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Clinical Study of a Patient with Lupus Vulgaris Before and After Injection of Dialyzable Transfer Factor

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Clinical Study of a Patient with Lupus Vulgaris Before and After Injection of Dialyzable Transfer Factor THEJOUilNAL ot' I NI'I::STIGAri\E 0ERMATOLOGL 68:10- 15. 197i Vol. 68. No. I Copyright © 19ii by Th£> Williams & Wilkins Co. Printed in U.S.A . CLINICAL STUDY OF A PATIENT WITH LUPUS VULGARIS BEFORE AND AFTER INJECTION OF DIALYZABLE TRANSFER FACTOR MAIJA H ORSMANHEIMO. M .D .. KAt KROHN. \1.D., AND MARTII YIROLAINEN, M.D. Department of Dermatology, University Central Hospital. Helsinki; Third Department of Pathology, University of Helsinki: Department of Biomedical S ciences. S chool of Medicine. University of Tampere, Finland: and Department of Basic and Clinical Im munology and Microbiology, Medical University of South Carolina, Charleston, South Carolina. U. '. A. This report describes the clinical improvement and acquisition of tuberculin skin-test sensitivity by a tuberculin-negative, drug-resistant patient with lupus vulgaris after a single injection of dialyzable transfer factor (TFd) from a tuberculin-positive healthy donor. The patient's lymphocytes showed a slight response to tuberculin in the leukocyte migration inhibition test and in the lymphocyte transformation test before T Fd injection. T he acquisition of cellular immunity to tuberculin was demonstrated in vitro by enhanced tuberculin-induced blast t ransformation. A good correlation between skin test and in vitro tuberculin sensitivity and clinical improvement was seen during the three years that the patient was observed. Delayed hypersensitivity skin reactions to vari­ lupus vulgaris following a single inject ion of TFd ous fungal, bacterial, and viral antigens can be from a healthy tuberculin-positive subject obtained in previously nonreacting individuals after injection of dialyzable extracts of leukocytes C'ASE HI. TORY from positively reacting donors (reviewed in [1 )) . The patient, a white male. first developed facial skin This has been thought to represent positive .. trans­ lesions at age .n. histologically diagnosed as lupus fer .. of specific delayed hypersensitivity by a spe­ vulgaris at age 48. Pulmonary tuberculosis was diagnosed cial substance termed dialyzable transfer fa ctor by chest x-ray findings also at age 48. The patient was (TFd) [1]. Thus. injections ofTFd have been given con~istently on antituberculosis treatment. On the basis to patients with immunodeficiencies, chronic in­ of the clinical diagnosis. before the diagnosis was histo­ logically confirmed. he receil'ed Isoniazid from age 45 for fections. autoimmune diseases. and neoplasia [1 ]. 2.5 years, then Isoniazid and Ethionamid for 2.5 years; In t his paper we describe the clinical course of a subsequently the treatment was changed to a combina­ patient with drug-resistant, tuberculin-negative tion of Capreomycin. Rifampicin. and Ethambutol. This treatment lasted for I year and was continued during this Manuscript received March 18. 1976: accepted for study. No clinical improvement was observed during any publication August 11, 1976. of the above treatments. Publication No. 60 from the Department of Basic and The patient was first seen at age 51 at the Department Clinical Immunology and Microbiology. Medical Univer­ of Dermatology. University Central Hospital. Helsinki, in sitY of South Carolina. October 1971. On admission, an extensive skin lesion was This work was done under a contract with ihe Associa­ seen in the fa ce. and the nose was almost totally tion of Finnish Life Insurance Companies. Financial destroyed (Fig.). Skin biopsy revealed morphologic support was also provided by the Finnish Anti-Tuber­ culosis Association and by USPHS Gran ts HD 09938 and changes consistent with active lupus vulgaris. A destruc­ AI 13484 . tive sinuitis was observed in both maxillae. and the A preliminary report of this work was presented at the diagnosis of tuberculosis was histologically confirmed by Third Meeting of the European ociety for Dermatologi­ biop~y. The right index finger was greatly thickened, and cal Research. Amsterdam. 1973. the diagnosis of tuberculous osteitis was confirmed on the Reprint requests to: Dr. M. Horsmanheimo, Depart­ basis of x-ray findings. ment of Basic and Clinical Immunology and Microbiol ­ ogy. Medical University of South Carolina. Charleston, MATERIALS A:'\0 METHODS South Carolina 29401 . Abbreviations: Skin tests. Skin tests performed by intradermal injec­ E-RFC: E-rosette-forming cells tion of 0.1 ml of each test antigen a nd saline control were MGG: May-Gruenwald-Giemsa (staining) read at 24 and 48 br after injection. Tbe antigens used Ml: migration index were purified protein derivative of tuberculin (PPD, PHA: phytohemagglutinin Statens Seruminstitut, Copenhagen). Candida albicans PPD: purified protein derivative of tuberculin antigen (Dermatophytin "0", HolHster-Stier Laborato­ SRC: sheep red cells ries, U.S.A.). Kveim preparation Lot 131 (Finnish Kveim TF: transfer factor TFd: dialyzable transfer factor material), and lepromin antigen. TU: tuberculin unit Preparation of TFd. TFd was prepared from a single VCA: virus capsid antigens healthy donor who had a strong positive ski n test to 0.1 WBC: white blood cells TV of PPD. Heparinized blood (450 ml) was collected 10 Jan. 1977 TRANSFER FACTOR lN A CASE OF LUPUS VULCARIS 11 FIG. Facial views before (left) and 13 months after (right) a single dose of t ransfer factor. into a Fenwal bag, and the leukocytes were separated of blasts, at least 100 blasts were scored or the blasts were from red cells by sedimentation for 60 min at 37° C after counted on an a rea calculated to correspond to at least addition of an equal volume of 6% dextran (Macrodex. 