The oral cavity in leprosy: what clinicians need to know

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, a bacillus that has a tropism for skin and peripheral nerves. Leprosy treatment is based on a multidrug therapy established by the World Health Organization in 1982 and, despite its widespread use, Brazil ranks second worldwide in numbers of cases. Oral involvement in leprosy has been poorly described in the literature, and few studies have shown that although the bacillus is found in mucosa, specific leprosy lesions are rare and affect patients with advanced stages of the disease. This review aimed to assess the literature on oral manifestations in leprosy and the aspects involving oral cavity in leprosy pathogenesis.

Oral treatment with Hev b 13 ameliorates experimental colitis in mice

Hev b 13 is an allergenic esterase obtained from the rubber tree Hevea brasiliensis, which has been shown recently to induce human mononuclear cells to release interleukin (IL)-10 in vitro. This immunoregulatory cytokine appears to play an important role in preventing inflammation and mucosal damage in animal models of colitis and in Crohn's disease patients. The aim of this study was to evaluate the therapeutic effect of Hev b 13 in mice with 2,4,6-trinitrobenzene sulphonic acid (TNBS)-induced colitis. Two hours following colonic instillation of the haptenizing agent, and daily thereafter for 5 days, Hev b 13 was administered by oral gavage. In mice treated with daily doses of either 0·5 mg/kg or 5·0 mg/kg of Hev b 13, the clinical signs of diarrhoea, rectal prolapse and body weight loss and also histological damage of the distal colon, were reduced significantly, in comparison with water-treated diseased mice. These findings suggest a potent anti-inflammatory activity of Hev b 13; this activity is speculated to be related to its interaction with cells from the immune system.

Use of anti-PGL-1 antibodies to monitor therapy regimes in leprosy patients

The suitability of IgM antibodies to PGL-1 for monitoring the response to multidrug therapy (MDT) was sequentially tested by ELISA in 105 leprosy patients, and bacterial indexes (BI) were also determined. Patients were divided into 3 groups: group 1, 34 multibacillary (MB) patients treated for 12 months with MDT-MB; group 2, 33 MB patients treated for 24 months with MDT-MB, and group 3, 38 paucibacillary (PB) patients treated for 6 months with MDT-PB. Untreated MB patients exhibited higher antibody levels (mean +/- SEM): group 1 (6.95 +/- 1.35) and group 2 (12.53 +/- 2.02) than untreated PB patients (1.28 +/- 0.35). There was a significant difference (P < 0.01) in anti-PGL-1 levels in group 1 patients: untreated (6.95 +/- 1.35) and treated for 12 months (2.78 +/- 0.69) and in group 2 patients: untreated (12.53 +/- 2.02) and treated for 24 months (2.62 +/- 0.79). There was no significant difference between untreated (1.28 +/- 0.35) and treated (0.62 +/- 0.12) PB patients. Antibody levels correlated with BI. The correlation coefficient (Pearson's r) was 0.72 before and 0.23 (P < 0.05) after treatment in group 1 and 0.67 before and 0.96 (P < 0.05) after treatment in group 2. BI was significantly reduced (P < 0.01) after 12 and 24 months on MDT (group 1: 1.26-0.26; group 2: 1.66-0.36). Our data indicate that monitoring anti-PGL-1 levels during MDT may be a sensitive tool for evaluating treatment efficacy. These data also indicate that the control of leprosy infection can be obtained with 12 months of MDT in MB patients.

Effect of the glycemic control on intracellular cytokine production from peripheral blood mononuclear cells of type 1 and type 2 diabetic patients

AIMS

To evaluate the intracellular production of tumor necrosis factor (TNF-alpha), interleukine-6 (IL-6), INF-gamma, IL-8 and IL-10 in peripheral blood lymphomononuclear cells from type 1 and type 2 diabetic patients, stratified according to the glycemic control.

METHODS

Thirty-five diabetic patients (17 type 1 and 18 type 2) and nine healthy individuals paired to patients in terms of sex and age were studied. Nine patients of each group were on inadequate glycemic controls. Intracellular cytokines were evaluated using flow cytometry. Cell cultures were stimulated with LPS to evaluate TNF-alpha and IL-6 or with PMA and Ionomycin to evaluate IFN-gamma, IL-8 and IL-10 intracellular staining.

