Immunological status of ENL (Erythema Nodosum Leprosum) patients: its relationship to bacterial load and levels of circulanting IL-2R

Vieira, Leila M.M.; Sampaio, Elisabeth P.; Nery, José A.C.; Duppre, Nadia C.; Albuquerque, Edson CA; Scheinberg, Morton A; Sarno, Euzenir N

doi:10.1590/S0036-46651996000200004

Abstracts

Recent data suggest that the clinical course of reactional states in leprosy is closely related to the cytokine profile released locally or systemically by the patients. In the present study, patients with erythema nodosum leprosum (ENL) were grouped according to the intensity of their clinical symptoms. Clinical and immunological aspects of ENL and the impact of these parameters on bacterial load were assessed in conjunction with patients' in vitro immune response to mycobacterial antigens. In 10 out of the 17 patients tested, BI (bacterial index) was reduced by at least 1 log from leprosy diagnosis to the onset of their first reactional episode (ENL), as compared to an expected 0.3 log reduction in the unreactional group for the same MDT (multidrug therapy) period. However, no difference in the rate of BI reduction was noted at the end of MDT among ENL and unreactional lepromatous patients. Accordingly, although TNF-alpha (tumor necrosis factor) levels were enhanced in the sera of 70.6% of the ENL patients tested, no relationship was noted between circulating TNF-alpha levels and the decrease in BI detected at the onset of the reactional episode. Evaluation of bacterial viability of M. leprae isolated from the reactional lesions showed no growth in the mouse footpads. Only 20% of the patients demonstrated specific immune response to M. leprae during ENL. Moreover, high levels of soluble IL-2R (interleukin-2 receptor) were present in 78% of the patients. Circulating anti-neural (anti-ceramide and anti-galactocerebroside antibodies) and anti-mycobacterial antibodies were detected in ENL patients' sera as well, which were not related to the clinical course of disease. Our data suggest that bacterial killing is enhanced during reactions. Emergence of specific immune response to M. leprae and the effective role of TNF-alpha in mediating fragmentation of bacteria still need to be clarified.

Leprosy; TNF-alpha; ENL; Cytokines; Mycobacterial antigens

Dados recentes sugerem que o curso clínico dos estados reacionais na lepra está estritamente relacionado à liberação local ou sistêmica de citocinas. Neste estudo, pacientes com ENL (erythema nodosum leprosum) foram grupados segundo a intensidade de seus sintomas clínicos. Os aspectos clínicos e imunológicos do ENL e os efeitos desses parâmetros na carga bacilar foram estabelecidos em conjunção com a resposta imune in vitro desses pacientes, a antígenos microbacterianos. Em 10 de 17 pacientes testados, o índice bacteriano (IB) foi reduzido cm pelo menos 1 log desde o diagnóstico da lepra até o aparecimento do primeiro episódio reacional, comparado a uma redução esperada de 0.3 log no grupo não reacional no mesmo período de MDT (multidrogaterapia). Entretanto, nenhuma diferença na taxa de redução do IB foi notada no final da MDT entre os pacientes ENL e os lepromatosos não reacionais. Assim também, embora os níveis de TNF-alfa (fator de necrose tumoral) estivessem aumentados no soro de 70,6% dos pacientes com ENL testados, nenhuma relação foi notada entre os níveis circulantes de TNF-alfa e a diminuição do IB detectada no aparecimento do primeiro episódio reacional. A avaliação da viabilidade bacteriana do M. leprae isolado de lesões reacionais não mostrou crescimento na pata de camundongo. Somente 20% dos pacientes demonstraram resposta imune específica ao M. leprae durante o ENL. Além disso altos níveis de IL-2R (receptor de interleucina 2) solúvel estiveram presentes em 78% dos pacientes. Anticorpos circulantes anti-nervo (anti-ceramídio e anti-galactocerebrosídio) e anti-micobacterianos foram também detectados no soro dos pacientes, e não estiveram relacionados ao curso clínico da doença. Nossos dados sugerem que a morte bacteriana está aumentada durante as reações. A emergência de resposta imune específica ao M. leprae e o papel efetivo do TNF-alfa na mediação de fragmentação bacteriana necessita ainda ser esclarecida

