Thesis (PhD) -- Stellenbosch University, 2002. / ENGLISH ABSTRACT: Children and adults may differ in their immune function. An adequate function of the individual's immune system is crucial to the risk for development of tuberculosis (TB) after infection with Mycobacterium tuberculosis (Mtb). Epidemiological evidence suggests an age-related incidence of TB. Furthermore, the prevailing clinical expression t ' of TB varies between age groups. -The aims of this study were to characterise the cellular immune response at different ages in TB patients and healthy individuals living in a region highly endemic for TB and to relate the findings to the clinical expression of TB in different age groups. A total of 150 persons of different ages were included in this study: 50 TB patients, (identified on the basis of clinical, radiological and microbiological characteristics), 49 healthy Mantoux positive (~15mm) and 51 healthy Mantoux negative (<15mm) subjects. All patients <12yrs were identified as having primary TB and postprimary TB was only diagnosed in patients ~12yrs. Haematologic indices were obtained from all the included subjects and found to be agerelated. With the exception of the absolute lymphocyte counts, all indices were significantly different in TB patients when compared to healthy controls. Whole blood was cultured and stimulated with PHA, PPD and ESAT -6 to measure lymphocyte proliferation and IFN-y, TNF-a, IL-2 and IL-10 production in the supernatants of the cultures. After stimulation with PHA, the production of IFN-y, TNF-a and IL-10 as well as lymphocyte proliferation were all age-related. After stimulation with PPD, age correlated positively with IFN-y production in healthy Mantoux positive subjects< 12yrs. In the age groups <20 yrs, patients produced similar amounts of IFN-y when compared to healthy age-related Mantoux positive controls. TNF-a and IL-2 production were not different between patients and controls. In this whole blood system, measuring any of these cytokines on their own did not differentiate patients from controls at all ages. The ratio of PPD stimulated IFN-y to TNF-a production was significantly less in patients with primary TB and postprimary TB when compared to Mantoux positive controls, irrespective of age. These findings indicate that calculated ratios between several cytokines may be useful markers of disease at all ages. ESA T -6 stimulated IFN -y production did not result in any significant correlation with age, but was significantly less in healthy Mantoux positive subjects ~12 yrs when compared to healthy Mantoux positive subjects <12 yrs and TB patients of all ages. This finding suggests that a positive immune response to ESAT -6 is indicative of recent immunological contact with Mtb. Total IgE was measured in serum. In children <12 yrs these values correlated with age and were highest in healthy Mantoux positive controls, thereby not confirming any inverse correlation between IgE and TB. Age should be recognised as a significant variable in quantitative measurements of cellular immune responses. / AFRIKAANSE OPSOMMING: Die immuunsisteem van kinders en volwassenes kan verskillend wees. Die mate van immuniteit van 'n individu is deurslaggewend vir die risiko om tuberkulose (TB) na infeksie met die Mycobacterium tuberculosis (M tb) te ontwikkel. Epidemiologiese bevindings suggereer dat die insidensie van TB ouderdomgebonde mag wees. V erder verskil die voorkomende kliniese beeld van TB ook tussen ouderdomsgroepe. Die doelstellings van hierdie studie was om die sellulere immuunrespons op verskillende ouderdomme by TB-pasiente en gesonde individue wat in 'n streek met hoogs endemiese TB-insidensie woon te vergelyk. Die doel was ook om vas te stel hoe hierdie bevindings by die kliniese beeld van TB by verskillende ouderdomsgroepe inpas. Daar is l50 persone van verskillende ouderdomme in hierdie studie ingesluit: 