Cardiovascular morbidity and mortality among persons diagnosed with tuberculosis: A systematic review and meta-analysis

Characterization and stratification of risk factors of stroke in people living with HIV: A theory-informed systematic review

BACKGROUND

Identification and stratification of risk factors for stroke among individuals living with HIV (PLWH) will facilitate primary prevention and prognostication, as well as strategies aimed at optimizing neurorehabilitation. This review sought to characterize and stratify the risk factors associated with stroke in PLWH.

METHODS

The review was structured in accordance with the preferred items for reporting systematic reviews and meta-analysis (PRISMA) checklist. The epidemiological triangle, Bradford criteria, and Rothman causality model further informed the review. The review outcomes encompassed cardiovascular factors, HIV-related factors, and personal and extrinsic factors associated with stroke in PLWH. We conducted searches in PubMed, Scopus, Medline, Web of Science, Cumulative Index for Nursing and Allied Health Literature, and African Journal (SABINET). Data screening and extraction were independently performed utilizing predefined eligibility criteria and a data-extraction template. Narrative synthesis and risk stratification were employed to analyze the results.

RESULTS

Thirty studies (22 cohorts and eight case-control) with a sample size of 353,995 participants were included in this review. The mean age of the participants was 45.1 ± 10.7 years. The majority of the participants (72.4%) were male. Risk factors for stroke in PLWH include cardiovascular factors (advanced age, tobacco use, hypertension, diabetes, atrial fibrillation, etc.), HIV-related factors (high viral load and low nadir CD4 count), personal factors (advanced age and female sex), and comorbidities (hepatitis C virus infection, chronic kidney disease, coronary artery disease, and liver fibrosis or cirrhosis). Diabetes, atrial fibrillation, smoking habits, hypertension, age, and viral load demonstrated a high likelihood of association with stroke in PLWH and should be prioritized when constructing clinical prediction algorithms for HIV-related stroke.

CONCLUSIONS

The most important factors were hypertension and chronic kidney disease, followed by smoking, dyslipidemia, diabetes, HCV, HBV, CD4 count, use of ART, TB, and substance use (cocaine). The least important factors were age, sex, ethnicity, obesity, alcohol use, ART duration, and viral load. The predictive significance of these factors is still evolving, given the average moderate certainty of evidence. Predictive and preventative models should target factors with a high causality index and low investigative costs.

TRIAL REGISTRATION

The review is part of a larger review registered with the PROSPERO (ID: CRD42024524494).

Association of prior tuberculosis with altered cardiometabolic profiles of people with HIV: A comparative cross-sectional study in Uganda

Background

Cardiovascular disease (CVD) is the leading cause of mortality among people with HIV (PWH), but the influence of co-infections like tuberculosis (TB) on CVD risk remains underexplored. We aimed to compare cardiometabolic profiles of PWH with and without prior TB to determine if prior TB is associated with distinct cardiometabolic profiles.

Methods

We conducted a comparative, cross-sectional study at a tertiary hospital in Kampala, Uganda. Participants were randomly sampled PWH aged ≥ 18 years on antiretroviral therapy. Specifically, we enrolled PWH with and without prior active TB (ratio of 1:1). Anthropometric measurements, blood pressure, fasting blood glucose (FBG), lipid profile, and glycated hemoglobin were assessed.

Results

A total of 396 participants were enrolled (196 TB survivors and 200 controls). TB survivors had higher median FBG (5.5 vs. 5.1 mmol/l, p < 0.001) and a higher prevalence of DM (17.9 % vs. 9.5 %, p = 0.015). However, they had lower body mass index (23.0 vs. 25.1 kg/m2, p < 0.001) and waist circumference (81.0 vs. 84.0 cm, p = 0.026). TB survivors had higher HDL-c levels (1.0 vs. 0.8 mmol/l, p < 0.001), lower LDL-c levels (2.7 vs. 3.1 mmol/l, p < 0.001) and lower prevalence of dyslipidemia (81.7 % vs. 96.5 %, p < 0.001). Prior TB was independently associated with higher prevalence of elevated FBG (adjusted prevalence ratio (aPR) 1.79, 95 % CI 1.10-2.92) and DM (aPR 2.34, 95 % CI 1.11-4.94), but decreased risk of obesity (aPR 0.42, 95 % CI 0.20-0.88).

Conclusion

TB survivors with HIV exhibit a higher risk of DM but lower risk of obesity compared to those without a history of TB, indicating a need for blood glucose monitoring among TB survivors.

Cardiometabolic Biomarkers and Systemic Inflammation in US Adolescents and Young Adults With Latent Tuberculosis Infection: A Population-Based Cohort Study

Background

Mycobacterium tuberculosis (Mtb) infection in adults increases incident type 2 diabetes and atherosclerotic cardiovascular disease risk. It is unknown if this cardiometabolic detriment occurs in young people. We investigated whether young persons with latent tuberculosis infection (LTBI) have worse cardiometabolic health than their peers who are uninfected.

Methods

Peripubescent adolescents (12-15 years old) and older adolescents/young adults (16-30 years old) were assessed for LTBI by tuberculin skin testing (induration ≥10 mm). Outcomes included fasting plasma glucose, hemoglobin A1c, C-peptide, N-terminal prohormone of brain natriuretic peptide, high-sensitivity cardiac troponin T, C-reactive protein, ferritin, diabetes/prediabetes (fasting plasma glucose ≥5.6 mmol/L and/or hemoglobin A1c ≥5.7%), and homeostatic model of insulin resistance. LTBI cases were propensity score matched 1:4 with controls who were uninfected with tuberculosis (TB) on sociodemographics to estimate adjusted median, mean difference, and odds ratio of cardiometabolic indices.

Results

Seventy-five LTBI cases were matched to 300 peers who were TB uninfected. Among older participants, LTBI was associated with higher inflammation (adjusted median [IQR]: C-reactive protein, 0.22 mg/dL [0.05-0.34] vs 0.11 [0.04-0.35], P = .027; ferritin, 55.0 ng/mL [25.1-90.3] vs 41.1 [29.5-136.2], P = .047) but not among peripubescent adolescents. No meaningful differences were observed in fasting plasma glucose (adjusted mean difference [95% CI], -0.05 mmol/L [-.22 to .12]; P = .57), hemoglobin A1c (0.0% [-.17% to .17%], P = .98), diabetes/prediabetes prevalence (adjusted odds ratio [95% CI], 0.9 [.29-2.29]; P = .85), insulin secretion/resistance, N-terminal prohormone of brain natriuretic peptide, or high-sensitivity cardiac troponin T by LTBI status.

Conclusions

Older adolescents and young adults with LTBI had higher inflammation than those without LTBI, while cardiometabolic profiles were similar. Unlike that in adults, Mtb infection in young people may not be associated with cardiometabolic derangement, though the long-term consequences of chronic inflammation require further study.

Association of prior tuberculosis with altered cardiometabolic profiles of people with HIV: A comparative cross-sectional study in Uganda

Background

Cardiovascular disease (CVD) is the leading cause of mortality among people with HIV (PWH), but the influence of co-infections like tuberculosis (TB) on CVD risk remains underexplored. We aimed to compare cardiometabolic profiles of PWH with and without prior TB to determine if prior TB is associated with distinct cardiometabolic profiles.

Methods

We conducted a comparative, cross-sectional study at a tertiary hospital in Kampala, Uganda. Participants were randomly sampled PWH aged ≥18 years on antiretroviral therapy. Specifically, we enrolled PWH with and without prior active TB (ratio of 1:1). Anthropometric measurements, blood pressure, fasting blood glucose (FBG), lipid profile, and glycated hemoglobin were assessed.

Results

A total of 396 participants were enrolled (196 TB survivors and 200 controls). TB survivors had higher median FBG (5.5 vs. 5.1 mmol/l, p<0.001) and a higher prevalence of DM (17.9% vs. 9.5%, p=0.015). However, they had lower body mass index (23.0 vs. 25.1 kg/m2, p<0.001) and waist circumference (81.0 vs. 84.0 cm, p=0.026). TB survivors had higher HDL-c levels (1.0 vs. 0.8 mmol/l, p<0.001), lower LDL-c levels (2.7 vs. 3.1 mmol/l, p<0.001) and lower prevalence of dyslipidemia (81.7% vs. 96.5%, p<0.001). Prior TB was independently associated with higher prevalence of elevated FBG (adjusted prevalence ratio (aPR) 1.79, 95% CI 1.10-2.92) and DM (aPR 2.34, 95% CI 1.11-4.94), but decreased risk of obesity (aPR 0.42, 95% CI 0.20-0.88).

Conclusion

TB survivors with HIV exhibit a higher risk of DM but lower risk of obesity compared to those without a history of TB, indicating a need for blood glucose monitoring among TB survivors.

Impact of hypertension on mortality in adults in Moramanga, Madagascar: a retrospective cohort study in the community

BACKGROUND

Hypertension remains a global public health problem. This study aimed to evaluate the impact of hypertension on premature mortality among people living in Moramanga, Madagascar.

