Abstract:
A method of testing for tuberculosis and leprosy in animals or humans and antigens used in the method. The method involves carrying out an assay on sera from humans or animals using an antigen to bind antibodies in sera. The antigens used in the method are synthetic pseudo cord factor-like glycolipids having the structures (I) or (II) below: ##STR1## wherein R represents a straight or branched chain alkyl group having 15 to 18 carbon atoms. The antigens can be produced by chemical synthesis, and can therefore be made available in suitable quantities, and are relatively stable at ambient temperatures while showing good sensitivity and specificity for tuberculosis and leprosy. The antigens can be used, for example, for enzyme-linked immunosorbent assays, and related &#34;spot tests&#34; for diagnosing tuberculosis and leprosy.

Description:
BACKGROUND OF THE INVENTION 
     I. Field of the Invention 
     This invention relates to glycolipids useful for serodiagnosis of tuberculosis and leprosy and to serodiagnosis techniques using such glycolipids. More particularly, the invention relates to synthetic pseudo cord factor-like glycolipids useful for these purposes. 
     II. Description of the Prior Art 
     Enzyme-linked immunosorbant assays (usually referred to as ELISA) and similar techniques (e.g. so-called &#34;spot tests&#34; which are a simplified form of ELISA test) for diagnosing diseases in human and animal patients have become very useful and popular in recent years because of their simplicity and their acceptable sensitivity and specificity. These techniques are based on the binding effects of antibodies and antigens. In one form of the ELISA assay, for example, an antigen produced by a specific organism is used to test for the presence of antibodies for the antigen in the sera of patients, thus providing an indication that the patients have been exposed to these organisms. The antigen is immobilized on a solid support and incubated with the serum to be tested. If a target antibody is present in the serum, indicating exposure of the patient to the disease-causing organism, it binds to the layer of antigen. The number of antigen/antibody bound molecular pairs produced in this way depends on the concentration of the antibody in the serum until saturation of the antigens in the layer takes place. After washing the layer attached to the support, a solution of an enzyme-linked antibody (e.g. goat-antihuman IgG) for the bound protein is contacted with the supported layer. After a second washing step, the layer is contacted with a solution of a substrate for the enzyme and the bound enzyme, if present, converts the substrate to a detectable product. 
     In the so-called &#34;spot tests&#34;, the microtiter plate usually used as a solid support for the antigen in the ELISA test is replaced by a strip of paper (cellulose nitrate, etc.). The strip is spotted with the antigen and for instance Protein A is used instead of the conjugate and a colloidal gold solution in place of the substrate. 
     ELISA and spot tests of this kind have been developed for detecting a number of disease-producing organisms. However, a satisfactory test has not yet been developed for tuberculosis produced by the bacterium Mycobacterium tuberculosis and leprosy produced by the bacterium Mycobacterium leprae, the two most widespread mycobacterial diseases affecting mankind. The difficulty in developing suitable tests has resulted from the fact that M. tuberculosis and M. leprae produce large numbers of immune response-producing proteins, some of which appear to be common to other microorganisms that may or may not be pathogenic. Hence, positive test results produced by known antigens are generally unreliable (false positives) and other tests have to be carried out to confirm the presence of the tuberculosis or leprosy infections. 
     Hopes of developing a reliable ELISA test for tuberculosis were heightened recently by the discovery of an M. tuberculosis species-specific trehalose-glycolipid provisionally designated as &#34;SL-IV&#34; (F. Papa, et.al., &#34;Serological Specificity of M. tuberculosis Glycolipids&#34; (1989), Acta Leprologica 7 (Suppl.1): 98-101). An ELISA serological procedure using this protein has been shown to have good potential for the diagnosis of tuberculosis and leprosy. However, SL-IV is extracted from cultures of strains of M. tuberculosis and this extraction and the following purification procedures are difficult, time-consuming and expensive. The available quantities of this antigen are therefore quite limited and, moreover, the resulting antigen is a complex mixture of 2,3-trehalose esters. This makes SL-IV of rather limited use for widespread application in ELISA testing. 
     Trehalose-based glycolipids are found in a variety of structural forms in the lipids of mycobacteria and related bacteria. Serologically active glycolipids extracted from M. bovis BCG have been described (Reggiardo et. al., &#34;Serologically Active Glycolipid Families From Mycobacterium bovis BCG&#34;, Am. J. Epidemiol. 100 (1975): pp 477-486). Three families of glycolipids called A, B and C reacted with sera from patients with tuberculosis and leprosy. Among the antigens studied, one designated A1 gave the lowest incidence of false negative serological reactions and was later shown to be 6-O-mycoloyltrehalose (TMM). On the other hand, so called &#34;cord factor&#34; (6,6&#39;-di-O-mycoloyltrehalose) (TDM), does not seem to be useful as a coating antigen (Goren, M. B., &#34;Mycobacterial Fatty Acid Esters of Sugars &amp; Sulfosugars&#34;, Handbook of Lipid Research (Ed. D.J. Hanahan), Vol. 6 (Ed. M. Kates), Glycolipids, Phospholipids and Sulfoglycolipds, pp. 363-396, 1990). Again, however, even the potentially useful antigens have to be extracted from bacterial cultures with the attendant disadvantages 
