- Email: [email protected]
Association of HLA and other genetic MAC in South Indian patients with pulmonary tuberculosis
Tubercle (1987) 68, 159-167 @ Longman Group UK Ltd. 1987
IN SOUTH INDIAN ASSOCIATION OF HIA AND OTHER BENRIIC PATIENTS WlTH PULMONARY TUBERCULOSIS S. S. Papiha,* B. N. Singh,t J. S. S. Lanchbury, * D. F. Roberts,* C. E. Parsad,t J. Wentzel,” and K. J. R. MurtyS *Department
of Human
Genetics,
University of Newcastle upon Tyne, UK, tState T B Centre, irrumnuma, India, SMahavir Hospital, Hyderabad, india
Hyderabad,
Summary Histocompatibility antigens (A, B & C loci) and 23 other single gene characters were studied in 204 pulmonary tuberculosis patients belonging to a single endogamous group in South India. None of the previously reported associations with HLA antigens was confirmed, nor any new one found. The blood 0 and Rh negative associations were also not confirmed, although a new association with the Jk blood group system appears possible. Of particular interest is the association with the phosphoglucomutase (PGMI) system, which parallels that found in a different population located some 1000 km away. Relative risks were calculated to measure the resistance of individuals with the PGMl*2+ allele. R68um6 Les antig&nes d’histocompatibilite (sites A, B et C) et 23 autres caracteres d&erminds par un seul gene ont 6th dtudies chez 204 tuberculeux pulmonaires appartenant 5 un groupe endogame unique d’lnde mkridionale. Aucune des associations avec des antigenes HLA rapport6es anterieurement n’a 6th confirmbe ni aucune nouvelle association n’a 6t6 trouv6e. Les associations avec les groupes sanguins 0 et Rh nbgatif n’ont pas 6tB confirmees non plus, bien qu’une nouvelle association avec le systeme de groupe sanguin Jk semble possible. L’association avec le systbme phosphoglucomutase (PGMI) revQt un int&& particulier; cette association peut Qtre rapprochbe de celle rencontree dans une population diffbrente sit&e quelque 1 000 km plus loin. Les auteurs ont calcul6 le risque relatif pour mesurer la r6sistance des sujets porteurs de I’all8le PGMl*l et la sensibilite accrue des sujets porteurs de I’all&le PGMl*2. Resumen En 204 enfermos con tuberculosis pulmonar pertenecientes a un grupo endogamico tinico en el sur de India, se estudi6 10s antigenos de histocompatibilidad (loci A, B y CI otros 23 caracteres determinados por un solo gen. No se confirm6 ninguna de las asociaciones con antigenos HLA informadas anteriormente, ni se encon& ninguna nueva asociacibn. Tampoco se confirm6 las asociaciones con 10s grupos sanguineos 0 y Rh negativo, aunque parece posible una nueva asociaciCtn con el sistema de grupo sanguine0 Jk. La asociacibn con el sistema fosfoglucomutasa (PGMI) reviste un inter& particular) esta asociacibn es comparable a la encontrada en una poblaci6n diferente situada a 1000 km de distancia, Se calcul6 el riesgo relativo para medir la resistencia de 10s sujetos portadores del alelo PGMI *I y la sensibilidad aumentada de 10s sujetos portadores del alelo PGMI *2+.
160
Papiha
and others Introduction
Examination of the association of genetic markers with tuberculosis has been a relatively recent approach to defining genetic susceptibility to the disease. An increased frequency of blood group 0 was shown in pulmonary tuberculosis patients in Europe [I], but of blood group Al3 and B in Indian and Eskimo patients respectively [2-4]. Other polymorphic loci examined but with which no definite association was found are Rhesus and MN blood groups, PTC tasting, secretor, haptoglobin, group specific component and acetylation status [5-91. However, for the red cell enzyme phosphoglucomutase 1, examined by isoelectric focusing in a single population of Hindu, Uttar Pradesh, India, there was an interesting negative association with the PGMl*l+ allele [IO]. Recently, association of various human leukocyte antigens (HLA) with pulmonary tuberculosis have been desribed. Nine studies from different ethnic groups show increased or decreased frequencies of various antigens at the B and DR loci, but no consistent association [II-191. There may be several reasons for the inconsistencies of these associations. One major draw-back common to several of these studies is the heterogeneous nature of the patients and the control populations investigated. The present study avoids this difficulty by examining genetic markers in patients and controls in a single endogamous group from south India with a high incidence of the disease. The study re-evaluates associations with the genetic markers already studied, and incorporates many more loci, several of which have a significant role in the biochemical and immunological functions of the body. Materials
and methods
All patients and controls were from a single endogamous group of Sunni Muslim from Hyderabad, the capital of the State of Andhra Pradesh, India. There were 204 patients who were sputum positive and in whom pulmonary tuberculosis was radiologically confirmed. The control group consisted of 175 individuals matched for age, sex and region. All the patients and controls belonged to the equivalent of social class IV. Procedures of blood and cell collection and transport were as described previously from this laboratory [IO, 151. I-/L4 typing: Using commercially available antisera (Biotest) and also some donated by NIH Bethesda Maryland, typing was performed using a modification of the NIH lymphocyte microcytotoxicity assay with incubation at 37 “C for 1 h. In all, 70 antisera were used to detect the following specificities. HLA-A 1, 2, 3, 9, ~23, ~24, 25, 26, 11, 28, 29, w39, ~31, ~32. HLA-B ~51, ~52, 7, 8, ~44, 13, 14, 15, ~16, 17, 18, 21, ~35, ~37, 40, ~41, ~42, ~53. HLA-C wl, w2, w3, w4, w5, w7. Other genetic markers: Blood groups were tested by standard serological procedures 1201 using the following antisera: anti-A, A,, B, A+B, C, c, C”“, D, E, e, M, N, S, s, P, K, k, Fya, Fyb and Jk”. Red cell lysates were prepared as described previously [21]. In typing the red cell enzymes and serum proteins (unless described otherwise) horizontal starch gel electrophoresis using Connaught hydrolysed starch was carried out in a cold room. Haptoglobin and transferrin typing was performed by using a discontinuous buffer system 1221. The C3 and Bf phenotypes were characterised by high voltage electrophoresis 1231. The phenotypes of Bf were examined by immunofixation using Bf specific antisera. The lysates were examined for various red cell enzyme systems according to the methods given by Harris and Hopkinson [24]. The PGMI and GC subtyping were performed by isoelectric focusing as described from this laboratory [IO].
