Oral BCG Research Articles

In vitro and in vivo assessments for developing an oral BCG vaccine formulation

The aim of this study was to establish in vitro analytical methods for assessing an investigated oral BCG vaccine formulation. In addition, in vivo immune response was also evaluated in guinea pigs by determining the potentially protective effect of the investigated formulation on tuberculosis. The bicinchoninic acid (BCA) method for BCG protein quantitation was developed for rapid measuring the content of BCG vaccine in the investigated formulation. The analytical method was conducted at 45°C to offer good precision (coefficient of variation <3.5%) and accuracy (error: -3.6∼2.6%) in the range of 150∼4000 μg/mL of BCG vaccine concentrations. In the simulation study of drug release from the investigated formulation in the gastrointestinal tract under physiological conditions, the investigated oral formulation could protect active component at lower pH (0.1 N HCl) and completely release active component at higher pH (phosphate buffer, pH 6.8). Although the investigated oral BCG vaccine formulation showed weak immune response to elicit IgG titer, the PPD (purified protein derivative) skin test in guinea pigs by oral dosing of 4 mg BCG vaccine formulation acquired about equal or higher response than that by 0.5 mg dose by subcutaneous vaccination. The analytical method and in vivo approach could be further applied in the development of oral BCG vaccine formulations.

Protective Effect of Oral BCG and Inactivated Mycobacterium bovis Vaccines in European Badgers (Meles meles) Experimentally Infected With M. bovis.

In Europe, badgers (Meles meles) are recognized as major tuberculosis (TB) reservoir hosts with the potential to transmit infection to associated cattle herds. Recent studies in Spain have demonstrated that vaccination with a heat-inactivated Mycobacterium bovis vaccine (HIMB) successfully protects captive wild boar and red deer against progressive disease. The aim of this study was to evaluate the efficacy of two oral vaccines against TB in a badger model: the live-attenuated M. bovis bacillus Calmette-Guérin BCG vaccine (Danish strain) and a HIMB vaccine. Twenty-four badgers were separated in three treatment groups: oral vaccinated with live BCG (108 CFU, n = 5), oral vaccinated with HIMB (107 CFU, n = 7), and unvaccinated controls (n = 12). All badgers were experimentally infected with M. bovis (103 CFU) by the endobronchial route targeting the right middle lung lobe. Throughout the study, clinical, immunological, pathological, and bacteriological parameters of infection were measured. Both vaccines conferred protection against experimental TB in badger, as measured by a reduction of the severity and lesion volumes. Based on these data, HIMB vaccination appears to be a promising TB oral vaccine candidate for badgers in endemic countries.

Survival of Mycobacterium bovis BCG oral vaccine during transit through a dynamic in vitro model simulating the upper gastrointestinal tract of badgers.

In developing an oral bait BCG vaccine against tuberculosis in badgers we wanted to understand the conditions of the gastrointestinal tract and their impact on vaccine viability. Conditions mimicking stomach and small-intestine caused substantial reduction in BCG viability. We performed in vivo experiments using a telemetric pH monitoring system and used the data to parameterise a dynamic in vitro system (TIM-1) of the stomach and small intestine. Some BCG died in the stomach compartment and through the duodenum and jejunum compartments. BCG survival in the stomach was greatest when bait was absent but by the time BCG reached the jejunum, BCG viability was not significantly affected by the presence of bait. Our data suggest that from a starting quantity of 2.85 ± 0.45 x 108 colony-forming units of BCG around 2 log10 may be killed before delivery to the intestinal lymphoid tissue. There are economic arguments for reducing the dose of BCG to vaccinate badgers orally. Our findings imply this could be achieved if we can protect BCG from the harsh environment of the stomach and duodenum. TIM-1 is a valuable, non-animal model with which to evaluate and optimise formulations to maximise BCG survival in the gastrointestinal tract.

