Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis

Diagnostic Accuracy of Therapeutic Drug Monitoring During Tuberculosis Treatment

Tuberculosis (TB) patients co-infected with human immunodeficiency virus (HIV) are more likely to have low blood concentrations of the first-line anti-TB drugs (associated with poor outcomes). Therapeutic drug monitoring (TDM) is recommended for certain TB patient populations at increased risk for a poor outcome. Our objective was to estimate the diagnostic accuracy of a 2-hour TDM serum sample for the first-line anti-TB drugs among HIV/TB patients, and evaluate the information gained by an additional 6-hour sample. We created a virtual (n = 1,000) HIV/TB patient population and performed pharmacokinetic (PK) simulations using published population models for isoniazid, rifampin, pyrazinamide, and ethambutol. We performed receiver-operating-characteristic (ROC) analysis to compare the diagnostic performance of a single 2-hour serum sample with samples obtained at 2- and 6-hours post-dosing. The sensitivity of a single 2-hour serum concentration to identify HIV/TB patients with adequate serum exposures was lowest for rifampin (54.9%, 95% CI 50.79-59.41%) and highest for ethambutol (70.8%, 95% CI 66.06-72.61%) for C_max targets. Diagnostic accuracy of a single 2-hour serum sample for the AUC_0-24 target was highest for isoniazid (93%, 95% CI 90.9-94.1%) and lowest for pyrazinamide (66.3%, 95% CI 62.6-70.0%). In summary, the diagnostic performance of TDM for C_max and AUC_0-24 targets demonstrated variability across the first-line anti-TB drugs. The addition of a 6-hour serum sample lead to the highest statistically significant improvement (p < 0.001) and highest increase in diagnostic accuracy (area under the ROC curve) for rifampin for C_max and AUC. The other first-line drugs had modest/negligible increases in diagnostic accuracy. This article is protected by copyright. All rights reserved.

The Microbiome as Part of the Contemporary View of Tuberculosis Disease

The study of the microbiome has changed our overall perspective on health and disease. Although studies of the lung microbiome have lagged behind those on the gastrointestinal microbiome, there is now evidence that the lung microbiome is a rich, dynamic ecosystem. Tuberculosis is one of the oldest human diseases, it is primarily a respiratory infectious disease caused by strains from the Mycobacterium tuberculosis Complex. Even today, during the COVID-19 pandemic, it remains one of the principal causes of morbidity and mortality worldwide. Tuberculosis disease manifests itself as a dynamic spectrum that ranges from asymptomatic latent infection to life-threatening active disease. The review aims to provide an overview of the microbiome in the tuberculosis setting, both in patients’ and animal models. We discuss the relevance of the microbiome and its dysbiosis, and how, probably through its interaction with the immune system, it is a significant factor in tuberculosis’s susceptibility, establishment, and severity.

Semi-Automated Therapeutic Drug Monitoring as a Pillar toward Personalized Medicine for Tuberculosis Management

Standard tuberculosis (TB) management has failed to control the growing number of drug-resistant TB cases worldwide. Therefore, innovative approaches are required to eradicate TB. Model-informed precision dosing and therapeutic drug monitoring (TDM) have become promising tools for adjusting anti-TB drug doses corresponding with individual pharmacokinetic profiles. These are crucial to improving the treatment outcome of the patients, particularly for those with complex comorbidity and a high risk of treatment failure. Despite the actual benefits of TDM at the bedside, conventional TDM encounters several hurdles related to laborious, time-consuming, and costly processes. Herein, we review the current practice of TDM and discuss the main obstacles that impede it from successful clinical implementation. Moreover, we propose a semi-automated TDM approach to further enhance precision medicine for TB management.

Tuberculous meningitis: progress and remaining questions

Tuberculous meningitis is a devastating brain infection that is caused by Mycobacterium tuberculosis and is notoriously difficult to diagnose and treat. New technologies characterising the transcriptome, proteome, and metabolome have identified new molecules and pathways associated with tuberculous meningitis severity and poor outcomes that could offer novel diagnostic and therapeutic targets. The next-generation GeneXpert MTB/RIF Ultra assay, when used on CSF, offers diagnostic sensitivity for tuberculous meningitis of approximately 70%, although it is not widely available and a negative result cannot rule out tuberculous meningitis. Small trials indicate that clinical outcomes might be improved with increased doses of rifampicin, the addition of linezolid or fluoroquinolones to standard antituberculosis therapy, or treatment with adjunctive aspirin combined with corticosteroids. Large phase 3 clinical trials are underway worldwide to address these and other questions concerning the optimal management of tuberculous meningitis; these studies also form a platform for studying pathogenesis and identifying novel diagnostic and treatment strategies, by allowing the implementation of new genomic, transcriptomic, proteomic, and metabolomic technologies in nested substudies.

Pediatric Osteoarticular Infections Caused by Mycobacteria Tuberculosis Complex: A 26-Year Review of Cases in San Diego, CA

BACKGROUND

Osteoarticular infections (OAIs) account for 10%-20% of extrapulmonary Mycobacteria tuberculosis (MTB) complex infections in children and 1%-2% of all pediatric tuberculosis infections. Treatment regimens and durations typically mirror recommendations for other types of extrapulmonary MTB, but there are significant variations in practice, with some experts suggesting a treatment course of 12 months or longer.

METHODS

We conducted a retrospective review of children diagnosed with MTB complex OAI and cared for between December 31, 1992, and December 31, 2018, at a tertiary care pediatric hospital near the United States-Mexico border.

RESULTS

We identified 21 children with MTB complex OAI during the study period. Concurrent pulmonary disease (9.5%), meningitis (9.5%), and intra-abdominal involvement (14.3%) were all observed. MTB complex was identified by culture from operative samples in 15/21 children (71.4%); 8/15 (53.3%) cultures were positive for Mycobacterium bovis. Open bone biopsy was the most common procedure for procurement of a tissue sample and had the highest culture yield. The median duration of antimicrobial therapy was 52 weeks (interquartile range, 46-58). Successful completion of therapy was documented in 15 children (71.4%). Nine children (42.9%) experienced long-term sequelae related to their infection.

CONCLUSION

Among the 21 children with MTB complex OAI assessed, 8 of 15 (53.3%) children with a positive tissue culture had M. bovis, representing a higher percentage than in previous reports and potentially reflecting its presence in unpasteurized dairy products in the California-Baja region. Bone biopsy produced the highest culture yield in this study. Given the rarity of this disease, multicenter collaborative studies are needed to improve our understanding of the presentation and management of pediatric MTB complex OAI.

Cost-effectiveness of a medication event monitoring system for tuberculosis management in Morocco

Background

Digital health technologies have been used to enhance adherence to TB medication, but the cost-effectiveness remains unclear.