Genetic markers in tuberculosis
161
Results Table I gives for each polymorphic system for pulmonary tuberculosis patients, and controls, the phenotype numbers and frequencies, and gene frequencies together with x2 or the exact probability (Fisher) showing the significance of the difference between the patient and control group. The phenotype percentage for HLA-A, B and C antigens in patients and controls are given in Table II. There was no increased frequency of the 0 blood group gene or of the AB phenotype as described in other studies. The slightly elevated frequency of the 6 blood group in patients was non-significant (x2=2.7; d.f. 1; p>O.O5) but parallels the observation on Eskimo patients. There was no association for the Rhesus or the MNSs phenotypes or haplotypes. When the MN and Ss loci were treated separately the slight increase in Ss heterozygote frequencies did not attain significance. Of the remaining blood group systems, P, Kell, Duffy and Kidd, only the Kidd system suggested an association. The frequency of the Jkfa-’ was significantly lower (barely) in the patient group. Among the five serum protein Hp, Tf, C3, BF and GC systems studied, transferrin was monomorphic. The frequency of the Hp*l, and BF*S and rare alleles, and C3*S genes in the patient group did not differ from that of controls. The variation of the GC*lS alleles was slight (patients 58 % vs. control 61 %). Among the thirteen red cell enzymes types SODI, LDH-A, LDH-B, PGM2, PGI were monomorphic. The slight rise in frequencies of GPT*2 and EsD*2 alleles in the patients did not attain significance. Of particular interest is the PGMI locus variation. There was a decrease of the PGMI +I phenotype in patients, while the PGMI +2+ phenotypes showed an increase. This reflected the different frequencies of the PGMI *I - and PGMl*2+ alleles. The association of each of these with patient status was significant (respectively x*=4.3; d.f. 1; ~~0.05 and x2=4.7; d.f. 1; ~~0.05). It was reflected in the relative risks; PGMl*lis apparently protective (RR=0.6; EF=-0.14) while PGM1*2+ confers increased likelihood of disease (RR=1.58; EF=0.18). Resistante ‘or susceptibility seems to be conferred when either allele *I - or *2+ is in a heterozygous combination with the *I + allele. The relative risk for phenotypes 1 +I - and 1+2+ are 0.47 and 1.65 respectively. For the HLA system 65 patients and 52 controls were successfully typed for HLA-A, B and C loci. Differences between patients and controls are slight and no antigen shows any significant association. Discussion Mourant and colleagues [II drew together data relating to ABO blood groups in 22966 tuberculosis patients from various parts of the world. The combined results showed a puzzling pattern of association. In a large number of investigations there was evidence of increased group 0 frequency; in the samples which were not classified for disease site, a marked increase in A gene frequency together with a decrease in 0 gene was evident, but when all the surveys were combined, this association virtually disappeared. tn addition to the disease and environmental heterogeneity, one possible reason for this finding could be the heterogeneity of the populations studied. In the present investigation where the genetic markers are reported from a single eridogamous group, and patients and controls can be recognized as drawn from an otherwise homogeneous population, the results suggest that the ABO antigens contribute little to susceptibility to pulmonary tuberculosis. An earlier study on the Rhesus blood group showed an increase in Rh negative individuals 1251.Since then five different studies (2, 5, 6,26, 271 have not confirmed these findings and neither do
and phenotype
BLOOD GROUPS AS0 0 Al A2 B AIB A2B Total Rhesus ccddee Ccddee c&Dee c&DEE ccDDEe CCDDee ccWDdee CcDDee CcDDEe Total Rhesus D D dd Total MNSs MMSS MMSS MMss MNSS MNSs MNss NNSS NNSs NNss Total MN M MN N Total
System
7.8 20.1 10.3 2.9 23.0 16.7 2.5 6.9 9.8
38.2 42.6 19.1
16 41 21 6 47 34 5 14 20 204
78 87 39 204
93.1 6.9
6.4 0.5 0.5 0.5 4.5 44.1 1 .o 30.2 12.4
13 1 1 1 9 89 2 61 25 202
190 14 204
31.9 17.2 5.9 40.2 2.9 2.0
(%I
Phenotype frequency
65 35 12 82 6 4 204
Number observed
M=0.596 N =0.404
MS=0.274 NS =0.108 MS =0.321 Ns =0.297
D=0.738 d=0.262
Cde =0.650 cDE =0.089 cDe =0.009 cde =0.231 Cwde=O.OOl Cde =O.OlO
pl=O.107 p2=0.046 q =0.263 r =0.5&4
Gene frequencies
8.6 17.1 14.9 5.7 15.4 24.6 1.7 5.1 6.9
40.6 45.7 13.7
71 80 24 175
96.0 4.0
15 30 26 10 27 43 3 9 12 175
168 7 175
31.4 10.9
55 19 175
-
4.0 0.6 1.2 9.7 46.3 -
-
35.4 23.4 2.8 32.0 4.0 2.3
Phenotype frequency (%!
M=0.634 N =0.366
MS=0.249 NS =0.099 MS =0.386 Ns =0.266
D=O.800 dE0.200
Cde =0.674 cDE =0.094 cDe ~0.015 cde =0.217 Cwde=O.OOO Cde =O.OOO
pl=O.l49 ~2~0.032 q =0.216 r =0.603
Gene frequencies
of blood group, serum
1 2 10 81
7
62 41 5 56 7 4 175
Number observed
Controls
number, phenotype frequency and gene frequencies with pulmonary tuberculosis and controls.
