calling for attention andeducation with respect to musculoskeletaldisorders, should reduce the impact andburden of crippling diseases worldwidethrough early clinicai diagnosis and appro-priate treatment. Authors' Abstract

Diggle, G. E. Thalidomide: 40 years ou.Int. J. Clin. Pract. 55 (2001) 627-631.

Thalidomide was marketed in the late-

1950s as a sedative and tranquillizer of ex-ceptionally low general toxicity, bui in1961 it was implicated separateiy by Lenzand MacBride as the cause of the epidemicof congenital malformations that had beenpuzzling the world for some years. II is avery potent teratogen in humans, but ia fewother mammalian species; damage to theembryo is produced at specitic stages ofgestation, but the mechanism of embryo-pathic action is still not understood. Fol-lowing the withdrawal of the drug world-wide, it was consigned to the history ofmedical tragedies. In 1965, however, Shes-kin discovered that it was effective in treat-ing erythema nodosum leprosum, a dis-tressing complication of leprosy. As thedrug is neither an antibiotic nor an anal-gesic, its action was assumed to be im-munosuppressive. In Brazil the drug wasused widely with few regulatory controls,since when more than 100 cases of congen-ital malformation have appeared. Sheskin'sdiscovery led to the experimental use ofthalidomide in many other indicationsthought to possess some immunoiogicalcomponent. In some cases, e.g., Behcet'ssyndrome, graft-versus-host disease andaphthous ulceration in HIV-positive pa-tients, the drug has been shown to possesssome efficacy. And there is some evidencethat it inhibits the replication of one of theimmunodeficiency viruses. The AIDS com-munity in the US has exerted much pres-sure on the FDA to allow the drug onto themarket, although the use of a potent im-munosuppressive drug of unknown mecha-nism in an immunodeficiency conditionraises further questions. Thalidornide is notaiways beneficiai; its use is associated withan increased mortality in epidermal necrol-ysis. In 1991, D'Amato confirmed it pos-sessed antiangiogenic properties and thisled to further trials in malignant conditions.Results were mixed, bui those in multiplemyeloma gave some grounds for optimism.In 1998, the FDA announced its extraordi-nary decision to grani marketing approvalfor thalidomide.—Author's Abstract

Lejbkowicz, F., Tsilman, B., Wexler, R.and Cohen, II. 1. Leprosy in Israel: animported disease^the support ofhistopathological examination for iIs de-

70, 1^ Curre nt Literature^ 59

tection. Acta Histochem. 103 (2001)433-436.

Leprosy is rare and non-endemic in Is-rael. Cases of leprosy are invariably im-ported by immigrants or foreign workers ar-ri ving from endemic areal. 1n view of therelative rarity of the disease, clinicians andpathologists are not always alert to the pos-sibility of the disease or recognize potentialsymptoms. A case history is presented of a31-year-old immigrant presenting symp-toms of skin lesions and nodules on thehands and facial region, especially the earlobe. Confirmation of the infection was pro-vided by histopathology of suspected le-sions stained for acid-fast bacilli (modihedFite-Faraco staining).—Authors' Abstract

Sasaki, S., Takeshita, F., Okuda, K. andIshii, N. J. Mycobacterium leprae andleprosy. Microbiol. Immunol. 45 (2001)729-736.

Leprosy is a chronic infectious diseasecaused by Mycobacierium leprae, which

was discovered by G. H. A. Hansen in 1873.M. leprae is an exceptional bacterium be-cause of its long generation time and nogrowth in artificial media. Entire sequencingof the bacterial g;enome revealed numerouspseudogenes (inactive reading frames withfunctional counterparts in NI. tuberculosis)which might be responsible for the very lim-ited metabolic activity of M. leprae. Theclinicai demonstration of the disease is deter-mined by the quality of host immune re-sponse. Thl-type immune response helps tokill the bacteria, but hosts are encroachedupon when Th2-type response is predomi-nant. The bacteria have affinity to the periph-eral nerves and are likely to cause neuropa-thy. M. leprae/laminin-alpha2 complexesbind to alpha/beta dystroglycan complexesexpressed on the Schwann cell surface.WHO recommends a chemotherapy protocol[multidrug therapy (MDT)] which effec-tively controls the disease and contributes tothe global elimination program. Leprosy hasbeen stigmatized throughout history, and re-cent topics regarding the disease in Japan arealso discussed.—Authors' Abstract

Chemotherapy

Chan, C. Y., Au-Yeang, C., Yew, W. W.,Hui, M. and Cheng, A. F. Postantibioticeffects of antituberculosis agents aloneand in combination. Antimicrob. AgentsChemother. 45 (2001) 3631-3634.

The postantibiotic effects (PAEs) ofseven antimycobacterial agents, tested attheir respective peak concentrations inserum alone and in different combinations,against Mycobacterium tuberctrlosis ATCC27294 were studied with a radiometric cul-tue system in parallel with the viable countmethod. Rifampin gave the longest PAE(67.8 hr) among the drugs used alone, andcombinations of first-fine drugs generallygave PAEs longer than 120 hr. The data ob-tained might help provide a better un-derstanding of the scientific balis of in-tcrmittently administered antituberculosischemotherapy—Authors' Abstract

Chen, B. J. Triptolide, a novel immunosup-pressive and anti-inflammatory agent pu-rified from a Chinese herb Tripterygiumrri/Jorclü hook F. Leuk. Lymphoma 42(2001) 253-265.

Triptolide is a diterpenoid triepoxide pu-rified from a Chinese herb Tripterygiumwilfordü Hook F (TWHF). TWHF has beenused in traditional Chinese medicine formore than two thousand years. However, itspotential value was recognized by the west-ern medicine only after investigators ob-served the effectiveness of TWHF in thetreatment of leprosy and rheumatoid arthri-tis. Triptolide has been identitied as the ma-jor component responsible for the immuno-suppressive and anti-inflammatory effectsof TWHF. Triptolide inhibits both Ca(2+)-dependent and Ca(2+)-independent path-ways and affects T cell activation through

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60^ International Journal of. Lepro,sy^ 2002

inhibition of interleukin-2 transcription at asite di ¡ferem from the target of cyclosporinA. Triptolide also has inhibitory effects on avariety of proinflammatory cytokines andmediators and on the expression ofsion molecules by endothelial cells. Trip-tolide is effective for the treatment of a va-riety of autoimmune diseases and inprevention of allograft rejection and graft-versus-host disease in both animais and hu-mans. Moreover, triptolide possesses antitu-mor and male anti-fertility effect. However,the toxicities of triptolide may be associatedwith renal, cardiac, hematopoietic and re-productive systems. Currently availabledata suggest that triptolide is a promisingimmunosuppressive and anti-inflammatoryagent and should be explored further in au-toimmune diseases and transplantation.—Author's Abstract

DeMaio, J., Schwartz, L., Cooley, P. andTice, A. The application of telemedi-cine technology to a directly observedtherapy program for tuberculosis: a pilotproject. Clin. Infect. Dis. 33 (2001)2082-2084.

We evaluated the use of videophone tech-nology to provide directly observed therapy(DOT) to patients with active tuberculosis.During 304 treatment doses, adherence ouvideophone DOT was 95%, and patient ac-ceptance of the technology was excellent.In selected cases, the use of videophonetechnology can maintain a high levei of ad-herence to DOT in a cost-effective man-ner.—Authors' Abstract

Clinical Sciences

Cooke, G. S. and Hill, A. V. Genetics ofsusceptibility to human infectious dis-case. Nat. Rev. Genet. 2 (2001) 967-977.

Before Robert Koch's work in the latenineteenth century, diseases such as tuber-culosis and leprosy were widely believed tobe inherited disorders. Heritability of sus-ceptibility to several infectious diseases hasbeen confirmed by studies in the twentiethcentury. Infectious diseases, old and new,continue to be an important cause of mor-tality worldwide. A greater understandingof disease processes is needed if more ef-fective therapies and more useful vaccinesare to be produced. As part of this effort,developments ia genetics have allowed amore systematic study of the impact that thehuman genome and infectious disease haveou each other. Authors' Abstract

Courtright, P., Kim, S. H., Tungpakorn,N., Cho, B. H., Lim, Y. K., Lee, H. J.and Lewallen, S. Lagophthalmos surgeryin leprosy: findings from a population-based survey in Korea. Lepr. Rev. 72(2001) 285-291.

Lagophthalmos continues to be a seriousproblem in cured leprosy patients. Weconducted a population-based survey oflagophthalmos surgical coverage (LSC),barriers to lagophthalmos surgery and °ui-come of lagophthalmos surgery ia leprosypatients in South Korea. In our survey, therewere 60 patients with lagophthalmos whohad needed surgery (>5 mm gap), 34 ofwhom had received surgery, resulting ia alagophthalmos surgery coverage of 57%.Among the 34 patients who had receivedlagophthalmos surgery, 18 needed furthersurgery. Among those who had never hadsurgery, none of the demographic indicatorspredicted surgical uptake; the primary rea-son given for failure to have surgery waslack of knowledge about it. Outcome ofsurgery (by eye) showed that 29% of eyesstill had a gap of 5 mm or more. The fre-quency of symptoms (tearing, blurring ofvision, pain, etc.) was high. Even in settingswith a good eye care infrastructure, such asKorea, uptake of surgery can still be lowand results may not be satisfactory to pa-tients. There is a need for practical guide-lines for leprosy control programs in the ar-eas of (a) patient recognition, (b) patient

70, l^ Current Literatare 61

education, (c) monitoring the uptake ofsurgery, and (d) monitoring the unicorne ofsurgery to ensure the best possible out-come.—Authors' Abstract

Ishikawa, A., Ishikawa, S. and Hi-rakawa, M. Osteoporosis, bone turnoverand hypogonadism in elderly men withtreated leprosy. Lepr. Rev. 72 (2001)322-329.

In inale hypogonadism associated withbone Ioss, it is inmportant to determinewhether bone Ioss continues with ageingand an increased risk of fracture. We stud-ied bone metabolism in 86 inale leprosy pa-tients, who were classified according to thepresence or absence of osteoporosis. Osteo-porosis was present when men had lombarcompression fractures or a mean BMD-2SD that of normal Japanese men in eachage decade. Four men had fractures. Seremconcentrations of 1,25-dihydroxyvitamin Dand high-sensitivity parathyroid hormonewere almost normal in both groups,whereas free testosterone and oestradiolwere significantly lower in the osteoporosisgroup than in the non-osteoporosis group(free testosterone: p <0.01, oestradiol: p<0.05.). The urinary concentrations ofpyridinoline and deoxypyridinoline, as amarker of bone absorption, were signifi-cantly higher in the osteoporosis group thanin the non-osteoporosis group (pyridino-line: p <0.01, deoxypyridinoline: p <0.01).The serem concentration of osteocalcin, amarker of bone formation, was significantlyhigher in the osteoporosis group than in thenon-osteoporosis group (p <0.01). Elevatedconcentration means that bone repair is in-creased possibly because of compensationmechanisms for increased bone Ioss. In theosteoporosis group, hypogonadism oc-curred, and high bone turnover continuedeven in older men. We recommend clinicaistudies of treatment such as replacementtherapy to preveni bone Ioss and increasingrisk of fractures in older men with lep-rosy—Authors' Abstract

Kulkarni, R. B., Rajeshwari, T. A. Patiland Pravecna. S. Actinomycotic myce-toma due to Nocardia brasiliensis in a

case of leprosy. Indian J. Lepr. 73 (2001)263-272.

Various bacterial and fungai infectionsassociated with non-healing ulcers in casesof leprosy have been reported (G Ebenzer,et ai., 2000, Rama Ramani et ai., 1990).There are no reports of mycetoma associ-ated with leprosy patients in the literature.We report here a case of actinomycoticmycetoma due to Nocardia brasiliensis as-sociated with the non-healing plantar ulcerof a leprosy patient.—Authors' Abstract

Petering, H., Kiehl, P., Vogelbruch, M.,Sticht-Gron, V., Kapp, A. and Werfel,T. Chemotherapy-induced erythema no-dosum leprosum: successful treatmentwith thalidomide. 52 (2001) 966-969 (inGerman).

The severity and outcome of a eliminegranulomatous infection caused by M. lep-rae depend on the cell-mediated immunitytowards the pathogen. The disease classifi-cation is based on the host's response to M.leprae ranging from high to low resistance(polar tuberculoid leprosy to polar leproma-tous leprosy). The host's position in thespectrum is not stable: leprosy reactions re-fiecting changed immune status may occurspontaneously or during chemotherapy. Thetype II reaction or erythema nodosum lep-rosum can most often be seen in patientswith lepromatous leprosy, a multiorgan dis-ease characterized by an unrestricted bacil-lary replication. Clinically, this reaction ischaracterized by crops of painful brightpink, dermal and subcutaneous nodulesarising in clinically normal skin, in associa-tion with fever, malaise, glomerulonephritisand arthralgias. Therefore, prompt institu-tion of immunosuppressive therapy withcorticosteroids or thalidomide is recom-mended. This case report describes the de-velopment of erythema nodosum leprosumduring chemotherapy treated successfullywith thalidomide. Furthermore, irnmuno-loãic effects and potencial side effects ofthis drug are discussed. Authors' Abstract

Santos, A. R., Balassiano, V., Oliveira, M.L., Pereira, M. A., Santos, P. B., De-

62^ International fournal of. Leprasy^ 2002

grave, W. NI. and Suffys, P. N. Detec-tion of Myrobacterium leprae DNA bypolymerase chain reaction in the bloodof individuais, eig,ht years after comple-tion of anti-leprosy therapy. 96 (2001)1123-1133.