Methods

We used the real data from the study conducted from April 2014 to December 2020 in Morocco using a smart pillbox with a web-based medication monitoring system, called Medication Event Monitoring Systems (MEMS). Cost-effectiveness was evaluated using a decision analysis model including Markov model for Multi-drug resistant (MDR) TB from the health system perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER) per disability adjusted life-year (DALY) averted. Two-way sensitive analysis was done for the treatment success rate between MEMS and standard of care.

Results

The average total per-patient health system costs for treating a new TB patient under MEMS versus standard of care were $398.70 and $155.70, respectively. The MEMS strategy would reduce the number of drug-susceptible TB cases by 0.17 and MDR-TB cases by 0.01 per patient over five years. The ICER of MEMS was $434/DALY averted relative to standard of care, and was most susceptible to the TB treatment success rate of both strategies followed by the managing cost of MEMS.

Conclusion

MEMS is considered cost-effective for managing infectious active TB in Morocco.

Minnesota refugees diagnosed with tuberculosis disease, January 1993–August 2019

Background

Refugees are screened for TB overseas using Technical Instructions (TIs) issued by the U.S. Centers for Disease Control and Prevention and after arrival during their refugee health assessment (RHA). We examined RHA results and TB outcomes of refugees to Minnesota.

Methods

Demographic and RHA results for 70,290 refugee arrivals to Minnesota from January 1993 to August 2019 were matched to 3595 non-U.S. born individuals diagnosed with TB disease during that time.

Results

Seven hundred fifty-nine (1.1%) were diagnosed with TB disease. Fifty-four percent were diagnosed within 2 years of U.S. arrival. Refugees screened using TIs implemented in 1991 were twice as likely to be diagnosed with TB disease within 1 year of arrival, compared to those evaluated using improved TIs implemented in 2007.

Conclusion

Few refugees were diagnosed with TB disease during the period examined. Enhancements to overseas protocols significantly reduced the proportion of refugees diagnosed within 1 year of arrival.

Vertebral destruction in an 11-month-old child with spinal tuberculosis: a case report and review of literature

Background

The incidence of tuberculosis is increasing especially in endemic countries. Spinal tuberculosis represents nearly the 50% of reported cases of skeletal tuberculosis. This is the youngest case of spinal tubercular disease that has been reported. The objective of this report is to describe a spinal tuberculosis case in an infant in thoracic spine, in order to show the importance of early diagnosis in this population, to limit the progression of this highly destructive disease and reduce the severe sequelae that this disease is associated.

Case presentation

An 11-month-old infant previously healthy born in the northeast Mexico. Physical examination revealed a mass lesion in the dorsal region, fixed to deep planes, indurated. Neurological examination found Frankel C paraparesis showing muscle strength 2/5 on the Lovett scale in both lower extremities, anal reflex present, and preserved sensitivity.

In the magnetic resonance of the spine, hyperintensities in the vertebral bodies of D6-D9 were observed in the T2 with destruction of the D7 and D8 bodies. A thoracotomy was performed with total mass resection with corpectomy of vertebrae D7 and D8, medullary decompression, and placement of fibula allograft between vertebrae D6 and D9. In the histopathological sample, a chronic granulomatous inflammatory process associated with acid-fast bacilli was observed, in addition to presenting a positive result in quantitative real-time PCR GeneXpert MTB/RIF sensitive to rifampicin. Twelve months later, he presented 5/5 muscular strength, without alterations in sensitivity, in addition to presenting ambulation onset at 18 months of age.

Conclusion

The spinal tuberculosis is a disease that occurs in endemic countries. A prompt diagnosis is necessary to limit the progression of a highly destructive disease. In addition, the fact of presenting at an early age produces hard making decisions for the adequate treatment of the disease and reduces the adverse effects of these procedures.

Tuberculosis treatment intermittency in the continuation phase and mortality in HIV-positive persons receiving antiretroviral therapy

BACKGROUND

Some tuberculosis (TB) treatment guidelines recommend daily TB treatment in both the intensive and continuation phases of treatment in HIV-positive persons to decrease the risk of relapse and acquired drug resistance. However, guidelines vary across countries, and treatment is given 7, 5, 3, or 2 days/week. The effect of TB treatment intermittency in the continuation phase on mortality in HIV-positive persons on antiretroviral therapy (ART), is not well-described.

METHODS

We conducted an observational cohort study among HIV-positive adults treated for TB between 2000 and 2018 and after enrollment into the Caribbean, Central, and South America network for HIV epidemiology (CCASAnet; Brazil, Chile, Haiti, Honduras, Mexico and Peru). All received standard TB therapy (2-month initiation phase of daily isoniazid, rifampin or rifabutin, pyrazinamide ± ethambutol) and continuation phase of isoniazid and rifampin or rifabutin, administered concomitantly with ART. Known timing of ART and TB treatment were also inclusion criteria. Kaplan-Meier and Cox proportional hazards methods compared time to death between groups. Missing model covariates were imputed via multiple imputation.

RESULTS

2303 patients met inclusion criteria: 2003(87%) received TB treatment 5-7 days/week and 300(13%) 2-3 days/week in the continuation phase. Intermittency varied by site: 100% of patients from Brazil and Haiti received continuation phase treatment 5-7 days/week, followed by Honduras (91%), Peru (42%), Mexico (7%), and Chile (0%). The crude risk of death was lower among those receiving treatment 5-7 vs. 2-3 days/week (HR = 0.68; 95% CI = 0.51-0.91; P = 0.008). After adjusting for age, sex, CD4, ART use at TB diagnosis, site of TB disease (pulmonary vs. extrapulmonary), and year of TB diagnosis, mortality risk was lower, but not significantly, among those treated 5-7 days/week vs. 2-3 days/week (HR 0.75, 95%CI 0.55-1.01; P = 0.06). After also stratifying by study site, there was no longer a protective effect (HR 1.42, 95%CI 0.83-2.45; P = 0.20).

CONCLUSIONS

TB treatment 5-7 days/week was associated with a marginally decreased risk of death compared to TB treatment 2-3 days/week in the continuation phase in multivariable, unstratified analyses. However, little variation in TB treatment intermittency within country meant the results could have been driven by other differences between study sites. Therefore, randomized trials are needed, especially in heterogenous regions such as Latin America.

Abdominal Tuberculosis Mimicking Ovarian Cancer: A Case Report and Review of the Literature

Introduction

Tuberculosis (TB) is a disease with high morbidity and mortality resulting from infection by Mycobacterium tuberculosis. TB can disseminate to any organ system of the body resulting in extrapulmonary tuberculosis. Interestingly, CA-125, which is a biomarker for some cancer, also rises in benign diseases such as pulmonary and extrapulmonary tuberculosis which may complicate diagnosis. In this case report, we present an abdominal tuberculosis patient that was initially presented as ovarian cancer.

