Diagnosis of Tuberculosis in HIV Co-infected Individuals: Current Status, Challenges and Opportunities for the Future

Construction and validation of a nomogram to predict 1-year mortality risk in patients with HIV/AIDS undergoing maintenance hemodialysis

This single-center retrospective study aimed to explore the 1-year mortality risk factors in 166 patients with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) undergoing maintenance hemodialysis (MH) between 6 June 2017 and 6 June 2023, and construct a 1-year mortality prediction model. The patients were classified into survival and mortality groups based on the 1-year follow-up results, and into training and validation sets at a ratio of 1:1 (53 mortalities and 53 survivors in the training set and 48 mortalities and 58 survivors in the validation set). Stepwise logistic regression was used to construct a 1-year mortality prediction model and to visualize it as a nomogram. Receiver operating characteristic (ROC) analysis, calibration curves, and decision curves were used for nomogram evaluation in the training set and validation in the validation set. Age (≥52 years) (OR (95% CI): 2.05 (3.191-18.892), p < .001), neutrophil to albumin ratio (NAR) (≥0.135) (OR (95% CI): 4.753 (2.011-11.234), p < .001), and HIV-RNA (≥24,650) (OR (95% CI): 13.786 (5.493-34.598), p < .001), represents three of five independent risk factors of 1-year mortality in HIV/AIDS undergoing MH. The AUC of the nomogram for the training and validation sets were 0.908 (95% CI: 0.853-0.963) and 0.939 (95% CI: 0.896-0.983), respectively. The 1-year mortality prediction showed good separation capacity, calibration capacity, and clinical net benefit, which may benefit the management of patients with HIV/AIDS undergoing MH.

A DNA methylation signature identified in the buccal mucosa reflecting active tuberculosis is changing during tuberculosis treatment

Tuberculosis (TB) poses a significant global health threat, with high mortality rates if left untreated. Current sputum-based TB treatment monitoring methods face numerous challenges, particularly in relation to sample collection and analysis. This pilot study explores the potential of TB status assessment using DNA methylation (DNAm) signatures, which are gaining recognition as diagnostic and predictive tools for various diseases. We collected buccal swab samples from pulmonary TB patients at the commencement of TB treatment (n = 10), and at one, two, and six-month follow-up intervals. We also collected samples from healthy controls (n = 10) and individuals exposed to TB (n = 10). DNAm patterns were mapped using the Illumina Infinium Methylation EPIC 850 K platform. A DNAm profile distinct from controls was discovered in the oral mucosa of TB patients at the start of treatment, and this profile changed throughout the course of TB treatment. These findings were corroborated in a separate validation cohort of TB patients (n = 41), monitored at two and six months into their TB treatment. We developed a machine learning model to predict symptom scores using the identified DNAm TB profile. The model was trained and evaluated on the pilot, validation, and two additional independent cohorts, achieving an R2 of 0.80, Pearson correlation of 0.90, and mean absolute error of 0.13. While validation is needed in larger cohorts, the result opens the possibility of employing DNAm-based diagnostic and prognostic tools for TB in future clinical practice.

Performance of stool-based molecular tests and processing methods for paediatric tuberculosis diagnosis: a systematic review and meta-analysis

BACKGROUND

There has been a global pursuit to improve the diagnosis of tuberculosis in young children by applying diagnostic methods on accessible biospecimens such as stool. We aimed to conduct a systematic review on the accuracy of stool-based molecular tests for tuberculosis diagnosis in children and to assess the impact of the available pre-processing methods and other design characteristics.

METHODS

In this systematic review and meta-analysis, we evaluated studies in children younger than 16 years with presumptive tuberculosis that were published in English, Spanish, French, and Portuguese from Jan 1, 2000, to May 3, 2024, in MEDLINE, Embase, and Embase Classic, comparing the molecular detection of Mycobacterium tuberculosis DNA in stool with microbiological tests on other samples or a clinical diagnosis. We did not exclude studies based on geographical location, sample size, or study design if they were reporting primary data. Two independent reviewers (LC-C and SM) screened titles, abstracts, and full-text articles for eligibility and extracted data on study characteristics, study population, and diagnostic performance. If information relevant to the main analysis was not reported in the article, the corresponding authors were contacted. Point estimates and 95% CIs were calculated for sensitivity and specificity for each study and for the different molecular tests (Xpert MTB/RIF, Xpert Ultra MTB/RIF [Cepheid, Sunnyvale, CA, USA], and other tests) versus a reference standard (culture only, any bacteriological confirmation, and tuberculosis case definition). Sensitivity and specificity were stratified by the stool processing method. We also quantified the additionality of stool Xpert Ultra tests for tuberculosis bacteriological confirmation. The protocol was registered with PROSPERO, CRD42022341514.