RESULTS

The percentages of CD33(+) cells bearing TNF-alpha and CD3(+) cells bearing IL-10 were increased in type 1 diabetic patients with inadequate glycemic control in relation to those with adequate control. In contrast, the percentage of CD3(+) cells bearing IL-8 was decreased in type 2 patients under inadequate glycemic control.

CONCLUSIONS

The glycemic control is important for the detection of intracellular cytokines, and may contribute towards the susceptibility to infections in diabetic patients.

Endocrine dysfunction in leprosy

Leprosy is still an endemic disease, especially in Third World countries, and, because of migration, it still persists in Europe and the United States. The disease affects the peripheral nerves, skin, and multiple internal organs, making its clinical recognition difficult. In particular, the endocrine manifestations caused by leprosy have been underestimated, even by specialists. The endocrine changes present in leprosy include hypogonadism, sterility, and osteoporosis. In addition, the spectral immune nature of leprosy offers an attractive model to investigate the pathogenetic correlation between the patterns of inflammation in the poles of its spectrum and the hormonal disarrangements observed in this disease. It is important that those involved in leprosy management be aware of the potential endocrine changes and their treatment to address the disease in all of its aspects. In this article, we review the findings on endocrine dysfunction in leprosy, including a survey of the literature and of our own work.

Impaired cytokine production by peripheral blood mononuclear cells in type 1 diabetic patients

AIMS

The objective of the present investigation was to study the production of IL-1, IL-6, IL-10, IFNgamma and TNFalpha in cultures of peripheral blood mononuclear cells (PBMC) taken from type 1 diabetic patients with inadequate metabolic control.

METHODS

Seventeen type 1 diabetic patients and a gender- and age-matched group of 17 healthy individuals were studied. PBMC cultures were stimulated with phytohemagglutinin (PHA; 20 microg/ml) and lipopolysaccharide (LPS; 10 microg/ml), and enzyme immunoassay (Elisa) was used to measure IL-1, IL-6, IL-10, IFNgamma and TNFalpha in the cell-culture supernatants.

RESULTS

IFNgamma levels in PHA-stimulated cultures were lower in the type 1 diabetics than in the non-diabetic controls (P<0.0001) while, in contrast, IL-10 levels were increased in the PHA-stimulated culture supernatants of the diabetics compared with the controls (P<0.0001). In addition, supernatant levels of the cytokines IL-1, IL-6 and TNFalpha released in the presence of LPS in the cell cultures from the diabetic patients were significantly lower than in the non-diabetic subjects (P<0.0001, P<0.0001 and P<0.03, respectively).

CONCLUSIONS

The impaired production of IL-1, IL-6, TNFalpha and IFNgamma, and the increased production of IL-10, in PBMC cultures from type 1 diabetics with inadequate metabolic control compared with healthy subjects may be an indication of a deficiency in mononuclear cell activation and, consequently, a deficient immune cellular adaptive response that, in turn, may be the cause of the increased incidence of infections in people with type 1 diabetes.

Effect of metabolic control on interferon-gamma and interleukin-10 production by peripheral blood mononuclear cells from type 1 and type 2 diabetic patients

The objective of the present study was to evaluate the production of cytokines, interferon-gamma (INF-gamma) and interleukin-10 (IL-10), in cultures of peripheral blood mononuclear cells (PBMC) from type 1 and type 2 diabetic patients and to correlate it with inadequate and adequate metabolic control. We studied 11 type 1 and 13 type 2 diabetic patients and 21 healthy individuals divided into two groups (N = 11 and 10) paired by sex and age with type 1 and type 2 diabetic patients. The PBMC cultures were stimulated with concanavalin-A to measure INF-gamma and IL-10 supernatant concentration by ELISA. For patients with inadequate metabolic control, the cultures were performed on the first day of hospitalization and again after intensive treatment to achieve adequate control. INF-gamma levels in the supernatants of type 1 diabetic patient cultures were higher compared to type 2 diabetic patients with adequate metabolic control (P < 0.001). Additionally, INF-gamma and IL-10 tended to increase the liberation of PBMC from type 1 and 2 diabetic patients with adequate metabolic control (P = 0.009 and 0.09, respectively). The increased levels of INF-gamma and IL-10 released from PBMC of type 1 and 2 diabetic patients with adequate metabolic control suggest that diabetic control improves the capacity of activation and maintenance of the immune response, reducing the susceptibility to infections.

