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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 76-82

Serum immunoglobulin a antibodies to glycopeptidolipid core antigen for Mycobacteroides abscessus complex lung disease


1 Department of Internal Medicine, National Hospital Organization, Kinki-Chuo Chest Medical Center, Sakai City, Osaka, Japan
2 Department of Infectious Diseases, Clinical Research Center, National Hospital Organization, Kinki-Chuo Chest Medical Center, Sakai City, Osaka, Japan
3 Clinical Research Center, National Hospital Organization, Kinki-Chuo Chest Medical Center, Sakai City, Osaka, Japan

Date of Submission29-Jan-2020
Date of Acceptance02-Feb-2020
Date of Web Publication6-Mar-2020

Correspondence Address:
Kazunari Tsuyuguchi
Department of Infectious Diseases, Clinical Research Center, National Hospital Organization, Kinki-Chuo Chest Medical Center, Sakai City, Osaka
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_14_20

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  Abstract 


Background: Mycobacteroides abscessus complex (MABC) exhibits smooth morphotypes, expressing glycopeptidolipid (GPL), and rough morphotypes, expressing diminished GPL, on the MABC cell wall. Few reports have focused on the relationship between anti-GPL-core immunoglobulin A (IgA) antibody and colony morphology in MABC lung disease. Methods: This study aimed to test GPL core antigen in patients with MABC lung disease to investigate the relationship between coinfection/contamination in other nontuberculous mycobacteria species and colony morphology variant in MABC isolates. Patients with MABC lung disease and contamination diagnosed between 2012 and 2017 at our hospital were enrolled retrospectively. Results: Of the assessed patients, 43 patients with MABC lung disease and 13 with MABC contamination were included. There was a significant difference in anti-GPL-core IgA antibody levels between them (P = 0.02). Forty-three patients with MABC lung disease were divided into two groups as positive and negative antibodies groups. A significant increase in the positive anti-GPL-core IgA antibody was observed in coexistence with both Mycobacterium avium complex (MAC) (P = 0.02) and the isolate of the smooth variant (P = 0.03) in MABC.Conclusions: Anti-GPL-core IgA antibodies in patients with MABC are greatly influenced by MAC coexistence, and colony morphology variant of the MABC isolate.

Keywords: Anti-glycopeptidolipid-core immunoglobulin A antibody, colony morphology variant, Mycobacterium avium complex, Mycobacteroides abscessus complex


How to cite this article:
Kobayashi T, Tsuyuguchi K, Yoshida S, Kurahara Y, Minomo S, Inoue Y, Suzuki K. Serum immunoglobulin a antibodies to glycopeptidolipid core antigen for Mycobacteroides abscessus complex lung disease. Int J Mycobacteriol 2020;9:76-82

How to cite this URL:
Kobayashi T, Tsuyuguchi K, Yoshida S, Kurahara Y, Minomo S, Inoue Y, Suzuki K. Serum immunoglobulin a antibodies to glycopeptidolipid core antigen for Mycobacteroides abscessus complex lung disease. Int J Mycobacteriol [serial online] 2020 [cited 2020 May 31];9:76-82. Available from: http://www.ijmyco.org/text.asp?2020/9/1/76/280135




  Introduction Top


Worldwide, the incidence and prevalence of nontuberculous mycobacterium (NTM) lung disease are rapidly increasing.[1],[2] Causative species of NTM lung disease are distributed according to country and region. In Japan, the most common species is Mycobacterium avium complex (MAC), comprising approximately 90% of all cases, followed by Mycobacterium kansasii and Mycobacteroides abscessus complex (MABC), comprising 4.3% and 3.3%, respectively.[1],[3],[4] MABC comprises a group of rapidly growing mycobacteria.[5] Clinical features of MABC, such as exhibiting pulmonary bronchiectasis, are similar to those of MAC lung disease.[6] MABC lung disease is often complicated with MAC lung disease.[7]

The glycopeptidolipid (GPL) antigen of the cell walls of MAC and MABC share the common structure of a GPL core.[8],[9] The usefulness of anti-GPL-core immunoglobulin A (IgA) antibody for the diagnosis of MAC lung disease has been well documented.[10],[11] The sensitivity and specificity of the test for diagnosing MAC lung disease were very high for serum IgA (52%–84% and 94%–100%, respectively).[10],[12],[13] However, the testing of the GPL core antigen in patients with MABC lung disease has been poorly documented. The levels of GPL core antigen in patients with MABC lung disease may be elevated by the coinfection or contamination of MAC or by the GPL antigen of the cell wall of MABC itself. This study was conducted as a retrospective study on the relationship among bacterial factors (the colony morphology variant) and factors within the host (the coexistence of other NTM species [especially MAC] causing lung disease, radiological findings, comorbidities, and anti-GPL-core IgA antibody) in patients with MABC lung disease.


