Borderline Lepromatous Patients Research Articles

Expression of annexin-A1 in blood and tissue leukocytes of leprosy patients.

INTRODUCTION In leprosy, immune system mediators that regulate the infectious process act in a complex manner and can lead to several clinical outcomes. To understand the behavior of these mediators we quantified the expression of annexin-A1 (ANXA1) in the peripheral blood and plasma as well as tissue leukocytes in all clinical forms of leprosy and compared with healthy controls. METHODS Seventy healthy controls and 70 patients with leprosy, tuberculoid (TT) (n = 13), borderline tuberculoid (BT) (n = 15), borderline borderline (BB) (n = 13), borderline lepromatous (BL) (n = 15), and lepromatous leprosy (LL) (n = 14), were selected. Phenotyping of the lymphocyte cells and the intracellular expression of ANXA1 in leukocytes was performed by immunofluorescence. Plasma protein levels were determined by enzyme-linked immunosorbent assay. RESULTS Histiocytes and CD4+ and CD8+ T cells in the skin of BL and LL patients had higher ANXA1 expression. ANXA1 expression was also high in circulating polymorphonuclear, monocytes, and CD4+ and CD8+ T cells in the blood of LL patients compared to those of TT, BT, BB, and BL patients, and these levels were similar to those in healthy controls. Plasma ANXA1 levels indicate an increase in paracrine release in patients with LL. CONCLUSIONS The data indicate that ANXA1 expression is enhanced in the leukocytes and plasma of patients with LL, and may contribute to the inhibition of leukocyte action, leading to inadequate functioning of the immune system and thus contributing to the spread of M. leprae infection.

Leprosy

Leprosy is a disease associated with great stigma due to the deformities it can produce. It is caused by Mycobacterium leprae. In 2008 a new mycobacteria, M. lepromatosis was recognized as the agent of Lucio leprosy. It is not known how leprosy is transmitted. Only infected people with a defect in their cell-mediated immunity, which is specific for M. leprae, develop the disease. Those with still high immunity will develop tuberculoid leprosy (TT), with a single skin lesion and no detectable bacilli; those with no CMI will develop lepromatous leprosy (LL), with areas of skin infiltrated by foamy histiocytes filled with leprosy bacilli. In between are the borderline patients, borderline tuberculoid (BT), mid-borderline (BB), and borderline lepromatous (BL), with decreasing levels of CMI and increasing bacillary load. For therapy, according to the WHO, patients are divided in paucibacillary (PB) (negative slit-skin smears, i.e. Indeterminate, TT, and BT) and multibacillary (MB) (positive slit-skin smears, i.e. BB, BL, and LL). PB patients are treated with six months of dapsone plus rifampicin; MB patients are treated with 12 months of dapsone plus rifampicin plus clofazimine. Two types of hypersensitivity reactions may occur, type 1 and type 2. Type 1 reaction is considered to be due to a change in the CMI and only happens in borderline patients (BT,BB,BL). It produces inflammation of the skin lesions and/or nerves; the drug of choice for it is prednisone. Type 2 reaction is considered to be due to antigen-antibody deposition in tissues, and only happens in BL and LL patients. The most common presentation is erythema nodosum leprosum, but it may present with fever and inflammation of several organs. The drug of choice for a severe reaction is thalidomide, but in a woman of child-bearing age it is contraindicated and prednisone should be used. Leprosy is a disease that can be easily diagnosed, and with appropriate early therapy can be cured with no sequelae.

A Systematic Review of Immunological Studies of Erythema Nodosum Leprosum.

Erythema nodosum leprosum (ENL) is a painful inflammatory complication of leprosy occurring in 50% of lepromatous leprosy patients and 5–10% of borderline lepromatous patients. It is a significant cause of economic hardship, morbidity and mortality in leprosy patients. Our understanding of the causes of ENL is limited. We performed a systematic review of the published literature and critically evaluated the evidence for the role of neutrophils, immune complexes (ICs), T-cells, cytokines, and other immunological factors that could contribute to the development of ENL. Searches of the literature were performed in PubMed. Studies, independent of published date, using samples from patients with ENL were included. The search revealed more than 20,000 articles of which 146 eligible studies were included in this systematic review. The studies demonstrate that ENL may be associated with a neutrophilic infiltrate, but it is not clear whether it is an IC-mediated process or that the presence of ICs is an epiphenomenon. Increased levels of tumor necrosis factor-α and other pro-inflammatory cytokines support the role of this cytokine in the inflammatory phase of ENL but not necessarily the initiation. T-cell subsets appear to be important in ENL since multiple studies report an increased CD4+/CD8+ ratio in both skin and peripheral blood of patients with ENL. Microarray data have identified new molecules and whole pathophysiological pathways associated with ENL and provides new insights into the pathogenesis of ENL. Studies of ENL are often difficult to compare due to a lack of case definitions, treatment status, and timing of sampling as well as the use of different laboratory techniques. A standardized approach to some of these issues would be useful. ENL appears to be a complex interaction of various aspects of the immune system. Rigorous clinical descriptions of well-defined cohorts of patients and a systems biology approach using available technologies such as genomics, epigenomics, transcriptomics, and proteomics could yield greater understanding of the condition.