METHODS

Three communes of Moramanga district have been monitored since 2012 as part of the MHURAM project (Moramanga Health Survey in Urban and Rural Areas in Madagascar). In 2013, individuals aged 15 years and above were surveyed to estimate the prevalence of hypertension and identify risk factors. A follow-up survey was conducted in 2016-2017 to record deaths; causes of death were assessed through verbal autopsy (VA). The occurrence of premature death was evaluated using a retrospective cohort study design applied to data collected from adults aged 30 to 70 who participated in the hypertension survey. Mortality rates and partial life expectancy by sex and hypertension status were estimated using survival analysis; covariates associated with premature risk of mortality were identified using a Cox proportional hazards model. The contribution of causes of death to the difference in partial life expectancy between hypertensive and non-hypertensive individuals was evaluated using a decomposition analysis.

RESULTS

There were 4,472 participants in the hypertension survey aged between 30 and 70 during the follow-up. The average follow-up was 2.7 years per individual, resulting in 11,892 person-years in total with 117 deaths reported giving a mortality rate of 9.8‰ (13.1‰ for males and 7.1‰ for females). An estimated 3.2 years of life was lost among those diagnosed with hypertension compared to normotensive (32.0 years and 35.2 years respectively). Adjusted for gender, smoking habit, sedentary lifestyle, and wealth index, hypertension is a risk factor for premature death [HR = 1.58 95%CI (1.07-2.36)]. Hypertensive individuals also experienced higher all-cause and communicable disease mortality in people aged between 30 and 39 years.

CONCLUSION

Hypertension is associated with higher risks of premature death in the community of Moramanga. In addition, hypertension contributes not only to mortality via cardiovascular diseases, but also through all causes combined. The health system should enhance prevention efforts, particularly for young hypertensive patients, when risk is most pronounced.

Tuberculosis and Increased Incidence of Cardiovascular Disease: Cohort Study Using United States and United Kingdom Health Records

BACKGROUND

Limited evidence suggests elevated risks of cardiovascular disease (CVD) among people diagnosed with tuberculosis (TB) disease, though studies have not adjusted for preexisting CVD risk. We carried out a cohort study using 2 separate datasets, estimating CVD incidence in people with TB versus those without.

METHODS

Using data from the United States (Veterans Health Administration) and the United Kingdom (Clinical Practice Research Datalink) for 2000-2020, we matched adults with incident TB disease and no CVD history 2 years before TB diagnosis (US, n = 2121; UK, n = 15 820) with up to 10 people without TB on the basis of age, sex, race/ethnicity and healthcare practice. Participants were followed beginning 2 years before TB diagnosis and for 2 years subsequently. The acute period was defined as 3 months before/after TB diagnosis. TB, CVD, and covariates were identified from electronic routinely collected data (primary and secondary care; mortality). Poisson models estimated incident rate ratios for CVD events in people with TB compared to those without.

RESULTS

CVD incidence was consistently higher in people with TB, including during the baseline period (pre-TB) and particularly in the acute period: incident rate ratios were US, 3.5 (95% confidence interval, 2.7-4.4), and UK, 2.7 (2.2-3.3). Rate ratios remained high after adjusting for differences in preexisting CVD risk: US, 3.2 (2.2-4.4); UK, 1.6 (1.2-2.1).

CONCLUSIONS

Increased CVD incidence was observed in people with TB versus those without, especially within months of TB diagnosis, persistent after adjustment for differences in preexisting risk. Enhancing CVD screening and risk management may improve long-term outcomes in people with TB.

Association of systemic inflammation response index with latent tuberculosis infection and all-cause mortality: a cohort study from NHANES 2011-2012

Background

The Systemic Inflammatory Response Index (SIRI) is a promising inflammatory marker; however, the relationship between SIRI and latent tuberculosis infection (LTBI), as well as its association with mortality rates, remains unclear. The present study aimed to explore the associations of the SIRI with LTBI and all-cause mortality.

Methods

We conducted a prospective cohort study using data from National Health and Nutrition Examination Survey (NHANES) cycles from 2011 to 2012. We explored the association between SIRI and LTBI prevalence using Multiple logistic regression models. We used Multivariate Cox proportional hazards model to analyze the association between SIRI and all-cause mortality. In addition, Kaplan-Meier curves, restricted cubic splines (RCS), stratified analysis, and interaction tests were performed.

Results

The study included a total of 4,983 adults who participated in NHANES 2011-2012. The mean follow-up period was 92.35 ± 16.82 months, and there were 525 deaths, representing a mortality rate of 10.54%. The occurrence of LTBI is significantly associated with low SIRI levels(OR=0.76, 95% CI: 0.66-0.89), after adjusting for confounders. Among LTBI patients, elevated SIRI levels are significantly correlated with an increased risk of all-cause mortality (adjusted HR = 1.48, 95% CI: 1.01-2.15). RCS revealed a linear relationship between SIRI and all-cause mortality in patients with LTBI (P =0.059[overall] and P = 0.391 [Nonlinear]). Furthermore, within the LTBI population, the area under the curve (AUC) of SIRI for all-cause mortality are 0.731 (1-year), 0.640 (3-year), and 0.634 (5-year).

Conclusion

The findings of this study indicate that elevated SIRI levels are independently associated with an increased risk of all-cause mortality in patients with LTBI. Notably, SIRI was significantly inversely associated with the incidence of LTBI. Therefore, SIRI may serve as an effective tool for risk stratification in adults with LTBI in the United States. Further research is needed to elucidate the underlying mechanisms and to explore any therapeutic implications of these findings.

Family support and prayer are invaluable coping strategies for our recovery: Experiences of persons living with cardiovascular diseases

BACKGROUND

It is estimated that 61% of deaths caused by Cardiovascular Diseases (CVDs) globally are attributed to lifestyle-related risk factors including tobacco use, alcohol abuse, poor diet, and inadequate physical activity. Meanwhile, inadequate knowledge and misperceptions about CVDs are disproportionately increasing the prevalence of CVDs in Africa. Moreover, pre-diagnosis awareness/knowledge about CVDs among patients is essential in shaping the extent and scope of education to be provided by healthcare workers.

OBJECTIVE

Explore the experiences of patients living with CVDs (PLwCVDs) and accessing care at the Cardiothoracic Centre, Ho Teaching Hospital, regarding their knowledge of CVD-risk factors and coping strategies that work for them.

METHOD

We leveraged descriptive phenomenological design to explore the experiences of patients accessing care at the Cardiothoracic Centre at the Ho Teaching Hospital, Ghana. Using the purposive sampling technique, 17 PLwCVDs for 3yrs and above were recruited and included in the study. Thematic analysis was conducted using the qualitative computerised data software, NVivo version 14. Recruitment of participants and general conduct of the study commenced on November 1, 2023 and ended on April 30, 2024.

FINDINGS

We found that PLwCVDs and accessing care at the Cardiothoracic Centre at Ho Teaching Hospital have adequate pre-diagnosis awareness about CVD-risk factors and their knowledge of same was optimal. Moreover, past unhealthy lifestyles (such as poor dieting, abuse of alcohol, smoking, and inadequate physical activity) may have contributed to participants developing the CVDs. Furthermore, prayers and participation in church activities were the main coping strategies employed by the participants in dealing with CVDs.

CONCLUSION

The PLwCVDs and receiving treatment at the Cardiothoracic Centre at the Ho Teaching Hospital are knowledgeable in the CVD-risk factors and adopting positive coping strategies. The Cardiothoracic Centre and government must explore social media facilities to intensify public education and also correct misconceptions about CVDs.

Risk Factors for Disseminated Tuberculosis and Associated Survival in Adults Without Human Immunodeficiency Virus

Background

The global resurgence of disseminated tuberculosis (TB) after the coronavirus disease 2019 pandemic highlights the necessity of understanding host risk factors, especially in adults without human immunodeficiency virus.

Methods

We reviewed TB cases admitted to Shanghai Public Health Clinical Center from 2017 to 2022. We analyzed baseline characteristics and outcomes. To identify risk factors for disseminated TB, as well as its subsite distribution and mortality, we employed logistic regression and Cox proportional hazards models.

Results

Among 1062 patients, including 283 with disseminated TB, 558 with pulmonary TB (PTB), and 221 with extrapulmonary TB, those with disseminated TB had the highest mortality rate. The following factors were associated with disseminated TB: age ≥45 years, body mass index (BMI) <18.5 kg/m², immunosuppressive therapy, and end-stage renal disease (ESRD). A BMI <18.5 kg/m² was found to correlate with all subsites of disseminated TB, while aged ≥45 years specifically increased incidence of bone and joint TB. Female patients showed a higher risk for lymphatic, peritoneal, and intestinal TB. Additionally, immunosuppressive therapy and ESRD were linked to various TB subsites. During a 12-month follow-up period, 19.8% of patients with disseminated TB died. Factors contributing to reduced survival included BMI <18.5 kg/m², immunosuppressive therapy, ESRD, pulmonary cavities, and meningeal involvement.

Conclusions

Age, low BMI, immunosuppressive therapy, and ESRD are significant risk factors for disseminated TB and also significantly impact patient survival rates. These findings are of great importance for the development of clinical management and preventive measures.