Case Report

A 30-year-old woman admitted to the emergency department with chief complaint of fatigue and shortness of breath since 3 months ago. She had lost around 20 kg weight in the past 5 months. She was previously suspected with ovarian cancer because of the characteristic features of malignancy, high levels of CA-125, and positive PET scan. She was later diagnosed with abdominal TB. Subsequently, the patient was given anti-TB drugs, and the patient showed clinical improvement.

Conclusion

In the case of an elevated CA-125, clinicians should consider extrapulmonary TB as a differential diagnosis of ovarian cancer, especially in countries with high burden of tuberculosis.

Practices of therapeutic drug monitoring in tuberculosis: an international survey

Tuberculosis (TB) is still one of the top 10 causes of death in low and lower-middle income countries [1]. TB's long and complex treatment, side-effects, and development of resistant bacteria compromise treatment success. To improve treatment outcomes, therapeutic drug monitoring (TDM) has been included in TB treatment guidelines [2–4] to be considered for specific situations in which there is documented or expected poor response to treatment, drug toxicity, or a lower drug concentration. Several strategies for implementation of TDM for programmatic use have been proposed to overcome barriers to widespread use of TDM [5, 6], including more accessible techniques such as dried blood spot analysis or saliva and urine testing [7], but uptake in programmatic care is still limited [8].

Survey responses indicate that there is concern surrounding cost-effectiveness and the resources available in different settings to implement therapeutic drug monitoring in TB. Robust research is needed to better inform of the potential long-term benefits. https://bit.ly/34PFSfd

Decrease in Tuberculosis Cases during COVID-19 Pandemic as Reflected by Outpatient Pharmacy Data, United States, 2020

We analyzed a pharmacy dataset to assess the 20% decline in tuberculosis (TB) cases reported to the US National Tuberculosis Surveillance System (NTSS) during the coronavirus disease pandemic in 2020 compared with the 2016–2019 average. We examined the correlation between TB medication dispensing data to TB case counts in NTSS and used a seasonal autoregressive integrated moving average model to predict expected 2020 counts. Trends in the TB medication data were correlated with trends in NTSS data during 2006–2019. There were fewer prescriptions and cases in 2020 than would be expected on the basis of previous trends. This decrease was particularly large during April–May 2020. These data are consistent with NTSS data, suggesting that underreporting is not occurring but not ruling out underdiagnosis or actual decline. Understanding the mechanisms behind the 2020 decline in reported TB cases will help TB programs better prepare for postpandemic cases.

Mind the gap - Managing tuberculosis across the disease spectrum

We currently have a binomial approach to managing tuberculosis. Those with active disease, ideally confirmed microbiologically, are treated with a standard 6-month, multi-drug regimen and those with latent infection and no evidence of disease with shorter, one or two drug regimens. Clinicians frequently encounter patients that fall between these two management pathways with some but not all features of disease and this will occur more often with the increasing emphasis on chest X-ray-based systematic screening. The view of tuberculosis as a spectrum of disease states is being increasingly recognised and is leading to new diagnostic approaches for early disease. However, the 6-month regimen for treating disease was driven by the duration required to treat the most extensive forms of pulmonary TB and shorter durations appear sufficient for less extensive disease. It is time undertake clinical trials to better define the optimal treatment for tuberculosis across the disease spectrum.

High intrapulmonary rifampicin and isoniazid concentrations are associated with rapid sputum bacillary clearance in patients with pulmonary tuberculosis

Background

Intrapulmonary pharmacokinetics may better explain response to tuberculosis (TB) treatment than plasma pharmacokinetics. We explored these relationships by modeling bacillary clearance in sputum in adult patients on first-line treatment in Malawi.

Methods

Bacillary elimination rates (BER) were estimated using linear mixed-effects modelling of serial time-to-positivity in mycobacterial growth indicator tubes for sputum collected during the intensive phase of treatment (weeks 0–8) for microbiologically confirmed TB. Population pharmacokinetic models used plasma and intrapulmonary drug levels at 8 and 16 weeks. Pharmacokinetic-pharmacodynamic relationships were investigated using individual-level measures of drug exposure (area-under-the-concentration-time-curve [AUC] and C_max) for rifampicin, isoniazid, pyrazinamide, and ethambutol, in plasma, epithelial lining fluid, and alveolar cells as covariates in the bacillary elimination models.

Results

Among 157 participants (58% human immunodeficiency virus [HIV] coinfected), drug exposure in plasma or alveolar cells was not associated with sputum bacillary clearance. Higher peak concentrations (C_max) or exposure (AUC) to rifampicin or isoniazid in epithelial lining fluid was associated with more rapid bacillary elimination and shorter time to sputum negativity. More extensive disease on baseline chest radiograph was associated with slower bacillary elimination. Clinical outcome was captured in 133 participants, with 15 (11%) unfavorable outcomes recorded (recurrent TB, failed treatment, or death). No relationship between BER and late clinical outcome was identified.

Conclusions

Greater intrapulmonary drug exposure to rifampicin or isoniazid in the epithelial lining fluid was associated with more rapid bacillary clearance. Higher doses of rifampicin and isoniazid may result in sustained high intrapulmonary drug exposure, rapid bacillary clearance, shorter treatment duration and better treatment outcomes.

Correlation Between CT Features of Active Tuberculosis and Residual Metabolic Activity on End-of-Treatment FDG PET/CT in Patients Treated for Pulmonary Tuberculosis

Patients who complete a standard course of anti-tuberculous treatment (ATT) for pulmonary tuberculosis and are declared cured according to the current standard of care commonly have residual metabolic activity (RMA) in their lungs on fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PER/CT) imaging. RMA seen in this setting has been shown to be associated with relapse of tuberculosis. The routine clinical use of FDG PET/CT imaging for treatment response assessment in tuberculosis is hindered by cost and availability. CT is a more readily available imaging modality. We sought to determine the association between CT features suggestive of active tuberculosis and RMA on FDG PET/CT obtained in patients who completed a standard course of ATT for pulmonary tuberculosis. We prospectively recruited patients who completed a standard course of ATT and declared cured based on negative sputum culture. All patients had FDG PET/CT within 2 weeks of completing ATT. We determined the presence of RMA on FDG PET images. Among the various lung changes seen on CT, we considered the presence of lung nodule, consolidation, micronodules in tree-in-bud pattern, FDG-avid chest nodes, and pleural effusion as suggestive of active tuberculosis. We determine the association between the presence of RMA on FDG PET and the CT features of active tuberculosis. We include 75 patients with a mean age of 36.09 ± 10.49 years. Forty-one patients (54.67%) had RMA on their FDG PET/CT while 34 patients (45.33%) achieved complete metabolic response to ATT. There was a significant association between four of the five CT features of active disease, p < 0.05 in all cases. Pleural effusion (seen in two patients) was the only CT feature of active disease without a significant association with the presence of RMA. This suggests that CT may be used in lieu of FDG PET/CT for treatment response assessment of pulmonary tuberculosis.

