Ex immunoassay to measure 51 cytokines in the Nil tube of whole blood QFT-GIT from four healthy and four infected donors in the presence or absence of poly(I:C) and LPS immunomodulation. The levels of IL-6, IL-12 p40, IFN-a, and other cytokines were significantly increased after stimulation of blood cells with poly(I:C) (40 mg/ml) and LPS (250 pg/ml) (Figure 4A and Table S2). However, immunomodulation of QFT-GIT assay with purified IL-6 at 200 and 2000 pg/ml, IL-12 at 12.5 and 25 pg/ml, and IFN-a at 15 and 30 pg/ml, alone or in combination, was not sufficient to recapitulate the effects of TLR agonists on the QFT-GIT assay (data not shown). To determine 1948-33-0 custom synthesis Whether immunomodulation withFigure 3. Immunomodulation of Quantiferon assay elicits an IFN-c response in IGRA-unresponsive subjects with LTBI. IFN-c response (TB Ag minus Nil) for individuals with history of LTBI. Each individual was tested with the QFT-GIT assay in the absence or presence of poly(I:C) 40 mg/ml, LPS 250 pg/ml, and imiquimod (IMQ) 2 mg/ml. The cut-off value for the standard QFT-GIT assay (dashed line) is shown for reference. doi:10.1371/journal.pone.0048027.gImmunomodulation of IGRA Enhances TB ResponseFigure 4. Immunomodulation of Quantiferon assay with TLR ligands enhances markers of innate immune activation. (Panel A) Induction of IL-6, IL-12, and IFN-a in whole blood stimulated with TLR agonists. Blood from four donors with LTBI (red symbols) and four uninfected controls (black symbols) was incubated in the QFT-GIT Nil tube in the absence or presence of poly(I:C) 40 mg/ml and LPS 250 pg/ml for 22 h. (Panel B) Flow cytometry analysis of surface expression of MHC class I and II and costimulatory molecules on monocytes stimulated with poly(I:C) and LPS. Whole blood from six donors was incubated in the QFT-GIT Nil tube in the absence (dashed red line) or presence (solid blue line) of 
poly(I:C) 40 mg/ml and LPS 250 pg/ml for 3 h. (Panel C) Kinetics of IFN-c response (IFN-c response, TB Ag minus Nil) in the QFT-GIT assay without and with immunomodulation with poly(I:C) 40 mg/ml and LPS 250 pg/ml. Data in B and C are representative of 6 individuals in each group. The Wilcoxon signed-rank test was used to compare responses with and without PRR ligands. The asterisks indicate significant difference. *, P#0.05, **, P#0.005, *** P#0.0005. doi:10.1371/journal.pone.0048027.ginfected subjects of Asian, Indian, and Caucasian ancestries, longitudinal studies with a larger number of participants and in more diverse populations are needed to determine the sensitivity and specificity of IGRA with immunomodulators at various cutoffs compared to the standard assay. Immunomodulation of IGRAmay be particularly useful in the pediatric and immunocompromised populations where IGRAs have had lower sensitivities [12,13]. It was recently shown that IFN-c response 
of T cells stimulated with M. get Nafarelin tuberculosis whole cell lysate (WCL) compared with purified secreted antigens better correlated with lower risk ofImmunomodulation of IGRA Enhances TB Responsesubsequent HIV-associated TB [36]. Given the abundance of potent PAMPs in the M. tuberculosis WCL, it would be interesting to determine whether immunomodulation of IGRA with PAMPs elicits an IFN-c response that better correlates with immunity to TB. In vitro immunomodulation may also have broader applications for sensitive diagnosis of infectious diseases and autoimmune disorders with T cell-mediated pathogenesis [37?9]. Whether immunomodulation of IG.Ex immunoassay to measure 51 cytokines in the Nil tube of whole blood QFT-GIT from four healthy and four infected donors in the presence or absence of poly(I:C) and LPS immunomodulation. The levels of IL-6, IL-12 p40, IFN-a, and other cytokines were significantly increased after stimulation of blood cells with poly(I:C) (40 mg/ml) and LPS (250 pg/ml) (Figure 4A and Table S2). However, immunomodulation of QFT-GIT assay with purified IL-6 at 200 and 2000 pg/ml, IL-12 at 12.5 and 25 pg/ml, and IFN-a at 15 and 30 pg/ml, alone or in combination, was not sufficient to recapitulate the effects of TLR agonists on the QFT-GIT assay (data not shown). To determine whether immunomodulation withFigure 3. Immunomodulation of Quantiferon assay elicits an IFN-c response in IGRA-unresponsive subjects with LTBI. IFN-c response (TB Ag minus Nil) for individuals with history of LTBI. Each individual was tested with the QFT-GIT assay in the absence or presence of poly(I:C) 40 mg/ml, LPS 250 pg/ml, and imiquimod (IMQ) 2 mg/ml. The cut-off value for the standard QFT-GIT assay (dashed line) is shown for reference. doi:10.1371/journal.pone.0048027.gImmunomodulation of IGRA Enhances TB ResponseFigure 4. Immunomodulation of Quantiferon assay with TLR ligands enhances markers of innate immune activation. (Panel A) Induction of IL-6, IL-12, and IFN-a in whole blood stimulated with TLR agonists. Blood from four donors with LTBI (red symbols) and four uninfected controls (black symbols) was incubated in the QFT-GIT Nil tube in the absence or presence of poly(I:C) 40 mg/ml and LPS 250 pg/ml for 22 h. (Panel B) Flow cytometry analysis of surface expression of MHC class I and II and costimulatory molecules on monocytes stimulated with poly(I:C) and LPS. Whole blood from six donors was incubated in the QFT-GIT Nil tube in the absence (dashed red line) or presence (solid blue line) of poly(I:C) 40 mg/ml and LPS 250 pg/ml for 3 h. (Panel C) Kinetics of IFN-c response (IFN-c response, TB Ag minus Nil) in the QFT-GIT assay without and with immunomodulation with poly(I:C) 40 mg/ml and LPS 250 pg/ml. Data in B and C are representative of 6 individuals in each group. The Wilcoxon signed-rank test was used to compare responses with and without PRR ligands. The asterisks indicate significant difference. *, P#0.05, **, P#0.005, *** P#0.0005. doi:10.1371/journal.pone.0048027.ginfected subjects of Asian, Indian, and Caucasian ancestries, longitudinal studies with a larger number of participants and in more diverse populations are needed to determine the sensitivity and specificity of IGRA with immunomodulators at various cutoffs compared to the standard assay. Immunomodulation of IGRAmay be particularly useful in the pediatric and immunocompromised populations where IGRAs have had lower sensitivities [12,13]. It was recently shown that IFN-c response of T cells stimulated with M. tuberculosis whole cell lysate (WCL) compared with purified secreted antigens better correlated with lower risk ofImmunomodulation of IGRA Enhances TB Responsesubsequent HIV-associated TB [36]. Given the abundance of potent PAMPs in the M. tuberculosis WCL, it would be interesting to determine whether immunomodulation of IGRA with PAMPs elicits an IFN-c response that better correlates with immunity to TB. In vitro immunomodulation may also have broader applications for sensitive diagnosis of infectious diseases and autoimmune disorders with T cell-mediated pathogenesis [37?9]. Whether immunomodulation of IG.