Genitourin Med: first published as 10.1136/sti.62.6.396 on 1 December 1986. Downloaded from
Genitourin Med 1986;62:396-8
Reduction of cell mediated immunity in patients with genital warts of long duration
G AVGERINOU, S GEORGALA, A THEODORIDIS, A VARELTZDIS, AND J STRATIGOS From the Department ofDermatology, A Sygros Hospital, University ofAthens, Athens, Greece
SUMMLARY Cell mediated immunity was studied by a leucocyte migration inhibition assay and by tuberculin and dinitrochlorobenzene skin tests in 30 patients with recurrent genital warts and in 34 healthy people (with no history of genital warts) who served as controls. Migration inhibition was significantly less in patients suffering from recurrences for more than one year than in controls (p < 0.001). Dinitrochlorobenzene and tuberculin sensitivity were also found to be impaired in those with infection of long duration (p < 0 001).
Introduction Patients, materials, and methods Infection with genital warts is a common condition. We investigated 30 patients (17 men and 13 women) Serological and epidemiological studies have shown aged 17 to 60 (mean 30) years. All patients had a copyright. that human papillomavirus (HPV) is responsible for history ofgenital warts ofvariable duraton. No patient genital wart infections.'2 Competence ofcell mediated suffered from any disease, such as the acquired immunity in patients with warts has been assessed by immune deficiency syndrome (AIDS) or lymphoma, measuring in vitro response to phytohaemagglutinin or was taking drugs, such as chemotherapeutic agents, and purified protein derivative of tuberculin. Patients that could be responsible for the reduction of cellular with genital warts were found to be less responsive immunity. Fourteen patients (group 1) gave a history than a control group, and this deficiency was related to ofhaving had warts for less than one year, 10 (group 2)
the duration of genital wart infection.3 The suggestion had had warts for one to three years, and six (group 3) http://sti.bmj.com/ has been made that cell mediated immune responses for more than three years. play a part in achieving successful resolution ofgenital The control group consisted of 34 healthy people wart virus infection.3-5 Ifthat is so, then possession ofa (23 men and 11 women) aged 24 to 60 (mean 30) competent cell mediated immune system would be a years, mainly from the hospital staff. prerequisite forthe successful resolution ofgenital warts in a patients.&8 As regression or resolution of genital LEUCOCYTE MIGRATION INHIBITION TEST
warts may be protracted in some patients, they may The leucocyte migration inhibition test was used as an on September 24, 2021 by guest. Protected have a different specific or non-specific cell mediated in vitro measure of cell mediated immunity. The test immune function from that of the general popula- was carried out according to the method described by tion.3-5 Bendixen and Soborg,9 as modified by Federlin et al. 0 We undertook the present study to test this Phytohaemagglutinin was used as an antigen at a possibility by comparing the cell mediated immune concentration of0-025 g/l ofculture medium. The area responses in patients with genital warts of varying of migration was assessed by projecting the culture duration with those of a control group. Three tests of chambers and then their contents on a screen (piece of such responses were studied; phytohaemagglutinin in white paper) and tracing the circumference of the vitro and skin tests with purified protein derivative and "fan" of cells, which was then accurately cut and dinitrochlorobenzene in vivo. weighed. The migration inhibition index was assessed as follows: weight in presence of phytohaemagglutinatinin Address for reprints: Dr A Theodorides, Department ofDermatology, A Sygros Hospital, University of Athens, Athens, Greece weight of migration area in control chambers An index of less than 0-8 was considered to show Accepted for publication 23 December 1985 appreciable migration inhibition. 396 Genitourin Med: first published as 10.1136/sti.62.6.396 on 1 December 1986. Downloaded from
