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Le X, Shen Y. Advances in Antiretroviral Therapy for Patients with Human Immunodeficiency Virus-Associated Tuberculosis. Viruses 2024; 16:494. [PMID: 38675837 PMCID: PMC11054420 DOI: 10.3390/v16040494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/09/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculosis is one of the most common opportunistic infections and a prominent cause of death in patients with human immunodeficiency virus (HIV) infection, in spite of near-universal access to antiretroviral therapy (ART) and tuberculosis preventive therapy. For patients with active tuberculosis but not yet receiving ART, starting ART after anti-tuberculosis treatment can complicate clinical management due to drug toxicities, drug-drug interactions and immune reconstitution inflammatory syndrome (IRIS) events. The timing of ART initiation has a crucial impact on treatment outcomes, especially for patients with tuberculous meningitis. The principles of ART in patients with HIV-associated tuberculosis are specific and relatively complex in comparison to patients with other opportunistic infections or cancers. In this review, we summarize the current progress in the timing of ART initiation, ART regimens, drug-drug interactions between anti-tuberculosis and antiretroviral agents, and IRIS.
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Affiliation(s)
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China;
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2
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Maenetje P, Baik Y, Schramm DB, Vangu MDTW, Wallis RS, Mlotshwa M, Tiemessen CT, Li Y, Kornfeld H, Churchyard G, Auld SC, Bisson GP. Circulating Biomarkers, Fraction of Exhaled Nitric Oxide, and Lung Function in Patients With Human Immunodeficiency Virus and Tuberculosis. J Infect Dis 2024; 229:824-832. [PMID: 37386883 PMCID: PMC10938205 DOI: 10.1093/infdis/jiad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/12/2023] [Accepted: 06/27/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Identification of proinflammatory factors responding to Mycobacterium tuberculosis is important to reduce long-term sequelae of pulmonary tuberculosis (TB). METHODS We examined the association between plasma biomarkers, the fraction of exhaled nitric oxide (FeNO), and lung function among a prospective cohort of 105 adults newly diagnosed with TB/human immunodeficiency virus (HIV) in South Africa. Participants were followed for 48 weeks from antiretroviral therapy (ART) initiation with serial assessments of plasma biomarkers, FeNO, lung function, and respiratory symptoms. Linear regression and generalized estimating equations were used to examine the associations at baseline and over the course of TB treatment, respectively. RESULTS At baseline, higher FeNO levels were associated with preserved lung function, whereas greater respiratory symptoms and higher interleukin (IL)-6 plasma levels were associated with worse lung function. After ART and TB treatment initiation, improvements in lung function were associated with increases in FeNO (rate ratio [RR] = 86 mL, 95% confidence interval [CI] = 34-139) and decreases in IL-6 (RR = -118 mL, 95% CI = -193 to -43) and vascular endothelial growth factor ([VEGF] RR = -178 mL, 95% CI = -314 to -43). CONCLUSIONS Circulating IL-6, VEGF, and FeNO are associated with lung function in adults being treated for TB/HIV. These biomarkers may help identify individuals at higher risk for post-TB lung disease and elucidate targetable pathways to modify the risk of chronic lung impairment among TB survivors.
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Affiliation(s)
- Pholo Maenetje
- The Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Yeonsoo Baik
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Diana B Schramm
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mboyo Di-Tamba Willy Vangu
- Department of Nuclear Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Caroline T Tiemessen
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, USA
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Sara C Auld
- Departments of Medicine and Epidemiology, Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia, USA
| | - Gregory P Bisson
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Yang H, Liu Q, Wu Y, He K, Zeng Q, Liu M. Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome in initiating ART among HIV-Infected patients in China-risk factors and management. BMC Infect Dis 2024; 24:5. [PMID: 38166781 PMCID: PMC10759358 DOI: 10.1186/s12879-023-08897-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND China is a country burdened with a high incidence of both tuberculosis (TB) and HIV, Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an important early complication in TB and HIV co-infected patients, but data from China are limited. Additionally, as an integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) regimen becomes the first-line treatment, concerns have arisen regarding the potential increase in the incidence of paradoxical TB-IRIS. Nevertheless, the existing data are inconclusive and contradictory. METHODS We conducted a retrospective study at Chongqing Public Health Clinical Center from January 2018 to December 2021. We collected demographic and clinical data of HIV/TB co-infected patients who initiated ART. We described the patient characteristics, identified predictors for TB-IRIS, and determined clinical outcomes. The Statistical Package for Social Science (SPSS 25) was used to analyse the data. Continuous variables were compared using Student's t-test or rank sum test. Counting data were compared using the chi-square test or Fisher's exact test. The variables with statistical significance in the univariate analysis were added to the binary logistic regression. A p-value less than 0.05 was considered statistically significant. RESULTS A total of 384 patients co-infected with naive HIV and pulmonary TB (PTB) who were given ATT and ART combination were included. 72 patients (18.8%) developed paradoxical TB-IRIS with a median of 15 (12, 21) days after initiating ART. Baseline age ≤ 40years, CD4 + T-cell counts ≤ 50cells/µL, HIV viral load ≥ 500,000 copies/mL were found to be significantly associated with development of paradoxical TB-IRIS. Mortality rates were similar in the TB-IRIS (n = 5, 6.9%) group and non-TB-IRIS (n = 13, 4.2%) group. Interestingly, CD4+ T-cell counts recovery post-ART was significant higher in the TB-IRIS group when compared to the non-TB-IRIS group at the end of 24 weeks (P = 0.004), as well as at 48 weeks (P = 0.015). In addition, we consider that INSTI- based ART regimen do not increased the risk of Paradoxical TB-IRIS. CONCLUSION Paradoxical TB-IRIS, while often leading to clinical deterioration and hospitalization, is generally manageable. It appears to have a positive impact on the recovery of CD4 + T-cell counts over time. Importantly, our data suggest that INSTI-based ART regimens do not elevate the risk of TB-IRIS. Thus, paradoxical TB-IRIS should not be considered an impediment to initiating ART in adults with advanced immunodeficiency, except in the case of tuberculous meningitis (TBM).
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Affiliation(s)
- Honghong Yang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Qian Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Yushan Wu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Kun He
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Qin Zeng
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China
| | - Min Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Shapingba District, Chongqing, 400036, China.
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Kalita J, Shukla R, Pandey PC, Singh V, Haldar R, Misra UK. mRNA profiling of cytokines to understand paradoxical response in HIV-uninfected tuberculous meningitis. Tuberculosis (Edinb) 2024; 144:102463. [PMID: 38101267 DOI: 10.1016/j.tube.2023.102463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
Paradoxical reaction (PR) in tuberculous meningitis (TBM) is a major management issue. We report mRNA profiling of cytokines to understand PR in HIV-uninfected TBM patients. 72 patients with TBM were included, and their clinical, MRI, and mRNA profiling of tumor necrosis factor (TNF) α, interleukin (IL) 6, IL10 and interferon (IFN) γ genes in the peripheral blood mononuclear cells were done at admission and 6 weeks of antitubercular treatment. Cytokine profiling was done using reverse transcriptase polymerase chain reaction. PR was defined if repeat MRI at 6 weeks revealed new or increase in exudates, tuberculoma, hydrocephalus or infarctions. Outcome was defined at 6 months using modified Rankin Scale (mRS), and categorized as death, poor and good. 44 (61.1 %) patients had PR, and 28 (38.9 %) had paradoxical tuberculoma (PT). The expression of IL6 and TNFα genes were higher in PR and PT groups. Stage of meningitis and hydrocephalus at admission predicted PR. Patients with PR and PT had more frequently poor outcome. About three-fifth HIV-uninfected TBM patients have PR and two-fifth have PT. Paradoxical reaction is associated with higher expression of IL6 and TNFα. Patients with severe meningitis with hydrocephalus develop PR more frequently.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India.
| | - Ruchi Shukla
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Prakash C Pandey
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Vivek Singh
- Department of Radio diagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Rudrashish Haldar
- Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
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Araújo-Pereira M, Krishnan S, Salgame P, Manabe YC, Hosseinipour MC, Bisson G, Severe DP, Rouzier V, Leong S, Mave V, Sawe FK, Siika AM, Kanyama C, Dadabhai SS, Lama JR, Valencia-Huamani J, Badal-Faesen S, Lalloo UG, Naidoo K, Mohapi L, Kityo C, Andrade BB, Gupta A. Effect of the relationship between anaemia and systemic inflammation on the risk of incident tuberculosis and death in people with advanced HIV: a sub-analysis of the REMEMBER trial. EClinicalMedicine 2023; 60:102030. [PMID: 37287871 PMCID: PMC10242630 DOI: 10.1016/j.eclinm.2023.102030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023] Open
Abstract
Background Tuberculosis (TB) is an infectious morbidity that commonly occurs in people living with HIV (PWH) and increases the progression of HIV disease, as well as the risk of death. Simple markers of progression are much needed to identify those at highest risk for poor outcome. This study aimed to assess how baseline severity of anaemia and associated inflammatory profiles impact death and the incidence of TB in a cohort of PWH who received TB preventive therapy (TPT). Methods This study is a secondary posthoc analysis of the AIDS Clinical Trials Group A5274 REMEMBER clinical trial (NCT0138008), an open-label randomised clinical trial of antiretroviral-naïve PWH with CD4 <50 cells/μL, performed from October 31, 2011 to June 9, 2014, from 18 outpatient research clinics in 10 low- and middle-income countries (Malawi, South Africa, Haiti, Kenya, Zambia, India, Brazil, Zimbabwe, Peru, and Uganda) who initiated antiretroviral therapy and either isoniazid TPT or 4-drug empiric TB therapy. Plasma concentrations of several soluble inflammatory biomarkers were measured prior to the commencement of antiretroviral and anti-TB therapies, and participants were followed up for at least 48 weeks. Incident TB or death during this period were primary outcomes. We performed multidimensional analyses, logistic regression analyses, survival curves, and Bayesian network analyses to delineate associations between anaemia, laboratory parameters, and clinical outcomes. Findings Of all 269 participants, 76.2% (n = 205) were anaemic, and 31.2% (n = 84) had severe anaemia. PWH with moderate/severe anaemia exhibited a pronounced systemic pro-inflammatory profile compared to those with mild or without anaemia, hallmarked by a substantial increase in IL-6 plasma concentrations. Moderate/severe anaemia was also associated with incident TB incidence (aOR: 3.59, 95% CI: 1.32-9.76, p = 0.012) and death (aOR: 3.63, 95% CI: 1.07-12.33, p = 0.039). Interpretation Our findings suggest that PWH with moderate/severe anaemia display a distinct pro-inflammatory profile. The presence of moderate/severe anaemia pre-ART was independently associated with the development of TB and death. PWH with anaemia should be monitored closely to minimise the occurrence of unfavourable outcomes. Funding National Institutes of Health.
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Affiliation(s)
- Mariana Araújo-Pereira
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Programa de Pós-Graduação em Patologia Humana e Experimental, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil
| | - Sonya Krishnan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Padmini Salgame
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Yukari C. Manabe
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mina C. Hosseinipour
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gregory Bisson
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Damocles Patrice Severe
- Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince HT6110, Haiti
| | - Vanessa Rouzier
- Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince HT6110, Haiti
| | - Samantha Leong
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Vidya Mave
- BJ Medical College Clinical Research Site, Pune, India
| | - Fredrick Kipyego Sawe
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Abraham M. Siika
- Department of Medicine, School of Medicine, Moi University, Eldoret, Kenya
| | - Cecilia Kanyama
- University of North Carolina Project, Kamazu Central Hospital, Lilongwe, Malawi
| | | | | | | | - Sharlaa Badal-Faesen
- Clinical HIV Research Unit, School of Clinical Medicine, University of Witwatersrand, Johannesburg, South Africa
| | | | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
- SA-Medical Research Council (MRC)-CAPRISA-HIV-TB Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Lerato Mohapi
- School of Clinical Medicine, University of Witwatersrand, Johannesburg, South Africa
| | - Cissy Kityo
- HIV Medicine, Joint Clinical Research Centre, Kampala, Uganda
| | - Bruno B. Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Programa de Pós-Graduação em Patologia Humana e Experimental, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil
| | - Amita Gupta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sant´Anna FM, Araújo-Pereira M, Schmaltz CAS, Arriaga MB, Andrade BB, Rolla VC. Impact of adverse drug reactions on the outcomes of tuberculosis treatment. PLoS One 2023; 18:e0269765. [PMID: 36749743 PMCID: PMC9904486 DOI: 10.1371/journal.pone.0269765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 12/27/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Adverse drug reactions (ADR) challenge successful anti-tuberculosis treatment (ATT). The aim of this study was to evaluate the impact of ATT-associated ADR and related factors on ATT outcomes. METHODS A prospective cohort study of persons with tuberculosis (TB) at a referral center in Rio de Janeiro, Brazil, from 2010 to 2016. Baseline information: race, sex, schooling, economic status, tobacco, drugs and alcohol abuse, HIV-infection status and comorbidities were captured during TB screening and diagnosis. Laboratory exams were performed to confirm TB diagnosis and monitor ADRs, favorable (cure and treatment completion) and unfavorable (death, loss to follow up and failure) outcomes were prospectively captured. The Kaplan-Meier curve was used to estimate the probability of ADR-free time. A logistic regression analysis (backward elimination) was performed to identify independent associations with unfavorable outcomes. RESULTS 550 patients were enrolled, 35.1% were people living with HIV (PLHIV) and ADR occurred in 78.6% of all participants. Smoking (OR: 2.32; 95% CI:1.34-3.99) and illicit-drug use (OR:2.02; 95% CI:1.15-3.55) were independent risk factors for unfavorable outcomes. In PLHIV, alcohol abuse and previous ART use were associated with unfavorable outcomes. In contrast, ADR increased the odds of favorable outcomes in the overall population. PLHIV more frequently experienced grade 3/4-ADR (18.36%), especially "liver and biliary system disorders". Lower CD4 counts (<100 cells/uL) were associated with hepatotoxicity (p = 0.03). ART-naïve participants presented a higher incidence of ADR in comparison with ART-experienced patients. CONCLUSION Substance use was associated with unfavorable outcomes, highlighting the need for better strategies to reduce this habit. In contrast, ADRs were associated with favorable outcomes. Attention to the occurrence of ADR in PLHIV is essential, especially regarding hepatotoxicity in those with high immunosuppression.