2000 lymphocytes. Percentages of blasts in PPD­ Leiras Pharamaceutical Co., Turku, Finland). The stimulated duplicate cultures did not differ by more than supernatant (containing leukocytes) was centrifuged at 5 vt, . and those in PHA-stimulated duplicate cultures by 1000 rpm for 20 min. The leukocytes were washed twice not more than 7o/r . The percentages o f blasts are given as with PB , counted, and dissolved in 2 ml of pyrogen-free means of the percentages of duplicate cultures. ln the water. Cell lys is was achieved by freezing and thawing 10 presentation of the data for PHA· and PPD-induced times. and the lysate was dialyzed against 200 ml of water lymphocyte transformation, the percentages of blasts in for 24 hr. The dialysate was concentrated by lyophiliza. control cultures without any stimulants have been sub­ tion. dissolved in 20 ml of PB . and sterilized with tracted. Millipore filtration (pore sizes 0.22 .urn). In the final Leukocyte migration inh1bition test. The leukocyte preparation I ml of TFd represented 0.9 >< JO" mononu· mi!!fation inhibition test [6 ] was used. Ten to 20 ml of clear cells. hepa rinized blood (50 IU/ ml) was mixed with equal Ly mphocyte cultures. The methods used a re described volumes of 6c:( dextran (Macrodex. Leiras Pharmaceuti­ elsewhere [2]. After sedimentation of venous blood. the cal Co., Turku. Finland) and kept at 37°C for 45 to 60 white blood cells (WBC'l were collected and washed. and min. The leukocyte-rich supernatant was collected, and the cell density was adjusted to 4 x 10' WBC per mi. the cells were washed twice with MEM and counted. Cell Cultures of 2.5 ml were set up in 35-mm plastic Petri concentration was adjusted to 10" cells per ml of MEM dishes with 80 'Y medium RPMI 1640 and 20"k the with 10% newborn calf serum (Orion Pharmaceutical Co .. patient's own plasma. All cultures were set up in dupli· Helsinki. Finland). and the suspension was drawn into cate. Phytohemagglutinin (PHA-P. Difco) was used in a 20-111 capillary tubes. The tubes were sealed with Seale final dilution of I :250. PPD was used in a concentra tion Ease (Clay-Adams lnc., ew York. .Y.) and cen­ of 10 .ug per mi. trifuged at 1000 rpm for 10 min. and then cut at the PHA-induced res ponse was measured on the third day cell- liquid interface and placed into the chambers. ter­ and PPD· induced response on the s ixth day, which in our ile. disposable leukocyte migration plates (Sterile-Limit­ previous studies [2.3] were found to be the days of ed. Richmond. Surrey) were used. PPD at concentrations maximum responsiveness of lymphocytes to these stimu­ of 25 .ug per ml were used. Controls were without PPD. lants. In our experience, the percentage of blasts relative Migration was recorded with a photographic e nlarger to lymphocytes is a m ore reliable method for measuring after 18 hr at 37°C. and the migration index (MI) was low blast responses than the amount of ["H TfdR incorpo­ calculated using the formula: ration into D A determined by liquid scintillation counting [3- 5 ]. T herefore, the results for PPD- and PHA­ MI " (meanarea of migrationwithantigen) x 100 stimulated cultures in the present study are given as the mean area of migration without antigen percentage of blasts. Cell preparations for May-Gruen­ wald- Giemsa (MGGl staining were made with a han­ "Rosette" formation (enumeration of T-cells). To don cytocentrifu!{e. For determination of the percentage determine the relative numbers of lymphocytes bearing 12 HORSMANHEIMO, KROHN, AND VIROLAINEN Vol. 68, N o. I receptors for sheep red cells (SRC) (E-rosettes), the At the site of the combined injection of TFd and method of Jondal et a.l f7 ), slightly modified, was used 100 TU of PPD, there was a redness and induration [8 ]. In addition to the lymphocyte purification method, 10 mm in diameter at 24 hr and 2 mm in diameter the main modification was counting of the E-rosettes in a at 48 hr. Systemic sensitivity to tuberculin was hemocytometer after incubation overnight in t he cold. observed in the leg at 24 hr as a redness and RESULTS induration of 10 mm in diameter in response to 100 Immunologic Findings before Injection of TFd TU of PPD; after 48 hr this reaction was 25 mm in diameter, and after 72 hr only redness was ob­ Before the TFd injection the patient's skin served.
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