INTERNATIONAL JOURNAL OF LEPROSY Volume 71 ...ila.ilsl.br/pdfs/v71n3a12.pdfINTERNATIONAL JOURNAL OF...

INTERNATIONAL JOURNAL OF LEPROSY Volume 71, Number 3 Printed in the U.S.A.

(ISSN 0148-916X)

Botting, J. The History of Thalidomide.Drug News Perspect. 15(9) (2002)604–611.

The first paper describing the pharmaco-logical actions of thalidomide was pub-lished in 1956. The drug, then designated asK17, was thought to have sedative effectssuperior to those of comparator drugs andwas thought to be virtually nontoxic. Only2 years after thalidomide’s launch as Con-tergan in Germany, its alleged lack of toxi-city came into question, with reports of thedrug causing numerous side effects. Shortlythereafter, thalidomide was connected withan epidemic of horrific deformities in chil-dren whose mothers had taken the drug dur-ing pregnancy. This disaster brought on bythalidomide’s teratogenic effects was re-sponsible for the institution of some regula-tory bodies, such as the United Kingdom’sCommittee on the Safety of Drugs, and forthe strengthening of others, such as the U.S.Food and Drug Administration. An objec-tive examination of published papers andcontemporary accounts confirms that thepreclinical tests on thalidomide were super-

ficial, and there is no doubt that it was neveradministered to pregnant animals prior toits use in patients. Within a short time afterits withdrawal from the market due to itssuspected association with fetal abnormali-ties, the drug was shown to produce fetaltoxicity in laboratory animals. Had therebeen more extensive testing on laboratoryanimals before the drug was launched, thedisaster could have been avoided.—Au-thor’s Abstract

Dolev, E. [The thalidomide story: a newchapter] Harefuah 142(3) (2003) 186–187, 239, 238. [Article in Hebrew]

Thalidomide, a medication the use ofwhich was banned about forty years agodue to its teratogenic effect, has returnedinto use due to its anti-angiogenic and im-munomodulatory virtues. It is used now asa novel treatment in several malignant dis-eases as well as in the treatment of variousinflammatory conditions. Recently it hasbeen found that thalidomide may antago-nize corneal blood vessels growth which is

CURRENT LITERATURE

This department carries selected abstracts of articles published in current medicaljournals dealing with leprosy and other mycobacterial diseases.

General & Historical 259Chemotherapy 262Clinical Sciences 268Immuno-Pathology 272

Leprosy 275Tuberculosis 277

Microbiology 284Leprosy 286Tuberculosis 287

Experimental Infections 289Epidemiology and Prevention 293Other Mycobacterial Diseases 294Molecular & Genetic Studies 300

General and Historical

258

71, 3 Current Literature 259

a late results of exposure to mustard gas.The story of thalidomide, which is very un-usual, may serve as the snake symbol inmedicine, to remind us about the possibledouble face of every medication, of whichevery physician should be aware.—Au-thor’s Abstract

Fusegawa, H., Wang, B. H., Sakurai, K.,Nagasawa, K., Okauchi, M., and Na-gakura, K. Outbreak of tuberculosis ina 2000-year-old Chinese population.Kansenshogaku Zasshi. 77(3) (2003)146–149.

The molecular identification of Mycobac-terium tuberculosis DNA in ancient humanremains has been achieved mainly in mum-mies with macroscopic changes but not inthe skeletons without bone tuberculosis.Using polymerase chain reaction studies,we identified mycobacterial DNA in 2000-year-old human skeletons without patho-logical changes. Our findings suggest thatthese people suffered from an outbreak oftuberculosis. Molecular examinations formycobacterial DNA in the bone marrow ofskeletons may contribute to the clarificationof ancient diseases in old human popula-tions.—Authors’Abstract

Gomez i Prat, J. and de Souza, S. M. Pre-historic tuberculosis in America: addingcomments to a literature review. Mem.Inst. Oswaldo Cruz. 98 (Suppl 1) (2003)151–159.

Tuberculosis is a prehistoric Americanhuman disease. This paper reviews the liter-ature and discusses hypotheses for originsand epidemiological patterns of prehistorictuberculosis. From the last decades, 24 pa-pers about prehistoric tuberculosis werepublished and 133 cases were reviewed. InSouth America most are isolated case stud-ies, contrary to North America where moreskeletal series were analyzed. Disease wasusually located at the deserts of Chile andPeru, Central Plains in USA, and Lake On-tario in Canada. Skeletal remains representmost of the cases, but 16 mummies havealso been described. Thirty individuals hadlung disease, 19 of them diagnosed by the

ribs. More then 100 individuals had osseoustuberculosis and 26 also had it in other or-gans. As today, transmission of the infec-tion and establishment of the disease werefavored by cultural and life-style changessuch as sedentarization, crowding, undernu-trition, use of dark and insulated houses,and by the frequency of interpersonal con-tacts. The papers confirm that despite previ-ous perceptions, tuberculosis seems to haveoccurred in America for millennia. It onlyhad epidemiological expression when spe-cial conditions favored its expansion. Oc-curring as epidemic bursts or low endemicdisease, it had differential impact on groupsor social segments in America for at leasttwo millennia.—Authors’Abstract

Mori, S., Kato, S., Yokoyama, H.,Tanaka, U., and Kaneda, S. [The his-tory of Yunosawa village and the policyof leprosy of Japan. II] Nihon Hansen-byo Gakkai Zasshi. 72(1) (2003) 27–44.[Article in Japanese]

There was a village which was calledYunosawa, lots of leprosy patients lived,existed from 1887 to 1941, Kusatu town,Gunma Prefecture, Japan. It was the onlyplace continued securing self-governmentto the last as area was free from the isola-tion policy of State in prewar days there.The aim of this study will make clear thedynamism of “The protection from the ten-sion of the society of leprosy patient cur-rently persecuted” to “The defense of thesociety from the leprosy patient who is asource of infection.” In this study, ex-plained the history of the Yunosawa villageand the shift of the policy of leprosy byState had relation to the village. In addition,the effort of residents and Christianitypersons’ activity are drawn in this paper.Moreover also drew what is desired how itis going to live under adverse circum-stances, and showed worth of free medical-treatment area here.—Authors’Abstract

Nwosu, M. C. and Nwosu, S. N. Leprosycontrol in the post leprosaria abolitionyears in Nigeria: reasons for default andirregular attendance at treatment centres.West Afr. J. Med. 21(3) (2002) 188–191.

260 International Journal of Leprosy 2003

A questionnaire was administered to allpatients with leprosy seen at the four lep-rosy clinics in Anambra State in a face toface interview. The questions covered,among other items, the clinic attendancebehaviour and the single most importantreason, monthly, for absenteeism in the pre-ceding year. The total and individual fre-quencies of the reasons for absenteeismwere determined for the various behav-ioural subgroups. The differences in fre-quencies and associations were analysed.Values of p


Aberg, J. A., Williams, P. L., Liu, T., Le-derman, H. M., Hafner, R., Torriani,F. J., Lennox, J. L.,Dube, M. P., Mac-Gregor, R. R., Currier, J. S., and AIDSClinical Trial Group 393 Study Team.A study of discontinuing maintenancetherapy in human immunodeficiencyvirus-infected subjects with dissemi-nated Mycobacterium avium complex:AIDS. J. Infect. Dis. 187(8)(2003) 1346.

The present nonrandomized prospectivestudy evaluated whether antimycobacterialtherapy for disseminated Mycobacteriumavium complex (MAC) could be withdrawnfrom human immunodeficiency virus-infected subjects who experienced im-munologic recovery while receiving highlyactive antiretroviral therapy (HAART). Eli-gible subjects had received macrolide-based therapy for least 12 months, wereasymptomatic for MAC, had receivedHAART for at least 16 weeks, and hadCD4+ T cell counts >100 cells/microL.Forty-eight subjects were enrolled, with amedian CD4+ T cell count of 240 cells/mi-croL at the time of discontinuation of MACtherapy. Forty-seven subjects remainedMAC free, whereas 1 subject developed lo-calized MAC osteomyelitis. The medianduration of follow-up while not receivingtherapy was 77 weeks, and the incidence ofMAC infection was 1.44/100 person-years(95% confidence interval, 0.04–8.01).Withdrawal of anti-MAC therapy appearsto be safe in patients who have been treatedwith a macrolide-based regimen for at least1 year and have an immunologic responseon HAART.—Authors’Abstract

Brown-Elliott, B. A., Crist, C. J., Mann,L. B., Wilson, R. W., and Wallace, R.J. Jr. In Vitro Activity of Linezolidagainst Slowly Growing NontuberculousMycobacteria. Antimicrob. AgentsChemother. 47(5) (2003) 1736–1738.

MICs of linezolid in broth microdilutionswere tested against 341 slowly growingnontuberculous mycobacteria (NTM) be-longing to 15 species. The proposed line-

zolid susceptibility MICs for all Mycobac-terium marinum, Mycobacterium szulgai,Mycobacterium kansasii, Mycobacteriummalmoense, and Mycobacterium xenopiisolates and for 90% of Mycobacteriumgordonae and Mycobacterium triplex iso-lates were ≤8 micro g/ml. Linezolid has ex-cellent therapeutic potential against mostspecies of NTM.—Authors’Abstract

Das, A. R., Dattagupta, N., Sridhar, C.N., and Wu, W. K. A novel thiocationicliposomal formulation of antisenseoligonucleotides with activity againstMycobacterium tuberculosis. Scand. J.Infect. Dis. 35(3) (2003) 168–174.

This study describes the development ofa novel thiocationic (OBEHYTOP) lipid-based formulation of phosphorothioate anti-sense oligonucleotides (PAOs) showing in-hibitory activity against Mycobacterium tu-berculosis (mTB) as measured by an invitro BACTEC 460TB assay. PAOs weredesigned based on sequences complemen-tary to essential regions of the mycobacte-rial genome from published nucleic aciddatabases in GenBank. These included thesuperoxide dismutase sod A gene (TBS3),catalase-peroxidase katG gene (TBK1,TBK10), RNA polymerase beta-subunit rpoB gene (TBR5) and diaminopimelate decar-boxylase lys A gene (TBL5). The effect ofPAOs (TBS3, K1, K10, R5 and L5) aloneon mTB was not significant compared withthe no-drug control over a period of expo-sure of 150 hr (ranges of –11.8 to +23.58%at 72 hr; 15.26 to +25.82% at 96 hr and–5.51 to +24.00% at 150 hr). Liposomalformulations (10:5:2 OBEHYTOP : oleicacid:vitamin D3) of PAOs resulted in statis-tically significant (p


–97.36%, respectively, indicating that thesethiocationic lipid-formulated PAOs showedinhibitory activity directed against mTB invitro.—Authors’Abstract

Dhople, A. M. and Namba, K. Activitiesof sitafloxacin (DU-6859a), either singlyor in combination with rifampin, againstMycobacterium ulcerans infection inmice. J. Chemother. 15(1) (2003) 47–52.