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Affiliation(s)
- Flávia M. Sant´Anna
- Postgraduate Program Clinical Research in Infectious Diseases, National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- Clinical Research Laboratory on Mycobacteria, (LAPCLIN-TB), National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Mariana Araújo-Pereira
- School of Medicine, Federal University of Bahia, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil
| | - Carolina A. S. Schmaltz
- Clinical Research Laboratory on Mycobacteria, (LAPCLIN-TB), National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - María B. Arriaga
- School of Medicine, Federal University of Bahia, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil
| | - Bruno B. Andrade
- School of Medicine, Federal University of Bahia, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Laboratory of Inflammation and Biomarkers, Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Brazil
- Curso de Medicina, Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil
- Curso de Medicina, Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil
- * E-mail:
| | - Valeria C. Rolla
- Postgraduate Program Clinical Research in Infectious Diseases, National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- Clinical Research Laboratory on Mycobacteria, (LAPCLIN-TB), National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome-An Extempore Game of Misfiring with Defense Arsenals. Pathogens 2023; 12:pathogens12020210. [PMID: 36839482 PMCID: PMC9964757 DOI: 10.3390/pathogens12020210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/21/2023] [Accepted: 01/28/2023] [Indexed: 01/31/2023] Open
Abstract
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.
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Duraikkannu D, Akbar AB, Sudharshan S, Poongulali S, Kumarasamy N, Jayavelu T, Chatterjee N. Differential Expression of miRNA-192 is a Potential Biomarker for HIV Associated Immune Recovery Uveitis. Ocul Immunol Inflamm 2022; 31:566-575. [PMID: 35947816 DOI: 10.1080/09273948.2022.2106247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
PURPOSE Notwithstanding well-established clinical features of Immune Recovery Uveitis (IRU), specific diagnostic tools to identify at-risk patients are lacking. Identification of biomarkers for IRU prediction can allow high-risk patients to benefit from specific preventive strategies, development of therapies, and elucidate immune reconstitution associated pathogenesis. METHODS HIV+ patients were classified into four groups (A, B, C and D) with and without ocular manifestations, with follow-up over a year. Patients' ocular parameters were examined and manifestations like uveitis and IRU noted. Selected miRNAs were investigated in PBMCs by using miRNA PCR assay. Bioinformatic analysis used miRNet to predict the targets of miRNA-192-5p and miRNA-543 and KOBAS for pathways. RESULTS Hsa-miR-192-5p and hsa-miR-543 levels were measured by qPCR using RNA isolated from PBMCs of HIVinfected patients. Hsa-miR-192-5p and hsa-miR-543 were down regulated in patients exhibiting ocular manifestations. Our results showed hsa-miR-192-5p (Group B vs D p 0.007) and hsa-miR-543 levels in PBMCs reliably distinguish between HIV patients diagnosed with IRU. Both miRNAs target multiple genes involved in inflammatory pathways as predicted by bioinformatic analysis. CONCLUSION Decreased expression levels of miRNA-192 in patients with ocular manifestations and IRU, could facilitate identification of the status of the disease in HIV patients.
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Affiliation(s)
- Durairaj Duraikkannu
- L&T Department of Ocular Pathology, Vision Research Foundation, Chennai, India.,Centre for Biotechnology, Anna University, Chennai, India
| | - Ashraf Banu Akbar
- L&T Department of Ocular Pathology, Vision Research Foundation, Chennai, India
| | - Sridharan Sudharshan
- Department of Uveitis, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | | | | | | | - Nivedita Chatterjee
- L&T Department of Ocular Pathology, Vision Research Foundation, Chennai, India
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9
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Zhao Y, Hohlfeld A, Namale P, Meintjes G, Maartens G, Engel ME. Risk of Immune Reconstitution Inflammatory Syndrome With Integrase Inhibitors Versus Other Classes of Antiretrovirals: A Systematic Review and Meta-analysis of Randomized Trials. J Acquir Immune Defic Syndr 2022; 90:232-239. [PMID: 35175970 PMCID: PMC7612870 DOI: 10.1097/qai.0000000000002937] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Integrase strand transfer inhibitors (InSTIs) decrease HIV plasma viral load faster than other antiretroviral classes. More rapid viral load decline has been associated with higher risk of immune reconstitution inflammatory syndrome (IRIS). There are conflicting reports on the association between InSTI and IRIS. We performed a systematic review and meta-analysis to compare the risk of IRIS among treatment-naive HIV-positive patients starting InSTI versus non-InSTI regimens. METHODS We searched PubMed, Scopus, Web of Science, Africa-Wide, and Cochrane databases from earliest available date to 26 November 2021, for randomized controlled trials (RCTs) having intervention arms with InSTI versus control arms without InSTI in patients initiating first-line antiretroviral therapy. The primary outcome was relative risk (RR) of IRIS, whereas the secondary outcome was RR of paradoxical tuberculosis-associated IRIS (TB-IRIS). Data were combined by random-effects meta-analysis according to the Mantel-Haenszel method. The protocol for this study is registered with PROSPERO, CRD42020213976. RESULTS We included 14 RCTs comprising 8696 participants from 6 continents for the primary outcome of IRIS and a subset of 674 participants (from 3 RCTs) for the secondary outcome of paradoxical TB-IRIS. Risk of IRIS was similar between InSTI and non-InSTI regimens (RR, 0.93; 95% confidence interval: 0.75 to 1.14). There was a trend towards a lower risk of paradoxical TB-IRIS with InSTI versus efavirenz regimens that was not statistically significant (RR, 0.64; 95% confidence interval: 0.34 to 1.19). CONCLUSIONS In this meta-analysis among treatment-naive patients commencing first-line antiretroviral therapy, InSTI regimens were not associated with higher risk of IRIS.
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Affiliation(s)
- Ying Zhao
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ameer Hohlfeld
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Phiona Namale
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Han X, Liu H, Wang Y, Wang P, Wang X, Yi Y, Li X. A nomogram for predicting paradoxical immune reconstitution inflammatory syndrome associated with cryptococcal meningitis among HIV-infected individuals in China. AIDS Res Ther 2022; 19:20. [PMID: 35473805 PMCID: PMC9044738 DOI: 10.1186/s12981-022-00444-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/11/2022] [Indexed: 01/08/2023] Open
Abstract
Background Cryptococcal meningitis (CM) associated immune reconstitution inflammatory syndrome (CM-IRIS) is the second most common complication in HIV-infected individuals with cryptococcal meningitis, with a reported mortality rate ranging from 8 to 30%. Given the devastating consequences of CM-IRIS related intracranial neuroinflammation and its challenging in diagnosis, we conducted a study to explore the risk factors and the occurrence of paradoxical CM-IRIS in HIV-infected patients, which is of great value for prevention and clinical management. Methods We conducted a retrospective cohort study to identify the indicators associated with paradoxical CM-IRIS among 86 HIV-infected patients with CM using univariate and multivariate cox analysis. A nomogram was constructed using selected variables to evaluate the occurrence of paradoxical CM-IRIS at 6 months and 12 months after ART initiation. The discrimination and calibration of the nomogram were assessed by concordance index (C-index) and calibration plots. Decision curves analysis (DCA) were used to evaluate clinical effectiveness of the nomogram. Subsequently, to help clinicians recognize patients at high risk faster, patients were divided into high-risk and low-risk groups according to the best cutoff point identified by X-tile. Results Of 86 AIDS patients with CM, 22.1% experienced paradoxical CM-IRIS at a median of 32 days after antiretroviral therapy (ART) initiation. The occurrence of paradoxical CM-IRIS was associated with age, ART initiation within 4 weeks of antifungal treatment, a four-fold increase in CD4 T cell counts, C-reactive protein levels, and hemoglobin levels independently. These five variables were further used to construct a predictive nomogram. The C-index (0.876) showed the favorable discriminative ability of the nomogram. The calibration plot revealed a high consistency between the predicted and actual observations. DCA showed that the nomogram was clinically useful. Risk stratification based on the total score of the nomogram showed well-differentiated in the high-risk and low-risk groups. Clinicians should pay attention to patients with total points high than 273. Conclusions We identified the predictive factors of paradoxical CM-IRIS and constructed a nomogram to evaluate the occurrence of paradoxical CM-IRIS in 6 months and 12 months. The nomogram represents satisfactory performance and might be applied clinically to the screening and management of high-risk patients.
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11
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Tibúrcio R, Narendran G, Barreto-Duarte B, Queiroz ATL, Araújo-Pereira M, Anbalagan S, Nayak K, Ravichandran N, Subramani R, Antonelli LRV, Satagopan K, Anbalagan K, Porter BO, Sher A, Swaminathan S, Sereti I, Andrade BB. Frequency of CXCR3+ CD8+ T-Lymphocyte Subsets in Peripheral Blood Is Associated With the Risk of Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome Development in Advanced HIV Disease. Front Immunol 2022; 13:873985. [PMID: 35432354 PMCID: PMC9011055 DOI: 10.3389/fimmu.2022.873985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a clinical aggravation of TB symptoms observed among a fraction of HIV coinfected patients shortly after the start of antiretroviral therapy (ART). Of note, TB-IRIS is characterized by exacerbated inflammation and tissue damage that occurs in response to the elevated production of CD4+ T cell-derived IFN-γ. Nevertheless, the possible participation of CD8+ T cells in TB-IRIS development remains unclear.MethodsWe performed a comprehensive assessment of the composition of CD8+ T cell memory subsets and their association with circulating inflammation-related molecules in TB-HIV coinfected patients initiating ART.ResultsWe found that TB-IRIS individuals display higher frequencies of Antigen-experienced CD8+ T cells during the onset of IRIS and that the levels of these cells positively correlate with baseline mycobacterial smear grade. TB-IRIS individuals exhibited higher frequencies of effector memory and lower percentages of naïve CD8+ T cells than their Non-IRIS counterparts. In both TB-IRIS and Non-IRIS patients, ART commencement was associated with fewer significant correlations among memory CD8+ T cells and cells from other immune compartments. Networks analysis revealed distinct patterns of correlation between each memory subset with inflammatory cytokines suggesting different dynamics of CD8+ T cell memory subsets reconstitution. TB-IRIS patients displayed lower levels of memory cells positive for CXCR3 (a chemokine receptor that plays a role in trafficking activated CD8+ T cells to the tissues) than Non-IRIS individuals before and after ART. Furthermore, we found that CXCR3+ naïve CD8+ T cells were inversely associated with the risk of TB-IRIS development. On the other hand, we noticed that the frequencies of CXCR3+ effector CD8+ T cells were positively associated with the probability of TB-IRIS development.ConclusionOur data suggest that TB-IRIS individuals display a distinct profile of memory CD8+ T cell subsets reconstitution after ART initiation. Moreover, our data point to a differential association between the frequencies of CXCR3+ CD8+ T cells and the risk of TB-IRIS development. Collectively, our findings lend insights into the potential role of memory CD8+ T cells in TB-IRIS pathophysiology.
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Affiliation(s)
- Rafael Tibúrcio
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Gopalan Narendran
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Beatriz Barreto-Duarte
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Curso de Medicina, Universidade Salvador (UNIFACS), Salvador, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Artur T. L. Queiroz
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
| | - Mariana Araújo-Pereira
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Selvaraj Anbalagan
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Kaustuv Nayak
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
- ICGEB-Emory Vaccine Centre, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | | | - Rajasekaran Subramani
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Lis R. V. Antonelli
- Laboratório de Biologia e Imunologia de Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brazil
| | | | | | - Brian O. Porter
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Soumya Swaminathan
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Bruno B. Andrade
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
- Curso de Medicina, Universidade Salvador (UNIFACS), Salvador, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Wellcome Trust Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Curso de Medicina, Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
- *Correspondence: Bruno B. Andrade,
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12
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Pal L, Nandani R, Kumar P, Swami B, Roy G, Bhaskar S. Macrophages Are the Key Players in Promoting Hyper-Inflammatory Response in a Mouse Model of TB-IRIS. Front Immunol 2021; 12:775177. [PMID: 34899731 PMCID: PMC8662811 DOI: 10.3389/fimmu.2021.775177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/29/2021] [Indexed: 01/01/2023] Open
Abstract
TB-IRIS is an abnormal inflammatory response in a subset of HIV-TB co-infected patients shortly after initiation of anti-retroviral therapy (ART). Therapy in these patients could have greatly improved the life expectancy as ART reconstitutes the function and number of CD4+ T cells and many patients see improvement in symptoms but paradoxically up to 54% of co-infected patients develop TB-IRIS. Different studies have indicated that both innate and adaptive immunity are involved in the pathology of IRIS but the role of macrophages in abnormal activation of CD4+ T cells is poorly understood. Since macrophages are one of the major antigen-presenting cells and are infected by M.tb at a high frequency, they are very much likely to be involved in the development of TB-IRIS. In this study, we have developed a mouse model of experimental IRIS, in which M.tb-infected T-cell knockout mice undergo a fatal inflammatory disease after CD4+ T cell reconstitution. Lung macrophages and blood monocytes from M.tb-infected TCRβ-/- mice showed upregulated expression of cell surface activation markers and also showed higher mRNA expression of inflammation-associated chemokines and matrix metalloproteases responsible for tissue damage. Furthermore, cytokine and TLR signaling feedback mechanism to control excessive inflammation was also found to be dysregulated in these macrophages under lymphopenic conditions. Previous studies have shown that hyperactive CD4+ T cells are responsible for disease induction and our study shows that somehow macrophages are in a higher activated state when infected with M.tb in an immune-deficient condition, which results in excessive activation of the adoptively transferred CD4+ T cells. Understanding of the mechanisms underlying the pathophysiology of TB-IRIS would facilitate identification of prospective biomarkers for disease development in HIV-TB co-infected patients before starting antiretroviral therapy.