Association of prior tuberculosis with cardiovascular status in perinatally HIV-1-infected adolescents

BACKGROUND

Whether, and how, co-occurring HIV-1 infection (HIV) and tuberculosis (TB) impact cardiovascular status, especially in adolescents with perinatally acquired HIV (APHIV), have not been examined. We hypothesised that APHIV with previous TB disease have worse cardiac efficiency than APHIV without TB, which is mediated by increased inflammation and disordered cardiometabolism.

METHODS

APHIV in Cape Town, South Africa, completed 3T cardiovascular magnetic resonance examination and high sensitivity C reactive protein (hsCRP), fasting plasma glucose (FPG), low-density lipoprotein (LDL) and triglyceride measurement. Ventriculoarterial coupling (VAC) was estimated as the ratio of arterial elastance (Ea) to ventricular end-systolic elastance (Ees). Regression models were applied to estimate cross-sectional associations between Ea/Ees ratio and TB status, with decomposition of these associations into direct and mediated effects of hsCRP, FPG and dyslipidaemia, if any, attempted.

RESULTS

We enrolled 43 APHIV with prior TB and 23 without TB of mean (SD) age 15.0 (1.5) and 15.4 (1.7) years, respectively. Prior TB was associated with lower Ea/Ees ratio (0.59 (0.56 to 0.64)) than no TB (0.66 (0.62 to 0.70)), which corresponded to an adjusted mean difference -0.06 (-0.12 to 0.01) (p=0.048). However, previous TB was not associated with increased hsCRP, FPG, LDL or triglycerides nor were hsCRP, FPG, LDL and triglycerides associated with Ea/Ees ruling out their mediated effects in the association between TB and cardiac efficiency.

CONCLUSIONS

Previous TB in APHIV is associated with comparatively reduced cardiac efficiency, related to altered VAC. The clinical significance of these findings requires further study, including a wider range of biomarkers of specific immune pathways.

Imaging and Circulating Biomarker-Defined Cardiac Pathology in Pulmonary Tuberculosis: A Systematic Review

Background

Pulmonary tuberculosis (PTB) is associated with increased cardiovascular disease (CVD) mortality. However, underlying pathophysiological mechanisms are poorly understood. This systematic review aims to synthesise the evidence on the prevalence of cardiac pathology based on cardiac imaging and circulating biomarkers in patients with PTB.

Methods

We systematically searched databases for studies in patients with PTB evaluating cardiac pathology (pericardial effusion or left ventricular dysfunction) on echocardiography; late gadolinium enhancement on cardiac magnetic resonance imaging (CMR); myocardial inflammation on positron-emission tomography (PET); coronary artery stenosis on CT coronary angiography (CTCA); and cardiac troponin (cTn) and/or B-type natriuretic peptides (BNP) assessment.

Results

Seven studies were included across 1,333 participants with PTB. Four studies used echocardiography (n = 1,111). The prevalence of pericardial effusion ranged from 14.1-55.9%; and left ventricular systolic impairment from 0-4.25%. One study used CMR and PET-CT (n = 26); and two studies used PET-CT alone (n = 196). The prevalence of pericardial and/or myocardial inflammation ranged from 0.6-21.8%. One study evaluated cTn, Creatine Kinase-MB (CK-MB), and BNP (n = 800), of whom 246 had raised cTn. No study reported cardiac pathology using CTCA.

Conclusion

Pericardial effusion is the commonest reported cardiac pathology in PTB. To date, only one study has evaluated cardiac biomarkers and studies evaluating myocardial or coronary disease on advanced imaging remain limited. Our study highlights the paucity of evidence on the presence of cardiac pathology in PTB. Studies are required to determine the prevalence of, and disease mechanisms associated with cardiac pathology among patients with PTB.

Pathogenesis of Post-Tuberculosis Lung Disease: Defining Knowledge Gaps and Research Priorities at the Second International Post-Tuberculosis Symposium

Post-tuberculosis (post-TB) lung disease is increasingly recognized as a major contributor to the global burden of chronic lung disease, with recent estimates indicating that over half of TB survivors have impaired lung function after successful completion of TB treatment. However, the pathologic mechanisms that contribute to post-TB lung disease are not well understood, thus limiting the development of therapeutic interventions to improve long-term outcomes after TB. This report summarizes the work of the Pathogenesis and Risk Factors Committee for the Second International Post-Tuberculosis Symposium, which took place in Stellenbosch, South Africa, in April 2023. The committee first identified six areas with high translational potential: 1) tissue matrix destruction, including the role of matrix metalloproteinase dysregulation and neutrophil activity; 2) fibroblasts and profibrotic activity; 3) granuloma fate and cell death pathways; 4) mycobacterial factors, including pathogen burden; 5) animal models; and 6) the impact of key clinical risk factors, including HIV, diabetes, smoking, malnutrition, and alcohol. We share the key findings from a literature review of those areas, highlighting knowledge gaps and areas where further research is needed.

Tuberculosis survivors and the risk of cardiovascular disease: analysis using a nationwide survey in Korea

Background

Although the association between tuberculosis (TB) and cardiovascular disease (CVD) has been reported in several studies and is explained by mechanisms related to chronic inflammation, few studies have comprehensively evaluated the association between TB and CVD in Korea.

Methods

Using the Korea National Health and Nutrition Survey, we classified individuals according to the presence or absence of previous pulmonary TB was defined as the formal reading of a chest radiograph or a previous diagnosis of pulmonary TB by a physician. Using multivariable logistic regression analyses, we evaluated the association between the 10-year atherosclerotic cardiovascular disorder (ASCVD) risk and TB exposure, as well as the 10-year ASCVD risk according to epidemiological characteristics.

Results

Among the 69,331 participants, 4% (n = 3,101) had post-TB survivor group. Comparing the 10-year ASCVD risk between the post-TB survivor and control groups, the post-TB survivor group had an increased 10-year ASCVD risk in the high-risk group (40.46% vs. 24.00%, P < 0.001). Compared to the control group, the intermediate- and high-risk groups had also significantly increased 10-year ASCVD risks (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.04-1.23 and OR 1.69, 95% CI 1.59-1.78, respectively) in the post-TB survivor group. In the association of CVD among post-TB survivors according to epidemiologic characteristics, age [adjusted OR (aOR) 1.10, 95% CI 1.07-1.12], current smoking (aOR 2.63, 95% CI 1.34-5.14), a high family income (aOR 2.48, 95% CI 1.33-4.62), diabetes mellitus (aOR 1.97, 95% CI 1.23-3.14), and depression (aOR 2.06, 95% CI 1.03-4.10) were associated with CVD in the post-TB survivor group.

Conclusions

Our study findings suggest a higher 10-year ASCVD risk among TB survivors than healthy participants. This warrants long-term cardiovascular monitoring and management of the post-TB population.

The effect of Mycobacterium tuberculosis treatment on thrombelastography-assessed haemostasis: a prospective cohort study

BACKGROUND AND OBJECTIVE

Tuberculosis disease (TB) and tuberculosis infection (TBI) have been associated with increased risk of cardiovascular disease which may be connected to infection-related haemostatic changes. It is unknown if treatment of Mycobacterium tuberculosis influences haemostasis. Here, we assessed if TB or TBI treatment affects thrombelastography (TEG)-assessed haemostasis.

METHODS

Individuals with TB or TBI were included from a TB outpatient clinic in Copenhagen, Denmark. Patients treated with antithrombotic medication or systemic immunosuppressants were excluded. TEG analysis was performed before and after TB/TBI treatment using the TEG®6s analyser to provide data on the reaction time of clot initiation (R) (min), the speed of clot formation (K) (min) and clot build-up (Angle) (°), maximum clot strength (MA) (mm), and clot breakdown/fibrinolysis (LY30) (%). Differences in TEG were assessed using paired t tests.

RESULTS

We included eleven individuals with TB with median [interquartile range] [IQR] age 52 (Liu et al. in Medicine (United States) 95, 2016) years and mean (standard deviation) (SD) body mass index (BMI) 24.7 (6.3) kg/m2 as well as 15 individuals with TBI with median [IQR] age 49 (Wells et al. in Am J Respir Crit Care Med 204:583, 2021) years and BMI 26.0 (3.2) kg/m2. Treatment reduced MA for both TB (64.0 (6.3) vs. 57.9 (5.2) mm, p = 0.016) and TBI (61.3 (4.1) vs. 58.6 (5.0) mm, p = 0.023) whereas R, K, Angle and LY30 were unaffected.

CONCLUSION

TEG analysis showed that treatments of TB and TBI were associated with reduced MA which may indicate the existence of cardiovascular benefits from therapy.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov 05 April 2021 with registration number NCT04830462.

Care for the cerebrovascular accident survivors: experiences of family caregivers

BACKGROUND

The role of family caregivers in the management of cerebrovascular accident survivors is invaluable. So far, there is a strong evidence affirming the effectiveness of family support for cerebrovascular accident survivors. Meanwhile, caring for cerebrovascular survivors can be labour and time intensive and pretty stressful for caregivers. The purpose of the study was to examine the lived experiences of family caregivers of cerebrovascular accident survivors in the Ho Municipality in the Volta Region of Ghana. This aims are to establish their caregivers' knowledge, preparedness, and impact of caregiving on the caregiver, and coping strategies caregivers adopted.