A Case of Accidental Isoniazid Overdose Presenting With Nonspecific Symptoms

A 68-year-old male with a history of end-stage renal disease and latent tuberculosis on isoniazid (INH), and no psychiatric history presented with a five-day history of anorexia, fatigue, and nausea. Physical exam in the emergency department was notable for somnolence, right upper extremity tremor, and diffuse abdominal pain. Initial workup revealed an anion gap metabolic acidosis with elevated lactate, prompting admission to the general ward for empiric IV antibiotics for suspected bacteremia from his permacath.

Within a few hours of admission, he became increasingly encephalopathic and had two episodes of copious hematemesis. Repeat studies revealed a cholestatic pattern of liver injury and new-onset coagulopathy. With an overall clinical picture consistent with fulminant hepatic failure, our pharmacy team initiated a comprehensive pill count of all his medications, which established that he had been inadvertently taking up to six times the recommended dose of INH.

With INH discontinuation and supportive therapy, he improved and was discharged on hospital day eight. Our experience provides lessons in the timely recognition and management of this rarely reported toxidrome in the United States.

New developments in tuberculosis diagnosis and treatment

Tuberculosis (TB) is a major cause of morbidity and mortality worldwide. It is estimated that 25% of the world's population are infected with Mycobacterium tuberculosis, with a 5–10% lifetime risk of progression into TB disease. Early recognition of TB disease and prompt detection of drug resistance are essential to halting its global burden. Culture, direct microscopy, biomolecular tests and whole genome sequencing are approved methods of diagnosis; however, their widespread use is often curtailed owing to costs, local resources, time constraints and operator efficiency. Methods of optimising these diagnostics, in addition to developing novel techniques, are under review. The selection of an appropriate drug regimen is dependent on the susceptibility pattern of the isolate detected. At present, there are 16 new drugs under evaluation for TB treatment in phase I or II clinical trials, with an additional 22 drugs in preclinical stages. Alongside the development of these new drugs, most of which are oral medications, new shorter regimes are under evaluation. The aim of these shorter regimens is to encourage patient adherence, and prevent relapse or the evolution of further drug resistance. Screening for TB infection, especially in vulnerable populations, provides an opportunity for intervention prior to progression towards infectious TB disease. New regimens are currently under evaluation to assess the efficacy of shorter durations of treatment in this population. In addition, there is extensive research into the use of post-exposure vaccinations in this cohort. Worldwide collaboration and sharing of expertise are essential to our ultimate aim of global eradication of TB disease.

Early detection of drug resistance is essential to our goal of global eradication of TB. Tolerable drugs and shorter regimens promote patient adherence. Treating TB infection in vulnerable groups will prevent further global spread of TB disease.https://bit.ly/3oUW0SN

Assessing the protective effect of Crassocephalum vitellinum against Rifampicin-induced hepatotoxicity in Wistar rats

Background

Crassocephalum vitellinum is widely used by traditional medical practitioners and local people in East Africa to manage a large number of ailments including hepatitis 1. However, its hepatoprotective effects had not been evaluated prior to this study. The aim of this study was to assess the effect of an ethanolic leaf extract of Crassocephalum vitellinum against rifampicin-induced liver toxicity in Wistar rats.

Methods

Increasing doses of an ethanolic leaf extract of C. vitellinum were administered to Wistar rats daily for 35 days, together with rifampicin given orally as suspension. After the treatment period, Assessment of hepatoprotective activity was done by analysis of serum levels of biochemical and histopathological effects on the liver.

Results

The results showed that administration of C. vitellinum extract significantly prevented drug- induced increase in serum levels of liver biomarker enzymes and also decreased the hepatocellular necrosis and inflammatory cells infiltration.

Conclusion

The plant extract loweres the liver biomarker enzymes (ALT, ALP, AST) and preserves the histomorphology of the hepatocytes which is suggestive that the plant possess hepatoprotective properties.

Successful endovascular treatment of abdominal aortic rupture secondary to bacillus Calmette-Guérin vaccine

Bacillus Calmette-Guérin (BCG) vaccine has been successfully used to treat bladder cancer. However, sporadic cases of mycotic arterial aneurysms have been reported. These patients typically develop a Mycobacterium bovis infection of an existing aneurysm or graft. In the present report, we have described the case of a patient with a ruptured nonaneurysmal abdominal aorta years after intravesicular BCG therapy. Emergent aortic endograft repair was successful. After subsequent evaluation confirmed M. bovis infection, the patient was treated with a prolonged course of antimycobacterial therapy. Vascular surgeons should maintain suspicion for atypical aortic ruptures in patients with exposure to intravesicular BCG therapy.

Video-Observed Therapy Versus Directly Observed Therapy in Patients With Tuberculosis

INTRODUCTION

This systematic review and meta-analysis synthesized evidence in the effects of video-observed therapy versus that of directly observed therapy on medication adherence, treatment completion, and tuberculosis resolution among patients with tuberculosis.

METHODS

Potential studies were identified from MEDLINE, Embase, CINAHLdirect, and Cochrane from inception to February 1, 2021. Inclusion criteria included (1) tuberculosis-infected population, (2) video-observed therapy as an intervention, (3) directly observed therapy as the comparison group, and (4) patient's medication adherence or clinical outcomes. Data were collected in 2021. Random-effects meta-analyses were conducted using Mantel-Haenszel methods with RR for dichotomous outcomes (medication adherence, treatment completion, and bacteriological resolution) and generic inverse variance methods with a weighted mean difference for continuous outcomes (proportion of doses observed).

RESULTS

A total of 9 studies were included in the systematic review and meta-analysis. Compared with patients receiving directly observed therapy, patients with video-observed therapy were associated with improved medication adherence (RR=2.79, 95% CI=2.26, 3.45, I²=25%), the proportion of doses observed (weighted mean difference=0.22, 95% CI=0.06, 0.39, I²=96%), and bacteriological resolution (RR=1.06, 95% CI=1.01, 1.11, I²=0%) but with similar treatment completion (RR=1.33, 95% CI=0.73, 2.43, I²=98%).

DISCUSSION

Implementation of video-observed therapy improved medication adherence and bacteriological resolution compared with that of directly observed therapy in tuberculosis-infected patients.

