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Wasserman S, Donovan J, Kestelyn E, Watson JA, Aarnoutse RE, Barnacle JR, Boulware DR, Chow FC, Cresswell FV, Davis AG, Dooley KE, Figaji AA, Gibb DM, Huynh J, Imran D, Marais S, Meya DB, Misra UK, Modi M, Raberahona M, Ganiem AR, Rohlwink UK, Ruslami R, Seddon JA, Skolimowska KH, Solomons RS, Stek CJ, Thuong NTT, van Crevel R, Whitaker C, Thwaites GE, Wilkinson RJ. Advancing the chemotherapy of tuberculous meningitis: a consensus view. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00512-7. [PMID: 39342951 PMCID: PMC7616680 DOI: 10.1016/s1473-3099(24)00512-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 08/02/2024] [Accepted: 08/05/2024] [Indexed: 10/01/2024]
Abstract
Tuberculous meningitis causes death or disability in approximately 50% of affected individuals and kills approximately 78 200 adults every year. Antimicrobial treatment is based on regimens used for pulmonary tuberculosis, which overlooks important differences between lung and brain drug distributions. Tuberculous meningitis has a profound inflammatory component, yet only adjunctive corticosteroids have shown clear benefit. There is an active pipeline of new antitubercular drugs, and the advent of biological agents targeted at specific inflammatory pathways promises a new era of improved tuberculous meningitis treatment and outcomes. Yet, to date, tuberculous meningitis trials have been small, underpowered, heterogeneous, poorly generalisable, and have had little effect on policy and practice. Progress is slow, and a new approach is required. In this Personal View, a global consortium of tuberculous meningitis researchers articulate a coordinated, definitive way ahead via globally conducted clinical trials of novel drugs and regimens to advance treatment and improve outcomes for this life-threatening infection.
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Affiliation(s)
- Sean Wasserman
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa; Infection and Immunity, St George's University of London, London, UK
| | - Joseph Donovan
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - James A Watson
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | - James R Barnacle
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa; The Francis Crick Institute, London, UK; Department of Infectious Diseases, Imperial College London, London, UK
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Felicia C Chow
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Fiona V Cresswell
- Infectious Diseases Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; HIV Interventions, Medical Research Council-Uganda Virus Research Institute MRC and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda; Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Angharad G Davis
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa; The Francis Crick Institute, London, UK
| | - Kelly E Dooley
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony A Figaji
- Division of Neurosurgery, Neuroscience Institute, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit, London, UK
| | - Julie Huynh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, UK
| | - Darma Imran
- Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Suzaan Marais
- Division of Neurology, Neuroscience Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David B Meya
- Infectious Diseases Institute, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Usha K Misra
- Medical College, Vivekanand Polyclinic and Institute of Medical Sciences and Apollo Medics Super Speciality Hospital, Lucknow, India
| | - Manish Modi
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mihaja Raberahona
- University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar
| | - Ahmad Rizal Ganiem
- Department of Neurology, Faculty of Medicine, Universitas Padjadjaran-Hasan Sadikin Hospital, Bandung, Indonesia
| | - Ursula K Rohlwink
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa; Division of Neurosurgery, Neuroscience Institute, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Rovina Ruslami
- Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran-Hasan Sadikin Hospital, Bandung, Indonesia
| | - James A Seddon
- Department of Infectious Diseases, Imperial College London, London, UK; Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Keira H Skolimowska
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa; Infection and Immunity, St George's University of London, London, UK
| | - Regan S Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Cari J Stek
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Claire Whitaker
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, UK
| | - Robert J Wilkinson
- Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa; The Francis Crick Institute, London, UK; Department of Infectious Diseases, Imperial College London, London, UK.
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Aggrohia A, Bhatia V, Saroch A, Pannu AK. Predicting cerebral infarction in tuberculous meningitis and its prognostic significance. Biomark Med 2024; 18:407-417. [PMID: 39041843 DOI: 10.1080/17520363.2024.2347194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/18/2024] [Indexed: 07/24/2024] Open
Abstract
Aim: Tuberculous meningitis (TBM) often causes cerebral infarction, but its predictive factors are not well understood. Methods: Patients aged ≥13 years admitted with TBM were enrolled prospectively. Cerebral infarction was diagnosed using magnetic resonance imaging. Results: Of 186 patients, 80 (43%) had infarction. Most infarctions were multiple and located in the cortical areas, basal ganglia and subcortical regions. Independent predictors of infarction at admission included high blood pressure, short illness duration, low Glasgow coma scale and hydrocephalus. Neuroimaging inflammation signs, cerebrospinal fluid analysis abnormalities and pre-existing cardiovascular risks did not predict infarction. In-hospital mortality was higher in TBM with infarction, particularly in those with advanced TBM (stage 3). Conclusion: Baseline parameters of raised intracranial pressure predict cerebral infarction in TBM.
