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Tuberculin responses were quantified by induration of the skin, velocity of blood flow in dermal microcirculation and composition of the cellular infiltrate in 125 patients with tuberculosis and 39 healty controls. The diameters of the tuberculin responses were greater in HLA-DR15-positive patients than in DR15-negative patients. The density of infiltrating CD(4+)-positive cells showed a positive correlation with induration in DR15-negative subjects (r = 0.54). A fraction of DR15-positive patients gave large tuberculin responses (> or = 15 mm) but with few CD4+ cells in the test site (< 500/mm2); these patients had a greater percentage of cells in the diffuse dermal infiltrate than in the perivascular region, greater blood flow velocities in the tuberculin response but more frequently with central relative slowing of blood flow and had higher total IgG and specific antimycobacterial antibody levels compared to other DR15-positive patients. If the inflammatory infiltrate in the lungs parallels that in the tuberculin skin test, the lack of immunocompetent cells and tissue hypoxia could permit pulmonary cavitation and explain the association of HLA-DR15 with smear-positive pulmonary tuberculosis.

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We have examined heat-stable opsonins to 4 species of gamma-irradiated mycobacteria (M. tuberculosis (H37Rv), M. avium (28A), M. scrofulaceum and M. leprae (cd 103)) in complement-depleted sera collected from Indonesian subjects with tuberculosis (106 patients),-leprosy (24 patients) and controls (40 hospital workers and 41 factory workers) indirectly by microtitre plate chemiluminescence (CL) assay and compared the results with antibody levels. The results indicate that there is a wide range of opsonic capacity for mycobacteria in complement-depleted sera. There was a poor correlation between the opsonic capacity as measured by CL and the anti-mycobacterial antibody content of sera measured by ELISA, suggesting that anti-mycobacterial antibody has little influence on the uptake of mycobacteria. However, a non-specific heat-stable opsonin appears to be present in some sera. Conversely, some sera from tuberculosis or leprosy patients suppress the production of reactive oxygen species from normal phagocytes in vitro when stimulated with M. tuberculosis. The relevance of this inhibition and the presence of heat-stable opsonins to the pathogenesis of tuberculosis have yet to be determined, but it is possible that the presence of opsonins may inhibit dissemination of tubercle bacilli to other organs.

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The typical turgid Koch type and the non-turgid variant form (Listeria-type) of the tuberculin skin test responses were studied in 76 newly diagnosed pulmonary tuberculosis patients and 29 apparently healthy factory worker controls from Surabaya in Indonesia; in general, the patients had more intense responses than the controls. The blood flow velocity (RBCflux) at the centre of the reaction was similar in all groups, but central relative slowing (a presumed forme fruste of severe ischaemia) was much more common in the Koch-type reactions in tuberculosis patients. In both groups of subjects, the overall density of cellular infiltrate (and the major populations of inflammatory cells) was greater in the typical Koch-type reactions than in the non-turgid variant reactions. Thus the Koch-type reactions were indubitably more intense in inflammatory terms than the non-turgid variant form, but the results of this study do not exclude the possibility that there were underlying qualitative differences in pathogenesis between reactions of the two types as well as the obvious difference in severity.

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Specific antibody levels and delayed-type hypersensitivity skin responses to antigens of Mycobacterium tuberculosis in 39 hospital staff who were heavily exposed to tuberculosis (TB) were compared with those in 36 factory employees from Indonesia. Antibody levels to the TB68 epitope of the 14-kDa antigen were significantly greater, while titers to the TB23 (19-kDa) and TB72 (38-kDa) epitopes and lipoarabinomannan (LAM) were lower in exposed than in nonexposed subjects (all P less than .02). The intensity of tuberculin responses correlated positively with anti-LAM and negatively with anti-19-kDa antibody levels. Possible reasons for the selective humoral response of chronically exposed healthy subjects to the 14-kDa antigen, but not to other antigens immunogenic in patients with tuberculosis, are discussed.

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The early (six hours) reaction to tuberculin skin testing was studied in 33 Indonesian hospital workers with frequent occupational exposure to M tuberculosis and compared with responses maximal at the usual time (48 hours) in factory workers, from the same locality but with only occasional occupational exposure, to determine the nature of the early reaction. The early reaction had the same general histopathological appearance as that seen in the conventional (48 hour) reaction, and both had an infiltrate consisting largely of T lymphocytes and macrophages. The cell densities were lower in the six hour reactions, but the relative concentration of macrophages was greater in the earlier response. These histometric measurements suggested that the six hour reaction was an accelerated delayed hypersensitivity reaction. Moreover, the absence of a specific IgE response or of particulate masses of Ig or complement, made it unlikely an anaphylactoid or Arthus-type reaction could have been responsible. It is concluded that those with frequent occupational exposure to M tuberculosis have larger numbers of circulating T cells reactive with mycobacterial antigens, so that the development of the skin test response to tuberculin is less dependent on "by-stander" cell infiltration to mediate the delayed hypersensitivity reaction than the reactions in those with less intense and less frequent natural exposure. The skin test response maximal at six hours is probably a hyperimmune reaction to an antigen recognised by T cells.

