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CASE REPORT

PROFILE IMMUNOGLOBULINE M ANTI PGL-1 IN 4 CASES


Shinta Novianti Barnas, Muhammad Dali Amiruddin,Sri Vitayani
Departement of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar

ABSTRACK
Phenolic glycolipid antigen (PGL-1) is the most widely studied because it has characteristics typical for M.leprae. Examination of IgM anti PGL-1 is one of the checks that can be used to detect subclinical stages of leprosy patients, and monitoring treatment outcomes. In this paper we will compare titers of IgM anti PGL-1 on household at home, without symptoms, prior treatment of leprosy cases and cases of leprosy with erythema nodosum leprosum reactions (ENL) and release from treatment (RFT) over 2 years. Keywords: Ig M anti PGL-1, leprosy, detection, and monitoring.

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Profile Immunoglobuline M Anti Pgl-1 In 4 Cases

INTRODUCTION
Leprosy is a chronic granulomatous infectious disease caused by Mycobacterium leprae (M.Leprae) that attacks the peripheral nerves, skin, oral mucosa, upper respiratory tract, reticuloendothelial system, eyes, muscles, bones and testes, except for the central nervous system. (1 -4) Leprosy is a very important issue because it can cause physical deformity and progressive problem with serious socioeconomic impacts. (2, 5) In early 2009, the global prevalence of leprosy was 213 036, the number of new cases detected was 254 525. prevalensi kusta di Indonesia adalah 17.441. (6)) prevalence of leprosy in Indonesia is 17 441. (6) The discovery of new leprosy cases are not diminished in the last 15 years, especially in endemic areas of leprosy, instead of showing the ineffectiveness of leprosy eradication program, but because of the possibility that both the phenomenon of subclinical leprosy cases. (7) The incidence of leprosy is more serious in certain groups, especially in the family. (1, 2) From the above data it can obtain information that the prevalence rate is still high and the discovery of new cases is high enough it is necessary to break the chain of transmission. One approach is through a bacterial cause (M.leprae) which is a component that plays an important role, namely Phenolic glycolipid (PGL-1), an antigen that can cause an antibody response in the body, and its presence can be detected through examination of PGL-1 serological test . (2, 8) IgM antibody anti-Phenolic glycolipid (PGL-1) are considered specific for M.leprae and there is no cross-reaction with M. tuberculosis infection serum, M.kansasii, M.avium and M.intracellulare. (9) Examination of ELISA allows the detection of antibodies to PGL-1 molecule. Soebono stated that the serological ELISA test that detects antibodies IgM anti PGL-1 is quite sensitive and specific as a diagnostic test M.leprae subclinical infection. PGL-1 antigen can stimulate

potent IgM antibody response to these Ig titers in the serum increased in proportion to the index M.leprae bacteria in patients and decreased with therapy. (10) Benefits serology against PGL-1 antibody that is: to help improve the accuracy of the classification of leprosy in field, to identify leprosy patients clinical stage, detect and predict the incidence of relapse, therapy keherhasilan monitor, predict the possibility of leprosy reactions. (11, 12) ELISA test is a laboratory test that requires special equipment and highly skilled, so that the leprosy is only done for special purposes, eg for research or specific cases. The advantage of this test is very sensitive, so it can detect antibodies in small amounts. (13) In this paper we will compare titers of IgM anti PGL-1 on household at home, without symptoms, prior treatment of leprosy cases and cases of leprosy with erythema nodosum leprosum reactions (ENL) over and release from treatment (RFT) 2 years.

MATERIAL AND METHOD


Cases examined are divided into 3 groups, namely, the case which is the household with the leprosy without skin lesions, cases of leprosy with ENL reaction and RFT over 2 years old and the new leprosy cases before treatment. ELISA is an examination that involves imunoassay using the antibody as a reagent that will bind to one of the reactants in a immunoassay which facilitates the calculation through a change in color after the addition of a suitable substrate. Examination procedures titer IgM anti PGL-1 by ELISA technique: 1. Coating buffer included 50 l and antigen NT-P-BSA working solution in a microplate that had been incubated for 1 h at 37 C. 2. Microplate washed 3 times with washing buffer (PBST solution /

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phosphate buffered saline + o, O5% Tween 20). 3. Blocking buffer included 200 l into the microplate, incubated for 1 h at 37 c. 4. Blocking buffer is removed. 5. 50 l serum was added to diluted with dilution buffer (1:30), into a microplate and incubated again for 1 h at 37 C. 6. Microplate washed with washing buffer 3 times. 7. 50 l antibody is inserted into the microplate, incubated for 1 h at 37 C (IgM diluted 1:2000 with dilution buffer as much). 8. Microplate washed again with washing buffer 3 times. 9. Substrate solution is given by 100 l into the microplate to yellow / orange. 10. Staining reaction was stopped after 10-30 minutes (counting time optimazation best staining) by adding 100 l stopping solution. stopping solution. 11. Uptake rates (OD) was calculated with the ELISA reader, the data is stored and processed by a computer program such as Biolise / X-read to be converted into Units / ml.
Table1. The results of ELISA test.