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Affiliation(s)
| | | | | | | | | | - Sangeeta Bhaskar
- Product Development Cell-1, National Institute of Immunology, New Delhi, India
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13
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Nosik M, Ryzhov K, Rymanova I, Sobkin A, Kravtchenko A, Kuimova U, Pokrovsky V, Zverev V, Svitich O. Dynamics of Plasmatic Levels of Pro- and Anti-Inflammatory Cytokines in HIV-Infected Individuals with M. tuberculosis Co-Infection. Microorganisms 2021; 9:microorganisms9112291. [PMID: 34835417 PMCID: PMC8624412 DOI: 10.3390/microorganisms9112291] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/24/2021] [Accepted: 11/02/2021] [Indexed: 12/27/2022] Open
Abstract
Tuberculosis (TB) and HIV have profound effects on the immune system, which can lead to the activation of viral replication and negatively regulate the activation of T cells. Dysregulation in the production of cytokines necessary to fight HIV and M. tuberculosis may ultimately affect the results of the treatment and be important in the pathogenesis of HIV infection and TB. This work presents the results of a study of the expression of pro- and anti-inflammatory cytokines (IFN-γ, TNF-α, IL-2, IL-4, IL-6, IL-10, IL-1RA) in drug-naïve patients with dual infection of HIV/TB at the late stages of HIV-infection, with newly diagnosed HIV and TB, and previously untreated HIV in the process of receiving antiretroviral (ART) and TB treatment vs. a cohort of patients with HIV monoinfection and TB monoinfection. The study revealed that during a double HIV/TB infection, both Th1 and Th2 immune responses are suppressed, and a prolonged dysregulation of the immune response and an increased severity of the disease in pulmonary/extrapulmonary tuberculosis is observed in HIV/TB co-infection. Moreover, it was revealed that a double HIV/TB infection is characterized by delayed and incomplete recovery of immune activity. High levels of IL-6 were detected in patients with HIV/TB co-infection before initiation of dual therapy (2.1-fold increase vs. HIV), which persisted even after 6 months of treatment (8.96-fold increase vs. HIV), unlike other cytokines. The persistent enhanced expression of IL-6 in patients with dual HIV/TB co-infection allows the consideration of it as a potential marker of early detection of M. tuberculosis infection in HIV-infected individuals. The results of multivariate regression analysis showed a statistical trend towards an increase in the incidence of IRIS in patients with high IL-1Ra levels (in the range of 1550–2500 pg/mL): OR = 4.3 (95%CI 3.7–14.12, p = 0.53), which also allows IL-1Ra to be considered as a potential predictive biomarker of the development of TB-IRIS and treatment outcomes.
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Affiliation(s)
- Marina Nosik
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia; (K.R.); (V.Z.); (O.S.)
- Correspondence:
| | - Konstantin Ryzhov
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia; (K.R.); (V.Z.); (O.S.)
| | - Irina Rymanova
- G.A. Zaharyan Moscow Tuberculosis Clinic, Department for Treatment of TB Patients with HIV Infection, 125466 Moscow, Russia; (I.R.); (A.S.)
| | - Alexandr Sobkin
- G.A. Zaharyan Moscow Tuberculosis Clinic, Department for Treatment of TB Patients with HIV Infection, 125466 Moscow, Russia; (I.R.); (A.S.)
| | - Alexey Kravtchenko
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (A.K.); (U.K.); (V.P.)
| | - Ulyana Kuimova
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (A.K.); (U.K.); (V.P.)
| | - Vadim Pokrovsky
- Central Research Institute of Epidemiology, 111123 Moscow, Russia; (A.K.); (U.K.); (V.P.)
| | - Vitaly Zverev
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia; (K.R.); (V.Z.); (O.S.)
| | - Oxana Svitich
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia; (K.R.); (V.Z.); (O.S.)
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14
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Tibúrcio R, Barreto-Duarte B, Naredren G, Queiroz ATL, Anbalagan S, Nayak K, Ravichandran N, Subramani R, Antonelli LRV, Satagopan K, Anbalagan K, Porter BO, Sher A, Swaminathan S, Sereti I, Andrade BB. Dynamics of T-Lymphocyte Activation Related to Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome in Persons With Advanced HIV. Front Immunol 2021; 12:757843. [PMID: 34691079 PMCID: PMC8529328 DOI: 10.3389/fimmu.2021.757843] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/22/2021] [Indexed: 12/29/2022] Open
Abstract
Most persons living with HIV (PLWH) experience a significant restoration of their immunity associated with successful inhibition of viral replication after antiretroviral therapy (ART) initiation. Nevertheless, with the robust quantitative and qualitative restoration of CD4+ T-lymphocytes, a fraction of patients co-infected with tuberculosis develop immune reconstitution inflammatory syndrome (TB-IRIS), a dysregulated inflammatory response that can be associated with significant tissue damage. Several studies underscored the role of adaptive immune cells in IRIS pathogenesis, but to what degree T lymphocyte activation contributes to TB-IRIS development remains largely elusive. Here, we sought to dissect the phenotypic landscape of T lymphocyte activation in PLWH coinfected with TB inititating ART, focusing on characterization of the profiles linked to development of TB-IRIS. We confirmed previous observations demonstrating that TB-IRIS individuals display pronounced CD4+ lymphopenia prior to ART initiation. Additionally, we found an ART-induced increase in T lymphocyte activation, proliferation and cytotoxicity among TB-IRIS patients. Importantly, we demonstrate that TB-IRIS subjects display higher frequencies of cytotoxic CD8+ T lymphocytes which is not affected by ART. Moreover, These patients exhibit higher levels of activated (HLA-DR+) and profilerative (Ki-67+) CD4+ T cells after ART commencenment than their Non-IRIS counterparts. Our network analysis reveal significant negative correlations between Total CD4+ T cells counts and the frequencies of Cytotoxic CD8+ T cells in our study population which could suggest the existance of compensatory mechanisms for Mtb-infected cells elimination in the face of severe CD4+ T cell lymphopenia. We also investigated the correlation between T lymphocyte activation profiles and the abundance of several inflammatory molecules in plasma. We applied unsupervised machine learning techniques to predict and diagnose TB-IRIS before and during ART. Our analyses suggest that CD4+ T cell activation markers are good TB-IRIS predictors, whereas the combination of CD4+ and CD8+ T cells markers are better at diagnosing TB-IRIS patients during IRIS events Overall, our findings contribute to a more refined understanding of immunological mechanisms in TB-IRIS pathogenesis that may assist in new diagnostic tools and more targeted patient management.
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Affiliation(s)
- Rafael Tibúrcio
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Beatriz Barreto-Duarte
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Curso de Medicina, Universidade Salvador (UNIFACS), Salvador, Brazil.,Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gopolan Naredren
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Artur T L Queiroz
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
| | - Selvaraj Anbalagan
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Kaustuv Nayak
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India.,ICGEB-Emory Vaccine Centre, International Centre for Genetic Engineering and Biotechnology, Aruna Asaf Ali Marg, India
| | | | - Rajasekaran Subramani
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Lis R V Antonelli
- Laboratório de Biologia e Imunologia de Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brazil
| | | | | | - Brian O Porter
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Soumya Swaminathan
- Wellcome Trust Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Bruno B Andrade
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Curso de Medicina, Universidade Salvador (UNIFACS), Salvador, Brazil.,Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Wellcome Trust Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Curso de medicina, Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
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15
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Gopalan N, Srinivasalu VA, Chinnayan P, Velayutham B, Bhaskar A, Santhanakrishnan R, Senguttuvan T, Rathinam S, Ayyamperumal M, Satagopan K, Rajendran D, Manoharan T, Lakshmanan S, Paramasivam P, Angamuthu D, Ganesan M, Easudoss Arockia JW, Venkatesan RB, Lakshmipathy V, Shanmugham S, Subramanyam B, Shankar S, Mohideen Shaheed J, Dhanaraj B, Paranji Ramiyengar N, Swaminathan S, Chandrasekaran P. Predictors of unfavorable responses to therapy in rifampicin-sensitive pulmonary tuberculosis using an integrated approach of radiological presentation and sputum mycobacterial burden. PLoS One 2021; 16:e0257647. [PMID: 34543329 PMCID: PMC8452066 DOI: 10.1371/journal.pone.0257647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/06/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Despite the exalted status of sputum mycobacterial load for gauging pulmonary tuberculosis treatment and progress, Chest X-rays supplement valuable information for taking instantaneous therapeutic decisions, especially during the COVID-19 pandemic. Even though literature on individual parameters is overwhelming, few studies have explored the interaction between radiographic parameters denoting severity with mycobacterial burden signifying infectivity. By using a sophisticated approach of integrating Chest X-ray parameters with sputum mycobacterial characteristics, evaluated at all the three crucial time points of TB treatment namely pre-treatment, end of intensive phase and completion of treatment, utilizing the interactive Cox Proportional Hazards model, we aimed to precisely deduce predictors of unfavorable response to TB treatment. MATERIALS AND METHOD We extracted de-identified data from well characterized clinical trial cohorts that recruited rifampicin-sensitive Pulmonary TB patients without any comorbidities, taking their first spell of anti-tuberculosis therapy under supervision and meticulous follow up for 24 months post treatment completion, to accurately predict TB outcomes. Radiographic data independently obtained, interpreted by two experienced pulmonologists was collated with demographic details and, sputum smear and culture grades of participants by an independent statistician and analyzed using the Cox Proportional Hazards model, to not only adjust for confounding factors including treatment effect, but also explore the interaction between radiological and bacteriological parameters for better therapeutic application. RESULTS Of 667 TB patients with data available, cavitation, extent of involvement, lower zone involvement, smear and culture grade at baseline were significant parameters predisposing to an unfavorable TB treatment outcome in the univariate analysis. Reduction in radiological lesions in Chest X-ray by at least 50% at 2 months and 75% at the end of treatment helped in averting unfavorable responses. Smear and Culture conversion at the end of 2 months was highly significant as a predictor (p<0.001). In the multivariate analysis, the adjusted hazards ratios (HR) for an unfavorable response to TB therapy for extent of involvement, baseline cavitation and persistence (post treatment) were 1.21 (95% CI: 1.01-1.44), 1.73 (95% CI: 1.05-2.84) and 2.68 (95% CI: 1.4-5.12) respectively. A 3+ smear had an HR of 1.94 (95% CI: 0.81-4.64). Further probing into the interaction, among patients with 3+ and 2+ smears, HRs for cavitation were 3.26 (95% CI: 1.33-8.00) and 1.92 (95% CI: 0.80-4.60) while for >2 zones, were 3.05 (95% CI: 1.12-8.23) and 1.92 (95% CI: 0.72-5.08) respectively. Patients without cavitation, zonal involvement <2, and a smear grade less than 2+ had a better prognosis and constituted minimal disease. CONCLUSION Baseline Cavitation, Opacities occupying >2 zones and 3+ smear grade individually and independently forecasted a poorer TB outcome. The interaction model revealed that Zonal involvement confined to 2 zones, without a cavity and smear grade up to 2+, constituting "minimal disease", had a better prognosis. Radiological clearance >50% along with smear conversion at the end of intensive phase of treatment, observed to be a reasonable alternative to culture conversion in predicting a successful outcome. These parameters may potentially take up key positions as stratification factors for future trials contemplating on shorter TB regimens.
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Affiliation(s)
- Narendran Gopalan
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
- * E-mail:
| | - Vignes Anand Srinivasalu
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Ponnuraja Chinnayan
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Banurekha Velayutham
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Adhin Bhaskar
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Ramesh Santhanakrishnan
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Thirumaran Senguttuvan
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Sridhar Rathinam
- Department of Thoracic Medicine, Government Hospital of Thoracic Medicine Tambaram, Chennai, Tamil Nadu, India
| | - Mahilmaran Ayyamperumal
- Department of Thoracic Medicine, Institute of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India
| | - Kumar Satagopan
- Department of Thoracic Medicine, Government Hospital of Thoracic Medicine Tambaram, Chennai, Tamil Nadu, India
| | - Dhanalakshmi Rajendran
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Tamizhselvan Manoharan
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Sekar Lakshmanan
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Paulkumaran Paramasivam
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Dhanalakshmi Angamuthu
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Mangalambal Ganesan
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - John Washington Easudoss Arockia
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Ramesh Babu Venkatesan
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Venkatesan Lakshmipathy
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Shivakumar Shanmugham
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Balaji Subramanyam
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Shakila Shankar
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Jawahar Mohideen Shaheed
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Baskaran Dhanaraj
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Narayanan Paranji Ramiyengar
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | | | - Padmapriyadarsini Chandrasekaran
- Department of Clinical Research, National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Indian Council of Medical Research, Chennai, Tamil Nadu, India
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16
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Vinhaes CL, Araujo-Pereira M, Tibúrcio R, Cubillos-Angulo JM, Demitto FO, Akrami KM, Andrade BB. Systemic Inflammation Associated with Immune Reconstitution Inflammatory Syndrome in Persons Living with HIV. Life (Basel) 2021; 11:life11010065. [PMID: 33477581 PMCID: PMC7831327 DOI: 10.3390/life11010065] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/19/2022] Open
Abstract
Antiretroviral therapy (ART) has represented a major advancement in the care of people living with HIV (PLWHH), resulting in significant reductions in morbidity and mortality through immune reconstitution and attenuation of homeostatic disruption. Importantly, restoration of immune function in PLWH with opportunistic infections occasionally leads to an intense and uncontrolled cytokine storm following ART initiation known as immune reconstitution inflammatory syndrome (IRIS). IRIS occurrence is associated with the severe and rapid clinical deterioration that results in significant morbidity and mortality. Here, we detail the determinants underlying IRIS development in PLWH, compiling the available knowledge in the field to highlight details of the inflammatory responses in IRIS associated with the most commonly reported opportunistic pathogens. This review also highlights gaps in the understanding of IRIS pathogenesis and summarizes therapeutic strategies that have been used for IRIS.
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Affiliation(s)
- Caian L. Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador 40290-000, Brazil
| | - Mariana Araujo-Pereira
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Rafael Tibúrcio
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Juan M. Cubillos-Angulo
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
| | - Fernanda O. Demitto
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
| | - Kevan M. Akrami
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
- Divisions of Infectious Diseases and Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, CA 92093, USA
| | - Bruno B. Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador 40296-710, Brazil; (C.L.V.); (M.A.-P.); (R.T.); (J.M.C.-A.); (K.M.A.)
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador 40210-320, Brazil;
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador 40290-000, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador 40110-100, Brazil
- Curso de Medicina, Centro Universitário Faculdade de Tecnologia e Ciências (UniFTC), Salvador 41741-590, Brazil
- Correspondence: ; Tel.: +55-71-3176-2264
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17
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Tuberculosis research conducted over the years at the ICMR-National Institute for Research in Tuberculosis (ICMR-NIRT). Indian J Tuberc 2020; 67:S7-S15. [PMID: 33308675 DOI: 10.1016/j.ijtb.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This review article highlights some of the key research conducted at the ICMR-National Institute for Research in Tuberculosis (ICMR-NIRT) over the years since its inception in 1956 till the present. The research carried out in the field of tuberculosis at ICMR-NIRT has been a joint effort between the ICMR, NIRT, the TB control program in India with assistance from World Health Organization (WHO) and the National Institutes of Health (NIH), USA. The research carried out at ICMR-NIRT has helped to formulate the national guidelines for the control and the management of tuberculosis in India. The major highlights of the research carried out at ICMR-NIRT are provided in this manuscript.