FINDINGS

A total of 4521 records were identified through the database search, one record was identified from an article bibliography, and 67 studies were retained for full-text reading. 39 studies were included in the qualitative synthesis, 35 of which were included in the meta-analyses. When using any bacteriological confirmation from a respiratory sample as the reference standard, stool Xpert sensitivity was 0·60 (95% CI 0·48-0·71), stool Xpert Ultra sensitivity was 0·73 (0·63-0·81), and sensitivity was 0·44 (0·29-0·60) for other in-house molecular methods combined. When using tuberculosis case definition as the reference standard, stool Xpert sensitivity was 0·23 (0·11-0·41), stool Xpert Ultra sensitivity was 0·38 (0·22-0·56), and sensitivity was 0·17 (0·09-0·23) for other in-house molecular methods. The addition of stool Xpert Ultra increased bacteriological confirmation of tuberculosis by 38·6% overall. Further, the utilisation of centrifuge-free simplified methods improved the sensitivity of stool Xpert Ultra when using any bacteriological confirmation as a reference standard (0·77 [0·66-0·85] for centrifuge-free methods vs 0·61 [0·41-0·78] for non-centrifuge-free methods).

INTERPRETATION

This systematic review and meta-analysis supports the use of Xpert Ultra in stool samples as a diagnostic tool for paediatric tuberculosis diagnosis. Stool-based Xpert Ultra can contribute to increase the bacteriological confirmation in this population, even when respiratory specimens are also tested.

FUNDING

The EDCTP2 programme supported by the EU via Stool4TB Project and the European Society of Pediatric Infectious Diseases.

Non-sputum-based samples and biomarkers for detection of Mycobacterium tuberculosis: the hope to improve childhood and HIV-associated tuberculosis diagnosis

In 2014, the World Health Organisation (WHO) published target product profiles (TPP) for development of novel tuberculosis (TB) diagnostics. One of the key highlights is the need for point-of-care non-sputum-based tests capable of detecting all forms of TB through identification of characteristic biomarkers or biosignatures. Compared to the limitations associated with sputum-based TB tests, non-sputum samples are easy to collect, non-invasive, with potential to improve TB diagnosis among children and among people living with HIV/AIDS (PLHIV). This review gives an overview of the existing evidence on TB diagnostic studies of non-sputum-based samples collected non-invasively from or through the oral-gastrointestinal tract (GI) and nasal pharynx regions of humans and the biomarkers detected. We further summarized evidence of these biomarkers and sample types from research done in paediatric and PLHIV. The review identified; saliva, cough aerosols, oral swabs, oral wash, dental plaque, tongue swabs, face mask sampling, exhaled breath, and stool, as the non-sputum samples investigated. These biomarkers can be categorized into Deoxyribose Nucleic Acid (DNA), Ribonucleic Acid (RNA), inflammatory, antigen-antibody, volatile and non-volatile compounds, microbiome and microbiota. The biomarkers identified were derived both from the host and pathogen. Similar biomarkers were identified in the general population, children and among PLHIV. These biomarkers have been detected by either already approved simple point of care or sophisticated devices. Differences in methodology and sample types investigated, small sample size of children and PLHIV populations, bias due to confounding factors, were some of the identified challenges in these studies. There is need to conduct larger and standardized multi centre studies to evaluate non-sputum-based biomarker-based tests in children and PLHIV.

HIV-MTB Co-Infection Reduces CD4+ T Cells and Affects Granuloma Integrity

Granuloma is a crucial pathological feature of tuberculosis (TB). The relationship between CD4+ T cells in both peripheral blood and granulomatous tissue, and the integrity of granulomas in Human Immunodeficiency Virus (HIV)-MTB co-infection, remains unexplored. This study collected biopsy specimens from 102 TB patients (53 with HIV-MTB co-infection and 49 only with TB). Hematoxylin and eosin (HE) staining and immunohistochemical staining were performed, followed by microscopic examination of the integrity of tuberculous granulomas. Through statistical analysis of peripheral blood CD4+ T cell counts, tissue CD4+ T cell proportion, and the integrity of granulomas, it was observed that HIV infection leads to poor formation of tuberculous granulomas. Peripheral blood CD4+ T cell counts were positively correlated with granuloma integrity, and there was a similar positive correlation between tissue CD4+ T cell proportions and granuloma integrity. Additionally, a positive correlation was found between peripheral blood CD4+ T cell counts and the proportion of CD4+ T cells in granuloma tissues. Therefore, HIV infection could impact the morphology and structure of tuberculous granulomas, with a reduced proportion of both peripheral blood and tissue CD4+ T lymphocytes.

Screening of bioactive compounds from selected mushroom species against putative drug targets in Mycobacterium tuberculosis: a multi-target approach

Mycobacterium tuberculosis (Mtb) is a notorious pathogen that causes one of the highest mortalities globally. Due to a pressing demand to identify novel therapeutic alternatives, the present study aims to focus on screening the putative drug targets and prioritizing their role in antibacterial drug development. The most vital proteins involved in the Biotin biosynthesis pathway and the Lipoarabinomannan (LAM) pathway such as biotin synthase (bioB) and alpha-(1->6)-mannopyranosyltransferase A (mptA) respectively, along with other essential virulence proteins of Mtb were selected as drug targets. Among these, the ones without native structures were modelled and validated using standard bioinformatics tools. Further, the interactions were performed with naturally available lead molecules present in selected mushroom species such as Agaricus bisporus, Pleurotus djamor, Hypsizygus ulmarius. Through Gas Chromatography-Mass Spectrometry (GC-MS), 15 bioactive compounds from the methanolic extract of mushrooms were identified. Further, 4 were selected based on drug-likeness and pharmacokinetic screening for molecular docking analysis against our prioritized targets wherein Benz[e]azulene from Pleurotus djamor illustrated a good binding affinity with a LF rank score of -9.036 kcal mol -1 against nuoM (NADH quinone oxidoreductase subunit M) and could be used as a prospective candidate in order to combat Tuberculosis (TB). Furthermore, the stability of the complex are validated using MD Simulations and subsequently, the binding free energy was calculated using MM-GBSA analysis. Thus, the current in silico analysis suggests a promising role of compounds extracted from mushrooms in tackling the TB burden.