Thirty-eight patients with indeterminateleprosy (HI), at least 4 to 6 years after dis-charge from multibacillary (MB) or pau-cibacillary (PB) schemes of anti-leprosymultidrug therapy (MDT), were submittedto traditional diagnostic procedures for lep-rosy and to polymerase chain reaction(PCR) analysis of different clinicai sampiesfor detection of Mycobacteriwn lepraeDNA. No significant difference was ob-served for any of the parameters anaiyzedbetween PB or MB schemes of treatmentand no indications were found for more ef-ficient outcome of HI using the MBscheme. Remarkably, 18 (54.5%) of the in-dividuais were PCR positive in at least oneof the samples: positivity of PCR was high-est in biood sampies and four individuaiswere PCR positive in blood and some othersampie. Upon comparison of PCR resultswith clinicai and histopathological parame-ters, no correlation was found betweenPCR-positivity and eventual reiapse. This isthe first report on detection of M. lepraeDNA in PB patients, more than haif adecade after compietion of MDT, suggest-ing that live bacilli are present and circulat-ing much longer than expected, aithoughreinfection of the individuais cannot be ex-cluded. Overall, we feel that because of thehigh sensitivity of the assay, extreme care

be taken abola association of PCRresults, efficacy of treatment and diseasestatus.--Authors' Abstract

Shanker Narayan, N. P., Ramu, G.,Ilangumaran, S., Desikan, K. V. andMuthukaruppan, V. R. Poor correlationof systemic immunological parameterswith clinicai features in macular leprosy.Indian J. Lepr. 73 (2001) 239-246.

Ou the basis of clinicai features and bac-teriological status, macular skin lesions ofnine cases of leprosy were ciassified asfailing within a spectrum between the tu-berculoid at one end and the lepromatous atthe other. While histoiogical correlationwas seen in 60% of cases, humoral and cel-lutar systemic immunologic features werefound to be uncharacteristic. II is suctoestedthat macular lesions forni an eariy stage inthe deveiopment of leprosy where the sys-temic immunoiogical response is yet to seti n fu 1 ly. A uthors' Abstract

Shaw, I. N., Ebenezer, G., Babu, B. andRao, G. S. Borderline tuberculoid lep-rosy of the scalp. Lepr. Rev. 72 (2001)357-359.

A case of borderline tubercuioid leprosyinvolving the hairy scaip is reported. To thebest of our knowledge, only two paucibacil-lary leprosy patients with scalp lesion havebeen reported, and in only one was thescaip covered with hair.—Authors' Abstract

Immuno-Pathology

Belkaid, Y., Hoffmann, K. F., Mendez, S.,Kamhawi, S., Udey, 1V1. C., Wynn, T.A. and Sacks, D. L. The role of Inter-leukin (1L)-10 in the persistence ofLeishmania major in the skin after heal-ing and the therapeutic potential of anti-IL-10 receptor antibody for sterile cure.J. Exp. Med. 19 (2001) 1497-1506.

Some pathogens (e.g., Mycobacteriumtuberculosis, Toxoplasma gondii, Leishma-nia spp.) have been shown to persist in their

host after clinicai cube, establishing the riskof disease reactivation. We anaiyzed theconditions necessary for the long termmaintenance of Leishmania major in genet-ically resistant C57BL/6 mice after sponta-neous healing of their derma] lesions. Inter-leukin (IL)-10 was found to play anessential role in parasite persistence as ster-ile cure was achieved in IL-10-deficient andIL-4/IL-10 doubie-deficient mice. The re-quirement for 1L-10 in establishing latencyassociated with natural infection was con-

70, I^ Current Literatura^ 63

firmed in IL-10-deficient coice challengedby bite of infected sand files. The host-parasite equilibrium was maintained byCD4(+) and CD8(+) T cells which wereeach able to release IL-10 or interferon(IFN)-gamma, and were found to accumu-late in chronic sites of infection, includingthe skin and draining lymph node. A highfrequency of the dermal CD4(+) T cells re-leased both IL-10 andIFN-gamma. Wild-type mice treated transiently during thechronic phase with anti-IL-10 receptor anti-bodies achieved sterile cure, suggesting anovel therapeutic approach to eliminate la-tency, infection reservoirs, and the risk ofreactivation disease.—Authors' Abstract

Brandt, L., Feino Cunha, J., WeinreichOlsen, A., Chilima, B., Hirsch, P., Ap-pelberg, R. and Andersen, P. Failure ofthe Mycobacterium bovis BCG vaccine:some species of environmental myco-bacteria block multiplication of BCGand induction of protective immunity totuberculosis. 70 (2002) 672-678.

The efficacy of Mvcobacterium boi'isbacillus Calmette-Guerin (BCG) vaccineagainst pulmonary tuberculosis (TB) variesenormously in different populations. Theprevailing hypothesis attributes this varia-tion to interactions between the vaccine andmycobacteria common in the environment,but the precise mechanism has so far notbeen clarified. Our study demonstrates thatprior exposure to live environmental myco-bacteria can result in a broad immune re-sponse that is recalled rapidly after BCGvaccination and controls the multiplicationof the vaccine. In these sensitized mice,BCG elicits only a transient immune re-sponse with a low frequency of mycobacte-rium-specific cells and no protective immu-nity against TB. In contrast, the efficacy ofTB subunit vaccines was unaffected byprior exposure to environmental mycobac-teria. Six different isolates from soil andsputum samples from Karonga district inNorthern Malawi (a region in which BCGvaccination has no effect against pulmonaryTB) were investigated in the mouse model,and two strains of the Mycobacteriumavium complex were found to block BCGactivity completely.—Authors' Abstract

Diniz, L. M., Zandonade, E., Dietze, R.,Pereira, F. E. and Ribeiro-Rodrigues,R. Short report: do intestinal nematodesincrease the risk for multibacillary lep-rosy? Am. J. Trop. Med. Hyg. 65 (2001)852-854.

Intestinal helminths are known to subvertthe host's immune response towards a Th2response, which in turn may lead to botheosinophilia and high immunoglobulin Etiters often associated with these parasites.Mycobacterium leprae infection may leadto different clinicai and pathological forms.Multibacillary forms are associated withTh2 cytokines, whereas paucibacillaryforms are associated with Th 1 cytokines.We report a significantly higher frequencyof intestinal helminthic infections in pa-tients with the lepromatous form, a multi-bacillary forro of leprosy (odds ratio, 2.99;95% confidence interval, 1.82-4.95; p =0.006) when compared with patients withpaucibacillary leprosy or to a control groupwithout leprosy. A direct correlation wasalso found between mycobacterial indexand the frequency of intestinal helminths.Our results suggest that the presence of in-testinal helminths may facilitate the estab-lishment of M. leprae infection or the pro-gression to more severe forms ofleprosy.—Authors' Abstract

Garcia, V. E., Quiroga, M. E, Ochoa, M.T., Ochoa, L., Pasquinelli, V.,Fainboim, L., Olivares, L. M., Valdez,R., Sordelli, D. O., Aversa, G., Modlin,R. L. and Sieling, P. A. Signalinglymphocytic activation molecule expres-sion and regulation in human intracel-lular infection correlate with Thl cyto-kine patterns. J. Immunol. 167 (2001)5719-5724.

Induction of Th l cytokines, those assoei-ated with cell-mediated immunity, is criticaifor host defense against infection by intra-cellular pathogens, including mycobacteria.Signaling lymphocytic activation molecule(SLAM, CD 150) is a transmembrane pro-tein expressed on lymphocytes that pro-motes T cell proliferation and IFN-gammaproduction. The expression and role ofSLAM in human infectious disease were

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64^ Iiternational.lottrnal Of Lepivsv^ 2002

investigated using leprosy as a nnodel. Wefound that SLAM niRNA and protein weremore strongly expressed in skin lesions oftuberculoid patients, those with measurableCMI to the pathogen, Mycobacterium lep-rae, compared with lepromatous patients,who have weak CMI against M. leprae. Pe-ripheral blood T cells from tuberculoid pa-tients showed a striking increase in the leveiof SLAM expression after stimulation withM. leprae, whereas the expression ofSLAM on T cells from lepromatous pa-tients show little change by M. leprae stim-ulation. Engagement of SLAM by an ago-nistic mAb up-regulated IFN-gammaproduction from tuberculoid patients andslightly increased the levels of IFN-gammain lepromatous patients. In addition, IFN-gamma augmented SLAM expression onM. leprae-sti mulated peripheral blood Tcells from leprosy patients. Signalingthrough SLAM after IFN-gamma treatmentof Ag-stimulated cells enhanced IFN -

gamma production in lepromatous patientsto the levels of tuberculoid patients. Ourdata suggest that the local release of IFN-gamma by M. leprae-activated T cells intuberculoid leprosy lesions leads to up-regulation of SLAM expression. Ligationof SLAM augments IFN-gamma produc-tion in the local microenvironment, creatinga positive feedback loop. Failure of T cellsfrom lepromatous leprosy patients toproduce IFN-gamma in response to M. lep-rae contributes to reduced expression ofSLAM. Therefore, the activation of SLAMmay promote the cell-mediated immuneresponse to intracellular bacterial patho-gens. Authors' Abstract

Hill, A. V. The genomics and genetics ofhuman infectious disease susceptibililty.Annu. Rev. Genomics Hum. Genetics 2(2001) 373-400.

A genetic basis for interindividual varia-tion in susceptibility to human infectiousdiseases has been indicated by twin,adoptee, pedigree, and candidate gene stud-ies. This has led to the identification of asmall number of strong genetic associationswith common variants for miaria, HIV in-fection, and infectious prion diseases. Nu-merous other genes have shown less strong

associations with these and some other in-fectious diseases, such as tuberculosis, lep-rosy, and persistent hepatitis virai infec-tions. Many immunogenetic loci influencesusceptibility to severa' infectious patho-gens. Recent genetic linkage analyses ofmeasu res of infection as well as of infec-tious disease, inclucling some genome-widescans, have found convincing evidence ofgenetic linkage to chromosomal regionswherein susceptibility genes have yet to beidentilied. These studies indicate a highlypolygenic basis for susceptibility to manycommon infectious diseases, with someemerging examples of interaction betweenvariants of specific polymorphic host andpathogen genes.—Author's Abstract

Jayapal, V., Selvibai, G., Mahalakshmi,K., Pushkala, Ragunath, K. and Sub-ramanian, S. Comparative study of anti-PGL-1, anti-35kDa and anti-lipoarabino-mannan assays for serodiagnosis ofleprosy. Indian J. Lepr. 73 (2001)229-237.

Three antibody assays (anti-PGL-1, anti-35kDa and anti-LAM) were used to deter-mine the levels of antibodies in the sera ofuntreated leprosy patients. All the three as-says showed higher levels of antibodies inBL/LL patients as compared to I and TT/BTpatients, as well as healthy controls. BL/LLpatients showed positivity of 100%, 84.2%and 78.9% by anti-PGL-1, anti-35kDa andanti-LAM assays respectively. All the threeassays were negative for leprosy in healthycontrols. Anti-PGL-1 assay was positive in20% of TT/BT patients and 17.9% of I pa-tients. Anti-35kDa assay was negative in alithe TT/BT patients and positive in 7.14% ofI patients. Anti-LAM assay was positive in13.3% of TT/BT patients and in 10.7% of Ipatients. Hence, while these assays are valu-able in diagnosing BL/LL patients, theirusefulness in diagnosing 1, BT or TT lep-rosy is limited. Authors' Abstract

Meisner, S. J., Mucklow, S., Warner, G.,Sow, S. O., Liendhardt, C. and Hill, A.V. Association of NRAMP 1 polymor-phism with leprosy type but not suscepti-bility to leprosy per se in west A fri can s.

70,1^ Current Literantre^ 65

Am. J. Trop. Med. Hyg. 65 (2001)733-735.

Twin and family studies indicate that hostgenetic -factors influence susceptibility toleprosy and, possibly, leprosy type. M urinestudies have suggested a role for the naturalresistance-associated macrophage protein(Nramp ) gene, which can influence cellu-lar immune responses to intracellularpathogens. We evaluated a variation in thehuman homolog, NRAMP I , recently asso-ciated with tuberculosis susceptibility inWest Africa. A total of 273 patients withleprosy and 201 controls from Mali weregenotyped for NRAMP 1 polymorphismspreviously associated with tuberculosis. Noassociation was found with leprosy per se(p = 0.83), but the NRAMP I 3'-untrans-1ated region 4-bp insertion/deletion poly-morphism was associated with leprosy type(p = 0.007). Heterozygotes were more fre-quent among multibacillary than pau-cibacillary leprosy cases. Thus, variation inor near the NRAMP 1 gene may exert an in-fluence on the clinicai presentation of lep-rosy, possibly by influencing cellular im-mune response type.—Authors' Abstract

Modlin, R. L. Learning from leprosy: in-sights into contemporary immunologyfrom an ancient disease. Skin Pharmacol.Appl. Skin Physiol. 15 (2002) 1-6.

