|Year : 2019 | Volume
| Issue : 2 | Page : 67-76
The immunopathology of tuberculosis, the mode of action of the Bacillus Calmette-Guérin, of the tuberculin and of the immunotherapy
Parabolic Biologicals, Rue de l' Ecluse, 2, 1320 Beauvechain, Belgium
|Date of Submission||09-Jan-2019|
|Date of Decision||24-Mar-2019|
|Date of Acceptance||09-Apr-2019|
|Date of Web Publication||17-Jun-2019|
Dr. Roland Maes
Parabolic Biologicals, Rue De L' Ecluse 2, 1320 Beauvechain
Source of Support: None, Conflict of Interest: None
The outer surface of the cell membrane of Mycobacterium tuberculosis is made of carbohydrates and lipids that do not readily induce the formation of antibodies by the invaded host. The absence of antibodies against the outer cell membrane of wild strains explains the long persistence of the pathogen in the invaded host. Its immunopathology sequence proceeds in four complex steps, some generating an immunodeficiency. TB presents a pronounced phenotypic variation, with the result that strains thriving in different parts of the world differ widely immunologically. The bacterium is ubiquitous, and the claim that the infection affects a quarter of the human population is an understatement. The Bacillus Calmette–Guerin (BCG) vaccination is a primo-infection that may generate an immunodepression and favor the infection of immunodepressed hosts. The BCG vaccine elicits a vigorous cellular immune response that prevents proliferation. This explains why BCG does not protect against infection but prevents dissemination from the primary foci to other parts of the body. The mycobacterium Mycobacterium vaccae fails to elicit a cellular immune response at a par with that generated by BCG. However, it is far superior to BCG at the humoral immunity level. The boosting of the synthesis of nitric oxide is possible by food supplements, as an adjuvant to immunotherapy.
Keywords: Bacillus Calmette–Guerin, chemotherapy, diagnostic, immunotherapy, serology, tuberculosis
|How to cite this article:|
Maes R. The immunopathology of tuberculosis, the mode of action of the Bacillus Calmette-Guérin, of the tuberculin and of the immunotherapy. Biomed Biotechnol Res J 2019;3:67-76
|How to cite this URL:|
Maes R. The immunopathology of tuberculosis, the mode of action of the Bacillus Calmette-Guérin, of the tuberculin and of the immunotherapy. Biomed Biotechnol Res J [serial online] 2019 [cited 2021 Oct 26];3:67-76. Available from: https://www.bmbtrj.org/text.asp?2019/3/2/67/260481
| Introduction|| |
The incidence of tuberculosis (TB) peaked in Europe between the 18th and 19th centuries. The disease receded in the 20th century after the end of World War II. This recession was attributed to the vaccination of the population worldwide starting in 1950 with the BCG and to the chemotreatment of symptomatic patients. The effect of better living conditions following the end of World War II was not considered. A resurgence of TB occurred in the West in the late 1980s, which appears irreversible. The existence since 1947 of a vaccine and of a simple chemotherapy induced the TB actors to ignore the dilemmas and paradoxes posed by the vaccination. At least a quarter of humanity is infected, but only 5%–10% of these subclinical cases develop into a clinical illness. At the benign end of the spectrum, in pleural TB, healing may occur without treatment. A transient worsening of pulmonary tuberculous lesions may appear at any time during treatment., To explain these paradoxes and enigmas, I postulated in 1996 an immunodepression generated by the pathogen and also by the drugs used to combat its multiplication. This review addresses the immunopathology of Mycobacterium tuberculosis, the action of the vaccine, the meaning of a positive tuberculin, and the advantages of an immunotherapy.
| The Mycobacterium Tuberculosis|| |
The cell wall of M. tuberculosis is principally made of lipids and sugars, the glycolipids being located on the outer surface, and a few proteins being located at the internal base of the membrane. Lipids and sugars are not known to induce a vigorous immune response. The various immunological responses elicited by a TB invasion, starting from the initial uptake to full-blown disease, were described in 1999.,
The first response is innate and addresses the mycobacterial whole cell. There is no oxidative burst and a poor uptake of the mycobacteria by immune-activated macrophages. Interleukin-6 is produced, which suppresses T-cell responses. The potential for an extension of the infection is there. The second response addresses the low-molecular-weight nonpeptide antigens that constitute 95% of the mycobacterial cell surface. The potential to control the infection by interferon-gamma and interleukin-2 is usually present in pediatric populations but may be dwarfed by the energy induced by interleukin-10, which inhibits the cytokines active in delayed-type hypersensitivity (DTH) reactions. In general, no symptoms are denoted during these two initial phases of infection. If the host is unable to eradicate the pathogen, he mounts an immune response against large molecular weight lipoarabinomannan (LAM) and mycolic acid, which are embedded in the mycobacterial cell wall. The LAM produced by the pathogen serves as a virulence factor, with inflammatory reactions.
