Proteomic analysis of purified protein derivative of Mycobacterium tuberculosis

Background

Purified protein derivative (PPD) has been used for more than half a century as an antigen for the diagnosis of tuberculosis infection based on delayed type hypersensitivity. Although designated as “purified,” in reality, the composition of PPD is highly complex and remains ill-defined. In this report, high resolution mass spectrometry was applied to understand the complexity of its constituent components. A comparative proteomic analysis of various PPD preparations and their functional characterization is likely to help in short-listing the relevant antigens required to prepare a less complex and more potent reagent for diagnostic purposes.

Results

Proteomic analysis of Connaught Tuberculin 68 (PPD-CT68), a tuberculin preparation generated from M. tuberculosis, was carried out in this study. PPD-CT68 is the protein component of a commercially available tuberculin preparation, Tubersol, which is used for tuberculin skin testing. Using a high resolution LTQ-Orbitrap Velos mass spectrometer, we identified 265 different proteins. The identified proteins were compared with those identified from PPD M. bovis, PPD M. avium and PPD-S2 from previous mass spectrometry-based studies. In all, 142 proteins were found to be shared between PPD-CT68 and PPD-S2 preparations. Out of the 354 proteins from M. tuberculosis–derived PPDs (i.e. proteins in either PPD-CT68 or PPD-S2), 37 proteins were found to be shared with M. avium PPD and 80 were shared with M. bovis PPD. Alignment of PPD-CT68 proteins with proteins encoded by 24 lung infecting bacteria revealed a number of similar proteins (206 bacterial proteins shared epitopes with 47 PPD-CT68 proteins), which could potentially be involved in causing cross-reactivity. The data have been deposited to the ProteomeXchange with identifier PXD000377.

Conclusions

Proteomic and bioinformatics analysis of different PPD preparations revealed commonly and differentially represented proteins. This information could help in delineating the relevant antigens represented in various PPDs, which could further lead to development of a lesser complex and better defined skin test antigen with a higher specificity and sensitivity.     

Retention of 14C-Labeled Tuberculin Purified Protein Derivative in the Skin of Sensitized and Nonsensitized Animals

Tuberculin purified protein derivative labeled with (14)C ([(14)C]PPD) with a biological potency equivalent to the International Standard for tuberculin PPD was used to study the retention of tuberculin PPD in the skin of sensitized and nonsensitized animals. We found that [(14)C]PPD was almost entirely cleared from the skin test site during the first 18 to 24 h after injection and that when approximately 5% of the initial concentration of [(14)C]PPD was present in the skin test site, the size of the tuberculin skin reaction in sensitized guinea pigs was at its maximum. Furthermore, the addition of 5 or 50 mug of Tween 80 per ml to a solution of PPD did not change either the rate of clearance of PPD from the skin test sites of sensitized guinea pigs or the size of the tuberculin skin reactions. There was no difference in the rate of clearance of [(14)C]PPD from the skin test sites between sensitized and nonsensitized guinea pigs and between guinea pigs of different age. However, there was a significant difference in the rate of clearance of [(14)C]PPD between the guinea pig and the mouse. Finally, the percentage of [(14)C]PPD retained in the site of injection at 24 h was in the neighborhood of 5% of the initial concentration of the solution of PPD injected. The significance of these phenomena is discussed.     

Interpretation of the PPD skin test in BCG-vaccinated children.

Skin testing with 5 tuberculin units (TU) of purified protein derivative (PPD) of tuberculin stabilized with polysorbate (Tween) 80 was done 3 months and 1 year after immunization with bacille Calmette-Guérin (BCG) vaccine in two groups of children: one group vaccinated at birth and another group at age 6 years. Interpretation of the PPD skin test with 5 TU is possible in children 1 year and older vaccinated with BCG at birth: if the diameter of induration is more than 10 to 12 mm the reaction cannot be ascribed to BCG vaccination and is highly suggestive of supervening infection with Mycobacterium tuberculosis or occasionally atypical mycobacteria. In contrast, the interpretation of a PPD test in children vaccinated at age 6 years is extremely difficult.     