Patients
Table I. Observed phenotype red cell enzymes in patients
2.0 NS
11.1 NS
1.0 NS
2.3 NS
6.2 NS
P
and
X2 Fisher’s
proteins
Pl P2
Total
Total
1. (continued)
Total
B lBFl
Component
C3 (C31
(HP)
Specific
1s 1FlS 1F 2-1s 2-1F 2 IS-VAR Total
Group
FS F FS07 sso7 FS-VAR Total
Factor S
FS F F!+VAR Total
Complement S
l-l l-2 2-2
Haptoglobin
SERUM PROTEINS
Jk (a+) Jk (a-) Total
Kidd
Total Duffv ~Fy’(a+b-1 Fy (a+b+) Fy (a-b+) Total
Kk k
Kell
P
S
SS S SS
Table
(Gc)
34 5 56 17 17 1 202
72
204
-
68 94 36 4 2
174 28 1 1 204
4 57 140 201
159 45 204
101 72 31 204
2 202 204
55 203
148
27 102 75 204
35.6 16.8 2.5 27.7 8.4 8.4 0.5
33.3 46.1 17.6 2.0 1.0 -
85.3 13.7 0.5 0.5
2.0 28.4 69.7
77.9 22.1
49.5 35.3 15.2
1.0 99.0
72.9 27.1
13.2 60.0 36.6
GC*lS =0.581 FC*lF =0.151 GC*2 =0.265 GC*VAR=0.003
BF*S =0.569 BF*F =0.417 BF*SO7 =0.014 BF*SVAR=O.OOO
c3*s =0.922 =0.076 C3*F C3*SVAR=0.002
Hp*l=O.162 Hp*2=0.838
Jk*=0.588 Jkb=0.412
Fya=0.672 Fyb=0.328
K=0.005 k =0.995
P =0.479 P2+p=O.521
S=O.382 s =0.618
173
-
64 33 4 51 10 11
67 66 34 3 3 1 174
174
145 28 1 -
3 42 128 173
141 24 165
81 74 20 175
2 173 175
131 44 175
28 66 81 175
37.0 19.1 2.3 29.5 5.8 6.4 -
38.5 37.9 19.5 1.7 1.7 0.6
83.3 16.1 0.5 -
1.7 24.3 74.0
85.5 14.5
46.3 42.3 11.4
1.1 98.9
74.9 25.1
16.0 37.7 46.3
GC*lS =0.613 GC*lF =0.148 GC’2 =0.239 GC*VAR=O.OOO
BF’S =0.583 BF*F =0.397 BF*SO7 =0.017 BF*SVAR=0.003
c3*s =0.914 =0.086 C3*F C3*SVAR=0.000
Hp*l=O.139 Hp*2=0.861
Jka=0.619 Jkb=0.381
Fya=0.674 Fyb=0.326
K=0.006 k =0.994
=0.499 P P2+p=O.501
s=o.349 s =0.651
1.7 NS
4.6 NS
0.35 NS
0.21 NS
0.04 SIG
2.4 NS
0.63 NS
0.37 NS
5.8 NS
RED CELL ENZYMES Glutamate pyruvate transaminase IGPJI 29 l-l l-2 101 73 2-2 203 Total Adenosine deaminase (ADA) 156 l-l 46 l-2 2 2-2 204 Total Esterase D (ESD) 95 l-l 91 l-2 2-2 18 204 Total Phosphoglucomutase locus 1 (PGMII 1+ 56 21 1+1l3 12 2+ 7 2+21+2+ 66 11 l-2+ 6 1-21+216 1 21 6 2+ 7 If 1 201 Total Acid phosphatase (APl 17 A BA 76 6 110 CB Total 203 Adenylate kinase (AK) l-l 165 37 l-2 1 2-2 Total 203 Phosphogluconate dehydrogenase (PGD) A 187 CA 16 203 Total Ma/ate dehydrogenase (MDHI l-l 202 1 I-VAR Total 203
Table 1. (continued)
ESD*1=0.689 ESD*2=0.311
46.6 44.6 8.8
AP*A=0.271 AP*B=0.729 AP*C=O.OOO
AK*1 =0.904 AK*2=0.096
PGD*A=0.961 PGD*C=0.039
MDH*l =0.997 MDH*VAR=0.003
8.4 37.4 54.2 -
81.3 18.2 0.5
92.1 7.9
99.5 0.5
PGM1*1+=0.537 PGMl*lb=0.109 PGM1*2+=0.271 PGM1*2-=0.077 PGMl”6 =0.003 PGM1*7 =0.003
ADA*1 =0.878 ADA*2=0.122
78.5 22.5 1.0
27.9 10.4 1.5 6.0 3.5 32.8 5.5 3.0 8.0 0.5 0.5 0.5
GPT* 1 zO.392 GPT*2=0.608
14.3 49.8 36.0
92.0 8.0
99.4 0.6
174 1 175
85.1 14.3 0.6
7.4 33.7 68.3 0.6
161 14 175
149 25 1 175
13 59 102 1 175
175
-
30.9 20.0 1.7 6.3 2.3 22.9 5.1 2.9 6.3 1.1 0.6 -
55.4 38.9 5.7
97 68 10 175 54 35 3 11 4 40 9 5 11 2 1
74.3 24.0 1.7
22.8 43.3 33.9
130 42 3 175
39 74 58 171
MDH*l zo.997 MDH’VAR==0.003
PGD*A=0.960 PGD*C=0.040
AK”1 =0.923 AK*2=0.077
AP*A=0.243 AP*B=0.754 AP*C=0.003
PGMl*l+=0.554 PGMI-@l-=0.157 PGMl;‘2+=0.217 PGMl*2-=0.069 PGM1*6 =0.003 PGMl”7 =O.OOO
ESD*l=O.749 ESD*2=0.251
ADA”1 =0.863 ADA*2=0.137
GPT*1=0.444 GPT*=0.556
0.71 NS
0.56 NS
0.19 NS
0.65 NS
9.5 NS
3.4 NS
0.35 NS
4.6 NS
Genetic markers in tuberculosis Table II.
HLA Antigen
Specificity
Tuberculosis patients (n=651
Control h=52)
Specificity
Tuberculosis patients fn=651
Control (n=52/
Specificity
Tuberculosis patients ln=65)
Control (n=52)
25 48 6 0 31 3 11 17 8 2 9 6 11
31 56 8 2 37 2 8 15 0 0 8 2 6
851 Bw52 87 BE 812 813 814 815 B16 817 Bl8 821 Bw22 827 Bw35 840 Bw41
28 5 32 3 15 6 3 8 2 20 3 3 5 8 3 20 5 2 3
31 0 23 2 15 10 0 8 0 13 4 4 10 8 0 25 4 0 4
Cwl cw2 cw3 cw4 cw5 cw7
23 0 18 17 8 11
15 0 23 12 6 13
A9
Al A2 A3 Aw23 1Aw24
AlO{A,2,; All A28 A29 Aw30 Aw31 Aw32
in pulmonary
Bw53 Phenotype
numbers
tuberculosis
165
patients and controls.
given as percentage
the present results. For other blood groups, except MN, there is no other report. Among the blood groups studied here for the first time, the barely significant decrease of the JKa gene frequency in the patient group deserves further attention, for if confirmed it may suggest resistance against tuberculosis. The serum proteins here studied include several acute phase reactants whose concentrations alter in infective disorders. A significant increase in the levels of C3 and haptoglobin and decrease in the levels of transferrin have been demonstrated in a series of Indonesian pulmonary tuberculosis patients [281. Although these acute phase associated proteins and other serum components may not be the primary factor affecting the immune response to M. tuberculosis, there is growing evidence that they may play an important secondary role in the cellular immune response to infectious agents. Among the specific and non-specific events in the immune response to M. tuberculosis are the production of specific antibodies to the mycobacterium and a general increase of immunoglobulin levels in patients [15]. Increased levels of some of these acute phase proteins correlated with level of IgM have been found in tuberculosis patients 1281.Whether these increases are related to each other or should be viewed as separate responses is not clear, but the variation of the levels of these proteins is to some extent under genetic control. The Hp l-l phenotype has a higher concentration of protein (mean=104 mg/dl) than Hp 2-2 (mean=74 mg/dl). Thus, if concentration differences of this order were functionally significant, then the patient’s genotype might be expected to influence immunologic events. Among the 13 red cell enzyme loci examined, only the PGMI locus shows a significant association with the disorder. That this is not attributable to chance is indicated by a previous survey of Hindu populations of Uttar Pradesh, India, where a similar association was reported [IO]. The samples of the present investigation are from a different ethnic group located about 1000 km from the previous Hindu sample. The suggestion from these
166
Papiha
and others
two independent surveys that individuals with ihe PGMI “.I - allele may be more resistant to the disease deserves serious consideration. The patient series reported here is more extensive that the previous one, and the consistency of the PGMI suballele association is encouraging. The exact mechanism by which PGMI may be associated with pulmonary tuberculosis needs further investigation, though in view of the relatively low level of association, genetic predisposition to the disease is likely to involve other loci as well as other contributory factors. The negative findings with HLA-A, B and C antigens in the present patients do not support the many different associations reported. Significant associations of antigens B8 (n=48; 54 % vs 20 % control), B18 (n=62; 20 % vs 3 % control) and Bw35 (n=lOl; 33 % vs 6 % control) have been reported in Newfoundland, American Negro and Chinese patients [II-131. A weak association with antigen B15 occurred in patients from Mexico and North India [14, 171 and, in another study from north India (Uttar Pradesh) a weak association with antigen B18 [15]. The results of the present investigation are compatible with a relatively recent investigation from North India [I61 which also showed no association with HLA antigens. On the available evidence it is as yet difficult to offer a mechanistic immunological explanation for various genetic associations with pulmonary tuberculosis. It is possible that some of those reported may be due to chance, while others may be due to linked genes, which have not yet been studied, so that the presence of a distinct haplotype or supratype differing from population to population may be responsible for the susceptibility. Acknowledgements The senior author is indebted to the Eugenic Society for financial help from the Marie Stopes Fund and to the E.E.C. for a grant to work in tropical regions which helped us establish control data for the region. We also thank Mrs D. Haggerty, Mrs V. Spencer and Mr Tony Jackson for their laboratory assistance.
