INTERNATIONAL JOURNALOF LEPROSY INTERNATIONAL JOURNAL OF LEPROSY · 2006-11-09 · 6 International Journal of Leprosy 2005 CLINICALCASES Case 1. A 76-year-old woman, occa-sional farmer,

1 Received for publication on 11 December 2003. Accepted for publication on 29 November 2004.2 J. Novales-Santa Coloma, M.D., Dermatologist and Chief of Dermatopathology Department; G. Navarrete-

Franco, M.D., Dermatologist and Dermatopathologist, Centro Dermatologico, Dr. Ladislao de la Pascua, MéxicoCity, Mexico; P. Iribe, M.D., Dermatologist and Dermatopathologist; L. D. López-Cepeda, M.D., Dermatologist,Centro Dermatológico Pascua.

Reprint requests to: Josefa Novales, M.D., Vertiz 464 Col. Buenos Aires, c.p. 06780, Mexico D.F., E-mail:[email protected]

INTERNATIONAL JOURNAL OF LEPROSY Volume 73, Number 1Printed in the U.S.A.

(ISSN 0148-916X)

INTERNATIONAL JOURNAL OF LEPROSY

and Other Mycobacterial Diseases

VOLUME 73, NUMBER 1 MARCH 2005

Ulcerative Cutaneous Mycobacteriosis

Due to Mycobacterium ulcerans: Report of

Two Mexican Cases1

Josefa Novales-Santa Coloma, Gisela Navarrete-Franco, Pedro Iribe, and Larissa Dorina López-Cepeda2

ABSTRACTWe report two patients from Central Mexico, with ulcerated cutaneous lesions containing

acid-fast bacilli (AFB) and ultimately diagnosed as Mycobacterium ulcerans disease. Thefirst patient had a long history (11 years) of disease involving multiple lesions of both upperand lower extremities. Histopathological changes included necrosis of the subcutaneous tis-sue with large numbers of extracellular AFB. Cultures at 32°C were “positive for mycobac-teria,” but were not further identified. The polymerase chain reaction for M. ulcerans per-formed on skin bopsies was positive. The lesions improved after treatment with rifampinand isoniazid (INH) for one month, followed by ethambutol and streptomycin.

The second case followed trauma to the right hand, which spread over 2 years to the rightupper extremity, the back, and both legs, with a loss of digits and metacarpal bones of theright hand. The histopathological findings were similar to the first case, including presenceof AFB. PCR for M. ulcerans on extracts of skin biopsies was positive. Rifampin, INH,pyrazinamide, and levofloxacin resulted in marked improvement of the ulcer; ethambutoland streptomycin were later used, also.

We report these cases because they are rare (approximately 6 previous cases were re-ported from Mexico), and both are unusually disseminated. They are significant in alertingthe medical community to M. ulcerans infection, which is still active in Mexico, and thetreatment used has not been reported previously.

RÉSUMÉCet article décrit la maladie de deux patients habitant la région centrale du Mexique, qui

souffraient de lésions cutanées ulcérées contenant des bacilles acido-alcoolo-résistants(AAR) et qui ont finalement été diagnostiqués comme souffrant de maladie causée par

5

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6 International Journal of Leprosy 2005

CLINICAL CASES

Case 1. A 76-year-old woman, occa-sional farmer, born and lived in EsperanzaTarimoro, (Guanajuato, Central Mexico),presented in 1995 with an eleven-year his-tory of an evolving dermatosis, affectingthe left forearm and elbow, index and mid-dle fingers and back of the right hand, theleft thigh on its anterior and lower sides, theknee, and posterior mid-left leg. The lesions

consisted of 10 nodules between 2 to 4 cmin diameter, red-violet in color, with a hardconsistency, and non-pitting edema. Somealso had ulcerations and were drainingbloodstained serum at the center (gummae).Seven ulcers measured 2 to 10 cm in diam-eter had open, undermined borders that al-lowed the introduction of a clamp. The un-derside was necrotic and partially coveredwith purulent secretion (Fig. 1, Case 1). Atthe right knee were three circular scars, 1

Mycobacterium ulcerans. Le premier patient présentait des commémoratifs d’une maladiechronique de 11 années, caractérisée par de nombreuses lésions de l’extrémité des membres.Les lésions histopathologiques comprenaient une nécrose du tissu sous-cutané, associée à detrès nombreux bacilles AAR extracellulaires. Des cultures réalisées à 32°C furent « positivespour les mycobactéries ». La réaction de polymérisation en chaîne (PCR) pour M. ulceransà partir de biopsies cutanées confirma le diagnostic. Les lésions rétrocédèrent après traite-ment par la rifampicine et l’isoniazide (INH) pendant 1 mois, suivi par l’éthambutole et lastreptomycine.

Le second cas était une maladie similaire observée après un traumatisme de la maindroite, qui a progressé chroniquement sur 2 années de l’extrémité du bras droit vers le dos,les deux jambes et qui s’est compliquée de la perte des doigts et des os métacarpiens de lamain droite. Les lésions histopathologiques étaient similaires au premier cas, avec notam-ment la présence de bacilles AAR. La PCR pour M. ulcerans à partir d’extraits de biopsiescutanées fut positive. Rifampicine, INH, pyrazinamide et lévofloxacine a permis d’atteindreune amélioration spectaculaire des lésions ulcérées ; l’éthambutole et la streptomycinefurent ensuite utilisées.

Nous rapportons ces deux cas parce qu’ils sont rares (approximativement 6 cas furentrapportés auparavant au Mexique) et les deux présentaient une forme disséminée inhab-ituelle. De plus, ils sont importants pour alerter la communauté médicale vis-à-vis du risqued’infection par M. ulcerans, qui est encore présent au Mexique, ainsi que pour les modalitésde traitement qui n’ont pas encore été rapportées.

RESUMEN En este artículo presentamos los casos de dos pacientes del Centro de la República Mex-

icana, con lesiones cutáneas ulceradas causadas por Mycobacterium ulcerans. El primer pa-ciente tenía una historia clínica prolongada (11 años) de su enfermedad y mostraba múltipleslesiones en las extremidades superiores e inferiores. Los estudios histopatológicos revelaronnecrosis del tejido subcutáneo, con grandes números de bacilos ácido-resistentes (BAAR).Los cultivos a 32°C fueron “positivos para micobacterias” pero no se hizo el intento de iden-tificar a los microorganismos. La reacción en cadena de la polimerasa (PCR) para M. ulcer-ans en una biopsia de piel fue positiva. En este paciente las lesiones remitieron después deltratamiento con rifampina e isoniazida (INH) durante 1 mes, seguido por etambutol y es-treptomicina.

El segundo caso se descubrió atendiendo un trauma en la mano derecha del paciente. Lainfección se diseminó en el transcurso de 2 años a la extremidad superior derecha, la es-palda, y ambas piernas, y ocasionó la pérdida de los huesos digitales y metacarpales de lamano derecha. Los hallazgos histopatológicos fueron similares a los del primer caso, in-cluyendo la presencia de bacilos ácido-resistentes. La PCR para M. ulcerans en el extractode una biopsia de piel también fue positiva. La rifampina, la INH, la pirazinamida y la lev-ofloxacina condujeron a una notable resolución de la úlcera, después también se usaronetambutol y estreptomicina.

Reportamos estos casos porque son raros (en México sólo se han reportado 6 casos pre-vios) y porque ambos fueron inusualmente diseminados. El reporte de estos casos es impor-tante porque alertará a la comunidad médica sobre la infección por M. ulcerans como unaenfermedad todavía existente en México. El tratamiento utilizado en estos casos no se ha re-portado previamente.

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73, 1 Coloma, et al.: Ulcerative Cutaneous Mycobacteriosis 7

cm in diameter, with erythema and markedswelling.

At the onset there were small, erythema-tous nodules on the legs. Some of these hadhealed spontaneously one year earlier, andnew lesions had appeared on her arms,which ulcerated after 9 mos. Previous treat-ments included home remedies. The initialclinical diagnosis was deep nodular tuber-culosis (Hutchinson type). General medicalexamination revealed a patient in good gen-eral condition. Laboratory analysis showedaleukocytosis with 14,900 white blood cells(83% segmented cells), an incrementedglobular sedimentation rate of 25 mm/hr,and normal hepatic function and chest x-rays.The skin test with 5TU purified protein de-rivate (PPD) was negative.

Two skin biopsies were taken, one fromthe border of the ulcer on the left forearmand the other from the nodule on the left

thigh. Histologically, we observed largenecrosis zones affecting the middle and deepdermis and hypodermis in both biopsies(Figs. 2 and 3). Fite-Faraco stains revealedlarge numbers of acid-fast bacilli (AFB) innecrotic areas, some in clusters and forming“globi,” (Figs. 4 to 7), similar to those de-scribed by MacCallum (15) and Connor(28).

Further analysis of an acid-fast smear ofthe purulent secretion from borders and bot-tom ulcers, using a Ziehl Neelsen stain,revealed clusters of AFB. Cultures onLowenstein-Jensen media at 32°C werepositive for mycobacteria. The cultureswere damaged before further identificationcould be obtained from a referral center.The final diagnosis was Ulcerative Cuta-neous Mycobacteriosis (UCM), species un-known.

Treatment with rifampin 600 mg/day andisoniazid 300 mg/day, and daily soaks of ul-

FIG. 1. Case 1. Ulcerative cutaneous mycobacte-riosis (UCM). Note undermined borders and differentsized ulcers with some purulent secretion.

FIG. 3. Case 1. UCM. Histologic aspect: largenecrotic zones in the subcutis (H&E Original magnifi-cation 20×).

FIG. 4. Case 1. UCM. Numerous acid-fast bacilliisolated or in groups in necrotic zones (H&E Originalmagnification 10×).

FIG. 2. Case 1. UCM. Histologic aspect: largenecrotic areas in the deep dermis and subcutis (H&EOriginal magnification 10×).

01.coloma.005 4/28/05 3:23 PM Page 7


cers in sulfate solution (1:1000) for onemonth resulted in improvement. Rifampinwas discontinued after the patient devel-oped clinical hepatitis attributable to thisdrug. Two weeks later, after hepatic func-tion tests returned to normal, treatment wasinitiated with ethambutol 600 mg/day andstreptomycin 1 gm/day for 15 days, then re-duced to 1 gm every three days, for a totalof 30 gr. With this regimen, the ulcershealed. At this stage the patient returned toher hometown and was lost to follow-up.

Case 2. A 23-year-old male horse-meatmerchant who lived in Chimalhuacán,Mexico (Central Mexico), presented with a2-year evolving dermatosis, affecting thelower right arm and elbow, forearm, anddorsum of the right hand, anterior aspect ofboth legs, and posterior aspect of the leftleg. There were four nodules of 2 cm in di-ameter and 10 ulcers between 1 and 5 cm indiameter with the characteristics describedfor the first case. Some ulcers were commu-nicating and alternated with small areas ofapparently normal skin. The largest ulcera-tive lesion was on the forearm, measuring15 × 25 cm in diameter, with viscous crust,surrounded by scar tissue (Fig. 8), in thearea previously grafted. Scars were present,3 cm in diameter. We also observed absenceof all of the fingers of the right hand, withexception of the thumb and the metacarpalbones.

The disease presented after trauma to theright hand from a prick with a horse bonechip; 15 days later, there was reddening andswelling of the area that quickly extendedto the forearm. At the trauma site, the pa-

tient observed necrosis, which was excised,but despite this the disease continued. Thepatient was then sent to the Instituto Na-cional de Ortopedia in Mexico City in Au-gust 1997, where the forearm lesion wasexcised, four fingers were amputated, andthe metacarpal zone was covered with askin graft. Results were poor and the dis-ease continued. Two years later, the patientwas sent to the Centro Dermatologico Pas-cua (CDP), where the initial clinical diag-nosis was cutaneous tuberculosis. The skintest with 5TU PPD showed 5 mm of indura-tion, and the physical examination was oth-erwise normal. With the history of traumaprecedents, long evolution, and poor re-sponse to the prescribed treatment, we con-sidered the possibility of a diagnosis ofUCM.

Four biopsy specimens were taken fromthe necrotic area on the ulcers of the fore-

FIG. 5. Case 1. UCM. Acid-fast bacilli isolated orin clusters in necrotic zones (H&E Original magnifica-tion 20×).

FIG. 6. Case 1. UCM. Acid-fast bacilli isolated orin clusters in necrotic zones (Fite Faraco. Originalmagnification 40×).

FIG. 7. Case 2. UCM. Acid-fast bacilli isolated or inclusters in necrotic zones (Fite Faraco. Oil immersion).

01.coloma.005 4/28/05 3:23 PM Page 8


arm and leg nodules. Microscopic findingswere similar in all specimens and identicalto those previously described in Case 1,confirming the clinical diagnosis.

Bacilloscopies revealed AFB and an en-zyme-linked immunosorbant assay (ELISA)was positive for Mycobacterium sp., but cul-tures for mycobacteria were negative. Rou-tine laboratory determinations were withinthe normal range.

Surgical cleaning and soaks with sulfatesolutions (1:1000) were carried out twice aday. Rifampin 600 mg/day, isoniazid 300mg/day, pyrazinamide 300 mg/day and levo-floxacin 400 mg/day, were administratedfor two months, with great improvement ofthe ulcers, marked by a decrease of purulentdrainage and necrosis. The nodules, how-ever, persisted. Surgical excision of noduleswas performed and microscopic analysisshowed necrotic zones and numerous acid-fast bacilli. Streptomycin 1 gr intramuscu-larly (IM) every three days (30 gr totaldose) and ethambutol 1200 mg/day werethen administered. Additionally, surgicalcleaning was performed once a week andtopical soaks with sulfate solutions was per-formed daily. After streptomycin was dis-continued, rifampin 600 mg/day was re-sumed with ethambutol 1200 mg/day againfor 10 months, and the cutaneous lesionshealed. (Fig. 9). At present, the patient isunder periodic monitoring and shows no le-sions, and a prosthesis has been fitted to thepatient’s right hand.

Paraffin blocks of biopsies from both pa-tients were sent to Dr. Francois Portaels atthe Institute for Tropical Medicine, Ant-werp, Belgium, for analysis by polymerase

chain reaction. Specimens from both pa-tients were found to contain DNA sequenceIS2404 from M. ulcerans.

DISCUSSIONThe skin ulceration caused by Mycobac-

terium ulcerans was described for the firsttime by MacCAllum, et al. in Australia in1948 (16). In 1950 in the Belgian Congo(now the Democratic Republic of Congo)the first African case was reported (29), andin the same year, Fenner (7) identified thebacillus and named it Mycobacterium ul-cerans. Since 1959, several authors havedescribed numerous patients with thisdisease in tropical and subtropical regionsof Central and West Africa(13). Buruli ulceris recognized as a public health problem,for example, in Uganda, Nigeria, Gabon,Ghana, Cameroon, Liberia, the Ivory Coast(1, 6, 17, 28, 30), Malaysia (22), New Guinea (14),Togo (15), French Guyana (5, 25), and the Re-public of Benin (20). In the Americas, it is anexceptionally rare disease and only a fewcases have been reported. In 1953, Lavalle,et al., reported the first UCM case in Mex-ico (11, 13) and until 1990, only five addi-tional cases from Guanajuato State in Cen-tral Mexico were reported (13, 14, 15).

This mycobacteriosis has been given sev-eral names according to the place where itoccurs or where it has been observed. Forexample, it was called Bairnsdale ulcer inAustralia (17), Buruli ulcer in Uganda (20), andTora ulcer and Mexican ulcer in México (13).Nevertheless, Lavalle proposed the nameof Ulcerative Cutaneous Mycobacteriosis,caused by Mycobacterium ulcerans (15).

Mycobacterium ulcerans is a slowly grow-

FIG. 8. Case 2. UCM. Largest ulcer with infil-trated borders.

FIG. 9. Case 2. UCM. Improvement of ulcers ofthe forearm after four months of treatment.

01.coloma.005 4/28/05 3:23 PM Page 9


ing, acid-fast organism generally consid-ered to be an environmental saprophyte. Itis usually observed in aquatic ecosystems inmarshy terrain, a soil rich in silica, and instagnant bodies of water or near rivers, attemperatures ranging between 32°C and33°C, with pH between 5.5 and 6.9 (8, 20, 21).The bacillus grows best in Lowenstein-Jensen culture medium at 32°C.

The disease affects both sexes and allages, but is more frequent in children be-tween 5 and 14 yrs old (28). In the countrieswhere it is endemic, it is frequent in farmersand may be considered an occupational dis-ease. After tuberculosis and leprosy, M. ul-cerans infection is considered the thirdmost common mycobacterial disease affect-ing non-immunocompromised humans (20).

The exact manner of transmission of M.ulcerans is not known. It is assumed that anot-yet identified environmental factor ex-ists that is related to slowly flowing or stag-nant water and near rivers. There are somereports suggesting possible transmission bymosquito or insect bites (3, 4, 24). However,inoculation appears to occur via trauma toskin, on uncovered, unprotected regions ofthe body. Its topography in adults includeslimbs, especially near joints, predominatlyon legs (knees) and forearms (elbows) (5, 8, 19),but in children it can be found anywhere.

M. ulcerans affects humans by producinga heat-stable exotoxin that causes extensive,chronic, necrotizing damage to the papil-lary skin, subcutaneous fat and muscle (fas-cia and bone are also sometimes affected),resulting in deformity and disability (12).

The lesion begins as a small subcuta-neous swelling, more palpable than visible,that grows slowly until it develops into anodule that is adherent to the skin but not todeep tissues. These nodules are soft, un-dergo liquefaction, and finally ulcerate,with an oily, purulent discharge. Ulcers areoften well defined and the borders are un-dermined. The base of the pristine ulcerscontains a whitish, cotton wool-like sloughand sometimes eschars. Skin surroundingthe lesion becomes hyper-pigmented (15).Ulcers can be small or extensive, involvingeven an entire extremity or large portions ofthe trunk. Microscopic alterations are usu-ally diagnostic, including extensive necrosisof the dermis and large numbers of extracel-lular AFB, in clumps or clusters (2, 6, 16).

Disease evolution can vary in severity. Insome areas, ulcers heal slowly with fibrosisand retraction, even while the disease mayprogress in other areas. Secondary bacterialinfection may develop, but the patient’s gen-eral condition is not affected. There is no re-gional clinical lymphadenopathy nor fever.

The two cases described in this report areparticularly interesting because of the un-usual dissemination of the disease and thelarge number of nodules and ulcers. Thepossible mode of transmission was not ap-parent in the first case, whereas in the sec-ond case, the initial lesion followed traumawith a horse bone chip, similar to one of theLavalle cases (15). This information allowsus to suspect that a direct inoculation wasmade in this case.

The last report of Buruli ulcer the diseasein Mexico was made several years ago, andno reports of other cases have been madesince. This may be attributable to possiblerarity of the disease in Mexico. As Lavallesuggests, the paucity of reports may be a re-sult of a lack of awareness of the disease, orto the status of the public health services inendemic areas. Innate or acquired immunityof the populations may also contribute tolow endemicity.

We conclude that the following featuresmust be considered for the diagnosis of M.ulcerans infection: (i) a chronic dermatosisin a patient with good general health; (ii)the histopathological findings of extensivenecrosis in the dermis and subcutaneous tis-sue and the presence of numerous extracel-lular acid-fast organisms (2, 5, 6).

Although it is difficult to culture this or-ganism, it is now possible to identify theagent by PCR analysis carried out on theskin specimen (10, 20), although in our opin-ion these studies are not necessary for thediagnosis. In both cases presented in this re-port, PCR analysis for M. ulcerans DNAwas performed on paraffin blocks of theskin biopsies, and these studies were donesome years after the diagnoses were made.The treatments were initiated on the basisof clinical and histopathological findings,and the patients healed. This indicates thatthe molecular studies are not indispensableif there is an adequate clinical and histolog-ical study, but PCR contributes to supportthe diagnosis by identifying the mycobacte-rial DNA sequence IS2404.

01.coloma.005 4/28/05 3:23 PM Page 10


Despite the fact that the first cases wereadequately described more than 50 yearsago, there remains no standard effectivetreatment. Surgical excision of skin lesionsand, if necessary, skin graft application inthe initial stages, are considered the besttreatment, in addition to anti-mycobacterialagents. Hyperbaric oxygenation has beenused experimentally (26). This schedule ofantimicrobial treatment was applied in Case2 as described in this report, obtaining acomplete recovery after 12 months. Theregimens used for treatment in both patientshave not been reported previously, and theygive affected patients the possibility ofhealing without important sequelae such asamputation. Additional preventive efforts,such as BCG vaccination (23) and wearinglong pants in endemic regions to protectlower extremities, may help to reduce theincidence of the disease (27).

Acknowledgment. The authors would like tothank Dra. Verónica Morán, for her suggestions forthis report; QFB Misael González, from Juárez Hospi-tal from the Secretaría de Salud in Mexico City, for thebacteriologic and immunologic analysis; and Prof.Françoise Portaels from the Mycobacteriology Depart-ment, Institute for Tropical Medicine, Belgium, for themolecular biology (PCR) studies.

REFERENCES1. CLANCEY, J. K., DODGE, O. G., LUNN, H. F., and

ODUORI, M. L. Mycobacterial skin ulcer inUganda. Lancet 2 (1961) 951–954.

2. CONNOR, D., and LUNN, H. F. Buruli ulceration. Aclinicopathologic study of 38 Ugandans with My-cobacterium ulcerans ulceration. Arch. Path. 81(1966) 183–199.

3. DEBACKER, M., ZINSOU, C., AGUIAR, J., MEYERS,W., and PORTAELS, F. First case of Mycobacte-rium ulcerans disease (Buruli ulcer) following ahuman bite. CID 36 (2003) 67–68.

4. DEBACKER, M., ZINSOU, C., AGUIAR, J., MEYERS,W., and PORTAELS, F. Mycobacterium ulceransdisease (Buruli ulcer) following human bite.Lancet 360 (2002) 1830.

5. DE GENTILE, L., MAHAZA, C., ROLLAND, F., CAR-BONNELLE, B., VERTE, J. L., and CHABASSE, D.L’Ulcere cutane a Mycobacterium ulcerans. APropos D’Une Observation en Provenance deGuyane Francaise. Bull. Soc. Path. Ex. 85 (1992)212–214.

6. DODGE, O. G. Mycobacterial skin ulcers inUganda and Experimental aspects. J. Path. Bact.88 (1964) 167–174.

7. FENNER, F. The significance of the incubation pe-

riod in infectious diseases. Med. J. Austral. 2(1950) 813–818.

8. GRANGE, J. M. Infection and disease due to theenvironmental mycobacteria. Trans. R. Soc. Trop.Med. 81 (1987) 179–182.

9. GRANGE, J. M. Mycobacteria and the skin. Int. J.Trop. Dermatol. 21 (1982) 497–503.

10. GUIMARAES-PERES, A., PORTAELS, F., DE RIJK, P.,FISSETTE, K., PATÍN, S. R., VAN VOOREN, J., andFONTEYNE, P. Comparison of two PCRs for detec-tion of Mycobacterium ulcerans. J. Clin. Micro-biol. 37 (1999) 206–208.

11. HAUTMANN, G., and LOTI, T. Atypical mycobac-terial infections of the skin. Dermatologic. Clinics12 (1994) 657–667.

12. KRIEG, R., HOCKMEYER, W., and CONNOR, D.Toxin of Mycobacterium ulcerans: production andeffects in guinea pig skin. Arch. Dermatol. 110(1974) 783–788.

13. LAVALLE, P. Infección humana por Mycobacte-rium ulcerans. Confirmación del primer caso ob-servado en México. Dermat. Rev. Mex. 1 (1956)5–15.

14. LAVALLE, P., DE OVANDO, F., NOVALES, J., and AY-ALA, J. L. Micobacteriosis cutanea ulcerosa. So-bretiro. Dermat. Rev. Mex. 25 (1981) 325–347.

15. LAVALLE, P., and NOVALES, J. Ulcerative cuta-neous mycobacteriosis by Mycobacterium ulcer-ans. The Mexican experience. Clinical Mycobac-teriology. Prous. Science, S.A.M. Casal Editor(1998) 367–376.

16. MACCALLUM, P., TOLHURST, J. C., BUCKLE, G.,and SISSONS, H. A. A new mycobacterial infectionin MA. J. Path. Bact. 60 (1948) 93–122.

17. MARSTON, B. J., DIALLO, M. O., HORSBURGH,C.R., JR., DIOMANDE, I., SAKI, M. Z., KANGA, J.M., PATRICE, G., LIPMAN, H. B., OSTROFF. S. M.,and GOOD, R. C. Emergence of Buruli Disease inthe Daloa Region of Cote D’Ivoire. Am. J. Trop.Med. Hyg. 52(3) (1995) 219–224.

18. MEYERS, W. M., CONNOR, D. H., MCCULLOUGH,B., BOURLAND, J., MORIS, R., and PROOS, L. Dis-tribution of Mycobacterium ulcerans infections inZaire, including the report of new foci. Ann. Soc.Belge. Med. Trop. 54(3) (1974) 147–157.

19. MEYERS, W. M., SHELLN, W. M., CONNOR, D. H.,and MEYERS, E. Human Mycobacterium ulceransinfections developing at sites of truama to skin. J.Trop. Med. Hyg. 23 (1974) 919–924.

20. MEYERS, W. M., TIGNOKPA, N., PRIULI, G. B., andPORTAELS, F. Mycobacterium ulcerans (Buruli ul-cer): first reported patients in Togo. Br. J. Derma-tol. 134 (1996) 1116–1121.

21. MUELDER, K., and NOUROU, A. Buruli ulcer inBenin. Lancet 336 (1990) 1109–1111.

22. PETTIT, J. H. S., MARCHETTE, N. J., and REES, R. J.W. Mycobacterium ulcerans infection. Clinicaland bacteriological study of the first cases recog-nized in South East Asia. Br. J. Dermatol. 78(1996) 187–197.

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23. PORTAELS, F., AGUIAR, J., DEBACKER, M., GUÈ-DÈNON, A., STEUNOU, C., ZINSOU, C. and MEYERS,W. Mycobacterium bovis BCG vaccination asprophylaxis against Mycobacterium ulcerans os-teomyelitis in Buruli ulcer disease. Infect. Immun.72 (2004) 62–65.

24. PORTAELS, F., ELSEN, P., GUIMARAES-PERES, A.,FONTEYNE, P. A., and MEYERS, W. Insects in thetransmission of Mycobacterium ulcerans infec-tion. Lancet 353 (1999) 986.

25. PRADINAUD, R. E. R., and GROSSHANS, E. LeProbléme des Mycobactérioses cutanées enGuyane Francaise. Bull. Soc. Fr. Derm. Syph. 79(1972) 684–686.

26. PSZOLLA, N., ROBINDRA, M., STRECKER, W., KERN,P., KINZL, L., MEYERS, W., and PORTAELS, F. Buruliulcer: a systemic disease. CID 37 (2003) 78–82.

27. SCHOLESSBERG, D. Other non-tuberculous myco-bacteria and Mycobacterium bovis. In: Tuberculo-sis and Nontuberculous Mycobacterial Infections.New York: WB Saunders Company, 1999. pp.401–402.

28. UGANDA BURULI GROUP: Clinical features andtreatment of pre-ulcerative Buruli lesions (Myco-bacterium ulcerans infections). Br. Med. J. 2(1970) 390–393.

29. VAN OYE, E., and BALLION, M. Faudra-T-Il TenirCompte de ’Une Nouvelle Affection. Á BacilesAcido-Résistants en Afrique (Note Prélimi naire).[Article in French]. Int. J. Lepr. Reprintes Articles19(3) (1951) 327–329.

30. ZIEFER, A., CONNOR, D., and GYBSON, D. W. My-cobacterium ulcerans infection of two patients inLiberia. Int. J. Dermatol. 6 (1981) 362–367.

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It is generally agreed that treatment forleprosy is best integrated into the generalhealth service provision. However, anec-dotal reports from the field suggest that thedecline in registered leprosy prevalence isimpacting the scope of service provisionsand the accessibility of referral services.

The declining investment in leprosy mayalso impact professionals seeking to developchallenging careers. High profile health anddevelopment issues (e.g., AIDS, environ-mental challenges, etc.), which arouse widepublic awareness and elicit strong financialsupport are likely to attract professional in-terest away from leprosy. The dilemma iscompounded because high profile healthand development issues, which arouse widepublic awareness and elicit strong financialsupport, attract the interest of professionalsseeking to develop challenging careers.Furthermore, much of the invaluable clini-cal experience and expertise that has hith-erto been a resource to field programs is in-vested in relatively few exceptional people,

1 Received for publication on 18 July 2004. Ac-cepted for publication on 6 December 2004.

2 H. Cross, B.Sc. Ph.D., Regional Prevention of Dis-ability Consultant (Asia), American Leprosy Missions,Cebu City, the Phillipines.

Reprint requests to: Dr. Hugh Cross, American Lep-rosy Missions, Boz 002, Mail and More, 2nd LevelPaseo Marina, Ayala Center, Cebu Business Park, CebuCity, the Phillipines, E-mail: [email protected]

A Delphi Consensus on Criteria for Contraindications,

Assessment Indicators and Expected Outcomes

Related to Tibialis Posterior Transfer Surgery1

Hugh Cross2

ABSTRACTA team of experts in the field of reconstructive surgery for leprosy-affected people was

identified. Using the Delphi method, an exercise was undertaken to ascertain whether a con-sensus on essential criteria and indicators for Tibialis Posterior Transfer (TPT) could bereached among the team. This paper describes the Delphi Exercise, giving results at eachstage of consensus development. The final outcome was that essential criteria, includingcontraindications for surgery, pre- and post- operative assessments and expected outcomes,were agreed. The criteria are presented with recommendations.

RÉSUMÉ Un groupe d’experts en chirurgie reconstructrice a été mis en place pour les patients souf-

frant de lèpre. En utilisant la méthode de Delphi, un exercice a été entrepris afin de vérifiersi un consensus pouvait être atteint au sein du groupe au sujet des critères essentiels d’indi-cation pour un Transfert du Tibialis Postérieur (TTP). Cet article décrit cet exercice selon laMéthode de Delphi et présente les résultats à chaque étape du développement du consensus.Le résultat final a été qu’un accord général a été obtenu sur des critères essentiels comme lescontre-indications à la chirurgie, les évaluations pré et post-opératoires et les résultats atten-dus. Les critères sont présentés avec des recommandations.

RESUMEN Para este estudio se contactó a un equipo de expertos en el campo de la cirugía recon-

structiva para personas afectadas de lepra. Usando el método Delphi, se realizó un ejerciciopara saber si el equipo podía llegar a un consenso sobre los criterios e indicadores esencialespara la Transferencia Tibial Posterior (TTP). En este artículo se describe el ejercicio de Del-phi y se proporcionan los resultados obtenidos en cada etapa del desarrollo del consenso. Elresultado final del ejercicio fue que hubo concordancia en los criterios esenciales, in-cluyendo las contraindicaciones de la cirugía, las valoraciones pre- y post-operatorias, y losresultados esperados. Se presentan los criterios y las recomendaciones del estudio.

13


(ISSN 0148-916X)

02.cross.013 4/28/05 3:27 PM Page 13


many of whom are already embracing re-tirement. The transfer of knowledge andpractice to ensure that a sound core of ex-pertise is maintained is an issue. There is aconsiderable body of published evidenceupon which a variety of clinical develop-ments can be based, but certain proceduresdo not readily lend themselves to empiricalinvestigation (e.g., criteria for assessmentsor the grading of outcomes). There is acompulsion to act expeditiously so that thewealth of wisdom and experience that doesstill exist may be tapped for present and fu-ture benefit.

A meeting of an international group con-cerned with issues related to the measure-ment of disability was convened in Delhi inDecember 2002. A sub group, mandatedwith the responsibility of discussing issuesrelated to the assessment and measurementof impairment, generated a number of re-search questions. One of the issues raisedwas that of standards for surgery. It wassuggested that surgeons and therapists havethere are widely differing views on criteriafor the variety of surgical interventionscommonly offered to people with the sec-ondary effects of leprosy. It was agreedthat, if possible, it would be beneficial topublish standard assessment criteria for twoprinciple reasons: (i) to assist inexperiencedsurgeons who may need authoritative guid-ance; and (ii) to have standardized proce-dures so that comparative studies may beconducted.

A method to gather information for guid-ance which is less compromised than that ofan individual’s clinical experience in isola-tion is the Delphi method of consensus gen-eration. A review of the method is includedin an article elsewhere in this JOURNAL(Consensus Methods: A Bridge BetweenClinical Reasoning and Clinical Research?See page 28 for this editorial).

It was agreed by the sub group that an at-tempt should be made to apply the method toaddress the issue of assessment criteria for acommon procedure for the correction of footdrop (tibialis posterior transfer a.k.a. TPT).

Some studies of the surgical procedurehave been published. In 1981, Malaviya (2)compared Selvapandian’s surgical methodwith Srinivasan’s. (Malaviya reported follow-up of 78 cases from one to nine years andreported good results for either procedure in

70% of cases.) Malaviya emphasized theimportance of post-operative physiotherapyas an important factor influencing outcome.When current protocols were reviewed forthis study it was found that physiotherapyassessment criteria, and outcome indicatorsgenerally differed between institutions.

Bari, et al. (1) conducted circumtibialtransfer of tibialis posterior and chose “heeltoe gait restoration” and “active dorsiflex-ion” as indicators of success. Soares (3, 4)compared circumtibial with interosseousmethods of tendon transfer. The outcome hewas primarily interested in was recurrentinversion deformity. From the review ofcurrent assessment protocols, it was foundthat the restoration of heel toe gait anddorisiflexion were common but inversiondeformity was not. (In the final draft, theoccurrence of inversion deformity is con-sidered to represent a “failed” procedure).

A criterion that was noticeable by its ab-sence in current assessment protocols wasclient satisfaction. Weber, et al. (5) studied25 cases of TPT using levels of patient sat-isfaction as the outcome of interest. Findingthat 18 were satisfied but 7 were not, Weberconsidered the procedure to be appropriatein a developing country (his study was un-dertaken in Pakistan).

The findings in all the studies cited abovewould have been strengthened if assess-ment methods had been standardized and awider set of outcomes had been considered.

METHODA list of names of internationally recog-

nized surgeons and therapists was gathered.Thirteen people were requested to considerparticipation in the process. Three declinedbut the remaining nine committed them-selves to participation in, and the outcomeof the Delphi Exercise. The participants,hereafter referred to as the “Delphi Team,”remained anonymous throughout the inves-tigation to comply with the demands of theDelphi Exercise.

The Delphi Team comprised: Dr. J. W.Brandsma RPT, PhD, Consultant Physiother-apist, International Nepal Fellowship, Nepal;Dr. M. Ebenezer MBBS, D.Ortho., M.S(Or-tho), Senior Specialist and Deputy Director,Schiefellin Leprosy Research and TrainingCenter, Karigiri, India; Dr. R. Kazan, MD,Formerly Head of Surgery ALERT, Addis

02.cross.013 4/28/05 3:27 PM Page 14

73, 1 Cross: Consensus on Tibialis Posterior Transfer 15

Ababa, Ethiopia, Ms. L. F. Lehman, OTR,MPH, C.Ped, Regional Prevention of Impair-ment and Disability Consultant, AmericanLeprosy Missions (Americas and Africa);Mrs. M. Mahato, MCSP, Prevention Of Dis-ability Coordinator, The Leprosy Mission(India); Dr. M. MacDonald, MB, ChB, Dip O(Auck), Reconstructive Surgeon and MedicalSuperintendent, Anandaban Hospital, TheLeprosy Mission (Nepal); Dr. Narayan Ku-mar, M.S., Consultant Surgeon, Hoina Lep-rosy Research Centre, Muniguda, Orissa, In-dia, Lepra India, German Leprosy ReliefAssociation-India, Swiss Emmaus LeprosyRelief Work-India; Dr. R. J. Schwarz, MD,FRCS, Reconstructive Surgeon and MedicalSuperintendent, Green Pastures Hospital andRehabilitation Centre, International NepalFelllowship; and Dr. H. Srinivasan, FRCS(Eng. & Edin), Formerly Sr. OrthopaedicSurgeon, Central Leprosy Teaching and Re-search Institute, Chingleput (S. India); Dr. M.Virmond, MD, PhD, Director, Instituto Laurode Souza Lima, Bauru, Brazil.

The Sequence of developments in theDelphi Exercise:

Stage 1. An initial letter explaining theDelphi process and inviting participationwas sent, by email, to potential Delphimembers. The message had a request that,should they agree to participate, theyshould submit any contemporaneous TPTassessment forms known to them.

Stage 2. Collation of information fromassessment forms.

Stage 3. Dispatch of collated criteria forrating by Team Members.

Stage 4. Scoring of results from ratingexercise.

Stage 5. Dispatch of agreed criteria forfurther refinement by Team Members: i.e.,contraindications, assessment indicatorsand expected outcomes.

Stage 6. Collation of results from refine-ment exercise

Stage 7. Dispatch of Draft “Gold Stan-dard” Criteria for final consideration byDelphi Team.

Stage 8. Final adjustments to Gold Stan-dard in accordance with feedback from Del-phi Team.

Stage 9. Presentation of final product(Gold Standard) to the Delphi Team.

Stage 10. Dissemination of the DelphiExercise outcome.

Stages 1 and 2: Collation of Informa-tion. Eight people submitted assessmentforms from which information was collatedby the coordinator. A list was compiledwhich included all the criteria contained inthe various forms. On examining the as-sessment forms, it was apparent that theprocess of assessment progressed throughstages with key components taking promi-nence at each stage. A total of 69 discretecriteria for screening and pre-operative as-sessment were identified in the assessmentforms that had been submitted. These crite-ria applied to five essential stages of assess-ment, which were identified as: (i) InitialScreening; (ii) Pre-Physiotherapy—Psycho-Social; (iii) Pre-Physiotherapy—Physical;(iv) Pre-Physiotherapy—Physical—MuscleGrading (MRC); and (v) Pre-OperativeScreening.

From the assessment forms that weresubmitted only 16 of 69 criteria were com-mon to 5 or more forms.

TPT assessment forms included post op-erative assessments. The number of discretecriteria identified in post-operative assess-ments was 44, but only 3 criteria werefound to be common to 5 or more of theforms submitted.

Stage 3. All discrete criteria were tabu-lated. The task, as explained to the DelphiTeam, is given below (Note. Full tablesavailable on-line from the ILA website,www.leprosy-ila.org. They may also be ob-tained from the author.)

(i) The tables contained lists of all thecriteria collated from the assessment formsthat were sent to the coordinator.

(ii) Eight people had submitted formsthat were in use, at divers’ institutions, atthe time of the exercise. Where 5 or morepeople submitted forms that contained thesame criteria, such criteria were considered“essential.” These criteria were listed in thetable but did not require any further consid-eration.

(iii) A column denoted “F” was in-cluded. The number related to the numberof forms from different institutions where aparticular criterion was already being used.

(iv) Each team member was required torank every criterion except those that werealready accepted as “essential.” The rankoptions were: Should be omitted, Not Use-ful, Neutral, Useful, and Essential.

02.cross.013 4/28/05 3:27 PM Page 15


Team members were informed that it wouldbe assumed that personal details of patients(including hospital number, etc.) would beincluded in all assessments, along with thename of the person undertaking the assess-ment. It was also assumed that the generalhealth of the patient will be assessed beforeconsideration of surgery. Criteria relating toGeneral Health, therefore, were not in-cluded either. Team members were re-minded, however, that an aim of the exer-cise was to produce an assessment form thatcould be used with confidence by surgeonsand therapists who may have limited or noexperience with leprosy.

Stage 4. Nine people responded to the re-quest to complete the task of ranking thecriteria.

Each rank was given a score. Descendingnegative scores were given where membershad ranked a criterion as either “Not useful”or “Should be omitted.” If a criterion wasranked as “Neutral” it was scored as 0. As-cending positive scores were given wheremembers had ranked a criterion as either“Useful” or “Essential.” With nine mem-bers contributing, the final score for eachcriterion represented the mean of the nineresponses.

Criteria were judged as follows:Score <1. The indication was that the cri-

terion is Not Acceptable and should be re-jected.

Score >1<2. The indication was that thecriterion is Acceptable and should thereforebe included for further consideration.

Score >2<3. The indication was that thecriterion is Useful and should therefore beincluded.

Score >3. The indication was that the cri-terion is Essential.

Stage 5. All criteria meeting acceptancewere tabulated and resubmitted to the Del-phi Team for their information (please seeAppendix 2). Two criteria were withdrawnbecause they caused confusion (gauged bycomments from team members).

This stage of the exercise also requiredthat the Delphi Team should again considerthe criteria and state how the criteria shouldbe used as indicators and contra-indicatorsfor surgery. Post operative assessment crite-ria were also tabulated with key assessmenttimes (according to the group vote). TheDelphi Team was asked to consider the cri-

teria for assessment and, to give a concisedescription of expected outcomes.

