Peripheral neuropathy in persons with tuberculosis

Effect of Multicomponent Exercise Program on Pain and Functional Mobility in Antitubercular Drug Therapy-Induced Peripheral Neuropathy in Pulmonary Tuberculosis Survivors

OBJECTIVES

 Exercise therapy is a pivotal component in the multidisciplinary approach to managing tuberculosis (TB)-related peripheral neuropathy (PN). A personalized exercise protocol maximizes therapeutic benefits while minimizing the risk of symptom exacerbation. This study aimed to determine the effect of multicomponent exercise programs on pain and functional mobility in antitubercular drug therapy-induced PN in pulmonary TB survivors.

METHODS

In the approved experimental study, 110 participants with antitubercular study drug-induced PN were randomly assigned to two groups, and data were analyzed using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States). The study's purpose was to evaluate the efficacy of a multicomponent exercise program on PN symptoms.

RESULTS

The study assessed a multicomponent exercise regimen's effectiveness in individuals with TB-related PN. The experiment group demonstrated noteworthy pain reduction (p < 0.0001), improvement in neurological symptoms (p < 0.0001), and better functional outcomes in the 12-minute walk test (p < 0.0001) and sit-and-reach test (p < 0.0001). Conversely, the control group exhibited less significant improvements. The low p-values indicate the intervention's effectiveness, emphasizing its impact on pain reduction, neurological symptoms, and functional abilities in comparing the experimental and control groups.

CONCLUSION

The study demonstrated the significant effectiveness of an eight-week multicomponent exercise program in individuals with pulmonary TB-related PN, showcasing notable improvements in pain reduction and functional mobility compared to a conventional single-component regimen in the control group.

Metabolic changes enhance necroptosis of type 2 diabetes mellitus mice infected with Mycobacterium tuberculosis

Previously, we found that Mycobacterium tuberculosis (Mtb) infection in type 2 diabetes mellitus (T2DM) mice enhances inflammatory cytokine production which drives pathological immune responses and mortality. In the current study, using a T2DM Mtb infection mice model, we determined the mechanisms that make T2DM mice alveolar macrophages (AMs) more inflammatory upon Mtb infection. Among various cell death pathways, necroptosis is a major pathway involved in inflammatory cytokine production by T2DM mice AMs. Anti-TNFR1 antibody treatment of Mtb-infected AMs from T2DM mice significantly reduced expression of receptor interacting protein kinase 3 (RIPK3) and mixed lineage kinase domain-like (MLKL) (necroptosis markers) and IL-6 production. Metabolic profile comparison of Mtb-infected AMs from T2DM mice and Mtb-infected AMs of nondiabetic control mice indicated that 2-ketohexanoic acid and deoxyadenosine monophosphate were significantly abundant, and acetylcholine and pyridoxine (Vitamin B6) were significantly less abundant in T2DM mice AMs infected with Mtb. 2-Ketohexanoic acid enhanced expression of TNFR1, RIPK3, MLKL and inflammatory cytokine production in the lungs of Mtb-infected nondiabetic mice. In contrast, pyridoxine inhibited RIPK3, MLKL and enhanced expression of Caspase 3 (apoptosis marker) in the lungs of Mtb-infected T2DM mice. Our findings demonstrate that metabolic changes in Mtb-infected T2DM mice enhance TNFR1-mediated necroptosis of AMs, which leads to excess inflammation and lung pathology.

Frostbite secondary to antimycobacterial-induced peripheral neuropathy: a case report

This case report describes a unique scenario in which antimycobacterial-induced peripheral neuropathy (PN) culminates in severe bilateral foot frostbite. Drug-induced peripheral neuropathy (DIPN) is explored in the context of TB treatment, highlighting the role of medications such as isoniazid (INH) and their potential to cause PN. The report highlights the importance of identifying PN in patients undergoing antimycobacterial treatment. Early recognition and proper management of PN is crucial to prevent complications. Notably, the report advocates for patient education regarding medication side effects and avoiding harmful practices, such as ice immersion, to alliviate neuropathic pain. Emphasis is directed towards the need for a multidisciplinary approach to patient care and a focus on preventative strategies to improve patient outcomes and avoid severe debilitating complications.

