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Immunology and Cell Biology (2000) 78, 349–355

Special Feature
Novel mechanisms in the immunopathogenesis of leprosy nerve
damage: The role of Schwann cells, T cells and Mycobacterium
E R I C S P I E R I N G S , 1 T J I T S K E D E B O E R , 1 L AU R E N C E Z U L I A N E L L O 1 , 2 a n d

Departments of 1Immunohematology and Blood Transfusion and 2Infectious Diseases, Leiden University Medical
Center, Leiden, The Netherlands

Summary The major complication of reversal (or type 1) reactions in leprosy is peripheral nerve damage. The
pathogenesis of nerve damage remains largely unresolved. In situ analyses suggest an important role for type 1
T cells. Mycobacterium leprae is known to have a remarkable tropism for Schwann cells that surround peripheral
axons. Reversal reactions in leprosy are often accompanied by severe and irreversible nerve destruction and are
associated with increased cellular immune reactivity against M. leprae. Thus, a likely immunopathogenic mecha-
nism of Schwann cell and nerve damage in leprosy is that infected Schwann cells process and present antigens of
M. Leprae to antigen-specific, inflammatory type 1 T cells and that these T cells subsequently damage and lyse
infected Schwann cells. Previous studies using rodent CD8+ T cells and Schwann cells have revealed evidence for
the existence of such a mechanism. Recently, a similar role has been suggested for human CD4+ T cells. These cells
may be more important in causing leprosy nerve damage in vivo, given the predilection of M. leprae for Schwann
cells and the dominant role of CD4+ serine esterase+ Th1 cells in leprosy lesions. Antagonism of molecular inter-
actions between M. leprae, Schwann cells and inflammatory T cells may therefore provide a rational strategy to
prevent Schwann cell and nerve damage in leprosy.

Key words: cytotoxicity, histocompatibility antigen class II, human, leprosy, Mycobacterium leprae, pathology,
Schwann cells, T-lymphocyte.

Leprosy of approximately 600 000 new cases annually. It is likely that

transmission continues to occur despite intense and well-
Leprosy is a chronic infectious disease that is caused by the
controlled MDT programs. Consequently, a large number of
intracellular pathogen Mycobacterium leprae. Although
M. leprae infected individuals that present clinical symptoms
leprosy has been found in many parts of the world in the past,
remains at risk of developing nerve damage during the clini-
the disease currently occurs mainly in tropical and subtropi-
cal course of disease, regardless of MDT.6
cal countries. Overall, approximately 2 million individuals
It is well established that host immunity to M. leprae
are disabled as a result of the disease.1 Leprosy is the leading
dictates the clinical outcome of leprosy. More than 99% of
cause of all non-traumatic peripheral neuropathies world-
the population is believed to develop adequate protective
wide.2 It frequently results in severe and irreversible nerve
immunity on infection and does not develop clinically
tissue damage, leading to deformities of hand, feet, face and
detectable symptoms.7,8 The minority of individuals that
eyes and to permanent loss of nerve function. This is the main
develop clinical leprosy can be classified in a five group
reason that leprosy represents a major social stigma. The
spectrum, depending on disease dissemination and the level
introduction of multiple drug therapy (MDT) in 1982 has
of cellular immunity (Fig. 1).9 On one side of the leprosy
caused a major decline in the prevalence of leprosy world-
spectrum are polar lepromatous leprosy patients, who have a
wide:3 the estimated number of leprosy patients declined
high humoral immune response and a low cellular response.
from 12 million in 1985 to less than 2 million in 1995 as a
These patients show an M. leprae-specific cellular non-
result of this.4,5 Despite this drop in prevalence, the number
responsiveness and fail to clear the bacteria. On the other side
of newly detected leprosy cases has remained stable at a level
of the spectrum polar tuberculoid leprosy patients can be
found, who have a low humoral immune response but display
strong acquired cellular immunity and delayed type hyper-
Correspondence: Eric Spierings, Department of Immunohema- sensitivity against M. leprae and typically have low bacterial
tology and Blood Transfusion, Leiden University Medical Center, loads. Most patients, however, are positioned in between
PO Box 9600, 2300 RC Leiden, The Netherlands. these two poles and are classified as borderline leprosy cases.
Email: These cases are further subdivided as borderline leproma-
Received 1 May 2000; accepted 1 May 2000. tous, mid-borderline and borderline tuberculoid leprosy.
350 E Spierings et al.

Figure 2 Myelinating (a) and non-myelinating (b) Schwann

cells and (c) the structure of peripheral nerves.