The disorders induced by an overproduction of LAM characterize postprimary infections, namely an inhibition of production of interferon-gamma and a suppression of DTH reactivity. Some TB patients presenting for specific treatment show T-lymphocytopenia and have 10-fold fewer interleukin-2-responsive T-cells than do controls. These patients need external help under the form of a therapy. At that level of infection, the bacterium suppresses immune responses against protein antigens, and if left unaided, the patient will become chronically infected and eventually die. The fourth response is specific for peptide antigens that are located within the mycobacterium. This stage may be reached spontaneously by the patient or else is obtained by a successful specific treatment. The evolution of the disease is given in [Table 1] and [Table 2].
|Table 2: The two last immunological responses to a tuberculosis infection|
Click here to view
Phenotype variation of tuberculosis strains
A flow-through method for the detection of the TB pathogen was developed, based on the capture of the pathogen on a membrane, labeling of the bacilli with antibodies raised against the cells of avirulent TB strain H37Ra and putting the immobilized antibodies in evidence with gold-labeled protein-A. The method tested in Brazil, India, Pakistan, Iran, and France gave results varying from negative (−) to strong positive (++++) with sputa and cerebro-spinal fluid (CRF) fluid that were positive by staining. Purified samples (Iran and France) did not fare better. A 100-fold increase in the bacterial load from 1.1 × 105 bacteria to 1.5 × 107 did not improve the outcome. The cause of this unexpected variable sensitivity ranging from very good to nil was the primary rabbit antibodies against avirulent H37Ra strain used to label the bacilli, which sometimes they failed to do so. Results are given in [Table 3].
|Table 3: Erratic recognition of wild tuberculosis strains by antibodies against strain H37Ra|
Click here to view
Extent of unapparent tuberculosis infections
About a quarter of the world population is said infected by TB in an unapparent way. This claim is consolidated by a monitoring of the presence of antibodies of the immunoglobulin G (IgG), IgM, and IgA classes against TB in the serum of blood donors in Nice, France. If the number of individuals possessing IgG and IgA antibodies is present in reduced amounts, the IgM antibodies are detectable in a great number of donors, betraying fleeting incipient infections that will be disposed of quietly, without symptoms [Figure 1].
|Figure 1: Monitoring of the presence of immunoglobulin M, immunoglobulin G, and immunoglobulin A antibodies in the serum of blood donors|
Click here to view
Kaustova confirmed this observation by analyzing the serum of cancer patients: Antigen 60 (A60) IgG seropositivity was restricted to only some cancer forms, and follow-up of patients indicated that seropositivity revealed a true mycobacterial disease, unapparent upon first evaluation. Mycobacterial infections, not necessarily TB, are also frequent in HIV positives, which are now universally accepted, but also in cancerous children and transplant patients.
| The Bacillus Calmette–guerin Vaccine|| |
This live Bacillus Calmette–Guerin vaccine derived from Mycobacterium bovis was claimed to be innocuous and protective in 1924, but its use was postponed until 1950. The pediatrician Ferru strongly opposed its application in 1977, and the failure of the BCG was noted in 1999.
Early evidence of inefficacy and infectiousness of Bacillus Calmette–Guerin
The attenuated live bacillus limited, in guinea pigs, the dissemination of inhaled TB bacilli toward the liver as well as their secondary dissemination toward the lung. However, this live vaccine provoked a general lymphatic disease that was claimed to heal spontaneously within 3 weeks. The vaccine lent no protection at all to monkeys at risk. Lignières showed in 1927 that the vaccine occasionally induced tuberculous meningitis instead of preventing it. Calmette refused to take these observations into account and vaccinated human newborns. The proof of efficacy of the vaccine in newborns was, according to Calmette, a reduction in general mortality of the vaccinees and the skin allergy the vaccine elicited. The statistician Greenwood observed in 1928 that the general infantile mortality, in the protected environment where the vaccinated children were confined, was 17% in 1922 and dropped to only 5.1% in 1926, when they were vaccinated, indicating that the reduction in mortality in the protected environment started well before the vaccination took place.
The value of the Bacillus Calmette–Guerin
After World War II, the UNICEF, pushed by the French pediatrician Debré, donated 3 million dollars to the WHO to eliminate the vaccine based on Mycobacterium chelonae, which gave entire satisfaction, and impose the BCG vaccination. The risk of adverse reactions due to BCG, mentioned as early as 1977, was declared in 1988 to be 10 times inferior to the adverse reactions observed with the Danish strain Copenhagen, reported in a prospective study in 1993. This 10-fold discrepancy was suggestive of a variable toxicity of different BCG strains, which will be discussed infra.
The WHO and UNICEF provided support for a BCG vaccine production center in Guindy, Madras/ Chennai, in 1948. Vaccination was extended to schools in almost all states of India in 1949. In 1950, Dr. P. V. Benjamin reported that TB infection was so widespread that no part of the country was free from it. Indian villagers were vaccinated in 1950, who showed an excess of 90% of TB cases. To salvage the BCG, a committee appointed jointly by the Indian Council of Medical Research (ICMR) and the WHO acknowledged that the BCG is powerless against lung TB but that it provided substantial protection against childhood forms of TB such as tubercular meningitis and miliary TB; it recommended to give the vaccine before the end of the 1st year after birth. The possibility of a variability of activity of BCG according to strain was not envisaged.
The French Empire and Libya
A vaccination trial was organized in Algeria in 1935, whose results concerning the general infantile morality were tooted superior to the results obtained by Calmette in France. The vaccination of the population of the French Empire and of Libya was started in 1950. Its efficacy was not verified, but local public health officers reported excess TB cases among the vaccines. In 1978, Henry Quiquendon divulged that the WHO had observed an excess of TB cases among vaccinees in Finland and Denmark, well ahead of its endorsement of the vaccine.
