Hypoalbuminemia and lymphocytopenia are predictive risk factors for in-hospital mortality in patients with tuberculosis

Factors Affecting Mortality in Critically Ill Patients With Tuberculosis: A Systematic Review and Meta-Analysis

OBJECTIVES

Critically ill patients with tuberculosis carry high mortality. Identification of factors associated with mortality in critically ill tuberculosis patients may enable focused treatment.

DATA SOURCES

An extensive literature search of PubMed (MEDLINE), Embase, the Cochrane Library, and Google Scholar was performed using Medical Subject Headings terms "tuberculosis," "critical care," "critical care outcome," and "ICU." We aimed to identify factors affecting mortality in critically ill tuberculosis patients.

STUDY SELECTION

All the studies comparing factors affecting mortality between survivors and nonsurvivors in critically ill tuberculosis patients were included. The database search yielded a total of 3017 records, of which 17 studies were included in the meta-analysis.

DATA EXTRACTION

Data were collected including the name of the author, year and country of publication, duration of the study, number of patients studied, type of tuberculosis, patient demography, smoking history, laboratory parameters, comorbidities, the requirement for mechanical ventilation, duration of ventilation, ICU and hospital length of stay (LOS), type of lung involvement, complications, and outcomes.

DATA SYNTHESIS

The major factors that contributed to mortality in critically ill tuberculosis patients were age, platelet count, albumin, C-reactive protein (CRP), the requirement and duration of invasive mechanical ventilation, Pa o2 /F io2 ratio, presence of acute respiratory distress syndrome, shock, hospital-acquired infections, renal replacement therapy, and ICU and hospital LOS.

CONCLUSIONS

Patient age, platelet count, albumin and CRP levels, the requirement and duration of invasive mechanical ventilation, Pa o2 /F io2 ratio, hospital-acquired infections, renal replacement therapy, and ICU LOS were variables associated with mortality.

Influence of N-acetyltransferase 2 polymorphisms and clinical variables on liver function profile of tuberculosis patients

BACKGROUND

Single nucleotide polymorphisms (SNPs) in the N-acetyltransferase 2 (NAT2) gene as well as several other clinical factors can contribute to the elevation of liver function test values in tuberculosis (TB) patients receiving antitubercular therapy (ATT).

RESEARCH DESIGN AND METHODS

A prospective study involving dynamic monitoring of the liver function tests among 130 TB patients from baseline to 98 days post ATT initiation was undertaken to assess the influence of pharmacogenomic and clinical variables on the elevation of liver function test values. Genomic DNA was extracted from serum samples for the assessment of NAT2 SNPs. Further, within this study population, we conducted a case control study to identify the odds of developing ATT-induced drug-induced liver injury (DILI) based on NAT2 SNPs, genotype and phenotype, and clinical variables.

RESULTS

NAT2 slow acetylators had higher mean [90%CI] liver function test values for 8-28 days post ATT and higher odds of developing DILI (OR: 2.73, 90%CI: 1.05-7.09) than intermediate acetylators/rapid acetylators.

CONCLUSION

The current study findings provide evidence for closer monitoring among TB patients with specific NAT2 SNPs, genotype and phenotype, and clinical variables, particularly between the period of more than a week to one-month post ATT initiation for better treatment outcomes.

Activities of Daily Living, Hypoxemia, and Lymphocytes Score for Predicting Mortality Risk in Patients With Pulmonary TB

BACKGROUND

A clinically applicable mortality risk prediction system for pulmonary TB may improve treatment outcomes, but no easy-to-calculate and accurate score has yet been reported. The aim of this study was to construct a simple and objective disease severity score for patients with pulmonary TB.

RESEARCH QUESTION

Does a clinical score consisting of simple objective factors predict the mortality risk of patients with pulmonary TB?

STUDY DESIGN AND METHODS

The data set from our previous prospective study that recruited patients newly diagnosed with pulmonary TB was used for the development cohort. Patients for the validation cohort were prospectively recruited between March 2021 and September 2022. The primary end point was all-cause in-hospital mortality. Using Cox proportional hazards regression, a mortality risk prediction model was optimized in the development cohort. The disease severity score was developed by assigning integral points to each variate.

RESULTS

The data from 252 patients in the development cohort and 165 patients in the validation cohort were analyzed, of whom 39 (15.5%) and 17 (10.3%), respectively, died in the hospital. The disease severity score (named the AHL score) included three clinical parameters: activities of daily living (semi-dependent, 1 point; totally dependent, 2 points); hypoxemia (1 point), and lymphocytes (< 720/μL, 1 point). This score showed good discrimination with a C statistic of 0.902 in the development cohort and 0.842 in the validation cohort. We stratified the score into three groups (scores of 0, 1-2, and 3-4), which clearly corresponded to low (0% and 1.3%), intermediate (13.5% and 8.9%), and high (55.8% and 39.3%) mortality risk in the development and validation cohorts.

INTERPRETATION

The easy-to-calculate AHL disease severity score for patients with pulmonary TB was able to categorize patients into three mortality risk groups with great accuracy.