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Affiliation(s)
- Asha Aggrohia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Vikas Bhatia
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education & Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Atul Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
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Lu HJ, Guo D, Wei QQ. Potential of Neuroinflammation-Modulating Strategies in Tuberculous Meningitis: Targeting Microglia. Aging Dis 2024; 15:1255-1276. [PMID: 37196131 PMCID: PMC11081169 DOI: 10.14336/ad.2023.0311] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/11/2023] [Indexed: 05/19/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most severe complication of tuberculosis (TB) and is associated with high rates of disability and mortality. Mycobacterium tuberculosis (M. tb), the infectious agent of TB, disseminates from the respiratory epithelium, breaks through the blood-brain barrier, and establishes a primary infection in the meninges. Microglia are the core of the immune network in the central nervous system (CNS) and interact with glial cells and neurons to fight against harmful pathogens and maintain homeostasis in the brain through pleiotropic functions. However, M. tb directly infects microglia and resides in them as the primary host for bacillus infections. Largely, microglial activation slows disease progression. The non-productive inflammatory response that initiates the secretion of pro-inflammatory cytokines and chemokines may be neurotoxic and aggravate tissue injuries based on damages caused by M. tb. Host-directed therapy (HDT) is an emerging strategy for modulating host immune responses against diverse diseases. Recent studies have shown that HDT can control neuroinflammation in TBM and act as an adjunct therapy to antibiotic treatment. In this review, we discuss the diverse roles of microglia in TBM and potential host-directed TB therapies that target microglia to treat TBM. We also discuss the limitations of applying each HDT and suggest a course of action for the near future.
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Affiliation(s)
- Huan-Jun Lu
- Institute of Special Environmental Medicine, Nantong University, Jiangsu, China
| | - Daji Guo
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian-Qi Wei
- Department of Infectious Diseases, General Hospital of Tibet Military Command, Xizang, China
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Inbaraj LR, Manesh A, Ponnuraja C, Bhaskar A, Srinivasalu VA, Daniel BD. Comparative evaluation of intensified short course regimen and standard regimen for adults TB meningitis: a protocol for an open label, multi-center, parallel arms, randomized controlled superiority trial (INSHORT trial). Trials 2024; 25:294. [PMID: 38693583 PMCID: PMC11064413 DOI: 10.1186/s13063-024-08133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Despite several incremental improvements in the management of tuberculous meningitis (TBM), the mortality rates remain high. In spite of national and international guidelines, variation in the choice, dose, and duration of drugs exist between countries and clinicians. We propose to evaluate a shorter and more effective regimen containing agents with augmented intracerebral drug exposure and anti-inflammatory approaches to improve disability-free survival among patients with TBM. Our strategy incorporates the various developments in the field of TBM over the last two decades and only few trials have evaluated a composite of these strategies in the overall outcomes of TBM. METHODS An open label, parallel arms, randomized controlled superiority trial will be conducted among 372 participants across 6 sites in India. Eligible participants will be randomly allocated in 1:1:1 ratio into one of the three arms. The intervention arm consists of 2 months of high-dose rifampicin (25 mg/kg), moxifloxacin (400 mg), pyrazinamide, isoniazid, aspirin (150 mg), and steroids followed by rifampicin, isoniazid, and pyrazinamide for 4 months. The second intervention arm includes all the drugs as per the first arm except aspirin and the patients in the control arm will receive treatment according to the National TB Elimination Program guidelines. All participants will be followed up for 1 year after the treatment. DISCUSSION: Current WHO regimens have agents with poor central nervous system drug exposure and is too long. It does not reflect the accumulating evidence in the field. We propose a comprehensive clinical trial incorporating the emerging evidence accrued over the last two decades to shorten the duration and improve the treatment outcomes. This multi-centric trial may generate crucial evidence with policy and practice implications in the treatment of TBM. TRIAL REGISTRATION Clinical Trial Registry India CTRI/2023/05/053314. Registered on 31 May 2023 ( https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=ODYzMzg=&Enc=&userName=CTRI/2023/05/053314 ). CLINICALTRIALS gov NCT05917340. Registered on 6 August 2023 ( https://classic. CLINICALTRIALS gov/ct2/show/NCT05917340 ). PROTOCOL VERSION Version 1.3 dated 12 July 2023.
