TUBERCULOSIS 0025-7125/93 $0.00 + .

20

IMMUNOLOGY OF
TUBERCULOSIS
Nancy E. Dunlap, MD, PhD, and David E. Briles, PhD

At the turn of the century, approximately 10% of all deaths in this

country were due to infection with Mycobacterium tuberculosis.lO As the
result of public health measures and the development of antituberculous
therapy, the incidence of tuberculosis (TB) has decreased at an annual
rate of approximately 5% per year-until recently. Dramatic increases in
the incidence of TB have occurred within the United States over the past
few years, and in many outbreaks of TB, the standard antituberculous
therapy has not been effective.
New vaccines and therapies for TB are under investigation, some of
which are designed to alter the host response to the organism. Immunity
to M. tuberculosis can lead to resistance or resolution of the disease. It is
clear, however, that the immune response to TB causes much of the
morbidity associated with active disease. Thus, an understanding of host
immunity to TB is vital for the rational use of these new therapeutic
modalities. In this article we describe what is currently known about the
pathogenesis of TB and the host immune response. The immunologic
basis for the tuberculin skin test and the use of the bacille Calmette-
Guerin (BCG) vaccine are also reviewed.

PATHOGENESIS OF MYCOBACTERIAL INFECTION

The tubercle bacillus generally enters the body through the lungs.
Droplets, 1 to 5 j.Lm in size, reach the alveoli where they are ingested by

From the Division of Pulmonary and Critical Care Medicine, University of Alabama at
Birmingham (NED, DEB); and the Veterans Administration Medical Center (NED),
Birmingham, Alabama

MEDICAL CLINICS OF NORTH AMERICA

VOLUME 77 • NUMBER 6 • NOVEMBER 1993 1235

1236 DUNLAP & BRILES

alveolar macrophages. 26 Whether an inhaled tubercle bacillus establishes

an infection in the lung depends on both the bacterial virulence and the
inherent microbicidal ability of the alveolar macrophage that ingests it. 26
If the bacillus is able to survive initial defenses, it can multiply within
the alveolar macrophage. M. tuberculosis is capable of escaping microbi-
cidal mechanisms of the macrophage, presumably through virulence fac-
tors such as sulfatides (high-molecular-weight glycolipid sulfates), cord
factor (trehalose dimycolate), and other acidic lipids. 35 One possible
mechanism by which these virulence factors work is through the disrup-
tion of phagosome-lysosome fusion. Studies by Armstrong et aP dem-
onstrate that phagosome-lysosome fusion is disrupted when macro-
phages ingest M. tuberculosis. Subsequently, Myrvik et al 60 demonstrated
that virulent M. tuberculosis can disrupt the phagosomes in alveolar mac-
rophages, while avirulent organisms remain within the phagosome.
Other mechanisms, however, may be operative. Even when phagosome-
lysosome fusion is promoted by artificial means, M. tuberculosis is not
killed. 4 Lowrie 51 showed that increased levels of cyclic adenosine mono-
phosphate (AMP) within phagosomes protect some mycobacteria from
digestion. Crowle80 demonstrated that some mycobacteria escape diges-
tion by pumping ammonium ions into the space immediately surround-
ing the organism.
The tubercle bacillus grows slowly, dividing approximately every 18
to 24 hours. M. tuberculosis has no known endotoxins or exotoxins, and
there is no immediate host response to infection. The organisms grow
essentially unimpeded until a cellular immune reaction develops after 4
to 8 weeks. An inflammatory response appears to develop, however,
once a threshold number of M. tuberculosis organisms is reached. This
inflammatory lesion is associated with the spread of tubercle bacilli
through the lymphatics to the hilar lymph nodes or through the blood-
stream.
Once cell-mediated immunity develops, collections of activated T
cells and macrophages form granulomas that wall off the M. tuberculosis
organisms. Granulomatous inflammation is a nonspecific host response
in which collections of T cells and macrophages in various stages of
activation come together in a loosely organized lesion. Organisms tend
to be localized in the central portion of the granuloma, which is often
necrotic (caseum). CD4 + T lymphocytes and monocytes recruited from
the blood surround the lesion. Monokines and lymphokines are released
that activate the surrounding cells. Tissue macrophages derived from
monocytes further transform into epitheliod cells and fuse to form mul-
tinucleated giant cells. 14, 20 A granuloma within the lung and draining
lymph nodes is called a primary complex or Ghon's complex.
Activated macrophages produce enzymes and toxins such as hydro-
gen peroxide and oxygen radicals to kill the organisms they ingest. 48
Hydrolytic enzymes such as acid phophatase and lysozyme attack the
cell wall. Free fatty acids are produced that inhibit growth of mycobac-
teria. 46 It is likely that both oxidative and nonoxidative mechanisms are
important in the killing of mycobacteria by activated macrophages. 24 ,32
For the majority of individuals with normal immune function, the
 IMMUNOLOGY OF TUBERCULOSIS 1237