  Methods Top


Study design

In our retrospective single-institution study, files from all consecutive patients referred to the National Hospital Organization Kinki Chuo Chest Medical Center, a 365-bed center in Southern Osaka specializing in pulmonary disease, between January 1, 2012, and December 31, 2017, were reviewed. Patients were defined as having MABC lung disease if they had MABC isolate and met the following the American Thoracic Society and Infectious Diseases Society of America diagnostic criteria:[5] the presence of at least two positive sputum cultures, one bronchoalveolar lavage culture, or one lung tissue biopsy specimen culture positive for MABC, along with pulmonary symptoms and chest computed tomography (CT) findings. Patients with MABC contamination were defined as having a single positive culture of MABC. Patients with other NTM coexistence were defined as either those having other NTM coinfection or contamination. Patients were enrolled if serum anti-GPL-core IgA antibody levels were measured at the date of diagnosis date MABC lung disease.

Concurrent infection was defined as the appearance of other NTM species at least twice, 2 months before or after the diagnosis of MABC lung disease. If NTM species other than MABC were isolated between 5 years and 2 months before the diagnostic date of MABC lung disease, then patients were diagnosed with other prior NTM species lung disease. The coexistence of other NTM species was defined as either the concurrent infection of an NTM species or a prior NTM species lung disease/contamination.

The Ethics Committee of the Kinki Chuo Chest Medical Center (June 8, 2018, No. 645) approved this study. Because of its nature, informed consent was waived.

Anti-glycopeptidolipid-core immunoglobulin A antibody

At the diagnosis date of MABC lung disease, anti-GPL-core IgA antibodies were measured using the Capilia MAC AB™ enzyme-linked immunosorbent assay (normal cut-off levels, 0.7 IU/mL; TAUNS Laboratory Inc., Shizuoka, Japan) according to the manufacturer's instructions.[14],[15]

Microbiological examination

Patients were diagnosed with MABC lung disease, and their sputum isolations were differentiated into three subspecies – Mycobacteroides abscessus subsp. abscessus (MAA), M. abscessus subsp. massiliense (MAM), and M. abscessus subsp. bolletii, which were identified by hsp65, rpoB, and erm (41), respectively.[16]

Morphotypes of smooth and rough

The frozen stock was streaked for isolation, and individual variants were cultured on 7H10 agar containing 10% OADC and glycerol (Kyokuto Pharmaceutical, Inc., Tokyo, Japan) and solid Ogawa medium (Serotec, Sapporo, Japan). MABCrough and MABCsmooth isolates were distinguished by colony morphotypes of the initial MABC isolates. For patients with MAC coexistence, the colony morphology of the initial MAC isolate was determined.

Evaluation of radiologic findings

Two patterns on chest CT findings – nodular/bronchiectatic and fibrocavitary – were used to classify radiographic features.[17]

Statistical analysis

Categorical variables were analyzed using Chi-square test or Fisher's exact test, and continuous variables were analyzed using Mann–Whitney U-test or t-test. All P values were two-sided. A P < 0.05 was considered statistically significant. Statistical analyses were conducted using JMP statistical software (12th version, SAS Institute Inc., Cary, NC). Proportions and medians were used to describe demographic, clinical, and radiographic characteristics.


  Results Top


Patient characteristics

Fifty-three patients with MABC lung disease and 20 with a single positive culture of MABC isolate collected between January 2012 and December 2017 at our institution were enrolled. Among these, 43 patients with MABC lung disease and 14 with MABC contamination underwent testing for anti-GPL-core IgA antibody. [Table 1] summarizes the characteristics of patients with MABC lung disease and those with MABC contamination. A significant difference was found between the two groups in anti-GPL-core IgA antibody levels (P = 0.02). Patients with MABC lung disease more frequently exhibited the MABCrough morphotype than those with MABC contamination (P = 0.01). No mixed variants (MABCroughandsmooth) were observed. Among patients with MABC lung disease, 20 (46.5%) patients were found with other coexisting NTM species: one (2.3%) with M. kansasii lung disease, three (7.0%) with both M. kansasii and MAC lung disease, 15 (34.9%) with MAC lung disease, and one (2.3%) with MAC contamination. Among 20 patients with other NTM species were 15 patients with concurrent infection and 5 with prior lung disease. Among patients with MABC contamination, three (21.4%) had prior MAC lung disease [Table 1].
Table 1: Patient characteristics of Mycobacteroides abscessus complex lung disease and contamination