     Accordingly, there is still a need for improved antigens for use in enzyme-linked immunosorbant assays and similar tests for detecting tuberculosis and leprosy. 
     OBJECTS OF THE INVENTION 
     An object of the invention is to provide a test capable of diagnosing tuberculosis and/or leprosy with acceptable reliability and specificity using antigen/antibody binding capabilities. 
     Another object of the invention is to provide glycolipids useful for detecting tuberculosis and leprosy, which glycolipids are relatively stable at ambient temperatures, thus avoiding the need for &#34;cold chain&#34; procedures when storing and distributing the glycolipids. 
     Still another object of the invention is to provide the components of a test kit for detecting tuberculosis and/or leprosy with acceptable reliability and specificity. 
     SUMMARY OF THE INVENTION 
     The invention is based on the finding that various synthetic pseudo cord factor-like glycolipids are suitable for the serodiagnosis of tuberculosis and leprosy. These glycolipids are analogs of natural cord factor (TDM) in that the 6-functional hydroxyl groups of the basic trehalose structure have been transformed either to carboxylic functions or, together with the adjacent --CH 2  --group, to amido functions. 
     The invention thus relates to a method of testing for tuberculosis or leprosy in humans or animals, which comprises carrying out an assay on sera from said humans or animals using an antigen to bind antibodies in said sera, wherein said antigen is a pseudo cord factor-like glycolipid having the formula (I) or (II) below: ##STR2## wherein R is a straight chain alkyl group having 15 to 18 carbon atoms. 
     In the case of the compounds of formula (I), the two R groups are preferably the same, but may be different. 
     These glycolipids have been found to have high serodiagnostic discriminating activity (sensitivity and specificity) for M. tuberculosis and M. Leprae and, without wishing to be bound to any particular theory, it is postulated that these synthetic molecules are either cross-reactants of similarly structured native glycolipids of M. tuberculosis or that they bear closer resemblance to actual phagosome-lysosome modified antigens than to native bacterial ones. 
     The glycolipids are also reasonably stable under ambient conditions and can thus be stored and distributed without resort to cold chain techniques. 
     The invention further relates to solid substrates, such as plate wells or paper substrates, suitable for enzyme-linked immunosorbant assays and spot tests for detecting tuberculosis in humans or animals, which solid substrates have an immobilized coating of a glycolipid of structure (I) or (II) above. These coated substrates can be used as components of ELISA test kits or spot test kits and the invention relates to kits of this kind. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     FIGS. 1(A) to 1(G) are graphs showing the results of sensitivity and specificity tests carried out for various compounds, as explained in Example 1 below; 
     FIGS. 2(A) to 2(D) are similar graphs produced according to Example 2 below; 
     FIG. 3(A) shows an abbreviated structure of `true ` cord factor (trehalose 6,6&#39; diesters); 
     FIG. 3(B) shows an abbreviated structure of `mirror` pseudo cord factors (ΨCF, esters of trehalose 6,6&#39; dicarboxylic acid); 
     FIG. 3(C) shows an abbreviated structure of `amide` ΨCF (amides of 6,6&#39;-diamino trehalose); and 
     FIG. 3(D) shows an abbreviated structure of `mirror amide` ΨCF (amides of trehalose 6,6&#39; dicarboxylic acid. 
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     Natural cord factor has the partial structure (III) below: ##STR3## wherein the group --CO--R 1  is the mycoloyl group. The mycolyl groups have 60 to 90 carbon atoms forming complex branched chains. 
     The compounds of the invention differ from natural cord factor in that they have regioinverted ester or amide groups at the terminal positions of the trehalose molecule and in that they contain unbranched lipid chains of intermediate length (15 to 18 carbon atoms). In the case of the esters (I), the structure is a &#34;mirror&#34; arrangement of the natural ester. In the case of the compounds of structure (II), a &#34;mirror&#34; di-N alkyl-substituted amide is present instead of the combined --CH 2  --and ester groups. 
     It should be noted that compounds of structures (I) and (II) have not been detected in the mycobacterial outer cell wall layers, nor indeed elsewhere in nature, and their recognition by antibodies in the sera of tuberculosis patients is thus unexpected. 
     In the case of the compounds of formula (I), the R group is preferably selected from the following groups: 
     