CLINICAL TRIAL REGISTRATION

University Hospital Medical Information Network Center; No. UMIN000012727 and No. UMIN000043849; URL: www.umin.ac.jp.

Impact of Nursing Interventions on Hospital Readmissions in Patients With Pulmonary Tuberculosis: A Quasi-Experimental Study

PURPOSE

Our study aimed to evaluate the effectiveness of the nursing care program on the incidence and rate of 28-day hospital readmissions among pulmonary tuberculosis (TB) patients.

METHODS

We conducted a quasi-experimental study using a historical control (usual care) group. Patients diagnosed with pulmonary TB who received nursing interventions between January 28, 2021, and May 31, 2021, were categorized as an intervention group, whereas historical controls were selected from January 1, 2020, to December 31, 2020. The primary outcomes were the incidence and rates of hospital readmissions within 28 days due to TB-related complications. The secondary outcome was the change in knowledge and self-care behavior scores at discharge and 28 days postdischarge. Cox models were used to assess the intervention's impact on the incidence of hospital readmission. Rates of readmission were compared by the Poisson model. Both Cox and Poisson models were adjusted for age, sex, sputum smears at diagnosis, serum albumin level, and diabetes mellitus at baseline.

RESULTS

Among 104 pulmonary TB patients included in the analysis (68 were in a historical control group and 36 were in an intervention group), 20 patients were readmitted due to TB-related complications. We found that our nursing care program resulted in a significant reduction in the incidence (adjusted hazard ratio was 0.16 [95% CI 0.03, 0.87]) and the rate of hospital readmissions (adjusted incidence rate ratio was 0.22 [95% CI 0.06, 0.85]). Furthermore, nursing interventions significantly improved knowledge and self-care behavior scores with significant score retention at 28 days postdischarge.

CONCLUSIONS

The nursing care program can significantly decrease the incidence and rate of 28-day hospital readmission and improve knowledge and self-care behavior scores in pulmonary TB patients.

Association of blood neutrophil-lymphocyte ratio with short-term prognosis and severity of tuberculosis meningitis patients without HIV infection

BACKGROUND

Predicting the short-term prognosis and severity of tuberculosis meningitis (TBM) patients without HIV infection can be challenging, and there have been no prior studies examining the neutrophil lymphocyte ratio (NLR) as a potential predictor of short-term prognosis or its relationship to TBM severity. We hypothesized that NLR might serve as an independent indicator of short-term prognostic significance and that there might be a correlation between NLR and severity. The aim of this study was to investigate the role of NLR as a predictor of short-term prognosis and its relationship to severity of tuberculosis meningitis patients without HIV infection.

METHODS

We retrospectively collected data from patients diagnosed with TBM in the West China Hospital, Sichuan University, from the period between January 1st, 2018 and August 1st, 2019. Multivariable analysis was executed by the logistic regression model to verify the independence of the 28-day mortality, the discriminative power for predicting short-term prognosis was evaluated using a Receiver Operating Characteristic (ROC) curve, survival outcomes were analyzed using the Kaplan-Meier method and Pearson's correlation analysis was performed to discuss correlation between NLR and the severity of TBM.

RESULTS

We collected data from 231 TBM patients without HIV infection. 68 (29.4%) patients are classified as stage (I) 138(59.8%) patients are stage (II) 25(10.8%) patients are stage (III) 16(6.9%) patients died during the follow-up period of 28 days. By multiple logistic regression analyses, the NLR (OR = 1.065, 95% CI = 1.001-1.133, P = 0.045), peripheral neurological deficit (OR 7.335, 95% CI 1.964-27.385, P = 0 0.003) and hydrocephalus (OR 11.338, 95% CI 2.397-53.633, P = 0 0.002) are independent risk factors of 28-day mortality. The area under the ROC curve (AUC) for predicting short prognosis using NLR is 0.683 (95% CI 0.540-0.826, P = 0.015), the optimal cutoff value is 9.99(sensitivity: 56.3%, specificity: 80.9%). The Kaplan-Meier analysis demonstrated that patients with higher NLR(>9.99) had significantly worse survival outcomes(P<0.01).Pearson's correlation analysis presents a significant positive correlation between the severity of TBM and NLR (r = 0.234, P<0.01).

CONCLUSIONS

NLR, peripheral neurological deficit, and hydrocephalus are independent risk factors of 28-day mortality, NLR can predict the short-term prognosis of TBM patients without HIV infection. NLR is also found to be significantly and positively correlated with the severity of TBM.