Efficacy of a new fluoroquinolone,sitafloxacin (DU-6859a), against Mycobac-terium ulcerans was evaluated in vivo usingthe mouse footpad system. The growth ofM. ulcerans in mouse footpads was com-pletely inhibited when mice were fed withsitafloxacin at a dose of 25 mg/kg bodyweight per day; on the other hand similareffects were observed with ofloxacin at adose of 100 mg/kg body weight per day. Inthe presence of rifampin, the above dose ofsitafloxacin could be reduced by 75% toachieve total inhibition, while, under simi-lar circumstances, the dose of ofloxacincould be reduced by only 50%. Either usedsingly or in combination with rifampin, theeffects of sitafloxacin were bactericidal.The results suggest that sitafloxacin shouldbe evaluated as a chemotherapeutic agentagainst M. ulcerans infection.—Authors’Abstract

Dhople, A. M. and Namba, K. In-vitro ac-tivity of sitafloxacin (DU-6859a), eithersingly or in combination with rifampinanalogs, against Mycobacterium leprae.J. Infect. Chemother. 9(1) (2003) 12–15.

The in-vitro antibacterial activity ofsitafloxacin (DU-6859a) against Mycobac-terium leprae was evaluated and comparedwith those of ofloxacin, levofloxacin, andciprofloxacin. Two biochemical indicators(intracellular ATP and uptake of [(3)H]-thymidine) were used to measure the in-vitro growth of M. leprae in Dhople-Hanks(DH) medium. Sitafloxacin was found to bemore potent than the other three commonlyused fluoroquinolones, with the minimuminhibitory concentration (MIC) against M.leprae being 0.1875 microg/ml and the ac-tion being bactericidal. The MIC’s of

ofloxacin, levofloxacin, and ciprofloxacinwere 1.5, 0.75, and 3.0 microg/ml, respec-tively. Similar to ofloxacin and levofloxacin,sitafloxacin also exhibited synergistic ac-tivity when combined with either rifabutinor KRM-1648, but not with rifampin. Thus,further studies on the incorporation ofsitafloxacin in multidrug therapy regimensin treating leprosy patients are suggested.—Authors’Abstract

Gordon, J. N. and Goggin, P. M. Thalido-mide and its derivatives: emerging fromthe wilderness. Postgrad. Med. J.79(929) (2003) 127–132.

Forty years on from its worldwide with-drawal, thalidomide is currently undergoinga remarkable renaissance as a novel andpowerful immunomodulatory agent. Overthe last decade it has been found to be ac-tive in a wide variety of inflammatory andmalignant disorders where conventionaltherapies have failed. Recently, consider-able progress has been made in elucidatingits complex mechanisms of action, whichinclude both anticytokine and antiangio-genic properties. However, in addition to itswell known teratogenic potential, it has asignificant side effect profile that leads tocessation of treatment in up to 30% of sub-jects. In response to this, two new classes ofpotentially safer and non-teratogenic deriv-atives have recently been developed. Thisreview summarises the biological effects,therapeutic applications, safety profile, andfuture potential of thalidomide and its de-rivatives.—Authors’Abstract

Hall, V. C., El-Azhary, R. A., Bouwhuis,S., and Rajkumar, S. V. Dermatologicside effects of thalidomide in patientswith multiple myeloma. J. Am. Acad.Dermatol. 48(4) (2003) 548–552.

BACKGROUND: Thalidomide, an an-tiangiogenic agent, was approved by theFood and Drug Administration in 1998 forthe treatment of erythema nodosum lepro-sum. Although its teratogenic and neuro-logic side effects are well known, its der-matologic side effects continue to bedefined. OBJECTIVE: We report the der-


matologic side effects in 87 patients withmultiple myeloma enrolled in a compara-tive, open-label, clinical trial treated withthalidomide alone (50 patients) or thalido-mide and dexamethasone (37 patients).METHOD: We reviewed the records of allpatients enrolled in the clinical trial. Thefrequency, type, severity, and time of onsetof all skin eruptions that were temporallyrelated to thalidomide treatment wererecorded. RESULTS: Minor to moderateskin eruptions were noted in 46% of pa-tients taking thalidomide alone and in 43%of those taking thalidomide and dexametha-sone. These included morbilliform, sebor-rheic, maculopapular, or nonspecific der-matitis. Severe skin reactions (exfoliativeerythroderma, erythema multiforme, andtoxic epidermal necrolysis) that requiredhospitalization and withdrawal of thalido-mide developed in 3 patients receivingthalidomide and dexamethasone. CON-CLUSION: The prevalence of dermatologicside effects of thalidomide appear to behigher than previously reported. Althoughin most patients they were minor, in a fewpatients they were quite severe, particularlywhen given in conjunction with dexametha-sone for newly diagnosed myeloma. Fur-ther studies are needed to verify the extentof the interaction between thalidomide anddexamethasone in this group of patients.—Authors’Abstract

Haslett, P. A., Hanekom, W. A., Muller,G., and Kaplan, G. Thalidomide and athalidomide analogue drug costimulatevirus-specific CD8+ T cells in vitro. J.Infect. Dis. 187(6) (2003) 946–955.

CD8(+) T cell immunity is critical forprotection from viral disease, such as thatcaused by the human immunodeficiencyvirus (HIV) or cytomegalovirus (CMV). Itis therefore important to identify therapiesthat can boost antiviral immunity. The re-cent finding that thalidomide acts as a T cellcostimulator suggested that this drug mayboost antiviral CD8(+) T cell responses. Inthis in vitro study, in a human autologousCD8(+) T cell/dendritic cell (DC) coculturesystem, thalidomide and a potent thalido-mide analogue were shown to enhancevirus-specific CD8(+) T cell cytokine pro-

duction and cytotoxic activity. The drug-enhanced antiviral activity was noted incells from both healthy donors and personschronically coinfected with HIV and CMV.This stimulatory effect was directed atCD8(+) T cells, and not DCs. These resultssuggest an application for thalidomide andthe thalidomide analogue as a novel im-mune-adjuvant therapy in chronic viral in-fections.—Authors’Abstract

Hegarty, A., Hodgson, T., and Porter, S.Thalidomide for the treatment of recalci-trant oral Crohn’s disease and orofacialgranulomatosis. Oral Surg. Oral Med.Oral Pathol. Oral Radiol. Endod. 95(5)(2003) 576–585.

It has been suggested that thalidomidemay be effective in the management ofCrohn’s disease, including the associatedoral lesions. We detail the clinical responseto low-dose thalidomide of 5 patients withclinical features of orofacial granulomatosisor oral Crohn’s disease recalcitrant to rec-ognized immunosuppressant therapy. Allpatients had clinical resolution of theirsymptoms and signs. Transient somnolencewas the only reported adverse effect. Re-mission was maintained by extending theperiod between thalidomide doses. Thalido-mide should be considered an effectivetherapy for the short-term treatment of se-vere orofacial granulomatosis in appropri-ately counseled patients.—Authors’ Ab-stract

Matthews, S. J. and McCoy, C. Thalido-mide: a review of approved and investi-gational uses. Clin. Ther. 25(2) (2003)342–395.

BACKGROUND: Thalidomide is bestknown as a major teratogen that causedbirth defects in up to 12,000 children in the1960s. More recently, this agent has beenapproved by the US Food and Drug Admin-istration for the treatment of erythemanodosum leprosum (ENL) through arestricted-use program. Its immunomodula-tory, anti-inflammatory, and antiangiogenicproperties are currently under study in anumber of clinical conditions. OBJEC-


TIVE: This article reviews the pharma-cology of thalidomide; its approved andoff-label uses in dermatologic, oncologic,and gastrointestinal conditions; and adverseevents associated with its use. METHODS:Relevant articles were identified throughsearches of MEDLINE (1966–June 2002),International Pharmaceutical Abstracts(1970–June 2002), and EMBASE (1990–June 2002). Search terms included but werenot limited to thalidomide, pharmacokinet-ics, pharmacology, therapeutic use, and ter-atogenicity, as well as terms for specificdisease states and adverse events. Furtherpublications were identified from the ref-erence lists of the reviewed articles. Ab-stracts of recent symposia were obtainedfrom the American Society of Clinical On-cology Web site. RESULTS: Thalidomideis thought to exert its therapeutic effectthrough the modulation of cytokines, par-ticularly tumor necrosis factor-alpha. In ad-dition to its approved indication for ENL,thalidomide has been studied in variousother conditions, including graft-versus-host disease, discoid lupus erythematosus,sarcoidosis, relapsed/refractory multiplemyeloma, Waldenstrom’s macroglobuline-mia, myelodysplastic syndromes, acute mye-loid leukemia, myelofibrosis with myeloidmetaplasia, renal cell carcinoma, malignantgliomas, prostate cancer, Kaposi’s sar-coma, colorectal carcinoma, oral aphthousulcers, Behcet’s disease, Crohn’s disease,and HIV/AIDS-associated wasting. Ad-verse events most frequently associatedwith its use include somnolence, consti-pation, rash, peripheral neuropathy, andthromboembolism. CONCLUSIONS: Useof thalidomide is limited by toxicity, limitedefficacy data, and restricted access. Evi-dence of its efficacy in conditions otherthan ENL awaits the results of controlledclinical trials.—Authors’Abstract

Mlambo, G. and Sigola, L. B. Rifampicinand dexamethasone have similar effectson macrophage phagocytosis of zy-mosan, but differ in their effects on ni-trite and TNF-alpha production. Int. Im-munopharmacol. 3(4) (2003) 513–522.

The antibiotic rifampicin is used exten-sively in the treatment of mycobacterial and

other infections. It has previously been sug-gested that rifampicin binds to and activatesthe glucocorticoid receptor potentially lead-ing to pharmacological glucocorticoid-likeeffects such as host immunosuppression(Calleja, et al.). This study compares the ef-fects of rifampicin with the synthetic gluco-corticoid dexamethasone, on macrophagephagocytosis of zymosan particles and pro-duction of nitric oxide (NO) and tumournecrosis factor-alpha (TNF-alpha) bysplenocytes or macrophages. Rifampicinand dexamethasone, partially suppressedzymosan phagocytosis by macrophages,respectively, and both effects were amelio-rated by the glucocorticoid receptor antago-nist RU486. In other experiments, ri-fampicin had no effects on NO responses;however, dexamethasone inhibited NO inan RU486-sensitive manner. At high doses,rifampicin moderately suppressed TNF-alpha while dexamethasone inhibited it in adose-dependent manner, which was amelio-rated by the presence of RU486. Thesefindings suggest that rifampicin has differ-ential immunomodulatory effects on theseinnate immune mechanisms.—Authors’Abstract

Okafor, M. C. Thalidomide for erythemanodosum leprosum and other applica-tions. Pharmacotherapy. 23(4) (2003)481–493.