50 TBpasiente (geidentifiseer op grond van kliniese, radiologiese en mikrobiologiese karakteristieke), 49 gesonde Mantoux -positiewe (:2':l5mm) en 5l gesonde Mantouxnegatiewe (<l5mm) persone. Alle pasiente <l2 jaar is gediagnoseer met primere TB. Postprimere TB is alleenlik gediagnoseer in pasiente :2':l2 jaar. Daar is aangetoon dat. hematologiese indekse van al die persone in hierdie studie ouderdomsverwant was. Daar was n beduidende verskil in alle indekse van TB-pasiente in vergelyking met die gesonde kontroles met die uitsondering van die absolute limfosiettellings. Kulture van volbloed is gedoen en gestimuleer met behulp van PHA, PPD en ESAT -6 om limfosiet-proliferasie, IFN-y-, TNF-a-, IL-2- en IL-l0-produksie in die supematante van die kulture te meet. Na stimulasie met PHA was die produksie van IFN-y, TNF-a en IL-l0, asook die limfosiet-proliferasie ouderdomsverwant Na stimulasie met PPD het ouderdom positief gekorreleer met IFN-y produksie in gesonde Mantoux-positiewe persone <l2 jaar. In die ouderdomsgroep <20 jaar het pasiente dieselfde hoeveelhede IFN-y geproduseer as gesonde, ouderdomsverwante Mantoux-positiewe kontroles. Daar was geen verskil tussen die produksie van TNF -a. en IL-2 tussen pasiente en kontroles nie. In hierdie volbloed-sisteem het die meet van nie een van hierdie sitokiene op sigself 'n verskil getoon tussen pasiente en kontroles van aile ouderdomme nie. Die verhouding van PPD-gestimuleerde IFN-y- tot TNF-a.-produksie was betekenisvol minder in pasiente met primere TB en postprimere TB in vergelyking met Mantouxpositiewe kontroles, ongeag ouderdom. Hierdie bevindings toon dat berekende verhoudings tussen verskillende sitokiene waardevoile merkers van 'n siektetoestand {TB) by aile ouderdomme kan wees. ESAT-6 gestimuleerde IFN-y-produksie het geen betekenisvoile korrelasie met ouderdom getoon nie. Daar was egter betekenisvol minder produksie in gesonde Mantoux-positiewe persone ~l2 jaar as in gesonde Mantoux-positiewe persone <l2 jaar, asook in vergelyking met TB-pasiente van aile ouderdomme. Hierdie bevinding kan daarop dui dat 'n positiewe immuun respons op ESAT -6 'n aanduiding van onlangse immunologiese kontak met M tb is. Totale IgE was in serum bepaal. In kinders <l2 jaar het hierdie waardes gekorreleer met ouderdomme en die waardes was die hoogste in gesonde Mantoux-positiewe kontroles. Hierdeur is daar nie bevestig dat daar 'n omgekeerde korrelasie tussen IgE en TB is nie. Ouderdom behoort dus as 'n belangrike veranderlike gesien te word in die kwantitatiewe meting van die sellulere immuunrespons.

Thesis (MScMedSc) -- Stellenbosch University, 1998. / Bibliography / ENGLISH ABSTRACT: There is a progressive maturation of the immune system from infancy to adulthood. The immature immune system in early life is characterised by impaired macrophage function and antigen presentation as well as a higher naIve to memory T cell ratio with subsequent diminished IFN-y production. Children with tuberculosis often present with lymphadenopathy, the complications thereof or with systemic spread of the organisms. Adults generally manifest with pronounced systemic effects (such as weight loss and high fever) and immunopathology (such as cavitation and fibrosis). We hypothesised that the immunopathology in adults may be due to enhanced cytokine production in comparison to children. The first aim of this study was therefore to measure cytokine responses in healthy children and adults. Cytokine responses in patients with tuberculosis will be examined in future studies. Peripheral blood mononuclear cells (PBMC) were isolated from whole blood obtained from 9 healthy children and 9 healthy adults. The cells were cultured in serum-free medium, unstimulated or polyclonally stimulated with Phytohaemagglutinin (PHA). Supernatants were harvested after which IFN-y, IL-2, TNF-a., IL-4 and IL-IO production was determined by means