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Affiliation(s)
- Leeberk Raja Inbaraj
- Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India.
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - C Ponnuraja
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Adhin Bhaskar
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Vignes Anand Srinivasalu
- Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Bella Devaleenal Daniel
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India.
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Barnacle JR, Davis AG, Wilkinson RJ. Recent advances in understanding the human host immune response in tuberculous meningitis. Front Immunol 2024; 14:1326651. [PMID: 38264653 PMCID: PMC10803428 DOI: 10.3389/fimmu.2023.1326651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024] Open
Abstract
Tuberculous meningitis (TBM), the most severe form of tuberculosis, causes death in approximately 25% cases despite antibiotic therapy, and half of survivors are left with neurological disability. Mortality and morbidity are contributed to by a dysregulated immune response, and adjunctive host-directed therapies are required to modulate this response and improve outcomes. Developing such therapies relies on improved understanding of the host immune response to TBM. The historical challenges in TBM research of limited in vivo and in vitro models have been partially overcome by recent developments in proteomics, transcriptomics, and metabolomics, and the use of these technologies in nested substudies of large clinical trials. We review the current understanding of the human immune response in TBM. We begin with M. tuberculosis entry into the central nervous system (CNS), microglial infection and blood-brain and other CNS barrier dysfunction. We then outline the innate response, including the early cytokine response, role of canonical and non-canonical inflammasomes, eicosanoids and specialised pro-resolving mediators. Next, we review the adaptive response including T cells, microRNAs and B cells, followed by the role of the glutamate-GABA neurotransmitter cycle and the tryptophan pathway. We discuss host genetic immune factors, differences between adults and children, paradoxical reaction, and the impact of HIV-1 co-infection including immune reconstitution inflammatory syndrome. Promising immunomodulatory therapies, research gaps, ongoing challenges and future paths are discussed.
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Affiliation(s)
- James R. Barnacle
- The Francis Crick Institute, London, United Kingdom
- Department of Infectious Disease, Imperial College, London, United Kingdom
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Angharad G. Davis
- The Francis Crick Institute, London, United Kingdom
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
| | - Robert J. Wilkinson
- The Francis Crick Institute, London, United Kingdom
- Department of Infectious Disease, Imperial College, London, United Kingdom
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
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Putera I, Schrijver B, Ten Berge JCEM, Gupta V, La Distia Nora R, Agrawal R, van Hagen PM, Rombach SM, Dik WA. The immune response in tubercular uveitis and its implications for treatment: From anti-tubercular treatment to host-directed therapies. Prog Retin Eye Res 2023:101189. [PMID: 37236420 DOI: 10.1016/j.preteyeres.2023.101189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 05/28/2023]
Abstract
Tubercular uveitis (TB-uveitis) remains a conundrum in the uveitis field, which is mainly related to the diverse clinical phenotypes of TB-uveitis. Moreover, it remains difficult to differentiate whether Mycobacterium tuberculosis (Mtb) is present in the ocular tissues, elicits a heightened immune response without Mtb invasion in ocular tissues, or even induces an anti-retinal autoimmune response. Gaps in the immuno-pathological knowledge of TB-uveitis likely delay timely diagnosis and appropriate management. In the last decade, the immunopathophysiology of TB-uveitis and its clinical management, including experts' consensus to treat or not to treat certain conditions with anti-tubercular treatment (ATT), have been extensively investigated. In the meantime, research on TB treatment, in general, is shifting more toward host-directed therapies (HDT). Given the complexities of the host-Mtb interaction, enhancement of the host immune response is expected to boost the effectiveness of ATT and help overcome the rising burden of drug-resistant Mtb strains in the population. This review will summarize the current knowledge on the immunopathophysiology of TB-uveitis and recent advances in treatment modalities and outcomes of TB-uveitis, capturing results gathered from high- and low-burden TB countries with ATT as the mainstay of treatment. Moreover, we outline the recent progress of HDT development in the pulmonary TB field and discuss the possibility of its applicability to TB-uveitis. The concept of HDT might help direct future development of efficacious therapy for TB-uveitis, although more in-depth research on the immunoregulation of this disease is still necessary.
