Caractérisation phénotypique et fonctionnelle des lymphocytes B dans la lymphocytose polyclonale chronique B

La lymphocytose polyclonale chronique B (LPCB) est un syndrome peu connu caractérisé par une élévation polyclonale du nombre de lymphocytes B et de l’IgM sérique. Elle se distingue des pathologies lymphoïdes classiques par son origine polyclonale, sa grande stabilité ainsi que sa symptomatologie discrète et affecte majoritairement des femmes fumeuses. La présence de caractéristiques morphologiques et cytogénétiques distinctives, notamment cellules binucléées et anomalies génétiques (réarrangements bcl2/Ig multiples, isochromosome +i(3q)), guide le diagnostic initial. Ces particularités associées à un processus de transformation maligne contrastent avec l’apparente bénignité de la LPCB. Néanmoins, elles n’ont pas permis la délimitation précise de la population B impliquée dans la lymphocytose. Nos travaux avaient pour but d’identifier la population et les mécanismes impliqués dans l’émergence du syndrome, et éventuellement d’estimer les risques de progression clinique. En premier lieu, l’évaluation détaillée du profil immunologique des lymphocytes sanguins chez plusieurs patientes nous a permis de circonscrire formellement la lymphocytose aux cellules B IgD+IgM+CD27+. Mettant à profit les récentes avancées techniques et théoriques concernant la biologie du développement chez le lymphocyte B mature, nous avons entrepris l’analyse moléculaire des régions variables des gènes des immunoglobulines. Ces investigations ont confirmé le statut mémoire des cellules B en expansion dans la LPCB. Elles n’ont toutefois pas révélé la signature moléculaire résultant de sélection antigénique, processus central de la réponse immunitaire T-dépendante. Parallèlement, nos études fonctionnelles ont attesté de l’intégrité des molécules CD40 et AID, deux régulateurs clés de la maturation chez le lymphocyte B. Il ressort de nos analyses qu’un défaut dans la régulation de la réponse immunitaire, permettant le contournement de la sélection antigénique dans les centres germinatifs, plutôt qu’un blocage de différenciation cellulaire, serait probablement à l’origine de la lymphocytose. Alternativement, ces cellules pourraient être dérivées d’une population nouvellement caractérisée, les lymphocytes B mémoires de la zone marginale splénique, aussi retrouvés dans le sang, provenant présumement d’une voie de diversification indépendante des centres germinatifs. En conclusion, nos résultats ont permis de préciser le portrait diagnostique de la LPCB et de délimiter de nouvelles pistes de recherche touchant tant les aspects cliniques que la biologie fondamentale du syndrome.Persistent polyclonal B cell lymphocytosis (PPBL) is an unusual haematological disorder, mainly detected in adult female smokers, that shares features of both benignity (polyclonal expansion, polyconal IgM secretion, lack of clinical symptoms, stable and mostly uneventful course); and features of malignancy (atypical binucleated cells, multiple bcl-2/Ig translocations, chromosome 3 anomalies, bone marrow involvement). Still, these morphological and clonal genetic anomalies have not been restricted to a distinctive B cell subset, and the apparent heterogeneity of the involved cellular population has long impeded further characterization of the syndrome. The aim of our research was to formally identify the population involved in the lymphocytosis, to gain some insight into the mechanisms at play in its development and to evaluate the risk for subsequent transformation in patients. Over the recent years, technical inputs from the molecular field have largely contributed to a better discrimination of the various B cells subsets and, by extension, of B cell lymphoid disorders. Thus, detailed immunophenotypic studies conducted in numerous PPBL patients allowed us to definitely circumscribe the disorder to IgD+IgM+CD27+ B lymphocytes, whereas exhaustive molecular analysis of immunoglobulin genes’ variable regions has corroborated the memory status of these cells. Yet, molecular signature of the antigenic selection process, the characteristic of a T-dependent immune response, was not detected. Sequencing of the CD40 and AID genes, key regulators in the diversification and affinity maturation of the immunoglobulin receptor, was additionally carried out and expression of both molecules was assessed. No anomaly was evidenced for either gene. In light of those observations, we conclude that a differentiation block in PPBL B lymphocytes is unlikely. Rather, we propose that defects in the affinity maturation process, namely impairment of the antigenic selection mechanism, allows the survival of low affinity IgD+IgM+CD27+ memory B lymphocytes in PPBL patients. Conversely, these cells could be related to the as yet scantily characterized IgD+IgM+CD27+ memory B cell subset from the splenic MZ, also found in the blood, and presumably derived from a germinal centre independent diversification pathway. Altogether, our results contributed to the elaboration of an accurate clinical definition for PPBL, and delineated avenues for future investigations regarding both the pathological aspects of the disorder and its purely fundamental biologic ramifications