Chromatographic analysis and immunobiologic properties of tuberculins]

Immunobiologic activities of tuberculin preparations and their components have been comparatively studied using gel filtration and high-performance liquid chromatography (HPLC) techniques. It is shown that high-molecular weight fraction of protein-purified derivate tuberculin (PPD) had higher activity as compared to nonfractionated preparation in skin tests on guinea pigs sensitized with Mycobacterium bovis BCG as well as in enzyme-linked immunosorbent assay with affinity purified rabbit antibodies against PPD. Using the preparative HPLC-technique we failed to isolate a component of PPD having greater tuberculin test potency than nonfractionated preparation.     

Variability of NPH Insulin Preparations

In 1968-69 certain juvenile diabetics receiving NPH insulin began having pre-breakfast glucosuria and mid-morning hypoglycemic reactions. A mail survey of our clinic population and a study done at the Quebec camp for diabetic children in 1969 revealed that certain lot numbers were associated with poor control and that a change to new lot numbers or alternate insulin preparations resulted in better control. “Suspect” insulin preparations and non-suspect insulins were given to newly diagnosed diabetics, and plasma insulin and glucose levels were measured over a 24-hour period. The data confirmed that the “suspect” insulins were causing early hypoglycemia and failing to control hyperglycemia during the latter hours of the 24-hour period. The lower glucose levels were associated with higher plasma insulin levels. The “suspect” insulins were further found to have elevated levels of free insulin in the supernatant fluid.The requirements for quality control of modified insulin preparations are reviewed and suggestions are offered for their improvement.     

Stability of mammalian tuberculin PPD.

Six lots of PPD prepared in 1937 met the requirements when tested in guinea pig potency assay in 1974. Reading of the skin reactions at 48 hr gave more consistent results than the 24 hr reading. Data were evaluated by analysis of variance and by a quick method developed for the estimation of identity of the standard and the test preparation. Although less sensitive than the analysis of variance, the quick method has been found suitable for estimation of the potency of tuberculin preparations.     

Immune reactions in patients with superficial bladder cancer after intradermal and intravesical treatment with bacillus Calmette-Guérin

Summary The immune reactivity of patients with strongly recurrent superficial bladder cancer was followed after combined intravesical and intradermal bacillus Calmette-Guérin (BCG) immunotherapy. All patients in this study were previously treated without success with intravesical chemotherapy. The BCG treatment regimen consisted of weekly administrations with BCG (RIVM) for six consecutive weeks, both intravesically and intradermally. In this study, sera and peripheral blood leukocytes (PBL) of patients were tested serially. Besides BCG-antigen-specific reactions, e.g. skin reactivity to purified protein derivatives of Mycobacterium tuberculosis (PPD), antibody formation and antigen stimulation of PBL in vitro, non-antigen-specific immune reactivities were also measured, e.g. mitogen response and spontaneous cytotoxic activity of PBL. In addition the antibody response to bladder carcinoma antigens and the cytotoxic activity of PBL for the bladder carcinoma cell line T24 and the natural-killer-sensitive K562 cell line were investigated. The results obtained from the various assays were evaluated for their prognostic value in relation to the length of the tumor-free interval after the BCG treatment. Because sera and PBL were only obtained during the first 6 months after the BCG treatment, the immune reactivity was compared to the clinical results at that same time. At 6 months after therapy 12 out of 40 BCG-treated patients were tumor-free whereas 28 out of 40 showed a recurrence. Skin reactivity to tuberculin PPD was measured in 40 patients during a period of 3–6 months after therapy. Of patients who showed a recurrence of the tumor within 6 months, 48% of them showed a transient response or developed no response at all to PPD. In the group of patients with a longer tumor-free period (n=10), only one patient lost the response to tuberculin PPD. Although PBL of a limited number of patients were tested, it was observed that the cytotoxicity to the bladder carcinoma cell line T24, and the natural-killer-sensitive K562 cell line increased in a number of the patients (7 out of 14, and 9 out of 14 respectively). Reactivity of PBL to mitogens and subset distribution (ratio T-helper: T-suppressor/cytotoxic) were not influenced by the BCG treatment. Antibody response to mycobacterial antigen was detected in 9 out of 23 patients investigated. Of these 9 patients, 8 belonged to the group with a recurrence of the tumor within 6 months (n=17). There was no correlation between the skin reactivity and the antibody response to tuberculin PPD. Furthermore, none of the 25 patients showed an antibody response to bladder carcinoma antigens. Sera of bladder carcinoma patients (n=19) reduced the mitogen-induced proliferation of lymphocytes, compared to sera of healthy controls (n=13), indicating the presence of circulating suppressor factor(s). Our results indicate that the absence of a Mantoux conversion or the presence of transient reaction to tuberculin PPD were highly related (91%) to a relapse of the disease. On the other hand, the cytotoxic activity of PBL to T24 and K562 cell lines, or their reactivity to tuberculin PPD or mitogens, gives no predictive information about the clinical results (tumor-free interval) of the BCG therapy. Abbreviations used: BCG, bacillus Calmette-Guérin; NK, natural killer; PBL, peripheral blood leukocytes; PPD, purified protein derivative of Mycobacterium tuberculosis; ELISA, enzyme-linked immunosorbent assay     