Leprosy providas an ideal model to studyimmune responses in humans and in skin.Learning from leprosy, we have gained in-sight into mechanisms of host resistanceand susceptibility to infection. New para-digms include the role of Thl/Th2 cy-tokines, the ability of CD1 to present non-peptide antigens to T cells, the ability ofmicrobial lipoproteins to stimulate anti mi-crobial activity in monocytes and thedemonstration that T cells can mediate a di-rect anti microbial activity through releaseof granulysin. Together, these findings pro-vida a rationale for developing new strate-gies to treat and prevent infectious dis-ease.—Author's Abstract

Rook, G. A., Lightman, S. L. and 1-Ie1j-nen, C. J. Can nerve damage disrupt

neuroendocrine immune homeostasis?Leprosy as a case in point. Trends Im-munol. 23 (2002) 18-22.

The crucial clinicai problem in leprosy isthe occurrence of acute inflammatoryepisodes that lead to nerve damage, even af-ter the infecting organisms have been killedby antibiotics. We suggest that the instabilityof these inflammatory sites is attributable toa disturbance of the role that nerves play inthe regulation of intlammation. The destruc-tion of sensory C fibers and sympathetic in-nervation will remove anti-inflammatoryfeedback circuits. Moreover, diminishingleveis of neuropeptides and changes in thecytokine profile will affect the cortisol-sensi-tivity of infiltrating T cells, and modulate thecortisol-cortisone shuttle so that the inflam-matory site becomes resistant to physiologi-cal leveis of anti-inflammatory adrenocorti-cal steroids.—Authors' Abstract

Schon, T., Hernandez-Pando, R. H.,Negesse, Y., Leekassa, R., Sundqvist,T. and Britton, S. Expression of in-ducible nitric oxide synthase and nitroty-rosine in borderline leprosy lesions. Br.J. Dermatol. 145 (2001) 809-815.

Background: In the response to T-helpercell (Th1)-type cytokines and interactionswith pathogens, high leveis of nitric oxide(NO) are produced by activated macro-phages expressing the inducible NO syn-thase (iNOS). The role and importance ofreactive nitrogen intermediates (RNIs) suchas NO and peroxynitrite in the host responseto diseases caused by intracellular patho-gens such as Mvcobacterium leprae and M.tuberculosis is unclear. Objectives: The aimof this study was to investigate the presenceof local production of NO and peroxynitritein borderline leprosy by using antibodiesproduct of peroxynitrite, nitrotyrosine (NT).Methods: We detected the presence of iNOSand NT in skin biopsies from borderline lep-rosy patients, with and without reversal re-action (RR), by immunohistochemistry (N26). Results: In general, the granulomasfrom borderline leprosy lesions with andwithout RR showed high and specific ex-pression of iNOS and NT. Moreover, strongimmunoreactivity to iNOS and NT was ob-

66^ International lournal of. Leprosy^ 2002

served in granulomas surrounding and infil-trating derma' nerves. The expression ofiNOS and NT was also strong in ker-atinocytes, tibroblasts and endothelial cellsin dose relation to the granulomatous reac-tion. In contrast, normal human skin showedno expression of i NOS and NT in thesecells. Conclusions: We conclude that iNOSand NT are expressed in granulomas fromborderline leprosy patients with and withoutRR and propose that RN1s might be in-volved in the nerve damage following RR inleprosy. Authors' Abstract

Seitzer, U., Kayser, K., Hohn, H., Entzian,P., Wacker, H. H., Ploetz, S., Flad, H.D., Gerdes, J. and Maeurer, M. J. Re-duced T-cell receptor CD3zeta-chainprotein and sustained CD3epsilon ex-pression at the site of mycobacterial in-fection. Immunology 104 (2001)269-277.

Control of mycobacterial infection by thecellular immune system relies both on anti-gen-presenting cells and ou T lymphocytes.The quality of an effective cellular immuneresponse is dependem ou functional signaltransduction residing in the cytoplasmictails of the T-cell receptor CD3 components.In order to investigate potential effects ofmycobacteria on T-cell receptor signalling,we examined the protein expression of T-cellsigna] transduction molecules (CD3zeta,ZAP-70, p59fyn, p561ck). In Western blotsof peripheral blood mononuclear cells ofMycobacterium tuberculosis infected pa-tients, only the CD3zeta-chain showed amarked reduction in protein expression. Toinvestigate the situation in situ, immunoen-zymatic and immunofluorescence stainingsfor CD3epsilon and CD3zeta expressionwere performed on sections of normal lym-phoid tissue, M. leprae infected and sarcoidtissue. CD3epsilon and CD3zeta expressionwere similar with respect to intensity, local-ization and the number of cells stained innormal lymphoid tissue and in sarcoid gran-ulomas. In contrast, the granulomas of M.leprae infected tissues showed a signifi-cantly reduced expression of CD3zeta com-pared to CD3epsilon. Using double im-munofluorescence analysis, virtually noCD3zeta expression could be detected in

comparison to the CD3epsilon expression inthe lesions. Apparently, mycobacteria arecapable of significantly reducing CD3zeta-chain expression, which may be restored bycytokines. 1L-2-enhanced zeta-chain expres-sion and T-cell effector functions, detined byinterferon-gamma release, in M. tubercu-losis-specitic and human leucocyte antigen-DR restricted CD4+ T cells isolated fromgranuloma lesions from patients with pul-monary tuberculosis. Because CD3zeta isessential for CD3 signalling and for elicit-ing T-cell effector functions, reduced CD3-zeta protein expression could result in al-tered signa! transduction and inefticientT-cell effector functions. Alternatively, re-duced CD3zeta-chain expression may pro-tect T cells from repetitive TCR stimulationassociated with anergy or apoptosis.—Au-thors' Abstract

Shanker Narayan, N. P., Ramn, G., De-sikan, K. V. and Vallishayee, R. S. Cor-relation of clinicai histological and im-munological features across the leprosyspectrum. Indian J. Lepr. 73 (2001)329-342.

The Ridley-Jopling system of classifica-tion of the variegated clinicai pattern of lep-rosy is based ou the specific cell-mediatedimmunity observed in the histopathology ofskin lesions conforming to a spectrum fromTT at one end to LL ah the other.

In this study a fairly large sample of 90patients was classified on clinicai grounds;the histopathology of the skin lesions wasstudied blind. There was an overall concor-dance of 90% between the clinicai and bis-tological classifications. In addition, the sys-temic cell-mediated and humoral immuneresponses were studied. The in vivo cell-me-diated immune response, namely the Mit-suda skin response, mostly conformed to theclinicai classification. While the in vitrolymphoproliferative responses to BCG andits sonicate were high, the lymphoprolifera-tive responses to Dharmendra leprominwere surprisingly poor. Humoral responsesto 35kDA protein of M. leprae and PGL-1were good in most LL, BL patients and ta-pered off towards TT. IgG antibodies to re-combinant ML 65kDa proteins denoted my-cobacterial presence.—Authors' Abstract

70, I^ Current Literature^ 67

Microbiology

Bentrup, K. H. and Russell, D. G. Myco-bacterial persistence: adaptation to achanging environment. Trends Micro-biol. 9 (2001) 597-605.

Mycobacterium tuberculosis is a bacterialpathogen that can persist within an infectedindividual for extended periods of timewithout causing overt, clinicai disease, in astate normally referred to as latent orchronic tuberculosis. Although the replica-tive state of the bacterium during this pe-riod is a matter of some conjecture, recentdevelopments have indicated that the bacte-rium requires the regulated expression of aset of genes and metabolic pathways tomaintain a persistent infection in an im-munocompetent host. The characterizationof these gene products and their role in bac-terial metabolism and physiology is startingto provide insights into the mechanisms thatM. tuberculosis has evolved to adopt itshighly successful mode of pathogenicity.-Authors' Abstract

Bhakta, S. and Basun, J. Overexpression,purification and biochemical character-ization of a class A high-molecular-masspenicillin-binding protein (PBP), PBP1 *and its soluble derivative from Mycobac-ter/um tuberculosis. Biochem. J. 361(2002) 635-639.

The product of the gene ponA present incosmid MTCY21 D4, one of the collectionof clones representing the genome of Myco-bacterium tuberculosis, has been namedpenicillin-binding protein 1 * (PBP1 *), byanalogy to the previously characterizedPBP1 * of M. leprae. This gene has beenoverexpressed in Escherichia coli. His(6)-tagged PBP1:.< localizes to the membranesof induced E. coli cells. Its susceptibility todegradation upon proteinase K digestion ofspheroplasts from E. coli expressing theprotein supports the view that the majorityof the protein translocates to the peri-plasmic sitie of the membrane. Recombi-nant PBP binds benzylpenicillin andseveral other beta-lactaras, notably cefo-

taxime, with high affinity. Truncation of theN-terminal 64 amino acid residues resultsin an expressed protein present exclusivelyin inclusion bodies and unable to associatewith the membrane. The C-terminal moduleencompassing amino acids 272-663 can beextracted from inclusion bodies under dena-turing conditions using guanidine/HCI andrefolded to give a protein fully competent inpenicillin-binding. Deletion of Gly(95)-Gln(143) results in the expression of a pro-tein, which is localized in the cytosol. Thesoluble derivative of PBP1 * binds ben-zylpenicillin with the same efficiency as thefull-length protein. This is the first report ofa soluble derivative of a class A high-molecular-mass PBP.—Authors' Abstract

Braunstein, M., Brown, A. M., Kurtz, S.and Jacobs, W. R. Jr. Two nonredun-dant SecA homologues function in my-cobacteria. J. Bacteriol. 183 (2001)6979-6990.

The proper extracytoplasmic localizationof proteins is an important aspect of myco-bacterial physiology and the pathogenesisof Mycobacterium tuberculosis. The proteinexport systems of mycobacteria have re-mained unexplored. The Sec-dependentprotein export pathway has been well char-acterized in Escherichia coli and is respon-sible for transport across the cytoplasmicmembrane of proteins containing signa] se-quences at their amino termini. SecA is acentral component of this pathway, and it ishighly conserved throughout bacteria. Herewe report on an unusual property of myco-bacterial protein export—the presence oftwo homologs of SecA (SecA) and SecA2).Using an allelic-exchange strategy in Myco-bacterium smegmatis, we demonstrate thatSecA 1 is an essential gene. In contrast,SecA2 cari be deleted and is the first ex-ample of a nonessential SecA homolog. Theessential nature of secA 1, which is consis-tent with the conserved Sec pathway, leadsus to believe that secA 1 represents theequivalent of E. coli SecA. The results of aphenotypic analysis of a DeltasecA2 mutant

68^ Internatioiu il.l0lirnal OfLepro,s'v^ 2002

01 M. smegmatis are presented here andalso indicate a role for SecA2 in protein ex-port. Based on our study, it appears thatSecA2 can assist SecA 1 in the export ofsome proteins via the Sec pathway. How-ever, SecA2 is not the functional equivalentof SecA 1. This finding, in combination withthe fact that SecA2 is highly conservedthroughout mycobacteria, suggests a sec-ond role for SecA2. The possibility existsthat another role for SecA2 is to export aspecific subset of proteins. Authors' Ab-stract

Brennan, M. J., Delogu, G., Chen, Y.,Bardarov, S., Kraiakov, J., Alavi, M.and Jacobs, W. R. ir. Evidence that my-cobacterial PE_PGRS proteins are cellsurface constituents that influence inter-actions with other cells. Infect. Ininiun.69 (2001) 7326-7333.

The elucidation of the genomic sequenceof Mycobacterium tuberculosis revealed thepresence of a novel multigene family des-ignated PE/PE_PGRS that encodes nu-merous, highly related proteins of unknownfunction. In this study, we demonstrate thata transposon insertion in a PE_PGRS gene(1818(PE_PGRS)) found in Mycobac-terium bovis BCG Pasteur, which is theBCG homolog of the M. tuberculosisH37Rv gene Rv 1818c, introduces new phe-notypic properties to this BCG strain. Theseproperties i nc 1 ude dispersed growth inliquid medium and reduced infection ofmacrophages. Complementation of the1818(PE_PGRS)::Tn5367 mutant with thewild-type gene restores both aggregativegrowth (clumping) in liquid medium andreestablishes infectivity of macrophages tolevels equivalent to those for the parentBCG strain. Western blot analysis using an-tisera raised against the 1818(PE_PGRS)protein shows that PE_PGRS proteins arefound in cell lysates of BCG and M. tuber-culosis H37Ra and in the cell wall fractionof M. tuberculosis H37Rv. Moreover, im-munofluorescent labeling of mycobacteriaindicates that certain PE_PGRS proteins arelocalized at the cell surface of BCG and M.tuberculosis. Together these resu l ts suggestthat certain PE_PGRS proteins may befound at the surface of mycobacteria and in-

fluence both cell surface interactions amongmycobacteria as well as the interactions ofmycobacteria with macrophages A ulthors'Abstract

Brennan, P. J. and Vissa, V. D. Genomicevidence for the retention of the essencialmycobacteria) cell wall in the otherwisedefective Mvcobacterium leprae. Lepr.Rev. 72 (2001) 415-428.

The obligate intracellularism of Mvco-bacterium leprae may be attributable to theeffects of mutations in major metabolic ar-eas due to a genome capable of encodingonly about 1600 proteins. Yet cell wallbiosynthesis capability remains relativelyintact and conlparisons with the genome ofMycobacterium tuberculosis provide i n-sights into the genetic basis of a minimalmycobacteria] cell wall. Authors' Ab-stract

Cambau, E., Bonnafous, P., Perani, E.,Sougakoff, W., Ji, B. and Jarlier, V.Molecular detection of rifampin andofloxacin resistance for patients who ex-perience relapse of multibacillary lep-rosy. Clin. Infect. Dis. 34 (2002) 39-45.