of ELISA analysis. Ri'J"A was ~ubsequently extracted from the cells followed by RT-PCR analysis for the semiquantitative determination of mRNA levels of these cytokines. PBMC isolated from healthy children produced significantly less IFN-y protein than adults. Futhermore, IFN-y production in the adults seemed to be trimodally distributed. No significant differences could be found in the production of IL-2, TNF-a, IL-4 and IL-] O. Although children produced low levels of IFN-y protein, their IFN-y, TNF-a, IL-2, IL-4 and IL-IO mRNA levels were comparable to that of adults. Tuberculosis is a major cause of mortality and morbidity, particularly in the third world. Ravensmead and Uitsig, two adjacent suburbs in the Western Cape, have a tuberculosis incidence of> I 000/100000 population. Also, up to 90 % of the children in the Western Cape have been reported to be infested by intestinal parasites such as Ascaris lumbricoides and Trichurius trichl/ria. Infection with M tuberculosis indut:es a Th 1 Stellenbosch University http://scholar.sun.ac.za iv In:.,c response, while intestinal parasites elicit a Th2 immune response. Th2 dominance induced by intestinal parasite infestations could predispose individuals to an enhanced susceptibility to M. tuberculosis. The second aim of this study was to investigate serum IgE levels, surrogate markers for Th2 activation, in the community. The serum 19B levels were subsequently correlated to the tuberculosis incidence per enumerator sub-district (ESD), crowding, female literacy and socio-economic levels. Similarly, the tuberculosis incidence per ESD was correlated with the above mentioned parameters. A significant positive correlation was found between tuberculosis incidence and the serum 19E levels in the community. However, further studies are needed to determine if intestinal parasites are the main cause of the high 19B levels in the community and to dCh111ine if parasite loads or Th2 dominance are causally linked to the incidence of tuberculosis. Correlation between serum 19E levels and tuberculosis incidence with the other parameters were significant, except in the case of crowding. The third aim of this study was to measure serum IgE and specific 19E levels against Ascaris and common allergens on presentation of tuberculosis and again after completion of successful treatment. Significant declines in serum 19B and Ascaris specific 19B levels were observed after completion of tuberculosis treatment. This down regulation of IgE levels may be due to an up regulation of ThI responses in patients following successful treatment for tuberculosis. / AFRIKAANSE OPSOMMING: Die immuunsisteem matureer toenemend vanaf kinderjare tot en met volwassewording. Die onvolwasse immuunsisteem van jong kinders word gekenmerk deur verswakte makrofaag-funksionering en antigeenpresentering, sowe) as 'n verhoogde naiwe tot geheue T-sel verhouding met gevolglikc verminderde IFN-y produksie. Kinders met tuberkulose presenteer gewoonlik met Iimfadenopatie, komplikasies daarvan of met gedissemineerde siekte. Volwassenes presenteer met sistemiese gevolge (soos gewigsverlies en hoe koors) en immunopatologie (soos kavitasie en fibrose). Ons hipotese is dat die immunopatologie in volwassenes die gevolg is van 'n verhoogde sitokienproduksie in vergelyking met kinders. Die eerste doelwit van die studie was om sitokienproduksie in gesonde kinders en volwassenes te meet. Sitokienproduksie in tuberkulose pasiente sal in 'n opvolgstudie bepaal word. Perifere bloed mononukleere selle was geisoleer vanuit heel bloed verkry vanaf 9 gesonde kinders en 9 gesonde volwassenes. Die selle was gekweek, ongestimuleer of gestimuleer met Phytohaemagglutinien (PHA). Supernatante was geoes vir die bepaling van IFN-y, IL-2, IL-4, IL-I0 en TNF-a. produksie, deur gebruik te maak van ELISA analise. RNA was gevolglik vanaf die selle ge-ekstraheer vir die tru-transkriptase