References 1 Mourant, A. E., Kopec, A. C., Domaniewska-Sobczak, K. (1978). In: Blood Groups and Diseases, Oxford Medical Publications, Oxford: p. 68. 2 Saha, N. & Banerjee, B. (1968). Incidence of AB and RH blood groups in pulmonary tuberculosis in different ethnic groups. Journal of Medical Genetics 55, 306. 3 Jain, R. C. (1970). ABO blood groups and pulmonary tuberculosis. Jubercle, 51, 322. 4 Overfield, T., Klauber, M. R. (1980). Prevalence of tuberculosis in Eskimos having blood group B gene. Human Biology, 52, 87. 5 Kooptzoff, O., Walsh, R. J. (1957). Blood groups and disease: pulmonav tuberculosis. Australian Anna/s of Medicine, 6, 53. 6 Milunicova, A., Dominec, M. (1966). Blood characteristics and PTC test in young patients suffering from pulmonary tuberculosis and diabetes mellitus. Rozhledy Juberkulose, 26, 545. 7 Hever, 0. (1969). Relations entre les phenotype d’haptoglobine dans diverses maladies. Presse Medicale, Paris, 77, 1081. 8 Sidhu, L. S., Singh, J., Bhatnagar, D. P., Pahuja, J. K. (1974). Association of pulmonary tuberculosis with ABO and Rh(D) blood groups. In: Sanghvi, L. D. et al. (eds.). Population Generics in lndia Orient Longman, India. p. 135. 9 Karim, A. K. M. B., Elfellah, M. S., Evans, D. A. P. (1981). Human acetylator polymorphism: estimation of allele frequency in Libya and details of global distribution. Journal of Medical Genetics, 16. 325. 10 Papiha, S. S., Agarwal, S. S., White, I. (1983). Association between phosphoglucomutase (PGM) and groupspecific component (Gc) subtypes and tuberculosis. Journal of Medical Genetics, 20, 220. 11 Selbv. R.. Barnard, J. M., Buchler, S. K., Crumley, J., Larsem, B., Marshal, W. H. (1978). Tuberculosis association “with HLA-B6, BfS.in a Newfoundland community study, Tissue Antigens, 11, 403. 12 Al-Arif, L. I., Goldstein, R. A., Affronti, L. F., Janicki, B. W. (1979). HLA-Bw15 and tuberculosis in North American Black population. American Review of Respiratory Disease, 120, 1275.
Genetic
13 Jiang, Z. F., An, H. B., Sun, Y. P., Mittal, K. K., Lee, T. D. (1983). Association 14
15 16 17 18 19
20 21 22 23 24 25
26 27 28
markers
in tuberculosis
of HLABw35
with tuberculosis
167
in the
Chinese. Tissue Antigens, 22, 86. Mehra, N. K., Singhai, K. K., Malawiya, A. N., Guleria, J. S., Vaidya, M. C. (1980). Susceptibility to tuberculosis may be HLA-linked. In: Proceedings of the Symposium on Cellular and Humoral Mechanisms in Immune Response, Department of Atomic Energy, Government of India. p. 60. S. S. (1985). Human leukocyte antigens and circulating Papiha, S. S., Wentzel, J., Behjati, F., Agarwal, immunoglobulin levels in Indian patients with pulmonary tuberculosis. Jubercle, 66, 25. Singh, S. P. N., Mehra, N. K., Dingley, H. B., Pande, J. N., Vaidya, H. C. (1983). HLA-A, -B, -C and -DR antigen profile in pulmonary tuberculosis in North India. Tissue Antigens, 21, 380. Cox, R. A., Arnold, 0. R., Cook, D., Lundberg, D. I. (1982). HLA phenotypes in Mexican Americans with tuberculosis. American Review of Respiratory Disease, 126, 653. Khomank0.A. G.,Averbach, M. M., Kalankhodghaev,A. A., Malenko, A. F., Chukanova, V. P., Moroz,A. M. (1980). Distribution of HLA antigens in tuberculosis patients, Terapeuticheskii Arkhiv, Moscow, 63, 135. Rosenthal, I., Scholz, I. S., Klimmek, R., Albert, E. 0. & Blaha, H. (1973). HLA antigens and haplotypes in patients with tuberculosis. Zeitschrift fur fmmunitatsforschung und Klinische immunologic 144, 424. Mourant, A. E., Kopec. A. C., Domaniewska-Sobczak, K. (1976). The Distribution of the Human Blood Groups and Other Polymorphisms, 2nd edn. Oxford University Press, Oxford. Papiha, S. S., Roberts, D. F., Wig, N. N., Singh, S. (1972). Red cell enzyme polymorphisms in Punjabis in North India. American Journal of Physical Anthropology, 37, 293. Poulik, M. D. (1958). Starch gel electrophoresis in discontinuous system of buffers. Nature (bond.), 180, 1477. Papiha, S. S., Rodger, R. S. C. (1986). C3 and Bf complement types in chronic renal failure. Human Genetics, 72, 260. Harris, H.. Hopkinson, D. A. (1976). Handbook of Enzyme Electrophoresis in Human Genetics, Elsevier, Amsterdam. Trobridge, G. F. (1956) Blood Groups in Tuberculosis. Doctoral Thesis, University of Birmingham, Quoted by Lewis, J. C. (1961). The ABO and rhesus blood groups in patients with respiratory disease. Jubercle, 42, 362. Campbell, A. E. R. (1956). Blood groups in tuberculosis. Tubercle, 37, 89. Viskum, K. (1973). Respiratory disease and ABO and Rhesus blood groups. Scandanavian Journal of Respiratory Disease, 64, 97. Grange, J. M., Kardjito, T., Setiabudi, I. (1984). A study of acute-phase reactant proteins in Indonesian patients with pulmonary tuberculosis. Jubercle, 65, 23.