Advances in technology for the laboratory diagnosis of individuals with HIV/AIDS coinfected with Mycobacterium tuberculosis

The high morbidity and mortality rate of individuals with human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS) coinfected with Mycobacterium tuberculosis (MTB) is a tough challenge for current global tuberculosis prevention and control efforts. HIV/MTB coinfection is more complex than a single infection, and the interaction between the two diseases aggravates the deterioration caused by the disease, resulting in increased hospitalizations and deaths. Rapid screening and early diagnosis facilitate the timely initiation of anti-tuberculosis treatment in HIV/MTB coinfected individuals, thereby reducing transmission and the incidence of adverse prognoses. To date, pathogenic detection has remained the gold standard for diagnosing tuberculosis, but its sensitivity and specificity are greatly affected by the body's immune status, which limits its application in the diagnosis of HIV/MTB coinfection. Recently, immunology and molecular detection technology has developed rapidly. New detection technologies, such as interferon-γ release assays, interferon-gamma inducible protein 10, and GeneXpert MTB/RIF assay have overcome the limitations of traditional detection methods, significantly improved the sensitivity and specificity of tuberculosis diagnosis, and brought new hope to the detection of HIV/MTB coinfection. In this article, the principle, scope of application, and latest research progress of relevant detection methods are reviewed to provide a reference for the early diagnosis of HIV/MTB coinfection.

Two cases of testicular tuberculosis in HIV patients with distinct clinical presentations

Genito-urinary tuberculosis (TB) corresponds to the second most common cause of extrapulmonary tuberculosis EPTB worldwide. It is however rare and is often clinically indistinguishable from testicular malignancy and infarction. HIV hugely increases the risk of TB in unusual sites; we present two such cases of testicular tuberculosis. The diagnosis was based respectively on histopathological findings, acid-bacilli smear of biopsy, semen, and culture.

Clinical characteristics and drug resistance of Nocardia in Henan, China, 2017-2023

BACKGROUND

The aim of this study was to investigate the clinical features of Nocardia infections, antibiotic resistance profile, choice of antibiotics and treatment outcome, among others. In addition, the study compared the clinical and microbiological characteristics of nocardiosis in bronchiectasis patients and non-bronchiectasis patients.

METHODS

Detailed clinical data were collected from the medical records of 71 non-duplicate nocardiosis patients from 2017 to 2023 at a tertiary hospital in Zhengzhou, China. Nocardia isolates were identified to the species level using MALDI-TOF MS and 16S rRNA PCR sequencing. Clinical data were collected from medical records, and drug susceptibility was determined using the broth microdilution method.

RESULTS

Of the 71 cases of nocardiosis, 70 (98.6%) were diagnosed as pulmonary infections with common underlying diseases including bronchiectasis, tuberculosis, diabetes mellitus and chronic obstructive pulmonary disease (COPD). Thirteen different strains were found in 71 isolates, the most common of which were N. farcinica (26.8%) and N. cyriacigeorgica (18.3%). All Nocardia strains were 100% susceptible to both TMP-SMX and linezolid, and different Nocardia species showed different patterns of drug susceptibility in vitro. Pulmonary nocardiosis is prone to comorbidities such as bronchiectasis, diabetes mellitus, COPD, etc., and Nocardia is also frequently accompanied by co-infection of the body with pathogens such as Mycobacterium and Aspergillus spp. Sixty-one patients underwent a detailed treatment regimen, of whom 32 (52.5%) received single or multi-drug therapy based on TMP-SMX. Bronchiectasis was associated with a higher frequency of Nocardia infections, and there were significant differences between the bronchiectasis and non-bronchiectasis groups in terms of age distribution, clinical characteristics, identification of Nocardia species, and antibiotic susceptibility (P < 0.05).

CONCLUSIONS

Our study contributes to the understanding of the species diversity of Nocardia isolates in Henan, China, and the clinical characteristics of patients with pulmonary nocardiosis infections. Clinical and microbiologic differences between patients with and without bronchiectasis. These findings will contribute to the early diagnosis and treatment of patients.

No extraction? No problem. Direct to PCR processing of tongue swabs for diagnosis of tuberculosis disease as an alternative to sputum collection

IMPORTANCE

Tuberculosis (TB) remains one of the world's leading infectious disease killers, despite available treatments. Although highly sensitive molecular diagnostics are available, expensive equipment and poor infrastructure have hindered their implementation in low-resource settings. Furthermore, the collection of sputum poses challenges as it is difficult for patients to produce and creates dangerous aerosols. This manuscript explores tongue swabs as a promising alternative to sputum collection. While previous studies have explored the sensitivity of tongue swabs as compared to sputum, existing literature has not addressed the need to standardize and simplify laboratory processing for easy implementation in high TB burden areas. This manuscript provides the first evidence that detection of TB from a tongue swab is possible without the use of DNA extraction or purification steps. The data provided in this manuscript will improve the collection and testing of tongue swabs for the diagnosis of TB disease.