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In a study of tuberculin skin tests in 216 consecutive untreated pulmonary tuberculosis patients, one showed central necrosis at 48 h: there was no effective blood flow at the centre of this lesion, but the periphery was markedly hyperaemic. Many dermal capillaries and venules contained deposits of fibrin, but none was occluded completely: the surviving cells in the dermal infiltrate were almost all macrophages. Five patients with strongly positive reactions at 48 h showed slower blood flow at the centre of the reaction than at the periphery (central relative slowing, CRS), possibly indicating central ischaemia short of necrosis: no fibrin deposits were seen in the dermal vessels of these skin test sites. The cellular infiltrate in the dermis was similar in distribution, but more abundant than that seen in uncomplicated positive reactions of comparable clinical size and with blood flow velocity maximal at the centre. At 48 h, lymphocytes were more numerous than macrophages in both groups, CD8 lymphocytes were more abundant in CRS reactions, but CD4 and CD25 (activated) T-lymphocytes and macrophages had a similar density in both groups. Epidermal CD1 cells were less frequent in CRS reactions than in uncomplicated positive reactions. Although CRS reactions showed more intense inflammation than the uncomplicated controls, none of the histometric measurements correlated with the extent of CRS. Follow-up studies showed that CRS reactions reverted to a normal hyperaemic blood flow pattern 5 days after antigen injection.(ABSTRACT TRUNCATED AT 250 WORDS)

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A radioallergosorbent assay (RAST) was developed and used to determine the levels of IgE antibodies to soluble antigens of Mycobacterium tuberculosis (BCG vaccine strain) in sera from patients with tuberculosis and leprosy and in healthy control subjects. Total IgE levels in the same sera were quantitated with a commercial radioimmunoassay kit. Patients with tuberculosis and leprosy had higher total and specific IgE levels than the control groups but the overlap of levels in patients and controls was too great to render the difference diagnostically useful. Specific IgE levels were elevated in both tuberculosis and leprosy patients, suggesting that this antibody response is towards the shared mycobacterial antigens. No differences in total or specific IgE levels were found between healthy hospital workers occupationally exposed to patients with tuberculosis and factory workers who are not exposed.

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Immunological and metabolic responses were studied in 110 patients with newly diagnosed pulmonary tuberculosis and 32 healthy controls from similar socioeconomic backgrounds. The severity of lung involvement was assessed radiologically, but this was not related to the current features of cell mediated immunity or to those of many aspects of the serological response to Mycobacterium tuberculosis. However, the patients with more extensive pulmonary tuberculosis showed higher titres of IgG2 antibody to whole killed M. tuberculosis and to the ML34 epitope shared by many species of mycobacteria. The patients with more extensive pulmonary tuberculosis showed a more marked metabolic response to infection as manifested by changes in serum levels of acute phase reactant proteins. Accordingly, the metabolic responses are considered to be more likely to prove of value in clinical monitoring of patients for severity of infection, or of reactivation of infection with M. tuberculosis, than immunological responses.

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In the search for HLA-linked immune response genes that control susceptibility to tuberculosis, we performed HLA typing and measured antibody titers to well-defined Mycobacterium tuberculosis antigenic determinants in 101 patients with sputum smear-positive pulmonary tuberculosis and 64 healthy controls from Surabaya, Indonesia. HLA-DR2 and DQw1 were associated with sputum smear-positive pulmonary tuberculosis (attributable risk = 36% and 39%, respectively), while DQw3 was associated even more strongly with the control group (preventive fraction = 57%). Antibody titers to the TB71 and TB72 epitopes of the 38-kDa protein, present only on tubercle bacilli, were strongly associated with DR2 (Pcorr = .001 and .024, respectively). The association of both the disease and the antibody response to the 38-kDa antigen of M. tuberculosis with Class II HLA genes HLA-DR2 indicates that Ir-gene-mediated regulation of the immune response to this antigen may be of pathogenic significance for the development of sputum smear-positive tuberculosis.

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The relationship of velocity of blood flow to density and microanatomical distribution of inflammatory cells in the dermis was studied in 20 human tuberculin tests. Most positive reactions showed maximal blood flow velocities (measured as red blood cell (RBC) flux) at the centre of the reaction, but the two most intense responses showed 'central relative slowing' (CRS) with higher RBC flux at the periphery. Two of the four clinically negative reactions showed a considerable acceleration of blood flow, but the other two showed no such acceleration. The packing density of lymphocytes/monocytes in the perivascular zone was greater in the stronger positives than in the weaker reactions. The density of cells in the intervening dermis was markedly lower than in the foci: the lesions with CRS had the highest density of cells in the diffuse infiltrate of the reticular dermis. At the centre of the reaction, blood flow velocity was generally related to density of cellular infiltrate, except in those with CRS, which had a disproportionately lower blood flow velocity. The finding that the circulatory adaptation to a delayed hypersensitivity reaction can be inadequate may explain the dermal acidosis previously observed in intense skin test reactions, and may be the underlying mechanism of necrosis in hypersensitivity reactions.