Thalidomide, administered as a sedativeand antiemetic decades ago, was consid-ered responsible for numerous devastatingcases of birth defects and consequentlywas banned from markets worldwide.However, the drug remarkably has resur-faced with promise of immunomodulatorybenefit in a wide array of immunologicdisorders for which available treatmentswere limited. It is approved by the Foodand Drug Administration for erythema no-dosum leprosum (ENL). Although therelative paucity of leprosy and ENL world-wide may perceivably limit interest in andknowledge about thalidomide, increasingnumbers of new and potential uses expandits applicability widely beyond ENL.Thalidomide, an inhibitor of tumor necro-sis factor a, is the best known agent forshort-term treatment of ENL skin manifes-


tations, as well as postremission mainte-nance therapy to prevent recurrence. Forthis indication, it is effective as monother-apy and as part of combination therapywith corticosteroids. Studies of thalido-mide in chronic graft-versus-host diseaseshowed benefit in children and adults astreatment, but not as prophylaxis. Theagent has been administered successfullyfor treatment of cachexia related to cancer,tuberculosis, and human immunodefi-ciency virus infection, although evidenceof efficacy is inconclusive. Thalidomidemonotherapy effectively induced objectiveresponse in trials in patients with bothnewly diagnosed and advanced or refrac-tory multiple myeloma. Combination ther-apy with thalidomide and corticosteroidswas also effective in these patients, as wellas in treatment of aphthous and genital ul-cers. Limited evidence supports the drug’sbenefit in treatment of Kaposi’s sarcoma.Other thalidomide applications includeCrohn’s disease, rheumatoid arthritis, andmultiple sclerosis. Somnolence, constipa-tion, and rash were the most frequentlycited adverse effects in studies, butthalidomide-induced neuropathy and idio-pathic thromboembolism were criticalcauses for drug discontinuation. Thalido-mide is still contraindicated in pregnantwomen, women of childbearing age, andsexually active men not using contracep-tion. Clinicians should be conversant withthalidomide in ENL (its primary applica-tion) in the natural course of leprosy, aswell as in the agent’s other applications.—Author’s Abstract

Pannikar, V. The Return of Thalidomide:New Uses and Renewed Concerns. WHOPharmaceuticals Newsletter, No. 2, 2003(available at http://www.who-umc.org)

Today, a large number of thalidomide ba-bies continue to be born each year possiblyreflecting regulatory insufficiency andwidespread use under inadequate supervi-sion. In Brazil, which has more than 1000registered thalidomide victims, the last of-ficially known case was born in 1995.There is evidence that second generationbabies with similar deformities are beingborn to thalidomide victims. In the US,

Celgene Corporation has had FDA ap-proval to market the drug since 1998 forthe cutaneous manifestations of moderateto severe erythema nodosum leprosum. InEurope, the US company Pharmion Corpand French rival Laphal have both securedorphan drug status for thalidomide andhave applied to market the drug as a ther-apy for multiple myeloma and for ENL inthe EU. The EU is currently holding dis-cussions on the re-launch of thalidomide.Whatever the outcome of the EU discus-sions, it cannot be over emphasized thatany potential benefit with thalidomide mustbe balanced with the known toxicity andthe accompanying ethical and legal con-straints on its use. Experience has shownthat it is virtually impossible to developand implement a fool-proof surveillancemechanism to combat misuse of thalido-mide.—Author’s Abstract

Pukrittayakamee, S., Prakongpan, S.,Wanwimolruk, S., Clemens, R., Looa-reesuwan, S., and White, N. J. Adverseeffect of rifampin on quinine efficacy inuncomplicated falciparum malaria. An-timicrob. Agents Chemother. 47(5)(2003) 1509–1513.

The effects of adding rifampin to quininewere assessed in adults with uncomplicatedfalciparum malaria. Patients were random-ized to receive oral quinine either alone (N =30) or in combination with rifampin (N =29). Although parasite clearance times wereshorter in the quinine-rifampin-treated pa-tients (mean ± standard deviation, 70 ± 21versus 82 ± 18 hr; p = 0.023), recrudescencerates were five times higher (N = 15 of 23;65%) than those obtained with quininealone (N = 3 of 25; 12%), p


and the doses of quinine should probably beincreased in patients who are already receiv-ing rifampin treatment.—Authors’Abstract

Schafer, P. H., Gandhi, A. K., Loveland,M. A., Chen, R. S., Man, H. W., Schnet-kamp, P. P., Wolbring, G., Govinda, S.,Corral, L. G., Payvandi, F., Muller, G.W., and Stirling, D. I.. Enhancement ofCytokine Production and AP-1 Tran-scriptional Activity in T Cells by Tha-lidomide-Related ImmunomodulatoryDrugs. J. Pharmacol. Exp. Ther. 305(3)(2003) 1222–1232.

CC-4047 (ACTIMID(TM)) and CC-5013(REVIMID(TM)) belong to a class ofthalidomide analogs, collectively known asthe immunomodulatory drugs (IMiDs(TM)),that are currently being assessed in thetreatment of patients with multiplemyeloma (MM) and other cancers. IMiDspotently enhance T cell and natural killer(NK) cell responses and inhibit TNF-alpha,IL-1beta, and IL-12 production from LPS-stimulated PBMC. However, the molecularmechanism of action for these compoundsis unknown. Herein we report on the abilityof the IMiDs to upregulate production ofIL-2 from activated human CD4(+) andCD8(+) peripheral blood T cells, produc-tion of IL-2 and IFN-gamma from Th1-typecells, and production of IL-5 and IL-10from Th2-type cells. Elevation of IL-2 pro-duction from Jurkat T cells was observed asearly as 6 hours post-stimulation and corre-lated with an increase in IL-2 promoter ac-tivity that was dependent upon the proximalbut not the distal AP-1 binding site. TheIMiDs enhanced AP-1-driven transcrip-tional activity 2 to 4-fold after 6 hours of Tcell stimulation, and their relative potenciesfor AP-1 activation correlated with theirpotencies for increased IL-2 production inJurkat T cells and in CD4(+) or CD8(+)human peripheral blood T cells. The mostpotent of these IMiDs, CC-4047, had noeffect on NFAT transcriptional activity,calcium signaling, or phosphorylation ofERK1/2, JNK1/2, p38 MAPK, or c-Jun/JunD in Jurkat T cells. These data suggest thatIMiDs increase T cell cytokine productionby potentiating AP-1 transcriptional ac-tivity.—Authors’Abstract

Valerio, G., Bracciale, P., Manisco, V.,Quitadamo, M., Legari, G., and Bel-lanova, S. Long-term tolerance and ef-fectiveness of moxifloxacin therapy fortuberculosis: preliminary results. J.Chemother. 15(1) (2003) 66–70.

The resurgence of tuberculosis is a ma-jor problem. Increasing multiple resistanceto current drugs used for therapy, non-compliance to therapy or co-morbidity arechallenging problems that do not allow useof standard therapy in all patients.Quinolones are claimed to be active drugsin TB infection. Moxifloxacin shows thehighest intracellular concentration in vitroand in experimental animals, but long-term tolerability is unknown. Our aim wasto observe in compliant patients, not eligi-ble for standard therapy, the effect of 6months of therapy with moxifloxacin, iso-niazid and rifampin. Nineteen patients, acontrol group, were observed for the sameperiod under therapy with streptomycin,pirazinamide, rifampin, isoniazid. The pa-tients were affected by indolent miliarypattern and concomitant lymphoma orleukemia in 3 cases; rare nodular involve-ment with genitourinary diseases in 3 oth-ers; segmental to lobar involvement in 4others with concomitant multidrug resis-tance, bone localization, hepatitis. Thecontrol group was more uniform andshowed segmental to lobar nodular in-volvement with pleuritis in 3 patients, to-gether with hepatitis in 3. Monthly checksof blood gas analysis, chest X-ray, func-tional testing, serum titers of antibodiesagainst antigen 60, sputum slides and com-plete chemical analysis were performed. Afollow-up visit was performed 1 month af-ter therapy. Patients under moxifloxacintherapy experienced no toxicity, almostcomplete sterilization and remission of thedisease. Sterilization was obtained in 15days. Patients under standard therapy alsohad a good clinical outcome, althoughtherapy was delayed in 3 cases because ofincreased transaminases within the first 15days of therapy. Moxifloxacin seems to bewell tolerated and combination therapy in-cluding moxifloxacin for TB seems to beas active as the standard therapy in pa-tients with complex illness.—Authors’Ab-stract


Bari, M. M. Surgical reconstruction of lep-rotic foot drop. Mymensingh Med. J.12(1) (2003) 11–12.

We have operated 152 patients for cor-rection of foot-drop due to leprosy fromMarch 1992 to July 1999. The method usedwas circumtibial transfer of the tibial is pos-terior to the tendons of extensor hellucislongus and the extensor digitorum longus inthe foot together with lengthening of theAchilles tendon. The results were satisfac-tory in 135 of these cases as judged by ade-quate restoration of heel—toe gait and ofactive dorsiflexion. The follow up periodranged from 6 months to 8 years. Inade-quate post-operative physiotherapy was thereason for unsatisfactory results in seven-teen cases.—Author’s Abstract

Davis, S. V., Shenoi, S. D., Balachandran,C., and Pai, S. B. A fatal case of ery-thema necroticans. Indian J. Lepr. 74(2)(2002) 145–149.

Erythema nodosum leprosum (ENL)classically presents as tender, erythematousnodules over the face, arms and legs. Se-vere ENL can become vesicular or bullousand break-down and is termed erythemanecroticans (Jopling and McDougall, 1996)and is treated with corticosteroids. Thecauses of death in a majority of leprosy pa-tients are the same as in the general popula-tion, with the exception of renal damage inlepromatous leprosy. There is possible in-creased mortality from side-effects of an-tileprosy drugs, steroids, or other drugsused in reactions, from toxaemia in severereactions, and from asphyxia due to glotticoedema (Jopling and McDougall, 1996).We report here a case of erythema necroti-cans, the cause of death being septicaemia,secondary to skin ulcers and urinary tractinfection, precipitated by corticosteroids.—Authors’Abstract

Girdhar, A., Chakma, J. K., and Girdhar,B. K. Pulsed corticosteroid therapy inpatients with chronic recurrent ENL: a

pilot study. Indian J. Lepr. 74(3) (2003)233–236.