         ______________________________________     n-C.sub.15 H.sub.31, pentadecyl     n-C.sub.16 H.sub.33, hexadecyl     n-C.sub.17 H.sub.35, heptadecyl     n-C.sub.18 H.sub.37, octadecyl.______________________________________ 
    
     In the case of the compound of formula (II), the octadecyl group --C 18  H 37  has a straight chain. 
     The compounds of the invention of formula (I) can be prepared by the methods described for example by Baer et. al. in &#34;Synthesis of a trehalose homolog, 6-deoxy-α-D-glucoheptopyranosly 6-deoxy-α-D-gluco-heptopyranoside, and the corresponding bis(heptosiduronic acid)&#34;, Carbohydr Res., 200:377-389. Two successful synthetic routes are disclosed, starting from α,α-trehalose. 
     A first route involves chain elongation involving ironcarbonyl chemistry. The protected starting material is reacted with sodium dicarbonylcyclopentadienyliron (NaFp) to form a sugar-iron intermediate which is then treated in situ with bromine and methanol or water to effect carbonyl insertion and methanolysis or hydrolysis. The resulting products can then be saponified. 
     A second route involves cyanide displacement of hexa-O-acetyl-α,α-trehalose-6,6&#39;-ditriflate, followed by O-deacylation and hydrolysis with alkaline hydrogen peroxide. 
     The amide compound (II) can be prepared by the method of Goren, M.B., et.al., &#34;Pseudo Cord Factors: Derivatives of α-D-glucopyranuronosyl (1-1) α-D-glucopyranuronoside&#34;, Chemistry and Physics of Lipids, 25 (1979) 209-224, in which derivatives are obtained by Pt-catalyzed oxidation of trehalose, followed by amidation or esterification of the resulting dicarboxylic acids. The text of the Goren et. al. article, which includes a description of the preparation of compound (II) of the present invention (compound (12) of Goren et. al.), is duplicated in part in the Appendix to this specification. 
     The glycolipids thus formed can be used in the conventional ways for ELISA and related tests. For example, the glycolipids, dissolved in suitable solutions, can be coated onto suitable solid supports, e.g. plate wells, and allowed to dry. The dried coating layers may then be incubated with the test sera following the known procedure. The coated solid substrate may be produced and distributed separately, or may be a component of a test kit. A suitable kit would normally comprise multiple-well (e.g. 96-well) microtiter plates precoated with the immunoreactant, commercially available conjugate, commercially available substrate and a package insert detailing the test procedure. 
     An example of suitable equipment for a spot test would comprise a strip of paper precoated with immunoreactant, a number of culture tubes (e.g. 12×75 mm), commercially available protein A--colloidal gold conjugate and a package insert detailing the testing procedure. 
     The effectiveness of the compounds of the invention for the serological diagnosis of tuberculosis and leprosy has been verified as shown in the Examples provided below. 
     EXAMPLE 1 
     Sera 
     One hundred and twelve (112) human sera samples were used in this Example. Of these, fifty six (56) belonged to bacteriologically confirmed tuberculosis patients, of which eight (8) obtained from Buenos Aires, Argentina, were smear negative. Twelve (12) were collected by the Canadian Red Cross and were previously tested as HIV (-) and Hepatitis B (-) and forty four (44) were obtained from a local hospital out-patient clinic. Pathologies among the outpatient group included dyspnea, arthritis, pneumonia, connective tissue disorders, vasculitis and peritonitis. 
     The sera were conserved at either -70° C. or at 4° C. with 0.05% sodium azide. 
     Antigens 
     The four preferred esters of structure (I) above and an n-octyl (n--C 8  H 17 ) analog were synthesized by the method of Baer et. al. mentioned above. 
     The amide of structure (II) above (i.e. trehalose dicarboxylic acid bis (N,N-dioctadecylamide)) (BDA.TDA) was provided by Dr. M. B. Goren of the National Jewish Center for Immunology and Respiratory Medicine, Denver, Colo. (prepared as described in &#34;Pseudo Cord Factors: Derivatives of α-D-glucopyranuronosyl (1-1) α-D-glucopyranuronoside&#34;, Chemistry and Physics of Lipids, 25 (1979) 209-224). 
     Natural cord factor (III) (TDM) was obtained from Dr. Goren and natural SL-IV was obtained from the Pasteur Institute, Paris, France. These were used as natural M. tuberculosis antigens for reference. 
     Enzyme-linked Immunosorbant Assay (ELISA). 
     All antigens were solubilized in hexane and 25 μl volumes of solution containing 100 ng of glycolipid were coated onto Dynatech Immulon 3 (trademark) polystyrene microtiter plate wells, and the plates were dried over night at 37° C. Wells treated in a similar manner with 25 μl of hexane without antigen were included for each test serum to check for nonspecific adsorption. All sera were diluted 1/250 in phosphate buffered saline (PBS) containing 0.5% BSA and tested in duplicate. 
     After saturation overnight at 4° C. with PBS containing 5% BSA, the plates were washed with PBS without Tween (trademark) in a Titertek Microplate Washer (trademark, Flow Laboratories). One hundred (100) μl of diluted human sera were added per well and incubated for 90 minutes. After washings, goat anti-human IgG (H+L)β-galactosidase conjugate (Sera Lab. Ltd., Sussex, England) was added and incubated for 120 minutes. 
     After further washings, O-nitrophenyl-β-D-galactoside (ONPG)(SIGMA) substrate was added and the plates were incubated at 37° C. for 60 minutes. The plates were read at 414 nm by a Titertek Multiskan MCC/340 (trademark) reader. 
     Positive and negative control sera were included in each plate and, for each serum tested, a blank test was performed (uncoated well). The 414 nm values were determined by subtracting test absorbance from blank absorbance. The values were further corrected by a factor obtained by making the absorbance of the well containing the conjugate plus the substrate (v/v, 100 μl ) equal to 100% response. The results were confirmed twice. 
     Data Analysis 
     Sensitivity, specificity and predictive values were calculated by Bayesian methods (Toman, 1981). To determine means, standard deviations, coefficient of variation as well as sensitivity and specificity at any given cut-off point, data were entered into a LOTUS 123 (trademark) program. At the intersection of sensitivity and specificity curves, their values are equivalent. Intersection points were obtained by varying the value of the cut-off point until the number of false positive and false negative sera became equivalent. Graphs were prepared using the PRINTGRAPH (trademark) program of LOTUS 123. 
     Results 
     Table 1 below shows mean values, standard deviations and coefficient of variation of ELISA results obtained in the testing of fifty six (56) sera belonging to the control population (presumably healthy individuals and patients with pathologies other than tuberculosis). 
     
