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Mo S, Shi C, Cai Y, Xu M, Xu H, Xu Y, Zhang K, Zhang Y, Liu J, Che S, Liu X, Xing C, Long X, Chen X, Liu E. Single-cell transcriptome reveals highly complement activated microglia cells in association with pediatric tuberculous meningitis. Front Immunol 2024; 15:1387808. [PMID: 38745656 PMCID: PMC11091396 DOI: 10.3389/fimmu.2024.1387808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Abstract
Background Tuberculous meningitis (TBM) is a devastating form of tuberculosis (TB) causing high mortality and disability. TBM arises due to immune dysregulation, but the underlying immune mechanisms are unclear. Methods We performed single-cell RNA sequencing on peripheral blood mononuclear cells (PBMCs) and cerebrospinal fluid (CSF) cells isolated from children (n=6) with TBM using 10 xGenomics platform. We used unsupervised clustering of cells and cluster visualization based on the gene expression profiles, and validated the protein and cytokines by ELISA analysis. Results We revealed for the first time 33 monocyte populations across the CSF cells and PBMCs of children with TBM. Within these populations, we saw that CD4_C04 cells with Th17 and Th1 phenotypes and Macro_C01 cells with a microglia phenotype, were enriched in the CSF. Lineage tracking analysis of monocyte populations revealed myeloid cell populations, as well as subsets of CD4 and CD8 T-cell populations with distinct effector functions. Importantly, we discovered that complement-activated microglial Macro_C01 cells are associated with a neuroinflammatory response that leads to persistent meningitis. Consistently, we saw an increase in complement protein (C1Q), inflammatory markers (CRP) and inflammatory factor (TNF-α and IL-6) in CSF cells but not blood. Finally, we inferred that Macro_C01 cells recruit CD4_C04 cells through CXCL16/CXCR6. Discussion We proposed that the microglial Macro_C01 subset activates complement and interacts with the CD4_C04 cell subset to amplify inflammatory signals, which could potentially contribute to augment inflammatory signals, resulting in hyperinflammation and an immune response elicited by Mtb-infected tissues.
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Affiliation(s)
- Siwei Mo
- Department of Respiratory Medicine, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Chenyan Shi
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
- School of Public Health, Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China
| | - Yi Cai
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Maozhu Xu
- Maternal and Child Care Health Hospital of Zunyi City, Zunyi, Guizhou, China
| | - Hongmei Xu
- Department of Infectious Diseases, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yuzhong Xu
- Department of Clinical Laboratory, Shenzhen Baoan Hospital, The Second Affiliated Hospital of Shenzhen University, Shenzhen University, Shenzhen, China
| | - Kehong Zhang
- Department of Clinical Laboratory, Shenzhen Baoan Hospital, The Second Affiliated Hospital of Shenzhen University, Shenzhen University, Shenzhen, China
| | - Yue Zhang
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Jiao Liu
- Pediatric Research Institute, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Siyi Che
- Department of Radiology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiangyu Liu
- Department of Respiratory Medicine, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chaonan Xing
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Xiaoru Long
- Department of Respiratory Medicine, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xinchun Chen
- Guangdong Provincial Key Laboratory of Regional Immunity and Diseases, Department of Pathogen Biology, School of Medicine, Shenzhen University, Shenzhen, China
| | - Enmei Liu
- Department of Respiratory Medicine, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Paradkar MS, Devaleenal D B, Mvalo T, Arenivas A, Thakur KT, Wolf L, Nimkar S, Inamdar S, Giridharan P, Selladurai E, Kinikar A, Valvi C, Khwaja S, Gadama D, Balaji S, Yadav Kattagoni K, Venkatesan M, Savic R, Swaminathan S, Gupta A, Gupte N, Mave V, Dooley KE. Randomized Clinical Trial of High-Dose Rifampicin With or Without Levofloxacin Versus Standard of Care for Pediatric Tuberculous Meningitis: The TBM-KIDS Trial. Clin Infect Dis 2022; 75:1594-1601. [PMID: 35291004 PMCID: PMC9617573 DOI: 10.1093/cid/ciac208] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Pediatric tuberculous meningitis (TBM) commonly causes death or disability. In adults, high-dose rifampicin may reduce mortality. The role of fluoroquinolones remains unclear. There have been no antimicrobial treatment trials for pediatric TBM. METHODS TBM-KIDS was a phase 2 open-label randomized trial among children with TBM in India and Malawi. Participants received isoniazid and pyrazinamide plus: (i) high-dose rifampicin (30 mg/kg) and ethambutol (R30HZE, arm 1); (ii) high-dose rifampicin and levofloxacin (R30HZL, arm 2); or (iii) standard-dose rifampicin and ethambutol (R15HZE, arm 3) for 8 weeks, followed by 10 months of standard treatment. Functional and neurocognitive outcomes were measured longitudinally using Modified Rankin Scale (MRS) and Mullen Scales of Early Learning (MSEL). RESULTS Of 2487 children prescreened, 79 were screened and 37 enrolled. Median age was 72 months; 49%, 43%, and 8% had stage I, II, and III disease, respectively. Grade 3 or higher adverse events occurred in 58%, 55%, and 36% of children in arms 1, 2, and 3, with 1 death (arm 1) and 6 early treatment discontinuations (4 in arm 1, 1 each in arms 2 and 3). By week 8, all children recovered to MRS score of 0 or 1. Average MSEL scores were significantly better in arm 1 than arm 3 in fine motor, receptive language, and expressive language domains (P < .01). CONCLUSIONS In a pediatric TBM trial, functional outcomes were excellent overall. The trend toward higher frequency of adverse events but better neurocognitive outcomes in children receiving high-dose rifampicin requires confirmation in a larger trial. CLINICAL TRIALS REGISTRATION NCT02958709.