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18
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Quinn CM, Poplin V, Kasibante J, Yuquimpo K, Gakuru J, Cresswell FV, Bahr NC. Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease. Life (Basel) 2020; 10:E262. [PMID: 33138069 PMCID: PMC7693460 DOI: 10.3390/life10110262] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Antiretroviral therapy (ART), while essential in combatting tuberculosis (TB) and HIV coinfection, is often complicated by the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Depending on the TB disease site and treatment status at ART initiation, this immune-mediated worsening of TB pathology can take the form of paradoxical TB-IRIS, unmasking TB-IRIS, or CNS TB-IRIS. Each form of TB-IRIS has unique implications for diagnosis and treatment. Recently published studies have emphasized the importance of neutrophils and T cell subtypes in TB-IRIS pathogenesis, alongside the recognized role of CD4 T cells and macrophages. Research has also refined our prognostic understanding, revealing how the disease can impact lung function. While corticosteroids remain the only trial-supported therapy for prevention and management of TB-IRIS, increasing interest has been given to biologic therapies directly targeting the immune pathology. TB-IRIS, especially its unmasking form, remains incompletely described and more data is needed to validate biomarkers for diagnosis. Management strategies remain suboptimal, especially in the highly morbid central nervous system (CNS) form of the disease, and further trials are necessary to refine treatment. In this review we will summarize the current understanding of the immunopathogenesis, the presentation of TB-IRIS and the evidence for management recommendations.
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Affiliation(s)
- Carson M. Quinn
- School of Medicine, University of California, San Francisco, CA 94143, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Victoria Poplin
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Kyle Yuquimpo
- Department of Medicine, University of Kansas, Kansas City, KS 66045, USA;
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda; (J.K.); (J.G.); (F.V.C.)
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Medical Research Council, Uganda Virus Research Unit, London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS 66045, USA; (V.P.); (N.C.B.)
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19
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Demitto FO, Araújo-Pereira M, Schmaltz CA, Sant'Anna FM, Arriaga MB, Andrade BB, Rolla VC. Impact of Persistent Anemia on Systemic Inflammation and Tuberculosis Outcomes in Persons Living With HIV. Front Immunol 2020; 11:588405. [PMID: 33072136 PMCID: PMC7541849 DOI: 10.3389/fimmu.2020.588405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022] Open
Abstract
Tuberculosis (TB) is associated with systemic inflammation and anemia, which are aggravated in persons living with HIV (PLWH). Here, we characterized the dynamics of hemoglobin levels in PLWH coinfected with TB undergoing antitubercular therapy (ATT). We also examined the relationships between anemia and systemic inflammatory disturbance as well as the association between persistent anemia and unfavorable clinical outcomes. Data on several blood biochemical parameters and on blood cell counts were retrospectively analyzed in a cohort of 256 TB/HIV patients from Brazil during 180 days of ATT. Multidimensional statistical analyses were employed to profile systemic inflammation of patients stratified by anemia status (hemoglobin levels <12 g/dL for female and <13.5 g/dL for male individuals) prior to treatment and to perform prediction of unfavorable outcomes, such as treatment failure, loss to follow up and death. We found that 101 (63.63%) of patients with anemia at pre-ATT persisted with such condition until day 180. Such individuals exhibited heightened degree of inflammatory perturbation (DIP), which in turn was inversely correlated with hemoglobin levels. Recovery from anemia was associated with increased pre-ATT albumin levels whereas persistent anemia was related to higher total protein levels in serum. Multivariable regression analysis revealed that lower baseline hemoglobin levels was the major determinant of the unfavorable outcomes. Our findings demonstrate that persistent anemia in PLWH during the course of ATT is closely related with chronic inflammatory perturbation. Early intervention to promote recovery from anemia may improve ATT outcomes.
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Affiliation(s)
- Fernanda O Demitto
- Programa de Pós-Graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Mariana Araújo-Pereira
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
| | - Carolina A Schmaltz
- Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Flávia M Sant'Anna
- Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - María B Arriaga
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil.,Universidade Salvador (UNIFACS), Laureate International Universities, Salvador, Brazil.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Valeria C Rolla
- Programa de Pós-Graduação em Pesquisa Clínica em Doenças Infecciosas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Laboratório de Pesquisa Clínica em Micobacterioses (LAPCLIN-TB), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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20
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Vinhaes CL, Sheikh V, Oliveira-de-Souza D, Wang J, Rupert A, Roby G, Arriaga MB, Fukutani KF, Sawe F, Shaffer D, Ananworanich J, Phanuphak N, Andrade BB, Sereti I. An Inflammatory Composite Score Predicts Mycobacterial Immune Reconstitution Inflammatory Syndrome in People with Advanced HIV: A Prospective International Cohort Study. J Infect Dis 2020; 223:1275-1283. [PMID: 32761193 DOI: 10.1093/infdis/jiaa484] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/07/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Immune reconstitution inflammatory syndrome (IRIS) is a common cause of morbidity among people with human immunodeficiency virus (PWH) who initiate antiretroviral therapy (ART) with severe lymphopenia. Easily accessible tools that reliably predict emergence and elucidate pathogenesis of IRIS are needed to facilitate improved clinical management. METHODS Plasma levels of biomarkers were measured before ART initiation in a large multinational cohort of ART-naive PWH with severe immunosuppression (CD4+ count <100 cells/mm3) in United States, Kenya, and Thailand. We performed a series of multiparametric analyses of inflammatory and clinical biomarkers and developed a composite score merging relevant biomarkers for use in a prediction model. RESULTS We identified a distinct baseline inflammatory profile and changes in inflammatory networks among biomarkers in participants who subsequently developed mycobacterial or viral IRIS. We also developed a composite score incorporating biomarkers associated with IRIS (interleukin-6 [IL-6], IL-10, IL-27, sCD14, interferon-γ, tumor necrosis factor-α, hyaluronic acid, D-dimer, body mass index, and hemoglobin) that accurately predicted mycobacterial IRIS and death in this cohort. CONCLUSIONS Systemic inflammatory profiles in PWH with severe immunosuppression are predictive of IRIS. Composite scores for the prediction of mycobacterial IRIS and death could be useful for risk stratification in PWH and lymphopenia initiating ART. CLINICAL TRIALS REGISTRATION NCT00286767.
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Affiliation(s)
- Caian L Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | - Virginia Sheikh
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Deivide Oliveira-de-Souza
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | - Jing Wang
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adam Rupert
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gregg Roby
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - María B Arriaga
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Kiyoshi F Fukutani
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil
| | - Fred Sawe
- Kenya Medical Research Institute, Henry Jackson Foundation Medical Research International, Bethesda, Maryland, USA
| | - Doug Shaffer
- Kenya Medical Research Institute, Henry Jackson Foundation Medical Research International, Bethesda, Maryland, USA
| | - Jintanat Ananworanich
- South East Asia Research Collaboration with Hawaii, Henry M. Jackson Foundation for the Advancement of Military Medicine, United States Military HIV Research Program, Bethesda, Maryland, USA
| | | | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.,Universidade Salvador, Laureate Universities, Salvador, Brazil.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Irini Sereti
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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21
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Foppiano Palacios C, Saleeb PG. Challenges in the diagnosis of tuberculous meningitis. J Clin Tuberc Other Mycobact Dis 2020; 20:100164. [PMID: 32462082 PMCID: PMC7240715 DOI: 10.1016/j.jctube.2020.100164] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Tuberculosis (TB) continues to pose a significant public health problem. Tuberculous meningitis (TBM) is the most severe form of extra-pulmonary TB. TBM carries a high mortality rate, including for those receiving treatment for TB. Diagnosis of TBM is difficult for clinicians as it can clinically present similarly to other forms of meningitis. The difficulty in diagnosis often leads to a delay in treatment and subsequent mortality. Those who survive are left with long-term sequelae leading to lifelong disability. The microbiologic diagnosis of TBM requires the isolation of Mycobacterium tuberculosis from the cerebrospinal fluid (CSF) of an infected patient. The diagnosis of tuberculous meningitis continues to be challenging for clinicians. Unfortunately, many cases of TBM cannot be confirmed based on clinical and imaging findings as the clinical findings are nonspecific, while laboratory techniques are largely insensitive or slow. Until recently, the lack of accessible and timely tests has contributed to a delay in diagnosis and subsequent morbidity and mortality for many patients, particularly those in resourcelimited settings. The availability of Xpert Ultra and point-of-care lipoarabinomannan (LAM) testing could represent a new era of prompt diagnosis and early treatment of tuberculous meningitis. However, clinicians must be cautious when ruling out TBM with Xpert Ultra due to its low negative predictive value. Due to the limitations of current diagnostics, clinicians should utilize a combination of diagnostic modalities in order to prevent morbidity in patients with TBM.
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Affiliation(s)
- Carlo Foppiano Palacios
- Departments of Internal Medicine and Pediatrics, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, United States
| | - Paul G. Saleeb
- Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, Baltimore, MD 21201, United States
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22
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Xue M, Xie R, Pang Y, Yan S, Du Y, Guan C, Chen B. Prevalence and risk factors of paradoxical tuberculosis associated immune reconstitution inflammatory syndrome among HIV-infected patients in Beijing, China. BMC Infect Dis 2020; 20:554. [PMID: 32736608 PMCID: PMC7393886 DOI: 10.1186/s12879-020-05225-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 07/03/2020] [Indexed: 01/01/2023] Open
Abstract
Background In this study, we aimed to describe the prevalence, clinical presentation and risk factors of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) cases in China. Methods We performed a descriptive analysis of demographic and clinical data of HIV/TB coinfected patients receiving ART at Beijing Ditan Hospital between January 2014 and October 2018. Results Of 199 patients included, 45 (22.6%) developed paradoxical TB-IRIS, and 19 (9.5%) TB-IRIS cases presented miliary TB. The pre-ART CD4 count lower than 50 cells/mm3 was found to be significantly associated with development of TB-IRIS. Similarly, patients with higher than 4-fold increase in CD4 cell count after antiretroviral therapy (ART) had significantly higher odds of having TB-IRIS. When patients aged 25–44 years were utilized as the control group, youths (< 25 years old) were more likely to have miliary TB. No significant difference was observed in the intervals from initiation of ART to IRIS presentation between miliary and non-miliary group. Conclusions In conclusion, our data demonstrate that approximate one quarter of patients coinfected with TB and HIV develop paradoxical TB-IRIS after initial of ART therapy in China. Lower baseline CD4 count and rapid increase in CD4 count are the major risk factors associated with the occurrence of paradoxical TB-IRIS.
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Affiliation(s)
- Ming Xue
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Ruming Xie
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Yu Pang
- National Clinical Laboratory on Tuberculosis, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, 101149, P. R. China
| | - Shuo Yan
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Yanni Du
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Chunshuang Guan
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China
| | - Budong Chen
- Department of Radiology, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, Beijing, 100015, P. R. China.
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23
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Sereti I, Sheikh V, Shaffer D, Phanuphak N, Gabriel E, Wang J, Nason MC, Roby G, Ngeno H, Kirui F, Pau A, Mican JM, Rupert A, Bishop R, Agan B, Chomchey N, Teeratakulpisarn N, Tansuphaswadikul S, Langat D, Kosgei J, French M, Ananworanich J, Sawe F. Prospective International Study of Incidence and Predictors of Immune Reconstitution Inflammatory Syndrome and Death in People Living With Human Immunodeficiency Virus and Severe Lymphopenia. Clin Infect Dis 2020; 71:652-660. [PMID: 31504347 PMCID: PMC7384325 DOI: 10.1093/cid/ciz877] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients living with human immunodeficiency virus (PLWH) with low CD4 counts are at high risk for immune reconstitution inflammatory syndrome (IRIS) and death at antiretroviral therapy (ART) initiation. METHODS We investigated the clinical impact of IRIS in PLWH and CD4 counts <100 cells/μL starting ART in an international, prospective study in the United States, Thailand, and Kenya. An independent review committee adjudicated IRIS events. We assessed associations between baseline biomarkers, IRIS, immune recovery at week 48, and death by week 48 with Cox models. RESULTS We enrolled 506 participants (39.3% were women). Median age was 37 years, and CD4 count was 29 cells/μL. Within 6 months of ART, 97 (19.2%) participants developed IRIS and 31 (6.5%) died. Participants with lower hemoglobin at baseline were at higher IRIS risk (hazard ratio [HR], 1.2; P = .004). IRIS was independently associated with increased risk of death after adjustment for known risk factors (HR, 3.2; P = .031). Being female (P = .004) and having a lower body mass index (BMI; P = .003), higher white blood cell count (P = .005), and higher D-dimer levels (P = .044) were also significantly associated with increased risk of death. Decision-tree analysis identified hemoglobin <8.5 g/dL as predictive of IRIS and C-reactive protein (CRP) >106 μg/mL and BMI <15.6 kg/m2 as predictive of death. CONCLUSIONS For PLWH with severe immunosuppression initiating ART, baseline low BMI and hemoglobin and high CRP and D-dimer levels may be clinically useful predictors of IRIS and death risk.
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Affiliation(s)
- Irini Sereti
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Virginia Sheikh
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Douglas Shaffer
- Walter Reed Army Institute of Research/US Army Medical Research Directorate–Africa, Nairobi, Kenya
- Walter Reed Army Institute of Research, US Military Human Immunodeficiency Virus Research Program, Silver Spring, Maryland, USA
| | - Nittaya Phanuphak
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Erin Gabriel
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Jing Wang
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc, National Cancer Institute Campus at Frederick, Maryland, USA
| | - Martha C Nason
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Gregg Roby
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Hellen Ngeno
- Walter Reed Army Institute of Research/US Army Medical Research Directorate–Africa, Nairobi, Kenya
| | - Fredrick Kirui
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
| | - Alice Pau
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joann M Mican
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Adam Rupert
- Applied and Developmental Research Directorate, AIDS Monitoring Laboratory, Leidos Biomedical Research, Inc, Frederick, Maryland, USA
| | - Rachel Bishop
- National Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Brian Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Nitiya Chomchey
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Nipat Teeratakulpisarn
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Deborah Langat
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Josphat Kosgei
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Martyn French
- University of Western Australia, Medical School and School of Biomedical Sciences, Nedlands, Australia
| | - Jintanat Ananworanich
- South East Asia Research Collaboration with Hawaii, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- US Military Human Immunodeficiency Virus Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Department of Global Health, Amsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Fredrick Sawe
- Kenya Medical Research Institute/US Army Medical Research Directorate–Africa–Kenya/ Henry Jackson Foundation Medical Research International, Kericho Clinical Research Center, Kenya
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
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Harypursat V, Zhou Y, Tang S, Chen Y. JC Polyomavirus, progressive multifocal leukoencephalopathy and immune reconstitution inflammatory syndrome: a review. AIDS Res Ther 2020; 17:37. [PMID: 32631361 PMCID: PMC7338111 DOI: 10.1186/s12981-020-00293-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/29/2020] [Indexed: 01/15/2023] Open
Abstract
The human neurotropic virus JC Polyomavirus, a member of the Polyomaviridae family, is the opportunistic infectious agent causing progressive multifocal leukoencephalopathy, typically in immunocompromised individuals. The spectrum of underlying reasons for the systemic immunosuppression that permits JCV infection in the central nervous system has evolved over the past 2 decades, and therapeutic immunosuppression arousing JCV infection in the brain has become increasingly prominent as a trigger for PML. Effective immune restoration subsequent to human immunodeficiency virus-related suppression is now recognized as a cause for unexpected deterioration of symptoms in patients with PML, secondary to a rebound inflammatory phenomenon called immune reconstitution inflammatory syndrome, resulting in significantly increased morbidity and mortality in a disease already infamous for its lethality. This review addresses current knowledge regarding JC Polyomavirus, progressive multifocal leukoencephalopathy, progressive multifocal leukoencephalopathy-related immune reconstitution inflammatory syndrome, and the immunocompromised states that incite JC Polyomavirus central nervous system infection, and discusses prospects for the future management of these conditions.