Proof of protection based on tuberculin allergy
Calmette observed in 1928 that, 2 years after the vaccination, only 28% of the vaccinees confined in a protected environment reacted on an intradermal tuberculin injection. The first Congress of BCG was held June 18, 1948. It claimed unanimously (with Ferru's abstention) that BCG provokes within a short time (48–72 h) a neat and lasting allergy detected by tuberculin. A second vaccination was recommended if the first one had not elicited a positive tuberculin reaction.
The congressional representatives neglected the observation made by Calmette in 1928. The skin allergy induced by a BCG inoculation was found in 1999 in Saudi Arabia to be of the order of 7.8%, 5 years after vaccination. An Italian study performed at the same time attributed a skin induration superior to 11 mm in vaccinated individuals not to BCG but to a tuberculous infection. The BCG does not or only rarely induce a DTH reaction, and the indurations >11 mm observed in vaccinees are due to unapparent TB infections. Comstock observed that vaccinees responded to a tuberculin skin test either not at all or else with a skin induration like the one obtained with TB patients. He also observed that the positive response was obtained mainly among vaccinated former TB patients.
These proofs that the reactivity to tuberculin following a BCG vaccination was not due to the vaccine but to a TB or other mycobacterial unapparent infections were corroborated by a Swedish study analyzing the sensitivity to tuberculin of vaccinated and nonvaccinated children. Three percent of the nonvaccinated controls were tuberculin reactive versus 49% of the vaccinated children. The children in Sweden spend the winter months at home, caring for pet animals (birds and fishes). The Swedish investigators controlled the skin reactivity of their individuals not only with tuberculin but also with avianin and scrofulascein, which would indicate infections with Mycobacterium avium and Mycobacterium scrofulaceum mycobacteria that infect birds and fishes. They found that 58% of the vaccinated children reacted to scrofulascein and 67% to avianin, while the frequencies found with these two sensitins in nonvaccinated children were only 25% for scrofulascein and 32% for avianin. The investigators concluded that BCG favored unapparent infections by atypical mycobacteria but refused to extend this obvious conclusion to TB.
The recommendation to revaccinate people who had remained inert to a previous vaccination was a sure way to infect them with TB.
Controlled clinical trials
The promotion of leprosy by BCG was published in 1960 and again twice in the nineties., A 9-fold excess of leprosy cases which affected only vaccinees <5 years was observed in 1989 in New Guinea, a TB-free zone, during the first 5 years following BCG vaccination. These warnings were all ignored, and the newspaper “The Hindu” of January 29, 2017, announced: “Why India needs to step up its fight: In 2015, the country accounted for 60% of new cases of leprosy globally.”
Warning that the vaccination with BCG was iatrogenic was given by Frimodt-Moller in 1978. A crushing observation by Tripathy in 1986 was that the vaccination applied to 260,000 Indians in 1970 (the Chingleput trial) resulted after a year in a 100% excess of symptomatic TB among the vaccinees. Four years after vaccination, the excess in symptomatic cases was 150%. A study made in Iran reported in 1996 that the adjusted effectiveness of BCG vaccination of adults in the protection of pulmonary TB was −0.37 (95% confidence intervals: −1.66–0.31), indicating that the BCG sometimes favors transmission.
The regression of the tuberculosis endemy grinded to a halt in France in 1987, followed by a 7% increase of TB cases in 1992 versus 1991. Grosset mentioned 10,000 new cases in 1994 in France and concluded that the fight against TB was a total failure.
The Proceedings of the National Academy of Sciences of the United States of America published in 1997 that the epidemic of TB occurring after the vaccination of the Yanomamo Amazonian tribe with BCG in 1994 was due to its immunological naivety. However, the first case of TB among the Yanomami was observed 29 years previously, in 1965, with more cases appearing in the 1970s. The population was vaccinated in 1994 because TB cases were uncovered among its members. The population was exposed to TB a long time before the vaccination took place and the TB patients present in its midst did not cause an epidemic. The result of the vaccination was that 82% of the vaccinated population contracted TB. The epidemiological proof that the origin of the epidemic was the vaccine is indisputable. The BCG vaccination of the Brazilian indigenous population proceeded further, with some villages showing an average incidence in the period 1991–2002 that was 2500 per 100000, almost 50 times higher than the regional average, with about half the cases diagnosed in children <15 years.
The protection lend by the Bacillus Calmette–Guerin to children and to severe forms of the disease
To justify its continued use in India, the ICMR and the WHO claimed in 1950 a protection given by the vaccine to children and its usefulness in severe forms of the disease, essentially tuberculous meningitis.
In Hong Kong, a vaccination campaign was started in 1954. It claimed a reduction of infant TB mortality rate from 100% to 0% within 16 years. [Figure 2], taken from Wong and Oppenheimer study, gives the results. What is misleading in this graph is the evolution of the infant TB mortality rate. Hidden is the fact that infant TB mortality rate had decreased by 40% within 2 years that preceded the vaccination campaign, as shown in [Figure 3].
|Figure 2: Stated reduction of infant mortality rate due to Bacillus Calmette–Guerin vaccination in Hong Kong|
Click here to view
|Figure 3: Amended Figure 2. The mortality rate had dropped well before the vaccination took place|
Click here to view
The proof of occasional infectiousness of BCG for meninges was given in France in 1927 and restated in 1988. It was negated in France in 1991 but confirmed in Iran in 1999. In this study of 100 children suffering from meningitis, only 10% responded to a tuberculin test, which indicates an immunosuppression, and only 22% were meninges-smear positive, which is the percentage defined as usual and normal for bacterioscopy by Mioerner in 1996. Of the 30 children with a history of vaccination, 9/30 died (30%) versus 20/70 (28.6%) among the nonvaccinated children. These percentages of mortality are very similar.