A pilot study has been undertaken tocompare the efficacy of small dose pulsedbetamethasone therapy with need basedoral steroids in chronic recurrent erythemanodosum leprosum (ENL) patients. Thoughthis mode of therapy was well tolerated, noadvantage with intermittent steroid admin-istration was observed. This could havebeen on account of small dose of steroidgiven monthly. Treatment of chronic recur-rent erythema nodosum leprosum (ENL)patients continues to be unsatisfactory, par-ticularly, because of nonavailability ofthalidomide. Though corticosteroids are ef-fective in suppressing all the manifestationsand even restoring partially or fully thefunctional impairment, their side effectsand dependence are equally troublesome.Based on (a) the reported efficacy andsafety of intermittent use of corticosteroidsin several immune complex mediated disor-ders (Cathcart, et al. 1976, Kimberly, et al.1979), Liebling, et al 1981 and Pasrichaand Gupta 1984) and (b) ENL (type II) re-actions having similar pathology, a pilotstudy has been undertaken to see the effi-cacy and the tolerance of pulsed steroids inchronic ENL patients.—Authors’Abstract

Keita, S., Faye, O., Konare, H. D., Sow, S.O. Ndiaye, H. T., and Traore, I. [Eval-uation of the clinical classification ofnew cases of leprosy. Study conducted atthe Marchoux Institute in Bamako, Mali]Ann. Dermatol. Venereol. 130(2) (2003)184–186. [Article in French]

INTRODUCTION: The difficulties re-lated to the bacilloscopic diagnosis ofleprosy, providing a more reliable classifi-cation of cases, in 1995 led the WHO torecommend the use of a new classification,in endemic countries, based on clinical crite-ria alone, in order to simplify the poly-chemotherapeutic regimens. According toour experience in the Marchoux Institute,this classification may lead to errors indiagnosis through overzealous or mis-

Clinical Sciences


interpretation of the two forms of leprosy.The aim of our study was to evaluate theconcordance between this clinical classifica-tion and that based on a bacilloscopic exam-ination. PATIENTS AND METHODS: Weconducted a descriptive study of new casesof leprosy seen at the Marchoux Institute,without distinction in gender or age, fromJanuary to December 2000. All the patientsincluded underwent clinical examination anda bacilloscopic exploration to provide a dou-ble classification. The concordance betweenthe two classifications was assessed usingthe Kappa test. RESULTS: Two hundrednew cases of leprosy were included. Out of126 clinically multi-bacillary cases, 61 wereconfirmed bacteriologically, and 65 werefalse positives. Out of 74 clinical cases withfew bacilli, 2 were bacteriologically multi-bacilli. The concordance between the twoclassifications was average (Kappa = 0.40).There was a significant difference betweenthe percentages of multi-bacilli observed inboth classifications (p


tion, does exist as a post-operative compli-cation after claw finger correction. A retro-spective study was carried out to examinethe occurrence of post-operative medianpalsy, in cases of isolated ulnar palsy, wherethe transferred motor tendon was routedthrough the carpal tunnel. We noted that sixpatients developed median nerve palsy fol-lowing claw finger correction. Medianpalsy developed at different times aftersurgery—the “early onset” type developingwithin three weeks post-operatively, “reac-tional” type developed when patient wasundergoing physiotherapy exercises andlearning to use the transfer and “delayed in-sidious” type presenting six months or moreafter operation. We could not succeed to getthe true prevalence of such occurrences be-cause all the operated hands could not bere-examined.—Author’s Abstract

Malaviya, G. N. Some more about un-favourable results after corrective surgeryas seen in leprosy. Indian J. Lepr. 74(3)(2002) 243–257.

The paper describes unfavourable out-comes of some of the commonly performedsurgical procedures in leprosy affected per-sons and the underlying causes. An aware-ness about unfavourable outcomes ofsurgery is helpful to the beginners becausethey can anticipate the problems and takeappropriate measures to prevent that andfailing which prepare themselves to faceand sort that out. Careful pre-operativeevaluation of the patient is an importantfirst step.—Author’s Abstract

Misra, U. K., Kalita, J., Mahadevan, A.,and Shankar, S. K. Pseudoathetosis in apatient with leprosy. Mov. Disord. 18(5)(2003) 598–601.

A 35-year-old man with borderline tuber-culoid leprosy developed Type I lepra reac-tion 12 days after anti-leprosy treatment.There was acute worsening of neuropathicsymptoms and skin lesions. He developedsevere sensory ataxia and pseudoathetosisresulting in marked disability. His symp-toms significantly improved on cortico-steroid therapy.—Authors’Abstract

Ozkan, T., Ozer, K., Yukse, A., and Gul-gonen, A. Surgical reconstruction of ir-reversible ulnar nerve paralysis in lep-rosy. Lepr. Rev. 74(1) (2003) 53–62.

Twenty-five patients with irreversibleleprotic ulnar nerve palsy having undergonelumbrical replacement with two differenttendon transfer techniques were assessed6–120 months after surgery. Nineteen pa-tients were reconstructed with the flexordigitorum four-tail procedure (FDS-4T),and six with Zancolli’s lasso procedure(ZLP). Mean paralysis times were 103months for FDS-4T, and 68 months forZLP. Mean age of the patients was 36 years(21–57). Grip strength measurements, im-provement in active range of motion at thePIP joints, patients’ ability to open andclose their hands fully, as well as sequenceof phalangeal flexion, were noted. Meangrip strength measurements during follow-up were 76% of the contralateral extremityin the FDS-4T group and 82% in the ZLPgroup. Comparison of the follow-up gripstrength with the preoperative value re-vealed 1% improvement in the FDS-4Tgroup and 20% in the ZLP group. Clawhand deformity was completely corrected in12 patients in FDS-4T group, and in fivepatients in the ZLP group. Residual flexioncontracture remained in five patients aftersurgery. Swan-neck deformity subsequentlydeveloped in seven fingers. Age, sex, meanfollow-up and surgical technique did not re-late statistically to the functional outcome.However, preoperative extensor lag of thePIP joint and mean paralysis time signifi-cantly affected the functional outcome. ZLPwas found to be a more effective procedurein restoring grip strength, whereas FDS-4Twas more effective in correcting claw handdeformity.—Authors’Abstract

Ramu, G. and Desikan, K. V. Reactions inborderline leprosy. Indian J. Lepr. 74(2)(2002) 115–128.

This is a retrospective study of 276 pa-tients consisting of 157 active and 119 reac-tive patients of borderline leprosy. Theywere followed up for 10 years after sul-phone monotherapy. The presenting symp-toms were carefully examined from the


records and systematically presented. Fre-quency of reactions was least in BT casesand most in BL cases. Risk factors of reac-tion appear to be the type of leprosy, multi-plicity of lesions, high BI and, possibly,psychological stress. Biopsy of skin lesionswas performed in all cases initially, and atthe subsidence of the disease. Histologicalfindings closely correlated with clinicalclassification. While all the cases showedclinical subsidence, histological subsidencewas found in 200 (73%) cases, and the con-dition was static in 36 cases (13%). Im-munological upgrading was seen in 110%,while 4% showed downgrading. Bacterio-logical status and lepromin reaction of ac-tive and reactive cases were compared. Allthese factors need to be taken into consider-ation for instituting prompt and propertreatment.—Authors’Abstract

Richard, B. M. Location of the extracra-nial extent of leprous facial nerve pathol-ogy may allow leprous facial palsy to bereanimated by free muscle transfer. Br. J.Plast. Surg. 56(1) (2003) 14–19.

Leprosy is a mycobacterial nerve andskin infection, which can be eradicated byantibiotics. Some patients affected by lep-rosy, once cured, have residual nerve im-pairment with paralysis and sensory neu-ropathy. A series of patients with facialnerve paralysis, investigated using clinical,histological and electrophysiological tech-niques, demonstrated that the nerve pathol-ogy was distal to the section of main trunkprior to its bifurcation. Facial reanimationwas achieved with a free gracilis-muscletransfer, coapting its motor nerve to the ip-silateral facial nerve trunk proximal to thesite of the leprosy pathology, with a moder-ate clinical result.—Author’s Abstract

Thappa, D. M., Dave, S., Karthikeyan,K., Laxmisha, C., and Jayanthi, S. Lo-calized lepromatous leprosy presentingas a painful nodule in a muscle. Indian J.Lepr. 74(3) (2002) 237–242.

Lepromatous leprosy is a generalizeddisease usually presenting with numerousmacules, papules, nodules or plaques in-

volving wide areas of the skin. It is gener-ally believed that in India lepromatous lep-rosy often originates from the borderlinespectrum (Jha, et al., 1991). Localized lep-romatous or borderline lepromatous dis-ease is a rare variant of multibacillary lep-rosy (Yoder, et al., 1985; Jha, et al., 1991;Pfaltzgraff and Ramu, 1994; Vijaikumar, etal., 2001). This variant usually presents asa single nodule or a localized area of nod-ules and papules, while most of the bodysurface appears normal (Pfaltzgraff andRamu, 1994; Vijaikumar, et al., 2001). Itsoccurrence in our case as a single painfulnodule in the bicep muscle of left forearmwas indeed intriguing, such presentationbeing rarely reported in the literature.—Authors’ Abstract

Yowan, P., Danneman, K., Koshy, S.,Richard, J., and Daniel, E. Knowledgeand practice of eye-care among leprosypatients. Indian J. Lepr. 74(2) (2002)129–135.

In one hundred and thirty leprosy patientsattending the Schieffelin Leprosy Researchand Training Center, Karigiri, Tamil Nadu,India, the knowledge, attitude and practiceof eye-care were ascertained using a ques-tionnaire developed by Mathews and Man-galam. 74.6% the patients surveyed wereaware of the disease, 60% knew about theearly signs of leprosy, 74.6% consideredleprosy curable and 36.9% knew the dura-tion of treatment with MDT. Less than halfof the patients (40.8%) knew that blindnessoccurred in leprosy and was preventable.More males had this knowledge (46.5%)than females (22.6%) (p = 0.001). Knowl-edge on how to take care of the eyes(26.9%), that eyes become anaesthetic dueto leprosy (27.7%), and that precautionsshould be taken if sensation is lost (27. 7%)was very poor. Knowledge on prevention ofdamage in eyes (57.7%) and the fact thatrubbing eyes could cause damage (55.4%)was found in more than half the patients.More males (64.6%) had knowledge on theprevention of damage in eyes than females(35.5%) (p = 0.008). Only 25.4% of the pa-tients tried some measures to prevent eyeinjury, 21.5% used home remedies and allhad the help of family members in their


Actor, J. K., Indrigo, J., Beachdel, C. M.,Olsen, M., Wells, A., Hunter, Jr. R. L.,and Dasgupta, A. Mycobacterial Gly-colipid Cord Factor Trehalose 6,6′-Dimycolate Causes a Decrease in SerumCortisol during the Granulomatous Re-sponse. Neuroimmunomodulation 10(5)(2003) 270–282.

