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Ramesh Kumar S, Narendran G, Padmapriyadarsini C. Role for Linezolid in drug sensitive tuberculosis. J Infect Public Health 2024; 17:172-174. [PMID: 38039860 DOI: 10.1016/j.jiph.2023.11.012] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 12/03/2023] Open
Abstract
Tuberculosis (TB) continues to be a global challenge. Reducing the duration of TB treatment for drug-sensitive TB (DSTB) has direct and distinct advantages. We ventured into the aspect of utilizing linezolid as a pivotal drug in shortening therapy in DSTB. Linezolid has gained prominence as it is faring well in resistant TB management. Only a few studies use the strategy of Linezolid in DS-TB but it seems a lucrative approach, the bactericidal effects have been reported favourably in the studies. There have been concerns about the potential adverse drug effects of Linezolid reported but clinical trials have demonstrated safety and tolerability when administered for shorter periods. If the safety and efficacy of giving Linezolid for a shorter period along with standard drugs for DSTB is established it could lead to newer avenues using Linezolid for shortening the duration of treatment for DSTB as an alternative to treat DSTB.
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Affiliation(s)
- S Ramesh Kumar
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Madurai unit, Madurai, India.
| | - G Narendran
- Department of Clinical Research,ICMR-National Institute for Research in Tuberculosis, Chennai, India
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Rosu L, Madan JJ, Tomeny EM, Muniyandi M, Nidoi J, Girma M, Vilc V, Bindroo P, Dhandhukiya R, Bayissa AK, Meressa D, Narendran G, Solanki R, Bhatnagar AK, Tudor E, Kirenga B, Meredith SK, Nunn AJ, Bronson G, Rusen ID, Squire SB, Worrall E. Economic evaluation of shortened, bedaquiline-containing treatment regimens for rifampicin-resistant tuberculosis (STREAM stage 2): a within-trial analysis of a randomised controlled trial. Lancet Glob Health 2023; 11:e265-e277. [PMID: 36565704 DOI: 10.1016/s2214-109x(22)00498-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The STREAM stage 2 trial assessed two bedaquiline-containing regimens for rifampicin-resistant tuberculosis: a 9-month all-oral regimen and a 6-month regimen containing an injectable drug for the first 2 months. We did a within-trial economic evaluation of these regimens. METHODS STREAM stage 2 was an international, phase 3, non-inferiority randomised trial in which participants with rifampicin-resistant tuberculosis were randomly assigned (1:2:2:2) to the 2011 WHO regimen (terminated early), a 9-month injectable-containing regimen (control regimen), a 9-month all-oral regimen with bedaquiline (oral regimen), or a 6-month regimen with bedaquiline and an injectable for the first 2 months (6-month regimen). We prospectively collected direct and indirect costs and health-related quality of life data from trial participants until week 76 of follow-up. Cost-effectiveness of the oral and 6-month regimens versus control was estimated in four countries (oral regimen) and two countries (6-month regimen), using health-related quality of life for cost-utility analysis and trial efficacy for cost-effectiveness analysis. This trial is registered with ISRCTN, ISRCTN18148631. FINDINGS 300 participants were included in the economic analyses (Ethiopia, 61; India, 142; Moldova, 51; Uganda, 46). In the cost-utility analysis, the oral regimen was not cost-effective in Ethiopia, India, Moldova, and Uganda from either a provider or societal perspective. In Moldova, the oral regimen was dominant from a societal perspective. In the cost-effectiveness analysis, the oral regimen was likely to be cost-effective from a provider perspective at willingness-to-pay thresholds per additional favourable outcome of more than US$4500 in Ethiopia, $1900 in India, $3950 in Moldova, and $7900 in Uganda, and from a societal perspective at thresholds of more than $15 900 in Ethiopia, $3150 in India, and $4350 in Uganda, while in Moldova the oral regimen was dominant. In Ethiopia and India, the 6-month regimen would cost tuberculosis programmes and participants less than the control regimen and was highly likely to be cost-effective in both cost-utility analysis and cost-effectiveness analysis. Reducing the bedaquiline price from $1·81 to $1·00 per tablet made the oral regimen cost-effective in the provider-perspective cost-utility analysis in India and Moldova and dominate over the control regimen in the provider-perspective cost-effectiveness analysis in India. INTERPRETATION At current costs, the oral bedaquiline-containing regimen for rifampicin-resistant tuberculosis is unlikely to be cost-effective in many low-income and middle-income countries. The 6-month regimen represents a cost-effective alternative if injectable use for 2 months is acceptable. FUNDING USAID and Janssen Research & Development.
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Affiliation(s)
- Laura Rosu
- Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Jason J Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Ewan M Tomeny
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Jasper Nidoi
- Makerere University Lung Institute, Kampala, Uganda
| | - Mamo Girma
- Addis Ababa Science and Technology University, Addis Ababa, Ethiopia
| | - Valentina Vilc
- Institute of Phthisiopneumology Chiril Draganiuc, Chisinau, Moldova
| | - Priyanka Bindroo
- Rajan Babu Institute for Pulmonary Medicine and Tuberculosis, Delhi, India
| | | | | | - Daniel Meressa
- St Peter's Tuberculosis Specialized Hospital and Global Health Committee, Addis Ababa, Ethiopia
| | | | | | - Anuj K Bhatnagar
- Rajan Babu Institute for Pulmonary Medicine and Tuberculosis, Delhi, India
| | - Elena Tudor
- Institute of Phthisiopneumology Chiril Draganiuc, Chisinau, Moldova
| | | | - Sarah K Meredith
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | | | | | | | - Eve Worrall
- Liverpool School of Tropical Medicine, Liverpool, UK
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Goodall RL, Meredith SK, Nunn AJ, Bayissa A, Bhatnagar AK, Bronson G, Chiang CY, Conradie F, Gurumurthy M, Kirenga B, Kiria N, Meressa D, Moodliar R, Narendran G, Ngubane N, Rassool M, Sanders K, Solanki R, Squire SB, Torrea G, Tsogt B, Tudor E, Van Deun A, Rusen ID. Evaluation of two short standardised regimens for the treatment of rifampicin-resistant tuberculosis (STREAM stage 2): an open-label, multicentre, randomised, non-inferiority trial. Lancet 2022; 400:1858-1868. [PMID: 36368336 PMCID: PMC7614824 DOI: 10.1016/s0140-6736(22)02078-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/05/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND The STREAM stage 1 trial showed that a 9-month regimen for the treatment of rifampicin-resistant tuberculosis was non-inferior to the 20-month 2011 WHO-recommended regimen. In STREAM stage 2, we aimed to compare two bedaquiline-containing regimens with the 9-month STREAM stage 1 regimen. METHODS We did a randomised, phase 3, non-inferiority trial in 13 hospital clinics in seven countries, in individuals aged 15 years or older with rifampicin-resistant tuberculosis without fluoroquinolone or aminoglycoside resistance. Participants were randomly assigned 1:2:2:2 to the 2011 WHO regimen (terminated early), a 9-month control regimen, a 9-month oral regimen with bedaquiline (primary comparison), or a 6-month regimen with bedaquiline and 8 weeks of second-line injectable. Randomisations were stratified by site, HIV status, and CD4 count. Participants and clinicians were aware of treatment-group assignments, but laboratory staff were masked. The primary outcome was favourable status (negative cultures for Mycobacterium tuberculosis without a preceding unfavourable outcome) at 76 weeks; any death, bacteriological failure or recurrence, and major treatment change were considered unfavourable outcomes. All comparisons used groups of participants randomly assigned concurrently. For non-inferiority to be shown, the upper boundary of the 95% CI should be less than 10% in both modified intention-to-treat (mITT) and per-protocol analyses, with prespecified tests for superiority done if non-inferiority was shown. This trial is registered with ISRCTN, ISRCTN18148631. FINDINGS Between March 28, 2016, and Jan 28, 2020, 1436 participants were screened and 588 were randomly assigned. Of 517 participants in the mITT population, 133 (71%) of 187 on the control regimen and 162 (83%) of 196 on the oral regimen had a favourable outcome: a difference of 11·0% (95% CI 2·9-19·0), adjusted for HIV status and randomisation protocol (p<0·0001 for non-inferiority). By 76 weeks, 108 (53%) of 202 participants on the control regimen and 106 (50%) of 211 allocated to the oral regimen had an adverse event of grade 3 or 4; five (2%) participants on the control regimen and seven (3%) on the oral regimen had died. Hearing loss (Brock grade 3 or 4) was more frequent in participants on the control regimen than in those on the oral regimen (18 [9%] vs four [2%], p=0·0015). Of 134 participants in the mITT population who were allocated to the 6-month regimen, 122 (91%) had a favourable outcome compared with 87 (69%) of 127 participants randomly assigned concurrently to the control regimen (adjusted difference 22·2%, 95% CI 13·1-31·2); six (4%) of 143 participants on the 6-month regimen had grade 3 or 4 hearing loss. INTERPRETATION Both bedaquiline-containing regimens, a 9-month oral regimen and a 6-month regimen with 8 weeks of second-line injectable, had superior efficacy compared with a 9-month injectable-containing regimen, with fewer cases of hearing loss. FUNDING USAID and Janssen Research & Development.
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Affiliation(s)
- Ruth L Goodall
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK.