Global Prevalence of Chronic Pain in Women with HIV: A Systematic Review and Meta-analysis

Chronic pain is common among people with human immunodeficiency virus (HIV) and detrimental to quality of life and overall health. It is often underdiagnosed, undertreated, and frankly dismissed in women with HIV, despite growing evidence that it is highly prevalent in this population. Thus, we conducted a systematic review and meta-analysis to estimate the global prevalence of chronic pain in women with HIV. The full protocol can be found on PROSPERO (identifier CRD42022301145). Of the 2984 references identified in our search, 36 were included in the systematic review and 35 in the meta-analysis. The prevalence of chronic pain was 31.2% (95% confidence interval [CI], 24.6%-38.7%; I2 = 98% [95% CI, 97%-99%]; P < .0001). In this global assessment, we found a high prevalence of chronic pain among women with HIV, underscoring the importance of understanding the etiology of chronic pain, identifying effective treatments, and conducting regular assessments in clinical practice.

Toxic neuropathies: a practical approach

Toxic neuropathies result from exogenous substances damaging the peripheral nerves. There are numerous causes, including prescribed and recreational drugs, heavy metals, industrial agents and biological toxins. Timely recognition of these neuropathies gives better outcomes, as they usually improve or stabilise once the toxin is removed. Most toxic neuropathies are axonal, length-dependent and sensory predominant, although some have significant motor involvement or can present acutely or subacutely. Here, we outline our clinical approach and discuss the major causes of toxic neuropathy, while emphasising the clinical and neurophysiological features and the neuropathy phenotype. We also include an update on newer medications that can cause neuropathy, including immune checkpoint inhibitors and BRAF/MEK inhibitors.

Peripheral Tubercular Neuritis: A Case Report

Peripheral neuropathy can affect sensory, motor, or autonomic nerves and manifest with a variety of symptoms. Tuberculosis as a major infectious disease that often affects many organs of the body. However, primary involvement of peripheral nerves is unusual. Peripheral neuropathy in patients with tuberculosis often is associated with other comorbidities, such as immunocompromised states, diabetes mellitus, malnutrition, and some antitubercular medications. This report describes the rare finding of peripheral tubercular neuritis with caseating abscesses of right median and radial nerve in a healthy 24-year man.

Prevalence of long-term physical sequelae among patients treated with multi-drug and extensively drug-resistant tuberculosis: a systematic review and meta-analysis

BACKGROUND

Physical sequelae related to multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) are emerging and under-recognised global challenges. This systematic review and meta-analysis aimed to quantify the prevalence and the types of long-term physical sequelae associated with patients treated for MDR- and XDR-TB.

METHODS

We systematically searched CINAHL (EBSCO), MEDLINE (via Ovid), Embase, Scopus, and Web of Science from inception through to July 1, 2022, and the last search was updated to January 23, 2023. We included studies reporting physical sequelae associated with all forms of drug-resistant TB, including rifampicin-resistant TB (RR-TB), MDR-TB, Pre-XDR-TB, and XDR-TB. The primary outcome of interest was long-term physical sequelae. Meta-analysis was conducted using a random-effect model to estimate the pooled proportion of physical sequelae. The sources of heterogeneity were explored through meta-regression using study characteristics as covariates. The research protocol was registered in PROSPERO (CRD42021250909).

FINDINGS

From 3047 unique publications identified, 66 studies consisting of 37,380 patients conducted in 30 different countries were included in the meta-analysis. The overall pooled estimate was 44.4% (95% Confidence Interval (CI): 36.7-52.1) for respiratory sequelae, 26.7% (95% CI: 23.85-29.7) for hearing sequelae, 10.1% (95% CI: 7.0-13.2) for musculoskeletal sequelae, 8.4% (95% CI: 6.5-10.3) for neurological sequelae, 8.1% (95% CI: 6.3-10.0) for renal sequelae, 7.3% (95% CI: 5.1-9.4) for hepatic sequelae, and 4.5% (95% CI: 2.7-6.3) for visual sequelae. There was substantial heterogeneity in the estimates. The stratified analysis showed that the pooled prevalence of hearing sequelae was 26.6% (95% CI: 12.3-40.9), neurological sequelae was 31.5% (95% CI: 5.5-57.5), and musculoskeletal sequelae were 21.5% (95% CI: 9.9-33.1) for patients with XDR-TB, which were higher than the pooled prevalence of sequelae among patients with MDR-TB. Respiratory sequelae were the highest in low-income countries (59.3%) and after completion of MDR-TB treatment (57.7%).