Loss of preservative from a tuberculin solution in rubber stoppered vials fastened with different seals

A tuberculin purified protein derivative (PPD) solution containing 0.3% phenol as a preservative was dispensed in glass vials closed with rubber stoppers fastened in three different ways, namely with Tear-off seals, Flip-off seals and partial seals. After various times of storage at 5 degrees C and 37 degrees C, the phenol content in the tuberculin solution was determined. It was found that the Flip-off seals allowed the phenol to escape at a faster rate than the Tear-off seals and that vials closed with partial seals showed the highest loss of phenol. Although these losses were much more pronounced at 37 degrees C than at 5 degrees C, the phenol content at the latter temperature was, over a period of three years, within the limits of acceptability for tuberculin products capped with Tear-off or Flip-off seals. A loss of phenol also occurred from tuberculin solution stored at -28 degrees C in vials capped with either Tear-off or partial seals. In addition to the Tear-off and Flip-off seals other seals such as the "controlled score' Flip-off seal and the Alcoa Steri-Twist cap were evaluated for their imperviousness to air. Except for the Alcoa Steri-Twist cap none of the seals we have investigated were air tight and hence entirely satisfactory to prevent losses of phenol by evaporation from tuberculin products.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lack of effect of levamisole on the immune function in melanoma patients

Summary The immune function of 24 patients with local and regional melanoma receiving levamisole as adjuvant treatment was followed during 12–36 months. There were only minimal changes in the number of the peripheral blood lymphocytes and of E-rosette-forming cells. There was no essential improvement in the responses of peripheral blood lymphocytes to phytohemagglutinin (PHA), concanavalin A (Con A), and purified protein derivative of tuberculin (PPD) during levamisole treatment. Only eight of 24 patients were without recurrence during the observation time of 12–36 months. Our results indicate that adjuvant levamisole therapy in melanoma patients does not exert significant beneficial effects.     

Tuberculin Test in Children with Malnutrition

Tuberculin tests with Heaf''s multiple-puncture method, as well as intradermal tests with varying strengths of old tuberculin, were carried out on 402 children with severe malnutrition. From the radiological and bacteriological findings 51 children (12.5%) were considered to have active tuberculosis. The Heaf test was positive in only 11 of these children, but the intradermal test using 100 tuberculin units was positive in a further 18. This confirms previous findings that tuberculin sensitivity is impaired in malnourished children, and suggests that a higher dose of tuberculin is more likely to elicit a positive response.     