Figure 1 Schematic representation of the clinical and immuno-

logical spectrum of leprosy. CMI, cell-mediated immunity; ENL,
erythema nodosum leprosum; TT, tuberculoid leprosy; BT,
borderline tuberculoid leprosy; BB, mid-borderline leprosy; BL, may take place in virtually all leprosy patients and that 30%
borderline lepromatous leprosy; LL, lepromatous leprosy. of the nerve fibres need to be destroyed before sensory
impairment becomes detectable.15
A nerve fibre consists of an axon that is almost com-
pletely enveloped in a sheath of Schwann cells. Axons can be
divided into myelinated and unmyelinated axons. Myelinated
Leprosy reactions and nerve damage
peripheral axons have a myelin sheath interposed between the
Superimposed on the leprosy spectrum, leprosy reactions can Schwann cells and the axon (Fig. 2a). This myelin sheath is
occur. Leprosy reactions can occur before treatment,10 but are derived from the Schwann cells. Unmyelinated axons lack a
mainly observed during or after MDT. Leprosy reactions typ- myelin sheath and lie in deep grooves in the surface of the
ically represent acute inflammatory episodes. Two major Schwann cells, with multiple axons enveloped by the same
types of reactions are discriminated: (i) erythema nodosum cell (Fig. 2b). Externally, Schwann cells are covered by a
leprosum (ENL) or type 2 leprosy reactions, which predom- basal lamina, which, in turn, is surrounded by endoneurial
inantly occur in patients on the lepromatous side of the spec- tissue (Fig. 2c). Several Schwann cell/axon units, which are
trum; and (ii) reversal reactions (RR), also designated as type embedded in endoneurium, are surrounded by the relatively
1 leprosy reactions, which occur particularly in patients with impermeable perineurium, which consists of randomly ori-
borderline leprosy, especially during treatment.11 Type 1 entated and highly concentrated collagen fibers. On the other
reactions are thought to represent episodes in which cell- side, tight junctions between the endothelial cells of the cap-
mediated responses towards M. leprae are strongly increased, illaries and the endothelial basement membrane separate the
resulting in an inflammatory response in the areas of the skin endoneurium from the circulation. The resulting physical
and nerves affected by the disease.12 Estimates of the overall ‘blood/nerve barrier’ is believed to be important for main-
prevalence of reversal reactions range from 8 to 30% in taining an appropriate physicochemical environment for
leprosy.13 axons and for protecting these against potentially harmful
From the point of view of clearing bacteria, such agents, including effector cells of the immune system. Nev-
increased cellular immune responses may be beneficial, ertheless, the junctions in particular can provide a route
because they promote bacterial killing mechanisms. How- through which bacteria or leucocytes can ultimately enter the
ever, the accompanying inflammation in and around infected peripheral nervous system.
nerve tissue or around nerves in close vicinity of inflamed
lesions can result in severe and irreversible damage within a
Mycobacterium leprae–Schwann cell interactions
matter of days, if not treated adequately. Clinically detectable
neural involvement occurs in approximately 10% of Mycobacterium leprae almost exclusively infects macro-
paucibacillary and 40% of multibacillary leprosy patients, phages and Schwann cells.16 Various receptor-mediated
particularly in patients with reversal reactions.14 It has, mechanisms, similar to those exploited for macrophage inva-
however, been suggested that subclinical neural involvement sion, may play a role in invasion of human Schwann cells by
Immunopathogenesis of leprosy nerve damage 351

