64,4^ Correspondence^ 453

antigen 85 in leprosy. Int. J. Lepr. 62 (1994)48-54.

5. MISTRY, N. F., MuRTY, S., SMINA, K. B., KUL-KARNI, V. C., ANTIA, N. II. and HARBOE, M. Im-munodiagnosis of tuberculosis and leprosy. (Let-ter) Natl. Med. J. India 6 (1993) 297.

6. MottAtv, C. J., TURK, J. L., RYDER, G. and WATERS,M. F. R. Evidence for circulating immune com-plexes in lepromatous leprosy. Lancet 2 (1972)572-573.

7. ota S. K. Elimination of leprosy as a pub-lic health problem: progress and prospects. Bull.WHO 73 (1995) 1-6.

8. PiissoLANI, M. C. V. and BRENNAN, P. J. My-cobacterium leprae produces extracellular ho-mologs of the antigen 85 complex. Infect. Immun.60 (1992) 4452-4459.

9. RAMASESH, N., HASTINGS, R. C. and KRAIIENBUI11.,J. L. Metabolism of Al. leprue in macrophages.Infect. Immun. 55 (1987) 1203-1206.

10. RUMSCHLAG, H. S., SIIINNICK, T. M. and COHEN,M. L. Serological responses of patients with lep-romatous and tuberculoid leprosy to 30-, 31-, and32-kilodalton antigens of Mycobacterium tubercu-losis. J. Chit. Microbiol. 26 (1988) 2200-2202.

11. SATISII, NI. and NATII, I. The uptake of 'H thymi-dine in Al. leprae-inoculated mouse macrophagesas a rapid indicator of bacterial viabilitiy. Int. J.Lepr. 49 (1981) 187-193.

12. SEHGAI., S. and KUMAR, B. Circulating and tissueimmune complexes in leprosy. Int. J. Lepr. 49(1981) 294-301.

13. WIRER, H. G. and HARBOE, M. The antigen 85complex: a major secretion product of M. tubercu-losis. Microbiol. Rev. 56 (1992) 648-661.

14. WIKta II. G., HARBOE, NI., NAGAI, S., PATAR-ROYO, M. E., RAMIREZ, C. and CRUZ, N. MI313 59,a widely cross-reacting protein of Mycobacteriumboris BCG. Int. Archs. Allergy Appl. Immun. 81(1986)307-314.

Prevalence of Antibodies to Hepatitis C Among RecentlyTreated Leprosy Patients in Senegal Parallels Those in

Normal Populations

To THE EDITOR:Recent reports focused on a higher

prevalence of hepatitis C (HCV) antibodies(Abs) in leprosy patients than in matcheduninfected individuals ( 3 . 5 ). Having fol-lowed a 175-patient cohort under field con-ditions, we do not confirm a higher carriageof hepatitis C among leprosy patients inSenegal, and we suggest that the high levelspreviously observed might rather be associ-ated with epidemiological conditions withinthe populations studied.

Infection with Mycobacterium leprue isaccompanied by a profound alteration ofcellular immunity leading to the differentaspects of the leprosy spectrum. Little isknown about the exact influence of the lackof T-cell immunity observed in leprosy andthe susceptibility to viral infections. In thisline, we investigated the seroprevalence toHCV using sequentially 2 third-generationELISAs (Ortho HCV 3.0°°; Chiron Corp.,Emeryville, California, U.S.A.; Murex anti-HCV version III, Templehill, England) andan immunoblot assay (Ortho RIBA 3.0.®;Chiron). Genotyping of positive HCV serawas carried out using an ELISA revealingcirculating antibodies to recombinant NS4

proteins (Murex HCO2) ('). Two othermarkers of viral infection were also exam-ined, i.e., the presence of hepatitis B virusantigen (HBs Ag) and HIV antibodies usingcommercially available kits; Monolisa' andElavia mixte", respectively (Sanofi-Pasteur,Marne la Coquette, France).

Subjects consisted of 147 newly diag-nosed patents and 28 previously treated(monotherapy) patients entering a new sur-vey for the efficacy of a fully supervised,intermittent, single-dose poly-antibiother-apy. Enrollment was done from March toDecember 1995; patients received full in-formation regarding this investigation andan initial blood sample was taken at thetime of the enrollment visit. During the sur-vey, serum was kept in a dry sterile tube at4°C (for approximately 12 hr) in the fieldand then frozen at —20°C until further assays.