Physicochemical and Biological Studies on Various Preparations of Tuberculin Purifield Protein Derivative

Tuberculin purified protein derivative (PPD) has been prepared by seven different precipitation methods from culture filtrate of Mycobacterium tuberculosis var. hominis. It was found to contain 48 to 99% tuberculoprotein, depending on the method of precipitation. The remaining percentage is represented by nucleic acid, polysaccharide, and ash. Activation analysis on tuberculin PPD and on tubercle bacilli has revealed the presence of trace elements. The molecular weight of tuberculin PPD has been found to be of the order of 14,800 to 27,800. The biological activity of tuberculin PPD varies from lot to lot and from method to method. A correlation between its molecular weight and its biological activity seems to exist.     

Serial QuantiFERON-TB Gold In-Tube assay and tuberculin skin test to diagnose latent tuberculosis in household Mexican contacts: conversion and reversion rates and associated factors using conventional and borderline zone definitions

A cohort of 123 adult contacts was followed for 18‐24 months (86 completed the follow-up) to compare conversion and reversion rates based on two serial measures of QuantiFERON (QFT) and tuberculin skin test (TST) (PPD from TUBERSOL, Aventis Pasteur, Canada) for diagnosing latent tuberculosis (TB) in household contacts of TB patients using conventional (C) and borderline zone (BZ) definitions. Questionnaires were used to obtain information regarding TB exposure, TB risk factors and socio-demographic data. QFT (IU/mL) conversion was defined as <0.35 to ≥0.35 (C) or <0.35 to >0.70 (BZ) and reversion was defined as ≥0.35 to <0.35 (C) or ≥0.35 to <0.20 (BZ); TST (mm) conversion was defined as <5 to ≥5 (C) or <5 to >10 (BZ) and reversion was defined as ≥5 to <5 (C). The QFT conversion and reversion rates were 10.5% and 7% with C and 8.1% and 4.7% with the BZ definitions, respectively. The TST rates were higher compared with QFT, especially with the C definitions (conversion 23.3%, reversion 9.3%). The QFT conversion and reversion rates were higher for TST ≥5; for TST, both rates were lower for QFT <0.35. No risk factors were associated with the probability of converting or reverting. The inconsistency and apparent randomness of serial testing is confusing and adds to the limitations of these tests and definitions to follow-up close TB contacts.     

Lymphocyte Sensitization in Sarcoidosis

Nineteen patients with sarcoidosis have all been shown to have lymphocytes in their blood sensitized to several antigens, including purified protein derivative of tuberculin and Kveim agent, though they had negative or greatly reduced Mantoux reaction. Two patients who repeatedly failed to “convert” after B.C.G. inoculation showed the same cell sensitization phenomena. No explanation can be offered for this anomaly.     

High Utility of Contact Investigation for Latent and Active Tuberculosis Case Detection among the Contacts: A Retrospective Cohort Study in Tbilisi,Georgia, 2010–2011

Setting

The study was conducted at the National Center for Tuberculosis and Lung Diseases (NCTBLD) in Tbilisi, Georgia.

Objective

To assess the utility of contact investigation for tuberculosis (TB) case detection. We also assessed the prevalence and risk factors for active TB disease and latent TB infection (LTBI) among contacts of active pulmonary TB cases.

Design

A retrospective cohort study was conducted among the contacts of active pulmonary TB cases registered in 2010–2011 at the NCTBLD in Tbilisi, Georgia. Contacts of active TB patients were investigated according to an “invitation model”: they were referred to the NCTBLD by the index case; were queried about clinical symptoms suggestive of active TB disease; tuberculin skin testing and chest radiographs were performed. Demographic, laboratory, and clinical data of TB patients and their contacts were abstracted from existing records up to February 2013.

Results

869 contacts of 396 index cases were enrolled in the study; a median of 2 contacts were referred per index case. Among the 869 contacts, 47 (5.4%) were found to have or developed active TB disease: 30 (63.8%) were diagnosed with TB during the baseline period (co-prevalent cases) and 17 (36.2%) developed active TB disease during the follow-up period (mean follow up of 21 months) (incident TB cases). The incidence rate of active TB disease among contacts was 1126.0 per 100 000 person years (95% CI 655.7–1802.0 per 100,000 person-years). Among the 402 contacts who had a tuberculin skin test (TST) performed, 52.7% (95% CI 47.7–57.7%) had LTBI.