                                           TABLE 1__________________________________________________________________________MEAN, STANDARD DEVIATIONS, POSSIBLE CUT-OFF POINTSAND CO-EFFICIENTS OF VARIATION OF OPTICAL DENSITY(O.D.) VALUES OBTAINED IN THE ELISA SERO DIAGNOSTICPROCEDURE USING PSEUDO CORD FACTORS AND NATURALANTIGENS.DATA DERIVED FROM THE TESTING OFBACTERIOLOGICALLY CONFIRMED TUBERCULOSIS PATIENTSANTIGEN  X* STD        X + STD**              X + 2STD                    X + 3STD                          CV %***__________________________________________________________________________&#34;SL-IV&#34;  151     77 227   304   381   51.06n-pentadecyl   96     54 150   204   258   56.74n-hexadecyl  117     60 178   238   298   51.34n-heptadecyl  152     89 241   331   420   59.00n-octadecyl  150     81 232   313   395   54.13BDA.TDA  205     96 300   396   492   46.62TDM     77     48 125   174   222   62.38__________________________________________________________________________ *X = Mean of 414*10.sup.-3 ; **STD = Standard Deviation; ***CV % = Coefficient of Variation % 
    
     The data included in this Table are useful to determine possible cut-off points for each of the tested antigens. The variation coefficient measures the relative importance of the standard deviation; thus, low values could indicate better reproducibility or results. Most variation coefficients clustered in the 50 to 65% range; antigens TDM and BDA.TDA yielded the highest and the lowest values, respectively. 
     A similar table (Table 2 below) was established for the ELISA results obtained in the testing of fifty six (56) sera belonging to tuberculosis patients. 
     