A similar prevalence of the viral markerswas found in sera from leprosy patients anda normal population. The HIV antibodyprevalence reported here is in line with pre-vious studies conducted on West Africanpopulations ( 21. Secondly, the HBs antigencarriage found in this study was not higherthan that found in recent determinations

454^ International Journal of Leprosy^ 1996

Tiii TABLE. Characteristics of the cohort of leprosy patients and results of the screen-ing for antibodies to HIV and HCV and for HhS antigen.

Patients Type of leprosy Positive serologyNo. Mean age P13' MB' HIV-1 HCV IlbS Ag

Males 103 31 50 53 1 16(48.5%) (51.5%) (15.5%)

Females 72 31 40 32 1 0 8(55.6%) (44.4%) (11.1%)

Total 175 31 90 85 2 1 24(6-65) (51.4%) (48.6%) (1.1%) (0.6%) (13.7%)

PB = paucibacillary; MB = multihacillary.PB leprosy (clinically BT).

that we carried out in the control populationbelonging to a matched study of hepatitiscases (19% of HBs+) (Renaudineau, Y. andRaphenon, G. Manuscript in preparation).

In addition, in contrast to data from oth-ers ( 3 . 5 ), we did not find a higher level ofprevalence of HCV in this leprosy popula-tion. Two explanations can be proposed:first, the use of third-generation ELISAsleads to more accurate results and probablyeliminates false positives; second, the pa-tients enrolled in this study did not live inconditions favoring transmission of HCV(such as observed in leprosarium) associ-ated with promiscuity and/or with poor san-itary conditions (4 . 5). As a matter of fact, us-ing the third-generation techniques, a rela-tively low frequency was found recently ina cohort of Senegalese patients sufferingfrom liver diseases (2 out of 67; the HCV+patients had hepatocarcinoma) as comparedto a control population (6 of 943 blooddonors). In addition, the HCV antibody-positive leprosy patient was from serotype2, which is the main circulating serotypesince it is found in 80% of the confirmedHCV+ serologies in our overall studies (Re-naudineau, Y. and Raphenon, G. Manu-script in preparation).

Taken together, our results suggest thatanergy or disorders of the immune systemwhich accompany leprosy are not associ-ated with chronic carriage of hepatitis Cwhen epidemiological conditions for M.leprae-infected patients do not favor hepati-tis C transmission.

—Yves Renaudineau, Pharm.D.Laboratoire de Biologie CliniqueInstitut Pasteur de DakarDakar, Senegal

—Ibrahima Mane, M.D.Institut de Leprologie Appliques de DakarDakar Senegal

—Georges Raphenon, M.D.Laboratoire de Biologie CliniqueInstitut Pasteur de DakarDakar Senegal

—Mbayame Ndiaye Niang, Pharm.D.Laboratoire d'InununologieInstitut Pasteur de DakarDakar, Senegal

—Jean-Louis Cartel, M.D.Institut de Leprologie Appliquê.e de DakarDakar Senegal

—Ronald Perraut, Pharm.D., Ph.D.Laboratoire d'ImmunologieInstitut Pasteur de Dakar36 At'. PasteurB.P. 220Dakar Senegal

Reprint requests to Dr. Perraut at addressabove or Fax 221-23-87-72; email =perraut@pasteur.pasteur.sn

Acknowledgment. The authors are very gratefulto Drs. 1. Pike and J. Botha for providing HCV detec-tion kits; to B. Diouf and Dr. A. Pellegrin for their con-tributions to this work, and to Dr. 0. Garraud for criti-cal reading of the manuscript.

REFERENCESBlIATTACIIERJEE, V., PRESCOTT, L. E., PIKE, I.,Roixalts, B., BELL, H., EI.-ZAYADI, A. R., KI:w, M.C., 0)NR/m:, J., LIN, C. K., MARSDEN, H. SAIaA. A., PARKER, D., YAP, P. L. and SimmoNps, P.Use of NS4 peptides to identify type-specific anti-

64, 4^ Correspondence^ 455

body to hepatitis C virus genotypes 1,2,3,4,5 and 6.J. Gen. Virol. 76 (1995) 1737-1748.