Dermatoses em pacientes com diabetes mellitus

OBJETIVO: Ainda é desconhecida a relação do diabetes com fatores determinantes ou precipitantes de lesões dermatológicas em pacientes diabéticos. Assim, o objetivo do estudo foi investigar a presença de lesões cutâneas, não referidas pelo paciente diabético e sua relação com o controle metabólico da doença. MÉTODOS: Foram examinados 403 pacientes, dos quais 31% eram diabéticos do tipo 1 e 69% do tipo 2. Em ambulatório de um hospital universitário, os pacientes foram atendidos por endocrinologista para a avaliação endócrino-metabólica e por dermatologista para a avaliação dermatológica. O grau de controle metabólico foi documentado em 136 pacientes por meio da dosagem de hemoglobina glicada. RESULTADOS: Houve predomínio de dermatofitoses (82,6%), seguido de grupo de dermatoses como acne e degeneração actínica (66,7%), piodermites (5%), tumores cutâneos (3%) e necrobiose lipoídica (1%). Entre as dermatoses mais comuns em diabéticos, foram confirmados com exame histológico: dois diagnósticos de necrobiose (0,4%), cinco de dermopatia diabética (1,2%) e três casos de mal perfurante plantar (0,7%). Os valores da hemoglobina glicada foram: 7,2% em pacientes com controle metabólico adequado nos dois tipos de diabetes e de 11,9% e 12,7% nos tipos 1 e 2, respectivamente, com controle inadequado. Nos pacientes com controle metabólico inadequado foi observada freqüência maior de dermatofitoses, em ambos os tipos de diabetes. CONCLUSÕES: Os dados revelaram freqüência elevada de lesão dermatológica nos pacientes diabéticos, especialmente dermatofitoses. Dessa forma, o descontrole metabólico do diabético propicia maior suscetibilidade a infecções cutâneas.

Dipstick assay to identify leprosy patients who have an increased risk of relapse

Classification of leprosy patients into paucibacillary (PB) and multibacillary (MB) determines the duration of treatment; misclassification increases the risk of relapse because of insufficient treatment if an MB patient is classified as PB. We explored the possibility of using a simple dipstick assay based on the detection of antibodies to the Mycobacterium leprae-specific phenolic glycolipid-I (PGL-I) as a tool for classification of patients into PB and MB for treatment purposes. The sensitivity of the dipstick test for detection of MB patients was 85.1%, the specificity 77.7%. We found that of the 71 dipstick negative PB patients 25 (35.2%) were clinically cured at the end of treatment, compared with only two (9.5%) of the 21 dipstick positive PB patients. Of 170 patients in the study population, nine (5.3%) relapsed within the 5-year follow-up period. Seven were MB patients, all dipstick positive. Two PB patients relapsed, one was dipstick negative and one was dipstick positive. Dipstick positivity is a risk factor for the future development of relapses, especially in those groups of patients who had received a shorter-than-usual course of treatment and the dipstick can be used as an additional, simple tool for classification of patients and for identification of those patients who have an increased risk of relapse.

Production of transforming growth factor-beta 1 (TGF-beta1) by blood monocytes from patients with different clinical forms of leprosy

In the present study, the concentration of TGF-beta1 secreted by adherent cells isolated from human peripheral blood mononuclear cells (PBMC) and either stimulated with PGL-1 or lipopolysaccharide (LPS) or left unstimulated was determined by ELISA. The cells were isolated from untreated patients with different clinical forms of leprosy and healthy individuals. The adherent cells exhibited spontaneous release of TGF-beta1 in all clinical forms of leprosy and in healthy individuals; however, lepromatous leprosy/borderline leprosy (LL/BL) patients presenting erythema nodosum leprosum (ENL) displayed significantly higher concentrations of TGF-beta1 than either the other patients studied or the controls. These high TGF-beta1 levels were consistently observed when LL/BL ENL cells were stimulated with phenolic glycolipid (PGL-1) or LPS, and even in the absence of a stimulus (P < 0.01). The most significant differences in TGF-beta1 levels were observed when comparing the results in the presence of PGL-1 from ENL with, in order of significance: tuberculoid leprosy (TT) patients (P < 0.001), LL/BL patients without ENL (P < 0.01), healthy individuals (P < 0.01) and borderline-borderline/borderline-tuberculoid (BB/BT) patients with reversal reaction (RR) (P < 0.01). The BB/BT patients produced equivalent levels of TGF-beta1 compared with LL/BL patients without ENL, for all types of stimuli (P > 0.05). In contrast, TT patients produced the lowest levels of TGF-beta1 among all the subjects studied (both patients and healthy controls), especially following PGL-1 stimulation (P < 0.001, and P < 0.05, respectively). In conjunction with our previous data regarding TGF-beta1 expression in dermal lesions, it appears that TGF-beta1 probably plays different roles in leprosy: (i) to mediate a suppressive action locally, associated with the presence of PGL-1, and (ii) to induce proinflammatory effects when secreted systemically by monocytes, thereby acting as a modulatory cytokine in the acute inflammatory reactions of ENL and associated with the Th2 immune response in multibacillary forms of leprosy.