polimeerketting reaksie analise, waartydens sitokien mRNA vlakke op 'n semi-kwantitatiewe wyse bepaal was. Perifere bloed mononukleere selle geisoleer vanaf die kinders het minder IFN-y geproduseer as die van volwassenes. Hierdie verminderde produksie was hoogs betekenisvol. Dit wou voorkom asof die IFN-y produksie deur volwassenes trimodaal versprei was. Geen betekenisvolle verskille tussen kinders en volwassenes kon gevind word in die produksie van IL-2, IL-4, IL-IO en TNF-a nie. Alhoewel kinders minder IFN-y proteien geproduseer het, het hulle IFN-y, IL-2, IL-4, IL-JO en TNF-a mRNA produksie met vlakke van volwassenes ooreengestem. Tuberkulose speel 'n groat rol in morbiditeit en mortaliteit in veral die derde wereld. Ravensmead en Uitsig, twee aangrensende voorstede in die Wes-Kaap, het 'n tuberkulose voorkomssyfer van> 1 000/1 00000 populasie. Verder, is tot 90 % van die kinders in die Stellenbosch University http://scholar.sun.ac.za VI Wes-Kaap gei'nfesteer met intestinale parasiete soos Ascaris Ilimbricoides en Trichllrills trichllria. M. tuberculosis infeksie induseer 'n Thl immuunrespons, terwyl intestinale parasiete 'n Th2 immuunrespons uitlok. 'n Dominante Th2 respons mag moontlik individue predisponeer tot 'n verhoogde vatbaarheid vir M. tuberculosis. Gevolglik was die tweede doelwit van die studie om serum IgE vlakke as surrogaat merkers vir Th2 aktivering in die gemeenskap bestudeer. Die serum IgE vlakke was gevolglik gekorreleer met die tuberkulose voorkoms per opnemerssensusgebied (OSG), saamdringing, vroulike geletterdheid en sosio-ekonomiese vlakke. Die tuberkulose voorkoms per OSG, is op dieselfde wyse gekorreleer met die bogenoemde parameters. 'n Betekenisvolle positiewe korrelasie is gevind tussen tuberkulose voorkoms en serum IgE vlakke in die gemeenskap. Verdere stuciies is egter nodig om te bepaal of intestinale parasiete weI die oorsaak van die hoe IgE vlakke in die gemeenskap is en of parasiet ladings of Th2 dominansie oorsaaklik verbind kan word aan die tuberkulose voorkoms. Die derde doelwit van die studie was om serum 19E en spesifieke IgE vlakke teen Ascaris en algemene allergene te meet met presentering van tuberkulose en weer na voltooing van suksesvolle behandeling. 'n Betekenisvolle afname in serum 19E en Ascaris spesifieke 19E vlakke is waargeneem na vohooing van tuberkulose behandeling. Die afregulering van 19E vlakke kan moontlik toegeskryf word aan die opregulering van Th1 response in pasi"ente na voltooing van suksesvolle behandeling van tuberkulose.

Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: The immune response against M. tuberculosis is multifactorial, involving a network of innate and adaptive immune responses. Characterization of the immune response, a clear understanding of the dynamics and interplay of different arms of the immune response and the identification of infection-stage specific biomarkers are critical to allow the development of better tools for combating tuberculosis. In an attempt to identify such biomarkers, we studied pulmonary tuberculosis patients and their contacts in Addis Ababa, Ethiopia as part of EDCTP and BMGF funded tuberculosis projects by using multiplex techniques. We analysed 45 genes using the Multiplex Ligation Dependent Probe Amplification (MLPA) technique and the expression of IL-4δ2, BLR1, MARCO, CCL-19, IL7R, Bcl2, FcyR1A, MMP9, and LTF genes discriminate TB cases from their healthy contacts. FoxP3, TGFß1 and CCL-19 discriminate latently infected from uninfected contacts. Single genes predict with an area under the Receiver Operating Characteristic (ROC) curve of 0.68 to 0.85 while a combination of genes identified up to 95% of the different groups. Similarly, the multiplex analysis of cytokines and chemokines also showed that single or combinations of plasma cytokines and chemokines discriminate between different clinical groups accurately. The