Molecular detection of rifampin resis-tance (rpoB analysis) in Mycobacteriumleprae was determined for 49 patients whoexperienced relapse of multibacillary lep-rosy and for 34 untreated patients. Molec-ular detection of ofloxacin resistance (gyrAanalysis) was determined for the 12 patientswho experienced relapse and who had re-ceived ofloxacin. Results of molecular testswere compared with the reference suscepti-bility test in the mouse footpad. Overall, theefficiency of molecular detection that is,positive DNA amplification was 95%,whereas that of the in vivo test was 55% (p<0.001). Results of molecular detection andin vivo test were fully concordant whenboth were available—that is, for 35rifampin-sensitive cases of leprosy (norpoB mutation), 4 ofloxacin-sensitive cases(no gyrA mutation), 11 rifampin-resistantcases (rpoB missense mutations), and 1ofloxacin-resistant case (gyrA mutation).rpoB and gyrA analysis appears to be an ef-

70,1^ Current Literature^ 69

fective method for detection of rifampinand olloxacin resistance in patients withleprosy.—Authors' Abstract

Chen, C. K., Barrow, E. W., Allan, P. W.,Bansal, N., Maddry, J.A., Suling,J., Barrow, W. W, and Parker, VV. B.The metabolism of 2-methyladenosine inMycobacterium smegmatis. M icrobiol-ogy 148 (2002) 289-295.

2-Methyladenosi ne ( methyl-ado ) hasdemonstrated selective activity against My-robacterium mbercidosis, which inclicatesthat differences in the substrate preferencesbetween mycobacterial and human purinemetabolic enzymes can be exploited to de-velop novel drugs for the treatment of my-cobacterial diseases. Therefore, in an effortto better understand the reasons for the anti-mycobacterial activity of methyl-ado, itsmetaboli SM lias been characterized in Mv-cobacterium smegmotis'. In a wild-typestrain, methyl-ado was phosphorylated byadenosine kinase to methyl-AMP, whichwas further convencei to methyl-ATP andincorporated into RNA. In contrast, a mu-tant strain of A4. smegmatis was isolatedthat was resistant to methyl-ado, deficientin adenosine kinase activity and was notable to generate methyl-ado metabolites incells treated with methyl-ado. These resultsindicated that phosphorylated metabolitesof methyl-ado were responsible for the cy-totoxic activity of this compound. Methyl-ado was not a substrate for either adenosinedeaminase or purine-nucleoside phosphory-lase from M. smegmatis. Treatment ofsmegmatis with methyl-ado resulted in theinhibition of ATP synthesis, which indi-cated that a metabolite of methyl-ado inhib-ited one of the enzymes involved in de novopurine synthesis. These studies demon-strated the importance of adenosine kinasein the activation of methyl-ado to toxicmetabolites in Al. smegmads.—Authors'Abstract

Cole, S. T., Supply, P. and Honoré, N.Repetitive sequences in Myrobacteriumleprae and thei r impact ou genome

Lepr. Rev. 72 (2001) 449-461.

About 2% of the genome of Mrcobacte-rim!) leprae is composed of repetitiveDNA. There are more than 26 extinct IS el-ements together with four families of dis-persed repeats, present in tive copies ormore, RLEP (37 copies), REPLEP (15copies), LEPREP (eight copies), and LEP-RPT (tive copies). Although there is no se-quence similarity to known transposable el-ements, RLEP occurs predominantly at the3'-end of genes and, in several cases, withinpseuelogenes, sugg,esting that it was capableof dissemination. Strikingly, ou comparisonof the genome sequences of M. leprae andthe closely related tubercle bacillus, Myco-bacteriam tuberculosis H37Rv, many ofthese repetitive sequences were found atsites of discontinuity in gene order. Evi-dence is presented that loss of synteny, in-version and genome downsizing may haveresulted from recombination between dis-persed copies of these repetitive ele-ments.—Authors' Summary

Dawes, S. S. and Mizrahi, V. DNA metab-olism in Mycobaderium leprae. Lepr.Rev. 72 (200!) 408-414.

Understanding the molecular basis un-derlying the hallmark features of Myco-bacterium leprae, such as its parasitism andextraordinarily slow growth rate, has stimu-lated research into the biology of thispathogen for decades, bui it is through thecompletion of its genome sequence that aquantum leap of progress has beenachieved. In this review, we analyze thegenes in M. leprae that are involved in thesynthesis and salvage of purines and pyrim-idines and in DNA replication and repair inan attempt to uncover the relationship be-tween the massive gene decay observed inthe M. leprae genome and its DNA meta-bolic capacity. This analysis has providedinshy,hts into possible mechanisms for thegenomic deterioration in the leprosy bacil-lus and supplements the sparse biochemicaldata hard won from this organism.—Au-thors' Abstract

Eiglmeier, K., Parkhill, J., Honoré, N.,Garnier, T., Tekaia, E, Telenti, A.,Klastser, P., James, K. D., Thomson,

70^ Internaiional Jou mal of. Leprosy^ 2002

N. R., VVheeler, P. R., Churcher, C.,Harris, D., Mungall, K., Barrell, B. G.and Cole, S. F. The elecaying genome ofMycobacterium leprae. Lepr. Rev. 72(2001) 387-398.

Everything that we need to know aboutMycobacterium leprae, a close relative ofthe tubercle bacillus, is encrypted in itsgenome. Inspection of the 3.27 Mb genomesequence of an armadillo-derived 1ndianisolate of the leprosy bacillus identified1605 genes encoding proteins and 50 genesfor stable RNA species. Comparison withthe genome sequence of Mycobacterium tu-berculosis revealed an extreme case of re-ductive evolution, since less than half of thegenome contaras functional genes while in-activated or pseudogenes are highly abun-dant. The levei of gene duplication was–34% and, on classification of the proteinsinto families, the largest functional groupswere found to be involved in the metabo-lism and modification of fatty acids andpolyketides, transport of metabolites, cellenvelope synthesis and gene regulation. Re-ductive evolution, gene decay and genomedownsizing have eliminated entire meta-bolic pathways, together with their regula-tory circuits and accessory functions, par-ticularly those involved in catabolism. Thismay explain the unusually long generationtime and account for our inability to culturethe leprosy bacillus. Authors' Abstract

Eiglmeier, K., Simon, S., Garnier, T. andCole, S. T. The integrated genome mapof Mycobacterium leprae. Lepr. Rev. 72(2001) 462-469.

The integrated map of the Mycobacte-rium leprae genome unveiled for the firsttime the genomic organization of this obli-gate intracellular parasite. Selected cosmidclones, isolated from a genomic library cre-ated in the cosmid vector Lorist6, wereidentified as representing nearly the com-plete genome and were subsequently usedin the M. leprae genome sequencing proj-ect. Now a new version of the integratedmap of M. leprae can be presented, com-bining the mapping results from the Lorist6cosmids with data obtained from a secondgenomic library constructed in an Escheri-

chia coli-mycobacterium shuttle cosmid,pY URIS. More than 98% of the M. lepraegenome is now covered by overlappinglarge insert genomic clones representing arenewable source of well defined DNA seg-ments and a powerful boi for functional ge-nomics.—Authors' Summary

Grosset, J. H. and Cole, S. T. Genomicsand the chemotherapy of leprosy. Lepr.Rev. 72 (2001) 429-440.

The information deduced from thegenome sequence of Mycobacterium lepraeis of immense value for the chemotherapyof leprosy. Knowing the complete set ofgenes, enzymes and proteins allows us tounderstand why some drugs are without ef-fect whereas others are fully active. It mayalso enable better use to be made of existingdrugs, such as [3-lactams, and opens newavenues for the development of novel com-pounds. M. leprae is relatively susceptibleto a wide range of drugs, unl ike the highlyrelated tubercle bacillus, and several newmultidrug regimens are in clinicai trials.Genomics provides a number of possibleexplanations for this broader susceptibilityas some of the genes encoding enzymes in-volved in antibiotic inactivation have de-cayed whereas the number of transportersavailable to contribute to drug efflux is con-siderably lower than in Mycobacterium tu-berculosis. Severa! leads for new drug tar-gets have been 11 ncove red Authors'Abstract

Haque, A. K. and Kashiwabara, Y. Detec-tion of Mycobacterium leprae by poly-merase chain reaction. Bangladesh Med.Res. Counc. Bull. 26 (2000) 87-91.

The improved procedure based on poly-merase chain reaction (PCR) for detectionof M. leprae has been developed. The sensi-tivity and specificity of this method weretested using different concentrations of ge-nomic DNA of M. leprae Thai 53 and ge-nomic DNAs from mycobacterial speciesand related microorganisms respectively.Application of this method to biopsy sam-pies obtained from Bangladesh was con-ducted and detected M. leprae DNA in 7 of

7 0, 1 Current Literature^ 71

the 10 clinical specimcns. Acid fast bacilliwere not detected in four of the seven posi-tive cases under the microscopic observa-tion. It was concluded that this method wassensitive and specific for detection of M.leprae in clinical specimens and also simpleto detect in only one step of PCR.—Au-thors' Abstract

Honoré, N., Roche, P. W., Grosset, J. H.and Cole, S. T. A method for rapid de-tection of rifampicin-resistant isolates ofMycobacterium leprae. Lepr. Rev. 72(2001) 441-448.

search results in a region in the genome.The user can also download or view theDNA sequence or the protein sequencefrom a single gene or from the list of asearch result. Authors' Summary

Maeda, S., Matsuoka, M., Nakata, N.,Kai, M., Maeda, Y., Hashimoto, K.,Kimura, H., Kobayashi, K. and Kashi-wahara, Y. Multidrug resistance Myco-bacterium leprae from patients with lep-rosy. Antimicrob. Agents Chemother. 45(2001) 3635-3639.

A genotypic method for predicting ri-fampicin resistance in Mycobacterium lep-rae has been developed and rigorouslytested on mouse footpad-derived and clini-cal specimens. A series of immobilizedoligonucleotide capture probes can discrim-inate between wild type and mutant rpoBaneles, and positive controls are availablefor the most frequent mutation affectingSer425. Two different non-radioactive de-tection formais have been tested with com-parable success in both an industrializedand a developing country. The standardizedprocedure could now be used in a prospec-tive study of potential rifampicin resistanceamong multibacillary patients.—Authors'Abstract

Jones, L., Moszer, I. and Cole, S. T. Lep-roma: a Mycobacterium leprae genomebrowser. Lepr. Rev. 72 (2001) 470-477.

Leproma is a powerful Web-based toolfor extracting information about annota-tions from a Mycobacterium leprae genomedatabase. The URL for the Leproma webcite is http://genolist.pasteur.fr/Leproma.

With Leproma, the user may search theM. leprae genome database using severa]search criteria. One can search by genename or synonym, by region in the genome,by gene function or classification, by DNAor protein patterns, by a BLAST or FASTAsearch in the DNA sequence or the proteinsequences, or by free text.

Search results can be in the forro of a listwhere the columns in the list are set by theuser or in the forro of a drawing if the

Sequences of the folP1, rpoB, and gyrAgenes were analyzed for 88 isolates of My-cobacterium leprae from leprosy patients inJapan, Haiti, Indonesia, Pakistan, and thePhilippines. Thirteen isolates (14.8%)showed representative mutations in morethan two genes, suggesting the emergenteof multidrug-resistant. M. leprae.—Au-thors' Abstract

Martin, E., Triccas, J. A., Kamath, A. T.,Winter, M. and Britton, W. J. Compar-ative protective effects of recombinantDNA and Mycobacterium bovis bacilliCalmette-Guerin vaccines against M.aviam infection. Clin. Exp. Immunol.126 (2001) 482-487.

A range of strategies are being exploredto develop more effective vaccines againstmycobacterial infection, including immu-nization with DNA plasmids encodingsingle mycobacterial bacterial genes andthe use of recombinant live vectors basedon the current vaccine, Mycobacterium bo-vis bacille Calmette-Guerin (BCG). Wehave compared these two approaches usinga model of virulent M. aviam infection, andthe gene for the immunodominant 35 kDaprotein which is shared by M. aviam and M.leprae, but absent from BCG. RecombinantBCG over-expressing the M. aviam 35 kDaprotein (BCG-35) induced strong antigen-specific proliferative and interferon-gamma(1FN-gamma)-secreting T cell responses.These were comparable to those induced bya single immunization with a ptasmid ex-pressing the same antigen (DNA-35); how-ever, repeat DNA-35 immunization evoked

1 ^•

72^

Internalional Journal of. Leprosy^ 2002

the strongest IFN-gamma release. Immu-nization with BCG-35 significantly reducedthe growth of virulent M. avium, althoughthis effect was similar to that induced bywild-type BCG. Immunization with DNA-35 resulted in significantly greater (2 x logi,,reduction in the growth ofM. avium. Prime-boost strategies combining DNA-35 andBCG-35 increased the protective effectabove that achieved by BCG-35, but theywere not more protective than DNA-35alone. Therefore, recombinant BCG-35 andBCG induced similar leveis of protection inthis model, and maximal protection againstM. avium infection was attained by immu-nization with DNA encoding the 35 kDaprotein.—Authors' Abstract

Spencer, J. S., Marques, M. A., Lima, M.C., Jungueira-Kipnis, A. P., Gregory,B. C., Truman, R. W. and Brennan, P.J. Antigenic specificity of the Mycobac-terium leprae homologue of ESAT-6. In-fect. Immun. 70 (2002) '1()10-1()13.

