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Montero-Vega MT, Matilla J, Bazán E, Reimers D, De Andrés-Martín A, Gonzalo-Gobernado R, Correa C, Urbano F, Gómez-Coronado D. Fluvastatin Converts Human Macrophages into Foam Cells with Increased Inflammatory Response to Inactivated Mycobacterium tuberculosis H37Ra. Cells 2024; 13:536. [PMID: 38534380 DOI: 10.3390/cells13060536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 03/28/2024] Open
Abstract
Cholesterol biosynthesis inhibitors (statins) protect hypercholesterolemic patients against developing active tuberculosis, suggesting that these drugs could help the host to control the pathogen at the initial stages of the disease. This work studies the effect of fluvastatin on the early response of healthy peripheral blood mononuclear cells (PBMCs) to inactivated Mycobacterium tuberculosis (Mtb) H37Ra. We found that in fluvastatin-treated PBMCs, most monocytes/macrophages became foamy cells that overproduced NLRP3 inflammasome components in the absence of immune stimulation, evidencing important cholesterol metabolism/immunity connections. When both fluvastatin-treated and untreated PBMCs were exposed to Mtb H37Ra, a small subset of macrophages captured large amounts of bacilli and died, concentrating the bacteria in necrotic areas. In fluvastatin-untreated cultures, most of the remaining macrophages became epithelioid cells that isolated these areas of cell death in granulomatous structures that barely produced IFNγ. By contrast, in fluvastatin-treated cultures, foamy macrophages surrounded the accumulated bacteria, degraded them, markedly activated caspase-1 and elicited a potent IFNγ/cytotoxic response. In rabbits immunized with the same bacteria, fluvastatin increased the tuberculin test response. We conclude that statins may enhance macrophage efficacy to control Mtb, with the help of adaptive immunity, offering a promising tool in the design of alternative therapies to fight tuberculosis.
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Affiliation(s)
- María Teresa Montero-Vega
- Servicio de Bioquímica-Investigación, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Joaquín Matilla
- Servicio de Bioquímica-Investigación, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Eulalia Bazán
- Servicio de Neurobiología-Investigación, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Diana Reimers
- Servicio de Neurobiología-Investigación, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Ana De Andrés-Martín
- Servicio de Inmunología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Rafael Gonzalo-Gobernado
- Departamento de Biología Molecular y Celular, Centro Nacional de Biotecnología (CNB), Consejo Superior de Investigaciones Científicas (CSIC), 28049 Madrid, Spain
| | - Carlos Correa
- Unidad de Cirugía Experimental y Animalario, Investigación, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Francisco Urbano
- Servicio Interdepartamental de Investigación (SIdI), Facultad de Medicina, Universidad Autónoma, 28029 Madrid, Spain
| | - Diego Gómez-Coronado
- Servicio de Bioquímica-Investigación, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
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Cevaal PM, Bekker LG, Hermans S. TB-IRIS pathogenesis and new strategies for intervention: Insights from related inflammatory disorders. Tuberculosis (Edinb) 2019; 118:101863. [PMID: 31561185 DOI: 10.1016/j.tube.2019.101863] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/29/2022]
Abstract
In almost one in five HIV/tuberculosis (TB) co-infected patients, initiation of antiretroviral therapy (ART) is complicated by TB immune reconstitution inflammatory syndrome (TB-IRIS). Corticosteroids have been suggested for treatment of severe cases, however no therapy is currently licensed for TB-IRIS. Hence, there is a strong need for more specific therapeutics, and therefore, a better understanding of TB-IRIS pathogenesis. Immune reconstitution following ART is a precariously balanced functional restoration of adaptive immunity. In those patients predisposed to disease, an incomplete activation of the innate immune system leads to a hyper-inflammatory response that comprises partially overlapping innate, adaptive and effector arms, eventually leading to clinical symptoms. Interestingly, many of these pathological mechanisms are shared by related inflammatory disorders. We here describe therapeutic strategies that originate from these other disciplines and discuss their potential application in TB-IRIS. These new avenues of interventions range from final-phase treatment of symptoms to early-phase prevention of disease onset. In conclusion, we propose a novel approach for the discovery and development of therapeutics, based on an updated model of TB-IRIS pathogenesis. Further experimental studies validating the causal relationships in the proposed model could greatly contribute to providing a solid immunological basis for future clinical trials on TB-IRIS therapeutics.
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Affiliation(s)
- Paula M Cevaal
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands.