IN SOUTH INDIAN ASSOCIATION OF HIA AND OTHER BENRIIC PATIENTS WlTH PULMONARY TUBERCULOSIS S. S. Papiha,* B. N. Singh,t J. S. S. Lanchbury, * D. F. Roberts,* C. E. Parsad,t J. Wentzel,” and K. J. R. MurtyS *Department
of Human
Genetics,
University of Newcastle upon Tyne, UK, tState T B Centre, irrumnuma, India, SMahavir Hospital, Hyderabad, india
Hyderabad,
Summary Histocompatibility antigens (A, B & C loci) and 23 other single gene characters were studied in 204 pulmonary tuberculosis patients belonging to a single endogamous group in South India. None of the previously reported associations with HLA antigens was confirmed, nor any new one found. The blood 0 and Rh negative associations were also not confirmed, although a new association with the Jk blood group system appears possible. Of particular interest is the association with the phosphoglucomutase (PGMI) system, which parallels that found in a different population located some 1000 km away. Relative risks were calculated to measure the resistance of individuals with the PGMl*2+ allele. R68um6 Les antig&nes d’histocompatibilite (sites A, B et C) et 23 autres caracteres d&erminds par un seul gene ont 6th dtudies chez 204 tuberculeux pulmonaires appartenant 5 un groupe endogame unique d’lnde mkridionale. Aucune des associations avec des antigenes HLA rapport6es anterieurement n’a 6th confirmbe ni aucune nouvelle association n’a 6t6 trouv6e. Les associations avec les groupes sanguins 0 et Rh nbgatif n’ont pas 6tB confirmees non plus, bien qu’une nouvelle association avec le systeme de groupe sanguin Jk semble possible. L’association avec le systbme phosphoglucomutase (PGMI) revQt un int&& particulier; cette association peut Qtre rapprochbe de celle rencontree dans une population diffbrente sit&e quelque 1 000 km plus loin. Les auteurs ont calcul6 le risque relatif pour mesurer la r6sistance des sujets porteurs de I’all8le PGMl*l et la sensibilite accrue des sujets porteurs de I’all&le PGMl*2. Resumen En 204 enfermos con tuberculosis pulmonar pertenecientes a un grupo endogamico tinico en el sur de India, se estudi6 10s antigenos de histocompatibilidad (loci A, B y CI otros 23 caracteres determinados por un solo gen. No se confirm6 ninguna de las asociaciones con antigenos HLA informadas anteriormente, ni se encon& ninguna nueva asociacibn. Tampoco se confirm6 las asociaciones con 10s grupos sanguineos 0 y Rh negativo, aunque parece posible una nueva asociaciCtn con el sistema de grupo sanguine0 Jk. La asociacibn con el sistema fosfoglucomutasa (PGMI) reviste un inter& particular) esta asociacibn es comparable a la encontrada en una poblaci6n diferente situada a 1000 km de distancia, Se calcul6 el riesgo relativo para medir la resistencia de 10s sujetos portadores del alelo PGMI *I y la sensibilidad aumentada de 10s sujetos portadores del alelo PGMI *2+.
160
Papiha
and others Introduction
Examination of the association of genetic markers with tuberculosis has been a relatively recent approach to defining genetic susceptibility to the disease. An increased frequency of blood group 0 was shown in pulmonary tuberculosis patients in Europe [I], but of blood group Al3 and B in Indian and Eskimo patients respectively [2-4]. Other polymorphic loci examined but with which no definite association was found are Rhesus and MN blood groups, PTC tasting, secretor, haptoglobin, group specific component and acetylation status [5-91. However, for the red cell enzyme phosphoglucomutase 1, examined by isoelectric focusing in a single population of Hindu, Uttar Pradesh, India, there was an interesting negative association with the PGMl*l+ allele [IO]. Recently, association of various human leukocyte antigens (HLA) with pulmonary tuberculosis have been desribed. Nine studies from different ethnic groups show increased or decreased frequencies of various antigens at the B and DR loci, but no consistent association [II-191. There may be several reasons for the inconsistencies of these associations. One major draw-back common to several of these studies is the heterogeneous nature of the patients and the control populations investigated. The present study avoids this difficulty by examining genetic markers in patients and controls in a single endogamous group from south India with a high incidence of the disease. The study re-evaluates associations with the genetic markers already studied, and incorporates many more loci, several of which have a significant role in the biochemical and immunological functions of the body. Materials
and methods
All patients and controls were from a single endogamous group of Sunni Muslim from Hyderabad, the capital of the State of Andhra Pradesh, India. There were 204 patients who were sputum positive and in whom pulmonary tuberculosis was radiologically confirmed. The control group consisted of 175 individuals matched for age, sex and region. All the patients and controls belonged to the equivalent of social class IV. Procedures of blood and cell collection and transport were as described previously from this laboratory [IO, 151. I-/L4 typing: Using commercially available antisera (Biotest) and also some donated by NIH Bethesda Maryland, typing was performed using a modification of the NIH lymphocyte microcytotoxicity assay with incubation at 37 “C for 1 h. In all, 70 antisera were used to detect the following specificities. HLA-A 1, 2, 3, 9, ~23, ~24, 25, 26, 11, 28, 29, w39, ~31, ~32. HLA-B ~51, ~52, 7, 8, ~44, 13, 14, 15, ~16, 17, 18, 21, ~35, ~37, 40, ~41, ~42, ~53. HLA-C wl, w2, w3, w4, w5, w7. Other genetic markers: Blood groups were tested by standard serological procedures 1201 using the following antisera: anti-A, A,, B, A+B, C, c, C”“, D, E, e, M, N, S, s, P, K, k, Fya, Fyb and Jk”. Red cell lysates were prepared as described previously [21]. In typing the red cell enzymes and serum proteins (unless described otherwise) horizontal starch gel electrophoresis using Connaught hydrolysed starch was carried out in a cold room. Haptoglobin and transferrin typing was performed by using a discontinuous buffer system 1221. The C3 and Bf phenotypes were characterised by high voltage electrophoresis 1231. The phenotypes of Bf were examined by immunofixation using Bf specific antisera. The lysates were examined for various red cell enzyme systems according to the methods given by Harris and Hopkinson [24]. The PGMI and GC subtyping were performed by isoelectric focusing as described from this laboratory [IO].