The sequence of the Mycobacterium lep-rae homolog of ESAT-6 shows only 36%amino acid correspondence to that fromMycobacterium tuberculosis. Anti-M. lep-rae ESAT-6 polyclonal and monoclonal an-tibodies and T-cell hybridomas reactedonly-with the homologous protein and al-lowed identification of the B- and T-cellepitopes. The protein is expressed in M.leprae and appears in the cell wall fraction.Thus, M. leprae ESAT-6 shows promise asa specific diagnostic agent for leprosy.—Authors' Abstract

Wheeler, P. R. The microbial physiolo-gist's guide to the leprosy genome. Lepr.Rev. 72 (2001) 399-407.

Obtaining a genome sequence should beregarded as a springboard to research on themicrobe in question. 1 hope in this short re-

view 1 have shown that this is a time topush forward with research luto M. lepme,a paradigm of obligate intracellular host-dependency. Fundamental questions for anintracellular pathogen abola iron metabo-lism can be addressed. How the loss of re-dundancy throughout the genome in com-parison with the tubercle bacilli has resultedin a specialized pathogen in contrast to theadaptable M. tuberculosis complex is an-other basic issue in mycobacteriology. Doesthe apparent limitation in virulence deter-minants and cellentry genes (Table 1) com-mit M. lepme to gaining access only to itsnarrow niche? While two of the threehemolysin genes found in M. tuberculosis,including IlyA, persist in M. leprae, ali foui-plc genes are lost. Will we find out the roleof PPEs and PEs in tubercle bacilli by mak-ing comparisons with M. leprae, a 'naturalmutant' for most of them? What else can welearn about tubercle bacilli by comparativegenomics now we have the leprosygenome? Why cannot M. leprae be grownaxenically; do the lesions in energy metab-olism only allow interrupted growth whenconditions are just right in the host? Aremedia too toxic, at least in aerobic condi-tions? With a massive loss of regulatoryfunctions have those that would allow M.leprae to adapt to axenic culture been lost?VVe are now in a position to generate betterdefined hypotheses. Soou the Mycobacte-rium ulcerans genome will be sequenced;will comparisons with this difficult to growmycobacterium help us to formulate newhypotheses for M. leprae? Finally, we candesign experiments that will provide a bet-ter understanding of the interaction betweenM. leprae and Schwann cells. With neuro-logical reactions still a major clinicai issuein the treatment of leprosy these are urgentexperiments. My conclusion would be torecommend the leprosy research commu-nity develops post-genomic research andinvestigates the expression of M. lepraegenes as a means of addressing the manybiological questions that still remain. Au-thor's Abstract

70, 1^ Currcnl Li/c ratitre^ 73

Epidemiology and Prevention

Souza, W. V., Barcellos, C. C., Brito, A.M., Carvalho, NI. S., Cruz, O. G., A1-burquerque Md. Mde. E., Alves, K. R.and Lapa, T. M. Empirical Bayesianmodel applied to the spatial analysis ofleprosy occurrence. (In Portuguese) Rev.Saude Publica. 35 (2001) 474-480.

Objective: To analyze the spatial distribu-tion of leprosy, identify arcas of potentialcase underreporting or high transmissionrisk, and to assess the ecological associa-tion of leprosy distribution with multibacii-lary cases. Methods: This study was carriedout in 94 neighborhoods of Recife, Brazil.Data was obtained from the Ministry ofHealth's Disease Reporting System. Anecological approach with the empiricalBayesian method was applied for local rateflattening, using data from a neighborhoodmatrix. Results: The mean annual occur-rence was 17.3% of new cases in individu-ais under the age of 15 (28.3% corre-sponded to multibacillary forms), revealingan intense disease transmission. The spatialdistribution of leprosy indicated three arcaswhere there was a concentration of high de-tection rates and low-incorre neighbor-hoods. Conclusions: The Bayesian methodallowed to reassess epidemiological indica-tors based on data from neighboring spatialunits. This enabled to identify arcas thatshould be prioritized in municipal controlprograms, either because of underreportingof cases or the higher number of occur-rences related to multibacillary forms in in-dividuais under 15.—Authors' Abstract

Van den Broeck, J., Van Jaarsveld, T., deRijk, A., Samson, K. and Patrobas, P.

Capture-recapture method to assess theprevalence of disabled leprosy patients.Lepr. Rev. 72 (2001) 292-301.

The capture-recapture technique was ap-plied in estimating the prevalence of dis-abled leprosy patients in four States inNorthern Nigeria. A two-sample capture-recapture method, using data from hospitaladmissions during 1997 and 1998 in threeleprosy referral hospitais, and from a sam-ple survey on leprosy patients with disabil-ities in the clinics in 1999. In the sample,1395 (ex) leprosy patients were found, 393with a disability. Of these 393 patients, 47had been admitted during 1997 and 1998 toone of three leprosy referral hospitais. Inthese hospitais, 151 individuais from the 24study Local Government Arcas (LGA) infour states of Northern Nigeria were admit-ted in 1997 and 1998. Using the Petersonestimator, we calculated the number of un-known disabled leprosy patients in the stud-ied LGAs to be 1262 (95% confidence in-terval 991-1533). This was nearly fourtimes greater than the field reported figure.The capture-recapture method can be ap-plied in a leprosy care program. Limitationsof the method are the completeness of re-porting after invitation in the field, as wellas the probable biased sample of leprosypatients admitted to hospital. Our findingimplies that relying on patients to report forprevention of disabilities and rehabilitationto the clinics, causes the real size of theproblem to be underestimated by a factor of3-4. We recommend the use of a special`care' register for disabled leprosy patientsto better address their needs for preventionof disabilities and rehabilitation.—Authors'Abstract

Rehabilitation

Benbow, C. and Tamiru, T. The experi-ence of self-care groups with people af-fected by leprosy: ALERT, Ethiopia.Lepr. Rev. 72 (2001) 31 1-321.

This paper describes the development ofself-care groups in Ethiopia by ALERT, and

the successes and failures experienced in theprocess. The groups were started in 1995 inresponse to two main problems, the increas-ing number of people dependem on ALERTto heal their wounds despite years of healtheducation, and the limited financial re-sources of ALERT for wound healing sup-

74^

Internationaal .bornal of . Leprosy^ 2002

plies. By December 1999, there were a totalof 72 established groups. Group member-ship was voluntary. There have been a num-ber of positive outcomes. Group membershave taken up responsihi l ity for managingand monitoring their own wounds and sup-plying their own wound healing materiais.More attention is paid to their personal hy-giene and personal appearance. They alsoreport increased confidence to participate insociety, restored dignity and self-respect,and a sense of helonging within the commu-nity. In addition, some members havestarted to pay more attention to their localenvironmental hygiene by building pit la-trines and Ovaste disposal cites. The ALERTstaff involved in this initiative had to changetheir role from that of a leprosy serviceprovider to a self-care group facilitator, butnot ali were successful in making this transi-tion. The remaining challenge for the pro-gram is sustainabi l ity and further develop-ment through the National Tuberculosis andLeprosy Control Programme, The EthiopianNational Association for s Ex-Leprosy Pa-tients and possibly other organizationstoo. Authors' Abstract

Bharath, S., Shamasundar, C., Raghu-ram, R. and Subbakrishna, D. K. Cor-relates of psychiatric morbidity in pa-tients with leprosy. Indian J. Lepr. 73(2001) 217-228.

The relationship between psychiatric mor-bidity in 30 leprosy patients under treatmentas assessed by the General Health Question-naire (GHQ-12) and certain variables of theirillness and psychosocial factors are exam-

ined in this paper. Physical disability and du-rati on of illness were the illness variablesconsidered; knowledge and adjustment werethe psychosocial variables included. Bell'sAdjustment Inventory (BAI) measured thelatter. Psychiatric morbidity was positivelycorrelated with physical disability (p <0.05),knowledge about the disease (p <0.01) andsocial, emotional and health maladjustment(p <0.01), but not with duration of illness (p>0.05). The importance of appropriateknowledge, social stigma and physical dis-ability in leprosy is discussed in addressingthe psychiatric morbidity of leprosy pa-tients. Authors' Abstract

Cross, H. and Newconlbe, L. An i ntensi veself care tralning programme reduces ad-nlissions for the treatment of plantar ul-cers. Lepr. Rev. 72 (2001) 276-284.

This paper describes, in detail, an i nten-si ve 14 day Self Care Training Programmethat is conducted at Lalgadh Leprosy Ser-vices Centre in Nepal. An evaluation of theprogram was undertaken in which hospitaladmission for infected plantar ulcerationwas the outcome measure. It was found thatthose who had undertaken the programwere less likely to have been admitted forhospital treatment in a 3-month follow-upperiod (chi e = 5.1, p = 0.02). An odds ratioof 1:1.8 (95% CI = 0.15-0.01) was also cal-culated. This paper presents an overview ofthe issues related to impairment, a descrip-tion of the Self Care Training Programme,an analysis of the evaluation results and adiscussion of the findings.—Authors' Ab-stract

Other Mycobacterial Diseases and Related Entities

Amaral, L., Viveiros, M. and Kris-tiansen, J. E. Phenothiazines: potentialalternatives for the management of an-tibiotic resistant infections of tuberculo-sis and mataria in developing countries.Trop. Med. Int. Health 6 (2001)1061-1022.

The in vitro and in vivo activity of phe-nothiazines against antibiotic susceptible

and antibiotic resistam Mycobacterium tu-berculosis and mataria-causing Plasmodiais reviewed. Given the facts that pulmonarytuberculosis and malacia are the majorcauses of death in developing countries,that both of these infections continue to es-calate in their resistance to antibiotics, thatthe cost for the management of these infec-tions is beyond that afforded by most devel-oping nations, and lastly, that new and ef-

70,1^ Current Literature^ 75

fective agents are not forthcoming from thepharmaceutical industry, the scientific ra-tionale for the potential use of select pite-nothiazines for the management of these in-fections is presented. Authors' Abstract

Amato, R. j. Thai idomide: an antineoplas-tic agent. Cur. Oncol. Rep. 4 (2002)56-62.

h lias been more than three decades sincethe withdrawal of thalidomide from the mar-ketplace. Thalidomide is attracting growinginterest because of its reported immunomod-ulatory and anti-inflammatory properties.Current evidence indicates that thalidomidereduces the activity of the inflammatory cy-tokine tumor necrosis factor-a by accelerat-ing the degradation of its messenger RNA.Thalidomide inhibits angiogenesis. Re-cently, thalidomide was approved for salein the United States for the treatment of ery-thema nodosum leprosum, an inflammatorycomplication of Hansen's disease. Thalido-mide has been used successfully in severa]other dermatologic disorders, includingaphthous stomatitis, Behcet's syndrome,chronic cutaneous systemic lupus erythe-matosus, and graft-versus-host disease, theapparent shared characteristic of which isimmune dysre.2ulation. Many recent studieshave evaluated thalidomide in patients withHIV infection, in which this drug is an effi-cacious agent against oral aphthous ulcers,HIV-associated wastitw syndrome, HIV-related diarrhea, and Kaposi's sarcoma.Only in the last several years has thalido-mide been aggressively investigated for itsantiangiogenic potential and immunomodu-latory properties in various tumor types.Current research on thalidomide in oncol-ogy covers investigation in a wide range ofboth solid tumors and hematologicnancies.—Author's Abstract

Ames, B. M. New concerns about thalido-mide. Obstet. Gynecol. 99 (2002)125-128.

Recently, the Food and Drug Administra-tion (FDA) approved thalidomide for thetreatment of the painful symptoms of ery-thema nodosum leprosum. This most recent

FDA decision is a marked reversa] to itsprevious rejection of Mis drug in the 1960s.The initial rejection by the FDA in the1960s spared countless American childrenas thalidomide was shown to cause birth de-fects and miscarriages worldwide. TheFDA's reputation as one of the tinest con-sumer safety authorities was strengthenedbecause of this decision. The recent ap-provai of thalidomide by the FDA, with ac-companying strict guidelines and monitor-ing procedures, has not only brought forthpotential benefits, but also created new po-tential problems—Author's Abstract

Bohlson, S. S., Strasser, J. A., Bower, J. J.and Schorey, J. S. Role of complementin Mycobacterium avium pathog,enesis:in vivo and ia vitro analyses of the hostresponse to infection in the absence ofcomplement component C3. Infect.mun. 69 (2001) 597-605.