The efficacy of Bloso fish (Glossogobius giuris sp.) in improving hemoglobin, hematocrit, platelet, and albumin levels of Wistar rats with hypoalbuminemia

Tuberculosis (TB) is an infectious disease worldwide that causes death. Common clinical manifestations of patients with TB include anemia, hypoalbuminemia, and malnutrition. Most patients with TB are infected with coccus bacteria, such as Staphylococcus aureus, that commonly attack the respiratory tract. However, the consumption of heme protein sources could improve the nutritional status of patients with TB. Fish comprise one of the most widely consumed sources of heme. The bloso fish (Glossogobius giuris sp.), considered a fish without economic value is a new alternative source of heme protein. This study aimed to develop supplements using bloso fish (Glossogobius giuris sp.). This study used an experimental pretest-post-test control group design. Seven male Wistar rats were used as the negative control group. Twenty- eight male Wistar rats were administered S. aureus, fed a protein-deficient diet, and divided into the positive control group, the K1 group, which received up to 675 mg/200 g of bloso fish flour, the K2 group, which received up to 67.5 mg/200 g of bloso fish oil, and the K3 group, which received up to 675 mg/200 g of bloso fish fluor from oil extraction dregs. Treatment was administered for 28 days. The hemoglobin (Hb), hematocrit (Ht), platelet, and albumin levels in blood serum from the retroorbital vein were measured. Data were processed using a paired t-test and one-way analysis of variance. The results showed differences in Hb, Ht, platelet, and albumin levels were observed before and after treatment. Additionally, differences in Hb, Ht, platelet, and albumin levels were observed in the groups that received bloso fish flour and bloso fish oil. Bloso fish flour and bloso fish oil increased the Hb, Ht, platelet, and albumin levels of rats with hypoalbuminemia.

Sleep quality and its associated factors among patients with tuberculosis: A cross-sectional study

Background

Tuberculosis (TB) patients commonly suffer from sleep issues owing to various adverse drug reactions (ADRs), disease symptoms, and the contagious nature of their disease. These sleep issues negatively affect the treatment outcome and quality of life. However, the prevalence of sleep disturbance and its associated factors among TB patients have rarely been reported.

Methods

A total of 497 inpatients with TB from three hospitals in China were enrolled in this cross-sectional study to investigate their sleep quality using the Pittsburgh sleep quality index (PSQI). Clinical data, including demographic information, TB-related stigma, perceived stress, and nutrition- and immunity-related indicators, were also collected to explore the factors associated with sleep disturbance among the recruited patients.

Results

Approximately 70% of the recruited patients reported a sleep disturbance to varying degrees, presenting poorer global and subjective sleep qualities, longer sleep latency, shorter sleep duration, lower sleep efficiency, more frequent sleep disturbances, greater use of sleeping medication, and more severe daytime dysfunction. Furthermore, the body mass index (BMI), hemoglobin levels, albumin levels, and T lymphocyte count of the patients in the poor sleep quality group were significantly lower than those in the good sleep quality group (p < 0.05). Increasing age, higher income, drug resistance, higher stigma or stress perception, lower albumin levels, and lower CD4 levels were significantly associated with sleep disturbance among TB patients (p < 0.05).

Conclusion

Three-quarters of the participants were found to suffer from a probable sleep disturbance. And sleep problems are linked to biological traits that interact with psychological, cultural, and social factors in complex ways. It is therefore important to pay attention to the sleep quality of TB patients, especially those with the identified risk factors. Besides, taking care of these risk factors may prove to be an effective sleep management strategy.

Transudative or masked exudative polyserositis in disseminated tuberculosis? A case report

Introduction

Polyserositis in disseminated tuberculosis (TB) is an uncommon presentation. The exudative nature of effusion in disseminated TB can be masked by presence of malnutrition due TB.

Case presentation

A 24-year-old female, diagnosed with disseminated TB, developed polyserositis with transudative nature of fluid. She was treated with anti-tubercular therapy (ATT).

Clinical discussion

Polyserositis, though an uncommon presentation in disseminated TB, was the clinical manifestation in our case. But transudative nature of the fluid was an unexpected finding. Hypoalbuminemia as a result of malnutrition due to TB was the cause for masking exudative effusion in TB.

Conclusions

Hypoalbuminemia as a result of malnutrition due to TB can be the reason for transudative nature of effusion in polyserositis.

•

Polyserositis is an uncommon presentation in disseminated TB.

•

The exudative nature of fluid is a common finding in polyserositis due to disseminated TB.

•

The transudative nature of the fluid can also be the finding in polyserositis due to disseminated TB.

•

Hypoalbuminemia as a result of malnutrition due to TB can lead to transudative polyserositis in disseminated TB.

Clinical Characteristics and Prognostic Analysis of Patients With Pulmonary Tuberculosis and Type 2 Diabetes Comorbidity in China: A Retrospective Analysis

Background: Tuberculosis (TB) is one of the leading communicable diseases, with significant morbidity and mortality. Diabetes can increase the risk of developing TB and the related adverse outcomes. This study retrospectively analyzed the clinical characteristics and prognosis of patients with pulmonary TB and type 2 diabetes comorbidity.

Methods: About 282 cases with pulmonary TB and type 2 diabetes comorbidity were identified from West China Hospital between January 1, 2010, and December 31, 2016, and were followed up for at least 3 years. We further used Kaplan–Meier methods and COX regression analysis to identify the influence factors for all-cause death.