Serum cortisol levels were evaluated inmice following intravenous administrationof purified mycobacterial glycolipid tre-halose 6,6′-dimycolate (TDM). C57BL/6mice develop lung granulomas in responseto TDM, while A/J mice are deficient inthis process. Administration of TDM toC57BL/6 mice led to a rapid reduction inserum cortisol, concurrent with initiation ofthe granulomatous response and cytokineand chemokine mRNA induction. Cortisollevels were lowest on day 5 after TDM ad-ministration, but there was significant pro-duction of IL-6, TNF-alpha and IL-1betamessages. Granuloma formation and fullimmune responsiveness to TDM were onlyapparent upon a sufficient decrease in levelsof systemic cortisol. Treatment of theC57BL/6 mice with hydrocortisone abol-ished inflammatory responses. Histologi-cally nonresponding A/J mice exhibitedhigher constitutive serum cortisol anddemonstrated different kinetics of cortisolreduction upon administration of TDM. A/Jmice demonstrated hyperplastic morphol-ogy in the suprarenal gland with a highdegree of vacuolization in the medullary re-gion and activation of cells in the zona fas-ciculata and zona reticularis. The A/J micewere dysregulated with respect to cytokineresponses thought to be necessary during

granuloma formation. The high constitutiveserum cortisol in the A/J mice may there-fore contribute to pulmonary immunore-sponsiveness and the establishment of anenvironment counterproductive to the initi-ation of granulomatous responses. Theidentification of a mycobacterial glycolipidable to influence serum cortisol levels isunique and is discussed in relation to im-munopathology during tuberculosis dis-ease.—Authors’Abstract

Bhattacharyya, A., Pathak, S., Basak, C.,Law, S., Kundu, M., and Basu, J. Exe-cution of macrophage apoptosis by My-cobacterium avium through apoptosissignal-regulating kinase 1/p38 mitogen-activated protein kinase signaling andcaspase 8 activation. J. Biol. Chem.278(29) (2003) 26517–26525.

Macrophage apoptosis is an importantcomponent of the innate immune defensemachinery (against pathogenic mycobacte-ria) responsible for limiting bacillary viabil-ity. However, little is known about themechanism of how apoptosis is executed inmycobacteria-infected macrophages. Apop-tosis signal-regulating kinase 1 (ASK1) wasactivated in M. avium-treated macrophagesand in turn activated p38 mitogen-activatedprotein (MAP) kinase. M. avium-inducedmacrophage cell death could be blocked incells transfected with a catalytically inac-tive mutant of ASK1 or with dominant neg-ative p38 MAP kinase arguing in favor of acentral role of ASK1/p38 MAP kinase sig-naling in apoptosis of macrophages chal-lenged with M. avium. ASK1/p38 MAP ki-

Immuno-Pathology

eye-care. More males (26.3%) used homeremedies than females (6.5%). The olderage group had better knowledge on takingcare of the eyes than those aged 40 and be-low (p = 0.026). Although more patientswith existing complications knew to takecare of their eyes than those who did nothave complications, the knowledge andpractice of eye-care in both these groups

were poor. Knowledge of leprosy in illiter-ate patients was not different from thosewho had some formal schooling, but thepractice of eye-care differed significantly (p= 0.02). Health education must be under-taken to increase the knowledge of eye-careamong leprosy patients, especially amongilliterate persons, women and younger pa-tients.—Authors’Abstract


nase signaling was linked to the activationof caspase 8. At the same time, M. aviumtriggered caspase 8 activation and celldeath occurred in a Fas-associated deathdomain (FADD)-dependent manner, sug-gesting the involvement of death receptorsignaling. FADD did not exert its effectthrough ASK1 activation. The death signalinduced upon caspase 8 activation linked tomitochondrial death signaling through theformation of truncated Bid (t-Bid), itstranslocation to the mitochondria and re-lease of cytochrome c (cyt c). Caspase 8inhibitor (z-IETD-FMK) could block therelease of cytochrome c as well as the acti-vation of caspases 9 and 3. The final stepsof apoptosis probably involved caspases 9and 3, since inhibitors of both caspasescould block cell death. Of foremost interestin the present study was the finding thatASK1/p38 signaling was essential for cas-pase 8 activation linked to M. avium-induced death signaling. It provides the firstelucidation of a signaling pathway in whichASK1 plays a central role in innate immu-nity.—Authors’Abtstract

Chiu, B. C., Freeman, C. M., Stolberg, V.R., Komuniecki, E., Lincoln, P. M.,Kunkel, S. L., and Chensue, S. W.Cytokine-Chemokine Networks in Ex-perimental Mycobacterial and Schistoso-mal Lung Granuloma Formation. Am. J.Respir. Cell. Mol. Biol. 29(1) (2003)106–116.

Type-1 and type-2 lung granulomas re-spectively elicited by bead immobilizedMycobacteria bovis (PPD) and Schisto-soma mansoni egg (SEA) Ags display dif-ferent patterns chemokine expression. Thisstudy tested the hypothesis that chemokineexpression patterns were related to up-stream cytokine signaling. Using quantita-tive transcript analysis we defined expres-sion profiles for 16 chemokines and thenexamined the in vivo effects of neutraliz-ing antibodies against interferon-gamma(IFNgamma), interleukin-4 (IL-4), IL-10,IL-12, and IL-13. Transcripts for CXCL2,5, 9, 10 and 11 and the CCL chemokines,CCL3 and lymphotactin (XCL1) werelargely enhanced by Th1-related cytokines,IFN gamma or IL-12. Transcripts for

CCL11, CCL22, CCL17 and CCL1 wereenhanced largely by Th2-related cy-tokines, IL-4, IL-10 or IL-13. Transcriptsfor CCL4, CCL2, CCL8, CCL7, andCCL12 were potentially induced by ei-ther Th1- or Th2-related cytokines al-though some of these showed biased ex-pression. IFNgamma and IL-4 enhanced thegreatest complement of transcripts and theirneutralization had the greatest anti-inflam-matory effect on type-1 and type-2 granulo-mas, respectively. Th1/Th2 cross-regulationwas evident since endogenous Th2 cy-tokines inhibited type-1, whereas Th1 cy-tokines inhibited type-2 biased chemokines.These findings reveal a complex cytokine-chemokine regulatory network that dictatesprofiles of local chemokine expression dur-ing T cell-mediated granuloma formation.—Authors’Abstract

Mendez-Samperio, P., Ayala, H., andVazquez, A. NF-kappaB Is Involved inRegulation of CD40 Ligand Expressionon Mycobacterium bovis BacillusCalmette-Guerin-Activated Human TCells. Clin. Diagn. Lab. Immunol. 10(3)(2003) 376–382.

Interaction between CD40L (CD154) onactivated T cells and its receptor CD40 onantigen-presenting cells has been reportedto be important in the resolution of infec-tion by mycobacteria. However, the mech-anism(s) by which Mycobacterium bovisbacillus Calmette-Guerin (BCG) up-regulates membrane expression of CD40Lmolecules is poorly understood. This studywas done to investigate the role of the nu-clear factor kappaB (NF-kappaB) signalingpathway in the regulation of CD40L ex-pression in human CD4(+) T cells stimu-lated with BCG. Specific pharmacologic in-hibition of the NF-kappaB pathway re-vealed that this signaling cascade wasrequired in the regulation of CD40L expres-sion on the surface of BCG-activatedCD4(+) T cells. These results were furthersupported by the fact that treatment ofBCG-activated CD4(+) T cells with thesepharmacological inhibitors significantlydown-regulated CD40L mRNA. In thisstudy, inhibitor kappaBalpha (IkappaBal-pha) and IkappaBbeta protein production


was not affected by the chemical proteaseinhibitors and, more importantly, BCG ledto the rapid but transient induction of NF-kappaB activity. Our results also indicatedthat CD40L expression on BCG-activatedCD4(+) T cells resulted from transcrip-tional up-regulation of the CD40L gene bya mechanism which is independent of denovo protein synthesis. Interestingly, BCG-induced activation of NF-kappaB and theincreased CD40L cell surface expressionwere blocked by the protein kinase C(PKC) inhibitors 1-[5-isoquinolinesulfonyl]-2-methylpiperazine and salicylate, both ofwhich block phosphorylation of IkappaB.Moreover, rottlerin a Ca(2+)-independentPKC isoform inhibitor, significantly down-regulated CD40L mRNA in BCG-activatedCD4(+) T cells. These data strongly suggestthat CD40L expression by BCG-activatedCD4(+) T cells is regulated via the PKCpathway and by NF-kappaB DNA bindingactivity.—Authors’Abstract

Venkatesh, J., Kumar, P., Murali-Krishna, P. S., Manjunath, R., andVarshney, U. Importance of uracil DNAglycosylase in Pseudomonas aeruginosaand Mycobacterium smegmatis, G+C-rich bacteria, in mutation prevention, tol-erance to acidified nitrite and endurancein mouse macrophages. J. Biol. Chem.278(27) (2003) 24350–24358.

Uracil DNA glycosylase (Ung or UDG),initiates the excision repair of an unusualbase, uracil in DNA. Ung is a highly con-served protein found in all organisms.Paradoxically, loss of this evolutionarilyconserved enzyme has not been seen to re-sult in severe growth phenotypes in the cel-lular life forms. In this study, we choseG+C rich genome containing bacteria(Pseudomonas aeruginosa and Mycobacte-rium smegmatis), as model organisms toinvestigate the biological significance ofung. Ung deficiency was created either byexpression of a highly specific inhibitorprotein, Ugi and/or by targeted disruptionof the ung gene. We show that abrogationof Ung activity in P. aeruginosa and M.smegmatis confers upon them an increasedmutator phenotype and sensitivity to reac-

tive nitrogen intermediates generated byacidified nitrite. Also, in a mouse macro-phage infection model, P. aeruginosa(Ung–) shows a significant decrease in itssurvival. Infections of the macrophages,with M. smegmatis, show an initial in-crease in the bacterial counts, which re-main at this level for up to 48 hr before adecline. Interestingly, abrogation of Ungactivity in M. smegmatis results in nearly atotal abolition of their multiplication andmuch-decreased residency in macrophagesstimulated with IFN. These observationssuggest Ung as a useful target to controlgrowth of G+C rich bacteria.—Authors’Abstract

Venketaraman, V., Dayaram, Y. K.,Amin, A. G., Ngo, R., Green, R. M.,Talaue, M. T., Mann, J., and Connell,N. D. Role of glutathione in macrophagecontrol of mycobacteria. Infect. Immun.71(4) (2003) 1864–1871.

Reactive oxygen and nitrogen intermedi-ates are important antimicrobial defensemechanisms of macrophages and otherphagocytic cells. While reactive nitrogenintermediates have been shown to play animportant role in tuberculosis control in themurine system, their role in human diseaseis not clearly established. Glutathione, atripeptide and antioxidant, is synthesized athigh levels by cells during reactive oxygenintermediate and nitrogen intermediate pro-duction. Glutathione has been recentlyshown to play an important role in apopto-sis and to regulate antigen-presenting-cellfunctions. Glutathione also serves as a car-rier molecule for nitric oxide, in the form ofS-nitrosoglutathione. Previous work fromthis laboratory has shown that glutathioneand S-nitrosoglutathione are directly toxicto mycobacteria. A mutant strain of Myco-bacterium bovis BCG, defective in thetransport of small peptides such as glu-tathione, is resistant to the toxic effect ofglutathione and S-nitrosoglutathione. Usingthe peptide transport mutant as a tool, weinvestigated the role of glutathione andS-nitrosoglutathione in animal and humanmacrophages in controlling intracellularmycobacterial growth.—Authors’Abstract


Worku, S. and Hoft, D. F. Differential ef-fects of control and antigen-specific Tcells on intracellular mycobacterialgrowth. Infect. Immun. 71(4) (2003)1763–1773.