IMMUNOLOGY

Immunological status of ENL (Erythema Nodosum Leprosum) patients: its relationship to bacterial load and levels of circulanting IL-2R

Perfil imunológico de pacientes com ENL (Erythema Nodosum Leprosum): relação entre carga bacilar e os níveis de IL-2R circulantes

Leila M.M. Vieira^I; Elisabeth P. Sampaio; José A.C. Nery; Nadia C. Duppre; Edson CA. Albuquerque; Morton A. Scheinberg^II; Euzenir N. Sarno

Leprosy Laboratory, Oswaldo Cruz Institute/Fiocruz, Avenida Brasil 4365, Manguinhos, 21045-900 Rio de Janeiro, RJ, Brazil

^IIPathology Department, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

^IIILaboratory of Diagnostic Investigation, São Paulo, SP, Brazil

^{Correspondence to} Correspondence to: Dr. Euzenir N. Sarno Leprosy Unit, Oswaldo Cruz Foundation Avenida Brasil 4365, Manguinhos 21045-900 Rio de Janeiro, RJ, Brazil

SUMMARY

Recent data suggest that the clinical course of reactional states in leprosy is closely related to the cytokine profile released locally or systemically by the patients. In the present study, patients with erythema nodosum leprosum (ENL) were grouped according to the intensity of their clinical symptoms. Clinical and immunological aspects of ENL and the impact of these parameters on bacterial load were assessed in conjunction with patients' in vitro immune response to mycobacterial antigens. In 10 out of the 17 patients tested, BI (bacterial index) was reduced by at least 1 log from leprosy diagnosis to the onset of their first reactional episode (ENL), as compared to an expected 0.3 log reduction in the unreactional group for the same MDT (multidrug therapy) period. However, no difference in the rate of BI reduction was noted at the end of MDT among ENL and unreactional lepromatous patients. Accordingly, although TNF-a (tumor necrosis factor) levels were enhanced in the sera of 70.6% of the ENL patients tested, no relationship was noted between circulating TNF-a levels and the decrease in BI detected at the onset of the reactional episode. Evaluation of bacterial viability of M. leprae isolated from the reactional lesions showed no growth in the mouse footpads. Only 20% of the patients demonstrated specific immune response to M. leprae during ENL. Moreover, high levels of soluble IL-2R (interleukin-2 receptor) were present in 78% of the patients. Circulating anti-neural (anti-ceramide and anti-galactocerebroside antibodies) and anti-mycobacterial antibodies were detected in ENL patients' sera as well, which were not related to the clinical course of disease.

Our data suggest that bacterial killing is enhanced during reactions. Emergence of specific immune response to M. leprae and the effective role of TNF-a in mediating fragmentation of bacteria still need to be clarified.

Keywords: Leprosy, M. leprae; TNF-a, interleukin-2 receptor; ENL; Cytokines; Mycobacterial antigens.

RESUMO

Dados recentes sugerem que o curso clínico dos estados reacionais na lepra está estritamente relacionado à liberação local ou sistêmica de citocinas. Neste estudo, pacientes com ENL (erythema nodosum leprosum) foram grupados segundo a intensidade de seus sintomas clínicos. Os aspectos clínicos e imunológicos do ENL e os efeitos desses parâmetros na carga bacilar foram estabelecidos em conjunção com a resposta imune in vitro desses pacientes, a antígenos microbacterianos. Em 10 de 17 pacientes testados, o índice bacteriano (IB) foi reduzido cm pelo menos 1 log desde o diagnóstico da lepra até o aparecimento do primeiro episódio reacional, comparado a uma redução esperada de 0.3 log no grupo não reacional no mesmo período de MDT (multidrogaterapia). Entretanto, nenhuma diferença na taxa de redução do IB foi notada no final da MDT entre os pacientes ENL e os lepromatosos não reacionais. Assim também, embora os níveis de TNF-a (fator de necrose tumoral) estivessem aumentados no soro de 70,6% dos pacientes com ENL testados, nenhuma relação foi notada entre os níveis circulantes de TNF-a e a diminuição do IB detectada no aparecimento do primeiro episódio reacional. A avaliação da viabilidade bacteriana do M. leprae isolado de lesões reacionais não mostrou crescimento na pata de camundongo. Somente 20% dos pacientes demonstraram resposta imune específica ao M. leprae durante o ENL. Além disso altos níveis de IL-2R (receptor de interleucina 2) solúvel estiveram presentes em 78% dos pacientes. Anticorpos circulantes anti-nervo (anti-ceramídio e anti-galactocerebrosídio) e anti-micobacterianos foram também detectados no soro dos pacientes, e não estiveram relacionados ao curso clínico da doença.