METHODS

Using a four-item (with 14 prompts) interview guide and descriptive phenomenological approach, we gathered and analysed data from 37 family caregivers in the Ho Municipality of Ghana.

RESULTS

We found that caregivers had limited knowledge about cerebrovascular disease-risk factors and were ill-prepared for their caregiving roles. Additionally, we found limited knowledge about coping strategies among the caregivers. We further report that some caregivers lost close relationships, and their jobs because of the caregiving, they also used fasting and prayer as coping strategies.

CONCLUSIONS

Caregivers suffered broken relationship, loss their jobs and incomes due to their caregiving roles. Moreover, some engaged in fasting and prayers, and alcohol use to cope with the stress associated with caring for the cerebrovascular accident survivors. We discussed the potential implications of our findings on the realisation of the Sustainable Development Goal 3.4. The aim of this goal is to reduce by 75% premature deaths due to cerebrovascular and other non-communicable diseases by 2030.

The burden and natural history of cardiac pathology at TB diagnosis in a high-HIV prevalence district in Zambia: protocol for the TB-Heart study

BACKGROUND

Tuberculosis (TB) continues to be a major cause of death across sub-Saharan Africa (SSA). In parallel, non-communicable disease and especially cardiovascular disease (CVD) burden has increased substantially in the region. Cardiac manifestations of TB are well-recognised but the extent to which they co-exist with pulmonary TB (PTB) has not been systematically evaluated. The aim of this study is to improve understanding of the burden of cardiac pathology in PTB in those living with and without HIV in a high-burden setting.

METHODS

This is a cross-sectional and natural history study to evaluate the burden and natural history of cardiac pathology in participants with PTB in Lusaka, Zambia, a high burden setting for TB and HIV. Participants with PTB, with and without HIV will be consecutively recruited alongside age- and sex-matched TB-uninfected comparators on a 2:1 basis. Participants will undergo baseline assessments to collect clinical, socio-demographic, functional, laboratory and TB disease impact data followed by point-of-care and standard echocardiography. Participants with PTB will undergo further repeat clinical and functional examination at two- and six months follow-up. Those with cardiac pathology at baseline will undergo repeat echocardiography at six months.

DISCUSSION

The outcomes of the study are to a) determine the burden of cardiac pathology at TB diagnosis, b) describe its association with patient-defining risk factors and biochemical markers of cardiac injury and stretch and c) describe the natural history of cardiac pathology during the course of TB treatment.

Coronary heart disease and tuberculosis: an unnoticed syndemia. Review of literature and management proposal

Tuberculosis is an increasing disease that affects about one-third of the global population. In line with the rise of tuberculosis, cardiovascular disease has shown a similar trend, with ischemic coronary heart disease becoming the leading cause of death worldwide. Based on the literature, a relationship can be drawn between tuberculosis and ischemic coronary heart disease through their shared multiple risk factors and a possible pathophysiological substrate linking them. The presentation of these two conditions reported so far is varied: it has been found as the onset of acute coronary syndrome in patients with active tuberculosis, the progressive development of coronary atherosclerosis in patients with latent tuberculosis, among others. Given this possible link and the progressive increase in their incidence rates, we can assert that we are facing an unnoticed syndemic, with their concurrent management posing a challenge due to significant pharmacological interactions. The purpose of this review is to clarify this possible link, propose an approach for diagnosis, and provide a treatment algorithm for the entire spectrum of coronary disease coexisting with tuberculosis according to the current available literature.

Effect of prior tuberculosis on cardiovascular status in perinatally HIV-1-infected adolescents

Whether, and how, co-occurring HIV-1 infection (HIV) and tuberculosis (TB) impact cardiovascular status, especially in adolescents with perinatally acquired HIV (APHIV), have not been examined. We hypothesized that APHIV with previous active TB have worse cardiac efficiency than APHIV without TB, which is mediated by increased inflammation. Arterial elastance (Ea) and ventricular end-systolic elastance (Ees) were assessed by cardiovascular magnetic resonance, and ventriculoarterial coupling (VAC) estimated as Ea/Ees ratio. Inflammation was measured by high sensitivity C-reactive protein (hsCRP). Previous TB in APHIV was associated with reduced cardiac efficiency, related to an altered ventriculoarterial coupling. However, we did not find evidence of hsCRP mediated effects in the association between prior TB and cardiac efficiency. The clinical significance of these findings requires further study, including a wider range of biomarkers of specific immune pathways.

Association between biomarkers of inflammation and dyslipidemia in drug resistant tuberculosis in Uganda

BACKGROUND

Active tuberculosis (TB) significantly increases the risk of cardiovascular disease, but the underlying mechanisms remain unclear. This study aimed to investigate the association between inflammation biomarkers and dyslipidemia in patients with drug-resistant TB (DR-TB).

METHODS

This was a secondary analysis of data from a cross-sectional multi-center study in Uganda conducted 2021. Participants underwent anthropometric measurements and laboratory tests included a lipid profile, full haemogram and serology for HIV infection. Dyslipidemia was defined as total cholesterol > 5.0 mmol/l and/or low-density lipoprotein cholesterol > 4.14 mmol/l, and/or triglycerides (TG) ≥ 1.7 mmol/l, and/or high density lipoprotein cholesterol (HDL-c) < 1.03 mmol/l for men and < 1.29 mmol/l for women. Biomarkers of inflammation were leukocyte, neutrophil, lymphocyte, monocyte, and platelet counts, as well as neutrophil/lymphocyte (NLR), platelet/lymphocyte, and lymphocyte/monocyte (LMR) ratios, mean corpuscular volume (MCV), and the systemic immune inflammation index (SII) (neutrophil × platelet/lymphocyte). Modified Poisson Regression analysis was used for determining the association of the biomarkers and dyslipidemia.

RESULTS

Of 171 participants, 118 (69.0%) were co-infected with HIV. The prevalence of dyslipidemia was 70.2% (120/171) with low HDL-c (40.4%, 69/171) and hypertriglyceridemia (22.5%, 38/169) being the most common components. Patients with dyslipidemia had significantly higher lymphocyte (P = 0.008), monocyte (P < 0.001), and platelet counts (P = 0.014) in addition to a lower MCV (P < 0.001) than those without dyslipidemia. Further, patients with dyslipidemia had lower leucocyte (P < 0.001) and neutrophil (P = 0.001) counts, NLR (P = 0.008), LMR (P = 0.006), and SII (P = 0.049). The MCV was inversely associated with low HDL-C (adjusted prevalence ratio (aPR) = 0.97, 95% CI 0.94-0.99, P = 0.023) but was positively associated with hypertriglyceridemia (aPR = 1.04, 95% CI 1.00-1.08, P = 0.052).

CONCLUSIONS

Individuals with dyslipidemia exhibited elevated lymphocyte, monocyte, and platelet counts compared to those without. However, only MCV demonstrated an independent association with specific components of dyslipidemia. There is need for further scientific inquiry into the potential impact of dyslipidemia on red cell morphology and a pro-thrombotic state among patients with TB.

Screening for post-TB lung disease at TB treatment completion: Are symptoms sufficient?

Pulmonary TB survivors face a high burden of post-TB lung disease (PTLD) after TB treatment completion. In this secondary data analysis we investigate the performance of parameters measured at TB treatment completion in predicting morbidity over the subsequent year, to inform programmatic approaches to PTLD screening in low-resource settings. Cohort data from urban Blantyre, Malawi were used to construct regression models for five morbidity outcomes (chronic respiratory symptoms or functional limitation, ongoing health seeking, spirometry decline, self-reported financial impact of TB disease, and death) in the year after PTB treatment, using three modelling approaches: logistic regression; penalised regression with pre-selected predictors; elastic net penalised regression using the full parent dataset. Predictors included demographic, clinical, symptom, spirometry and chest x-ray variables. The predictive performance of models were examined using the area under the receiver-operator curve (ROC AUC) values. Key predictors were identified, and their positive and negative predictive values (NPV) determined. The presence of respiratory symptoms at TB treatment completion was the strongest predictor of morbidity outcomes. TB survivors reporting breathlessness had higher odds of spirometry decline (aOR 20.5, 95%CI:3-199.1), health seeking (aOR 10.2, 2.4-50), and symptoms or functional limitation at 1-year (aOR 16.7, 3.3-133.4). Those reporting activity limitation were more likely to report symptoms or functional limitation at 1-year (aOR 4.2, 1.8-10.3), or severe financial impact of TB disease (aOR2.3, 1.0-5.0). Models were not significantly improved by including spirometry or imaging parameters. ROC AUCs were between 0.65-0.77 for the morbidity outcomes. Activity limitation at treatment completion had a NPV value of 78-98% for adverse outcomes. Our data suggest that whilst challenging to predict the development of post-TB morbidity, the use of symptom screening tools at TB treatment completion to prioritise post-TB care should be explored. We identified little benefit from the additional use of spirometry or CXR imaging.