Results: Compared to the survival patients, patients who died were older, exhibited significantly lower albumin and hemoglobin levels, but higher Charlson Comorbidity Index (CCI) score at admission, and had a lower usage rate of metformin. The all-cause mortality rates at 1 and 5 years were 5.67 and 20.59%, separately. For 1-year all-cause death, higher albumin level (HR = 0.90, 95% CI: 0.81–0.99) was the independently protective factor, but older age (HR = 1.07, 95% CI: 1.01–1.13) and CCI score ≥3 (HR = 6.77, 95% CI: 1.40–32.69) were the independent risk factors. For long-term all-cause death, higher albumin level (HR = 0.94, 95% CI: 0.88–1.00), the use of metformin (HR = 0.21, 95% CI: 0.07–0.59), insulin (HR = 0.27, 95% CI: 0.10–0.74), or sulfonylureas (HR = 0.23, 95% CI: 0.07–0.74) were the independently protective factors, but older age (HR = 1.03, 95% CI: 1.00–1.07) and CCI score ≥3 (HR = 7.15, 95% CI: 2.56–19.92) were the independent risk factors.

Conclusions: The lower albumin level, older age, and CCI score ≥3 were predictors of all-cause death in patients with pulmonary TB and type 2 diabetes comorbidity. In the long run, patients who use metformin, insulin, or sulfonylureas as hypoglycemic agents may have a lower incidence of death.

Pathogen Metagenomics Reveals Distinct Lung Microbiota Signatures Between Bacteriologically Confirmed and Negative Tuberculosis Patients

Understanding the dynamics of lung microbiota in tuberculosis patients, especially those who cannot be confirmed bacteriologically in clinical practice, is imperative for accurate diagnosis and effective treatment. This study aims to characterize the distinct lung microbial features between bacteriologically confirmed and negative tuberculosis patients to understand the influence of microbiota on tuberculosis patients. We collected specimens of bronchoalveolar lavage fluid from 123 tuberculosis patients. Samples were subjected to metagenomic next-generation sequencing to reveal the lung microbial signatures. By combining conventional bacterial detection and metagenomic sequencing, 101/123 (82%) tuberculosis patients were bacteriologically confirmed. In addition to Mycobacterium tuberculosis, Staphylococcus aureus, Kluyveromyces lactis, and Pyricularia pennisetigena were also enriched in the bacteriological confirmation group. In contrast, Haemophilus parainfluenzae was enriched in the bacteriologically negative group. Besides, microbial interaction exhibits a different state between bacteriologically confirmed and negative tuberculosis patients. Mycobacterium tuberculosis was confirmed correlated with clinical characteristics such as albumin and chest cavities. Our study comprehensively demonstrates the correlation between unique features of lung microbial dynamics and the clinical characteristics of tuberculosis patients, suggesting the importance of studying the pulmonary microbiome in tuberculosis disease and providing new insights for future precision diagnosis and treatment.

Posttreatment Lymphopenia Is Associated With an Increased Risk of Redeveloping Nontuberculous Lung Disease in Patients With Mycobacterium avium Complex Lung Disease

BACKGROUND

Lymphopenia has been reported as a risk factor for poor prognosis in various infectious diseases, including Mycobacterium avium complex lung disease (MAC-LD), and recurrence in several infectious diseases. However, the association between lymphopenia and the risk of redeveloping nontuberculous lung disease (NTM-LD) after completed treatment for MAC-LD is unknown.

METHODS

We performed a retrospective cohort study with 147 patients with MAC-LD who successfully completed guideline-based therapy. Lymphopenia was defined as an absolute lymphocyte count (ALC) <1000 cells/μL based on commonly accepted reference values.

RESULTS

During the median follow-up period of 41.9 months after treatment completion, 59 (40.1%) patients redeveloped NTM-LD. Patients with NTM-LD redevelopment had significantly lower posttreatment ALCs (median, 1260 vs 1420 cells/μL) than those without, and the univariate Cox proportional hazard analysis identified posttreatment ALC as a predictive factor for redevelopment (hazard ratio, .94 [95% confidence interval, .89-.99] for every increase of 100 cells/μL; P = .04). In the multivariate analysis, posttreatment ALC and the extent of bronchiectasis were independently associated with NTM-LD redevelopment. The cumulative rate of NTM-LD redevelopment was significantly higher in patients with posttreatment lymphopenia than in those without (P = .008).

CONCLUSIONS

Posttreatment lymphopenia could predict an increased risk of NTM-LD redevelopment after completed treatment for MAC-LD.

[Polymethylmethacrylate-augmented screw fixation in treatment of senile thoracolumbar tuberculosis combined with severe osteoporosis]

Objective

To explore the safety and effectiveness of polymethylmethacrylate-augmented screw fixation (PASF) in the treatment of elderly thoracolumbar tuberculosis combined with severe osteoporosis.

