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Dolezalova K, Hadlova P, Ibrahimova M, Golias J, Baca L, Kopecka E, Sukholytka M, Koziar Vasakova M. Flow cytometry-based method using diversity of cytokine production differentiates between Mycobacterium tuberculosis infection and disease. Tuberculosis (Edinb) 2024; 147:102518. [PMID: 38739968 DOI: 10.1016/j.tube.2024.102518] [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: 03/01/2024] [Revised: 05/04/2024] [Accepted: 05/07/2024] [Indexed: 05/16/2024]
Abstract
Authors present a pilot study of the development of innovative flow cytometry-based assay with a potential for use in tuberculosis diagnostics. Currently available tests do not provide robust discrimination between latent tuberculosis infection (TBI) and tuberculosis disease (TB). The desired application is to distinguish between the two conditions by evaluating the production of a combination of three cytokines: IL-2 (interleukin-2), IFNɣ (interferon gamma) and TNFɑ (tumor necrosis factor alpha) in CD4+ and CD8+ T cells. The study was conducted on 68 participants, divided into two arms according to age (paediatric and adults). Each arm was further split into three categories (non-infection (NI), TBI, TB) based on the immune reaction to Mycobacterium tuberculosis (M.tb) after a close contact with pulmonary TB. Each blood sample was stimulated with specific M.tb antigens present in QuantiFERON tubes (TB1 and TB2). We inferred TBI or TB based on the predominant cytokine response of the CD4+ and/or CD8+ T cells. Significant differences were detected between the NI, TBI and the TB groups in TB1 in the CD4+TNFɑ+parameter in children. Along with IL-2, TNFɑ seems to be the most promising diagnostic marker in both CD4+and CD8+ T cells. However, more detailed analyses on larger cohorts are needed to confirm the observed tendencies.
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Affiliation(s)
- Karolina Dolezalova
- Department of Paediatrics of the First Faculty of Medicine, Charles University, Thomayer University Hospital, Prague, Czech Republic.
| | - Petra Hadlova
- Childhood Leukaemia Investigation Prague (CLIP), 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marketa Ibrahimova
- Laboratory of Immunology, Thomayer University Hospital, Prague, Czech Republic
| | - Jaroslav Golias
- Laboratory of Immunology, Thomayer University Hospital, Prague, Czech Republic
| | - Lubos Baca
- Department of Paediatrics of the First Faculty of Medicine, Charles University, Thomayer University Hospital, Prague, Czech Republic
| | - Emilia Kopecka
- Department of Respiratory Medicine of the First Faculty of Medicine Charles University, Thomayer University Hospital, Prague, Czech Republic
| | - Mariia Sukholytka
- Department of Respiratory Medicine of the First Faculty of Medicine Charles University, Thomayer University Hospital, Prague, Czech Republic
| | - Martina Koziar Vasakova
- Department of Respiratory Medicine of the First Faculty of Medicine Charles University, Thomayer University Hospital, Prague, Czech Republic
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2
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Chin KL, Anibarro L, Sarmiento ME, Acosta A. Challenges and the Way forward in Diagnosis and Treatment of Tuberculosis Infection. Trop Med Infect Dis 2023; 8:tropicalmed8020089. [PMID: 36828505 PMCID: PMC9960903 DOI: 10.3390/tropicalmed8020089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
Globally, it is estimated that one-quarter of the world's population is latently infected with Mycobacterium tuberculosis (Mtb), also known as latent tuberculosis infection (LTBI). Recently, this condition has been referred to as tuberculosis infection (TBI), considering the dynamic spectrum of the infection, as 5-10% of the latently infected population will develop active TB (ATB). The chances of TBI development increase due to close contact with index TB patients. The emergence of multidrug-resistant TB (MDR-TB) and the risk of development of latent MDR-TB has further complicated the situation. Detection of TBI is challenging as the infected individual does not present symptoms. Currently, there is no gold standard for TBI diagnosis, and the only screening tests are tuberculin skin test (TST) and interferon gamma release assays (IGRAs). However, these tests have several limitations, including the inability to differentiate between ATB and TBI, false-positive results in BCG-vaccinated individuals (only for TST), false-negative results in children, elderly, and immunocompromised patients, and the inability to predict the progression to ATB, among others. Thus, new host markers and Mtb-specific antigens are being tested to develop new diagnostic methods. Besides screening, TBI therapy is a key intervention for TB control. However, the long-course treatment and associated side effects result in non-adherence to the treatment. Additionally, the latent MDR strains are not susceptible to the current TBI treatments, which add an additional challenge. This review discusses the current situation of TBI, as well as the challenges and efforts involved in its control.
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Affiliation(s)
- Kai Ling Chin
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia
- Borneo Medical and Health Research Centre, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia
- Correspondence: (K.L.C.); (L.A.); (A.A.)
| | - Luis Anibarro
- Tuberculosis Unit, Infectious Diseases and Internal Medicine Department, Complexo Hospitalario Universitario de Pontevedra, 36071 Pontevedra, Spain
- Immunology Research Group, Galicia Sur Health Research Institute (IIS-GS), 36312 Vigo, Spain
- Correspondence: (K.L.C.); (L.A.); (A.A.)
| | - Maria E. Sarmiento
- School of Health Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
| | - Armando Acosta
- School of Health Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
- Correspondence: (K.L.C.); (L.A.); (A.A.)