Nossos dados sugerem que a morte bacteriana está aumentada durante as reações. A emergência de resposta imune específica ao M. leprae e o papel efetivo do TNF-a na mediação de fragmentação bacteriana necessita ainda ser esclarecida.

Full text available only in PDF format.

Texto completo disponível apenas em PDF.

ACKNOWLEDGEMENTS

We thank to R.B. Oliveira for technical assistance. Thanks are also due to A.R. de Moura and M.M.S.B. Pinheiro for the graphic work and E.R. Leite for efficient secretarial help. Dr. L.M.M. Vieira is a Visiting Professor at Leprosy Laboratory, Oswaldo Cruz Foundation, and a FAPERJ fellow. This study was supported in part by UNDP/World Bank/TDR-WHO.

Recebido para publicação em 25/09/1995

Aceito para publicação em 14/02/1996

1. ATTIYAH, R.A.; MORENO, C. & ROOK, G.A.W. - TNF-a-mediated tissue damage in mouse footpads primed with mycobacterial preparations. Res. Immunol., 143: 601-610, 1992.
2. BOYUM, A. - Isolation of mononuclear cells and granulocytes from human blood. Scand. J. clin. Invest., 21 (suppl.): 97-105, 1968.
3. CAMPEN, D.H.; HORWITZ, D.A.; QUISMORIO JR., F.P.; EHRESMANN, G.R. & MARTIN, W.J.- Serum levels of interleukin-2 receptor and activity of rheumatic diseases characterized by immune system activation. Arthr. and Rheum., 31: 1358-1364, 1988.
4. CHANG, T.W.; MCKINNEY, S.; LIU, V. et al. - Use of monoclonal antibodies as sensitive and specific probes for biologically active human g-interferon. Proc. nat. Acad. Sci. (Wash.), 81: 5219-5222, 1984.
5. CÓRSICO, B.; CROCE, M.V.; MUKHERJEE, R. & SEGAL-EIRAS, A. - Identification of myelin basic proteins in circulating immune complexes associated with lepromatous leprosy. Clin. Immunol. Immunopath., 71: 38-43, 1994.
6. KAPLAN, G.; WEINSTEIN, D.E.; STEINMAN, R.M. et al. - An analysis of in vitro T cell responsiveness in lepromatous leprosy. J. exp. Med., 159: 917-929, 1985.
7. KINDLER, V; SAPPINO, A.P.; GRAU, G.E.; PIGUET, P.F. & VASSALI, P. - The inducing role of tumor necrosis factor in the development of bactericidal granulomas during BCG infection. Cell, 56: 731-740, 1989.
8. LAAL, S.; BHUTANI, L.K. & NATH, J. - Natural emergence of antigen-reactive T cells in lepromatous leprosy patients during erythema nodosum leprosum. Infect. Immun., 50: 887-892, 1985.
9. MEDEIROS, G.N.; CAVALIERI, H.; KNOBEL, M. et al. - Tyroid autoantibodies and soluble interleukin-2 receptor levels in patients with active and inactive acromegaly. Endocr. J., 2: 289-295, 1994.
10. MUKHERJEE, R.; THOMAS, B.M.; VEMURI, N. & TALWAR, G.P. - Nerve antigen based serological tests for the diagnosis and prognosis of leprosy. Trop. Med. Parasit., 41: 357-358, 1991.
11. PARIDA, S.K.; GRAU, G.E.; ZAHFER, S.A. & MUKHERJEE, R. - Serum tumor necrosis factor and interleukin 1 in leprosy and during lepra reactions. Clin. Immunol. Immunopath., 62: 23-27, 1992.
12. PISA, P.; GENNENE, M.; SODER, O. et al. - Serum tumor necrosis factor levels and disease dissemination in leprosy and leishmaniasis. J. infect. Dis., 161: 988-991, 1990.
13. RAO, R.D. & RAO, P.R. - Enhanced cell-mediated immune response in erythema nodosum leprosum reactions of leprosy. Int. J. Leprosy, 55: 36-41, 1987.