Stage 6. Contraindications for TPT sur-gery. Eight people submitted suggestions forcontraindications. Where 4 or more peopleidentified the same or similar contraindica-tion, the suggestion was recorded as an “ab-solute contraindication.” Where fewer than 4people submitted a suggestion, the con-traindication was recorded as a “relative con-traindication.”

Expected Post Operative Outcomes. Whilesimilar in meaning, the outcomes that weresubmitted were different in the way theywere expressed. This was due mainly to themethod, which at this stage was more opento personalized expression. To tabulate theexpected outcomes, the most representativeexpression of an item was selected by thecoordinator. The manner in which itemswere represented was also edited for clarityand conformity by the coordinator.

Stage 7. On receipt of the responses fromstage 6, the assessment criteria, with con-traindications, were again tabulated as werethe expected outcomes. These tables wereresubmitted to the Delphi Team as “thedraft Gold Standard.” Assurance was giventhat should 4 or more people requestchanges to any one item in the tables, suchrequests would be implemented (this wasbecause the wording had been edited by thecoordinator and was therefore subject to hisinterpretation). It was reiterated, however,that the screening, assessment and outcomecriteria per se were no longer negotiable(see Appendix 3).

At this stage, team members were madeknown to each other and the process wasopened for discussion should the team wishto inter-relate, mindful that the objective ofthe exercise was to present a consensus oncriteria that could be recommended as“Gold Standards” for TPT protocol. Theaim was not to produce an actual protocol,but that the criteria should represent the keyelements for prospective protocols (actualprotocols will be institution-specific).

Members were requested to consider thefollowing options and then to indicate theirchoice to the coordinator: (i) Endorse theelements as they stood. (This was to be thepreferred choice if members were satisfiedwith the contraindications, assessment cri-teria, and expected outcomes as given in the

02.cross.013 4/28/05 3:27 PM Page 16


draft “Gold Standard.” If at least 70% of themembers agreed to endorse the criteria thenthe element would be presented as a “GoldStandard.”); (ii) Endorse the elements, butoffer personal comments to augment them;(iii) Request delay of endorsement pendingfurther discussion; (iv) Reject the elements.

Stage 8. Nine members responded to therequest for refinement of the draft “GoldStandard.” Three members endorsed the el-ements as they stood. Six others had somecriticism of, or sought clarification of dif-ferent criteria, but no criterion had morethan 2 requests for the removal or alterationof the criterion. None of the members ex-pressed dissatisfaction with the outcome inits entirety.

In response to requests, the coordinatoraltered the wording of three elements thathad consistently caused confusion.

Stage 9. The final draft of Gold StandardCriteria for TPT was circulated to all mem-bers with expressions of gratitude for theircollaboration.

Stage 10. Papers drawn from the processand outcome of the exercise were writtenup for publication.

RESULTSOn the basis of consensus as described in

Delphi methodology, a list of criteria wasagreed on by a panel of recognized experts.The list includes:

• Criteria for the initial screening of po-tential candidates for Tibialis PosteriorTransfer (foot drop correction). Thereare 10 essential criteria that should beconsidered when screening patients forsuitability for surgery. Relative and ab-solute contraindications (or both) aregiven (Table 1).

• Pre-operative assessments. There are20 criteria that should be considered es-sential aspects of examination beforephysiotherapy to prepare a person forsurgery, and 5 essential criteria thatshould be satisfied during a surgeonspre-operative examination. For each ofthese examination criteria, either a rela-tive or absolute contraindication (orboth) are given (Table 2).

• Post-operative assessments. There are17 essential criteria that should be ex-amined post-operatively. Expected out-

comes at periods after surgery are given(Table 3). Key post operative dates arefixed at: (i) one day after plaster ofParis removal; (ii) four weeks after postoperative physiotherapy; (iii) between3 to 6 months after post operative phys-iotherapy.

DISCUSSIONSound empirical evidence is the most re-

liable basis on which clinical practiceshould be developed. There are situations,however, where the authority of individualsis validated by peer recognition of their ex-perience and expertise. It is not sound torecommend practice based on the reputa-tion of a single individual. Where a ho-mogenous group of recognized experts candevelop and endorse recommendations,however, the outcomes have internal valid-ity and can be recommended. The valida-tion of standardized assessment criteriawill, furthermore, facilitate comparativestudies which may yield empirical data thatwill further enhance the development ofclinical practice.

Delphi is a method of consensus develop-ment among homogenous groups. Whilethe design does control the negative effectsof open group interaction it does also losesome of the positive effects of open interac-tion: e.g., idea generation. In this study,some members registered frustration withthe isolation demanded by anonymity andseclusion and suggested that they wouldhave preferred direct discussion and per-sonal interaction. However, domination andcontrol were avoided by the process thus al-lowing greater freedom of expression bysome who may otherwise have perceivedthreat.

A Delphi Exercise is often protracted.The investigation presented here took 18months to complete. The principal reasonfor this problem was the demands on thetime of individuals in the Delphi Team.Without the immediacy and urgency dic-tated by the constraints of a physical meet-ing, members may be distracted from thetask to attend to more pressing matters.However, an advantage of the method isthat it can draw on the resources of individ-uals from diverse locations without thecosts and inconvenience of physically as-sembling an international group.

02.cross.013 4/28/05 3:27 PM Page 17


TAB

LE

1.Sc

reen

ing

for

TP

TC

andi

date

s

Cri

teri

onA

bsol

ute

Con

trai

ndic

atio

nR

elat

ive

Con

trai

ndic

atio

n

Pre-

Phys

ioth

erap

y—D

eter

min

e L

epro

sy S

tatu

sT

reat

men

t sta

tus

Patie

nt h

as n

ot c

ompl

eted

3 m

onth

s of

PB

le

pros

y tr

eatm

ent o

r 6

mon

ths

MB

lepr

osy

Patie

nt is

cur

rent

ly ta

king

MD

Ttr

eatm

ent

trea

tmen

tD

urat

ion

of p

aral

ysis

Les

s th

an 6

mon

ths

(If

unce

rtai

n of

dur

atio

n, q

uery

neu

rolo

gica

l te

stin

g an

d tr

eatm

ent g

iven

bef

ore

proc

eedi

ng)

Pre-

Phys

ioth

erap

y—D

eter

min

e N

euro

logi

cal S

tatu

sM

onofi

lam

ent S

ensi

bilit

y Te

stIs

ther

e a

hist

ory

of r

eact

ion

in th

e pr

evio

us 6

mon

ths

Patie

nt h

as p

rese

nted

with

rea

ctio

n, o

r ac

ute

neur

itis

with

in 6

mon

ths

prio

r to

co

nsid

erat

ion

for

surg

ery.

Has

the

patie

nt b

een

on s

tero

id tr

eatm

ent w

ithin

the

prev

ious

Pa

tient

has

rec

eive

d st

eroi

d th

erap

y w

ithin

6

mon

ths

3 m

onth

s pr

ior

to c

onsi

dera

tion

for

surg

ery

Pre-

Phys

ioth

erap

y—Ps

ycho

Soc

ial S

cree

ning

Wha

t is

the

patie

nt’s

occ

upat

ion

Doe

s th

e pa

tient

und

erst

and:

•Pa

tient

app

ears

to h

ave

unre

alis

tic e

xpec

tatio

ns•

Obj

ectiv

es o

f su

rger

y•

If th

ere

is n

o un

ders

tand

ing

of r

equi

rem

ent f

or

•T

hat s

urge

ry w

ill n

ot c

hang

e lo

ss o

f ne

rve

mod

aliti

esac

tive

part

icip

atio

n su

rger

y sh

ould

be

•T

hat a

ctiv

e co

llabo

ratio

n w

ill b

e re

quir

ed f

orde

laye

d un

til a

cle

ar u

nder

stan

ding

and

su

cces

sful

out

com

eco

mm

itmen

t can

be

assu

red

Doe

s th

e pa

tient

und

erst

and

and

acce

pt:

•T

ime

requ

ired

(in

clud

ing

pre

and

post

ope

rativ

e Pa

tient

can

not c

omm

it to

at l

east

1 m

onth

Patie

nt s

how

s di

sint

eres

t to

do a

dequ

ate

phys

ioth

erap

y)in

activ

ity (

wor

k, f

amily

obl

igat

ions

or

pre

surg

ical

trai

ning

and

pre

para

tion

dist

ance

may

pro

hibi

t)•

Tim

e of

red

uced

act

ivity

req

uire

d be

fore

res

umin

g no

rmal

act

ivity

Can

the

patie

nt d

emon

stra

te a

dequ

ate

self

car

eD

oes

not p

ract

ice

Self

-car

eH

as th

ere

been

an

asse

ssm

ent o

f th

e ac

tiviti

es o

f da

ily li

ving

and

the

patie

nts

part

icip

atio

n in

soc

ial a

ctiv

ities

02.cross.013 4/28/05 3:27 PM Page 18


TAB

LE

2.E

xam

inat

ion

of T

PT

Can

dida

tes

Cri

teri

onA

bsol

ute

Con

trai

ndic

atio

nR

elat

ive

Con

trai

ndic

atio

n

Pre

Phys

ioth

erap

y—Ph

ysic

al E

xam

inat

ion

Any

sig

ns (

or h

isto

ry)

of n

euro

logi

cal b

one

diso

rgan

izat

ion

Act

ive

neur

olog

ical

bon

e di

sorg

aniz

atio

n (N

BD

)H

isto

ry o

f N

BD

Skin

Con

ditio

nU

lcer

atio

n, f

unga

l inf

ectio

n or

der

mat

itis

on th

eU

lcer

atio

n on

any

oth

er b

ody

part

foot

to b

e op

erat

ed o

nA

ny o

ther

eye

han

d or

foo

t im

pair

men

tsIn

abili

ty to

use

cru

tche

sIs

ther

e an

y co

ntra

ctur

e of

pla

ntar

flexo

r m

uscl

esJo

int L

imita

tion

/ blo

ck r

estr

ictin

g do

rsifl

exio

n(M

ay b

e ad

dres

sed

prio

r to

sur

gery

)W

hat i

s th

e po

sitio

n of

the

foot

at r

est (

inve

rted

or

ever

ted)

If th

e fo

ot is

fixe

d in

eith

er in

vers

ion

or e

vers

ion

Defi

ne q

ualit

y an

d ra

nge

of m

otio

n at

foo

t joi

nts

othe

r th

an th

ean

kle

join

tD

efine

gai

t pat

tern

App

aren

t CN

S pr

oble

ms

caus

ing

gait

chan

ges

(spa

stic

ity)

Des

crib

e ar

ch a

rchi

tect

ure

Asc

erta

in w

heth

er p

atie

nt c

an u

se c

rutc

hes

Des

crib

e th

e ty

pe o

f fo

otw

ear

that

has

bee

n us

ed a

nd th

edu

ratio

n of

usa

geM

RC

Gra

ding

:T

ib. A

nter

ior

Ext

. Hal

. Lon

gus

Ext

. Dig

. Lon

gus

Flex

. Hal

. Lon

gus

Flex

. Dig

. Lon

gus

Per.

Lon

gus

Per.

Bre

vis

Tib

. Pos

teri

orL

ess

than

MR

C g

rade

4Te

ndo

Ach

. / G

asto

chne

miu

sIs

ther

e ev

iden

ce o

f cl

aw to

esPr

e O

pera

tive

Exa

min

atio

nSk

in c

ondi

tion

Ulc

erat

ion,

fun

gal i

nfec

tion

or d

erm

atiti

s on

Ulc

erat

ion

on a

ny o

ther

bod

y pa

rtth

e fo

ot to

be

oper

ated

on

Pass

ive

dors

iflex

ion

/ Kne

e in

flex

ion

/ Kne

e in

ext

ensi

onA

ctiv

e do

rsifl

exio

n / K

nee

in fl

exio

n / K

nee

in e

xten

sion

Act

ive

plan

tarfl

exio

nPa

ssiv

e ra

nge

of m

otio

n (a

nkle

)E

xclu

de if

<10

deg

dor

sifle

xion

(unl

ess

caus

ed b

y co

rrec

tabl

e co

ntra

ctur

e)

02.cross.013 4/28/05 3:27 PM Page 19


TAB

LE

3.P

ost T

ibia

lis

Pos

teri

or T

rans

fer

Ass

essm

ent

Cri

teri

onE

xpec

ted

Out

com

es a

nd C

onsi

dera

tions

1 D

ay a

fter

PO

Pre

mov

alA

fter

4 W

eeks

Phy

siot

hera

pyB

etw

een

3 to

6m

onth

s

Posi

tion

of f

oot a

t res

t (ev

ersi

on /

NA

Neu

tral

to s

light

eve

rsio

nN

eutr

al to

slig

ht e

vers

ion

inve

rsio

n)A

ctiv

e ra

nge

of m

otio

n/K

nee

inN

A20

deg

rees

dor

sifle

xion

with

Bet

wee

n 10

and

20

degr

ees

flexi

onre

cove

ring

pla

ntar

flexi

ondo

rsifl

exio

n w

ith b

etw

een

10 a

nd 2

0 de

gree

s pl

anta

rflex

ion

Pass

ive

dors

iflex

ion

/ Kne

e in

20–2

5 de

gree

s fr

om a

nkle

neu

tral

15 to

20

degr

ees

from

ank

le jo

int

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Control of coordinator bias can be an is-sue. It is imperative that the coordinator ofthe Delphi Team maintains complete impar-tiality and strives to ensure that all submis-sions are correctly interpreted and that allrequests for clarification are conveyed. It ispreferable that when a Delphi Exercise iscommissioned, a coordinator is appointedwho will not have a vested interest in theoutcome of the process. Presenting ideasunambiguously and with sufficient clarityfor all members to grasp is an essential anddemanding task. For this reason simplicityand brevity are recommended.

Consensus does not imply unanimity. It isthe product of negotiation and compromiseand represents a general agreement. Not allthe members of the Delphi Team endorsedall the criteria recorded (although only avery few criteria evoked criticism). The fi-nal outcome is a valid reflection of the cor-porate opinion of the experts who partici-pated in the Delphi Exercise. Individualtherapists and surgeons will add featuresthat they may consider will give more de-tailed information on a case by case basis.

CONCLUSION

A consensus was reached on the essentialcriteria to be considered when surgeons and

therapists are planning and executing Tib-ialis Posterior Transfer to address the prob-lem of foot drop. That the exercise was nec-essary is supported by the observation thatthe pre- and post-operative protocols thatwere submitted at the start of the exercisediffered greatly in the assessment criteriaused.

The outcomes are presented with tworecommendations: (i) best practice can bedeveloped on the basis of the criteria sug-gested; and (ii) comparative studies of theTPT procedures will benefit from standard-ized protocol based on the recommenda-tions of the Delphi Team.

REFERENCES1. BARI, M. M. Surgical reconstruction of leprotic

foot drop. Mymensingh. Med. J. 12 (2003) 11–12.2. MALAVIYA, G. N. Surgery of foot drop in leprosy

by tibialis posterior transfer. Lepr. India 53 (1981)360–368.

3. SOARES, D. Tibialis posterior transfer in the correc-tion of foot drop due to leprosy. Lepr. Rev. 66(1995) 229–234.

4. SOARES, D. Tibialis posterior transfer for the cor-rection of foot drop due to leprosy. Long-term out-come. J. Bone Jioint Surg. Br. 78 (1996) 61–62.

5. WEBER, M. W., VAN SOEST, A., NEFF, G., CHIANG,T., and PFAU, R. Results of surgical proceeduresfor the correction of foot drop and of lagiphthalmusdue to leprosy. Lepr. Rev. 63 (1992) 255–262.

02.cross.013 4/28/05 3:27 PM Page 21

Leprosy is a chronic granulomatous dis-ease characterized by hypopigmented andanesthetic skin lesions. Visible lesions oc-curring over the face, especially those situ-ated over the malar region or over the eye-lids, are known to be associated withlagophthalmos (3). Although the face has arich sensory nerve supply, it has beenshown that areas of anesthesia can exist inthe face in leprosy patients (1, 4). Patients areoften unaware of injuries that occur overthese anesthetic areas. We report on onesuch patient who sustained an injury overthe left upper eyelid and three years laterthe skin taken from that region duringsurgery for entropion disclosed histopatho-logically, a foreign body granuloma.

CASE REPORTA 53-yr-old female presented with se-

vere itching of the left eye due to a flaccidentropion and trichiasis. Skin and muscleexcision over the left upper eyelid withdeep sutures to correct the entropion wasdone and the excised skin sent for routinehistopathological examination. The patientwas diagnosed as having lepromatous lep-rosy 35 yrs ago. Her initial skin smears,done in 1965 for acid-fast bacilli (AFB)had an average bacterial index of 1.80+.She was treated with Dapsone monother-apy for 17 yrs followed by the Multidrug

Therapy (MDT) recommended by theWorld Health Organization (WHO) fortwo years. From 1979 onwards her skinsmears, done every year, had been nega-tive for AFB.

On examination, there was a glove andstocking anesthesia, both ulnar nerves wereenlarged, and collapsed nose was present.The 5th toe of the right foot was lost. Theright eye had a best corrected visual acuityof 6/24, madarosis, flaccid entropion, trichi-asis, decreased corneal sensation, old ker-atic precipitates, non-reacting pupil, iris at-rophy, and cataract. The left eye had avisual acuity of counting fingers at 1 meter,mild lagophthalmos, which on gentle clo-sure of the lids did not expose the cornea,flaccid entropion, trichiasis, decreasedcorneal sensation, and vascularized cornealopacity.

Histopathology of the skin from the eye-lid displayed granulomas composed of for-eign body giant cells and histiocytes in thestroma (Fig. 1). When a polarizer was usedto view the field, polarizing foreign parti-cles were seen (Fig. 2). Acid-fast stainingdid not reveal any AFB. The patient had notvolunteered any history of injury, but onquestioning whether any injury had oc-curred, said that a piece of sugar cane hadlodged in her upper lid when she was cut-ting it three years ago. There was no painand the open lesion had healed. Sensationover the face was checked using threegrades of Semmes Weinstein monofila-ments (2) and disclosed large areas of anes-thesia over the face including the lids ofboth eyes.

COMMENTDetection of the foreign body granuloma

by histopathology was accidental. It islikely that the fiber-like foreign bodies en-gulfed by the giant cells are the sugarcanefibers that had lodged in the upper eyelid

1Received for publication on 27 July 2004. Aceptedfor publication on 17 September 2004.

2 E Daniel, MBBS, MS, DO, MPH, MAMS, Head,Department of Ophthalmology; and G J. Ebenezer,MBBS, MD, Head, Department of Histopathology,Schieffelin Leprosy Research and Training Centre, Ka-rigiri, Vellore District, Tamilnad, India.

Reprint requests to: Ebenezer Daniel, MBBS, MS,DO, MPH, MAMS, Head, Department of Phthal-mology, Schieffelin Leprosy Research and TrainingCentre, Karigiri, Vellore District, Tamilnad, India –632 106.

CASE REPORT

Anesthesia of Face Uncovered by Histopathology1

Ebenezer Daniel and Gigi Ebenezer2

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73, 1 Daniel and Ebenezer: Anesthesia of Face Uncovered by Histopathology 23

three years ago. The significant aspect ofthe injury was that a considerable period oftime had passed without the patient attach-ing any undue importance to it, but washighlighted because of the incidentalhistopathological finding and retrospectivequestioning.

Sensory loss over the limbs can lead todestruction of the extremities and this hasled to the establishment of numerous pre-vention of disability (POD) programs inplaces where leprosy is still endemic. Theseprograms hardly ever take into account orevaluate loss of sensation over the face.

FIG. 1. Photomicrograph showing granulomas composed of foreign body giant cells and histiocytes in thestroma of eyelid skin. (H&E, ×200.)

FIG. 2. Polarized photomicrograph showing foreign bodies in the stroma. (H&E, ×200.)



This report emphasizes the fact that sensoryloss over the face could also result in in-juries that go unnoticed and uncared for bythe patient. In this case, the injury was triv-ial but if the injury had occurred on an in-sensitive cornea, a fungal corneal ulcer de-stroying the eye would not only have been apossibility but, had it occurred, could haveled to blindness and added to the sufferingof a group of people already overwhelm-ingly disadvantaged.

REFERENCES1. BELL-KROTOSKI, J. A. Light touch/deep pressure

testing using Semmes Weinstein monofilaments. In:

Rehabilitation of the Hand, 3rd edn. C.V. MosbyCo., 1989. pp. 575–593.

2. DANIEL, EBENEZER, RAMASWAMY PREMKUMAR,SHEENA KOSHY, PARAMANANDAM YOWAN, NISHA

KURIAN, and TIMOTHY FFYTCHE. Hypopigmentedface patches: their distribution and relevance to oc-ular complications in leprosy. Int. J. Lepr. OtherMycobact. Dis. 67 (1999) 338–391.

3. HOGWEG, M., KIRAN, K. U., and SUNEETHA, S. Thesignificance of face patches and Type 1 reaction forthe development of facial nerve damage in leprosy.A retrospective study among 1226 paucibacillaryleprosy patients. Lepr. Rev. 62 (1991) 143–149.

4. RAMASWAMY, P., DANIEL, EBENEZER, SUNEETHA, SU-JAI, and YOVAN, P. Quantitative assessment of fa-cial sensation in leprosy. Int. J. Lepr. Other My-cobact. Dis. 66 (1998) 348–355.


A century ago, most of those who workedon leprosy did so in near isolation, scientif-ically and geographically. Their situationwas chaotic, intellectually and otherwise:leprosy had a confusing diversity of clinicalmanifestations, classifications, and compli-cations. It was incurable, and caused enor-mous upheaval in the families and commu-nities where it occurred. Most workers weremissionaries, and there was little financialsupport for research. The overall situationimproved after dapsone became available tocure the infection, but leprosy still did notattract many medical scientists.

This situation changed dramatically inthe 1960s, with an extraordinary coinci-dence of scientific thinking and discoverythat led to a “golden age” of leprosy re-search. In a chapter on “The Immunopatho-logic Spectrum of Leprosy” (1964), OlafSkinsnes presented the first full formulationof the concept we now consider basic to theunderstanding of leprosy, i.e., that the di-versity of clinical, pathological, and micro-biological findings in leprosy are a result ofvarying degrees of cellular immunity toMycobacterium leprae in different patients(6). Scarcely two years later, Drs. Ridleyand Jopling published their practical classi-fication system that was congruent with thistheoretical foundation (5). Based on clinicaland histopathologic findings, this classifica-tion system enabled physician investigatorsaround the world to classify patients ac-cording to a common standard. The combi-nation of a well-grounded theory and apractical method of universal classificationgave new impetus to research.

Meanwhile, during the 1960s immunolo-gists identified the distinction between Tcells and B cells, and recognized their re-

spective roles in cellular and humoral im-munity (e.g., references 3 and 4). Scientistsrapidly developed an entirely new set oftools, and simultaneously discovered lep-rosy as a challenging human disease thatappeared to be an ideal model in which toexamine theories and methods related tocellular immunity in man.

The convergence of these developmentsprompted an extraordinary burst of researcheffort and publications that increased in alinear fashion from a nadir of 3 papers in1962 to a maximum of 172 papers in 1989(The Figure). This approach to assess theextent of scientific effort expended per yearis crude, and may miss some publications.It does, nevertheless, offer a reasonable es-timate of the trend with respect to the levelof research activity as reflected by publica-tion in the scientific literature. A total ofover 2000 medical and scientific publica-tions indexed on “leprosy AND immunol-ogy” appeared during this period of time.

And then, around 1989–90, the bottomappeared to fall out of this effort. The num-ber of papers published annually on the im-munology of leprosy began a decline that isas precipitous as its rise had been only adecade before (The Figure). At the currentrate, we can expect that around 2010–11there will once again be only 3 papers pub-lished on the immunology of leprosy.

What happened? Did the ability to cureinfection with M. leprae bring an end to theinquiry? Were the compelling questionsconcerning human immunity answered?The answer to these questions is “no.”

Even after effective monotherapy withdapsone was available, and additional ef-fective agents were added to the treatmentregimen, medical scientists were emphati-

EDITORIALEditorial opinions expressed are those of the writers.

Leprosy Research Declines, but Most of the Basic

Questions Remain Unanswered

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cally agreed that it was imperative to under-stand the underlying mechanisms of thisdisease. The earnest introductions to hun-dreds of papers published from the 1960sthrough the 1980s brim with the convictionthat leprosy was not only a major problemin the world, but that an understanding of itsimmunological characteristics would unlockprofoundly important insights into this andother diseases. An unsuspecting observermight think that around 1990 the important,basic questions about leprosy had suddenlyand decisively been answered; the mechan-isms underlying the remarkable spectrum ofleprosy must have been discovered, and im-munotherapies and vaccines developed, andthis scourge had been eliminated.

Among the developments during this pe-riod of time were new global health prob-lems, especially HIV/AIDS, and a renewedconcern about tuberculosis. These compet-ing imperatives, however, do not obviatethe oft-repeated assessment that leprosy re-ally does present an extraordinary scientificchallenge that will yield important lessonsfor other diseases, as well. Another impor-tant factor was the inauguration in 1991 ofthe World Health Organization campaign toeliminate leprosy as a public health prob-lem by the year 2000. The elimination hasnot happened, however, and sound, scien-tific epidemiological evidence and modelsclearly indicate that it will not happen any-time soon with only the methods of diagno-

sis and treatment now available (1, 2). Re-search into the underlying immunologicalmechanisms of this infection, however, hasnearly been eliminated, as evidenced by thedecline in publications.

What were the basic questions in leprosythat scientists of the 1960s, 70s, and 80sfound so compelling? The proceedings ofseveral ILA Congresses and workshopsfrom the 1960s to the present, and the re-ports of WHO committees and advisorygroups in the same half century, repeatedlyasserted the high priority of the followingbasic research questions:

1. What is the mechanism of transmissionof M. leprae?

2. Why is M. leprae an obligate intracel-lular parasite? What is this organism lack-ing that it cannot be cultivated?

3. What is the mechanism underlying theunique spectrum of cellular immune re-sponses in leprosy, and the selective non-responsiveness of polar lepromatous pa-tients?

4. What is the mechanism of Type 1 reac-tions?

5. What is the mechanism of Type 2 reac-tions?

6. What is the mechanism of nerve injury?All of these questions remain unan-

swered today, and the last 4 of 6 in this listare closely related to the immune responseto M. leprae. However, the perception thatthe elimination of leprosy is imminent hasundoubtedly discouraged many scientistsand funding sources from pursuing it fur-ther. The unfortunate experience of prema-ture de-emphasis on research in such infec-tious diseases as tuberculosis and malaria,however, suggest that with a disease asslow but persistent as leprosy, continued ef-fort to understand the underlying mecha-nisms of disease is essential to the quest forgenuine success in conquering it.

—DMS

REFERENCES1. MEIMA, A., GUPTE, M. D., VAN OORTMARSSEN, G. J.,

and HABBEMA, J. D. SIMLEP: a simulation modelfor leprosy transmission and control. Int. J. Lepr.Other Mycobact. Dis. 67 (1999) 215–236.

2. MEIMA, A., SMITH, W. C., VAN OORTMARSSEN, G. J.,RICHARDUS, J. H., and HABBEMA, J. D. The futureincidence of leprosy: a scenario analysis. Bull.World Health Organ. 82 (2004) 373–380.

THE FIGURE. PubMed citations on the immunol-ogy of leprosy, 1952–2003. The annual number of ci-tations retrieved from the National Library of Medi-cine’s PubMed database, using the search expression“leprosy AND immunology,” is shown from 1952 (theearliest year for which such information is available inthis database), through 2003.

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73, 1 Editorial 27

3. MILLER, J. F. A. P. Immunological function of thethymus. Lancet 10(Sept) (1961) 748–749.

4. MITCHELL, G. F., and MILLER, J. F. A. P. 1968, Cell-to-cell interaction in the immune response. II. The source of hemolysin-forming cells in irradatedmice given bone marrow and thymus or thoracic ductlyphocytes. J. Exp Med. 128 (1968) 821–838.

5. RIDLEY, D. S., and JOPLING, W. H. Classification ofleprosy according to immunity, A five-group sys-tem. Int. J. Lepr. Other Mycobact. Dis. 34 (1966)255–273.

6. SKINSNES, O. K. The immunological spectrum ofleprosy. In: Leprosy in Theory and Practice. Balti-more: Williams and Wilkins, 1964. pp. 156–162.

04.edit.025 4/28/05 3:27 PM Page 27

COMMENTARYIntroductory note:As the JOURNAL embarks on a policy encouraging papers of medical and scientific value

from disciplines sometimes unfamiliar to us, such as the social sciences, readers may findthat the some of the methods used to collect or analyze data are also unfamiliar. In thisissue, we present an important report concerning evaluation of techniques for surgicalreconstruction (Page 13). A consensus method was used to reach the conclusions in thisreport, based on responses from several highly experienced individuals. Dr. Hugh Crosshas kindly consented to provide the following background information regarding theconsensus method used in this study. Ed.

Consensus Methods: A Bridge Between Clinical

Reasoning and Clinical Research?ABSTRACT

Evidence-Based Practice does head the “hierarchy of evidence” upon which develop-ments in clinical practice should be based. There are, however, situations where evidence iseither unavailable, unclear, or results between studies are at variance. Consensus is a reliablecontingency, and approaches to reaching consensus have acceptable construct validity(Nominal Group Technique, Delphi, and Consensus Development Conference).

Consensus is reached when: (i) the method of investigation tightly controls communica-tion to reduce the obscuring “noise” of divergent discussion; (ii) statistical measures ofagreement or dissent screen out the bias that would otherwise be produced by the dictate ofvociferous minorities or coalitions that may represent vested interests; (iii) all participantscontribute equally to the product of the investigation.

RÉSUMÉLe concept de la pratique médicale basée sur des données établies (dénommée « Evidence-

Based Practice ») permet réellement d’établir une « hiérarchie des preuves », à partir de laquelledes développements utiles pour la pratique médicale cliniques peuvent être déployés. Il y acependant des situations où les données cliniques ne permettent pas de clairement étayer unehypothèse médicale ou soutenir une observation; ou bien les résultats observés d’une étude àune autre présentent une variation importante. Le Consensus est alors une méthode robustedans de tels cas, et la plupart des approches pour atteindre un consensus, telle que par exem-ple la Technique du Groupe Désigné, la Méthode de Delphi et la Conférence de Développe-ment du Consensus, présente une démarche bien construite et de validité acceptable.

Un consensus est atteint lorsque: (i) la méthode d’investigation contrôle efficacement lacommunication, afin de réduire le bruit de fond parasite et inutile des discussions diver-gentes; (ii) des mesures statistiques d’accord ou de désaccord filtrent les biais qui pourraientêtre produits par le dictat de minorités véhémentes ou bien de coalitions qui pourraient avoirdes intérêts cachés; et (iii) tous les participants contribuent de façon équilibrée au produit del’investigation.

RESUMENLa Práctica Basada en la Evidencia reconoce la “jerarquía de la evidencia” como la base

sobre la cual deben apoyarse los avances en la práctica clínica. Hay, sin embargo, situa-ciones donde la evidencia no es accesible, es poco clara, o hay variación en los resultadosobtenidos. El consenso es una contingencia confiable y los intentos de alcanzar el consensotienen una aceptable validez constructiva (Nominal Group Technique, Delphi, and Consen-sus Development Conference).

El consenso se alcanza cuando: (i) el método de investigación controla estrechamente lacomunicación para reducir el ruido de la discusión divergente, (ii) las mediciones estadísticasde concordancia o de no concordancia toman en cuenta todas las tendencias o inclinacionesya que de otra manera las opiniones de minorías o coaliciones vociferantes podrían ser domi-nantes, (iii) todos los participantes contribuyen igualmente al producto de la investigación.

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73, 1 Commentary 29

Consensus is reached when: (i) the methodof investigation tightly controls communi-cation to reduce the obscuring “noise” of di-vergent discussion; (ii) statistical measuresof agreement or dissent screen out the biasthat would otherwise be produced by thedictate of vociferous minorities or coalitionsthat may represent vested interests; (iii) allparticipants contribute equally to the prod-uct of the investigation.

With the publication of the Report of theInternational Leprosy Association TechnicalForum (1) it has become broadly acceptedthat, wherever possible, further decisions onany proposed developments in clinical prac-tice should be evidence-based. Proponentsof evidence-based practice (EBP) suggestthat decisions based on the empirical para-digm of science are less likely to be com-promised by the unpredictable elements ofsubjectivity that are probably inextricablefrom clinical reasoning.

There are, however, circumstances whereEBP does not provide answers for thosewho face problems of decision-making. Forsituations where there is already a plethoraof confusing information, statistical meth-ods such as meta-analysis are now in com-mon use. Where published information isinadequate, non-existent, or contradictory,however, consensus methods provide ameans of synthesizing the insights of expertsto create a product that decision-makers canuse with relative confidence.

Consensus as a valid construct has beensupported through exercises in the fields ofsocial science with the result that threeobjective methods of consensus buildingand reporting are now in common use: TheDelphi Investigation, The Nominal GroupTechnique (NGT), and Consensus Develop-ment Conference. Each shares the commonobjective of synthesizing judgments when astate of uncertainty exists, but whereas Del-phi and NGT are appropriate for smallerscale investigations, the Consensus Devel-opment Conference was designed to resolveconflicting opinions and contentious issuesthat impact on health policy at national orinternational levels. (Henceforth, this com-munication will only consider Delphi andNominal Group Technique as these liewithin the experience of the author.)

The central question of consensus reliabil-ity was investigated in early studies by Del-becq and Van de Ven (3) who ascertained that

judgmental accuracy may be achieved wherethe following features are encapsulated in themethod of investigation: (i) individuals makeindependent judgments; (ii) individual judg-ments are be expressed through mathematicalrank-ordering and/or rating of items; themean value of independent judgments are ac-cepted as indicating group decision; re-votingshould follow discussion of the mean values.

More recent studies have shown that anindication of the distribution or dispersal ofparticipants’ judgments, not just the mea-sure of central tendency, is more appropri-ate. In general, the median and the inter-quartile range are more robust than themean and standard deviation. Further the-matic content analysis of comments anddiscussion can also enhance the quality ofoutcomes. (2, 3, 4, 5)

The Nominal Group Technique. An es-sential feature that characterizes a “group”is verbal communication. The reason thatthe term “Nominal” was adopted is that itdenotes group situations in which non-verbalcommunication is permissible (the group istherefore, by definition only nominally agroup). Early researchers applied the termrigidly, and no verbal communication waspermitted. However, most contemporaryNGT investigations are essentially a devel-opment of the approach as both verbal andnon-verbal stages are incorporated. Re-search has shown that by allowing the com-bination of verbal and non-verbal stages,the optimal benefit from a NGT investiga-tion can be achieved.

Delbecq, et al. (6) approached the issue ofconsensus development from psycho-socialstudies of decision making processes. Theirfirst considerations were the various effectsof normative behavior on individuals ingroups and on a group as an entity. They alsoconsidered studies of alternative processeson the performance of group decision mak-ing in terms of the quantity and quality ofideas generated; the affectional (emotionaland expressive) overtones of interaction;and the nature of facilitative and inhibitiveinfluences on creative problem solving.

An objective of the NGT is that norma-tive behavior (which basically favors theperformance of dominant or aggressivecharacters) will be controlled by nonconfor-mance tactics so that performance and out-come are maximized, while hidden agendasand negative group dynamics are sup-

05.comm.028 4/28/05 3:26 PM Page 29


pressed. The NGT aims to draw out minor-ity opinions and promote the tolerance ofconflicting ideas.

Effective creative, or judgmental, prob-lem solving passes through two essentialphases simply defined as the “fact findingphase” and the “evaluation phase.” NGT in-cludes processes that encourage deep con-sideration of problems and the enhance-ment of idea generation (fact finding), theclarification and synthesis of ideas (evalua-tion), and extends to all participants, anequal opportunity to contribute to the groupproduct and to influence the direction of thedecision outcome.

“The fact finding phase.” Van de Venand Delbecq (7) had reported the humantendency to seek solutions before a questionor problem has been adequately grasped (aneffect exacerbated by relative degrees ofheightened anxiety over the nature of thetopic or the perceived situational threat.This tendency leads to poor quality deci-sions). They also observed that where ver-bal communication is the method of ideageneration, there is the possibility of “focuseffect.” “Focus effect” denotes a situationwhere group members are distracted and asingle train of thought may be given inap-propriate status. As a consequence, time ismonopolized without the compensation ofenhanced productivity. Van de Ven and Del-becq (7) also found that where group mem-bers are denied the opportunity for privatereflection on independent thoughts, ideaswere expressed as generalizations leavingindividuals reluctant to be specific. TheNGT method was developed to addressthese confounding effects as well.

The “fact finding phase” of the NGT isessentially a process where data (in this in-stance “ideas“) are generated in silence andparticipants are required to write ideas inprivacy. Writing forces participants to thinkthrough problems and creates a greatersense of task commitment and performancethan verbal expression. The “fact findingphase” of the NGT, characterized by the de-mand for silent reflection and considerationwas found to produce a wider range of bet-ter quality ideas than interactive verbalmethods, e.g., brainstorming.

“The evaluation phase.” The process ofidea evaluation requires a different ap-proach. NGT was further developed on thebasis of investigations that suggested that,

following the generation of ideas, the syn-thesis of ideas is enhanced by verbal inter-action (8). This second phase in the NGT al-lows verbal interaction where clarificationof submitted responses may be required. Alimited defense or criticism of ideas mayalso be permitted, but digressions and pro-longed argument are not permitted.

Equality of participation. Selection biasand the definition of expertise are the mostcommonly cited flaws in consensus investi-gations generally (2, 9, 10, 11). The choice ofparticipants is a salient consideration. Com-mitment to the process requires an internalacknowledgment of participant homogene-ity and an external recognition of the exper-tise represented in the group. A tenet of TheNominal Group technique is that idea qual-ity and not presenter status is predominant.

The Delphi investigation. Since its con-ception in the 1950s when it was used bythe Rand Corporation for use in defense re-lated problems (12), Delphi has been appliedextensively to clarify issues that have re-quired sharper definition. The method isusually adjusted to suit the requirements ofindividual applications (it has been widelyapplied among health disciplines for inves-tigations as diverse as the determination ofdiagnoses, through policy development toascertaining criteria for professional com-petence). Essentially the Delphi method issupported on the same theoretical basis asthe NGT but the interaction, controlled by acentral facilitator, is conducted by mail. Ithas the advantage of including participantswho are separated geographically. The iso-lated and wholly anonymous situations inwhich participants process and respond toinformation, without the pressure of imme-diate response, does result in a broaderarray of high quality ideas. However thepositive affects of the group interactioncomponent in the NGT are also lost. It is forthis reason that some consider the Delphimethod to be inferior to NGT.

Delbecq, et al. (6) were instrumental inthe early developments of the DelphiMethod. They suggested that for a Delphiinvestigation, sample size should be dic-tated by the homogeneity of the group andthe nature of the investigation. A large sam-ple is necessary if the principal reason forconducting the procedure is to developawareness within a group, or where diversereference groups are involved. Where the

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73, 1 Commentary 31

desired outcome is to validate opinionsbased on experience, they suggested that agroup of ten to fifteen participants is ade-quate for a homogenous group. Increasingthe size of a homogenous group beyond 30will not result in more information and onlyincreases administration difficulties.

Methodological details vary according tothe requirements of individual Delphi projects.The general approach has been that sequential,structured questionnaires have been used forparticipants to rank, or rate, responses to indi-cate his/her priorities related to the topics ofinterest. On receipt of returned question-naires, information is collated and analyzedbefore being redistributed for further refine-ment and for final comments.

Information, in the form of a statisticalanalysis, should be dispatched to partici-pants at subsequent rounds of the proce-dure. Feedback analysis should include thefrequency with which participants selectedanswers, with the mean and/or median andone measure of dispersion. Individuals areasked to reconsider the scores applied pre-viously (in the light of aggregated re-sponses of all members) and, in this man-ner, consensus is generated.

As with NGT, the selection and definitionof experts is cited as being the most poten-tially confounding effect on a Delphi out-come. Panelists are usually (though not ex-clusively) recruited by merit of an intimateacademic or experiential association withthe topic under investigation. Acknowl-edged expertise or influence may validate achoice of participants; however, Delbecq, etal. (6) suggested that such attributes per seare insufficient for the inclusion of partici-pants. They cautioned that commitment tothe investigation, motivation to complywith the demands of procedure and the ac-ceptance of the consensus (even though itmay be at variance with personal inclina-tion) are fundamental. The “nature of therespondent panel, the obligations of partici-pants, the length of time the Delphi processwill take and the information that will beshared among participants” are variableslikely to effect the co-operation of invitedindividuals and should be declared at theinitial stages of recruitment.