Lucio's phenomenon: clinical and therapeutic aspects

We report four cases of necrotizing reactions of the Lucio's phenomenon type, an entity rarely observed in Brazil despite the high prevalence of leprosy. Clinical, histopathological and therapeutic aspects are described and compared to those reported in the literature for cases classified as diffuse, non-nodular lepromatous leprosy with Lucio's phenomenon.

The use of bone scintigraphy to detect active Hansen's disease in mutilated patients

Mutilation of extremities was very frequent in patients affected by leprosy in the past; although it is now much less common, it is still seen, mainly in patients with long-term disease. In general, mutilation of the nose and ears is caused by the bacillus and mutilation of the hands and feet a consequence of chronic trauma. Leprosy must be chronically treated and any decision to interrupt therapy is based on laboratory tests and biopsy. Scintigraphy is a non-invasive procedure which could be of great value in to determining disease activity. We studied eight patients (five males and three females, aged 64-73 years) who presented with mutilation of the nose (2), ear (1), feet (3) or foot and hand (2). Conventional three-phase bone scintigraphy (750 MBq) and X-ray examinations of the affected areas were performed in all patients. Bone scintigraphy was abnormal in four patients (the presence of bacilli was confirmed by biopsy in two of them), and normal in the other four. In all patients except for the one with ear mutilation, radiography only showed the absence of bone. We conclude that bone scintigraphy is very useful to determine disease activity in cases of mutilation caused by leprosy. It seems to be superior to conventional radiography and may enable bone biopsies to be avoided.

Nephrotoxicity attributed to meglumine antimoniate (Glucantime) in the treatment of generalized cutaneous leishmaniasis

BACKGROUND

Pentavalent antimonials have became of basic importance for the treatment of leishmaniasis. Their most severe side effects have been reported to be increased hepatic enzyme levels and electrocardiographic abnormalities. Nephrotoxicity has been rarely related.

OBSERVATIONS

We report a case of generalized cutaneous leishmaniasis involving a 50-year old male patient who was submitted to treatment with meglumine antimoniate (Glucantime). He developed acute renal failure (ARF) due to acute tubular necrosis (ATN), followed by death after receiving a total of 53 ampoules of Glucantime.

CONCLUSIONS

The treatment with Glucantime was responsible by ARF diagnosed in this patient. The previous urine osmolarity and serum creatinine levels were normal and the autopsy showed ATN. It should be pointed out if ARF may also be explained by massive deposits of immunocomplexes by leishmania antibodies and antigens due to the antigenic break by the antimonial compound, since our patient presented countless lesions covering the entire tegument, similar to the Hexheimer phenomenon, but at the autopsy no glomerular alterations were seen.

Efficacy, safety and tolerability of terbinafine for Tinea capitis in children: Brazilian multicentric study with daily oral tablets for 1,2 and 4 weeks

BACKGROUND

Tinea capitis is a common skin disease seen predominantly in children. The standard therapies for this disease are griseofulvin and ketoconazole. Nevertheless, these drugs have drawbacks in that they are only fungistatic and require treatment for at least 6 weeks. Previous studies with oral terbinafine for the treatment of Tinea capitis have shown that this agent is effective when given for 4 weeks, comparable to an 8-week regimen with griseofulvin. To date there is no data on the use of oral terbinafine in Brazilian children.

OBJECTIVES

To assess the efficacy, safety and tolerability of oral terbinafine in short-term treatments (1-, 2- and 4-week treatment) of Tinea capitis in children.