Reduction of cell mediated immunity in patients with genital warts oflong duration 397 PURIFIED PROTEIN DERIVATIVE SKIN TEST TABLE I Results of leucocyte migration inhibition assay The standard solution of purified protein derivative analysed according to duration ofgenital wart infection (PPD RT 23 with 0-005% polysorbate (Tween) 80) from Statents Seruministitut, Copenhagen, was used for this skin test."I 12 We injected intradermally 0 1 ml Duration Mean (SD) IU (equivalent to 0-02 ,ugofPPD), and read the results (years) of No of migration after 48 hours. Patients with induration of less than 5 Group iqfection patients inhibition index mm in diameter were considered to be Mantoux 1 1 14 0-20 (0 06) negative. An induration of between 5 and 12 mm in 2 1-3 10 040(005) diameter was arbitrarily considered to be a weak 3 >3 6 0-60 (0-01) Mantoux positive reaction, whereas larger indurations Controls 34 0-22 (007) were considered to be strongly positive. Migration inhibition index = migration area with phytohaemagglutinin * area in control chambers in leucocyte migration inhibition test. DINITROCHLOROBENZENE SKIN TEST Dinitrochlorobenzene reactivity was assessed using the method described by Catalona et all3 and Strauss less than in group 1. No difference in skin test et al. 14 Doses of50 and 2000 ,ug dinitrochlorobenzene reactivity was found between group 1 patients and in 0 1 ml ofacetone were applied to 3 cm ofthe forearm the controls. and upper arm, respectively. After 14 days patients responding to both test doses were recorded as giving DINITROCHLOROBENZENE SKIN TEST grade 4 responses. Ifa flare occurred at the higher dose Table II shows that significantly (p < 0001) less only, the reaction was recorded as a grade 3 response. reactivity was found in group 2 than in group 1 and that If after 14 days no reaction occurred, an additional the reactivity of group 3 was significantly (p < 001) challenge dose of 50 lag dinitrochlorobenzene was less than that of group 2. No difference was found applied to the other forearm. If a conspicuous reaction between group 1 and the control group. It thus became
was seen it was assessed as grade 2. In the case of a apparent that the dinitrochlorobenzene skin test copyright. negative reaction, a punch biopsy specimen was taken reactivity was reduced with longer durations of and examined histologically for evidence of a delayed recurrent genital wart hypersensitivity reaction. If it was microscopically positive the reaction was considered to be grade 1. If the reaction was negative it was recorded as grade Controls (n=34) 0. 40- Statistical analyses were done using Student's t 20- test. un - . r-f,- --i http://sti.bmj.com/ Group 1 (n=14) Results 40- 20] 77 H The results were recorded for the three groups, accord- ing to the duration of the infection, and for the fourth (control) group. The differences between the groups 9 40]60 Group 2(n=61) were evaluated statistically. la 20] on September 24, 2021 by guest. Protected LEUCOCYTE MIGRATION INHIBITION ASSAY Table I shows that leucocyte migration was signifi- cantly less in patients in group 2 than in group 1 (p
398 G Avgerinou, S Georgala, A Theodoridis, A Vareltzdis, and J Stratigos
TABLE II Results ofdinitrochlorobenzene(DNCB) skin test found to be unimpaired. Thus the effect of the according to duration ofgenital wart infection suppressed delayed hypersensitivity seems to become important after at least one year of infection. These findings indicate that non-specific cell Duration Mean (SD) mediated immune responses are to some extent defec- (years) of No of DNCB DNCB Group infection patients grade grade tive in patients with a long history ofgenital wart infec- tion. We therefore postulate that the lack ofa fully cell 9 4} mediated immune system may well be the reason that 1 14 3 3 35(076) the genital warts of some patients are so difficult to 2 2J eradicate. 2 1-3 10o 7 2 23 (048)