INTERPRETATION

This systematic review found that long-term physical sequelae such as respiratory, hearing, musculoskeletal, neurological, renal, hepatic, and visual sequelae were common among survivors of MDR- and XDR-TB. There was a significant difference in the prevalence of sequelae between patients with MDR- and XDR-TB. Post-MDR- and XDR-TB treatment surveillance for adverse outcomes needs to be incorporated into the current programmatic management of MDR-TB to enable early detection and prevention of post-treatment sequelae.

FUNDING

Australian National Health and Medical Research Council, through an Emerging Leadership Investigator grant, and the Curtin University Higher Degree Research scholarship.

Update on Toxic Neuropathies

Purpose of Review

Toxic neuropathies are an important preventable and treatable form of peripheral neuropathy. While many forms of toxic neuropathies have been recognized for decades, an updated review is provided to increase vigilant in this area of neurology. A literature review was conducted to gather recent information about toxic neuropathies, which included the causes, clinical findings, and treatment options in these conditions.

Recent Findings

Toxic neuropathies continue to cause significant morbidity throughout the world and the causative agents, particularly with regards to medications, do not appear to be diminishing. A wide variety of causes of toxic neuropathies exist, which include alcohol, industrial chemicals, biotoxins, and medications. Unfortunately, no breakthrough treatments have been developed and prevention and symptom management remain the standard of care.

Summary

A detailed medication, occupational and hobby exposure history is critical to identifying toxic neuropathies. Increased research is warranted to identify mechanisms of neurotoxic susceptibility and potential common pathomechanistic pathways for treatment across diverse toxic neuropathies.

A Case Report: Ethambutol Causes a Rare Adverse Effect of Peripheral Neuropathy

Mycobacterium gordonae is a slow-growing acid-fast bacilli mycobacterium with low pathogenic potential. Patients with this infection are treated with antimycobacterial agents such as ethambutol, clarithromycin, and rifampin. We present a rare side effect of ethambutol causing peripheral neuropathy, along with regression of this upon discontinuation of the inciting medication. A 78-year-old male with a past medical history of lumbar degenerative disc disease and lumbosacral radiculopathy presented to the clinic with three weeks of progressively worsening rhinorrhea, nasal congestion, and productive cough with yellow sputum. After a bronchoalveolar lavage (BAL) and a chest computed tomography (CT) scan, he was diagnosed with an M. gordonae infection. He was started on a 12-month triple regimen of rifampin, clarithromycin, and high-dose ethambutol. During the first three months of antibiotic therapy, the patient began to have symptoms of gastrointestinal upset and worsening numbness in bilateral lower extremities, especially at night. Because he was unable to tolerate these adverse effects, the patient stopped taking these medications three months into his 12-month course. Upon stopping the antimycobacterial therapy, the patient’s neuropathy began to return to baseline. Based on imaging, electromyography (EMG), nerve conduction studies (NCS), and a literature search of antimycobacterial medicines, we concluded that the high dose of ethambutol is the most likely cause of this patient’s peripheral neuropathy. An important takeaway is that while ethambutol is a well-known cause of optic neuritis, it may also lead to peripheral neuropathy, which may regress upon discontinuation of the medication.

Tuberculosis related disability: a systematic review and meta-analysis

BACKGROUND

The sustainable development goals aim to improve health for all by 2030. They incorporate ambitious goals regarding tuberculosis (TB), which may be a significant cause of disability, yet to be quantified. Therefore, we aimed to quantify the prevalence and types of TB-related disabilities.

METHODS

We performed a systematic review of TB-related disabilities. The pooled prevalence of disabilities was calculated using the inverse variance heterogeneity model. The maps of the proportions of common types of disabilities by country income level were created.

RESULTS

We included a total of 131 studies (217,475 patients) that were conducted in 49 countries. The most common type of disabilities were mental health disorders (23.1%), respiratory impairment (20.7%), musculoskeletal impairment (17.1%), hearing impairment (14.5%), visual impairment (9.8%), renal impairment (5.7%), and neurological impairment (1.6%). The prevalence of respiratory impairment (61.2%) and mental health disorders (42.0%) was highest in low-income countries while neurological impairment was highest in lower middle-income countries (25.6%). Drug-resistant TB was associated with respiratory (58.7%), neurological (37.2%), and hearing impairments (25.0%) and mental health disorders (26.0%), respectively.

CONCLUSIONS

TB-related disabilities were frequently reported. More uniform reporting tools for TB-related disability and further research to better quantify and mitigate it are urgently needed.

PROSPERO REGISTRATION NUMBER

CRD42019147488.