Methods

The clinical data of 20 elderly patients with thoracolumbar tuberculosis and severe osteoporosis who underwent PASF after anterior or posterior debridement and bone grafting and met the selection criteria between December 2012 and December 2014 were retrospectively analyzed. There were 8 males and 12 females with an average age of 68.5 years (range, 65-72 years). T value of bone mineral density was -4.2 to -3.6, with an average of -3.9. There were 12 cases of thoracic tuberculosis, 3 cases of thoracolumbar tuberculosis, and 5 cases of lumbar tuberculosis. The diseased segments involved T ₃-L ₄, including 11 cases of single-segment disease, 6 cases of double-segment disease, and 3 cases of multi-segment disease. The disease duration was 3-9 months, with an average of 6 months. The preoperative spinal nerve function of the patients was evaluated by the American Spinal Injury Association (ASIA) grading. There were 2 cases of grade A, 5 cases of grade B, 6 cases of grade C, 4 cases of grade D, and 3 cases of grade E. Postoperative imaging examination was used to evaluate the bone graft fusion and paravertebral abscess absorption, and to measure the Cobb angle of the segment to evaluate the improvement of kyphosis. The levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were tested. The visual analogue scale (VAS) score, Oswestry disability index (ODI), and ASIA grading were used to evaluate the effectivreness before operation, at 1 month after operation, and at last follow-up. The clinical cure of tuberculosis was also evaluated.

Results

All operation successfully completed. The operation time was 154-250 minutes, with an average of 202 minutes; the intraoperative blood loss was 368-656 mL, with an average of 512 mL. All 20 patients were followed up 18-42 months, with an average of 26.8 months. The postoperative pain and symptoms of tuberculosis in all patients relieved, and the paravertebral abscess was absorbed, reaching the cure standard for spinal tuberculosis. All bone grafts fusion achieved within 1 year after operation. Only 1 case had asymptomatic bone cement leakage into the paravertebral veins, and the remaining patients had no serious complications such as bone cement leakage in the spinal canal, pulmonary embolism, and neurovascular injury. At last follow-up, spinal cord nerve function significantly improved when compared with preoperative one. Among them, ASIA grading were 7 cases of grade C, 8 cases of grade D, and 5 cases of grade E, showing significant difference when compared with preoperative one ( Z=2.139, P=0.000). VAS score, ODI score, segmental Cobb angle, ESR, and CRP at 1 month after operation and at last follow-up were significantly improved when compared with preoperative ones ( P<0.05); there was no significant difference between 1 month after operation and last follow-up ( P>0.05). During the follow-up, no complications such as failure of internal fixation, proximal junctional kyphosis, or tuberculosis recurrence occurred.

Conclusion

For elderly patients with thoracolumbar tuberculosis and severe osteoporosis, PASF treatment is safe and effective.

The impact of performance status on tuberculosis-related death among elderly patients with lung tuberculosis: A competing risk regression analysis

While advanced age is a main prognostic factor in patients with tuberculosis, the factors that specifically affect tuberculosis-related death are unclear because elderly people are at a risk for other age-related lethal diseases. We aimed to assess the impact of performance status on tuberculosis-related death among elderly patients with lung tuberculosis. Elderly patients (≥65 years of age) admitted to our hospital for bacteriologically-diagnosed lung tuberculosis were included, and analyzed the influence of performance status on tuberculosis-related in-hospital death, with non-tuberculosis-related death as a competing risk. Forty and 19 of the 275 patients died from tuberculosis-related causes and non-tuberculosis-related causes, respectively. The tuberculosis-related death group had a greater number of patients with a poor performance status (defined as category 3 and 4 [HR 21.022; 95%CI 2.881-153.414; p = 0.003]), a lower serum albumin level (HR 0.179; 95%CI 0.090-0.359; p < 0.001) and a higher C-reactive protein level (HR1.076; 95%CI 1.026-1.127; p = 0.002). A multivariate competing risk regression analysis showed that a poor performance status (HR 7.311; 95%CI 1.005-53.181; p = 0.049) and low albumin level (HR 0.228; 95%CI 0.099-0.524); p = 0.001) significantly predicted tuberculosis-related death. Performance status can be a useful scale for predicting tuberculosis-related death among elderly patients with pulmonary tuberculosis.

A mini systematic review of prognostic factors in elderly patients with tuberculosis

BACKGROUND

While advanced age has been suggested as a prognostic factor in patients with tuberculosis, the characteristics associated with a poor outcome in elderly patients have remained unclear. The aim of this systematic review was to describe the risk factors for a poor outcome in elderly patients with tuberculosis.

METHODS

We identified 1255 studies published between 1919 and 2017 from the PubMed database by using combinations of the keywords "tuberculosis [Title/Abstract]" and "elderly [Title/Abstract]". Full texts of the studies that met the inclusion criteria were further evaluated by two independent investigators.

RESULTS

even retrospective cohort studies were included in this systematic review. More advanced age, comorbidities, and nutritional status were likely to be prognostic factors in Taiwan (aging country) and Japan (super-aged country), while human immunodeficiency virus infection and severe tuberculosis were associated with a poor outcome in low-income countries. Two studies from Taiwan investigated the prognostic factors of tuberculosis-specific death and non-tuberculosis-specific death separately, but no significant differences were found in the factors between the two types of death.