We investi2;ated the importance of thehost complement system in the pathogenesisof disease medi ated by the intramacrophagepathogen Mycobacterium avium. Mycobac-teria opsonized with complement are effi-ciently ingested by macrophages throughvarious complement receptors. Furthermore,unlike other bacteria, mycobacteria can acti-vate both the alternative and classical com-plement pathways in the absence of specificantibodies. Therefore, to examine the role ofcomplement in the mycobacterial infectionprocess in vivo, mice deficient in comple-ment component C3 were infected with M.avitun. Surprisingly, C3-deficient mice in-fected intravenously with M. avitun dis-played no difference in bacterial burden orgranulomatous response compared to wild-type control mice. C3-sufficient mice andC3-deficient mice were equally susceptibleto infection by M. avium regardless of thegenotype at the bcg locus, a locus known toconfer susceptibility to infection with intra-cellular pathogens. Ia vitro studies usingmouse bone marrow-derived macrophagesresulted in significam M. apium invasion ofmacrophag,es in the absence of C3; however,the kinetics of infection were delayed com-pared to complement-mediated invasion.The data indicate that complement does notplay an essential role in mediating M. avium

76^ International Journal of Leprosy^ 2002

infections in the mouse and suggest eitherthat other invasion mechanisms can com-pensate for the absence of complement-mediated entry or that complement is not amajor mycobacterial opsonin iii vivo. Au-thors' Abstract

Borgdorff, M. W., Nagelkerke, N. ,J., deHaas, P. E. and van Soolingen, D.Transmission of Mvcobacterium tuber-culosis depending ou the age and sex ofsource cases. Am. .1. Epidemiol. 154(2001) 934-943.

This study estimated to what extent tu-berculosis transmission in the Netherlandsdepends ou the age and sex of source cases.DNA fingerprints of Mycobacterium tuber-culosis isolates were matched to patient in-formation in the Netherlands TuberculosisRegister for 1993-1998. Clusters were de-fined as groups of patients with pulmonarytuberculosis whose isolates had identicalDNA fingerprints. Source' cases were as-signed by using two models. The first-casemodel assumed that the first diagnosed casewas the source case. The incidence ratemodel estimated source case probabilitiesfrom the incidence rates of potential sourcecases and the time of diagnosis. DNA fin-gerprints of 6102 isolates were matched topatient information on 5080 (83%) cases,3479 of whom had pulmonary disease. Ac-cording to both models, the number of in-fectious cases generated per source casewas lower for female than for male sourcecases and decreased with increasing age ofthe source case. The authors concluded thattransmission of tuberculosis is associatedwith the age and sex of source cases as wellas the age of secondary cases. Increasedtransmission among immigrant groups inthe Netherlands is largely attributable to therelatively young age of immigrant sourcecases.—Authors' Abstract

Bryceson, A. A policy for leishmaniasiswith respect to the prevention and con-trol of drug resistance. Trop. Med. 6(2001) 928-934.

At the moment no country has a policy de-signed to control or prevent drug resistance

in leishmaniasis. The risk of resistance ishigh in arcas of anthroponotic visceral leish-maniasis, for example North Bihar,where the rate in some arcas is 60%. Post-epidemic Sudan is tlso at risk. Zoonotic ar-eas in which HIV co-infection is commoncould also be at risk as sandtlies can becomeinfected from co-infected individuais. Manyfactors determine the choice of drug for thetreatment of visceral leishmaniasis, and drugresistance may not be the over-riding pri-ority. In anthroponotic arcas reduction intransmission through public health measureswill be important, but the use of two drugs incombination should be seriously considered.Pharmacokinetic and other features of thedrugs available, relevam to their use in com-bination are discussed and tentative sugges-tions made concerning trials of possiblecombinations. These include miltefosineplus paromomycin and allopurinol plus anazole. Lessons may be learned from the ex-periences of similar problems in malaria,leprosy and tuberculosis. Guidelines are of-fered for the introduction of policies to useclrugs in combination, which differ betweenanthroponotic and zoonotic arcas of trans-mission.^Author's Abstract

Bryk, R., Lima, C. D., Erdjument-hromage, H., Tempst, P. and Nathan,C. Metabolic enzymes of mycobacterialinked to antioxidant defense by a thiore-doxin-like protein. Science 295 (2002)1073-1077.

Mycobacterium tuberculosis (Mtb) mountsa stubborn defense against oxidative and ni-trosative components of the immune re-sponse. Dihydrolipoamide dehydrogenase(Lpd) and dihydrolipoamide succinyltrans-ferase (SucB) are components of alpha-ke-toacid dehydrogenase complexes central tointermediary metabolism. We find that Lpdand SucB support Mtb's antioxidant de-fense. The peroxiredoxin alkyl hydroperox-ide reductase (AhpC) is linked to Lpd andSucB by an adaptor protein, AhpD. The 2.()A AlipD crystal structure reveals a thiore-doxin-like active site that is responsive tolipoamide. We propose that Lpd, SucB (theonly lipoyl protein detected in Mtb), AhpD,and AhpC together comprise an NADH-dependent peroxidase and peroxynitrite re-

70, 1^ Curmnt Literature^ 77

ductase. AhpD represents a new class ofthioredoxin-like molecules that enables anovel antioxidant defense.—Authors' Ab-stract

Cadapan, L. D., Arslanian, R. L., Car-ney, J. R., Zavala, S. M., Small, P. L.and Licari, P. Suspension cultivation ofMvcobacterium ulceraras fo r the produc-tion of mycolactones. FEMS Microbiol.Lett. 205 (2001) 385-389.

Mycolactones are polyketide toxins pro-duced by Mycobacteriunm ulceraras, thecausative agent of the tropical skin diseaseknown as Buruli ulcer. Developnment ofnovel therapeutic agents from mycolac-tones has been hindered by the difficulty ofproducing sufficient amounts of material.Here, we describe the successful adaptationof M. ulceraras to Suspension cultivationand the development of a fed-batch fermen-tation process that was scaled up to 150 1.In addition to producing mycolactones Aand B, a number of new mycolactone-related compounds were also observed.-Authors' Abstract

Cantrell, C. L., Franzblau, S. G. and Fis-cher, N. H. Antimycobacterial plana ter-penoids. Planta med. 67 (2001) 685-694.

Tuberculosis (TB), mainly caused by Mv-cobacterium tuberculosis, is the leadingkiller among ali infectious diseases world-wide and is responsible for more than twomillion deaths annually. For over thirtyyears no antitubercular agents with newmechanisms of action have been developed.The recent increase ira the number of multi-drug resistant clinicai isolates of M. tuber-culosis' has created ara urgent need for thediscovery and development of new antitu-berculosis leais. This review covers recentreports on plant-derived terpenoids thathave demonstrated moderate to high ac-tivity in ia ritro bioassays against M. tuber-culosis. In Chis review, mono-, sesyui-, di-and triterpenes, and sterols, their structuralanalogs and semisynthetic derivatives wi IIbe discussed, with particular emphasis outhe structural features essencial for antimy-cobacterial activity.—Authors' Abstract

Cappelli, G., Volpe, P., Sanduzzi, A., Sac.-chi, A., Colizzi, V. and Mariani, F. Hu-man macrophage gamma interferon de-creases gene expression but notreplication of Mycobacterium tuberculo-ses: analysis of the shot-pathogen recip-roca) iniluence on transcription in a com-parison of strains H37Rv and CMT97.In fect. lmmun. 69 (2001) 7262-7270.

Mycobacteriunm tuberculosis is an intra-cellular pathogen that readily survives andreplicates in human macrophages (MO).Host cells have developed different my-cobactericidal mechanisms, including theproduction of inflammatory cytokines. Theaim of chis study was to compare the MO re-sponse, in terras of cytokine gene expres-sion, to infection with the M. tuberculosislaboratory strain H37Rv and the clinicai M.tuberculosis isolate CMT97. Both strainsinduce the production of interleukin-12 (IL-12) and IL-16 at comparable levels. How-ever, the clinicai isolate induces a signifi-cantly higher and more proionged M^activation, as shown by reverse transcrip-tion-PCR analysis of IL-)beta, IL-6, IL-10,transforming growth factor beta, tumornecrosis factor alpha, and gamma interferon(IFN-gamma) transcripts. Interestingly,when IFN-gamma transcription is high, thenumber of M. tuberculosis genes expresseddecreases and vice versa, whereas no my-cobactericidal effect was observed ira termsof bacterial growth. Expression of II geneswas also studied in the two M. tuberculosisstrains by infecting resting or activated M^and compared to bacterial intracellular sur-vival. In both cases, a peculiar inverse cor-relation between expression of these genesand multiplication was observed. The num-ber and type of genes expressed by the twostrains differed significantly. Authors' Ab-stract

D'Amato, R. J., Lentzsch, S., Anderson,K. C. and Rogers, M. S. Mechanism ofaction of thalidomide and 3-aminotha-lidomide ira multiple myeloma. Semin.Oncol. 28 (2001) 597-601.

We have explored the mechanism of theantiangiogenic effects of thalidomide bystructure-activity studies. These investiga-

78^ Initernational Journal of Leprosy^ 2002

tions revealed that angiogenesis inhibitioncorrelates with teratogenicity but not with ti;-mor necrosis factor-alpha (TFA-alpha) inhi-bition. Additionally, one analog of tha-lidomide, 3-aminothalidomide, exhibited anunusual capacity to directly inhihit myelomacell proliferation. This activity did notcorrelate with TNF-alpha inhibition. Thus3-aminothalidomide was found to inhihitmultiple myeloma through effects on both thetumor and vascular compartment. The effectsof an inhibitor of both the tumor and vascularcompartments of a tumor on tumor growthmay be synergistic. Authors' Abstract

Davies, P. and Grange, ,J. The genetics ofhost resistance and susceptibility to tu-berculosis. Ann. N.Y. Acad. Sci. 953(2001) 151-156.

The study of human genomics has the po-tential to aid our understanding of the in-terindividual and interpopulation differ-ences in susceptibility to tuberculosis.Resistance to infection is affected by theability of macrophages to phagocytose anddestroy the bacilli. Severa] genes are in-volved in this process, and two have beenthe focus of recent intereSt: the naturalresistance-associated protein (NRAMP 1)gene and the genes coding for the vitaminD receptor. S uscepti bi l i ty genes have alsobeen discovered—for example, one on theX chromosome that may explain the in-creased susceptibility of males to tuberculo-sis. Studies have also focused on the varia-tions in virulence of the bacillus in both itsdrug-susceptible and drug-resistant forms.These mechanisms must be understood inorder to prevent, or combat, the emergenceof a virulent, multidrug-resistant form ofthe bacillus that would be uncontrollable bymeans of today's treatment strategies Au-thors' Abstract

Delogu, G., Li, A., Repique, C., Collins, F.and Morris, S. L. DNA vaccine combi-nations expressing either tissue plas-minogen activator signal sequence fu-sion proteins or ubiquitin-conjugatedantigens induce sustained protective im-munity in a mouse model of pulmonarytuberculosis. Infect. I nlmun. 70 292-302.

DNA vaccination lias emerged as a pow-eríul approach in the search for a more ef-ficacious vaccine against tuberculosis. InChis study, we evaluated the effectiveness ofimmunizing with combinations of 10 differ-ent tuberculosis DNA vaccines that ex-pressed mycobacterial proteins fused at theN terminas to eukaryotic intracellular tar-geting sequences. In one vaccine combina-tion, the genes were fused to the tissue plas-minogen activator signal sequence (TPA),while in a second combination the same 10genes were expressed as ubiquitin (Ub)-conjugated proteins. In ex vivo studies inwhich the secretion of gamma interferonwas measured, cellular immune responseswere detected in coice vaccinated witheither the TPA DNA vaccine combinationor the Ub DNA vaccine combination at 7and 14 days following a low-dose My-cobacterium tuberculosis challenge. More-over, mice vaccinated with the TPAcombination, the Ub combination, and My-cobacterium bovis BCG were able to limitthe growth of tubercle bacilli in the lungand spleen after a virulent tuberculousaerosol challenge. Histopathological analy-ses also showed that mice immunized withthe DNA vaccine combinations had sub-stantially improved postinfection lungpathology relative to the naive controls. Fi-nally, in three different tong-terra experi-ments, the survival periods following aero-genic challenge were extended as much assevenfold for vaccinated mice compared tonaive controls. Interestingly, in all three ex-periments, no significant differences weredetected in the mean times to death formice immunized with the TPA combinationor the Ub combination relative to the BCGcontrols. In conclusion, these studiesdemonstrate the effectiveness of immuniza-tion with DNA vaccine combinationsagainst tuberculosis and suggest that furthertesting of these plasmid cocktails is war-ranted. Authors' Abstract

Dutta, T. K., Goci, A., Chotekar, L. H.,Hamide, A., Badhe, B. A. and Basu, D.Dapsone in treatment of chronic idio-pathic thrombocytopenic purpura inadults. J. Assoc. Physicians India 49(2001) 421-425.

70, 1^ Current Literature^ 79

Background: When a patient is steroid-dependem, a currently available strategychronic idiopathic thrombocytopenic pur-pura (ITP) is to follow a trial and error ap-proach with any of the known drugs whichhas beca found effective in the condition.Objective: To evaluate the response ofchronic ITP to dapsone, an inexpensivedrug now reported to be etTective ia the dis-case. Design: A controlled trial o(' absti-nence and rechallenge type. Subjects: Eightsubjects with chronic ITP. Interventions:Phase I—Intake of 100 ITILT of dapsone dailyuniu l response (ia form of rise of plateletcount ia blood), Phase 11—Above followedby drug abstinence, ai i ai mu ia for fourweeks, and then rechallenge with the drug.Main outcome measures: Platelet countsduring various phases viz during drugintake, withdrawal and rechal lenge. Re-sults: Four (50%) patients responded totreatment. The mean pre-dapsone and post-dapsone platelet counts of blood were 29.6x and 142.5 x 10/1 respectively duringthe first phase of iria!. The rechallenge wasdone ia tive patients following withdrawalof drug and the mean values of plateletcount before and after rechallenQe were32.2 x 109/1 and 83 x respectively.There was a remarkable response ia two pa-tients; one is now off the drug and the otheron a maintenance dose of 50 mg of dapsonedaily. Conclusion: Dapsone caused signifi-cant rise of platelet cotim ia some patientsof chronic ITP. It can be tried as 'ali alterna-tive to other second-line drugs ia chronicITP.—Authors' Abstract

Frances, C., El Khoury, S., Gompel, A.,Becherel, P. A., Chosidow, O. andPiette, J. C. Transient secondary amen-orrhea ia women treated by thalidomide.Eur. J. Dermatol. 12 (2002) 63-65.

