320^ International Journal of Leprosy^ 1991

raeinurnint infection. Infect. Immun. 24 (1979)492-500.

5. DAVIS, B. D., DULBECCO, R., EISEN, H. N.,GINSBERG, M., WOOD, W. B., JR. and MCCARTY,M. Cell mediated hypersensitivity and immunity.In: Microbiology; Including Immunology and Mo-lecular Genetics. 2nd ed. Hagerstown, Maryland:Harper and Row, 1973, pp. 560-561.

6. GORMUS, B. J., WOLF, R. H., BASKIN, G. B., Ott-KAWA, S., GERONE, P. J., WALSH, G. P., MEYERS,W. M., BINFORD, C. H. and GREER, W. E. A sec-ond sooty mangabey monkey with naturally ac-quired leprosy: first reported possible monkey-to-monkey transmission. Int. J. Lepr. 56 (1988) 61-65.

7. JOB, C. K., KIRCHHEIMER, W. F. and SANCHEZ, R.M. Tissue response to lepromin, an index of sus-ceptibility of the armadillo to Al. leprae infec-tion—a preliminary report. Int. J. Lepr. 50 (1982)177-182.

8. Lamb, F. 1., Singh, N. B. and COLSTON, M. J. Thespecific 18-kilodaltion antigen of M. leprae is pres-ent in Al. habana and functions as a heat shockprotein. J. Immunol. 144 (1990) 1922-1925.

9. ORTIZ-ORTIZ, L., ZAMACONA, G., GARMILLA, C.and ARELLANO, M. T. Migration inhibition testin leukocytes from patients allergic to penicillin.J. Immunol. 113 (1974) 993-997.

10. RIDLEY, D. S. and JOI'LING, W. H. Classificationof leprosy according to immunity; a five-groupsystem. Int. J. Lepr. 34 (1966) 255-263.

11. SENGUPTA, U., RAMU, G. and DESIKAN, K. V. As-sessment of the Dharmendra antigen. II. Stan-dardization of the antigen. Lepr. India 51 (1979)316-322.

12. SINGH, N. B. Characterization of M. habana an-tigens (in press).

13. SINGH, N. B., LOWE, C.A.R.E., REES, R. J. W. andCOLSTON, M. J. Vaccination of mice against M.leprae infection. Infect. Immun. 57 (1989) 653-655.

14. SKINSNES, 0. K. The immunological spectrum ofleprosy. In: Leprosy in Theory and I'ractice. 2nded. Cochrane, R. G. and Davey, T. F., eds. Bristol,England: John Wright and Sons, 1964, p. 156-182.

15. THOMAS, J., JOSEPH, M., RAMANUJAM, K., CHACKO,C. J. G. and JOB, C. K. The histology of Mitsudareaction and its significance. Lepr. Rev. 51 (1980)329-339.

16. TURK, J. L. Cell mediated immunological processin leprosy. Bull. WHO 41 (1969) 779-792.

17. WOLF, R. H., GORMUS, B. J., MARTIN, L. N., BAS-KIN, G. B., WALSH, G. P., MEYERS, W. M. andBINFORD, C. H. Experimental leprosy in threespecies of monkeys. Science 227 (1985) 529-531.

Reactions to Antigens from Actinomycetes IncludingMycobacterium leprae in Leprosy Patients

To THE EDITOR:Several investigators have discussed the

possibility that contact with bacteria cross-reacting with Mycobacterium leprae is ofimportance for the development of leprosy(5). It has also been claimed that exposureto such organisms influences the clinical typeof leprosy which develops ( 2). Not only my-cobacteria, but also many other actinomy-cetes share antigens with the leprosy organ-ism (4).

The present communication gives a briefaccount of a study in which the humoraland cellular immune responses in leprosypatients and healthy controls to various ac-tinomycetes antigens were investigated. Theeffect of M. leprae antigens on the cellularresponse to some of these antigens was alsostudied.