Interim Guidance: 4-Month Rifapentine-Moxifloxacin Regimen for the Treatment of Drug-Susceptible Pulmonary Tuberculosis - United States, 2022

On May 5, 2021, CDC's Tuberculosis Trials Consortium and the National Institutes of Health (NIH)-sponsored AIDS Clinical Trials Group (ACTG) published results from a randomized controlled trial indicating that a 4-month regimen containing rifapentine (RPT), moxifloxacin (MOX), isoniazid (INH), and pyrazinamide (PZA) was as effective as the standard 6-month regimen for tuberculosis (TB) treatment (1). On the basis of these findings, CDC recommends the 4-month regimen as a treatment option for U.S. patients aged ≥12 years with drug-susceptible pulmonary TB and provides implementation considerations for this treatment regimen.

Updates in Pediatric Tuberculosis in International Settings

Childhood tuberculosis (TB) has been underreported and underrepresented in TB statistics across the globe. Contributing factors include health system barriers, diagnostic barriers, and community barriers leading to an underdetected epidemic of childhood tuberculosis. Despite considerable progress in childhood TB management, there is a concerning gap in policy and practice in high-burden countries leading to missed opportunities for active case detection, early diagnosis and treatment of TB exposure, and infection and disease in children regardless of human immunodeficiency virus status. Bridging this gap requires multisectoral coordination and political commitment along with an eye to research and innovation with potential to scale.

Health and economic burden due to alcohol-associated liver diseases in the Union Territory of Delhi: A Markov probabilistic model approach

BACKGROUND

Nearly one-fifth of all deaths attributable to alcohol are due to liver diseases.

METHODS

The study employs a Markov Probabilistic Modeling approach considering various clinical spectrum of alcohol-associated liver diseases (ALD), to gauge the health and economic burden due to ALD for the national capital territory of Delhi, from March 2017 to February 2018. The health impact was estimated through Disability Adjusted Life Years (DALYs), years of life lost (YLL), and total deaths due to ALD. The economic burden of ALD was assessed assuming the current health-seeking preferences and assuming that all the diseased individuals are cared for in the public health systems. Sensitivity analysis was done by Monte Carlo simulations.

RESULTS

Total number of estimated deaths due to ALD in the national capital territory of Delhi for one year period from March 2017 was 8367. The DALYs due to ALD were estimated to be 0.247 million life years; this includes 0.178 million YLL and 0.069 million life years lost due to disability. The total cost of treating ALD was estimated to be 92.94 billion Indian rupees, if patients sought care based on current preferences and 55.52 billion Indian rupees if all diseased individuals were cared for in public health systems. The total excise revenue due to alcohol to the Government is being Indian rupees 43.1 billion in the said year.

CONCLUSION

The high burden of ALD in terms of lives lost, DALYs lost, and more than two times higher estimated expense for care than the revenue generation due to alcohol clearly indicates that it would be prudent to initiate social engineering and preventive strategies to lessen the growing burden of ALD in India. The Delhi model for health and economic burden of ALD could help the country develop policies for better health outcomes of these patients.

Recent advancement in drug development of nitro(NO2 )-heterocyclic compounds as lead scaffolds for the treatment of Mycobacterium tuberculosis

Tuberculosis (TB) is an infectious disease caused predominantly by Mycobacterium tuberculosis (Mtb). It was responsible for approximately 1.4 million deaths worldwide in 2019. The lack of new drugs to treat drug-resistant strains is a principal factor for the slow rise in TB infections. Our aim is to aid the development of new TB treatments by describing improvements (last decade, 2011-2021) to nitro(NO₂ )-based compounds that have shown activity or pharmacological properties (e.g., anti-proliferative, anti-kinetoplastid) against Mtb. For all compounds, we have included final correlations of minimum inhibitory concentrations against Mtb (H₃₇ Rv).

Strengthening Tuberculosis Services for Children and Adolescents in Low Endemic Settings

In low tuberculosis-burden countries, children and adolescents with the highest incidence of tuberculosis (TB) infection or disease are usually those who have immigrated from high-burden countries. It is, therefore, essential that low-burden countries provide healthcare services to immigrant and refugee families, to assure that their children can receive proper testing, evaluation, and treatment for TB. Active case-finding through contact tracing is a critical element of TB prevention in children and in finding TB disease at an early, easily treated stage. Passive case-finding by evaluating an ill child is often delayed, as other, more common infections and conditions are suspected initially. While high-quality laboratory services to detect Mycobacterium tuberculosis are generally available, they are often underutilized in the diagnosis of childhood TB, further delaying diagnosis in some cases. Performing research on TB disease is difficult because of the low number of cases that are spread over many locales, but critical research on the evaluation and treatment of TB infection has been an important legacy of low-burden countries. The continued education of medical providers and the involvement of educational, professional, and non-governmental organizations is a key element of maintaining awareness of the presence of TB. This article provides the perspective from North America and Western Europe but is relevant to many low-endemic settings. TB in children and adolescents will persist in low-burden countries as long as it persists throughout the rest of the world, and these wealthy countries must increase their financial commitment to end TB everywhere.

Hesitancy Regarding Medical Advice on COVID-19: An Emergency Department Perspective

Objective:

The rejection of or non-compliance with treatment arises for different reasons by patients who receive treatment recommendations for various diseases. These states are described by various concepts, such as discharge against medical advice (DAMA) and medication nonadherence (MNA). The basis of the study is to determine how these states have arisen during the coronavirus disease (COVID-19) pandemic.

Method:

The data of this study were collected through standardized interviews with 103 volunteer participants who were diagnosed with COVID-19 at different times and who did not use their prescribed medicine during the pandemic in Turkey. The data obtained in the research were analyzed through the MAXQDA qualitative analysis program.

Results:

As a result of the analysis of the data, 4 main themes and sub-codes have been reached: (1) prescribed medicine, (2) an information source for the COVID-19 period/treatment, (3) the reason for medication nonadherence, and (4) treatment of choice. When the approach toward treatment of patients who were diagnosed with COVID-19 and had started treatment by a physician was evaluated, it was revealed that the nonadherence state emerged as a cycle. In the initial period, nonadherence due to the medication itself was observed. The second period is when the patients recognize their disease and collect information from their environment. Although this period begins before the disease, the search for informative sources intensifies, especially once the diagnosis has been received. In the third period, with their diagnosis and the information they had obtained, patients consider the reasons to use the medication and then decide whether or not to use it. In the fourth period, the patients who will not use antivirals consider other medications, such as anti-flu, anticoagulant, supplements, and nutrition.

Conclusion:

Since a specific treatment protocol has not yet been revealed for COVID-19, a new conceptual framework is required. In the current condition, the state of “hesitation for medical advice” arises for non-hospitalized patients.

An overview of sulfonamide-based conjugates: Recent advances for tuberculosis treatment

In 2019, tuberculosis (TB) caused approximately 1.4 million deaths around the world. TB is an infectious respiratory disease mainly caused by Mycobacterium tuberculosis. The lack of new drugs to treat drug-resistant strains is a principal factor for the continuous slow rise in TB infections. Sulfonamides are active moieties in various drugs used against several sicknesses, including TB. Our aim is to aid the development of new TB treatments and drugs by describing recent improvements (2011-2021) to sulfonamide-based compounds.