median plasma level of EGF, fractalkine, IFN-y, IL-4, MCP-3 and IP-10 is significantly different (p<0.05) in active tuberculosis and non active tuberculosis infection and the median plasma levels of IFN-y, IL-4, MCP-3, MIP-1ß and IP-10 were significantly different (p<0.05) before and after treatment. We also found a significant difference (p<0.05) in plasma levels of cytokines of patients infected with the different lineages and different families of the modern lineage. The plasma level of IL-4 was significantly higher in patients infected with lineage 3 (p<0.05) as compared to lineage 4 and the CAS familyinfected patients had a higher plasma level of IL-4 (P<0.05) as compared to patients infected with H and T families but there was no difference between H and T families. We identified genes and cytokines which had been reported from other studies in different settings and we believe that these molecules are very promising biomarkers for classifying active tuberculosis, latent infection, absence of infection and treated infection. These markers may be suitable for the development of clinically useful tools but require further validation and qualification in different populations and in larger studies. / AFRIKAANSE OPSOMMING: Die immuunrespons teen M. tuberculosis is multifaktoriaal en betrek ‘n netwerk van niespesifieke and spesifieke immuunresponse. Karakterisering van die immuunrespons, ‘n duidelike insig in die dinamika en tussenspel deur die verskillende arms van die immuunrespons en die identifikasie van spesifieke biomerkers is krities belangrik om die ontwikkeling van nuwe hulpmiddels teen tuberkulose te bevorder. In ‘n poging om sulke biomerkers te identifiseer het ons pulmonale tuberkulose pasiënte en hulle kontakte in Addis Ababa, Etiopië, as deel van die EDCTP en BMGF befondste tuberkulose projekte bestudeer met multipleks tegnieke. Ons het 45 gene analiseer met ‘Multiplex Ligation Dependent Probe Amplification (MLPA)’ en gevind dat die geenuitdrukking van IL-4•2, BLR1, MARCO, CCL-19, IL7R, Bcl2, Fc•R1A, MMP9, en LTF TB pasiënte van hulle kontakte onderskei. FoxP3, TGF•1 en CCL-19 onderskei tussen latent infekteerde en ongeïnfekteerde kontakte. Enkele gene voorspel met ‘n area onder die ‘Receiver Operating Characteristic (ROC)’ kurwe van 0.68 tot 0.85 terwyl die kombinasie van gene 95% van die verskillende groepe identifiseer. Soortgelyk het multipleks analise van sitokiene en chemokiene verskillende kliniese groepe akkuraat van mekaar onderskei. Die mediane plasmavlakke van EGF, fractalkine, IFN-•, IL-4, MCP-3 en IP-10 is beduidend verskillend (p<0.05) in aktiewe tuberkulose en nie-aktiewe tuberkulose infeksie en die mediane plasmavlak van IFN-•, IL-4, MCP-3, MIP-1• en IP-10 was beduidend verskillend voor en na behandeling. Ons het ook beduidende verskille (p<0.05) in plasmavlakke van sitokiene in pasiënte gevind wat infekteer is met verskillende stamme and verskillende families van die moderne stamme. Die plasmavlak van IL-4 was beduidend hoër in pasiënte wat infekteer is met stam 3 (p<0.05) teenoor stam 4 en die CAS familie-infekteerde pasiënte het ‘n hoër plasmavlak van IL-4 (p<0.05) teenoor pasiënte met H en T familie infeksie hoewel daar geen versikke was tussen die H en T families nie. Ons het gene en sitokiene identifiseer wat deur ander werkers onder verskillende omstandighede ook beskryf is en ons glo dat hierdie molekules baie belowende biomerkers is om aktiewe tuberkulose, latent tuberkulose, die afwesigheid van infeksie en behandelde infeksie van mekaar te onderskei. Hierdie merkers mag toepaslik wees vir die ontwikkeling van bruikbare kliniese hulpmiddele maar benodig verdere validasie en kwalifikasie in verskillende populasiegroepe en in groter studies. / Bill and Melinda Gates Foundation (BMGF) / European and Developing Countries Clinical Trials Partnership (EDCTP) / African European Tuberculosis Consortium (AE TBC).