Comorbidity and drug resistance of smear-positive pulmonary tuberculosis patients in the yi autonomous prefecture of China: a cross-sectional study

BACKGROUND

Tuberculosis (TB) has a high morbidity and mortality rate, and its prevention and treatment focus is on impoverished areas. The Liangshan Yi Autonomous Prefecture is a typical impoverished area in western China with insufficient medical resources and high HIV positivity. However, there have been few reports of TB and drug resistance in this area.

METHODS

We collected the demographic and clinical data of inpatients with sputum smear positive TB between 2015 and 2021 in an infectious disease hospital in the Liangshan Yi Autonomous Prefecture. Descriptive analyses were used for the epidemiological data. The chi-square test was used to compare categorical variables between the drug-resistant and drug-susceptible groups, and binary logistic regression was used to analyse meaningful variables.

RESULTS

We included 2263 patients, 79.9% of whom were Yi patients. The proportions of HIV (14.4%) and smoking (37.3%) were higher than previously reported. The incidence of extrapulmonary TB (28.5%) was high, and the infection site was different from that reported previously. When drug resistance gene detection was introduced, the proportion of drug-resistant patients became 10.9%. Patients aged 15-44 years (OR 1.817; 95% CI 1.162-2.840; P < 0.01) and 45-59 years (OR 2.175; 95% CI 1.335-3.543; P < 0.01) had significantly higher incidences of drug resistance than children and the elderly. Patients with a cough of ≥ 2 weeks had a significantly higher chance of drug resistance than those with < 2 weeks or no cough symptoms (OR 2.069; 95% CI 1.234-3.469; P < 0.01). Alcoholism (OR 1.741; 95% CI 1.107-2.736; P < 0.05) and high bacterial counts on sputum acid-fast smears (OR 1.846; 95% CI 1.115-3.058; P < 0.05) were significant in the univariate analysis.

CONCLUSIONS

Sputum smear-positive TB predominated in Yi men (15-44 years) with high smoking, alcoholism, and HIV rates. Extrapulmonary TB, especially abdominal TB, prevailed. Recent drug resistance testing revealed higher rates in 15-59 age group and ≥ 2 weeks cough duration. Alcohol abuse and high sputum AFB counts correlated with drug resistance. Strengthen screening and supervision to curb TB transmission and drug-resistant cases in the region.

Clinical symptoms and immune injury reflected by low CD4/CD8 ratio should increase the suspicion of HIV coinfection with tuberculosis

BACKGROUND

Patients who are coinfected with human immunodeficiency virus 1 (HIV) and Mycobacterium tuberculosis (TB) benefit from timely diagnosis and treatment. In the present study frequencies of CD3+, CD4+, and CD8+ T cells among peripheral blood mononuclear cells (PBMCs) of patients in the Kashi region of China infected with HIV, TB, and both HIV and TB (HIV-TB) were investigated to provide a basis for rapid identification of coinfected patients.

METHODS

A total of 62 patients with HIV, TB, or HIV-TB who were first hospitalized at our institution were included in the study, as were 30 controls. PBMCs were isolated, and the frequencies of CD3+, CD4+, and CD8+ T cells were determined via flow cytometry.

RESULTS

The frequency of CD4+ T cells and the CD4/CD8 ratio were significantly lower in the HIV-TB group than in the other three groups. In fever patients the frequency of CD4+ T cells and the CD4/CD8 ratio were significantly lower in the HIV-TB group than in the HIV group and the TB group. In patients who exhibited rapid weight loss there were no significant differences in the frequency of CD4+ T cells or the CD4/CD8 ratio between the groups. The results of treatment were compared in the HIV, TB, and HIV-TB groups after 7 days, and there were obvious improvements in the frequency of CD4+ T cells and the CD4/CD8 ratio.

CONCLUSION

Clinical symptoms and the degree of immune injury can heighten suspicion for HIV-TB coinfection.

Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome-An Extempore Game of Misfiring with Defense Arsenals

The lethal combination involving TB and HIV, known as "syndemic" diseases, synergistically act upon one another to magnify the disease burden. Individuals on anti-retroviral therapy (ART) are at risk of developing TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). The underlying inflammatory complication includes the rapid restoration of immune responses following ART, eventually leading to exaggerated inflammatory responses to MTB antigens. TB-IRIS continues to be a cause of morbidity and mortality among HIV/TB coinfected patients initiating ART, and although a significant quantum of knowledge has been acquired on the pathogenesis of IRIS, the underlying pathomechanisms and identification of a sensitive and specific diagnostic marker still remain a grey area of investigation. Here, we reviewed the latest research developments into IRIS immunopathogenesis, and outlined the modalities to prevent and manage strategies for better clinical and diagnostic outcomes for IRIS.