initial infection with M. tuberculosis appears to be arrested once cell-

mediated immunity develops, although small numbers of viable bacilli
within granuloma remain. Although a primary complex can sometimes
be seen on chest radiograph, the majority of pulmonary TB infections are
inapparent. 21 A positive tuberculin skin test is the only apparent vestige
of an M. tuberculosis infection. Individuals with TB infection but not
active disease are not infectious and thus cannot spread the disease to
other people. These individuals are not considered to have TB, but are at
risk for developing active disease if not treated. Untreated, approxi-
mately 10% of individuals with normal immunity will develop active TB
within their lifetime, 5% within the first 2 years of infection.83
If cell-mediated immunity is unable to contain the M. tuberculosis
infection, the infected individual progresses to active disease. The mani-
festations of active TB are the result of a balance between host defenses
and bacterial virulence and therefore produce a continuum of disease.
Four manifestations of disease that are frequently seen are described
next.

Miliary TB

Miliary or disseminated TB occurs when large numbers of tubercle

bacilli spread via the bloodstream, resulting in small (approximately
2 mm) granulomatous lesions throughout the body. The name, miliary
TB, was given by pathologists because the small lesions resembled a
sprinkling of millet seeds. This massive spread of TB only occurs in hosts
who have inadequate cell-mediated immunity. Miliary TB is seen in
infants and young children less than 5 years old who have not yet fully
developed cellular immunity, or adults with malignancy, poor nutri-
tional status, alcoholism, or who are being treated with immunosuppres-
sive therapy. Patients infected with HIV also have an increased incidence
of miliary TB.
Miliary TB usually develops insidiously with systemic symptoms
such as fever, weakness, weight loss, fatigue, and anorexia. Cough and
dyspnea may also be prominent symptoms.88 The mean duration of
symptoms approaches 16 weeks, but some individuals may go undi-
agnosed for over 2 years?5 The systemic manifestations of miliary TB are
likely the result of immune mediator release (tumor necrosis factor, inter-
leukins) as the body attempts to fight the infection.

Initial Infection

The initial TB infection in the lung, sometimes referred to as primary

infection or TB of childhood, may cause an inflammatory infiltrate seen
on chest radiograph. The middle or lower lung zones are most com-
monly affected because these areas are better ventilated than the upper
lung zones and thus have more exposure to infectious particles. 20 The
1238 DUN LAP & BRILES

draining lymph nodes may become large and compress adjacent bronchi.
This occurs more often in children and infants than in adults. The par-
enchymal disease usually clears as cell-mediated immunity develops,
and tends to clear more rapidly than nodal involvement. In certain pa-
tients, however, notably those who are pregnant or have diabetes melli-
tus, cavitation can occur within the infiltrate or in the adjacent lung
tissue. 2o Cavitation results from release of immune mediators, and there-
fore usually occurs when cell-mediated immunity is activeY
In approximately 10% of patients, the initial infection with M. tuber-
culosis is manifested by a pleural effusion. Presumably this results when
a caseous focus from peripheral initial infection occurring 3 to 6 months
previously ruptures into the pleural space.1, 8 Initially, the pleural fluid
has characteristics of acute inflammation with a predominance of poly-
morphonuclear cells. Later, the pleural fluid has a predominance of
mononuclear cells, including large numbers of TB-specific CD4 + T lym-
phocytes. 27 Tuberculous pleuritis is usually symptomatic and causes an
acute illness characterized by cough, fever, and pleuritic chest pain. 5o
Without treatment, the pleuritis will resolve, but approximately half of
all patients will develop active TB later.65,74 The numbers of M. tubercu-
losis organisms in the fluid are relatively low, with positive cultures of
fluid in less than 25% of cases. 50 Pleural biopsy shows granulomatous
inflammation in approximately 60% of patients.50 When culture of three
biopsy specimens is combined with microscopic examination, however,
the diagnosis can be made in approximately 90% of cases. 49