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
| | - Sabine Hermans
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands; Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
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Dellière S, Guery R, Candon S, Rammaert B, Aguilar C, Lanternier F, Chatenoud L, Lortholary O. Understanding Pathogenesis and Care Challenges of Immune Reconstitution Inflammatory Syndrome in Fungal Infections. J Fungi (Basel) 2018; 4:E139. [PMID: 30562960 PMCID: PMC6308948 DOI: 10.3390/jof4040139] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 12/16/2022] Open
Abstract
Immune deficiency of diverse etiology, including human immunodeficiency virus (HIV), antineoplastic agents, immunosuppressive agents used in solid organ recipients, immunomodulatory therapy, and other biologics, all promote invasive fungal infections. Subsequent voluntary or unintended immune recovery may induce an exaggerated inflammatory response defining immune reconstitution inflammatory syndrome (IRIS), which causes significant mortality and morbidity. Fungal-associated IRIS raises several diagnostic and management issues. Mostly studied with Cryptococcus, it has also been described with other major fungi implicated in human invasive fungal infections, such as Pneumocystis, Aspergillus, Candida, and Histoplasma. Furthermore, the understanding of IRIS pathogenesis remains in its infancy. This review summarizes current knowledge regarding the clinical characteristics of IRIS depending on fungal species and existing strategies to predict, prevent, and treat IRIS in this patient population, and tries to propose a common immunological background to fungal IRIS.
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Affiliation(s)
- Sarah Dellière
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Romain Guery
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Sophie Candon
- Medical School, Paris-Descartes University, INSERM U1151-CNRS UMR 8253APHP, Necker-Enfants Malades Hospital, APHP, Clinical Immunology, 75015 Paris, France.
| | - Blandine Rammaert
- Medical School, Poitiers University, Poitiers, France; Poitiers University Hospital, Infectious Disease Unit, Poitiers, France; INSERM U1070, 86022 Poitiers, France.
| | - Claire Aguilar
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Fanny Lanternier
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
- Pasteur Institute, Molecular Mycology Unit, National Reference Center for Invasive Fungal Disease and Antifungals, CNRS UMR 2000, 75015 Paris, France.
| | - Lucienne Chatenoud
- Medical School, Paris-Descartes University, INSERM U1151-CNRS UMR 8253APHP, Necker-Enfants Malades Hospital, APHP, Clinical Immunology, 75015 Paris, France.
| | - Olivier Lortholary
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
- Pasteur Institute, Molecular Mycology Unit, National Reference Center for Invasive Fungal Disease and Antifungals, CNRS UMR 2000, 75015 Paris, France.
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Ravimohan S, Bisson GP. To have and have not: dissecting protective and pathologic immune recovery in TB-IRIS. Future Virol 2015. [DOI: 10.2217/fvl.15.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a growing concern for advanced HIV/TB coinfected patients in an era where antiretroviral therapy (ART) is started shortly after TB treatment initiation. This perspective discusses potential mechanisms underlying TB-IRIS, focusing on recent studies that implicate coordinated recovery in adaptive and innate immune responses following ART initiation in TB-IRIS. More broadly, HIV/TB patients are probably a heterogeneous group whose outcomes are determined by the direction in which these immune responses change following ART initiation. Finally, in addition to treatment interventions that are in the pipeline for TB-IRIS, we highlight the need for holistic management of HIV/TB coinfected patients, which go beyond the current definition of TB-IRIS and take into consideration long-term consequences of robust immune recovery on ART.
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Affiliation(s)
- Shruthi Ravimohan
- Perelman School of Medicine at the University of Pennsylvania, Department of Medicine, Division of Infectious Diseases, 502 Johnson Pavilion, 3610 Hamilton Walk, Philadelphia, PA 19104-60732, USA
- Botswana–UPenn Partnership, University of Botswana, Main Campus, 244G – Room 103, Gaborone, Botswana
| | - Gregory P Bisson
- Perelman School of Medicine at the University of Pennsylvania, Department of Medicine, Division of Infectious Diseases, 502 Johnson Pavilion, 3610 Hamilton Walk, Philadelphia, PA 19104-60732, USA
- Botswana–UPenn Partnership, University of Botswana, Main Campus, 244G – Room 103, Gaborone, Botswana
- Perelman School of Medicine at the University of Pennsylvania, Department of Biostatistics & Epidemiology, Center for Clinical Epidemiology & Biostatistics, Philadelphia, PA 19104, USA
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Gopalan N, Andrade BB, Swaminathan S. Tuberculosis-immune reconstitution inflammatory syndrome in HIV: from pathogenesis to prediction. Expert Rev Clin Immunol 2014; 10:631-45. [PMID: 24580108 DOI: 10.1586/1744666x.2014.892828] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is an exaggerated, dysregulated immune response against dead or viable antigens of Mycobacterium tuberculosis that frequently occurs after initiation of antiretroviral therapy despite an effective suppression of HIV viremia. Scientific advances in IRIS pathogenesis have led researchers and clinicians to postulate risk factors that could possibly predict this syndrome, in an attempt to reduce the incidence and the severity of IRIS, with appropriate anti-inflammatory therapy. This review is a summary of the available literature on pathogenic mechanisms involved from the macro to the micro level, the clinical spectrum, available predictors and the scope of these biomarkers to function as specific therapeutic targets, that could effectively modulate or ameliorate this syndrome in future.