| | - Sarah K Meredith
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Adamu Bayissa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Anuj K Bhatnagar
- Rajan Babu Institute for Pulmonary Medicine & Tuberculosis, Delhi, India
| | | | - Chen-Yuan Chiang
- Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; International Union against Tuberculosis and Lung Disease, Paris, France
| | | | | | - Bruce Kirenga
- Makerere University Lung Institute, Mulago Hospital, Kampala, Uganda
| | - Nana Kiria
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Daniel Meressa
- St Peter's Tuberculosis Specialized Hospital and Global Health Committee, Addis Ababa, Ethiopia
| | - Ronelle Moodliar
- Tuberculosis & HIV Investigative, Doris Goodwin Hospital, Pietermaritzburg, South Africa
| | | | | | - Mohammed Rassool
- Clinical HIV Research Unit, Helen Joseph Hospital, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Sanders
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | | | - S Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Elena Tudor
- Institute of Phthisiopneumology Chiril Draganiuc, Chisinau, Moldova
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Tibúrcio R, Narendran G, Barreto-Duarte B, Queiroz ATL, Araújo-Pereira M, Anbalagan S, Nayak K, Ravichandran N, Subramani R, Antonelli LRV, Satagopan K, Anbalagan K, Porter BO, Sher A, Swaminathan S, Sereti I, Andrade BB. Frequency of CXCR3+ CD8+ T-Lymphocyte Subsets in Peripheral Blood Is Associated With the Risk of Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome Development in Advanced HIV Disease. Front Immunol 2022; 13:873985. [PMID: 35432354 PMCID: PMC9011055 DOI: 10.3389/fimmu.2022.873985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a clinical aggravation of TB symptoms observed among a fraction of HIV coinfected patients shortly after the start of antiretroviral therapy (ART). Of note, TB-IRIS is characterized by exacerbated inflammation and tissue damage that occurs in response to the elevated production of CD4+ T cell-derived IFN-γ. Nevertheless, the possible participation of CD8+ T cells in TB-IRIS development remains unclear.MethodsWe performed a comprehensive assessment of the composition of CD8+ T cell memory subsets and their association with circulating inflammation-related molecules in TB-HIV coinfected patients initiating ART.ResultsWe found that TB-IRIS individuals display higher frequencies of Antigen-experienced CD8+ T cells during the onset of IRIS and that the levels of these cells positively correlate with baseline mycobacterial smear grade. TB-IRIS individuals exhibited higher frequencies of effector memory and lower percentages of naïve CD8+ T cells than their Non-IRIS counterparts. In both TB-IRIS and Non-IRIS patients, ART commencement was associated with fewer significant correlations among memory CD8+ T cells and cells from other immune compartments. Networks analysis revealed distinct patterns of correlation between each memory subset with inflammatory cytokines suggesting different dynamics of CD8+ T cell memory subsets reconstitution. TB-IRIS patients displayed lower levels of memory cells positive for CXCR3 (a chemokine receptor that plays a role in trafficking activated CD8+ T cells to the tissues) than Non-IRIS individuals before and after ART. Furthermore, we found that CXCR3+ naïve CD8+ T cells were inversely associated with the risk of TB-IRIS development. On the other hand, we noticed that the frequencies of CXCR3+ effector CD8+ T cells were positively associated with the probability of TB-IRIS development.ConclusionOur data suggest that TB-IRIS individuals display a distinct profile of memory CD8+ T cell subsets reconstitution after ART initiation. Moreover, our data point to a differential association between the frequencies of CXCR3+ CD8+ T cells and the risk of TB-IRIS development. Collectively, our findings lend insights into the potential role of memory CD8+ T cells in TB-IRIS pathophysiology.
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Affiliation(s)
- Rafael Tibúrcio
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Gopalan Narendran
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Beatriz Barreto-Duarte
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Curso de Medicina, Universidade Salvador (UNIFACS), Salvador, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Artur T. L. Queiroz
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
| | - Mariana Araújo-Pereira
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Selvaraj Anbalagan
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Kaustuv Nayak
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
- ICGEB-Emory Vaccine Centre, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | | | - Rajasekaran Subramani
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Lis R. V. Antonelli
- Laboratório de Biologia e Imunologia de Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brazil
| | | | | | - Brian O. Porter
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Soumya Swaminathan
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Bruno B. Andrade
- Laboratório de Inflamação e Biomarcadores, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
- Curso de Medicina, Universidade Salvador (UNIFACS), Salvador, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Wellcome Trust Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Curso de Medicina, Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States
- *Correspondence: Bruno B. Andrade,
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Esmail H, Narendran G, Nunn A. Drug-resistant tuberculosis: Promising progress with a note of caution. Indian J Med Res 2022; 155:325-328. [PMID: 36124505 PMCID: PMC9707677 DOI: 10.4103/ijmr.ijmr_677_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Hanif Esmail
- Medical Research Council (MRC), Clinical Trials Unit at UCL, London, UK,Institute for Global Health, Faculty of Population Health Sciences, University College London, London, UK,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease & Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gopalan Narendran
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai 600 031, Tamil Nadu, India
| | - Andrew Nunn
- Medical Research Council (MRC), Clinical Trials Unit at UCL, London, UK,For correspondence:
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Shanmugam S, Bachmann NL, Martinez E, Menon R, Narendran G, Narayanan S, Tripathy SP, Ranganathan UD, Sawleshwarkar S, Marais BJ, Sintchenko V. Whole genome sequencing based differentiation between re-infection and relapse in Indian patients with tuberculosis recurrence, with and without HIV co-infection. Int J Infect Dis 2021; 113 Suppl 1:S43-S47. [PMID: 33741489 DOI: 10.1016/j.ijid.2021.03.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/09/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Differentiation between relapse and reinfection in cases with tuberculosis (TB) recurrence has important implications for public health, especially in patients with human immunodeficiency virus (HIV) co-infection. We compared Mycobacterial Interspersed Repeat Unit (MIRU) typing and spoligotyping with whole genome sequencing (WGS) to differentiate between relapse and reinfection in patients (HIV-positive and HIV-negative) with TB recurrence. We also assessed the value of WGS to track acquired drug resistance in those with relapse after successful treatment. METHOD Forty-one paired M. tuberculosis isolates collected from 20 HIV-positive and 21 HIV-negative patients were subjected to WGS in addition to spoligotyping and MIRU typing. Phylogenetic and Single Nucleotide Substitution (SNP) clustering analyses were performed to determine whether recurrences were due to relapse or re-infection. RESULTS Comparison of M. tuberculosis genomes indicated that 95% of TB recurrences in the HIV-negative cohort were due to relapse, while the majority of TB recurrences (75%) in the HIV-positive cohort was due to reinfection (P = 0.0001). New drug resistance mutations were acquired in 5/24 cases (20.8%) that experienced relapse. CONCLUSIONS WGS provided increased resolution, but differentiation between relapse and reinfection was broadly consistent with MIRU and spoligotyping. The high contribution of reinfection among HIV infected patients experiencing TB recurrence warrants further study to explore risk factors for TB exposure.
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Affiliation(s)
- Sivakumar Shanmugam
- ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Nathan L Bachmann
- Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Sydney, New South Wales, Australia.
| | - Elena Martinez
- Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ranjeeta Menon
- Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Sydney, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - G Narendran
- ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Sujatha Narayanan
- ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Srikanth P Tripathy
- ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Uma Devi Ranganathan
- ICMR-National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Shailendra Sawleshwarkar
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, New South Wales, Australia
| | - Vitali Sintchenko
- Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Sydney, New South Wales, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
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Narendran G, Jyotheeswaran K, Senguttuvan T, Vinhaes CL, Santhanakrishnan RK, Manoharan T, Selvaraj A, Chandrasekaran P, Menon PA, Bhavani KP, Reddy D, Narayanan R, Subramanyam B, Sathyavelu S, Krishnaraja R, Kalirajan P, Angamuthu D, Susaimuthu SM, Ganesan RRK, Tripathy SP, Swaminathan S, Andrade BB. Characteristics of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome and its influence on tuberculosis treatment outcomes in persons living with HIV. Int J Infect Dis 2020; 98:261-267. [PMID: 32623087 DOI: 10.1016/j.ijid.2020.06.097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The influence of tuberculosis (TB)-immune reconstitution inflammatory syndrome (IRIS) on TB treatment outcomes and its risk factors were investigated among people with human immunodeficiency virus (HIV) and co-infected with TB. METHODS Newly diagnosed, culture-confirmed, pulmonary TB patients with HIV and enrolled in a clinical trial (NCT00933790) were retrospectively analysed for IRIS occurrence. Risk factors and TB outcomes (up to 18 months after initiation of anti-TB treatment [ATT]) were compared between people who experienced IRIS (IRIS group) and those who did not (non-IRIS group). RESULTS TB-IRIS occurred in 82 of 292 (28%) participants. Significant baseline risk factors predisposing to TB-IRIS occurrence in univariate analysis were: lower CD4+ T-cell count, CD4/CD8 ratio, haemoglobin levels, presence of extra-pulmonary TB focus, and higher HIV viral load; the last two retained significance in the multivariate analysis. After 2 months of ATT commencement, sputum smear conversion was documented in 45 of 80 (56.2%) vs. 124 of 194 (63.9%) (p=0.23), culture conversion was in 75 of 80 (93.7%) vs. 178 of 194 (91.7%) (p=0.57) and the median decline in viral load (log10copies/mm3) was 2.7 in the IRIS vs. 1.1 in the non-IRIS groups (p<0.0001), respectively. An unfavourable response to TB therapy was detected in 17 of 82 (20.7%) and 28 of 210 (13.3%) in the IRIS and non-IRIS groups, respectively (p=0.14). CONCLUSIONS TB-IRIS frequently occurred in people with advanced HIV infection and in those who presented with extra-pulmonary TB lesions, without influencing subsequent TB treatment outcomes.
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Affiliation(s)
- Gopalan Narendran
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Keerthana Jyotheeswaran
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Thirumaran Senguttuvan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil; Curso de Medicina, Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil
| | - Ramesh K Santhanakrishnan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Tamizhselvan Manoharan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Anbhalagan Selvaraj
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Pradeep A Menon
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Kannabiran P Bhavani
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Devarajulu Reddy
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Ravichandran Narayanan
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, Tamil Nadu, India
| | - Balaji Subramanyam
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Sekhar Sathyavelu
- Rajiv Gandhi Government General Hospital, Park Town, Chennai, Tamil Nadu, India
| | - Raja Krishnaraja
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, Tamil Nadu, India
| | - Pownraj Kalirajan
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Dhanalakshmi Angamuthu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | - Stella Mary Susaimuthu
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Srikanth P Tripathy
- National Institute for Research in Tuberculosis, Indian Council of Medical Research Chennai, Tamil Nadu, India
| | | | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil; Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil; Curso de Medicina, Faculdade de Tecnologia e Ciências (UniFTC), Salvador, Brazil; Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil; Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil; Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Narendran G, Oliveira-de-Souza D, Vinhaes CL, Akrami K, Fukutani KF, Banu K, Chandrasekaran P, Ravichandran N, Sereti I, Swaminathan S, Andrade BB. Multifocal tuberculosis-associated immune reconstitution inflammatory syndrome - a case report of a complicated scenario. BMC Infect Dis 2019; 19:529. [PMID: 31208430 PMCID: PMC6580602 DOI: 10.1186/s12879-019-4182-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [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: 04/11/2019] [Accepted: 06/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB)-associated Immune reconstitution inflammatory syndrome (TB-IRIS) is an aberrant inflammatory response in TB patients with advanced human immunodeficiency virus coinfection, after antiretroviral therapy commencement. CASE PRESENTATION We present a rare case of a 51-year-old woman living with HIV who developed a series of TB-IRIS events occurring at multiple sites sequentially, highlighting the clinical complexity in diagnosis and management. CONCLUSION This case illustrates how complicated a clinical scenario of successive TB-IRIS episodes can be, in terms of clinical management.