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Affiliation(s)
- Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Yihong Zhou
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Shengquan Tang
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, 109 Baoyu Road, Geleshan Town, Shapingba District, Chongqing, 400036, People's Republic of China.
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25
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Narendran G, Jyotheeswaran K, Senguttuvan T, Vinhaes CL, Santhanakrishnan RK, Manoharan T, Selvaraj A, Chandrasekaran P, Menon PA, Bhavani KP, Reddy D, Narayanan R, Subramanyam B, Sathyavelu S, Krishnaraja R, Kalirajan P, Angamuthu D, Susaimuthu SM, Ganesan RRK, Tripathy SP, Swaminathan S, Andrade BB. Characteristics of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome and its influence on tuberculosis treatment outcomes in persons living with HIV. Int J Infect Dis 2020; 98:261-267. [PMID: 32623087 DOI: 10.1016/j.ijid.2020.06.097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The influence of tuberculosis (TB)-immune reconstitution inflammatory syndrome (IRIS) on TB treatment outcomes and its risk factors were investigated among people with human immunodeficiency virus (HIV) and co-infected with TB. METHODS Newly diagnosed, culture-confirmed, pulmonary TB patients with HIV and enrolled in a clinical trial (NCT00933790) were retrospectively analysed for IRIS occurrence. Risk factors and TB outcomes (up to 18 months after initiation of anti-TB treatment [ATT]) were compared between people who experienced IRIS (IRIS group) and those who did not (non-IRIS group). RESULTS TB-IRIS occurred in 82 of 292 (28%) participants. Significant baseline risk factors predisposing to TB-IRIS occurrence in univariate analysis were: lower CD4+ T-cell count, CD4/CD8 ratio, haemoglobin levels, presence of extra-pulmonary TB focus, and higher HIV viral load; the last two retained significance in the multivariate analysis. After 2 months of ATT commencement, sputum smear conversion was documented in 45 of 80 (56.2%) vs. 124 of 194 (63.9%) (p=0.23), culture conversion was in 75 of 80 (93.7%) vs. 178 of 194 (91.7%) (p=0.57) and the median decline in viral load (log10copies/mm3) was 2.7 in the IRIS vs. 1.1 in the non-IRIS groups (p<0.0001), respectively. An unfavourable response to TB therapy was detected in 17 of 82 (20.7%) and 28 of 210 (13.3%) in the IRIS and non-IRIS groups, respectively (p=0.14). CONCLUSIONS TB-IRIS frequently occurred in people with advanced HIV infection and in those who presented with extra-pulmonary TB lesions, without influencing subsequent TB treatment outcomes.
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Affiliation(s)
- Gopalan Narendran
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Keerthana Jyotheeswaran
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Thirumaran Senguttuvan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil; Curso de Medicina, Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil
| | - Ramesh K Santhanakrishnan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Tamizhselvan Manoharan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Anbhalagan Selvaraj
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Pradeep A Menon
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Kannabiran P Bhavani
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Devarajulu Reddy
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Ravichandran Narayanan
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, Tamil Nadu, India
| | - Balaji Subramanyam
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Sekhar Sathyavelu
- Rajiv Gandhi Government General Hospital, Park Town, Chennai, Tamil Nadu, India
| | - Raja Krishnaraja
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, Tamil Nadu, India
| | - Pownraj Kalirajan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Dhanalakshmi Angamuthu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Stella Mary Susaimuthu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Srikanth P Tripathy
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil; Curso de Medicina, Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil; Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil; Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil; Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Suryana K. <p>A Challenge in Diagnosis of Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome (TB-IRIS)</p>. HIV AIDS (Auckl) 2020; 12:263-269. [PMID: 32801925 PMCID: PMC7398877 DOI: 10.2147/hiv.s254105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/27/2020] [Indexed: 12/05/2022] Open
Abstract
Tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) in HIV-infected patients is the sign and symptom of exacerbation, or radiological manifestation of Mycobacterium tuberculosis (Mtb) infection, can describe the improvement of the immune system after initiating highly active antiretroviral therapy (HAART). No approved or explicit symptomatic tests for TB-IRIS exist, the diagnosis depends on the clinical manifestations. Here we report a TB-IRIS case with diagnostic challenges.
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Affiliation(s)
- Ketut Suryana
- Department of Internal Medicine, Merpati Clinic, HIV and Allergy - Clinical Immunology Services Unit, Wangaya Hospital, Denpasar, Bali, Indonesia
- Correspondence: Ketut Suryana Department of Internal Medicine; Merpati Clinic; HIV and Allergy - Clinical Immunology Services Unit, Wangaya Hospital, Akasia Street, VIII No. 22, Denpasar, Bali80235, IndonesiaTel +628 5953783944 Email
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27
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Meintjes G, Brust JCM, Nuttall J, Maartens G. Management of active tuberculosis in adults with HIV. Lancet HIV 2020; 6:e463-e474. [PMID: 31272663 DOI: 10.1016/s2352-3018(19)30154-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 04/25/2019] [Accepted: 05/08/2019] [Indexed: 12/11/2022]
Abstract
Every year, about 1 million people living with HIV worldwide develop tuberculosis. Although the drug regimens used to treat tuberculosis in these patients are the same as those used in HIV-negative patients, cotreatment of tuberculosis with antiretroviral therapy involves challenges including the optimal timing of antiretroviral initiation, drug-drug interactions, drug tolerability, and the prevention and treatment of tuberculosis-associated immune reconstitution syndrome. Furthermore, mortality is high in people with HIV who are diagnosed with tuberculosis during a hospital admission, and in those with tuberculous meningitis. Studies in this field have better characterised these challenges and informed optimal management and guideline revisions. In patients with tuberculosis, antiretroviral therapy improves survival, is well tolerated, and can be adjusted to manage drug-drug interactions with rifampicin. Prednisone is effective in both preventing and treating the paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Infectious Diseases and HIV Medicine, Department of Medicine, South Africa.
| | - James C M Brust
- University of Cape Town, Observatory, South Africa; Divisions of General Internal Medicine and Infectious Diseases, Albert Einstein College of Medicine, New York, NY, USA
| | - James Nuttall
- Department of Paediatrics and Child Health, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, South Africa; Division of Clinical Pharmacology, Department of Medicine, South Africa
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28
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Arpagaus A, Franzeck FC, Sikalengo G, Ndege R, Mnzava D, Rohacek M, Hella J, Reither K, Battegay M, Glass TR, Paris DH, Bani F, Rajab ON, Weisser M. Extrapulmonary tuberculosis in HIV-infected patients in rural Tanzania: The prospective Kilombero and Ulanga antiretroviral cohort. PLoS One 2020; 15:e0229875. [PMID: 32130279 PMCID: PMC7055864 DOI: 10.1371/journal.pone.0229875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, diagnosis and management of extrapulmonary tuberculosis (EPTB) in people living with HIV (PLHIV) remains a major challenge. This study aimed to characterize the epidemiology and risk factors for poor outcome of extrapulmonary tuberculosis in people living with HIV (PLHIV) in a rural setting in Tanzania. METHODS We included PLHIV >18 years of age enrolled into the Kilombero and Ulanga antiretroviral cohort (KIULARCO) from 2013 to 2017. We assessed the diagnosis of tuberculosis by integrating prospectively collected clinical and microbiological data. We calculated prevalence- and incidence rates and used Cox regression analysis to evaluate the association of risk factors in extrapulmonary tuberculosis (EPTB) with a combined endpoint of lost to follow-up (LTFU) and death. RESULTS We included 3,129 subjects (64.5% female) with a median age of 38 years (interquartile range [IQR] 31-46) and a median CD4+ cell count of 229/μl (IQR 94-421) at baseline. During the median follow-up of 1.25 years (IQR 0.46-2.85), 574 (18.4%) subjects were diagnosed with tuberculosis, whereof 175 (30.5%) had an extrapulmonary manifestation. Microbiological evidence by Acid-Fast-Bacillus stain (AFB-stain) or Xpert® MTB/RIF was present in 178/483 (36.9%) patients with pulmonary and in 28/175 (16.0%) of patients with extrapulmonary manifestations, respectively. Incidence density rates for pulmonary Tuberculosis (PTB and EPTB were 17.9/1000person-years (py) (95% CI 14.2-22.6) and 5.8/1000 py (95% CI 4.0-8.5), respectively. The combined endpoint of death and LTFU was observed in 1058 (33.8%) patients, most frequently in the subgroup of EPTB (47.2%). Patients with EPTB had a higher rate of the composite outcome of death/LTFU after TB diagnosis than with PTB [HR 1.63, (1.14-2.31); p = 0.006]. The adjusted hazard ratios [HR (95% CI)] for death/LTFU in EPTB patients were significantly increased for patients aged >45 years [HR 1.95, (1.15-3.3); p = 0.013], whereas ART use was protective [HR 0.15, (0.08-0.27); p <0.001]. CONCLUSIONS Extrapulmonary tuberculosis was a frequent manifestation in this cohort of PLHIV. The diagnosis of EPTB in the absence of histopathology and mycobacterial culture remains challenging even with availability of Xpert® MTB/RIF. Patients with EPTB had increased rates of mortality and LTFU despite early recognition of the disease after enrollment.
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Affiliation(s)
- Armon Arpagaus
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabian Christoph Franzeck
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - George Sikalengo
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Saint Francis Referral Hospital, Ifakara, United Republic of Tanzania
| | - Robert Ndege
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Saint Francis Referral Hospital, Ifakara, United Republic of Tanzania
| | - Dorcas Mnzava
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Martin Rohacek
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Jerry Hella
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tracy Renee Glass
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Daniel Henry Paris
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Farida Bani
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | | | - Maja Weisser
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
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Dong RJ, Huang SZ, Upadhyay P, Shrestha S, Zhai YJ, Li YY. Thalidomide in the Treatment of Sweet's Syndrome and Eosinophilic Folliculitis Associated With Immune Reconstitution Inflammatory Syndrome. Front Med (Lausanne) 2020; 6:343. [PMID: 32039221 PMCID: PMC6985142 DOI: 10.3389/fmed.2019.00343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/27/2019] [Indexed: 12/02/2022] Open
Abstract
Sweet's syndrome and eosinophilic folliculitis are aseptic inflammatory dermatitis mainly because of infiltrated neutrophils and eosinophils on skin, respectively. These diseases rarely overlap or coexist in the same patient, especially co-occur in HIV infected patient. Here, we report a rare case of an AIDS patient who developed eosinophilic folliculitis and Sweet's syndrome within 1 month of initial antiretroviral therapy, presumably due to immune reconstitution inflammatory syndrome. The CD4+ T cell counts increased dramatically from 70 to 249 cells/μL within a period of 1 month. Interestingly, the patient was rapidly and strikingly responsive to thalidomide, which has anti-inflammatory, immune regulation, inhibition of neutrophil chemotaxis etc. Moreover, we focused our attention on discussing the clinical, pathological, and possible pathogenic aspects of the rare overlap of HIV complicated with neutrophilic and eosinophilic dermatosis.
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Affiliation(s)
- Rong-Jing Dong
- Department of Dermatology and Venereology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shi-Zhen Huang
- Yunnan Provincial Hospital of Infectious Disease/Yunnan AIDS Care Center (YNACC), Anning, China
| | - Pratishtha Upadhyay
- Department of Dermatology and Venereology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Samip Shrestha
- Department of Medical Imaging, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ya-Jie Zhai
- Department of Dermatology and Venereology, Jining Second People's Hospital, Jining, China
| | - Yu-Ye Li
- Department of Dermatology and Venereology, First Affiliated Hospital of Kunming Medical University, Kunming, China
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30
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Ayelign B, Workneh M, Molla MD, Dessie G. Role Of Vitamin-D Supplementation In TB/HIV Co-Infected Patients. Infect Drug Resist 2020; 13:111-118. [PMID: 32021325 PMCID: PMC6959508 DOI: 10.2147/idr.s228336] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/28/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE This review aimed to assess the role of vitamin D supplementation on the decrement of mortality and morbidity rate among tuberculosis (TB)/human immune deficiency virus (HIV) co-infected clients.Method: Pub Med, google scholar and google search were accessed to find out all document to describe this review article. RESULTS Nowadays TB/HIV co-infection has become a major global concern, particularly in low and middle-income countries. Mycobacterium tuberculosis and HIV infections are co-endemic and more susceptible to the progression of TB. Immunosuppression associated with HIV is a strong risk factor for the reactivation of latent TB to the active form. Immune cells like macrophages recognized Mycobacterium tuberculosis through TLR2/1, and it increases the expression of the vitamin D receptor (VDR) and CYP27B1. The synthesis of 1,25-dihydroxy vitamin D promotes VDR-mediated transactivation of the antimicrobial peptide cathelicidin and the killing of intracellular Mycobacterium tuberculosis. Cathelicidins have a direct antimicrobial effect through membrane disruption. Besides, it has also antiviral effects via inhibition of retrovirus (HIV) replication. In fact, as some studies showed, there was a lower induction of cathelicidin in monocytes who have low vitamin D levels.Conclusion: Therefore, vitamin D supplementation can be directly involved in the reduction of TB/HIV co-infection and its progression.