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In patients with MABC lung disease, 24 (55.8%) had MAA lung disease and 19 (44.2%) had MAM lung disease. No patients were identified as having M. abscessus subsp. bolletii or MAA/MAM mixed lung disease [Table 1].

Patient characteristics and antibody levels in patients with Mycobacteroides abscessus complex lung disease

The 43 patients with MABC lung disease were classified into two groups – the positive antibodies group with anti-GPL-core IgA antibodies levels of >0.7 IU/mL[15] and the negative antibodies group with anti-GPL-core IgA antibodies levels of <0.7 IU/mL. The positive antibodies group included 17 patients (39.5%), and the negative antibodies group included 26 patients (61.5%) [Table 2]. The median age, proportion of men, and prevalence of comorbidities were similar between the two groups. In the positive antibodies group, more patients had complications with MAC lung disease or contamination (P = 0.02). Compared with patients in the negative antibodies group, those in the positive antibodies group more frequently exhibited the MABCsmooth morphotype: 4/20 (20.0%) versus negative antibodies group: 9/13 (69.2%); P = 0.01). No patients in the positive antibodies group and three in the negative antibodies group had comorbidities of lung cancer (0 [0.0%] vs. 3 [11.5%], P = 0.15) [Table 2].
Table 2: Patient characteristics of Mycobacteroides abscessus complex lung disease

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This study demonstrated that serum IgA antibody levels were higher in MABC patients with MAC coexistence than in those without MAC coexistence (median anti-GPL-core IgA antibody levels with MAC coinfection: 2.35 U/mL [0.0–17.48 U/mL] and without MAC coinfection: 0.14 U/mL [0.00–8.32 U/mL]; P = 0.002) [Figure 1]. In the subanalysis among MABC lung disease patients without MAC coexistence, anti-GPL-core IgA antibody levels were higher in patients with MABCsmooth than in those with MABCrough(median anti-GPL-core IgA antibody levels: MABCrough: 0.12 IU/mL [0.00–8.32 IU/mL], MABCsmooth: 0.54 IU/mL [0.12–5.87 IU/mL]; P = 0.039). However, in patients with MABC lung disease without MAC coexistence, the difference between positive rates for the enzyme immunoassay in patients with MABCrough and those with MABCsmooth was not statistically significant (MABCrough: 3 [16.7%] vs. MABCsmooth: 2 [33.3%], P = 0.568) because of the small sample size [Figure 1]. In this study, MABCsmooth was more frequently observed in the isolate from patients with MABC lung disease with MAC coexistence than in those with MABC lung disease without MAC coexistence (with MAC coexistence: 13 [68.4%], without MAC coexistence: 6 [25.0%], P = 0.006) [Table 3].
Figure 1: The distribution of the anti-GPL-core IgA antibody in patients with MABC (with or without MAC coexistence). (a) Patients who had the MABCroughisolate with MAC coexistence, (b) those who had the MABCsmoothisolate with MAC coexistence, (c) those who had the MABCroughisolate without MAC coexistence, and (d) those who had the MABCsmoothisolate without MAC coexistence. GPL: Glycopeptidolipid, MABC: Mycobacteroides abscessus complex, MAC: Mycobacterium avium complex, IgA: Immunoglobulin A

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Table 3: Association between Mycobacterium avium complex coexistence and the colony variants in Mycobacteroides abscessus complex

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  Discussion Top


Enzyme immunoassay was developed for the anti-GPL-core IgA antibody, which is an important epitope of the cell wall of MAC.[18] NTM organisms, including MAC and MABC, possess GPL,[9] leading to the reportedly high levels of serum IgA antibody to the GPL core antigen in both patients with MABC and those with MAC lung disease.[15] MABC grows on solid medium, with appearances of the colonies distinguishing the smooth and rough morphotypes. The most obvious manifestation of GPL expression is the bacterial colony morphotype – smooth when GPL is expressed on the cell wall and rough when it is absent – as demonstrated in naturally occurring variants of both MABC and MAC.[19],[20],[21] However, few reports have focused on the relationship between GPL antibody and colony morphology in NTM lung disease, including MABC lung disease.