Efficacy of oral BCG vaccination in protecting free-ranging cattle from natural infection by Mycobacterium bovis

Vaccination of cattle against bovine tuberculosis could be a valuable control strategy, particularly in countries faced with intractable ongoing infection from a disease reservoir in wildlife. A field vaccination trial was undertaken in New Zealand. The trial included 1286 effectively free-ranging cattle stocked at low densities in a remote 7600ha area, with 55% of them vaccinated using Mycobacterium bovis BCG (Danish strain 1311). Vaccine was administered orally in all but 34 cases (where it was injected). After inclusion, cattle were exposed to natural sources of M. bovis infection in cattle and wildlife, most notably the brushtail possum (Trichosurus vulpecula). Cattle were slaughtered at 3–5 years of age and were inspected for tuberculous lesions, with mycobacteriological culture of key tissues from almost all animals. The prevalence of M. bovis infection was 4.8% among oral BCG vaccinates, significantly lower than the 11.9% in non-vaccinates. Vaccination appeared to both reduce the incidence of detectable infection, and to slow disease progression. Based on apparent annual incidence, the protective efficacy of oral BCG vaccine was 67.4% for preventing infection, and was higher in cattle slaughtered soon after vaccination. Skin-test reactivity to tuberculin was high in vaccinates re-tested 70days after vaccination but not in non-vaccinates, although reactor animals had minimal response in gamma-interferon blood tests. In re- tests conducted more than 12 months after vaccination, skin-test reactivity among vaccinates was much lower. These results indicate that oral BCG vaccination could be an effective tool for greatly reducing detectable infection in cattle.

Co-administration of Oal Polio Vaccine and Bacillus Calmette Guerin in Infants: Systematic Review of Low and Middle-income Countries

Background Immunization decreases 2 to 3 million deaths annually; however, an additional 1.5 million deaths could be avoided if global vaccination coverage improves. Immunization is one of the cornerstone interventions to reach the Millennium Development Goals (MDGs), especially the goal to decrease deaths among children under five years old. Childhood vaccinations have been illustrated to be effective in protecting children against vaccine preventable diseases in low and middle income countries. As one of the earliest vaccines of the World Health Organization’s (WHO) Expanded Program on Immunization established in 1974, Bacillus Calmette-GuA©rin (BCG) is a main stone of childhood vaccination. Administering OPV together with BCG might down regulate the response to BCG vaccine (Kaur 2002; Faridi 2015). Reviewing different studies, it has reported that this may downregulate response to BCG in the form of fewer numbers of scar formation, reduced scar size, reduced in vivo response to purified protein derivative (PPD) and significantly lower IL-13 and IFN-I³ and a tendency to have lower IL-10 in response to PPD at 6 weeks following immunization. Objectives To investigate whether co-administration of BCG and oral polio vaccine increase infant mortality rate. To investigate whether co-administration of oral polio vaccine and BCG attenuate the immune response to BCG compared to the administration of BCG alone. Search methods We searched through the following databases: MEDLINE, Register of Controlled Trials (CENTRAL); Scopus; CINAHL (EBSCO); Google scholar; Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP). Main results We found 1777 studies were through systematic electronic search. Therefore 1356 studies remained after excluding duplicated studies. We assessed and screened 855 studies and only 11 articles were fully assessed. Among them, 6 studies were included in mata-analysis There is high evidence that infant mortality rate was reduced by 22 % in BCG group compared to BCG-OPV group with p-value of 0.09. Therefore, the evidence was moderate and low in specific mortality rate respectively boys and girls. Then, the mortality rate was reduced by 28% and 15 % respectively in boys and girls (p-value of 0.09 and 0.31). Local immune reaction (scar) was 41 % less likely present in BCG-OPV group compared to BCG alone. ). Therefore, the 95% CI is very wide and including the null value. Authors' conclusions An increasing number of vaccines targeting some of the leading causes of morbidity and mortality are reaching the world’s children. Evidence suggests that receipt of BCG reduce overall infant mortality. This review has shown that co-administration BCG-OPV could increase infant mortality. Therefore, the results could be considered in a context of several limitations. .