Reactivation Disease

During the majority of initial TB infections, small numbers of orga-

nisms are hematogenously disseminated and some become seeded in the
apices of the lung. The organisms appear to grow preferentially in this
well-oxygenated, less-well-perfused environment and can develop a
subsequent infection months or years after the initial infection has
cleared. This accounts for the characteristic location of reinfection or
reactivation disease, which in 95% of cases occurs in the apical or poste-
rior segments of the upper lobes?5 Because reactivation disease only
occurs after cell-mediated immunity has been established, the clinical
manifestations are generally different from the initial infection.
Reactivation TB is characterized by inflammation, and typically
there is airspace consolidation. Granulomatous inflammation, resulting
from cellular immunity, is characteristic, and there may be caseation.
Caseum is avascular and has an acidic pH.21 Minute foci of caseous
necrosis and the tubercle bacilli within them can probably be eliminated
by macrophages, which progressively phagocytize the debris at the pe-
riphery.21 Larger areas of caseation may remain, however, containing
viable M. tuberculosis. Liquefaction of the caseous centers with hydrolysis
of the protein, lipid, and nucleic acid components of the tissue is also
associated with cell-mediated immunity. The liquefied caseum is an ex-
 IMMUNOLOGY OF TUBERCULOSIS 1239

cellent culture medium for M. tuberculosis, and high concentrations of

organisms can be attained. 14 Cavitation results when areas of liquefied
caseum rupture into an adjacent bronchus. 21 Large numbers of bacilli can
then gain access to the outside environment and be spread to other
individuals.
In areas of chronic infection, fibrosis may occur. Fibrosis is often
associated with the healing of granulomas and is likely caused by the
activation of fibroblasts by immune mediators such as platelet-derived
growth factor-~87 or transforming growth factor-~.53 Fibrosis also occurs
in areas of caseation. Fibrocaseous lesions may contain live mycobacteria
for many years, and these are the lesions that may reactivate years later.18
Deep within these fibrocaseous lesions, there are no cells, and mycobac-
teria are extracellular. Protective cellular immunity helps to keep these
lesions dormant, and calcification of these lesions frequently occurs. Cal-
cified lesions tend to have decreased numbers of live organisms, and
approximately 85% of calcified lesions are sterile. 14

Extrapulmonary TB

As tubercle bacilli are spread during the initial infection, they can
lodge in any organ and produce a focus of infection. Approximately 15%
of patients with active TB have an extrapulmonary form of disease.lO The
most common sites for extrapulmonary TB are those in well-vascularized
areas such as the kidney, meninges, spine, and the growing ends of long
bones. Laryngeal TB can occur from direct extension of infection through
the tracheobronchial tree. Although rare, gastric TB can result from swal-
lowing infectious sputum. The host response to infection in these extra-
pulmonary sites is similar to that occurring in reactivation disease.

DEVELOPMENT OF IMMUNITY TO M. TUBERCULOSIS

Early Host Response

Early after infection with M. tuberculosis, there may be an inflamma-

tory or exudative response within the lung that is characterized by vaso-
dilatation, edema, fibrinous exudate, and the influx of leukocytes, includ-
ing polymorphonuclear cells, lymphocytes, and monocytes. 57 During this
stage, tubercle bacilli can proliferate because cell-mediated immunity has
not yet developed. The course that the TB infection takes is the result of
a balance between the host response and bacterial virulence. In some
lesions a fibrinous reaction develops. The numbers of bacilli in this type
of lesion have been noted to be relatively small. 14 In other lesions, poly-
morphonuclear neutrophils (PMNs) predominate. The presence of PMNs
is likely due to the release of chemotactic substances from alveolar mac-
rophages. 59 The numbers. of bacilli in these PMN-rich lesions tend to be
relatively high.14 Although there are indications that the PMNs in TB
1240 DUN LAP & BRlLES

subjects are at a higher state of activation compared with uninfected

individuals6 ,62 and they readily ingest opsonized mycobacteria,86 there is
controversy as to whether or not PMNs are able to kill M, tuberculosis
effectively,23, 41, 86 PMNs are important for the formation of granulomas
and precede monocytes in areas of granulomatous inflammation,56 PMNs
are known to release chemotaxins that attract monocytes2 and may even
indirectly activate monocytes. 38