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Affiliation(s)
- Birhanu Ayelign
- Department of Immunology and Molecular Biology, School of Biomedical And Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Meseret Workneh
- Department of Immunology and Molecular Biology, School of Biomedical And Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Meseret Derbew Molla
- Department of Biochemistry, School of Medicine, College of Medicine And Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gashaw Dessie
- Department of Biochemistry, School of Medicine, College of Medicine And Health Sciences, University of Gondar, Gondar, Ethiopia
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31
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Cevaal PM, Bekker LG, Hermans S. TB-IRIS pathogenesis and new strategies for intervention: Insights from related inflammatory disorders. Tuberculosis (Edinb) 2019; 118:101863. [PMID: 31561185 DOI: 10.1016/j.tube.2019.101863] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/29/2022]
Abstract
In almost one in five HIV/tuberculosis (TB) co-infected patients, initiation of antiretroviral therapy (ART) is complicated by TB immune reconstitution inflammatory syndrome (TB-IRIS). Corticosteroids have been suggested for treatment of severe cases, however no therapy is currently licensed for TB-IRIS. Hence, there is a strong need for more specific therapeutics, and therefore, a better understanding of TB-IRIS pathogenesis. Immune reconstitution following ART is a precariously balanced functional restoration of adaptive immunity. In those patients predisposed to disease, an incomplete activation of the innate immune system leads to a hyper-inflammatory response that comprises partially overlapping innate, adaptive and effector arms, eventually leading to clinical symptoms. Interestingly, many of these pathological mechanisms are shared by related inflammatory disorders. We here describe therapeutic strategies that originate from these other disciplines and discuss their potential application in TB-IRIS. These new avenues of interventions range from final-phase treatment of symptoms to early-phase prevention of disease onset. In conclusion, we propose a novel approach for the discovery and development of therapeutics, based on an updated model of TB-IRIS pathogenesis. Further experimental studies validating the causal relationships in the proposed model could greatly contribute to providing a solid immunological basis for future clinical trials on TB-IRIS therapeutics.
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Affiliation(s)
- Paula M Cevaal
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands.
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
| | - Sabine Hermans
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands; Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
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Abstract
Three decades of research in hematopoietic stem cell transplantation and HIV/AIDS fields have shaped a picture of immune restoration disorders. This manuscript overviews the molecular biology of interferon networks, the molecular pathogenesis of immune reconstitution inflammatory syndrome, and post-hematopoietic stem cell transplantation immune restoration disorders (IRD). It also summarizes the effects of thymic involution on T cell diversity, and the results of the assessment of diagnostic biomarkers of IRD, and tested targeted immunomodulatory treatments.
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Affiliation(s)
- Hesham Mohei
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Usha Kellampalli
- Department of Medicine, University of Minnesota, Minneapolis, USA
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Narendran G, Oliveira-de-Souza D, Vinhaes CL, Akrami K, Fukutani KF, Banu K, Chandrasekaran P, Ravichandran N, Sereti I, Swaminathan S, Andrade BB. Multifocal tuberculosis-associated immune reconstitution inflammatory syndrome - a case report of a complicated scenario. BMC Infect Dis 2019; 19:529. [PMID: 31208430 PMCID: PMC6580602 DOI: 10.1186/s12879-019-4182-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB)-associated Immune reconstitution inflammatory syndrome (TB-IRIS) is an aberrant inflammatory response in TB patients with advanced human immunodeficiency virus coinfection, after antiretroviral therapy commencement. CASE PRESENTATION We present a rare case of a 51-year-old woman living with HIV who developed a series of TB-IRIS events occurring at multiple sites sequentially, highlighting the clinical complexity in diagnosis and management. CONCLUSION This case illustrates how complicated a clinical scenario of successive TB-IRIS episodes can be, in terms of clinical management.
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Affiliation(s)
- Gopalan Narendran
- National Institute for Research in Tuberculosis, Chennai, 600031, India
| | - Deivide Oliveira-de-Souza
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | - Caian L Vinhaes
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | - Kevan Akrami
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Division of Infectious Diseases, Department of Medicine, University of California, San Diego, USA
| | - Kiyoshi F Fukutani
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | | | | | | | - Irini Sereti
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Bruno B Andrade
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil. .,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil. .,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil. .,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, 7925, South Africa. .,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA. .,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, 41720-200, Brazil. .,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, 40290-000, Brazil.
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Meya DB, Okurut S, Zziwa G, Cose S, Boulware DR, Janoff EN. HIV-Associated Cryptococcal Immune Reconstitution Inflammatory Syndrome Is Associated with Aberrant T Cell Function and Increased Cytokine Responses. J Fungi (Basel) 2019; 5:jof5020042. [PMID: 31126019 PMCID: PMC6616503 DOI: 10.3390/jof5020042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/24/2019] [Accepted: 04/29/2019] [Indexed: 12/11/2022] Open
Abstract
Cryptococcal meningitis remains a significant opportunistic infection among HIV-infected patients, contributing 15-20% of HIV-related mortality. A complication of initiating antiretroviral therapy (ART) following opportunistic infection is immune reconstitution inflammatory syndrome (IRIS). IRIS afflicts 10-30% of HIV-infected patients with cryptococcal meningitis (CM), but its immunopathogenesis is poorly understood. We compared circulating T cell memory subsets and cytokine responses among 17 HIV-infected Ugandans with CM: 11 with and 6 without CM-IRIS. At meningitis diagnosis, stimulation with cryptococcal capsule component, glucuronoxylomannan (GXM) elicited consistently lower frequencies of CD4+ and CD8+ T cell memory subsets expressing intracellular cytokines (IL-2, IFN-γ, and IL-17) among subjects who subsequently developed CM-IRIS. After ART initiation, T cells evolved to show a decreased CD8+ central memory phenotype. At the onset of CM-IRIS, stimulation more frequently generated polyfunctional IL-2+/IL-17+ CD4+ T cells in patients with CM-IRIS. Moreover, CD8+ central and effector memory T cells from CM-IRIS subjects also demonstrated more robust IL-2 responses to antigenic stimulation vs. controls. Thus, ART during CM elicits distinct differences in T cell cytokine production in response to cryptococcal antigens both prior to and during the development of IRIS, suggesting an immunologic foundation for the development of this morbid complication of CM infection.
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Affiliation(s)
- David B Meya
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda.
- Department of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, Minneapolis, MN 55455, USA.
- School of Medicine, College of Health Sciences, Makerere University, Kampala P.O. Box 7072, Uganda.
| | - Samuel Okurut
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda.
| | - Godfrey Zziwa
- Research Department, Makerere University Walter Reed Project, Plot 42, Nakasero Road, Kampala P.O. Box 1624, Uganda.
| | - Stephen Cose
- Clinical Research Department, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Entebbe P.O.Box 49, Uganda.
| | - David R Boulware
- Department of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Edward N Janoff
- Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado, Denver, Aurora, CO 80045, USA.
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Silveira-Mattos PS, Narendran G, Akrami K, Fukutani KF, Anbalagan S, Nayak K, Subramanyam S, Subramani R, Vinhaes CL, Souza DOD, Antonelli LR, Satagopan K, Porter BO, Sher A, Swaminathan S, Sereti I, Andrade BB. Differential expression of CXCR3 and CCR6 on CD4 + T-lymphocytes with distinct memory phenotypes characterizes tuberculosis-associated immune reconstitution inflammatory syndrome. Sci Rep 2019; 9:1502. [PMID: 30728405 PMCID: PMC6365576 DOI: 10.1038/s41598-018-37846-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/12/2018] [Indexed: 11/09/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) occurs in up to 40% of individuals co-infected with pulmonary tuberculosis (PTB) and HIV, primarily upon antiretroviral therapy (ART) initiation. Phenotypic changes in T-cells during TB-IRIS and their relationship with systemic inflammation are not fully understood. In this prospective cohort study, we followed 48 HIV-positive patients with PTB from South India before and after ART initiation, examining T-lymphocyte subsets and inflammatory biomarkers in peripheral blood. Quantification of naïve (CD27+CD45RO-) as well as effector memory CD4+ T cells (CD27-CD45RO+) at weeks 2-6 after ART initiation could distinguish TB-IRIS from non-IRIS individuals. Additional analyses revealed that ART reconstituted different quantities of CD4+ T lymphocyte subsets with preferential expansion of CXCR3+ CCR6- cells in TB-IRIS patients. Moreover, there was an expansion and functional restoration of central memory (CD27+CD45RO+) CXCR3+CCR6- CD4+ lymphocytes and corresponding cytokines, with reduction in CXCR3-CCR6+ cells after ART initiation only in those who developed TB-IRIS. Together, these observations trace a detailed picture of CD4+ T cell subsets tightly associated with IRIS, which may serve as targets for prophylactic and/or therapeutic interventions in the future.
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Affiliation(s)
- Paulo S Silveira-Mattos
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | | | - Kevan Akrami
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Division of Infectious Diseases, Department of Medicine, University of California, San Diego, United States of America
| | - Kiyoshi F Fukutani
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | | | - Kaustuv Nayak
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | - Deivide Oliveira-de Souza
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | - Lis R Antonelli
- Laboratório de Biologia e Imunologia de Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais, Brazil
| | - Kumar Satagopan
- Government Hospital of Thoracic Medicine, Tambaram, Chennai, India
| | - Brian O Porter
- Clinical HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Irini Sereti
- Clinical HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil. .,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil. .,Wellcome Trust Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa. .,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Bahia, Brazil. .,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Bahia, Brazil. .,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
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36
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Meintjes G, Stek C, Blumenthal L, Thienemann F, Schutz C, Buyze J, Ravinetto R, van Loen H, Nair A, Jackson A, Colebunders R, Maartens G, Wilkinson RJ, Lynen L. Prednisone for the Prevention of Paradoxical Tuberculosis-Associated IRIS. N Engl J Med 2018; 379:1915-1925. [PMID: 30428290 DOI: 10.1056/nejmoa1800762] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early initiation of antiretroviral therapy (ART) in human immunodeficiency virus (HIV)-infected patients who have tuberculosis reduces mortality among patients with low CD4 counts, but it increases the risk of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (IRIS). METHODS We conducted this randomized, double-blind, placebo-controlled trial to assess whether prophylactic prednisone can safely reduce the incidence of paradoxical tuberculosis-associated IRIS in patients at high risk for the syndrome. We enrolled HIV-infected patients who were initiating ART (and had not previously received ART), had started tuberculosis treatment within 30 days before initiating ART, and had a CD4 count of 100 cells or fewer per microliter. Patients received either prednisone (at a dose of 40 mg per day for 14 days, then 20 mg per day for 14 days) or placebo. The primary end point was the development of tuberculosis-associated IRIS within 12 weeks after initiating ART, as adjudicated by an independent committee. RESULTS Among the 240 patients who were enrolled, the median age was 36 (interquartile range, 30 to 42), 60% were men, and 73% had microbiologically confirmed tuberculosis; the median CD4 count was 49 cells per microliter (interquartile range, 24 to 86), and the median HIV type 1 RNA viral load was 5.5 log10 copies per milliliter (interquartile range, 5.2 to 5.9). A total of 120 patients were assigned to each group, and 18 patients were lost to follow-up or withdrew. Tuberculosis-associated IRIS was diagnosed in 39 patients (32.5%) in the prednisone group and in 56 (46.7%) in the placebo group (relative risk, 0.70; 95% confidence interval [CI], 0.51 to 0.96; P=0.03). Open-label glucocorticoids were prescribed to treat tuberculosis-associated IRIS in 16 patients (13.3%) in the prednisone group and in 34 (28.3%) in the placebo group (relative risk, 0.47; 95% CI, 0.27 to 0.81). There were five deaths in the prednisone group and four in the placebo group (P=1.00). Severe infections (acquired immunodeficiency syndrome-defining illnesses or invasive bacterial infections) occurred in 11 patients in the prednisone group and in 18 patients in the placebo group (P=0.23). One case of Kaposi's sarcoma occurred in the placebo group. CONCLUSIONS Prednisone treatment during the first 4 weeks after the initiation of ART for HIV infection resulted in a lower incidence of tuberculosis-associated IRIS than placebo, without evidence of an increased risk of severe infections or cancers. (Funded by the European and Developing Countries Clinical Trials Partnership and others; PredART ClinicalTrials.gov number, NCT01924286 .).
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Affiliation(s)
- Graeme Meintjes
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Cari Stek
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Lisette Blumenthal
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Friedrich Thienemann
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Charlotte Schutz
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Jozefien Buyze
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Raffaella Ravinetto
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Harry van Loen
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Amy Nair
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Amanda Jackson
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Robert Colebunders
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Gary Maartens
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Robert J Wilkinson
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
| | - Lutgarde Lynen
- From the Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine (G. Meintjes, C. Stek, L.B., F.T., C. Schutz, A.N., A.J., R.J.W.), the Department of Medicine (G. Meintjes, C. Stek, F.T., C. Schutz, R.J.W.), and the Division of Clinical Pharmacology, Department of Medicine (G. Maartens), University of Cape Town, Cape Town, South Africa; the Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium (C. Stek, J.B., R.R., H.L., R.C., L.L.); the Department of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland (F.T.); and the Department of Medicine, Imperial College London and the Francis Crick Institute, London (R.J.W.)
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Kang HS, Lee HY, Jung JI, Kim JS, Kim YH, Kim SJ, Kim SC, Kwon SS, Kim YK, Kang JY. Clinical significance of Glasgow Prognostic Score in patients with tuberculous pleurisy. J Thorac Dis 2018; 10:6077-6087. [PMID: 30622779 DOI: 10.21037/jtd.2018.10.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The Glasgow Prognostic Score (GPS) reflects the host systemic inflammatory response and is a validated, independent prognostic factor for various malignancies. We investigated the clinical significance of the GPS in patients with tuberculosis (TB) pleurisy, focusing on treatment outcomes including paradoxical response (PR). Methods This was a retrospective study performed between January 2010 and December 2015 in two referral and university hospitals in South Korea, with intermediate incidences of TB. In all, 462 patients with TB pleurisy were registered in the study. The patients were classified into three groups based on GPS score, as follows: (I) GPS of 2, elevated CRP level (>1.0 mg/dL) and hypoalbuminemia (<3.5 g/dL); (II) GPS of 1, elevated CRP level or hypoalbuminemia; and (III) GPS of 0, neither elevated CRP level nor hypoalbuminemia. Results A total of 367 patients with TB pleurisy were finally included. PR occurred in 102 (27.8%) patients after a mean of 75 days following initiation of anti-TB treatment. The proportion of PR occurrence was significantly lower in the GPS 2 group (P=0.007). Successful treatment outcomes including cure and completion were also significantly lower in the GPS 2 group (P=0.001), while all-cause mortality and TB-specific mortality were higher in the GPS 2 group (P=0.001 and <0.001, respectively). Old age over than 65 years old was an independent predicting factor for high mortality and lower PR occurrence. However, the TB relapse rate was not different among the three GPS groups. Conclusions Higher GPS value and elderly age were identified as prognostic factors for poor outcomes in TB pleurisy and as predicting factors for lower PR occurrence. More prospective studies are needed to clarify the utility of GPS in patients with TB pleurisy.