Distinct healthcare utilization profiles of high healthcare use tuberculosis survivors: A latent class analysis

BACKGROUND

Recent data have demonstrated that healthcare use after treatment for respiratory tuberculosis (TB) remains elevated in the years following treatment completion. However, it remains unclear which TB survivors are high healthcare users and whether any variation exists within this population. Thus, the primary objective of this study was to identify distinct profiles of high healthcare-use TB survivors to help inform post-treatment support and care.

METHODS

Using linked health administrative data from British Columbia, Canada, we identified foreign-born individuals who completed treatment for incident respiratory TB between 1990 and 2019. We defined high healthcare-use TB survivors as those in the top 10% of annual emergency department visits, hospital admissions, or general practitioner visits among the study population during the five-year period immediately following TB treatment completion. We then used latent class analysis to categorize the identified high healthcare-use TB survivors into subgroups.

RESULTS

Of the 1,240 people who completed treatment for respiratory TB, 258 (20.8%) people were identified as high post- TB healthcare users. Latent class analysis results in a 2-class solution. Class 1 (n = 196; 76.0%) included older individuals (median age 71.0; IQR 59.8, 79.0) with a higher probability of pre-existing hypertension and diabetes (41.3% and 33.2%, respectively). Class 2 (n = 62; 24.0%) comprised of younger individuals (median age 31.0; IQR 27.0, 41.0) with a high probability (61.3%) of immigrating to Canada within five years of their TB diagnosis and a low probability (11.3%) of moderate to high continuity of primary care.

DISCUSSION

Our findings suggest that foreign-born high healthcare-use TB survivors in a high-resource setting may be categorized into distinct profiles to help guide the development of person-centred care strategies targeting the long-term health impacts TB survivors face.

Healthcare Utilization After Respiratory Tuberculosis: A Controlled Interrupted Time Series Analysis

BACKGROUND

Despite data suggesting elevated morbidity and mortality among people who have survived tuberculosis disease, the impact of respiratory tuberculosis on healthcare utilization in the years following diagnosis and treatment remains unclear.

METHODS

Using linked health administrative data from British Columbia, Canada, we identified foreign-born individuals treated for respiratory tuberculosis between 1990 and 2019. We matched each person with up to four people without a tuberculosis diagnosis from the same source cohort using propensity score matching. Then, using a controlled interrupted time series analysis, we measured outpatient physician encounters and inpatient hospital admissions in the 5 years following respiratory tuberculosis diagnosis and treatment.

RESULTS

We matched 1216 individuals treated for respiratory tuberculosis to 4864 non-tuberculosis controls. Immediately following the tuberculosis diagnostic and treatment period, the monthly rate of outpatient encounters in the tuberculosis group was 34.0% (95% confidence interval [CI]: 30.7%, 37.2%) higher than expected, and this trend was sustained for the duration of the post-tuberculosis period. The excess utilization represented an additional 12.2 (95% CI: 10.6, 14.9) outpatient encounters per person over the post-tuberculosis period, with respiratory morbidity a large contributor to the excess healthcare utilization. Results were similar for hospital admissions, with an additional 0.4 (95% CI: .3, .5) hospital admissions per person over the post-tuberculosis period.

CONCLUSIONS

Respiratory tuberculosis appears to have long-term impacts on healthcare utilization beyond treatment. These findings underscore the need for screening, assessment, and treatment of post-tuberculosis sequelae, as it may provide an opportunity to improve health and reduce resource use.

Using a theory-informed approach to guide the initial development of a post-tuberculosis care package in British Columbia, Canada

BACKGROUND

The importance of addressing the long-term needs of tuberculosis (TB) survivors is gaining increasing attention. One promising approach to improving post-TB care is implementing a post-TB care package. With a specific focus on the perspectives of healthcare providers in British Columbia, Canada, this study aimed to (1) determine a set of components to be included in a post-TB care package, (2) explore barriers and facilitators influencing their implementation, and (3) propose potential solutions to overcome identified challenges.

METHODS

Employing a multi-method approach guided by the Theoretical Domains Framework, we first conducted virtual workshops with TB care providers and utilized a modified Delphi process to establish a preliminary list of care package components. Then, we surveyed healthcare providers using closed-ended, Likert-scale questions to identify implementation barriers and enablers. Lastly, we mapped the identified barriers and enablers to establish behaviour change techniques to identify possible solutions to overcome the challenges identified.

RESULTS

Eleven participants attended virtual workshops, and 23 of 51 (45.1%) healthcare providers completed questionnaires. Identified components of the post-TB care package included: 1. Linking people with TB to a primary care provider if they do not have one. 2. Referring people with pulmonary TB for an end-of-treatment chest x-ray and pulmonary function testing. 3. Referring people with TB who smoke to a smoking cessation specialist. 4. Sharing a one-page post-TB information sheet with the patient's primary care provider, including a summary of post-TB health concerns, complications, and recommendations to prioritize age-appropriate screening for cardiovascular disease, lung cancer, and depression. Survey results indicated that domain scores for 'environment, context, and resources' were the lowest, suggesting potential implementation barriers. Care navigation services to help individuals overcome health system barriers while transitioning from TB care, information leaflets, and checklists summarizing key post-TB health concerns for patients and healthcare providers to help facilitate discussions may help overcome the identified barriers.

CONCLUSION

Healthcare providers in British Columbia acknowledge that post-TB care is integral to comprehensive health care but are limited by time and resources. Care navigation services, a post-TB checklist, and patient information leaflets may help resolve some of these barriers.

Exploring the link between cardiovascular risk factors and manifestations in latent tuberculosis infection: a comprehensive literature review

BACKGROUND

The global burden of tuberculosis (TB) and cardiovascular disease (CVD) is overt, and the prevalence of this double burden disease remains steadily rising, particularly in low- and middle-income countries. This review aims to explore the association between latent tuberculosis infection (LTBI) and the development of cardiovascular diseases and risk factors. Furthermore, we elucidated the underlying pathophysiological mechanisms that contribute to this relationship.

MAIN BODY

Approximately 25% of the global population carries a dormant form of tuberculosis (TB) infection. During this latent stage, certain subsets of mycobacteria actively reproduce, and recent research suggests that latent TB infection (LTBI) is connected to persistent, long-term low-grade inflammation that can potentially contribute to the development of atherosclerosis and cardiovascular disease (CVD). The presence of LTBI can be confirmed through a positive result on either a tuberculin skin test (TST) or an interferon-gamma release assay (IGRA). Several plausible explanations for the association between LTBI and CVD include increased inflammation, autoimmunity related to heat shock proteins (HSP), and the presence of pathogens within the developing atherosclerotic plaque. The most commonly observed cardiovascular events and risk factors associated with LTBI are acute myocardial infarction, coronary artery stenosis, diabetes mellitus, and hypertension.

CONCLUSIONS

This article highlights the critical role of LTBI in perpetuating the tuberculosis disease cycle and its association with cardiovascular risk factors. Chronic and persistent low inflammation underlined the association. Identifying high-risk LTBI patients and providing targeted preventive medication are crucial strategies for global TB eradication and interrupting transmission chains.

A multi-center, prospective cohort study of whole blood gene expression in the tuberculosis-diabetes interaction

Diabetes mellitus (DM) increases tuberculosis (TB) severity. We compared blood gene expression in adults with pulmonary TB, with or without diabetes mellitus (DM) from sites in Brazil and India. RNA sequencing (RNAseq) performed at baseline and during TB treatment. Publicly available baseline RNAseq data from South Africa and Romania reported by the TANDEM Consortium were also analyzed. Across the sites, differentially expressed genes varied for each condition (DM, TB, and TBDM) and no pattern classified any one group across all sites. A concise signature of TB disease was identified but this was expressed equally in TB and TBDM. Pathway enrichment analysis failed to distinguish TB from TBDM, although there was a trend for greater neutrophil and innate immune pathway activation in TBDM participants. Pathways associated with insulin resistance, metabolic dysfunction, diabetic complications, and chromosomal instability were positively correlated with glycohemoglobin. The immune response to pulmonary TB as reflected by whole blood gene expression is substantially similar with or without comorbid DM. Gene expression pathways associated with the microvascular and macrovascular complications of DM are upregulated during TB, supporting a syndemic interaction between these coprevalent diseases.

Multimorbidity prevalence and chronic disease patterns among tuberculosis survivors in a high-income setting

OBJECTIVES

Multimorbidity is the presence of two or more chronic health conditions. Tuberculosis (TB) survivors are known to have higher prevalence of multimorbidity, although prevalence estimates from high-income low-TB incidence jurisdictions are not available and potential differences in the patterns of chronic disease among TB survivors with multimorbidity are poorly understood. In this study, we aimed to (1) compare the prevalence of multimorbidity among TB survivors with matched non-TB controls in a high-income setting; (2) assess the robustness of aim 1 analyses to different modelling strategies, unmeasured confounding, and misclassification bias; and (3) among people with multimorbidity, elucidate chronic disease patterns specific to TB survivors.