Development of Cellular Immunity

Cell-Mediated Immunity Versus Delayed Hypersensitivity

The ability of a host to control infection with M. tuberculosis resides
in its ability to mount an effective cullular immune response. Cellular
immunity develops when T cells become sensitized after recognizing
their specific antigen and then release mediators that modulate macro-
phage function. The specificity of cell-mediated immunity thus depends
primarily on the T lymphocyte, not the macrophage,21 Cell-mediated
immunity is thought to produce activated macrophages that are capable
of containing or killing the M. tuberculosis organisms.22
Cell-mediated immunity and delayed hypersensitivity (DTH) are
closely related phenomena that occur in the host as a result of T cells
becoming specifically activated. Both phenomena are a result of the same
immunologic mechanism and alter the response of the host to subse-
quent exposure to antigen. DTH is an immunologic reaction of the host
to infection, but is not involved in killing or containing the infective
organism. For example, DTH is responsible for the positive tuberculin
skin test reaction. so DTH is considered to be responsible for many of the
observed detrimental effects of TB, especially if the antigen is present in
excessive amounts. 80 DTH has been implicated in caseation and cavita-
tion. 89 Caseation follows the early exudative lesions in the lung and
results when blood vessels adjacent to the areas of inflammation throm-
bose causing tissue necrosis,21 DTH is also involved in the liquefaction of
caseous lesions, probably as a result of lymphokine production, which
attracts and activates macrophages. Macrophages then release hydrolytic
enzymes that digest the necrotic debris. 22 Thus, DTH is considered to be
a detrimental process, whereas cell-mediated immunity is beneficial. The
balance between DTH and cell-mediated immunity is different among
individuals and is likely genetically determined. so This balance is an
important determinant of how an individual will respond to an active
infection with M. tuberculosis.

Role of T Lymphocytes
T lymphocytes become specifically activated as they recognize anti-
gen through aT-cell receptor, Over 90% of peripheral T cells have a T-
cell receptor composed of an a- and p-chain, whereas less than 10% of T
cells express a receptor composed of "1- and o-chains. 67 The alP T cells
 IMMUNOLOGY OF TUBERCULOSIS 1241

are further subdivided into subsets that express cluster designation (CD)
antigens of CD4 (helper /inducer) or CDS (cytotoxic/suppressor). It was
originally believed that the functional properties of a given T cell could
be inferred from its surface antigens, and thus the terms T-helper/indu-
cer and T-cytotoxic/suppressor cells are sometimes used. This concept is
no longer valid, because occasionally dissociations between classic cell
markers and functions occur. 66 Of relevance to mycobacterial infections,
cytotoxic T cells expressing the CD4 antigen instead of the usual CDS
antigen may be important in lysing macrophages containing mycobac-
teria. 11 These cytotoxic CD4 + T cells are modulated by lymphokines and
thus may be regulated differentially in different areas of an infection.
CD4 + cells recognize antigen in the context of the class 11 major
histocompatibility complex (MHC) whereas CDS + cells recognize anti-
gen associated with class I MHC gene products. In the murine system,
CD4 + T cells can be further subdivided into subgroups determined by
the lymphokines they produce. For example, the Thl subgroup secretes
interferon gamma (IFN'Y), interleukin-2, and tumor necrosis factor beta
(TNF[3), and elicits DTH reactions. 66 Th2 cells secrete interleukins 4, 5,
and 10. Subsets of CD4 + T cells have also been identified in humans,
but a clearly defined lymphokine repertoire for each subset has not been
found. The finding that there are subpopulations of T cells with different
capabilities raises the possibility that the balance between cell-mediated
immunity and DTH for different individuals may result from differential
activation of T-cell subsets. There is some evidence that specific antigens
preferentially activate one functional CD4 + subset.66 This may explain
differences in the response to mycobacterial infections in different indi-
viduals and may explain the observation that the protective response of
some vaccines (cell-mediated immunity) does not always correlate with
the skin test reactivity (DTH).
Both the CD4+ and CDS+ T-cell subsets are likely to be important
in the protective response to M. tuberculosis. Mice that were depleted of
either CD4 + T cells or CDS + T cells and then infected with M. tubercu-
losis showed increased numbers of bacteria indicating an inability to
control the infection. The depletion of both T-cell subsets in the same
animals did not cause additional exacerbation of the infection. 45 CDS +
T-cell clones have also been established from mice immunized with M.
tuberculosis. These T cells will lyse host macrophages pulsed with myco-
bacterial proteins, indicating that these CDS + T cells possibly participate
in immunity to mycobacteria. 16
The role of the 'Y /8 T cell is not well understood. The majority of the
'Y /8 T cells lack the CD4 and the CDS molecule but respond to mycobac-
terial antigens, particularly heat-shock proteins. 12, 42 When peripheral
blood leukocytes from normal individuals are stimulated in vitro with
mycobacterial lysates, a marked expansion of 'Y /8 T cells occurs. An
increase from less than 10% of total T cells to more than 40% has been
observed. 44 Thus 'Y /8 T cells can be poly clonally expanded. However, 'Y /
8 T cells can also expres~ antigen-specific activity. When these cells are
stimulated with either mycobacteria or streptococci, they show specific
killing of autologous cells infected with the stimulating agent. 58 In addi-
1242 DUN LAP & BRILES