DISCUSSION
Widely used methods to monitor disease activity and treatment effect in patients with leprosy, M.leprae load and assess the bacteriological index (BI) from skin biopsies and skin smears. (14) At present some progress in the serological detection of leprosy have been reported. Several types of leprosy infection serology has been reported. One type of leprosy serology test is enzyme-linked immunesorbent assay (ELISA). (15) IgM class antibodies are the first to arise when there is stimulation of antigen leprosy germs. In most cases, PGL-1 antibody titer began to decline since the treatment started. Long-term treatment of leprosy was reported successful in reducing antibodies to PGL-1. Typically 25-50% decrease each year, (16) but varies among individuals. To determine the threshold value (cut off) from the results of this ELISA test, usually determined after knowing the value of the individual equivalent of the leper, and that is not leprosy. But for leprosy endemic areas, many healthy people also showed PGL-1 antibody titer is high enough, so the determination of this threshold value varies from one place to another place. In the area of East Java threshold value for antibody IgM anti PGL1 has been known to about 600 u / ml. (17) In the case of A which is the treatment of patients post MDT (RFT 2 years) with a history of 3 times the experience ENL reaction. These patients at the results of titer IgM anti PGL-1 obtained the results of 502 u / ml, still below the threshold value. This is according to Meeker et al, which states that the decline in antibody titer of PGL-1 linear and fast, but there is a slow decrease and remained positive for several years after treatment, probably because there are dead or dormant bacteria. (18) Research conducted by Mukhtar (2010) also showed more positive IB (60%) was found in RFT shorter (2 to 2.5 years) compared to RFT 2.5 - <3

NO 1. 2. 3. 4.

CASE A B C D

RESULTS IgM (u / ml) 502 82 221 1631

The table showed case A which is post MDT IgM 502 u/ml, case B and C which is household of leprosy patient Ig M 82 u/ml and 221 u/ml, and case D pasient suspected leprosy with a typical clinical symptoms found elevated levels of Ig M 1631 u/ml. Threshold value used is the value of the laboratory where the laboratory examination of Leprosy Disease Institute Airlangga University, 600 u / ml.

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years. (19) In this patient a bacteriological index ( IB) = 1.5 and the morphology index (MI) = 0. Case B is household, while case C is domiciled in leprosy endemic areas. Both of them without clinical symptoms which support towards leprosy. From the results obtained IgM anti PGL-1 in patient B and patient C 82u/ml 221 u / ml. The results obtained are still below the threshold value (600 u / ml). Examination of IgM anti PGL1 can be used as early detection of bacterial infection M.leprae in people at high risk such as household or in an endemic area. (20) Case D is a patient suspected of leprosy patients with complaints of erythematous lesions on the face of hipoesthesia, ulcers pedis and facial palsy. Histopathologic examination of the results are not obtained the picture of leprosy. On examination of IgM anti PGL-1 RESULTS 1631 u / ml, the number is higher than the threshold value (600 u / ml). In the study conducted Listiawan et al, on the type of MB leprosy patients before the RFT in Surabaya showed that there is a relationship between high levels of BI with IgM anti PGL-1 is the higher the BI, levels of IgM anti PGL-1 also increased. (21) PGL-1 antigen is the most widely studied because it has a useful serological characteristics, for example, the specific nature to M.leprae, a lot of numbers in patients with leprosy and its ability to stimulate antibody PGL-1 has a linear correlation with clinical bacterial index patient, resulting in high blood levels are found in MB leprosy patients but only low levels are found in PB leprosy patients. (22, 23) In this paper could not be determined whether the case A has declined not because the titer or IgM anti PGL-examination of a one time only. While in the case of B and C should be examined IgM anti PGL-1 each year for early detection. A study in Colombia where the examination IgM anti PGL-1 in 2001 and later re-examination conducted in

2007 found the occurrence of positive seroconversion in household as much as 28%. (24)

CONCLUSION
PGL-1 antigen is the most widely studied because it has characteristics typical for M.leprae. Examination of IgM anti PGL-1 is one of the checks that can be used to detect subclinical stages of leprosy patients, and monitoring treatment outcomes.

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