Analyses of the humoral immune re-sponse. Sera from 51 leprosy patients (clin-

ical types are given in The Table) and 30healthy controls from Sweden and Ethiopiawere analyzed, using antigen preparationsfrom 21 strains of Nocardia, Nocardiopsis,Streptornyces, Streptoverticillium (collec-tively referred to as streptomycetes), fromfour strains of Mycobacterium, and from M.leprae. The serological method used wasimmunodiffusion and the results are givenin The Table. The analyses demonstratedthat antibodies against antigens from strep-tomycetes are common in leprosy patientsas well as in healthy controls, while anti-bodies against mycobacteria only arc com-mon in lepromatous patients, but not in tu-berculoid or healthy controls.

Analyses of the cellular immune response.The responses to the above-mentioned an-tigen preparations were analyzed by a lym-phoproliferation assay (') using peripheralblood mononuclear cells from six border-

59, 2^ Correspondence^ 321

THE TABLE. Number of sera reacting withthe bacterial antigen preparations.

Antigen preparations

1^4 Myco-Strepto- bacteria^M.(except^lepraemycetes Al. leprae)

LL^17^14^17^13"BL^16^8^11^13BT^16^2^0^2TT^2^0^0^0He Et^15^4^1^0 'He Sw^15^6^1^O a

LL = lepromatous leprosy; BL = borderline lep-romatous; BT = borderline tuberculoid; TT = tuber-culoid; He Et = healthy Ethiopians; He Sw = healthySwedes.

b Only 15 tested.Only 9 tested.Only 12 tested.

line tuberculoid patients and nine lepro-matous patients (BL or LL). Most of thestreptomycetes antigens tested did not in-duce proliferative cellular response in eithertuberculoid or lepromatous leprosy pa-tients, while most patients responded to theantigens from mycobacteria (apart from M.leprae in lepromatous patients). However,a limited number of streptomycetes anti-gens were recognized by the cells, but theresponders were randomly distributed be-tween the two patient groups (Fig. 1). A sim-

9 40000I-I' 20000

0-

•

14000

La./^12000z •10000 •0000 .90 • sd

F- •6000

4000 s̀i ••0

I'• A—o_U^2000

00A A

0ALP 'In

•S. exfoliatus^H. phlei

^CH

FIG. 1. Lymphoproliferative responses to S. exfo-liatus ^, M. phlei 0, M. leprae o, and culture medium(CM, 0) in lepromatous (open symbols) and tubercu-loid (solid symbols) leprosy patients. Statistically sig-nificant differences in responsiveness between the twogroups were only for responses to Al. leprae (p < 0.025).Cellular responses to other Streptomycetes antigens wereonly observed sporadically. Three healthy Ethiopiancontrols responded only to mycobacterial antigens (notshown).

( 1 65K)

(153K)

100000

90000

80000

70000

z 60000

< 50000Otoa. 40000

oU 30000

20000F-

E 10000U

BCG BCGML PPD PPDML

FIG. 2. Selective reduction of responsiveness to BCGbut not PPD in cells from lepromatous but not tuber-culoid leprosy patients in the presence of Al. leprae.Peripheral blood mononuclear cells of leprosy patientswere incubated with mycobacterial antigens in thepresence (i.e., BCGML or PPDML) or absence (i.e.,BCG or PPD) of Al. leprae. Solid circles represent tu-berculoid patients and open circles, lepromatous lep-rosy patients.

ilar response was obtained when the antigenpreparation from the environmental strainof M. phlei was tested (Fig. 1). The inves-tigations thus indicate that the presence ofstreptomycetes and certain mycobacteria inthe environment is not of importance forthe development of leprosy in spite of thefact that these organisms share antigens withM. leprae and humans produce antibodiesagainst them.

The effect of the presence of M. leprae onthe cellular immune response to strepto-mycetal and mycobacterial antigens was alsoinvestigated. Significant reduction of re-sponses to BCG and Streptomyces exfolia-tes was observed, but not to the other or-ganisms tested, nor to PPD or PHA, andonly in lepromatous not in tuberculoid pa-tients (Fig. 2). These findings make the hy-pothesis that such depressions arc due toendotoxin (3) less likely. The results further

Serum^Totalclass"^no.