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Affiliation(s)
- Gopalan Narendran
- National Institute for Research in Tuberculosis, Chennai, 600031, India
| | - Deivide Oliveira-de-Souza
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | - Caian L Vinhaes
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | - Kevan Akrami
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Division of Infectious Diseases, Department of Medicine, University of California, San Diego, USA
| | - Kiyoshi F Fukutani
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil.,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil.,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil
| | | | | | | | - Irini Sereti
- National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Bruno B Andrade
- Instituto GonçaloMoniz, Fundação Oswaldo Cruz, Salvador, 40296-710, Brazil. .,Multinational Organization Network SponsoringTranslationaland Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, 40210-320, Brazil. .,Curso de Medicina, Faculdade de Tecnologia e Ciências (FTC), Salvador, 40290-150, Brazil. .,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, 7925, South Africa. .,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA. .,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, 41720-200, Brazil. .,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, 40290-000, Brazil.
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9
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Silveira-Mattos PS, Narendran G, Akrami K, Fukutani KF, Anbalagan S, Nayak K, Subramanyam S, Subramani R, Vinhaes CL, Souza DOD, Antonelli LR, Satagopan K, Porter BO, Sher A, Swaminathan S, Sereti I, Andrade BB. Author Correction: Differential expression of CXCR3 and CCR6 on CD4 + T-lymphocytes with distinct memory phenotypes characterizes tuberculosis-associated immune reconstitution inflammatory syndrome. Sci Rep 2019; 9:8036. [PMID: 31123316 PMCID: PMC6533265 DOI: 10.1038/s41598-019-44429-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Paulo S Silveira-Mattos
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | | | - Kevan Akrami
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Division of Infectious Diseases, Department of Medicine, University of California, San Diego, United States of America
| | - Kiyoshi F Fukutani
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | | | - Kaustuv Nayak
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | - Deivide Oliveira-de Souza
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | - Lis R Antonelli
- Laboratório de Biologia e Imunologia de Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais, Brazil
| | - Kumar Satagopan
- Government Hospital of Thoracic Medicine, Tambaram, Chennai, India
| | - Brian O Porter
- Clinical HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Irini Sereti
- Clinical HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil. .,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil. .,Wellcome Trust Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa. .,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Bahia, Brazil. .,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Bahia, Brazil. .,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
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10
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Natrajan M, Sridhar R, Narendran G, Ramachandran G, Kumar VV, Tripathy S. Crusade for TB: Bringing Treatment to Masses at their Doorsteps. Indian J Med Res 2019; 149:S89-S93. [PMID: 31070184 PMCID: PMC6515743 DOI: 10.4103/0971-5916.251664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Mohan Natrajan
- ICMR - National Institute For Research in Tuberculosis (ICMR - NIRT), Chennai, India
| | | | - Gopalan Narendran
- ICMR - National Institute For Research in Tuberculosis (ICMR - NIRT), Chennai, India
| | - Geetha Ramachandran
- ICMR - National Institute For Research in Tuberculosis (ICMR - NIRT), Chennai, India
| | | | - Srikanth Tripathy
- ICMR - National Institute For Research in Tuberculosis (ICMR - NIRT), Chennai, India
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11
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Silveira-Mattos PS, Narendran G, Akrami K, Fukutani KF, Anbalagan S, Nayak K, Subramanyam S, Subramani R, Vinhaes CL, Souza DOD, Antonelli LR, Satagopan K, Porter BO, Sher A, Swaminathan S, Sereti I, Andrade BB. Differential expression of CXCR3 and CCR6 on CD4 + T-lymphocytes with distinct memory phenotypes characterizes tuberculosis-associated immune reconstitution inflammatory syndrome. Sci Rep 2019; 9:1502. [PMID: 30728405 PMCID: PMC6365576 DOI: 10.1038/s41598-018-37846-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/12/2018] [Indexed: 11/09/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) occurs in up to 40% of individuals co-infected with pulmonary tuberculosis (PTB) and HIV, primarily upon antiretroviral therapy (ART) initiation. Phenotypic changes in T-cells during TB-IRIS and their relationship with systemic inflammation are not fully understood. In this prospective cohort study, we followed 48 HIV-positive patients with PTB from South India before and after ART initiation, examining T-lymphocyte subsets and inflammatory biomarkers in peripheral blood. Quantification of naïve (CD27+CD45RO-) as well as effector memory CD4+ T cells (CD27-CD45RO+) at weeks 2-6 after ART initiation could distinguish TB-IRIS from non-IRIS individuals. Additional analyses revealed that ART reconstituted different quantities of CD4+ T lymphocyte subsets with preferential expansion of CXCR3+ CCR6- cells in TB-IRIS patients. Moreover, there was an expansion and functional restoration of central memory (CD27+CD45RO+) CXCR3+CCR6- CD4+ lymphocytes and corresponding cytokines, with reduction in CXCR3-CCR6+ cells after ART initiation only in those who developed TB-IRIS. Together, these observations trace a detailed picture of CD4+ T cell subsets tightly associated with IRIS, which may serve as targets for prophylactic and/or therapeutic interventions in the future.
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Affiliation(s)
- Paulo S Silveira-Mattos
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | | | - Kevan Akrami
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Division of Infectious Diseases, Department of Medicine, University of California, San Diego, United States of America
| | - Kiyoshi F Fukutani
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | | | - Kaustuv Nayak
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Caian L Vinhaes
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | - Deivide Oliveira-de Souza
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil
| | - Lis R Antonelli
- Laboratório de Biologia e Imunologia de Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais, Brazil
| | - Kumar Satagopan
- Government Hospital of Thoracic Medicine, Tambaram, Chennai, India
| | - Brian O Porter
- Clinical HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Irini Sereti
- Clinical HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Salvador, Bahia, Brazil. .,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Bahia, Brazil. .,Wellcome Trust Centre for Infectious Disease Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa. .,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Bahia, Brazil. .,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Bahia, Brazil. .,Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
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12
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Padmapriyadarsini C, Ramesh K, Sekar L, Ramachandran G, Reddy D, Narendran G, Sekar S, Chandrasekar C, Anbarasu D, Wanke C, Swaminathan S. Factors affecting high-density lipoprotein cholesterol in HIV-infected patients on nevirapine-based antiretroviral therapy. Indian J Med Res 2018; 145:641-650. [PMID: 28948955 PMCID: PMC5644299 DOI: 10.4103/ijmr.ijmr_1611_15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background & objectives: Cardiovascular disease (CVD) risk with low high-density lipoprotein cholesterol (HDL-C) and high triglycerides is common in the general population in India. As nevirapine (NVP)-based antiretroviral therapy (ART) tends to increase HDL-C, gene polymorphisms associated with HDL-C metabolism in HIV-infected adults on stable NVP-based ART were studied. Methods: A cross-sectional study was conducted between January 2013 and July 2014 among adults receiving NVP-based ART for 12-15 months. Blood lipids were estimated and gene polymorphisms in apolipoprotein C3 (APOC3), cholesteryl ester transfer protein (CETP) and lipoprotein lipase (LPL) genes were analyzed by real-time polymerase chain reaction. Framingham's 10-yr CVD risk score was estimated. Logistic regression was done to show factors related to low HDL-C levels. Results: Of the 300 patients included (mean age: 38.6±8.7 yr; mean CD4 count 449±210 cell/μl), total cholesterol (TC) >200 mg/dl was observed in 116 (39%) patients. Thirty nine per cent males and 47 per cent females had HDL-C levels below normal while 32 per cent males and 37 per cent females had TC/HDL ratio of 4.5 and 4.0, respectively. Body mass index [adjusted odds ratio (aOR)=1.70, 95% confidence interval (CI) 1.01-2.84, P=0.04] and viral load (aOR=3.39, 95% CI: 1.52-7.52, P=0.003) were negatively associated with serum HDL-C levels. The 10-yr risk score of developing CVD was 11-20 per cent in 3 per cent patients. Allelic variants of APOC3 showed a trend towards low HDL-C. Interpretation & conclusions: High-risk lipid profiles for atherosclerosis and cardiovascular disease were common among HIV-infected individuals, even after 12 months of NVP-based ART. Targeted interventions to address these factors should be recommended in the national ART programmes.
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Affiliation(s)
- C Padmapriyadarsini
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - K Ramesh
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - L Sekar
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Geetha Ramachandran
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Devaraj Reddy
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - G Narendran
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - S Sekar
- ART Centre, Rajiv Gandhi Government General Hospital, Chennai, India
| | - C Chandrasekar
- Nodal ART Medical Officer, Government Hospital of Thoracic Medicine, Chennai, India
| | - D Anbarasu
- ART Centre, Government Vellore Medical College & Hospital, Vellore, India
| | - Christine Wanke
- Department of Medicine, Tufts University School of Medicine, Boston, USA
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13
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Narendran G, Swaminathan S. TB-HIV co-infection: a catastrophic comradeship. Oral Dis 2017; 22 Suppl 1:46-52. [PMID: 27109272 DOI: 10.1111/odi.12389] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 08/07/2015] [Accepted: 11/12/2015] [Indexed: 11/30/2022]
Abstract
The symbiotic association of tuberculosis (TB) and HIV poses a challenge to human survival. HIV complicates every aspect of TB including presentation, diagnosis and treatment. HIV-TB patients encounter unique problems like drug-drug interactions, cumulative toxicity, immune reconstitution inflammatory syndrome (IRIS), lower plasma drug levels and emergence of drug resistance during treatment despite adherence. TB may also be overdiagnosed in HIV due to a number of diseases that closely resemble TB. Notable among them are non-tuberculous mycobacteria, Pneumocystis Jirovecii and Nocardia. Even though diagnostic procedures have improved over the years, patients in developing countries usually seek health care at later stage of the disease. Research data ascertains the duration of therapy for TB to be 6 months with rifampicin and isoniazid, reinforced with ethambutol and pyrazinamide in the first 2 months. The schedule of therapy is still debatable with daily regimens being preferred in the context of HIV. Many reasons exist for persistence of Mycobacterium Tuberculosis (M.TB) in sputum, or delayed-clearance of TB from sputum smears in HIV, apart from emergence of drug resistance and non-compliance. Acquired rifampicin resistance (ARR) is a unique phenomenon complicating HIV-associated TB when an intermittent regimen of antituberculosis therapy (ATT) is used without timely initiation of highly active antiretroviral therapy (HAART), especially in patients harbouring isoniazid-resistant strains Immune restoration is often incomplete ('swiss cheese' pattern) even with effective HAART if not started early. Immune reconstitution inflammatory syndrome (IRIS) is the paradoxical worsening of the patient's condition often with radiological deterioration, due to an enhanced immune response with HAART. IRIS occurs despite an effective virological suppression and a favourable response to ATT. The incidence of IRIS in HIV has reached up to 54%, requiring utilization of experts and tertiary care which forms an obstacle to the decentralization of patients in the ART programme. Research in HIV-TB immunology and management needs further exploration in order to understand the diseases and offer appropriate treatment. The following paragraphs provide scientific evidences generated through research that could potentially guide management.