                       TABLE 2______________________________________MEAN, STANDARD DEVIATIONS,AND VARIATION COEFFICIENTSOF OPTICAL DENSITY (O.D.) VALUES OBTAINEDIN ELISA SERO DIAGNOSTIC PROCEDURE USINGPSEUDO CORD FACTOR AND NATURAL ANTIGENS.DATA RECEIVED FROM THE TESTING OF BACTERI-OLOGICALLY CONFIRMED TUBERCULOSIS PATIENTSANTIGEN     X      STD      X + STD CV %______________________________________&#34;SL-IV&#34;     473    296      768     62.54n-pentadecyl       422    284      706     67.26n-hexadecyl 383    280      664     73.18n-heptadecyl       452    301      753     66.70n-octadecyl 470    321      791     68.15BDA.TDA     648    267      914     41.17TDM         278    332      610     119.43______________________________________ 
    
     The data in this Table show that the highest absorbance results were obtained in the testing of antigen BDA.TDA, the other antigens clustering in the 420 to 470 OD×10 -3  level range, except for natural cord factor (TDM) which gave 278OD×10 -3  and showed the greatest test variation coefficient. Results obtained with the n-octyl analog were not included in the Table because this product was very poorly recognized by the test sera. Alternatively, the n-octyl analog may not dissolve adequately in hexane; or it may be desorbed during contact with the several aqueous systems. 
     FIGS. 1(A) to 1(G) comprises graphs showing the variation of sensitivity and specificity values as a function of increasing absorbance cut-off values for each of the antigens included in this ELISA evaluation. FIG. 1(A) is for TDM: FIG. 1(B) is for SL-IV; FIG. 1(C) is for the n-pentadecyl ester; FIG. 1(D) is for the n-hexadecyl ester; FIG. 1(E) is for the n-heptadecyl ester; FIG. 1(F) is for the n-octadecyl ester; and FIG. 1(G) is for BDA.TDA. The point where the sensitivity and specificity curves meet, called an intersect, determines the cut-off absorbance value at which sensitivity and specificity become equivalent: i.e. the cut-off value at which the test yields an equal number of false positive and false negative results. 
     It is evident from the graphs of FIG. 1 and from the determined intersect values that among all the antigens tested, BDA.TDA showed the highest serodiagnostic discriminatory power, with 93% specificity and sensitivity values. Natural cord factor (TDM) showed the lowest discriminatory power whereas the rest of the antigens tested cluster in the acceptable 80 to 90% range (Table 3). 
     
                       TABLE 3______________________________________SENSITIVITY AND SPECIFICITYVALUES CALCULATED AT THE INTERSECTIONOF CURVES IN FIG. 1. CUT-OFF POINTSVALUES EXPRESSED AS 414*10.sup.-3 UNITSANTIGEN   414 INTERSECT*10.sup.-3                     SENS. &amp; SPEC. %______________________________________&#34;SL-IV&#34;   229             83.93n-pentadecyl     179             89.29n-hexadecyl     150             80.36n-heptadecyl     230             80.36n-octadecyl     208             82.14BDA.TDA   300             92.86TDM        80             58.93______________________________________ 
    
     Finally, it is interesting to note that the calculated intersect values are identical or very close to Mean +1 Standard deviation values for all antigens tested except cord factor. 
     EXAMPLE 2 
     Sera 
     One hundred and thirty-seven (13 g) human sera were tested in this study, of which 81 were taken from leprosy patients. According to the Ridley-Jopling classification, 10 sera belonged to the polar tuberculoid (TT) form, 16 to the polar lepromatous (LL) form, 8 to the borderline tuberculoid (BT) form, 7 to the indeterminate (IND) form, 8 to the midborderline (BB) form and 7 to the borderline lepromatous (BL) form. Twenty-five (25) other human leprosy sera were obtained from the Institute Fame Pereo in Port au Prince, Haita; 9 were classified as multibacillary and 16 paucibacillary. The other 58 sera were obtained from the Canadian Red Cross, and from a local hospital&#39;s out-patient clinic. The latter sera belonged either to healthy individuals or to patients suffering from a variety of diseases other than tuberculosis or leprosy. 
     Antigens 
     Trehalose dicarboxylic acid bis (N, N-dioctadecylamide) (BDA.TDA) was provided by one of the inventors (see Goren M. B. and Jiang K. S., &#34;Pseudo Cord Factors: Derivatives of α-D-glucopyranuronosyl (1-1) α-D-glucopyranuronoside,&#34; Chemistry and Physics of Lipids., 25, (1979), 209-224) while SL-IV was obtained from the Pasteur Institute of Paris. 
     Enzyme-Linked Immunosorbent Assay (ELISA) 
     Twenty five (25) microliters of hexane containing 100 ng of glycolipid antigen were coated onto Dynatech Immulon (Trademark) polystyrene microtiter plate wells using a single pipet and dried at 37° C. Wells similarly treated but without antigen were used to check for non-specific serum absorption. After overnight saturation at 4° C. with phosphate buffer saline (PBS) containing 5% bovine serum albumin (BSA), the plates were washed with PBS without Tween (Trademark) in a Titertek Microplate Washer (Trademark, ICN Biomedicals, Inc., Huntsville, Ala., U.S.A.). Test sera, diluted 1/250 in PBS were added in 100 microliter volumes into each well. After 90 minutes of incubation followed by further washing, goat antihuman IgG and IgM (H+L) β-galactosidase conjugates (Biosys, Compiegne, France) were added to the wells which were then incubated for 120 minutes. After an additional washing, O-nitrophenyl-β-D-galactoside (ONPG) (SIGMA, St. Louis, Mo., U.S.A.) substrate was added and the plates were incubated at 37° C. for 60 minutes. Plates were read at 414 nm by a Titertek Multiskan MCC/340 reader (Trademark, ICN Biomedicals, Inc., Huntsville, Ala., U.S.A.).  414 O.D. values were determined by subtracting blank absorbance values from test absorbance values and by using a correction factor obtained by making the absorbance in wells containing the conjugate plus the substrate (v/v, 100 microliters), equal to the 100% response; results were confirmed once. 
     Data Analysis 
     Sensitivity, specificity and predictive values were calculated by Bayesian methods. To determine mean, standard deviation, coefficient of variation as well as sensitivity and specificity values at any chosen cut-off point, data were entered into a &#34;LOTUS 123&#34; (Trademark) specially designed program. In order to compare the antigens cut-off points were chosen yielding maximum specificity values. Graphs were prepared using the &#34;PRINTGRAPH&#34; (Trademark) program of &#34;LOTUS 123&#34;. Dual modes of testing were compared and analyzed with a special designed LOTUS program in which antigens are compared one on one and the Bayesian characteristics calculated accordingly. 
     Results 
     Table 4 shows mean values, standard deviation and coefficient of variation for sera from the leprosy patient group and for sera belonging to presumably healthy individuals and patients suffering from pathologies other than tuberculosis. 
     