High-dose rifamycins in the treatment of TB: a systematic review and meta-analysis

BACKGROUND

There is growing interest in using high-dose rifamycin (HDR) regimens in TB treatment, but the safety and efficacy of HDR regimens remain uncertain. We performed a systematic review and meta-analysis comparing HDR to standard-dose rifamycin (SDR) regimens.

METHODS

We searched MEDLINE, Embase, CENTRAL, Cochrane Database of Systematic Reviews and clinicaltrials.gov for prospective studies comparing daily therapy with HDRs to SDRs. Rifamycins included rifampicin, rifapentine and rifabutin. Our primary outcome was the rate of severe adverse events (SAEs), with secondary outcomes of death, all adverse events, SAE by organ and efficacy outcomes of 2-month culture conversion and relapse. This study was prospectively registered in the International Prospective Register of Systematic Reviews (CRD42020142519).

RESULTS

We identified 9057 articles and included 13 studies with 6168 participants contributing 7930 person-years (PY) of follow-up (HDR: 3535 participants, 4387 PY; SDR: 2633 participants, 3543 PY). We found no significant difference in the pooled incidence rate ratio (IRR) of SAE between HDR and SDR (IRR 1.00, 95% CI 0.82 to 1.23, I ²=41%). There was no significant difference when analysis was limited to SAE possibly, probably or likely medication-related (IRR 1.07, 95% CI 0.82 to 1.41, I ²=0%); studies with low risk of bias (IRR 0.98, 95% CI 0.79 to 1.20, I ²=44%); or studies using rifampicin (IRR 1.00, 95% CI 0. 0.75-1.32, I ²=38%). No significant differences were noted in pooled outcomes of death, 2-month culture conversion and relapse.

CONCLUSIONS

HDRs were not associated with a significant difference in SAEs, 2-month culture conversion or death. Further studies are required to identify specific groups who may benefit from HDR.

In-Person vs Electronic Directly Observed Therapy for Tuberculosis Treatment Adherence: A Randomized Noninferiority Trial

IMPORTANCE

Electronic directly observed therapy (DOT) is used increasingly as an alternative to in-person DOT for monitoring tuberculosis treatment. Evidence supporting its efficacy is limited.

OBJECTIVE

To determine whether electronic DOT can attain a level of treatment observation as favorable as in-person DOT.

DESIGN, SETTING, AND PARTICIPANTS

This was a 2-period crossover, noninferiority trial with initial randomization to electronic or in-person DOT at the time outpatient tuberculosis treatment began. The trial enrolled 216 participants with physician-suspected or bacteriologically confirmed tuberculosis from July 2017 to October 2019 in 4 clinics operated by the New York City Health Department. Data analysis was conducted between March 2020 and April 2021.

INTERVENTIONS

Participants were asked to complete 20 medication doses using 1 DOT method, then switched methods for another 20 doses. With in-person therapy, participants chose clinic or community-based DOT; with electronic DOT, participants chose live video-conferencing or recorded videos.

MAIN OUTCOMES AND MEASURES

Difference between the percentage of medication doses participants were observed to completely ingest with in-person DOT and with electronic DOT. Noninferiority was demonstrated if the upper 95% confidence limit of the difference was 10% or less. We estimated the percentage of completed doses using a logistic mixed effects model, run in 4 modes: modified intention-to-treat, per-protocol, per-protocol with 85% or more of doses conforming to the randomization assignment, and empirical. Confidence intervals were estimated by bootstrapping (with 1000 replicates).

RESULTS

There were 173 participants in each crossover period (median age, 40 years [range, 16-86 years]; 140 [66%] men; 80 [37%] Asian and Pacific Islander, 43 [20%] Black, and 71 [33%] Hispanic individuals) evaluated with the model in the modified intention-to-treat analytic mode. The percentage of completed doses with in-person DOT was 87.2% (95% CI, 84.6%-89.9%) vs 89.8% (95% CI, 87.5%-92.1%) with electronic DOT. The percentage difference was -2.6% (95% CI, -4.8% to -0.3%), consistent with a conclusion of noninferiority. The 3 other analytic modes yielded equivalent conclusions, with percentage differences ranging from -4.9% to -1.9%.

CONCLUSIONS AND RELEVANCE

In this trial, the percentage of completed doses under electronic DOT was noninferior to that under in-person DOT. This trial provides evidence supporting the efficacy of this digital adherence technology, and for the inclusion of electronic DOT in the standard of care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03266003.

Effect of Rifabutin in Dolutegravir Dosing: A Case Series

Background: Tuberculosis (TB) is the leading cause of death in human immunodeficiency virus (HIV)-infected people worldwide. Currently there are no studies examining the use of Rifabutin (RBN) and Dolutegravir (DTG) in co-infected persons. This is a case series of 4 co-infected patients receiving both agents who underwent Pharmacokinetic (PK) analysis. Methods and Results: This is a retrospective chart review study of four patients diagnosed with both HIV and TB, receiving RBN and DTG and undergoing therapeutic drug monitoring. All 4 cases had lower than expected DTG concentrations at least once, including those on the current recommended dose of DTG with RBN, and even those receiving higher doses. Conclusions: Given the frequency of low DTG and RBN concentrations, therapeutic drug monitoring (TDM) for these drugs is advisable. Prospective clinical studies are needed to further determine the PK interactions between RBN and DTG, and virologic response to treatment.

Single-cell profiling reveals distinct subsets of CD14+ monocytes drive blood immune signatures of active tuberculosis

Introduction

Previous studies suggest that monocytes are an important contributor to tuberculosis (TB)-specific immune signatures in blood.

Methods

Here, we carried out comprehensive single-cell profiling of monocytes in paired blood samples of active TB (ATB) patients at diagnosis and mid-treatment, and healthy controls.

Results

At diagnosis, ATB patients displayed increased monocyte-to-lymphocyte ratio, increased frequency of CD14+CD16- and intermediate CD14+CD16+ monocytes, and upregulation of interferon signaling genes that significantly overlapped with previously reported blood TB signatures in both CD14+ subsets. In this cohort, we identified additional transcriptomic and functional changes in intermediate CD14+CD16+ monocytes, such as the upregulation of inflammatory and MHC-II genes, and increased capacity to activate T cells, reflecting overall increased activation in this population. Single-cell transcriptomics revealed that distinct subsets of intermediate CD14+CD16+ monocytes were responsible for each gene signature, indicating significant functional heterogeneity within this population. Finally, we observed that changes in CD14+ monocytes were transient, as they were no longer observed in the same ATB patients mid-treatment, suggesting they are associated with disease resolution.