METHODS

A population-based cohort study of people immigrating to British Columbia, Canada, 1985-2015, using health administrative data. Participants were divided into two groups: people diagnosed with TB (TB survivors) and people not diagnosed with TB (non-TB controls) in British Columbia. Coarsened exact matching (CEM) balanced demographic, immigration, and socioeconomic covariates between TB survivors and matched non-TB controls. Our primary outcome was multimorbidity, defined as ≥2 chronic diseases from the Elixhauser comorbidity index.

RESULTS

In the CEM-matched sample (n=1962 TB survivors; n=1962 non-TB controls), we estimated that 21.2% of TB survivors (n=416), compared with 12% of non-TB controls (n=236), had multimorbidity. In our primary analysis, we found a double-adjusted prevalence ratio of 1.74 (95% CI: 1.49-2.05) between TB survivors and matched non-TB controls for multimorbidity. Among people with multimorbidity, differences were observed in chronic disease frequencies between TB survivors and matched controls.

CONCLUSION

TB survivors had a 74% higher prevalence of multimorbidity compared with CEM-matched non-TB controls. TB-specific multimorbidity patterns were observed through differences in chronic disease frequencies between the matched samples. These findings suggest a need for TB-specific multimorbidity interventions in high-income settings such as Canada. We suggest TB survivorship as a framework for developing person-centred interventions for multimorbidity among TB survivors.

Latent Tuberculosis Infection (LTBI) as a predictor of coronary artery disease: A systematic review and meta-analysis

Background

A converging epidemic of Latent tuberculosis infection (LTBI) is observed over past two decades. LTBI is a state of persistent immune stimulation by Mycobacterium tuberculosis but with no active clinical manifestation. Also, there has been as increasing trend for incidence of cardiovascular problems in patients suffering from latent TB infection. Reportedly, the risk of coronary artery disease spikes up to 1.52 times in patient with latent TB infection. Considering the fact that cardiovascular diseases account to be leading cause of death globally, we found a dire need to investigate the role of Latent TB infection in producing coronary artery disease and unveil this unconventional relationship.

Purpose

We aim to conduct a meta-analysis to evaluate Latent TB infection as a predictor for coronary artery disease (CAD).

Methods

A systemic search was conducted on electronic databases (PubMed/Medline, Cochrane Library, and Google Scholar) from inception to 24^th June 2022. Studies meeting predefined inclusion criteria underwent statistical analysis on Review Manager 5.4.1. We calculated odds ratio (OR) with 95% confidence intervals (CI) and graphically represented it through fixed-effect forest plot. Heterogeneity of I²>75% and p-value of p < 0.05 was considered to be significant.

Results

Pooled analysis of four selected studies showed that patient with Latent TB infection significantly developed Coronary Artery Disease (OR = 2.15 [1.48, 3.12]; p < 0.0001; I ²  = 0%).

Conclusions

Latent TB infection can be a potential useful predictor for Coronary Artery Disease. However, there is need for further investigation on a greater number of studies before this can truly become clear.

Post-TB health and wellbeing

TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.

Cardiovascular Manifestation in Tuberculosis Cases: A Systematic Review and Meta-Analysis

A considerable epidemiological and pathogenetic overlap exists between tuberculosis (TB) and cardiovascular diseases (CVD). The objective of this study was to establish the prevalence of CVD in the TB population. A systematic literature search was performed using Scopus, PubMed, EBSCO, ProQuest, Web of Science on January 25, 2023 using the keywords: "Tuberculosis," "TB," "mycobacterium tuberculosis," and "cardiovascular disease," "CVD" and with individual terms of various CVDs. Observational Studies were included if they reported the prevalence of CVD in the presence of TB in an adult population. The Newcastle-Ottawa Scale was used for quality evaluation. Statistical analyses were performed using STATA version 17. From 10 studies involving 46715 TB patients, a combined prevalence of CVDs was found to be 11% (CI: 95%, 5-16) with significant heterogeneity across studies (I² = 96.72%). This study showed a considerable prevalence of CVD among TB patients suggesting TB patients to consider cardiac examination.

Cardiovascular Involvement in Tuberculosis: From Pathophysiology to Diagnosis and Complications-A Narrative Review

Although primarily a lung disease, extra-pulmonary tuberculosis (TB) can affect any organ or system. Of these, cardiovascular complications associated with disease or drug toxicity significantly worsen the prognosis. Approximately 60% of patients with TB have a cardiovascular disease, the most common associated pathological entities being pericarditis, myocarditis, and coronary artery disease. We searched the electronic databases PubMed, MEDLINE, and EMBASE for studies that evaluated the impact of TB on the cardiovascular system, from pathophysiological mechanisms to clinical and paraclinical diagnosis of cardiovascular involvement as well as the management of cardiotoxicity associated with antituberculosis medication. The occurrence of pericarditis in all its forms and the possibility of developing constrictive pericarditis, the association of concomitant myocarditis with severe systolic dysfunction and complication with acute heart failure phenomena, and the long-term development of aortic aneurysms with risk of complications, as well as drug-induced toxicity, pose complex additional problems in the management of patients with TB. In the era of multidisciplinarity and polymedication, evidence-based medicine provides various tools that facilitate an integrative management that allows early diagnosis and treatment of cardiac pathologies associated with TB.

Tuberculosis and risk of cancer: A systematic review and meta-analysis

INTRODUCTION

Cancer is a major cause of death among people who experience tuberculosis (TB), but little is known about its timing and incidence following TB treatment. Our primary objectives were to estimate the pooled risk of all and site-specific malignancies in people with TB compared to the general population or suitable controls. Our secondary objective was to describe the pooled risk of cancer at different time points following TB diagnosis.

METHODS

This study was prospectively registered (PROSPERO: CRD42021277819). We systematically searched MEDLINE, Embase, and the Cochrane Database for studies published between 1980 and 2021. We included original observational research articles that estimated cancer risk among people with TB compared to controls. Studies were excluded if they had a study population of fewer than 50 individuals; used cross-sectional, case series, or case report designs; and had a follow-up period of less than 12 months. Random-effects meta-analysis was used to obtain the pooled risk of cancer in the TB population.

RESULTS

Of the 5,160 unique studies identified, data from 17 studies were included. When compared to controls, the pooled standardized incidence ratios (SIR) of all cancer (SIR 1.62, 95% CI 1.35-1.93, I2 = 97%) and lung cancer (SIR 3.20, 95% CI 2.21-4.63, I2 = 90%) was increased in the TB population. The pooled risk of all cancers and lung cancer was highest within the first year following TB diagnosis (SIR 4.70, 95% CI 1.80-12.27, I2 = 99%) but remained over five years of follow-up.

CONCLUSIONS

People with TB have an increased risk of both pulmonary and non-pulmonary cancers. Further research on cancer following TB diagnosis is needed to develop effective screening and early detection strategies. Clinicians should have a high index of suspicion for cancer in people with TB, particularly in the first year following TB diagnosis.

Pro-Inflammatory Alterations of Circulating Monocytes in Latent Tuberculosis Infection

Background

Latent tuberculosis infection (LTBI) has been associated with increased cardiovascular risk. We investigated the activation and pro-inflammatory profile of monocytes in individuals with LTBI and their association with coronary artery disease (CAD).

Methods

Individuals 40-70 years old in Lima, Peru, underwent QuantiFERON-TB testing to define LTBI, completed a coronary computed tomography angiography to evaluate CAD, and provided blood for monocyte profiling using flow cytometry. Cells were stimulated with lipopolysaccharide to assess interleukin-6 (IL-6) and tumor necrosis factor (TNF)-α responses.

Results

The clinical characteristics of the LTBI (n = 28) and non-LTBI (n = 41) groups were similar. All monocyte subsets from LTBI individuals exhibited higher mean fluorescence intensity (MFI) of CX3CR1 and CD36 compared with non-LTBI individuals. LTBI individuals had an increased proportion of nonclassical monocytes expressing IL-6 (44.9 vs 26.9; P = .014), TNF-α (62.3 vs 35.1; P = .014), and TNF-α⁺IL-6⁺ (43.2 vs 36.6; P = .042). Among LTBI individuals, CAD was associated with lower CX3CR1 MFI on classical monocytes and lower CD36 MFI across all monocyte subsets. In multivariable analyses, lower CD36 MFI on total monocytes (b = -0.17; P = .002) and all subsets remained independently associated with CAD in LTBI.

Conclusions

Individuals with LTBI have distinct monocyte alterations suggestive of an exacerbated inflammatory response and tissue migration. Whether these alterations contribute to cardiovascular disease pathogenesis warrants further investigation.

Cardiovascular risk factors among people with drug-resistant tuberculosis in Uganda

BACKGROUND

Tuberculosis (TB) and its risk factors are independently associated with cardiovascular disease (CVD). We determined the prevalence and associations of CVD risk factors among people with drug-resistant tuberculosis (DRTB) in Uganda.

METHODS

In this cross-sectional study, we enrolled people with microbiologically confirmed DRTB at four treatment sites in Uganda between July to December 2021. The studied CVD risk factors were any history of cigarette smoking, diabetes mellitus (DM) hypertension, high body mass index (BMI), central obesity and dyslipidaemia. We used modified Poisson regression models with robust standard errors to determine factors independently associated with each of dyslipidaemia, hypertension, and central obesity.