The serological proof of inefficiency of infants' vaccination by the Bacillus Calmette–Guerin
Failure by Bacillus Calmette–Guerin to generate antibodies against antigen 60
At the hospital of Necker-Enfants Malades, Paris, France, non-BCG vaccinated infants less than 2 years old were compared to BCG-vaccinated infants less than and older than 5 years for IgG antibodies' production against A60. A60 is an immunodominant protein antigen located inside the bacterium, not at its surface. The BCG failed to produce antibodies against its A60. No IgG antibodies were detected in the nonvaccinated group, as was expected, but antibodies in the two vaccinated groups were also absent, with respectively two very weakly positive cases and one case barely emerging above the cutoff line [Figure 4]. Considering the considerable extent of unapparent fleeting infections by TB [Figure 1], these borderline-positive cases may be traced to increased exposure of the children to contacts outside the home (i.e., nursery, kindergarten, and kissing and hugging relatives).
|Figure 4: Immunoglobulin G antibodies' production by vaccinated and nonvaccinated infants in Paris (France)|
Click here to view
Comparison of production by newborns of antibodies against antigen 60 and purified protein derivative (PPD)
An analysis of the humoral immune response induced after BCG vaccination of newborns monitored to produce IgG and IgM antibodies against PPD and A60 for 3 years was done in Ankara. PPD contains an array of antigens among which LAM, a mycobacterial factor of virulence, while A60 is a dominant thermostable macromolecular antigen (TMA) factor of protection.
[Figure 5] shows that, at birth, a considerable number of infants had received passively from their mothers, IgG antibodies against the factor of protection A60, as well as against PPD. The study was performed in Ankara, and the possibility of latent TB infections in about 50% of the mothers, who would have IgG antibodies, is by no means an irrational hypothesis. IgM antibodies against A60 and PPD, which do not cross the placental barrier, were of course absent in the serum of newborns. At birth, about half of the babies were thus passively protected by maternal IgG antibodies, which disappeared 2–4 months after birth, despite the inoculation of the BCG vaccine. There was virtually no production of IgG antibodies against either A60 or PPD during the first 4 months following vaccination, and these rose only timidly thereafter. Fifteen months after vaccination, all the children, without any exception, began to produce large amounts of IgM antibodies against PPD. Fewer children produced in the meantime IgM antibodies against the factor of protection (A60). This large number of IgM antibodies against PPD versus IgM antibodies against A60 [Figure 1] indicates that the evaluation of transient fleeting TB infections is largely underestimated.
|Figure 5: Production of immunoglobulin G and immunoglobulin M antibodies' classes against PPD and antigen 60 by vaccinated newborns for 3 years, in Ankara (Turkey)|
Click here to view
Phenotype variations of Bacillus Calmette–Guerin
The failure of rabbit antibodies against TB to protect rabbits passively against an aerobic TB challenge was reported in 1974. This observation does in no way inform about humoral protective antibodies synthetized during a human infection, yet it comforted the conclusion drawn from research of development of a serological test, ill-conducted in the absence of any biological understanding, that antibodies play no significant role in the host's immune defense against mycobacterial infections, and all immunological protections continue to be traced in 2019 to the cellular immunity evidenced by a skin test. Applying to BCG the flow-through method described supra for the detection of wild strains, we found that antibodies against BCG play as great a role in protection as cellular immunity.
a. In [Table 4]:
|Table 4: Recognition of whole Bacillus Calmette-Guerin cells (Pasteur Institute of Brabant and Aventis) and inner components by antibodies against whole cells of avirulent tuberculosis strain H37Ra and the inner components of Bacillus Calmette-Guerin Pasteur Institute of Brabant (A60) and sonicate of Bacillus Calmette-Guerin-Copenhagen|
Click here to view
1. The antigens used to sensitize the membrane were:
- Live biomass of BCG bacilli received from the Pasteur Institute of Brabant (PIB)
- Freeze-dried live BCG bacilli from Aventis-Pasteur Monovax lot W5586-2
- A 60 isolated by us from M. bovis, strain BCG received from PIB
- Cytoplasm obtained by us from M. bovis, strain BCG received from PIB.
The A60 antigen and the cytoplasm antigen were obtained by cell disruption and, in the case of the A60 complex, chromatographic isolation by standard methods.
2. The antibodies used to label the cells and the antigens trapped on the membrane were:
- Rabbit antibodies against inactivated freeze-dried M. tuberculosis strain H37Ra (Difco 231141)
- Rabbit antibodies against A60 of BCG PIB
- Rabbit antibodies against a whole sonicate of the Copenhagen strain of BCG (Dako, Denmark)
This [Table 4] reveals that the antibodies against whole H37Ra cells and the antibodies raised against the inner contents of the BCG obtained from the Pasteur Institute of Brabant (PIB) and from a Copenhagen strain, all three recognize very poorly whole BCG bacilli, but all three antibodies react well with cytoplasmic antigens.