2. BLUM, L., OGOUGHENIY, M., M' Bout', S., GRINIAUD,

J., MILIAN, J., LAtiNots, P., GAYE, Y., Li: GUENNO,

B., GAYE, A. and PLAGEUL, B. Etude epiderni-ologique de la seroprevalence de l'infection par leVIII dans one population hansenienne au Senegal.Acta Leprolo. 8 (1922) 35-41.

3. DENIS, F., AUSSEL, L., RANGER, S., MARTIN, P.,lioun-N'cAPoRD, A., FRommEt., D., TECKLE-

HAINIANOT, R. T., SANGARE, A., M'Bout', S., MIL-

IAN, J. and At. Quivcri, Y. Prevalence of antibodiesto hepatitis C virus among patients with leprosy inseveral African countries and the Yemen. J. Med.Virol. 43 (1994) 1-4.

4. FAKUNLE, Y. M. and WHITTLE, H. C. Hepatitis-Bvirus infection in patients with leprosy; a serologi-cal study in a leprosarium in northern Nigeria.Trans. R. Soc. Trop. Med. Hyg. 75 (1981)623-625.

5. FRommE1., D., TECKLE-HAINIANOT, R. T., BERIIE,

N., Ausst a ., L., VERDIER, M., PREUX, M. P. and DE-

NIS, F. A survey of antibodies to hepatitis C virusin Ethiopia. Am. J. Trop. Med. Hyg. 49 (1993)435-439.

6. TOUNKARA, A., ForANA, Y., DIARATE, N. and SAN-

CARE, D. Etude de la seroconversion anti-V1Hchez les lepreux lepromateux au Mali. Med. Afr.Noire 38 (1991) 89-91.

Dormancy, Drug Resistance or Dependency; SomeThoughts to Ponder

To THE EDITOR:This study, using the mouse foot pad

method, was aimed at investigating M VCO-

bacterium leprae persistors in the skin andnerves of leprosy patients and their sensitiv-ity to drugs after a fixed duration of theWorld Health Organization-recommendedmultidrug treatment (WHO/MDT). Certainobservations were intriguing and persuasive.

Secondary resistance to dapsone (DDS)(0.01 g%) and rifampin (0.001 g%) wererecorded in two of the multibacillary casestreated and released from WHO/MDT. Itwas noted, however, that in both patientsthe percentages of takes (in second passage,mice to mice) were higher in the presenceof DDS. Both were 80% as compared to un-treated mice of 60% and 16.6%, respec-tively (The Table), and the average fold in-creases/foot pad of M. leprae were 10 timesmore in DDS-treated mice, suggesting thatthese organisms grew better in the presenceof 0.01 g% DDS given by oral feeding.

A reconfirmation of the results wassought in these two patients. A second skinbiopsy was obtained from each patient 3years after release from treatment (RFT).The bacterial index (BI) of these biopsieswere: Patient CS had a BI of 5+ and a mor-phological index (MI) of 1%; patient DShad a BI of 4.5+ and a MI of 1%.

Inocula were appropriately diluted togive I x 10 1/0.03 ml and injected into thefoot pads of normal Swiss white mice, and

a direct test for sensitivity to the same con-centration of DDS (0.01 g%) and a higherconcentration of rifampin (0.03 g%) wascarried out.

Contrary to our expectations, both inoc-ula showed no recordable count in the footpads of mice at 6, 7, 8 and 12 months. How-ever, significant counts were obtained at 16months in both of the control groups ofmice. The percentage take in patient CSwas 80% (4/5); in patient DS, 67% (4/6).Only inocula from patient CS showedgrowth in the foot pads of drug-treated mice(percentage take with DDS 0.01 g% = 25%(1/4); with rifampin 0.03 g% = 33% (2/6),thus confirming resistance to both DDS andrifampin using highest concentrations.

Since there were no mice left, furtherharvests and confirmation of growth couldnot be carried out. Nevertheless, these cu-mulative data have raised several questions.

Results from the first part of the study in-dicate that there was a subpopulation of M.leprae that were not only refractory to DDSbut grew better in the presence of DDS (?DDS dependence) and a doubtful rifampinresistance considering the concentration ofrifampin used in this test was only 0.001 g%.

Three years after RFT, the second biop-sies obtained from the same patients, inspite of showing a good BI and 1% MI,failed to show a normal growth pattern.Since the harvests were carried out at regu-lar intervals beginning from month 6, the