Compared with other side effects inducedby thalidomide, amenorrhea lias beca rela-tively poorly investigated althoinh it wasfirst reportecl ia 1989. The aim of this studywas to determine the prevalence of amenor-rhea ia consecutive women treated withthalidomide ia our institution from 1995 to1999. During that period, 21 women re-ceived thalidomide associatecl with pra-gestin contraception. Their clinicai and bio-

logical data were retrospectively reviewed.Data concernira!, their genital life were sys-tematically checked by phone with a simplequestionnaire. Transient secondary amenor-rhea occurred ia 5 women (24%) treated forrefractory cutaneous lupus erythematosus(4 cases) or complex aphthosis (1 case).The link between thalidomide and amenor-rhea WaS suggested by the resumption ofmenses 2 to 3 months after drug withdrawal,recurrence of amenorrhea after reintroduc-tion of thalidomide (1 case) and high serumleveis of pituitary gonadotrophins. Amenor-rhea secondary to ovarian failure is fre-quently observed ia women treated withthalidomide. Its precise mechanism remainsto he elucidated—Authors' Abstract

Fujita, J., Mestre, J. R., Zeldis„I.Subbaramaiah, K. and Dannenberg,A. .1. Thalidomide and its analogues in-hibit lipopolysaccharide-mediated induc-tion aí cyclooxygenase-2. Chin. CancerRes. 7 (2001) 3349-3355.

We investigated the effect of thalidomide,a compound with immunomodulatory andantiangiogenic properties, ou lipopolysac-chariele (LPS)-mediated induction of cy-clooxygenase-2 (Cox-2) and prostaglanclin(PG) biosynthesis ia murine macrophages.Thalidomide caused a dose-dependent inhi-bition of LPS-mediated induction ofPGE(2) synthesis ia RAW 264.7 cells. Theinduction of Cox-2 protein and mRNA byLPS was also suppressed by thalidomide.Based on the residis of nuclear run-off as-says and transient transfections, treatmentwith LPS stimulated Cox-2 transcription,an effect that was unaffected by thalido-mide. Thalidomide decreased the stabilityof Cox-2 mRNA. A series of structuralanalogs of thalidomide also inhibited LPS-mediated induction of Cox-2 and PGE(2)synthesis. Taken together, these data pro-vide new insights into the antineoplasticand anti-intlammatory properties of that ido-mide.--Authors' Abstract

Juffermans, N. P., Leemans, J. C.,Florquin, S., Verbon, A., Kolk, A. H.,Speelman, P., vau Deventer, S. J. andvau der Poll, T. CpG oligodeoxynu-

á

80^

International Jou mal of. Leprosy^ 2002

cleotides enhance host defense duringmurine tuberculosis. lnfect. Immun. 70(2002) 147-152.

Oligodeoxynucleotides (ODNs) contaM-ing unmethylated CpG motifs activate im-mune cells to produce cytokines. CpGODNs protect mice against infections withintracellular bacteria by the induction of a Thelper 1 (Th 1 ) response. To determine theeffect of CpG ODNs in pulmonary tubercu-losis, mice were treated with CpG ODNs orcontrol ODNs at the time of intranasal in-fection. CpG ODNs reduced mycobacterialoutgrowth for up to 5 weeks after Mvcobac-terium tuberculosis infection and wereassociated with a decrease in inflammationin lung tissue. CpG treatment was also as-sociated with elevated leveis of gamma in-terferon (IFN-gamma) and decreased leveisof interleukin 4 in the lungs and anincreased capacity of splenocytes to secreteTh 1 -type cytokines. CpG ODNs given 2weeks after infection were still able to re-duce mycobacterial outgrowth and to en-hance a Th 1 response 5 weeks postinfec-tion. Administration of CpG ODNs toIFN-gamma-gene-deficient mice failed toreduce mycobacterial outgrowth. Thesedata suggest that CpG ODN1 improve hostdefense during pulmonary tuberculosis byan IFN-gamma-dependent mechanism.—Authors' Abstract

Klein, M. R. and Fox, A. Mycobacterium-specific human CD8 T cell responses.Arch. Immunol. Ther. Exp. 49 (2001)379-389.

Tuberculosis (TB) remains a globalhealth problem. There is an intense effort toidentify correlates of protective immunityand to design new TB vaccines. CD8 Tcells are thought to play a significara role incontrolling Mycobacterium tuberculosis in-fection. Relatively little has been publishedabout the antigens and epitopes targeted bymycobacteria-specific CD8 T cells. Herewe present an update of our 1999 overviewof human CD8 T cell epitopes in mycobac-terial antigens and discuss related issuesrelevant to TB diagnosis and vaccine devei-opment.—Authors' Abstract

Lounis, IN., Bentoucha, A., Truffot-Pernot,C., ii, B., O'Brien, R. j., Vernon, A.,Roscigno, G. and Grosset, J. Effective-ness of once-weekly rifapentine andmoxifloxacin regimens against Myco-bacterium tuberculosis in mice. Antimi-crob. Agents Chemother. 45 (2001)3482-3486.

Mice infected with 1.6 x 107 CFU of My-cobacterium tuberculosis were treateel 14days later for 6 months with a regime') ofonce-weekly 10 mg of rifapentine and 75mg of isoniazid per kg of body weight sup-plemented with either 150 mg of strepto-mycin per kg or 100 mg of moxifloxacinper kg during either both the 2-week dailyinitial and once-weekly continuation phasesor only in the daily 2-week initial phase. Oucompletion of treatment, all lung cultueswere negative, except for three mice, eachwith a single colony: two whose rifapentine-isoniazid regimen was supplemented withstreptomycin during the whole course oftherapy and one whose rifapentine-isoniazidregimen had no initial daily phase, but wassupplemented with streptomycin and moxi-floxacin during the whole course of therapy.After 3 months of follow-up, positive lungcultures were obtained from 61 and 56% ofmice supplemented with streptomycin dur-ing either the full course of therapy or onlythe daily 2-week initial phase, respectively,and 15 and 50% of mice supplemented withmoxifloxacin during either the full courseof therapy or only the daily 2-week initialphase, respectively. These results suggestthat moxifloxacin lias sterilizing activityagainst M. tuberculosis. —Authors' Ab-stract

Liu, S., Zheng, M., Li, Z. et al. The pro-tective effects of thalidomide on acuteliver failure. Zhonghua Nei Ke Za Zhi 38(1999) 688-690 (in Chinese).

Objective: To understand whether thalido-mide (Thai) has the same protective effectsas it does in leprosy reaction type II, im-munologic and inflammatory diseases.Methods: D-Galactosamine (D-Ga1N, 600mg/kg body weight, intraperitoneally) andlipopolysaccharide (LPS, 5 !..tg/rat, hypoder-mically) were used to produce a model of

70, I^ Current Literatr u re^ 81

acure liver failure in Wistar rats. The mor-tality of the mudeis was counted. Theplasma peak levels of various cytokines andtransaminases were measured. The patha-logical alterations of the livers were exam-inci with hematoxylin and eosin stain un-der light microscopy. The expression oftumor necrosis factor (TNF)alpha mRNAwas determined by dot blot hybridizationcombined with semiquantitative analysis.Results: It was found that Thal could lowerthe mortality of the models (p <0.05); re-duce the peak levels of plasma cytokines,especially TNFalpha, and transminases p<0.05), alleviate the degree of liver injuryand suppress the expression of TNFalphamRNA (p <0.05). Conclusion: It is fullydemonstrated that Thal has definite protec-tive effect on acute liver failure, as it doesin other diseases. Even though Thal pos-sesses teratogenic effect in patients withpregnancy, it is still believed that Thai hasan important curative significance in thetreatment of patients who are not preg-nant.—Authors' Abstract

Marriott, J. B., Muller, G., Stirling, D.,and Dalgleish, A. G. Immunotherapeu-tic and antitumour potential of thalido-mide analogues. Expert. Opin. Biol.Ther. 1 (2001) 675-682.

The immunomodulatory drug thalidomidehas been shown to be clinically useful in anumber of conditions including variousimmunological disorders and cancers.Clinica! activity in vico is attributed to thewide ranging immunological and non-immunological properties possessed by thisdrug; these include anti-TNF-alpha, T-cellco-stimulatory, anti-angiogenic activitiesand also direct antitumor activity. Recently,the design of compounds based on thethalidomide structure has led to the synthe-sis of analogs with greatly enhanced im-munological activity and with similarly de-creased toxicity. These derivatives faLl rotoat least two categories; selective cytokineinhibitory drugs (SeiCID), which are phos-phodiesterase Type 4 (PDE4) inhibitors andimmunomodulatory drugs (IMiD), similarto thalidomide which act via unknownmechanism(s). These compounds are in theprocess of being characterized in laboratory

studies and are also now being assessed inPhase I and Phase 1/II clinicai studies. Inthis review we will highlight the propertiesof these two novel classes of compound interms of their effects on both immunologi-cal and non-immunological systems incirno. We will also describe how these stud-ies are enabling the characterization and de-velopment of these compounds lato clini-cally relevam drugs in widely varyingdiseases. To this end we will describe thevarious clinicai studies of lead compoundsthat are in progress and speculate as to thepotential and future development of theseexciting compounds.—Authors' Abstract

Miller, B. H. and Shinnick, T. M. Identifi-cation of two Mrcobacte riam tuberculo-sis H37Rv ORFs involved in resistanceto killing by human macrophages. BMCMicrobiol. 1 (2001) 26.

Background: The ability of Mycobacte-riem tuberculosis to survive and replicate inmacrophages is crucial for the mycobacte-rium's ability to infect the host and causetuberculosis. To identify Mycobacterinm tu-berculosis genes involved in survival inmacrophages, a library of non-pathogenicMycobacteriunr sele gmatis bacteria, eachcarrying an individual integrated cosmidcontaining M. tuberculosis H37Rv genomicDNA, was passed through THP-1 humanmacrophages three times. Results: Two ofthe clones recovered from this enrichmentprocess, sur2 and sur3, exhibited signiti-cantly increased survival relative to wild-type bacteria. In coinfection experimenta,the ratio of sur2 colonies to wild-typecolonies was 1:1 at O hours but increased to20:1 at 24 hours post phagocytosis. The ra-tio of sur3 colonies to wild-type colonieswas 1:1 at O hours and 5:1 at 24 hours. TheM. tuberculosis ORFs responsible for in-creased survival were shown to be Rv0365cfor the sur2 clone and Rv2235 for the sur3clone. These ORFs encode proteins with as-of-yet unknown functions. Conclusions: Weidentified two M. niberculosis ORFs whichmay be involved in the ability of tuberclebacilli to survive in macrophages.—Au-thors' Abstract

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82^ InternationaLlournal of Leprasy^ 2002

Nlueller-Ortiz, S. L., Wanger, A. R andNorris, S. J. Mycobacterial protein HbhAbinds human complement component C3.Infect. Immun. 69 (2001) 7501-7511.

Mycobacterium tuberculosis and Myco-bacterium avium are facultative intracellu-lar pathogens that are able to survive andreplicate in mononuclear phagocytes. Hu-man complement component C3 has previ-ously been shown to mediate attachmentand phagocytosis of these bacteria bymononuclear phagocytes. In this study, aC3 ligand affinity blot protocol was used toidentify a 30-kDa C3-binding protein in M.tuberculosis and Mycobacterium smegmatisand a 31-kDa C3-binding protein in M.avium. The C3-bintling proteins in M. tu-berculosis and M. avium localized to thecell membrane fraction and partitioned tothe detergent fraction during Triton X-114phase partitioning. The C3-binding proteinfrom M. tuberculosis was partially purifiedusing a cation exchange column and wasshown to bind concanavalin A. The N ter-minus and an internal fragment of the par-tially purified C3-binding protein were sub-jected to amino acid sequence analysis. Theresulting amino acid sequences matched theM. tuberculosis heparin-binding hemagglu-tiniu (HbhA) protein. Recombinant full-length HbhA and the C terminus of HbhAfused to maltose-binding protein, but notrecombinant HbhA lacking the C-terminalregion, bound human C3. Recombinantfull-length HbhA coated on polystyrenebeads, was found to enhance the adherenceand/or phagocytosis of the coated beads toJ774.A1 cells in both the presence and ab-sence of human serum. The presence ofcomplement-sufficient serum increased theadherence of the HbhA-coated beads to theJ774.A1 cells in a C3-dependent manner. IfHbhA within the bacterial cell membranefunctions similarly to isolated HbhA, thisprotein may enhance the adherence andphagocytosis of M. tuberculosis and M.avium to mononuclear phagocytes throughthe binding of C3 and interaction with C3receptors on mononuclear phagocytes.—Authors' Abstract

Thalidomide, a metabolite of thalido-mide, inhibits angiogenesis. Ther. DrugMonit. 24 (2002) 104-110.