14. RIDLEY, D.S. & JOPLING, W.H. - Classification of leprosy according to immunity. A five group system. Int. J. Leprosy, 34: 255-273, 1966.
15. RIDLEY, D.S. - Bacterial indices. In: COCHRANE, R.G. & DAVEY, T., ed. Leprosy in theory and practice. 2. ed. Bristol, John Wright & Sons, 1964. Appendix III, p. 612-622.
16. SAMPAIO, E.P.; MOREIRA, A.L.; SARNO, E.N.; MALTA, A.M. & KAPLAN, G. - Prolonged treatment with recombinant interferon-g induces erythema nodosum leprosum in lepromatous leprosy patients. J. exp. Med., 175: 1729-1737, 1992.
17. SAMPAIO, E.P.; KAPLAN, G.; MIRANDA, A. et al. - The influence of thalidomide on the clinical and immunological manifestation of ENL. J. infect. Dis., 168: 408-414, 1993.
18. SARNO, E.N.; GRAU, G.E.; VIEIRA, L.M.M. & NERY, J. A. - Serum levels of tumour necrosis factor-alpha and interleukin-1b during leprosy reactional states. Clin. exp. Immunol., 84: 103-108, 1991.
19. SCHEINBERG, M.A.; IKEJIRI, M.; SILVA, H.M. & MOTA, M.I. - Interleukin-2 receptor membrane and in soluble form in the aqueous humor and peripheral blood of patients with acute untreated uveites. J. Reum., 29: 1362-1363, 1962.
20. SCHULZE-OSTHOFF, K.; BAKKER, A.C.; VANHAESEBROECK, B. et al. - Cytotoxic activity of tumor necrosis factor is mediated by early damage of mitochondrial functions. J. biol. Chem., 267: 5317-5320, 1993.
21. SHEPARD, C.C. - The experimental disease that follows the injection of human leprosy bacilli into footpads of mice. J. exp. Med., 112: 445-454, 1960.
22. SHEPARD, C.C. & McRAE, D.H. - Mycobacterium leprae in mice: minimal infectious dose, relationship between staining quality and infectivity and effect of cortisone. J. Bact., 89: 365-372, 1965.
23. SILVA, C.L. & FOSS, N.T. -Tumor necrosis factor in leprosy patients. J. infect. Dis., 159: 787-790, 1989.
24. SULLIVAN, L.; SANO, S.; PIRMEZ, C. et al. - Expression of adhesion molecules in leprosy lesions. Infect. Immun., 59: 4154-4160, 1991.
25. SYMONS, J.A.; WOOD, N.C.; DI GIOVINE, F.S. & DUFF, G.W. - Souble IL-2 receptor in rheumatoid arthritis. Correlation with disease activity, IL-1 and IL-2 inhibition. J. Immunol., 141: 2612-2618, 1988.
26. TUNG, K.S.K.; UMLAND, E.; MATZNER, P. et al. - Soluble serum interleukin 2 receptor levels in leprosy patients. Clin. exp. Immunol., 68: 10-15, 1987.
27. VOGELS, M.T.E.; HERMSEN, C.C.; HUYS, H.L.P.; ELING, W.M.C. & MEER, W.M. - Role of tumor necrosis factor alpha, granulocyte-macrophage colony-stimulating factor, platelet-activating factor, and arachidonic acid metabolites in interleukin-1 - induced resistance to infection in neutropenic mice. Infect. Immun., 62: 2065-2070, 1994.
28. WASIK, M.A.; SIOUTOS, N.; TUTTLE, M. et al. - Constitutive secretion of soluble interleukin-2 receptor by human T cell lymphoma xenografted into SCID mice. Correlation of tumor volume with concentration of tumor-derived soluble interleukin-2 receptor in body fluids of the host mice. Amer. J. Path., 144: 1089-1097, 1994.
29. WATERS, M.F.R.; TURK, J.L. & WEMAMBU, S.N.C. - Mechanisms of reactions in leprosy. Int. J. Leprosy, 39: 417-428, 1971.
30. WEMAMBU, S.N.C; TURK, J.L.; WATERS, M.F.R & REES, R.J.W. - Erythema nodosum leprosum: a clinical manifestation of the arthus phenomenon. Lancet, 2: 933-935, 1969.