We investigated the effects of peripheralblood mononuclear cells expanded with ir-relevant control and mycobacterial antigenson the intracellular growth of Mycobacte-rium bovis bacillus Calmette-Guerin (BCG)in human macrophages. More than 90% ofthe cells present after 1 week of in vitroexpansion were CD3(+). T cells were ex-panded from purified protein derivative-negative controls, persons with latent tuber-culosis, and BCG-vaccinated individuals. Tcells expanded with nonmycobacterial anti-gens enhanced the intracellular growth ofBCG in suboptimal cultures of macro-phages. T cells expanded with live BCG orlysates of Mycobacterium tuberculosis di-rectly inhibited intracellular BCG. Recentintradermal BCG vaccination significantlyenhanced the inhibitory activity of T cellsexpanded with mycobacterial antigens (p lipoarabinomannan > 38kd >Ag85B > Mtb39) expanded inhibitory Tcells, demonstrating the involvement ofantigen-specific T cells in intracellular BCGinhibition. We studied the T-cell subsets andmolecular mechanisms involved in thememory-immune inhibition of intracellularBCG. Mycobacteria-specific gammadelta Tcells were the most potent inhibitors ofintracellular BCG growth. Direct contactbetween T cells and macrophages was nec-essary for the BCG growth-enhancing andinhibitory activities mediated by control andmycobacteria-specific T cells, respectively.Increases in tumor necrosis factor alpha, in-terleukin-6, transforming growth factorbeta, and vascular endothelial growth factormRNA expression were associated with theenhancement of intracellular BCG growth.Increases in gamma interferon, FAS, FASligand, perforin, granzyme, and granulysinmRNA expression were associated with in-tracellular BCG inhibition. These culturesystems provide in vitro models for studyingthe opposing T-cell mechanisms involved inmycobacterial survival and protective hostimmunity.—Authors’Abstract

Immuno-Pathology (Leprosy)

Buhrer-Sekula, S., Smits, H. L., Gus-senhoven, G. C., Van Leeuwen, J.,Amador, S., Fujiwara, T., Klatser, P.R., and Oskam, L. Simple and fast lat-eral flow test for classification of lep-rosy patients and identification of con-tacts with high risk of developing lep-rosy. J. Clin. Microbiol. 41(5) (2003)1991–1995.

The interruption of leprosy transmissionis one of the main challenges for leprosycontrol programs since no consistent evi-dence exists that transmission has been re-duced after the introduction of multidrugtherapy. Sources of infection are primarilypeople with high loads of bacteria with orwithout clinical signs of leprosy. The avail-ability of a simple test system for the detec-tion of antibodies to phenolic glycolipid-I(PGL-I) of Mycobacterium leprae to iden-tify these individuals may be important inthe prevention of transmission. We have de-

veloped a lateral flow assay, the ML Flowtest, for the detection of antibodies to PGL-Iwhich takes only 10 min to perform. Anagreement of 91% was observed betweenenzyme-linked immunosorbent assay andour test; the agreement beyond chance(kappa value) was 0.77. We evaluated theuse of whole blood by comparing 539blood and serum samples from an area ofhigh endemicity. The observed agreementwas 85.9% (kappa = 0.70). Storage of thelateral flow test and the running buffer at 28degrees C for up to 1 year did not influencethe results of the assay. The sensitivity ofthe ML Flow test in correctly classifyingMB patients was 97.4%. The specificity ofthe ML Flow test, based on the results ofthe control group, was 90.2%. The MLFlow test is a fast and easy-to-performmethod for the detection of immunoglobu-lin M antibodies to PGL-I of M. leprae. Itdoes not require any special equipment, andthe highly stable reagents make the test ro-


bust and suitable for use in tropical coun-tries.—Authors’Abstract

Hernandez, M. O., Neves, I., Sales, J. S.,Carvalho, D. S., Sarno, E. N., andSampaio, E. P. Induction of apoptosis inmonocytes by Mycobacterium leprae invitro: a possible role for tumour necrosisfactor-alpha. Immunology. 109(1) (2003)156–164.

A diverse range of infectious organisms,including mycobacteria, have been reportedto induce cell death in vivo and in vitro. Al-though morphological features of apoptosishave been identified in leprosy lesions, ithas not yet been determined whether Myco-bacterium leprae modulates programmedcell death. For that purpose, peripheralblood mononuclear cells obtained fromleprosy patients were stimulated with dif-ferent concentrations of this pathogen. Fol-lowing analysis by flow cytometry on7AAD/CD14+ cells, it was observed thatM. leprae induced apoptosis of monocyte-derived macrophages in a dose-dependentmanner in both leprosy patients and healthyindividuals, but still with lower efficiencyas compared to M. tuberculosis. Expressionof tumour necrosis factor-alpha (TNF-alpha), Bax-alpha, Bak mRNA and TNF-alpha protein was also detected in these cul-tures; in addition, an enhancement in therate of apoptotic cells (and of TNF-alpharelease) was noted when interferon-gammawas added to the wells. On the other hand,incubation of the cells with pentoxifyllineimpaired mycobacterium-induced celldeath, the secretion of TNF-alpha, and geneexpression in vitro. In addition, diminishedbacterial entry decreased both TNF-alphalevels and the death of CD14+ cells, albeitto a different extent. When investigatingleprosy reactions, an enhanced rate of spon-taneous apoptosis was detected as com-pared to the unreactive lepromatouspatients. The results demonstrated that M.leprae can lead to apoptosis of macro-phages through a mechanism that could beat least partially related to the expression ofpro-apoptotic members of the Bcl-2 proteinfamily and of TNF-alpha. Moreover, whilephagocytosis may be necessary, it seemsnot to be crucial to the induction of cell

death by the mycobacteria.—Authors’ Ab-stract

Kiszewski, A. E., Becerril, E., Baquera,J., Ruiz-Maldonado, R., and Hern-Andez Pando, R. Expression of cy-clooxygenase type 2 in lepromatous andtuberculoid leprosy lesions. Br. J. Der-matol. 148(4) (2003) 795–798.

BACKGROUND: Leprosy is an infec-tious disease with two polar forms, tubercu-loid leprosy (TL) and lepromatous leprosy(LL), which are dominated by T-helper (Th)1 and Th2 cells, respectively. High concen-trations of prostaglandin E2 produced bythe inducible enzyme cyclooxygenase type2 (COX-2) in LL could inhibit Th1 cy-tokine production, contributing to T-cellanergy. Objectives To compare the COX-2expression in LL and TL. Methods Skinbiopsies from 40 leprosy patients (LL, N =20; TL, N = 20) were used to determine byimmunohistochemistry and automated mor-phometry the percentage of COX-2 im-munostained cells. Results Most COX-2-positive cells were macrophages; theirpercentages in the inflammatory infiltratelocated in the papillary dermis, reticulardermis and periadnexally were significantlyhigher in LL than TL (p


indicating the presence of triacylatedlipoproteins. A genome-wide scan of M. lep-rae detected 31 putative lipoproteins. Syn-thetic lipopeptides representing the 19-kDand 33-kD lipoproteins activated both mono-cytes and dendritic cells. Activation was en-hanced by type-1 cytokines and inhibited bytype-2 cytokines. In addition, interferon(IFN)-gamma and granulocyte-macrophagecolony-stimulating factor (GM-CSF) en-hanced TLR1 expression in monocytes anddendritic cells, respectively, whereas IL-4downregulated TLR2 expression. TLR2 andTLR1 were more strongly expressed in le-sions from the localized tuberculoid form (T-lep) as compared with the disseminated lep-romatous form (L-lep) of the disease. Thesedata provide evidence that regulated expres-sion and activation of TLRs at the site of dis-ease contribute to the host defense againstmicrobial pathogens.—Authors’Abstract

Lee, S. B., Kim, B. C., Jin, S. H., Park, Y.G., Kim, S. K., Kang, T. J., and Chae,G. Missense mutations of the inter-leukin-12 receptor beta 1(IL12RB1) andinterferon-gamma receptor 1 (IFNGR1)genes are not associated with susceptibil-ity to lepromatous leprosy in Korea. Im-munogenetics 55(3) (2003) 177–181.

Interleukin-12 receptor beta 1 (IL12RB1),interleukin-12 receptor beta 2 (IL12RB2),

and interferon gamma receptor 1 (IFNGR1)perform important roles in the host defenseagainst intracellular pathogens such asMycobacteria. Several mutations withintheir genes have been confirmed as asso-ciated with increased susceptibility to my-cobacterial infection. However, the associa-tion between mutations of the IL12RB1,IL12RB2, and IFNGR1 encoding genes andlepromatous leprosy has not been studied.This study screened for polymorphismswithin IL12RB1, IL12RB2, and IFNGR1encoding genes in the Korean populationsusing polymerase chain reaction (PCR)/single-strand conformation polymorphism(SSCP) DNA sequencing assay, and an as-sociation study was performed using themissense mutations of 705 A/G (Q214R),1196 G/C (G378R), 1637 G/A (A525T),and 1664 C/T (P534S) of the IL12RB1, 83G/A (V14M), and 1443 T/C (L467P) forthe IFNGR1 encoding genes. There wereno differences in the genotype and allelefrequencies of IL12RB1 and IFNGR1genes between 93 lepromatous leprosy pa-tients and 94 control subjects. In conclu-sion, missense mutations of 705 A/G(Q214R), 1196 G/C (G378R), 1637 G/A(A525T), 1664 C/T (P534S) of theIL12RB1, 83 G/A (V14 M), and 1443 T/C(L467P) of the IFNGR1 encoding geneshave no association with the susceptibilityto lepromatous leprosy in the Korean popu-lation.—Authors’ Abstract

Immuno-Pathology (Tuberculosis)

Boshoff, H. I., Reed, M. B., Barry, C. E.,and Mizrahi, V. DnaE2 PolymeraseContributes to In Vivo Survival and theEmergence of Drug Resistance in Myco-bacterium tuberculosis. Cell. 113(2)(2003) 183–193.

The presence of multiple copies of themajor replicative DNA polymerase (DnaE)in some organisms, including importantpathogens and symbionts, has remained anunresolved enigma. We postulated that onecopy might participate in error-prone DNArepair synthesis. We found that UV irradia-tion of Mycobacterium tuberculosis results

in increased mutation frequency in the sur-viving fraction. We identified dnaE2 as agene that is upregulated in vitro by severalDNA damaging agents, as well as during in-fection of mice. Loss of this protein reducesboth survival of the bacillus after UV irradi-ation and the virulence of the organism inmice. Our data suggest that DnaE2, and nota member of the Y family of error-proneDNA polymerases, is the primary mediatorof survival through inducible mutagenesisand can contribute directly to the emergenceof drug resistance in vivo. These results mayindicate a potential new target for therapeu-tic intervention.—Authors’Abstract


Brennan, P. J. Structure, function, and bio-genesis of the cell wall of Mycobacte-rium tuberculosis. Tuberculosis (Edinb).83(1–3) (2003) 91–97.