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3
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Dreesman A, Corbière V, Libin M, Racapé J, Collart P, Singh M, Locht C, Mascart F, Dirix V. Specific Host Signatures for the Detection of Tuberculosis Infection in Children in a Low TB Incidence Country. Front Immunol 2021; 12:575519. [PMID: 33790886 PMCID: PMC8005539 DOI: 10.3389/fimmu.2021.575519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
Diagnosis of tuberculosis (TB) in children remains challenging due to unspecific clinical presentation and low bacillary load. In low TB incidence countries, most cases are diagnosed by a contact screening strategy after exposure to an index TB case. Due to the severity of TB in young children, the priority is to determine whether a child is infected or not, whereas differential diagnosis between active TB (aTB) and latent TB constitutes a second step. In Belgium, a low TB incidence country, we prospectively included 47 children with a defined M. tuberculosis infection status (12 children with aTB, 18 with latent TB, and 17 uninfected) (exploratory cohort), and determined the optimal combinations of cytokines secreted by their peripheral blood mononuclear cells in response to a 5-days in vitro stimulation with four different mycobacterial antigens, in an attempt to classify the children according to their infectious status. Correct identification of all infected children was obtained by several combinations of two purified protein derivative (PPD)-induced cytokines (IFN-γ and either GM-CSF, MIP-1α, sCD40L or TNF-α), or by combining PPD-induced IFN-γ with culture-filtrate protein-10 (CFP-10)-induced TNF-α. Alternatively, combining CFP-10-induced TNF-α and IP-10 with heparin-binding haemagglutinin (HBHA)-induced-IFN-γ was more effective in testing recently BCG-vaccinated children or those suspected to be infected with non-tuberculous mycobacteria, providing a correct classification of 97% of the M. tuberculosis-infected children. This combination also correctly classified 98% of the children from a validation cohort comprising 40 M. tuberculosis infected children and 20 non-infected children. Further differentiation between aTB and children with latent TB was more difficult. Combining ESAT-6-induced MIP1-α and IP-10, CFP-10-induced MIG, and HBHA-induced MIG provided a correct classification of 77% of the children from the exploratory cohort but only of 57.5% of those from the validation cohort. We conclude that combining the measurement of 2–4 cytokines induced by three different mycobacterial antigens allows an excellent identification of M. tuberculosis-infected children, whereas differentiating children with aTB from those with latent TB remains far from perfect.
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Affiliation(s)
- Alexandra Dreesman
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium.,Pediatric Department, Centre Hospitalo-Universitaire Saint-Pierre, Brussels, Belgium
| | - Véronique Corbière
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium
| | - Myriam Libin
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium
| | - Judith Racapé
- Biomedical Research Center, Erasme Hospital, Brussels, Belgium.,Centre de recherche Epidémiologie, Biostatistiques, Recherche Clinique, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Collart
- Centre de recherche Epidémiologie, Biostatistiques, Recherche Clinique, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Mahavir Singh
- Lionex Diagnostics and Therapeutics, Braunschweig, Germany
| | - Camille Locht
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019 - UMR9017 - CIIL - Center for Infection and Immunity of Lille, Lille, France
| | - Françoise Mascart
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium
| | - Violette Dirix
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium
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4
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Sudbury EL, Clifford V, Messina NL, Song R, Curtis N. Mycobacterium tuberculosis-specific cytokine biomarkers to differentiate active TB and LTBI: A systematic review. J Infect 2020; 81:873-881. [PMID: 33007340 DOI: 10.1016/j.jinf.2020.09.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/21/2020] [Accepted: 09/18/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES New tests are needed to overcome the limitations of existing immunodiagnostic tests for tuberculosis (TB) infection, including their inability to differentiate between active TB and latent TB infection (LTBI). This review aimed to identify the most promising cytokine biomarkers for use as stage-specific markers of TB infection. METHODS A systematic review was done using electronic databases to identify studies that have investigated Mycobacterium tuberculosis (MTB)-specific cytokine responses as diagnostic tools to differentiate between LTBI and active TB. RESULTS The 56 studies included in this systematic review measured the MTB-specific responses of 100 cytokines, the most frequently studied of which were IFN-γ, IL-2, TNF-α, IP-10, IL-10 and IL-13. Ten studies assessed combinations of cytokines, most commonly IL-2 and IFN-γ. For most cytokines, findings were heterogenous between studies. The variation in results likely relates to differences in the study design and laboratory methods, as well as participant and environmental factors. CONCLUSIONS Although several cytokines show promise as stage-specific markers of TB infection, this review highlights the need for further well-designed studies, in both adult and paediatric populations, to establish which cytokine(s) will be of most use in a new generation of immunodiagnostic tests.