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Affiliation(s)
- Mandar S Paradkar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Bella Devaleenal D
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Tisungane Mvalo
- UNC Project Malawi, Lilongwe, Malawi,Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ana Arenivas
- Section of Neuropsychology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York, USA
| | - Lisa Wolf
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Smita Nimkar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Sadaf Inamdar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Prathiksha Giridharan
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | | | - Aarti Kinikar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Department of Pediatrics, BJ Government Medical College, Pune, India
| | - Chhaya Valvi
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Department of Pediatrics, BJ Government Medical College, Pune, India
| | - Saltanat Khwaja
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | | | - Sarath Balaji
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Krishna Yadav Kattagoni
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Mythily Venkatesan
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Radojka Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | | | - Amita Gupta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nikhil Gupte
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vidya Mave
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly E Dooley
- Correspondence: K. Dooley, Johns Hopkins University School of Medicine, 600 N Wolfe St, Osler 527, Baltimore, MD 21287 ()
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Salih R, van Toorn R, Seddon JA, Solomons RS. The Impact of Hyponatremia on the Severity of Childhood Tuberculous Meningitis. Front Neurol 2022; 12:703352. [PMID: 35069403 PMCID: PMC8766708 DOI: 10.3389/fneur.2021.703352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Hyponatremia and/or hypoglycorrhachia are commonly encountered biochemical derangements during the acute stage of childhood tuberculous meningitis (TBM). Few studies have explored the correlation between these derangements and the staging of TBM disease (severity), or explored their role as biomarkers for vascular ischemic events, hydrocephalus, or seizures. Methods: We aimed to identify the prevalence and the correlation between serum hyponatremia (mild, moderate and severe) and/or hypoglycorrhachia in relation to clinical TBM features such as stage of disease, seizures and stroke in children diagnosed with definite and probable TBM, between 1985 and 2015, at Tygerberg Hospital, Cape town, South Africa. Results: The prevalence of hyponatremia was 344 out of 481 (71.5%) patients; 169 (49.1%) had mild hyponatremia, 146 (42.4%) moderate hyponatremia and 29 (8.4%) severe hyponatremia. Children with severe hyponatremia had higher frequency of stroke [odds ratio (OR) 4.36, 95% confidence interval (CI) 1.24-15.35; p = 0.01], brainstem dysfunction (OR 7.37, 95% CI 2.92-18.61; p < 0.01), cranial nerve palsies (OR 2.48, 95% CI 1.04-5.91; p = 0.04) and non-communicating hydrocephalus (OR 2.66, 95% CI 1.09-6.44; p = 0.03). Children with moderate hyponatremia and mild hyponatremia compared to those without hyponatremia similarly were more likely to exhibit signs of brainstem dysfunction (OR 1.91, 95% CI 1.11-3.28; p = 0.02) and hydrocephalus (OR 3.18, 95% CI 1.25-8.09; p = 0.01), respectively. On multivariable analysis only brainstem dysfunction was significantly associated with severe hyponatremia [adjusted odds ratio (aOR) 4.46, 95% CI 1.62-12.30; p < 0.01]. Children with hypoglycorrhachia compared to normoglycorrhachia were more likely to have had longer symptom duration prior to admission (OR 1.87, 95% CI 1.09-3.20; p = 0.02), non-communicating hydrocephalus (OR 1.64, 95% CI 0.99-2.71; p = 0.05), higher cerebrospinal white cell counts (OR 3.00, 95% CI 1.47-6.12; p < 0.01) and higher CSF protein concentrations (OR 2.51, 95% CI 1.49-4.20; p < 0.01). On multivariable analysis raised CSF protein concentration >1 g/L was significantly associated with hypoglycorrhachia (aOR 2.52, 95% CI 1.44-4.40; p < 0.01). Death rates did not differ by sodium level category or presence of hypoglycorrachia, however an increasing trend of children that had demised was noted the more severe the sodium category. Conclusion: Hyponatremia and/or hypoglycorrhachia occur in more than two-thirds of children with TBM. Severe TBM disease complications such as brainstem dysfunction was associated with moderate hyponatremia, while severe hyponatremia was associated with brainstem dysfunction, stroke, cranial nerve palsies and non-communicating hydrocephalus. Cerebrospinal fluid (CSF) glucose depletion correlated with non-communicating hydrocephalus and increased CSF inflammation.