tion, mycobacterium-reactive -y /8 T cells have been found to produce

interleukin-2 and a factor that synergizes with granulocyte/macrophage
colony stimulating factor. 5s , 58

Role of the Macrophage

The macrophage is the effector cell in cell-mediated immunity and
is dependent on interaction with activated lymphocytes. In TB, there is
an increased monocytopoiesis and premature release of monocytes from
the bone marrow?7 Blood monocytes then leave the circulation and be-
come tissue macrophages. In the tissues, they come in contact M. tuber-
culosis and become primed or activated by lymphokines. Activated mac-
rophages are larger and have a higher metabolic rate and an increased
content of lysosomes and enzymesY' 26 Dead mycobacteria do not acti-
vate macrophages. They only cause an inflammatory response with ac-
cumulation of granulocytes and macrophages. 61 Once activated, macro-
phages more efficiently perform different functions such as phagocytosis,
digestion, microbial killing, enzyme secretion, and antigen processing. 20
It cannot be assumed, however, that all macrophages are the same. There
is evidence that particular macrophage subsets perform specific func-
tions/ o but specific surface antigens to identify these macrophage subsets
are not yet available. Whether local factors present in areas of inflam-
mation contribute to the macrophage differentiation is unknown.
The processing of antigens for presentation to T cells is an important
function of macrophages for effective cell-mediated immunity. Bacterial
antigens are phagocytosed and processed in the endosomal compartment
of the macrophage. While in this compartment, the processed antigen
associates with the MHC class 11 molecules, and the complex is expressed
on the surface of the macrophage. C04 + T cells, thought to be the
dominant T cells in mycobacterial immunity, can recognize the complex
and become activated?6 These activated C04 + T cells can then secrete
lymphokines, which activate additional macrophages.
Bacterial antigens that gain access to the cytoplasmic compartment
of macrophages can associate with MHC class I molecules.44 This antigen
complex can then stimulate COS + T cells. The role for COS + T cells in
mycobacterial immunity is not well understood. One possible role is that
activated COS + T cells facilitate the release of bacteria entrapped in
macrophages that are unable to kill their intracellular mycobacteria. In
this way, bacteria can be released from ineffective macrophages and
phagocytosed by more efficient effector cells. 44 Once mycobacteria are
released from these ineffective cells, it has been hypothesized that acti-
vated granulocytes may then play an important role in phagocytosing
and killing the free mycobacteria}3, 47, 64
Activation of monocytes is dependent on lymphokines, but the spe-
cific lymphokines required are unknown. IFN-y, secreted predominantly
by C04 + T cells, has been shown to activate macrophages. In vitro
exposure of macrophages to IFN-y will cause the macrophages to increase
expression of la antigens, increase superoxide release, and kill intracel-
lular Toxoplasma gondii. 25 The effects of IFN-y on macrophage killing of
 IMMUNOLOGY OF TUBERCULOSIS 1243