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Affiliation(s)
- Eva L Sudbury
- Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital Melbourne, Parkville, Australia; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Australia.
| | - Vanessa Clifford
- Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital Melbourne, Parkville, Australia; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Australia; Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Australia.
| | - Nicole L Messina
- Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital Melbourne, Parkville, Australia; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Australia.
| | - Rinn Song
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK; Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital Melbourne, Parkville, Australia; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Australia; Infectious Diseases Unit, The Royal Children's Hospital, Parkville, Australia.
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5
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Robison HM, Escalante P, Valera E, Erskine CL, Auvil L, Sasieta HC, Bushell C, Welge M, Bailey RC. Precision immunoprofiling to reveal diagnostic signatures for latent tuberculosis infection and reactivation risk stratification. Integr Biol (Camb) 2020; 11:16-25. [PMID: 30722034 DOI: 10.1093/intbio/zyz001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/05/2018] [Accepted: 01/02/2019] [Indexed: 11/12/2022]
Abstract
Latent tuberculosis infection (LTBI) is estimated in nearly one quarter of the world's population, and of those immunocompetent and infected ~10% will proceed to active tuberculosis (TB). Current diagnostics cannot definitively identify LTBI and provide no insight into reactivation risk, thereby defining an unmet diagnostic challenge of incredible global significance. We introduce a new machine-learning-driven approach to LTBI diagnostics that leverages a high throughput, multiplexed cytokine detection technology and powerful bioinformatics to reveal multi-marker signatures for LTBI diagnosis and risk stratification. This approach is enabled through an individualized normalization procedure that allows disease-relevant biomarker signatures to be revealed despite heterogeneity in basal immune response. Specifically, cytokines secreted from antigen-challenged peripheral blood mononuclear cells were detected using silicon photonic sensor arrays and multidimensional data correlation of individually-normalized immune responses revealed signatures important for LTBI status. These results demonstrate a powerful combination of multiplexed biomarker detection technologies, precision immune normalization, and feature selection algorithms that revealed positively correlated multi-biomarker signatures for LTBI status and reactivation risk stratification from a relatively simple blood-based assay.
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Affiliation(s)
- Heather M Robison
- Department of Chemistry, University of Illinois at Urbana-Champaign, 600 South Mathews Avenue, Urbana, IL, USA
| | - Patricio Escalante
- Mycobacterial and Bronchiectasis Clinic, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, and Mayo Clinic Center for Tuberculosis, 200 First Street SW, Rochester, MN, USA.,Mayo-Illinois Alliance for Technology-Based Healthcare
| | - Enrique Valera
- Department of Chemistry, University of Illinois at Urbana-Champaign, 600 South Mathews Avenue, Urbana, IL, USA
| | - Courtney L Erskine
- Mycobacterial and Bronchiectasis Clinic, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, and Mayo Clinic Center for Tuberculosis, 200 First Street SW, Rochester, MN, USA
| | - Loretta Auvil
- National Center for Supercomputing Applications, 1205 W. Clark St., Urbana, IL, USA
| | - Humberto C Sasieta
- Mycobacterial and Bronchiectasis Clinic, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, and Mayo Clinic Center for Tuberculosis, 200 First Street SW, Rochester, MN, USA
| | - Colleen Bushell
- Mayo-Illinois Alliance for Technology-Based Healthcare.,National Center for Supercomputing Applications, 1205 W. Clark St., Urbana, IL, USA
| | - Michael Welge
- Mayo-Illinois Alliance for Technology-Based Healthcare.,National Center for Supercomputing Applications, 1205 W. Clark St., Urbana, IL, USA
| | - Ryan C Bailey
- Department of Chemistry, University of Illinois at Urbana-Champaign, 600 South Mathews Avenue, Urbana, IL, USA.,Mayo-Illinois Alliance for Technology-Based Healthcare.,Department of Chemistry, University of Michigan, 930 North University Avenue, Ann Arbor, MI, USA
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6
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Comella-Del-Barrio P, Abellana R, Villar-Hernández R, Jean Coute MD, Sallés Mingels B, Canales Aliaga L, Narcisse M, Gautier J, Ascaso C, Latorre I, Dominguez J, Perez-Porcuna TM. A Model Based on the Combination of IFN-γ, IP-10, Ferritin and 25-Hydroxyvitamin D for Discriminating Latent From Active Tuberculosis in Children. Front Microbiol 2019; 10:1855. [PMID: 31474956 PMCID: PMC6702835 DOI: 10.3389/fmicb.2019.01855] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/29/2019] [Indexed: 01/31/2023] Open
Abstract
In recent years, pediatric research on tuberculosis (TB) has focused on addressing new biomarkers with the potential to be used as immunological non-sputum-based methods for the diagnosis of TB in children. The aim of this study was to characterize a set of cytokines and a series of individual factors (ferritin, 25-hydroxyvitamin D [25(OH)D], parasite infections, and nutritional status) to assess different patterns for discriminating between active TB and latent TB infection (LTBI) in children. The levels of 13 cytokines in QuantiFERON-TB Gold In-Tube (QFT-GIT) supernatants were analyzed in 166 children: 74 with active TB, 37 with LTBI, and 55 uninfected controls. All cytokines were quantified using Luminex or ELISA. Ferritin and 25(OH)D were also evaluated using CLIA, and Toxocara canis Ig-G antibodies were detected with a commercial ELISA kit. The combination of IP-10, IFN-γ, ferritin, and 25(OH)D achieved the best diagnostic performance to discriminate between active TB and LTBI cases in children in relation to the area under receiver operating characteristic (ROC) curve 0.955 (confidence interval 95%: 0.91–1.00), achieving optimal sensitivity and specificity for the development of a new test (93.2 and 90.0%, respectively). Children with TB showed higher ferritin levels and an inverse correlation between 25(OH)D and IFN-γ levels. The model proposed includes a combination of biomarkers for discriminating between active TB and LTBI in children to improve the accuracy of TB diagnosis in children. This combination of biomarkers might have potential for identifying the onset of primary TB in children.