The effect of newborn vitamin A supplementation on infant immune functions: Trial design, interventions, and baseline data

In recent years, neonatal vitamin A supplementation is considered as an essential infant-survival intervention but the evidence is not conclusive. This randomized controlled clinical trial was conducted to evaluate the effect of vitamin A on immune competence in early infancy. Results would provide a mechanistic basis for understanding the effect of this intervention on infant survival. Within 2days of birth, infants born at one maternity clinic located in a poor slum area of Dhaka city were supplemented with either 50,000IU vitamin A or placebo. Live attenuated oral polio vaccine (OPV) and BCG vaccine were provided after supplementation. Infants also receive diphtheria, pertussis, tetanus (TT), hepatitis B (HBV) and Haemophilus influenzae B vaccines (pentavalent combination) along with OPV at 6, 10 and 14weeks of age. Infant thymus size, anthropometry, feeding practice and morbidity data were collected at regular interval. Infant blood samples were collected to determine T-cell-receptor excision circle (TREC), total, naïve and memory T cells and mucosal targeting lymphocytes including Treg cells. TT-, HBV-, BCG- and OPV-specific T cell blastogenic, cytokine and plasma cell antibody responses were also measured. In 16 mo enrollment period, 306 newborns, equal number of boys and girls, were enrolled. ~95% completed the 4-month follow-up period. Baseline characteristics are presented here. Anthropometry and immune assays with fresh blood samples were completed immediately while stored samples were analyzed in single batches at the end of the trial. Connecting different aspects of immunological data in early infancy will help elucidate immune competence for protecting infection.Trial registrationClinicalTrials.gov: NCT01583972.

Assessment of an Oral Mycobacterium bovis BCG Vaccine and an Inactivated M. bovis Preparation for Wild Boar in Terms of Adverse Reactions, Vaccine Strain Survival, and Uptake by Nontarget Species

Wildlife vaccination is increasingly being considered as an option for tuberculosis control. We combined data from laboratory trials and an ongoing field trial to assess the risk of an oral Mycobacterium bovis BCG vaccine and a prototype heat-inactivated Mycobacterium bovis preparation for Eurasian wild boar (Sus scrofa). We studied adverse reactions, BCG survival, BCG excretion, and bait uptake by nontarget species. No adverse reactions were observed after administration of BCG (n = 27) or inactivated M. bovis (n = 21). BCG was not found at necropsy (175 to 300 days postvaccination [n = 27]). No BCG excretion was detected in fecal samples (n = 162) or in urine or nasal, oral, or fecal swab samples at 258 days postvaccination (n = 29). In the field, we found no evidence of loss of BCG viability in baits collected after 36 h (temperature range, 11°C to 41°C). Camera trapping showed that wild boar (39%) and birds (56%) were the most frequent visitors to bait stations (selective feeders). Wild boar activity patterns were nocturnal, while diurnal activities were recorded for all bird species. We found large proportions of chewed capsules (29%) (likely ingestion of the vaccine) and lost baits (39%) (presumably consumed), and the proportion of chewed capsules showed a positive correlation with the presence of wild boar. Both results suggest proper bait consumption (68%). These results indicate that BCG vaccination in wild boar is safe and that, while bait consumption by other species is possible, this can be minimized by using selective cages and strict timing of bait deployment.

Method for assessing IFN-γ responses in guinea pigs during TB vaccine trials

We sought to develop a new method that enables the assessment of the immune response of guinea pigs during TB vaccine evaluation studies, without the need to cull or anaesthetize animals. Guinea pigs were vaccinated with five different formulations of oral BCG. One week prior to challenge with Mycobacterium bovis, blood (50-200 μl) was taken from the ears of vaccinated subjects. Host RNA was isolated and amplified following antigenic restimulation of PBMCs for 24 h with 30 μg of bovine PPD. The up- or down-regulation of γ-interferon (IFN-γ), a key cytokine involved in protection against tuberculosis, was assessed using real-time PCR. The relative expression of prechallenge IFN-γ mRNA in the vaccinated groups (n=5) correlated (P<0·001) with protection against M. bovis challenge. We have demonstrated that it is possible to take blood samples and track IFN-γ responses in guinea pigs that then go on to be exposed to M. bovis, thus providing prechallenge vaccine uptake information. This methodology will also be applicable for tracking the immune responses of vaccinated guinea pigs over time that then go on to be challenged with M. tuberculosis during human TB vaccine evaluation studies.