lesions of patients with RR compared with lesions of leprosy

patients without reactions. The T cells in the granulomata are
predominantly CD4+, whereas CD8+ T cells are mostly
present in the mantle area surrounding the granuloma.12,27,28
A strong increase of type-1 cytokines has been noted during
reversal reactions28,29,30 and, indeed, T cell clones isolated
from skin biopsies of patients with RR are predominantly of
the Th1 type.31,32 The microanatomical location of serine
esterase-positive cells within tuberculoid granulomata and
RR overlaps with the CD4+ CD45RO+ subpopulation,28 indi-
cating that these T cells contain cytotoxic granules. Further-
more, analysis of M. leprae-reactive CD4+ cytotoxic T cell
clones has confirmed that these cells are indeed highly cyto-
Figure 3 Phagocytosis of mycobacteria by human Schwann toxic for a variety of human target cells.33 It is therefore likely
cells. (a) Mycobacterium leprae, (b) Mycobacterium smegmatis. that Th1-like cytotoxic T cells may not only contribute to pro-
Mycobacterium smegmatis adhesion to Schwann cells is observed tective immunity, but also to the immunopathology of leprosy
(b), but it significantly reduced compared to M. leprae (a). neuritis in which Schwann cells function as their target.
Adhesion of mycobacteria to non-professional APC (COS1 cells; Murine Schwann cells have already been shown to function
c, M. leprae; d, M. smegmatis) underlines the existence of as antigen presenting cells for CD8+ cytotoxic T cells in an
receptors for the entry of pathogens that are not restricted to MHC class I-restricted, mycobacterial antigen-dependent
Schwann cells. manner.34 As a result of antigen recognition, Schwann cells
were killed. Rodent Schwann cells are also able to stimulate
CD4+ T cells via MHC class II.35,36 It remains unknown to
what extent these rodent studies can be extrapolated to
mycobacteria. Candidates are Fc receptors,17 complement leprosy neuritis, largely as a result of the inability to culture
receptors,17,18 the fibronectin binding protein19 and mannose human Schwann cells, precluding such analyses in humans.
receptors.20 These mechanisms are, however, not restricted to We have recently succeeded in establishing human
Schwann cells and thus do not explain why M. leprae specif- Schwann cell cultures that yield sufficient numbers of cells
ically homes to neural tissue. The neurotropism of M. leprae for further studies. These cells express the Schwann cell
may be attributed to its affinity for the G-domain of laminin- markers S-100β, glial fibrillary acidic protein (GFAP),
α2, an extracellular matrix protein that is present in the basal and 2′,3′-cyclic nucleotide-3′-phosphohydrolase (CNPase),
lamina of Schwann cells.21 In turn, M. leprae/laminin-α2 whereas control fibroblasts and peripheral blood mono-
complexes bind to α/β dystroglycan complexes expressed on nuclear cells do not express these molecules. A number of
the Schwann cell surface.22 Recently, a 21 kDa laminin molecules involved in antigen presentation and T-cell stimu-
binding receptor on M. leprae has been identified, being a lation, such as MHC class I and II, ICAM-1, and CD80 is
histone-like protein (HLP).23,24 This mycobacterial receptor also detectable (E Spierings et al., unpubl. data, 1997). The
may function as a critical surface adhesin for the G-domain expression of HLA class II on human Schwann cells in vivo
of laminin-α2. has been a point of controversy. Although a number of studies
Although these interactions may play a major role in has failed to demonstrate expression,37–39 other studies have
M. leprae/Schwann cell attachment and perhaps invasion, it reported HLA class II molecules on Schwann cells.40,41
is not unlikely that other receptors may also be involved. Furthermore, inflammatory cytokines such as IFN-γ and
Indeed, blocking of the dystroglycan complex could not TNF-α, as well as Schwann cell invasion by M. leprae, have
inhibit M. leprae/Schwann cell adhesion completely.22 Other been reported to result in upregulation of MHC class II by
candidate (co)receptors may include integrins, which are also rodent Schwann cells.42–44 In leprosy, Schwann cells have
able to bind to laminin-α2, and an as yet uncharacterized been found to express MHC class II.45 Schwann cells may
25 kDa phosphoprotein that is expressed by Schwann cells, therefore well be actively involved in the immunopathology
to which M. leprae has been reported to bind.25 Thus, other of leprosy neuritis by presenting M. leprae antigens to cyto-
receptor/ligand interactions may also be involved in toxic T cells. Thus, although human Schwann cells may not
M. leprae/Schwann cell attachment and invasion. express HLA class II molecules under non-pathological con-
ditions, infection with M. leprae and/or the subsequent local
immune response probably induce MHC expression by
T-cell mediated and Schwann cell damage
human Schwann cells.
Several pathogenic mechanisms may be responsible for nerve In order to analyse specific M. leprae antigen presentation
damage in leprosy, including biochemical interference of by Schwann cells, we have pulsed human Schwann cells with
M. leprae with host cell metabolism, mechanical damage due M. leprae or Mycobacterium smegmatis (Fig. 3). Incubation
to the large influx of cells and fluid, or immunological for 30 min resulted in bound bacilli to the surface of Schwann
damage. Because RR are accompanied by an increased cell- cells. Membrane-anchored bacilli, entering Schwann cells,
mediated immunity (CMI) and because acute nerve damage could be detected within 1 h (Fig. 3a), while M. leprae inter-
particularly occurs during these reactions, a role for the nalization was clearly detectable after an overnight incubation
immune system in causing nerve damage during RR has long period, as confirmed by confocal microscopy analyses (data
been suspected.12,26 CD4+ T cells are more abundant in skin not shown). In addition, M. smegmatis internalisation was
352 E Spierings et al.