Mediastinal tuberculous lymphadenitis presenting with insidious back pain in a male adult: a case report and review of the literature

Mediastinal tuberculous lymphadenitis (MTL) is mostly observed in primary tuberculosis in infants, children and adolescents, and is not found commonly in adults. Mediastinal tuberculous lymphadenitis cases may present with an insidious progression of tuberculous symptoms, including gradual deterioration in the lungs and a variety of clinical characteristics; however, initial symptoms are rarely only chronic back pain. We present the case of a 33-year-old man with mediastinal tuberculous lymphadenitis misdiagnosed as myofascitis. Since such individuals do not develop respiratory symptoms in the initial stages, they often go undiagnosed and can potentially spread tuberculosis.

Bilateral Foot-Drop Secondary to Axonal Neuropathy in a Tuberculosis Patient With Co-Infection of COVID-19: A Case Report

Tuberculosis (TB) is a global pandemic and is one of the top 10 causes of death worldwide as well as the leading cause of death from a single infectious agent. It can cause a wide array of complications including peripheral neuropathy. In addition to TB pandemic the recent pandemic of coronavirus disease 2019 (COVID-19) has led to an increased interest in the co-infection of TB patients and COVID-19 and whether TB increases risk for COVID-19 and its role in causing severity of disease and vice-versa. This case report discusses about a young cachectic man who was found to have bilateral foot-drop under the setting of TB with co-infection of COVID-19 later confirmed to be axonal neuropathy on nerve conduction study. The report highlights the importance of differential diagnosis of TB in COVID-19 patients as well as the consideration of TB in a patient with peripheral neuropathy after nutritional causes have been ruled out.

Diagnosing peripheral neuropathy in South-East Asia: A focus on diabetic neuropathy

Burning and stabbing pain in the feet and lower limbs can have a significant impact on the activities of daily living, including walking, climbing stairs and sleeping. Peripheral neuropathy in particular is often misdiagnosed or underdiagnosed because of a lack of awareness amongst both patients and physicians. Furthermore, crude screening tools, such as the 10-g monofilament, only detect advanced neuropathy and a normal test will lead to false reassurance of those with small fiber mediated painful neuropathy. The underestimation of peripheral neuropathy is highly prevalent in the South-East Asia region due to a lack of consensus guidance on routine screening and diagnostic pathways. Although neuropathy as a result of diabetes is the most common cause in the region, other causes due to infections (human immunodeficiency virus, hepatitis B or C virus), chronic inflammatory demyelinating polyneuropathy, drug-induced neuropathy (cancer chemotherapy, antiretrovirals and antituberculous drugs) and vitamin deficiencies (vitamin B1 , B6 , B12 , D) should be actively excluded.

Distal Sensory Peripheral Neuropathy in Human Immunodeficiency Virus Type 1-Positive Individuals Before and After Antiretroviral Therapy Initiation in Diverse Resource-Limited Settings

BACKGROUND

Distal sensory peripheral neuropathy (DSPN) is a complication of human immunodeficiency virus (HIV). We estimate DSPN prevalence in 7 resource-limited settings (RLSs) for combination antiretroviral therapy (cART)-naive people living with HIV (PLWH) compared with matched participants not living with HIV and in PLWH virally suppressed on 1 of 3 cART regimens.

METHODS

PLWH with a CD4+ count <300 cells/mm3 underwent standardized neurological examination and functional status assessments before and every 24 weeks after starting cART. Matched individuals not living with HIV underwent the same examinations once.Associations between covariates with DSPN at entry were assessed using the χ2 test, and virally suppressed PLWH were assessed using generalized estimating equations.

RESULTS

Before initiating cART, 21.3% of PLWH had DSPN compared with 8.5% of people not living with HIV (n = 2400; χ2(df = 1) = 96.5; P < .00001). PLWH with DSPN were more likely to report inability to work [χ2(df = 1) = 10.6; P = .001] and depression [χ2(df = 1) = 8.9; P = .003] than PLWH without DSPN. Overall prevalence of DSPN among those virally suppressed on cART decreased: 20.3%, week 48; 15.3%, week 144; and 10.3%, week 192. Incident DSPN was seen in 127 PLWH. Longitudinally, DSPN was more likely in older individuals (P < .001) and PLWH with less education (P = .03). There was no significant association between cART regimen and DSPN.

CONCLUSIONS

Although the prevalence of DSPN decreased following cART initiation in PLWH, further research could identify strategies to prevent or ameliorate residual DSPN after initiating cART in RLSs.