Protection against Tuberculosis in Eurasian Wild Boar Vaccinated with Heat-Inactivated Mycobacterium bovis

Tuberculosis (TB) caused by Mycobacterium bovis and closely related members of the Mycobacterium tuberculosis complex continues to affect humans and animals worldwide and its control requires vaccination of wildlife reservoir species such as Eurasian wild boar (Sus scrofa). Vaccination efforts for TB control in wildlife have been based primarily on oral live BCG formulations. However, this is the first report of the use of oral inactivated vaccines for controlling TB in wildlife. In this study, four groups of 5 wild boar each were vaccinated with inactivated M. bovis by the oral and intramuscular routes, vaccinated with oral BCG or left unvaccinated as controls. All groups were later challenged with a field strain of M. bovis. The results of the IFN-gamma response, serum antibody levels, M. bovis culture, TB lesion scores, and the expression of C3 and MUT genes were compared between these four groups. The results suggested that vaccination with heat-inactivated M. bovis or BCG protect wild boar from TB. These results also encouraged testing combinations of BCG and inactivated M. bovis to vaccinate wild boar against TB. Vaccine formulations using heat-inactivated M. bovis for TB control in wildlife would have the advantage of being environmentally safe and more stable under field conditions when compared to live BCG vaccines. The antibody response and MUT expression levels can help differentiating between vaccinated and infected wild boar and as correlates of protective response in vaccinated animals. These results suggest that vaccine studies in free-living wild boar are now possible to reveal the full potential of protecting against TB using oral M. bovis inactivated and BCG vaccines.

Study of oral BCG encapsulated in alginate microsphere to prepare DNA vaccine

Study of oral BCG encapsulated in alginate microsphere to prepare DNA vaccine

Progress in the control of bovine tuberculosis in Spanish wildlife

Despite the compulsory test and slaughter campaigns in cattle, bovine tuberculosis (bTB) is still present in Spain, and the role of wildlife reservoirs is increasingly recognized. We provide an update on recent progress made in bTB control in Spanish wildlife, including aspects of epidemiology, surveillance, host–pathogen interaction and wildlife vaccination. At the high densities and in the particular circumstances of Mediterranean environments, wild ungulates, mainly Eurasian wild boar and red deer, are able to maintain Mycobacterium bovis circulation even in absence of domestic livestock. Infection is widespread among wild ungulates in the south of the country, local infection prevalence being as high as 52% in wild boar and 27% in red deer. Risk factors identified include host genetic susceptibility, abundance, spatial aggregation at feeders and waterholes, scavenging, and social behaviour. An increasing trend of bTB compatible lesions was reported among wild boar and red deer inspected between 1992 and 2004 in Southwestern Spain. Sporadic cases of badger TB have been detected, further complicating the picture. Gene expression profiles were characterized in European wild boar and Iberian red deer naturally infected with M. bovis. The comparative analysis of gene expression profiles in wildlife hosts in response to infection advanced our understanding of the molecular mechanisms of infection and pathogenesis, revealed common and distinctive host responses to infection and identified candidate genes associated with resistance to bTB and for the characterization of host response to infection and vaccination. Ongoing research is producing valuable knowledge on vaccine delivery, safety and efficacy issues. Baits for the oral delivery of BCG vaccine preparations to wild boar piglets were developed and evaluated. The use of selective feeders during the summer was found to be a potentially reliable bait-deployment strategy. Safety experiments yielded no isolation of M. bovis BCG from faeces, internal organs at necropsy and the environment, even after oral delivery of very high doses. Finally, preliminary vaccination and challenge experiments suggested that a single oral BCG vaccination may protect wild boar from infection by a virulent M. bovis field strain.