Figure 4 Presentation of myco-

bacterial antigens by human
Schwann cells. Human Schwann
cells are able to present antigens
from intact Mycobacterium leprae
bacilli to CD4+ T cells, which
respond with proliferation (a), the
production of IFN-γ (b) and
killing of the Schwann cells (c).

observed after an overnight incubation, but the number of important pathway. Interaction between Fas and Fas-L on
internalized bacilli was significantly lower (Fig. 3b). Cell target and effector, respectively, initiates an intracellular
surface binding analyses of M. leprae and M. smegmatis to cascade that finally results in apoptosis of the target cell.49
COS1 cells clearly showed mycobacterial adhesion to non- There has been some debate on the issue of whether this
professional antigen-presenting cells (Fig. 3c,d). However, pathway also results in elimination of intracellular bacteria.
binding of M. leprae to these cells was much reduced when Reduced bacterial viability has been reported by some,50
compared to the invasion of Schwann cells. while others see no effect.51,52 These latter results are
Using the described ex vivo isolated human Schwann cell supported by the finding that the course of M. bovis BCG
cultures, we have been able to demonstrate that human infection in Fas-receptor-defective mice was not altered.48
Schwann cells can process and present intact M. leprae bac- A third mechanism of target cell killing is induction of
teria and M. leprae antigens to CD4+ cytotoxic T cells. Pre- apoptosis via extracellular ATP.53 The ATP, which may also be
sentation induces T cell proliferation (Fig. 4a) and IFN-γ produced by immune effector cells, can interact with P2Y or
production (Fig. 4b), and is MHC class II restricted (data not P2Z receptors on target cells and induce apoptosis.54 Extra-
shown). Importantly, as shown in Fig. 3c, M. leprae-pulsed cellular ATP has not only been shown to kill targets via P2
Schwann cells are highly susceptible to killing by type 1 receptors,55 but also affects the viability of intracellular
CD4+ T cell clones from leprosy patients. Schwann cell bacteria.56 Interestingly, individuals can be classified into
killing is antigen dependent and HLA class II restricted (data three groups, based upon their response to ATP:57 some
not shown). These results clearly show that human Schwann individuals show responses to ATP in the absence of IFN-γ,
cells can process and present M. leprae to M. leprae-specific while others only respond intermediately. The response of
CD4+ cytotoxic T cells and are subsequently killed during the intermediate group can be enhanced by IFN-γ. A third
this event. Particularly during inflammatory CD4+ T cell- group responds neither to ATP alone, nor to ATP in combi-
mediated RR, this mechanism may play an important role in nation with IFN-γ. These responses are correlated with the
causing local peripheral nerve damage in leprosy. We propose level of P2 receptors on their APC and may thus explain dif-
that this may represent a novel immunopathogenic mecha- ferences in susceptibility to ATP-mediated apoptosis between
nism of nerve damage in leprosy. individuals.
Because the pathway of Schwann cell killing may well
influence the fate of mycobacteria, we have tested the
Effector mechanism of T cell-mediated Schwann cell
involvement of these different killing mechanisms in
Schwann cell killing. Although human Schwann cells were
Different mechanisms may be involved in the lysis of found to express Fas (Fig. 5a) and are susceptible to ATP-
infected Schwann cells. First, following recognition of mediated lysis (Fig. 5b), apoptosis-inducing Fas antibodies
infected Schwann cells via MHC/peptide/T cell receptor were not able to induce Schwann cell killing. The ATP
interactions, CD4+ Th1 cells can secrete lytic granules that inhibitor hexokinase strongly reduced ATP- but not T cell-
contain granulysin, granzymes and perforins.46 Granulysin mediated lysis of Schwann cells in response to specific
and perforin have been reported to act in concert in attacking peptides or to the mitogenic lectin ConA (Fig. 5b,c). Addition
infected macrophages: perforin permeabilizes the eucaryotic of MgCl2-EGTA, however, reduced antigen-specific, T cell-
cell membrane, allowing the granulysin to enter the cells,47 mediated lysis by approximately 35–40%, indicating that
which subsequently affects intracellular bacteria by altering granule-mediated, but not Fas- or ATP-dependent, lysis is
their membrane integrity, thus inducing bacterial killing. likely an important pathway for T cell-mediated Schwann cell
Knocking out perforin, however, does not alter the capability killing (Fig. 5d).
of mice to control M. tuberculosis or Mycobacterium bovis
Bacillus Calmette–Guérin (BCG) infection, indicating that
Nerve destruction as collateral damage
alternative killing pathways are likely to exist.48
Apart from granule-mediated lysis, killing of target cells In addition to nerve damage resulting from cognate T
via the Fas or Fas-related ‘death-receptors’ appears to be an cell/Schwann cell interactions, non-specific bystander effects
Immunopathogenesis of leprosy nerve damage 353

Figure 6 The potentially harmful effect of protective anti-

mycobacterial immunity. dc, Dendritic cell; mø, macrophage.