CONCLUSIONS

The prognostic factors of tuberculosis in elderly patients varied according to the income levels of the countries. The factors in Taiwan and Japan were mainly associated with host factors, irrespective of the cause of death, which may reflect senile deterioration due to old age.

Depressed Gamma Interferon Responses and Treatment Outcomes in Tuberculosis Patients: a Prospective Cohort Study

Immunosuppression induced by Mycobacterium tuberculosis is important in the pathogenesis of active tuberculosis (TB). However, the impact of depressed TB-specific and non-TB-specific gamma interferon (IFN-γ) response on the treatment outcomes of TB patients remains uncertain. In this prospective cohort study, culture- or pathology-proven active TB patients were enrolled and QuantiFERON-TB Gold In-Tube (QFT-GIT) assays were performed before the initiation of anti-TB treatment. TB-specific IFN-γ responses (TB antigen tube subtracted from the nil tube) and non-TB-specific IFN-γ responses (mitogen tube subtracted from the nil tube) were measured and associated with treatment outcomes, including 2-month culture conversion and on-treatment mortality. A total of 212 active TB patients were included in the analysis. We observed a close correlation between decreased lymphocyte count and lower non-TB-specific IFN-γ responses but not TB-specific IFN-γ responses. Patients with lower non-TB-specific IFN-γ responses had lower 2-month culture conversion rate (71.1% versus 84.7%, respectively; P = 0.033) and higher on-treatment mortality (22.6% versus 5.7%, respectively; P = 0.001) than those with higher non-TB-specific IFN-γ responses. In multivariate analysis, depressed non-TB-specific IFN-γ response was an independent factor associated with 2-month sputum culture nonconversion (odds ratio [OR], 2.49; 95% CI [95% confidence interval], 1.05 to 5.90) and on-treatment mortality (hazard ratio [HR], 2.76; 95% CI, 1.15 to 6.62). In contrast, depressed TB-specific IFN-γ responses were significantly associated with higher on-treatment mortality in univariate analysis but not in multivariate analysis. Our findings suggest that depressed non-TB-specific responses, but not TB-specific IFN-γ responses, as measured by QFT-GIT before the initiation of anti-TB treatment, were significantly associated with worse treatment outcomes in TB patients.

Predictors of In-Hospital Mortality among Patients with Pulmonary Tuberculosis: A Systematic Review and Meta-analysis

Background: There is uncertainty regarding which factors are associated with in-hospital mortality among patients with pulmonary TB (PTB). The aim of this systematic review and meta-analysis is to identify predictors of in-hospital mortality among patients with PTB. Methods: We searched MEDLINE, EMBASE, and Global Health, for cohort and case-control studies that reported risk factors for in-hospital mortality in PTB. We pooled all factors that were assessed for an association, and presented relative associations as pooled odds ratios (ORs). Results: We identified 2,969 records, of which we retrieved 51 in full text; 11 cohort studies that evaluated 5,468 patients proved eligible. Moderate quality evidence suggested an association with co-morbid malignancy and in-hospital mortality (OR 1.85; 95% CI 1.01–3.40). Low quality evidence showed no association with positive sputum smear (OR 0.99; 95% CI 0.40–2.48), or male sex (OR 1.09, 95% CI 0.84–1.41), and very low quality evidence showed no association with diabetes mellitus (OR 1.31, 95% IC 0.38–4.46), and previous TB infection (OR 2.66, 95% CI 0.48–14.87). Conclusion: Co-morbid malignancy was associated with increased risk of in-hospital death among pulmonary TB patients. There is insufficient evidence to confirm positive sputum smear, male sex, diabetes mellitus, and previous TB infection as predictors of in-hospital mortality in TB patients.

High blood neutrophil-lymphocyte ratio associated with poor outcomes in miliary tuberculosis

Background

It is difficult to predict the prognosis of miliary tuberculosis (TB). We hypothesized that blood neutrophil-lymphocyte ratio (NLR) is an indicator of inflammatory status to reflect independent prognostic significance in patients with miliary TB. The aim of this study is to investigate the relationship between NLR and outcome in miliary TB.

Methods

We retrospectively collected data from patients diagnosed with miliary TB in a tertiary referral hospital between January 1995 and January 2016.

Results

A total of 96 patients were enrolled. Seventeen patients (18%) died during hospitalization due to miliary TB, and 9 (9%) died additionally during the 1-year follow-up period. Eighteen patients (19%) were diagnosed with acute respiratory distress syndrome (ARDS). In multiple logistic regression analyses, increased NLR was associated with ARDS [adjusted odds ratio, 1.15; 95% confidence interval (CI), 1.03-1.28]. By multivariate Cox regression analysis with adjustment of known prognostic factors including age, sex, body mass index, serum aspartate aminotransferase (AST), and hemoglobin, NLR was an independent predictor of in-hospital mortality [adjusted hazard ratio (aHR), 1.08; 95% CI, 1.03-1.13] and 1-year mortality (aHR, 1.08; 95% CI, 1.05-1.12).

Conclusions

Pre-treatment NLR at admission may be a useful biomarker for mortality and development of ARDS in patients with miliary TB.