Correspondence to:

Dr. Euzenir N. Sarno

Leprosy Unit, Oswaldo Cruz Foundation

Avenida Brasil 4365, Manguinhos

21045-900 Rio de Janeiro, RJ, Brazil

Publication Dates

Publication in this collection
22 Sept 2006
Date of issue
Apr 1996

History

Accepted
14 Feb 1996
Received
25 Sept 1995

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. ATTIYAH, R.A.; MORENO, C. & ROOK, G.A.W. - TNF-a-mediated tissue damage in mouse footpads primed with mycobacterial preparations. Res. Immunol., 143: 601-610, 1992.

[2] 2. BOYUM, A. - Isolation of mononuclear cells and granulocytes from human blood. Scand. J. clin. Invest., 21 (suppl.): 97-105, 1968.

[3] 3. CAMPEN, D.H.; HORWITZ, D.A.; QUISMORIO JR., F.P.; EHRESMANN, G.R. & MARTIN, W.J.- Serum levels of interleukin-2 receptor and activity of rheumatic diseases characterized by immune system activation. Arthr. and Rheum., 31: 1358-1364, 1988.

[4] 4. CHANG, T.W.; MCKINNEY, S.; LIU, V. et al. - Use of monoclonal antibodies as sensitive and specific probes for biologically active human g-interferon. Proc. nat. Acad. Sci. (Wash.), 81: 5219-5222, 1984.

[5] 5. CÓRSICO, B.; CROCE, M.V.; MUKHERJEE, R. & SEGAL-EIRAS, A. - Identification of myelin basic proteins in circulating immune complexes associated with lepromatous leprosy. Clin. Immunol. Immunopath., 71: 38-43, 1994.

[6] 6. KAPLAN, G.; WEINSTEIN, D.E.; STEINMAN, R.M. et al. - An analysis of in vitro T cell responsiveness in lepromatous leprosy. J. exp. Med., 159: 917-929, 1985.

[7] 7. KINDLER, V; SAPPINO, A.P.; GRAU, G.E.; PIGUET, P.F. & VASSALI, P. - The inducing role of tumor necrosis factor in the development of bactericidal granulomas during BCG infection. Cell, 56: 731-740, 1989.

[8] 8. LAAL, S.; BHUTANI, L.K. & NATH, J. - Natural emergence of antigen-reactive T cells in lepromatous leprosy patients during erythema nodosum leprosum. Infect. Immun., 50: 887-892, 1985.

[9] 9. MEDEIROS, G.N.; CAVALIERI, H.; KNOBEL, M. et al. - Tyroid autoantibodies and soluble interleukin-2 receptor levels in patients with active and inactive acromegaly. Endocr. J., 2: 289-295, 1994.

[10] 10. MUKHERJEE, R.; THOMAS, B.M.; VEMURI, N. & TALWAR, G.P. - Nerve antigen based serological tests for the diagnosis and prognosis of leprosy. Trop. Med. Parasit., 41: 357-358, 1991.

[11] 11. PARIDA, S.K.; GRAU, G.E.; ZAHFER, S.A. & MUKHERJEE, R. - Serum tumor necrosis factor and interleukin 1 in leprosy and during lepra reactions. Clin. Immunol. Immunopath., 62: 23-27, 1992.

[12] 12. PISA, P.; GENNENE, M.; SODER, O. et al. - Serum tumor necrosis factor levels and disease dissemination in leprosy and leishmaniasis. J. infect. Dis., 161: 988-991, 1990.

[13] 13. RAO, R.D. & RAO, P.R. - Enhanced cell-mediated immune response in erythema nodosum leprosum reactions of leprosy. Int. J. Leprosy, 55: 36-41, 1987.

[14] 14. RIDLEY, D.S. & JOPLING, W.H. - Classification of leprosy according to immunity. A five group system. Int. J. Leprosy, 34: 255-273, 1966.