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Affiliation(s)
- Patricia Comella-Del-Barrio
- Research Institute Germans Trias i Pujol, CIBER Respiratory Diseases, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Rosa Abellana
- Department of Basic Clinical Practice, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Raquel Villar-Hernández
- Research Institute Germans Trias i Pujol, CIBER Respiratory Diseases, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | - Lydia Canales Aliaga
- Radiology Service, Research Unit of the Mútua Terrassa Foundation, University Hospital Mútua Terrassa, Terrassa, Spain
| | | | | | - Carlos Ascaso
- Department of Basic Clinical Practice, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Irene Latorre
- Research Institute Germans Trias i Pujol, CIBER Respiratory Diseases, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Jose Dominguez
- Research Institute Germans Trias i Pujol, CIBER Respiratory Diseases, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Tomas M Perez-Porcuna
- Department of Pediatrics, Tuberculosis and International Health Care Unit, Primary Care and Mútua Terrassa University Hospital, University of Barcelona, Terrassa, Spain
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7
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Dreesman A, Dirix V, Smits K, Corbière V, Van Praet A, Debulpaep S, De Schutter I, Felderhof MK, Malfroot A, Singh M, Locht C, Mouchet F, Mascart F. Identification of Mycobacterium tuberculosis Infection in Infants and Children With Partial Discrimination Between Active Disease and Asymptomatic Infection. Front Pediatr 2019; 7:311. [PMID: 31404140 PMCID: PMC6669376 DOI: 10.3389/fped.2019.00311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 07/09/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Improved diagnostic tests are needed for the early identification of Mycobacterium tuberculosis-infected young children exposed to an active TB (aTB) index case. We aimed to compare the diagnostic accuracy of new blood-based tests to that of the tuberculin skin test (TST) for the identification of all infected children and for a potential differentiation between aTB and latent TB infection (LTBI). Methods: 144 children exposed to a patient with aTB were included, and those who met all inclusion criteria (130/144) were classified in three groups based on results from classical investigations: non-infected (NI: n = 69, 53%, median age 10 months), LTBI (n = 28, 22%, median age 96 months), aTB disease (n = 33, 25%, median age 24 months). The first whole blood assay consisted of a 7-days in vitro stimulation of blood with four different mycobacterial antigens (40 μl/condition), followed by flow cytometric measurement of the proportions of blast cells appearing among lymphocytes as a result of their specific activation. Thresholds of positivity were determined by Receiver Operating Characteristic (ROC) curve analysis (results of NI children vs. children with LTBI/aTB) in order to identify infected children in a first stage. Other cut-offs were determined to discriminate subgroups of infected children in a second step (results from children with aTB/LTBI). Analysis of blood monocytes and dendritic cell subsets was performed on 100 μl of blood for 25 of these children as a second test in a pilot study. Results: Combining the results of the blast-induced CD3+ T lymphocytes by Heparin-Binding Haemagglutinin and by Culture Filtrate Protein-10 identified all but one infected children (sensitivity 98.2% and specificity 86.9%, compared to 93.4 and 100% for the TST). Further identification among infected children of those with aTB was best achieved by the results of blast-induced CD8+ T lymphocytes by purified protein derivative (sensitivity for localized aTB: 61.9%, specificity 96.3%), whereas high proportions of blood type 2 myeloid dendritic cells (mDC) were a hallmark of LTBI. Conclusions: New blood-based tests requiring a very small volume allow the accurate identification of M. tuberculosis-infected young children among exposed children and are promising to guide the clinical classification of children with aTB or LTBI.