Criticisms. Some have considered con-sensus methods from an epistemologicalperspective and cautioned against “over-selling” the methods (2). A principal con-

cern is that there is a risk that observersmay place too great a reliance on consensusoutcomes than may be warranted. This is avalid concern because consensus methodsare used to generate quantitative estimateswhich could be misconstrued in some cul-tures as representing a “correct” answer.Consensus, is of course not synonymouswith being invariably correct, but a respon-sibility lies with investigators to presentoutcomes with due consideration for thetarget readership. Sackman (9) representsthe views of some who argue that Delphioutcomes represent a “forced” consensusthat is further compromised because partic-ipants are not allowed to discuss issues.

Murphy, et al. (3) conducted an extensivereview of published research using consen-sus methods. A result of their endeavor isthat a guide has been published that shouldbe considered by those considering the useof either method. One of the objectives oftheir survey was “To identify the factorsthat affect the decisions that emerge fromconsensus development methods.” Theirstudy identified recurring methodologicalissues which they sought to isolate and ad-dress. What their study has shown is thatthe methodological issues that have causedthe most controversy can be addressed.

—Hugh CrossAmerican Leprosy MissionsCebu City, The Philippines

REFERENCES1. ANONYMOUS. Report of the International Leprosy

Association Technical Forum. Lepr. Rev.73(Suppl) (2002) S3–S61.

2. DELBECQ, A. L., VAN DE VEN, A. H., and GUSTAFSON,D. H. Group Techniques For Programme Planning:A Guide To Nominal Group and Delphi Processes.Illinois: Scott Forresman & Company, 1975.

3. DOWNING, A. M., and HUNTER, D. G. Validatingclinical reasoning: a question of perspective, butwhose perspective? Man. Ther. 8(2) (2003) 117–119.

4. HELMER, O., and RESCHER, N. On the epistemol-ogy of the inexact science. Management Science6(1) (1959) 25–52.

5. MOSTYN, B. The content analysis of qualitativeresearch data: a dynamic approach. In: The Re-search Interview, 1985.

6. MURPHY, M. K., BLACK, N. A., LAMPING, D. L.,MCKEE, C. M., SANDERSON, C. F., ASKHAM, J., andMARTEAU, T. Consensus development methods,and their use in clinical guideline development.Health Technol. Assess. 2(3) (1998) 1–88.

05.comm.028 4/28/05 3:26 PM Page 31


7. SACKMAN, H. Delphi Critique. Lexington: Lex-ington Books, 1975.

8. SHARKEY, S. B., and SHARPLES, A. Y. An approachto consensus building using the Delphi technique:developing a learning resource in mental health.Nurse Educ. Today 21(5) (2001) 398–408.

9. TONG, R. The epistemology and ethics of consen-sus: uses and misuses of ‘ethical’ expertise. J.Med. Philos. 16(4) (1991) 409–426.

10. VAN DE VEN, A. H., and DELBECQ, A. L. The nom-

inal group technique as a research instrument forexploratory health studies. Exploratory HealthStudies. March (1972) 337–342.

11. VROOM, V. H., GRANT, L. D., and COTTON, T. J. Theconsequences of social interaction in group problemsolving. J. Appl. Psychol. 53(4) (1969) 338–341.

12. WORTMAN, P. M., VINOKUR, A., and SECHREST, L.J. Do consensus conferences work? A processevaluation of the NIH Consensus. Health Polit.Policy Law. 13(3) (1988) 469–498.

COMMENTARY

A Potentially New Treatment for Tuberculosis; Will a

Diarylquinoline Work for Leprosy?

The recent publication by Koen Andries,et al. (1) (see Current Literature of this is-sue, p. 43), describing the extraordinaryanti-tuberculosis activity of the new di-arylquinoline “R207910” from Johnson andJohnson, may bode well for several of themycobacterioses including leprosy. Basicstudies had revealed mutations in resistantisolates of Mycobacterium tuberculosis andM. smegmatis that mapped to an ATPasethat is involved with ion transport. Interest-ingly, this protein had not previously beenproposed as a drug target although it is ap-parently essential for in vitro growth andhas little sequence homology with its hu-man counterpart.

Might this compound or compound classbe of value in the treatment of leprosy? Thebroad spectrum activity of R207910 againsta range of mycobacteria (but not of non-mycobacterial species) suggests that it willlikely be active against the leprosy bacillusas well. In addition, the M. tuberculosis andM. leprae ATPase proteins share 92.6%identity, again suggesting that the latter maywell be highly susceptible. The long half-life and ability to shorten the treatment du-ration required for organ sterilization in M.tuberculosis-infected mice suggests that,should the spectrum of activity extend to M.leprae, this compound (or compound class)may help shorten the duration of leprosytreatment as well. Combinations containing

R207910, a rifamycin and a fluoroquino-lone—all of which appear to be both bacte-ricidal and to have the ability to eliminatesome percentage of persistent mycobacte-ria—may dramatically shorten treatmentduration in both tuberculosis and leprosy,even in patients with a relatively high bac-terial loads.

Of course much of this speculation re-garding leprosy can be put to rest by a fewwell designed in vitro and in vivo experi-ments with M. leprae. While a phase I clin-ical trial has looked promising, the ultimateclinical utility in tuberculosis and in leprosyand other mycobacterioses can only be de-termined following phase II/III studies inthese diseases.

—Scott Franzblau, Ph.D., Professor

Institute of Tuberculosis ResearchUniversity of Illinois Abraham LincolnSchool of MedicineChicago, Ill. USA

REFERENCES1. ANDRIES, K., P. VERHASSELT, J. GUILLEMONT, H. W.

GOHLMANN, J. M. NEEFS, H. WINKLER, J. VAN GES-TEL, P. TIMMERMAN, M. ZHU, E. LEE, P. WILLIAMS,D. DE CHAFFOY, E. HUITRIC, S. HOFFNER, E. CAM-BAU, C. TRUFFOT-PERNOT, N. LOUNIS, and V. JAR-LIER. A diarylquinoline drug active on the ATP syn-thase of Mycobacterium tuberculosis. Sciencexpress10 (2004) 1126/science.1106753.

05.comm.028 4/28/05 3:26 PM Page 32

COMMENTARYIntroductory note:As the JOURNAL embarks on a policy encouraging papers of medical and scientific value

from disciplines sometimes unfamiliar to us, such as the social sciences, readers may findthat the some of the methods used to collect or analyze data are also unfamiliar. In thisissue, we present an important report concerning evaluation of techniques for surgicalreconstruction (Page 13). A consensus method was used to reach the conclusions in thisreport, based on responses from several highly experienced individuals. Dr. Hugh Crosshas kindly consented to provide the following background information regarding theconsensus method used in this study. Ed.

Consensus Methods: A Bridge Between Clinical

Reasoning and Clinical Research?ABSTRACT

Evidence-Based Practice does head the “hierarchy of evidence” upon which develop-ments in clinical practice should be based. There are, however, situations where evidence iseither unavailable, unclear, or results between studies are at variance. Consensus is a reliablecontingency, and approaches to reaching consensus have acceptable construct validity(Nominal Group Technique, Delphi, and Consensus Development Conference).

Consensus is reached when: (i) the method of investigation tightly controls communica-tion to reduce the obscuring “noise” of divergent discussion; (ii) statistical measures ofagreement or dissent screen out the bias that would otherwise be produced by the dictate ofvociferous minorities or coalitions that may represent vested interests; (iii) all participantscontribute equally to the product of the investigation.

RÉSUMÉLe concept de la pratique médicale basée sur des données établies (dénommée « Evidence-

Based Practice ») permet réellement d’établir une « hiérarchie des preuves », à partir de laquelledes développements utiles pour la pratique médicale cliniques peuvent être déployés. Il y acependant des situations où les données cliniques ne permettent pas de clairement étayer unehypothèse médicale ou soutenir une observation; ou bien les résultats observés d’une étude àune autre présentent une variation importante. Le Consensus est alors une méthode robustedans de tels cas, et la plupart des approches pour atteindre un consensus, telle que par exem-ple la Technique du Groupe Désigné, la Méthode de Delphi et la Conférence de Développe-ment du Consensus, présente une démarche bien construite et de validité acceptable.

Un consensus est atteint lorsque: (i) la méthode d’investigation contrôle efficacement lacommunication, afin de réduire le bruit de fond parasite et inutile des discussions diver-gentes; (ii) des mesures statistiques d’accord ou de désaccord filtrent les biais qui pourraientêtre produits par le dictat de minorités véhémentes ou bien de coalitions qui pourraient avoirdes intérêts cachés; et (iii) tous les participants contribuent de façon équilibrée au produit del’investigation.

RESUMENLa Práctica Basada en la Evidencia reconoce la “jerarquía de la evidencia” como la base

sobre la cual deben apoyarse los avances en la práctica clínica. Hay, sin embargo, situa-ciones donde la evidencia no es accesible, es poco clara, o hay variación en los resultadosobtenidos. El consenso es una contingencia confiable y los intentos de alcanzar el consensotienen una aceptable validez constructiva (Nominal Group Technique, Delphi, and Consen-sus Development Conference).

El consenso se alcanza cuando: (i) el método de investigación controla estrechamente lacomunicación para reducir el ruido de la discusión divergente, (ii) las mediciones estadísticasde concordancia o de no concordancia toman en cuenta todas las tendencias o inclinacionesya que de otra manera las opiniones de minorías o coaliciones vociferantes podrían ser domi-nantes, (iii) todos los participantes contribuyen igualmente al producto de la investigación.

28


(ISSN 0148-916X)

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Consensus is reached when: (i) the methodof investigation tightly controls communi-cation to reduce the obscuring “noise” of di-vergent discussion; (ii) statistical measuresof agreement or dissent screen out the biasthat would otherwise be produced by thedictate of vociferous minorities or coalitionsthat may represent vested interests; (iii) allparticipants contribute equally to the prod-uct of the investigation.

With the publication of the Report of theInternational Leprosy Association TechnicalForum (1) it has become broadly acceptedthat, wherever possible, further decisions onany proposed developments in clinical prac-tice should be evidence-based. Proponentsof evidence-based practice (EBP) suggestthat decisions based on the empirical para-digm of science are less likely to be com-promised by the unpredictable elements ofsubjectivity that are probably inextricablefrom clinical reasoning.

There are, however, circumstances whereEBP does not provide answers for thosewho face problems of decision-making. Forsituations where there is already a plethoraof confusing information, statistical meth-ods such as meta-analysis are now in com-mon use. Where published information isinadequate, non-existent, or contradictory,however, consensus methods provide ameans of synthesizing the insights of expertsto create a product that decision-makers canuse with relative confidence.

Consensus as a valid construct has beensupported through exercises in the fields ofsocial science with the result that threeobjective methods of consensus buildingand reporting are now in common use: TheDelphi Investigation, The Nominal GroupTechnique (NGT), and Consensus Develop-ment Conference. Each shares the commonobjective of synthesizing judgments when astate of uncertainty exists, but whereas Del-phi and NGT are appropriate for smallerscale investigations, the Consensus Devel-opment Conference was designed to resolveconflicting opinions and contentious issuesthat impact on health policy at national orinternational levels. (Henceforth, this com-munication will only consider Delphi andNominal Group Technique as these liewithin the experience of the author.)

The central question of consensus reliabil-ity was investigated in early studies by Del-becq and Van de Ven (3) who ascertained that

judgmental accuracy may be achieved wherethe following features are encapsulated in themethod of investigation: (i) individuals makeindependent judgments; (ii) individual judg-ments are be expressed through mathematicalrank-ordering and/or rating of items; themean value of independent judgments are ac-cepted as indicating group decision; re-votingshould follow discussion of the mean values.

More recent studies have shown that anindication of the distribution or dispersal ofparticipants’ judgments, not just the mea-sure of central tendency, is more appropri-ate. In general, the median and the inter-quartile range are more robust than themean and standard deviation. Further the-matic content analysis of comments anddiscussion can also enhance the quality ofoutcomes. (2, 3, 4, 5)

The Nominal Group Technique. An es-sential feature that characterizes a “group”is verbal communication. The reason thatthe term “Nominal” was adopted is that itdenotes group situations in which non-verbalcommunication is permissible (the group istherefore, by definition only nominally agroup). Early researchers applied the termrigidly, and no verbal communication waspermitted. However, most contemporaryNGT investigations are essentially a devel-opment of the approach as both verbal andnon-verbal stages are incorporated. Re-search has shown that by allowing the com-bination of verbal and non-verbal stages,the optimal benefit from a NGT investiga-tion can be achieved.

Delbecq, et al. (6) approached the issue ofconsensus development from psycho-socialstudies of decision making processes. Theirfirst considerations were the various effectsof normative behavior on individuals ingroups and on a group as an entity. They alsoconsidered studies of alternative processeson the performance of group decision mak-ing in terms of the quantity and quality ofideas generated; the affectional (emotionaland expressive) overtones of interaction;and the nature of facilitative and inhibitiveinfluences on creative problem solving.

An objective of the NGT is that norma-tive behavior (which basically favors theperformance of dominant or aggressivecharacters) will be controlled by nonconfor-mance tactics so that performance and out-come are maximized, while hidden agendasand negative group dynamics are sup-

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pressed. The NGT aims to draw out minor-ity opinions and promote the tolerance ofconflicting ideas.

Effective creative, or judgmental, prob-lem solving passes through two essentialphases simply defined as the “fact findingphase” and the “evaluation phase.” NGT in-cludes processes that encourage deep con-sideration of problems and the enhance-ment of idea generation (fact finding), theclarification and synthesis of ideas (evalua-tion), and extends to all participants, anequal opportunity to contribute to the groupproduct and to influence the direction of thedecision outcome.

“The fact finding phase.” Van de Venand Delbecq (7) had reported the humantendency to seek solutions before a questionor problem has been adequately grasped (aneffect exacerbated by relative degrees ofheightened anxiety over the nature of thetopic or the perceived situational threat.This tendency leads to poor quality deci-sions). They also observed that where ver-bal communication is the method of ideageneration, there is the possibility of “focuseffect.” “Focus effect” denotes a situationwhere group members are distracted and asingle train of thought may be given inap-propriate status. As a consequence, time ismonopolized without the compensation ofenhanced productivity. Van de Ven and Del-becq (7) also found that where group mem-bers are denied the opportunity for privatereflection on independent thoughts, ideaswere expressed as generalizations leavingindividuals reluctant to be specific. TheNGT method was developed to addressthese confounding effects as well.

The “fact finding phase” of the NGT isessentially a process where data (in this in-stance “ideas“) are generated in silence andparticipants are required to write ideas inprivacy. Writing forces participants to thinkthrough problems and creates a greatersense of task commitment and performancethan verbal expression. The “fact findingphase” of the NGT, characterized by the de-mand for silent reflection and considerationwas found to produce a wider range of bet-ter quality ideas than interactive verbalmethods, e.g., brainstorming.

“The evaluation phase.” The process ofidea evaluation requires a different ap-proach. NGT was further developed on thebasis of investigations that suggested that,

following the generation of ideas, the syn-thesis of ideas is enhanced by verbal inter-action (8). This second phase in the NGT al-lows verbal interaction where clarificationof submitted responses may be required. Alimited defense or criticism of ideas mayalso be permitted, but digressions and pro-longed argument are not permitted.

Equality of participation. Selection biasand the definition of expertise are the mostcommonly cited flaws in consensus investi-gations generally (2, 9, 10, 11). The choice ofparticipants is a salient consideration. Com-mitment to the process requires an internalacknowledgment of participant homogene-ity and an external recognition of the exper-tise represented in the group. A tenet of TheNominal Group technique is that idea qual-ity and not presenter status is predominant.

The Delphi investigation. Since its con-ception in the 1950s when it was used bythe Rand Corporation for use in defense re-lated problems (12), Delphi has been appliedextensively to clarify issues that have re-quired sharper definition. The method isusually adjusted to suit the requirements ofindividual applications (it has been widelyapplied among health disciplines for inves-tigations as diverse as the determination ofdiagnoses, through policy development toascertaining criteria for professional com-petence). Essentially the Delphi method issupported on the same theoretical basis asthe NGT but the interaction, controlled by acentral facilitator, is conducted by mail. Ithas the advantage of including participantswho are separated geographically. The iso-lated and wholly anonymous situations inwhich participants process and respond toinformation, without the pressure of imme-diate response, does result in a broaderarray of high quality ideas. However thepositive affects of the group interactioncomponent in the NGT are also lost. It is forthis reason that some consider the Delphimethod to be inferior to NGT.

Delbecq, et al. (6) were instrumental inthe early developments of the DelphiMethod. They suggested that for a Delphiinvestigation, sample size should be dic-tated by the homogeneity of the group andthe nature of the investigation. A large sam-ple is necessary if the principal reason forconducting the procedure is to developawareness within a group, or where diversereference groups are involved. Where the

05.comm.028 4/28/05 3:26 PM Page 30

73, 1 Commentary 31

desired outcome is to validate opinionsbased on experience, they suggested that agroup of ten to fifteen participants is ade-quate for a homogenous group. Increasingthe size of a homogenous group beyond 30will not result in more information and onlyincreases administration difficulties.

Methodological details vary according tothe requirements of individual Delphi projects.The general approach has been that sequential,structured questionnaires have been used forparticipants to rank, or rate, responses to indi-cate his/her priorities related to the topics ofinterest. On receipt of returned question-naires, information is collated and analyzedbefore being redistributed for further refine-ment and for final comments.

Information, in the form of a statisticalanalysis, should be dispatched to partici-pants at subsequent rounds of the proce-dure. Feedback analysis should include thefrequency with which participants selectedanswers, with the mean and/or median andone measure of dispersion. Individuals areasked to reconsider the scores applied pre-viously (in the light of aggregated re-sponses of all members) and, in this man-ner, consensus is generated.

As with NGT, the selection and definitionof experts is cited as being the most poten-tially confounding effect on a Delphi out-come. Panelists are usually (though not ex-clusively) recruited by merit of an intimateacademic or experiential association withthe topic under investigation. Acknowl-edged expertise or influence may validate achoice of participants; however, Delbecq, etal. (6) suggested that such attributes per seare insufficient for the inclusion of partici-pants. They cautioned that commitment tothe investigation, motivation to complywith the demands of procedure and the ac-ceptance of the consensus (even though itmay be at variance with personal inclina-tion) are fundamental. The “nature of therespondent panel, the obligations of partici-pants, the length of time the Delphi processwill take and the information that will beshared among participants” are variableslikely to effect the co-operation of invitedindividuals and should be declared at theinitial stages of recruitment.

Criticisms. Some have considered con-sensus methods from an epistemologicalperspective and cautioned against “over-selling” the methods (2). A principal con-

cern is that there is a risk that observersmay place too great a reliance on consensusoutcomes than may be warranted. This is avalid concern because consensus methodsare used to generate quantitative estimateswhich could be misconstrued in some cul-tures as representing a “correct” answer.Consensus, is of course not synonymouswith being invariably correct, but a respon-sibility lies with investigators to presentoutcomes with due consideration for thetarget readership. Sackman (9) representsthe views of some who argue that Delphioutcomes represent a “forced” consensusthat is further compromised because partic-ipants are not allowed to discuss issues.

Murphy, et al. (3) conducted an extensivereview of published research using consen-sus methods. A result of their endeavor isthat a guide has been published that shouldbe considered by those considering the useof either method. One of the objectives oftheir survey was “To identify the factorsthat affect the decisions that emerge fromconsensus development methods.” Theirstudy identified recurring methodologicalissues which they sought to isolate and ad-dress. What their study has shown is thatthe methodological issues that have causedthe most controversy can be addressed.

—Hugh CrossAmerican Leprosy MissionsCebu City, The Philippines

REFERENCES1. ANONYMOUS. Report of the International Leprosy

Association Technical Forum. Lepr. Rev.73(Suppl) (2002) S3–S61.

2. DELBECQ, A. L., VAN DE VEN, A. H., and GUSTAFSON,D. H. Group Techniques For Programme Planning:A Guide To Nominal Group and Delphi Processes.Illinois: Scott Forresman & Company, 1975.

3. DOWNING, A. M., and HUNTER, D. G. Validatingclinical reasoning: a question of perspective, butwhose perspective? Man. Ther. 8(2) (2003) 117–119.

4. HELMER, O., and RESCHER, N. On the epistemol-ogy of the inexact science. Management Science6(1) (1959) 25–52.

5. MOSTYN, B. The content analysis of qualitativeresearch data: a dynamic approach. In: The Re-search Interview, 1985.

6. MURPHY, M. K., BLACK, N. A., LAMPING, D. L.,MCKEE, C. M., SANDERSON, C. F., ASKHAM, J., andMARTEAU, T. Consensus development methods,and their use in clinical guideline development.Health Technol. Assess. 2(3) (1998) 1–88.

05.comm.028 4/28/05 3:26 PM Page 31


7. SACKMAN, H. Delphi Critique. Lexington: Lex-ington Books, 1975.

8. SHARKEY, S. B., and SHARPLES, A. Y. An approachto consensus building using the Delphi technique:developing a learning resource in mental health.Nurse Educ. Today 21(5) (2001) 398–408.

9. TONG, R. The epistemology and ethics of consen-sus: uses and misuses of ‘ethical’ expertise. J.Med. Philos. 16(4) (1991) 409–426.

10. VAN DE VEN, A. H., and DELBECQ, A. L. The nom-

inal group technique as a research instrument forexploratory health studies. Exploratory HealthStudies. March (1972) 337–342.

11. VROOM, V. H., GRANT, L. D., and COTTON, T. J. Theconsequences of social interaction in group problemsolving. J. Appl. Psychol. 53(4) (1969) 338–341.

12. WORTMAN, P. M., VINOKUR, A., and SECHREST, L.J. Do consensus conferences work? A processevaluation of the NIH Consensus. Health Polit.Policy Law. 13(3) (1988) 469–498.

COMMENTARY

A Potentially New Treatment for Tuberculosis; Will a

Diarylquinoline Work for Leprosy?

The recent publication by Koen Andries,et al. (1) (see Current Literature of this is-sue, p. 43), describing the extraordinaryanti-tuberculosis activity of the new di-arylquinoline “R207910” from Johnson andJohnson, may bode well for several of themycobacterioses including leprosy. Basicstudies had revealed mutations in resistantisolates of Mycobacterium tuberculosis andM. smegmatis that mapped to an ATPasethat is involved with ion transport. Interest-ingly, this protein had not previously beenproposed as a drug target although it is ap-parently essential for in vitro growth andhas little sequence homology with its hu-man counterpart.

Might this compound or compound classbe of value in the treatment of leprosy? Thebroad spectrum activity of R207910 againsta range of mycobacteria (but not of non-mycobacterial species) suggests that it willlikely be active against the leprosy bacillusas well. In addition, the M. tuberculosis andM. leprae ATPase proteins share 92.6%identity, again suggesting that the latter maywell be highly susceptible. The long half-life and ability to shorten the treatment du-ration required for organ sterilization in M.tuberculosis-infected mice suggests that,should the spectrum of activity extend to M.leprae, this compound (or compound class)may help shorten the duration of leprosytreatment as well. Combinations containing

R207910, a rifamycin and a fluoroquino-lone—all of which appear to be both bacte-ricidal and to have the ability to eliminatesome percentage of persistent mycobacte-ria—may dramatically shorten treatmentduration in both tuberculosis and leprosy,even in patients with a relatively high bac-terial loads.

Of course much of this speculation re-garding leprosy can be put to rest by a fewwell designed in vitro and in vivo experi-ments with M. leprae. While a phase I clin-ical trial has looked promising, the ultimateclinical utility in tuberculosis and in leprosyand other mycobacterioses can only be de-termined following phase II/III studies inthese diseases.

—Scott Franzblau, Ph.D., Professor

Institute of Tuberculosis ResearchUniversity of Illinois Abraham LincolnSchool of MedicineChicago, Ill. USA

REFERENCES1. ANDRIES, K., P. VERHASSELT, J. GUILLEMONT, H. W.

GOHLMANN, J. M. NEEFS, H. WINKLER, J. VAN GES-TEL, P. TIMMERMAN, M. ZHU, E. LEE, P. WILLIAMS,D. DE CHAFFOY, E. HUITRIC, S. HOFFNER, E. CAM-BAU, C. TRUFFOT-PERNOT, N. LOUNIS, and V. JAR-LIER. A diarylquinoline drug active on the ATP syn-thase of Mycobacterium tuberculosis. Sciencexpress10 (2004) 1126/science.1106753.

05.comm.028 4/28/05 3:26 PM Page 32

TO THE EDITOR:

The World Health Organization (WHO)suggests the use of corticosteroids to differ-entiate a relapse from a reaction in cases inwhich new lesions appear after the comple-tion of treatment with multi-drug therapy(MDT) (8). If lesions improve, it is a case oftype 1 reaction that must be treated only withsuch drugs. This immunological phenome-non would not have significance other thanthe fact of being a response to remaining My-cobacterium leprae antigens that would beexposed to the host defenses. If a patientkeeps having reactional episodes after anti-leprosy treatment, the anti-inflammatorytherapy should be continued.

Nevertheless, I believe that reactionalepisodes may result from multiplication ofbacilli that were not destroyed by treatment.If this hypothesis could be demonstrated,these reactions would be considered re-lapses, and that would be a reason for theWHO’s statistics on relapses to be changed.

In general, type 1 reactions occur in pre-existing lesions that may appear as hypo-chromic macules with sensory changes,sensation or well constituted borderline ortuberculoid lesions with chronic evolution.These reactions are often times exuberantand occur before, during, or even after re-lease from treatment (3).

All these reactions are presented with thesame clinical characteristics. The bacil-loscopy may be negative or positive, and ifpositive, bacilli may show degeneration in

reactional episodes occurring before treat-ment, as well as during treatment.

In the pre-sulphone era, the authors care-fully observed the natural history of somereactional cases and reported tuberculoidpatients with certain reactions in whichbacilli and lesions disappeared sponta-neously. After some time or even years ofquiescence, reactions reappeared with le-sions and bacilli (1, 5, 6). These observationssuggest that the M. leprae may remain forlong periods in a state of metabolic inactiv-ity, inaccessible to organic defenses (possi-bly as persisters). At a certain moment,maybe because of intercurrent diseases orother immunological changes, bacilli startto multiply again, initiating a new reac-tional episode.

If that happened in the past, it may alsohappen today, i.e., the bacilli can remain aspersisters and not be destroyed by the im-mune defenses or treatment. The cell medi-ated type 1 reaction may somehow be relatedto multiplication of bacilli. The degeneratedaspect of the bacilli may result from the mul-tiplication of bacilli and their exposure to theeffects of drugs that are being used, or to theimmune defenses. The microorganisms aredestroyed and release antigens that give riseto a hypersensitivity reaction (type 1 reac-tion). In reactions occurring after treatment,if the number of bacilli is low, the patientsbecome cured because the body defenses de-stroy the bacilli. If there are many bacilli andthe organic defenses are unable to control theinfection, there will be new reactions and

CORRESPONDENCE

This department is for the publication of informal communications that are of interestbecause they are informative and stimulating, and for the discussion of controversialmatters. The mandate of the JOURNAL is to disseminate information relating to leprosy inparticular and also other mycobacterial diseases. Dissident comment or interpretation onpublished research is of course valid, but personality attacks on individuals would seemunnecessary. Political comments, valid or not, also are unwelcome. They might result ininterference with the distribution of the JOURNAL and thus interfere with its prime purpose.

Some Considerations on the Origin of

Type 1 Reactions in Leprosy1

33


(ISSN 0148-916X)

06.corr.033 4/28/05 3:26 PM Page 33


risk of nerve involvement and developmentof disabilities.

Recently, Shetty, et al. (4) studied 25 casesof borderline-tuberculoid leprosy that pre-sented with new lesions from 1 to 13 yearsafter being released from treatment. Viablebacilli were found in the footpad of inocu-lated mice in 48% of the biopsies of thosepatients. Remarkably, the incidence of vi-able bacilli was higher (58%) in those pa-tients whose histopathology showed evi-dences of reversal reaction.

Waters (7) commentary on Shetty’s work,referred to his own patient with a tubercu-loid lesion on the face that appeared 40years after the patient had been apparentlycured, and admitted that the authors pre-sented evidence that viable bacilli can causerelapse in borderline-tuberculoid leprosy,and that these relapses may be associatedwith reversal reactions.

I also studied a patient similar to Waters(2). She was a patient who presented withextensive erythemato-hypochromic flat le-sions on the trunk and extremities, with anegative bacilloscopic index (BI), whichdisappeared after 2 years of treatment withchaulmoogra oil. More than 40 years latershe presented a reactional episode with largeerythematous plaques on the entire skin,with a positive BI (++++) of the lesions,during an unbalanced diabetes mellitus.

These observations reinforce my inter-pretation of type 1 reactions, i.e., they arethe result of multiplication of persisters.

There are no proofs of this hypothesis be-ing true, but on the other hand, there isnothing showing it to be wrong.

I think the WHO should look at type 1 re-actions more carefully during the evalua-tion of MDT results.

—D.V.A. Opromolla

Division of Training and ResearchInstituto Lauro de Souza LimaAddress: P.O. Box 3021. Bauru. SP. Brazil.17034-970

Dr. Opromolla passed away while this is-sue was in production. The JOURNAL extendsits condolences to the family of this long-time professional in the leprosy field. Dr.Opromolla’s obituary will appear in theJune issue of the JOURNAL.

REFERENCES1. LIMA, LAURO DE SOUZA, and MAURANO, FLAVIO.

Reação leprótica. Rio de Janeiro: Ministério daSaúde, 1949.

2. OPROMOLLA, DILTOR, and ARAÚJO, VLADIMIR. Re-cidiva ou reação reversa? Hansen Int. Bauru 19(1)1994.

3. PFALTZGRAFF, ROY E., and RAMU, GOPAL. Clinicalleprosy. In: Leprosy, 2nd edn. Edinbugh: ChurchillLivingstone, 1994.

4. SHETTY, V. P., WAKADE, A., and ANTIA, N. H. A. Ahigh incidence of viable Mycobacterium leprae inpost-MDT recurrent lesions in tuberculoid leprosypatients. Lepr. Rev. 72(3) (2001) 337–344.

5. WADE, H. W. Tuberculoid changes in leprosy. II.Lepra reaction in tuberculoid leprosy. Int. J. Lepr.Other Mycobact. Dis. 2(2) (1934) 279–292.

6. WADE, H. W., RODRIGUEZ, J. N., and TOLENTINO, J.G. The course of open cases of tuberculoid leprosyat the Cebu Leprosarium. Int. J. Lepr. Other My-cobact. Dis. 7(4) (1939) 473–494.

7. WATERS, M. F. R. Distinguishing between relapseand late reversal reaction in multidrug (MDT)treated BT leprosy (Editorial). Lepr. Rev. 2(3)(2001) 250–253.

8. WHO EXPERT COMMITTEE ON LEPROSY. Sixth Re-port. Geneva: World Health Organization, 1988.Tech. Rep. Ser. 768.

TO THE EDITOR:

It was interesting to read the article“Neuropathic pain in leprosy patients” byStump, et al. (3). They have noted that a fairnumber of patients continue to suffer fromneuropathic pain in leprosy. This probablyis due to the treatment cut off point of 6months or 12 months, depending upon thetype of leprosy. Some patients do continueto complain of paresthesia even long afterthe activity is subsided. The series of

Stump, et al. includes cases that were stillon treatment.

The clinical activity takes fairly longerthan the bacteriological cure. The WorldHealth Organization regimens are meant to“kill” the maximum number of germs inshortest possible time. The body has to takecare of the scavenging and it might suffer inthe process. The process of nerve regenera-tion further complicates the issue, and if ir-ritants are present, paresthesia develops.Moreover, the compressing elements con-

06.corr.033 4/28/05 3:26 PM Page 34

73, 1 Correspondence 35

tinue to persist and are “assisted” by intra-neural and perineural fibrosis. As a conse-quence, a “neuroma in continuity” developsand the pain continues.

Mishra, et al. (1, 2), while reporting theirobservations on development of leprosy le-sions, noted that at least some of the lesionsstart as a vague dysthesia, meaning thatpositive phenomena occurs before a nega-tive phenomena (sensory loss). “Painless”nerve damage has been glorified as silentneuropathy. It is very likely that thosenerves have whispered before destruction,which patients were not able to hear due tothe faintness of the sound or their preoccu-pation with other things. Logically, pain(including paresthesia and dysthesia is apart of neural affection its intensity mayvary depending upon the type of affectionand the speed of damage.

Probably, both neuropathic pain and in-flammatory pain exist together in leprosy.Even in acute neuritis, the pain is more thanwhat is expected in pain of a purely noci-ceptive nature. That is probably the reasonthat many times acute neuritis is referred toas acute painful neuritis. The contributionfrom inflammation and neuropathy mayvary from patient to patient and from timeto time. The paresthesia complained of isusually of an annoying type, and with theadvancing age of patients many other dis-comforts are added to it. It will be interest-ing to relate the paresthesia with disease ac-tivity in “cured” patients but, on the other

hand, it also scares me. Any suggestion ordiscussion about pain might exacerbate theproblems because patients are relatively un-stable emotionally and tend to develop de-pendence because of peculiar psychosocialeffects of the disease.

Mild paresthesia can be managed withsuggestions and counseling, whereas dis-abling paresthesia needs drugs in addition.But before all that can be formulated andput into practice, treatment of leprosy has tobe modified from community approach toindividualized approach.

—Dr. G. N. Malaviya

Department of Plastic & ReconstructiveSurgery

Central Jalma Institute for LeprosyTajganj, Agra (India) PIN 282 001E-mail: [email protected]

REFERENCES1. MISHRA, B., MUKHERJEE, A., GIRDHAR, A., HUSAIN,

S., MALAVIYA, G. N., and GIRDHAR, B. K. Evolu-tion of early lesions in leprosy. Lepr. Rev. 64(1993) 259–266.

2. MISHRA, B., MUKHERJEE, A., GIRDHAR, A., HUSAIN,S., MALAVIYA, G. N., and GIRDHAR, B. K. Neuriticleprosy: further progression and significance. ActaLeprologica 9 (1995) 187–194.

3. STUMP, P. R. N. A. G., BACCARELLI, R., MARCIANO,L. H. S. C., LAURIS, J. R. P., TEIXEIRA, M. J., URA,S., and VIRMOND, M. C. L. Neuropathic pain inleprosy patients. Int J Lepr. Other Mycobact. Dis.72 (2004) 134–138.

06.corr.033 4/28/05 3:26 PM Page 35

TO THE EDITOR:

The World Health Organization (WHO)suggests the use of corticosteroids to differ-entiate a relapse from a reaction in cases inwhich new lesions appear after the comple-tion of treatment with multi-drug therapy(MDT) (8). If lesions improve, it is a case oftype 1 reaction that must be treated only withsuch drugs. This immunological phenome-non would not have significance other thanthe fact of being a response to remaining My-cobacterium leprae antigens that would beexposed to the host defenses. If a patientkeeps having reactional episodes after anti-leprosy treatment, the anti-inflammatorytherapy should be continued.

Nevertheless, I believe that reactionalepisodes may result from multiplication ofbacilli that were not destroyed by treatment.If this hypothesis could be demonstrated,these reactions would be considered re-lapses, and that would be a reason for theWHO’s statistics on relapses to be changed.

In general, type 1 reactions occur in pre-existing lesions that may appear as hypo-chromic macules with sensory changes,sensation or well constituted borderline ortuberculoid lesions with chronic evolution.These reactions are often times exuberantand occur before, during, or even after re-lease from treatment (3).

All these reactions are presented with thesame clinical characteristics. The bacil-loscopy may be negative or positive, and ifpositive, bacilli may show degeneration in

reactional episodes occurring before treat-ment, as well as during treatment.

In the pre-sulphone era, the authors care-fully observed the natural history of somereactional cases and reported tuberculoidpatients with certain reactions in whichbacilli and lesions disappeared sponta-neously. After some time or even years ofquiescence, reactions reappeared with le-sions and bacilli (1, 5, 6). These observationssuggest that the M. leprae may remain forlong periods in a state of metabolic inactiv-ity, inaccessible to organic defenses (possi-bly as persisters). At a certain moment,maybe because of intercurrent diseases orother immunological changes, bacilli startto multiply again, initiating a new reac-tional episode.

If that happened in the past, it may alsohappen today, i.e., the bacilli can remain aspersisters and not be destroyed by the im-mune defenses or treatment. The cell medi-ated type 1 reaction may somehow be relatedto multiplication of bacilli. The degeneratedaspect of the bacilli may result from the mul-tiplication of bacilli and their exposure to theeffects of drugs that are being used, or to theimmune defenses. The microorganisms aredestroyed and release antigens that give riseto a hypersensitivity reaction (type 1 reac-tion). In reactions occurring after treatment,if the number of bacilli is low, the patientsbecome cured because the body defenses de-stroy the bacilli. If there are many bacilli andthe organic defenses are unable to control theinfection, there will be new reactions and

CORRESPONDENCE

This department is for the publication of informal communications that are of interestbecause they are informative and stimulating, and for the discussion of controversialmatters. The mandate of the JOURNAL is to disseminate information relating to leprosy inparticular and also other mycobacterial diseases. Dissident comment or interpretation onpublished research is of course valid, but personality attacks on individuals would seemunnecessary. Political comments, valid or not, also are unwelcome. They might result ininterference with the distribution of the JOURNAL and thus interfere with its prime purpose.

Some Considerations on the Origin of

Type 1 Reactions in Leprosy1

33


(ISSN 0148-916X)


risk of nerve involvement and developmentof disabilities.

Recently, Shetty, et al. (4) studied 25 casesof borderline-tuberculoid leprosy that pre-sented with new lesions from 1 to 13 yearsafter being released from treatment. Viablebacilli were found in the footpad of inocu-lated mice in 48% of the biopsies of thosepatients. Remarkably, the incidence of vi-able bacilli was higher (58%) in those pa-tients whose histopathology showed evi-dences of reversal reaction.

Waters (7) commentary on Shetty’s work,referred to his own patient with a tubercu-loid lesion on the face that appeared 40years after the patient had been apparentlycured, and admitted that the authors pre-sented evidence that viable bacilli can causerelapse in borderline-tuberculoid leprosy,and that these relapses may be associatedwith reversal reactions.

I also studied a patient similar to Waters(2). She was a patient who presented withextensive erythemato-hypochromic flat le-sions on the trunk and extremities, with anegative bacilloscopic index (BI), whichdisappeared after 2 years of treatment withchaulmoogra oil. More than 40 years latershe presented a reactional episode with largeerythematous plaques on the entire skin,with a positive BI (++++) of the lesions,during an unbalanced diabetes mellitus.

These observations reinforce my inter-pretation of type 1 reactions, i.e., they arethe result of multiplication of persisters.

There are no proofs of this hypothesis be-ing true, but on the other hand, there isnothing showing it to be wrong.

I think the WHO should look at type 1 re-actions more carefully during the evalua-tion of MDT results.

—D.V.A. Opromolla

Division of Training and ResearchInstituto Lauro de Souza LimaAddress: P.O. Box 3021. Bauru. SP. Brazil.17034-970

Dr. Opromolla passed away while this is-sue was in production. The JOURNAL extendsits condolences to the family of this long-time professional in the leprosy field. Dr.Opromolla’s obituary will appear in theJune issue of the JOURNAL.

REFERENCES1. LIMA, LAURO DE SOUZA, and MAURANO, FLAVIO.

Reação leprótica. Rio de Janeiro: Ministério daSaúde, 1949.

2. OPROMOLLA, DILTOR, and ARAÚJO, VLADIMIR. Re-cidiva ou reação reversa? Hansen Int. Bauru 19(1)1994.

3. PFALTZGRAFF, ROY E., and RAMU, GOPAL. Clinicalleprosy. In: Leprosy, 2nd edn. Edinbugh: ChurchillLivingstone, 1994.

4. SHETTY, V. P., WAKADE, A., and ANTIA, N. H. A. Ahigh incidence of viable Mycobacterium leprae inpost-MDT recurrent lesions in tuberculoid leprosypatients. Lepr. Rev. 72(3) (2001) 337–344.

5. WADE, H. W. Tuberculoid changes in leprosy. II.Lepra reaction in tuberculoid leprosy. Int. J. Lepr.Other Mycobact. Dis. 2(2) (1934) 279–292.

6. WADE, H. W., RODRIGUEZ, J. N., and TOLENTINO, J.G. The course of open cases of tuberculoid leprosyat the Cebu Leprosarium. Int. J. Lepr. Other My-cobact. Dis. 7(4) (1939) 473–494.

7. WATERS, M. F. R. Distinguishing between relapseand late reversal reaction in multidrug (MDT)treated BT leprosy (Editorial). Lepr. Rev. 2(3)(2001) 250–253.