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Affiliation(s)
- Hye Seon Kang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwa Young Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Im Jung
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Sang Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Hyun Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Joon Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Chan Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soon Seog Kwon
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kyoon Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Young Kang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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38
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Manion M, Uldrick T, Polizzotto MN, Sheikh V, Roby G, Lurain K, Metzger D, Mican JM, Pau A, Lisco A, Laidlaw E, Hammoud DA, Whitby D, Yarchoan R, Sereti I. Emergence of Kaposi's Sarcoma Herpesvirus-Associated Complications Following Corticosteroid Use in TB-IRIS. Open Forum Infect Dis 2018; 5:ofy217. [PMID: 30568973 DOI: 10.1093/ofid/ofy217] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 10/02/2018] [Indexed: 11/13/2022] Open
Abstract
Corticosteroid use was associated with development of Kaposi's sarcoma or multicentric Castleman disease in 3 patients with mycobacterial immune reconstitution inflammatory syndrome (IRIS) treated with corticosteroids. Monitoring for development of Kaposi's sarcoma and alternative treatment may be beneficial for patients with IRIS, especially in the presence of preexisting co-infection with Kaposi's sarcoma-associated herpesvirus.
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Affiliation(s)
- Maura Manion
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
| | | | | | - Virginia Sheikh
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
| | - Gregg Roby
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
| | | | - Dorinda Metzger
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
| | - JoAnn M Mican
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
| | - Alice Pau
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
| | - Andrea Lisco
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
| | - Elizabeth Laidlaw
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
| | - Dima A Hammoud
- Center for Infectious Diseases Imaging, NIH, Bethesda, Maryland
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | | | - Irini Sereti
- National Institute of Allergy and Infectious Disease, National Institutes of Health (NIH), Bethesda, Maryland
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Wilson D, Moosa MYS, Cohen T, Cudahy P, Aldous C, Maartens G. Evaluation of Tuberculosis Treatment Response With Serial C-Reactive Protein Measurements. Open Forum Infect Dis 2018; 5:ofy253. [PMID: 30474046 PMCID: PMC6240901 DOI: 10.1093/ofid/ofy253] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 10/05/2018] [Indexed: 12/21/2022] Open
Abstract
Background Novel biomarkers are needed to assess response to antituberculosis therapy in smear-negative patients. Methods To evaluate the utility of C-reactive protein (CRP) in monitoring response to antituberculosis therapy, we conducted a post hoc analysis on a cohort of adults with symptoms of tuberculosis and negative sputum smears in a high–tuberculosis and HIV prevalence setting in KwaZulu-Natal, South Africa. Serial changes in CRP, weight, and hemoglobin were evaluated over 8 weeks. Results Four hundred twenty-one participants being evaluated for smear-negative tuberculosis were enrolled, and 33 were excluded. Two hundred ninety-five were treated for tuberculosis (137 confirmed, 158 possible), and 93 did not have tuberculosis. One hundred and eighty-three of 213 (86%) participants who agreed to HIV testing were HIV positive. At week 8, the on-treatment median CRP reduction in the tuberculosis group (interquartile range [IQR]) was 79.5% (25.4% to 91.7%), the median weight gain was 2.3% (−1.0% to 5.6%), and the median hemoglobin increase was 7.0% (0.8% to 18.9%); P < .0001 for baseline to week 8 comparison of absolute median values. Only CRP changed significantly at week 2 (median reduction [IQR], 75.1% [46.9% to 89.2%]) in the group with confirmed tuberculosis and in the possible tuberculosis group (median reduction [IQR], 49.0% [−0.4% to 80.9%]). Failure of CRP to reduce to ≤55% of the baseline value at week 2 predicted hospitalization or death in both tuberculosis groups, with 99% negative predictive value. Conclusions Change in CRP may have utility in early evaluation of response to antituberculosis treatment and to identify those at increased risk of adverse outcomes.
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Affiliation(s)
- Douglas Wilson
- Department of Internal Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Mahomed-Yunus S Moosa
- Division of Medicine, Department of Infectious Diseases, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Patrick Cudahy
- Section of Infectious Disease, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Collen Aldous
- School of Clinical Medicine, Nelson R Mandela (NRMSM) Campus, University of Durban, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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40
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Amaral EP, Riteau N, Moayeri M, Maier N, Mayer-Barber KD, Pereira RM, Lage SL, Kubler A, Bishai WR, D'Império-Lima MR, Sher A, Andrade BB. Lysosomal Cathepsin Release Is Required for NLRP3-Inflammasome Activation by Mycobacterium tuberculosis in Infected Macrophages. Front Immunol 2018; 9:1427. [PMID: 29977244 PMCID: PMC6021483 DOI: 10.3389/fimmu.2018.01427] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/08/2018] [Indexed: 01/09/2023] Open
Abstract
Lysosomal cathepsin B (CTSB) has been proposed to play a role in the induction of acute inflammation. We hypothesised that the presence of active CTSB in the cytosol is crucial for NLRP3-inflammasome assembly and, consequently, for mature IL-1β generation after mycobacterial infection in vitro. Elevated levels of CTSB was observed in the lungs of mice and rabbits following infection with Mycobacterium tuberculosis (Mtb) H37Rv as well as in plasma from acute tuberculosis patients. H37Rv-infected murine bone marrow-derived macrophages (BMDMs) displayed both lysosomal leakage, with release of CTSB into the cytosol, as well as increased levels of mature IL-1β. These responses were diminished in BMDM infected with a mutant H37Rv deficient in ESAT-6 expression. Pharmacological inhibition of cathepsin activity with CA074-Me resulted in a substantial reduction of both mature IL-1β production and caspase-1 activation in infected macrophages. Moreover, cathepsin inhibition abolished the interaction between NLRP3 and ASC, measured by immunofluorescence imaging in H37Rv-infected macrophages, demonstrating a critical role of the enzyme in NLRP3-inflammasome activation. These observations suggest that during Mtb infection, lysosomal release of activated CTSB and possibly other cathepsins inhibitable by CA07-Me is critical for the induction of inflammasome-mediated IL-1β processing by regulating NLRP3-inflammasome assembly in the cytosol.
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Affiliation(s)
- Eduardo P Amaral
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Nicolas Riteau
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Mahtab Moayeri
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Nolan Maier
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Katrin D Mayer-Barber
- Inflammation and Innate Immunity Unit, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Rosana M Pereira
- Laboratory of Immunology of Infectious Diseases, Department of Immunology, Institute of Biomedical Science, University of São Paulo, São Paulo, Brazil
| | - Silvia L Lage
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Andre Kubler
- Department of Medicine, Imperial College London, London, United Kingdom.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - William R Bishai
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Maria R D'Império-Lima
- Laboratory of Immunology of Infectious Diseases, Department of Immunology, Institute of Biomedical Science, University of São Paulo, São Paulo, Brazil
| | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Bruno B Andrade
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, José Silveira Foundation, Salvador, Brazil.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States.,Universidade Salvador (UNIFACS), Laureate University, Salvador, Bahia, Brazil.,Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
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41
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Esmail H, Riou C, Bruyn ED, Lai RPJ, Harley YXR, Meintjes G, Wilkinson KA, Wilkinson RJ. The Immune Response to Mycobacterium tuberculosis in HIV-1-Coinfected Persons. Annu Rev Immunol 2018; 36:603-638. [PMID: 29490165 DOI: 10.1146/annurev-immunol-042617-053420] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Globally, about 36.7 million people were living with HIV infection at the end of 2015. The most frequent infection co-occurring with HIV-1 is Mycobacterium tuberculosis-374,000 deaths per annum are attributable to HIV-tuberculosis, 75% of those occurring in Africa. HIV-1 infection increases the risk of tuberculosis by a factor of up to 26 and alters its clinical presentation, complicates diagnosis and treatment, and worsens outcome. Although HIV-1-induced depletion of CD4+ T cells underlies all these effects, more widespread immune deficits also contribute to susceptibility and pathogenesis. These defects present a challenge to understand and ameliorate, but also an opportunity to learn and optimize mechanisms that normally protect people against tuberculosis. The most effective means to prevent and ameliorate tuberculosis in HIV-1-infected people is antiretroviral therapy, but this may be complicated by pathological immune deterioration that in turn requires more effective host-directed anti-inflammatory therapies to be derived.
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Affiliation(s)
- Hanif Esmail
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,Department of Medicine, Imperial College London, London W2 1PG, United Kingdom.,Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, United Kingdom
| | - Catherine Riou
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Elsa du Bruyn
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | | | - Yolande X R Harley
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Katalin A Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,The Francis Crick Institute, London NW1 2AT, United Kingdom
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,Department of Medicine, Imperial College London, London W2 1PG, United Kingdom.,The Francis Crick Institute, London NW1 2AT, United Kingdom
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Gopalan N, Santhanakrishnan RK, Palaniappan AN, Menon PA, Lakshman S, Chandrasekaran P, Sivaramakrishnan GN, Reddy D, Kannabiran BP, Agiboth HKK, Krishnamoorthy V, Rathinam S, Chockalingam C, Manoharan T, Ayyamperumal M, Jayanthi N, Satagopan K, Narayanan R, Krishnaraja R, Sathiyavelu S, Kesavamurthy B, Suresh C, Selvachitiram M, Arasan G, Susaimuthu S, Rathinam P, Angamuthu P, Jayabal L, Murali L, Ramachandran R, Tripathy SP, Swaminathan S. Daily vs Intermittent Antituberculosis Therapy for Pulmonary Tuberculosis in Patients With HIV: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:485-493. [PMID: 29507938 PMCID: PMC5885164 DOI: 10.1001/jamainternmed.2018.0141] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE The benefit of daily over thrice-weekly antituberculosis therapy among HIV-positive patients with pulmonary tuberculosis (TB) who are receiving antiretroviral therapy remains unproven. OBJECTIVE To compare the efficacy and safety of daily, part-daily, and intermittent antituberculosis therapy regimens in the treatment of HIV-associated pulmonary TB. DESIGN, SETTING, AND PARTICIPANTS This open-label, randomized clinical trial was conducted by the National Institute for Research in Tuberculosis, south India. Adults infected with HIV with newly diagnosed, culture-positive, pulmonary TB were enrolled between September 14, 2009, and January 18, 2016. INTERVENTIONS Patients were randomized to daily, part-daily, and intermittent antituberculosis therapy regimens, stratified by baseline CD4 lymphocyte count and sputum smear grade. Antiretroviral therapy was initiated as per national guidelines. Clinical and sputum microbiological examinations of patients were performed monthly until 18 months after randomization. Adverse events were recorded using standard criteria. MAIN OUTCOMES AND MEASURES The primary outcome was favorable response, defined as treatment completion with all available sputum cultures negative for Mycobacterium tuberculosis during the last 2 months of treatment. Unfavorable responses included treatment failures, dropouts, deaths, and toxic effects among regimens. RESULTS Of 331 patients (251 [76%] male; mean [SD] age, 39 [9] years; mean [SD] HIV viral load, 4.9 [1.2] log10 copies/mL; and median [interquartile range] CD4 lymphocyte count, 138 [69-248] cells/μL), favorable responses were experienced by 91% (89 of 98), 80% (77 of 96), and 77% (75 of 98) in the daily, part-daily, and intermittent regimens, respectively. With the difference in outcome between daily and intermittent regimens crossing the O'Brien-Fleming group sequential boundaries and acquired rifampicin resistance emergence (n = 4) confined to the intermittent group, the data safety monitoring committee halted the study. A total of 18 patients died and 18 patients dropped out during the treatment period in the 3 regimens. Six, 4, and 6 patients in the daily, part-daily, and intermittent regimens, respectively, had TB recurrence. CONCLUSIONS AND RELEVANCE Among HIV-positive patients with pulmonary TB receiving antiretroviral therapy, a daily anti-TB regimen proved superior to a thrice-weekly regimen in terms of efficacy and emergence of rifampicin resistance. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00933790.
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Affiliation(s)
| | | | | | | | - Sekar Lakshman
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | | | | | | | | | | | | | | | | | | | - Kumar Satagopan
- Government Hospital of Thoracic Medicine, TB Sanatorium, Tambaram, Chennai, India
| | | | - Raja Krishnaraja
- Government Hospital of Thoracic Medicine, TB Sanatorium, Tambaram, Chennai, India
| | | | | | - Chandra Suresh
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | | | | | | | | | | | | | | | - Soumya Swaminathan
- Indian Council of Medical Research and Health Research, New Delhi, India
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Ene L. Human Immunodeficiency Virus in the Brain-Culprit or Facilitator? Infect Dis (Lond) 2018; 11:1178633717752687. [PMID: 29467577 PMCID: PMC5815409 DOI: 10.1177/1178633717752687] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/15/2017] [Indexed: 01/21/2023] Open
Abstract
Introduction: Human immunodeficiency virus (HIV) enters the brain early, where it can persist, evolve, and become compartmentalized. Central nervous system (CNS) disease can be attributed to HIV alone or to the complex interplay between the virus and other neurotropic pathogens. Aim: The current review aims to describe the direct impact of HIV on the brain as well as its relationship with other pathogens from a practitioner’s perspective, to provide a general clinical overview, brief workup, and, whenever possible, treatment guidance. Methods: A review of PubMed was conducted to identify studies on neuropathogenesis of HIV in relation to host responses. Furthermore, the interaction between the CNS pathogens and the host damage responses were revised in the setting of advanced and also well-controlled HIV infection. Results: Similar to other pathogens, HIV leads to CNS immune activation, inflammation, and viral persistence. Therefore, almost half of the infected individuals present with neurocognitive disorders, albeit mild. Compartmentalized HIV in the CNS can be responsible in a minority of cases for the dramatic presentation of symptomatic HIV escape. Disruption of the immune system secondary to HIV may reactivate latent infections or allow new pathogens to enter the CNS. Opportunistic infections with an inflammatory component are associated with elevated HIV loads in the cerebrospinal fluid and also with greater cognitive impairment. The inflammatory immune reconstitution syndrome associated with CNS opportunistic infections can be a life-threatening condition, which needs to be recognized and managed by efficiently controlling the pathogen burden and timely balanced combination antiretroviral therapy. Latent neurotropic pathogens can reactivate in the brain and mimic HIV-associated severe neurological diseases or contribute to neurocognitive impairment in the setting of stable HIV infection. Conclusions: As HIV can be responsible for considerable brain damage directly or by facilitating other pathogens, more effort is needed to recognize and manage HIV-associated CNS disorders and to eventually target HIV eradication from the brain.