Two notable clinically relevant issues related to the anti-GPL-core IgA antibody were underscored in patients with MABC lung disease in this study.

First, serum IgA antibody levels were higher in patients with MABC with MAC coexistence than in those without MAC coexistence. Although the measurement of serum IgA antibodies was a useful tool in the diagnosis of MAC lung disease,[14] reacting to the GPL core antigen derived from either GPL of MABC and MAC may influence the high levels of serum IgA antibodies of both MABC lung disease and MAC lung disease.[15] The present study revealed that MAC coexistence might elevate serum IgA antibody levels in patients with MABC.

Second, positive rates for enzyme immunoassay were higher in patients with MABC lung disease with MABCsmooth isolation than in those with MABCrough. Bacterial colony morphotypes manifest GPL expression; the colony is generally smooth when GPL on the cell wall is expressed and rough when it is absent. Recently, Kim et al. have reported that the MABCrough isolation of MAM is genetically acquired through deletion events at the GPL gene locus.[22] Reduction in anti-GPL-core IgA antibody levels in patients with MABC lung disease with MABCrough isolate is partly accounted for by the GPL gene locus deletion.

MABCsmooth was more frequently observed in the isolate from patients with MABC lung disease with MAC coexistence than in that from patients without MAC coexistence. The coexistence isolation of multiple NTM species and co-culture MAC was observed among 20% of patients with MABC lung disease.[7] Lee et al. have reported that several patients with NTM treatment experience changes in the NTM species during or after treatment completion (particularly changes from MAC to MABC or from MABC to MAC).[23] In our study, MABCsmooth of the isolate was more frequently observed in patients with MABC lung disease with MAC coexistence than in those without MAC coexistence. GPL expression enhanced a smooth colony variant biofilm-forming phenotype, whereas the rough colony variant was a nonbiofilm-forming phenotype.[19],[20],[24],[25] The presence of GPL in MABC prevents Toll-like receptor 2 (TLR2) signaling in respiratory epithelial cells, which may allow for lung colonization.[26] The more frequent exhibiting of MABCsmooth in the isolate from patients with MAC coexistence may be attributable to TLR2 suppression by the presence of GPL on the cell wall[26],[27] or the characterization of biofilm-forming in MABCsmooth.[19],[24]

The present study had several limitations. First, its retrospective nature resulted in a small sample size and selection bias. Anti-GPL-core IgA antibody assay could not be routinely performed. Second, the study lacked a control group. Jeong et al. have reported that 0.52 UL/mL of GPL antibody is the proper cut-off to distinguish both MAC and MABC lung disease from other diseases (such as tuberculosis), but in their study, patients with MABC included those with a complication of MAC lung disease. Further studies are required to confirm the level of 0.7 UL/mL as an appropriate cut-off of GPL antibody in the diagnosis of MABC lung disease.

Our study focused on the testing of the GPL core antigen in patients with MABC lung disease and confirmed the relationship between the coexistence of other NTM species and colony morphology variant in MABC isolates. Previous reports have demonstrated that in patients with MAC lung disease, anti-GPL-core IgA levels could be affected by comorbidities such as immunocompromised deficiency disease and malignancy.[13],[28],[29] However, no such influence of comorbidities, such as an immunocompromised state or malignancy, was observed on anti-GPL-core IgA antibody levels in patients with MABC lung disease in this study. Further studies are needed to clarify this.


  Conclusions Top


The colony morphotype of MABC isolate might be associated with MAC coexistence in patients with MABC lung disease. Anti-GPL-core IgA antibody levels are greatly affected by both MAC coexistence and colony morphology variant of MABC.

Acknowledgement

We acknowledge Mika Kihara and Motohisa Tomita (Kinki-Chuo Chest Medical Center) for technical support with distinguishing colony morphotype of the MABC isolate. This study is supported in the idea by Nontuberculous mycobacteriosis and bronchiectasis- Japan Research Consortium (Tokyo). We are grateful thank to Dr. Nagatoshi Fujiwara (Faculty of Contemporary Human Life Sciences, Tezukayama University) for his assistance in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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