b. [Table 5] shows that an antiserum raised against a wild TB strain (whole cell) obtained from the Pasteur Institute of Tehran does barely react (±) with the cytoplasm of BCG PIB. Conversely, antiserum against the A60 of BCG PIB recognizes poorly (++/−) the cytoplasmic constituents of a wild TB strain
|Table 5: Antibodies against wild tuberculosis (Iran) and against H37Ra do not recognize the cytoplasm of Bacillus Calmette-Guerin Pasteur Institute of Brabant|
Click here to view
c. [Table 6] compares the interaction of three antibodies raised against A60-BCG strain Pasteur GL-2, against BCG sonicate strain Copenhagen, and against the whole cells of a wild strain obtained in Tehran, with the whole cells and the dissolved cells of a pathogenic TB strain and three BCG strains. Clearly, BCG Aventis differs from BCG Pasteur GL-2 and from BCG Copenhagen.
|Table 6: Interaction of three Bacillus Calmette -Guéerin strains (whole cells and disrupted cells) with antibodies from Bacillus Calmette -Guéerin and a pathogenic tuberculosis strain|
Click here to view
| Conclusion|| |
These data indicate that BCG induces the production of antibodies mainly against antigens only exposed when bacterial cells are lysed and thus when the infection is well established. I will show infra that the BCG vaccine elicits a vigorous cellular immune response, slow to shape and not detected by a skin test, which prevents proliferation. We therewith provide a simple explanation why BCG does not protect against infection but prevents dissemination from the primary foci to other parts of the body. The absence of creation of antibodies against the outer cell membrane of wild strains also explains the long persistence of the pathogen in the invaded host. The data further indicate that geographical variations in antigens observed among M. tuberculosis strains may be the cause of the discrepant results found when BCG efficacy is analyzed in different parts of the world. In addition, the outer cell membrane of BCG presents a phenotype variation according to strain. The efficacy of some BCG strains to synthesize antibodies against surface antigens of some pathogenic strains is therewith further compromised.
The essential contribution of immunotherapeutic agents would be to assist chemicals powerless in the suppression of an established immunodepressive infection. However, [Table 1] and [Table 2] show that not all TB patients undergo an abrogation of their immune defenses inflicted either by the pathogen or else by the drugs used to eliminate the pathogen. The potential of the immunotherapeutic agent is masked in those patients whose chemotreatment is enough to restore their immune defenses and heal the patients. Two different types of immunotherapy may be applied.
Success and failure of trials
Stanford et al. answered the TB challenge with Mycobacterium vaccae immunotherapy in 1994. The proposed strategy elicited high expectations as well as violent rebuttals. Promising results were published in 1995, but the study performed at Durban in 1999 ruined the project. This study's purpose was to shorten a short-course anti-TB chemotherapy further, by the addition of killed M. vaccae at the start of the short-course anti-TB chemotherapy applied, which would accentuate the decrease in time needed to achieve a negative sputum culture. The conclusion was that M. vaccae immunotherapy has no benefit when added at the start of a presumably successful anti-TB chemotherapy. This outcome was evident. A single inoculation of killed M. vaccae at the beginning of the chemotreatment of patients of whom all the controls not receiving the immunotherapy survived had an immediate effect so limited that M. vaccae immunotherapy was claimed mistakenly useless. The same erroneous approach was taken in the following two trials made in 2000 and 2002 with HIV-infected adults., Yet, proof of efficacy was given already in 1999 and was successful because the immunodepression of the patients was considered. When the agent was used repeatedly, i.e., injected intramuscular monthly for 6 months to chronic patients resistant to isoniazid, streptomycin, and rifampin, 9 of 24 cases were cured after 18-month follow-up versus 1 of 24 cases in the control group.
Mode of action of Mycobacterium vaccae
M. vaccae is a saprophyte mycobacterium used as a killed preparation. It generates a humoral and a cellular immune response, both of which may prove beneficial.
- [Table 7] shows the interaction between four antimycobacterial antibodies and the whole cells of a pathogenic TB strain (Tehran) and the whole cells of M. vaccae. It shows that antibodies against the pathogenic TB strain recognize very well (++++) the M. vaccae cells, much better than the pathogenic strain itself (+++/−). Antibodies against A60 from BCG Pasteur GL-2 are inferior in their recognition of whole cells of the pathogenic strain and of whole cells of M. vaccae. The antibodies against a sonicate of BCG strain Copenhagen also react better with whole cells of M. vaccae than with the whole cells of a pathogenic strain.
- [Table 8] presents the interaction between four antimycobacterial antibodies and the TMAs (A60) of BCG strain Pasteur GL-2 and the thermostable antigen (A60) of M. vaccae. One observes that M. vaccae presents epitopes on its cell surface that are better recognized by antibodies against a pathogenic TB strain (score ++++) than are the pathogenic TB antigens themselves (score +++), while on the other hand, the A60 of M. vaccae reacts very poorly with antibodies against A60 of BCG strain Pasteur GL-2 (score +), indicating a great difference in composition.
|Table 7: Comparison of the interactivity of Mycobacterium vaccae and a wild tuberculosis strain with various antibodies|
Click here to view
|Table 8: Interaction between antigen 60 of Bacillus Calmette -Guéerin Pasteur GL-2 and of antigen 60 of Mycobacterium vaccae r4 different antibodies|
Click here to view
Cellular immune activity
It appeared desirable to compare the capacities of M. vaccae and of M. bovis extracts to induce a cellular immune activity in vivo. To this end, we chose the experimental arthritic syndrome model. Mycobacterial elements included in a water-in-oil emulsion (Freund's incomplete adjuvant [FIA]) induce an arthritic syndrome in rats, which betrays a cellular immunity. This cellular immunity is not an allergic reaction as the hypersensitivity reaction induced by tuberculin, observable after 48–72 h, but takes at least 8 days and may appear only 17 days after the challenge, depending on the race of the animals. The lysates of M. vaccae and M. bovis strain BCG Pasteur GL-2 as well as their isolated TMAs (A60) were emulsified in FIA and inoculated deep at the base of the tails of two rats. The treatment induces a swelling of the hind paws of the animals, which is a cellular immune reaction.