mycobacteria, however, have been variable. 2s, 86 It is likely that other

cytokines, alone or in combination, are required to enhance the effects of
IFN-y in vivo. The B-cell stimulatory factors IL-4 and IL-6 may also play
a role in macrophage activation. IL-4 and IL-6 appear to act on macro-
phages later in infection than IFN-y, but their specific effects on macro-
phages are unknown?3, 34, 42
Other nonlymphokine, macrophage activators may also play a role
in immunity to mycobacteria. Calcitriol appears to be the most effective
activator of antituberculosis activity in human monocytes yet defined,
but its role in human disease is unclear.72 When granulomatous inflam-
mation is active, 1-hydrolase activity within macrophages converts the
inactive circulating form of vitamin D3 (25[OH] cholecalciferol) into cal-
ciferol. Calciferol activates macrophages and increases the response to
IFN-y in human macrophages?O It is unknown if this effect is important
in mycobacterial disease. At times, however, excess calciferol is produced
and alters not only the local, inflammatory milieu, but alters systemic
calcium metabolism. This results in the hypercalcemia noted in some
cases of active TB.
Activation of macrophages not only results in the control of infec-
tion, but also may involve the secretion of harmful molecules. Tumor
necrosis factor-a (TNFa), a secretory product of activated macrophages,
has been reported to cause inhibition of M. avium in human macro-
phages. 9 TNFa may also work synergistically with IFN-y in the activation
of macrophages to kill M. tuberculosis. 33 TNFa, however, is also respon-
sible for many of the systemic manifestations of TB. Fever, weight loss,
and tissue necrosis are attributable to known effects of TNFa?O As long
as levels of TNFa are low and confined to the site of microbial multipli-
cation, the protective effects of TNFa will likely dominate. If the host
response is overly vigorous, however, the immune response itself may
kill the host. TNFa has been identified in tuberculous pleural effusions. s
Although free TNF has not been detected in the serum of TB patients,
high levels of an inhibitor to this mediator have been seen?!

Humoral Immunity

Mycobacterial infections stimulate humoral antibody responses, but

specific immunoglobulins seem to play little or no role in the immunity
to tuberculosis. 68 Phagocytosis of mycobacteria by macrophages does not
appear to be significantly affected by opsonizing antibodies. 52 The addi-
tion of specific immune antiserum to a mycobacterial suspension just
before its exposure to normal macrophages, however, may increase the
degree of lysosomal fusion with the phagosomal membrane. Interest-
ingly, this has no discernible effect on the subsequent rate of intracellular
killing. 4 Specific antibodies may be important, however, in the PMN
response to mycobacterial infection. The role of the PMN in TB is not
well understood, but studies have shown that PMNs, particularly when
autologous serum is present, can diminish growth of M. tuberculosis by
1244 DUNLAP & BRILES

nonoxidative processes. Whether this is of overall importance to protec-

tion against mycobacteria is unknown.
Methods to detect specific antituberculous antibody have been de-
vised in an attempt to diagnose active disease. Because both those indi-
viduals infected with the organism and those with active disease produce
antibodies, however, serologic tests have not been very clinically useful.
Recently, studies measuring the levels of antibodies against antigens that
are secreted from viable mycobacteria have been performed in efforts to
distinguish these patient populations. 19
Circulating immune complexes are found in the serum of patients
with active tuberculosis. 15,54 These complexes are composed of IgG, IgM,
and IgA and contain mycobacterial antigens. Increasing levels of circu-
lating immune complexes correlate with a poor prognosis. 40 Immune
complex nephritis can occur in patients with tuberculosis as a result of
the circulating immune complexes?9