Increased expression of interleukin-17A in the lesional skin indicates increase of serum antibody anti-phenolic glycolipid-I in leprosy patients

Background: In lepromatous type of leprosy, the serum titer of the antibody against phenolic glycolipid (PGL)-I-a-specific antigen in leprosy that is produced by B cell is high. Whereas, the interleukin (IL)-17A expressed by T-helper 17 cells could induce B-cell differentiation. The role of IL-17A in leprosy is still unknown. Hence, this study aimed to assess a correlation between IL-17A expression in the lesional skin and anti-PGL-I immunoglobulin (Ig) M serum levels in leprosy patients. Methods: This study was performed in Leprosy Clinic, Dr. Hasan Sadikin Hospital Bandung, Indonesia, using a cross-sectional analytical study. A punch biopsy obtained from 49 leprosy patients was included through consecutive sampling for measurement of IL-17A expression in the skin by immunohistochemistry scoring (histoscore). Furthermore, the anti-PGL-I IgM level in serum is evaluated by enzyme-linked immunosorbent assay. Results: The IL-17A expressions in the skin biopsies of tuberculoid (TT), borderline tuberculoid (BT), mid-borderline (BB), borderline lepromatous (BL), and lepromatous leprosy (LL) patients using histoscore were 1.00, 2.31, 4.63, 5.06, and 10.14, respectively, and they showed significant differences ( P = 0.0001). The titer of anti-PGL-I IgM levels was 89 pg/ml, 555 pg/ml, 1.244 pg/ml, 1.920 pg/ml, and 23.591 pg/ml in TT, BT, BB, BL, and LL patients, respectively, and they showed significant differences ( P = 0.005). The results of Rank–Spearman correlation analysis between IL-17A expression in the skin and anti-PGL-I IgM serum levels were as follows: r = 0.767 and P = 0.0001. Conclusion: These results suggested that the increase of IL-17A expression in the lesional skin indicates the increase of anti-PGL-I IgM serum levels in leprosy.

Comparing the Clinical and Histological Diagnosis of Leprosy and Leprosy Reactions in the INFIR Cohort of Indian Patients with Multibacillary Leprosy

BackgroundThe ILEP Nerve Function Impairment in Reaction (INFIR) is a cohort study designed to identify predictors of reactions and nerve function impairment in leprosy. The aim was to study correlations between clinical and histological diagnosis of reactions.Methodology/Principal FindingsThree hundred and three newly diagnosed patients with World Health Organization multibacillary (MB) leprosy from two centres in India were enrolled in the study. Skin biopsies taken at enrolment were assessed using a standardised proforma to collect data on the histological diagnosis of leprosy, leprosy reactions and the certainty level of the diagnosis. The pathologist diagnosed definite or probable Type 1 Reactions (T1R) in 113 of 265 biopsies from patients at risk of developing reactions whereas clinicians diagnosed skin only reactions in 39 patients and 19 with skin and nerve involvement. Patients with Borderline Tuberculoid (BT) leprosy had a clinical diagnosis rate of reactions of 43% and a histological diagnosis rate of 61%; for patients with Borderline Lepromatous (BL) leprosy the clinical and histological diagnosis rates were 53.7% and 46.2% respectively. The sensitivity and specificity of clinical diagnosis for T1R was 53.1% and 61.9% for BT patients and 61.1% and 71.0% for BL patients. Erythema Nodosum Leprosum (ENL) was diagnosed clinically in two patients but histologically in 13 patients. The Ridley-Jopling classification of patients (n = 303) was 42.8% BT, 27.4% BL, 9.4% Lepromatous Leprosy (LL), 13.0% Indeterminate and 7.4% with non-specific inflammation. This data shows that MB classification is very heterogeneous and encompasses patients with no detectable bacteria and high immunological activity through to patients with high bacterial loads.Conclusions/SignificanceLeprosy reactions may be under-diagnosed by clinicians and increasing biopsy rates would help in the diagnosis of reactions. Future studies should look at sub-clinical T1R and ENL and whether they have impact on clinical outcomes.