Most of the results, recorded from day 1 to day 23 of the experiment, were negative. The hind paws of all the inoculated rats remained unchanged until 8 days after inoculation. At later times, only the hind paws of one of the two animals inoculated with the lysate of M. bovis cells strain BCG Pasteur GL-2 swelled considerably on day 9–11. The swelling induced with A60 from BCG Pasteur GL-2 followed the same pattern in two rats, indicating that these two BCG inducers possessed about the same potency, far superior to that of the M. vaccae extracts, which induced no arthritic syndrome.
The potential of the M. vaccae immunotherapeutic agent, essentially the formation of antibodies interacting with surface and with cytoplasmic antigens of TB, is masked in those patients whose chemotreatment is amply sufficient to heal the patients and is manifest in patients where the drugs are either not available on a regular basis or unable to fight the progress of the disease. The very weak cellular immune reactivity of M. vaccae is overcome by repeat inoculations of the immunotherapeutic, which proved save.
Nitric oxide generated by uleine
The first line of defense against an invading pathogen is the production of the highly reactive nitric oxide (NO) by macrophages and other cells. Yet, the TB pathogen grows in macrophages and suppresses their synthesis of NO. In addition to a specific immunotherapy provided by M. vaccae, the unspecific boosting of the immune defenses of the organism by stimulation of NO production is a second way to assist recalcitrant cases. The antimicrobial properties of NO are well established since 1995. It is synthesized by consumption of L-arginine and O2, with production of citrulline. Synthesis of NO in humans is more restricted than in other mammalian species as mice and rats, and this restriction largely avoids autotoxicity of NO. Food supplements boosting the immune defenses of the organism by promoting the synthesis of NO through uleine are available and cheap compared to drugs. They were shown innocuous but efficacious against HIV-infected patients. Since NO is active in vivo against M. tuberculosis, the supplement should be active against TB.
[Table 9] records the healing effect of a food supplement based on uleine on HIV patients under a tri-therapy that was noneffective. The administered food supplement Para aspido 80 units was sometimes completed with cytokines and nucleic acids. One observes that the chemotreatment given between time -1 month and time 0, when the food supplement was added, did not favor a gain in weight; the gain was minimal and sometimes was a loss but improved considerably after a food supplement treatment of 3 months, based on uleine. The same positive effect was observed for lymphocytes counts.
|Table 9: Treatment with food supplement based on uleine (Para -aspido) of HIV patients under failed tri-therapy|
Click here to view
| Conclusion|| |
The world population has recently enormously increased in size, of which a sizable amount has been impoverished in the West, where it lives in crowded shacks and is poorly fed or underfed, whereas in other parts of the world, it is still deprived of the most elementary means of a decent living as electricity, running water, flushing toilets, sewage disposal, and soap. The dismal living conditions inflicted to the poorest are currently enhanced by the climate change provoked by the richest. Both impoverished groups are subject to stresses generated by dispossession, hunger, social exclusion, and war. These derelict populations, constantly exposed to TB infections, immigrate in cities where the possibility of transmission is amplified by gatherings at sporting events, dancing halls, crowded buses, and other transport means or else supermarkets where they take refuge in winter. TB is an immunological chronic disease generated by poverty and unhealthy living conditions and is backed by the vaccine meant to combat it. An immunotherapy based on M. vaccae and a food supplement boosting the immune defenses of the organism by promoting the synthesis of NO through uleine are available but not used.
Financial support and sponsorship
Conflicts of interest
I developed a serological test for TB, a flow-through method of diagnostic and of phenotype variation detection of wild TB strains and BCG strains, a food supplement boosting the synthesis of NO, and a food supplement stimulating the multiplication of immunocytes.
| References|| |
Houben RM, Dodd PJ. The global burden of latent tuberculosis infection: A re-estimation using mathematical modelling. PLoS Med 2016;13:e1002152.
Choremis CB, Padiatellis C, Zou Mbou Lakis D, Yannakos D. Transitory exacerbation of fever and roentgenographic findings during treatment of tuberculosis in children. Am Rev Tuberc 1955;72:527-36.
Afghani B, Lieberman JM. Paradoxical enlargement or development of intracranial tuberculomas during therapy: Case report and review. Clin Infect Dis 1994;19:1092-9.
Maes HH, Causse JE, Maes RF. Mycobacterial infections: Are the observed enigmas and paradoxes explained by immunosuppression and immunodeficiency? Med Hypotheses 1996;46:163-71.
Besra GS, Brennan PJ. The mycobacterial cell wall: Biosynthesis of arabinogalactan and lipoarabinomannan. Biochem Soc Trans 1997;25:845-50.
Maes RF. The tuberculosis enigma: Need for a new paradigm: Importance of a knowledge of the immune status of the patients. Biomedicine (India) 1999;19:1-14.