8. WHO EXPERT COMMITTEE ON LEPROSY. Sixth Re-port. Geneva: World Health Organization, 1988.Tech. Rep. Ser. 768.

TO THE EDITOR:

It was interesting to read the article“Neuropathic pain in leprosy patients” byStump, et al. (3). They have noted that a fairnumber of patients continue to suffer fromneuropathic pain in leprosy. This probablyis due to the treatment cut off point of 6months or 12 months, depending upon the

type of leprosy. Some patients do continueto complain of paresthesia even long afterthe activity is subsided. The series ofStump, et al. includes cases that were stillon treatment.

The clinical activity takes fairly longerthan the bacteriological cure. The WorldHealth Organization regimens are meant to“kill” the maximum number of germs in

Neuropathic Pain in Leprosy Patients

73, 1 Correspondence 35

shortest possible time. The body has to takecare of the scavenging and it might suffer inthe process. The process of nerve regenera-tion further complicates the issue, and if ir-ritants are present, paresthesia develops.Moreover, the compressing elements con-tinue to persist and are “assisted” by intra-neural and perineural fibrosis. As a conse-quence, a “neuroma in continuity” developsand the pain continues.

Mishra, et al. (1, 2), while reporting theirobservations on development of leprosy le-sions, noted that at least some of the lesionsstart as a vague dysthesia, meaning thatpositive phenomena occurs before a nega-tive phenomena (sensory loss). “Painless”nerve damage has been glorified as silentneuropathy. It is very likely that thosenerves have whispered before destruction,which patients were not able to hear due tothe faintness of the sound or their preoccu-pation with other things. Logically, pain(including paresthesia and dysthesia is apart of neural affection its intensity mayvary depending upon the type of affectionand the speed of damage.

Probably, both neuropathic pain and in-flammatory pain exist together in leprosy.Even in acute neuritis, the pain is more thanwhat is expected in pain of a purely noci-ceptive nature. That is probably the reasonthat many times acute neuritis is referred toas acute painful neuritis. The contributionfrom inflammation and neuropathy mayvary from patient to patient and from timeto time. The paresthesia complained of isusually of an annoying type, and with theadvancing age of patients many other dis-

comforts are added to it. It will be interest-ing to relate the paresthesia with disease ac-tivity in “cured” patients but, on the otherhand, it also scares me. Any suggestion ordiscussion about pain might exacerbate theproblems because patients are relatively un-stable emotionally and tend to develop de-pendence because of peculiar psychosocialeffects of the disease.

Mild paresthesia can be managed withsuggestions and counseling, whereas dis-abling paresthesia needs drugs in addition.But before all that can be formulated andput into practice, treatment of leprosy has tobe modified from community approach toindividualized approach.

—Dr. G. N. Malaviya

Department of Plastic & ReconstructiveSurgery

Central Jalma Institute for LeprosyTajganj, Agra (India) PIN 282 001E-mail: [email protected]

REFERENCES1. MISHRA, B., MUKHERJEE, A., GIRDHAR, A., HUSAIN,

S., MALAVIYA, G. N., and GIRDHAR, B. K. Evolu-tion of early lesions in leprosy. Lepr. Rev. 64(1993) 259–266.

2. MISHRA, B., MUKHERJEE, A., GIRDHAR, A., HUSAIN,S., MALAVIYA, G. N., and GIRDHAR, B. K. Neuriticleprosy: further progression and significance. ActaLeprologica 9 (1995) 187–194.

3. STUMP, P. R. N. A. G., BACCARELLI, R., MARCIANO,L. H. S. C., LAURIS, J. R. P., TEIXEIRA, M. J., URA,S., and VIRMOND, M. C. L. Neuropathic pain inleprosy patients. Int J Lepr. Other Mycobact. Dis.72 (2004) 134–138.

Reconstructive Surgery & Rehabilitationin Leprosy and other Neuropathies.Richard Schwarz, and Wim Brandsma.ISBN 99933-1-371-8. EKTA, Kathmandu,Nepal GBP 20, 2004

This 388-page multi-authored paperbackfocuses on aspects of surgical reconstruc-tion and rehabilitation for impairments inleprosy and complications in diabetic feet.The editors, one a surgeon and the other aleprosy physiotherapist, have dedicated thebook to the late Dr. Paul Brand who pio-neered reconstructive surgery in leprosy atthe Christian Medical College Hospital,Vellore, India, and who, with extraordinaryforesight, concurrently introduced rehabili-tation of the leprosy disabled at a “NewLife Centre” within the hospital for chan-nelling the skills of the affected individualsto safer vocations to prevent damage oftheir hands and feet. The Centre came to berecognized as “the birthplace of hand reha-bilitation.”

The text has a wide variation in style andemphasis between chapters, which is to beexpected in a book with authors of variedexperience. Chapters elaborating generalprinciples of reconstructive surgery, func-tional assessment, and motor and sensoryassessments are well written and contain alot of new details in the respective areas.Quick referencing would have been mucheasier had such useful information beenplaced under suitable subheadings.

A book which title ends with “other neu-ropathies” ideally requires a Neurologistand/or Neurophysiologist as a co-author toelaborate several neuropathies that have fea-tures akin to leprosy in order to have greaterappeal in countries were leprosy is uncom-mon. Terms like (a)sensate and (re)occur-rence rather than the accepted “insensate”and “recurrence,” respectively, are ambigu-ous in describing clinical states and can makefor imprecise field level reporting. The chap-ter on Neuritis is projected well with empha-sis that steroids by itself are more beneficialfor early nerve impairment. I think therewere grounds for stressing the need for con-

trolled studies of fascicular nerve decom-pression under magnification alongside ste-roid therapy in early neuritis for providing amore significant sensory recovery and indeedmotor improvement, since loupes and oper-ating microscopes are used in several largecenters in the developing world.

The chapters covering surgical recon-struction in the hands, feet, face, and noseare comprehensive with most segments ofthese texts re-emphasizing the foundationprocedures, a testimony in itself to whatmost of these work-horse reconstructivesurgeries had adequately accomplishedover the past five decades. Tension adjust-ment techniques for tendon transfers in thehand do not include a discussion on thenewer proposals to measure intraoperativesarcomere length with laser diffractiontechnique that also combine information onbiomechanical modelling generated fromnormative values of the muscle architec-ture, tendon compliance, and joint momentin order to optimize function of transferredtendons.

The chapters on Neuropathic feet, andManagement of Ulcers in the Neurologi-cally impaired feet are chapters that standalone, providing a welcome trend in evolv-ing strategies for treating persistent sec-ondary impairments of the feet. There isgreater clarity on salvage procedures ofNeuropathic feet and this taken togetherwith Appendices C, D, and E makes for anexcellent source of reference in managingdifficult complications in leprosy and dia-betic feet.

The chapter on pre- and post-operativetherapy techniques already well establishedby physiotherapists of the past genre is re-visited adequately. The chapters on Or-thotics and Prosthetics, and Rehabilitationare concise and clear. The figures in the textare acceptable for the paper they have beenprinted on. The caveat in the line illustra-tions is for surgeons in training and thosejust starting out to realize that these are in-tended to conceptualize the procedurerather than provide precise technical detailsfor obtaining the best results.

BOOK REVIEWS

36


(ISSN 0148-916X)

07.book.036 4/28/05 3:25 PM Page 36

73, 1 Book Reviews 37

There are few typographic and syntacti-cal errors, and wrong referencing. Other de-ficiencies are the absence of a chapter onoperating theater techniques to aid leprosycenters; the absence of a listing and illustra-tion of common assortments of instrumentsfor tendon transfer surgery, bone surgery,and some special instrumentation for arthro-desis, skin grafting, and flap cover; and theabsence of evaluation/grading systems tostudy the results of various surgeries so thatyoung surgeons can learn from large cen-ters, compare outcomes and improve ontechniques. Contradictory remarks on inter-nationally accepted surgical procedures areplaced as editorial inserts in few areas ofthe text. However these deficiencies shouldnot be considered as limiting in the impor-tance of this book which the editors presentin a 2 columns per page format at the af-fordable price of GBP 20.

At a time when molecular biologists areassiduously mining Mycobacterium lepraegenome in search for better diagnostics andvaccines, and sero-epidemiologists newlyresearch the prevention of leprosy, moreground is being covered by social and be-havioral scientists to influence the course of

the disease and its total control, and defor-mity rates are plummeting below 2 perthousand from the 20 per thousand it oncewas on record, the editors are to be congrat-ulated for updating a text on reconstructivesurgery for residual deformities in leprosy.This book should be in hospital librariesalongside the well known classics in lep-rosy reconstruction and rehabilitation so asto benefit special interest groups like youngsurgeons and trainees in orthopaedics, plas-tic and general surgery, and leprosy thera-pists attached to hospitals dedicated to thecare of leprosy patient and the diabetic.

—Dr. George A. Anderson, M.S. Orth.,D. Orth., MNAMS, M.Ch. Orth.,

FAMS, FACS

Professor of Orthopaedic Surgery &Head:

Dr Paul Brand Hand Surgery & Leprosy Reconstructive Surgery Centre

Christian Medical College Hospital, Vellore 632004, Tamil Nadu, India

E-mail: [email protected],[email protected]

Reconstructive Surgery & Rehabilitationin Leprosy and other Neuropathies.

Reconstructive Surgery & Rehabilitationin Leprosy and other Neuropathies, editedby Schwartz and Brandsma, is a twenty-four chapter, three-hundred and eighty pagetext which provides a review of surgicaland therapeutic modalities for the health-care providers treating leprosy. The editorsare diverse in their discipline, one a surgeonand the other a physiotherapist. The editorsauthored some of the chapters, but solicitedeighteen other professional contributorswith international experience to author themajority of the chapters. Although the bookis not totally comprehensive for every sur-gical technique or modality available, it isbroad-based concerning leprosy care.

The information in each chapter is pre-sented clearly. The material is well illus-trated, including both drawings and pho-tographs to assist the reader in understandingthe surgical techniques or concept of treat-ment. The appendices provide sample as-sessment protocols as well as a section con-cerning casting techniques.

The book was dedicated to the memoryof Dr. Paul Brand. Dr. Paul Brand was a re-searcher, surgeon who developed surgicaltechniques, and rehabilitation physicianwho treated patients in an holistic manner.By combining all these gifts, Dr. Brand di-rectly treated thousands of patients withdisabilities caused by leprosy. More so thanhis direct treatment of leprosy patients, Dr.Brand understood the importance of train-ing other individuals in the care of leprosy

07.book.036 4/28/05 3:25 PM Page 37


patients and sharing the information that heacquired concerning this treatment. Dr.Brand devoted most of his life to this mis-sion of teaching therapist and surgeons.Schwartz and Brandsma need to be congrat-ulated in continuing Dr. Brand’s mission byproviding an excellent resource for health-

care providers involved in the care of lep-rosy patients.

—Dr. Ronnie Mathews

Orthopedic ConsultantNational Hansen’s Disease Programs

07.book.036 4/28/05 3:25 PM Page 38

Reconstructive Surgery & Rehabilitationin Leprosy and other Neuropathies.Richard Schwarz, and Wim Brandsma.ISBN 99933-1-371-8. EKTA, Kathmandu,Nepal GBP 20, 2004

This 388-page multi-authored paperbackfocuses on aspects of surgical reconstruc-tion and rehabilitation for impairments inleprosy and complications in diabetic feet.The editors, one a surgeon and the other aleprosy physiotherapist, have dedicated thebook to the late Dr. Paul Brand who pio-neered reconstructive surgery in leprosy atthe Christian Medical College Hospital,Vellore, India, and who, with extraordinaryforesight, concurrently introduced rehabili-tation of the leprosy disabled at a “NewLife Centre” within the hospital for chan-nelling the skills of the affected individualsto safer vocations to prevent damage oftheir hands and feet. The Centre came to berecognized as “the birthplace of hand reha-bilitation.”

The text has a wide variation in style andemphasis between chapters, which is to beexpected in a book with authors of variedexperience. Chapters elaborating generalprinciples of reconstructive surgery, func-tional assessment, and motor and sensoryassessments are well written and contain alot of new details in the respective areas.Quick referencing would have been mucheasier had such useful information beenplaced under suitable subheadings.

A book which title ends with “other neu-ropathies” ideally requires a Neurologistand/or Neurophysiologist as a co-author toelaborate several neuropathies that have fea-tures akin to leprosy in order to have greaterappeal in countries were leprosy is uncom-mon. Terms like (a)sensate and (re)occur-rence rather than the accepted “insensate”and “recurrence,” respectively, are ambigu-ous in describing clinical states and can makefor imprecise field level reporting. The chap-ter on Neuritis is projected well with empha-sis that steroids by itself are more beneficialfor early nerve impairment. I think therewere grounds for stressing the need for con-

trolled studies of fascicular nerve decom-pression under magnification alongside ste-roid therapy in early neuritis for providing amore significant sensory recovery and indeedmotor improvement, since loupes and oper-ating microscopes are used in several largecenters in the developing world.

The chapters covering surgical recon-struction in the hands, feet, face, and noseare comprehensive with most segments ofthese texts re-emphasizing the foundationprocedures, a testimony in itself to whatmost of these work-horse reconstructivesurgeries had adequately accomplishedover the past five decades. Tension adjust-ment techniques for tendon transfers in thehand do not include a discussion on thenewer proposals to measure intraoperativesarcomere length with laser diffractiontechnique that also combine information onbiomechanical modelling generated fromnormative values of the muscle architec-ture, tendon compliance, and joint momentin order to optimize function of transferredtendons.

The chapters on Neuropathic feet, andManagement of Ulcers in the Neurologi-cally impaired feet are chapters that standalone, providing a welcome trend in evolv-ing strategies for treating persistent sec-ondary impairments of the feet. There isgreater clarity on salvage procedures ofNeuropathic feet and this taken togetherwith Appendices C, D, and E makes for anexcellent source of reference in managingdifficult complications in leprosy and dia-betic feet.

The chapter on pre- and post-operativetherapy techniques already well establishedby physiotherapists of the past genre is re-visited adequately. The chapters on Or-thotics and Prosthetics, and Rehabilitationare concise and clear. The figures in the textare acceptable for the paper they have beenprinted on. The caveat in the line illustra-tions is for surgeons in training and thosejust starting out to realize that these are in-tended to conceptualize the procedurerather than provide precise technical detailsfor obtaining the best results.

BOOK REVIEWS

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73, 1 Book Reviews 37

There are few typographic and syntacti-cal errors, and wrong referencing. Other de-ficiencies are the absence of a chapter onoperating theater techniques to aid leprosycenters; the absence of a listing and illustra-tion of common assortments of instrumentsfor tendon transfer surgery, bone surgery,and some special instrumentation for arthro-desis, skin grafting, and flap cover; and theabsence of evaluation/grading systems tostudy the results of various surgeries so thatyoung surgeons can learn from large cen-ters, compare outcomes and improve ontechniques. Contradictory remarks on inter-nationally accepted surgical procedures areplaced as editorial inserts in few areas ofthe text. However these deficiencies shouldnot be considered as limiting in the impor-tance of this book which the editors presentin a 2 columns per page format at the af-fordable price of GBP 20.

At a time when molecular biologists areassiduously mining Mycobacterium lepraegenome in search for better diagnostics andvaccines, and sero-epidemiologists newlyresearch the prevention of leprosy, moreground is being covered by social and be-havioral scientists to influence the course of

the disease and its total control, and defor-mity rates are plummeting below 2 perthousand from the 20 per thousand it oncewas on record, the editors are to be congrat-ulated for updating a text on reconstructivesurgery for residual deformities in leprosy.This book should be in hospital librariesalongside the well known classics in lep-rosy reconstruction and rehabilitation so asto benefit special interest groups like youngsurgeons and trainees in orthopaedics, plas-tic and general surgery, and leprosy thera-pists attached to hospitals dedicated to thecare of leprosy patient and the diabetic.

—Dr. George A. Anderson, M.S. Orth.,D. Orth., MNAMS, M.Ch. Orth.,

FAMS, FACS

Professor of Orthopaedic Surgery &Head:

Dr Paul Brand Hand Surgery & Leprosy Reconstructive Surgery Centre

Christian Medical College Hospital, Vellore 632004, Tamil Nadu, India

E-mail: [email protected],[email protected]

Reconstructive Surgery & Rehabilitationin Leprosy and other Neuropathies.

Reconstructive Surgery & Rehabilitationin Leprosy and other Neuropathies, editedby Schwartz and Brandsma, is a twenty-four chapter, three-hundred and eighty pagetext which provides a review of surgicaland therapeutic modalities for the health-care providers treating leprosy. The editorsare diverse in their discipline, one a surgeonand the other a physiotherapist. The editorsauthored some of the chapters, but solicitedeighteen other professional contributorswith international experience to author themajority of the chapters. Although the bookis not totally comprehensive for every sur-gical technique or modality available, it isbroad-based concerning leprosy care.

The information in each chapter is pre-sented clearly. The material is well illus-trated, including both drawings and pho-tographs to assist the reader in understandingthe surgical techniques or concept of treat-ment. The appendices provide sample as-sessment protocols as well as a section con-cerning casting techniques.

The book was dedicated to the memoryof Dr. Paul Brand. Dr. Paul Brand was a re-searcher, surgeon who developed surgicaltechniques, and rehabilitation physicianwho treated patients in an holistic manner.By combining all these gifts, Dr. Brand di-rectly treated thousands of patients withdisabilities caused by leprosy. More so thanhis direct treatment of leprosy patients, Dr.Brand understood the importance of train-ing other individuals in the care of leprosy

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patients and sharing the information that heacquired concerning this treatment. Dr.Brand devoted most of his life to this mis-sion of teaching therapist and surgeons.Schwartz and Brandsma need to be congrat-ulated in continuing Dr. Brand’s mission byproviding an excellent resource for health-

care providers involved in the care of lep-rosy patients.

—Dr. Ronnie Mathews

Orthopedic ConsultantNational Hansen’s Disease Programs

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Notice. from Asia.International Course on Rehabilitation

and Prevention of Disability (RPOD) andCourse in Community Based Rehabilita-tion (CBR)

For many years now a much needed andvery successful international course on Re-habilitation and Prevention of Disabilities(RPOD) has been conducted in Pokhara,Nepal. The international faculty are veryexperienced in clinical leprosy and the re-habilitation of persons affected by leprosy.

The RPOD-Management course willaim at teaching concepts in rehabilitationand POD, approaches to rehabilitation, re-habilitation and POD management, specifi-cally as it relates to leprosy affected per-sons.

The course will include sessions aboutmonitoring and evaluation of activities inthese areas. The course will be based on theconcepts and terminology used in the Inter-national Classification of Functioning, Dis-ability and Health (ICF) published by theWorld Health Organization.

For a limited number of participants anopportunity will be offered for additionalin-service training during the week(s) fol-lowing the management course. The partic-ipants will be assigned on a one-to-one ba-sis to a tutor who will guide them through aself-learning program.

Available topics include institutional re-habilitation, CBR, expanding the servicesof a leprosy hospital to serve people withother rehabilitation needs, agricultural reha-bilitation, statistics and information sys-tems, footwear, prosthesis and orthoses,physiotherapy and occupational therapy.These placements will be available strictlyby arrangement prior to the course only.

CBR-course. Increasingly, rehabilita-tion, and prevention of disability takesplace in the community with the active in-volvement and participation of the commu-nity. Approriate technology is advocated,self help groups are formed, microfinance

business training is started, etc. Everythingis geared towards the empowerment ofpeople with disability and the communitiesin which they live.

The main objective of the course is thatparticipants will have a working knowledgeof all the important aspects related to CBR.Besides plenary theoretical sessions therewill be a variety of practical (skill) sessions.

For those interested in both courses in-service training if desired can also bearranged following the CBR course.

DATES: RPOD course 7 to 18 March,2005 (2 weeks) [+optional week(s) if pre-arranged]

CBR course March 21 to April 1, 2005 (2weeks) (in-service, if pre-arranged)

TARGET GROUP: Managers of reha-bilitation and/or POD programs, senior hos-pital staff, senior leprosy control staff anddoctors and therapists with managerial re-sponsibilities for RPOD/ CBR activities.

VENUE: The Green Pastures TrainingCentre in Pokhara, Nepal

COURSE FEES (including board &lodging): $350 per week

FURTHER INFORMATION: Detailedinformation can be obtained from:

The Training OfficerGPTCP.O. Box 28Pokhara 33701 Nepaltel +977 61 524562fax +977 61 520430E-mail: [email protected]

Notice. from Africa.The All Africa Leprosy, TB, Rehabilita-

tion Research and Training Center (ALERT)announces its calendar of internationaltraining courses for 2005 (see Calendar).Courses vary from 1 to 6 weeks on topicsincluding community based rehabilitation,

NEWS and NOTESThis department furnishes information concerning institutions, organizations, and

individuals engaged in work on leprosy and other mycobacterial diseases, and makes noteof scientific meetings and other matters of interest.

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basic and clinical leprosy, TB, and HIV forphysicians, sentionr field staff, and physi-cians.

For further information contact the ALERTTraining Division, PO Box 165, Addis Ab-baba, Ethiopia. Tel 251-1-211-341 FAX251-1-211-351.E-mail: [email protected]: www.telecom.net.et/tdalert

Notice. from South AmericaWorkshop on Hansen’s Disease: TheChallenge to Integrate Diagnose andTreatment Activities into Basic Care.

Last November 2004, a workshop washeld in Brasilia (DF) on the integration ofleprosy services in the basic health services.Guest lecturers were Dr. S. K. Noordeen,President of ILA, and Dr. Denie Daumeriefrom the World Health Organization. Theone-day workshop was organized by theMinistry of Health of Brazil and coordi-nated by Dr. Rosa Castálisa França SoaresRibeiro, which is leading the National Pro-gram for Leprosy Elimination in Brazil.The meeting was attended by coordinatorsof the state programs of elimination, con-sultants from PAHO and MoH, and mem-bers of municipal health services and

MORHAN. Dr. Noordeen addressed the In-dian experience on integration of leprosyservices in the general health services,which was a valuable contribution to thediscussion of this same process in Brazil. Inthe agenda of the workshop, it was also in-cluded the discussion of the targets andchallenges for the year 2005 in what re-gards the elimination of leprosy in Brazil.

Successful experiences in disease con-trol in Brazil presented at 4th Expoepi.Minister of Health Humberto Costa andSecretary of Health Surveillance JarbasBarbosa inaugurated the 4th National Exhi-bition of Successful Experiences in Epi-demiology and Disease Prevention andControl (Expoepi—exhibit on epidemiol-ogy experiences). The objectives of theevent, the most important in its area in all ofBrazil, are to bring to light and reward ac-tions implemented in states and cities thathad a positive impact on the prevention andcontrol of diseases of importance to publichealth by improving the quality of epidemi-ological surveillance. In the competitive ex-hibit, 27 experiences are being presented, innine categories, including successful expe-riences in the elimination of leprosy, whichreceived on of the top prizes.

A national award to Dr. Diltor V. A.Orpomolla. During the opening ceremony

Participants of the Workshop on Integration of Leprosy in the General Health Services included (left to right)Dr. M. Virmond (Bauru), Dr. D. Daumeire (WHO), Dr. S. K. Noordeen (ILA), Prof. Vera Andrade(PAHO/WHO), The honorable Ministry of Health Dr. Humberto Costa, Dr. Rosa Castália (MoH), Dr. Jarbas Bar-bosa (MoH) and Mr. Artur Custódio (MORHAN).

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73, 1 News and Notes 41

Calendar of Meetings and Events

Day mm/yy Location Details Contact e-mail

7–18 Mar-05 The Green Pastures International course on Rehabilitation Wim Brandsma [email protected]

Training Centre and Prevention of Disability

Pokhara, Nepal

21–1 Mar–Apr 05 The Green Pastures Community Based Rehabilitation course Wim Brandsma [email protected]

Training Centre

Pokhara, Nepal

21–8 Mar–Apr 05 ALERT, Addis Abbaba, Essentials of leprosy and tuberculosis for ALERT Training [email protected]

Ethiopia administrative & program support staff Division www.telecom.net.et/

tdalert

18–6 Apr–May 05 ALERT, Addis Abbaba, Essentials of leprosy and tuberculosis for ALERT Training [email protected]

Ethiopia physicians & scientists Division www.telecom.net.et/

tdalert

28–30 Jul-05 Sheraton Hotel, US-Japan Cooperative Medical Science Gail G. Jacobs, [email protected]

Seattle, USA Program Tuberculosis/Leprosy Panel Program Officer

NIAID/NIH

12–30 Sep-05 ALERT, Addis Abbaba, Clinical leprosy & tropical dermatology ALERT Training [email protected]

Ethiopia for Physicians Division www.telecom.net.et/

tdalert

3–28 Oct-05 ALERT, Addis Abbaba, Management of combined leprosy and ALERT Training [email protected]

Ethiopia tuberculosis, HIV/AIDS control Division www.telecom.net.et/

programmes for physicians and tdalert

operational research methods in

epidemiology

7–16 Nov–Dec 05 ALERT, Addis Abbaba, Clinical leprosy and management of ALERT Training [email protected]

Ethiopia combined leprosy, tuberculosis, and Division www.telecom.net.et/

HIV/AIDS control programmes for tdaler

senior field staff

tba Nov-05 Joao Pessoa 10th Brazilian Congress of Hansenology Francisca Estrela

for 4th Expoepi, Minister of the HealthHumberto Costa reaffirmed the federal gov-ernment’s commitment to do whatever ittakes to eliminate the disease. In addition, agroup of scientist were honored by the Min-istry of Health in the opening night and one

of those was Dr. Diltor V. A. Opromolla,renowned worldwide as a symbol of thestruggle against leprosy. Among many con-tribution of Prof. Opromolla is the introduc-tion of rifampicin as a leading drug in thetreatment of leprosy.

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Blau, S., and Yagodin V. Osteoarchaeologi-cal evidence for leprosy from western Cen-tral Asia. Am. J. Phys. Anthropol. 126(2)(2004) 150–158 [Epub. ahead of print]

Published reports of paleopathologicalanalyses of skeletal collections from CentralAsia are, to date, scarce. During the macro-scopic examination of skeletal remains dat-ing to the early first millennium AD fromthe Ustyurt Plateau, Uzbekistan, diagnosticfeatures suggestive of leprosy were foundon one individual from Devkesken 6. Thisadult female exhibited rhinomaxillary changesindicative of leprosy: resorption of the ante-rior nasal spine, rounding and widening ofthe nasal aperture, erosion of the alveolarmargin, loss of a maxillary incisor, and in-flammatory changes in the hard palate.While it is unclear whether the bones of thehands and the feet from this individual wereabsent as a result of collection strategy orpoor preservation, lesions affecting the tibiaand fibula were recorded, and the ways inwhich they may be related to a diagnosis ofleprosy are discussed. This is the first skele-tal evidence of leprosy from Central Asiaand raises questions not only about thespread of the disease in the past, but alsoabout the living conditions of what tradi-

CURRENT LITERATURE

This department carries selected abstracts of articles published in current medicaljournals dealing with leprosy and other mycobacterial diseases.

General and Historical 42Chemotherapy 43Clinical Sciences 46Immunopathology 52

Leprosy 58Tuberculosis 61

Microbiology 67Leprosy 67Tuberculosis 69

Experimental Infections and Vaccines 71Epidemiology and Prevention 76Rehabilitation 77Other Mycobacterial Diseases 78Molecular and Genetic Studies 84

General and Historical

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tionally were thought of as nomadic peo-ples.—Authors’Abstract

Boldsen, J. L. Leprosy and mortality in theMedieval Danish village of Tirup. Am. J.Phys. Anthropol. 126(2) (2004) 159–168.[Epub. ahead of print].

Leprosy was a well-recognized anddreaded disease in Denmark in the MiddleAges (AD 1000–1536). A large fraction ofthe population was affected by leprosy inthe 13th century. This paper analyzes thecorrelation between signs of leprosy andrisk of dying in the small Danish village ofTirup (AD 1150–1350). Seven different di-chotomous osteological lesions indicativeof leprosy are analyzed, and it is possible toscore at least one of these conditions on 135skeletons of adult or adolescent people(aged 14 or more). Scores were transformedto a statistic, lambda, indicating the likeli-hood that the person to whom the skeletonbelonged suffered from leprosy. The analy-ses indicate that the prevalence of leprosyamong adult people in Tirup was 26% (95%confidence interval, 17–35%). The lambdastatistic indicates that people who died withsigns of leprosy did not differ in the distribu-tion of age at death from those who did not

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73, 1 Current Literature, Chemotherapy 43

ment programs for persons living with thehuman immunodeficiency virus in parts ofsub-Saharan Africa. Ensuring adequate ad-herence to antiretroviral drug therapy is oneof the principal challenges facing success-ful implementation in Africa, where 70% ofthe world’s infected persons live. Tubercu-losis and leprosy are two diseases of globalimportance whose control programs canprovide important lessons for developingantiretroviral drug adherence strategies.This paper examines various approachesused in tuberculosis and leprosy controlwhich could help enhance adherence to an-tiretroviral therapy in resource-limited set-tings.—Authors’Abstract

Tayles, N., and Buckley, H. R. Leprosyand tuberculosis in Iron Age SoutheastAsia? Am. J. Phys. Anthropol. 125(3)(2004) 239–256.

The recent excavation of a sample of 120human skeletons from an Iron Age site in thevalley of the Mun River, a tributary of theMekong River on the Khorat Plateau in north-east Thailand, has provided the largest samplefrom this period in the region to date. Thispaper reviews three individuals from thesample with pathological changes for whichthe differential diagnosis includes systemicinfectious disease. In two of these, bothmales with lesions of the hands and feet, lep-rosy and psoriatic arthritis are discussed asdifferential diagnoses, with leprosy the mostprobable. In the third, a female with lesions ofthe spine, the differential diagnosis includestuberculosis and nonspecific osteomyelitis.Tuberculosis is the most probable diagnosis.Although the focus of this paper is a presen-tation of the evidence for infectious diseaseat Noen U-Loke, the significance of probablediagnoses of mycobacterial diseases for thehistory of the diseases and for prehistory inmainland Southeast Asia is also briefly dis-cussed.—Authors’Abstract

have such signs. Skeletons showing dentalenamel hypoplasia were less likely to comefrom skeletons with high lambda-values.The association between lambda and dentalenamel hypoplasia indicates a relationshipbetween stress in early childhood (ages 1–6years) and subsequent development of signsof leprosy.—Authors’Abstract

Ishii, N., Mori, S., and Nakajima, H. [Sum-mary of questionnaires on leprosy in Yoko-hama City area and university hospitals].Nihon Hansenbyo Gakkai Zasshi. 73(3)(2004) 207–215. [Article in Japanese]

We sent a questionnaire to members ofYokohama Medical Association and De-partments of University Hospital to get anoverview of leprosy patients in the clinic.Yokohama Medical Association: The rate ofcollection was approximately 47%. Fewdoctors have taken medical care of Leprosypatients. Half of the doctors will take med-ical care, but they have little informationabout Leprosy. Aged doctors do not takemedical care compared with young doctors.Departments of University Hospital: Therate of collection was approximately 74%.Doctors in the University Hospitals do nothesitate to take medical care of leprosy pa-tients. Dermatologists actively take medicalcare and have a chance of getting informa-tion about leprosy. It is necessary to givedoctors information about leprosy and itshistory of stigma.—Authors’Abstract

Reid, S. E., Reid, C. A., and Vermund, S.H. Antiretroviral therapy in sub-SaharanAfrica: adherence lessons from tubercu-losis and leprosy. Int. J. STD AIDS.15(11) (2004) 713–716.

Declining drug costs and increases in in-ternational donor interest are leading togreater availability of antiretroviral treat-

ChemotherapyAndries, K., Verhasselt, P, Guillemont,

J., Göhlmann, Neefs, J.-M., Winkler,H., van Gestel, J., Timmerman, P.,Zhu, M., Lee, E., Williams, P., de

Chaffoy, D., Huitric, E., Hoffner, S.,Cambau, E., Truffot-Pernot, C., Lou-nis, N., and Jarlier, V. A Diarylquino-line Drug Active on the ATP Synthase of

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Mycobacterium tuberculosis. Science.Epub. 9 December 2004.

Tuberculosis has been increasing signifi-cantly on a world-wide absis over the pastdecade, but no tuberculosis-specific drugshave been discovered in 40 years. We iden-tifies a diarylquinoline, R207910, that po-tently inhibits both drug-sensitive and drug-resistant Mycobacterium tuberculosis invitro (MIC 0.06 g/ml). In mice, R207910exceeds the bacterial activities of isoniazidand rifampin by at least 1 log. Substitutionof drugs included the World health Organ-ization’s first-line tuberculosis treatmentregimen (rifampin, isoniazid, and pyrazi-namide) with R207910 accelerates bacteri-cidal activity, leading to complete cultureconversion after 2 months of treatment onsome combinations. A single dose ofR207910 inhibits mycobacterium growthfor 1 week. Plasma levels associated withefficacy in mice are well tolerated inhealthy human volunteers. Mutants selectedin vitro suggest the proton pump of ATPsynthase to be the target for the drug.—Au-thors’Abstract

[Please see Commentary on this articlein this issue of the JOURNAL, p. 32.]

Barrow. R. R. Microsphere technology forchemotherapy of mycobacterial infec-tions. Curr. Pharm. Des. 10(26) (2004)3275–3284.

The purpose of this review article is toexamine the various studies that have eval-uated microspheres for delivery of antimy-cobacterial drugs. Some of the studiesstrictly involve the development and evalu-ation of microspheres for use in antimy-cobacterial drug delivery, whereas othersactually use drug-loaded microspheres totreat mycobacterial infections in cell linesand small animals. Although there is a po-tential to use microspheres to treat a varietyof mycobacterial infections, it appears thatmost of the studies so far have focused onthe etiological agent of tuberculosis, Myco-bacterium tuberculosis. As a result, the in-fectious studies presented here all entail thetreatment of that mycobacterial agent. Thisreview will address the following aspectsthat are important if microspheres are to beconsidered an acceptable therapeutic tool:

1) in vitro release characteristics, 2) deliv-ery, release and efficacy in macrophages, 3)effectiveness in infected small animal mod-els, 4) safe and combined use with otherantimycobacterial agents, and 5) reducedtoxicity. It is hoped that once all of these pa-rameters are evaluated, a conclusion regard-ing the benefit of microsphere technology inthe treatment of mycobacterial diseases canbe reached.—Author’s Abstract

Bermudez, L E., and Yamazaki, Y. Effectsof macrolides and ketolides on mycobac-terial infections. Curr. Pharm. Des.10(26) (2004) 3221–3228.

New macrolides, such as clarithromycinand azithromycin, are active agents to My-cobacterium avium complex (MAC). Bothclarithromycin and azithromycin are well-known for the ability to improve the prog-nosis of AIDS patients with disseminatedMAC infection. However, the administra-tion of monotherapy with a macrolide isusually associated with the emergence ofdrug resistance after a few months of use.Therefore, the recommended treatment forMAC infection involved the use of at leasttwo antibiotics, which includes a macrolidein combination with rifabutin, moxifloxacinand/or ethambutol. When used as prophy-lactic therapy in AIDS patients, azithro-mycin is more convenient (1200 mg, once aweek) than clarithromycin (500 mg, twice aday). Ketolides are a semi-synthetic deriva-tive of erythromycin A, which differs fromerythromycin A by substitution of a 3-ketogroup for L-cladinose. Telithromycin has acarbamate group linked to an imidazoliumand pyridium nucleus at C11–C12. In micemodel, both telithromycin and ABT-733were active in vivo against MAC.—Au-thors’Abstract

Jacobs, M. R. Fluoroquinolones as chemo-therapeutics against mycobacterial infec-tions. Curr. Pharm. Des. 10(26) (2004)3213–3220.

The antimicrobial agents used in thetreatment of mycobacterial infections haveremained largely unchanged for severaldecades. Primary treatment of tuberculosisrelies on four drugs, isoniazid, a rifamycin,

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73, 1 Current Literature, Chemotherapy 45

pyrazinamide, and ethambutol (or strepto-mycin), and generally results in >95% curein uncomplicated tuberculosis infection.Drug resistance greatly complicates treat-ment of this disease. Treatment of tubercu-losis caused by multiply drug-resistantstrains with “second-line” drugs remainscomplex, and is generally tailored to the in-dividual patient and strain. Several of thefluoroquinolones have shown promise assecond line drugs for treatment of activedisease and, in combination with clarith-romycin or azithromycin, ethambutol, andother agents, for treatment of Mycobacte-rium avium complex infection. While largeclinical trials are not possible with secondline drugs, clinical treatment data are avail-able and suggest that the quinolones havevarious degrees of promise in treatment ofthese infections. Bacterial type II DNAtopoisomerases, DNA gyrase and topoiso-merase IV, are the targets of quinolones, andprovide the genetic basis for quinolone ac-tivity in mycobacteria. Mutations in theseenzymes results in resistance, and charac-terization of resistant mutants allows cor-relation of genotype with susceptibilityphenotype. Structure-activity relationshipstudies have provided further insight intooptimal use of quinolones in mycobacterialinfections. Care should be taken in treatingpneumonia with fluoroquinolones if there isa degree of suspicion of tuberculosis, sincequinolone monotherapy may rapidly selectfor quinolone resistance, thereby removingthat class of antibiotic from the small rangeof treatment options.—Author’s Abstract

Khuller, G. K., Kapur, M., and Sharma, S.Liposome technology for drug deliveryagainst mycobacterial infections. Curr.Pharm. Des. 10(26) (2004) 3263–3274.

Mycobacteria are intracellular pathogensthat invade and reside inside macrophages.There has been a rapid resurgence in infec-tions caused by the genus mycobacteria.Chemotherapy of mycobacterial infectionsis prolonged, hepatotoxic and very often in-adequate in achieving optimal drug concen-trations inside the cells. Recent advances incontrolled delivery systems for drugs suchas liposomes have sparked a renewed inter-est in their potential application for thetreatment of mycobacterial infections.

The versatility of liposomes in incorpora-tion of hydrophilic/hydrophobic compo-nents, non-toxic nature, biodegradability,biocompatibility and property of sustainedrelease makes them attractive candidatesfor the delivery of antitubercular drugs. Li-posome research in the area of mycobacte-rial diseases has evolved and maturedthrough several phases; from the laboratoryto the clinics. This review, thus focuses onthe use of liposomes for the treatment ofvarious types of mycobacterial diseases.—Authors’Abstract

Sharma, A., Pandey, R., Sharma, S., andKhuller, G. K. Chemotherapeutic effi-cacy of poly (DL-lactide-co-glycolide)nanoparticle encapsulated antituberculardrugs at sub-therapeutic dose against ex-perimental tuberculosis. Int. J. Antimi-crob. Agents. 24(6) (2004) 599–604.

The present study was designed to evalu-ate the chemotherapeutic efficacy of poly(DL-lactide-co-glycolide) (PLG) nanoparti-cles (NP) encapsulating three front-line an-titubercular drugs (ATDs: rifampicin, RIF;isoniazid, INH and pyrazinamide, PZA) at2/3rd therapeutic dose. PLG nanoparticlesprepared by the double emulsion and sol-vent evaporation technique were adminis-tered orally at 2/3rd therapeutic dose toguinea pigs. A single oral administration ofthe formulation resulted in sustained druglevels in the plasma for 7–12 days and inthe organs for 11–14 days with a significantimprovement in mean residence time aswell as drug bioavailability. The adminis-tration of PLG nanoparticles every 10 days(five doses) to Mycobacterium tuberculosisH(37)Rv infected guinea pigs led to un-detectable bacilli in the organs, as did 46conventional doses. Therefore, nanoparticlebased antitubercular chemotherapy forms asound basis for a reduction in dosing fre-quency and also offers the possibility of re-ducing the drug dosage.—Authors’Abstract

Stephan, J., Mailaender, C., Etienne, G.,Daffe, M., and Niederweis, M. Mul-tidrug resistance of a porin deletion mu-tant of Mycobacterium smegmatis. An-timicrob. Agents Chemother. 48(11)(2004) 4163–4170.