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Affiliation(s)
- Alexandra Dreesman
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium.,Pediatric Department, CHU Saint-Pierre, Brussels, Belgium
| | - Violette Dirix
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium
| | - Kaat Smits
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium
| | - Véronique Corbière
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium
| | - Anne Van Praet
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium
| | - Sara Debulpaep
- Pediatric Department, CHU Saint-Pierre, Brussels, Belgium
| | - Iris De Schutter
- Department of Pediatric Pulmonology, Cystic Fibrosis Clinic and Pediatric Infectious Diseases, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Mariet-Karlijn Felderhof
- Department of Pediatric Pulmonology, Cystic Fibrosis Clinic and Pediatric Infectious Diseases, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Anne Malfroot
- Department of Pediatric Pulmonology, Cystic Fibrosis Clinic and Pediatric Infectious Diseases, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Mahavir Singh
- Lionex Diagnostics and Therapeutics, Braunschweig, Germany
| | - Camille Locht
- INSERM, U1019, Lille, France.,CNRS, UMR8204, Lille, France.,Université de Lille, Lille, France.,Centre d'Infection et d'Immunité de Lille, Institut Pasteur de Lille, Lille, France
| | | | - Françoise Mascart
- Laboratory of Vaccinology and Mucosal Immunity, Université Libre de Bruxelles, Brussels, Belgium.,Immunobiology Clinic, Hôpital Erasme, U.L.B., Brussels, Belgium
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8
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O'Halloran C, McCulloch L, Rentoul L, Alexander J, Hope JC, Gunn-Moore DA. Cytokine and Chemokine Concentrations as Biomarkers of Feline Mycobacteriosis. Sci Rep 2018; 8:17314. [PMID: 30470763 PMCID: PMC6251861 DOI: 10.1038/s41598-018-35571-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/02/2018] [Indexed: 12/16/2022] Open
Abstract
Mycobacteriosis is an emerging zoonotic disease of domestic cats and timely, accurate diagnosis is currently challenging. To identify differential cytokine/chemokine concentrations in serum/plasma of cats, which could be diagnostic biomarkers of infection we analysed plasma/serum from 116 mycobacteria-infected cats, 16 healthy controls and six cats hospitalised for unrelated reasons was analysed using the Milliplex MAP Feline Cytokine Magnetic Bead multiplex assay. Three cytokines; sFAS, IL-13 and IL-4 were reduced while seven; GM-CSF, IL-2, PDGF-BB, IL-8, KC, RANTES and TNF-α were elevated in mycobacteria-infected cats compared to healthy controls. However, IL-8 and KC concentrations were not significantly different from cats hospitalised for other reasons. Elevations in TNF-α and PDGF-BB may have potential to identify M. bovis and M. microti infected cats specifically while GM-CSF, IL-2 and FLT3L were increased in MTBC infected cats. This study demonstrates potential use of feline tuberculosis as a spontaneously occurring model of this significant human disease. Cytokine profiling has clear diagnostic potential for mycobacteriosis of cats and could be used discriminate tuberculous from non-tuberculous disease to rapidly inform on zoonotic risk. Future work should focus on the in-field utility of these findings to establish diagnostic sensitivity and specificity of these markers.
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Affiliation(s)
- C O'Halloran
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Easter Bush Campus, Edinburgh, Scotland, EH25 9RG, UK. conor.o'
| | - L McCulloch
- UK Dementia Research Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, Scotland, EH16 4SB, UK
| | - L Rentoul
- MilliporeSigma (a Division of Merck KGaA, Darmstadt, Germany), 3050, Spruce Street, St. Louis, MO, USA
| | - J Alexander
- Waltham Centre for Pet Nutrition, Leicestershire, UK
| | - J C Hope
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Easter Bush Campus, Edinburgh, Scotland, EH25 9RG, UK
| | - D A Gunn-Moore
- Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Easter Bush Campus, Edinburgh, Scotland, EH25 9RG, UK
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9
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Togun TO, MacLean E, Kampmann B, Pai M. Biomarkers for diagnosis of childhood tuberculosis: A systematic review. PLoS One 2018; 13:e0204029. [PMID: 30212540 PMCID: PMC6136789 DOI: 10.1371/journal.pone.0204029] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 08/31/2018] [Indexed: 12/14/2022] Open
Abstract
Introduction As studies of biomarkers of tuberculosis (TB) disease provide hope for a simple, point-of-care test, we aimed to synthesize evidence on biomarkers for diagnosis of TB in children and compare their accuracy to published target product profiles (TPP). Methods We conducted a systematic review of biomarkers for diagnosis of pulmonary TB in exclusively paediatric populations, defined as age less than 15 years. PubMed, EMBASE and Web of Science were searched for relevant publications from January 1, 2000 to November 27, 2017. Studies using mixed adult and paediatric populations or reporting biomarkers for extrapulmonary TB were excluded. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies—2 (QUADAS-2) framework. No meta-analysis was done because the published childhood TB biomarkers studies were mostly early stage studies and highly heterogeneous. Results The 29 studies included in this systematic review comprise 20 case-control studies, six cohort studies and three cross-sectional studies. These studies reported diverse and heterogeneous forms of biomarkers requiring different types of clinical specimen and laboratory assays. Majority of the studies (27/29 [93%]) either did not meet the criteria in at least one of the four domains of the QUADAS-2 reporting framework or the assessment was unclear. However, the diagnostic performance of biomarkers reported in 22 studies met one or both of the WHO-recommended minimal targets of 66% sensitivity and 98% specificity for a new diagnostic test for TB disease in children, and/or 90% sensitivity and 70% specificity for a triage test. Conclusion We found that majority of the biomarkers for diagnosis of TB in children are promising but will need further refining and optimization to improve their performances. As new data are emerging, stronger emphasis should be placed on improving the design, quality and general reporting of future studies investigating TB biomarkers in children.