Genetic markers in tuberculosis
161
Results Table I gives for each polymorphic system for pulmonary tuberculosis patients, and controls, the phenotype numbers and frequencies, and gene frequencies together with x2 or the exact probability (Fisher) showing the significance of the difference between the patient and control group. The phenotype percentage for HLA-A, B and C antigens in patients and controls are given in Table II. There was no increased frequency of the 0 blood group gene or of the AB phenotype as described in other studies. The slightly elevated frequency of the 6 blood group in patients was non-significant (x2=2.7; d.f. 1; p>O.O5) but parallels the observation on Eskimo patients. There was no association for the Rhesus or the MNSs phenotypes or haplotypes. When the MN and Ss loci were treated separately the slight increase in Ss heterozygote frequencies did not attain significance. Of the remaining blood group systems, P, Kell, Duffy and Kidd, only the Kidd system suggested an association. The frequency of the Jkfa-’ was significantly lower (barely) in the patient group. Among the five serum protein Hp, Tf, C3, BF and GC systems studied, transferrin was monomorphic. The frequency of the Hp*l, and BF*S and rare alleles, and C3*S genes in the patient group did not differ from that of controls. The variation of the GC*lS alleles was slight (patients 58 % vs. control 61 %). Among the thirteen red cell enzymes types SODI, LDH-A, LDH-B, PGM2, PGI were monomorphic. The slight rise in frequencies of GPT*2 and EsD*2 alleles in the patients did not attain significance. Of particular interest is the PGMI locus variation. There was a decrease of the PGMI +I phenotype in patients, while the PGMI +2+ phenotypes showed an increase. This reflected the different frequencies of the PGMI *I - and PGMl*2+ alleles. The association of each of these with patient status was significant (respectively x*=4.3; d.f. 1; ~~0.05 and x2=4.7; d.f. 1; ~~0.05). It was reflected in the relative risks; PGMl*lis apparently protective (RR=0.6; EF=-0.14) while PGM1*2+ confers increased likelihood of disease (RR=1.58; EF=0.18). Resistante ‘or susceptibility seems to be conferred when either allele *I - or *2+ is in a heterozygous combination with the *I + allele. The relative risk for phenotypes 1 +I - and 1+2+ are 0.47 and 1.65 respectively. For the HLA system 65 patients and 52 controls were successfully typed for HLA-A, B and C loci. Differences between patients and controls are slight and no antigen shows any significant association. Discussion Mourant and colleagues [II drew together data relating to ABO blood groups in 22966 tuberculosis patients from various parts of the world. The combined results showed a puzzling pattern of association. In a large number of investigations there was evidence of increased group 0 frequency; in the samples which were not classified for disease site, a marked increase in A gene frequency together with a decrease in 0 gene was evident, but when all the surveys were combined, this association virtually disappeared. tn addition to the disease and environmental heterogeneity, one possible reason for this finding could be the heterogeneity of the populations studied. In the present investigation where the genetic markers are reported from a single eridogamous group, and patients and controls can be recognized as drawn from an otherwise homogeneous population, the results suggest that the ABO antigens contribute little to susceptibility to pulmonary tuberculosis. An earlier study on the Rhesus blood group showed an increase in Rh negative individuals 1251.Since then five different studies (2, 5, 6,26, 271 have not confirmed these findings and neither do
and phenotype
BLOOD GROUPS AS0 0 Al A2 B AIB A2B Total Rhesus ccddee Ccddee c&Dee c&DEE ccDDEe CCDDee ccWDdee CcDDee CcDDEe Total Rhesus D D dd Total MNSs MMSS MMSS MMss MNSS MNSs MNss NNSS NNSs NNss Total MN M MN N Total
System
7.8 20.1 10.3 2.9 23.0 16.7 2.5 6.9 9.8
38.2 42.6 19.1
16 41 21 6 47 34 5 14 20 204
78 87 39 204
93.1 6.9
6.4 0.5 0.5 0.5 4.5 44.1 1 .o 30.2 12.4
13 1 1 1 9 89 2 61 25 202
190 14 204
31.9 17.2 5.9 40.2 2.9 2.0
(%I
Phenotype frequency
65 35 12 82 6 4 204
Number observed
M=0.596 N =0.404
MS=0.274 NS =0.108 MS =0.321 Ns =0.297
D=0.738 d=0.262
Cde =0.650 cDE =0.089 cDe =0.009 cde =0.231 Cwde=O.OOl Cde =O.OlO
pl=O.107 p2=0.046 q =0.263 r =0.5&4
Gene frequencies
8.6 17.1 14.9 5.7 15.4 24.6 1.7 5.1 6.9
40.6 45.7 13.7
71 80 24 175
96.0 4.0
15 30 26 10 27 43 3 9 12 175
168 7 175
31.4 10.9
55 19 175
-
4.0 0.6 1.2 9.7 46.3 -
-
35.4 23.4 2.8 32.0 4.0 2.3
Phenotype frequency (%!
M=0.634 N =0.366
MS=0.249 NS =0.099 MS =0.386 Ns =0.266
D=O.800 dE0.200
Cde =0.674 cDE =0.094 cDe ~0.015 cde =0.217 Cwde=O.OOO Cde =O.OOO
pl=O.l49 ~2~0.032 q =0.216 r =0.603
Gene frequencies
of blood group, serum
1 2 10 81
7
62 41 5 56 7 4 175
Number observed
Controls
number, phenotype frequency and gene frequencies with pulmonary tuberculosis and controls.
Patients
Table I. Observed phenotype red cell enzymes in patients
2.0 NS
11.1 NS
1.0 NS
2.3 NS
6.2 NS
P
and
X2 Fisher’s
proteins
Pl P2
Total
Total
1. (continued)
Total
B lBFl
Component
C3 (C31
(HP)
Specific
1s 1FlS 1F 2-1s 2-1F 2 IS-VAR Total
Group
FS F FS07 sso7 FS-VAR Total
Factor S
FS F F!+VAR Total
Complement S
l-l l-2 2-2
Haptoglobin
SERUM PROTEINS
Jk (a+) Jk (a-) Total
Kidd
Total Duffv ~Fy’(a+b-1 Fy (a+b+) Fy (a-b+) Total
Kk k
Kell
P
S
SS S SS
Table
(Gc)
34 5 56 17 17 1 202
72
204
-
68 94 36 4 2
174 28 1 1 204
4 57 140 201
159 45 204
101 72 31 204
2 202 204
55 203
148
27 102 75 204
35.6 16.8 2.5 27.7 8.4 8.4 0.5
33.3 46.1 17.6 2.0 1.0 -
85.3 13.7 0.5 0.5
2.0 28.4 69.7
77.9 22.1
49.5 35.3 15.2
1.0 99.0
72.9 27.1
13.2 60.0 36.6
GC*lS =0.581 FC*lF =0.151 GC*2 =0.265 GC*VAR=0.003
BF*S =0.569 BF*F =0.417 BF*SO7 =0.014 BF*SVAR=O.OOO
c3*s =0.922 =0.076 C3*F C3*SVAR=0.002
Hp*l=O.162 Hp*2=0.838
Jk*=0.588 Jkb=0.412
Fya=0.672 Fyb=0.328
K=0.005 k =0.995
P =0.479 P2+p=O.521
S=O.382 s =0.618
173
-
64 33 4 51 10 11
67 66 34 3 3 1 174
174
145 28 1 -
3 42 128 173
141 24 165
81 74 20 175
2 173 175
131 44 175
28 66 81 175
37.0 19.1 2.3 29.5 5.8 6.4 -
38.5 37.9 19.5 1.7 1.7 0.6
83.3 16.1 0.5 -
1.7 24.3 74.0
85.5 14.5
46.3 42.3 11.4
1.1 98.9
74.9 25.1
16.0 37.7 46.3
GC*lS =0.613 GC*lF =0.148 GC’2 =0.239 GC*VAR=O.OOO
BF’S =0.583 BF*F =0.397 BF*SO7 =0.017 BF*SVAR=0.003
c3*s =0.914 =0.086 C3*F C3*SVAR=0.000
Hp*l=O.139 Hp*2=0.861
Jka=0.619 Jkb=0.381
Fya=0.674 Fyb=0.326
K=0.006 k =0.994