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Mycobacteria contain an outer membraneof unusually low permeability which con-tributes to their intrinsic resistance to manyagents. It is assumed that small and hy-drophilic antibiotics cross the outer mem-brane via porins, whereas hydrophobic an-tibiotics may diffuse through the membranedirectly. A mutant of Mycobacterium smeg-matis lacking the major porin MspA wasused to examine the role of the porin path-way in antibiotic sensitivity. Deletion of themspA gene caused high-level resistance ofM. smegmatis to 256 microg of ampicillin/ml by increasing the MIC 16-fold. The per-meation of cephaloridine in the mspA mu-tant was reduced ninefold, and the resis-tance increased eightfold. This established aclear relationship between the activity andthe outer membrane permeation of cepha-loridine. Surprisingly, the MICs of the largeand/or hydrophobic antibiotics vancomy-cin, erythromycin, and rifampin for themspA mutant were increased 2- to 10-fold.This is in contrast to those for Escherichiacoli, whose sensitivity to these agents wasnot affected by deletion of porin genes. Up-take of the very hydrophobic steroid cheno-deoxycholate by the mspA mutant wasretarded threefold, which supports the hy-pothesis that loss of MspA indirectly re-duces the permeability by the lipid path-way. The multidrug resistance of the mspAmutant highlights the prominent role ofouter membrane permeability for the sensi-tivity of M. smegmatis to antibiotics. An un-derstanding of the pathways across the

outer membrane is essential to the success-ful design of chemotherapeutic agents withactivities against mycobacteria.—Authors’Abstract

Zhang, Y. The Magic Bullets and Tubercu-losis Drug Targets. Annu. Rev. Pharma-col.Toxicol. (2004) Oct. 07; [Epub.ahead of print].

Modern chemotherapy has played a ma-jor role in our control of tuberculosis. Yettuberculosis still remains a leading infec-tious disease worldwide, largely owing topersistence of tubercle bacillus and inade-quacy of the current chemotherapy. Theincreasing emergence of drug-resistant tu-berculosis along with the HIV pandemicthreatens disease control and highlightsboth the need to understand how our cur-rent drugs work and the need to developnew and more effective drugs. This reviewprovides a brief historical account of tu-berculosis drugs, examines the problem ofcurrent chemotherapy, discusses the tar-gets of current tuberculosis drugs, focuseson some promising new drug candidates,and proposes a range of novel drug targets forintervention. Finally, this review addressesthe problem of conventional drug screensbased on inhibition of replicating bacilli andthe challenge to develop drugs that targetnonreplicating persistent bacilli. A newgeneration of drugs that target persistentbacilli is needed for more effective treat-ment of tuberculosis.—Author’s Abstract

Clinical SciencesAgrawal, S. K., Singal, A., Pandhi, D.,

and Oberoi, S. Involvement of gen-itofemoral nerve with genital lesions inlepromatous leprosy. Indian J. Lepr. 76(1)(2004) 71–77.

The case of a male patient diagnosed tohave lepromatous leprosy with type 2 reac-tion on multibacillary multidrug therapy,with unusual, widespread involvement ofgenitalia in the form of plaque and nodulesof leprosy over scrotum and perimeatal re-gion of glans, necrotic lesions of erythemanodosum leprosum over scrotum, neuritisof genital branch of genitofemoral nerve bi-

laterally, and azoospermia, is reported.—Authors’Abstract

[Anonymous]. [No authors listed]. [Lep-rous neuropathies]. Zh. Nevrol. Psikhi-atr. Im. S. S. Korsakova. 104(11) (2004)19–24. [Article in Russian].

The damage to the peripheral nervoussystem (PNS) is a marker of Mycobacte-rium leprae (M. leprae) infection that de-velops as a result of the M. leprae invasionto the Schwann cells. Clinical, functional(skin-deep and stimulating electromyogra-

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73, 1 Current Literature, Clinical Sciences 47

phy, determination of the spreading velocityof the pulsatory wave along the arteries ofmuscle type, direct and volumetric sphing-mography, reovasography, skinning elec-trotermometry) and immunological (evalu-ation of antibodies to neuroantigenes byELISA) methods were used to study 132patients with leprous neuropathy. Sensoryimpairment (descend of superficial sensibil-ity, combination of the spotted, trunk andpolyneuritic types of sensory injury), hy-pertrophy of the peripheral nerves and theirpainfulness by palpation were shown to de-velop at the initial stage, with the followingjoining of motor and trophic disturbances,such as amyotrophy, contractures, shorten-ing of digits, trophic ulcer. Skin-deep andstimulating electromyography revealed thesubclinical manifestation of neuromuscularsystem injuries in clinically normal muscles.A neuroantigen’s entrance into the blood-stream and antibody reactions to them werecharacteristic of LN. High antibody levels,as a rule, corresponded to the exacerbationsof leprous neuropathy, activation of leprousprocess, relapses of the disease and reac-tions of leprous erythema nodosum type.An association between specific humoralresponse to the antigens of the M. lepraeand production of the antibodies to neuro-markers was found.—Author’s Abstract

Couri, C. E., Foss, N. T., Dos Santos, C.S., and de Paula, F. J. Hypercalcemiasecondary to leprosy. Am. J. Med. Sci.328(6) (2004) 357–359.

Despite the high prevalence of leprosy inundeveloped countries, hypercalcemia sec-ondary to leprosy is rare. One of most im-portant mechanisms responsible for thisdisorder seems to be high serum concentra-tions of 1,25-dihydroxyvitamin D producedextrarenally by the granulomatous tissue.Serum levels of parathyroid hormone-related protein (PTHrP) have never beenanalyzed in this disorder. We report here acase of hypercalcemia in a patient with lep-rosy. Serum levels of 1,25-dihydroxyvitaminD were normal in spite of low levels of 25-dihydroxyvitamin D and acute renal failure.Suppressed serum levels of parathyroidhormone and PTHrP were also remarkable.In this case, PTHrP seems not to play an

important role in the pathogenesis of hyper-calcemia. Our data indicate that this disor-der may be due, at least in part, to abnormalcalcitriol overproduction by granulomatoustissue. Further investigations of the preva-lence and pathogenesis of this type of hy-percalcemia are needed.—Authors’Abstract

Duerksen, F. Leprosy and Neuropathy seenfrom the perspective of a surgeon.Hansen Int. 29(1) (2004) 41–45. No Ab-stract Available.

Farshchian, M., and Kheirandish, A.Clinico-pathological study of 12 cases ofpatients with leprosy admitted to SinaHospital, Hamadan, Iran, from 1991 to2000. Int. J. Dermatol. 43(12) (2004)906–910.

BACKGROUND: Leprosy is considereda chronic disabling condition. Many clini-cal and immunological aspects of the dis-ease remain ill defined. AIM: The study ofclinico-pathological and laboratory findingsof patients with leprosy admitted to SinaHospital, Hamadan, Iran, from 1991 to2000. METHODS AND PATIENTS: Thisis a descriptive retrospective cross-sectionalstudy. The statistical community comprisedall patients diagnosed leprosy. This diagno-sis was clinical and confirmed throughpathology (skin-biopsy) and laboratory (pe-ripheral smear) measures. RESULTS: Inthis study, the disease was more common inmales than females with a mean age of 48.5± 16.2 years. Most of the patients weremore than 40 years old. Among 12 patientsin this study, six cases were urban and sixcases were rural. Six cases were living inHamadan province and two cases migratedto Hamadan province (one of them fromAfghanistan and the other from Kurdestan).Clinical diagnosis was confirmed by pathol-ogy in 11 cases, but in one case the clinicaldiagnosis did not match the pathology. Infour cases the clinical diagnosis did notmatch the peripheral smear. Eight caseswere admitted just once. Four cases had ahistory of recurrence and readmission (twopatients had one time recurrence and theother two patients had two recurrences).There was no difference in the clinical find-ings between first presentation and recur-

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rence. From the point of complication anddisability, extremity disability was morecommon than eye disability. Increasedseverity of complications was found in pa-tients with a delayed diagnosis and incom-plete treatment. CONCLUSION: Thisstudy showed that a rapid and correct diag-nosis and complete treatment was necessaryfor prevention of complication and disabil-ity in patients with leprosy. Also the accu-racy of pathology (skin biopsy) in the diag-nosis exceeded the peripheral smear. Skinbiopsy is recommended to confirm the diag-nosis in all cases of leprosy. In the absenceof pathology, patients must be consideredas multibacillary patients and treated assuch.—Authors’Abstract

Gopinath, D. V., Thappa, D. M., andJaishankar, T. J. A clinical study of theinvolvement of cranial nerves in leprosy.Indian J. Lepr. 76(1) (2004) 1–9.

A clinical descriptive study was con-ducted to assess the frequency and pattern ofinvolvement of cranial nerves in leprosy andto study the relationship of cranial nerve in-volvement with a leprosy patch or patcheson facial skin. One hundred consecutive pa-tients of leprosy, diagnosed by clinical fea-tures and/or slit skin smear and histopathol-ogy, were studied; of these, 22 patients hadcranial nerve involvement. The mean age ofpatients with cranial nerve involvement was41.2 years. 16 patients (72.7%) with cranialnerve involvement were in the age-group of20–49 years. The male-to-female ratio was3.4:1. The mean duration of the disease inthese patients was 5.73 years. The durationof the disease in the majority of patientswith cranial nerve involvement was lessthan 5 years. Impairment of cranial nerveswas seen in 12 BT patients, 6 BL patients,and 4 LL patients. No significant differencewas noted between involvement of cranialnerves in PB and MB patients. Among thecranial nerves, facial nerve was the mostcommon nerve involved (10/22), followedby olfactory (9/22), trigeminal (7/22) andauditory (3/22) nerves. Among the risk fac-tors, it was found that facial nerve impair-ment was significantly associated with facialpatch(es) and also type 1 lepra reaction.—Authors’Abstract

Jardim, M. R., Chimelli, L., Faria, S. C.,Fernandes, P. V., Da Costa Neri, J. A.,Sales, A. M., Sarno, E. N., and GomesAntunes, S. L. Clinical, electroneuromyo-graphic and morphological studies of pureneural leprosy in a Brazilian referral cen-tre. Lepr. Rev. 75(3) (2004) 242–253.

Nineteen patients with pure neuralleprosy were analyzed with clinical exami-nation, electroneuromyography and histo-pathology of nerve biopsies. Clinical exam-ination showed sensory loss (78.9%),paresis (78.9%), nerve enlargement (68.4%)and nerve pain (42.1%). Electroneuromyo-graphic study revealed an axonal pattern in18 patients (94.7%) and a demyelinatingpattern in one (0.5%). Mononeuropathy mul-tiplex was the most frequent presentation(78.9%), followed by mononeuropathy sim-plex (10.5%) and polyneuropathy (10.5%).The histopathological study showed thepresence of inflammatory infiltrate com-posed of epithelioid granuloma (42.1%),mononuclear infiltrate (36.8%) or macro-phages positive for bacilli (21%). Fibrosiswas present in 78.9% of the biopsies. Ex-amination of semithin sections revealed,besides inflammatory infiltrate, myelinatedfiber loss (94.7%), remyelination (42%),axonal degeneration (10%) as well as re-generation (31.5%). Based on these results,the pathogenesis of leprosy neuropathy inthis group of patients is briefly discussed.—Authors’Abstract

Joshua J., and Sarkar S. Management of34 chronic heel sinuses in leprosy, usinga modification of a local rotation flap inKolkata, India. Lepr. Rev. 75(3) (2004)254–265.

We have seen 55 trophic ulcers of theheel in 2 years in our hospital, betweenMarch 2000 and February 2002. Thirty-four were chronic heel sinuses, six cases ofmultiple sinuses and 28 cases of single si-nus of the plantar aspect of the heel. Allthese cases were treated by excision of thesinus, paring the prominence of the calca-neum, or excision of the cavity within thecalcaneum and coverage by a rotation flapor a modification of this flap. Over the past6 years, we have evolved a modification of

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a rotation flap that requires a fusiform inci-sion to excise the sinus, and a curved inci-sion for the flap extending through the in-step and the non-weight bearing heel. Thefusiform excision, rather than the traditionaltriangulation, causes the flap to partly trans-pose rather than rotate completely. The flapis raised superficial to the plantar aponeuro-sis, exposing the aponeurosis from mid-soleto the heel. It is a modification of a rotationflap. The scarring over the weight-bearingsole is minimal, restricted only to the inci-sion necessary for the excision of the heelsinus and this is its main advantage. Twenty-one of the 34 cases healed without compli-cations. Thirteen cases had complications,of which six were treated non-operativelyand seven required either a redo of the flapor another flap cover.—Authors’Abstract

Khan, A., Koranne, R. V., Bajaj, P., andRavi, B. Clinico-histopathological corre-lation of skin and nerve in leprosy. J.Dermatol. 31(8) (2004) 632–636.

The histopathological features of skin tis-sue sections in patients clinically diagnosedas leprosy were correlated with the histo-pathological features of nerve specimensobtained from the same patients. Fifty un-treated leprosy patients attending the Out-patient Department of the Department ofDermatology and Sexually TransmittedDiseases of Smt. Sucheta Kriplani andKalawati Saran Children’s Hospitals, NewDelhi, India were included in the study. Oncorrelating the histological features of skinand nerve tissue sections, concordant find-ings were found in 24 out of the 50 patients(48%) but discordance between the histo-pathological features of skin and nerve tis-sue sections were found in 26 out of 50cases (52%). Of these 26 cases, the nervetissue histology when compared with theskin histology showed features lower downthe disease spectrum in 17 (34%) cases.Seven of the 50 patients (14%) showed his-tological features of leprosy higher in thedisease spectrum in the nerve tissue sec-tions than in the skin biopsy sections. Onepatient clinically LL leprosy demonstratedhistopathological features of Histoid lep-rosy in the skin sections and LL in the nervesections. The remaining one patient had

features of TT leprosy in the skin tissue sec-tions while the nerve tissue histopathologyshowed non-specific changes. Histologicalfeatures of the skin tissue sections wereconsistent with the clinical diagnosis in 33out of 50 cases (66%). When the clinicalgroups were correlated with the histologicalfeatures of the nerve tissue sections, con-cordance was found in 30 of the 50 cases(60%). On comparison of the histologicalfeatures of skin and nerve tissue sectionswith the clinical diagnosis, concordancewas still lower i.e., 19 out of 50 cases(38%). Thus the histological features of theskin tissue sections correlated more fre-quently with the clinical diagnosis than didthose of the nerve sections. The importanceof neural histology lies in the fact that itshows a higher BI and a lower histologicalgrading in some cases and if not performedthe lapse can result in inadequate treatment,drug resistance and even relapse.—Au-thors’Abstract

Martins, R. S., Siqueira, M. G., and Car-valho, A. A. A case of isolated tuberculoidleprosy of antebrachial medial cutaneousnerve. Neurol. Sci. 25(4) (2004) 216–219.

Leprosy is an infectious disease of preva-lence still high in endemic areas in Brazil.The neurological presentation depends onthe involved nerve and is usually associatedwith skin lesions and the formation of mul-tiple abscesses. We present a case of iso-lated tuberculoid leprosy, discuss the occur-rence, the differential diagnosis and thetreatment of this rare presentation and reaf-firm the importance of considering leprosyin the differential diagnosis of patients withpolyneuropathy or nerve enlargement withno skin lesions.—Authors’Abstract

Mathew, D., Kishore, B. N., Shwethadri,G. K., Sukumar, and Shetty, N. J. AnEvaluation of clinical and histopathologi-cal status in paucibacillary leprosy patientsafter completion of fixed duration therapy.Indian J. Lepr. 76(1) (2004) 11–18.

The present study was carried out involv-ing 25 patients with paucibacillary leprosywho attended the outpatient department of

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dermatology of Father Muller’s MedicalCollege Hospital during the period January2001 to March 2002. All the patients wereexamined clinically and histopathologicallyat the beginning and at the end of six monthsof MDT and relevant data recorded. Clinico-pathological correlation with histopatho-logical classification before MDT was 72%and 68% at the end of MDT in our study. Atthe end of treatment 4 (16%) cases were clin-ically active and 8 (32%) were histopatho-loglcally active. The study showed that activecases were significantly reduced as a resultof MDT, both clinically and histopathologi-cally. The histopathological activity thatoutlasts MDT may be due to the bacillaryfragments that persist; but clinical activitycoupled with histopathological activity seenin 2 patients at the end of 6 months of MDTwas possibly an indicator of relapse andthese patients and similar others need to befollowed up for a longer duration. In thisstudy, resolution of granuloma and clinicalactivity after completion of MDT were as-sessed.—Authors’Abstract

Nienhuis, W. A., van Brakel, W. H., But-lin, C. R., and van der Werf, T. S. Mea-suring impairment caused by leprosy:inter-tester reliability of the WHO dis-ability grading system. Lepr. Rev. 75(3)(2004) 221–232.

This paper reports the results of a studyon the inter-tester reliability of the WHOdisability grading system. The WHO dis-ability grading system is the most fre-quently used method of grading impairmentin leprosy patients. With this method, agrade of 0–2 is assigned to each of six indi-vidual body sites (both eyes, hands andfeet). The maximum grade of any of thesesites is used as an overall indicator of theperson’s impairment status. To date, theWHO disability grading scale has not beensubjected to reliability testing. The reliabil-ity of the grading system depends on theoperational definitions of the grades, theway the tester interprets these definitionsand the skill of the tester. It is therefore im-portant that the definitions are unambiguousand leave as little room as possible for mul-tiple interpretations. Three testers with vary-ing degrees of experience did paired assess-

ments on a total of 150 leprosy patients inthe Leprosy Mission Hospital Purulia, In-dia, using recently published operationaldefinitions of the WHO disability grades.For every patient, they determined the max-imum grade (minimum 0, maximum 2), andcalculated the impairment sum-score (EHFscore), adding up the six grades for eyes,hands and feet (minimum 0, maximum 12).The weighted Kappa statistic (Kw) wasused as the coefficient of inter-tester relia-bility. A kappa of 0 represents agreement nobetter than chance, and 1.0 complete(chance-corrected) agreement. Kw valuesof ≥0.80 are considered very good and ade-quate for monitoring and research.Weighted Kappa analysis yielded a reliabil-ity coefficient of 0.89 (95% CI 0.84–0.94)for the maximum grade and a Kw of 0.97(95% CI 0.96–0.98) for the EHF score. Weconcluded that, when using standard opera-tional definitions, the WHO disability grad-ing system can be used reliably in the handsof both experienced and inexperiencedtesters, provided adequate training has beengiven. Reliability should be evaluated fur-ther in a field setting, when used by primaryhealth care workers. It is recommended thatthe ‘WHO disability grading’ be renamed‘WHO impairment grading’, using the ter-minology as defined by the InternationalClassification of Functioning, Disabilityand Health (ICF).—Authors’Abstract

Pereira, G. A., Stefani, M. M., AraujoFilho, J. A., Souza, L. C., Stefani, G.P., and Martelli, C. M. Human immu-nodeficiency virus type 1 (HIV-1) andMycobacterium leprae co-infection:HIV-1 subtypes and clinical, immuno-logic, and histopathologic profiles in aBrazilian cohort. Am. J. Trop. Med. Hyg.71(5) (2004) 679–684.

Co-infections with human immunode-ficiency virus (HIV) and Mycobacteriumleprae represent unique opportunities to in-vestigate the interaction of both pathogens.We determined the immunologic, virologic,and histopathologic characteristics of 22 co-infected Brazilian patients (median age = 38years, 81.8% males, 72.2% with paucibacil-lary leprosy, and 95.4% with acquired im-munodeficiency syndrome). The HIV-1 sub-

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types B and BF predominated in envelopeand gag heteroduplex mobility analysis. Bor-derline tuberculoid (BT), tuberculoid, lepro-matous, and indeterminate morphology withCD3+, CD8+, and CD68+ cell distributionscompatible with leprosy patients not infectedwith HIV were observed. Histologic evi-dence of nerve damage was observed in BTlesions. IgM antibody to M. leprae-specificphenolic glycolipid I was not detected. Twoof six co-infected patients monitored duringhighly active antiretroviral therapy (HAART)developed a leprosy type 1 reaction after an in-crease in CD4+ cells, suggesting an immunerestoration phenomenon. Clinical, immuno-logic, histopathologic, and virologic featuresamong these HIV-leprosy co-infected pa-tients indicate that each disease progressed asin single infection. However, HAART im-mune reconstitution may trigger potential ad-verse effects, such as leprosy acute inflam-matory episodes.—Authors’Abstract

Pfausler B, Bosch S, Sepp N, and Schmutz-hard E. [Multibacillary leprosy in Tyrol.]Wien Klin Wochenschr. 115(Suppl 3)(2003) 72–75. [Article in German].

Five cases of multibacillary leprosy havebeen diagnosed in a period of 15 years(1987–2001) at the outpatient Department ofNeurology of the University Hospital Inns-bruck. All patients presented with dermato-logical and mild to severe polyneuropathicsigns and symptoms. 4/5 patients recoveredfully, whereas 1 patient with an initiallysevere polyneuropathy showed persistentpolyneuropathy as long-term sequela. Theprevalence of leprosy in the catchment areaof the Department of Neurology, UniversityHospital Innsbruck (comprising the entireprovince of Tyrol—650,000 inhabitants) isto be calculated as 0.5/1 million. The inci-dence of newly diagnosed leprosy withinthis province of Tyrol is 0.04/100,000/year.The aim of the presentation of these 5 pa-tients is—beside the epidemiologic aspect—to alert all neurologists and dermatologiststhat this disease still exists—despite decreas-ing prevalence and incidence rates on aglobal scale; this is of particular importancesince neurological long-term sequelae canonly be avoided by early diagnosis.—Au-thors’Abstract

Rodriguez, G., Pinto, R., Laverde, C.,Sarmiento, M., Riveros, A., Valder-rama, J., and Ordonez, N. [Relapsesafter multibacillary leprosy treatment.]Biomedica. 24(2) (2004) 133–139. [Arti-cle in Spanish].

Leprosy relapses are mainly due to bacil-lary persistence and diamino-diphenyl-sulphone (DDS) monotherapy. Case his-tories were examined for 33 patients withlepromatous leprosy (LL), diagnosed 7–48years before the relapse and treated onlywith DDS during 4 to 38 years. Twenty-eight patients received irregular non-supervised polychemotherapy (PCT) since1983. Five patients received only DDS, andpresented relapses 13–20 years after thetreatment was stopped. Relapses were diag-nosed by clinical methods, including thereappearance of lesions or presence of newanesthetic areas. All cases were confirmedby bacilloscopy, and a subset of 20 cases byskin biopsy. Four patients presented inde-terminate leprosy (IL) and one patient bor-derline tuberculoid leprosy (BT) in thebiopsy. The latter 5 demonstrated presenceof intraneural bacilli; the remainder wereLL. Two patients relapsed even with PCTtreatment. The others were cured with su-pervised PCT. Predisposing factors for re-lapses were as follows: DDS monotherapy,irregular PCT with inadequate dosage, un-supervised treatment, treatment uncompli-ance, and inadequate relationship betweenthe patient and the health staff. Inspectionsfor relapse in leprosy is recommended forin all multibacillary patients that weretreated with DDS. The clinical appearanceof new lesions or new anesthetic zones, thebacilloscopy and skin biopsy, used together,are effective in establishing the presence ofrelapses.—Authors’Abstract

Schwarz, R. J., and Macdonald, M. A ra-tional approach to nasal reconstruction inleprosy. Plast. Reconstr. Surg. 114(4)(2004) 876–882; discussion 883–884.

Destruction of the nasal septum and nasalbones by Mycobacterium leprae and subse-quent infection is still seen regularly in lep-rosy endemic areas. The social stigma asso-ciated with this deformity is significant.

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Many different procedures have been devel-oped to reconstruct the nose. Patients oper-ated on at Anandaban Hospital and the GreenPastures Hospital and Rehabilitation Centerbetween 1986 and 2001 were reviewed.There were 48 patients with an average ageof 47 years. Five deformities were mild, 22were moderate, 13 were severe, and eightwere not graded. Bone grafting with na-solabial skin flaps was performed in 14cases, bone grafting alone was performed in10 cases, flaps alone were performed inseven cases, and cartilage grafting was per-formed in 10 cases. In three patients, a pros-thesis was inserted, and in three patients agull-wing forehead flap was performed.Overall, excellent or good cosmetic resultswere obtained in 83 percent of cases. Graft-ing with conchal cartilage was associatedwith the best cosmetic results and had min-imal complications. Bone grafting with or

without nasolabial flaps was associatedwith a 50 percent complication rate of in-fection or graft resorption. In mild to mod-erate deformities, cartilage grafting is rec-ommended; for more severe deformities,bone grafting with bony fixation and skinflaps is recommended. Perioperative antibi-otics must be used, and these proceduresshould be performed by an experienced sur-geon. In very severe cases with skin defi-ciency, reconstruction with a forehead flapgives good results.—Authors’Abstract

Serrano-Pozo, A., Gomez-Aranda, F.,Giles, M., Chinchon, D., Chinchon, I.,and Bautista-Lorite, J. Sensory poly-neuropathy as initial manifestation of en-demic leprosy in Spain. Eur Neurol.52(4) (2004) 256–258. Epub. (2004)Dec. 2. [Abstract unavailable]

Immunopathology

Breton, G., Duval, X., Estellat, C., Poa-letti, X., Bonnet, D., Mvondo Mvondo,D., Longuet, P., Leport, C., and Vilde,J. L. Determinants of immune reconsti-tution inflammatory syndrome in HIVtype 1-infected patients with tuberculosisafter initiation of antiretroviral therapy.Clin. Infect. Dis. 39(11) (2004) 1709–1712. Epub. (2004) Dec. 1.

Immune reconstitution inflammatory syn-drome (IRIS) occurred in 16 of 37 antiretro-viral-naive patients who were treated subse-quently for tuberculosis and humanimmunodeficiency virus (HIV) type 1 infec-tion. IRIS was related to increases in theCD4 cell percentage and in the ratio of CD4cells to CD8 cells after 1 month of anti-retroviral therapy and to dissemination of tu-berculosis. These results have implicationsfor the diagnosis of IRIS and the understand-ing of its pathogenesis.—Authors’Abstract

Co, D. O., Hogan, L. H., Kim, S. I., and

Sandor, M. Mycobacterial granulomas:keys to a long-lasting host-pathogen re-lationship. Clin. Immunol. 113(2) (2004)130–136.

Chronic infection with mycobacteria iscontrolled by the formation of granulomas.The failure of granuloma maintenance re-sults in reactivation of disease. Macro-phages are the dominant cell type in granu-lomas, but CD4+ T cells are the masterorganizers of granuloma structure and func-tion. Recent work points to an unrecog-nized role for nonspecific T cells in main-taining granuloma function in the chronicphase of infection. In addition, it has be-come clear that mycobacteria and host Tcells collaborate in formation of granulo-mas. Further understanding of how nonspe-cific T cells contribute to granuloma forma-tion, as well as how bacteria and T cellsmaintain a harmonious relationship over thelife of the host, will facilitate the develop-ment of new strategies to treat mycobacte-rial disease.—Authors’Abstract

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73, 1 Current Literature, Immunopathology 53

Deretic, V., Vergne, I., Chua, J., Master,S., Singh, S. B., Fazio, J. A., and Kyei,G. Endosomal membrane traffic: conver-gence point targeted by Mycobacteriumtuberculosis and HIV. Cell. Microbiol.6(11) (2004) 999–1009.

Inhibition of phagolysosome biogenesisin infected macrophages is a classicalpathogenesis determinant of Mycobacte-rium tuberculosis. In this review we primar-ily cover the cellular mechanisms of M. tu-berculosis phagosome maturation arrest. Adetailed picture is beginning to emerge, in-volving regulators of membrane traffickingin mammalian cells and phagosomal inter-actions with endosomal organelles and thetrans-Golgi network. We also present a hy-pothesis that overlaps may exist betweenthe mycobacterial interference with the hostcell membrane trafficking processes and thetargeting of the late endosomal sorting ma-chinery by HIV during viral budding inmacrophages. We propose that interferencewith the endosomal sorting machinery con-tributes to the synergism between the twosignificant human diseases—AIDS and tu-berculosis.—Authors’Abstract

Florido, M., and Appelberg, R. Granu-loma necrosis during Mycobacteriumavium infection does not require tumornecrosis factor. Infect. Immun. 72(10)(2004) 6139–6141.

The infection of tumor necrosis factor(TNF)-deficient mice with low doses of thevirulent Mycobacterium avium strain 25291led to the appearance of necrotic granulo-mas at 93 days of infection, i.e., sooner thannecrotic granulomas appeared in C57BL/6animals. Additionally, TNF-deficient miceexhibited higher mycobacterial loads in theinfected organs, had extremely exacerbatedgamma interferon responses as evaluated inthe sera of infected animals, and showed re-duced survival. Thus, TNF is not requiredfor granuloma necrosis.—Authors’Abstract

Gutierrez, M. G., Master, S. S., Singh, S.B., Taylor, G. A., Colombo, M. I., andDeretic, V. Autophagy Is a defensemechanism inhibiting BCG and Myco-

bacterium tuberculosis survival in in-fected macrophages. Cell. 119(6) (2004)753–766.

Mycobacterium tuberculosis is an intra-cellular pathogen persisting within phago-somes through interference with phagoly-sosome biogenesis. Here we show thatstimulation of autophagic pathways inmacrophages causes mycobacterial phago-somes to mature into phagolysosomes.Physiological induction of autophagy or itspharmacological stimulation by rapamycinresulted in mycobacterial phagosome colo-calization with the autophagy effector LC3,an elongation factor in autophagosome for-mation. Autophagy stimulation increasedphagosomal colocalization with Beclin-1, asubunit of the phosphatidylinositol 3-kinasehVPS34, necessary for autophagy and atarget for mycobacterial phagosome matu-ration arrest. Induction of autophagy sup-pressed intracellular survival of mycobac-teria. IFN-gamma induced autophagy inmacrophages, and so did transfection withLRG-47, an effector of IFN-gamma re-quired for antimycobacterial action. Thesefindings demonstrate that autophagic path-ways can overcome the trafficking blockimposed by M. tuberculosis. Autophagy,which is a hormonally, developmentally,and, as shown here, immunologically regu-lated process, represents an underappreci-ated innate defense mechanism for controlof intracellular pathogens.—Authors’ Ab-stract

Jing, G., Hollis, G., Polaczyk, A., Eluru,H. B., Kinkle, B., Mast, D., Oerther, D.B., and Papautsky I. Developing rapiddetection of mycobacteria using micro-waves. Analyst. 129(10) (2004) 963–969.Epub. (2004) Aug. 19.

In this paper, we describe the develop-ment of a culture-based biochip device forrapid detection of mycobacteria in environ-mental samples. Individual biochips relyupon the unique paraffinophilic nature ofmycobacteria to rapidly and selectively ad-here to the surface of the device. We usedprototype biochips to experimentally dem-onstrate the concept of rapid and selectivedetection of mycobacteria by testing pure

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cultures and using epifluorescence mi-croscopy to visualize microorganisms onthe surface. As an alternative, rapid ap-proach for identifying the biomass on thebiochip surface, we used microwaves in the10 to 26 GHz frequency range. The resultsof this study indicate that different microor-ganisms are responsible for specific shiftsin resonance frequencies of a microwavecavity. By combing the semi-selectiveparaffin surface of the biochip with themicroorganism-specific response to the mi-crowaves, we have developed an improvedanalytical system with the potential torapidly identify and enumerate mycobacte-ria in environmental samples in as little as 2hr.—Authors’Abstract

Kobayashi, K. [Molecular pathogenesis ofmycobacterial diseases]. Nihon Hansen-byo Gakkai Zasshi. 73(3) (2004) 263–270.[Article in Japanese]

Mycobacterial diseases, including tuber-culosis, leprosy, and disease due to nontu-berculous mycobacteria, are the majorcause of death from infectious diseasesaround the world. About one-third of theworld population is latently infected withMycobacterium tuberculosis. Over 8 mil-lion new cases and nearly 2 million deathsoccur each year. Tuberculosis presents asignificant health threat to the world. Thepathogenicity of mycobacteria is related totheir ability to escape killing by ingestedmacrophages, latent infection, and inducedelayed type hypersensitivity. This has beenattributed to several components of the my-cobacterial cell wall, such as surface gly-colipids, lipoarabinomannan, complementactivation factor, heat-shock protein, andmycobacterial DNA binding protein. Fromthe aspect of my research interests, I havefocused on mycobacterial glycolipids andmycobacterial DNA binding protein in thisarticle. Surface molecules of mycobacteriaexert pleiotropic activities in both the mi-crobe and host, and thus participate in thepathogenesis of mycobacterial diseases.The better understanding of mycobacterialpathogenicity may open the new avenue forthe development of therapeutic and prophy-lactic interventions.—Author’s Abstract

Machowski, E. E., Dawes, S., and Miz-rahi, V. TB tools to tell the tale—molec-ular genetic methods for mycobacterialresearch. Int. J. Biochem. Cell. Biol.37(1) (2005) 54–68.

In spite of the availability of drugs and avaccine, tuberculosis—one of man’s med-ical nemeses—remains a formidable publichealth problem, particularly in the develop-ing world. The persistent nature of the tu-bercle bacillus, with one third of the world’spopulation is estimated to be infected, com-bined with the emergence of multi drug-resistant strains and the exquisite suscep-tibility of HIV-positive individuals, hasunderscored the urgent need for in-depthstudy of the biology of Mycobacterium tu-berculosis address the resurgence of TB. Inaiming to understand the mechanisms bywhich mycobacteria react to their immedi-ate environments, molecular genetic toolshave been developed from naturally occur-ring genetic elements. These include pro-tein expressing genes, and episomal andintegrating elements, which have been de-rived mainly from prokaryotic but alsofrom eukaryotic organisms. Molecular ge-netic tools that had been established as rou-tine procedures in other prokaryotic generawere thus mimicked. Knowledge of the un-derlying mechanisms greatly expedited theharnessing of these elements for mycobac-teriological research and has brought us to apoint where these molecular genetic toolsare now employed routinely in laboratoriesworldwide.—Authors’Abstract

Pai, M., Riley, L. W., and Colford, J. M.,Jr. Interferon-gamma assays in the im-munodiagnosis of tuberculosis: a sys-tematic review. Lancet Infect. Dis. 4(12)(2004) 761–776.

A major challenge in tuberculosis controlis the diagnosis and treatment of latent tu-berculosis infection. Until recently, therewere no alternatives to the tuberculin skintest (TST) for diagnosing latent tuberculo-sis. However, an alternative has nowemerged in the form of a new in vitro test:the interferon-gamma assay. We did a sys-tematic review to assess the performance ofinterferon-gamma assays in the immunodi-

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agnosis of tuberculosis. By searching data-bases, contacting experts and test manufac-turers, we identified 75 relevant studies.The results suggest that interferon-gammaassays that use Mycobacterium tuberculosis-specific region of difference 1 (RD1) anti-gens (such as early secretory antigenic tar-get 6 and culture filtrate protein 10) mayhave advantages over the TST, in terms ofhigher specificity, better correlation withexposure to M. tuberculosis, and less cross-reactivity due to BCG vaccination and non-tuberculous mycobacterial infection. How-ever, interferon-gamma assays that useRD1 antigens in isolation may maximizespecificity at the cost of sensitivity. Assaysthat use cocktails of RD1 antigens seem toovercome this problem, and such assays havethe highest accuracy. RD1-based interferon-gamma assays can potentially identify thosewith latent tuberculosis who are at high riskfor developing active disease, but this re-quires confirmation. There is inadequate ev-idence on the value of interferon-gammaassays in the management of immunocom-promised individuals, children, patientswith extrapulmonary or non-tuberculousmycobacterial disease, and populations incountries where tuberculosis is endemic.Current evidence suggests that interferon-gamma assays based on cocktails of RD1antigens have the potential to become use-ful diagnostic tools. Whether this potentialcan be realized in practice remains to beconfirmed in well designed, long-term stud-ies.—Authors’Abstract

Pathak, S. K., Bhattacharyya, A., Pathak,S., Basak, C., Mandal, D., Kundu, M.,and Basu, J. Toll-like receptor 2 andmitogen- and stress-activated kinase 1are effectors of Mycobacterium avium-induced cyclooxygenase-2 expression in macrophages. J Biol Chem. 279(53) (2004) 55127–55136. Epub. (2004)Oct. 20.

Understanding how pathogenic myco-bacteria subvert the protective immune re-sponse is crucial to the development ofstrategies aimed at controlling mycobac-terial infections. Prostaglandin E(2) exertsan immunosuppressive function in the con-text of mycobacterial infection. Because

cyclooxygenase-2 (COX-2) is a rate-limitingenzyme in prostaglandin biosynthesis, thereis a need to delineate the mechanismsthrough which pathogenic mycobacteriaregulate COX-2 expression in macro-phages. Our studies demonstrate that theNF-kappaB and CRE elements of the COX-2promoter are critical to Mycobacteriumavium-induced COX-2 gene expression. M.avium-triggered signaling originates at theToll-like receptor 2 (TLR2). Ras associateswith TLR2 and activates the mitogen-activated protein kinase (MAPK) extracel-lular signal-regulated kinase (ERK),whereas tumor necrosis factor receptor-associated factor 6 (TRAF6)/transforminggrowth factor beta-activated kinase 1(TAK1)-dependent signaling activates p38MAPK. Both ERK and p38 MAPK activa-tion converge to regulate the activation ofmitogen- and stress-activated kinase 1(MSK1). MSK1 mediates the phosphory-lation of the transcription factor CREBaccounting for its stimulatory effect on CRE-dependent gene expression. M. avium-triggered cytoplasmic NF-kappaB activa-tion following IkappaB phosphorylation isnecessary but not sufficient for COX-2promoter-driven gene expression. MSK1activation is also essential for M. avium-triggered NF-kappaB-dependent gene ex-pression, presumably mediating nucleosomalmodifications. These studies demonstratethat the nuclear kinase MSK1 is necessaryin regulating the pathogen-driven expres-sion of a gene by controlling two transcrip-tion factors. The attenuation of MSK1 maytherefore have potential benefit in restrict-ing survival of pathogenic mycobacteria inmacrophages.—Authors’Abstract

Pavlou, A. K., Magan, N., Jones, J. M.,Brown, J., Klatser, P., and Turner, A.P. Detection of Mycobacterium tubercu-losis (TB) in vitro and in situ using anelectronic nose in combination with aneural network system. Biosens. Bio-electron. 20(3) (2004) 538–544.

The use of volatile production patternsproduced by Mycobacterium tuberculosisand associated bacterial infections fromsputum samples were examined in vitro andin situ using an electronic nose based on a

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14 sensor conducting polymer array. Invitro, it was possible to successfully dis-criminate between M. tuberculosis (TB)and control media, and between M. tuber-culosis and M. avium, M. scrofulaceum andPseudomonas aeruginosa cultures in thestationary phase after 5–6 hr incubation at37°C based on 35 samples. Using neuralnetwork (NN) analysis and cross-validationit was possible to successfully identify100% of the TB cultures from others. A sec-ond in vitro study with 61 samples all fourgroups were successfully discriminatedwith 14 of 15 unknowns within each of thefour groups successfully identified usingcross-validation and discriminant functionanalysis. Subsequently, lipase enzymeswere added to 46 sputum samples directlyobtained from patients and the head spaceanalysed. Parallel measurements of bacte-rial contamination were also carried out forconfirmation using agar media. NN analysiswas carried out using some of the samplesas a training set. Based on the NN and ge-netic algorithms of up to 10 generations itwas possible to successfully cross-validate9 of 10 unknown samples. PCA was able todiscriminate between TB infection alone,the controls, M. avium, P. aeruginosa and amixed infection. These findings will havesignificant implications for the develop-ment of rapid qualitative systems forscreening of patient samples and clinical di-agnosis of tuberculosis.—Authors’Abstract

Pearl, J. E., Khader, S. A., Solache, A.,Gilmartin, L., Ghilardi, N., deSauvage,F., and Cooper, A. M. IL-27 signalingcompromises control of bacterial growthin mycobacteria-infected mice. J. Im-munol. 173(12) (2004) 7490–7496.

Resistance to tuberculosis (TB) is depen-dent on the induction of Ag-specific CD4Th1 T cells capable of expressing IFN-gamma. Generation of these T cells is depen-dent upon IL-12p70, yet other cytokines havealso been implicated in this process. Onesuch cytokine, IL-27, augments differentia-tion of naive T cells toward an IFN-gamma-producing phenotype by up-regulating thetranscription factor T-bet and promoting ex-pression of the IL-12Rbeta2 chain allowingT cells to respond to IL-12p70. We showthat the components of IL-27 are induced

during TB and that the absence of IL-27signaling results in an altered disease pro-file. In the absence of the IL-27R, there isreduced bacterial burden and an increasedlymphocytic character to the TB granu-loma. Although the number of Ag-specificCD4 IFN-gamma-producing cells is unaf-fected by the absence of the IL-27R, thereis a significant decrease in the level ofmRNA for IFN-gamma and T-bet withinthe lungs of infected IL-27R(–/–) mice. Ag-specific CD4 T cells in the lungs of IL-27R(–/–) also produce less IFN-gammaprotein per cell. The data show that expres-sion of IL-27 during TB is detrimental tothe control of bacteria and that although itdoes not affect the number of cells capableof producing IFN-gamma it does reduce theability of CD4 T cells to produce largeamounts of IFN-gamma. Because IFN-gamma is detrimental to the survival of ef-fector T cells, we hypothesize that the re-duced IFN-gamma within the IL-27R(–/–)lung is responsible for the increased accu-mulation of lymphocytes within the myco-bacterial granuloma.—Authors’Abstract

Shen, Y., Shen, L., Sehgal, P., Huang, D.,Qiu, L., Du, G., Letvin, N. L., andChen, Z. W. Clinical latency and re-activation of AIDS-related mycobacte-rial infections. J. Virol. 78(24) (2004)14023–14032.