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Affiliation(s)
- G Narendran
- National Institute for Research in Tuberculosis, Chennai, India
| | - S Swaminathan
- National Institute for Research in Tuberculosis, Chennai, India
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14
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Narendran G, Kavitha D, Karunaianantham R, Gil-Santana L, Almeida-Junior JL, Reddy SD, Kumar MM, Hemalatha H, Jayanthi NN, Ravichandran N, Krishnaraja R, Prabhakar A, Manoharan T, Nithyananthan L, Arjunan G, Natrajan M, Swaminathan S, Andrade BB. Role of LTA4H Polymorphism in Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome Occurrence and Clinical Severity in Patients Infected with HIV. PLoS One 2016; 11:e0163298. [PMID: 27643598 PMCID: PMC5028072 DOI: 10.1371/journal.pone.0163298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/03/2016] [Indexed: 11/24/2022] Open
Abstract
Background Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an inflammatory phenomenon complicating HIV management in coincidental tuberculosis (TB) infection, upon immune reconstitution driven by antiretroviral therapy (ART). Leukotriene A4 hydroxylase (LTA4H), an enzyme which converts LTA4 to LTB4, regulates the balance between the anti-inflammatory lipoxins and pro-inflammatory LTB4, with direct implications in TB-driven inflammation. In humans, a single nucleotide polymorphism (SNP) in the LTA4H promoter which regulates its transcriptional activity (rs17525495) has been identified and described to impact clinical severity of TB presentation and response to corticosteroid therapy. Notably, the role of LTA4H on TB-IRIS has not been previously evaluated. Here, we performed an exploratory investigation testing the association of LTA4H polymorphism with respect to frequency of TB-IRIS occurrence and severity of TB-IRIS presentation in HIV-TB co-infected individuals. Methods Genotypic evaluation of the LTA4H enzyme from available samples was retrospectively correlated with clinical data captured in case sheets including IRIS details. The cohort included patients recruited from a prospective cohort study nested within a randomized clinical trial (NCT0933790) of ART-naïve HIV+ patients with newly diagnosed rifampicin sensitive pulmonary TB in South India. Frequency of the wild type genotype (CC), as well as of the mutant genotypes (CT or TT) in the IRIS and non-IRIS patients was estimated. Comparative analyses were performed between wild genotype (CC) and the mutant genotypes (CT or TT) and tested for association between the LTA4H polymorphisms and IRIS incidence and clinical severity. Results A total of 142 eligible ART-naïve patients were included in the analyses. Eighty-six individuals exhibited the wild genotype (CC) while 56 had mutant genotypes (43-CT and only 13-TT). Variant allele frequency was 0.23 and 0.26 in non-IRIS group and in IRIS group, respectively. Upon ART initiation, 51 patients developed IRIS while 91 did not. IRIS incidence was 34% and 37% in the wild (CC) and mutant type (CT/TT), respectively (p = 0.858) with a higher frequency of severe IRIS presentation in the mutant genotype group compared to the wild type genotype (p = 0.0006). A logistic regression model confirmed the association between the presence of CT/TT genotypes and occurrence of severe IRIS. Corticosteroid therapy successfully resolved IRIS in all cases irrespective of the LTA4H genotype. Conclusion A higher incidence of severe IRIS among patients with mutant LTA4H genotypes (CT and TT) was observed compared to the wild type, despite similar IRIS incidence and immune restoration in both groups. Steroids were effective in alleviating IRIS in all the genotypes.
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Affiliation(s)
| | | | | | - Leonardo Gil-Santana
- Unidade de Medicina Investigativa, Laboratótio Integrado de Microbiologia e Imunorregulação, Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | - Jilson L. Almeida-Junior
- Unidade de Medicina Investigativa, Laboratótio Integrado de Microbiologia e Imunorregulação, Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
| | | | | | | | | | | | - Raja Krishnaraja
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, India
| | | | | | | | | | - Mohan Natrajan
- National Institute for Research in Tuberculosis, Chennai, India
| | - Soumya Swaminathan
- National Institute for Research in Tuberculosis, Chennai, India
- India Council of Medical Research, Health secretary, Department of Health Research, Ministry of Health and Family Welfare, New Delhi, India
| | - Bruno B. Andrade
- Unidade de Medicina Investigativa, Laboratótio Integrado de Microbiologia e Imunorregulação, Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Fundação José Silveira, Salvador, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
- * E-mail:
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15
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Ramachandran G, Hemanthkumar AK, Rajasekaran S, Padmapriyadarsini C, Narendran G, Anitha S, Subramanyam S, Kumaraswami V, Swaminathan S. Steady-State Pharmacokinetics of Nevirapine in HIV-1 Infected Adults in India. ACTA ACUST UNITED AC 2016; 6:251-4. [PMID: 18216399 DOI: 10.1177/1545109707301344] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVES A variety of demographic factors, sex, and degree of immunosuppression can influence antiretroviral drug concentrations. The authors studied the influence of immune status, sex, and body mass index (BMI) on the steady-state pharmacokinetics of nevirapine delivered as a fixed-dose combination in HIV-1-infected patients in India. METHODS Twenty-six HIV-1-infected adult patients undergoing treatment with nevirapine-based highly active antiretroviral therapy regimens participated in the study. Pharmacokinetic variables were compared between patients divided based on CD4 cell counts, sex, and BMI. RESULTS Patients with higher BMI had lower peak and trough concentration and exposure of nevirapine than those with lower BMI; none of the differences in the pharmacokinetic variables of nevirapine between the various patient groups was statistically significant. CONCLUSIONS Patients' immune status, sex, or BMI had no impact on the pharmacokinetics of nevirapine. Plasma nevirapine concentrations were maintained within the therapeutic range of the drug in the majority of the patients.
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Affiliation(s)
- Geetha Ramachandran
- HIV/AIDS Division, Tuberculosis Research Centre (Indian Council of Medical Research), Chennai, India
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16
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Hemanth Kumar AK, Narendran G, Kumar RS, Ramachandran G, Sekar L, Raja K, Swaminathan S. RMP exposure is lower in HIV-infected TB patients receiving intermittent than daily anti-tuberculosis treatment. Int J Tuberc Lung Dis 2016; 19:805-7. [PMID: 26056105 DOI: 10.5588/ijtld.14.0702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We compared the pharmacokinetics of rifampicin (RMP) during daily and intermittent (thrice weekly) anti-tuberculosis treatment in human immunodeficiency virus infected tuberculosis patients. Patients treated with a thrice-weekly regimen had significantly lower plasma peak concentration, area under the time concentration curve from 0 to 24 h and higher oral clearance of RMP than those treated with the daily regimen. The median values were respectively 3.7 and 6.4 μg/ml (P < 0.001), 20.7 and 29.4 μg/ml.h (P = 0.03) and 21.7 and 15.3 ml/min (P = 0.03).
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Affiliation(s)
| | - G Narendran
- National Institute for Research in Tuberculosis, Chennai, India
| | - R S Kumar
- National Institute for Research in Tuberculosis, Chennai, India
| | - G Ramachandran
- National Institute for Research in Tuberculosis, Chennai, India
| | - L Sekar
- National Institute for Research in Tuberculosis, Chennai, India
| | - K Raja
- Government Hospital of Thoracic Medicine, Chennai, India
| | - S Swaminathan
- National Institute for Research in Tuberculosis, Chennai, India
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17
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Narendran G, Swaminathan S. Reply to Daskapan et al. Clin Infect Dis 2015; 61:138-9. [PMID: 25810287 DOI: 10.1093/cid/civ240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Andrade BB, Singh A, Narendran G, Schechter ME, Nayak K, Subramanian S, Anbalagan S, Jensen SMR, Porter BO, Antonelli LR, Wilkinson KA, Wilkinson RJ, Meintjes G, van der Plas H, Follmann D, Barber DL, Swaminathan S, Sher A, Sereti I. Mycobacterial antigen driven activation of CD14++CD16- monocytes is a predictor of tuberculosis-associated immune reconstitution inflammatory syndrome. PLoS Pathog 2014; 10:e1004433. [PMID: 25275318 PMCID: PMC4183698 DOI: 10.1371/journal.ppat.1004433] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 08/29/2014] [Indexed: 01/07/2023] Open
Abstract
Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an aberrant inflammatory response occurring in a subset of TB-HIV co-infected patients initiating anti-retroviral therapy (ART). Here, we examined monocyte activation by prospectively quantitating pro-inflammatory plasma markers and monocyte subsets in TB-HIV co-infected patients from a South Indian cohort at baseline and following ART initiation at the time of IRIS, or at equivalent time points in non-IRIS controls. Pro-inflammatory biomarkers of innate and myeloid cell activation were increased in plasma of IRIS patients pre-ART and at the time of IRIS; this association was confirmed in a second cohort in South Africa. Increased expression of these markers correlated with elevated antigen load as measured by higher sputum culture grade and shorter duration of anti-TB therapy. Phenotypic analysis revealed the frequency of CD14++CD16− monocytes was an independent predictor of TB-IRIS, and was closely associated with plasma levels of CRP, TNF, IL-6 and tissue factor during IRIS. In addition, production of inflammatory cytokines by monocytes was higher in IRIS patients compared to controls pre-ART. These data point to a major role of mycobacterial antigen load and myeloid cell hyperactivation in the pathogenesis of TB-IRIS, and implicate monocytes and monocyte-derived cytokines as potential targets for TB-IRIS prevention or treatment. Tuberculosis and HIV majorly impact host immune responses, resulting in immune deregulation and inflammation-driven tissue damage. Initiation of anti-retroviral therapy in patients with HIV-TB co-infection may result in immune reconstitution inflammatory syndrome (TB-IRIS), a disorder associated with increased immunopathology due to unfettered inflammation after CD4+ T-cell reconstitution. Monocytes are critical to the innate immune system and play an important role in several inflammatory conditions associated with chronic infections. Immunopathogenesis of TB-IRIS has been linked to activation of the adaptive immune response against opportunistic infection, yet the role of monocytes is still unknown. Here we investigated associations between soluble markers of monocyte activation, differential activation of monocyte subsets and TB-IRIS prospectively in two geographically distinct HIV-TB co-infected patient cohorts. Prior to ART initiation, patients who developed IRIS displayed a biosignature of elevated soluble monocyte activation markers, which were closely related to the mycobacterial antigen load in sputum samples. Amongst monocyte subsets, we observed that pre-ART circulating CD14++CD16− cell frequency independently predicted TB-IRIS and expanded during IRIS events. This monocyte subset was tightly associated with systemic markers of inflammation, and was found to produce inflammatory cytokines. Identification of this monocyte subset and its link with inflammation may lead to conception of novel therapies reducing immunopathology in TB-IRIS.