Murine immune responses to oral BCG immunization in the presence or absence of prior BCG sensitization

Oral delivery of live Mycobacterium bovis BCG in a lipid matrix invokes cell-mediated immune (CMI) responses in mice and consequent protection against pulmonary challenge with virulent mycobacteria. To investigate the influence of prior BCG sensitization on oral vaccine efficacy, we assessed CMI responses and BCG colonization of the alimentary tract lymphatics 5 months after oral vaccination, in both previously naive mice and in mice that had been sensitized to BCG by injection 6 months previously. CMI responses did not differ significantly between mice that received subcutaneous BCG followed by oral BCG and those that received either injected or oral BCG alone. In vivo BCG colonization was predominant in the mesenteric lymph nodes after oral vaccination; this colonizing ability was not influenced by prior BCG sensitization. From this murine model study, we conclude that although prior parenteral-route BCG sensitization does not detrimentally affect BCG colonization after oral vaccination, there is no significant immune-boosting effect of the oral vaccine either.

First data on Eurasian wild boar response to oral immunization with BCG and challenge with a Mycobacterium bovis field strain

The Eurasian wild boar (Sus scrofa) is considered a reservoir for bovine tuberculosis (bTB) caused by Mycobacterium bovis and closely related members of the Mycobacterium tuberculosis complex in south-central Spain. The vaccination of wildlife with BCG offers an alternative to culling and to movement restriction for the control of bTB among wildlife reservoirs. In this study, we hypothesized that oral BCG immunization of wild boar would affect the expression of immunoregulatory genes and confer protection against M. bovis. Three groups were used to describe the infection, pathological findings and gene expression profiles in wild boar: BCG-vaccinated and M. bovis-challenged (vaccinated challenged group; N=6), non-vaccinated and M. bovis-challenged (non-vaccinated challenged group; N=4), and non-vaccinated and mock-infected (control group; N=2) animals. M. bovis was isolated from 50% (3/6) and 75% (3/4) of vaccinated challenged and non-vaccinated challenged animals, respectively. All four wild boar from the non-vaccinated challenged group developed bTB-compatible lesions 114 days after challenge. In contrast, only 50% of vaccinated challenged wild boar developed lesions. The PBMC mRNA levels of IL4, RANTES, C3, IFN-gamma and methylmalonyl-CoA mutase (MUT) were analyzed at several days post-vaccination (dpi). When vaccinated challenged animals were compared to controls, all five genes were significantly upregulated at the time of M. bovis infection at 186dpi but IFN-gamma levels were also upregulated at 11 and 46dpi. The C3 and MUT mRNA levels were higher at 46dpi, and 11 and 186dpi, respectively, in vaccinated protected wild boar when compared to non-vaccinated challenged animals. At the end of the experiment (300dpi), the mRNA levels of selected genes were lower in non-vaccinated challenged animals when compared to control wild boar. Exposing wild boar to a dose of 104cfu of M. bovis by the oropharyngeal route is an adequate protocol to produce an infection model in this species. Our results suggested that oral BCG immunization of wild boar results in the upregulation of immunoregulatory genes that may be associated with protective response to M. bovis infection in this species. More studies on vaccine efficacy, delivery, and safety will be needed to confirm if oral vaccination with BCG could be used in bTB control programs for reducing M. bovis infection and clinical disease in wild boar.

Protection of free-living and captive possums against pulmonary challenge with Mycobacterium bovis following oral BCG vaccination

In New Zealand, possums (Trichosurus vulpecula) are the main wildlife reservoir for bovine tuberculosis (Tb), which they transmit to livestock. This study investigated oral vaccination with lipid-formulated Mycobacterium bovis BCG and subsequent protection against virulent M. bovis challenge in wild-caught possums. Possums were trapped from the field and either hand-vaccinated and released back into the wild, or acclimatised to captive conditions prior to voluntary uptake of flavoured vaccine. Possums were subsequently exposed to pulmonary challenge with virulent M. bovis, administered either by instillation of a liquid suspension as an intra-tracheal challenge (field animals) or in micro-droplets as an aerosol (captive animals). Field studies indicated that the relative risk of death in wild possums due to Tb was 2.4 times greater in control compared with orally-vaccinated possums, with the vaccine conferring protection to possums in both good and poor body condition. Laboratory studies indicated that oral vaccination conferred protection in cage-acclimatised possums, with >3log(10) reduction in lung bacterial burdens among vaccinated animals. This study provides evidence that lipid-formulated BCG oral vaccine can provide significant protection to possums in field as well as laboratory conditions, which may favour the use of this formulation as a delivery method for controlling wildlife Tb.