PATIENTS AND METHODS

One hundred and thirty-two children aged 1-14 years were enrolled in this study, but only 107 were considered for the final efficacy analysis. Diagnosis included clinical assessment and examination by Wood's light. Confirmation was obtained by direct microscopy and culture for fungus. Terbinafine dosage (125 or 250 mg/day) was adjusted according to patient weight. Efficacy was evaluated both by clinical and mycological assessment. Safety and tolerability variables included data on adverse reaction and clinical laboratory evaluations.

RESULTS

Mycological evaluation in the follow-up visit at week 12 showed negative direct microscopy and culture results in 48.6, 60.5 and 69.7% patients in groups 1-, 2- and 4-week, respectively (n.s.). At week 12, 84.8% patients in group 4-week achieved clinical cure with a significant difference compared to groups 1- and 2-week, 54.3 and 60.5%, respectively (P < 0.01). Adverse reactions were present in 4.8, 6.8 and 10.9% of patients in groups 1-, 2- and 4-week, respectively. terbinafine was not associated with clinically relevant increases in liver function tests.

CONCLUSIONS

Terbinafine is an effective, well tolerated and safe antifungal agent for the treatment of Tinea capitis in children. The shorter duration of treatment resulted in lower cure rates. However, it is important to note that depending on the severity of the disease, a 1-week-only treatment can also be effective in this indication.

Generalized cutaneous leishmaniasis in acquired immunodeficiency syndrome

BACKGROUND

Leishmaniasis associated with HIV/AIDS has been reported in the last decade.

CASE REPORT

A case of generalized cutaneous leishmaniasis in a patient with AIDS is described. The case is paradoxical in that the cutaneous lesions resemble anergic leishmaniasis caused by Leishmania (L.) amazonensis and Jorge Lobo's disease, but the positive Montenegro test and the clinical improvement with antimonial are more commonly observed in leishmaniasis caused by L.(V.) braziliensis.

COMMENT

The immunosuppression due to HIV/AIDS seen in this patient may explain the dissemination of the lesions, but the positive specific response to leishmanial antigen may explain the good response to the antimonial treatment.

The use of glucan as immunostimulant in the treatment of paracoccidioidomycosis

A group of 10 patients, nine of them seriously infected with Paracoccidioides brasiliensis (G1), received glucan (beta-1,3 polyglucose) as an immunostimulant intravenously once a week for one month, followed by monthly doses (10 mg) over an 11-month period, together with a specific anti-fungal agent as an immunostimulant. A second group of eight moderately infected patients (G2) was treated with only the anti-fungal agent. Among the patients in G1, there was only one case of relapse compared with five in G2. Values for the erythrocyte sedimentation rate (ESR) showed a significant difference (P < 0.001) post-treatment in G1 patients, when compared with the pretreatment levels. There was also a significant reduction (P < 0.001) in the level of serum antibodies to P. brasiliensis in the G1 patients in post-treatment examinations. The phytohemagglutinin (PHA) skin test showed a positive reaction among the patients in G1 (P < 0.01) post-treatment and there was a tendency towards an increase in the number of CD4+ T lymphocytes in both groups after treatment. The serum level of tumor necrosis factor (TNF) proved to be significantly higher (P < 0.02) in the G1 patients during treatment. In the G1 patients, the correlation between ESR and TNF tended to be negative whereas that between ESR and serum antibodies was positive. The present results indicate that the patients who received glucan, in spite of being more seriously ill, had a stronger and more favorable response to therapy.

Detection of transforming growth factor-beta 1 in dermal lesions of different clinical forms of leprosy

Immunohistochemical studies were performed to determine the presence and distribution of polypeptide transforming growth factor (TGF)-beta 1, a cytokine with macrophage-suppressing activity, in skin biopsies from 41 patients with different clinical forms of leprosy. We used an anti-TGF-beta 1 polyclonal antibody and the avidinbiotin-peroxidase (ABC complex) method. The results demonstrated that the lesions of the lepromatous and borderline lepromatous forms presented intense cytoplasm staining for TGF-beta 1 in the cells of the dermal infiltrate. A reaction of moderate intensity was observed in the cells of granulomas from borderline borderline cases, whereas no detectable immunoreaction was observed in granuloma cells from the tuberculoid and borderline tuberculoid forms. Considering that in the lepromatous leprosy form Mycobacterium leprae multiplies in the cytoplasm of macrophages and the lesions are diffuse and consist of poorly differentiated young macrophages, we believe that these alternations may be explained at least in part by the presence of TGF-beta 1 in the dermal infiltrate. Production of the cytokine may be induced by the presence of the bacillus itself and of its constituents, causing a mechanism of parasite evasion. Similarly, the absence of TGF-beta 1 in tuberculoid leprosy, which progresses with a specific immune response to M. leprae, may explain the intense differentiation of macrophage cells with the formation of well defined epithelioid granulomas capable of eliminating most of the bacilli.