Updated Review on Nocardia Species: 2006-2021

This review serves as an update to the previous Nocardia review by Brown-Elliott et al. published in 2006 (B. A. Brown-Elliott, J. M. Brown, P. S. Conville, and R. J. Wallace. Jr., Clin Microbiol Rev 19:259-282, 2006, https://doi.org/10.1128/CMR.19.2.259-282.2006). Included is a discussion on the taxonomic expansion of the genus, current identification methods, and the impact of new technology (including matrix-assisted laser desorption ionization-time of flight [MALDI-TOF] and whole genome sequencing) on diagnosis and treatment. Clinical manifestations, the epidemiology, and geographic distribution are briefly discussed. An additional section on actinomycotic mycetoma is added to address this often-neglected disease.

Screening for tuberculosis of patients with HIV-infection. New possibilities

Background. Tuberculosis associated with HIV infection is becoming almost a new disease, where not only new approaches to treatment are being formed, but there is also a need to improve the quality and search for new means of early diagnosis of tuberculosis infection.

The aim. To evaluate the diagnostic performance of the T-SPOT.TB test for the detection of latent tuberculosis infection and clinical forms of tuberculosis in patients with HIV infection.

Materials and methods. 396 patients registered at the AIDS Center for more than a year were examined. Everyone underwent standard examinations for pulmonary tuberculosis using sputum bacterioscopy techniques with Ziehl – Neelsen staining; a molecular genetic method based on hybridization technology – HAIN-GenoType MTBDRplus; crops on liquid media in the automated BACTEC MGIT 960 system and on Löwenstein–Jensen dense medium. T-SPOT.TB was conducted as a screening for everyone. With positive T-SPOT.TB results, negative results of the MBT search, absence of specific changes on the X-ray a conclusion was made about latent tuberculosis infection. Statistical data processing was carried out using the software package Statistica 10 (StatSoft Inc., USA).

Results. According to the results of a comprehensive examination, tuberculosis was diagnosed in 174 patients, verified using various methods of searching for Mycobacterium tuberculosis in 116 patients (66.6 %). Infiltrative (63.8 %) and disseminated (24.7 %) tuberculosis were more often diagnosed. Latent tuberculosis infection was diagnosed in 52 patients, 170 HIV-infected patients have no data for tuberculosis at this stage.

Conclusions. T-SPOT.TB can be used in the diagnostic complex of monitoring patients with HIV infections – as a screening method to detect latent tuberculosis, for preventive chemotherapy.

Addressing TB-related mortality in adults living with HIV: a review of the challenges and potential solutions

Tuberculosis (TB) is the leading cause of death in people living with HIV (PLHIV) globally, causing 208,000 deaths in PLHIV in 2019. PLHIV have an 18-fold higher risk of TB, and HIV/TB mortality is highest in inpatient facilities, compared with primary care and community settings. Here we discuss challenges and potential mitigating solutions to address TB-related mortality in adults with HIV. Key factors that affect healthcare engagement are stigma, knowledge, and socioeconomic constraints, which are compounded in people with HIV/TB co-infection. Innovative approaches to improve healthcare engagement include optimizing HIV/TB care integration and interventions to reduce stigma. While early diagnosis of both HIV and TB can reduce mortality, barriers to early diagnosis of TB in PLHIV include difficulty producing sputum specimens, lower sensitivity of TB diagnostic tests in PLHIV, and higher rates of extra pulmonary TB. There is an urgent need to develop higher sensitivity biomarker-based tests that can be used for point-of-care diagnosis. Nonetheless, the implementation and scale-up of existing tests including molecular World Health Organization (WHO)-recommended diagnostic tests and urine lipoarabinomannan (LAM) should be optimized along with expanded TB screening with tools such as C-reactive protein and digital chest radiography. Decreased survival of PLHIV with TB disease is more likely with late HIV diagnosis and delayed start of antiretroviral (ART) treatment. The WHO now recommends starting ART within 2 weeks of initiating TB treatment in the majority of PLHIV, aside from those with TB meningitis. Dedicated TB treatment trials focused on PLHIV are needed, including interventions to improve TB meningitis outcomes given its high mortality, such as the use of intensified regimens using high-dose rifampin, new and repurposed drugs such as linezolid, and immunomodulatory therapy. Ultimately holistic, high-quality, person-centered care is needed for PLHIV with TB throughout the cascade of care, which should address biomedical, socioeconomic, and psychological barriers.

Anti-mycobacterial activity evaluation of designed peptides: cryptic and database filtering based approach

Worldwide, TB is one of the deadly airborne diseases, which accounts for 10.4 million deaths annually. Serious toxicity issue, prolonged treatment regimens of the current drugs, rise in multidrug-resistant strains, and the unique defensive mechanism makes the development of novel therapeutic molecules against Mycobacterium tuberculosis (MT) an urgent need. As MT has a lengthy latent phase and unique cell wall architecture, a reasonable approach is needed to find molecules having a different killing mechanism rather than traditional approaches. Host defence peptides (HDPs) will be the most promising alternative, potential therapeutic candidates as they target the microbial membrane in particular and are an essential part of the innate immunity of humans. This works demonstrates the utility of "Database filtering" and three-dimensional (3D) modelling approach in finding novel AMPs with appreciable activity towards MT. Results of this study indicate that peptides with 70% hydrophobicity, but without hydrophobicity patches (> 4 hydrophobic amino acids in series) and charge of + 4 or + 5 are most likely to be good anti-tubercular candidates.