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Affiliation(s)
- Rashid Salih
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ronald van Toorn
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A. Seddon
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Regan S. Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Rohlwink UK, Mauff K, Wilkinson KA, Enslin N, Wegoye E, Wilkinson RJ, Figaji AA. Biomarkers of Cerebral Injury and Inflammation in Pediatric Tuberculous Meningitis. Clin Infect Dis 2017; 65:1298-1307. [PMID: 28605426 PMCID: PMC5815568 DOI: 10.1093/cid/cix540] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/08/2017] [Indexed: 12/27/2022] Open
Abstract
Background Tuberculous meningitis (TBM) leads to death or disability in half the affected individuals. Tools to assess severity and predict outcome are lacking. Neurospecific biomarkers could serve as markers of the severity and evolution of brain injury, but have not been widely explored in TBM. We examined biomarkers of neurological injury (neuromarkers) and inflammation in pediatric TBM and their association with outcome. Methods Blood and cerebrospinal fluid (CSF) of children with TBM and hydrocephalus taken on admission and over 3 weeks were analyzed for the neuromarkers S100B, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP), in addition to multiple inflammatory markers. Results were compared with 2 control groups: patients with (1) a fatty filum (abnormal filum terminale of the spinal cord); and (2) pulmonary tuberculosis (PTB). Imaging was conducted on admission and at 3 weeks. Outcome was assessed at 6 months. Results Data were collected from 44 patients with TBM (cases; median age, 3.3 [min-max 0.3-13.1] years), 11 fatty filum controls (median age, 2.8 [min-max 0.8-8] years) and 9 PTB controls (median age, 3.7 [min-max 1.3-11.8] years). Seven cases (16%) died and 16 (36%) had disabilities. Neuromarkers and inflammatory markers were elevated in CSF on admission and for up to 3 weeks, but not in serum. Initial and highest concentrations in week 1 of S100B and NSE were associated with poor outcome, as were highest concentration overall and an increasing profile over time in S100B, NSE, and GFAP. Combined neuromarker concentrations increased over time in patients who died, whereas inflammatory markers decreased. Cerebral infarcts were associated with highest overall neuromarker concentrations and an increasing profile over time. Tuberculomas were associated with elevated interleukin (IL) 12p40, interferon-inducible protein 10, and monocyte chemoattractant protein 1 concentrations, whereas infarcts were associated with elevated tumor necrosis factor α, macrophage inflammatory protein 1α, IL-6, and IL-8. Conclusions CSF neuromarkers are promising biomarkers of injury severity and are predictive of mortality. An increasing trend suggested ongoing brain injury, even though markers of inflammation declined with treatment. These findings could offer novel insight into the pathophysiology of TBM.
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Affiliation(s)
- Ursula K Rohlwink
- Division of Neurosurgery
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, and
| | - Katya Mauff
- Department of Statistical Science, University of Cape Town, South Africa; and
| | - Katalin A Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, and
- Francis Crick Institute and
| | | | | | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, and
- Francis Crick Institute and
- Department of Medicine, Imperial College London, United Kingdom
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Rohlwink UK, Kilborn T, Wieselthaler N, Banderker E, Zwane E, Figaji AA. Imaging Features of the Brain, Cerebral Vessels and Spine in Pediatric Tuberculous Meningitis With Associated Hydrocephalus. Pediatr Infect Dis J 2016; 35:e301-10. [PMID: 27213261 DOI: 10.1097/INF.0000000000001236] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric tuberculous meningitis (TBM) leads to high rates of mortality and morbidity. Prompt diagnosis and initiation of treatment are challenging; imaging findings play a key role in establishing the presumptive diagnosis. General brain imaging findings are well reported; however, specific data on cerebral vascular and spinal involvement in children are sparse. METHODS This prospective cohort study examined admission and followed up computed tomography brain scans and magnetic resonance imaging scans of the brain, cerebral vessels (magnetic resonance angiogram) and spine at 3 weeks in children treated for TBM with hydrocephalus (HCP; inclusion criteria). Exclusion criteria were no HCP on admission, treatment of HCP or commencement of antituberculosis treatment before study enrollment. Imaging findings were examined in association with outcome at 6 months. RESULTS Forty-four patients (median age 3.3 [0.3-13.1] years) with definite (54%) or probable TBM were enrolled. Good clinical outcome was reported in 72%; the mortality rate was 16%. Infarcts were reported in 66% of patients and were predictive of poor outcome. Magnetic resonance angiogram abnormalities were reported in 55% of patients. Delayed tuberculomas developed in 11% of patients (after starting treatment). Spinal pathology was more common than expected, occurring in 76% of patients. Exudate in the spinal canal increased the difficulty of lumbar puncture and correlated with high cerebrospinal fluid protein content. CONCLUSION TBM involves extensive pathology in the central nervous system. Severe infarction was predictive of poor outcome although this was not the case for angiographic abnormalities. Spinal disease occurs commonly and has important implications for diagnosis and treatment. Comprehensive imaging of the brain, spine and cerebral vessels adds insight into disease pathophysiology.
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