Experimental Mycobacterium bovis infection in three white rhinoceroses (Ceratotherium simum): Susceptibility, clinical and anatomical pathology

Tuberculosis caused by Mycobacterium bovis is endemic in the African buffalo (Syncerus caffer) population in the Kruger National Park and other conservation areas in South Africa. The disease has been diagnosed in a total of 21 free ranging or semi-free ranging wildlife species in the country with highly variable presentations in terms of clinical signs as well as severity and distribution of tuberculous lesions. Most species are spillover or dead-end hosts without significant role in the epidemiology of the disease. White rhinoceroses (Ceratotherium simum) are translocated from the Kruger National Park in substantial numbers every year and a clear understanding of their risk to manifest overt tuberculosis disease and to serve as source of infection to other species is required. We report the findings of experimental infection of three white rhinoceroses with a moderately low dose of a virulent field isolate of Mycobacterium bovis. None of the animals developed clinical signs or disseminated disease. The susceptibility of the white rhinoceros to bovine tuberculosis was confirmed by successful experimental infection based on the ante mortem isolation of M. bovis from the respiratory tract of one rhinoceros, the presence of acid-fast organisms and necrotizing granulomatous lesions in the tracheobronchial lymph nodes and the detection of M. bovis genetic material by PCR in the lungs of two animals.

Age, Dehydration, Respiratory Failure, Orientation Disturbance, and Blood Pressure Score Predicts In-hospital Mortality in HIV-negative Non-multidrug-resistant Smear-positive Pulmonary Tuberculosis in Japan

The A-DROP scoring system was originally designed to assess clinical severity of community acquired pneumonia using the following parameters: advanced Age, Dehydration, Respiratory failure, Orientation disturbance (confusion); and, low blood Pressure. Total A-DROP score ranges zero to five assigning one point for each component, wherein five indicates the poorest prognosis. The purpose of this single-center retrospective study was to determine whether A-DROP could predict the risk for death in patients with pulmonary tuberculosis. We reviewed consecutive HIV-negative, non-multidrug-resistant smear-positive adult pulmonary tuberculosis patients. The cohort consisted of 134 men (38.8%), 211 women (61.2%), 272 who discharged alive (28.8%), and 73 who died in-hospital (21.2%) with a median age of 72 (IQR: 54-82) years. A one-point increase in the A-DROP score was associated with a higher risk for in-hospital mortality with odds ratio of 3.8 (95% confidence interval 2.8-5.2, P < 0.001). The area under receiver operating characteristics curve was 0.86. The total score cutoff of 1.5 provided the best Youden Index of 0.61. Using this criteria, total score >1.5, sensitivity was 85% and specificity was 76%. Kaplan-Meier curve clearly indicated that in-hospital mortality increased with higher A-DROP scores (Log-rank test <0.001). In conclusion, A-DROP score clearly indicate pulmonary tuberculosis in-hospital mortality.

Lymphocytopenia may be a new indicator for infected obstructed kidneys secondary to urinary stone disease

Objective:

Infected obstructed kidney (IOK) is a urological emergency. We wanted to look at the role of serum inflammatory markers in these patients.

Materials and Methods:

Patients with IOK requiring percutaneous nephrostomy (PCN) at our university hospital were identified, and data were collected on lymphocyte count, C-reactive protein (CRP) and microbiology results.

Results:

Thirty-nine patients had PCN for IOK. Lymphocytopenia was seen in two-thirds of these patients. Severe lymphocytopenia was associated with a significant rise in CRP in all cases and following PCN, lymphocytopenia improved in the majority of cases.

Conclusions:

Lymphocytopenia seems to be associated with the severity of infection and could be a surrogate marker on its own or in conjunction with CRP for initial diagnosis and monitoring response to treatment in patients with IOKs.

Evaluation of Humoral Immunity to Mycobacterium tuberculosis-Specific Antigens for Correlation with Clinical Status and Effective Vaccine Development

Although tuberculosis remains a major global health problem, Bacille Calmette-Guérin (BCG) is the only available vaccine. However, BCG has limited applications, and a more effective vaccine is needed. Cellular mediated immunity (CMI) is thought to be the most important immune response for protection against Mycobacterium tuberculosis (Mtb). However, the recent failure of a clinical trial for a booster BCG vaccine and increasing evidence of antibody-mediated immunity prompted us to evaluate humoral immunity to Mtb-specific antigens. Using Enzyme-Linked ImmunoSpot and Enzyme-Linked ImmunoSorbent Assays, we observed less correlation of both CMI and IgG titers with patient clinical status, including serum concentration of C reactive protein. However, IgA titers against Mtb were significantly correlated with clinical status, suggesting that specific IgA antibodies protect against Mtb proliferation. In addition, in some cases, IgA antibody titers were significantly associated with the serum concentration of total albumin, which supports the idea that humoral immunity can be influenced by the nutritional status. Based on these observations, we propose that the induction of humoral immunity should be included as an option in TB vaccine development strategies.