Neonatal lupus erythematosus

The patient is a newborn girl, born at term by cesarian section, weighing 3,550 g, and measuring 50 cm in length. According to her mother, she had been presenting erythematous spots involving the scalp, face, and trunk since birth that had increased in size with time. The mother denied any other changes and reported normal growth and development. Physical examination at 2 months of age revealed an infant in good general condition, hydrated, with no fever and no abnormalities detected on careful physical examination. The dermatologic examination revealed numerous circumscribed erythematous-brownish flat maculae with sharp borders and irregular contours, with no follicular hyperkeratosis, but with telangiectasias and areas of atrophy. They were lenticular and nummular, especially on the face (peri-orbital heliotropic lesions), and appeared as plaques on the trunk, with a tendency to confluence. The lesions also involved the scalp, neck, and extremities (Fig. 1). Histopathologic examination revealed an atrophic epidermis with focal areas of hydropic degeneration of the basal layer. A discrete perivascular and periannexal lymphohistiocytic infiltrate was observed in the superficial dermis, with melaninophages, frequent extravasation of red blood cells, angiectasia, and edema (Fig. 2). Serologic tests were reactive for antinuclear factor (ANF) (titer 1:100) of the speckled pattern, the presence of anti-Ro antibodies, and absence of anti-RNA and anti-Sm antibodies (Table 1). Blood counts and electrocardiogram were normal (Table 1). HLA typing showed positivity for DR-3 (Table 2). At 5 months of age the patient already showed a marked improvement of the skin lesions with only some areas of discrete pigmentation, a few atrophic areas, and rare telangiectasis (Fig. 3). The serologic tests (ANF, anti-Ro) had become nonreactive and the anti-RNA and anti-Sm tests continued to be negative. Examination of the mother revealed an asymptomatic 25-year-old woman reporting no manifestations suggestive of lupus. General and special physical examination revealed no abnormalities. Dermatologic examination showed no active or residual lesions of discoid or systemic lupus erythematosus. The pregnancy had been uneventful. Histopathologic examination of the girl's skin revealed the epidermis without obvious changes, minimal edema in the dermis, and a discrete perivascular inflammatory mononuclear cell infiltrate. Direct immunofluorescence of normal skin not exposed to the sun was negative. Blood counts revealed mild anemia and a tendency to leukopenia and thrombocytopenia (Table 1). Serologic tests showed reactive ANF (titers 1:400 and 1:800, speckled pattern), the presence of anti-Ro antibodies, and the absense of anti-RNA and anti-Sm antibodies (Table 1). HLA-typing revealed positivity for DR-3 (Table 2).

Entomophthoramycosis: therapeutic success by using amphotericin B and terbinafine

A 12-year-old girl had been presenting a woody infiltration and erythema in the frontal region and on the entire left half of the face, leading to deformity of the nose and buccal fissure, and adenomegaly in a posterior cervical chain, for the last 18 months. Sinusitis was diagnosed and treated with antibiotics, and submitted to ethmoid sinusotomy, with no improvement. Several laboratory tests were made to find the correct diagnosis. An intradermal test for delayed hypersensitivity showed a positive reaction (5 mm) with necrosis for metabolic antigens for Conidiobolus. An oral mucosa biopsy showed a dense lymphohistiocytic infiltrate and focal points of necrosis. Gomori staining for fungi revealed countless wide, nonseptate hyphae. Amphotericin B was prescribed during 35 days, with no improvement. Terbinafine given orally was started in association with amphotericin B. Reduction of the lesions was observed 2 months later. No side effects were seen during 4 months of treatment.