The immune mechanisms associated withthe evolution from latent to clinically activemycobacterial coinfection in humanimmunodeficiency virus type 1 (HIV-1)-infected humans remain poorly understood.Previous work has demonstrated thatmacaques infected with simian immunode-ficiency virus (SIVmac) can develop persis-tent Mycobacterium bovis BCG coinfectionand a fatal SIV-related tuberculosis-like dis-ease by 4 months after BCG inoculation. Inthe present study, SIVmac-infected mon-keys that developed clinically quiescentmycobacterial infection after BCG inocula-tion were followed prospectively for the re-activation of the BCG and the developmentof SIV-related tuberculosis-like disease.The development of clinically latent BCGcoinfection in these SIVmac-infected mon-keys was characterized by a change fromhigh to undetectable levels of bacterial or-

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ganisms, with or without measurable BCGmRNA expression in lymph node cells. Thereactivation of clinically latent BCG coin-fection and development of SIV-relatedtuberculosis-like disease were then ob-served in these SIVmac-BCG-coinfectedmonkeys during a 21-month period offollow-up. The reactivation of SIV-relatedtuberculosis-like disease in these animalscoincided with a severe depletion of CD4 Tcells and a loss of BCG-specific T-cell re-sponses. Interestingly, bacterial superantigenchallenge of the SIVmac-BCG-coinfectedmonkeys resulted in an up-regulation of clin-ically latent BCG coinfection, suggestingthat infection with superantigen-producingmicrobes may increase the susceptibility ofindividuals to the reactivation of AIDS-related mycobacterial coinfection. Thus, re-activation of latent mycobacterial infectionsin HIV-1-infected individuals may resultfrom a loss of T-cell immunity or from a su-perimposed further compromise of the im-mune system.—Authors’Abstract

van de Vosse, E., Hoeve, M. A., and Ot-tenhoff, T. H. Human genetics of intra-cellular infectious diseases: molecularand cellular immunity against mycobac-teria and salmonellae. Lancet Infect. Dis.4(12) (2004) 739–749.

See Current Literature, Molecular andGenetic Studies, p. 86

Vergne, I., Chua, J., Singh, S. B., andDeretic, V. Cell biology of Mycobacte-rium tuberculosis phagosome. Annu.Rev. Cell. Dev. Biol. 20 (2004) 367–394.

Phagocytosis and phagolysosome bio-genesis represent fundamental biologicalprocesses essential for proper tissue homeo-stasis, development, elimination of invad-ing microorganisms, and antigen processingand presentation. Phagosome formationtriggers a preprogrammed pathway of mat-uration into the phagolysosome, a processcontrolled by Ca2+ and the regulators of or-ganellar trafficking centered around thesmall GTP-binding proteins Rabs and theirdownstream effectors, including lipid ki-nases, organellar tethering molecules, andmembrane fusion apparatus. Mycobacte-

rium tuberculosis is a potent human patho-gen parasitizing macrophages. It interfereswith the Rab-controlled membrane traffick-ing and arrests the maturing phagosome at astage where no harm can be done to thepathogen while the delivery of nutrients andmembrane to the vacuole harboring the mi-croorganism continues. This process, re-ferred to as the M. tuberculosis phagosomematuration arrest or inhibition of phago-some-lysosome fusion, is critical for M. tu-berculosis persistence in human popula-tions. It also provides a general modelsystem for dissecting the phagolysosomebiogenesis pathways. Here we review thefundamental trafficking processes targetedby M. tuberculosis and the mycobacterialproducts that interfere with phagosomalmaturation.—Authors’Abstract

Villenuve, C., Gilleron, M., Maridonneau-Parini, I., Daffe, M., Astarie-Dequeker,C., and Etienne, G. Surface-exposed gly-copeptidolipids and phosphatidylinositolmannosides participate in the receptor-dependent phagocytosis of mycobacteriaby human macrophages. J. Lipid. Res.(2004) Dec 1. [Epub. ahead of print].

We have recently shown that two sub-families of the glycopeptidolipids (GPL) lo-cated on the surface of Mycobacteriumsmegmatis, along with unknown phospho-lipids, participate in the nonopsonic phago-cytosis of mycobacteria by human macro-phages (Villeneuve, et al., 2003, J. Biol.Chem., 278, 51291–300). The latter com-pounds were purified and identified and theirmolecular mechanisms of action were exam-ined in the present study. We showed that aphospholipid mixture that derived from themethanol-insoluble fraction inhibited thephagocytosis of M. smegmatis. This inhibi-tion was attributable to phosphatidylinositolmannosides (PIM), namely PIM2 and PIM6,since the purified phosphatidylethanolamine,phosphatidylglycerol and phosphatidylinosi-tol were inactive. This observation was con-firmed using purified PIM2 and PIM6 fromM. bovis BCG that decreased by half the in-ternalization of M. smegmatis. Both gly-cophospholipids also inhibited the uptake ofM. tuberculosis and M. avium but had no ef-fect on the internalization of zymosan used asa control particle of the phagocytic process.

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When coated on latex beads, PIM2 and polarGPL (GPL III) favored the particle entrythrough complement receptor 3 (CR3). GPLIII, but not PIM2, also directed particles entrythrough the mannose receptor (MR). There-fore, surface-exposed mycobacterial PIMand polar GPL participate to the receptor-dependent internalization of mycobacteria inhuman macrophages. As such, they consti-tute tools to dissect receptor-signalling path-way and, as inhibitors of phagocytosis, mayhelp to design pharmacological drugs for thecontrol of mycobacterial infections.—Au-thors’Abstract

Wang, J., Santosuosso, M., Ngai, P., Zga-niacz, A., and Xing, Z. Activation ofCD8 T cells by mycobacterial vaccina-tion protects against pulmonary tubercu-losis in the absence of CD4 T cells. J.Immunol. 173(7) (2004) 4590–4597.

We have investigated whether both pri-mary CD8 T cell activation and CD8 T cell-mediated protection from Mycobacteriumtuberculosis challenge could occur inmycobacterial-vaccinated CD4 T cell-deficient (CD4KO) mice. Different fromwild-type C57BL/6 mice, s.c. vaccinationwith bacillus Calmette-Guerin (BCG) inCD4KO mice failed to provide protection

from secondary M. tuberculosis challengeat 3 wk postvaccination. However, similarto C57BL/6 mice, CD4KO mice were wellprotected from M. tuberculosis at weeks 6and 12 postvaccination. This protection wasmediated by CD8 T cells. The maintenanceof protective effector/memory CD8 T cellsin CD4KO mice did not require the contin-uous presence of live BCG vaccine. As inC57BL/6 mice, similar levels of primaryactivation of CD8 T cells in CD4KO miceoccurred in the draining lymph nodes at 3wk after BCG vaccination, but differentfrom C57BL/6 mice, the distribution ofthese cells to the spleen and lungs ofCD4KO mice was delayed, which coin-cided with delayed acquisition of protectionin CD4KO mice. Our results suggest thatboth the primary and secondary activationof CD8 T cells is CD4 T cell independentand that the maintenance of these CD8 Tcells is also independent of CD4 T cells andno longer requires the presence of live my-cobacteria. However, the lack of CD4 Tcells may result in delayed distribution ofactivated CD8 T cells from draining lymphnodes to distant organs and consequently adelayed acquisition of immune protection.Our findings hold implications in rationaldesign of tuberculosis vaccination strate-gies for humans with impaired CD4 T cellfunction.—Authors’Abstract

Immunopathology (Leprosy)Bagwan, I. N., Khandekar, M. M.,

Kadam, P., Jadhav, M. V., and Desh-mukh, S. D. A study of mast cells ingranulomatous lesions of skin, with spe-cial emphasis on leprosy. Indian J. Lepr.76(1) (2004) 31–37.

Seventy-six skin biopsies that includedmaterial from 7 controls, 65 granulomatousskin lesions and 2 each of granulation tissueand chronic non-specific inflammation,were subjected to histopathological evalua-tion on haematoxylin and eosin and perti-nent special stains. Mast cell study was doneon slides stained by toluidine blue method,with special reference to their location, andmorphology and cell count were done withthe help of occculomicrometer. In normalskin, mast cell density was 11.43/mm2 with

a range of 6–22/mm2 and an S.D. of 5.94.Highest value in the whole series was seen inTVC (66/mm2), followed by lupus vulgaris(50/mm2). Mast cell counts were normal inindeterminate and TT leprosy and showed arise over the immunological spectrum BT toLL, with values in LL being 32.86/mm2

(28–40/mm2).—Authors’Abstract

Faber, W. R., Iyer, A. M., Fajardo, T. T.,Dekker, T., Villahermosa, L. G., Aba-los, R. M., and Das, P. K. Serial mea-surement of serum cytokines, cytokinereceptors and neopterin in leprosy pa-tients with reversal reactions. Lepr. Rev.75(3) (2004) 274–281.

Serum levels of cytokines (IL-4, IL-5,IFN-gamma, TNF-alpha), cytokine recep-

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73, 1 Current Literature, Immunopathology (Leprosy) 59

tors (TNFR I and II) and one monokine(neopterin) were estimated in seven leprosypatients to establish disease associated mark-ers for reversal reactions (RR). Sera werecollected at diagnosis of leprosy, at the on-set of reversal reaction and at different timepoints during and at the end of prednisonetreatment of reactions. It was expected thatthe serum cytokine and monokine profilebefore and at different time points duringreactions would provide guidelines for thediagnosis and monitoring of reversal reac-tions in leprosy. The cytokines and cytokinereceptors were measured by ELISA,whereas a radioimmunoassay was used forneopterin measurement. Six of the sevenpatients showed increased levels ofneopterin either at the onset of RR or 1month thereafter, and levels declined onprednisone treatment to that seen at the timeof diagnosis without reactions. No consis-tent disease associated cytokine profile wasobserved in these patients. Interestingly,serum TNF-alpha levels were increased inthe same patients even after completion ofprednisone treatment, indicating ongoingimmune activity. In conclusion, this studydemonstrates that despite cytokines levelsin leprosy serum being inconsistent in rela-tion to reversal reactions, serum neopterinmeasurement appears to be an useful bio-marker in monitoring RR patients duringcorticosteroid therapy.—Authors’Abstract

Gandhi, G., and Singh, B. DNA damagestudies in untreated and treated leprosy pa-tients. Mutagenesis. 19(6) (2004) 483–488.

The alkaline single cell gel electrophore-sis assay was performed on peripheralblood lymphocytes of lepromatous and tu-bercloid leprosy patients (untreated andthose undergoing treatment) in order to as-certain whether differential damage toDNA occurs. The study group included 28male and 2 female patients and 15 healthymales who were matched for age and socio-economic status. The results revealed DNAdamage in all patients, with a mean DNAmigration length of 29.88 ± 3.39 micromand 38% of their cells damaged when com-pared with the respective values obtained inhealthy controls (1.28 ± 0.40 microm, 5%).Multiple regression analysis for effects ofconfounding factors revealed antibiotic

treatment in patients and alcohol consump-tion in controls as the only variables influ-encing DNA damage. In lepromatous andtubercloid patients, both untreated andthose undergoing treatment, DNA damageincreased significantly from that observedin control individuals, with greater in-creased damage in lepromatous patients. Anincrease in treatment time increased DNAdamage linearly. Furthermore, an arbitraryclassification of damaged cells (categoriesI–IV) was made based on observed taillengths in leprosy patients (5.00–225.00microm). The number of damaged cells inuntreated patients was lower than in thoseundergoing treatment; the latter also hadmore cells with greater DNA migrationlengths. There were no category III or IVcells in the control group. The results of thestudy therefore reveal that patients under-going therapy had significantly greaterDNA damage than untreated patients, indi-cating bacterial infection and drug therapyas the causal factors, since lepromatous-type disease is the more severe form withthe patients having lower resistance to My-cobacterium leprae and requiring heavierand prolonged dosage of antibiotics. Thestudy also corroborates that the assay offersan opportunity for correlating levels oftherapy-induced DNA damage with admin-istered dose and for modulating the dose-schedule so as to achieve lower levels ofgenotoxic damage.—Authors’Abstract

Moura, A. C., Bastos, A. P., Cordeiro, R.S., and Henriques, M. G. Effect of My-cobacterium leprae lipids on BCG- andcarrageenan-induced cellular recruitmentin mouse pleurisy. Inflammopharmacol-ogy 12(3) (2004) 247–60.

Pathogenic mycobacteria survive insidemacrophages and deactivate these cells, us-ing a mechanism that is still poorly under-stood. Mycobacterial cell wall lipids consti-tute the first contact with the host cell.Although Mycobaterium leprae and M.bovis BCG share common antigens, theyinduce opposite inflammatory responses.Apolar M. leprae lipids have been shown tobe anti-inflammatory by down-regulatingmacrophage activation and T-cell functions.We wonder if these lipids would influencecellular migration to BCG or to other in-

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flammatory agent. We investigated the ef-fect of M. leprae, its lipids or delipidatedbacteria on acute and chronic BCG- orcarrageenan-induced pleurisy. Previous injec-tion of intact or delipidated M. leprae didnot alter either the BCG- or carrageenan-induced pleural inflammatory reaction. How-ever, M. leprae lipids enhanced carrageenan-induced acute cellular migration withoutimpairing BCG inflow; moreover, they re-duced BCG chronic response. Togetherthese data suggest distinct mechanisms forintracellular deactivation and pleural cellrecruitment exerted by mycobacterial struc-tures.—Authors’Abstract

Quiroga, M. F., Martinez, G. J.,Pasquinelli, V., and Garcia, V. E. [TheSLAM-associated protein (SAP) regu-lates IFN-gamma expression in leprosy].Medicina (B Aires). 64(5) (2004)436–438. [Article in Spanish]

The SLAM-associated protein (SAP) regu-lates IFN-gamma expression in leprosy. Tu-berculoid leprosy patients locally produceTh1 cytokines, while lepromatous patientsproduce Th2 cytokines. Signaling lympho-cytic activation molecule (SLAM) and theSLAM-associated protein (SAP) participatein the differentiation process that leads tothe production of specific patterns of cy-tokines by activated T cells. To investigatethe SLAM/SAP pathway in M. leprae in-fection, we determined the expression ofSAP, IFN-gamma and SLAM RNA mes-senger in leprosy patients. We found a di-rect correlation of SLAM expression withIFN-gamma expression, whereas the ex-pression of SAP was inversely correlatedwith the expression of both SLAM andIFN-gamma. Therefore, our data indicatethat SAP might interfere with Th1 cytokineresponses while SLAM expression maycontribute to Th1 responses in leprosy. Thisstudy further suggests that the SLAM/SAPpathway might be a focal point for thera-peutic modulation of T cell cytokine re-sponses in diseases characterized by dysfunc-tional Th2 responses.—Authors’Abstract

Save, M. P., Shetty, V. P., Shetty, K. T.,and Antia, N. H. Alterations in neuro-

filament protein(s) in human leprousnerves: morphology, immunohistochem-istry and Western immunoblot correla-tive study. Neuropathol. Appl. Neuro-biol. 30(6) (2004) 635–650.

Using a specific antibody (SMI 31), thestate of phosphorylation of high andmedium molecular weight neurofilaments(NF-H and NF-M) was studied in 22 leprousand four nonleprous human peripheralnerves by means of immunohistochemistry,sodium dodecyl sulfate-poly acrylamide gelelectrophoresis (SDS-PAGE) and Westernimmunoblot (WB). The results thus ob-tained were compared with morphologicalchanges in the respective nerves studiedthrough light and electron microscopy.Many of the leprous nerves showing mini-mal pathology revealed lack of or weakstaining with SMI 31, denoting dephospho-rylation. Remyelinated fibres stained in-tensely with SMI 31 antibody. The WBanalysis of Triton X-100 insoluble cyto-skeletal preparation showed absence of reg-ular SMI 31 reactive bands corresponding to200 and 150 kDa molecular weight (NF-Hand NF-M, respectively) in 10 nerves. Threeof the 10 nerves revealed presence of NFprotein bands in SDS-PAGE but not in WB.Presence of additional protein band (follow-ing NF-M) was seen in four nerves. Twonerves revealed NF-H band but not NF-Mband and one nerve showed trace positivity.In the remaining five nerves presence of allthe three NF bands was seen. Thus, 77.3%(17/22) of human leprous nerves studiedshowed abnormal phosphorylation of NFprotein(s). The ultrastructural study showedabnormal compaction and arraying of NF atthe periphery of the axons in the fibres withaltered axon to myelin thickness ratio (atro-phied fibres) as well as at the Schmidt-Lantermann (S-L) cleft region. Such NFchanges were more pronounced in the se-verely atrophied axons suggesting a directcorrelation. The observed well-spaced NF inthe remyelinated fibers under ultrastructuralstudy was in keeping with both intense SMI31 staining and presence of NF triplet bandsseen in WBs in four of leprous nerves thatshowed a large number of regenerating fi-bres suggesting reversal of changes with re-generation. Findings in the present studysuggest that atrophy, that is, the reduction in

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axonal calibre and paranodal demyelination,seen in leprous nerves may result from de-phosphorylation of NF-H and NF-M pro-teins.—Authors’Abstract

Sergio, N. F., Cecilia, G. V., Sonia, L., laMora Pedro, G. D., Joaquin, G. E., andMary, F. M. Electrochemical antigen-retrieval of formaldehyde fixed andparaffin-embedded archived leprosy skinbiopsies. J. Mol. Histol. 35(5) (2004)433–441.

While formaldehyde fixation preservestissue morphology, it often hinders immuno-detection of antigens in paraffin-embeddedtissue because the antigens are masked.Antigen unmasking can be achieved withtreatments such as microwave irradiationbut they often lead to excessive tissue dam-age. Therefore, an electrochemical antigen-retrieval method (EAR) was devised inwhich an alternating electric current ispassed through the tissue in a chamber con-taining an electrolyte buffer. The results ob-tained with this method were compared tothose after microwave irradiation usingarchived samples of formaldehyde-fixedand paraffin-embedded lepromatous leprosy

skin. The efficacy of the two unmaskingprocedures was assessed by the immuno-detectability of several marker antigens us-ing 24 antibodies. Fifteen antibodies thatwere directed against transmembrane pro-teins (CD), and the remaining 9 againstcytokeratins 18.6 and 19, laminin, vimentin,S100a, BCG, Ulex europaeus lectin, PCNA,and P21ras. Simple and double immuno-histochemistry was performed using the uni-versal ENVISION and LSAB + AP detec-tion systems. After unmasking with theEAR method, immunoreactivity was clearlydetected with 22 of the 24 antibodies insingle labeling reactions. They include thecritical antigens CD3 and CD4 for identify-ing the T lymphocyte lineages. In contrast,only 20 of the antibodies reacted after mi-crowave irradiation. After double immuno-labeling, immunoreactivity was quantita-tively similar with both methods. However,the EAR unmasking produced a stronger la-beling reaction. Thus, with double labelingimmunohistochemistry, EAR made it possi-ble to use higher antibody dilutions andshorter incubation times. Heat damage wasalso prevented. In conclusion, EAR treat-ment produces better staining results thanmicrowave irradiation treatment.—Authors’Abstract

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Immunopathology (Tuberculosis)

Deng, J. Y., Zhang, X. E., Lu, H. B., Liu,Q., Zhang, Z. P., Zhou, Y. F., Xie, W.H., and Fu, Z. J. Multiplex detection ofmutations in clinical isolates of rifampin-resistant Mycobacterium tuberculosis byshort oligonucleotide ligation assay onDNA chips. J. Clin. Microbiol. 42(10)(2004) 4850–4852.

A new approach, short-oligonucleotide-ligation assay on DNA chip (SOLAC), isdeveloped to detect mutations in rifampin-resistant Mycobacterium tuberculosis. Themethod needs only four common probes todetect 15 mutational variants of the rpoBgene within 12 hr. Fifty-five rifampin-resistant M. tuberculosis isolates were ana-lyzed, resulting in 87.3% accuracy and83.6% concordance relative to DNA se-quencing.—Authors’Abstract

Fremond CM, Yeremeev V, Nicolle DM,Jacobs M, Quesniaux VF, Ryffel B. FatalMycobacterium tuberculosis infection de-spite adaptive immune response in the ab-sence of MyD88. J. Clin. Invest. 114(12)(2004) 1790–1799.

Toll-like receptors (TLRs) such as TLR2and TLR4 have been implicated in host re-sponse to mycobacterial infection. Here,mice deficient in the TLR adaptor moleculemyeloid differentiation factor 88 (MyD88)were infected with Mycobacterium tubercu-losis (MTB). While primary MyD88(–/–)macrophages and DCs are defective in TNF,IL-12, and NO production in response tomycobacterial stimulation, the upregulationof costimulatory molecules CD40 andCD86 is unaffected. Aerogenic infection ofMyD88(–/–) mice with MTB is lethal

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within 4 weeks with 2 log(10) higher CFUin the lung; high pulmonary levels of cy-tokines and chemokines; and acute, necroticpneumonia, despite a normal T cell responsewith IFN-gamma production to mycobacte-rial antigens upon ex vivo restimulation. Vac-cination with Mycobacterium bovis bacillusCalmette-Guerin conferred a substantial pro-tection in MyD88(–/–) mice from acuteMTB infection. These data demonstrate thatMyD88 signaling is dispensable to raise anacquired immune response to MTB.Nonetheless, this acquired immune re-sponse is not sufficient to compensate forthe profound innate immune defect and theinability of MyD88(–/–) mice to controlMTB infection.—Authors’Abstract

Hernandez-Pando, R., Aguilar-Leon, D.,Orozco, H., Serrano, A., Ahlem, C.,Trauger, R., Schramm, B., Reading,C., Frincke, J., and Rook, G. A. 16alpha-Bromoepiandrosterone Restores THelper Cell Type 1 Activity and acceler-ates Chemotherapy-Induced BacterialClearance in a Model of Progressive Pul-monary Tuberculosis. J. Infect. Dis.191(2) (2005) 299–306. Epub. (2004)Dec. 09.

BALB/c mice with pulmonary tuberculo-sis develop a T helper cell type 1 responsethat peaks at 3 weeks, temporarily control-ling bacterial growth. Then bacterial pro-liferation recommences, accompanied byincreasing interleukin (IL)-4 levels and de-creasing interferon (IFN)-gamma, tumornecrosis factor (TNF)-alpha , and induciblenitric oxide synthase (iNOS) levels. Thesechanges mimic those in the human disease.In a previous study, administration of dehy-droepiandrosterone (DHEA) beginning onday 60 after infection reversed thesechanges and protected the mice. However,DHEA is suboptimal for human use, partlybecause it is readily metabolized into sexsteroids. 16 alpha-Bromoepiandrosterone(EpiBr; 16 alpha-bromo-5 alpha-androstan-3beta-ol-17-one) is a synthetic adrenal steroidderivative that does not enter sex steroidpathways. In the present study, when tuber-culous BALB/c mice were treated withEpiBr 3 times/week beginning on day 60,inhibition of bacterial proliferation and in-

creased expression of TNF-alpha, IFN-gamma, and iNOS were observed, althoughdecreased expression of IL-4 was also ob-served. Moreover, when given as an adjunctto conventional chemotherapy, EpiBr en-hanced bacterial clearance. Trials for the useof EpiBr in the treatment of human tubercu-losis are now justified.—Authors’Abstract

Kamath, A. B., Alt, J., Debbabi, H., Tay-lor, C., and Behar, S. M. The major his-tocompatibility complex haplotype af-fects T-cell recognition of mycobacterialantigens but not resistance to Mycobac-terium tuberculosis in C3H mice. Infect.Immun. 72(12) (2004) 6790–6798.

Both innate and adaptive immunity playan important role in host resistance to My-cobacterium tuberculosis infection. Al-though several studies have suggested thatthe major histocompatibility complex(MHC) haplotype affects susceptibility toinfection, it remains unclear whether themodulation of T-cell immunity by the MHClocus determines the host’s susceptibility totuberculosis. To determine whether allelicdifferences in the MHC locus affect the T-cellimmune response after M. tuberculosis in-fection, we infected inbred and H-2 con-genic mouse strains by the respiratoryroute. The H-2 locus has a profound effecton the antigen-specific CD4+-T-cell re-sponse after M. tuberculosis infection. CD4+T cells from infected mice of the H-2(b) hap-lotype produced more gamma interferon(IFN-gamma) after in vitro stimulation withmycobacterial antigens than mice of the H-2(k) haplotype. A higher level of IFN-gamma was also detected in bronchoalveo-lar lavage fluid from infected mice of the H-2(b) haplotype. Furthermore, C3.SW-H2(b)/SnJ mice generate and recruit acti-vated T cells to the lung after infection.Despite a robust immune response, C3.SW-H2(b)/SnJ mice succumbed to infectionearly and were similarly susceptible to in-fection as other C3H (H-2(k)) substrains.These results suggest that although theMHC haplotype has a profound impact onthe T-cell recognition of M. tuberculosisantigens, the susceptibility of C3H mice toinfection is MHC independent.—Authors’Abstract


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Kamath, A. B., Woodworth, J., Xiong, X.,Taylor, C., Weng, Y., and Behar, S. M.Cytolytic CD8+ T cells recognizingCFP10 are recruited to the lung after My-cobacterium tuberculosis infection. J.Exp. Med. 200(11) (2004) 1479–1489.Epub. (2004) Dec. 6.

Optimum immunity against Mycobacte-rium tuberculosis requires both CD4(+) andCD8(+) T cells. In contrast with CD4(+) Tcells, few antigens are known that elicitCD8(+) T cells during infection. CD8(+) Tcells specific for culture filtrate protein-10(CFP10) are found in purified protein deriv-ative positive donors, suggesting thatCFP10 primes CD8(+) T cells in vivo. Us-ing T cells from M. tuberculosis-infectedmice, we identified CFP10 epitopes recog-nized by CD8(+) T cells and CD4(+) T cells.CFP10-specific T cells were detected asearly as week 3 after infection and at theirpeak accounted for up to 30% of CD8(+) Tcells in the lung. IFNgamma-producingCD8(+) and CD4(+) T cells recognizingCFP10 epitopes were preferentially re-cruited to the lungs of M. tuberculosis-infected mice. In vivo cytolytic activity ofCD8(+) T cells specific for CFP10 andTB10.3/10.4 proteins was detected in thespleen, pulmonary lymph nodes, and lungsof infected mice. The cytolytic activity per-sisted long term and could be detected 260days after infection. This paper highlightsthe cytolytic function of antigen-specificCD8(+) T cells elicited by M. tuberculosisinfection and demonstrates that large num-bers of CFP10-specific cytolytic CD8(+) Tcells are recruited to the lung after M. tuber-culosis infection.—Authors’Abstract

Leemans, J. C., Thepen, T., Weijer, S.,Florquin, S., van Rooijen, N., van deWinkel, J. G., and van der Poll, T.Macrophages play a dual role during pul-monary tuberculosis in mice. J. Infect.Dis. 191(1) (2005) 65–74. Epub. (2004)Nov. 29.

Pulmonary macrophages provide the pre-ferred hiding and replication site of Myco-bacterium tuberculosis but display antimi-crobial functions. This raises questionsregarding the role of macrophages during

tuberculosis. We depleted lungs of activatedmacrophages (activated macrophage(–)mice) and compared this with nonselectivemacrophage depletion (macrophage(–)mice). Although nonselective depletion ofmacrophages after infection improved clin-ical outcome, depletion of activated macro-phages led to impaired resistance, reflectedby enhanced mycobacterial outgrowth. Theproduction of tumor necrosis factor-alphaand numbers of granuloma decreased afterdepletion of activated macrophages. Bothmacrophage(–) and activated macro-phage(–) mice showed polarized productionof interferon-gamma by splenocytes andlymph-node cells and were able to attractand activate T cells in the lung. These datademonstrate that the dual role of macro-phages is associated with the activationstate of macrophages and that extensiveapoptosis found in patients with tuberculo-sis could be part of a host defense strategy,as long as these cells are not activated.—Authors’Abstract

Mahuad, C., Bay, M. L., Farroni, M. A.,Bozza, V., Del Rey, A., Besedovsky, H.,and Bottasso, O. A. Cortisol and dehy-droepiandrosterone affect the response ofperipheral blood mononuclear cells to my-cobacterial antigens during tuberculosis.Scand. J. Immunol. 60(6) (2004) 639–646.

The effect of cortisol and/or dehydro-epiandrosterone (DHEA) on the immune re-sponse to antigens obtained from Mycobac-terium tuberculosis was studied in vitro byusing peripheral blood mononuclear cellsobtained from patients at various stages oflung tuberculosis (TB) and from healthycontrol people (HCo). The results obtainedshow for the first time that addition of corti-sol within concentrations of physiologicalrange can inhibit the mycobacterial antigen-driven proliferation of cells from HCo andTB patients and the production of inter-feron-gamma (IFN-gamma), indicating thatendogenous levels of cortisol may con-tribute to the decreased lymphoid cell re-sponse to mycobacterium antigens ob-served in TB patients. DHEA did not affectlymphoid cell proliferation, IFN-gammaproduction and the cortisol-mediated in-hibitory effects. Interestingly, we found that


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DHEA, but not cortisol, suppressed the invitro transforming growth factor-beta pro-duction by lymphoid cells from TB patientswith an advanced disease, which is indica-tive of a selective direct effect of this hor-mone.—Authors’Abstract

Pai, R. K., Pennini, M. E., Tobian, A. A.,Canaday, D. H., Boom, W. H., andHarding, C. V. Prolonged toll-like re-ceptor signaling by Mycobacterium tu-berculosis and its 19-kilodalton lipopro-tein inhibits gamma interferon-inducedregulation of selected genes in macro-phages. Infect. Immun. 72(11) (2004)6603–6614.

Infection of macrophages with Mycobacte-rium tuberculosis or exposure to M. tubercu-losis 19-kDa lipoprotein for >16 hr inhibitsgamma interferon (IFN-gamma)-inducedmajor histocompatibility complex class II(MHC-II) expression by a mechanism in-volving Toll-like receptors (TLRs). M. tuber-culosis was found to inhibit murine macro-phage MHC-II antigen (Ag) processingactivity induced by IFN-gamma but not byinterleukin-4 (IL-4), suggesting inhibition ofIFN-gamma-induced gene regulation. We de-signed an approach to test the ability of M. tu-berculosis-infected cells to respond to IFN-gamma. To model chronic infection with M.tuberculosis with accompanying prolongedTLR signaling, macrophages were infectedwith M. tuberculosis or incubated with M. tu-berculosis 19-kDa lipoprotein for 24 hr priorto the addition of IFN-gamma. Microarraygene expression studies were then used to de-termine whether prolonged TLR signaling byM. tuberculosis broadly inhibits IFN-gammaregulation of macrophage gene expression.Of 347 IFN-gamma-induced genes, M. tu-berculosis and 19-kDa lipoprotein inhibitedinduction of 42 and 36%, respectively. Keygenes or gene products were also examinedby quantitative reverse transcription-PCRand flow cytometry, confirming and extend-ing the results obtained by microarray stud-ies. M. tuberculosis inhibited IFN-gamma in-duction of genes involved in MHC-II Agprocessing, Ag presentation, and recruitmentof T cells. These effects were largely depen-dent on myeloid differentiation factor 88, im-plying a role for TLRs. Thus, prolonged TLR

signaling by M. tuberculosis inhibits certainmacrophage responses to IFN-gamma, par-ticularly those related to MHC-II Ag presen-tation. This inhibition may promote M. tuber-culosis evasion of T-cell responses andpersistence of infection in tuberculosis.—Au-thors’Abstract

Raja, A., Uma Devi, K. R., Ramalingam,B., and Brennan, P. J. Improved diagno-sis of pulmonary tuberculosis by detec-tion of free and immune complex-boundanti-30 kDa antibodies. Diagn. Micro-biol. Infect. Dis. 50(4) (2004) 253–259.

The 30 kDa secreted antigen of Mycobac-terium tuberculosis was purified to homo-geneity by serial chromatography, and en-zyme linked immunosorbent assay (ELISA)was used to evaluate its diagnostic value inpatients with pulmonary tuberculosis. Theimmunoglobulin (Ig) antibodies G, A, andM were estimated in the two groups: pa-tients who were smear- and culture-positive(S+C+) for pulmonary tuberculosis and nor-mal healthy subjects (NHS). Sensitivity of67.4%, 14.8%, and 14.3%, with the speci-ficity of 99%, 96.7%, and 92% were obtainedfor the 3 isotypes respectively. Combinationof the results of IgG and IgA increased thesensitivity to 71%, with 97% specificity.Polyethylene glycol precipitation of the cir-culating immune complexes (CIC) in serawas carried out. The CIC bound antibodiesoffered a sensitivity of 92.5%, 85.4%, and68.7%, respectively for the S+C+, S–C+,and S–C-patients, while the specificity was96.6%. Thus CIC-bound antibodies promiseto be a better diagnostic tool in the detectionof tuberculosis.—Authors’Abstract

Rivera-Marrero, C. A., Stewart, J.,Shafer, W. M., and Roman, J. Thedown-regulation of cathepsin G in THP-1monocytes after infection with Mycobac-terium tuberculosis is associated with in-creased intracellular survival of bacilli.Infect. Immun. 72(10) (2004) 5712–5721.

Cathepsin G (CatG) is a serine proteasefound in the azurophilic granules of mono-cytes that is known to have antimicrobialproperties, but its role in Mycobacterium


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tuberculosis infection is unknown. Wefound that M. tuberculosis infection of hu-man THP-1 monocytic cells induced thedown-regulation of CatG mRNA expres-sion, as demonstrated by gene array analy-sis and reverse transcription-PCR. This wasassociated with a concomitant decrease inCatG protein and enzymatic activity. Incontrast, the expression of lysosomal cathep-sins B and D was up-regulated in infectedcells. This effect was also observed whenTHP-1 cells were induced to differentiateinto adherent macrophages by exposure to bacterial lipopolysaccharide (LPS). Inagreement with this, CatG expression wasnull in adherent macrophages isolated frombronchoalveolar lavages and normal blood.We wanted to determine if the down-regulation of CatG would be relevant to M.tuberculosis infection. First, we found thataddition of CatG to THP-1 cells prior to in-fection resulted in decreased bacillary via-bility, presumably due to extracellularkilling of bacilli. However, pretreatment ofcells with LPS, which decreases intracellu-lar CatG expression, resulted in increasedbacillary viability. Second, we found thatCatG cationic peptides killed M. tubercu-losis bacilli and were five- to sevenfoldmore bactericidal than full-length CatG.These observations suggest that M. tubercu-losis infection of human monocytic cellsresults in a “cathepsin switch” with down-regulation of CatG rendering M. tuberculo-sis bacilli more viable. Therefore, the down-regulation of CatG in macrophages isadvantageous to M. tuberculosis bacilli andpossibly is an important mechanism bywhich M. tuberculosis is able to evade the host immune defenses.—Authors’ Ab-stract

Serafin-Lopez, J., Chacon-Salinas, R.,Munoz-Cruz, S., Enciso-Moreno, J.A., Estrada-Parra, S. A., and Estrada-Garcia, I. The effect of iron on the expres-sion of cytokines in macrophages infectedwith Mycobacterium tuberculosis. Scand.J. Immunol. 60(4) (2004) 329–337.

Iron is known to play an important role indifferent bacterial infections and, in partic-ular, in their development. One example isinfection with Mycobacterium tuberculosis

where iron contributes to growth and sur-vival of the bacteria within the host cell.The majority of studies performed on tuber-culosis have focused on the direct effect ofiron on bacterial growth; however, little isknown about how iron modifies the myco-bacterial-host interaction. In order to ad-dress this, we have investigated the effect ofiron on intracellular growth of M. tubercu-losis in J774 macrophages and the molec-ular mechanisms that are affected duringthis interaction. We observed that iron mod-ifies intracellular growth of the mycobacte-ria and that their growth kinetics was modi-fied from that observed for the extracellularsituation in the presence of iron. Similarly,when iron was present during the infection,there was a reduced release of tumournecrosis factor-alpha and it was related to ahigher number of bacilli inside the host celland low expression of interleukin-1 (IL-1)and IL-6 mRNA. Hence, this work demon-strates that iron, besides promoting myco-bacterial growth, also regulates the relation-ship between macrophage and bacteria.—Authors’Abstract

Stokes, R. W., Norris-Jones, R., Brooks,D. E., Beveridge, T. J., Doxsee, D., andThorson, L. M. The glycan-rich outerlayer of the cell wall of Mycobacteriumtuberculosis acts as an antiphagocyticcapsule limiting the association of thebacterium with macrophages. Infect. Im-mun. 72(10) (2004) 5676–5686.

Mycobacterium tuberculosis, the causa-tive agent of tuberculosis, is a facultativeintracellular pathogen that infects macro-phages and other host cells. We show thatsonication of M. tuberculosis results in theremoval of material from the surface cap-sule-like layer of the bacteria, resulting inan enhanced propensity of the bacteria tobind to macrophages. This effect is ob-served with disparate murine and humanmacrophage populations though, interest-ingly, not with freshly explanted alveolarmacrophages. Enhanced binding to macro-phages following sonication is significantlygreater within members of the M. tubercu-losis family (pathogens) than within theMycobacterium avium complex (oppor-tunistic pathogens) or for Mycobacterium


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smegmatis (saprophyte). Sonication doesnot affect the viability or the surface hy-drophobicity of M. tuberculosis but does re-sult in changes in surface charge and in thebinding of mannose-specific lectins to thebacterial surface. The increased binding ofsonicated M. tuberculosis was not mediatedthrough complement receptor 3. These re-sults provide evidence that the surface cap-sule on members of the M. tuberculosisfamily may be an important virulence factorinvolved in the survival of M. tuberculosisin the mammalian host. They also questionthe view that M. tuberculosis is readily in-gested by any macrophage it encountersand support the contention that M. tubercu-losis, like many other microbial pathogens,has an antiphagocytic capsule that limitsand controls the interaction of the bacteriumwith macrophages.—Authors’Abstract

Volkman, H. E., Clay, H., Beery, D.,Chang, J. C., Sherman, D. R., and Ra-makrishnan, L. Tuberculous granulomaformation is enhanced by a mycobacte-rium virulence determinant. PLoS Biol.2(11) (2004) e367. Epub. (2004) Nov.

Granulomas are organized host immunestructures composed of tightly interposedmacrophages and other cells that form in re-sponse to a variety of persistent stimuli,both infectious and noninfectious. The tu-berculous granuloma is essential for hostcontainment of mycobacterial infection, al-though it does not always eradicate it.Therefore, it is considered a host-beneficial,if incompletely efficacious, immune re-sponse. The Mycobacterium RD1 locus en-codes a specialized secretion system thatpromotes mycobacterial virulence by anunknown mechanism. Using transparentzebrafish embryos to monitor the infectionprocess in real time, we found that RD1-deficient bacteria fail to elicit efficient gran-uloma formation despite their ability to growinside of infected macrophages. We showedthat macrophages infected with virulentmycobacteria produce an RD1-dependentsignal that directs macrophages to aggre-gate into granulomas. This Mycobacterium-induced macrophage aggregation in turn istightly linked to intercellular bacterial dis-

semination and increased bacterial numbers.Thus, mycobacteria co-opt host granulomasfor their virulence.—Authors’Abstract

Yamashiro, S., Kawakami, K., Uezu, K.,Kinjo, T., Miyagi, K., Nakamura, K.,and Saito, A. Lower expression of Th1-related cytokines and inducible nitric ox-ide synthase in mice with streptozotocin-induced diabetes mellitus infected withMycobacterium tuberculosis. Clin. Exp.Immunol. 139(1) (2005) 57–64.