Serum albumin as a significant prognostic factor in patients with malignant pleural mesothelioma

Our aim was to evaluate the prognostic role of the pretreatment serum albumin level in patients with malignant pleural mesothelioma (MPM) receiving platinum-based systemic chemotherapy. From 1995 to 2013, a total of 97 patients receiving platinum-based systemic chemotherapy for newly diagnosed MPM were enrolled. All clinical information and laboratory results were retrospectively collected from the medical records. The Kaplan-Meier method was used to calculate survival. The Cox proportional hazards model was used to identify significant independent prognostic factors for predicting survival. In total, 34 of the 97 patients (35.1 %) had hypoalbuminaemia (albumin ≤ 35 g/l). The 1-year overall survival rate was 44.1 % for patients with hypoalbuminaemia and 72.0 % for patients with a normal albumin level. Multivariate analysis indicated that pretreatment albumin was an independent prognostic factor in MPM. Patients with hypoalbuminaemia had a greater risk of death than those with a normal albumin level [hazard ratio (HR) 1.778; 95 % confidence interval (CI) 1.504-2.998; P = 0.031]. When albumin was entered as a continuous variable in the Cox regression model, the HR of death was significantly decreased by 9.8 % (95 % CI 0.851-0.956) for each 1-g/l increment. The pretreatment serum albumin level is a simple, inexpensive and easily measurable marker with prognostic significance in MPM patients treated with platinum-based systemic chemotherapy.

[Development of exudative tuberculosis during treatment for aspiration pneumonia in an elderly post-stroke patient with symptomatic epilepsy]

A 90-year-old man with a previous history of brain infarction and diabetes mellitus presented with a gait disturbance. Although brain computed tomography (CT) showed no abnormalities, except for the old infarction, the patient experienced recurrent epileptic seizures. He was therefore admitted to our hospital for a further examination of the seizures. However, upon admission, he also presented with a fever and elevated C-reactive protein levels, indicating systemic inflammation. Based on the presence of bilateral infiltration visible on a chest X-radiograph, the patient was diagnosed with aspiration pneumonia. The administration of 4.5 g of sulbactam and ampicillin did not reduce the inflammation or resolve the abnormal lung findings. Therefore, he was intubated and placed on a ventilator. With the patient under ventilator management, we subsequently performed bronchoscopic alveolar lavage. Elevated neutrophil and lymphocyte counts were noted in the alveolar lavage fluid; therefore, we administered pulse steroid therapy with 500 mg of methylprednisolone. The sputum and alveolar lavage fluid samples collected 13 and 14 days, respectively, after admission were negative for Mycobacterium according to a smear test. In contrast, the cultured sputum samples collected on day 13 were positive for Mycobacterium tuberculosis; polymerase chain reaction testing confirmed the sputum culture results. A postmortem pathological examination of the lungs revealed neutrophilic exudative pneumonia as well as acute fibrinous and organizing pneumonia. Although Ziehl-Neelsen staining demonstrated a large number of positive bacteria, no epithelioid-cell granulomas were observed. M. tuberculosis lesions were also found in the liver, spleen, bones, and adrenal glands, suggesting hematogenous dissemination. Aspiration pneumonia is very common in elderly patients with a history of stroke, and these patients are also at risk of other pulmonary disorders and infections including M. tuberculosis. Prior to administering treatment for aspiration pneumonia, clinicians should consider the potential for other pulmonary infiltration disorders in the differential diagnosis, particularly in elderly post-stroke patients.

Effect of albumin on transthyretin and amyloidogenic transthyretin Val30Met disposition and tissue deposition in familial amyloidotic polyneuropathy

AIMS

Transthyretin (TTR)-related familial amyloidotic polyneuropathy (FAP) is characterized by the systemic accumulation of amyloid fibrils caused by amyloidogenic. Our previous studies demonstrated that albumin played a role in the inhibition of TTR amyloid-formation. The aim of this study was to evaluate the effect of albumin on TTR disposition and tissue deposition in vivo.

MAIN METHODS

For pharmacokinetic studies, recombinant wild-type TTR (rTTR) and recombinant amyloidogenic TTR Val30Met (rATTR V30M) were labeled with iodine and administered to Sprague-Dawley rats and analbuminemia rats (NAR: Nagase Analbuminemia Rats). The deposition of ATTR V30M was also analyzed by immunohistochemistry in the transgenic (Tg) rats possessing a human ATTR V30M gene (ATTR V30M Tg rats) and NAR possessing a human ATTR V30M gene (ATTR V30M Tg NAR).

KEY FINDINGS

The presence of albumin had no effect on the tissue distribution of either rTTR or rATTR V30M. However, more ATTR V30M was deposited in the hearts, stomachs and small intestines of ATTR V30M Tg NAR rats, compared to ATTR V30M Tg rats.

SIGNIFICANCE

Although the disposition of TTR and ATTR V30M was unaffected by the presence of albumin, the deposition of ATTR V30M in some organs was apparently increased in the absence of albumin compared to the presence of albumin. These results show that albumin would contribute to suppressing the tissue deposition of TTR in pathogenesis of FAP, but does not affect the disposition of TTR.