Differential correlation between interleukin patterns in disseminated and chronic human paracoccidioidomycosis

In an attempt to understand better the immunoregulatory disorders in paracoccidioidomycosis (PCM), the possible correlation between interleukin pattern, lymphoproliferation, C-reactive protein (CRP) and specific antibody levels was investigated in the polarized clinical forms of this disease. We studied 16 PCM patients, eight with the disseminated disease (four under treatment and four non-treated) and eight with the chronic disease. The patients with disseminated disease exhibited high antibody titres specific to Paracoccidioides brasiliensis antigen compared with patients with the chronic form of disease. Tumour necrosis factor (TNF), IL-1, IL-6 and CRP in the serum of non-treated disseminated PCM patients were increased, which correlated positively with the low mitogenic response of peripheral blood mononuclear cells (PBMC) to phytohaemagglutinin (PHA) (P < 0.01) and with the high antibody titres (P < 0.001) of these patients. Moreover, we found in the disseminated PCM patients positive correlations between IL-1 and IL-6 (P = 0.0007); IL-1 and TNF (P = 0.0045); IL-1 and IL-6 with the high antibody titres (P = 0.0834 and P = 0.0631, respectively); IL-1, IL-6 and TNF with CRP levels. By contrast, no correlations were found with those interleukins in the treated disseminated and chronic patients or in controls. It was interesting to find an inverse correlation between IL-4 and antibody production in non-treated disseminated PCM (r = -0.4770); moreover, a significant correlation (P = 0.0820) was found in chronic PCM patients with respect to the low level of either IL-4 and antibody titres against fungus antigen. Chronic PCM patients also had IL-2 levels inversely correlated with antibody production (r = -0.6313; P = 0.0628). Inverse correlations were also observed between IL-2 and IL-6 levels in non-treated disseminated patients (P = 0.0501) and between IL-2 and IL-4 in chronic patients (P = 0.0131). The inflammatory cytokines might have a pivotal role in the genesis and in control of some aspects of the disease, such as granulomatous reaction, hypergammaglobulinaemia and depression of T cell-mediated immunity in PCM.

Correlation between TNF production, increase of plasma C-reactive protein level and suppression of T lymphocyte response to concanavalin A during erythema nodosum leprosum

The complex symptoms observed in lepromatous leprosy patients with reactive episodes of the erythema nodosum leprosum (ENL) type are associated with different serum components actively participating in the acute inflammatory reaction. Among them are the tumor necrosis factor (TNF) and the acute-phase protein C-reactive protein (CRP). TNF and CRP were found at significantly more elevated concentrations in the serum of patients with ENL, with a positive correlation of about 95% when compared with patients with nonreactive lepromatous leprosy (L) or tuberculoid leprosy (T) or with control individuals. Furthermore, in another series of experiments CRP had a specific and significant suppressive action on concanavalin A (ConA)-induced lymphoproliferation in cultures from patients and controls, the reduction being more marked (75%) in patients with ENL. By extrapolation from its known actions, production of TNF may have a number of potential consequences for the immunobiology of ENL. Thus, TNF may cause direct injury to compromised cells, facilitating mononuclear cell activation and production of cytokines such as interleukin-1 and interleukin-6, and upregulating hepatocyte expression of CRP. Both CRP and TNF in high serum concentrations have the ability to enhance the acute inflammatory process in ENL, favoring increased macrophage activation and phagoctyosis, and contributing to the elimination of damaged cells and bacilli, as well as in the reduction of T-suppressor cells, with a consequent improvement in the immunologic response of ENL patients.

Renal transplantation in leprosy patients

We report four cases of leprosy in renal transplant recipients, two of whom had the disease before transplantation and no signs of relapse even in the presence of immunosuppressive drugs. The other two cases presented with lepromatous and borderline (dimorphous) leprosy 5 months and 5 years after transplantation, respectively. The disease of the last patient was controlled with sulfone even in the presence of immunosuppressive drugs, but the mechanism whereby the first patient rapidly developed lepromatous leprosy is unclear, even though he was a home contact of a patient with lepromatous leprosy (his wife). In view of the data presented here, we do not contraindicate renal transplantation in patients with leprosy who frequently suffer changes in renal function. We believe that renal function should be periodically evaluated in patients with borderline and lepromatous leprosy.