Specificity of IgG subclass antibodies in different clinical manifestations of leprosy.

We analysed specific IgG subclasses levels to Mycobacterium leprae sonicate extract (MSE), lipoarabinomannan B (LAM) and phenolic glycolipid I (PGL-I) in the sera of leprosy patients with different clinical manifestations. IgG2 was found to be the predominant antibody to MSE regardless of clinical manifestations, and IgG1 response was mostly seen in lepromatous patients. IgG3 reacted only rarely but IgG4 reacted relatively more in certain clinical groups such as borderline lepromatous and lepromatous with erythema nodosum leprosum (ENL) reaction. Most of the IgG subclass responses to MSE could be accounted for reactivity with LAM, suggesting that LAM is the major immunogen involved in the pathogenesis of leprosy. In contrast to LAM, PGL-I antigen showed considerably lower reactivities for IgG subclasses. An association between IgG subclass responses and clinical manifestations of leprosy was also seen. Whereas borderline lepromatous patients were found to have significantly higher levels of IgG2 and IgG4 to MSE, lepromatous patients had elevated levels of IgG1 and lower levels of IgG2. An interesting observation, however, was the significantly higher levels of IgG2 to LAM in the pure neuritic leprosy patients.

Utility of serodiagnostic tests for leprosy: a study in an endemic population in South India

In order to evaluate the usefulness of natural disaccharide (PGL1) and 35 kDa antigens based serology in diagnosis of leprosy and in detecting high risk groups for leprosy, this study was conducted in an endemic population in South India. Out of 3346 cases and their households and neighbouring household contacts, serum samples from 2994 and 2875 individuals were screened for antibodies against PGL1 and 35kDa antigens respectively. While the overall positivity for contacts and leprosy cases was 3.3% for PGL1 antibody, the positivity for 35 kDa antibody was 6.3%. The positivity for contact population was 2.7% and 5.4% for PGL1 and 35 kDa antibodies, respectively. Lepromatous and borderline lepromatous patients showed positivity of 35.1% for PGL1 antibody and 45.7% for 35 kDa antibody. Follow-up of contacts showed that the majority (>90%) remained seronegative for both the antibodies and most of the new cases emerged from the seronegative group. The study clearly indicates that specific serological assays are not sensitive enough for application, both for diagnosis and for identifying any individual at risk for leprosy in the south Indian endemic population.

An assessment of the value of midfinger smears in multibacillary leprosy patients

In view of the different opinions on fingers as sites for persisting bacilli in multibacillary leprosy patients, it was decided to examine the midfingers for the presence of acid-fast bacilli (AFB) and establish its usefulness. Sixty-nine multibacillary leprosy patients, [lepromatous (LL) and borderline lepromatous (BL)] treated with multidrug therapy for fixed duration (2 years) were analysed. The bacillary load in the midfinger sites was lower when compared to that in the 'compulsory' (both earlobes) and 'optional' (four active lesions) sites. The midfinger bacterial index (BI) was higher among LL patients when compared to BL patients (p < 0.001). However, the difference in mean BI in 'optional' and 'compulsory sites' was not significant. The overall fall in BI was gradual and on expected lines for all sites, including midfingers, during treatment and follow-up period. Except in one case, at no time were the smears from midfinger sites positive when all other sites were negative, and their inclusion did not contribute to the early detection of relapse. Furthermore, the collection of blood-free smears from this site is technically difficult and often painful for the patient. The inclusion of midfinger smears in this study in patients in South India did not contribute useful information to that which is routinely available from smears of earlobes and other active sites.