=0.499 P P2+p=O.501
s=o.349 s =0.651
1.7 NS
4.6 NS
0.35 NS
0.21 NS
0.04 SIG
2.4 NS
0.63 NS
0.37 NS
5.8 NS
RED CELL ENZYMES Glutamate pyruvate transaminase IGPJI 29 l-l l-2 101 73 2-2 203 Total Adenosine deaminase (ADA) 156 l-l 46 l-2 2 2-2 204 Total Esterase D (ESD) 95 l-l 91 l-2 2-2 18 204 Total Phosphoglucomutase locus 1 (PGMII 1+ 56 21 1+1l3 12 2+ 7 2+21+2+ 66 11 l-2+ 6 1-21+216 1 21 6 2+ 7 If 1 201 Total Acid phosphatase (APl 17 A BA 76 6 110 CB Total 203 Adenylate kinase (AK) l-l 165 37 l-2 1 2-2 Total 203 Phosphogluconate dehydrogenase (PGD) A 187 CA 16 203 Total Ma/ate dehydrogenase (MDHI l-l 202 1 I-VAR Total 203
Table 1. (continued)
ESD*1=0.689 ESD*2=0.311
46.6 44.6 8.8
AP*A=0.271 AP*B=0.729 AP*C=O.OOO
AK*1 =0.904 AK*2=0.096
PGD*A=0.961 PGD*C=0.039
MDH*l =0.997 MDH*VAR=0.003
8.4 37.4 54.2 -
81.3 18.2 0.5
92.1 7.9
99.5 0.5
PGM1*1+=0.537 PGMl*lb=0.109 PGM1*2+=0.271 PGM1*2-=0.077 PGMl”6 =0.003 PGM1*7 =0.003
ADA*1 =0.878 ADA*2=0.122
78.5 22.5 1.0
27.9 10.4 1.5 6.0 3.5 32.8 5.5 3.0 8.0 0.5 0.5 0.5
GPT* 1 zO.392 GPT*2=0.608
14.3 49.8 36.0
92.0 8.0
99.4 0.6
174 1 175
85.1 14.3 0.6
7.4 33.7 68.3 0.6
161 14 175
149 25 1 175
13 59 102 1 175
175
-
30.9 20.0 1.7 6.3 2.3 22.9 5.1 2.9 6.3 1.1 0.6 -
55.4 38.9 5.7
97 68 10 175 54 35 3 11 4 40 9 5 11 2 1
74.3 24.0 1.7
22.8 43.3 33.9
130 42 3 175
39 74 58 171
MDH*l zo.997 MDH’VAR==0.003
PGD*A=0.960 PGD*C=0.040
AK”1 =0.923 AK*2=0.077
AP*A=0.243 AP*B=0.754 AP*C=0.003
PGMl*l+=0.554 PGMI-@l-=0.157 PGMl;‘2+=0.217 PGMl*2-=0.069 PGM1*6 =0.003 PGMl”7 =O.OOO
ESD*l=O.749 ESD*2=0.251
ADA”1 =0.863 ADA*2=0.137
GPT*1=0.444 GPT*=0.556
0.71 NS
0.56 NS
0.19 NS
0.65 NS
9.5 NS
3.4 NS
0.35 NS
4.6 NS
Genetic markers in tuberculosis Table II.
HLA Antigen
Specificity
Tuberculosis patients (n=651
Control h=52)
Specificity
Tuberculosis patients fn=651
Control (n=52/
Specificity
Tuberculosis patients ln=65)
Control (n=52)
25 48 6 0 31 3 11 17 8 2 9 6 11
31 56 8 2 37 2 8 15 0 0 8 2 6
851 Bw52 87 BE 812 813 814 815 B16 817 Bl8 821 Bw22 827 Bw35 840 Bw41
28 5 32 3 15 6 3 8 2 20 3 3 5 8 3 20 5 2 3
31 0 23 2 15 10 0 8 0 13 4 4 10 8 0 25 4 0 4
Cwl cw2 cw3 cw4 cw5 cw7
23 0 18 17 8 11
15 0 23 12 6 13
A9
Al A2 A3 Aw23 1Aw24
AlO{A,2,; All A28 A29 Aw30 Aw31 Aw32
in pulmonary
Bw53 Phenotype
numbers
tuberculosis
165
patients and controls.
given as percentage
the present results. For other blood groups, except MN, there is no other report. Among the blood groups studied here for the first time, the barely significant decrease of the JKa gene frequency in the patient group deserves further attention, for if confirmed it may suggest resistance against tuberculosis. The serum proteins here studied include several acute phase reactants whose concentrations alter in infective disorders. A significant increase in the levels of C3 and haptoglobin and decrease in the levels of transferrin have been demonstrated in a series of Indonesian pulmonary tuberculosis patients [281. Although these acute phase associated proteins and other serum components may not be the primary factor affecting the immune response to M. tuberculosis, there is growing evidence that they may play an important secondary role in the cellular immune response to infectious agents. Among the specific and non-specific events in the immune response to M. tuberculosis are the production of specific antibodies to the mycobacterium and a general increase of immunoglobulin levels in patients [15]. Increased levels of some of these acute phase proteins correlated with level of IgM have been found in tuberculosis patients 1281.Whether these increases are related to each other or should be viewed as separate responses is not clear, but the variation of the levels of these proteins is to some extent under genetic control. The Hp l-l phenotype has a higher concentration of protein (mean=104 mg/dl) than Hp 2-2 (mean=74 mg/dl). Thus, if concentration differences of this order were functionally significant, then the patient’s genotype might be expected to influence immunologic events. Among the 13 red cell enzyme loci examined, only the PGMI locus shows a significant association with the disorder. That this is not attributable to chance is indicated by a previous survey of Hindu populations of Uttar Pradesh, India, where a similar association was reported [IO]. The samples of the present investigation are from a different ethnic group located about 1000 km from the previous Hindu sample. The suggestion from these
166
Papiha
and others
two independent surveys that individuals with ihe PGMI “.I - allele may be more resistant to the disease deserves serious consideration. The patient series reported here is more extensive that the previous one, and the consistency of the PGMI suballele association is encouraging. The exact mechanism by which PGMI may be associated with pulmonary tuberculosis needs further investigation, though in view of the relatively low level of association, genetic predisposition to the disease is likely to involve other loci as well as other contributory factors. The negative findings with HLA-A, B and C antigens in the present patients do not support the many different associations reported. Significant associations of antigens B8 (n=48; 54 % vs 20 % control), B18 (n=62; 20 % vs 3 % control) and Bw35 (n=lOl; 33 % vs 6 % control) have been reported in Newfoundland, American Negro and Chinese patients [II-131. A weak association with antigen B15 occurred in patients from Mexico and North India [14, 171 and, in another study from north India (Uttar Pradesh) a weak association with antigen B18 [15]. The results of the present investigation are compatible with a relatively recent investigation from North India [I61 which also showed no association with HLA antigens. On the available evidence it is as yet difficult to offer a mechanistic immunological explanation for various genetic associations with pulmonary tuberculosis. It is possible that some of those reported may be due to chance, while others may be due to linked genes, which have not yet been studied, so that the presence of a distinct haplotype or supratype differing from population to population may be responsible for the susceptibility. Acknowledgements The senior author is indebted to the Eugenic Society for financial help from the Marie Stopes Fund and to the E.E.C. for a grant to work in tropical regions which helped us establish control data for the region. We also thank Mrs D. Haggerty, Mrs V. Spencer and Mr Tony Jackson for their laboratory assistance.