BCG vaccination of full-term infants with chronic intrauterine malnutrition: influence of immunization age on development of post-vaccination, delayed tuberculin hypersensitivity

To determine the effect of intrauterine growth retardation (IUGR) on the response to BCG vaccination, we evaluated the specific delayed tuberculin hypersensitivity of 57 full-term infants with symmetric IUGR (SGA or small for gestational age) and 52 full-term infants with normal intrauterine growth (AGA or appropriate for gestational age). The infants were evaluated using post-vaccination skin tests to tuberculin purified protein derivative (PPD) and tuberculin lymphocyte transformation tests. Using a positive response to the skin test as an indicator of delayed hypersensitivity, we found that the rate of response to BCG in the SGA and AGA groups was similar. A total of 65% of infants with IUGR responded to BCG vaccination. The response rate among SGA infants who were vaccinated at 5 days of age, about 26 days of age (weight > or = 2500 g), 3 months of age, and 6 months of age was 68%, 47%, 69%, and 88%, respectively. The overall response rate for infants with no IUGR was 71%; the rate response to BCG vaccination among this group was 52% (those vaccinated at 5 days of age), 90% (3 months of age), and 80% (6 months of age). Our data suggest that the immunogenicity of BCG vaccine is similar in term infants who have normal or abnormal intrauterine growth and the presence of IUGR should not be a reason for delaying BCG vaccination.

Amyloidosis and the serum amyloid A protein response to muramyl dipeptide analogs and different mycobacterial species

Serum amyloid A protein (SAA) elevation accompanies induction of secondary amyloidosis in mice given Mycobacterium butyricum in Freund adjuvant. The synthesis of SAA by cultured hepatocytes is induced by a macrophage-derived mediator, which has been identified as interleukin 1. In these studies, SAA synthesis has been used as an index of macrophage activation to examine the in vivo response of mice to challenge with seven different mycobacteria and with synthetic analogs of the immunoadjuvant N-acetylmuramyl-L-alanyl-D-isoglutamine [MDP(L-D)]. SAA synthesis was stimulated by administration (by the intraperitoneal route) of the mycobacteria dissolved in saline, with Mycobacterium vaccae being the most active and Mycobacterium leprae being the least stimulatory. MDP(L-D), which is the minimal structure (molecular weight, 492) able to substitute for mycobacteria in Freund adjuvant, stimulated SAA synthesis, whereas the MDP(D-D) isomer was inactive. The butyl ester of MDP, which induces no detectable pyrogenicity but retains adjuvanticity, required a 100-fold greater dosage than MDP(L-D) in stimulating SAA synthesis. Amyloidosis was detected histologically only when active SAA inducers MDP(L-D), M. vaccae, and M. butyricum, were administered in incomplete Freund adjuvant, with amyloid-enhancing factor. These studies demonstrated that SAA elevation was a sensitive in vivo marker of the capacity of antigens to stimulate macrophages to produce interleukin 1. A point of considerable relevance to the human use of MDP was the observation that repeated injections of the adjuvant MDP in saline did not induce secondary amyloidosis.

The biology of SAA: identification of the inducer, in vitro synthesis, and heterogeneity demonstrated with monoclonal antibodies

Continued studies of the macrophage-derived mediator of SAA synthesis (SAA Stimulating Factor) confirm our previous observations that SAASF copurified with leukocytic pyrogen (LP) and lymphocyte activating factor (LAF). Moreover, new data demonstrate three separate isoelectric points for human LP-LAF-SAASF each of which possess the three biological activities. During the purification of 15,000 MW LP from crude stimulated mononuclear cell supernatants, only those fractions with pyrogenic activity in rabbits caused augmented stimulation of lymphocytes (LAF) and induced SAA synthesis in mice. Purified human LP stimulated isolated mouse hepatocytes in vitro to synthesize SAA in a dose-responsive manner. Colchicine treatment of hepatocytes led to decreased secretion of SAA into the medium and to an intracellular accumulation of SAA. Messenger RNA was isolated from the livers of endotoxin-stimulated mice and translated in a wheat-germ cell-free system. A major product was identified at 13-14,000 MW. Immunoprecipitation with anti-mouse AA identified several bands on autoradiography of polyacrylamide gels. These larger SAA precursors may account for the previously noted heterogeneity of human SAA, comprising at least 6 SAA isomers, of similar molecular weight but different solubility and electrophoretic charge characteristics. Two monoclonal antibodies (IgM-K and IgG1-K) have been prepared using standard cell hybridization techniques. They are directed at the variable COOH terminal region of SAA since they detect differences between the 6 human SAAs but do not react with human, monkey, dog or mouse AA proteins, human AP, C-reactive protein, IgG nor albumin. These antibodies will be useful in examining the origin, structure and function of SAA.