EFFICACY OF ORAL AND PARENTERAL ROUTES OF MYCOBACTERIUM BOVIS BACILLE CALMETTE-GUERIN VACCINATION AGAINST EXPERIMENTAL BOVINE TUBERCULOSIS IN WHITE-TAILED DEER (ODOCOILEUS VIRGINIANUS): A FEASIBILITY STUDY

We investigated the efficacy of oral and parenteral Mycobacterium bovis bacille Calmette-Guerin Danish strain 1331 (BCG) in its ability to protect white-tailed deer (Odocoileus virginianus) against disease caused by M. bovis infection. Twenty-two white-tailed deer were divided into four groups. One group (n=5) received 10(9) colony-forming units (cfu) BCG via a lipid-formulated oral bait; one group (n=5) received 10(9) cfu BCG in culture directly to the oropharynx, one group (n=6) was vaccinated with 10(6) cfu BCG subcutaneously, and one group served as a control and received culture media directly to the oropharynx (n=6). All animals were challenged 3 mo after vaccination. Five months postchallenge the animals were examined for lesions. Results indicate that both oral forms of BCG and parenterally administered BCG offered significant protection against M. bovis challenge as compared to controls. This study suggests that oral BCG vaccination may be a feasible means of controlling bovine tuberculosis in wild white-tailed deer populations.

Modulation of humoral immune response to oral BCG vaccination by Mycobacterium bovis BCGMoreau Rio de Janeiro (RDJ) in healthy adults

BackgroundOral administration of BCG was the route initially used by Calmette and Guérin, but was replaced by intradermal administration in virtually all countries after the Lubeck accident. However, Brazil continued to administer oral BCG Moreau RDJ, which was maintained until the mid-1970s when it was substituted by the intradermal route. Although BCG vaccination has been used in humans since 1921, little is known of the induced immune response. The aim of this study was to analyse immunological responses after oral vaccination with M. bovis BCG Moreau RDJ.MethodsThis study in healthy volunteers has measured cellular and humoral aspects of the immunological response to oral M. bovis BCG Moreau RDJ in Rio de Janeiro, Brazil. T-cell trafficking and Th1 and Th2 cytokine responses are described, as well as isotype-specific antibody production using novel techniques.ResultsOral immunisation has no adverse effects. We have shown that there are cellular and humoral immunological responses after oral immunisation. Oral revaccination does not induce a positive skin test in responsive individuals and multiple booster orally was able to induce modulation in humoral immunological responses (switch from IgG to IgA) in previously immunised subjects and incapable of inducing tolerance. In contrast, the cellular immune response does not differ between vaccinated individuals with positive and negative skin test reactions.ConclusionAll subjects, including those who did not respond to the skin test at study commencement, were capable of mounting humoral and cellular immune response to the antigens tested.

Immune Response Following Oral Immunization with BCG Encapsulated in Alginate Microspheres.

Different methods have been used for BCG vaccination. Alginate microspheres are useful in delivery of vaccines to the gastrointestinal tract by oral route. To compare the immune response following oral microencapsulated and subcutaneous (SC) route administration of BCG vaccine in BALB/c mice. Alginate microspheres were produced by an internal emulsification method within olive oil. Four groups of mice were studied, including two groups receiving oral gavages of microencapsulated and free BCG, one receiving SC injection of BCG, and a control group. T cell proliferation, specific anti-BCG total IgG, and IgG subclasses (IgG1 and IgG2a) were compared between groups 5 and 12 weeks after vaccination. The best result was achieved using oral microencapsulated form in comparison with oral BCG alone. Delivery of oral BCG with alginate microspheres is an effective way to induce immune response in BALB/c mice.