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Affiliation(s)
- Bruno B. Andrade
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail: (BBA); (IS)
| | - Amrit Singh
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Melissa E. Schechter
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Kaustuv Nayak
- National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Stig M. R. Jensen
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Brian O. Porter
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Lis R. Antonelli
- Laboratório de Imunopatologia, Centro de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais, Brazil
| | - Katalin A. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Imperial College London, London, United Kingdom
- MRC National Institute for Medical Research, London, United Kingdom
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Helen van der Plas
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Dean Follmann
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Daniel L. Barber
- T-Lymphocyte Biology Unit, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Alan Sher
- Immunobiology Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Irini Sereti
- Clinical and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail: (BBA); (IS)
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Narendran G, Menon PA, Venkatesan P, Vijay K, Padmapriyadarsini C, Ramesh Kumar S, Bhavani KP, Sekar L, Gomathi SN, Chandrasekhar C, Kumar S, Sridhar R, Swaminathan S. Acquired rifampicin resistance in thrice-weekly antituberculosis therapy: impact of HIV and antiretroviral therapy. Clin Infect Dis 2014; 59:1798-804. [PMID: 25156114 DOI: 10.1093/cid/ciu674] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Risk factors for acquired rifampicin resistance (ARR) in human immunodeficiency virus (HIV)/tuberculosis coinfection, in the highly active antiretroviral therapy (HAART) era, needs evaluation. We studied the impact of HIV and HAART on ARR among patients taking thrice-weekly antituberculosis therapy. METHODS This cross-protocol analysis included patients with newly diagnosed, rifampicin-susceptible pulmonary tuberculosis, with and without HIV, enrolled in clinical trials (who took >80% of medication) at the National Institute for Research in Tuberculosis between 1999 and 2013. All patients received rifampicin and isoniazid for 6 months reinforced with pyrazinamide and ethambutol in the first 2 months, given thrice-weekly throughout the study along with HAART in one of the groups. Outcomes were categorized and multivariate logistic regression analysis performed to identify risk factors for ARR. RESULTS The per-protocol results included patients with tuberculosis: 246 HIV-uninfected patients (HIV(-)TB(+)), 212 HIV patients not on HAART (non-HAART), and 116 HIV-infected patients on HAART. Median CD4 counts of the latter 2 groups were 150 and 93 cells/µL, respectively, and the median viral loads were 147 000 and 266 000 copies/mL, respectively. Compared with HIV(-)TB(+), the relative risks (RRs) for an unfavorable response in the coinfected, non-HAART and HAART groups were 2.1 (95% confidence interval [CI], 1.7-14.8; P<.0001) and 2.1 (95% CI, .9-5.2; P=.3), whereas for ARR, the RRs were 21.1 (95% CI, 2.6-184; P<.001) and 8.2 (95% CI, .6-104; P=.07), respectively. CONCLUSIONS HIV-infected patients with tuberculosis treated with a thrice-weekly antituberculosis regimen are at a higher risk of ARR, compared with HIV-uninfected patients, in the presence of baseline isoniazid resistance. HAART reduces but does not eliminate the risk of ARR.
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Affiliation(s)
- Gopalan Narendran
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Chetpet
| | - Pradeep Aravindan Menon
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Chetpet
| | - Perumal Venkatesan
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Chetpet
| | - Krishnamoorthy Vijay
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Chetpet
| | | | | | | | - Lakshmanan Sekar
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Chetpet
| | | | | | - Satagopan Kumar
- Government Hospital of Thoracic Medicine, Tambaram Sanatorium
| | | | - Soumya Swaminathan
- National Institute for Research in Tuberculosis (formerly Tuberculosis Research Centre), Chetpet
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Kumar R, Menon PA, Ponnuraja C, Padmapriyadarsini C, Narendran G, Iliayas S, Subramanyam S, Kumar V, Swaminathan S. HIV-infected patients retreated for tuberculosis with intermittent Category II regimen--treatment outcome at 24-month follow-up. Indian J Tuberc 2014; 61:43-50. [PMID: 24640344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND The management of tuberculosis re-treatment in HIV-infected individuals is complex. The clinical and radiological manifestations in this group and response to Category II treatment is not well described. METHODS We performed a prospective cohort study of HIV-infected patients retreated for TB due to failure, relapse or default after treatment, at Tuberculosis Research Centre, Chennai, between February 2001 to September 2005. The Category II regimen followed in the TB programme in India (RNTCP) was administered (2 months of Streptomycin (S), Ethambutol (E), INH (H), Rifampicin (R), Pyrazinamide (Z)/1 month of EHRZ/5 months of HRE all given thrice weekly). Antiretroviral treatment was not routinely available at that time. RESULTS Of the 42 patients enrolled, 35 (83%) were males. The mean age was 33.2 (SD-6.3) years. Cough was the commonest (67%) presenting symptom and opacities were the commonest (48%) radiographic occurrence. 31 patients were culture-positive at baseline, drug susceptibility results showed that 21 (68%) were fully susceptible to all first line drugs, four patients (13%) had MDR TB and four had resistance to INH alone. Among the 31 culture-positive patients, 15 patients (48.4%) completed treatment and were declared cured, of whom two subsequently relapsed. All four MDR patients died. Six patients who received ART, survived. CONCLUSION Only 50% of HIV-infected, ART-naive patients who were retreated for tuberculosis using an intermittent Category II regimen had a favourable response to treatment. Early detection of MDRTB and concurrent antiretroviral therapy could contribute to improved outcomes.
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Narendran G, Andrade BB, Porter BO, Chandrasekhar C, Venkatesan P, Menon PA, Subramanian S, Anbalagan S, Bhavani KP, Sekar S, Padmapriyadarshini C, Kumar S, Ravichandran N, Raja K, Bhanu K, Mahilmaran A, Sekar L, Sher A, Sereti I, Swaminathan S. Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) in HIV patients with culture confirmed pulmonary tuberculosis in India and the potential role of IL-6 in prediction. PLoS One 2013; 8:e63541. [PMID: 23691062 PMCID: PMC3656926 DOI: 10.1371/journal.pone.0063541] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 04/02/2013] [Indexed: 12/14/2022] Open
Abstract
Background The incidence, manifestations, outcome and clinical predictors of paradoxical TB-IRIS in patients with HIV and culture confirmed pulmonary tuberculosis (PTB) in India have not been studied prospectively. Methods HIV+ patients with culture confirmed PTB started on anti-tuberculosis therapy (ATT) were followed prospectively after anti-retroviral therapy (ART) initiation. Established criteria for IRIS diagnosis were used including decline in plasma HIV RNA at IRIS event. Pre-ART plasma levels of interleukin (IL)-6 and C-reactive protein (CRP) were measured. Univariate and multivariate logistic regression models were used to evaluate associations between baseline variables and IRIS. Results Of 57 patients enrolled, 48 had complete follow up data. Median ATT-ART interval was 28 days (interquartile range, IQR 14–47). IRIS events occurred in 26 patients (54.2%) at a median of 11 days (IQR: 7–16) after ART initiation. Corticosteroids were required for treatment of most IRIS events that resolved within a median of 13 days (IQR: 9–23). Two patients died due to CNS TB-IRIS. Lower CD4+ T-cell counts, higher plasma HIV RNA levels, lower CD4/CD8 ratio, lower hemoglobin, shorter ATT to ART interval, extra-pulmonary or miliary TB and higher plasma IL-6 and CRP levels at baseline were associated with paradoxical TB-IRIS in the univariate analysis. Shorter ATT to ART interval, lower hemoglobin and higher IL-6 and CRP levels remained significant in the multivariate analysis. Conclusion Paradoxical TB–IRIS frequently complicates HIV-TB therapy in India. IL-6 and CRP may assist in predicting IRIS events and serve as potential targets for immune interventions.
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Affiliation(s)
| | - Bruno B. Andrade
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Brian O. Porter
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | | | | | | | | | | | | | | | - Satagopan Kumar
- Government Hospital of Thoracic Medicine, Tambaram, Chennai, India
| | | | - Krishnaraj Raja
- Government Hospital of Thoracic Medicine, Tambaram, Chennai, India
| | | | | | | | - Alan Sher
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Soumya Swaminathan
- National Institute for Research in Tuberculosis, Chennai, India
- * E-mail:
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Swaminathan S, Padmapriyadarsini C, Venkatesan P, Narendran G, Ramesh Kumar S, Iliayas S, Menon PA, Selvaraju S, Pooranagangadevi NP, Bhavani PK, Ponnuraja C, Dilip M, Ramachandran R. Efficacy and safety of once-daily nevirapine- or efavirenz-based antiretroviral therapy in HIV-associated tuberculosis: a randomized clinical trial. Clin Infect Dis 2011; 53:716-24. [PMID: 21890776 DOI: 10.1093/cid/cir447] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Nevirapine (NVP) can be safely and effectively administered once-daily but has not been assessed in human immunodeficiency virus (HIV)-infected patients with tuberculosis (TB). We studied the safety and efficacy of once-daily NVP, compared with efavirenz (EFV; standard therapy); both drugs were administered in combination with 2 nucleoside reverse-transcriptase inhibitors. METHODS An open-label, noninferiority, randomized controlled clinical trial was conducted at 3 sites in southern India. HIV-infected patients with TB were treated with a standard short-course anti-TB regimen (2EHRZ(3)/4RH(3); [2 months of Ethambutol, Isoniazid, Rifampicin, Pyrazinamide / 4 months of Isoniazid and Rifampicin] thrice weekly) and randomized to receive once-daily EFV at a dose of 600 mg or NVP at a dose of 400 mg (after 14 days of 200 mg administered once daily) with didanosine 250/400 mg and lamivudine 300 mg after 2 months. Sputum smears and mycobacterial cultures were performed every month. CD4+ cell count, viral load, and liver function test results were monitored periodically. Primary outcome was a composite of death, virological failure, default, or serious adverse event (SAE) at 24 weeks. Both intent-to-treat and per protocol analyses were done, and planned interim analyses were performed. RESULTS A total of 116 patients (75% [87 patients] of whom had pulmonary TB), with a mean age of 36 years, a median CD4+ cell count of 84 cells/mm(3), and a median viral load of 310 000 copies/mL, were randomized. At 24 weeks, 50 of 59 patients in the EFV group and 37 of 57 patients in the NVP group had virological suppression (P = .024). There were no deaths, 1 SAE, and 5 treatment failures in the EFV arm, compared with 5 deaths, 2 SAEs, and 10 treatment failures in the NVP arm. The trial was halted by the data and safety monitoring board at the second interim analysis. Favorable TB treatment outcomes were observed in 93% of the patients in the EFV arm and 84% of the patients in the NVP arm (P = .058). CONCLUSIONS Compared with a regimen of didanosine, lamivudine, and EFV, a regimen of once-daily didanosine, lamivudine, and NVP was inferior and was associated with more frequent virologic failure and death. Clinical Trials Registration. NCT00332306.
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Affiliation(s)
- Soumya Swaminathan
- Department of Clinical Research, Tuberculosis Research Centre, Indian Council of Medical Research, Chennai, India.