Safety implications of combined antiretroviral and anti-tuberculosis drugs

Introduction: Antiretroviral and anti-tuberculosis (TB) drugs are often co-administered in people living with HIV (PLWH). Early initiation of antiretroviral therapy (ART) during TB treatment improves survival in patients with advanced HIV disease. However, safety concerns related to clinically significant changes in drug exposure resulting from drug-drug interactions, development of overlapping toxicities and specific challenges related to co-administration during pregnancy represent barriers to successful combined treatment for HIV and TB.Areas covered: Pharmacokinetic interactions of different classes of ART when combined with anti-TB drugs used for sensitive-, drug-resistant (DR) and latent TB are discussed. Overlapping drug toxicities, implications of immune reconstitution inflammatory syndrome (IRIS), safety in pregnancy and research gaps are also explored.Expert opinion: New antiretroviral and anti-tuberculosis drugs have been recently introduced and international guidelines updated. A number of effective molecules and clinical data are now available to build treatment regimens for PLWH with latent or active TB. Adopting a systematic approach that also takes into account the need for individualized variations based on the available evidence is the key to successfully integrate ART and TB treatment and improve treatment outcomes.

Hydrothermal Synthesize of HF-Free MIL-100(Fe) for Isoniazid-Drug Delivery

Sustainable development of drug delivery materials with good biocompatibility and controlled-release is a popular topic among researchers. In this research study, we demonstrated the potential of the metal-organic framework, that is MIL-100(Fe), as a drug delivery platform for isoniazid (INH). The MIL-100(Fe) was prepared by using the hydrofluoric acid-free hydrothermal method. Several physical measurements were conducted to characterize the MIL-100(Fe), including x-ray diffraction (XRD), scanning electron microscopy (SEM), nitrogen sorption, and thermal-gravimetric (TG). The synthesized MIL-100(Fe) has octahedron-shaped particles with superior properties, that is large surface area (1456.10 m2/g) and pore volume (1.25 cm3/g). The drug loading rate and capacity were determined by means of adsorption kinetic and isotherm. The studied INH@MIL-100(Fe) adsorption system kinetics follow the pseudo-first-order model, while the isotherm system follows the Langmuir model with the maximum adsorption capacity of 128.5 mg/g at 30 °C. MIL-100(Fe) shows adequate biocompatibility, also exhibits a reasonable and controlled drug release kinetics. The results obtained show that MIL-100 (Fe) can be a good choice of drug delivery platform among other available platforms.

Pharmacokinetics of isoniazid: The good, the bad, and the alternatives

Although isoniazid (INH) has been successful in treating Tuberculosis (TB) since its introduction in 1952, there has been continual reports of drug-associated hepatotoxicity in TB patients. These toxic side effects may reveal more about the recipient of the drug, than the drug itself. A combination of pharmacogenetic and pharmacokinetic studies have identified polymorphisms within enzymes involved in INH metabolism and detoxification. These essential metabolic enzymes include N-acetyltransferase 2, Cytochrome P450 2E1, and glutathione S transferases. Different phenotypes of these enzymes can affect the rate of INH metabolism, resulting in production of hepatotoxic metabolites. This review is intended to elucidate the pharmacokinetics of INH by examining its Administration, Distribution, Metabolism, and Elimination, while suggesting potential alternatives within INH personalized treatment to help reduce hepatotoxicity.

A Network Pharmacology Approach for the Identification of Common Mechanisms of Drug-Induced Peripheral Neuropathy

Drug-induced peripheral neuropathy is a side effect of a variety of therapeutic agents that can affect therapeutic adherence and lead to regimen modifications, impacting patient quality of life. The molecular mechanisms involved in the development of this condition have yet to be completely described in the literature. We used a computational network pharmacology approach to explore the Connectivity Map, a large collection of transcriptional profiles from drug perturbation experiments to identify common genes affected by peripheral neuropathy-inducing drugs. Consensus profiles for 98 of these drugs were used to construct a drug-gene perturbation network. We identified 27 genes significantly associated with neuropathy-inducing drugs. These genes may have a potential role in the action of neuropathy-inducing drugs. Our results suggest that molecular mechanisms, including alterations in mitochondrial function, microtubule and cytoskeleton function, ion channels, transcriptional regulation including epigenetic mechanisms, signal transduction, and wound healing, may play a critical role in drug-induced peripheral neuropathy.