Discussion

Together, our study demonstrates for the first time that both intermediate and classical monocytes individually contribute to blood immune signatures of ATB and identifies novel subsets and associated gene signatures that may hold disease relevance.

Multiple Extrapulmonary Tuberculous Abscesses Developed Postpartum in a Non-HIV Patient Under Anti-tuberculosis Chemotherapy

Although abscess formation constitutes a recognized complication of tuberculous lymphadenitis, the concomitant development of multiple tuberculous abscesses in the course of tuberculous lymphadenitis has rarely been described in the literature among HIV-negative patients under appropriate chemotherapy. Adherence and sensitivity to the administered anti-tuberculosis chemotherapy have to be verified in such patients. We report a case of deteriorating tuberculous lymphadenitis, presenting with the development of multiple extrapulmonary abscesses (cervical, psoas, and retroperitoneal) in an HIV-negative patient who had complied with appropriate anti-tuberculosis chemotherapy for four months. Mycobacterium tuberculosis was the identified pathogen in specimens from the abscesses. Continuation of anti-tuberculosis medications and concurrent administration of antibiotics, along with CT-guided percutaneous drainage of the psoas abscess, resulted in gradual resolution of the patient's lesions. Interestingly, our patient had recent childbirth, indicating a potential association between the immunomodulatory processes during the postpartum period and the development of the so-called paradoxical reaction. Awareness of such complications should be raised, as a timely recognition and subsequent therapeutical treatment are essential for a favorable outcome.

Addressing TB-related mortality in adults living with HIV: a review of the challenges and potential solutions

Tuberculosis (TB) is the leading cause of death in people living with HIV (PLHIV) globally, causing 208,000 deaths in PLHIV in 2019. PLHIV have an 18-fold higher risk of TB, and HIV/TB mortality is highest in inpatient facilities, compared with primary care and community settings. Here we discuss challenges and potential mitigating solutions to address TB-related mortality in adults with HIV. Key factors that affect healthcare engagement are stigma, knowledge, and socioeconomic constraints, which are compounded in people with HIV/TB co-infection. Innovative approaches to improve healthcare engagement include optimizing HIV/TB care integration and interventions to reduce stigma. While early diagnosis of both HIV and TB can reduce mortality, barriers to early diagnosis of TB in PLHIV include difficulty producing sputum specimens, lower sensitivity of TB diagnostic tests in PLHIV, and higher rates of extra pulmonary TB. There is an urgent need to develop higher sensitivity biomarker-based tests that can be used for point-of-care diagnosis. Nonetheless, the implementation and scale-up of existing tests including molecular World Health Organization (WHO)-recommended diagnostic tests and urine lipoarabinomannan (LAM) should be optimized along with expanded TB screening with tools such as C-reactive protein and digital chest radiography. Decreased survival of PLHIV with TB disease is more likely with late HIV diagnosis and delayed start of antiretroviral (ART) treatment. The WHO now recommends starting ART within 2 weeks of initiating TB treatment in the majority of PLHIV, aside from those with TB meningitis. Dedicated TB treatment trials focused on PLHIV are needed, including interventions to improve TB meningitis outcomes given its high mortality, such as the use of intensified regimens using high-dose rifampin, new and repurposed drugs such as linezolid, and immunomodulatory therapy. Ultimately holistic, high-quality, person-centered care is needed for PLHIV with TB throughout the cascade of care, which should address biomedical, socioeconomic, and psychological barriers.

Reframing Intersectional Stigma for a South African Context Integrating Tuberculosis, HIV and Poverty Stigmas

ABSTRACT

Intersectionality is closely intertwined with Black feminism within the context of the United States. As a result, intersectionality is often overlooked in non-Western contexts where racial homogeneity may reduce some of the impact of race on marginalization. This article will look at intersectional stigma from the South African context using the tuberculosis/HIV (TB/HIV) treatment environment in South Africa to exemplify intersectionality's versatility as an analytic method outside of the United States. We will use colonial history and contemporary research to reframe intersectionality considering a new set of stigmatized identities, including HIV stigma, TB stigma, and poverty stigma, to create a situation-specific framework adapted from a model by Bulent Turan and colleagues.

Mycobacterial infections in solid organ transplant recipients

Mycobacterium tuberculosis (MTB) infection in solid organ transplant (SOT) recipients remains a major challenge for physicians and surgeons. Active tuberculosis (TB) is associated with increased morbidity and mortality in SOT recipients. MTB usually develops after transplantation in a recipient with latent TB infection (LTBI) before transplantation and may also be transmitted from the donor or acquired from the community. Therefore, screening for LTBI in donors and recipients before transplantation is very important in preventing active disease after transplantation. This review article is based on recently published data, case series, and expert recommendations. We reviewed updated information about the epidemiology, diagnosis, and treatment of latent and active TB before and after transplantation. We also reviewed recent treatments for multidrug-resistant TB.

Anti-Mycobacterial Drug Resistance in Japan: How to Approach This Problem?

Mycobacteriosis is mainly caused by two groups of species: Mycobacterium tuberculosis and non-tuberculosis mycobacteria (NTM). The pathogens cause not only respiratory infections, but also general diseases. The common problem in these pathogens as of today is drug resistance. Tuberculosis (TB) is a major public health concern. A major challenge in the treatment of TB is anti-mycobacterial drug resistance (AMR), including multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis. Recently, the success rate of the treatment of drug-resistant tuberculosis (DR-TB) has improved significantly with the introduction of new and repurposed drugs, especially in industrialized countries such as Japan. However, long-term treatment and the adverse events associated with the treatment of DR-TB are still problematic. To solve these problems, optimal treatment regimens designed/tailor-made for each patient are necessary, regardless of the location in the world. In contrast to TB, NTM infections are environmentally oriented. Mycobacterium avium-intracellulare complex (MAC) and Mycobacterium abscessus species (MABS) are the major causes of NTM infections in Japan. These bacteria are naturally resistant to a wide variation of antimicrobial agents. Macrolides, represented by clarithromycin (CLR) and amikacin (AMK), show relatively good correlation with treatment success. However, the efficacies of potential drugs for the treatment of macrolide-resistant MAC and MABS are currently under evaluation. Thus, it is particularly difficult to construct an effective treatment regimen for macrolide-resistant MAC and MABS. AMR in NTM infections are rather serious in Japan, even when compared with challenges associated with DR-TB. Given the AMR problems in TB and NTM, the appropriate use of drugs based on accurate drug susceptibility testing and the development of new compounds/regimens that are strongly bactericidal in a short-time course will be highly expected.