Boosting of Cellular Immunity against Mycobacterium tuberculosis and Modulation of Skin Cytokine Responses in Healthy Human Volunteers by Mycobacterium bovis BCG Substrain Moreau Rio de Janeiro Oral Vaccine

Oral immunization of healthy adults with 10(7) CFU BCG Moreau Rio de Janeiro was well tolerated and significantly boosted gamma interferon responses to purified protein derivative, Ag85, and MPB70 from previous childhood intradermal BCG immunization. Oral BCG offers the possibility of a needle-free tuberculosis vaccine and of boosting the protective immunity from intradermal tuberculosis vaccines.

Basic science of host immunity in osteoarticular tuberculosis -A clinical study

Background : Osteoarticular tuberculosis is coming back with vengeance. Host immunity plays a major role in either containing the disease or allowing the spread. Number of resistant cases and drug defaulters are on the rise. Immunepotentiation (immunomodulation) has shown beneficial response in pulmonary tuberculosis in various studies. Methods : This study was done to assess immune status of various categories of patients of osteoarticular tuberculosis, to modulate (alter or change) the immune system in non responder patients and to add immunomodulation therapy in some patients from the very beginning of antitubercular chemotherapy and observe their clinical response and objectively assess their immune status. Prospective study was done in two phases involving 103 patients suffering from osteoarticular tuberculosis. In phase one 61 patients (Two Groups - Group 1 called fresh virgin/responder cases given first line antitubercular drugs (ATT) = 41 patients; Group 2 called Non responders immunomodulated with cycles of oral levamisole, BCG and DPT vaccine as an adjuvant to ATT = 20 patients) assessed for their cellular immune profile. In second phase 42 patients (In three Groups - Group 3A who received only ATT = 15 patients; Group 3B who received ATT and immunomodulation from very beginning = 15 patients; Group 4 who were non responders, put on immunomodulation after minimum three months of ATT =12 patients) were assessed for their interleukin profiles at presentation and after three months of therapy in respective groups. The immune parameters of all above mentioned patients (n=103) were correlated with the type of clinical presentation, course of disease, response to therapy and response to immunomodulation. Follow up in all the groups ranges from 24 - 49 months (mean 27.2 months). Results : Group1 (n=41): Thirty nine out of 41 patients showed clinicoradiological response at three months of therapy. The CD4 cell counts in these patients rose to a statistically significant (p=. 000) mean of 1140±452.6 cumm indicating that tuberculosis is an important cause of this reversible CD4 T cell lymphopenia. Group 2 (n=20): Thirteen patients showed favorable clinical response to immunomodulation. The CD4 cell counts showed statistically significant (P Overall, out of total 32 nonresponder patients in the present study, 23 responded to immunomodulation regime. No side effect related to immunomodulation was observed. No patient in this study was diabetic or HIV+ve. Conclusions : Correlation of above immune parameters with the clinical presentation, the course of disease and the response to therapy reflected various patterns of host immune responses in osteoarticular tuberculosis. If immunomodulating drugs (Immunotherapy) are given along with ATT from very beginning, these beneficial changes are quantitatively more (more marked) indicating robust host immune response to infection, helping control the disease early. Adjuvant immunomodulation has the potential of shortening the total duration of antitubercular chemotherapy, besides inducing beneficial clinical and host immune responses.

Considerações sobre o tratamento cirúrgico do melanoma maligno anorretal

São analisados os resultados do tratamento cirúrgico em cinco casos de melanoma maligno anorretal (MMAR). Um paciente encontrava-se no estádio clínico I, dois no estádio clínico II e dois no estádio III. Todos os pacientes foram operados, sendo quatro submetidos a excisão local do tumor, e um a amputação abdômino-perineal do reto. Este último sobreviveu por apenas sete meses, enquanto uma paciente, estádio clínico II e submetida apenas à excisão local, sobreviveu por 168 meses. Os autores questionam a validade do estadiamento clínico I (tumores localizados) como fator prognóstico, já que desconsidera o grau de penetração do tumor na parede anorretal. Sugerem ainda a realização de estudos multicêntricos, para que se possa estabelecer uma uniformidade terapêutica para o MMAR.