The development and validation of a diagnostic scoring system to differentiate pulmonary tuberculosis from non-tuberculosis pulmonary infections in HIV-infected patients with severe immune suppression

Background

It remains challenging to differentiate tuberculosis (TB) from non-TB pulmonary infections in HIV-infected patients. Herein, we developed a scoring system aimed to rapidly determine the likelihood of TB or non-TB pathology in HIV-infected patients presenting with pulmonary infections.

Methods

We collected and collated data of hospitalized HIV-infected patients with pulmonary infections, followed by univariate and multivariate data analyses to determine risk variables that were significantly different between HIV/TB patients and HIV/non-TB patients. Subsequently, a regression coefficient was calculated for each variable, and a score was assigned to each variable in line with its regression coefficient. The sum of the scores for each variable in our scoring model was used to predict the likelihood of TB or non-TB pulmonary infection in each patient. Finally, we tested the diagnostic accuracy of the scoring system in our retrospective cohort, as well as in a prospective cohort.

Results

A total of 598 HIV-infected patients were enrolled in our retrospective cohort, among whom 288 had TB and 310 had non-TB pulmonary infections. Eight variables, including fever, highest body temperature, erythrocyte sedimentation rate (ESR), cervical lymphadenopathy, hilar and/or mediastinum lymphadenopathy, pulmonary cavitation, pleural effusion, and miliary nodules, were found to be mathematically significantly different via univariate analysis and multivariate logistic regression analysis. After regression coefficient calculation followed by score assignment, a receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated to be 0.902. When the total score for a patient is > 12, the sensitivity and specificity for TB prediction using our scoring system were 76.4% and 87.7% respectively in the retrospective cohort, and its diagnostic accuracy was 82.7% in the prospective cohort.

Conclusions

Our results demonstrate that our proposed diagnostic scoring system could be helpful in differentiating pulmonary TB from non-TB pulmonary infections in HIV-infected patients.

New management approaches to tuberculosis in people living with HIV

PURPOSE OF REVIEW

People living with HIV (PLWH) are commonly coinfected with Mycobacterium tuberculosis, particularly in high-transmission resource-limited regions. Despite expanded access to antiretroviral therapy and tuberculosis (TB) treatment, TB remains the leading cause of death among PLWH. This review discusses recent advances in the management of TB in PLWH and examines emerging therapeutic approaches to improve outcomes of HIV-associated TB.

RECENT FINDINGS

Three recent key developments have transformed the management of HIV-associated TB. First, the scaling-up of rapid point-of-care urine-based tests for screening and diagnosis of TB in PLWH has facilitated early case detection and treatment. Second, increasing the availability of potent new and repurposed drugs to treat drug-resistant TB has generated optimism about the treatment and outcome of multidrug-resistant and extensively drug-resistant TB. Third, expanded access to the integrase inhibitor dolutegravir to treat HIV in resource-limited regions has simplified the management of TB/HIV coinfected patients and minimized serious adverse events.

SUMMARY

While it is unequivocal that substantial progress has been made in early detection and treatment of HIV-associated TB, significant therapeutic challenges persist. To optimize the management and outcomes of TB in HIV, therapeutic approaches that target the pathogen as well as enhance the host response should be explored.

Coinfection of Tuberculosis in an Undiagnosed HIV, AIDS Patient Presenting With Shortness of Breath, Constitutional Symptoms and Lymphadenopathy

Tuberculosis (TB) has long been known as an acquired immunodeficiency syndrome (AIDS) defining illness in human immunodeficiency virus (HIV) patients, causing reciprocal advantage for both pathogens throughout the course of the disease, not just constituting a burden for the patient, but also impacting public health globally. We report a case of a 42-year-old man who presented with shortness of breath, generalized lymphadenopathy and weight loss. Subsequently diagnosed with HIV/AIDS and generalized ganglionar TB. Initial computed tomography (CT) of the chest showed extensive mediastinal involvement with large right loculated pleural effusion, with growth of acid-fast bacilli (AFB) on culture. Biopsy of lymph nodes confirmed pathologic changes correlating with M. tuberculosis (Caseating granulomatous inflammation), ruling out the possibility of lymphoproliferative disorder. Multiple factors contribute to the immune system decline in AIDS patients, moreover the rapid depletion of Tuberculosis antigen-specific CD4+ T before generalized CD4+T cells. Early assessment for the presence of co-infection and guidance of targeted therapy is critical for management and an important factor in the expected recovery of such patients. Therefore, understanding the pathogenesis of the co-infection, diagnostic approach, possible complications, and the action of concurrent therapy highly active antiretroviral therapy (HAART)/anti-Tuberculosis treatment as well as drug cytotoxicity is paramount.