Immunohistochemical analysis of cell surface markers in leprosy patients

Nine biopsy specimens from 3 tuberculoid (TT), 1 borderline tuberculoid (BT), 2 borderline (BB), 2 borderline lepromatous (BL), and 1 lepromatous (LL) patients were studied using immunoperoxidase procedures with monoclonal antibodies. In TT patients 4B4+, TCR alpha beta+, CD4+ T cells were dominant in dermal granulomas. In LL patient, dermal granulomas with 4B4+, TCR alpha beta+, CD4+ T cells and 2H4+, TCR alpha beta+, CD4+ T cells also had CD8+ T cells. The proportion of 4B4+ T cells increased in granulomas from LL to TT and 2H4+ T cells proportionately increased from TT to LL. TCR gamma delta+ T cells were detected only in BB and BL patients. However, there is no difference of staining pattern of ICAM-1 or LFA-1 antigen in any type of leprosy. These results indicate that the immunohistochemical pattern of T cells (CD4, CD8, 4B4, 2H4, TCR) may be useful in the diagnosis of the spectrum of leprosy.

Serodiagnosis of leprosy: relationships between antibodies to Mycobacterium leprae phenolic glycolipid I and protein antigens.

Sera from leprosy patients and controls were assayed for immunoglobulin M (IgM) and IgG antibodies to the Mycobacterium leprae-specific phenolic glycolipid I antigen (PG) by enzyme-linked immunosorbent assay, for IgG antibodies to M. leprae protein antigens by Western immunoblot, and for antibodies to a 65-kilodalton (kDa) protein antigen of M. leprae by a competition antibody binding assay. Elevated levels of anti-PG IgM were seen in lepromatous and borderline lepromatous patients, and elevated levels of anti-PG IgG were seen in borderline lepromatous patients. There was a significant correlation between the bacillary index (BI) and anti-PG IgM whether all leprosy patients or only multibacillary patients were analyzed. A significant correlation was seen between anti-PG IgG and BI when all leprosy patients were used for analysis, but not when only multibacillary patients were used. IgG antibodies to protein antigens of M. leprae, as detected by Western immunoblot, were more prevalent in lepromatous and borderline lepromatous patients than in borderline tuberculoid patients, while one of eight controls showed one weak band. There were significant correlations between the number of M. leprae protein antigens detected by the sera of patients and both BI and the level of anti-PG IgM. The 65-kDa competition antibody binding assay detected active multibacillary leprosy. Patients positive for antibody to the 65-kDa antigen had a significantly higher BI and levels of anti-PG IgM and anti-PG IgG than did patients that were negative. In addition, the level of antibody to the 65-kDa antigen correlated with both the BI and anti-PG IgM. We conclude that testing for antibodies to protein antigens of M. leprae may provide a useful adjunct to testing for antibodies to PG.

Cloned suppressor T cells from a lepromatous leprosy patient suppress Mycobacterium leprae reactive helper T cells

Leprosy is a chronic infectious disease caused by Mycobacterium leprae. A characteristic feature of the disease is its remarkable spectrum of clinical symptoms correlating with the cellular immune responsiveness of the patient. At one pole of this spectrum are tuberculoid patients displaying both acquired cell-mediated immunity and delayed type hypersensitivity against the bacillus. At the other pole are lepromatous patients which show a specific T-cell unresponsiveness against M. leprae. In between those two poles variable degrees of tuberculoid and lepromatous features may be seen in borderline leprosy patients. Thus far, studies on the mechanism of the antigen specific unresponsiveness in lepromatous leprosy have been contradictory and difficult to interpret, probably because of the use of heterogeneous cell populations in those experiments. We have now succeeded in cloning M. leprae stimulated T-helper (TH) as well as T-suppressor (TS) cells from a borderline lepromatous patient. The TS-clones of this patient specifically suppress responses of peripheral TH cells as well as TH clones induced by both M. leprae and other mycobacteria, but not unrelated antigen or mitogen. These TS cells also completely suppress TH cell responses against a M. leprae specific protein with a relative molecular mass of 36,000 (36K), suggesting the presence of a suppression inducing determinant on this 36K M. leprae protein.