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The lymphocytes in the perivascular foci of tuberculin skin tests have a similar CD4:CD8 ratio to those in the peripheral blood, suggesting that these subsets do not show bias in their initial emigration. By contrast, the diffusely infiltrating lymphocytes show a relative preponderance of CD4 cells which is progressively greater in successive 250 micron layers into the dermis. A generally similar pattern is seen in healthy controls and in patients with untreated pulmonary tuberculosis, treated leprosy, haemophilia A and chronic obstructive lung disease (COLD) patients treated with prednisolone, but the gradient of increasing CD4:CD8 ratio with depth into the dermis is significantly less steep in patients with tuberculosis, haemophilia and prednisolone-treated COLD than in the healthy controls. Selective migration results in a relative preponderance of CD4 cells in the diffuse infiltrate and it is suggested that this is a mechanism likely to potentiate defensive reaction to Mycobacterium tuberculosis: any deficiency in selective migration may make immunological defences less effective and so contribute to the chronicity of the lesions of tuberculosis.

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Antibodies to a cytosolic fraction of Mycobacterium tuberculosis in sera from 104 patients with pulmonary tuberculosis and 141 age-matched healthy control subjects were quantitated by solid-phase radioimmunoassay (SPRIA) and an enzyme-linked immunosorbent assay (ELISA) technique. The SPRIA gave a greater discrimination than ELISA: in the former test 92% of patients had antibody levels in excess of those occurring in 97% of controls, while the corresponding figure with the latter was only 73%.

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Antigen preparations extracted from Mycobacterium tuberculosis by different procedures--PPD and 'New tuberculin'--were compared with respect to the cytology of the Type IV reaction they elicit in the dermis. The numbers and microanatomical localization of cells of the major lymphocyte and monocyte subsets were measured histometrically in immunocytochemically-stained sections of biopsies of the 48 h reactions. Despite the close similarity in size of the external appearance of the reactions provoked by the two preparations, 'New tuberculin' elicited a more extensive perivascular infiltrate and more numerous diffusely infiltrating M3-bearing cells: the number of diffusely infiltrating CD4 and CD8 lymphocytes was similar in reactions against the two antigen preparations. Thus the method used to prepare a skin test reagent may affect the nature of the cellular reaction it provokes: differences in content of various classes of antigenic macromolecules are probably important, but the relative content of other irritant constituents may also be important.

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Discrimination between patients with smear-positive pulmonary tuberculosis and healthy adults achieved by the assay of serum anti-mycobacterial antibodies in the major immunoglobulin class (IgG) was greatly improved by assay of antibodies in its four subclasses. By the former method, only 55 of 107 (51%) patients had antibody levels above the upper limit of 31 control sera, but 96 (90%) patients had levels above the upper control level in one or more of the IgG subclasses. Antibody levels in the IgA and IgM classes were less discriminative, but four patients with no elevated levels in the IgG subclasses had elevated IgA antibody levels, bringing the total of patients with significant serological changes compatible with tuberculosis to 100 (93.5%).

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Allotypes were determined in 121 cases of smear-positive pulmonary tuberculosis and 33 healthy controls from Indonesia. It was found that the occurrence of Km1 was significantly lower in patients than in controls (p = 0.011), and that phenotypes lacking G1m (17) and G3m(21) as well as Km1 occurred much more frequently among patients than controls (p = 0.0025). Some evidence for an allotypic influence on the antibody response to mycobacterial antigens was found. A lack of G1m(17) or G3m(21) was associated with increased antibody levels in the IgG2 subclass in control subjects and a lack of Km1 with decreased antibody levels in the IgG4 subclass in patients.

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Multiple skin testing with reagents (new tuberculins) prepared from different mycobacterial species places individuals in three categories: those reacting to all reagents (Category 1), those reacting to none (Category 2) and those reacting to some but not all (Category 3). This pattern of reactivity led to the postulate that Category 3 individuals respond only to those antigens that are unique to each individual species, while Category 1 individuals respond to antigens common to all mycobacteria, though a few of the latter may be responding independently to the specific antigens of all the reagents used. The percentage of patients with tuberculosis responding to all of four new tuberculins was much lower than among healthy subjects--a pattern of reactivity observed previously in leprosy. These findings strongly suggest that patients with mycobacterial diseases fail to respond to shared mycobacterial antigens.

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