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Affiliation(s)
- Luminita Ene
- HIV Department, "Dr. Victor Babes" Hospital for Infectious and Tropical Diseases, Bucharest, Romania
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44
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Narendran G, Swaminathan S. TB-HIV co-infection: a catastrophic comradeship. Oral Dis 2017; 22 Suppl 1:46-52. [PMID: 27109272 DOI: 10.1111/odi.12389] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 08/07/2015] [Accepted: 11/12/2015] [Indexed: 11/30/2022]
Abstract
The symbiotic association of tuberculosis (TB) and HIV poses a challenge to human survival. HIV complicates every aspect of TB including presentation, diagnosis and treatment. HIV-TB patients encounter unique problems like drug-drug interactions, cumulative toxicity, immune reconstitution inflammatory syndrome (IRIS), lower plasma drug levels and emergence of drug resistance during treatment despite adherence. TB may also be overdiagnosed in HIV due to a number of diseases that closely resemble TB. Notable among them are non-tuberculous mycobacteria, Pneumocystis Jirovecii and Nocardia. Even though diagnostic procedures have improved over the years, patients in developing countries usually seek health care at later stage of the disease. Research data ascertains the duration of therapy for TB to be 6 months with rifampicin and isoniazid, reinforced with ethambutol and pyrazinamide in the first 2 months. The schedule of therapy is still debatable with daily regimens being preferred in the context of HIV. Many reasons exist for persistence of Mycobacterium Tuberculosis (M.TB) in sputum, or delayed-clearance of TB from sputum smears in HIV, apart from emergence of drug resistance and non-compliance. Acquired rifampicin resistance (ARR) is a unique phenomenon complicating HIV-associated TB when an intermittent regimen of antituberculosis therapy (ATT) is used without timely initiation of highly active antiretroviral therapy (HAART), especially in patients harbouring isoniazid-resistant strains Immune restoration is often incomplete ('swiss cheese' pattern) even with effective HAART if not started early. Immune reconstitution inflammatory syndrome (IRIS) is the paradoxical worsening of the patient's condition often with radiological deterioration, due to an enhanced immune response with HAART. IRIS occurs despite an effective virological suppression and a favourable response to ATT. The incidence of IRIS in HIV has reached up to 54%, requiring utilization of experts and tertiary care which forms an obstacle to the decentralization of patients in the ART programme. Research in HIV-TB immunology and management needs further exploration in order to understand the diseases and offer appropriate treatment. The following paragraphs provide scientific evidences generated through research that could potentially guide management.
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Affiliation(s)
- G Narendran
- National Institute for Research in Tuberculosis, Chennai, India
| | - S Swaminathan
- National Institute for Research in Tuberculosis, Chennai, India
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Pérez-Rueda M, Hernández-Cabrera M, Francés-Urmeneta A, Angel-Moreno A, Pisos-Álamo E, Jaén-Sánchez N, Carranza-Rodríguez C, Pérez-Arellano JL. Immune Reconstitution Inflammatory Syndrome in HIV-Infected Immigrants. Am J Trop Med Hyg 2017; 97:1072-1077. [PMID: 28820685 DOI: 10.4269/ajtmh.16-0773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) includes a group of potentially serious inflammatory processes that may be present in HIV-infected patients after initiating highly active antiretroviral therapy (HAART). Paradoxical IRIS is a worsening of symptoms, after an overwhelming response to a previously diagnosed opportunistic infection (OI); unmasking IRIS reveals a previously occult OI. The main objective of the study was to describe the epidemiological, clinical, and outcome data of HIV-infected immigrants, stratified according to high- or low-income countries of origin, who developed IRIS and to compare them with native-born Spanish patients. This retrospective study reviewed all patients with HIV infection admitted to the Unit of Infectious Diseases and Tropical Medicine between 1998 and 2014. IRIS was identified in 25/138 (18%) immigrant patients and 24/473 (5%) native-born Spanish patients infected with HIV. Most cases, 19/25 (76%), were of unmasking IRIS. The time elapsed between initiation of HAART and development of IRIS was significantly longer in patients with unmasking versus paradoxical IRIS. OIs, in particular due to mycobacteria, were the most frequently involved processes. Twenty percent of patients died. The comparison of immigrant and native-born patients found significant differences for both IRIS type (higher incidence of paradoxical forms among immigrants) and for the absence of malignancies in native-born patients. No significant differences were found when the data of immigrants from low- and high-income countries were compared.
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Affiliation(s)
- María Pérez-Rueda
- Internal Medicine, Hospital San Roque Maspalomas (HSRM), Gran Canaria, Spain
| | - Michele Hernández-Cabrera
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain.,Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain
| | - Adela Francés-Urmeneta
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain
| | | | - Elena Pisos-Álamo
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain.,Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain
| | - Nieves Jaén-Sánchez
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain.,Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain
| | - Cristina Carranza-Rodríguez
- Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain.,Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain
| | - Jose-Luis Pérez-Arellano
- Department of Medical and Surgical Sciences, University of Las Palmas, Las Palmas, Spain.,Unit of Infectious Diseases and Tropical Medicine, Hospital Universitario Insular de Gran Canaria (HUIGC), Las Palmas, Spain
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Bell L, Peyper JM, Garnett S, Tadokera R, Wilkinson R, Meintjes G, Blackburn JM. TB-IRIS: Proteomic analysis of in vitro PBMC responses to Mycobacterium tuberculosis and response modulation by dexamethasone. Exp Mol Pathol 2017; 102:237-246. [PMID: 28209523 PMCID: PMC5446321 DOI: 10.1016/j.yexmp.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/11/2017] [Indexed: 12/02/2022]
Abstract
Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) occurs in 8-54% of South African patients undergoing treatment for tuberculosis/human immunodeficiency virus co-infection. Improved TB-IRIS molecular pathogenesis understanding would enhance risk stratification, diagnosis, prognostication, and treatment. We assessed how TB-IRIS status and dexamethasone influence leukocyte proteomic responses to Mycobacterium tuberculosis (Mtb). Patient blood was obtained three weeks post-anti-retroviral therapy initiation. Isolated mononuclear cells were stimulated ex vivo with heat-killed Mtb in the presence/absence of dexamethasone. Mass spectrometry-based proteomic comparison of TB-IRIS and non-IRIS patient-derived cells facilitated generation of hypotheses regarding pathogenesis. Few represented TB-IRIS-group immune-related pathways achieved significant activation, with relative under-utilisation of "inter-cellular interaction" and "Fcγ receptor-mediated phagocytosis" (but a tendency towards apoptosis-related) pathways. Dexamethasone facilitated significant activation of innate-related pathways. Differentially-expressed non-IRIS-group proteins suggest focused and co-ordinated immunological pathways, regardless of dexamethasone status. Findings suggest a relative deficit in TB-IRIS-group responses to and clearance of Mtb antigens, ameliorated by dexamethasone.
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Affiliation(s)
- Liam Bell
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa; Centre for Proteomic and Genomic Research (CPGR), Observatory, 7925 Cape Town, South Africa
| | - Janique M Peyper
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa
| | - Shaun Garnett
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa
| | - Rabecca Tadokera
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa; Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; HIV/AIDS, STIs and TB Programme, Human Sciences Research Council, Arcadia, 0002 Pretoria, South Africa
| | - Robert Wilkinson
- Department of Medicine, Imperial College, London W2 1PG, UK; Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; Department of Medicine, University of Cape Town, Observatory, 7925 South Africa; Francis Crick Institute, Mill Hill Laboratory, London NW7 1AA, UK
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, IDM, University of Cape Town, Observatory, 7925 South Africa; Department of Medicine, University of Cape Town, Observatory, 7925 South Africa
| | - Jonathan M Blackburn
- Department of Integrative Biomedical Sciences & Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, South Africa.
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Nouhin J, Pean P, Madec Y, Chevalier MF, Didier C, Borand L, Blanc FX, Scott-Algara D, Laureillard D, Weiss L. Interleukin-1 receptor antagonist, a biomarker of response to anti-TB treatment in HIV/TB co-infected patients. J Infect 2017; 74:456-465. [PMID: 28189712 DOI: 10.1016/j.jinf.2017.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 01/10/2017] [Accepted: 01/16/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Despite the high frequency of tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in human immunodeficiency virus (HIV)/TB co-infected patients, no diagnostic test is available. Here, we investigated whether monocyte/macrophage activation markers can predict TB-IRIS occurrence and if they are modulated by anti-TB treatment. METHODS Frozen plasma was obtained from 127 HIV/TB co-infected adults naïve for antiretroviral therapy, enrolled in the CAMELIA trial, 36 of whom developed TB-IRIS. Concentrations of IL-1Ra, sCD14, and sCD163 were measured at anti-TB treatment onset (baseline), after 8 weeks of anti-TB treatment and at TB-IRIS time. RESULTS At baseline, IL-1Ra and sCD14 concentrations were similar in TB-IRIS and non-IRIS patients. sCD163 concentrations, although significantly higher in TB-IRIS patients, did not remain associated with TB-IRIS occurrence in multivariate analysis. At the time of TB-IRIS, patients displayed higher concentrations of IL-1Ra (p = 0.002) and sCD14 (p < 0.001). The most striking result was the significant decrease in IL-1Ra after 8 weeks of anti-TB treatment (median reduction: -63% (p < 0.0001)). CONCLUSIONS None of the biomarkers tested was associated with TB-IRIS occurrence. However, repeated measurement of IL-1Ra could help for the diagnosis of TB-IRIS. The substantial reduction of IL-1Ra under treatment suggests that IL-1Ra could be a surrogate biomarker of anti-TB treatment response in HIV-infected patients.
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Affiliation(s)
- Janin Nouhin
- HIV/Hepatitis Unit, Pasteur Institute in Cambodia, Phnom Penh, Cambodia; Université Paris Diderot-Paris 7, Sorbonne Paris-Cité, Paris, France
| | - Polidy Pean
- Immunology Platform, Pasteur Institute in Cambodia, Phnom Penh, Cambodia
| | - Yoann Madec
- Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France
| | - Mathieu F Chevalier
- Unité "Régulation des Infections Rétrovirales", Institut Pasteur, Paris, France
| | - Celine Didier
- Unité "Régulation des Infections Rétrovirales", Institut Pasteur, Paris, France
| | - Laurence Borand
- Epidemiology and Public Health Unit, Pasteur Institute in Cambodia, Phnom Penh, Cambodia
| | | | - Daniel Scott-Algara
- Unité "Régulation des Infections Rétrovirales", Institut Pasteur, Paris, France
| | - Didier Laureillard
- Infectious and Tropical Diseases Department, University Hospital, Nîmes, France
| | - Laurence Weiss
- Unité "Régulation des Infections Rétrovirales", Institut Pasteur, Paris, France; AP-HP, Hôpital Européen Georges Pompidou, Paris, France; Université Paris Descartes, Sorbonne Paris-Cité, Paris, France.
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Jaganmohan D, Chakkalakkoombil SV, Beena AA, Krishnan N. Neurotuberculosis immune reconstitution inflammatory syndrome in the setting of HIV infection: A case report and review of literature. Indian J Radiol Imaging 2017; 26:446-450. [PMID: 28104935 PMCID: PMC5201071 DOI: 10.4103/0971-3026.195782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated immune response which can occur with various coinfections in human immunodeficiency virus (HIV) infected patients, of which the most commonly implicated in central nervous system (CNS)-IRIS are progressive multifocal leukoencephalopathy (PML), cryptococcosis, and tuberculosis (TB). TB-IRIS is a known complication of pulmonary TB or TB lymphadenitis coinfection in HIV infected patients who are on antituberculosis treatment (ATT) after the initiation of antiretroviral therapy (ART). However, development of IRIS in extrapulmonary TB such as CNS TB is very rare. Our case is that of an isolated CNS-TB-IRIS, presenting as increase in the size and perilesional edema of the ring enhancing lesions in the brain, which was observed in two sequential magnetic resonance imaging done over a period of 2 months in a retropositive patient who presented with clinical deterioration after commencement of ART. As prompt diagnosis was made and specific management aimed at IRIS was started without delay, the patient improved symptomatically.
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Affiliation(s)
- Deepasree Jaganmohan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Sunitha V Chakkalakkoombil
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Anjana A Beena
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Nagarajan Krishnan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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Gopal R, Rapaka RR, Kolls JK. Immune reconstitution inflammatory syndrome associated with pulmonary pathogens. Eur Respir Rev 2017; 26:26/143/160042. [PMID: 28049128 PMCID: PMC5642276 DOI: 10.1183/16000617.0042-2016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/09/2016] [Indexed: 12/21/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated immune response to a variety of pathogens in response to antiretroviral therapy-mediated recovery of the immune system in HIV-infected patients. Although IRIS can occur in many organs, pulmonary IRIS, associated with opportunistic infections such as Mycobacterium tuberculosis and Pneumocystis jirovecii, is particularly associated with high morbidity and mortality. The pathology of IRIS is associated with a variety of innate and adaptive immune factors, including CD4+ T-cells, CD8+ T-cells, γδ T-cells, natural killer cells, macrophages, the complement system and surfactant proteins, Toll-like receptors and pro-inflammatory cytokines and chemokines. Although there are numerous reports about the immune factors involved in IRIS, the mechanisms involved in the development of pulmonary IRIS are poorly understood. Here, we propose that studies using gene-deficient murine and nonhuman primate models will help to identify the specific molecular targets associated with the development of IRIS. An improved understanding of the mechanisms involved in the pathology of pulmonary IRIS will help to identify potential biomarkers and therapeutic targets in this syndrome. Mechanisms of pulmonary IRIS in HIV-infected individuals recently initiated on ART are poorly definedhttp://ow.ly/AAOR301Bh36
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Affiliation(s)
- Radha Gopal
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Rekha R Rapaka
- Division of Infectious Diseases and Center for Vaccine Development, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jay K Kolls
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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Wong CS, Richards ES, Pei L, Sereti I. Immune reconstitution inflammatory syndrome in HIV infection: taking the bad with the good. Oral Dis 2016; 23:822-827. [PMID: 27801977 DOI: 10.1111/odi.12606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 12/27/2022]
Abstract
In this review, we will describe the immunopathogies of immune reconstitution inflammatory syndrome, IRIS. IRIS occurs in a small subset of HIV patient, initiating combination antiretroviral therapy (ART), where immune reconstitution becomes dysregulated, resulting in an overly robust antigen-specific inflammatory reaction. We will discuss IRIS in terms of the associated coinfections: mycobacteria, cryptococci, and viruses.
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Affiliation(s)
- C-S Wong
- HIV Pathogenesis Section, Laboratory of Immunoregulation, NIAID/NIH, Bethesda, MD, USA
| | - E S Richards
- HIV Pathogenesis Section, Laboratory of Immunoregulation, NIAID/NIH, Bethesda, MD, USA
| | - L Pei
- HIV Pathogenesis Section, Laboratory of Immunoregulation, NIAID/NIH, Bethesda, MD, USA
| | - I Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, NIAID/NIH, Bethesda, MD, USA
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