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Affiliation(s)
- Ikhwanuliman Putera
- Department of Ophthalmology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Benjamin Schrijver
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Vishali Gupta
- Retina and Uvea Services, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rina La Distia Nora
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Ophthalmology and Visual Sciences Academic Clinical Program, Duke NUS University, Singapore; Singapore Eye Research Institute, Singapore; Moorfields Eye Hospital, London, United Kingdom
| | - P Martin van Hagen
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands; Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - S M Rombach
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Abdel Shaheed C, Beardsley J, Day RO, McLachlan AJ. Immunomodulatory effects of pharmaceutical opioids and antipyretic analgesics: Mechanisms and relevance to infection. Br J Clin Pharmacol 2022; 88:3114-3131. [PMID: 35229890 DOI: 10.1111/bcp.15281] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 12/12/2022] Open
Abstract
Understanding how pharmaceutical opioids and antipyretic analgesics interact with the immune system potentially has major clinical implications for management of patients with infectious diseases and surgical and critical care patients. An electronic search was carried out on MEDLINE, EMBASE, PsycINFO, CENTRAL and the Cochrane library to identify reports describing the immunomodulatory effects of opioid analgesics and antipyretic analgesics, and their effects in infectious diseases. In adaptive immunity, nonsteroidal anti-inflammatory drugs have divergent effects: augmenting cell-mediated immunity but inhibiting humoral immunity. Nonsteroidal anti-inflammatory drugs have demonstrated a beneficial role in Mycobacterium tuberculosis infection and histoplasmosis in animals, and may be plausible adjuvants to antimicrobial agents in these diseases. There is a need to evaluate these findings rigorously in human clinical trials. There is preliminary evidence demonstrating antiviral effects of indomethacin in SARS CoV-2 in vitro; however, uncertainty regarding its clinical benefit in humans needs to be resolved in large clinical trials. Certain opioid analgesics are associated with immunosuppressive effects, with a developing understanding that fentanyl, morphine, methadone and buprenorphine suppress innate immunity, whilst having diverse effects on adaptive immunity. Morphine suppresses key cells of the innate immunity and is associated with greater risk of infection in the postsurgical setting. Efforts are needed to achieve adequate analgesia whilst avoiding suppression of the innate immunity in the immediate postoperative period caused by certain opioids, particularly in cancer surgery.
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Affiliation(s)
- Christina Abdel Shaheed
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Justin Beardsley
- Westmead Institute for Medical Research, Sydney, Australia.,Sydney Institute for Infectious Diseases, University of Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Andrew J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, Australia
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Paradoxical manifestations during tuberculous meningitis treatment among HIV-negative patients: a retrospective descriptive study and literature review. Neurol Sci 2021; 43:2699-2708. [PMID: 34705128 DOI: 10.1007/s10072-021-05693-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most frequent, severe, and disabling form of central nervous system (CNS) tuberculosis (TB). TBM paradoxical manifestations are characterized by clinical or paraclinical worsening after 1 month of effective anti-TB treatment in patients who initially responded to treatment despite the use of adjunctive corticosteroids. METHODS Retrospective descriptive study of consecutive HIV-negative adult patients (≥ 18 years) with definitive TBM who developed a paradoxical manifestation following anti-TB in a tertiary-care hospital in Mexico from 2009 to 2019; we also conducted a literature review of published cases/series of paradoxical manifestations in HIV-negative patients from 1980 to 2020. RESULTS We detected 84 cases of definitive TBM; 55 (68.7%) HIV-negative patients and 29 (36.3%) HIV-infected patients. Among HIV-negative patients, four (7.3%), three female and one male (19-49 years old), developed a paradoxical manifestation within 4-14 weeks following treatment initiation despite receiving adequate corticosteroid doses; Mycobacterium bovis was isolated from the cerebrospinal fluid of three cases and Mycobacterium tuberculosis in one more. Two patients developed vasculopathy-related cerebral infarctions, one severe basilar meningitis, and hydrocephalus, one more a tuberculoma. Two were treated with intravenous cyclophosphamide, and two with steroids. One of the patients treated with steroids died; patients who received cyclophosphamide had a good clinical response. CONCLUSIONS This case series illustrates the diverse clinical/radiologic paradoxical manifestations of TBM in HIV-negative patients. Cyclophosphamide may be safe and effective in treating TBM-associated paradoxical manifestations. Specific diagnostic and care protocols for these patients are needed.
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