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Abstract
Human immunodeficiency virus (HIV) associated tuberculosis (TB) remains a major global public health challenge, with an estimated 1.4 million patients worldwide. Co-infection with HIV leads to challenges in both the diagnosis and treatment of tuberculosis. Further, there has been an increase in rates of drug resistant tuberculosis, including multi-drug (MDR-TB) and extensively drug resistant TB (XDRTB), which are difficult to treat and contribute to increased mortality. Because of the poor performance of sputum smear microscopy in HIV-infected patients, newer diagnostic tests are urgently required that are not only sensitive and specific but easy to use in remote and resource-constrained settings. The treatment of co-infected patients requires antituberculosis and antiretroviral drugs to be administered concomitantly; challenges include pill burden and patient compliance, drug interactions, overlapping toxic effects, and immune reconstitution inflammatory syndrome. Also important questions about the duration and schedule of anti-TB drug regimens and timing of antiretroviral therapy remain unanswered. From a programmatic point of view, screening of all HIV-infected persons for TB and vice-versa requires good co-ordination and communication between the TB and AIDS control programmes. Linkage of co-infected patients to antiretroviral treatment centres is critical if early mortality is to be prevented. We present here an overview of existing diagnostic strategies, new tests in the pipeline and recommendations for treatment of patients with HIV-TB dual infection.
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Affiliation(s)
- C. Padmapriyadarsini
- National Institute for Research in Tuberculosis (Indian Council of Medical Research), Chennai, India
| | - G. Narendran
- National Institute for Research in Tuberculosis (Indian Council of Medical Research), Chennai, India
| | - Soumya Swaminathan
- National Institute for Research in Tuberculosis (Indian Council of Medical Research), Chennai, India
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Padmapriyadarsini C, Ramesh Kumar S, Terrin N, Narendran G, Menon PA, Ramachandran G, Subramanyan S, Venkatesan P, Wanke C, Swaminathan S. Dyslipidemia among HIV-infected Patients with tuberculosis taking once-daily nonnucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in India. Clin Infect Dis 2011; 52:540-6. [PMID: 21252141 PMCID: PMC3060904 DOI: 10.1093/cid/ciq195] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Our aim was to study the incidence and pattern of dyslipidemia among human immunodeficiency virus (HIV)-infected patients with tuberculosis (TB) who received once-daily antiretroviral therapy (ART). METHODS Antiretroviral-naive HIV-infected patients with TB were recruited to a trial of once-daily nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based ART and treated with rifampicin-based thrice-weekly antituberculosis treatment (ATT); participants were randomized to receive didanosine (250/400 mg) and lamivudine (300 mg) with either efavirenz (600 mg) or nevirapine (400 mg) once-daily after an intensive phase of ATT. Fasting triglyceride (TG) level, total cholesterol (TC) level, low-density cholesterol (LDL-c) level and high-density cholesterol (HDL-c) level were measured at baseline and at 6 and 12 months. Lipid levels at 6 and 12 months were compared with baseline values with use of repeated measures analyses. McNemar test was used to compare the proportion of patients with lipid abnormality at baseline versus at 12 months, and χ² test was used to compare between the 2 groups. RESULTS Of 168 patients (79% men; mean age, 36 years; mean weight, 42 kg; median CD4+ cell count, 93 cells/mm³), 104 received efavirenz-based ART, and 64 received nevirapine-based ART. After 6 months, TC levels increased by 49 mg/dL, LDL-c levels by 30 mg/dL, and HDL-c levels increased by 18 mg/dL (P < .001 for all). At baseline and at 12 months, TC was >200 mg/dL for 1% and 26% of patients, respectively; LDL-c level was >130 mg/dL for 3% and 23%, respectively; HDL-c level was <40 mg/dL for 91% and 23%, respectively; and blood glucose level was >110 mg/dL for 14% and 13%, respectively. TC level >200 mg/dL was more common among patients who received efavirenz than among those who received nevirapine (32% vs 16%; P = .04). CONCLUSIONS HIV-infected patients with TB who initiate NNRTI-based ART undergo complex changes in lipid profile, highlighting the importance of screening and treating other cardiovascular disease risk factors in this population.
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Abstract
The human immunodeficiency virus (HIV) epidemic has led to an increase in the incidence of tuberculosis globally, particularly in sub-Saharan Africa. Coinfection with HIV leads to difficulties in both the diagnosis and treatment of tuberculosis. Because of the poor performance of sputum smear microscopy in HIV-infected patients, more sensitive tests-such as liquid culture systems, nucleic acid amplification assays, and detection of mycobacterial products in various body fluids-are being investigated. The treatment of coinfected patients requires antituberculosis and antiretroviral drugs to be administered concomitantly; challenges include pill burden and patient compliance, drug interactions, overlapping toxic effects, and immune reconstitution syndrome. Both multidrug-resistant and extensively drug-resistant tuberculosis can spread rapidly among an immunocompromised population, with resulting high mortality rates. Current guidelines recommend starting antiretroviral treatment within a few weeks of antituberculosis therapy for patients with CD4 cell counts <350 cells/microL; however, important questions about the drug regimens and timing of antiretroviral therapy remain. Ongoing trials may answer many of these unresolved questions.
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Affiliation(s)
- Soumya Swaminathan
- Tuberculosis Research Centre, Indian Council of Medical Research, Chennai, India.
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Padmapriyadarsini C, Swaminathan S, Karthipriya MJ, Narendran G, Menon PA, Thomas BE. Morphologic and body composition changes are different in men and women on generic combination antiretroviral therapy--an observational study. J Assoc Physicians India 2010; 58:375-377. [PMID: 21125779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Increasingly effective therapies for HIV infection, combination antiretroviral therapy, are now widely available in developing countries. A range of metabolic complications presenting as abnormalities of body-fat mass distribution in association with dyslipidemia and glucose homeostasis dysregulation, have been recognized as important toxicities in patients treated with these drugs. With increasing use of antiretroviral therapy in India, we examined the association between gender and body shape and composition, one year after initiating combination antiretroviral therapy and attempted to identify simple clinical markers to detect and monitor these changes. METHODS Patients on combination antiretroviral therapy (2 NRTIs + 1 NNRTI), attending a HIV clinic between July 2005 and December 2006 had anthropometry clinical examination and bioelectric impedance analysis (BIA) performed along with blood tests at baseline and after 1 year. RESULTS Of the 34 patients on combination antiretroviral therapy, 5 males and 12 females had noticeable changes in their body shape. Significant decrease in triceps skin fold thickness, an increase in waist circumference and waist: hip ratio was observed in females. BIA did not show any change in total body fat in either sex. CONCLUSIONS Since the presence and severity of fat redistribution could affect adherence as well as the success of antiretroviral therapy, close monitoring is required to detect and prevent this complication early.
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Affiliation(s)
- C Padmapriyadarsini
- Department of Clinical Research, Tuberculosis Research Centre (ICMR), Chennai, India
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Narayanan S, Swaminathan S, Supply P, Shanmugam S, Narendran G, Hari L, Ramachandran R, Locht C, Jawahar M, Narayanan P. Impact of HIV Infection on the Recurrence of Tuberculosis in South India. J Infect Dis 2010; 201:691-703. [DOI: 10.1086/650528] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Swaminathan S, Narendran G, Venkatesan P, Iliayas S, Santhanakrishnan R, Menon PA, Padmapriyadarsini C, Ramachandran R, Chinnaiyan P, Suhadev M, Sakthivel R, Narayanan PR. Efficacy of a 6-month versus 9-month intermittent treatment regimen in HIV-infected patients with tuberculosis: a randomized clinical trial. Am J Respir Crit Care Med 2009; 181:743-51. [PMID: 19965813 DOI: 10.1164/rccm.200903-0439oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The outcome of fully intermittent thrice-weekly antituberculosis treatment of various durations in HIV-associated tuberculosis is unclear. OBJECTIVES To compare the efficacy of an intermittent 6-month regimen (Reg6M: 2EHRZ(3)/4HR(3) [ethambutol, 1,200 mg; isoniazid, 600 mg; rifampicin, 450 or 600 mg depending on body weight <60 or > or =60 kg; and pyrazinamide, 1,500 mg for 2 mo; followed by 4 mo of isoniazid and rifampicin at the same doses]) versus a 9-month regimen (Reg9M: 2EHRZ(3)/7HR(3)) in HIV/tuberculosis (TB). METHODS HIV-infected patients with newly diagnosed pulmonary or extrapulmonary TB were randomly assigned to Reg6M (n = 167) or Reg9M (n = 160) and monitored by determination of clinical, immunological, and bacteriological parameters for 36 months. Primary outcomes included favorable responses at the end of treatment and recurrences during follow-up, whereas the secondary outcome was death. Intent-to-treat and on-treatment analyses were performed. All patients were antiretroviral treatment-naive during treatment. MEASUREMENTS AND MAIN RESULTS Of the patients, 70% had culture-positive pulmonary TB; the median viral load was 155,000 copies/ml and the CD4(+) cell count was 160 cells/mm(3). Favorable response to antituberculosis treatment was similar by intent to treat (Reg6M, 83% and Reg9M, 76%; P = not significant). Bacteriological recurrences occurred significantly more often in Reg6M than in Reg9M (15 vs. 7%; P < 0.05) although overall recurrences were not significantly different (Reg6M, 19% vs. Reg9M, 13%). By 36 months, 36% of patients undergoing Reg6M and 35% undergoing Reg9M had died, with no significant difference between regimens. All 19 patients who failed treatment developed acquired rifamycin resistance (ARR), the main risk factor being baseline isoniazid resistance. CONCLUSIONS Among antiretroviral treatment-naive HIV-infected patients with TB, a 9-month regimen resulted in a similar outcome at the end of treatment but a significantly lower bacteriological recurrence rate compared with a 6-month thrice-weekly regimen. ARR was high with these intermittent regimens and neither mortality nor ARR was altered by lengthening TB treatment. Clinical Trials Registry Information: ID# NCT00376012 registered at www.clinicaltrials.gov.
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Affiliation(s)
- Soumya Swaminathan
- Tuberculosis Research Center, Indian Council of Medical Research, Chetput, Chennai, India.