Demonstration of mycobacterial antigens in nerve biopsies from leprosy patients using peroxidase-antiperoxidase immunoenzyme technique

Peripheral nerve biopsies from patients with leprosy were stained with anti- Mycobacterium bovis (BCG) in a peroxidase-antiperoxidase (PAP) system to demonstrate intraneural mycobacterial antigens. Most M. leprae antigens have been shown to crossreact with BCG. Of the 30 biopsies from borderline tuberculoid (BT) patients 18 had acid-fast bacilli while 26 of them had demonstrable mycobacterial antigens in their nerves. All borderline lepromatous (BL) and lepromatous leprosy (LL) nerve biopsies had both M. leprae and mycobacterial antigens within them. Most of the antigens in the BT patients were seen to be extracellular. In BL and LL patients antigens were seen both extracellularly and intracellularly in Schwann cells and infiltrating macrophages. Mycobacterial antigens in BT nerves were always seen to be surrounded by a mononuclear cell reaction while in the BL and LL patients antigens could be seen with minimal cellular infiltrate and the neural architecture was more or less preserved. While bacilli could not be seen in BT patients who had been released from treatment for more than 4 years, mycobacterial antigens could still be seen in some patients who had been released from treatment for up to 5 years. Patients with no skin lesions but with large, painful, or tender nerves were found to have intraneural inflammation surrounding mycobacterial atigens, while those with a similar clinical picture but without tender or painful nerves showed no marked inflammation within their nerves despite the presence of mycobacterial antigens. From these findings it was concluded that immunologically mediated inflammatory response toward intraneurally located M. leprae antigens in conjunction with other host factors may be necessary for nerve damage in the BT leprosy patients. In the BL and LL patients the mechanisms of nerve damage are still unknown with certainty but local effects and immune-complex damage secondary to abundant M. leprae antigens are worth exploring. The use of immunohistological techniques should offer a new approach in the study of the immunopathology of leprosy.

Defective gamma interferon production in leprosy. Reversal with antigen and interleukin 2.

Antigen and mitogen-induced gamma interferon (gamma-IFN) production was studied in peripheral blood mononuclear cells from 34 leprosy patients. 17 of 18 lepromatous leprosy and borderline lepromatous patients (LL and BL) failed to release gamma-IFN in response to specific antigen (Mycobacterium leprae) and displayed reduced responses to mitogen (concanavalin A) stimulation. In contrast, cells from six tuberculoid and borderline tuberculoid patients (TT and BT) produced considerable levels of gamma-IFN under the same experimental conditions. Normal controls failed to respond to M. leprae and most displayed good responses to concanavalin A. Mid-borderline patients (BB) showed intermediate levels of gamma-IFN release. gamma-IFN release by lepromatous patients could be partially restored with purified interleukin 2 and M. leprae antigen but not with interleukin 2 alone.

Serum trace elements and vitamin A in leprosy subtypes

Serum zinc, copper, iron, and vitamin A levels were determined in patients with leprosy and healthy controls. Leprosy patients were classified according to the Ridley and Jopling classification and divided into two main groups as follows: tuberculoid, which consisted mainly of borderline tuberculoid patients and lepromatous, which consisted of borderline lepromatous and true lepromatous patients. The lepromatous group was found to have significantly lower serum levels of zinc and iron and elevated levels of copper. Vitamin A levels were also significantly lower in the lepromatous groups than in the tuberculoid group. Furthermore, the true lepromatous vitamin A determinations were significantly lower than those of the borderline lepromatous patients. The mechanism of these alterations in trace elements is probably due to a redistribution of these metals from the blood to various tissues; brought about by the release of leucocyte endogenous mediators by continuing phagocytosis of tissue macrophages in the lepromatous group of patients.

Immune response of leprosy patients to hepatitis B virus.

The Immune responses of 323 Melanesian leprosy patients and 290 controls to hepatitis virus type B were examined by analyzing prevalence rates of hepatitis B antigen (HBsAg) and its antibody (anti-HBs) in an area of Papua New Guinea hyperendemlc for the virus. By use of multivariate techniques, extraneous variables known to be correlated with both leprosy severity and HBsAg prevalence, such as Institutionalization, age, sex and place of residence, could be statistically controlled. In multivariate analysis of HBsAg rates, after removal of the variation due to age, which was the most important single factor contributing to HBsAg carrier-status, lepromatous leprosy was a significant determinant of antigenemla. Similarly, when the series was grouped Into three Immune-response categories of HBsAg, anti-HBs or no serologic evidence of exposure to the virus, disease severity was a significant factor In determining immune response. For lepromatous and borderline lepromatous patients, the probability of responding antigenically to the virus, given that some measurable response has occurred (HBsAg/(HBsAg + anti-HBs)) was 0.42. The corresponding probability for tuberculoid patients was 0.25 and for healthy controls, 0.29. These probabilities indicate that lepromatous patients have an Impaired Immune response that not only predisposes them to the most severe form of leprosy but may also decrease their efficiency In terminating HBsAg Infection with anti-HBs.