Summary Diabetes mellitus is an impor-tant predisposing factor for tuberculosis. Theaim of this study was to investigate themechanism underlying this association usinga murine model. Mice with streptozotocin-induced diabetes mellitus were prone toMycobacterium tuberculosis infection, asindicated by increased numbers of live bac-teria in lung, liver and spleen. In diabeticmice, the levels of IL-12 and IFN-gammain the lung, liver and spleen were lowerthan those in control animals on day 14postinfection, while the opposite was truefor IL-4 levels in the lung and liver. The ex-pression pattern of inducible nitric oxidesynthase (iNOS), in the two mice types wasas for IL-12 and IFN-gamma. In addition,peritoneal exudate cells obtained from dia-betic mice produced lower amounts of IL-12 and NO than those from control mice,when stimulated in vitro with M. bovisBCG. Spleen cells from diabetic mice in-fected with M. tuberculosis produced a sig-nificantly lower amount of IFN-gammaupon restimulation with purified protein de-rivatives (PPD) than those from infectednondiabetic mice. Interestingly, addition ofhigh glucose levels (33 mM) to the culturesof PPD-restimulated spleen cells reducedthe synthesis of IFN-gamma only in dia-betic mice, and not in nondiabetic mice. Fi-nally, control of blood glucose levels by in-sulin therapy resulted in improvement ofthe impaired host protection and Th1-related cytokine synthesis. Our results sug-gest that the reduced production of Th1-related cytokines and NO account for thehampered host defense against M. tubercu-losis infection under diabetic conditions.—Authors’Abstract


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73, 1 Current Literature, Microbiology (Leprosy) 67

Microbiology

Allix, C., Supply, P., and Fauville-Dufaux,M. Utility of fast mycobacterial inter-spersed repetitive unit-variable numbertandem repeat genotyping in clinical my-cobacteriological analysis. Clin. Infect.Dis. 39(6) (2004) 783–789. Epub. (2004)Aug 27.

BACKGROUND: Analysis of variablenumbers of tandem repeats (VNTR) of ge-netic elements called mycobacterial inter-spersed repetitive units (MIRUs) is a recentlydescribed, polymerase chain reaction (PCR)-based method used to genotype Mycobacte-rium tuberculosis. It is much faster, requiresa smaller amount of DNA, and has approx-imately the same discriminatory power asthe standard IS6110 restriction fragment-length polymorphism (RFLP) method. Wereport the adaptation and optimization ofMIRU-VNTR genotyping on a capillaryelectrophoresis system. We describe its ap-plication to 3 typical clinical situations en-countered in our laboratory (Institut Pasteurde Bruxelles, Laboratoire Tuberculose etMycobacteries; Brussels, Belgium). METH-ODS: MIRU-VNTR genotyping was per-formed on heat-inactivated M. tuberculosiscultures obtained from clinical specimenson Lowenstein solid medium or in myco-bacteria growth indicator liquid tubes (Bec-

ton Dickinson). After amplification of 12genomic loci using 4 different multiplexPCRs, DNA fragments were separated bycapillary electrophoresis using the ABIPrism 3100-Avant Genetic Analyzer (Ap-plied Biosystems). Sizing of the PCR frag-ments and assignment of the various MIRU-VNTR alleles were done using the GeneScanand customized Genotyper software pack-ages (PE Applied Biosystem). RESULTS:Clustering on the basis of IS6110 finger-printing of isolates from 3 different patientsattending the same hospital was confirmedby MIRU-VNTR typing. This concordancebetween 2 independent, highly discrimina-tory techniques was decisive in triggering anepidemiological inquiry that led to identifi-cation of a bronchoscopy-related tuberculo-sis nosocomial infection. A mixed tuberculo-sis infection in a patient whose infection wasinitially suspected as a result of the IS6110RFLP method was clearly identified byMIRU-VNTR typing. Finally, automatedMIRU-VNTR analysis permitted the identi-fication of laboratory contamination in 6 liq-uid cultures of M. tuberculosis within severalhours. CONCLUSION: These examples il-lustrate the utility of this genotyping tech-nique for quick and accurate resolution ofproblems commonly encountered in clinicalmycobacteriology.—Authors’Abstract

Microbiology (Leprosy)

Kai, M. [Diaminodiphenylsulfone resis-tance of Mycobacterium leprae due tomutations in the dihydropteroate syn-thase gene]. Nihon Hansenbyo GakkaiZasshi 73(3) (2004) 221–226. [Article InJapanese]

The relation between diaminodiphenyl-sulfone (called dapsone)-resistance andpoint mutations of the dihydropteroate syn-thase (DHPS) gene was analyzed usingdapsone resistant Mycobacterium lepraeisolates derived from Japanese leprosy pa-tients. The muataion was found at aminoacid residues 53 or 55 of the DHPS. Thisfinding suggests that two specific mutations

in the DHPS gene involved in dapsone re-sistance of M. leprae.—Author’s Abstract

Maeda, S. [Multi-drug resistant Mycobacte-rium leprae from patients with leprosy.]Nihon Hansenbyo Gakkai Zasshi. 73(3)(2004) 227–233. [Article in Japanese]

DNA sequences of Mycobacterium lep-rae in particular regions of the gyrA, rpoB,and folP genes responsible for resistance tonew quinolones, rifampicin and dapsone,respectively, were analyzed. Among 88 iso-lates of M. leprae from leprosy patients inJapan, Haiti, Indonesia, Pakistan, and the

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Philippines, eleven isolates had mutationalchanges in 2 genes (resistance to 2 drugs),and 2 isolates (Shinsei-1 and Zensho-4)showed mutations in 3 genes (resistance to 3drugs). These findings are suggesting emer-gence of multi-drug resistant M. leprae.

Parkash, O., Singh, H. B., Rai, S., Pandey,A., Katoch, V. M., and Girdhar, B. K.Detection of Mycobacterium leprae DNAfor 36kDa protein in urine from leprosypatients: a preliminary report. Rev. Inst.Med. Trop. Sao Paulo. 46(5) (2004)275–277. Epub. (2004) Oct. 22.

We have searched for Mycobacterium lep-rae DNA for 35kDa protein in urine using aM. leprae specific PCR technique. A limitednumber of 16 patients (of which 11 belongedto lepromatous leprosy and five to tubercu-loid leprosy) and eight healthy individualswere included for the present study. Thenumber of urine samples positive by PCRwere 36.4% (4/11) in lepromatous patientsand 40% (2/5) in tuberculoid patients. Noneof the samples from healthy individuals waspositive. To our knowledge, the results indi-cate, for the first time, the presence of M.leprae DNA in urine from leprosy patients.Another important finding obtained out ofthe study is that amongst treated patients66.6% (4/6) were positive whereas amongstuntreated only 20% (2/10) were positive.From the present indicative data it appearsthat treatment improves the PCR results withurine as a sample. Thus, the approach couldprove to be useful for monitoring the treat-ment response of individual patients andneeds to be further evaluated with a largenumber of patients.—Authors’Abstract

Shenoy, A. R., Sreenath, N. P., Maha-lingam, M., and Visweswariah, S. S.Characterization of phylogenetically dis-tant members of the adenylyl cyclasefamily from mycobacteria: Rv1647 fromM. tuberculosis and its ortholog ML1399from M. leprae. Biochem. J. (2004) Oct.25; [Epub. ahead of print].

Analysis of the genome sequence of My-cobacterium tuberculosis H37Rv has identi-fid 16 genes that are similar to the mam-

malian adenylyl and guanylyl cyclases.Rv1647 was predicted to be an active adeny-lyl cyclase but its position in a phylogeneti-cally distant branch from the other enzymescharacterized so far from M. tuberculosis,makes it an interestingly divergent nu-cleotide cyclase to study. In agreement withits divergence at the sequence level fromother nucleotide cyclases, cloning, expres-sion and purification of Rv1647 revealed dif-ferences in its biochemical properties fromthe earlier characterized Rv1625c adenylylcyclase. Adenylyl cyclase activity of Rv1647was activated by detergents but was resistantto high concentrations of salt. Mutations ofsubstrate specifying residues to those presentin guanylyl cyclases failed to convert the en-zyme to a guanylyl cyclase, but did not alterits oligomeric status. Orthologs of Rv1647could be found in M. leprae, M. avium andM. smegmatis. The ortholog from M. leprae(ML1399) was cloned, protein expressed,purified and shown biochemically to be anadenylyl cyclase, thus representing the firstadenylyl cyclase to be described from M.leprae. Importantly, Western blot analysis ofsubcellular fractions from M. tuberculosisand M. leprae revealed that Rv1647 andML1399 gene products were expressed inthese bacteria respectively. Additionally, M.tuberculosis was also found to exress theRv1625c adenylyl cyclase, suggesting thatmultiple adenylyl cyclase proteins may beexpressed simultaneously in this organism.These results suggest that Class III cyclase-like gene products are likely to have an im-portant role to play in the physiology andperhaps the pathology of these medically im-portant bacteria.—Authors’Abstract

You, E. Y., Kang, T. J., Kim, S. K., Lee, S.B., and Chae, G. T. Mutations in genesrelated to drug resistance in Mycobacte-rium leprae isolates from leprosy patientsin Korea. J. Infect. 50(1) (2005) 6–11.

Objective. Identification of the presenceand drug resistance of Mycobacterium lep-rae is key to the diagnosis and treatment ofleprosy in non-endemic countries like Korea.The aim of this study was to screen the drugtarget DNA such as folP, rpoB, gyr, and 23SrRNA of drug resistance strain of M. leprae.


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Patients and methods. Sequences of thosegenes were analyzed for the 104 bacterialindex positive cases out of 171 leprosy pa-tients in Korea using touchdown PCR,single stranded conformational polymor-phism. Results. Twenty (19.2%) cases haveshown the mutations in folP gene of dapsone-resistant M. leprae in which three (2.89%)cases were mutations in two genes, folP andrpoB, of multidrug resistant strains to dap-sone and rifampin, and two (1.92%) casesin folP and gyr genes of resistance to dap-sone and ofloxacin, respectively. Besidesdouble mutation for folP gene was one case(0.96%) and for rpoB gene one case, re-spectively. There were no mutant isolates in23S rRNA gene against clarithromycin,Conclusions. This result should lead to abetter understanding of the status of mul-tidrug resistant leprosy in Korea and mayassist in the rapid diagnosis of drug resistantM. leprae and the choice of the appropriatetreatment regimens.—Authors’Abstract

Young, S. K., Taylor, G. M., Jain, S., Su-neetha, L. M., Suneetha, S., Lockwood,D. N., and Young, D. B. Microsatellitemapping of Mycobacterium leprae popu-

lations in infected humans. J. Clin. Mi-crobiol. 42(11) (2004) 4931–4936.

To investigate genetic diversity in a bacte-rial population, we measured the copy num-bers of simple sequence repeats, or mi-crosatellites, in Mycobacterium leprae frompatients living in and around Hyderabad, In-dia. Three microsatellite loci containingtrinucleotide or dinucleotide repeats wereamplified from infected tissues, and thecopy numbers were established by sequenceanalysis. Extensive diversity was observedin a cross-sectional survey of 33 patients,but closely related profiles were found formembers of a multicase family likely toshare a common transmission source. Sam-pling of multiple tissues from single individ-uals demonstrated identical microsatelliteprofiles in the skin, nasal cavity, and blood-stream but revealed differences at one ormore loci for M. leprae present in nerves.Microsatellite mapping of M. leprae repre-sents a useful tool for tracking short trans-mission chains. Comparison of skin andnerve lesions suggests that the evolution ofdisease within an individual involves the ex-pansion of multiple distinct subpopulationsof M. leprae.—Authors’Abstract

73, 1 Current Literature, Microbiology (Tuberculosis) 69

Microbiology (Tuberculosis)

Boshoff, H. I., and Barry, C. E., 3rd. Tu-berculosis—metabolism and respirationin the absence of growth. Nat. Rev. Mi-crobiol. 3(1) (2005) 70–80.

Human tuberculosis is a complex diseasecaused by bacterial populations that are lo-cated in discrete lesions (microenvironments)in a single host. Some of these microenviron-ments are conducive to replication, whereasothers restrict bacterial growth without nec-essarily sterlizing the infecting microorgan-isms. The physical and biochemical milieu inthese lesions is poorly defined. None of theexisting animal models for tuberculosis (ex-cept perhaps non-human primates) reproducethe diversity of disease progression that isseen in humans. Nonetheless, transcriptomicsand studies using bacterial mutants have ledto testable hypotheses about metabolic func-tions that are essential for viability in the ab-

sence of replication. A complete picture ofbacterial metabolism must balance reducingequivalents while maintaining an energizedmembrane and basic cellular processes.—Authors’Abstract.

Dahl, J. L. Electron microscopy analysisof Mycobacterium tuberculosis cell di-vision. FEMS Microbiol. Lett. 240(1)(2004) 15–20.

The ultrastructure of Mycobacterium tu-berculosis cells undergoing division wasexamined by electron microscopy. Two fea-tures of cell division were observed and aredescribed here. First, cells are capable of un-dergoing a type of “snapping” post-fissionmovement. This movement is likely due toa multi-layered cell wall in which the innerlayer participates in septum formation

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while the outer layer ruptures first on oneside. A second feature related to cell divi-sion is the ability of dividing cells to formtransient branching structures.—Author’sAbstract

Garcia-Tapia, A., Rodriguez, J. C., Ruiz,M., and Royo, G. Action of fluoro-quinolones and Linezolid on logarithmic-and stationary-phase culture of Myco-bacterium tuberculosis. Chemotherapy50(5) (2004) 211–213. Epub. (2004)Nov.

BACKGROUND: The new challenges in-volved in the chemotherapy of tuberculosismake it necessary to find novel drugs, espe-cially ones that are useful in the latent phaseof the disease. METHODS: We evaluatedthe activity of linezolid and fluoroquinolonesagainst logarithmic- and stationary-phase My-cobacterium tuberculosis. RESULTS: Weobserved that linezolid exhibits antibacterialaction, although slowly, in both situations.Quinolones with an 8-methoxy group exhibitgreater activity than levofloxacin in logarith-mic growth phases, whereas levofloxacin ex-hibits greater activity in stationary-phasegrowth. CONCLUSION: The study of theactivity of drugs against the M. tuberculosismicroorganism in the latent phase is one ofthe most important tools available in thefight against the tuberculosis epidemic, andboth linezolid and the new fluoroquinolonesappear to be promising drugs.—Authors’Abstract

Kaur, D., Brennan, P. J., and Crick, D. C.Decaprenyl diphosphate synthesis in My-cobacterium tuberculosis. J. Bacteriol.186(22) (2004) 7564–7570.

Z-prenyl diphosphate syntheses catalyzethe sequential condensation of isopentenyldiphosphate with allylic diphosphates tosynthesize polyprenyl diphosphates. In my-cobacteria, these are precursors of de-caprenyl phosphate, a molecule which playsa central role in the biosynthesis of essentialmycobacterial cell wall components, such asthe mycolyl-arabinogalactan-peptidoglycancomplex and lipoarabinomannan. Recently,it was demonstrated that open reading frame

Rv2361c of the Mycobacterium tuberculosisH37Rv genome encodes a unique prenyldiphosphate synthase (M. C. Schulbach, P.J. Brennan, and D. C. Crick, J. Biol. Chem.275: 22876–22881, 2000). We have nowpurified the enzyme to near homogeneity byusing an Escherichia coli expression systemand have shown that the product of this en-zyme is decaprenyl diphosphate. The en-zyme catalyzes the addition of isopentenyldiphosphate to geranyl diphosphate, neryldiphosphate, omega,E,E-farnesyl diphos-phate, omega,E,Z-farnesyl diphosphate, oromega,E,E,E-geranylgeranyl diphosphate,with Km values for the allylic substrates of490, 29, 84, 290, and 40 microM, respec-tively. This is a first report of a bacterial Z-prenyl diphosphate synthase that pref-erentially utilizes an allylic diphosphateprimer having the alpha-isoprene unit in theZ configuration, indicating that Rv1086(omega,E,Z-farnesyl diphosphate synthase)and Rv2361c act sequentially in the bio-synthetic pathway that leads to the formationof decaprenyl phosphate in M. tubercuosis.—[Abbreviated authors’ abstract by the Editor]

Montero, M. T., Matilla, J., Gomez-Mampaso, E., and Lasuncion, M. A.Geranylgeraniol regulates negativelycaspase-1 autoprocessing: implication inthe Th1 response against Mycobacteriumtuberculosis. J. Immunol. 173(8) (2004)4936–4944.

Caspase-1 is a cysteine protease com-posed by two 20-kDa and two 10-kDa sub-units that processes pro-IL-1beta and pro-IL-18 to their mature forms. This enzyme ispresent in cells as a latent zymogen that be-comes active through a tightly regulatedproteolytic cascade. Activation is initiated bythe oligomerization of an adaptor molecule,or by the formation of a multiprotein com-plex named inflammasome. Negative regu-lation of caspase-1 activation is exerted byproteins that compete with the adaptor mol-ecule or with the inflammasome formation.We previously reported that fluvastatin, an inhibitor of 3-hydroxy-3-methylglutarylcoenzyme A reductase, increases caspase-1activity in PBMC. This effect was strength-ened by Mycobacterium tuberculosis, rend-ing an exacerbated IL-1beta, IL-18, and


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IFN-gamma production. Mevalonate, theproduct of 3-hydroxy-3-methylglutaryl co-enzyme A reductase, is a precursor for bothnonsterol isoprenoid and sterol formation.In this study, we studied the involvement ofmevalonate derivatives in the regulation ofcaspase-1 activation. inhibition of sterolformation by SKF-104976 or haloperidolhad no effect on IL-1beta release. However,the isoprenoid geranylgeraniol preventedboth caspase-1 activation and the exacer-bated IL production induced by fluvastatin.This isoprenoid significantly reduced the

release of IL-18 and IFN-gamma by PBMCtreated with mycobacteria, even in the ab-sence of fluvastatin. In correlation with theincreased caspase-1 activity, fluvastatinstimulated the proforms cleavage, enhanc-ing the formation of active subunit p10.Geranylgeraniol not only prevented this ef-fect, but induced proforms accumulation.Present results suggest that, once the proteo-lytic cascade is initiated, geranylgeraniolmay exert an additional negative regulationon caspase-1 cleavage process.—Authors’Abstract

73, 1 Current Literature, Experimental Infections 71

Experimental Infections and Vaccines

Brandt, L., Skeiky, Y. A., Alderson, M.R., Lobet, Y., Dalemans, W., Turner,O. C., Basaraba, R. J., Izzo, A. A.,Lasco, T. M., Chapman, P. L., Reed, S.G., and Orme, I. M. The protective ef-fect of the Mycobacterium bovis BCGvaccine is increased by coadministrationwith the Mycobacterium tuberculosis 72-kilodalton fusion polyprotein Mtb72F inM. tuberculosis-infected guinea pigs. In-fect. Immun. 72(11) (2004) 6622–6632.

Tuberculosis vaccine candidate consist-ing of a 72-kDa polyprotein or fusion pro-tein based upon the Mtb32 and Mtb39 anti-gens of Mycobacterium tuberculosis anddesignated Mtb72F was tested for its pro-tective capacity as a potential adjunct to theMycobacterium bovis BCG vaccine in themouse and guinea pig models of this dis-ease. Formulation of recombinant Mtb72F(rMtb72F) in an AS02A adjuvant enhancedthe Th1 response to BCG in mice but didnot further reduce the bacterial load in thelungs after aerosol challenge infection. Inthe more stringent guinea pig diseasemodel, rMtb72F delivered by coadministra-tion with BCG vaccination significantly im-proved the survival of these animals com-pared to BCG alone, with some animalsstill alive and healthy in their appearance at>100 weeks post-aerosol challenge. A simi-lar trend was observed with guinea pigs inwhich BCG vaccination was boosted byDNA vaccination, although this increasewas not statistically significant due to ex-cellent protection conferred by BCG alone.

Histological examination of the lungs oftest animals indicated that while BCG con-trols eventually died from overwhelminglung consolidation, the majority of guineapigs receiving BCG mixed with rMtb72F orboosted twice with Mtb72F DNA hadmostly clear lungs with minimal granulo-matous lesions. Lesions were still promi-nent in guinea pigs receiving BCG and theMtb72F DNA boost, but there was consid-erable evidence of lesion healing and air-way remodeling and reestablishment. Thesedata support the hypothesis that the coad-ministration or boosting of BCG vaccina-tion with Mtb72F may limit the lung con-solidation seen with BCG alone and maypromote lesion resolution and healing. Col-lectively, these data suggest that enhancingBCG is a valid vaccination strategy for tu-berculosis that is worthy of clinical evalua-tion.—Authors’Abstract

Colston, M. J., Hailes, H. C., Stavropou-los, E., Herve, A. C., Herve, G., Good-worth, K. J., Hill, A. M., Jenner, P.,Hart, P. D., and Tascon, R. E. Anti-mycobacterial calixarenes enhance in-nate defense mechanisms in murinemacrophages and induce control of My-cobacterium tuberculosis infection inmice. Infect. Immun. 2004 72(11) (2004)6318–6323.

Tuberculosis remains the leading causeof death among infectious diseases, ac-counting for more than two million deaths

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annually. The incidence of the disease is in-creasing globally, partially because of theresurgence of drug-resistant strains of My-cobacterium tuberculosis. Calixarenes aremacrocyclic oligomers, some of which areable to modify the growth of M. tuberculo-sis in infected cells. Most experimentalwork has been carried out with Macrocy-clon, also known as HOC 12.5EO. In thisstudy, we demonstrate that Macrocyclon iseffective in controlling M. tuberculosis in-fections, and we provide evidence that itseffect is partially mediated by an l-arginine-dependent mechanism of macrophage acti-vation that involves the activity of the in-ducible nitric oxide synthase. We also showthat Macrocyclon is effective in athymicand major histocompatibility complex classII–/– mice and synthesized a number ofstructurally related calixarenes expressingsignificant antimycobacterial activity.—Au-thors’Abstract

Copenhaver, R. H., Sepulveda, E., Armit-ige, L. Y., Actor, J. K., Wanger, A.,Norris, S. J., Hunter, R. L., and Jagan-nath, C. A mutant of Mycobacterium tu-berculosis H37Rv that lacks expressionof antigen 85A is attenuated in mice butretains vaccinogenic potential. Infect Im-mun. 72(12) (2004) 7084–7095.

The fbpA and fbpB genes encoding the85A and 85B proteins of Mycobacteriumtuberculosis H37Rv, respectively, were dis-rupted, the mutants were examined for theirability to survive, and the strain lacking85A (DeltafbpA) was tested for its ability toimmunize mice. The DeltafbpA mutant wasattenuated in mice after intravenous oraerosol infection, while replication of theDeltafbpB mutant was similar to that of thewild type. Complementation of the fbpAgene in DeltafbpA restored its ability togrow in the lungs of mice. The DeltafbpAmutant induced a stronger expression ofpulmonary mRNA messages in mice for tu-mor necrosis factor alpha, interleukin-1beta (IL-1beta), gamma interferon, IL-6,IL-2, and inducible nitric oxide (NO) syn-thase, which led to its decline, while H37Rvpersisted despite strong immune responses.H37Rv and DeltafbpA both induced NO inmacrophages and were equally susceptibleto NO donors, although DeltafbpA was

more susceptible in vitro to peroxynitriteand its growth was enhanced by NO in-hibitors in mice and macrophages. Aerosol-infected mice, which cleared a low-doseDeltafbpA infection, resisted a challengewith virulent M. tuberculosis. Mice subcu-taneously immunized with DeltafbpA orMycobacterium bovis BCG and challengedwith M. tuberculosis also showed similarlevels of protection, marked by a reductionin the growth of challenged M. tuberculo-sis. The DeltafbpA mutant was thus attenu-ated, unlike DeltafbpB, but was also vac-cinogenic against tuberculosis. Attenuationwas incomplete, however, since DeltafbpArevived in normal mice after 370 days, sug-gesting that revival was due to immunose-nescence but not compensation by the fbpBor fbpC gene. Antigen 85A thus affects sus-ceptibility to peroxynitrite in M. tuberculo-sis and appears to be necessary for its opti-mal growth in mice.—Authors’Abstract

Ferraz, J. C., Stavropoulos, E., Yang, M.,Coade, S., Espitia, C., Lowrie, D. B.,Colston, M. J., and Tascon, R. E. A het-erologous DNA priming-Mycobacteriumbovis BCG boosting immunizationstrategy using mycobacterial Hsp70,Hsp65, and Apa antigens improves pro-tection against tuberculosis in mice. In-fect. Immun. 72(12) (2004) 6945–6950.

Tuberculosis is responsible for >2 milliondeaths a year, and the number of new casesis rising worldwide. DNA vaccination com-bined with Mycobacterium bovis bacillusCalmette Guerin (BCG) represents a poten-tial strategy for prevention of this disease.Here, we used a heterologous prime-boostimmunization approach using a combina-tion of DNA plasmids and BCG in order toimprove the efficacy of vaccination againstMycobacterium tuberculosis infection inmice. As model antigens, we selected theM. tuberculosis Apa (for alanine-proline-rich antigen) and the immunodominantHsp65 and Hsp70 mycobacterial antigenscombined with BCG. We demonstrated thatanimals injected with a combination ofDNA vectors expressing these antigens,when boosted with BCG, showed increasedspecific antimycobacterial immune re-sponses compared to animals vaccinatedwith BCG alone. More importantly, the pro-


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tection achieved with this regimen was alsosignificantly better than with BCG alone.—Authors’Abstract

Ghosh, S., and Saxena, R. K. Early effectof Mycobacterium tuberculosis infectionon Mac-1 and ICAM-1 expression onmouse peritoneal macrophages. Exp.Mol. Med. 36(5) (2004) 387–395.

Effect of M. tuberculosis infection wasstudied on the expression of intercellularadhesion molocule-1 (ICAM-1) and Mac-1markers on murine peritoneal macrophages.Intraperitoneal administration of M. tuber-culosis resulted in a marked increase in theproportion of Mac-1(+) cells whereas theproportion of ICAM-1(+) cells declinedsharply 4 hr post infection. Absolute num-bers of Mac-1(+) and ICAM-1(+) cellshowever increased at all time points afterthe infection. Comparison of kinetics ofchanges observed in Mac-1(+) and ICAM-1(+) cell populations with differentialleukocyte counts in peritoneal cells indi-cated that these alterations could be due tocellular influx, especially that of neu-trophils, or up regulation of these markerson macrophages and other peritoneal cells.In adherent peritoneal macrophages in-fected in vitro with M. tuberculosis, propor-tion of Mac-1(+) and ICAM-1(+) cells in-creased markedly within 24 hr of infection.Mean expression of these markers on percell basis also increased significantly. Simi-lar results were obtained by using RAW264.7 mouse macrophage cell line, suggest-ing that the enhanced expression of Mac-1and ICAM-1 markers was a direct effect ofM. tuberculosis infection and not mediatedby contaminating cell types present in ad-herent macrophage preparations. Mac-1and ICAM-1 expression was further studiedon macrophages that had actually engulfedM. tuberculosis and compared with by-stander macrophages without intracellularM. tuberculosis. For this purpose M. tuber-culosis pre-stained with DilC18 fluorescentdye were used for infecting adherent peri-toneal macrophages. Mac-1 and ICAM-1expression on gated DilC18 positive andnegative cell populations was analyzed.Our results indicate that the expression ofMac-1 and ICAM-1 markers was signifi-cantly enhanced on all macrophages incu-

bated with M. tuberculosis but was morepronounced on macrophages with internal-ized mycobacteria. Taken together, our re-sults suggest that the expression of Mac-1and ICAM-1 markers is significantly upregulated as a result of exposure and infec-tion with M. tuberculosis. Since thesemarkers play important role in the uptake ofmycobacteria as well as in the process ofantigen presentation by macrophages, theirupregulation may be beneficial for genera-tion of a protective immune response to M.tuberculosis.—Authors’Abstract

Gilbertson, B., Germano, S., Steele, P.,Turner, S., de St Groth, B. F., andCheers, C. Bystander activation of CD8+T lymphocytes during experimental my-cobacterial infection. Infect. Immun.72(12) (2004) 6884–6891.

Infection of C57BL/6 mice with Myco-bacterium avium leads to the activation ofboth CD4+ and CD8+ gamma interferon(IFN-gamma)-producing T cells, althoughthe CD8+ cells play no role in protectionagainst infection. Using transfer of differentlines of transgenic T cells with T-cell recep-tors (TCRs) which recognize irrelevantantigens, we show here that transferredCD8+ T cells from two of the three lineswere activated to the same degree as thehost cells, suggesting that the majority ofthe IFN-gamma-producing CD8+ T cells ofthe host represented bystander activation.The third line, specific for the male HYantigen, showed no activation. Activationrequired the participation of the CD28 co-receptor on T cells and was unaffected bythe removal of CD44(hi) (memory pheno-type) T cells. The transferred CD8+ T cellsproliferated in vivo, although this was notessential for IFN-gamma production. Takentogether, these data are highly reminiscentof homeostatic proliferation of TCR trans-genic T cells upon transfer to lymphopenichosts, and suggest low-affinity stimulationthrough the TCR, possibly by self peptides.The findings are discussed in relation tohomeostatic proliferation and their signifi-cance in the possible induction of autoim-mune disease.—Authors’Abstract

Izzo, A. A., Izzo, L. S., Kasimos, J., andMajka, S. A matrix metalloproteinase


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inhibitor promotes granuloma formationduring the early phase of Mycobacteriumtuberculosis pulmonary infection. Tuber-culosis (Edinb). 84(6) (2004) 387–396.

OBJECTIVE: The host response to pul-monary Mycobacterium tuberculosis (Mtb)infection results in granuloma formation inan effort to limit infection, but the host im-mune cells also provide an environment inwhich Mtb persists. Granuloma formationrequires immune cell infiltration and con-current extensive remodeling of pulmonarytissue which we hypothesize to be the resultof increased matrix metalloproteinases(MMP) activity. DESIGN: C57BL/6 miceinfected with virulent Mtb (H37Rv) via in-tratracheal inoculation were treated with asynthetic inhibitor of MMP activity (BB-94). Mice were assessed for colony formingunits, granuloma morphology, leukocyte re-cruitment and cytokine levels over 90 daysof infection. RESULTS: BB-94 treatedmice had significantly decreased numbersof pulmonary and blood-borne Mtb earlyduring disease, increased collagen depo-sition within early granulomas and sig-nificantly decreased pulmonary leukocyterecruitment when compared to vehicle-treated, Mtb-infected mice. Cytokine ex-pression did not differ significantly betweengroups. CONCLUSION: Events of earlygranuloma formation can be modified byinhibiting MMP activity, by decreasingleukocyte recruitment, a major source ofMMPs during infection, enhancing the es-tablishment of granulomas and decreasingblood-borne dissemination of Mtb.—Au-thors’Abstract

Maldonado-Garcia, G., Chico-Ortiz, M.,Lopez-Marin, L. M., and Sanchez-Garcia, F. J. High-polarity Mycobacte-rium avium-derived lipids interact withmurine macrophage lipid rafts. Scand. J.Immunol. 60(5) (2004) 463–470.

Cholesterol- and sphingolipid-rich mem-brane microdomains (lipid rafts) are widelyrecognized as portals for pathogenic micro-organisms. A growing body of evidencedemonstrates mobilization of host plasmacell membrane lipid rafts towards the site ofcontact with several pathogens as well as a

strict dependence on cholesterol for appro-priate internalization. The fate of lipid raftsonce the pathogen has been internalized andthe nature of the pathogen components thatinteract with them is however less under-stood. To address both these issues, infec-tion of the J774 murine cell line with Myco-bacterium avium was used as a model.After demonstrating that M. avium induceslipid raft mobilization and that M. aviuminfects J774 by a cholesterol-dependentmechanism, it is shown here that mycobac-terial phagosomes harbor lipid rafts, whichare, at least in part, of plasma cell mem-brane origin. On the other hand, by usinglatex microbeads coated with any of thethree fractions of M. avium-derived lipidsof different polarity, we provide evidencethat high-polarity, in contrast to low-polarityand intermediate-polarity, mycobacteriallipids or uncoated latex beads have a strongcapacity to induce lipid raft mobilization.These results suggest that high-polarity my-cobacterial lipid(s) interact with host cellcholesterol-enriched microdomains whichmay in turn influence the course of infec-tion.—Authors’Abstract

Nicolle, D., Fremond, C., Pichon, X., Bou-chot, A., Maillet, I., Ryffel, B., andQuesniaux, V. J. Long-term control ofMycobacterium bovis BCG infection inthe absence of Toll-like receptors (TLRs):investigation of TLR2-, TLR6-, or TLR2-TLR4-deficient mice. Infect. Immun.72(12) (2004) 6994–7004.

Live mycobacteria have been reported tosignal through both Toll-like receptor 2(TLR2) and TLR4 in vitro. Here, we inves-tigated the role of TLR2 in the long-termcontrol of the infection by the attenuatedMycobacterium, Mycobacterium bovis BCG,in vivo. We sought to determine whetherthe reported initial defect of bacterial con-trol (K. A. Heldwein, et al., J. Leukoc.Biol. 74:277–286, 2003) resolved in thechronic phase of BCG infection. Here weshow that TLR2-deficient mice survived a6-month infection period with M. bovisBCG and were able to control bacterialgrowth. Granuloma formation, T-cell andmacrophage recruitment, and activationwere normal. Furthermore, the TLR2 core-


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ceptor, TLR6, is also not required sinceTLR6-deficient mice were able to controlchronic BCG infection. Finally, TLR2-TLR4-deficient mice infected with BCGsurvived the 8-month observation period.Interestingly, the adaptive response ofTLR2- and/or TLR4-deficient mice seemedessentially normal on day 14 or 56 after in-fection, since T cells responded normallyto soluble BCG antigens. In conclusion,our data demonstrate that TLR2, TLR4, orTLR6 are redundant for the control of M.bovis BCG mycobacterial infection.—Au-thors’ Abstract

Olsen, A. W., Williams, A., Okkels, L. M.,Hatch, G., and Andersen, P. Protectiveeffect of a tuberculosis subunit vaccinebased on a fusion of antigen 85B andESAT-6 in the aerosol guinea pig model.Infect Immun. 72(10) (2004) 6148–6150.

A fusion protein of antigen 85B (Ag85B)and ESAT-6 administered in cationic lipidvesicles conferred a highly significant levelof protection against Mycobacterium tuber-culosis in the guinea pig aerosol model ofinfection. The protection was manifested asdelayed clinical illness and prolonged sur-vival. Neither Ag85B nor ESAT-6 (indepen-dently or as a cocktail) induced significantprotection in this model.—Authors’ Ab-stract

Silva, C. L., Bonato, V. L., Coelho-Castelo, A. A., De Souza, A. O., Santos,S. A., Lima, K. M., Faccioli, L. H., andRodrigues, J. M. Immunotherapy withplasmid DNA encoding mycobacterialhsp65 in association with chemotherapyis a more rapid and efficient form oftreatment for tuberculosis in mice. GeneTher. (2004) Nov. 04; [Epub. ahead ofprint].

Tuberculosis (TB) remains a threat forpublic health, killing around 3 millionpeople a year. Despite the fact that mostcases can be cured with antibiotics, thetreatment is long and patients relapse ifchemotherapy is not continued for at least 6months. Thus, a better characterization ofthe working principles of the immune sys-

tem in TB and identification of new im-munotherapeutic products for the develop-ment of shorter regimens of treatment areessential to achieve an effective manage-ment of this disease. In the present work,we demonstrate that immunotherapy with aplasmid DNA encoding the Mycobacteriumleprae 65 kDa heat-shock protein (hsp65)in order to boost the efficiency of the im-mune system, is a valuable adjunct to an-tibacterial chemotherapy to shorten the du-ration of treatment, improve the treatmentof latent TB infection and be effectiveagainst multidrug-resistant bacilli (MDR-TB). We also showed that the use of DNA-hsp65 alone or in combination with otherdrugs influence the pathway of the immuneresponse or other types of inflammatory re-sponses and should augment our ability toalter the course of immune response/inflam-mation as needed, evidencing an importanttarget for immunization or drug interven-tion.—Authors’Abstract

Verma, I., Pandey, R., and Khuller, G.K. Liposomes as adjuvant for anti-mycobacterial vaccine development. In-dian J. Exp. Biol. 42(10) (2004) 949–954.

Mycobacteria are intracellular pathogensthat invade and reside inside the macro-phages. Recent advances in controlled de-livery systems for vaccines such as lipo-somes have sparked a renewed interest intheir potential application for the preven-tion of mycobacterial infections. The versa-tility of liposomes in the incorporation ofhydrophilic/hydrophobic components, theirnon-toxic nature, biodegradability, biocom-patibility, adjuvanticity, induction of cellu-lar immunity, property of sustained releaseand prompt uptake by macrophages, makesthem attractive candidates for the deliveryof antigens. This review focuses on lipo-some research in the area of mycobacterialdiseases and highlights how the variousmycobacterial components may be ex-ploited as powerful antigens with liposomesas adjuvants.—Authors’Abstract

Xue, T., Stavropoulos, E., Yang, M.,Ragno, S., Vordermeier, M., Cham-bers, M., Hewinson, G., Lowrie, D.


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B., Colston, M. J., and Tascon, R. E.RNA encoding the MPT83 antigen in-duces protective immune responsesagainst Mycobacterium tuberculosis in-fection. Infect. Immun. 72(11) (2004)6324–6329.

We have previously demonstrated thatvaccination of mice with plasmid DNAvectors expressing immunodominant myco-bacterial genes induced cellular immune re-sponses and significant protection againstchallenge with Mycobacterium tuberculo-sis. We demonstrate here, using in vitro-

synthesized RNA, that vaccination withDNA or RNA constructs expressing the M.tuberculosis MPT83 antigen are capable ofinducing specific humoral and T-cell im-mune responses and confer modest but sig-nificant protection against M. tuberculosischallenge in mice. This is the first report ofprotective immunity conferred against in-tracellular bacteria by an RNA vaccine.This novel approach avoids some of thedrawbacks of DNA vaccines and illustratesthe potential for developing new antimy-cobacterial immunization strategies.—Au-thors’Abstract


Epidemiology and Prevention Almeida, E. C., Martinez, A. N., Maniero,

V. C., Sales, A. M., Duppre, N. C.,Sarno, E. N., Santos, A. R., and Moraes,M. O. Detection of Mycobacterium lepraeDNA by polymerase chain reaction in theblood and nasal secretion of Brazilianhousehold contacts. Mem. Inst. OswaldoCruz. 99(5) (2004) 509–511. Epub. (2004)Nov. 03.

DNA samples from blood and nasalswabs of 125 healthy household contactswas submitted to amplification by poly-merase chain reaction (PCR) using a Myco-bacterium leprae-specific sequence as atarget for the detection of subclinical infec-tion with M. leprae. All samples were sub-mitted to hybridization analysis in order toexclude any false positive or negative re-sults. Two positive samples were con-firmed from blood out of 119 (1.7%) andtwo positive samples from nasal secretionout of 120 (1.7%). The analysis of thefamilies with positive individuals showedthat 2.5% (N = 3) of the contacts were rel-atives of multibacilary patients while 0.8%of the cases (N = 1) had a paucibacilary asan index case. All positive contacts werefollowed up and after one year none ofthem presented clinical signs of the dis-ease. In spite of the PCR sensitivity to de-tect the presence of the M. leprae in a sub-clinical stage, this molecular approach didnot seem to be a valuable tool to screenhousehold contacts, since we determined aspurious association of the PCR positivity

and further development of leprosy.—Au-thors’ Abstract

Jianping, S., Gupte, M. D., Manickam,P., Meiwen, Y., Wenzhong, L., andLiangbin, Y. Trends in case detection in-fluenced by leprosy elimination cam-paigns in certain areas of China. Indian J.Lepr. 76(1) (2004) 39–50.

LECs were carried out from 1998 to 2000in eight counties of west China. The num-ber of cases detected during the year ofLECs was much higher than that detectedby routine methods before the year of theLEC. However, the annual number of casesdetected during the year after the LECshowed different patterns. One pattern isthat the number of new cases detected in theyear after the LEC declined to the levelsimilar to that before the year of the LEC.The second pattern is that the number ofnew cases detected in the year after theLEC declined steeply to less than that de-tected before the year of the LEC. Follow-ing peak case-detection during the year ofthe LEC, a gradual decrease in the numberof new cases was observed in the subse-quent years. The repeat LEC brought aweakly rebounding peak case-detectionduring the year following the first LEC car-ried out 3 years earlier. The operational,epidemiological and technical factors influ-encing the trends of case-detection duringthe LECs are discussed.—Authors’Abstract

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73, 1 Current Literature, Rehabilitation 77

Rehabilitation

Buxton, M., Hanney, S., and Jones, T. Es-timating the economic value to societiesof the impact of health research: a criti-cal review. Bull. World Heath Org.82(10) (2004) 733–739.