Much of the early structural definition ofthe cell wall of Mycobacterium spp. was ini-tiated in the 1960s and 1970s. There was along period of inactivity, but more recent de-velopments in NMR and mass spectral analy-sis and definition of the M. tuberculosisgenome have resulted in a thorough under-standing, not only of the structure of the my-cobacterial cell wall and its lipids but also thebasic genetics and biosynthesis. Our under-standing nowadays of cell-wall architectureamounts to a massive “core” comprised ofpeptidoglycan covalently attached via alinker unit (L-Rha-D-GlcNAc-P) to a lineargalactofuran, in turn attached to severalstrands of a highly branched arabinofuran, inturn attached to mycolic acids. The mycolicacids are oriented perpendicular to the planeof the membrane and provide a truly speciallipid barrier responsible for many of thephysiological and disease-inducing aspects ofM. tuberculosis. Intercalated within this lipidenvironment are the lipids that have intriguedresearchers for over five decades: the phthio-cerol dimycocerosate, cord factor/dimycolyl-trehalose, the sulfolipids, the phosphatidyli-nositol mannosides, etc. Knowledge of theirroles in “signaling” events, in pathogenesis,and in the immune response is now emerg-ing, sometimes piecemeal and sometimes inan organized fashion. Some of the more in-triguing observations are those demonstratingthat mycolic acids are recognized by CD1-restricted T-cells, that antigen 85, one of themost powerful protective antigens of M. tu-berculosis, is a mycolyltransferase, and thatlipoarabinomannan (LAM), when “capped”with short mannose oligosaccharides, is in-volved in phagocytosis of M. tuberculosis.Definition of the genome of M. tuberculosishas greatly aided efforts to define the biosyn-thetic pathways for all of these exotic mole-cules: the mycolic acids, the mycocerosates,phthiocerol, LAM, and the polyprenyl phos-phates. For example, we know that synthesisof the entire core is initiated on a decaprenyl-Pwith synthesis of the linker unit, and thenthere is concomitant extension of the galactanand arabinan chains while this intermediate istransported through the cytoplasmic mem-

brane. The final steps in these events, the at-tachment of mycolic acids and ligation topeptidoglycan, await definition and willprove to be excellent targets for a new gener-ation of anti-tuberculosis drugs.—Author’sAbstract

Ehlers, S., Holscher, C., Scheu, S., Tertilt,C., Hehlgans, T., Suwinski, J., Endres,R., and Pfeffer, K. The Lymphotoxinbeta Receptor Is Critically Involved inControlling Infections with the Intracel-lular Pathogens Mycobacterium tubercu-losis and Listeria monocytogenes. J. Im-munol. 170(10) (2003) 5210–5218.

Containment of intracellularly viable mi-croorganisms requires an intricate coopera-tion between macrophages and T cells, themost potent mediators known to date beingIFN-gamma and TNF. To identify novelmechanisms involved in combating intracel-lular infections, experiments were performedin mice with selective defects in the lympho-toxin (LT)/LTbetaR pathway. When micedeficient in LTalpha or LTbeta were chal-lenged intranasally with Mycobacterium tu-berculosis, they showed a significant in-crease in bacterial loads in lungs and liverscompared with wild-type mice, suggesting arole for LTalphabeta heterotrimers in resis-tance to infection. Indeed, mice deficient inthe receptor for LTalpha(1)beta(2) het-erotrimers (LTbetaR-knockout (KO) mice)also had significantly higher numbers of M.tuberculosis in infected lungs and exhibitedwidespread pulmonary necrosis already byday 35 after intranasal infection. Further-more, LTbetaR-KO mice were dramaticallymore susceptible than wild-type mice to i.p.infection with Listeria monocytogenes.Compared with wild-type mice, LTbetaR-KO mice had similar transcript levels ofTNF and IFN-gamma and recruited similarnumbers of CD3(+) T cells inside granulo-matous lesions in M. tuberculosis-infectedlungs. Flow cytometry revealed that the LT-betaR is expressed on pulmonary macro-phages obtained after digestion of M. tuber-culosis-infected lungs. LTbetaR-KO miceshowed delayed expression of inducible NOsynthase protein in granuloma macrophages,implicating deficient macrophage activationas the most likely cause for enhanced sus-


ceptibility of these mice to intracellular in-fections. Since LIGHT-KO mice proved tobe equally resistant to M. tuberculosis infec-tion as wild-type mice, these data demon-strate that signaling of LTalpha(1)beta(2)heterotrimers via the LTbetaR is an essentialprerequisite for containment of intracellularpathogens.—Authors’Abstract

Fenhalls, G., Squires, G. R., Stevens-Muller, L., Bezuidenhout, J., Am-phlett, G., Duncan, K., and Lukey, P.T. Associations between Toll-like Re-ceptors and IL-4 in the Lungs of Patientswith Tuberculosis. Am. J. Respir. Cell.Mol. Biol. 29(1) (2003) 28–38.

Toll-like receptors (TLRs) are implicatedin the intracellular killing of Mycobacte-rium tuberculosis and their expression ismodulated by interleukin-4 (IL-4) in vitro.Our aim was to examine the expression ofTLRs at the site of pathology in tubercu-lous lung granulomas and to explore theeffect of the immune response on TLR ex-pression. Immunohistochemistry was per-formed on lung granulomas from ninepatients with tuberculosis undergoinglobectomy for haemoptysis. All nine pa-tients expressed all of the TLRs studied(TLRs1–5 and 9), whereas only five out ofthe nine patients had any granulomas posi-tive for IL-4. Statistical analysis of TLRand cytokine staining patterns in 183 indi-vidual granulomas from the nine patientsrevealed significant associations betweenpairs of receptors and IL-4. A positive as-sociation between TLR2 and TLR4 (p


excluded from the analysis due to the lackof internal control testing. Of the remaining34 specimens, 22 were PCR positive for the16S rRNA gene. Among them, 18 speci-mens were PCR positive for both the 16SrRNA gene and IS6110. Cutaneous tubercu-losis could be diagnosed in these 18 cases(56.2%). Out of the 18 cases, there were 8women and 10 men. The age range was15–77 years (mean: 44.2 years). After re-viewing their clinical presentation, 11 caseswere considered as tuberculosis verrucosacutis, 6 cases as lupus vulgaris, and 1 caseas erythema induratum. The remaining 4cases (12.5%) positive only for 16S rRNAgene were considered as possible atypicalmycobacteria infection. CONCLUSIONS:These results show that in paucibacillaryform of cutaneous tuberculosis with unclas-sical clinical and histological presentation,this PCR system provides rapid and sensi-tive detection of M. tuberculosis DNA informalin-fixed, paraffin-embedded speci-mens. Cutaneous tuberculosis represents asignificant proportion in specimens show-ing granulomatous inflammation. In areaslike Taiwan, where prevalence of pul-monary tuberculosis is still high, tuberculo-sis verrucosa cutis and lupus vulgaris arecommon forms of cutaneous tuberculosisand are seen more frequently than atypicalmycobacterial infection.—Authors’ Ab-stract

Jung, Y. J., Ryan, L., LaCourse, R., andNorth, R. J. Increased interleukin-10expression is not responsible for failureof T helper 1 immunity to resolve air-borne Mycobacterium tuberculosis infec-tion in mice. Immunology 109(2) (2003)295–299.

With a view to determining whether fail-ure of mice to resolve Mycobacterium tu-berculosis (Mtb) infection is a consequenceof downregulation of T helper 1 (Th1) im-munity by interleukin (IL)-10, mice deletedof the gene for IL-10 were compared withwild-type (WT) mice in terms of theirability to make IL-10 mRNA, generateTh1-mediated immunity [as measured bysynthesis of mRNA for interferon-gamma(IFN-gamma)], IL-12p40 and inducible ni-tric oxide synthase (iNOS), and to control

lung infection. It was found that the re-sponse of WT mice to infection included asubstantial and sustained increase in IL-10mRNA synthesis in the lungs. A Th1 re-sponse in the lungs of WT and IL-10–/–mice was evidenced by a large and sus-tained increase in the synthesis of mRNAfor IFN-gamma, IL-12p40 and iNOS, withsomewhat higher levels of these mRNAspecies being made in the lungs of IL-10–/–mice, particularly at an early stage of infec-tion. However, IL-10–/– mice were nomore capable than WT mice at combatinginfection.—Authors’Abstract

Kaul, D., Coffey, M. J., Phare, S. M., andKazanjian, P. H. Capacity of neu-trophils and monocytes from human im-munodeficiency virus-infected patientsand healthy controls to inhibit growth ofMycobacterium bovis. J. Lab. Clin. Med.141(5) (2003) 330–334.

We compared the differences in growthinhibition of Mycobacterium bovis bymonocytes and neutrophils from human im-munodeficiency virus (HIV)-infected per-sons (N = 12; mean CD4 count =451/mm(3)) and healthy controls (N = 6).Phagocytes from all HIV-infected patientswere incubated with or without exogenousgranulocyte-macrophate colony-stimulatingfactor (GMCSF; 500–1000 U/mL). In twoof the HIV-infected patients, phagocyteswere incubated with or without interleukin(IL)-2 or IL-8 (500–1000 U/mL). Com-pared with that in HIV-infected patients, thereduction of M. bovis growth at 24 hourswas 81% greater among monocytes and69% greater among neutrophils fromhealthy controls (p = .03 and .04, respec-tively). Among HIV-infected patients, wenoted greater mycobacterial reduction inmonocytes (49%, p = .04) and neutrophils(42%, p = .05) from the early-stage patients(mean CD4 count = 760/mm(3)) comparedwith that in late-stage patients (mean CD4count = 172/mm(3)). Incubation with GM-CSF, IL-2, or IL-8 did not augment my-cobactericidal activity. These findings sug-gest that the capacity of neutrophils andmonocytes from HIV-infected patients toinhibit the growth of M. bovis is impaired,and this impairment is more pronounced in


later stages of HIV infection.—Authors’Abstract

Koguchi, Y., Kawakami, K., Uezu, K.,Fukushima, K., Kon, S., Maeda, M.,Nakamoto, A., Owan, I., Kuba, M.,Kudeken, N., Kadota, J. I., Mukae, H.Kohno, S., Uede, T., and Saito, A. Highplasma osteopontin level and its relation-ship with IL-12-mediated Th1 responsein tuberculosis. Am. J. Respir. Crit. CareMed. 167(10) (2003) 1355–1359.