Diagnosis of tuberculosis: a consensus statement from the Brazilian Thoracic Association

Early, accurate diagnosis of tuberculosis is one of the major pillars of the control of the disease. The purpose of this consensus statement is to provide health professionals with the most current, useful evidence for the diagnosis of tuberculosis in Brazil. To that end, the Tuberculosis Committee of the Brazilian Thoracic Association brought together 14 members of the Association with recognized expertise in tuberculosis in Brazil to compose the statement. A nonsystematic review of the following topics was carried out: clinical diagnosis, bacteriological diagnosis, radiological diagnosis, histopathological diagnosis, diagnosis of tuberculosis in children, and diagnosis of latent tuberculosis infection.

Pulmonary tuberculosis: Evaluation of current diagnostic strategy

OBJECTIVE

To identify tools that will result in faster diagnosis, making the current pulmonary tuberculosis strategy more efficient.

PATIENTS AND METHODS

A 4-year (2015-2018) retrospective study. The gold standard for diagnosis was a positive culture from a respiratory specimen. All sputum, fibroscopy and post-fibroscopy specimens (for smear negative patients) were collected. Each specimen was analyzed through smear examination and culture. All nucleic acid amplification testing results were included. Analyses looked at the incremental yield of positive cases of each successive specimen collection, and time to diagnosis.

RESULTS

A total of 354 patients had at least one positive culture. Sputum allowed a diagnosis in 92% of cases (including a gain in sensitivity of around 7% for the third sputum specimen), with 160 smear-positive patients (45%). Among smear-negative patients, 109 underwent a fibroscopy procedure (culture sensitivity of 75%), and 59 had a post-fibroscopy specimen collected, which together identified the rest of the patients (8%). Molecular testing was used in 237 specimens. Median time to diagnosis was 11 days, which was significantly reduced among smear-negative patients when molecular testing was used (P<0.001). Shortening the delay between sputum specimen collections did not alter procedure sensitivity.

CONCLUSIONS

We identified several aspects of the French tuberculosis diagnosis algorithm that could be improved, and posed the basis for a prospective study. Centers in higher incidence areas could benefit from a dedicated, predefined procedure exploring suspicions of tuberculosis. A high suspicion score of tuberculosis could drive the reasoned use of molecular testing in such settings.

Comparison of different bacteriological testing strategies and factors for bacteriological confirmation among pulmonary TB patients: a retrospective study in Tianjin, China, 2017-2018

Background

Bacteriological confirmation (BC) proportion among notified pulmonary TB patients in China is among the lowest in the world. This study was to understand the yield of BC using different testing strategies and patient-level factors associated with BC among pulmonary TB patients in Tianjin, China during 2017–2018.

Methods

A retrospective study was conducted, enrolling pulmonary TB patients reported to National TB Information Management System (TBIMS) in Tianjin during 2017–2018. BC was defined as a positive result by any of the followings: smear microscopy, culture, or nucleic acid amplification test. Individual characteristics were compared between patients with positive and negative bacteriological results using contingency tables and χ² test. Multivariable logistic regression was applied to analyze factors associated with BC, calculating adjusted odds ratios (aOR) and 95% confidence intervals (CI) (α = 0.05).

Results

Of 6364 reported patients, 4181 (65.7%) were bacteriologically confirmed. Positivity proportion was 43.1% (2746/6364) for smear microscopy, 57.7% (3380/5853) for culture, 61.7% (1608/2605) for Xpert® MTB/RIF assay (Xpert) and 73.4% (1824/2484) for combination of the three. The unemployed (aOR = 1.5, 95% CI: 1.0–2.2) and farmers (aOR = 1.7, 95% CI: 1.1–2.8) compared with students; diagnosis by inpatient hospitals compared with TB clinics (aOR = 3.4, 95% CI: 2.6–4.4); having symptoms for ≥2 weeks (aOR = 1.4, 95% CI: 1.1–1.8); cough (aOR = 2.2, 95% CI: 1.8–2.8); blood sputum (aOR = 1.5, 95% CI: 1.0–2.2); cavitation on chest X-ray (aOR = 3.3, 95% CI: 2.5–4.3); bilateral lung lobes affected (aOR = 1.7, 95% CI: 1.4–2.2) were factors associated with BC.

Conclusions

Combination test was an effective way to improve BC among pulmonary TB patients. Being unemployed, farmers, having prolonged symptoms, and more severe in TB condition were factors associated with BC. We recommend combination of tests to improve BC for pulmonary TB patients, especially who are in early stage of the disease or with conditions tend to be bacteriologically negative.

Serological biomarkers for monitoring response to treatment of pulmonary and extrapulmonary tuberculosis in children and adolescents

Key measures to halt the spread of tuberculosis (TB) include early diagnosis, effective treatment, and monitoring disease management. We sought to evaluate the use of serum immunoglobulin levels against antigens present in cell envelope of Mycobacterium tuberculosis to monitor TB treatment response in children and adolescents with pulmonary (PTB) or extrapulmonary TB (EPTB). Blood samples were collected prior to and one, two, and six months following treatment initiation. Serum immunoglobulin levels against cardiolipin, sulfatide, mycolic acid and Mce1A protein were measured by ELISA. Serum from 53 TB patients and 12 healthy participants were analyzed. After six months of successful treatment, there was a significant decrease (p < 0.0001) in IgM levels against cardiolipin, sulfatide, mycolic acid and Mce1A protein and IgG levels against Mce1A protein when compared to baseline immunoglobulin levels. There was no significant variation in antibody levels during follow-up between participants with PTB and EPTB, confirmed and unconfirmed TB diagnosis, and HIV infection status. Antibody levels in control participants without TB did not decrease during follow-up. These results suggest that immunoglobulin responses to mycobacterial cell wall products may be a useful tool to monitor treatment response in children and adolescents with PTB or EPTB.