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Affiliation(s)
- Toyin Omotayo Togun
- McGill International TB Centre, and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- * E-mail:
| | - Emily MacLean
- McGill International TB Centre, and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Beate Kampmann
- Vaccines and Immunity Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Atlantic Boulevard, Fajara, The Gambia
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Madhukar Pai
- McGill International TB Centre, and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Manipal McGill Centre for Infectious Diseases, Manipal University, Manipal, India
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10
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Clifford V, Tebruegge M, Zufferey C, Germano S, Forbes B, Cosentino L, Matchett E, McBryde E, Eisen D, Robins-Browne R, Street A, Denholm J, Curtis N. Cytokine biomarkers for the diagnosis of tuberculosis infection and disease in adults in a low prevalence setting. Tuberculosis (Edinb) 2018; 114:91-102. [PMID: 30711163 DOI: 10.1016/j.tube.2018.08.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/19/2018] [Accepted: 08/22/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Accurate and timely diagnosis of tuberculosis (TB) is essential to control the global pandemic. Currently available immunodiagnostic tests cannot discriminate between latent tuberculosis infection (LTBI) and active tuberculosis. This study aimed to determine whether candidate mycobacterial antigen-stimulated cytokine biomarkers can discriminate between TB-uninfected and TB-infected adults, and additionally between LTBI and active TB disease. METHODS 193 adults were recruited, and categorised into four unambiguous diagnostic groups: microbiologically-proven active TB, LTBI, sick controls (non-TB lower respiratory tract infections) and healthy controls. Whole blood assays were used to determine mycobacterial antigen (CFP-10, ESAT-6, PPD)-stimulated cytokine (IL-1ra, IL-2, IL-10, IL-13, TNF-α, IFN-γ, IP-10 and MIP-1β) responses, measured by Luminex multiplex immunoassay. RESULTS The background-corrected mycobacterial antigen-stimulated cytokine responses of all eight cytokines were significantly higher in TB-infected participants compared with TB-uninfected individuals, with IL-2 showing the best performance characteristics. In addition, mycobacterial antigen-stimulated responses with IL-1ra, IL-10 and TNF-α were higher in participants with active TB compared those with LTBI, reaching statistical significance with PPD stimulation, although there was a degree of overlap between the two groups. CONCLUSION Mycobacterial antigen-stimulated cytokine responses may prove useful in future immunodiagnostic tests to discriminate between tuberculosis-infected and tuberculosis-uninfected individual, and potentially between LTBI and active tuberculosis.
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Affiliation(s)
- Vanessa Clifford
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia; Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia
| | - Marc Tebruegge
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia; Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia; Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Christel Zufferey
- Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia
| | - Susie Germano
- Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia
| | - Ben Forbes
- Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia
| | - Lucy Cosentino
- Victorian Tuberculosis Program, Peter Doherty Institute, Parkville, VIC 3052, Australia
| | - Elizabeth Matchett
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC 3052, Australia
| | - Emma McBryde
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC 3052, Australia
| | - Damon Eisen
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC 3052, Australia
| | - Roy Robins-Browne
- Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia; Department of Microbiology and Immunology, University of Melbourne, VIC 3052, Australia
| | - Alan Street
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC 3052, Australia
| | - Justin Denholm
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC 3052, Australia; Department of Microbiology and Immunology, University of Melbourne, VIC 3052, Australia; Victorian Tuberculosis Program, Peter Doherty Institute, Parkville, VIC 3052, Australia
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia; Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia.
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11
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Llibre A, Duffy D. Immune response biomarkers in human and veterinary research. Comp Immunol Microbiol Infect Dis 2018; 59:57-62. [PMID: 30290889 PMCID: PMC7172169 DOI: 10.1016/j.cimid.2018.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 05/22/2018] [Accepted: 09/17/2018] [Indexed: 11/30/2022]
Abstract
Biomarkers are increasingly utilised in biological research and clinical practice for diagnosis of disease, monitoring of therapeutic prognosis, or as end points in clinical studies. Cytokines are small molecules that orchestrate immune responses and as such have great potential as biomarkers for both human and veterinary fields. Given the ease of sampling in the blood, and their high prevalence in clinical applications we will focus on protein detection as an area for biomarker discovery. This is facilitated by new technological developments such as digital ELISA that have led to significant increases in sensitivity. Two highly relevant examples include type I interferons, namely IFNα, that is now directly quantifiable by digital ELISA from biological samples. The application of this approach to the study of the unique bat interferon response may reveal novel findings with applications in both human and veterinary research. As a second example we will describe the use of CXCL10 as a disease biomarker in Tuberculosis, highlighting findings from human and mouse studies that should be considered in veterinary research. In summary, we describe how cytokines may be applied as novel biomarkers and illustrate two key examples where human and veterinary research may complement each other in line with the One Health objectives.