References 1 Mourant, A. E., Kopec, A. C., Domaniewska-Sobczak, K. (1978). In: Blood Groups and Diseases, Oxford Medical Publications, Oxford: p. 68. 2 Saha, N. & Banerjee, B. (1968). Incidence of AB and RH blood groups in pulmonary tuberculosis in different ethnic groups. Journal of Medical Genetics 55, 306. 3 Jain, R. C. (1970). ABO blood groups and pulmonary tuberculosis. Jubercle, 51, 322. 4 Overfield, T., Klauber, M. R. (1980). Prevalence of tuberculosis in Eskimos having blood group B gene. Human Biology, 52, 87. 5 Kooptzoff, O., Walsh, R. J. (1957). Blood groups and disease: pulmonav tuberculosis. Australian Anna/s of Medicine, 6, 53. 6 Milunicova, A., Dominec, M. (1966). Blood characteristics and PTC test in young patients suffering from pulmonary tuberculosis and diabetes mellitus. Rozhledy Juberkulose, 26, 545. 7 Hever, 0. (1969). Relations entre les phenotype d’haptoglobine dans diverses maladies. Presse Medicale, Paris, 77, 1081. 8 Sidhu, L. S., Singh, J., Bhatnagar, D. P., Pahuja, J. K. (1974). Association of pulmonary tuberculosis with ABO and Rh(D) blood groups. In: Sanghvi, L. D. et al. (eds.). Population Generics in lndia Orient Longman, India. p. 135. 9 Karim, A. K. M. B., Elfellah, M. S., Evans, D. A. P. (1981). Human acetylator polymorphism: estimation of allele frequency in Libya and details of global distribution. Journal of Medical Genetics, 16. 325. 10 Papiha, S. S., Agarwal, S. S., White, I. (1983). Association between phosphoglucomutase (PGM) and groupspecific component (Gc) subtypes and tuberculosis. Journal of Medical Genetics, 20, 220. 11 Selbv. R.. Barnard, J. M., Buchler, S. K., Crumley, J., Larsem, B., Marshal, W. H. (1978). Tuberculosis association “with HLA-B6, BfS.in a Newfoundland community study, Tissue Antigens, 11, 403. 12 Al-Arif, L. I., Goldstein, R. A., Affronti, L. F., Janicki, B. W. (1979). HLA-Bw15 and tuberculosis in North American Black population. American Review of Respiratory Disease, 120, 1275.
Genetic
13 Jiang, Z. F., An, H. B., Sun, Y. P., Mittal, K. K., Lee, T. D. (1983). Association 14
15 16 17 18 19
20 21 22 23 24 25
26 27 28
markers
in tuberculosis
of HLABw35
with tuberculosis
167
in the
Chinese. Tissue Antigens, 22, 86. Mehra, N. K., Singhai, K. K., Malawiya, A. N., Guleria, J. S., Vaidya, M. C. (1980). Susceptibility to tuberculosis may be HLA-linked. In: Proceedings of the Symposium on Cellular and Humoral Mechanisms in Immune Response, Department of Atomic Energy, Government of India. p. 60. S. S. (1985). Human leukocyte antigens and circulating Papiha, S. S., Wentzel, J., Behjati, F., Agarwal, immunoglobulin levels in Indian patients with pulmonary tuberculosis. Jubercle, 66, 25. Singh, S. P. N., Mehra, N. K., Dingley, H. B., Pande, J. N., Vaidya, H. C. (1983). HLA-A, -B, -C and -DR antigen profile in pulmonary tuberculosis in North India. Tissue Antigens, 21, 380. Cox, R. A., Arnold, 0. R., Cook, D., Lundberg, D. I. (1982). HLA phenotypes in Mexican Americans with tuberculosis. American Review of Respiratory Disease, 126, 653. Khomank0.A. G.,Averbach, M. M., Kalankhodghaev,A. A., Malenko, A. F., Chukanova, V. P., Moroz,A. M. (1980). Distribution of HLA antigens in tuberculosis patients, Terapeuticheskii Arkhiv, Moscow, 63, 135. Rosenthal, I., Scholz, I. S., Klimmek, R., Albert, E. 0. & Blaha, H. (1973). HLA antigens and haplotypes in patients with tuberculosis. Zeitschrift fur fmmunitatsforschung und Klinische immunologic 144, 424. Mourant, A. E., Kopec. A. C., Domaniewska-Sobczak, K. (1976). The Distribution of the Human Blood Groups and Other Polymorphisms, 2nd edn. Oxford University Press, Oxford. Papiha, S. S., Roberts, D. F., Wig, N. N., Singh, S. (1972). Red cell enzyme polymorphisms in Punjabis in North India. American Journal of Physical Anthropology, 37, 293. Poulik, M. D. (1958). Starch gel electrophoresis in discontinuous system of buffers. Nature (bond.), 180, 1477. Papiha, S. S., Rodger, R. S. C. (1986). C3 and Bf complement types in chronic renal failure. Human Genetics, 72, 260. Harris, H.. Hopkinson, D. A. (1976). Handbook of Enzyme Electrophoresis in Human Genetics, Elsevier, Amsterdam. Trobridge, G. F. (1956) Blood Groups in Tuberculosis. Doctoral Thesis, University of Birmingham, Quoted by Lewis, J. C. (1961). The ABO and rhesus blood groups in patients with respiratory disease. Jubercle, 42, 362. Campbell, A. E. R. (1956). Blood groups in tuberculosis. Tubercle, 37, 89. Viskum, K. (1973). Respiratory disease and ABO and Rhesus blood groups. Scandanavian Journal of Respiratory Disease, 64, 97. Grange, J. M., Kardjito, T., Setiabudi, I. (1984). A study of acute-phase reactant proteins in Indonesian patients with pulmonary tuberculosis. Jubercle, 65, 23.