Features of Epidemic Process of Tuberculosis in the Territory with High Prevalence of HIV Infection

Scales of epidemic process of HIV-associated of tuberculosis are especially noticeable in regions with high prevalence of HIV infection and tuberculosis. A striking example of this situation is the Irkutsk region – the territory with the highest prevalence of HIV infection in the Russian Federation and one of the most unsuccessful one on tuberculosis – in 2010 became Russian “leader” and in prevalence of the HIV-associated tuberculosis, keeping a position “in the first five” so far. It is clear, that all this cannot but imply negative manifestations of two considered epidemic processes at their simultaneous development in one territory. The above-said facts predetermined carrying out the retrospective epidemiological analysis of spread of tuberculosis among the cumulative population in the Irkutsk region, a territory of high risk of HIV infection.The purpose of the work was to assess features of spread of tuberculosis in the territory of the large center of HIV infection (Irkutsk region).Results. The expressed negative impact of HIV infection on epidemic process of tuberculosis in the studied region, shown in divergence of trends and higher levels of epidemiological indicators in comparison to the all-Russian data is established.Conclusion. As a result of a research the trend of regional incidence of tuberculosis, multidirectional with the all-Russian indicators, is established from the moment of epidemic spread of HIV infection that demonstrates integration of epidemic processes of the studied infections. Even on condition of regress of epidemic process of tuberculosis at the end of the analyzed period which is followed by decrease in incidence of all population, HIV infection has a significant impact on his tension that, certainly, demands the strengthened measures of epidemiological control of these socially important infections.

An Observational Case-Control Study to Determine Human Immunodeficiency Virus and Host Factor Influence on Biomarker Distribution and Serodiagnostic Potential in Adult Pulmonary Tuberculosis

Influence of host factors, including human immunodeficiency virus (HIV) co-infection, on the distribution and diagnostic potential of previously evaluated biomarkers of pulmonary tuberculosis (PTB), such as anti-antigen 60 (A60) immunoglobulin (Ig) G, anti-A60 IgA, and C-reactive protein (CRP), remain unclear. Anti-A60 IgG, anti-A60 IgA, and CRP in PTB and non-PTB patient sera (n = 404, including smear-positive/negative, culture-positive (SPCP/SNCP) and HIV+ve/-ve) were measured by enzyme-linked immunoassay and statistically analysed. In multinomial logistic regression, expectoration, chest pain, wasting, and culture count positively associated with CRP (p < 0.001), while smear count positively associated with anti-A60 IgG (p = 0.090). Expectoration and enlarged lymph nodes negatively associated with anti-A60 IgA (p = 0.018). Biomarker distribution and diagnostic potential varied significantly by symptoms and bacilli burden, and across different PTB subpopulations. CRP was correlated poorly with anti-A60 antibodies, while anti-A60 IgA and IgG were correlated in non-tuberculosis (TB) and SPCP patients (p < 0.001). When combined, anti-A60 IgG and CRP best discriminated SPCP/HIV-ve from non-TB (AUC: 0.838, 95% CI: 0.783⁻0.894), while anti-A60 IgA and CRP performed best in discriminating HIV+ve PTB from non-TB (AUC: 0.687, 95% CI: 0.598⁻0.777). Combined CRP and anti-A60 antibodies had significantly reduced accuracy in SNCP and SNCP/HIV+ve compared to SPCP/HIV-ve subpopulations. The complex relationships between host factors and biomarkers suggest their limited utility, especially in SNCP/HIV+ve subpopulations, highlighting the importance of examining host response and immune biomarkers across relevant patient subpopulations.

The complexities and challenges of preventing and treating nontuberculous mycobacterial diseases

Seemingly innocuous nontuberculous mycobacteria (NTM) species, classified by their slow or rapid growth rates, can cause a wide range of illnesses, from skin ulceration to severe pulmonary and disseminated disease. Despite their worldwide prevalence and significant disease burden, NTM do not garner the same financial or research focus as Mycobacterium tuberculosis. In this review, we outline the most abundant of over 170 NTM species and inadequacies of diagnostics and treatments and weigh the advantages and disadvantages of currently available in vivo animal models of NTM. In order to effectively combat this group of mycobacteria, more research focused on appropriate animal models of infection, screening of chemotherapeutic compounds, and development of anti-NTM vaccines and diagnostics is urgently needed.

Reimagining the Research Approach to Tuberculosis†

Controlling and ultimately ending tuberculosis (TB) as a public health scourge will require a multifaceted and comprehensive approach involving the intensification of public health efforts, including scaling-up the delivery of current diagnostic, preventive, and therapeutic tools. However, a critically important element in the effort to end TB is an accelerated biomedical research effort to address the many unanswered questions about the disease process itself and to develop improved and innovative countermeasures. An intensive effort toward these research goals will facilitate the achievement of the aspirational goal of ending TB.