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Affiliation(s)
- Alba Llibre
- Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France; INSERM U1223, Paris, France
| | - Darragh Duffy
- Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France; INSERM U1223, Paris, France.
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12
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Venturini E, Tersigni C, Chiappini E, de Martino M, Galli L. Optimizing the management of children with latent tuberculosis infection. Expert Rev Anti Infect Ther 2017; 15:341-349. [PMID: 28074660 DOI: 10.1080/14787210.2017.1279541] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The management of latent tuberculosis (LTBI) in children represents an important issue for paediatricians because of the disease burden, the lack of a gold standard for the diagnosis and the high annual risk of progression to active disease. Areas covered: A review of English language articles on LTBI in children, published between the 1st of January 2010 and the 1st of July 2016, was conducted using multiple keywords and standardized terminology in PubMed database. This review provides an updated overview of the available tests for LTBI diagnosis in children, management strategies and treatment options. Expert commentary: Two tests are available for LTBI diagnosis: tuberculin skin test and interferon-gamma release assays, both with a suboptimal specificity and sensitivity, and both with the lack of capability in distinguishing between infection and disease. Several new markers have been identified but further studies are needed. Among all treatment regimes, because of the high safety and efficacy profile showed and to avoid the poor completion rate, the treatment with a three-month course of isoniazid and rifampicin is currently recommended. New vaccines are needed because of the spread of the disease despite BCG vaccination in high risk countries. Currently, 15 new vaccines are in the pipeline.
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Affiliation(s)
- E Venturini
- a Department of Health Sciences , University of Florence, Anna Meyer Children's University Hospital , Florence , Italy
| | - C Tersigni
- a Department of Health Sciences , University of Florence, Anna Meyer Children's University Hospital , Florence , Italy
| | - E Chiappini
- a Department of Health Sciences , University of Florence, Anna Meyer Children's University Hospital , Florence , Italy
| | - M de Martino
- a Department of Health Sciences , University of Florence, Anna Meyer Children's University Hospital , Florence , Italy
| | - L Galli
- a Department of Health Sciences , University of Florence, Anna Meyer Children's University Hospital , Florence , Italy
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13
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Novel T-cell assays for the discrimination of active and latent tuberculosis infection: the diagnostic value of PPE family. Mol Diagn Ther 2016; 19:309-16. [PMID: 26245995 DOI: 10.1007/s40291-015-0157-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The diagnosis of active and latent tuberculosis remains a challenge. Although a new approach based on detecting Mycobacterium tuberculosis-specific T-cells has been introduced, it cannot distinguish between latent infection and active disease. The aim of this study was to evaluate the diagnostic potential of interleukin-2 (IL-2) as biomarker after specific antigen stimulation with PE35 and PPE68 for the discrimination of active and latent tuberculosis infection (LTBI). METHOD The production of IL-2 was measured in the antigen-stimulated whole-blood supernatants following stimulation with recombinant PE35 and PPE68. RESULTS The discrimination performance (assessed by the area under ROC curve) for IL-2 following stimulation with recombinant PE35 and PPE68 between LTBI and patients with active TB were 0.837 [95 % confidence interval (CI) 0.72-0.97] for LTBI diagnosis and 0.75 (95 % CI 0.63-0.89) for active TB diagnosis, respectively. Applying the 6.4 pg/mL cut-off for IL-2 induced by PE35 in the present study population resulted in sensitivity of 78 %, specificity of 83 %, PPV of 83 % and NPV of 78 % for the discrimination of active TB and LTBI. In addition, a sensitivity of 81 %, specificity of 71 %, PPV of 68 and 83 % of NPV was reported based on the 4.4 pg/mL cut-off for IL-2 induced by PPE68. CONCLUSION This study confirms IL-2 induced by PE35 and PPE68 as a sensitive and specific biomarker and highlights IL-2 as new promising adjunct markers for discriminating of LTBI and active TB disease.