Osteopontin (OPN, also known as Eta-1),a noncollagenous matrix protein producedby macrophages and T lymphocytes, is ex-pressed in granulomatous lesions caused byMycobacterium tuberculosis infection. Inthe present study, we compared plasmaconcentrations of OPN in patients with ac-tive pulmonary tuberculosis with those ofhealthy control subjects and patients withsarcoidosis, another disease associated withgranuloma formation. Plasma OPN levelswere significantly higher in patients withtuberculosis (N = 48) than control subjects(N = 34) and patients with sarcoidosis (N =20). OPN levels correlated well with sever-ity of pulmonary tuberculosis, as indicatedby the size of lung lesions on chest X-rayfilms. Furthermore, chemotherapy resultedin a significant fall in plasma OPN levels.In patients with tuberculosis, plasma OPNconcentrations correlated significantly withthose of interleukin (IL)-12. In vitro exper-iments showed that OPN production by pe-ripheral blood mononuclear cells infectedwith M. bovis BCG preceded the synthesisof IL-12 and interferon (IFN)-gamma, andthat neutralizing anti-OPN monoclonal an-tibody significantly reduced the productionof IL-12 and IFN-gamma. Our results sug-gest that OPN may be involved in thepathological process associated with activepulmonary tuberculosis by inducing IL-12-mediated Th1 responses.—Authors’ Ab-stract

Munoz, S., Hernandez-Pando, R., Abra-ham, S. N., and Enciso, J. A. Mast cellactivation by Mycobacterium tuberculo-sis: mediator release and role of CD48. J.Immunol. 170(11) (2003) 5590–5596.

Mast cells (MC) are abundant in the lungand other peripheral tissue, where they par-ticipate in inflammatory processes againstbacterial infections. Like other effectorcells of the innate immune system, MC in-teract directly with a wide variety of infec-tious agents. This interaction results in MCactivation and inflammatory mediator re-lease. We demonstrated that MC interactwith Mycobacterium tuberculosis, trigger-ing the release of several prestoredreagents, such as histamine and beta-hexosaminidase, and de novo synthesizedcytokines, such as TNF-alpha and IL-6. Anumber of M. tuberculosis Ags, ESAT-6,MTSA-10, and MPT-63, have been impli-cated in MC activation and mediator re-lease. A MC plasmalemmal protein, CD48,was implicated in interactions with myco-bacteria because CD48 appeared to aggre-gate in the MC membrane at sites of bacte-rial binding and because Abs to CD48inhibited the MC histamine response to my-cobacteria. Cumulatively, these findingssuggest that MC, even in the absence of op-sonins, can directly recognize M. tuberculo-sis and its Ags and have the potential toplay an active role in mediating the host’sinnate response to M. tuberculosis infec-tion.—Authors’Abstract

Natarajan, K., Latchumanan, V. K.,Singh, B., Singh, S., and Sharma, P.Down-regulation of T helper 1 responsesto mycobacterial antigens due to matu-ration of dendritic cells by 10-kDaMycobacterium tuberculosis secretoryantigen. J. Infect. Dis. 187(6) (2003)914–928.

Interactions of 10-kDa Mycobacterium tu-berculosis secretory antigen (MTSA) withdendritic cells (DCs) were investigated toelucidate the role of secretory antigens inregulating immune responses to M. tubercu-losis early in the course of infection. MTSAinduced the maturation of different DC sub-sets. The cytokine profiles of these DCs werecharacteristic to each DC subset. Of interest,coculture of M. tuberculosis whole-cell ex-tract (CE)-pulsed, MTSA-matured DCs withCE-specific T cells led to a marked reductionin interleukin (IL)-2 and interferon (IFN)-gamma production, thereby down-regulating


proinflammatory responses to mycobacterialantigens. Attenuation of IL-2 and IFN-gamma levels of CE-specific T cells also wasobtained when M. tuberculosis culture fil-trate protein-activated DCs were employedas antigen-presenting cells, which suggeststhat MTSAs induce maturation of DCs atsites of infection, probably to down-regulateproinflammatory immune responses to my-cobacteria that may subsequently be releasedfrom infected macrophages.—Authors’ Ab-stract

Rhoades, E., Hsu, F., Torrelles, J. B.,Turk, J., Chatterjee, D., and Russell,D. G. Identification and macrophage-activating activity of glycolipids releasedfrom intracellular Mycobacterium bovisBCG. Mol. Microbiol. 48(4) (2003)875–888.

Intracellular mycobacteria release cellwall glycolipids into the endosomal net-work of infected macrophages. Here, wecharacterize the glycolipids of Mycobac-terium bovis BCG (BCG) that are re-leased into murine bone marrow-derivedmacrophages (BMMO). Intracellularly re-leased mycobacterial lipids were har-vested from BMMO that had been in-fected with 14C-labelled BCG. ReleasedBCG lipids were resolved by thin-layerchromatography, and they migrated simi-larly to phosphatidylinositol dimannosides(PIM2), mono- and diphosphatidylglycerol,phosphatidylethanolamine, trehalose mono-and dimycolates and the phenolic glycol-ipid, mycoside B. Culture-derived BCGlipids that co-migrated with the intracellu-larly released lipids were purified and iden-tified by electrospray ionization mass spec-trometry. When delivered on polystyrenemicrospheres, fluorescently tagged BCGlipids were also released into the BMMO,in a manner similar to release from viableor heat-killed BCG bacilli. To determinewhether the released lipids elicited macro-phage responses, BCG lipid-coated mi-crospheres were delivered to interferongamma-primed macrophages (BMMO orthioglycollate-elicited peritoneal macro-phages), and reactive nitrogen intermedi-ates as well as tumour necrosis factor-alphaand monocyte chemoattractant protein-1

production were induced. When fraction-ated BCG lipids were delivered on the mi-crospheres, PIM2 species reproduced themacrophage-activating activity of total BCGlipids. These results demonstrate that intra-cellular mycobacteria release a heteroge-neous mix of lipids, some of which elicit theproduction of proinflammatory cytokinesfrom macrophages that could potentiallycontribute to the granulomatous response intuberculous diseases.—Authors’Abstract

Shams, H., Wizel, B., Lakey, D. L.,Samten, B., Vankayalapati, R., Val-divia, R. H., Kitchens, R. L., Griffith,D. E., and Barnes, P. F. The CD14 re-ceptor does not mediate entry of Myco-bacterium tuberculosis into humanmononuclear phagocytes. FEMS Im-munol. Med. Microbiol. 36(1–2) (2003)63–69.

Prior reports have suggested that CD14mediates uptake of Mycobacterium tuber-culosis into porcine alveolar macrophagesand human fetal microglia, but the contri-bution of CD14 to cell entry in humanmacrophages has not been studied. To ad-dress this question, we used flow cytometryto quantify uptake by human monocytesand alveolar macrophages of M. tuberculo-sis expressing green fluorescent protein.Neutralizing anti-CD14 antibodies did notaffect bacillary uptake and the efficiency ofbacillary entry was similar in THP-1 cellsexpressing low and high levels of CD14.However, most internalized bacteria werefound in CD14+ but not in CD14– mono-cytes because M. tuberculosis infection up-regulated CD14 expression. We concludethat: (1) CD14 does not mediate cellular en-try by M. tuberculosis; (2) M. tuberculosisinfection upregulates CD14 expression onmononuclear phagocytes, and this may fa-cilitate the pathogen’s capacity to modulatethe immune response.—Authors’Abstract

Stein, C. M., Guwatudde, D., Nakakeeto,M., Peters, P., Elston, R. C., Tiwari, H.K., Mugerwa, R., and Whalen, C. C.Heritability analysis of cytokines as in-termediate phenotypes of tuberculosis. J.Infect. Dis. 187(11) (2003) 1679–1685.


Numerous studies have provided supportfor genetic susceptibility to tuberculosis(TB); however, heterogeneity in disease ex-pression has hampered previous geneticstudies. The purpose of this work was to in-vestigate possible intermediate phenotypesfor TB. A set of cytokine profiles, includingantigen-stimulated whole-blood assays forinterferon (IFN)-gamma, tumor necrosisfactor (TNF)-alpha, transforming growthfactor (TGF)-beta, and the ratio of IFN toTNF, were analyzed in 177 pedigrees froma community in Uganda with a high preva-lence of TB. The heritability of these vari-ables was estimated after adjustment for co-variates, and TNF-alpha, in particular, hadan estimated heritability of 68%. A princi-pal component analysis of IFN-gamma,TNF-alpha, and TGF-beta reflected the im-munologic model of TB. In this analysis,the first component explained >38% of thevariation in the data. This analysis illus-trates the value of such intermediate pheno-types in mapping susceptibility loci for TBand demonstrates that this area deservesfurther research.—Authors’Abstract

Ulrichs, T., Moody, D. B., Grant, E., Kauf-mann, S. H., and Porcelli, S. A. T-cell re-sponses to CD1-presented lipid antigensin humans with Mycobacterium tubercu-losis infection. Infect. Immun. 71(6)(2003) 3076–3087.

CD1-restricted presentation of lipid orglycolipid antigens derived from Mycobac-terium tuberculosis has been demonstratedby in vitro experiments using cultured T-cell lines. In the present work, the fre-quency of T-cell responses to natural myco-bacterial lipids was analyzed in ex vivostudies of peripheral blood lymphocytesfrom human patients with pulmonary tuber-culosis, from asymptomatic individualswith known contact with M. tuberculosisdocumented by conversion of their tuber-culin skin tests, and from healthy tuberculinskin test-negative individuals or individualsvaccinated with Mycobacterium bovisBCG. Proliferation and gamma interferonenzyme-linked immunospot assays usingperipheral blood lymphocytes and autolo-gous CD1(+) immature dendritic cells re-vealed that T cells from asymptomatic M.

tuberculosis-infected donors respondedwith significantly greater magnitude andfrequency to mycobacterial lipid antigenpreparations than lymphocytes from unin-fected healthy donors. By use of thesemethods, lipid-antigen-specific proliferativeresponses were minimally detectable or ab-sent in blood samples from patients with ac-tive tuberculosis prior to chemotherapy butbecame detectable in blood samples drawn2 weeks after the start of treatment. Lipidantigen-reactive T cells were detectedpredominantly in the CD4-enriched T-cellfractions of circulating lymphocytes, andanti-CD1 antibody blocking experimentsconfirmed the CD1 restriction of these T-cell responses. Our results provide furthersupport for the hypothesis that lipid anti-gens serve as targets of the recall responseto M. tuberculosis, and they indicate thatCD1-restricted T cells responding to theseantigens comprise a significant portion of thecirculating pool of M. tuberculosis-reactiveT cells in healthy individuals with previousexposure to M. tuberculosis.—Authors’Ab-stract

Vordermeier, M., Whelan, A. O., andHewinson, R. G. Recognition of myco-bacterial epitopes by T cells across mam-malian species and use of a program thatpredicts human HLA-DR binding pep-tides to predict bovine epitopes. Infect.Immun. 71(4) (2003) 1980–1987.

Bioinformatics tools have the potentialto accelerate research into the design ofvaccines and diagnostic tests by exploitinggenome sequences. The aim of this studywas to assess whether in silico analysiscould be combined with in vitro screeningmethods to rapidly identify peptides thatare immunogenic during Mycobacteriumbovis infection of cattle. In the first in-stance the M. bovis-derived protein ESAT-6was used as a model antigen to describepeptides containing T-cell epitopes thatwere frequently recognized across mam-malian species, including natural hosts fortuberculosis (humans and cattle) and small-animal model

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