322^ International Journal of Leprosy^ 1991

suggest a specific interaction between BCG,M. leprae, and lymphocytes from lepro-matous patients. In view of the use of themixture of BCG and M. leprae as a vaccine,the interaction of these two antigens meritsfurther investigation.

—Ronny Ohman, M.D.Department of Medical

Microbiology and ImmunologyUniversity of GOteborgGötborg, Sweden

— Charlotte WalfordDepartment of BiologyBogazici UniversityIstanbul, Turkey

— Paul Converse, Ph.D.Department of Immunology

and Infectious DiseasesThe Johns Hopkins UniversityBaltimore, Maryland, U.S.A.

— Malin Ridell, Ph.D.Department of Medical

Microbiology and ImmunologyUniversity of GöteborgGuldhedagatan 10S-413 46 G5teborg, Sweden

Reprints requests to Dr. Ridell.

Acknowledgment. Most of the studies were per-formed at the Armauer Hansen Research Institute

(AHRI), Addis Ababa, Ethiopia. AHRI is supportedby the Norwegian and Swedish Save the Children Fundsand by the Norwegian (NORAD) and Swedish (SAR-EC) international development agencies. AHRI is af-filiated with the All Africa Leprosy Rehabilitation andTraining Center (ALERT). We are particularly gratefulto Dr. Martin Dietz (ALERT), who identified patientmaterial for inclusion in the study. Financial supportfor this study from SAREC and King Oscar Irs JubileeFund, Sweden, is gratefully acknowledged.

REFERENCES1. CONVERSE, P. J., OTTENHOFF, T. H. M., GEBRE, N.,

EHRENBERG, J. P. and KIESSLING, R. Cellular, hu-moral and gamma interferon responses to Al. lepraeand BCG antigens in healthy individuals exposedto leprosy. Scand. J. Immunol. 27 (1988) 515-525.LYONS, N. F. and NAAFS, B. Influence of environ-mental mycobacteria on the prevalence of leprosyclinical type. Int. J. Lepr. 55 (1987) 637-645.

3. MOLLOY, A., GAUDERNACK, G., LEVIS, W. R., COHN,Z. A. and KAPLAN, G. Suppression of T-cell pro-liferation by Al. leprae and its products: the role oflipopolysaccharide. Proc. Natl. Acad. Sci. U.S.A.87 (1990) 973-977.

4. RIDELL, M. Cross-reactivity between Af. leprae andvarious actinomycetes and related organisms. Int.J. Lepr. 51 (1983) 185-190.

5. SHIELD, M. J. The importance of immunologicaleffective contact with evironmental mycobacteria.In: The Biology of Mycobacteria. Vol. 2. Immu-nological and Environmental Aspects. Ratledge, C.and Stanford, J., eds. London: Academic Press, 1983,pp. 343-415.

Precautionary Note for Observing Signs of Activity(or Relapse) in Treated Leprosy Patients

To THE EDITOR:We would like to bring to the attention

of leprosy workers two points which appearto be of significance when reviewing treatedleprosy patients for signs of the disease.

A 22-year-old man had a borderline tu-berculoid plaque of leprosy on the upperpart of his left forearm. After 6 months ofregular treatment with multidrug therapy(MDT), rifampin 600 mg monthly super-vised and dapsone 100 mg daily unsuper-vised, the plaque subsided well and he waskept under surveillance. During the thirdmonth of surveillance, he reported withmildly pruritic, erythematous and scaly le-

sions on the site where the leprosy plaquehad been (The Figure). The lesions were of5 weeks' duration and did not look like thoseof leprosy. A scraping for fungus in 10%potassium hydroxide was negative. He wasadvised to apply topical betamethasone val-erate and to take oral antihistaminic tablets.Within a month the lesions regressed, re-moving all fear from the patient's mind. Asimilar occurrence was seen in two morepatients with tuberculoid leprosy after a2-year surveillance period. Although thesecases are seen in rare instances, it is im-portant to recognize them so that benignlesions are not confused with signs of lep-

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