Conclusions

A high prevalence of LTBI and active TB disease was found among the contacts of TB cases in Tbilisi, Georgia. Our findings demonstrated that an “invitation” model of contact investigation was an effective method of case detection. Therefore, contact investigation should be scaled up in Georgia.     

The effects of different inactivating agents on the potency, toxicity and stability of pertussis vaccine

The effect of heat (56 degrees C for 10 min), formaldehyde (0.1% at 37 degrees for 24h), glutaraldehyde (0.05% at room temperature for 10 min), thimerosal (0.02% at 37 degrees C for 24h), acetone-I (three treatments at room temperature) and acetone-II (three treatments at room temperature and fourth treatment at 37 degrees C), when used as inactivating agents in the preparation of pertussis suspension, was studied with regard to potency, toxicity and stability. Five batches each of Bordetella pertussis strains 134 and 509 were used for the study. The thimerosal inactivated pertussis (TIP) preparation was 1.5-2 times more potent than the heat inactivated pertussis (HIP) preparation. The potency values of the formaldehyde inactivated pertussis (TIP) and glutaraldehyde inactivated pertussis (GIP) preparations were similar to those of the HIP preparation, while the potencies of the acetone-I treated pertussis (A(I)TP) and acetone-II treated pertussis (A(II)TP) preparations were about half those of the HIP preparation. The FIP preparation was the least toxic showing maximum weight gain in the mouse weight-gain test (MGWT), while the TIP preparation did not pass the MWGT. The weight gains shown the GIP, A(I)TP and A(II)TP preparations were greater than those shown by the HIP preparation. The potency of pertussis component in the adsorbed diphtheria-pertussis-tetanus (DPT) vaccine was stable at 4-8 degrees C and 25 degrees C for three months for all types of pertussis vaccine. There was about 54-65% loss in the potency of the samples after three months at 35 degrees C. The inactivating agents used in the manufacture of pertussis preparations had no effect on the stability of the vaccine.     

Disc Immuno-Immobilization Method for Simultaneous Typing and Isolation of Salmonella Flagellar Phases

Salmonella organisms of an unknown serotype are inoculated in the center of a motility agar plate, and paper discs impregnated with antiflagellar antisera are placed in the periphery of the plate. The plate is incubated at room temperature overnight. During this time, the bacteria spread in a widening circle toward the discs, while the antiserum from each disc, in turn, diffuses centrifugally. When the motile organisms encounter an antiserum reacting with their flagella, they are immobilized. A semicircular line of immobilization is noted around the reactive antiserum disc. Eleven different Salmonella isolates were typed in duplicate by a standard method and by the immuno-immobilization method. Results obtained by the two methods were essentially identical. Simultaneously, single phases were isolated from the zone between the immobilization line and its antiserum disc. Isolates from this region were of the phase not immobilized by the antiserum disc. The dried discs, prepared in tris(hydroxymethyl)aminomethane buffer and stored at 4 C, were stable for at least 5 months. The method can be used for the study of relatedness of surface antigens of motile, growing bacteria, thus circumventing the need for solubilization of these antigens. The results obtained can be interpreted in a similar fashion to the “identity”-“nonidentity” lines of the Ochterlony double-diffusion technique for soluble antigens.     

Vaccination with Freeze-Dried BCG

Sixty first-year medical students, negative to 1:2000 and 1:100 dilutions of old tuberculin (OT), were vaccinated with freezedried BCG vaccine. At six months, 98.3% were found to be positive reactors as ascertained by the intracutaneous (Mantoux) method, using 1:2000 and 1:100 dilutions of OT, and 73.7% as ascertained by the Heaf test, using a tuberculin PPD solution containing 100,000 T.U. per ml.     