Maes HH, Causse JE, Maes RF. Tuberculosis I: A conceptual frame for the immunopathology of the disease. Med Hypotheses 1999;52:583-93.
Rennou M, Maes MC, Maes HH, Maes RF, Kidwai Z, Tasbiti H, et al
. Antibodies against BCG and M. tuberculosis
H37Ra do not consistently recognize pathogenic M. tuberculosis
whole cells but recognize their cytoplasmic constituents. Implications for the variability and protective efficacy of the vaccine. Clin Microbiol 2016;5:2-10.
Kaustová J. Serological IgG, IgM and IgA diagnosis and prognosis of mycobacterial diseases in routine practice. Eur J Med Res 1996;1:393-403.
Graham JC, Tweddle DA, Jenkins DR, Pollitt C, Pedler SJ. Non-tuberculous mycobacterial infection in children with cancer. Eur J Clin Microbiol Infect Dis 1998;17:394-7.
Patel R, Roberts GD, Keating MR, Paya CV. Infections due to nontuberculous mycobacteria in kidney, heart, and liver transplant recipients. Clin Infect Dis 1994;19:263-73.
Ferru M. La faillite du BCG. In: M. Ferru, editor. Témoignages d'Hier et d'Aujourd'Hui. France, Saint Gratien: ed. on Author's account;1977-1995.
Maes RF. Tuberculosis II: The failure of the BCG vaccine. Med Hypotheses 1999;53:32-9.
Lignières J. in M. Ferru, editor: The failure of the BCG, testimonies from yesterday and from today (in French) M. Ferru, Saint Gratien, France. Ed: author account, 1997-1995.
Quiquandon H. Douze Balles Pour un Veto. 2nd
ed., Vol. 2. Paris: Agriculture et Vie; 1978.
Dahlström G, Sjögren I. Side-effects of BCG vaccination. J Biol Stand 1977;5:147-8.
Lotte A, Wasz-Hockert O, Poisson N, Engbaek H, Landmann H, Quast U, et al.
Second IUATLD study on complications induced by intradermal BCG-vaccination. Bull Int Union Tuberc Lung Dis 1988;63:47-59.
Romanus V, Fasth A, Tordai P, Wiholm BE. Adverse reactions in healthy and immunocompromised children under six years of age vaccinated with the Danish BCG vaccine, strain Copenhagen 1331: Implications for the vaccination policy in Sweden. Acta Paediatr 1993;82:1043-52.
Frimodt-Moller J. Observations on the protective effect of BCG in a South Indian rural population. Bull Int Union TB 1978;48:40-9.
Sergent E, Catanei A, Ducros H. Anti-tuberculous protection by the BCG. Controlled campaign pursued at Alger since 1935. Arch Inst Pasteur Algér 1960;38:131-7.
Bugiani M, Arossa W, Cavellero M, Caria E, Carosso A, Piccioni P. Tuberculin Reactivity in BCG-Vaccinated Subjects. 30th
IUATLD World Conference on Lung Health. Madrid; 1999.
Comstock GW. The international tuberculosis campaign: A pioneering venture in mass vaccination and research. Clin Infect Dis 1994;19:528-40.
Larsson LO, Magnusson M, Skoogh BE, Lind A. Sensitivity to sensitins and tuberculin in Swedish children. IV. The influence of BCG-vaccination. Eur Respir J 1992;5:584-6.
Wade H. BCG-induced activations. Int J Leprosy 1960;28:179-81.
Muliyil J, Nelson KE, Diamond EL. Effect of BCG on the risk of leprosy in an endemic area: A case control study. Int J Lepr Other Mycobact Dis 1991;59:229-36.
Thuc NV, Abel L, Lap VD, Oberti J, Lagrange PH. Protective effect of BCG against leprosy and its subtypes: A case-control study in Southern Vietnam. Int J Lepr Other Mycobact Dis 1994;62:532-8.
Bagshawe A, Scott GC, Russell DA, Wigley SC, Merianos A, Berry G. BCG vaccination in leprosy: Final results of the trial in Karimui, Papua New Guinea, 1963-79. Bull World Health Organ 1989;67:389-99.
Tripathy SP. Fifteen years follow up of the Indian BCG prevention trial. XXVth
World Conference of the International Union against TB, Singapore 1986. Results Presented and Analysed. In: Davies PO, editors. Clinical Tuberculosis. London: Chapman and Hall Medical; 1994.
Majdzadeh SR, Holakoei K, Golkari H, Mohammad K, Tabatabai SJ, Nadim A. Effectiveness of the BCG Vaccination Program in Prevention of Pulmonary Tuberculosis, Tehran Province, Iran, 1996-1997. 30th
IUATLD World Conference on Lung Health. Madrid; 1999. p. 14-8.
Grosset J. Tuberculosis in France. The situation Quotidien; 1994.
Sousa AO, Salem JI, Lee FK, Verçosa MC, Cruaud P, Bloom BR, et al.
An epidemic of tuberculosis with a high rate of tuberculin anergy among a population previously unexposed to tuberculosis, the Yanomami Indians of the Brazilian amazon. Proc Natl Acad Sci U S A 1997;94:13227-32.
Carlos EA, Coimbra CE Jr., Basta PC. The burden of tuberculosis in indigenous peoples in Amazonia, Brazil. Trans R Soc Trop Med Hyg 2007;101:635-6.