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Raghavan S, Selvaraj P, Swaminathan S, Narendran G. Short communication: association of HLA-A*1101 with resistance and B*4006 with susceptibility to HIV and HIV-TB: an in silico analysis of promiscuous T cell epitopes. AIDS Res Hum Retroviruses 2009; 25:1023-8. [PMID: 19803716 DOI: 10.1089/aid.2009.0022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We have shown the association of HLA-A*11 with resistance and HLA-B*40 and -DR2 with susceptibility to HIV and HIV-TB. In the present study, we performed high-resolution subtyping of HLA-A*11 and -B*40 to identify the subtype level association, using the polymerase chain reaction-based sequence-specific oligonucleotide probe method. Underrepresentation of HLA-A*1101 was observed in overall HIV [p(c) = 0.012, OR 0.42 (95% confidence interval (CI) 0.24-0.72)] and HIV(+)TB(+) [p(c) = 0.001, OR 0.18 (95% CI 0.06-0.46)] compared to healthy controls. Significantly higher frequencies of HLA-B*4006 were observed in overall HIV [p = 0.0001, p(c) = 0.004, OR 2.71 (95% CI 1.58-4.75)], HIV(+)TB(-) [p = 0.0003, p(c) = 0.008, OR 2.82 (95% CI 1.56-5.17)], and HIV(+)TB(+) [p = 0.003, p(c) = 0.086, OR 2.56 (95% CI 1.33-4.95)] compared to healthy controls. An in silico analysis of potential T cell epitopes of consensus Gag and Pol sequences of HIV-1 subtype C Indian strains revealed relatively higher number of promiscuous HLA-B40, HLA-DRB1*1501, and -DRB1*1502 (HLA-DR2)-restricted epitopes in contrast to limited numbers of promiscuous binders restricted by HLA-A*1101. The results suggest that HLA-A*1101 may be associated with protection against HIV and the development of TB in HIV patients while HLA-B*4006 may be associated with susceptibility to HIV and TB development in HIV patients. The present study also suggests that the extent of promiscuity of T cell epitopes of HIV-1 subtype C restricted by HLA alleles exerting opposing effects might differ.
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Affiliation(s)
- S. Raghavan
- Department of Immunology, Tuberculosis Research Centre, Indian Council of Medical Research, Chetput, Chennai-600 031, India
| | - P. Selvaraj
- Department of Immunology, Tuberculosis Research Centre, Indian Council of Medical Research, Chetput, Chennai-600 031, India
| | - S. Swaminathan
- Department of Clinical Research, Tuberculosis Research Centre, Indian Council of Medical Research, Chetput, Chennai-600 031, India
| | - G. Narendran
- Department of Clinical Research, Tuberculosis Research Centre, Indian Council of Medical Research, Chetput, Chennai-600 031, India
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Hemanth Kumar AK, Ramachandran G, Rajasekaran S, Padmapriyadarsini C, Narendran G, Anitha S, Subramanyam S, Kumaraswami V, Swaminathan S. Pharmacokinetics of lamivudine & stavudine in generic fixed-dose combinations in HIV-1 infected adults in India. Indian J Med Res 2009; 130:451-7. [PMID: 19942751 PMCID: PMC2853745] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND & OBJECTIVES Antiretroviral drug concentrations are important determinants of clinical response to a drug accounting for both toxicity and efficacy. Several factors such as age, ethnicity, body weight and patients' immune status may influence antiretroviral drug concentrations. The aim of the study was to determine the influence of immunological status, sex and body mass index on the steady state pharmacokinetics of lamivudine (3TC) and stavudine (d4T) in HIV-infected adults, who were undergoing treatment with generic fixed dose combinations (FDC) of these drugs in India. METHODS Twenty seven HIV-1 infected patients receiving antiretroviral treatment (ART) for at least two weeks at the Government ART clinic at Tambaram, Chennai, took part in the study. Serial blood samples were collected predosing and at different time points after drug administration. Plasma 3TC and d4T levels were estimated by HPLC. RESULTS The patients' immune status, sex or body mass index had no impact on the pharmacokinetics of 3TC. In the case of d4T, peak concentration was significantly lower in patients with CD4 cell counts < 200 cells/microl than those with > or = 200 cells/ microl (P < 0.05), but were within the therapeutic range. The mean CD4 cell counts increased from 101 cells/microl at initiation of ART to 366 cells/microl at 12 months of treatment. INTERPRETATION & CONCLUSIONS Blood levels of 3TC and d4T drugs that are part of generic FDCs commonly used by HIV-infected individuals in India were within the therapeutic range and not influenced by nutritional or immune status. There was a significant improvement in CD4 cell counts over 12 months of treatment. Indian generic FDCs manufactured and used widely in the developing world provide effective concentrations of antiretroviral drugs.
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Affiliation(s)
- A K Hemanth Kumar
- Department of Clinical Research, Tuberculosis Research Centre (ICMR), Chennai, India
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Alagarasu K, Selvaraj P, Swaminathan S, Raghavan S, Narendran G, Narayanan PR. CCR2, MCP-1, SDF-1a & DC-SIGN gene polymorphisms in HIV-1 infected patients with & without tuberculosis. Indian J Med Res 2009; 130:444-450. [PMID: 19942750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND & OBJECTIVES Variability in the clinical outcome of persons exposed to and infected with HIV-1 and tuberculosis (TB) is determined by multiple factors including host genetic variations. The aim of the present study was to find out whether chemokine, chemokine receptor and DC-SIGN gene polymorphisms were associated with susceptibility or resistance to HIV and HIV-TB in south India. METHODS CCR2 V64I (G/A), monocyte chemoattractant protein-1 (MCP-1) -2518 A/G, stromal cell derived factor-1alpha; (SDF-1alpha) 3'UTR G/A and DC-SIGN gene polymorphisms were studied by polymerase chain reaction based methods in HIV-1 infected patients without TB (n=151), with pulmonary TB (PTB) (n=81) and extrapulmonary TB (n=31), 155 PTB patients without HIV and 206 healthy controls. RESULTS The genotype frequencies of CCR2 V64I, MCP-1 -2518 and DC-SIGN polymorphisms did not differ significantly between the study groups. A significantly increased frequency of GG genotype of SDF-1alpha polymorphism was observed among HIV+PTB+ patients compared to healthy controls (P=0.009, Pc=0.027). INTERPRETATION & CONCLUSIONS Our data suggest that GG genotype of SDF-1alpha 3'UTR polymorphism may be associated with susceptibility to PTB in HIV-1 infected patients. A better understanding of genetic factors that are associated with TB could help target preventive strategies to those HIV patients likely to develop tuberculosis.
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Affiliation(s)
- K Alagarasu
- Tuberculosis Research Centre (ICMR), Chennai, India
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Raghavan S, Selvaraj P, Swaminathan S, Alagarasu K, Narendran G, Narayanan PR. Haplotype analysis of HLA-A, -B antigens and -DRB1 alleles in south Indian HIV-1-infected patients with and without pulmonary tuberculosis. Int J Immunogenet 2009; 36:129-33. [PMID: 19392836 DOI: 10.1111/j.1744-313x.2009.00835.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We have shown earlier the association of human leucocyte antigen (HLA)-A11 with resistance and HLA-B40 and -DR2 with susceptibility to HIV and HIV-TB. In the present study, we have attempted to find out the HLA-DR2 subtypes and the possible HLA-A/-B/-DRB1 haplotype combinations that are associated with susceptibility or resistance to HIV and HIV with pulmonary tuberculosis (HIV+PTB+). HLA-DR2 subtyping was carried out by polymerase chain reaction-based sequence-specific oligonucleotide probe method. Overrepresentation of HLA-DRB1*1501 in HIV-positive PTB-negative (HIV+PTB-) patients (P = 0.004, P(c) = 0.06) and -DRB1*1502 in HIV-positive PTB-positive (HIV+PTB+) patients (P = 0.019) was observed as compared to healthy controls. Haplotype analysis revealed an increased frequency of HLA-A2-DRB1*1501 haplotype in HIV+PTB- patients (P = 0.008) and HLA-A2-DRB1*1502 among HIV+PTB+ patients (P = 0.01) compared to healthy controls. The haplotypes B40-DRB1*1501 and B40-DRB1*04 were found to be moderately increased in HIV+PTB(-) and HIV+PTB+ patients (P < 0.05). The study suggests that HLA-A2-DRB1*1501 haplotype may be associated with HIV infection while HLA-A2-DRB1*1502 haplotype might be associated with susceptibility to PTB in HIV patients. Moreover, HLA-B40-DRB1*1501 and HLA-B40-DRB1*04 haplotypes may be associated with susceptibility to HIV infection and to PTB in HIV patients.
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Affiliation(s)
- S Raghavan
- Tuberculosis Research Centre, Indian Council of Medical Research, Mayor V. R. Ramanathan Road, Chetput, Chennai 600031, India
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Ramachandran G, Ramesh K, Hemanth Kumar AK, Jagan I, Vasantha M, Padmapriyadarsini C, Narendran G, Rajasekaran S, Swaminathan S. Association of high T allele frequency of CYP2B6 G516T polymorphism among ethnic south Indian HIV-infected patients with elevated plasma efavirenz and nevirapine. J Antimicrob Chemother 2009; 63:841-3. [PMID: 19218571 DOI: 10.1093/jac/dkp033] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Selvaraj P, Alagarasu K, Swaminathan S, Harishankar M, Narendran G. CD209 gene polymorphisms in South Indian HIV and HIV-TB patients. Infect Genet Evol 2008; 9:256-62. [PMID: 19126442 DOI: 10.1016/j.meegid.2008.12.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Revised: 12/03/2008] [Accepted: 12/08/2008] [Indexed: 12/23/2022]
Abstract
Dendritic-cell-specific intercellular adhesion molecule-3 (ICAM-3)-grabbing non-integrin (DC-SIGN), a pattern recognition receptor, is associated with immune functions and is also exploited by HIV-1 and Mycobacterium tuberculosis as a part of their immune evasion strategy. In the present study we investigated whether variants in the DC-SIGN encoding CD209 gene are associated with susceptibility to or protection against HIV-1 infection as well as development of tuberculosis (TB) among HIV-1 infected south Indian patients. CD209 gene variants in the promoter region (-336 and -139), in the intron and 3'-untranslated regions (In2+11 and 2281) were studied using polymerase chain reaction-based genotyping methods in 131 HIV patients without TB (HIV+TB-) and 107 HIV patients with TB (HIV+TB+), 107 HIV negative pulmonary TB patients (HIV-PTB+) and 157 healthy controls. Results revealed a decreased frequency of -336 G/G genotype among all HIV patients compared to healthy controls and -336 G/G genotype was not observed among HIV+TB- individuals (p=0.005; odds ratio (OR) 0 (95% confidence intervals (CI) 0-0.46); Peto's odds ratio 0.149 (95% CI 0.045-0.50)). Among HIV+ patients, those with TB had a significantly increased frequency of -336 G/G genotype (p=0.003; OR undefined; Peto's odds ratio 9.8 (95% CI 2.2-44.3)) compared to those without TB. Other polymorphisms were not significantly different between the various study groups. The results suggest that -336 G/G genotype while associated with protection against HIV-1 infection the same genotype is also associated with susceptibility to HIV-TB among south Indians.
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Affiliation(s)
- P Selvaraj
- Department of Immunology, Tuberculosis Research Centre, Indian Council of Medical Research, Mayor V.R. Ramanathan Road, Chetput, Chennai 600031, India.