RESULTS

Among 212 participants, 118 (55.7%) had HIV. Overall, 196 (92.5%, 95% confidence interval (CI) 88.0-95.3) had ≥ 1 CVD risk factor. The prevalence; 95% CI of individual CVD risk factors was: dyslipidaemia (62.5%; 55.4-69.1), hypertension (40.6%; 33.8-47.9), central obesity (39.3%; 32.9-46.1), smoking (36.3%; 30.1-43.1), high BMI (8.0%; 5.0-12.8) and DM (6.5%; 3.7-11.1). Dyslipidaemia was associated with an increase in glycated haemoglobin (adjusted prevalence ratio (aPR) 1.14, 95%CI 1.06-1.22). Hypertension was associated with rural residence (aPR 1.89, 95% CI 1.14-3.14) and previous history of smoking (aPR 0.46, 95% CI 0.21-0.98). Central obesity was associated with increasing age (aPR 1.02, 95%CI 1.00-1.03), and elevated diastolic blood pressure (aPR 1.03 95%CI 1.00-1.06).

CONCLUSION

There is a high prevalence of CVD risk factors among people with DRTB in Uganda, of which dyslipidaemia is the commonest. We recommend integrated services for identification and management of CVD risk factors in DRTB.

Associations of hyponatremia and SIADH with increased mortality, young age and infection parameters in patients with tuberculosis

BACKGROUND AND OBJECTIVE

Hyponatremia and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) are associated with and can be caused by tuberculosis (TB) through meningitis by locally invading the hypothalamus, adrenal, or pituitary glands or possibly through ectopic ADH production. This study assessed the association of TB mortality with hyponatremia and SIADH in a large cohort of a university hospital in Austria.

METHODS

This retrospective study enrolled patients with hyponatremia and patients diagnosed with TB from 01/2001-11/2019 to assess the prevalence of TB in hyponatremia and TB morbidity and mortality in patients with and without hyponatremia. Sex, age, microbiological results, laboratory tests and comorbidities were analysed and used to calculate survival rates.

RESULTS

Of 107.532 patients with hyponatremia (0.07%) and 186 patients with TB (43%), 80 patients were diagnosed with both-hyponatremia and TB. Only three TB patients had SIADH, precluding further SIADH analysis. In hyponatremia, young age and high CRP levels showed significant associations with TB diagnosis (p<0.0001). Survival rates of patients diagnosed with TB with moderate to profound hyponatremia were significantly lower than those without hyponatremia (p = 0.002).

CONCLUSION

In this study of a large cohort from a tertiary care hospital in a non-endemic area of TB, 0.07% of patients presenting with hyponatremia, but especially younger patients and patients with high CRP values, were diagnosed with TB. Crucially, patients with moderate to profound hyponatremia had a significantly higher mortality rate and thus required increased medical care.

Prevalence of cardiovascular risk factors in active tuberculosis in Africa: a systematic review and meta-analysis

People with tuberculosis (TB) are at risk of major adverse cardiovascular events. We estimated the prevalence of cardiovascular risk (CVR) factors among people with active TB in Africa. This was a systematic review and meta-analysis of studies from Africa. We searched EMBASE, MEDLINE through PubMed, Web of Science, the Cochrane Central Register of Controlled Trials, mRCTs, Clinical trials.gov, and International Clinical Trials Registry Platform from inception to 31st December 2021. Among 110 eligible studies, 79 (238,316 participants) were included in the meta-analysis for smoking, 67 (52,793 participants) for current alcohol use, 30 (31,450 participants) for hazardous alcohol use, 51 (37,879 participants) for diabetes mellitus (DM), 19 (18,211 participants) for hypertension and 18 (13,910 participants) for obesity. The pooled prevalence was 26.0% (95% confidence interval 22.0–29.0) for smoking, 30.0% (25.0–35.0) for any current alcohol use, 21.0% (17.0–26.0) for hazardous alcohol use, 14.0% (9.0–18.0) for hypertension, 7.0% (6.0–9.0) for DM, and 4.0% (2.0–5.0) for obesity. Cost-effective strategies are needed to screen for CVR factors among people with active TB in Africa.

Cigarette smoking is associated with an increase in blood monocytes in people with tuberculosis: A cross-sectional study

The effect of smoking on immune responses in people with tuberculosis (TB) is not well elucidated. We aimed to compare peripheral blood counts of CD4+ and CD87 + T-lymphocytes, monocytes, and neutrophils and the CD4:CD8 ratio in TB patients with and without history of cigarette smoking. We further determined factors associated with current smoking. Participants with TB were consecutively enrolled in a cross-sectional study at a national TB treatment center in Uganda in 2018. We compared cell counts and the CD4:CD8 ratio using the median test among never smokers, past smokers (>6 months ago) and current smokers (≤6 months). Factors associated with current smoking were determined using logistic regression. A post hoc analysis for factors associated with an increase in the monocytes was also performed. Of 363 participants, there were 258 (71.1%) never smokers, 50 (13.8%) past smokers, and 55 (15.2%) current smokers. Most current smokers (49.1%) had a high sputum mycobacterial load. They also had the lowest body mass index and the highest axillary temperature. The median (interquartile range [IQR]) monocyte count among current smokers was 815 (540-1425) cells/mm3 and was significantly higher than that among past smokers (610 (350-900) cells/mm3, P = .017) and never smokers (560 [400-800] cells/mm3, P = .001). The monocyte counts positively correlated with the number of cigarettes smoked per day among current smokers (R = 0.43, P = .006). Current smokers also had higher neutrophil and CD4+ T-cell counts than never smokers. In a multivariable logistic regression model, an increase in the monocyte count was associated with current cigarette smoking (adjusted odds ratio [aOR] = 4.82, 95% confidence interval 1.61-14.39, P = .005). Similarly, current cigarette smoking was independently associated with an increase in the monocyte count (aOR = 1.80, 95% CI 1.39-2.32, P < .001). Cigarette smoking is associated with an increase in the blood monocytes in people with TB in a dose- and time-dependent manner. Further, current smoking is associated with an increase in neutrophils and CD4+ T-lymphocytes. The findings suggest that current smokers have systemic inflammation that is not necessarily beneficial to TB control in TB patients.

Differentially Represented Proteins in Response to Infection with Mycobacterium tuberculosis Identified by Quantitative Serum Proteomics in Asian Elephants

Tuberculosis is a major global concern. Tuberculosis in wildlife is a risk for zoonotic transmission and becoming one of the challenges for conservation globally. In elephants, the number of cases is likely rising. The aim of this study was to identify proteins related to tuberculosis infection in elephants, which could then be used for the development of diagnostic tools and/or vaccines. A serum proteomics approach was used to characterize differentially represented proteins in response to Mycobacterium tuberculosis in Asian elephants (Elaphas maximus). Blood samples were collected from eight elephants, four of which were antibody positive for tuberculosis and four were antibody negative. Proteomics analysis identified 26 significantly dysregulated proteins in response to tuberculosis. Of these, 10 (38%) were identified as immunoglobulin and 16 (62%) as non-immunoglobulin proteins. The results provided new information on the antibody response to mycobacterial infection and biomarkers associated with tuberculosis and protective response to mycobacteria in Asian elephants. Protective mechanisms included defense against infection (Alpha-1-B glycoprotein A1BG, Serpin family A member 1 SERPINA1, Transthyretin TTR), neuroprotection (TTR), and reduced risks of inflammation, infections, and cancer (SERPINA1, Keratin 10 KRT10). Using a translational biotechnology approach, the results provided information for the identification of candidate diagnostic, prognostic, and protective antigens for monitoring and control of tuberculosis in Asian elephants.

Clinical Characteristics and Outcomes in Chronic Kidney Disease Patients with Tuberculosis in China: A Retrospective Cohort Study

Background

The diverse manifestations of tuberculosis (TB) in chronic kidney disease (CKD) patients can cause difficulty in diagnosis, delayed treatment, even death. Therefore, this study investigated the clinical characteristics and the risk factors for mortality in CKD patients with TB.

Methods

This retrospective study included 167 patients diagnosed with active TB at two tertiary medical centers in Chongqing within six years. Clinical characteristics and outcomes of anti-TB treatment in patients with and without CKD were collected, and the predictive mortality values of variables were analyzed.

Results

Of the 167 patients, 66.7% (44/66) hemodialysis (HD), 41.1% (21/51) pre-HD, and 32.0% (16/50) non-CKD patients had extrapulmonary TB. The pleura and lymph node were the common sites in CKD patients. Clinical presentations of cough and hemoptysis in CKD patients were less common than those in non-CKD patients, 13.7% (16/117) of CKD patients even not having any clinical symptoms. The positive rates of tuberculin skin test, TB-polymerase chain reaction and acid-fast bacilli in sputum in HD patients were lower than those in pre-HD and non-CKD patients (p<0.05). CKD patients were more prone to gastrointestinal and neurological side effects during anti-TB treatment. The mortality rates of non-CKD, pre-HD and HD patients was 6.1%, 31.9% and 37.3%, respectively. Multivariate Cox analysis revealed that age≥40 years (HR: 5.871; p=0.019), hypoalbuminemia (HR:2.879; p=0.004), CKD stage 4–5 (HR:4.719; p=0.018) and HD (HR:6.13; p=0.005) were associated with mortality.