Despite its known teratogenic efrects,thalidomide has been used to treat a varietyof diseases ranging from alleviation of au-toimmune disorders to prevention of metas-tasis of cancers. The exact method of actionof thalidomide and its derivatives is still un-der investigation. Thalidomide undergoesvery little metabolism by the cytochrome450 system in vitro, but at least two hydrox-ylated metabolites have been found in hu-mans. The two metabolites are 5-hydroxy-thalidomide, formed by hydroxylation of thephthalimide ring, possibly via arene oxides,and 5;-hydroxytha1idomide, formed byhydroxylation of the glutarimide ring, lead-ing to diastereomeric products. These twometabolites, along with another minormetabolite of thalidomide, were tested in arat aortic ring assay, a human saphenousvem n model, and a tube formation assay toassess the metabolite's ability to inhibit an-giogenesis. Of the metabolites tested, only5;-0H-thalidomide showed biologic activityin the rat aortic ring assay, and none of themetabolites showed activity in the humanmodel. The studies with thalidomide andthalidomide metabolites underline the diffi-culty and complexity of trying to isolate andevaluate a single biologically active agem.These studies, however, do suggest that atleast one metabolite, 5;-OH-thalidomide,has moderate antiangiogenic activity at highconcentrations. Unfortunately, because ofthe lack of observed activity of 5;-0H-thalidomide in the human saphenous vemnassay, it remains unclear whether there isspecies specificity for the activity of thismetabolite.—Authors' Abstract

Ramachandra, L., Noss, E., Boom, W. H.and Harding, C. V. Processing of Mvco-bacterium tuberculosis antigen 85B in-volves intraphagosomal formation of pep-tide-major histocompatibility complex IIcomplexes and is inhibited by live bacillithat decrease phagosome maturation. J.Exp. Med. 194 (2001) 1421-1432.

Price, D. K., Ando, Y., Druger, E. A.,^Mycobacterium tuberculosis (MTB) in-Weiss, M. and Figg, W. D. 5:-OH- hibits phagosomal maturation to promote

70, I^ Current Lúci -ature^ 83

its survival incide macrophages. Controlof MTB infection requires CD4 T cell re-sponses and major histocompatibilitycomplex (MHC) class 11 (MHC-11) pro-cessing of MTB antigens (Ags). To inves-tigate phagosomel processing of MTBAgs, phagosomes containing heat-killed(HK) or live MTB were purilied from in-te rferon -gani ma (IFN-gani ma)-activatedmacrophages by differential centrifuga-tion and Percoll density gradient sub-cellular fractionation. Flow organellome-try and Western blot analysis showed thatMTB phagosomes acquired lysosome-associated membrane protein-1 (LAMP-1), MHC-II, and H2-DM. T hybridomacells were used to detect MTB Ag85B(241-256)-I-A(b) complexes in iso-lated phagosomes and other subcellularfractions. These complexes appearedinitially (within 20 min) in phagosomesand subsequently (>20 min) on the plasmamembrane, but never within late en-docytic compartments. Macrophagesprocessed HK MTB more rapidly and effi-ciently than live MTB; phagosomescontaining live MTB expressed fewer Ag85B(241-256)-I-A(b) complexes thanphagosomes containing HK MTB. This isthe first study of bacterial Ag processingto directly show that peptide-MHC-IIcomplexes are formed within phagosomesand not after export of bacterial Ags fromphagosomes to endocytic Ag processingcompartments. Live MTB can alter phago-some maturation and decrease MHC-II Agprocessing, providing a mechanism forMTB to evade immune surveillance andenhance its survival within the host. Au-thors' Abstract

Sonnenberg, P., Murray, J., Glynn, J. R.,Shearer, S., Kambashi, B. and God-frey-Faussett, P. HIV-1 and recurrence,relapse, and reinfection of tuberculosisafter cure: a cohort study in SouthAfrican mineworkers. Lancet 358 (2001)1687-1693.

Background: The proportion of recur-rent tuberculosis cases attributable to re-lapse or reinfection and the risk factors as-sociated with these difTerent mechanismsare poorly understood. We followed up a

cohort of 326 South African mineworkers,who had successfully completed treatmentfor pulmonary tuberculosis in 1995, to de-termine the rate and mechanisms of recur-rence. Methods: Patients were examined 3and 6 months after cure, and then weremonitored by the routine tuberculosis sur-veillance system until December, 1998.1S6110 DNA fingerprints from initial andsubsequent episodes of tuberculosis werecompared to determine whether recurrencewas due to relapse or reinfection. All pa-tients gave consent for HIV-1 testing.Findings: During follow-up (median 25.1months, IQR 13.2-33.4), 65 patients(20%) had a recurrent episode of tubercu-losis, a recurrence rate of 10.3 episodesper 100 person-years at risk (PYAR)-16.0per 100 pyar in H I V-1-positive patientsand 6.4 per 100 pyar in HIV-1-negativepatients. Paired DNA lingerprints wereavailable in 39 of 65 recurrences: 25 pairswere identical (relapse) and 14 were dif-ferent (reinfection). 93% (13/14) of recur-rences within the first 6 months were at-tributable to relapse compared with 48%(12/25) of later recurrences. HIV-1 infec-tion was a risk factor for recurrence (haz-ard ratio 2.4, 95% CI 1.5-4.0), due to itsstrong association with disease caused byreinfection (18.7 2.4-143), but not relapse(0.58; 0.24-1.4). Residual cavitation andincreasing years of employment at themine were risk factors for relapse. Inter-pretation: In a setting with a high risk oftuberculous infection, HIV-1 increases therisk of recurrent tuberculosis because of anincreased risk of reinfection. Interventiunsto prevent recurrent disease, such as life-long chemoprophylaxis in HIV-1-positivetuberculosis patients, should be further as-sessed—Authors' Abstract

Tansuphasiri, U. Detection of Mvcobacte-rium tuberculosis from sputum collectedon filter paper and stored at room tem-perature for 5 days by PCR assay andculture. J. Med. Assoc. Thai 84 (2001)1183-1189.

The efficacy of PCR assay and culture fordirect detection of M. tuberculosis (MTB)from sputum specimens collected on filterpaper and stored at room temperature for 5

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84^ International Journal of Lepro,s v^ 2002

days was evaluated in comparison withconventional culture of fresh sputum speci-men. A total of 231 sputum specimens wereexamined. MTB was recovered from 124samples by culture from fresh sputum sam-ples before storage. The culture positivityrate was significantly decreased to 70 percent after 5 day's storage on filter paper. ForPCR assay, a fragment of 377-bp of theIS61 10 sequence was ampl i fied and de-tected using nested PCR. Compared withculture results performed on fresh sputumsamples, the sensitivity, specificity, and ef-ficiency for the nested PCR were 96.0, 97.2and 96.5 per cent, respectively. The nestedPCR showed sensitivity and specificity withno significant difference (p >0.05) from cul-ture of fresh sputum specimens. Conclu-sion: The collection and storage of sputumon filter paper at room temperature for 5days had no apparent effect on the perfor-mance of nested PCR. Sputum samples col-lected by this method could be sent by postin a minimum of space and inexpensiveway and will enable a large number of sam-ples collected in the field or from peripheralhealth centers to be sent to central laborato-ries for analysis by trained technicians andunder a well-equipped and well-establishedquality control system. The rapid and reli-able detection by PCR-base'd assay will behelpful for optimal patient management oftherapy and effective control of tuberculo-sis.—Author's Abstract

Terry, S., Timothy, N. H., Zurlo, J. J. andManders, E. K. Mycobacterium che-lonae: nonhealing leg ulcers treated suc-cessfully with an oral antibiotic. J. Am.Board Fam. Pract. 14 (2001) 457- 461.

Background: Mycobacterium chelonae isan important human pathogen and shouldbe considered when a physician is facedwith nonhealing cutaneous wounds, includ-ing ulcers of the lower leg. Methods: Themedical literature was searched from 1965to the present using the key words "My-cobacterium chelonae" and "leg ulcers." Acase of Mvcobacterium chelonae infectionis reported. Results and Conclusion: Clarith-romycin as single-agent oral therapy hasbeen effective in treating these infectionsonce the proper diagnosis is established.

Diagnosis of M. chelonae infection requiresbeing alert to this infectious agent andobtaining cultures for mycobacteria. Ag-gressive surgical debridement with directexcision of the wound inight now be un-necessary because of the effectiveness oforal clarithromycin administered as a singleoral agent. Authors' Abstract

van Crevel, R., Nelwan, R. H., de Lenne,W., Veeraragu, Y., van Der Zanden, A.G., Amin, Z., van Der Meer, J. W. andvan Soolingen, D. Mycobacterium tu-berculosis Beijing genotype strains asso-ciated with febrile response to treatment.Emerg. Infect. Dis. 7 (2001) 880-883.

DNA fingerprinting has demonstratedpredominance of the Beijing genotypeamong Mycobacterium tuberculosis strainsisolated in Southeast Asia. We prospec-tively examined the occurrence of Beijinggenotype strains in tuberculosis patients inIndonesia. Early in treatment, patients in-fected with Beijing genotype strains moreoften had fever unrelated to disease sever-ity, toxicity, or drug resistance, indicatingthat Beijing genotype strains may have spe-cific pathogenic properties.—Authors' Ab-stract

Velmulapalli, R. K., Cantey, J. R., Steed,L. L., Knapp, T. L. and Thielman, N.M. Emergence of resistance to clarith-romycin during treatment of dissemi-nated cutaneous Mycobacterium che-lonae infection: case report and literaturereview. J. Infect. 43 (2001) 163-168.

Results of in vige susceptibility studiesand one clinicai trial have led to recommen-dations of clarithromycin monotherapy forthe treatment of disseminated cutaneousMvcobacterium chelonae infections. Wedescribe the case of a 65-year-old woman,immunocompromised by the use of chronicsteroid therapy, who developed dissemi-nated cutaneous infection with M. chelonaeand failed clarithromycin monotherapy dueto the development of drug resistance. Inthe relapse isolate we document the pres-ence of a single point mutation at position2058 in the gene coding for 23S rRNA pep-

70, 1^ Current Literature^ 85

tidyltransferase regions, a mutation previ-ously implicated in the development ofresistance to clarithromycin. Two suscep-tible control isolates lacked the mutation.Three additional reports in the literature ofpatients developing recurrent skin lesionswith clarithromycin-resistant M. chelonnefollowing initial response to monotherapyare summarized. We demonstrate that clarith-romycin monotherapy in patients with dis-seminated cutaneous infections can lead toclarithromycin resistance and therapeuticfailure associated with a single poliu: mula-tion ai position 2058 of 23S rRNA.—Au-thors' Abstract

Wang, C. H., Lin, H. C., Liu, C. Y.,Huang, K. H., Huang, T. T., Yu, C. T.and Kuo, H. P. Upregulation of in-ducible nitric oxide synthase and cy-tokine secretion in peripheral bloodmonocytes from pulmonary tuberculosispatients. J. Tubercul. Lung Dis. 5 (2001)983-291.

A study was conducted to identifywhether inducible nitric oxide synthase(iNOS) expression and cytokine release ofperipheral blood monocytes (PBM) are up-regulated and have a connection in tubercu-losis (TB) infection 'date not giveni. Theexpression of iNOS immunoreactivity onPBM from TB patients (N = 18; 12 males, 6females; aged 57.0 ± 4.5 years) and normalsubjects (N 14; 8 males, 6 females; meanage, 46.5 ± 4.3 years) from Taiwan, wasmeasured by loading with anti-macrophau-eiNOS polycolonal primar), antibodylyzed by How cytometry. Expression ofiNOS mRNA in PBM was detected by RT-PCR. The spontaneous generation of nitrite

and cytokines (IL-13 and TNF-u) by cul-tured monocytes was also determined. Re-sults revealed that iNOS immunoreactivity,the capacity for spontaneous nitrite genera-tion and the levei of TNF-a or 1L-1f3 secre-tion of PBM were siwnficantly higher inTB patients than in normal subjects. Theamount of nitrite, TNF-a and 1L-113 re-leased from PBM of TB patients was in-hibited by NG-monomethyl-L-arginine (L-NMMA), a competitive inhibitor of NOS.The levei of iNOS immunoreactivity onPBM was highly correlated with nitrite gen-eration both in all the subjects studied andin TB patients alone. Spontaneous TNF-aproduction showed a stronger correlationwith nitrite production than with IL-1[3. It isconcluded that the NO and cytokine syn-thase activities of monocytes appear to beconcomitantly upregulated in response tomycobacterial infection. The enhanced NOgeneration by monocytes in TB patientsmay play an autoregulatory role in amplify-inu the synthesis of pro-inllammatory cy-tokines.—Trop. Dis. Bull.

Yerokhin, V. V., Punga, V. V. and Rybka,L. N. Tuberculosis in Russia and theproblem of multiple dru{lresistance. Ann.N.Y. Acad. Sei. 953 (2001) 133-137.

Tuberculosis cases in Russia doubledfrom 1991 to 2000. when the incidencereached 90 per 100,000; and Russian TBmortality rates are the highest in Europe.Implementation of WHO-recommendedDOTS stratelly is in the preliminary stages.The epidemiological data are presented asis the implementation strategy for stabiliz-ing the epidemic.—Authors' Abstract

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