Estimating the economic value to societiesof health research is a complex but essentialstep in establishing and justifying appropri-ate levels of investment in research. Thepractical difficulties encountered include:identifying and valuing the relevant researchinputs (when many pieces of research maycontribute to a clinical advance); accuratelyascribing the impact of the research; and ap-propriately valuing the attributed economicimpact. In this review, relevant studies iden-tified from the literature were grouped intofour categories on the basis of the methodsused to value the benefits of research. Thefirst category consists of studies that valuedirect cost savings that could arise form re-search leading either to new, less-costlytreatments or to developments such as vac-cines that reduce the number of patientsneeding treatment. The second categorycomprises studies that consider the value tothe economy of a healthy workforce. Ac-cording to this “human capital” approach, in-direct cost savings arise when better healthleads to the avoidance of lost production.The third category includes studies that ex-amine gains to the economy in terms ofproduct development, consequent employ-ment and sale. The studies placed in thefourth category measure the intrinsic valueto society of the health gain, by placing amonetary value on a life. The review did notidentify any consistency of methodology, butthe fourth approach has most promise as ameasure of social value. Many of the studiesreviewed come from industrialized nationsand proposal is made by the present review-ers for an international initiative, coveringdeveloped and developing countries, to un-derstand further methodology analysis andtesting.—Tropical Diseases Bulletin

Kerr-Pontes, L. R. S., Montenegro, A. C.D., Barreto, M. L., Werneck, G. L.,and Feldmeier, H. Inequality and lep-rosy in Northeast Brazil: an ecologicalstudy. Int. J. Epidemiol. 33(2) (2004)262–269.

Background: Leprosy is an importantpublic health problem in many developingcountries and many features of its determi-nants are still obscure. Methods: To investi-gate whether the incidence of leprosy isrelated to certain environmental and socio-economic determinants, and ecologicalstudy was undertaken in 165 manipulates ofthe state of Ceará, Brazil. Social, economic,education, sanitation, demography, meteo-rology, and health data were collected. Thedependent variable was the average inci-dence rate of leprosy from 1991 to 1999.Simple and multiple linear regressions wereperformed to assess the relationship be-tween the dependent and the independentvariables. Results: The average incidencerate for all the municipalities for the1991–1999 period, varied from 0.06 to14.68 per 10,000 persons per year. The levelof inequality (β = 1.67, p = 0.011), the meanyears of study among the population >25 yrsold (β + 1.35, p <0.001), the populationgrowth from 1991–1996 (β = 0.02, p =0.007), the percentage of children 7 to 14years old that did not go to school (β = 0.02,p = 0.028), and the presence of a railroad inthe municipality (β = 0.45, p = 0.038) werefound to be predictors of the incidence rateof leprosy in Ceará. Conclusion: Our find-ings fit the assumption that, in Ceará, lep-rosy is associated with a high level ofpoverty and uncontrolled urbanization. Weput forward the hypothesis that urbanizationincreases not only social inequality eventu-ally leading to strong polarization, but alsoexcludes people from social and materialopportunities. Apparently, such deprivationsrender them susceptible for leprosy.—Trop-ical Diseases Bulletin

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Adekambi, T., and Drancourt, M. Dissec-tion of phylogenetic relationships among19 rapidly growing Mycobacteriumspecies by 16S rRNA, hsp65, sodA,recA and rpoB gene sequencing. Int. J.Syst. Evol. Microbiol. 54(Pt. 6) (2004)2095–2105.

The current classification of non-pigmented and late-pigmenting rapidlygrowing mycobacteria (RGM) capable ofproducing disease in humans and animalsconsists primarily of three groups, the My-cobacterium fortuitum group, the Mycobac-terium chelonae-abscessus group and theMycobacterium smegmatis group. Since1995, eight emerging species have beententatively assigned to these groups on thebasis of their phenotypic characters and 16SrRNA gene sequence, resulting in confus-ing taxonomy. In order to assess further tax-onomic relationships among RGM, com-plete sequences of the 16S rRNA gene(1483–1489 bp), rpoB (3486–3495 bp) andrecA (1041–1056 bp) and partial sequencesof hsp65 (420 bp) and sodA (441 bp) weredetermined in 19 species of RGM. Phyloge-netic trees based upon each gene sequence,those based on the combined dataset of thefive gene sequences and one based on thecombined dataset of the rpoB and recA genesequences were then compared using theneighbor-joining, maximum-parsimony andmaximum-likelihood methods after usingthe incongruence length difference test.Combined datasets of the five gene se-quences comprising nearly 7000 bp and ofthe rpoB+recA gene sequences comprisingnearly 4600 bp distinguished six phyloge-netic groups, the M. chelonae-abscessusgroup, the Mycobacterium mucogenicumgroup, the M. fortuitum group, the Myco-bacterium mageritense group, the Myco-bacterium wolinskyi group and the M.smegmatis group, respectively comprisingfour, three, eight, one, one and two species.The two protein-encoding genes rpoB andrecA improved meaningfully the bootstrapvalues at the nodes of the different groups.The species M. mucogenicum, M. mageri-tense and M. wolinskyi formed new groups

separated from the M. chelonae-abscessus,M. fortuitum and M. smegmatis groups,respectively. The M. mucogenicum groupwas well delineated, in contrast to the M.mageritense and M. wolinskyi groups. Forphylogenetic organizations derived fromthe hsp65 and sodA gene sequences, thebootstrap values at the nodes of a few clus-ters were <70%. In contrast, phylogeneticorganizations obtained from the 16S rRNA,rpoB and recA genes were globally similarto that inferred from combined datasets, in-dicating that the rpoB and recA genes ap-peared to be useful tools in addition to the16S rRNA gene for the investigation ofevolutionary relationships among RGMspecies. Moreover, rpoB gene sequenceanalysis yielded bootstrap values higherthan those observed with recA and 16SrRNA genes. Also, molecular signatures inthe rpoB and 16S rRNA genes of the M.mucogenicum group showed that it was asister group of the M. chelonae-abscessusgroup. In this group, M. mucogenicumATCC 49650(T) was clearly distinguishedfrom M. mucogenicum ATCC 49649 withregard to analysis of the five gene se-quences. This was in agreement with phe-notypic and biochemical characteristics andsuggested that these strains are representa-tives of two closely related, albeit distinctspecies.—Authors’Abstract

Adekambi, T., Reynaud-Gaubert, M.,Greub, G., Gevaudan, M. J., La Scola,B., Raoult, D., and Drancourt, M.Amoebal coculture of “Mycobacteriummassiliense” sp. nov. from the sputum ofa patient with hemoptoic pneumonia. J.Clin. Microbiol. 42(12) (2004) 5493–5501.

A nonphotochromogenic, rapidly grow-ing Mycobacterium strain was isolated inpure culture from the sputum and the bron-choalveolar fluid of a patient with hemop-toic pneumonia by using axenic media andan amoebal coculture system. Both isolatesgrew in less than 7 days at 24 to 37°C withan optimal growth temperature of 30°C.

Other Mycobacterial Diseases


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The isolates exhibited biochemical andantimicrobial susceptibility profiles over-lapping those of Mycobacterium abscessus,Mycobacterium chelonae, and Mycobacte-rium immunogenum, indicating that theybelonged to M. chelonae-M. abscessusgroup. They differed from M. abscessus in beta-galactosidase, beta-N-acetyl-beta-glucosaminidase, and beta-glucuronidaseactivities and by the lack of nitrate reduc-tase and indole production activities, aswell as in their in vitro susceptibilities tominocycline and doxycycline. These iso-lates and M. abscessus differed from M.chelonae and M. immunogenum by exhibit-ing gelatinase and tryptophane desaminaseactivities. Their 16S rRNA genes had com-plete sequence identity with that of M. ab-scessus and >99.6% similarity with those ofM. chelonae and M. immunogenum. Furthermolecular investigations showed that par-tial hsp65 and sodA gene sequences dif-fered from that of M. abscessus by five andthree positions over 441 bp, respectively.Partial rpoB and recA gene sequence analy-ses showed 96 and 98% similarities with M.abscessus, respectively. Similarly, 16S–23SrRNA internal transcribed spacer sequenceof the isolates differed from that of M. abscessus by a A→G substitution at posi-tion 60 and a C insertion at position 102.Phenotypic and genotypic features of thesetwo isolates indicated that they wererepresentative of a new mycobacterialspecies within the M. chelonae-M. absces-sus group. Phylogenetic analysis suggestedthat these isolates were perhaps recently de-rived from M. abscessus. We propose thename of “Mycobacterium massiliense” forthis new species. The type strain has beendeposited in the Collection Institut Pasteuras CIP 108297(T) and in Culture Collectionof the University of Goteborg, Goteborg,Sweden, as CCUG 48898(T).—Authors’Abstract

Alcaide, F., Calatayud, L., Santin, M.,and Martin, R. Comparative in vitro ac-tivities of linezolid, telithromycin, clarith-romycin, levofloxacin, moxifloxacin, andfour conventional antimycobacterial drugsagainst Mycobacterium kansasii. Anti-microb Agents Chemother. 48(12) (2004)4562–4565.

Mycobacterium kansasii is one of themost pathogenic and frequent nontubercu-lous mycobacteria isolated from humans.Patients with adverse drug reactions, resis-tant isolates, or suboptimal response requirealternative treatment regimens. One hun-dred forty-eight consecutive clinical iso-lates of M. kansasii were tested for antimi-crobial susceptibilities by the BACTEC 460system (NCCLS) with two different inocu-lation protocols, one conventional and onealternative. In the alternative protocol, theinoculum 12B vial was incubated until thegrowth index was between 250 and 500.Four conventional antimycobacterial drugs(isoniazid, rifampin, streptomycin, andethambutol) were studied with standardcritical concentrations. The in vitro activi-ties of linezolid, telithromycin, clarith-romycin, levofloxacin, and moxifloxacinwere determined by measuring radiometricMICs. All isolates tested were identified asM. kansasii genotype I and were resistant toisoniazid at a concentration of 0.4 mug/ml.One hundred twenty isolates (81.1%) wereinhibited by 1 microg of isoniazid per ml. Ahigh level of resistance to isoniazid (>10microg/ml) was observed in six isolates(4.1%). Only five strains (3.4%) were resis-tant to rifampin (>1 microg/ml). All isolatesstudied were susceptible to streptomycinand ethambutol. The MICs at which 90% ofthe isolates were inhibited (in microgramsper milliliter) were as follows: linezolid, 1(range, ≤0.25 to 2); telithromycin, >16(range, 4 to >16); clarithromycin, 0.5(range, ≤0.03 to 1); levofloxacin, 0.12(range, 0.12 to 0.25); and moxifloxacin,0.06 (range, ≤0.06 to 0.12). The susceptibil-ity testing results with both inoculation pro-tocols showed perfect correlation. In con-clusion, all M. kansasii isolates showeddecreased susceptibility to isoniazid, butresistance to rifampin was infrequent. Quino-lones, especially moxifloxacin, were themost active antimicrobial agents tested, fol-lowed by clarithromycin. Linezolid alsoshowed good activity against these mi-croorganisms, but telithromycin’s in vitroactivity was poor.—Authors’Abstract

Chacon, O., Bermudez, L. E., and Bar-letta, R. G. Johne’s disease, inflamma-tory bowel disease, and Mycobacterium

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paratuberculosis. Annu. Rev. Microbiol.58 (2004) 329–363.

Johne’s disease is a chronic diarrhea af-fecting all ruminants. Mycobacterium aviumsubsp. paratuberculosis (MAP), a slowlygrowing mycobacteria, is the etiologicagent. There is also a concern that MAPmight be a causative agent of some cases ofinflammatory bowel disease in humans, es-pecially Crohn’s disease. Food products in-cluding pasteurized bovine milk have beensuggested as potential sources of human in-fection. This review addresses microbialfactors that may contribute to its patho-genicity. In addition, the experimental evi-dence defining MAP as the cause of Johne’sdisease and the issues and controversiessurrounding its potential pathogenic role inhumans are discussed.—Authors’Abstract

Chen, H. H., Hsiao, C. H., and Chiu, H.C. Successive development of cutaneouspolyarteritis nodosa, leucocytoclasticvasculitis and Sweet’s syndrome in a pa-tient with cervical lymphadenitis causedby Mycobacterium fortuitum. Br. J. Der-matol. 151(5) (2004) 1096–1100.

Mycobacterium fortuitum is a rapidlygrowing mycobacterium found in soil andwater throughout the world. It can causediseases in immunocompetent patients,usually resulting in localized skin and softtissue infections. Cervical lymphadenitiscaused by M. fortuitum is rare. We report a46-year-old woman in whom skin lesions ofcutaneous polyarteritis nodosa, leucocyto-clastic vasculitis and Sweet’s syndrome hadsuccessively developed before the diagno-sis of cervical lymphadenitis caused by M.fortuitum was made. The skin lesions re-sponded to colchicine and systemic corti-costeroids but recurred intermittently. Afterestablishment of the diagnosis, she receivedtreatment with clarithromycin and cipro-floxacin. The cervical lymph nodes decreasedin size 6 months later and no more new skinlesions were found.—Authors’Abstract

Dai, Y. S., Liang, M. G., Gellis, S. E.,Bonilla, F. A., Schneider, L. C., Geha, R.S., and Orange, J. S. Characteristics of

mycobacterial infection in patients with im-munodeficiency and nuclear factor-kappaBessential modulator mutation, with orwithout ectodermal dysplasia. J. Am.Acad. Dermatol. 51(5) (2004) 718–722.

Hypomorphic mutations of the nuclearfactor kappaB essential modulator genecause ectodermal dysplasia and immunode-ficiency. Affected patients have increasedsusceptibility to mycobacterial disease in-cluding cutaneous manifestations. We de-scribe clinical and histopathologic charac-teristics of 5 patients with nuclear factorkappaB essential modulator gene mutationsand mycobacterial infections, two of whomhad mycobacterial cutaneous infections.—Authors’Abstract

Debacker, M., Aguiar, J., Steunou, C.,Zinsou, C., Meyers, W. M., Scott, J. T.,Dramaix, M., and Portaels, F. Myco-bacterium ulcerans disease: role of ageand gender in incidence and morbidity.Trop. Med. Int. Health 9(12) (2004) 1297–1304.

During the 5-year period, 1997–2001,1700 patients with a clinical diagnosis ofMycobacterium ulcerans disease [Buruli ul-cer (BU)] were treated at the Centre Sani-taire et Nutritionnel Gbemoten, Zagnanado,Benin. The patients lived in the four regionsof southern Benin: Atlantique, Mono,Oueme and Zou, with the largest numbercoming from the Zou Region where thecenter is located. The median age of BU pa-tients was 15 years (q1 = 7, q3 = 30). Lowerlimbs are involved 3.2 times more fre-quently than upper limbs in older patientsand younger patients have the highestprevalence of multiple lesions. The latterare frequently associated with bone lesions.Specific detection rates for age and gendershowed a distribution with maximum peaksin the 10–14 years group and among adultsbetween 75 and 79 years. Over 59 years,males are more at risk of developing M. ul-cerans disease than females. Children un-der 15 years represent the largest part of theBU disease burden and of the general popu-lation. The highest detection rates (per100,000 population) were in the 75–79-year-old patients. The most likely explana-


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tion of this was reactivation of disease froma latent infection of M. ulcerans. Educa-tional programs should target especiallythese two groups of population at risk.—Authors’Abstract

Ferdinand, S., Legrand, E., Goh, K. S.,Berchel, M., Mazzarelli, G., Sola, C., Tortoli, E., and Rastogi, N. Taxo-nomic and phylogenetic status of non-tuberculous mycobacteria in a Caribbeansetting. Mol. Cell. Probes. 18(6) (2004)399–408.

This report describes detailed taxo-nomic and phylogenetic analysis of 15non-tuberculous mycobacteria (NTMs)isolated from human pathological specimensin a Caribbean setting (12 slow-growersand three rapid-growers) that were not iden-tified by cultural and biochemical tests anddrug-susceptibility results. These isolateswere further studied using PCR restrictionfragment length polymorphism analysis(PRA) of a 441bp hsp65 fragment, as wellas the sequencing of 16S rDNA and hsp65DNA, and HPLC of the mycolic acids. Ourresults showed that taxonomic position ofwell-defined NTMs was resolved by PRAand sequencing of hsp65, nonetheless, itwas not suitable to investigate rarely ob-served or new strains that required 16SrDNA sequencing and HPLC for a definiteresponse. Unrooted neighbor-joining phylo-genetic trees were drawn based upon the16S rDNA and hsp65 sequences of the 15NTMs compared with those from describedspecies (73 for 16S rDNA and 45 forhsp65). For most of the NTMs not showingan exactly matching sequence with eitherhsp65 or 16S rDNA in the GenBank, thephylogenetic tree was able to provide withuseful indications about their relatedness toknown species. In such a case, a concordingHPLC pattern with the sequence data andthe place of the strain within the tree couldlead to a potential identification. We alsoidentified three identical isolates that definea new mycobacterial species within thegroup of M. simiae-related mycobacteria.The isolation and characterization of myco-bacteria from new settings may lead toidentify potential pathogens that may pro-pogate in future because of increased hu-

man migration, travels, and climatic andecological changes of the modern world.—Authors’Abstract

Ferguson, D. D., Gershman, K., Jensen,B., Arduino, M. J., Yakrus, M. A.,Cooksey, R. C., and Srinivasan, A. My-cobacterium goodii infections associatedwith surgical implants at Colorado hos-pital. Emerg. Infect. Dis. 10(10) (2004)1868–1871.

From February to October 2003, Myco-bacterium goodii wound infections wereidentified among three patients who receivedsurgical implants at a Colorado hospital.This report summarizes the investigation ofthe first reported nosocomial outbreak of M.goodii. Increased awareness is needed aboutthe potential for nontuberculous mycobacte-ria to cause postoperative wound infec-tions.—Authors’Abstract

Ghadiali, A. H., Strother, M., Naser, S. A.,Manning, E. J., and Sreevatsan, S. My-cobacterium avium subsp. paratuberculo-sis strains isolated from Crohn’s diseasepatients and animal species exhibit simi-lar polymorphic locus patterns. J. Clin.Microbiol. 42(11) (2004) 5345–5348.

Analysis of short sequence repeats ofMycobacterium avium subsp. paratubercu-losis isolated from Crohn’s disease patientsidentified two alleles, both of which clus-tered with strains derived from animalswith Johne’s disease. Identification of alimited number of genotypes among humanstrains implies the existence of humandisease-associated genotypes and strainsharing with animals.—Authors’Abstract

Han, J. Y., Rosenzweig, S. D., Church, J.A., Holland, S. M., and Ross, L. A.Variable presentation of disseminatednontuberculous mycobacterial infectionsin a family with an interferon-gamma re-ceptor mutation. Clin. Infect. Dis. 39(6)(2004) 868–870. Epub. (2004) Aug 27.

A previously healthy 13-year-old childwho had disseminated Mycobacterium


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avium infection is described. Further his-tory revealed disseminated mycobacterialinfections in the patient’s father and uncle,starting at 9 years old and 1 year old, re-spectively. Autosomal dominant interferon-gamma receptor mutation was subsequentlyidentified. Clinical variability among the af-fected members of the same family is con-sistent with previous reports suggestingsubstantial variability in the clinical courseof this disorder.—Authors’Abstract

Jogi, R., and Tyring, S. K. Therapy ofnontuberculous mycobacterial infections.Dermatol. Ther. 17(6) (2004) 491–498.

Mycobacterial infections are increasingin incidence worldwide, partly as a result ofthe increase in immunocompromised in-dividuals. They cause a large number of cu-taneous infections with a broad array ofmanifestations. Because of their diversemanifestations and sometimes fastidiousnature, infections with mycobacteria are of-ten misdiagnosed, leading to delay in andsometimes failure of therapy. In addition,many mycobacteria display both in vitroand in vivo drug resistance to antimicrobialagents. Early recognition of affected pa-tients, initiation of appropriate antimicro-bial therapy based on current guidelines,and tailoring of therapy after susceptibilitytesting is available are therefore essential tothe successful treatment of mycobacterialinfections.—Authors’Abstract

Katoch, V. M. Infections due to non-tuber-culous mycobacteria (NTM). IndianJ.Med. Res. 120(4) (2004) 290–304.

The membership list of genus mycobac-terium is ever expanding and it has grownto 95 in year 2003. While leprosy and tu-berculosis are specific diseases caused bymycobacteria, other members are usuallysaprophytes but can be opportunistic and attimes deadly pathogens. These other myco-bacteria are referred to as atypical myco-bacteria, non-tuberculous mycobacteria(NTM) or mycobacteria other than tuberclebacilli (MOTT). These organisms can pro-duce localized disease in the lungs, lymphglands, skin, wounds or bone. Occasionally

they may produce disseminated disease. Ofthe more than 90 known species of NTM,about one third have been associated withdisease in humans. The species causing hu-man disease are : Mycobacterium avium, M.intracellulare, M. kansasii, M. paratuber-culosis, M. scrofulaceum, M. simiae, M. ha-bana, M. interjectum, M. xenopi, M.heckeshornense, M. szulgai, M. fortuitum,M. immunogenum, M. chelonae, M. mar-inum, M. genavense, M. haemophilum, M.celatum, M. conspicuum, M. malmoense,M. ulcerans, M. smegmatis, M. wolinskyi,M. goodii, M. thermoresistible, M. neoau-rum, M. vaccae, M.palustre, M. elephantis,M. bohemicam and M. septicum. Isolationof these mycobacteria from representativespecimens and their rapid identification isvery important as the treatment strategy fortuberculosis and other mycobacterioses isdifferent. Several biochemical, chemical(lipid) and molecular techniques have beendeveloped for rapid identification of thesespecies. Along with suggestive clinical fea-tures, poor response to antitubercular treat-ment and repeated isolation of the organismsfrom the clinical specimens these techniquescan help in establishing correct diagnosis.Further, many drugs like rifampicin, ri-fabutin, ethambutol, clofazimine, amikacin,new generation quinolones and macrolideseffective against mycobacterial infectionsare available that can be used in appropriatecombinations and dosage to treat these infec-tions.—Author’s Abstract

Kessler A. T., and Kourtis A. P. Mycobac-terium abscessus as a cause of pacemakerinfection. Med. Sci. Monit. 10(10) (2004)CS60–CS62. Epub. (2004) Sep. 23.

BACKGROUND: Mycobacterial infec-tions of a pacemaker insertion site are veryrare clinical events. Such infections arecaused primarily by staphylococci andstreptococci and, less frequently, Gram-negative organisms. CASE REPORT: Wedescribe a case of pacemaker infectioncaused by Mycobacterium abscessus whichis, to our knowledge, only the second suchcase described in the literature. The patientresponded well to removal of the pace-maker wire and treatment with six monthsof clarithromycin. CONCLUSIONS: My-


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cobacteria have been very infrequently re-ported as causes of pacemaker infections.To our knowledge, only one case of suchinfection caused by M. abscessus has beendescribed in the literature. Herein we pre-sent the second case of a patient with pace-maker infection caused by Mycobacteriumabscessus. This case underscores the impor-tance of considering atypical mycobacteriain pacemaker infections, particularly if theGram stain or the standard cultures are neg-ative. Removal of the contaminated foreignbody seems to be an integral part of suc-cessful management.—Authors’Abstract

Lee, S. A., Raad, I. I., Adachi, J. A., andHan, X. Y. Catheter-related bloodstreaminfection caused by Mycobacterium bru-mae. J. Clin. Microbiol. 42(11) (2004)5429–5431.

Mycobacterium brumae is a rapidly grow-ing environmental mycobacterial speciesidentified in 1993; so far, no infections by thisorganism have been reported. Here we pre-sent a catheter-related M. brumae blood-stream infection in a 54-year-old woman withbreast cancer. The patient presented with highfever (39.7°C), and >1000 colonies of M.brumae grew from a quantitative culture ofblood drawn through the catheter. A pairedperipheral blood culture was negative, how-ever, suggesting circulational control of theinfection. The patient was treated empiricallywith meropenem and vancomycin, and thefever resolved within 24 hr. The catheter wasremoved a week later, and from the tip M.brumae was isolated a second time, suggest-ing catheter colonization. The organism wasidentified by colonial morphology, sequenceanalysis of the 16S rRNA gene, and bio-chemical tests.—Authors’Abstract

McShane, H., Pathan, A. A., Sander, C.R., Keating, S. M., Gilbert, S. C., Huy-gen, K., Fletcher, H. A., and Hill, A. V.S. Recombinant modified vaccinia virusAnkara expressing antigen 85A boostsBCG-primed and naturally acquired an-timycobacterial immunity in humans.Nature Med. 10(11) (2004) 1240-1244.

No Abstract Available.

Manfredi, R., Nanetti, A., Valentini, R.,Ferri, M., Morelli, S., and Calza, L.Epidemiological, clinical and therapeuticfeatures of AIDS-related Mycobacteriumkansasii infection during the HIV pan-demic: an 11-year follow-up study. HIVMed. 5(6) (2004) 431–436.

OBJECTIVES: Optimal diagnosis andtimely treatment of atypical mycobacterio-sis, and especially Mycobacterium kansasiidisease, remain a serious challenge for clin-icians engaged in the management of theimmuno-compromised host. METHODSAND RESULTS: From more than 2700hospitalizations (over 1800 patients) attrib-utable to HIV-associated disorders over an11-year period, 12 patients were found tohave a confirmed M. kansasii infection.This reflects the recent reduction in the fre-quency of this HIV-related complication,which virtually disappeared after the intro-duction of potent antiretroviral combina-tions in 1996. In the early 1990s, the lack ofeffective antiretroviral regimens made fre-quent the association with AIDS, a meanCD4 lymphocyte count of nearly 20cells/microL, and an extremely variablechest X-ray features. The recent detectionof a further case was attributable to laterecognition of very advanced HIV disease,complicated by multiple opportunistic dis-orders. CONCLUSIONS: Mycobacteriumkansasii respiratory or disseminated infec-tion continues to occur, and poses diagnos-tic problems in terms of late or missed iden-tification as a result of slow culture andfrequently concurrent opportunistic disease.Serious therapeutic difficulties also arisefrom the unpredictable in vitro antimicro-bial susceptibility profile of these organ-isms, and from the need to start an effectivecombination therapy that does not interferewith other medications as soon as possi-ble.—Authors’Abstract

Martin-Casabona, N., Bahrmand, A. R.,Bennedsen, J., Thomsen, V. O., Cur-cio, M., Fauville-Dufaux, M., Feld-man, K., Havelkova, M., Katila, M. L.,Koksalan, K., Pereira, M. F., Ro-drigues, F., Pfyffer, G. E., Portaels, F.,Urgell, J. R., Rusch-Gerdes, S., Tor-toli, E., Vincent, V., Watt, B.; and the


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Spanish Group for Non-TuberculosisMycobacteria. Non-tuberculous myco-bacteria: patterns of isolation. A multi-country retrospective survey. Int. J. Tu-berc. Lung Dis. 8(10) (2004) 1186–1193.

OBJECTIVE: To collect data on non-tuberculous mycobacteria (NTM) isolatedfrom clinical laboratories in different coun-tries to establish: 1) whether the isolation ofNTM was increasing, 2) which specieswere increasing, and 3) whether there wasany pattern of geographical distribution.DESIGN: In 1996, the Working Group ofthe Bacteriology and Immunology Sectionof the International Union Against Tubercu-losis and Lung Disease contacted 50 labora-tories in different countries for the neces-sary information. RESULTS: The numberof patients reported with NTM was 36099from 14 countries. Mycobacterium aviumcomplex, M. gordonae, M. xenopi, M.kansasii and M. fortuitum were the fivespecies most frequently isolated. There wasa significant upward trend for M. aviumcomplex and M. xenopi. Pigmented myco-bacteria predominated in Belgium, theCzech Republic and the Mediterraneancoast of Spain. Non-chromogenic myco-bacteria were found to be predominant inthe area of the Atlantic coast of Brazil andin Turkey, the United Kingdom, Finlandand Denmark. CONCLUSIONS: There wasan increase in the number of NTM isolatedfrom clinical samples of patients. Isolationof the most frequent species is constantlychanging in most of the geographical areas,and newer species are emerging due to bet-ter diagnostic techniques to detect and iden-tify NTM.—Authors’Abstract

Mateo, L., Rufi, G., Nolla, J. M., and Al-caide, F. Mycobacterium chelonae teno-synovitis of the hand. Semin. Arthritis.Rheum. 34(3) (2004) 617–622.

Objective Tenosynovitis of the hand dueto atypical mycobacteria is an uncommoncondition. We present a case of tenosynovi-tis of the hand due to Mycobacterium che-lonae in a patient without a recognizedpenetrating injury, who was treated success-fully with clarithromycin and antitubercu-lous medications and without debridement.We reviewed the available literature to sum-marize the experience with this infectiousentity. Methods Case report and review ofthe literature (MEDLINE 1976–2003). Onlycases that were sufficiently detailed were in-cluded. Results Twelve cases of upper ex-tremity infection due to M. chelonae havebeen reported: hand tenosynovitis in mostand arthritis in a few. These infections re-sulted from percutaneous inoculation orhematogenous seeding. The clinical coursewas indolent initially but insidiously de-structive. Previously, treatment always in-cluded surgical excision of the infected tis-sues and antibiotic therapy. This is the firstcase of M. chelonae musculoskeletal infec-tion that resolved with only antimicrobialtherapy. Conclusions Musculoskeletal infec-tions by nontuberculous mycobacteria areclinically indistinguishable from those of tu-berculosis and diagnosis is usually delayed.Prompt diagnosis of atypical mycobacteriawith appropriate antimicrobial treatmentmay avoid the need for surgical debride-ment. Relevance We recommend a trial ofantibiotics for M. chelonae before surgicaldebridement.—Authors’Abstract


Molecular & Genetic Studies Almeida, E. C., Martinez, A. N., Maniero,

V. C., Sales, A. M., Duppre, N. C., Sarno,E. N., Santos, A. R., and Moraes, M. O.Detection of Mycobacterium leprae DNAby polymerase chain reaction in the bloodand nasal secretion of Brazilian householdcontacts. Mem. Inst. Oswaldo Cruz. 99(5)(2004) 509–511. Epub. (2004) Nov. 03.

See Current Literature, Epidemiology andPrevention, p. 76

Fitness, J., Floyd, S., Warndorff, D. K.,Sichali, L., Malema, S., Crampin, A.C., Fine, P. E., and Hill, A. V. Large-scale candidate gene study of tuberculo-sis susceptibility in the Karonga districtof northern Malawi. Am. J. Trop. Med.Hyg. 71(3) (2004) 341–349.

Twenty-seven polymorphisms from 12genes have been investigated for associa-tion with tuberculosis (TB) in up to 514

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cases and 913 controls from Karonga dis-trict, northern Malawi. Homozygosity forthe complement receptor 1 (CR1) Q1022Hpolymorphism was associated with suscep-tibility to TB in this population (odds ratio[OR] = 3.12, 95% Confidence interval [CI]= 1.13–8.60, p = 0.028). This associationwas not observed among human immuno-deficiency virus (HIV)-positive TB cases,suggesting either chance association or thatHIV status may influence genetic associa-tions with TB susceptibility. Heterozygosityfor a newly studied CAAA insertion/deletionpolymorphism in the 3′-untranslated regionof solute carrier family 11, member 1(SLC11A1, formerly NRAMP1) was asso-ciated with protection against TB in bothHIV-positive (OR = 0.70, 95% CI =0.49–0.99, p = 0.046) and HIV-negative(OR = 0.65, 95% CI = 0.46–0.92, p =0.014) TB cases, suggesting that theSLC11A1 protein may have a role in innateTB immune responses that influence sus-ceptibility even in immunocompromisedindividuals. However, associations of othervariants of SCLA11A with TB reportedfrom other populations were not replicatedin Malawi. Furthermore, associations withvitamin D receptor, interferon-gamma, andmannose-binding lectin observed else-where were not observed in this Karongastudy. Genetic susceptibility to TB inAfricans appears polygenic. The relevantgenes and variants may vary significantlybetween populations, and may be affectedby HIV infection status.—Authors’ Ab-stract

Machowski, E. E., Dawes, S., andMizrahi, V. TB tools to tell the tale-molecular genetic methods for mycobac-terial research. Int. J. Biochem. Cell.Biol. 37(1) (2005) 54–68.

See Current Literature, Immunopathol-ogy, p. 54

Mawuenyega, K. G., Forst, C. V., Dobos,K. M., Belisle, J. T., Chen, J., Brad-bury, E. M., Bradbury, A. R., andChen, X. Mycobacterium tuberculosisfunctional network analysis by globalsubcellular protein profiling. Mol. Biol.

Cell. 16(1) (2005) 396–404. Epub. (2004)Nov 03.

Trends in increased tuberculosis infectionand a fatality rate of approximately 23%have necessitated the search for alternativebiomarkers using newly developed postge-nomic approaches. Here we provide a sys-tematic analysis of Mycobacterium tubercu-losis (Mtb) by directly profiling its geneproducts. This analysis combines high-throughput proteomics and computationalapproaches to elucidate the globally ex-pressed complements of the three subcellu-lar compartments (the cell wall, membrane,and cytosol) of Mtb. We report the identifi-cations of 1044 proteins and their corre-sponding localizations in these compart-ments. Genome-based computational andmetabolic pathways analyses were per-formed and integrated with proteomics datato reconstruct response networks. From thereconstructed response networks for fattyacid degradation and lipid biosynthesispathways in Mtb, we identified proteinswhose involvements in these pathwayswere not previously suspected. Further-more, the subcellular localizations of theseexpressed proteins provide interesting in-sights into the compartmentalization ofthese pathways, which appear to traversefrom cell wall to cytoplasm. Results of thislarge-scale subcellular proteome profile ofMtb have confirmed and validated the com-putational network hypothesis that func-tionally related proteins work together inlarger organizational structures.—Authors’Abstract

Overduin, P., Schouls, L., Roholl, P., vander Zanden, A., Mahmmod, N., Her-rewegh, A., and van Soolingen, D. Useof multilocus variable-number tandem-repeat analysis for typing Mycobacteriumavium subsp. paratuberculosis. J. Clin.Microbiol. 42(11) (2004) 5022–5028.

The etiology of Crohn’s disease in hu-mans is largely unknown. Clinical signs ofCrohn’s disease partly resemble the clinicalpicture of Johne’s disease in ruminantscaused by Mycobacterium avium subsp.paratuberculosis. Because of the high prev-alence of these bacteria in (products of) ru-

73, 1 Current Literature, Molecular & Genetic Studies 85

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minants and their remarkable thermosta-bility, concern has been raised about thepossible role of these bacteria in the patho-genesis of Crohn’s disease. In an attempt todevelop a molecular typing method to facil-itate meaningful comparative DNA finger-printing of M. avium subsp. paratuberculosisisolates from the human and animal reser-voirs, multilocus variable-number tandem-repeat analysis (MLVA) was explored andcompared to IS900 restriction fragmentlength polymorphism (RFLP) typing. MLVAtyping subdivided the most predominantRFLP type, R01, into six subtypes and thusprovides a promising molecular subtypingapproach to study the diversity of M. aviumsubsp. paratuberculosis.—Authors’Abstract

van de Vosse, E., Hoeve, M. A., and Ot-tenhoff, T. H. Human genetics of intra-cellular infectious diseases: molecularand cellular immunity against mycobac-teria and salmonellae. Lancet Infect. Dis.4(12) (2004) 739–749.

The ability to develop adequate immu-nity to intracellular bacterial pathogens isunequally distributed among human beings.In the case of tuberculosis, for example, in-fection with Mycobacterium tuberculosisresults in disease in 5–10% of exposed in-dividuals, whereas the remainder controlinfection effectively. Similar interindividualdifferences in disease susceptibility arecharacteristic features of leprosy, typhoidfever, leishmaniasis, and other chronic in-fectious diseases, including viral infections.The outcome of infection is influenced bymany factors, such as nutritional status, co-infections, exposure to environmental mi-crobes, and previous vaccinations. It isclear, however, that genetic host factorsalso play an important part in controllingdisease susceptibility to intracellular patho-gens. Recently, patients with severe infec-tions due to otherwise poorly pathogenic

mycobacteria (non-tuberculous mycobacte-ria or Mycobacterium bovis BCG) or Sal-monella spp. have been identified. Many ofthese patients were unable to produce or re-spond to interferon gamma, due to deleteri-ous mutations in genes that encode majorproteins in the type 1 cytokine (interleukin12/interleukin 23/interferon gamma) axis(interleukin 12p40/interleukin 23p40, IL12receptor beta1/IL23 receptor beta1, inter-feron gamma receptors 1 and 2, or signaltransducer and activator of transcription 1).This axis is a major immunoregulatory sys-tem that bridges innate and adaptive immu-nity. Unusual mycobacterial infections werealso reported in several patients with ge-netic defects in inhibitor of NFkappaB ki-nase gamma, a key regulatory molecule inthe nuclear factor kappaB pathway. Newfindings discussed in this review providefurther and sometimes surprising insightsinto the role of type 1 cytokines, and intothe unexpected heterogeneity seen in thesesyndromes.—Authors’Abstract

You, E. Y., Kang, T. J., Kim, S. K., Lee, S.B., and Chae, G. T. Mutations in genesrelated to drug resistance in Mycobacte-rium leprae isolates from leprosy pa-tients in Korea. J. Infect. 50(1) (2005)6–11.

See Current Literature, Microbiology(Leprosy), p. 68

Young, S. K., Taylor, G. M., Jain, S.,Suneetha, L. M., Suneetha, S., Lock-wood, D. N., and Young, D. B. Mi-crosatellite mapping of Mycobacteriumleprae populations in infected humans. J.Clin. Microbiol. 42(11) (2004) 4931–4936.

See Current Literature, Microbiology(Leprosy), p. 69


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*Aide aux Lepreux Emmaus-Suisse, Spi-talgasse, CH-3011 Berne, Switzerland.

*American Leprosy Missions, One ALMWay, Greenville, South Carolina 29601,U.S.A.

*Amici dei Lebbrosi, Foundazione ItalianaRaoul Follereau, Via Borselli 4, 40135Bologna, Italy.

Damien-Dutton Society, 616 Bedford Ave-nue, Bellmore, New York 11710, U.S.A.

*Damien Foundation (DF/APD), 16 RueStevin, B-1040 Bruxelles, Belgium.

*Deutsches Aussatzigen-Hilfswerk e. V.,Postfach 9062, D-97090 Würzberg 11,Germany.

*Le Secours aux Lépreux (Canada), 1275Rue Hodge Bureau 12, Montreal H4N3H4, Canada

*Netherlands Leprosy Relief, Wibaut-straat 137K, 1097 DN Ansterdam, TheNetherlands.

*Pacific Leprosy Foundation, 115 Sher-borne Street, Bag 4730, Christchurch,New Zealand.

*Sasakawa Memorial Health Founda-tion, Senpaku Shinko Bldg., 1-15-16Toranomon, Minato-ku, Tokyo 105,Japan.

ACKNOWLEDGMENT

The Board of Directors of the INTERNATIONAL JOURNAL OF LEPROSY gratefully ac-knowledges the financial assistance from special grantors and sustaining memberswhich, with the special donations of certain members, has made possible the con-tinuation of publication of the JOURNAL directly by the International Leprosy Asso-ciation. Without this assistance the official organ of the ILS, so essential to leprosyworkers everywhere, could not be published.

SPECIAL GRANTORS

87


(ISSN 0148-916X)

10.ack.087 4/28/05 3:23 PM Page 87

*Aide aux Lepreux Emmaus-Suisse, Spi-talgasse, CH-3011 Berne, Switzerland.

*American Leprosy Missions, One ALMWay, Greenville, South Carolina 29601,U.S.A.

*Amici dei Lebbrosi, Foundazione ItalianaRaoul Follereau, Via Borselli 4, 40135Bologna, Italy.

Damien-Dutton Society, 616 Bedford Ave-nue, Bellmore, New York 11710, U.S.A.

*Damien Foundation (DF/APD), 16 RueStevin, B-1040 Bruxelles, Belgium.

*Deutsches Aussatzigen-Hilfswerk e. V.,Postfach 9062, D-97090 Würzberg 11,Germany.

*Le Secours aux Lépreux (Canada), 1275Rue Hodge Bureau 12, Montreal H4N3H4, Canada

*Netherlands Leprosy Relief, Wibaut-straat 137K, 1097 DN Ansterdam, TheNetherlands.

*Pacific Leprosy Foundation, 115 Sher-borne Street, Bag 4730, Christchurch,New Zealand.

*Sasakawa Memorial Health Founda-tion, Senpaku Shinko Bldg., 1-15-16Toranomon, Minato-ku, Tokyo 105,Japan.

ACKNOWLEDGMENT

The Board of Directors of the INTERNATIONAL JOURNAL OF LEPROSY gratefully ac-knowledges the financial assistance from special grantors and sustaining memberswhich, with the special donations of certain members, has made possible the con-tinuation of publication of the JOURNAL directly by the International Leprosy Asso-ciation. Without this assistance the official organ of the ILS, so essential to leprosyworkers everywhere, could not be published.

SPECIAL GRANTORS

87


(ISSN 0148-916X)

10.ack.087 4/28/05 3:23 PM Page 87

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INTERNATIONAL JOURNALOF LEPROSY INTERNATIONAL JOURNAL OF LEPROSY · 2006-11-09 · 6 International Journal of Leprosy 2005 CLINICALCASES Case 1. A 76-year-old woman, occa-sional farmer,