3 >3 6.14 2 1-3(0-53) Controls 34 22 4 3-7 (0 48) References 1. Ogilvie MM. Serological studies with human papova (wart) DNCB grade 4 = reaction to 50,ug and 2000 mg DNCB; grade 3 = virus. J Hyg (Lond) 1970;68:479-82. reaction to higher dose only; grade 2 = reaction to additional challenge 2. Cubie HA. Serological studies in student population prone to of 50 ,ug after no initial reaction; grade 1 = no clinical reaction, but infection with human papilloma virus. J Hyg (Lond) punch biopsy specimen microscopically positive. 1972;70:677-81. 3. Morisson WI. Cell-mediated immune responses in patients with warts. Br J Dermatol 1975;93:553-6. 4. Morisson WL. In vitro assay of cell-mediated immunity to Discussion human wart antigen. Br J Dermatol 1974;90:531-4. 5. Reid TM, Fraser NG, Kemohan IR Generalized warts and Genital warts are defined as non-keratotic fleshy immune deficiency Br J Dermatol 1976;95:559-64. lesions occuring in moist areas of the body at the 6. Korand FC, Dehmel EM, Kahn C, Penn I. Cutaneous complication in immunosuppressed renal homograft recipients. copyright. junction of the squamous epithelium and mucous JAMA 1974;221:419-24. membrane, and should be distinguished from common 7. Perry TL, Harman L. Warts in diseases with immune defects. warts that may also occur in the genital area.'5 There Cutis 1974;13:359-62. are no morphological differences between the virus of 8. Spencer ES, Andersen HK. Clinically evident, non terminal warts infections with herpesviruses and the wart virus in immuno- ordinary skin and that causing genital warts, but suppressed renal allograft recipients. Br Med J 1970;iii:251-4. there are antigenic differences as shown by one way 9. Bendixen G, Soborg M. A leucocyte migration technique for in cross reactivity between genital and skin wart vitro detection of cellular (delayed type) hypersensitivity. Dan antibodies. 16-18 Med Bull 1969;16:1-4. Genital warts are common, and in 10. Federlin K, Maini RN, Russel AS, Dumode DC. A micro- http://sti.bmj.com/ general they method for peripheral leucocyte migration in tuberculin probably develop not because of any significant sensitivity. J Clin Pathol 197 l;24:533-6. immune or other deficiency, but rather as a result of 11. Bentzon JM. Effect of certain infectious diseases on tuberculin exposure to the virus.3-5 There is, however, noticable allergy. Tubercle 1953;34:34-5. variation in the ability of patients to control and eradi- 12. Viac J, Thivolet J, Chardonnet Y. Specific immunity in patients suffering from recurring warts before and after repetitive cate the infection, and some patients have what appear intradermal tests with human papilloma virus. Br J Dermatol to be very resistant warts.57 Observations that patients 1977;97:365-70. with immunodeficiency have an increased incidence of 13. Catalona WJ, Taylor PT, Robson AS, Chretien PB. A method on September 24, 2021 by guest. Protected HPV 6-815 19 show for dinitrochlorobenzene contact sensitization. N Engl J Med infection3 that cell mediated 1972;286:399-401. immunity plays a part in genital wart regression. 14. Strauss GH, Greaves M, Price M, Bridges BA, Half-Smith P, In the study published here cell mediated immunity Velba-Briffa D. Inhibition of delayed hypersensitivity reaction correlated well with the duration of genital wart infec- in skin (DNCB test) by 8 methoxypsoralen photo- tion. From the results of this study, we consider that chemotherapy. Lancet 1980;i:556-9. 15. Felman YM. Condylomata accuminata. Cutis 1984;33: 118- delayed hypersensitivity, expressed both as tuberculin 20. and contact sensitivity, decreases with the duration 16. Almeida JD. Virologic aspects of genital warts. In: Catterall of infection. RD, Nicol CS, eds. Sexually transmitted diseases. London: The result of the migration inhibition assay, which Academic Press, 1976:179-83. 17. Oriel JD. Genital warts: the clinical problems. In: Catterall RD, represents an in vitro correlation of cell mediated Nicol CS, eds. Sexually transmitted diseases. London: immunity, paralleled those of the in vivo tests. Thus Academic Press, 1976:186-192. significantly higher migration indices were found in 18. Oriel JD. Natural history of genital warts. British Journal of patients with infection of long duration than in those Venereal Diseases 197 1;47:1-13. 19. Thivolet J, Cencig MC, Clandy A. Frequence des verrues apres with short duration infection. It is interesting to note transplantation renale. Lyon: Compterendus Seminaire that within the first year delayed hypersensitivity was Fondation Merieux, 1975.