Discussion

CKD patients with TB have atypical clinical manifestations and high mortality. Age, hypoalbuminemia, CKD stage 4–5, and HD were independent predictors of mortality.

Invited Commentary: The Role of Tuberculosis Screening Among Migrants to Low-Incidence Settings in (Not) Achieving Elimination

The cost-effectiveness of migrant tuberculosis prevention programs is highly relevant to many countries with low tuberculosis incidence as they attempt to eliminate the disease. Dale et al. (Am J Epidemiol. 2022;191(2):255-270) evaluated strategies for tuberculosis infection screening and treatment among new migrants to Australia. Screening for infection before migration, and then administering preventive treatment after arrival, was more cost-effective than performing both screening and treatment after arrival. From the Australian health payer perspective, the improved cost-effectiveness of premigration screening partly reflected the shift of screening costs to migrants, which may raise ethical concerns. Key sensitivity analyses highlighted the influence of health disutility associated with tuberculosis preventive treatment, and of posttreatment sequelae of tuberculosis disease. Both considerations warrant greater attention in future research. For all strategies, the impact on tuberculosis incidence among migrants was modest (<15%), suggesting enhanced migrant screening will not achieve tuberculosis elimination in low-incidence settings. This emphasizes the need to increase investment and effort in global tuberculosis prevention and care, which will ultimately reduce the prevalence of tuberculosis infection and therefore the risk of tuberculosis disease among migrants. Such efforts will benefit high and low tuberculosis incidence countries alike, and advance all countries further toward tuberculosis elimination.

Ang II-Induced Hypertension Exacerbates the Pathogenesis of Tuberculosis

It has been known that infection plays a role in the development of hypertension. However, the role of hypertension in the progression of infectious diseases remain unknown. Many countries with high rates of hypertension show geographical overlaps with those showing high incidence rates of tuberculosis (TB). To explore the role of hypertension in tuberculosis, we compared the effects of hypertension during mycobacterial infection, we infected both hypertensive Angiotensin II (Ang II) and control mice with Mycobacterium tuberculosis (Mtb) strain H37Ra by intratracheal injection. Ang II-induced hypertension promotes cell death through both apoptosis and necrosis in Mtb H37Ra infected mouse lungs. Interestingly, we found that lipid accumulation in pulmonary tissues was significantly increased in the hypertension group compared to the normal controls. Ang II-induced hypertension increases the formation of foamy macrophages during Mtb infection and it leads to cell death. Moreover, the hypertension group showed more severe granuloma formation and fibrotic lesions in comparison with the control group. Finally, we observed that the total number of mycobacteria was increased in the lungs in the hypertension group compared to the normal controls. Taken together, these results suggest that hypertension increases intracellular survival of Mtb through formation of foamy macrophages, resulting in severe pathogenesis of TB.

The association of atherosclerotic cardiovascular disease and statin use with inflammation and treatment outcomes in tuberculosis

Tuberculosis (TB) and atherosclerotic cardiovascular disease (ASCVD) have a close epidemiological and pathogenetic overlap. Thus, it becomes essential to understand the relationship between ASCVD and TB outcomes. From our retrospective cohort on drug-susceptible TB patients at the National Taiwan University Hospital, we assessed the association of pre-existing ASCVD (coronary artery disease (CAD) and atherothrombotic stroke (ATS)) with 9-month all-cause and infection-related mortality and the extent of mediation by systemic inflammatory markers. We determined the effect of pre-existing ASCVD on 2-month sputum microbiological status. Among ASCVD patients, we assessed the association of statin use on mortality. Nine-month all-cause mortality was higher in CAD patients with prior acute myocardial infarction (CAD⁺AMI⁺) (adjusted HR 2.01, 95%CI 1.38–3.00) and ATS patients (aHR 2.79, 95%CI 1.92–4.07) and similarly, for infection-related mortality was higher in CAD⁺AMI⁺ (aHR 1.95, 95%CI 1.17–3.24) and ATS (aHR 2.04, 95%CI 1.19–3.46) after adjusting for confounding factors. Pre-existing CAD (AMI^- or AMI⁺) or ATS did not change sputum culture conversion or sputum smear AFB positivity at 2 months. The CAD⁺AMI⁺ group had significantly higher levels of CRP at TB diagnosis in the multivariable linear regression analysis (Adjusted B(SE) 1.24(0.62)). CRP mediated 66% (P = 0.048) and 25% (P = 0.033) of the association all-cause mortality with CAD⁺AMI⁻ and CAD⁺AMI⁺, respectively. In summary, patients with ASCVD have higher hazards of 9-month all-cause and infection-related mortality, with elevated serum inflammation mediating one to three-quarters of this association when adjusted for confounders. Statin use was associated with lower all-cause mortality among patients with ASCVD.

Latent Tuberculosis Infection and Subclinical Coronary Atherosclerosis in Peru and Uganda

BACKGROUND

Tuberculosis has been linked to an increased risk of atherosclerotic cardiovascular disease (ASCVD). We assessed whether latent tuberculosis infection (LTBI) is associated with subclinical coronary atherosclerosis in two TB-prevalent areas.

METHODS

We analyzed cross-sectional data from studies conducted in Lima, Peru, and Kampala, Uganda. Individuals ≥40 years old were included. We excluded persons with known history of ASCVD events or active TB. Participants underwent QuantiFERON®-TB (QFT) testing to define LTBI, and computed tomography angiography to examine coronary atherosclerosis. A Coronary Artery Disease-Reporting Data System (CAD-RADS) score ≥3 defined obstructive CAD (plaque causing ≥50% stenosis).

RESULTS

113 persons with LTBI and 91 persons without LTBI were included. There were no significant differences between LTBI and non-LTBI participants in terms of age (median [interquartile range]; 56 [51-62] vs. 55 [49-64], p=0.829), male sex (38% vs. 42%; p=0.519), or 10-year ASCVD risk scores (7.1 [3.2-11.7] vs. 6.1 [2.8-10.8]; p=0.533). CAD prevalence (any plaque) was similar between groups (29% vs. 24%; p=0.421). Obstructive CAD was present in 9% of LTBI and 3% of non-LTBI individuals; p=0.095. LTBI was associated with obstructive CAD after adjusting for ASCVD risk score, HIV status, and study site (adjusted odds ratio, 4.96, 95% CI 1.05-23.44; p=0.043). Quantitative QFT TB antigen minus nil interferon-gamma responses were associated with obstructive CAD (adjusted odds ratio, 1.2, 95% CI 1.03-1.41; p=0.022).

CONCLUSIONS

LTBI was independently associated with an increased likelihood of subclinical obstructive CAD. Our data indicates that LTBI is a non-traditional correlate of ASCVD risk.

Mycobacterium bovis Bacille-Calmette-Guérin Infection Aggravates Atherosclerosis

Tuberculosis has been associated with increased risk of atherosclerotic cardiovascular disease. To examine whether mycobacterial infection exacerbates atherosclerosis development in experimental conditions, we infected low-density lipoprotein receptor knockout (Ldlr^-/-) mice with Mycobacterium bovis Bacille-Calmette-Guérin (BCG), an attenuated strain of the Mycobacterium tuberculosis complex. Twelve-week old male Ldlr^-/- mice were infected with BCG (0.3–3.0x10⁶ colony-forming units) via the intranasal route. Mice were subsequently fed a western-type diet containing 21% fat and 0.2% cholesterol for up to 16 weeks. Age-matched uninfected Ldlr^-/- mice fed with an identical diet served as controls. Atherosclerotic lesions in aorta were examined using Oil Red O staining. Changes induced by BCG infection on the immunophenotyping profile of circulating T lymphocytes and monocytes were assessed using flow cytometry. BCG infection increased atherosclerotic lesions in en face aorta after 8 weeks (plaque ratio; 0.021±0.01 vs. 0.013±0.01; p = 0.011) and 16 weeks (plaque ratio, 0.15±0.13 vs. 0.06±0.02; p = 0.003). No significant differences in plasma cholesterol or triglyceride levels were observed between infected and uninfected mice. Compared to uninfected mice, BCG infection increased systemic CD4/CD8 T cell ratio and the proportion of Ly6C^low non-classical monocytes at weeks 8 and 16. Aortic plaque ratios correlated with CD4/CD8 T cell ratios (Spearman’s rho = 0.498; p = 0.001) and the proportion of Ly6C^low non-classical monocytes (Spearman’s rho = 0.629; p < 0.001) at week 16. In conclusion, BCG infection expanded the proportion of CD4⁺ T cell and Ly6C^low monocytes, and aggravated atherosclerosis formation in the aortas of hyperlipidemic Ldlr^-/- mice. Our results indicate that mycobacterial infection is capable of enhancing atherosclerosis development.