Can Hypertrophy of the Contralateral Testis Predict the Absence of a Viable Testis in Infancy with Cryptorchidism: A Prospective Analysis

This prospective study aimed to evaluate whether Contralateral compensatory testicular hypertrophy (CTH) is valid as a predictive tool for a non-viable testis in children aged between 6 and 18 months, and whether CTH is affected by mini-puberty. Seventy-two testes from 60 boys aged between 6 and 18 months were categorized into three groups: 24 testes contralateral to surgically removed non-viable testes (NVTs), 24 testes contralateral to surgically corrected undescended testes (UDTs), and 24 testes from a normal controls. Contralateral testicular length and volume were measured with ultrasonography and compared among the groups. Group 1 (NVT) had a significantly longer length and larger volume than group 2 (UDT). The length and volume of each group among three developmental periods (6–10, 10–14, and 14–18 months) were also analyzed. In the controls, the length was significantly larger at 6–10 months than at 10–14 months in accordance with previously reported changes in testicular size due to the effect of “mini-puberty.” The volume of controls showed a similar pattern, though without statistical significance. However, this pattern was not observed in the NVT and UDT groups. A receiver operating curve revealed that a testicular length of 16.1 mm or a volume of 0.59 ml had the highest sensitivity and specificity for predicting NVTs. The CTH was also found to be valid as a predictive tool for a NVT in children of ages 6 to 18 months, as the effect of mini-puberty appeared to be absent in the NVT and UDT groups. However, the cut-off values were less than those of previous reports. The proper cut-off level according to the age and measurement method should be applied in this developmental period.     

MHC control of T lymphocyte-macrophage interactions

Identity at the major histocompatibility complex (MHC) of primed T cells and macrophages was essential for the development of a T cell proliferative response to Purified Protein Derivative of tuberculin (PPD) in the presence of macrophage-associated antigen and potential allogeneic effects were eliminated by the use of one-way fetal liver chimeras as a T cell source. By contrast, such MHC restriction could not be shown for the T cell—macrophage interaction when antigen was present in soluble form.It was found that the proliferative response of primed (responder × nonresponder) F₁ T cells to the Ir-gene controlled antigen, TNP-18 [Glu-Tyr-Lys (TNP) (Glu-Tyr-Ala)₅], could only be restored by responder macrophages with bound antigen, while both responder and nonresponder macrophages reconstituted the response to soluble TNP-18. Supernatants from cultured responder or nonresponder macrophages could at least partially replace viable macrophages in the latter case.These results argue for two distinct antigen presentation mechanisms, depending on the physical state of the antigen rather than its chemical nature: one involves recognition of antigen in association with MHC-coded determinants and shows H-2 restriction, while the other, mediated by soluble factors and antigen, does not.     

Florid Suprascapular Neuropathy after Primary Rotator Cuff Repair Attributed to Suprascapular Notch Constriction in the Setting of Double Crush Syndrome

This report describes a patient who had an open repair of a small supraspinatus tendon tear performed 6 months after an arthroscopic acromioplasty with debridement had failed to provide pain relief. Three months prior to the tendon repair, he had a two-level cervical spine discectomy and fusion (C4–5, C5–6) that improved his neck pain. Florid suprascapular neuropathy was detected 10 weeks after the open rotator cuff repair. Evidence of some nerve recovery resulted in a long period of observation. But unsatisfactory improvement warranted decompression of the suprascapular notch, which was found to be very stenotic. At surgery, there was no evidence of neuroma, cyst, or other compressing lesion or tissue. Therefore, it was ultimately hypothesized that there was an exacerbation of a preexisting, but clinically unrecognized, entrapment of the suprascapular nerve in the suprascapular notch in the setting of cervical radiculopathy (primarily C5). Retrospectively it was also concluded that had this compressive etiology been recognized, it would have favored prompt decompression rather than the long observation period. Three years was required to achieve a good result following suprascapular notch decompression. The underlying C5 radiculopathy may have created a “double crush syndrome” that contributed to the propensity for injury and the prolonged recovery. There should be heightened awareness of this problem in patients who do not have satisfactory improvement in shoulder pain from previous shoulder and neck surgery.