Obtaining Valid Laboratory Data in Clinical Trials Conducted in Resource Diverse Settings: Lessons Learned from a Microbicide Phase III Clinical Trial

BACKGROUND: Over the last decade several phase III microbicides trials have been conducted in developing countries. However, laboratories in resource constrained settings do not always have the experience, infrastructure, and the capacity to deliver laboratory data meeting the high standards of clinical trials. This paper describes the design and outcomes of a laboratory quality assurance program which was implemented during a phase III clinical trial evaluating the efficacy of the candidate microbicide Cellulose Sulfate 6% (CS) [1]. METHODOLOGY: In order to assess the effectiveness of CS for HIV and STI prevention, a phase III clinical trial was conducted in 5 sites: 3 in Africa and 2 in India. The trial sponsor identified an International Central Reference Laboratory (ICRL), responsible for the design and management of a quality assurance program, which would guarantee the reliability of laboratory data. The ICRL provided advice on the tests, assessed local laboratories, organized trainings, conducted supervision visits, performed re-tests, and prepared control panels. Local laboratories were provided with control panels for HIV rapid tests and Chlamydia trachomatis/Neisseria gonorrhoeae (CT/NG) amplification technique. Aliquots from respective control panels were tested by local laboratories and were compared with results obtained at the ICRL. RESULTS: Overall, good results were observed. However, discordances between the ICRL and site laboratories were identified for HIV and CT/NG results. One particular site experienced difficulties with HIV rapid testing shortly after study initiation. At all sites, DNA contamination was identified as a cause of invalid CT/NG results. Both problems were timely detected and solved. Through immediate feedback, guidance and repeated training of laboratory staff, additional inaccuracies were prevented. CONCLUSIONS: Quality control guidelines when applied in field laboratories ensured the reliability and validity of final study data. It is essential that sponsors provide adequate resources for implementation of such comprehensive technical assessment and monitoring systems. TRIAL REGISTRATION: ClinicalTrials.gov NCT00153777 and Current Controlled Trials ISRCTN9563838

The 2021 WHO catalogue of Mycobacterium tuberculosis complex mutations associated with drug resistance: a genotypic analysis.

Background: Molecular diagnostics are considered the most promising route to achievement of rapid, universal drug susceptibility testing for Mycobacterium tuberculosis complex (MTBC). We aimed to generate a WHO-endorsed catalogue of mutations to serve as a global standard for interpreting molecular information for drug resistance prediction. Methods: In this systematic analysis, we used a candidate gene approach to identify mutations associated with resistance or consistent with susceptibility for 13 WHO-endorsed antituberculosis drugs. We collected existing worldwide MTBC whole-genome sequencing data and phenotypic data from academic groups and consortia, reference laboratories, public health organisations, and published literature. We categorised phenotypes as follows: methods and critical concentrations currently endorsed by WHO (category 1); critical concentrations previously endorsed by WHO for those methods (category 2); methods or critical concentrations not currently endorsed by WHO (category 3). For each mutation, we used a contingency table of binary phenotypes and presence or absence of the mutation to compute positive predictive value, and we used Fisher's exact tests to generate odds ratios and Benjamini-Hochberg corrected p values. Mutations were graded as associated with resistance if present in at least five isolates, if the odds ratio was more than 1 with a statistically significant corrected p value, and if the lower bound of the 95% CI on the positive predictive value for phenotypic resistance was greater than 25%. A series of expert rules were applied for final confidence grading of each mutation. Findings: We analysed 41 137 MTBC isolates with phenotypic and whole-genome sequencing data from 45 countries. 38 215 MTBC isolates passed quality control steps and were included in the final analysis. 15 667 associations were computed for 13 211 unique mutations linked to one or more drugs. 1149 (7·3%) of 15 667 mutations were classified as associated with phenotypic resistance and 107 (0·7%) were deemed consistent with susceptibility. For rifampicin, isoniazid, ethambutol, fluoroquinolones, and streptomycin, the mutations' pooled sensitivity was more than 80%. Specificity was over 95% for all drugs except ethionamide (91·4%), moxifloxacin (91·6%) and ethambutol (93·3%). Only two resistance mutations were identified for bedaquiline, delamanid, clofazimine, and linezolid as prevalence of phenotypic resistance was low for these drugs. Interpretation: We present the first WHO-endorsed catalogue of molecular targets for MTBC drug susceptibility testing, which is intended to provide a global standard for resistance interpretation. The existence of this catalogue should encourage the implementation of molecular diagnostics by national tuberculosis programmes. Funding: Unitaid, Wellcome Trust, UK Medical Research Council, and Bill and Melinda Gates Foundation