The application of ultrasound shear wave elastography in the prediction of paradoxical upgrading reaction in tuberculous lymphadenitis. a pilot study

BACKGROUND

Paradoxical upgrading reaction (PUR) indicates the unanticipated deterioration during therapy in patients with tuberculous lymphadenitis. We investigated the diagnostic performance of the ultrasonography and shear wave elastography (SWE) in predicting the therapeutic response of peripheral tuberculous lymphadenitis.

METHODS

A prospective observational study was conducted from December 2017 to August 2020. Participants diagnosed with peripheral tuberculous lymphadenitis were included for a longitudinal follow-up utilizing ultrasonography with two-dimensional SWE to record sonographic features and the maximum elasticity value (Emax). We defined PUR as the development of any worsening symptoms of the pre-existing lymphadenitis within one month after the previous ultrasonography.

RESULTS

A total of 108 sonographic and SWE examinations were performed in 20 enrollees (75% woman), and their mean ( ± standard deviation) age was 49.6 ( ± 22.7) years. The area under the receiver operating characteristic curve of Emax to predict the next-month PUR was 0.906 at the cut-point of 85 kPa, with an accuracy of 87.0%, a sensitivity of 81.1% and a specificity of 87.9%. Multivariate analysis indicated that Emax > 85 kPa (OR: 24.85, 95% CI: 4.01-154.08, p < 0.001), Emax increment rate >2 kPa/month (OR: 15.14, 95% CI: 4.24-54.06, p < 0.001), and heterogeneous echogenicity (OR: 4.37, 95% CI: 1.16-16.43, p = 0.029) were independent sonographic predictors for PUR in the coming month.

CONCLUSIONS

A high and non-declining Emax level and heterogeneous echogenicity were associated with the next-month PUR of tuberculous lymphadenitis. Ultrasonography with SWE may be a potential radiologic marker to predict the therapeutic response of tuberculous lymphadenitis.

Tuberculosis in the Elderly

The tuberculosis (TB) epidemic is most prevalent in the elderly, and there is a progressive increase in the notification rate with age. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. The mortality rate from tuberculosis remains higher in elderly patients. Symptoms of active TB are nonspecific and less pronounced in the elderly. Diagnostic difficulties in the elderly are common in many diseases but it is important to use all possible techniques to make a microbiological diagnosis. Recognising frailty to prevent loss of independence is a major challenge in dealing with the therapeutic aspects of elderly patients. Several studies report contrasting data about poorer tolerance of TB drugs in this population. Adherence to antituberculosis treatment is a fundamental issue for the outcome of treatment. Decreased completeness of treatment was shown in older people as well as a higher risk of treatment failure.

Subsequent Antituberculous Treatment May Not Be Mandatory Among Surgically Resected Culture-Negative Pulmonary Granulomas: A Retrospective Nationwide Multicenter Cohort Study

Background

Histologic diagnosis of granuloma is often considered clinically equivalent to a definite diagnosis of pulmonary tuberculosis (TB) in endemic areas. Optimal management of surgically resected granulomatous inflammation in lung with negative mycobacterial culture results, however, remains unclear.

Methods

From 7 medical institutions in northern, middle, and southern Taiwan between January 2010 and December 2018, patients whose surgically resected pulmonary nodule(s) had histological features suggestive of TB but negative microbiological study results and who received no subsequent anti-TB treatment were identified retrospectively. All patients were followed up for 2 years until death or active TB disease was diagnosed.

Results

A total of 116 patients were enrolled during the study period. Among them, 61 patients (52.6%) were clinically asymptomatic, and 36 (31.0%) patients were immunocompromised. Solitary pulmonary nodule accounted for 44 (39.6%) of all cases. The lung nodules were removed by wedge resection in 95 (81.9%), lobectomy in 17 (14.7%), and segmentectomy in 4 (3.4%) patients. The most common histological feature was granulomatous inflammation (n=116 [100%]), followed by caseous necrosis (n=39 [33.6%]). During follow-up (218.4 patient-years), none of the patients developed active TB.

Conclusions

In patients with surgically resected culture-negative pulmonary granulomas, the incidence rate of subsequent active TB is low. Watchful monitoring along with regular clinical, radiological, and microbiological follow-up, instead of routine anti-TB treatment, may also be a reasonable option.

Pharmacodynamics and the Bactericidal Activity of Bedaquiline in Pulmonary Tuberculosis

Bedaquiline is a diarylquinoline antimycobacterial drug and a key component of several regimens in clinical development for treatment of tuberculosis (TB), but with ongoing phase 3 trials that include assessment of simplified dosing. A pharmacokinetic-pharmacodynamic model of bedaquiline Mycobacterium tuberculosis killing kinetics in adults with pulmonary TB was developed to inform dose selection of bedaquiline-containing regimens. The model parameters were estimated with data from the 14-day early bactericidal activity (EBA) study TMC207-CL001 conducted in Cape Town, South Africa. The study included 60 adult males and females with drug-susceptible pulmonary TB, who were administered bedaquiline with loading doses on the first two days followed by once daily 100 mg, 200 mg, 300 mg, or 400 mg. The modeling results included expected values (mean±SD) for a maximum drug kill rate constant equal to 0.23±0.03 log₁₀ CFU/mL sputum/day, a half-maximum effect plasma concentration equal to 1.6±0.3 mg/L, and an average time to onset of activity equal to 40±7 h. Model simulations showed once daily 200 mg, 300 mg, and 400 mg (without loading doses) attained 40%, 50%, and 60%, respectively, of an expected maximum 14-day EBA equal to 0.18 log₁₀ CFU/mL/day, or 10 h/day assessed by liquid culture time to positivity (TTP). Additional simulations illustrated efficacy outcomes during eight weeks of treatment with the recommended and alternative dosages. The results demonstrate a general mathematical and statistical approach to analysis of EBA studies with broad application to TB regimen development.

Diagnostic and Neurological Overview of Brain Tuberculomas: A Review of Literature

Tuberculosis is a disease caused by a bacteria named Mycobacterium tuberculosis (M. tb). It is estimated by World Health Organization (WHO) that nearly a quarter of the world's population is infected. Tuberculoma of the brain is one of the most severe extrapulmonary forms that affects patients younger than 40 years of age. Brain parenchymal tuberculoma develops in nearly one of 300 non-treated cases of pulmonary tuberculosis cases. In endemic regions, tuberculomas account for as many as 50% of all intracranial masses. Tuberculoma results in a hematogenous spread of M. tb from an extracranial source. Tuberculomas can mimic a variety of diseases and can present themselves in a subacute or chronic course, from asymptomatic to severe intracranial hypertension. Diagnosis is based on computed tomography (CT) scan and magnetic resonance imaging (MRI) studies with a similar ring-enhancing lesion. Treatment is primarily medical, and the duration for brain tuberculoma can vary from six to 36 months. In certain cases, surgery is recommended.