[15] 15. RIDLEY, D.S. - Bacterial indices. In: COCHRANE, R.G. & DAVEY, T., ed. Leprosy in theory and practice. 2. ed. Bristol, John Wright & Sons, 1964. Appendix III, p. 612-622.

[16] 16. SAMPAIO, E.P.; MOREIRA, A.L.; SARNO, E.N.; MALTA, A.M. & KAPLAN, G. - Prolonged treatment with recombinant interferon-g induces erythema nodosum leprosum in lepromatous leprosy patients. J. exp. Med., 175: 1729-1737, 1992.

[17] 17. SAMPAIO, E.P.; KAPLAN, G.; MIRANDA, A. et al. - The influence of thalidomide on the clinical and immunological manifestation of ENL. J. infect. Dis., 168: 408-414, 1993.

[18] 18. SARNO, E.N.; GRAU, G.E.; VIEIRA, L.M.M. & NERY, J. A. - Serum levels of tumour necrosis factor-alpha and interleukin-1b during leprosy reactional states. Clin. exp. Immunol., 84: 103-108, 1991.

[19] 19. SCHEINBERG, M.A.; IKEJIRI, M.; SILVA, H.M. & MOTA, M.I. - Interleukin-2 receptor membrane and in soluble form in the aqueous humor and peripheral blood of patients with acute untreated uveites. J. Reum., 29: 1362-1363, 1962.

[20] 20. SCHULZE-OSTHOFF, K.; BAKKER, A.C.; VANHAESEBROECK, B. et al. - Cytotoxic activity of tumor necrosis factor is mediated by early damage of mitochondrial functions. J. biol. Chem., 267: 5317-5320, 1993.

[21] 21. SHEPARD, C.C. - The experimental disease that follows the injection of human leprosy bacilli into footpads of mice. J. exp. Med., 112: 445-454, 1960.

[22] 22. SHEPARD, C.C. & McRAE, D.H. - Mycobacterium leprae in mice: minimal infectious dose, relationship between staining quality and infectivity and effect of cortisone. J. Bact., 89: 365-372, 1965.

[23] 23. SILVA, C.L. & FOSS, N.T. -Tumor necrosis factor in leprosy patients. J. infect. Dis., 159: 787-790, 1989.

[24] 24. SULLIVAN, L.; SANO, S.; PIRMEZ, C. et al. - Expression of adhesion molecules in leprosy lesions. Infect. Immun., 59: 4154-4160, 1991.

[25] 25. SYMONS, J.A.; WOOD, N.C.; DI GIOVINE, F.S. & DUFF, G.W. - Souble IL-2 receptor in rheumatoid arthritis. Correlation with disease activity, IL-1 and IL-2 inhibition. J. Immunol., 141: 2612-2618, 1988.

[26] 26. TUNG, K.S.K.; UMLAND, E.; MATZNER, P. et al. - Soluble serum interleukin 2 receptor levels in leprosy patients. Clin. exp. Immunol., 68: 10-15, 1987.

[27] 27. VOGELS, M.T.E.; HERMSEN, C.C.; HUYS, H.L.P.; ELING, W.M.C. & MEER, W.M. - Role of tumor necrosis factor alpha, granulocyte-macrophage colony-stimulating factor, platelet-activating factor, and arachidonic acid metabolites in interleukin-1 - induced resistance to infection in neutropenic mice. Infect. Immun., 62: 2065-2070, 1994.

[28] 28. WASIK, M.A.; SIOUTOS, N.; TUTTLE, M. et al. - Constitutive secretion of soluble interleukin-2 receptor by human T cell lymphoma xenografted into SCID mice. Correlation of tumor volume with concentration of tumor-derived soluble interleukin-2 receptor in body fluids of the host mice. Amer. J. Path., 144: 1089-1097, 1994.

[29] 29. WATERS, M.F.R.; TURK, J.L. & WEMAMBU, S.N.C. - Mechanisms of reactions in leprosy. Int. J. Leprosy, 39: 417-428, 1971.

[30] 30. WEMAMBU, S.N.C; TURK, J.L.; WATERS, M.F.R & REES, R.J.W. - Erythema nodosum leprosum: a clinical manifestation of the arthus phenomenon. Lancet, 2: 933-935, 1969.