                       TABLE 4______________________________________MEANS, STANDARD DEVIATIONAND COEFFICIENT OF VARIATIONS OF ELISATESTING OF LEPROSY (+) AND NON-LEPROSY (-)HUMAN SERA. UNLESS OTHERWISE INDICATED,THE DATA EXPRESSED ARE IN  414.10.sup.-3 UNITS      IgG   IgG       IgM     IgM      SLIV  BDA       SLIV    BDA______________________________________MEAN &#34;-&#34;     77      197       65    188STD          54      103       67    128MEAN + 1 STD 131     301       132   316MEAN + 2 STD 184     404       199   444CV %         69.8%   52.5%     104.3%                                68.3%MEAN &#34;+&#34;     307     524       264   332STD          234     279       224   261CV %         76.2%   53.3%     84.9% 78.8%______________________________________ 
    
     The means values of non leprosy sera are higher for the synthetic antigen BDA.TDA than for the natural antigen SL-IV, in both the IgG and IgM antibody classes. However, the coefficient of variation was almost twice as high for SL-IV than for BDA.TDA. The Table also shows that sera belonging to leprosy patients recognize the synthetic antigen more strongly then the natural antigen (O.D. 0.524 vs. O.D. 0.307) but only in the IgG class and that the coefficient of variation for the synthetic product is lower than that of SL-IV (53% vs. 76%). 
     The discriminating power of ELISA testing of these two substances in the serodiagnosis of leprosy in the IgG and IgM classes is depicted in FIGS. 2(A)-2(D) which shows the variation of the sensitivity and specificity parameters as a function of the increasing O.D. values of the cut-off point. FIG. 2(A) is for IgG SL-IV; FIG. 2(B) is for IgM SL-IV; FIG. 2(C) is for IgG BDA.TDA; and FIG. 2(D) is for IgM BDA.TDA. 
     High cut-off points i.e. Mean plus two standard deviations, can be chosen to maximize the specificity of the test and to facilitate the comparison of the performance of the antigens (Table 5). 
     
                       TABLE 5______________________________________SENSITIVITY (SENS)SPECIFICITY (SPEC), PREDICTIVE VALUEOF POSITIVITY PVP PREDICTIVE VALUE OF NEGA-TIVITY OF ELISA TESTING OF SL IV AND BDA.TDACUT-OFF POINTS EXPRESSED IN  414.10.sup.-3 UNITSBAYESIAN     IgG      IgG      IgM    IgMANALYSIS     SLIV     BDA      SLIV   BDA______________________________________SENS         63.0%    63.0%    44.4%  26.0%SPEC         98.3%    96.5%    94.8%  96.5%PVP          98.0%    96.2%    92.3%  91.3%PVN          65.5%    65.1%    55.0%  48.3%CUT OFF POINT        184      404      199    444______________________________________ 
    
     The two antigens have similar capabilities in the IgG class, i.e. BDA.TDA shows a sensitivity of about 63% at a specificity of about 97% with the cutoff value at O.D. 0.350 versus about 63% at a specificity of about 98% respectively for SL-IV with tahe cutoff value at O.D. 0.150. The data obtained in the IgM class using the corresponding cut-off values yielded lower sensitivity levels, especially in the case of BDA.TDA. 
     Of the 81 leprosy sera included in this study, 41 can be considered as paucibacillary (TT, BT, IND) and 40 as multibacillary (BB, BL, LL). Table 6 shows the mean, standard deviation and coefficient of variation obtained in sera from multibacillary and paucibacillary leprosy patients with both SL-IV and BDA.TDA. 
     