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Affiliation(s)
- Narendran Gopalan
- National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai 600 031, India
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Lawn SD, Meintjes G, McIlleron H, Harries AD, Wood R. Management of HIV-associated tuberculosis in resource-limited settings: a state-of-the-art review. BMC Med 2013; 11:253. [PMID: 24295487 PMCID: PMC4220801 DOI: 10.1186/1741-7015-11-253] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/07/2013] [Indexed: 01/08/2023] Open
Abstract
The HIV-associated tuberculosis (TB) epidemic remains a huge challenge to public health in resource-limited settings. Reducing the nearly 0.5 million deaths that result each year has been identified as a key priority. Major progress has been made over the past 10 years in defining appropriate strategies and policy guidelines for early diagnosis and effective case management. Ascertainment of cases has been improved through a twofold strategy of provider-initiated HIV testing and counseling in TB patients and intensified TB case finding among those living with HIV. Outcomes of rifampicin-based TB treatment are greatly enhanced by concurrent co-trimoxazole prophylaxis and antiretroviral therapy (ART). ART reduces mortality across a spectrum of CD4 counts and randomized controlled trials have defined the optimum time to start ART. Good outcomes can be achieved when combining TB treatment with first-line ART, but use with second-line ART remains challenging due to pharmacokinetic drug interactions and cotoxicity. We review the frequency and spectrum of adverse drug reactions and immune reconstitution inflammatory syndrome (IRIS) resulting from combined treatment, and highlight the challenges of managing HIV-associated drug-resistant TB.
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Affiliation(s)
- Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Anthony D Harries
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
- International Union against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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7
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Meintjes G, Scriven J, Marais S. Management of the immune reconstitution inflammatory syndrome. Curr HIV/AIDS Rep 2012; 9:238-50. [PMID: 22752438 DOI: 10.1007/s11904-012-0129-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) is a frequent early complication of antiretroviral therapy (ART) in patients with advanced HIV. Because there is no confirmatory diagnostic test, the diagnosis is based on clinical presentation and exclusion of alternative causes for deterioration, such as antimicrobial drug resistance. Opportunistic infection treatment should be optimized. Mild cases may require symptomatic therapy alone or nonsteroidal anti-inflammatory drugs. Corticosteroids have been used to treat more severe cases of IRIS associated with mycobacterial and fungal infections. There is evidence from a randomized controlled trial that prednisone reduces morbidity and improves symptoms in paradoxical tuberculosis (TB)-IRIS. Neurological TB-IRIS is potentially life-threatening; high-dose corticosteroids are indicated and ART interruption should be considered if level of consciousness is depressed. When considering corticosteroid treatment clinicians should be aware of their side effects and only use them when the diagnosis of IRIS is certain. In viral forms of IRIS corticosteroids are generally avoided.
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Affiliation(s)
- Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Sung KU, Lee HE, Choi WR, Seo MC, Yoon HJ. Molluscum contagiosum as a skin manifestation of immune reconstitution inflammatory syndrome in an AIDS patient who is receiving HAART. Korean J Fam Med 2012; 33:182-5. [PMID: 22787541 PMCID: PMC3391644 DOI: 10.4082/kjfm.2012.33.3.182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 04/30/2012] [Indexed: 11/15/2022] Open
Abstract
Highly active antiretroviral therapy (HAART), which restores specific immune responses, may paradoxically cause an inflammatory reaction known as immune reconstitution inflammatory syndrome (IRIS). We report a patient with acquired immune deficiency syndrome, who presented Molluscum contagiosum as IRIS after HAART, the first case in Korea.
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Affiliation(s)
- Kyung Uk Sung
- Department of Internal Medicine, Eulji University School of Medicine, Daejeon, Korea
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9
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[Immune reconstitution syndrome]. Z Rheumatol 2012; 71:187-98. [PMID: 22527213 DOI: 10.1007/s00393-011-0858-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) represents a heterogeneous group of conditions. Whilst they typically present in HIV-infected patients with advanced immunodeficiency, IRIS have also been described in HIV-negative patients with immune reconstitution due to other causes of immunosuppression. Frequently IRIS results from an immune response against underlying infection (pathogen-associated IRIS). However, IRIS might become evident during immune reconstitution without an underlying pathogen such as a sarcoid-like illness or an autoimmune thyropathy. Here we report on the epidemiology and risk factors of IRIS along with diagnosis and management of this clinically important inflammatory syndrome.
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Lawn SD, Meintjes G. Pathogenesis and prevention of immune reconstitution disease during antiretroviral therapy. Expert Rev Anti Infect Ther 2011; 9:415-30. [PMID: 21504399 DOI: 10.1586/eri.11.21] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The risks of unmasking and paradoxical forms of immune reconstitution disease in HIV-infected patients starting antiretroviral therapy (ART) are fuelled by a combination of the late presentation of patients with advanced immunodeficiency, the associated high rates of opportunistic infections (OIs) and the need for rapid initiation of ART to minimize overall mortality risk. We review the risk factors and our current knowledge of the immunopathogenesis of immune reconstitution disease, leading to a discussion of strategies for prevention. Initiation of ART at higher CD4 counts, use of OI-preventive therapies prior to ART eligibility, intensified screening for OIs prior to ART initiation and optimum therapy for OIs are all needed. In addition, use of a range of pharmacological agents with immunosuppressive and immunomodulatory activity is being explored.
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Affiliation(s)
- Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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