Figure 5 Susceptibility of human Schwann cells to FAS-, ATP-

and granule-mediated cytotoxicity. (a) Human Schwann cells
express FAS molecules on their surface. Cytotoxicity inducing
T cells, in addition to M. leprae-specific T cells. Such
FAS antibodies, however, did not induce Schwann cells lysis
autoreactive T cells may be primed by cross-reacting
(not shown). Schwann cells are susceptible to extracellular
mycobacterial antigens (molecular mimicry). An obvious
ATP-induced cell lysis (b, ,). Addition of 50 µg/mL ATP-
candidate auto-antigen is HSP60. Mycobacterial HSP60-
inhibitor hexokinase (m) reduced lysis by exogenously added
reactive murine T cells are indeed able to lyse uninfected
ATP (b), but not by T cells, either in response to Mycobacterium
macrophages61,62 and IFN-γ-stressed target cells.63 Further-
leprae or to the mitogen Con A (c). (d) MgCl2 + EGTA blocked
more, transfer of an HSP60-specific CD8+ T-cell clone into
antigen-dependent T-cell mediated Schwann cell lysis with
immunocompromised mice leads to severe immunopathol-
±35% of the peptide response, indicating that human Schwann
ogy.61,64 These data indicate that presentation of peptides from
cells are susceptible to granule-mediated lysis.
endogenous proteins can be responsible for cell-mediated,
autoimmune-like tissue destruction. However, it is also
possible that, during inflammation, T cells are primed against
non-cross-reacting Schwann cell or nerve-associated auto-
during inflammation may also be involved in triggering antigens, perhaps by crosspriming, and that such autoreactive
nerve damage. Possible mediators are TNF-α, proteases and T cells can contribute to peripheral neuropathy in leprosy.
urokinase.58 In relation to leprosy, TNF-α mRNA and protein Analysis of the antigen specificity of lesion-infiltrating T
are more abundant in lesions of patients with RR.30,59 It is pre- cells will be needed to address the role of self-antigen versus
dominantly produced by M. leprae-responsive type 1 T cells M. leprae antigen recognition in the immunopathology of
derived from patients undergoing RR,31 but infected and leprosy neuritis.
activated macrophages can also be responsible for the pro-
duction. Tumour necrosis factor-α hardly has a toxic effect on
Schwann cells on its own, but in combination with trans-
forming growth factor (TGF)-β it has been reported to cause
significant Schwann cell detachment and lysis.60 Little is In summary, human Schwann cells may be central players in
known about the effect of TNF-α-mediated target killing on leprosy nerve damage. Destruction of Schwann cells, and
mycobacterial survival. Tumour necrosis factor-α-mediated subsequently of the nerves they surround, is likely not only as
lysis has been reported to have a similar effect on myco- the result of collateral damage, but also from the direct effect
bacterial viability to Fas/Fas-L-mediated lysis,50 but for both of CD4+ cytolytic T cells. These T cells are instrumental in
Fas and TNF-α this topic is highly disputed. controlling the outgrowth of M. leprae bacilli in lesions by
activating, as well as killing, M. leprae-infected macro-
phages. Unfortunately, however, when infected Schwann
Mycobacterium leprae-specific versus autoreactive
cells are killed as well, this may lead to nerve damage, which
T cells in leprosy lesions
may progress to irreversible loss of peripheral nerve tissue
So far it is unknown which antigens are recognized by (Fig. 6). Although this process can involve both CD834 and
lesional T cells. Mycobacterium leprae-specific T cells can CD4 (Spierings et al., unpubl. data, 1999) cytotoxic T cells,
be isolated from both inflamed skin31 and nerve tissue particularly, the latter type may be of importance, because
(E Spierings et al., unpubl. obs., 1997). It is possible that CD4+ T cells are present in high numbers in the centre of
nerve damage may be caused or enhanced by autoreactive granulomas of leprosy patients with RR.
354 E Spierings et al.

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