                       TABLE 6______________________________________MEAN VALUES, STANDARD DEVIATION (ST. DEV) ANDCOEFFICIENT OF VARIATION (CV) OF THE ELISATESTING OF PAUCIBACILLARY AND MULTIBACILLARYLEPROSY SERA. DATA, UNLESS OTHERWISEINDICATED, ARE EXPRESSED IN  414 × 10.sup.-3 UNITS        IgG     IgG       IgM   IgMORIGIN       SLIV    BDA       SLIV  BDA______________________________________PaucibacillaryMEAN         258     527       224   325ST. DEV      188     261       180   229CV %         73.0%   49.6%     80.1% 70.5%MultibacillaryMEAN         358     521       304   338ST. DEV      264     297       255   290CV %         73.7%   57.0%     84.0% 85.9%______________________________________ 
    
     It is evident from this Table that the level of antigen recognition is higher in multibacillary patients than in paucibacillary patients for SL-IV in both the IgG and IgM antibody classes. This is not the case for BDA.TDA since the mean values vary only as a function of antibody class i.e. IgG means are higher than IgM means, but there are no differences in the level of recognition between paucibacillary and multibacillary disease. 
     At the cut-off points which were chosen above and for data obtained in the IgG class, SL-IV detected above 61% (25/41) of the paucibacillary cases and about 65% (26/40) of the multibacillary cases whereas BDA.TDA detected about 59% (24/41) and about 63% (25/40) respectively. 
     APPENDIX 
     The following is a duplication in part of an article by Goren et. al., Chemistry and Physics of Lipids, 25 (1979) 209-224. 
     PSEUDO CORD FACTORS: DERIVATIVES OF α-D-GLUCOPYRANURONOSYL (1-1) α-D-GLUCOPYRANURONOSIDE 
     MAYER B. GOREN* and KUO-SHII JIANG 
     From FIGS. 3A-3(D), it is clear that what we have termed `mirror` pseudo cord factors and `mirror amide` Ψ CF are based upon a core-carbohydrate α-D-glucopyranuronosyl (1-1) α-D-glucopyranuronoside, 1-`trehalose dicarboxylic acid`, or `TDA`, whose synthesis we have described [2]. As shown in FIG. 4, this `dimer` of glucuronic acid is obtained by platinum-catalyzed oxidation of trehalose according to methods that Mehltretter has described for various other starting substances [3]. From TDA, the dimethyl ester, 2, and the hexa O-acetyl diacid, 3, and diacid chloride, 4, were prepared [2] as reactive intermediates for the synthesis of `mirror` and `mirror amide` Ψ CF. 
     Trehalose dicarboxylic acid hexaacetate as a synthesis intermediate. The preparation of hexa-O-acetyl TDA, 3, and of the diacid chloride, 4, (FIG. 4) was described earlier [2]. By means of 4, more complex amides of TDA were obtainable than could be synthesized from the dimethyl ester, 2, by aminolysis. 
     Bis-N-di-n-octadecylamide of `trehalose dicarboxylic acid`: `BDA.TDA`, 12 As shown in FIG. 5, with a secondary amine (`Armeen-2HT`, a commercial product of Armak Chemical Division, consisting principally of di-n-octadecylamine, but with some lower homologs), the diacid chloride hexaacetate was readily converted into the symmetrical diamide hexaacetate, 11. The acetyl groups were removed either by solvolysis in CH 3  OH on a column of DEAE cellulose (free base form [5,6]); or by methanolysis in the presence of NaOCH 3 . The deacetylated product, 12, with mobility in thin layer chromatography similar to natural cord factor, is recovered from the deacetylation mixture by chromatography on a column of DEAE cellulose (acetate form) and cellulose in an overall yield of approx. 50% based on hexaacetyl TDA. This choice of a secondary amine for condensation with TDA was predicated on our intent to prepare `mirror amide` Ψ cord factors of higher molecular weight, and to mimic more closely the α-branched structure of natural cord factors, which in this analog is conferred by the two alkyl groups of the amine. The availability of an inexpensive commercial product, albeit not homogeneous, nevertheless enhances the practical aspects of the Ψ cord factors, if they find utility as substitutes for the natural glycolipid, which is obtainable only with difficulty. Indeed although the `bis-dioctadecyl amide of trehalose dicarboxylic acid` (12, BDA.TDA) had low toxicity in mice, it was nevertheless an excellent substitute for cord factor in exhibiting comparable antitumor activity in the strain 2 guinea pig line-10 tumor system of Rapp and colleagues [4]. 