Wong GW, Oppenheimer SJ. Childhood TB. In: Davies PO, editors. Clinical Tuberculosis. London: Chapman and Hall Medical; 1994.
Tardieu M, Truffot-Pernot C, Carriere JP, Dupic Y, Landrieu P. Tuberculous meningitis due to BCG in two previously healthy children. Lancet 1988;1:440-1.
Grosset J, Schwoebel V. Active survey of tuberculous meningitis in France in 1990 (in French). Bull Epidémiol Hebd 1991;48:209-10.
Bagghaie N, Masjedi M, Velayati AA. Accuracy of BCG Vaccination in Prevention of Tuberculous Meningitis. 30th
IUATLD World Conference. Madrid; 1999. p. 413.
Miörner H, Ganlöv G, Yohannes Z, Adane Y. Improved sensitivity of direct microscopy for acid-fast bacilli: Sedimentation as an alternative to centrifugation for concentration of tubercle bacilli. J Clin Microbiol 1996;34:3206-7.
Delacourt C, Gobin J, Gaillard JL, de Blic J, Veron M, Scheinmann P. Value of ELISA using antigen 60 for the diagnosis of tuberculosis in children. Chest 1993;104:393-8.
Rota S, Beyazova U, Karsligil T, Cevheroǧlu C. Humoral immune response against antigen 60 in BCG-vaccinated infants. Eur J Epidemiol 1994;10:713-8.
Mshana RN, Closs O, Harboe M. Antibody response in rabbits to Mycobacterium bovis
BCG. Scand J Immunol 1979;9:175-82.
Reggiardo Z, Middlebrook G. Failure of passive serum transfer of immunity against aerogenic tuberculosis in rabbits. Proc Soc Exp Biol Med 1974;145:173-5.
Maes R. Tuberculosis serology is useful in rural areas. Biomed Biotech Res J 2017;1:85-93.
Maes R. Failing the public health: the ban of tuberculosis serology and the WHO. Biomed Biotech Res J 2018;2:87-93.
Cocito C, Vanlinden F. Preparation and properties of antigen 60 from Mycobacterium bovis
BCG. Clin Exp Immunol 1986;66:262-72.
Stanford JL, Stanford CA, Rook GA, Grange JM. Immunotherapy for tuberculosis. investigative and practical aspects. Clin Immunother 1994;1:430-40.
Onyebujoh PC, Abdulmumini T, Robinson S, Rook GA, Stanford JL. Immunotherapy with Mycobacterium vaccae
as an addition to chemotherapy for the treatment of pulmonary tuberculosis under difficult conditions in Africa. Respir Med 1995;89:199-207.
Immunotherapy with Mycobacterium vaccae
in patients with newly diagnosed pulmonary tuberculosis: A randomised controlled trial. Durban immunotherapy trial group. Lancet 1999;354:116-9.
Johnson JL, Kamya RM, Okwera A, Loughlin AM, Nyole S, Hom DL, et al.
Randomized controlled trial of Mycobacterium vaccae
immunotherapy in non-human immunodeficiency virus-infected Ugandan adults with newly diagnosed pulmonary tuberculosis. The Uganda-case Western reserve University research collaboration. J Infect Dis 2000;181:1304-12.
Mwinga A, Nunn A, Ngwira B, Chintu C, Warndorff D, Fine P, et al. Mycobacterium vaccae
(SRL172) immunotherapy as an adjunct to standard antituberculosis treatment in HIV-infected adults with pulmonary tuberculosis: A randomised placebo-controlled trial. Lancet 2002;360:1050-5.
Shui-Hua L. Immunotherapy with Mycobacterium vaccae
Vaccine to Multidrug-Resistant Pulmonary Tuberculosis. Madrid Spain: Abstract Book 30th
IUATLD World Conference on Lung Health; 1999. p. 14-8.
Rennou M, Maes MC, Maes HH, Maes RF, Khalilzadeh S, Tasbiti A, et al
. Immune reactivity of Mycobacterium bovis
(Strain BCG) and Mycobacterium vaccae
. Tanaffos 2004;3:7-18.
Newbould BB. Chemotherapy of arthritis induced in rats by mycobacterial adjuvant. Br J Pharmacol Chemother 1963;21:127-36.
Maes RF, Claverie N. The effect of preparations of human chorionic gonadotropin on lymphocyte stimulation and immune response. Immunology 1977;33:351-60.
Schoedon G, Schneemann M, Walter R, Blau N, Hofer S, Schaffner A. Nitric oxide and infection: Another view. Clin Infect Dis 1995;21 Suppl 2:S152-7.
De Groote MA, Fang FC. NO inhibitions: Antimicrobial properties of nitric oxide. Clin Infect Dis 1995;21 Suppl 2:S162-5.
Souza WM, Brehmer F, Nakao LS, Stinghen AE, Santos CM. Action of uleine on the production of nitric oxide in cells RAEC and B16F10. Rev Bras Farmacogn 2007;17:191-6.
Federlin JD, Maes D, Maes R. Aspidosperma subincanum
I. Characterisation, extraction of an uleine-enriched fraction and potential health hazard due to the contaminant ellipticine. Rev Bras Farmacogn 2014;24:293-7.
Maes D, Maes R. Aspidosperma subincanum
II. Usefulness of uleine and ribonucleic fragments in the treatment of AIDS patients. Rev Bras Farmacogn 2015;25:42-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]