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Selvaraj P, Raghavan S, Swaminathan S, Alagarasu K, Narendran G, Narayanan PR. HLA-DQB1 and -DPB1 allele profile in HIV infected patients with and without pulmonary tuberculosis of south India. Infect Genet Evol 2008; 8:664-71. [PMID: 18652916 DOI: 10.1016/j.meegid.2008.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 06/23/2008] [Accepted: 06/30/2008] [Indexed: 11/19/2022]
Abstract
We made an attempt to find out whether Human Leucocyte Antigen (HLA)-DQB1 and -DPB1 alleles are associated with susceptibility or resistance to Human Immunodeficiency Virus (HIV) infection and development of pulmonary tuberculosis (PTB) in HIV infected patients. The allelic profile of HLA-DQB1 and -DPB1 was studied among HIV patients without pulmonary tuberculosis (HIV+PTB-) (n = 115), HIV patients with pulmonary TB (HIV+PTB+) (n = 59), HIV negative PTB patients (HIV-PTB+) (n = 110) and healthy controls (n=112) by polymerase chain reaction and sequence specific oligonucleotide probe method. Increased frequency of HLA-DQB1*050301 was observed in HIV+PTB- [p = 0.024, Odds Ratio (OR) 2.30, 95% Confidence Interval (CI) 1.11-4.90] and HIV+PTB+ patients (p = 0.044, OR 2.41, 95% CI 1.01-5.73) compared to healthy controls, suggesting that DQB1*050301 may be associated with susceptibility to HIV infection as well as development of PTB in HIV patients. Underrepresentation of HLA-DPB1*1501 was observed in HIV-PTB+ (p = 0.002, Pc = 0.034) and HIV+PTB+ (p = 0.036) patients compared to healthy controls, suggesting that DPB1*1501 may be associated with protection against PTB development both in HIV positive and negative subjects. Analysis on the amino acid variation in the peptide binding pocket at beta69 position of HLA-DPB1 molecules revealed that the beta69 arginine containing HLA-DPB1 alleles and the genotype lysine/arginine were underrepresented in HIV-PTB+ (allele: p = 0.003, Pc = 0.009; genotype: p = 0.0002, Pc = 0.001) and HIV+PTB+ (allele: p = 0.016, Pc = 0.048; genotype: p = 0.026). This suggests that HLA-DPB1 alleles with arginine may be associated with protection against development of PTB in both HIV infected as well as uninfected individuals. Further, the haplotypes HLA-DRB1*1502-DPB1*0201 and HLA-DQB1*0601-DPB1*0201 (Pc < 0.001) and HLA-DRB1*1502-DQB1*0601-DPB1*0201 (p = 0.006, OR 5.09, 95% CI 1.42-22.66) were significantly overrepresented in HIV+PTB+ patients compared to healthy controls suggesting that genetic susceptibility to PTB development in HIV patients may be modulated by interplay between HLA class II alleles, besides HLA class I alleles.
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Affiliation(s)
- P Selvaraj
- Tuberculosis Research Centre, Indian Council of Medical Research, Mayor V.R. Ramanathan Road, Chetput, Chennai 600031, India.
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Bakshi S, Ramachandran G, Ramesh K, Hemanthkumar AK, Anitha S, Padmapriyadarsini C, Narendran G, Menon PA, Rajasekaran S, Swaminathan S. Study of ABCB1 polymorphism (C3435T) in HIV-1-infected individuals from South India. Br J Clin Pharmacol 2008; 65:791-2. [PMID: 18241284 DOI: 10.1111/j.1365-2125.2007.03093.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Alagarasu K, Selvaraj P, Swaminathan S, Raghavan S, Narendran G, Narayanan PR. Mannose binding lectin gene variants and susceptibility to tuberculosis in HIV-1 infected patients of South India. Tuberculosis (Edinb) 2007; 87:535-43. [PMID: 17855170 DOI: 10.1016/j.tube.2007.07.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 07/30/2007] [Accepted: 07/31/2007] [Indexed: 11/16/2022]
Abstract
Mannose binding lectin (MBL) plays an important role in innate immunity. Plasma MBL levels and MBL2 gene polymorphisms were studied in HIV-1 infected patients without tuberculosis (HIV+TB-) (n=151) and with tuberculosis (HIV+TB+) (n=109), HIV negative tuberculosis patients (HIV-TB+) (n=148) and healthy controls (n=146) by ELISA and genotyping by polymerase chain reaction based methods. MBL levels were significantly increased among HIV-TB+ and HIV+TB+ patients than controls and HIV+TB- patients (P<0.05). A significantly increased frequency of OO genotype of structural polymorphism and YY genotype of -221Y/X was observed among HIV-TB+ patients than controls. In HIV+TB+ patients, a significantly increased frequency of YA/YA diplotype (associated with very high MBL levels) was observed compared to controls (P=0.03). In HIV+TB+ patients, a significantly decreased frequency of medium MBL expression diplotypes (XA/XA and YA/YO) were noticed compared to HIV+TB- and healthy controls. The results suggest that YA/YA diplotype associated with very high MBL levels may predispose HIV-infected patients to tuberculosis while O/O genotype associated with very low MBL levels may be associated with susceptibility to tuberculosis in HIV uninfected individuals. Medium MBL expression diplotypes might protect against development of TB in HIV-infected patients.
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Affiliation(s)
- Kalichamy Alagarasu
- Tuberculosis Research Centre, Indian Council of Medical Research, Mayor V.R. Ramanathan Road, Chetput, Chennai 600031, India
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Selvaraj P, Swaminathan S, Alagarasu K, Raghavan S, Narendran G, Narayanan P. Association of Human Leukocyte Antigen-A11 With Resistance and B40 and DR2 With Susceptibility to HIV-1 Infection in South India. J Acquir Immune Defic Syndr 2006; 43:497-9. [PMID: 17099315 DOI: 10.1097/01.qai.0000233312.36226.76] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Immune reconstitution syndrome (IRS) is the transient worsening or appearance of new signs, symptoms or radiological manifestation of an opportunistic infection occurring after the initiation of Highly active antiretroviral therapy (HAART) and is not due to treatment failure or new infection. We describe a case of a HIV infected child with tubercular (mediastinal) lymphadenitis with worsening of clinical and radiological features on starting HAART.
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Affiliation(s)
- G Narendran
- Tuberculosis Research Centre, Chetput, Chennai, India
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Ramachandran G, Hemanthkumar AK, Rajasekaran S, Padmapriyadarsini C, Narendran G, Sukumar B, Sathishnarayan S, Raja K, Kumaraswami V, Swaminathan S. Increasing Nevirapine Dose Can Overcome Reduced Bioavailability Due to Rifampicin Coadministration. J Acquir Immune Defic Syndr 2006; 42:36-41. [PMID: 16639340 DOI: 10.1097/01.qai.0000214808.75594.73] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We studied the effect of rifampicin on steady-state pharmacokinetics of nevirapine and the impact of increasing the dose of nevirapine on its peak (Cmax) and trough (Cmin) levels in 13 HIV-infected patients on regular antiretroviral treatment with nevirapine-containing regimens (200 mg twice daily). A baseline pharmacokinetic study was conducted and repeated after 1 week of daily rifampicin (450/600 mg). The study was repeated in 7 of 8 patients who had subtherapeutic Cmin nevirapine levels after increasing nevirapine dose to 300 mg twice daily. Liver function was monitored. Rifampicin caused significant reductions in Cmax (42%), Cmin (53%), and exposure (46%) of nevirapine (P <.01). The Cmin of nevirapine fell below the therapeutic range of 3 microg/ml in 8 of 13 patients. An increase of nevirapine to 300 mg twice daily raised Cmin to therapeutic range in all 7 patients without exceeding the toxic level of 12 microg/mL. There were no clinical or laboratory adverse events. Our findings suggest that decreased bioavailability of nevirapine because of rifampicin coadministration could be overcome by increasing the dose of nevirapine from 200 to 300 mg twice daily without short-term adverse events. Further studies to evaluate the long-term safety of higher dose of nevirapine are required.
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Affiliation(s)
- Geetha Ramachandran
- HIV/AIDS Division, Tuberculosis Research Centre (Indian Council of Medical Research), Chennai, India
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Kumar AKH, Ramachandran G, Saradha B, Narendran G, Swaminathan S. Urine nevirapine as a predictor of antiretroviral adherence. Indian J Med Res 2006; 123:565-8. [PMID: 16783049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND & OBJECTIVE Incomplete adherence is a major contributor to failure of antiretroviral therapy. Although the available methods to monitor adherence to therapy have proved to be predictive of outcomes, the results are variable. We assessed the feasibility of detecting nevirapine (NVP) in spot urine samples to monitor patient adherence to antiretroviral treatment and to study the urinary excretion of NVP in healthy volunteers after oral administration of a single dose of NVP (200 mg). METHODS Spot urine samples were collected from 50 HIV-infected patients (36 on treatment regimen containing NVP and 14 on drugs other than NVP) and tested for NVP by HPLC in a blinded manner. Sixteen healthy volunteers (9 males and 7 females) were administered a single oral dose of 200 mg NVP and spot urine samples were collected on day '0' before drug administration, and thereafter every 24 h up to 9 days and tested for NVP. RESULTS All the urine samples collected from patients undergoing treatment with NVP-containing regimens at different time points after drug administration tested positive for NVP. Thirteen out of 14 samples from patients not on NVP yielded a negative result. The drug was detected in the urine of healthy volunteers up to 9 days. The urinary excretion of NVP was prolonged in females than in males. INTERPRETATION & CONCLUSION In view of its long half-life, NVP gets excreted in urine for a long period of time. Hence, testing spot urine samples for NVP may not be a useful measure to monitor patient adherence to treatment.
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Affiliation(s)
- A K Hemanth Kumar
- HIV/AIDS Division, Tuberculosis Research Centre (ICMR), Mayor V.R. Ramanathan Road, Chetput, Chennai 600 031, India
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Swaminathan S, Padmapriyadarsini C, Narendran G, Thomas BE, Anand S, Rajyalakshmi A. Immune reconstitution syndrome following initiation of antiretroviral therapy in a patient with HIV infection and multidrug-resistant tuberculosis. Indian J Chest Dis Allied Sci 2005; 47:299-304. [PMID: 16255403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Paradoxical exacerbation of the signs and symptoms of tuberculosis may occur not only after antituberculosis therapy, but also soon after the initiation of a potent combination of antiretroviral drugs in human immunodeficiency virus (HIV) serpositive patients with tuberculosis. We report a case of immune reconstitution syndrome in response to antiretroviral therapy in a HIV-positive patient on antituberculosis therapy for multidrug-resistant tuberculosis.
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Affiliation(s)
- Soumya Swaminathan
- HIV/AIDS Division, Tuberculosis Research Centre, Chetput, Chennai, India.
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