     Materials and Methods 
     All microanalyses were carried out by the Galbraith Laboratories, Knoxville, Tenn. 
     The synthesis and properties of α-D-Glucopyranuronosyl (1-1) α-D-glucopyranuronoside, 1, its dimethyl ester, 2, hexa-O-acetate, 3, and hexa-O-acetate dicarboxylic acid chloride, 4, have been previously described [2]. 
     α-D-glucopyranuronosyl (1-1) α-D-glucopyranuronoside, bis-N-di-1,1&#39;-octadecyl)amide (BDA.TDA), 12. The diacid chloride was prepared [2] from 0.18 g hexaacetyl TDA. Di n octadecylamine (`Armeen 2HT`) (0.54 g) in 5 ml benzene was added to the acid chloride and the mixture held at reflux for 1.5 h. The mixture was evaporated to dryness and extracted three times with 10-15 ml portions of hexane to dissolve the reaction product and some excess amine. The hexane-soluble product was recovered by evaporation, dissolved in 5 ml CH 3  OH/CHCl 3  (2:1) and, for deacetylation, introduced into a column of cellulose and DEAE-cellulose (free base form) (5.4-2.7 g) for 18 h contact, when the column was eluted with the same solvent. Deacetylation was complete (infrared spectrum). The bis-N-di-n-octadecylamide of trehalose dicarboxylic acid (BDA:TDA) was purified by chromatography in the same cellulose-DEAE cellulose column in the acetate form. The product was loaded in hexane solution and eluted with: (1) 200 ml hexane; (2) 300 ml hexane/CHCl 3  (1:1); (3) 1500 ml CHCl 3  ; (4) 150 ml CHCl 3  /5% CH 3  OH; (5) 150 ml CHCl 3  /10% CH 3  OH. Homogeneous BDA.TDA was recovered from the CHCl 3  eluates (0.171 g) and an additional 0.041 g was recovered by rechromatography of the earlier fractions, (yield 54%). The CHCl 3  /CH 3  OH eluates contained both BDA.TDA and a much more polar product judged to be the monoamide of TDA and dioctadecyl amine. BDA.TDA was recrystallized from ethanol to yield a waxy product. It sinters at approx. 50° C. and gives nondescript melting from 105° C., yielding a clear viscous melt at about 135° C. [α] 24   D  +45 (c=1.47 in C 2  H 5  OH/CHCl 3 , 2:1). 
     NMR data--in CDCl 3  : carbohydrate protons unrelaxed with broad clumped peaks from τ 4.82 to 6.62. A similar aspect is presented in CDCl 3  solutions of cord factor (H. Fales, pers. commun.). The protons in the aliphatic amine chains gave appropriate peaks at τ 8.74 and 9.1. There was no evidence of residual acetate (τ 7.92). 
     Found: C, 72.53%; H, 11.99%; N, 2.03%. Calc. for C 84  H 164  N 2  O 11  : C, 73.20%; H, 11.95%; N, 2.11%. 
     The infrared spectrum of BDA.TDA (not shown) has many features of the spectrum of native cord factor: broad deep hydroxyl absorption peaking at about 3300 cm -1  and deep bands associated with the CH 2  stretching vibration at 2850-2900 cm -1  that are essentially absent in the spectrum of TDA and simple derivatives; a single carbonyl (amide) band at about 1640 cm -1  in the region 1000-1200 -1  fingerprint absorptions associated with trehalose as well as the weak trehalose band at 805 cm -1  [6]. Thus the contributions of both moieties of the Ψ cord factor are prominent. 
     References 
     1. H. Bloch, J. Exp. Med., 91 (1950) 197. 
     2. N. B. Goren and K. S. Jiang, submitted. 
     3. C. L. Mehltretter, Adv. Carbohydr. Chem., 8(1953)231. 
     4. H. J. Rapp, Israel J. Med. Sci., 9(1973)366. 
     5. M. B. Goren and O. Brokl, Recent Results Cancer Res., 47(1974)251. 
     6. M. B. Goren, O. Brokl, P. Roller, H. M. Fales and B. C. Das, Biochemistry, 15 (1976)2728.