TUBERCULIN SKIN TEST

Purified protein derivative (PPD) is a crude mixture prepared from
filtrates of heat-sterilized cultures of M. tuberculosis. It was developed by
Florence Siebert in 1939 and remains the reference standard material for
all tuberculins (PPD-S; Siebert's Lot 49608). Most of the constituents of
PPD are small proteins with molecular weights of approximately 10,000
d, but there are also polysaccharides and some lipids. 19 The relatively
small size of the protein constituents in PPD is the reason that PPD does
not normally sensitize individuals who have not been exposed to myco-
bacteria. 19
The immunologic basis of the PPD skin test is not completely
known. Induration at the site of PPD injection is thought to caused by
both the influx of sensitized T cells into the area as well as the release of
lymphokines from these T cells. 82 The release of lymphokines results in
local vasodilatation, edema, and recruitment of other inflammatory cells
to the area.
Reactivity of the PPD skin test in a given individual can suggest, but
not confirm, the diagnosis of TB. Reactivity of the PPD can also provide
a measure of the patient's DTH immune responsiveness. 19 The size of the
dermal reaction cannot be used to evaluate the extent of disease. For
example, a large PPD reaction could signify that the individual has a
high resistance to infection because it is able to recruit large numbers of
activated lymphocytes and monocytes to the area. A large dermal reac-
tion, however, could also signify that the individual has a low resistance
to infection and thus has allowed large numbers of organisms to accu-
mulate providing a large anti genic stimulation and a vigorous DTH
response. 21

Booster Phenomenon
In most individuals, PPD skin test sensitivity persists throughout
life. If all mycobacterial organisms and their antigens are eliminated,
 IMMUNOLOGY OF TUBERCULOSIS 1245

however, the number of PPD-specific T cells will decrease with time, and
in some individuals the tuberculin skin test may even disappear. 21 If PPD
is administered to these individuals whose skin tests have waned, there
may be an accentuation of response on repeated testing. This is called
the booster effect and can be misinterpreted as a skin test conversion.
The Centers for Disease Control recommend that when periodic testing
is done, such as in yearly follow-up of hospital personnel, initial skin
testing of negative responders should be repeated 1 week after the origi-
nal test. 84 If the second test is positive, then a booster effect has occurred.
If it is negative, subsequent conversion of the PPD skin test can be
accurately interpreted.

Anergy

Not all individuals with active TB respond to PPD skin testing. Skin
test unresponsiveness or "anergy" may develop after an initial tubercu-
lin skin test reactivity as the TB infection progresses. In two separate
studies, 17% and 30% of newly recognized cases of TB that required
admission to the hospital had negative PPD skin tests. 39, 81 Anergy may
relate to the extent of disease because patients with miliary TB are more
likely to exhibit anergy than are patients with pulmonary disease. 28 As a
rule, skin test reactivity reappears as TB is successfully treated?3, 85
The basis for the anergic state in TB is not completely understood.
Compartmentalization of sensitized CD4 + T cells to sites of active dis-
ease may play a role. 69 Because these cells are sequestered in the lung or
at other sites of inflammation, they are unavailable at the site of PPD
instillation and thus no skin test reaction develops. Another likely com-
ponent of anergy is the presence of suppressor cells in the peripheral
blood. Ellner28 has shown that removal of an adherent suppressor cell
population from the blood of anergic donors will restore T-cell respon-
siveness to the antigen. Circulating immune complexes, mycobacterial
cell wall components, and prostaglandins may also interfere with T-cell
responsiveness to PPD by blocking antigen receptors or stimulating the
suppressor cell populations. 57
Loss of skin test reactivity also occurs in cases of concomitant malig-
nancy, syphilis, severe systemic viral infections, sarcoidosis, malnutri-
tion, and HIV infection. In all of these conditions, cellular immunity is
depressed and therefore the lack of skin test reactivity correlates with
increased susceptibility to M. tuberculosis infection.

ANTIGENICITY OF MYCOBACTERIA

The tubercle bacillus is structurally quite complex, and lipid, pro-

tein, and polysaccharide cell components are all immunogenic. Some of
these components are immunosuppressive, whereas others lead to or
induce granuloma formation, macrophage activation, and host toxicity.26
1246 DUNLAP & BRILES

Although over a dozen somatic and secreted antigens of M. tuberculosis

have been cloned,90 it is unknown which are important for engendering
protective immunity. Because killed mycobacteria are far less protective
in animal models than live bacteria, current hopes for protective antigens
center around secreted molecules. 63 Fundamental questions remain about
the nature of immune responses required for protection.