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14
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Profiling the human immune response to Mycobacterium tuberculosis by human cytokine array. Tuberculosis (Edinb) 2016; 97:108-17. [PMID: 26980502 DOI: 10.1016/j.tube.2015.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 12/26/2015] [Indexed: 11/23/2022]
Abstract
OBJECT Tuberculosis (TB) continues to be one of the most serious infectious diseases in the world, however, no effective biomarkers can be used for rapid screening of latent tuberculosis infection (LTBI) and active TB. In this study, serum cytokines were screened and tested as potential biomarker for TB diagnosis. METHOD Cytokine array was used to track the cytokine profile and its dynamic change after TB infection. The different expressions of cytokines were confirmed by ELISA assay. ROC curve analyses were used to evaluate the efficacy of a cytokine or cytokine combination for diagnosis. RESULTS Eotaxin-2, ICAM-1, MCSF, IL-12p70, and IL-11 were significantly higher in the LTBI individuals. I-309, MIG, Eotaxin-2, IL-8, ICAM-1, IL-6sR, and Eotaxin were significantly higher in active TB patients. ROC curve analyses gave AUCs of 0.843, 0.898, and 0.888 for I-309, MIG, and IL-8, respectively, and 0.894 for the combination panel in active TB diagnosis. IFN-γ/IL-4 and IL-2/TNF-α ratios exhibit dynamic changes in the healthy control and LTBI to different stages of active TB. CONCLUSIONS Serum cytokines, including I-309 and MIG, IL-8, Extoxin-2, ICAM-1 and combinations of cytokines, including IFN-γ/IL-4 and IL-2/TNF-α, can be used as serum biomarkers for LTBI and active TB screening, thus indicating prospective clinical applications.
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15
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Discriminating between latent and active tuberculosis: The role of interleukin-2 as biomarker. J Infect 2015; 70:429-31. [DOI: 10.1016/j.jinf.2014.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 12/23/2014] [Indexed: 11/18/2022]
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Hamzaoui A. [Childhood tuberculosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2015; 71:168-180. [PMID: 24932504 DOI: 10.1016/j.pneumo.2014.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 03/12/2014] [Accepted: 03/15/2014] [Indexed: 06/03/2023]
Abstract
Childhood TB is an indication of failing TB control in the community. It allows disease persistence in the population. Mortality and morbidity due to TB is high in children. Moreover, HIV co-infection and multidrug-resistant diseases are as frequent in children as in adults. Infection is more frequent in younger children. Disease risk after primary infection is greatest in infants younger than 2 years. In case of exposure, evidence of infection can be obtained using the tuberculin skin test (TST) or an interferon-gamma assay (IGRA). There is no evidence to support the use of IGRA over TST in young children. TB suspicion should be confirmed whenever possible, using new available tools, particularly in case of pulmonary and lymph node TB. Induced sputum, nasopharyngeal aspiration and fine needle aspiration biopsy provide a rapid and definitive diagnosis of mycobacterial infection in a large proportion of patients. Analysis of paediatric samples revealed higher sensitivity and specificity values of molecular techniques in comparison with the ones originated from adults. Children require higher drugs dosages than adults. Short courses of steroids are associated with TB treatment in case of respiratory distress, bronchoscopic desobstruction is proposed for severe airways involvement and antiretroviral therapy is mandatory in case of HIV infection. Post-exposure prophylaxis in children is a highly effective strategy to reduce the risk of TB disease. The optimal therapy for treatment of latent infection with a presumably multidrug-resistant Mycobacterium tuberculosis strain is currently not known.
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Affiliation(s)
- A Hamzaoui
- Pavillon B, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie.
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17
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Mamishi S, Pourakbari B, Teymuri M, Rubbo PA, Tuaillon E, Keshtkar AA, Mahmoudi S. Diagnostic accuracy of IL-2 for the diagnosis of latent tuberculosis: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2014; 33:2111-9. [PMID: 24993150 DOI: 10.1007/s10096-014-2190-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
Abstract
We conducted a systematic review and meta-analysis to evaluate the diagnostic potential of interleukin-2 (IL-2) as biomarkers for the diagnosis of latent tuberculosis. Related studies were identified through searches of PubMed, Embase, Web of Science, and complementary manual searches up to December 30, 2013. We used standard methods recommended for meta-analyses of diagnostic test evaluations. The analysis was based on a summary receiver operating characteristic (SROC) curve. Meta-regression analysis was used to assess the effects of some confounding factors on the results of the meta-analysis. The potential presence of publication bias was tested using the Deeks' funnel plots. The pooled estimates of IL-2 for latent tuberculosis infection (LTBI) diagnosis were as follows: sensitivity, 0.81 [95 % confidence interval (CI), 0.60 to 0.92]; specificity, 0.95 (95 % CI, 0.90 to 0.97); positive likelihood ratio (PLR), 15.2 (95 % CI, 8.1to 28.4); negative likelihood ratio (NLR), 0.20 (95 % CI, 0.09 to 0.47). We found that the SROC curve is positioned near the upper left corner of the curve and the area under the curve (AUC) was 0.96 (95 % CI, 0.94 to 0.98). In conclusion, according to the meta-analysis, IL-2 is a valid marker for the diagnosis of LTBI. When there is no definite gold standard for the diagnosis of LTBI, IL-2 release assay in addition to interferon-gamma release assays (IGRAs) can improve the ability of IGRAs to identify individuals with LTBI.
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Affiliation(s)
- S Mamishi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Children's Medical Center Hospital, Dr. Gharib Street, Keshavarz Boulevard, Tehran, Iran
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Cytokine responses to quantiferon peptides in pediatric tuberculosis: A pilot study. J Infect 2014; 68:62-70. [DOI: 10.1016/j.jinf.2013.08.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 07/25/2013] [Accepted: 08/05/2013] [Indexed: 12/11/2022]
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