BACILLUS CALMETTE-GUERIN VACCINATION

Intracutaneous inoculation with bacillus Calmette-Guerin (BCG) is

currently used as a vaccination against TB. BCG is named after the two
French investigators responsible for developing the vaccine from an at-
tenuated strain of Mycobacterium bovis. Millions of people around the
world have been vaccinated with BCG, but even so, the efficacy of the
vaccine is uncertain. There are ample data that indicate that the BCG
vaccine protects against disseminated TB and meningitis in children?8
However, BCG's protection against pulmonary disease in both children
and adults is not proven. Multiple trials have been done to evaluate the
vaccine's effect, but results have varied between -50% and 77% protec-
tion for the vaccine, with - 50% reflecting increased susceptibility to
disease in those vaccinated. 29 ,30 Interestingly, skin test reactivity resulting
from vaccination did not correlate with protection against tuberculosis
in these trials?? This suggests that in some individuals, vaccination may
favor either cell-mediated immunity or DTH. Genetic variability of the
subjects vaccinated, the nature of the mycobacteria endemic in different
parts of the world, the use of different strains of BCG for immunization,
and the use of different doses of bacteria and different schedules of
immunization may all contribute to this variability in efficacyY
BCG vaccination is not commonly used in the United States. Because
the infection rate for TB in this country is relatively low, there is value in
detecting M. tuberculosis infection with the tuberculin skin test. BCG
vaccination would limit the value of skin testing, and may not signifi-
cantly protect against active disease.

DEFECTS IN HOST IMMUNITY

Diseases or medications that suppress cellular immunity lead to an

increased incidence of tuberculosis? Malnutrition, malignancy, and treat-
ment with immunosuppressive agents increase an individual's suscepti-
bility to disease if the M. tuberculosis organism is inhaled. Silicosis also
increases the incidence of TB, presumably because of depressed alveolar
macrophage function. 2o Because the clinical manifestations of active TB
are the result of a balance between host defenses and bacterial virulence,
the presentation of disease may be different in immunocompromised
individuals.
The HIV epidemic has produced a large number of individuals who
 IMMUNOLOGY OF TUBERCULOSIS 1247

are more susceptible to TB. Infection with HIV affects cell-mediated

immunity by decreasing the numbers and function of CD4 + T cells. 57
Macrophages may be a reservoir for HIV, but the macrophages from
HIV infected persons do not show an altered ability to inhibit intracellu-
lar growth of M. tuberculosis organisms in vitro.so Altered lymphokine
production in HIV-infected individuals may be responsible for the unu-
sual clinical manifestations seen in patients with coexisting TB. Also,
lymphokines produced in response to a TB infection may change the
course of the HIV infection. TNF has been shown in vitro to cause
activation of HIV in human cell lines and increase the circulating levels
of HIV antigen?O
TB is a sentinel disease for AIDS because it is frequently the first
indication of HIV infection. The risk of developing reactivation of latent
TB for individuals who have positive PPD and then seroconvert to HIV
positivity is about 8% a year. lO This is in contrast to the 10% lifetime risk
for PPD-positive healthy individuals. B3 The course of TB in HIV seropos-
itive individuals tends to be rapid, and the clinical manifestations of
disease may be altered. In seriously immunocompromised hosts, lesions
containing M. tuberculosis tend to be diffuse with poor or absent granu-
loma formation. Extensive necrosis and marked neutrophil predomi-
nance in the areas of inflammation are noted. Macrophages may be
foamy in appearance and laden with bacteria. 3 ! The burden of mycobac-
terial organisms may be extremely large. There are reports of M. tuber-
culosis organisms being isolated from blood cultures?6 Although patients
with coexistent HIV infection but minimal immunodeficiency may show
a normal pattern of the disease, miliary TB and extrapulmonary disease
such as meningitis are common. Diagnosis of TB in patients with HIV
infection is often difficult because PPD anergy may be present and chest
radiographs may show only diffuse patterns of infiltration?!

SUMMARY

TB is a chronic, necrotizing infection caused by M. tuberculosis. The

clinical manifestations of disease are the result of a balance between the
host response and bacterial virulence. Cellular immunity is responsible
for effective control of infection, but cytokines released during the proc-
ess of cellular immunity may also cause harm to the host. Humoral
immunity plays little part in protection against TB. Individuals with
defective cellular immunity are much more susceptible to disease from
M. tuberculosis and are more likely to have a disseminated form of TB.

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Address reprint requests to

Nancy E. Dunlap, MD, PhD
Department of Medicine
OHB 246
University Hospitals
Birmingham, Alabama 35233